Special Considerations in Treating Children
Although prepubertal children with gender dysphoria may show gender atypical behavior ‘from birth’, they often don’t present for treatment until they begin school due to social conflict. Although parents vary in their willingness to allow their children to explore gender variant behavior, the issue often doesn’t escalate until the child expresses him or herself in public, such as in school. Families may come to treatment when parents either cannot tolerate or don’t know how to approach the issue, or when the child begins to have conflicts with school peers, including bullying. Many of these children present with anxiety and depression that require treatment.
Treatment of gender dysphoria in prepubertal children is controversial. Hormone treatments can lead to irreversible changes (see “Medical Treatment Options for Transitioning Gender” below). There is no consensus within the medical community on how to make such treatment decisions.
There are currently three approaches to treatment of these children: corrective, supportive, and affirmative (Olson J et al, Arch Ped Adolesc Med 2011;165(2):T71-T76).
Corrective treatment. Since 1984, the corrective approach has been the standard clinical approach and most researched, using strategies that aim to align gender identity with biological sex. However, many experts express concern over the harm done to youth by invalidating their sense of self and note that this approach is “unscientific, unethical, and misguided, comparable to reparative therapy for homosexuality” (Drescher J, LGBTHealth 2014;1(1):10-14).
Supportive therapy takes a ‘wait and see’ approach and does not focus on gender specifically, but may focus on anxiety or depression, and helping families protect their children from bullying by working with the school system. You neither validate nor invalidate the patient’s expressed gender identity. You simply work with the negative consequences as they experience them.
In the affirmative approach, you support the child and encourage active exploration of gender identity. You talk to the parents about the appropriateness of gender transition in some children. Over the past several years there have been more first-hand accounts of parents supporting their young gender variant children, advocating that their child be allowed to attend school with their chosen gender identity and name, beginning as early as elementary school (Gulli C. What Happens When Your Son Tells You He’s Really a Girl? MacLean’s January 14, 2013 [http://bit.ly/1nLZekd]). Sometimes this means needing to move to a new school/neighborhood/state as the child ends one school year in one gender and enters the new school year transitioned. Critics of this approach believe supporting gender transition in childhood can inappropriately encourage young people to persist in efforts to change genders (Drescher J, op.cit).
It is difficult to know what is the “right” approach for these children, and you have to judge each case on its own merits, being aware that you may have your own biases. For example, which is the better outcome: to be a happy transgender adult or to be a gay or heterosexual cisgender adult who may have lifelong issues with gender identity?
In the absence of scientific consensus, my approach is to pay attention to the extremes. I have seen a few cases where parents are strongly opposed to raising a child who may become a transgender or homosexual. In these cases, my role is to help the parents become more accepting of the different possible outcomes, providing them with resources to broaden their viewpoint. PFLAG [Parents, Families, and Friends of Lesbians and Gays] is one resource that provides support to families (http://community.pflag.org/). At the other extreme, parents may be too many steps ahead of their child regarding gender transition. In order to adjust to a new gender, some parents may choose to change the environment so the child presents as a new student in the preferred gender, as opposed to transitioning in the same environment. New peers then don’t know that this was someone of an opposite gender previously. However, several studies show moving/changing schools can be traumatic, especially for vulnerable children. In these cases, I may encourage the parents to slow down the transitioning process, allowing the child to take more of a lead.
Ultimately, the most crucial message you can give parents is that these are their children, they are special and unique, and they deserve to live authentic and happy lives.