Supporting Transgender Children

An important discussion, fueled by scientific studies showing what appears to be opposing outcomes, is currently taking place about how best to support transgender children. To be clear, this is not about anything close to the “conversion therapy” that has rightly been discredited or discriminatory laws that some states are trying to pass. Rather, the dilemma surrounds the direction for parents and clinicians to take when especially younger children begin expressing everything from what is called “gender incongruent” behavior to the wish or full belief that they are of the gender different from their natal sex.

In one camp are those who hold that at least the first step is to encourage the child to understand that the gender concepts of being a boy or girls are much broader than the typical stereotypes. Just because a boy likes pink, or doesn’t like football, for example, doesn’t mean that he is actually a girl. This perspective tends to advocate, at least initially, holding off on things like using a different name for the child or allowing the child to use a different bathroom in school, in part based on some data showing that most young children with gender nonconforming ideas and behavior do not wind up as transgender adults and transitioning to a different gender and then back again can be difficult. Also bolstering this perspective are a number of studies, including a very recent one, showing quite high rates of anxiety, depression and other mental health problems among transgender youth, even among those how have been given hormonal support in adolescence as part of their social transition.

On the other side are those who believe that the most important thing to do is to support a child’s affirmed gender and facilitate their gender “journey” as much as possible. This means avoiding actions that could be felt as disapproving or invalidating to the child and spending the bulk of one’s effort as a parent or educator ensuring that the child’s views and preferences will be accepted without condemnation, ridicule, or abuse. In support of this view is another very recent study demonstrating that young transgender children who are supported in their social transition showed no increased depressive problems compared to controls and only minimal elevations in anxiety.

Closely linked to this debate about approach is the one surrounding whether or not the psychiatric diagnosis of Gender Dysphoria, previously known as Gender Identity Disorder, should be retained. Many, including myself, have argued in the medical literature that there are many parallels between this discussion now and that which existed about 30 years ago, after which homosexuality was officially removed as an diagnosis.

In trying to reconcile these different views and divergent scientific findings, psychologist Kristina Olson, Director of the TransYouth project, wrote a column in the most recent edition of the Journal of the American Academy of Child and Adolescent Psychiatry. She argues that most studies that claim to study transgender youth actually contain a mix of children who vary importantly on their view of gender. Some behave in gender “atypical” ways without actually insisting they are of the “opposite” gender, others express a desire to be the other gender mainly as a wish, while still others don’t see gender as a binary concept anyway and position themselves as somewhere in between. Finally, there are those children who both do see gender as a binary entity and who “consistently, persistently, and insistently (pg 155)” identify themselves as the gender opposite of their natal sex. For this latter group, Olson states, there is stronger evidence that these identifications are going to be maintained over time and stronger evidence that that supporting their affirmed gender as much as possible will have the best mental health outcome.

What the best course of action is for the other three groups isn’t answered in this article and remains an active and important question. While everyone agrees with the critical need to protect gender nonconforming children from what can be viscous and cruel treatment and with the need to avoid harsh and punitive responses, there remains debate on this subject among good and open-minded people who truly have a child’s best interest in mind.

@copyright by David Rettew, MD

David Rettew is author of Child Temperament: New Thinking About the Boundary Between Traits and Illness and a child psychiatrist in the psychiatry and pediatrics departments at the University of Vermont College of Medicine.

Follow him at @PediPsych and like PediPsych on Facebook.