But What If They Change Their Mind?!

Consider this post a close cousin to my last post, “On Being ‘Sure”. Related to loved ones’ fears about a transgender person being “sure” about transitioning are the fears that they may one day regret the transition or “change their mind” about being transgender. Yes, I hear this a lot. From doctors, from parents. It’s a valid concern, although I’m not sure the frequency with which it happens is correlated with the amount of concern about it.

It seems that at first parents hope their child (either a youth or their adult child) will change their minds when a transgender identity is first revealed. Later, this thought turns into a fear as transition nears or progresses.

In my opinion, some of the fear and anxiety comes from good intentions, trying to use their own perspective to understand. If they put themselves in the transgender person’s shoes, they would imagine not only would they “change their minds”, but they would want to “switch back” immediately. It’s really important to try to not use your own perspective in this situation if you have never once struggled with your gender identity. For as sure as you are about your gender identity, your transgender loved one is likely just as sure about their gender identity.

But what about the studies?? Oh, the studies. The studies that scare everyone. There are plenty of studies that show gender nonconformity in childhood doesn’t persist. That even those who insist they are the “other” gender do not go on to transition. Keep in mind some of these studies were written by doctors who were actively trying to get the child to conform to their birth gender. Additionally, all the dynamics at play with the child’s gender identity are not known in those studies.

Not everyone follows the same path. Not everyone has the same personality, confidence, support system, encouragement, discrimination, access to resources, parents, communities, ego strength, temperament, role models etc. All of these factors, and many more, can affect whether or not someone chooses to transition.

Someone may decide that having their body be different from their affirmed gender identity is more distressing than having their birth gender identity be different from their affirmed gender identity. Everyone is different. People experience distress in different ways and because of different things. Just because someone chooses not to transition, or later “de-transitions” does not mean they are not transgender. It means that they (or others in their life) decided transitioning was ultimately not the best choice for them.

I believe that most of the children/teens/adults who say they are “sure” and then transition do not live to regret this decision. I have anecdotal evidence with my own clients. Don’t believe me? In 2011, a man named Colin Close conducted a survey about how medically-assisted transition
affects the lives of transgender people. The study examined the
experiences of 448 individuals to identify the impacts transition on
gender dysphoria, quality of life, emotional well-being, personality
traits, and sexuality.

The outcome?

  • 94% of trans* people reported an improvement in their quality of life due to transitioning
  • 96% answered that their sense of well-being improved
  • 9 out of 10 responded that their overall personality improved due to transition
  • 85% described their emotional stability as “improved” (11% reported no change)
  • 96% reported an overall satisfaction with transition
  • 97% reported a satisfaction with hormone therapy
  • 96% reported satisfaction with chest surgery
  • 90% reported satisfaction with genital surgery

You can download the full report here.

Are there those that do change their minds and regret transitioning? Yes, there are. I can’t speak to exactly what dynamics led to this, as only they know everything that went into all of their decisions. However, I believe they deserve just as much support “de-transitioning” as they did transitioning. It is their gender. It is their life. It is their journey.

We as humans (probably as self-protective measure) tend to look at the “worst case scenarios” and feel scared by risks associated with choices, no matter how small. It’s natural. However, those small percentages of things often scare us from taking the leap to do something we want to do.

Let me use this as an example: what if the ratio of successful airplane flights to the number of airplane crashes was roughly equivalent to the ratio of people who are satisfied about transitioning to those who regret it?

If we all based our sense of safety on thinking about the small percentage of airplane crashes, none of us would want to fly again. There a risk to much everything we do, and there are no guarantees. Yet with risk often comes adventure, new possibilities, fulfillment, joy! Think of transitioning as your loved one spreading their wings to fly. :)

What about the kids, you say? They are not adults. How can they POSSIBLY make such a huge decision as this? Well, gender identity is not a decision. It is a way one is. For children who have shown a persistent and consistent cross-gender identification during childhood and express a strong desire to be seen as the gender with which their brain identifies, they should be allowed to do so. Transitioning is something one does about one’s gender identity if it doesn’t match one’s body. Parents and professionals need to help youth access the resources they need to do so; that is the vehicle for supporting one’s true identity, not just a “big decision”.

Bear with me for a moment while I expand upon the decision about marriage as a metaphor of sorts for gender transition as I did in my last blog post. I don’t know what the current percentage is, but last I heard 50% of marriages end in divorce. 50%! That’s HALF of the people who decide to commit themselves to someone for the rest of their lives, and essentially “change their minds”. I can tell you that is FAR higher than the number of individuals who will regret their gender transition! Now, does this mean we should increase the hoops one should jump through in order to get married? Should one’s mental health be evaluated before entering into marriage and signed off by a licensed therapist?Does the person who is performing the marriage have to have some sort of guarantee that this marriage will last forever before conducting the ceremony? Of course not. If both parties are entering into the marriage willingly and are able to make sound decisions for themselves, they should have every right to do so. Informed consent is the name of the game when it comes to getting married, as it should be with gender transition.

Is there a chance your loved one may regret the decision? Yes. Is there a chance you may die the next time you get in your car or the next time you take an airplane flight? Yes. There are no guarantees. But I can say this: there are more risks associated with not transitioning or allowing your child to transition that there is with transition. Acknowledge your fear but don’t let it hold you (or your loved one) back. Soon you’ll all be ready for takeoff.

On Being “Sure”

One of the first things that comes to most loved ones’ minds when told about someone’s transgender identity or plans to transition is “Are you sure??” In fact, this is often a question many of my pre-transition clients are asking themselves; “Am I sure??”. The question is worth asking, but the answer may not be a simple “yes” or “no”.

Most people are pretty darn sure of their gender identity. Cisgender and transgender alike, most are pretty darn sure. What confounds things is that only transgender people have to navigate through having a brain gender identity that differs from their birth sex, and having to first understand and then explain this to others. Still, most are pretty darn sure. Remember, gender identity is different than making the decision to transition. Often times, knowing one’s gender identity is the “easy” part. Pursuing a life to align one’s gender presentation with one’s brain gender identity? Now that’s the more challenging part.

So, “Are you sure?”. If you are a loved one who finds yourself asking this question, try to clarify what you are asking about. Are you asking about your loved one’s gender identity or plans to transition? If you separate the two, you may find more confidence in the first than the latter. If your loved one is sure of their (trans)gender identity, asking if they are sure about their transition may contribute to fears and anxieties surrounding this “decision”. Instead, ask “How can I help? What’s the first step?”.

Many clients I’ve met with who are contemplating transition have said to me, “I want to be 100% sure”.  My clients tend to be intelligent, high-functioning individuals who are used to doing things well, and they want this to be no exception. They research, they inquire, they ruminate, they agonize, they weigh the risks and benefits ad nauseum. After all this, they are still “not sure”. Why? Because there ARE risks, and because the process isn’t easy. Therefore, anxiety about this huge undertaking can be interpreted as not being “sure”. Again, not so much about the gender identity- if I can bring them back to that aspect of themselves instead of just the “decision” to transition, they are much more sure about their gender identity. A good example might be left-handedness. People are born left-handed, no? It used to be lefties were encouraged to use their right hands until it became habit. Gender identity is similar in that it is inborn.  It can be stifled to present differently, but that doesn’t mean it’s good for the person. And what gender one presents as is far more pervasive than which hand is dominant!

One of my clients, a happy and insightful trans man, made mention to not feeling completely sure until AFTER he had transitioned. I later contacted him to write a little blurb for this blog post, and he delivered beautifully. Here is what he had to say:

“To be honest I wasn’t 100% sure about transitioning until I was already pretty far into it. One day about 4 years in I looked in the mirror and for the first time in my life I recognized myself. I don’t think you can ever be 100% sure about anything in life, any decision, any path…it’s all educated guesses wrapped up in a hope for happiness.”

Isn’t this the case for most things? We make huge decisions all the time that will affect the rest of our lives: where to live, where to go to school, the career path to follow, to marry or not to marry, if yes who to marry, to have kids or not have kids, if yes how many, etc. Yet these decisions typically aren’t as agonized over as much or as misunderstood as gender transition.

I’m reluctant to compare gender transition to getting married, but the analogy really sticks in my mind. How many people are “sure” when they get married that they will be with the other person “forever”? Of the couples who eventually divorce, if you could ask them “but were you SURE when you got married?”, most of them would unequivocally say “yes”. Some may argue that gender transition is a more “serious” decision than getting married, but is it? Marriages often result in children, who are thereby affected by a divorce if it were to occur. If a capable individual decides to get married, they get married. However, if a capable individual decides to go through gender transition, the issue of being “sure” is one they will have to answer over and over again. I guess it’s because other people can understand marriage, but have a harder time wrapping their brains around gender transition. However, this should not matter when it comes to others and their decisions about their own lives. Not to mention the rate of transgender individuals later “changing their minds” about transition is FAR, FAR less than the current rate of successful vs. unsuccessful marriages!

I suppose feeling more at ease with one’s decision comes down to trust. If your loved one is telling you who they are what they have decided to do, trust them. If you are transgender and have decided to transition, trust yourself. If the person making this decision is of sound judgment and mind, there is no real reason to think this is an irrational decision that will ever be regretted. Additionally, if one has come to the decision to transition, it has not come lightly. Many transgender people agonize about the decision to transition long after one’s true gender identity has become consciously aware.

Perhaps being “sure” is an evolutionary process, and one that can only happen after the first step. I do know that trusting yourself is a good idea… of that I am sure. ;)

For those of you how have transitioned, how “sure” did you feel before? After?

The Pronoun Corrector

Want to be a super hero? Who doesn’t? There’s a very special kind of super hero when it comes to supporting a newly transitioning transgender person.

Is it a bird? Is it a plane?? NO! It’s:

The PRONOUN CORRECTOR!!!

Someone in the early stages of social transition often experiences a lot of anxiety about how they are being “read” and if they are passing as their preferred gender. They can experience a lot of fear and anxiety about being read as their assigned (birth) gender.

When someone is already feeling unsure and a little anxious, it’s certainly hard to find the courage to correct pronouns and other clarifiers such as “sir” or “ma’am”. I’ve coached numerous clients and groups on how to do this in a friendly, confident fashion.  But it remains incredibly difficult for many individuals, and I can’t say I blame them.

I was having a conversation with one of my teen clients the other day.* When I asked how he was doing correcting pronouns in one of his classes as needed, he said, “Well, I have a friend in that class. She does the correcting for me.”  I was happy and relieved for him. I’m all about empowering someone to speak up for themselves; this client and all my other clients do plenty of speaking up for themselves.  When others intervene on their behalf it is a much needed break!

I said to him, “Oh, you’ve got a Pronoun Corrector in that class! How awesome. That’s a special kind of superhero, a Pronoun Corrector.” He smiled because he knew exactly what I meant. I wonder if his friend even understands the power of her intervention. Perhaps one of these days my client will let her know.

Pronoun Correctors play a huge role in a friend or loved one’s transition. They model and prompt correct use of pronouns. They can be assertive and strong when the transgender individual is not feeling up to the task. Pronoun Correctors show how important it is to use the correct pronouns, and not to let the “wrong” pronouns slip by as if unnoticed or as if they didn’t matter. Typically, a Pronoun Corrector will have far less anxiety about correcting someone than the individual themselves. They are in the perfect position to speak up!

I felt this blog post was timely given the holidays are soon upon us. Many trans* people will be seeing family members and disclosing their transgender status for the first time. Many will be seeing family members for the time since disclosure. Many will be in a room with some people who are supportive of their gender transition, and some who are not. They will be in rooms where some people use their birth pronouns and some use their preferred (a.k.a. the “correct”) pronouns. Sadly, holidays can bring an extra dose of anxiety to someone going through gender transition.

If you are the loved one of a newly transitioning transgender person, won’t you consider earning your cape?  Someone said “he” in reference to a MTF individual? Say “she”.  Someone said “her” in reference to an FTM individual? Say “him”.

If you are the parent of a newly transitioning child, you are in the perfect position to be their superhero!

If you are transgender and feel you need a Pronoun Corrector in your life or over the holidays, explicitly ask someone you trust. Send them this blog post and say “Will you be my Superhero?” :)

Have/had a Pronoun Corrector in your life? Let them know what it means to you.

Pronoun Correcting Etiquette:

  • Smile when you correct. Being friendly goes a long way. People will tend to follow your lead more when they don’t sense hostility from you or feel they need to go on the defensive.
  • Say it quietly, but assertively. State it as simply as possible, and nod as if to indicate, “It’s ok, keep going, just wanted to be sure you understand the correct pronoun.”
  • Be thoughtful about your target audience and recipient of the correction. Correcting pronouns is often most helpful to help someone understand one’s gender identity, or modeling for several people who may not be sure about preferred pronouns (and who then may appreciate the clarification).
  • Be gentle with loved ones. Is it necessary to correct every slip? Absolutely not. If a loved one (particularly a parent) is trying, and making a conscious effort to use the correct pronouns, let slips pass by. After a “slip”, you can subtly use a correct pronoun later when you are talking, just as a gentle reminder. If “slips” continue well into the transition, the transgender individual may need to sit down with the loved one to discuss how the loved one’s “transition” is going in regards to understanding, accepting, etc.
  • If a loved one is not ready or has expressed a strong resistance to using the preferred pronouns, don’t push it. Give them space and time. Use the correct pronouns yourself, and don’t comment on their choice of pronouns. Pushing someone before they are ready may close them off to future acceptance and understanding.

Check out my first Bitstrip below!

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*Much thanks to my client for giving me permission to write about our conversation in this blog.

A.B. 1266- School Success and Opportunity Act

The day Assembly Bill 1266 was signed into law by Governor Brown was a very good day in my books. A.B. 1266, otherwise named the “School Success and Opportunity Act”, requires that California public schools respect students’ gender identity and ensures that students can fully participate in all school activities, sports teams, programs, and facilities that match their gender identity. The issues affected by this bill are not just concepts to me, but things I think about and talk about on a very regular basis. More importantly, I see and hear about the impact this issue has on many different kids and teens all the time.

In my practice, I have heard about a student being told they may not participate in everyday activities at school like changing for PE with the rest of their peers, making them clearly stand out.  I have seen kids who feel rejected and ostracized at school because they are forced to use the nurse’s bathroom and may not use the bathroom with their peers. I have had my teen clients tell me they dehydrate themselves and “hold it” all day to avoid having to use the bathroom at all.   I have had teen clients have to mask their true gender identity in order to be allowed to continue to play a sport they love and at which they excel. Therefore, you can only imagine my elation when I heard about the bill that will protect students like this. However, not long after the celebration of this victory came the opposition. People speaking up who adamantly oppose the existence of this bill. I (again) find myself surprised at the ignorance and discrimination I hear and read.

Many opponents of this bill have inaccurately named it “The Bathroom Bill” because they seem to ignore the other aspects of equality that are being offered by the bill going into law and focus solely on what it means for transgender students being allowed to use the appropriate bathroom. Therefore, I will focus on that part of the bill in this blog post, for now.

So what are we talking about here? We are talking about girls being able to use the girls’ restroom, and boys being able to use the boys’ restroom. It explicitly states a student may use the facilities consistent with his or her gender identity, irrespective of the gender listed on the pupil’s records.  It does not say “all students” can pick which bathroom they want to go in, depending on their mood. We are NOT talking about boys using the girls’ bathroom and girls using the boys’ bathroom. We’re just not. If someone says we are, he or she does not understand what makes someone a boy or a girl.

Having a penis or a vagina does not make someone a boy or a girl.  Being a boy or a girl references one’s gender identity, which exists in one’s brain. Talking about genitals only references one’s natal sex. (For more information on this, re-read my post “Gender Vs. Sex”.) For those people who insist having a penis or a vagina is what determines whether someone is a boy or a girl, why??  WHY must genitals trump brains? I don’t understand. What is this focus on genitals? Why do some people act as though what someone has in their pants is more important than what they have in their heads?? I mean, you could function and lead a productive life without a penis or a vagina (provided there were modifications made for the elimination of urine), but you can’t function or lead a productive life without a brain. Brains trump genitals, as they should in the gender debate and many other issues I won’t mention here!

Speaking of being hyper-focused on genitals, people seem to be confused about how transgender people use their genitals in the bathroom. Some seem to think it will be a transgender person’s goal to show off their genitals in the bathroom. I recently read a quote in the LA Times:  “What if a kid with a penis is standing at the boys’ urinal wearing a dress and a pretty hair bow?”  This is not quite how it’s going to go down, guys. First of all, if this quote references a transgirl and being allowed to use the restroom that matches her gender identity, she would be in the girls’ restroom. There are no urinals in the girls’ restroom. Additionally, transgender children and adults are typically going to be incredibly careful to stay covered when using the restroom. You’d probably have a greater chance of being struck by lightning than seeing a transperson’s genitalia in a public or school restroom.

Others seem convinced a transgender person is going to be interested in looking at other people’s genitals in the bathroom.  That whole “man in a dress in the women’s restroom” argument? Only serves to prove the ignorance of the opponents. A transgender woman is not a man in a dress, she is a woman. She likely has the same interest in seeing the genitals of the other women in the restroom as the general population. (How high do you think that is? Pretty low, I would imagine. I’ve not seen a lot of girls/women trying to catch glimpses over the bathroom stalls in all my years of using school and public restrooms, but I digress.)

Want to know how I think a transgender child, teen, or adult uses their genitals in the bathroom? To eliminate urine. Surprise! Oh, and thanks to social stigmatization and ignorance, that same individual will probably do their business and then hurry out of the restroom as fast as possible. Not what I want for the people I care about.

Lastly, I’ve heard and read concerns that a male child or teen may “pretend” to be transgender just to get to use the girls’ restroom. (The fact that no one is worried that a “girl” is going to “pretend” to be a boy just to get a peek in the boys’ bathroom says other negative things about society at large). Let me tell you, I just don’t see that happening. Bear in mind this is not about “I feel like a girl today” or “I feel like a boy today”. This is about a consistent, persistent cross-gender identification that will likely be discussed and explored at length by parents and professionals prior to a child transitioning and therefore using a bathroom different than that in line with their natal sex.

To the opponents: please, sit down. Be quiet. You know not what you do. You are protecting children who do not need protecting and harming children who do. As a professional who has cared for and worked with many transgender kids/teens/families/adults, I know more about this issue than you do. I understand what it means to be transgender more than you do. I understand the bathroom behavior of transgender individuals better than you do. I care about this issue more than you do, and I’m on the other side.

This is about being treated like a decent, normal student along with one’s peers. This is about being able to play on the team in line with one’s gender identity and be included with same-gender peer for activities such a P.E. This is about not forcing a GIRL to play on a boys’ team or not forcing a BOY to be in a girls’ group for P.E.

Even if this bill “sticks”, and I hope it does, everyone is not yet safe. Transgender individuals being “allowed” to use the restroom that matches their brain gender identity is not enough. The understanding of gender identity needs to be increased in the general population. Please, if you care about this issue, speak up. Urge those around you to avoid signing petitions in opposition to this bill. Educate others who may misunderstand what this bill is all about. Consider signing this pledge to support transgender youth. https://www.change.org/petitions/i-support-transgender-students

For more in-depth information about this bill and to read more about “myths” about this bill, please visit: http://www.americanprogress.org/issues/lgbt/news/2013/08/23/72800/californias-new-protections-for-transgender-students/. It’s one of the better articles I’ve read.

Clip from “The Doctors” Show

Recently I had the opportunity to appear on the show “The Doctors” on an episode about a gender nonconforming child, subject of the blog and book “Raising My Rainbow” by Lori Duron. Here is a 3 minute clip in which I discuss the terms “gender nonconforming” and “transgender”. Click here to see the clip. 

RLE- Really!? Why requirement for “Real Life Experience” is/was detrimental

Recently in my quest for a doctor to provide hormones for a teenager outside of San Diego, the issue of “Real Life Experience” came up. The doctor made reference to the fact that this teen had “less than a year of Real Life Experience”. I wanted to respond, “Really!? This teen, who has minimal family support or advocacy, has socially transitioned and has tried to present as male for almost a year, with no medical assistance??”. I think that’s amazing. Another doctor told a (then future) client of mine he would need at least 3 months of RLE before getting any type of medical assistance with transitioning. This is an overwhelming concept for most, and I’m glad my client pursued a session with me even after that! I think asking someone to have “real life experience” as the gender with which they identify in order to receive hormones is like asking someone to earn a prosthetic leg by running a marathon!

For those of you who don’t know, “Real Life Experience” used to be a REQUIREMENT for those seeking gender transition. It is, thankfully, becoming an antiquated concept. In the Standards of Care Version 6 (2001), the Real Life Experience is defined this way:  “The act of fully adopting a new or evolving gender role or gender presentation in everyday life is known as the real-life experience. The real-life experience is essential to the transition to the gender role that is congruent with the patient’s gender identity. Since changing one’s gender presentation has immediate profound personal and social consequences, the decision to do so should be preceded by an awareness of what the familial, vocational, interpersonal, educational, economic, and legal consequences are likely to be. Professionals have a responsibility to discuss these predictable consequences with their patients. Change of gender role and presentation can be an important factor in employment discrimination, divorce, marital problems, and the restriction or loss of visitation rights with children. These represent external reality issues that must be confronted for success in the new gender presentation. These consequences may be quite different from what the patient imagined prior to undertaking the real-life experiences. However, not all changes are negative.”

Yes, there may be negative outcomes to transitioning. Transitioning can be one of the most (if not the most) stressful undertakings an individual ever experiences in his or her lifetime. However, these negative outcomes are not a reason not to do it, they are side effects of someone living true to one’s self.  Asking someone to transition without any assistance medically is quite simply a set-up for more discrimination, and decreases the chance of a positive outcome. The ability to present more as the gender with which someone identifies while transitioning increases the chance of being accepted and acknowledged as one’s asserted gender. This individual described it beautifully:

“Whilst individuals vary greatly, some people have considerably more difficulty being read as their gender prior to HRT [Hormone Replacement Therapy], and AMAB (Assigned Male at Birth) people are more likely to receive certain forms of harassment if people read them incorrectly. Forcing people into public facing roles to get the treatment they need puts them at direct risk of violence, harassment and discrimination.  What ‘real life’ is being experienced? From my own and others’ experience, I know that living full time as a woman pre HRT is vastly different to being full-time after a year on HRT. The near daily abuse and marginalization, with incumbent stress, is not the real life I’m experiencing now, but was a feature of living as a woman who was visibly trans*. The RLE required is entirely unrepresentative.”

In my opinion, the Real Life Experience requirement was a very tricky, if not dangerous, requirement for kids or adults to do before receiving hormone treatment. Being teased, rejected, and bullied can be more of a risk when one is trying to present as the “opposite” gender and not being able to pass due the presence of natal sex markers and the absence of traits of one’s asserted gender. I understand it feels riskier to prescribe quickly with a youth, but the decision-making should be based more on how consistent and persistent his male gender identity has been, his distress at being read as female, etc. Doctors seem to be just as resistant to prescribing hormones right away for adults who have decided to transition. So many people are worried about making certain the individual is “sure”. I can understand this, however- how many people do you think are going to decide to transition when they are unsure about their gender identity, really? The most common source of indecision is the choice about if/when to transition, not one’s gender identity. About that most people are sure, especially when they make the big decision to undergo gender transition.  Attempting to transition while struggling to “pass” may make someone more unsure about their decision to transition, but doesn’t change their gender identity.

I recently watched “TRANS”, a documentary feature film.  When speaking about Christine McGinn, a successful and eloquent doctor, they tell about the steps of her transition like this: “First, live life as a woman.”  Really?! That’s FIRST?? With no medical assistance of hormones to soften male facial structure, redistribute body fat, etc.? Just simply, “live life as a woman”? This seems completely backwards. It simply makes more sense to create physical changes first to assist in passing as one’s asserted gender (the gender identity in line with their brain).  Allowing a transgender individual to medically transition IS the way to allow them to get on with life- their real life. Making medical transition harder and less accessible is a sure way to increase stress, depression, and the risk of suicide in a population that already struggles with these issues far more than the general population.

Wondering what the current version (Version 7, 2011) of the Standards of Care says about “Real Life Experience”? Absolutely nothing.  From a weblog written by Dr. Kelley Winters: “The tone and language of the SOC7 are more positive than in previous versions, with more emphasis on care and less emphasis on barriers to care. Some highlights include […] removal of the three month requirement for either “real life experience” (living in a congruent gender role) or psychotherapy before access to hormonal care.”

Here’s to you, and living YOUR real life, whatever that may be.

Helping Your Gender Variant Child With Teasing (Gender Spectrum Workshop)

Due to a family emergency, I was forced to cancel my presentation at Gender Spectrum this year. My workshop was titled, “Helping Your Gender Variant Child With Teasing”. I have been contacted by parents who had anticipated attending the workshop and who had been looking forward to gathering information on the topic. For that purpose, I’ve outlined and summarized what I was going to discuss. Please feel free to contact me if you have any questions! An important part of my workshop was going to be role playing, so if that makes you squirm, you got lucky… this time. ;)

My presentation was going to be based largely on this blog post: Your Gender Variant Child: Teasing.

Please read it before reading this blog post if you haven’t already.

One of the main points of my previous blog post was about the importance of parents avoiding warning a child about how their interests, way of dress, etc. may result in teasing. This increases anxiety and makes the child wary, rather than equipping them with coping skills.

Helping Your Gender Nonconforming Child With Teasing

Key concepts:

Gender Identity: How someone identifies in his or her brain; male or female.

Gender Expression: How a person may choose to dress or express gender; feminine or masculine.   May be in line with gender identity or may not; may be in line with assigned birth gender and may not.

Gender Nonconformity: Conform means to “behave according to socially acceptable conventions or standards”. Being gender nonconforming is not subscribing to society’s gender “rules”; what colors/dress/interests are for girls and which are for boys. These societal rules are always changing, and it’s my belief these gender rules won’t always be so rigid.

Coaching your child: It’s our job as parents to teach our kids how to behave, right? Remember, gender identity is not a behavior. It is simply a core characteristic of a person: whether they feel male or female. Gender expression, if it is a reflection of their gender identity, is not a behavior that should be molded or changed to prevent teasing. If your child has a behavior that is negatively impacting others, and is a behavior he or she can change, coach them about this. (Examples of this might be if they themselves are teasing peers, if they are physically aggressive, bossy in play, etc.) If it’s not a behavior they can change, teach them how to care for themselves in response to behavior from others.

Why do kids tease?

There are so many reasons why kids tease: because they themselves have been teased, they want to feel powerful, they want to impress other kids, etc.

Why does gender nonconformity elicit teasing? A gender variant child is even more susceptible to teasing given that they tend to behave or dress in a way that can be unexpected by other children or deemed by other children to be “different”. As most of us know, those that are “different” or in the minority are more likely to be teased, get teased more often, and often more severely than other children.

Also, kids are focused on rules. Since the day they begin exploring their world, they begin learning about rules. Don’t touch that, don’t do that, can’t go there, don’t eat that, etc. It’s how kids learn about the world around them and learn what works. Things fit into categories so that it makes the world make sense. The more one is able to categorize something, the less thinking one has to do about it, and the less discomfort it brings up. When something doesn’t follow the “rules” a child has been taught, there is discomfort, possible anxiety- and kids work to have their world make sense again. They have been taught specific rules, “pink is for girls, boys don’t cry, girls don’t like sports, boys can’t wear skirts, etc.” When a peer’s gender expression doesn’t fall in line with these “rules”, kids can compulsively make it their job to let them know they are not following the “rules”. Additionally, because kids are essentially being controlled much of the time, it is likely an outlet for them to try to be the one to control others occasionally.

Teasing vs. Bullying- what’s the difference?

Teasing: Can be done by friends or kids who are not friends, can be done in a friendly/fun way, or in a mean way. Typically mild by nature. Does not cause major distress on behalf of the child being teased.

Bullying: Greater intensity, more frequent, and can also be much more hurtful or damaging. Typically mean-spirited.

Important distinctions between the two: teasing is a behavior or an act that is temporary or occasional. Bullying may be ongoing, daily, etc. Most important clarification is how much distress it brings to your child. If child starts to have somatic complaints (headaches, stomachaches), wants to avoid school, etc. he or she may likely be getting bullied at school.

Responses by caregivers to both:

Teasing: Caregivers process incident (talk about feelings) with child and empower child to stand up for self, ignore, problem solve.

Bullying: Caregivers may need to intervene, get school (or other) authorities involve, advocate, make sure bullying is addressed.

Ways to support and empower your gender nonconforming child:

  • Stay connected. Ask the best and worst parts of day at bedtime/dinnertime. If your child seems to clam up under one-on-one questioning, as questions in the car. With your eyes on the road and not on the child, some children tend to open up more.
  • When your child reports teasing, ask questions; fight the impulse to just give “answers”. You will find out a lot more about your child’s feelings about and ability to handle the teasing if you avoid jumping in and trying to “fix”.
  • Again, don’t warn about the potential to be teased. If your child asks if you think he or she may be teased, be honest. “Maybe.” Ask questions. “What do you think?” Model confidence that even if you do think teasing may result, your child can handle it. (If you are nervous about the potential of your child being teased for an interest, toy, clothing choice, don’t show it. Fake it ‘till you make it! J)
  • If your child comes home and is sad or upset about teasing they encountered, ACT like it’s not upsetting to you. You can show compassion for your child without showing it is hurting you.  Your child may avoid telling you about being teased if they know it upsets you. See my first blog about teasing to read about ways to take care of your feelings.
  • Support your child’s true self at home.  Teach your child I AM AWESOME JUST THE WAY I AM, until they believe it and it is a part of their core self.  (This is important for ALL kids, not just gender nonconforming kids!)
  • Model appropriate responses to others if they question or mock your child’s gender expression or reflection of gender identity. Be it in response to a family friend or a stranger at the grocery store, don’t apologize for your child’s behavior, gender expression, etc. or act like you are sorry for how your child is making them feel.

Equipping Your Child

Work with your child on having a toolbox of responses (both verbal and behavioral) to teasing. You can write these down and put them in an actual box your child can revisit from time to time. Or, make a list you can review in the car on the way to school.

  • Verbal responses are best used in regards to children your child considers to be a friend. “That hurts my feelings”, “Please don’t say that”, “Please stop”, etc. (Saying these verbal responses to children who are not your child’s friend, or who are mean to your child on a consistent basis, may open your child up to more teasing.)
  • Practice assertiveness skills. Chin up, eye contact, shoulders back, looking strong. Facing the person they are talking to. Using a firm but kind voice.
  • First teasing is usually a “test”- help them pass. Explain the importance of “acting” like it doesn’t bother them. If a child senses the teasing has “gotten to” your child, it may fuel the fire. Teach your child to hold back emotion until they are in a safe place or speaking to an adult they trust. Also discuss the importance of not “fighting back” with their own mean words.
  • Ignore. Act as though the other child is invisible. Can’t see ‘em, can’t hear ‘em.
  • Walk away! Move to another area of the playground. Approach another group of kids or another kid who is typically friendly.
  • Stay in adult eyesight or earshot. Kids aren’t going to relentlessly tease or bully other kids who are near an adult. Talk with your child about what it might look like if they were “subtly” trying to stay near an adult.
  • Get adult help. If the teasing is getting to your child, your child is having difficulty ignoring, may act out in response to the teasing, or is in physical danger, teach your child to get adult help right away. Explain the importance of saying “I need help because ____________” rather than presenting it as “telling on” a peer.
  • Role play! I can’t stress the importance of role plays enough. If your child reports being teased, or is worried themselves about being teased, practice at home. Have your child tease you, and model appropriate responses. Then switch!

Dealing with teasing can be stressful for both the gender nonconforming child and their parent(s). I hope these tips make you and your child feel somewhat more equipped! Please feel free to comment about other specific topics you would like to see covered in this blog.

Published in: on August 1, 2013 at 5:56 pm  Comments (6)  

Kaiser’s New Policy In Response to DMHC’s Ruling

As I wrote about earlier, California’s Department of Managed Health Care (DMHC) has ordered California’s health plans to remove exclusions of coverage based on gender identity and expressionKaiser is the first I’ve seen to release more information about what they are specifically doing in response to these changes.

I couldn’t get my hands on an official document or website that outlines these changes, but I have been speaking with a couple of Kaiser representatives who have been answering my questions about the latest developments re: Kaiser and surgeries/treatments for transgender individuals. Part of this comes from an internal Kaiser document, so I did not post it in its entirety.

Here are the main points:

  • The transgender benefit includes sexual reassignment surgery and mastectomy/chest reconstruction services, in addition to behavioral health and hormone therapy services. 
  • hysterectomies/oophorectomies are included as covered procedures in “bottom surgeries” for FTM individuals. If a hysterectomy is medically necessary for other reasons, surgery is covered no questions asked. If this surgery is pursued as it relates to gender transition, the surgery has to be reviewed by the “transgender surgical review board process”.
  • MTF breast augmentation is not a covered benefit
  • Cost sharing for these services is the same as cost sharing for other medical services for the employer group or individual’s plan (e.g., inpatient hospital cost share, office visit cost share, etc.).
  • The benefit has no lifetime dollar cap on services, even for employer groups that previously purchased KP’s optional transgender surgery rider that included a lifetime dollar cap.

What other KP lines of business include transgender benefits?

  • Medi-Cal
  • KPIC insured plans, based on regulations issued by the CA Dept of Insurance (KPIC is currently determining the scope of transgender benefits required under the regulations)
  • Benefits in these plans are not affected by the DMHC April 9 directive.

Which plans and market segments are not in scope for transgender benefits at this time?

  • FEHB
  • Medicare (except for Group KPSA (Kaiser Permanente Senior Advantage) plans in instances where the employer group has purchased optional coverage for transgender services)
  • Self-Funded employer groups (except for self-funded groups that have specifically elected to cover transgender services)

What travel and lodging is covered as part of the transgender benefits?

The travel and lodging is covered for:

  • ·      NCAL members traveling to Arizona
  • ·      SCAL members traveling to either Arizona or San Francisco

Are other states taking similar action?

  • Yes.  Regulators in Colorado, Oregon and the District of Columbia have taken similar action as in California.  No determinations have been made in those regions yet in terms of immediate action steps or changes to practice.  Other states may take similar or different action in the future.

Southern California Contact:  Anna Pitinyan anna.pitinyan@kp.org.

Northern California Contact: Terri Hupfer Terri.Hupfer@kp.org

www.kp.org/eastbay/transgender

Not sure what your insurance company is doing about this? Call them! Ask them how their policies have changed and what procedures are now covered. Please, let me know what you find out at tandotherapy@me.com.

Update 8/1/13: Matt Wood of the Transgender Law Center offers further explanation and clarification:

Kaiser is an insurer, and as such it offers a variety of plans.  It’s important to help people understand the difference between a plan and an insurer.  In the past, certain plans included care for SRS, and certain ones didn’t.  So people used to call me and ask if they should insure themselves with Kaiser or Blue Cross, because they heard Kaiser offered trans care. The truth of the matter was that all insurers offered all care – it just depended upon what plan you or your employer contracted for.  We have argued all along the while exclusions themselves weren’t unlawful, those based upon gender identity were. The problem was that Kaiser and other insurers had exclusions that were worded as if they solely applied to trans people (“no care related to transsexualism”) as opposed to exclusions based upon procedures (“no hysterectomies”).

As a result, the DMHC issued its letter saying that all medical care that is medically necessary for gender transition and that is available to non-trans people cannot be excluded. There’s no distinction between MTF and FTM care, or bottom and top surgery. All *could* be covered, depending upon a person’s unique medical circumstances.  But we’re hearing right now that they don’t want to do any trans related surgeries for people with plans that formerly had exclusions until they have received more information from DMHC. We’re not sure why this is. We expect to get more clarification within 6 months, but that is a huge burden for many people with HMOs, not just Kaiser.

Medi-cal is different.  Medi-cal is a federal program administered by states at the county level. Medi-Cal has never excluded transition-related care (top, bottom surgery or HRT). However, depending upon which provider the county contracted with, that provider might have been misinformed and told a person there was an exclusion.  Some people have Medi-Cal through HMOs. Some have it through fee for service (find their own doctor who accepts and get reimbursed).  The affordable care act will make it more likely that people will have HMOs.  Some counties contract with Kaiser (esp here in the Bay Area). But other counties don’t.  But Exclusions don’t now, and haven’t in the past, been a legal barrier to care. Barriers have been ignorance of providers and lack of available providers (those that accept medi-cal reimbursement rates, which are supposedly among the lowest in the nation).

The Director’s letter applies to *all* HMOs, not just to Kaiser, as well as to all plans – including those offered by employers and schools, as well as those purchased by individuals. The only exception is that it does not apply to HMO plans that are offered by companies that are to “self-insured.” Many large companies are self insured, so check your plan carefully. If your company is self-insured and offers an HMO plan, it is not subject to the Director’s letter.

What this means:
1) An HMO cannot deny to a transgender patient the same medical procedure it covers for a non-transgender person. So if an HMO will cover a non-trans person’s hormone therapy for some medical reason, it must cover hormone therapy related to gender transitions for trans people. Similarly, if an HMO offers genital surgery to a non-trans person for some reason, it cannot deny it to a transgender person who seeks it as part of their treatment for gender dysphoria/GID.

2) HMOs are not required to cover all types of transition-related care. Rather, they are required treat trans and non-trans people the same in the provision of covered care. So, for example, if an HMO does not provide coverage for a hysterectomy for a non-trans woman, then it does not have to provide coverage for a hysterectomy for a transman based upon his gender transition.

3) HMOs offer “managed care” and a primary way they save costs is by contracting with specific physicians and surgeons. These medical professionals then become part of the HMO’s “network.” As a result, if the HMO already has someone in network who can perform top surgery or GRS, then you must use that in-network provider. If you want to go to a specific surgeon that you choose, ask them first if they are part of the HMO’s network. If they are not and you still want to go to them, you’ll have to pay for the procedure out-of-pocket. In some rare cases, as deemed appropriate by the HMO and based upon a person’s unique medical circumstances, the HMO may choose to cover medical care by a provider who is not in its network.

4) Finally, there is still much confusion about what the Director’s letter means, and we are aware of transpeople who are still being denied covered care by HMOs. If this happens to you, please contact the Transgender Law Center at 415-865-0176 x306 or online at: http://transgenderlawcenter.org/help

To read the Director’s letter and learn more, go to TLC’s website -http://transgenderlawcenter.org/archives/4273

Published in: on June 21, 2013 at 2:46 pm  Comments (4)  

Cross-Sex Hormones for Transgender Youth

A topic that comes up often in my work is the question of whether or not to treat transgender youth with cross-sex hormones. (For those of you who don’t know, this would include a Male to Female preteen/teen taking Estrogen, and a Female to Male preteen/teen taking Testosterone, in order for them to go through puberty in line with their brain gender identity. Read more about it here).  I know this is a controversial topic, and there are as many opinions about this as there are professionals, if not people.

Of course, the first step in treating a transgender child about to enter puberty is usually hormone blockers. While incredibly expensive, I think most parents and doctors are more willing to allow the child/pre-teen to go on these because a) it buys them time, b) it prevents physical changes from happening during puberty that have to be “undone” later, and c) the changes are reversible. Remove the hormone blocker, and the individual goes through the puberty of their natal sex. Not so with cross-sex hormones. Many changes are irreversible, and can have life-long impact on one’s reproductive system. I understand the anxiety parents and doctors feel about transgender pre-teens starting hormones. I’m still a proponent of it, on a case by case basis.

I recently learned that the Endocrine Society guidelines recommend that endocrinologists wait to put pre-teens/teens on cross-sex hormones until the age of 16. In my opinion, this is too late. Most of their peers will be going through or will have gone through puberty by that age. One argument I’ve heard about this is that there are “late bloomers”. Sure, there are “late bloomers”, but these teens need not be.  Being late to enter puberty means something entirely different to a non-transgender teen and a transgender teen. The former may be anxiously awaiting puberty. The latter may be close to suicide.

For those youth who do receive hormone blockers, this is a life-changer: their body is not going to go through the “wrong” puberty. However, even these pre-teens and teens struggle with gaining those important “gender markers” in order to help them pass in society; a deeper voice and facial hair for male teenagers, a more curvaceous figure for female teenagers. Without the needed physical help from hormones, passing can be very difficult. And being read as the wrong gender every day is an agony no teen should have to go through.

In my opinion, treatment before the age of 16 is medically necessary to support the mental health of transgender youth. I suppose if more people sat across from transgender pre-teens and teenagers the way I do, more people would agree. I see a sadness and a desperation in their eyes I simply do not think has to be a part of this process. I don’t have all the answers; I don’t have a medical degree that would help me understand exactly the process of cross-sex hormones in an adolescent’s body. I’m coming from a therapist’s standpoint who understands how crucial it is for teens to feel as though they fit in with their peers -as well as the need to be seen for who they really are- and the depression and suicidality that results when they don’t.

In the words of Karen, the mother of an FTM individual and author of the blog  Trans*forming Family, “When a child is as sure as my son is, I think it is senseless and really torturous to make them wait until they reach some arbitrary age guideline. I realize this is anecdotal, but every trans teen I’ve known of who has been suicidal, depressed, or has self-harmed has been in that age range where they cannot get cross-gender hormones and/or surgery and are miserable due to dysphoria[…] the negative symptoms lift after medical transition, so why prolong their suffering unnecessarily?”.

Monica Nuñez-Cham leads the family support group for families with gender nonconforming and transgender children in San Diego. She is also the mother of Isaac (now 18), an FTM individual who started medical transition (cross-sex hormones soon followed by surgery) at the age of 13. “He wanted so badly to appear male and experience the same changes his friends were having (lower voice, facial hair, etc). He was very uncomfortable in his body and hated every feminine form (hips, butt, chest). I knew that the physical changes of T would help others who knew him as a “girl” to perceive him as male. The risks (that nobody could explain with certainty to me because there is not much research) were much lower than the 100% reality of seeing my dearest child in emotional pain every day and withdrawing himself from life. […] I always tried to listen to my heart and do what I thought was the best for him, with the tools I had at the time.  

Hormones and surgery were the best decision we could have made. Isaac as a little boy was a happy one, always singing, talking, making friends and very easily expressed his feelings by kissing, hugging and verbally. Close to puberty he stopped being happy, to the point of not allowing me to touch him. After the T, he came back, not little by little, suddenly he was the same happy kid. After the surgery I was very surprised to see him just BLOSSOM in a spectacular manner.

I attribute his success as a person (academically, socially, emotionally) to the fact that we acted as soon as we knew how.”

 The Harry Benjamin (now WPATH) Standards of Care were revised 7 times. In my opinion, the first version was hopelessly damaging to transgender individuals seeking treatment. By the 7th version, it is finally coming around to the way it should be: professionals supporting and making life easier for transgender individuals, not harder. Additionally, the Standards of Care were only created to be general guidelines to give those who are inexperienced some semblance of a plan. They are not laws that govern how a professional chooses to treat a transgender individual. Such is the same as the guidelines for the Endocrine Society, in fact it says so in their disclaimer statement: “Clinical Practice Guidelines are developed to be of assistance to endocrinologists by providing guidance and recommendations for particular areas of practice. The Guidelines should not be considered inclusive of all proper approaches or methods, or exclusive of others. The Guidelines cannot guarantee any specific outcome, nor do they establish a standard of care. The Guidelines are not intended to dictate the treatment of a particular patient. Treatment decisions must be made based on the independent judgment of health care providers and each patient’s individual circumstances.”

Wondering what the latest version of the Standards of Care say (in part) regarding prescribing hormones to transgender adolescents? “Refusing timely medical interventions for adolescents might prolong gender dysphoria and contribute to an appearance that could provoke abuse and stigmatization. As the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010), withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents.”

The reality is I know of two gender clinics in all of Southern California who medically treat transgender youth.* Of those two clinics, only one regularly prescribes cross-sex hormones before the age of 16. That clinic, as you can imagine, is impacted due to the high demand and sheer number of patients in need. Both clinics are willing to prescribe hormone blockers with the consent of parents.

I’ve said it before, and I’ll say it again. I see my role as helping individuals live their lives as the gender they are in their brains. Most of the time this is not about helping them figure out their gender identity, but figuring out what they are going to do about it. For those children/pre-teens/teens who know who they are, and what they want to do, let’s help them do it.

Most people will doubt your judgment because of your age. It may take a lot more talking to convince the ‘adults’ that you really know who you are.  -Chris, 19 (From the Advocates for Youth pamphlet, “I Think I Might Be Transgender, Now What Do I Do?”.)

*If anyone reading this has more information on endocrinologists who treat transgender youth in California, please private message me or include in the comments.

Not Enough Resources!

The recent directive disallowing exclusions in California healthcare plans for care related to gender transition is significant progress! I continue to be excited by what this may mean for transgender CA residents with health insurance.  The next obstacle to overcome? The absolute dearth of trans-friendly/trans-competent resources in many parts of the country.

I get emails from people from all over the US, seeking gender transition and not living near any well-known resources in order to be assisted therapeutically or medically. I often go immediately to Google after receiving such an email, for which I always chide myself. My peeps know how to Google, and Google well. Do I really think I can Google resources in their area, and something is magically going to appear for me that did not for them? No. If a resource was available on the internet, it would have been found. “Did you try Laura’s Playground?”. Yes, they have usually looked for resources on Laura’s Playground. Then I’m stumped. I start reaching out to people who may happen to know of something that is not easily accessed on the web.

(A special shout out to Zander Keig, an incredible advocate for the trans* community and someone who is always willing to help me look for resources when I hit a brick wall.)

It would be one thing if this were just about logistics; it’s not. These are not just emails looking for resources; they are pleas for help. Pleas for help peppered with “I don’t know how much longer I can do this” and “I can’t remember the last time I was happy.” There’s an urgency inherent in these emails that cannot be ignored, and makes finding no resources in their area all the more frustrating.

I may not be able to see them in person, but I can still picture the look in their eyes, and on their faces. It’s a look I’ve seen countless times before in many of the clients I’ve had the honor of meeting with face-to-face.  It’s a look that tells me the internal obstacles they’ve overcome were overwhelming enough; obstacles to resources are sometimes more than they can bear.

There needs to be MORE gender therapists, gender clinics, and endocrinologists/doctors willing to treat this population.  Every major medical center and hospital should have doctors employed who are knowledgeable and equipped to medically prescribe hormones to the transgender citizens of this country.  I think back to my first transgender client; I knew next to nothing about the therapeutic and medical needs of this community.  This first client gave me a chance and the rest, as they say, is history.

If you are a transgender person or a loved one, seek resources where you think there are none. Talk to therapists and doctors to see if they are willing to get educated and begin working with this population. There are excellent sources of information to guide professionals new to this arena, such as the World Professional Association for Transgender Health (WPATH) Standards of Care and the Center for Excellence Primary Care Protocol.  Somehow we’ve got to make this circle bigger so that care is readily available to ALL.

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