There’s been lots of attention focused lately on the transgender population, from Medicare lifting the ban on transgender surgical procedures to TV star Neil Patrick Harris playing a transgender entertainer in Hedwig and the Angry Inch on Broadway.
Transgender rights are currently seen as the next frontier for equal rights. But from a practical standpoint, what do we do when a family comes to us with a child with gender variant expression?
Transgender is defined as a person who feels that their gender identity does not match the gender assigned at birth. The prevalence in the US is low, but hardly negligible: it is estimated that 0.3% of adults, or close to one million people, identify as transgender (Stroumsa D, Am JPublic Health 20l4;104(3):e38). There are no reliable prevalence figures for children.
Life is not easy for the transgendered, at any age, because they deal with significant discrimination and stigma, which leads to a high prevalence of psychosocial problems. Transgender people have a particularly high likelihood of using drugs, alcohol, or smoking as a way to cope with discrimination. They are at increased risk of being victims of violence (including homicide) and suicide. For example, one study noted a 41% lifetime suicide attempt rate, compared to 1.6% in the general population (Injustice at Every Turn: A Report of the National Transgender Discrimination Survey 2011; http://bit.ly/1teXC7Y).
In addition, transgender people, particularly those of color and of low income, encounter significant discrimination in healthcare settings. One study found 19% reported being denied healthcare by a provider because of their gender identity, and 28% reported verbal harassment in a medical setting (Injustice at Every Turn, op.cit).
Treating Transgender Teens
The most common psychiatric issue that you will see in transgender teens is “gender dysphoria.” This is defined in DSM-5 as “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six month’s duration,” in addition to the usual stipulation of “clinically significant distress or impairment in important areas of functioning” (American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Addition. Arlington, VA, American Psychiatric Association, 2013). (See “Making Progress in Diagnosis” above.)
Gender dysphoria is often caused by the teen’s struggle with gender identity and social difficulties such as the lack of acceptance from their peers.
A good approach to working with these teens is to start by meeting with the youth individually, which often entails helping him or her cope with the coming out process. Only later is the family involved, because the teen must be emotionally prepared to discuss the issue with family and only when it is safe to do so. Parental acceptance is its own process, often requiring family therapy. This is a crucial part of treatment, since being rejected by parents increases the risk of attempted suicide, depression, use of illegal drugs, and unprotected sex (Ryan C et al, Pediatrics 2009;123(1):346-352). I will generally tell parents directly that family acceptance is one of the best “treatments” for lesbian, gay, bisexual, and transgender (LGBT) teens.
In working directly with adolescents, I emphasize that I accept their gender identity. It’s important that teachers and peers refer to them by their preferred name and pronouns, and that they understand and accept that some teens may associate a gay identity with taking on some gender atypical behaviors. For example, they might experiment with cross-dressing or may take on an opposite gender name.
In addition to discussing social adjustment issues, you should also ask your patient whether they use hormones or would like to use them. Very few physicians are willing to provide cross-gender hormones or puberty-suppressing hormones, even if a psychiatrist is part of the treatment team. You may need to be your patients advocate to find a physician willing to provide hormone treatment. It is generally accepted that the earlier the transition, before development of secondary sex characteristics, the higher the chances of a successful gender transition, leading to a better quality of life. Teens who cannot find a doctor to prescribe hormones may access street hormones, with the risk of unclean needles (HIV, hepatitis) and inappropriate hormones/ dosages.