Monique* is an African-American 16-year-old youth from a small city in Southern California who lives with her foster parents. She was referred to a community-based mental health provider because of significant depression and anxiety. In working with her, the therapist discovers that gender worries are at the core of her psychiatric distress.
Assigned male at birth, Monique has felt for several years that she is not male, but female. The therapist, recognizing that she has not been trained as a gender specialist, continues to treat Monique but makes a referral to a specialized gender clinic, where Monique gains access to a clinician who can better understand her core gender issues in the context of her other psychological symptoms.
*The patient’s name has been changed for privacy purposes.
The young woman in the case was referred to our clinic, the University of California San Francisco Benioff Children’s Hospital Child and Adolescent Gender Center Clinic, an interdisciplinary program serving the needs of gender-nonconforming children since 2011. Similar clinics are opening across the country. Why the proliferation of these programs within the past decade? Because there has been a need for them. More and more children are expressing to their parents questions, worries, or declarations about their gender. At our clinic, we are referred approximately 20 new patients per month.
Approach to assessment and diagnosis
Our experience is that medical, mental health, educational, and legal expertise all contribute to optimal care of gender patients. Gender clinics typically use a team approach; patients are cared for by a large interdisciplinary team that includes psychologists, psychiatrists, social workers, pediatricians, pediatric endocrinologists, nurse practitioners, educational specialists, and legal advisors.
Let us circle back to Monique. If the gender clinic provider had gone into the assessment equipped only with teaching received in medical or graduate school about gender development, she might have walked out of the session with deep concerns about Monique’s mental health. Monique told the provider that, although born a boy, she knew from the time she was 1 year old that “boy” did not feel right. By the time she was 3, she, then a child named Samuel, was borrowing her sister’s toys and clothes. By seventh grade, she could no longer live as a boy and announced that she was a girl. She had identified as a girl ever since—not as a transgender girl, but as just a girl. She was sure she had never been male; she had a body with a penis but had a girl self.
The mental health provider’s early training might have suggested that Monique was delusional, that she had failed to receive the gender socialization that would have allowed her to accept her boy body and her male sex assignment, and that the traumas and attachment disruptions in her early life had set her askew in her—or rather, his—normative gender development.
Instead, the assessment uncovered the following: Monique had a very early history of female gender identification; it had never wavered; it went far beyond just wanting to do girl things and extended to the very core of her being. Corroborated by her foster parents’ report, she had not said, “I want to be a girl” but rather, “I am a girl”—this certainty is one of the signifiers that differentiates transgender children from children who are simply exploring their gender identity. From an early age, Monique had been distressed about having a penis (another signifier). Puberty was highly stressful for her, if not traumatic, as her body betrayed her by sprouting male secondary sex characteristics.