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 expression. Kaiser 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. If you have questions about  your specific Kaiser plan, the best thing to do is call member services at 800-464-4000.

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:  TransgenderCare@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 (17)  

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.”

I know of two gender clinics in all of Southern California who medically treat transgender youth.* These clinics, as you can imagine, have long waiting times due to the high demand and sheer number of patients in need. 

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.

Published in: on May 21, 2013 at 2:47 pm  Comments (34)  
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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.

Published in: on April 19, 2013 at 3:46 pm  Comments (2)  
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Insurance Victory

An issue that has caused frustration, sadness, and exasperation (and that is just for me- imagine how my clients must feel!) is the issue of exclusions for transition-related services for transgender individuals. Most healthcare plans have specific exclusions for anything related to gender transition. This includes but is not limited to hormone blockers, hormones, and needed surgery for transgender individuals.  In my opinion, this is as outrageous as healthcare plans excluding other major medical conditions. These exclusions leave me feeling very helpless, as I can see so clearly what my clients need: medical transition. And I cannot provide this!

As important as being able to access medical transition is being able to access EARLY medical transition when clinically necessary. However, even with the support and assistance of their parents, many transgender youth run into roadblocks when trying to get hormone suppressors. They are outrageously expensive, and most health insurances have exclusions that state they will not pay for anything related to gender transition. (Can you imagine, being one of these preteens/teens who are right on the doorstep of getting the treatment they so desperately need to survive, but they cannot afford it?)

Such is the same for many of my transgender adult clients. Surgery is an important part of the transition for most of my adult transgender clients, and yet most insurances will not cover it. This is a major power problem for those who cannot afford to pay for such surgeries out-of-pocket. It is my opinion that they shouldn’t have to.

On April 9, 2013, a ground-breaking ruling was made on this issue:

“California’s Department of Managed Health Care (DMHC) has ordered California’s health plans to remove exclusions of coverage based on gender identity and expression…The newly issued DMHC letter instructs health plans to revise current plan documents to remove exclusions and limitations related to gender transition.  For transgender people, how and when they transition is typically a private decision made with their doctor. The American Medical Association, American Psychological Association, American Psychiatric Association, and the American Academy of Family Physicians have all deemed transition-related care to be medically necessary for transgender patients.” Read more about it here.

I am truly curious to see how this plays out with all of my clients, and hope it is in reality as good as it sounds! To progress!

Published in: on April 11, 2013 at 2:27 pm  Comments (6)  
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Honored! Recipient of 2013 Media Award

Honestly it was quite the honor to be nominated, but I am thrilled to announce this gender blog won “Best Single Topic Blog” for the 2013 National Association of Social Workers Media Awards! Thank you to everyone who voted, and to those of you who read and enjoy this blog. I am intensely passionate about this topic, and hope this blog helps educate, advocate, and raise awareness about this issue.

Published in: on April 11, 2013 at 2:21 pm  Comments (12)  

Simply Put: Worksheets for children about gender identity and transition

When I was asked to help a child understand the gender transition their loved one was about to go through, I created a one-page overview of the process in simple terms. I also created a little “worksheet” that would encourage the child to think about how this change was going to affect them, and their loved one, specifically. The worksheet facilitates conversations between the child and adults; fill-in-the-blanks are a great way to find out what is on a child’s mind. While I was at it, I created a one-page summary for gender nonconforming children, complete with a brief fill-in-the-blank portion at the bottom.

These summaries/worksheets have come in very handy when working with transgender youth and the young loved ones of my transgender adult clients. I thought others may benefit from using them as well, so they are attached below. Please feel free to use, copy, and distribute as needed to assist children on their journey to understanding. (Who knows, sometimes concepts stated in simple terms can help adults, too. ;)).

For those of you not in the field of mental health or well-trained in interviewing children, here are a few tips for completing this worksheet:

  • Don’t make a big deal of the sheet. Just say you’re going to do a little something and do it. Act like it’s no big deal and you’re not nervous, even if you are.
  • Don’t look at the child being interviewed. Look at the worksheet.
  • Poise your pen or pencil over the blanks and begin asking the questions. Write the answer in the blank as soon as they are stated, without a reaction (facial expression, question, anything!) Children are incredibly in tune with others’ responses to what they are saying, particularly if the “other” is a parent.
  • When the worksheet is completed, go back and ask questions for clarification.

If you have any trouble with the way they are opening on your computer or printing out, please email me at tandotherapy@me.com and I will email you copies.

Kidworksheet

kidinfotrans

transitionworksheet

Published in: on March 29, 2013 at 2:41 pm  Comments (1)  
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Your Gender-Expansive Child: Teasing

Most children get teased at one point or another in school. Sadly, teasing has become part of the social culture at schools and often goes on away from adult supervision. 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.

You know that one tone of voice children use when tattling? “MOO-ooomm, Johnny HIT Meeee!”. It’s universal. I’m convinced kids are born knowing how to use this voice, without ever having it modeled for them. Parents have a similar standard tone/cadence when warning their child about natural and logical consequences to choices. “Okaaayy, you can go on that water ride, but you’ll probably get soaked and feel cold the rest of the day!”. It just comes with the parenting territory. Letting your child choose behaviors while warning possible ramifications is a parenting basic.

Warning about being teased for being gender nonconforming gets tricky, however. Being gender nonconforming is not a behavior; it is a way a person is. Warning about teasing that may come from displaying a core characteristic/something the child cannot change is dangerous territory. Yes, the child can choose to act on or express their way of being, or choose to inhibit it. But they cannot change being gender nonconforming or transgender.  While I can appreciate and recognize a parent’s urge to warn and possibly prevent teasing that may come from a way of dress, behavior, or interest, this can quickly be translated to shame and self doubt. The problem is, in these scenarios we’re not talking about nose-picking or some other minor social infractions that a child can learn how to avoid. We’re talking about children being who they are, and who are doing absolutely nothing wrong. “Warning” the child  by saying something like “If you choose to play with ‘boy things’, you might get teased at school”, “Girls don’t usually have really short hair, so you might get teased,  but you can cut it if you want”, “Boys don’t usually walk or talk like that, but if you want to go ahead. Just know you might get teased” may not have the protective nature parents are going for.  In fact, it may teach the child to prescribe to what others say is the best way for them to be. Remember my Oxygen blog? Much like you wouldn’t “warn” a child about being teased for wearing an oxygen tank to combat oxygen deprivation, try not to warn your gender nonconforming child to avoid their natural gender expression.

I want to again acknowledge that most parents are coming from a very loving place when they explain what may lay ahead. My worry is that this can instill fear and dread in the place of blissful innocence. It may make the child LESS equipped to deal with the teasing that may come with being gender nonconforming.  If my parents had sat me down as a child and said, “Just so you know, little girls with hazel eyes sometimes get teased. Some people think hazel eyes are wrong and some people just don’t like kids with hazel eyes.  You can go ahead and wear those hazel eyes to school, but just know you might get teased”, I would have experienced childhood differently. I may have been fearful to let my true eye color show, even though I couldn’t change it. I may have looked at (or looked away from) everyone I met with just a little bit of suspicion or mistrust. I may have thought, “Is this one of the people who hate kids with hazel eyes?”. I may have chosen to grow up wearing sunglasses, even indoors. Many parents warn their children about being gender nonconforming much in the same way, even though it’s not something the child can change. Yes, the child could change their behavior to HIDE who they really are, but that’s not what we want for our children, is it?  Children become inhibited based on the response of others soon enough.

So, what’s a parent to do? Parents can help their child by unconditionally supporting who they are on the inside so they know without a doubt I AM AWESOME JUST THE WAY I AM.  This won’t prevent the pain associated with teasing, but it will help build the ego strength in the child so that they understand their basic worth doesn’t change based on what others say.

If your child asks you if you think they may be teased for wearing something, doing something, etc., be honest. Say “maybe”, and then discuss how the child might best handle it.  Communicate (even if you have to “fake it”) that you know your child will be ok even if they are teased. This energy is something they will absorb from you.

If your child comes home and reports being teased, ASK QUESTIONS; you don’t have to be the one with all the answers. This will help you get a feel for how much understanding your child has about the reasons behind the teasing. “Why do you think they teased you about wearing a skirt?” “Why do you think they said that?” (Not what they are used to, they don’t understand, they feel differently, etc.)

At dinnertime, bedtime, etc. ask your child about the best and worst parts of their day. If they report teasing, process it with them. Talk with them about how it made them feel, and how they can take care of themselves when they have that feeling. Discuss and practice possible responses based on the teasing so they feel more equipped should it happen again.

Last but not least, take care of yourself and your own feelings! Listening about your child being teased can be a very hard thing for a parent to take. Talk to your friends, talk to other parents, talk to a therapist. Remind yourself this is not something you can “fix” or prevent, but you are doing right by your child by nurturing his or her true self.

Published in: on March 7, 2013 at 8:15 pm  Comments (3)  
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Feelin’ The Love: Watching the journey of parents

My work with my transgender clients often includes not only the transgender individual, but the family as well. As important as it is to be an advocate for my clients, it’s also essential I understand the process that is being undertaken by the loved ones of the individual. (See “It’s Hard for Moms”.) Many parents of my adult clients are very resistant to the idea of their “child” being transgender or transitioning, and are initially quite wary of me for supporting this venture. Typically with my adult clients I only hear of the resistance expressed by the parents without witnessing it directly. In session, I am privy to the intense longing of the individual for support and acceptance by their parents, no matter how old they may be.  This is yet another reminder that unconditional love from parents is crucial at every stage in one’s life.

When I work with parents of transgender youth, it’s a little different story. These parents are willingly seeking gender therapy for their children, searching for answers and a roadmap for this unforeseen journey. Fear and resistance are often still a part of the work, but there’s so much more than that.

I have seen parents evolve in the journey with their transgender/gender nonconforming child from tearful and terrified to peaceful and resolute. I’ve seen parents give their child space to express themselves in a way that allows the child to be honored and embraced, even if the parents are scared by the possible ramifications. Some parents accept very quickly while others fight to hang onto what feels safer and more familiar. Some become advocates, others are willing to share their stories, still others remain very private; all of them intensely love their child. To see a parent accept something they never wanted or saw coming is a source of true inspiration for me, and a very touching part of the work I do. I respect and admire these parents more than they know.

The passion I sense from these parents for their child can be expressed in all sorts of ways: fear, anger, pride, doubt, guilt, sadness, grief, bravery; the list goes on and on. I’ve always loved children, but it wasn’t until I became a parent that I could truly understand the passionate love a parent has for their child. The kind of love that makes you willing to do anything for another’s happiness, willing to sacrifice, fight, and conquer all for the sake of your little person even in the face of your own anxiety or trepidation.

Sometimes I feel hot tears spring to my eyes* in the middle of one of these sessions with parents, especially with those early in the journey. What brings on these tears? Is it sadness? No. It’s not quite something I can explain. It feels like a mixture of compassion, inspiration, and awe at the intense love I’m witnessing, along with honor that I get to be a part of such a life-changing journey.  I’m definitely feeling the love, and in the end, I know the child will too.

*Not a robot.

Published in: on January 10, 2013 at 2:00 pm  Comments (7)  
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Gender Lesson: For Schools

I created this “gender lesson” for teachers to present in schools based on the needs of gender nonconforming children I see in my private practice and those I read about online. Please share with any and all classrooms/teachers! Below is the lesson, and following that will be a PDF with the lesson and a list of “expectations” that can be posted in the classroom.

This lesson was created in particular for those teachers who have gender nonconforming children in their classrooms. However, it is my belief that this curriculum is needed in ALL classrooms, to change society’s stereotypes, reduce stigmatization of children, decrease bullying, and increase acceptance of each other.

This lesson is to be presented at the very beginning of the school year to set standards of expectations for behavior, and can be reviewed as needed throughout the school year. It should be appropriate for grades K-5; please modify as needed. Role plays are included at the end of the lesson for comprehension reinforcement. Give the child the scenario and have them attempt the correct response first; give suggestions as needed. Lastly, please hang the attached rules in your classroom as a reminder of the acceptance that is expected.

For a very long time, people have been separating things into what girls like and what boys like. A lot of people think these things are very different, and call them “boy things” and “girl things”. Have YOU noticed that?

What are some things some people might say are “girl things” or “boy things”?  What might some people say are “girl toys” and “boy toys”?

The truth is, all children get to pick what they like, and everyone likes different things.  Repeat after me: There is no such thing as a “boy thing” or a “girl thing”. Some kids are boys who like things that other people think are for girls. Some kids are girls who like things that other people think are for boys. It can hurt their feelings if you or someone else says something to them about it, or acts like there are rules about how someone should be. That would be like saying only girls can eat ice cream, and only boys can eat jelly beans!! That would just be SILLY! Sweets and treats are to be enjoyed by everyone, just like most things in life. 🙂

Are there certain colors that some people think only girls like and colors that only boys like? Most people think girls like pink and purple, which is ok, but it’s silly to think that ONLY girls like pink and purple! There are plenty of boys out there who like pink and purple, too. Lots of people think only boys can like blue! Girls can like blue, too. All the colors of the rainbow are for everyone, and it’s fun that we all get to pick our favorite. You don’t want anyone telling YOU what your favorite color should be, do you??

Some people also have very strong ideas about how boys and girls should look and dress. Is it ok for some girls to have short hair, and some boys to have long hair? Of course it is!  How someone chooses to dress is up to them, too. Some girls wear skirts and dresses, and some girls wear shorts and pants. Some boys wear shorts and pants, and some boys wear skirts and dresses.  This may surprise some people, but it certainly isn’t wrong.

How someone dresses and wears their hair is a part of their “style”. Everyone’s style is different! What if everyone were to dress and look exactly alike? BOR-ING!  The next time you see someone who wears their hair a little different than you expected or is wearing something that surprises you, be kind and say, “I like your style”.

How wonderful would it be to have a classroom (or a WORLD) where kids just get to like what they like? Are you ready to help create a world like that?

One of the most important things to remember is to be KIND to one another. Ask yourself how you would feel if you were the other person. Be sure to avoid saying anything that would hurt someone else’s feelings. If you can see another kid likes something, don’t tell them why they shouldn’t. Remind yourself, “different people like different things”, “it’s OK to be different”, and “I am accepting of others”.

If you hear someone telling another kid there are rules about how to play, how to be, or how to dress, stand up for them! Remember, you are helping create a world that is more accepting. Nicely tell the other person what you have learned from this lesson. You can say something like this:

“That’s their style, and I like it.”

“Anyone can play with anything.”

“Everyone is different. Different people like different things.”

“Please don’t tease my friend. I like him/her just the way he/she is.”

Remember:

THERE IS NO SUCH THING AS A “BOY THING” OR A “GIRL THING”!

All toys are for all children.

Colors are for everyone.

People are different, and everyone likes different things.

Everyone gets to pick how they wear their hair.

Everyone gets to pick the way they dress.

Everyone gets to pick their own style.

Role Plays:

Act out the RIGHT way to handle the following situations:

You are playing house, and a girl wants to be the dad.

You hear someone teasing a boy about wearing a skirt.

A group of boys playing soccer tells a girl, “You can’t play! No girls allowed!”

You’re having a tea party and a boy wants to join in.

You see a girl getting teased for having short hair.

You see a boy wearing a pink backpack.

In Our Classroom…

We are kind to each other.

All toys are for all children.

Colors are for everyone.

Everyone gets to pick their own style.

Being different is OK.

We stand up for others.

GENDER LESSON PDF

Published in: on August 19, 2012 at 9:51 am  Comments (27)  
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Choosing/Evaluating a Gender Therapist for Your Child

The Hunt

Finding a good gender therapist for your child can be a daunting task. If you are in the process of looking for a gender therapist, this means there is already a lot going on in your family! Gender dysphoria or gender nonconformity can at times cause distress for parents and the child who is experiencing it.

There doesn’t seem to be many of us out there (gender therapists who work with gender nonconforming youth), and I wish there were more. So once you’ve found one in your area (or relatively close to you), how do you know if the therapist is a “good” one? As with every profession and specialty, there are the good, the bad, and the ugly.

If someone claims to be a gender “expert”, don’t just assume your hunt is over. Ask questions (see below for a sample list) and go with your gut instincts.  Ultimately, YOU are the expert on your child.

After you have met with the therapist for 1-3 times, re-evaluate how the sessions are going for both you and your child. Is your child comfortable? Are you? If not, address your concerns with the therapist.  The therapist should be open to your feedback and be able to explain their reasoning behind the treatment methods. If things don’t change, begin your search again!

Let the Client (Child) Lead

As with any therapy, or reason for seeking therapy, the gender therapist should not enter into therapeutic work with you and your family with an agenda. If you get the sense on the phone that they have their mind on accomplishing something (such as getting your child to transition or not transition), consider that a red flag. Every child and family is different, with a different story and different needs. Some of the interventions and suggestions will be similar to those used with other families, but most will be tailor-made to your family.

Your child will be the best source of information re: their gender identity. Children of a very young age are aware of what gender they are, and/or what gender expression they are comfortable with. You, the parent(s), will be excellent historians for how your child has expressed their gender from an early age, current significant behaviors, etc. Of course, part of the gender therapist’s job will be working with the parents in regards to their feelings about their child’s gender nonconformity, and feelings about potential options for their child.

Red Herrings

Many parents see their child’s gender nonconformity AND a lot of other emotions and behaviors. Some of these emotions and behaviors will be related to their child’s gender identity; others may not. Those that seem unrelated to the gender identity but may actually be symptoms of the distress the gender nonconformity is causing are what I call “red herrings”. The gender therapist can help you sift through some of these factors to find out what needs to be addressed first. It is common for some emotions and behaviors to be resolved once the gender identity is validated. One good way to narrow down what is really going on for your child is to focus on what seems to be causing the most distress. For example, if your child is having social skills problems, academic problems, gender nonconformity/expressions of gender identity that does not match their body, anger outbursts, and anxiety, what seems to bring them the most mental distress? What do they talk about the most? What do they shed the most tears over? This is what needs to be addressed first.

Often times things such as the anger outbursts/academic problems are what bring the parents the most distress, and therefore this is what the parents want addressed first. This may be like putting a Band-Aid on something without treating the cause. In some cases, it will be the therapist’s job to gently prevent you, the parents/guardians, from following the red herrings. If your gender therapist seems determined to only focus on these other things, and not address the gender issues, this should also be a red flag for you. While you may feel some relief that the gender therapist is recommending holding off on making any major decisions or is wanting to address everything else other than the gender identity, pay attention to what your gut is telling you. You know your child. If the therapist’s recommendations seem to bring your child more distress, something has gone awry!

Hormone Suppression/Therapy

Your gender therapist may help you (and your child) explore whether or not your child is gender nonconforming or transgender. If the consensus is your child is the latter, your gender therapist can help you navigate the next steps in your child’s journey. Your gender therapist can be your ally in deciding if hormone blockers/therapy is the right decision for your child, and if so, when to start. Sometimes, making this move can help ease some of the other symptoms that may have arisen for your child. Many times the child may express being ready for hormone blockers or hormones before the parents feel ready. The gender therapist can help parents walk through many of the anxious and difficult feelings that may arise during this significant decision-making time.

Structure of Sessions

There is no exact science to how a gender therapist might structure their sessions with you, but in general there should be a good balance of meeting with you and meeting with your child. The therapist should meet alone with you as part of the assessment process and at other times as needed throughout treatment. This is because you need to have free reign to say what you want to say about your child’s gender expression and your feelings about it. Your child should not hear all of your thoughts, opinions, and feelings about their gender expression or possible transgender identity. Children tend to try to take care of their parents and avoid causing their parents distress; therefore hearing statements made my parents (particularly those expressing resistance) can impact their ability to say what they want and need in regards to gender expression, transitioning, etc. This can have serious ramifications on their mental health and futures.

Similarly, your child should have the opportunity to speak alone with the gender therapist and speak their mind without censoring things out of regard for their parents. The gender therapist will not tell you exactly what your child has said while in private, but should help your child communicate better with you when you are all together. For this reason, joint sessions are also called for when it comes to working with youth. It is important for family members to learn how to talk to one another about the gender identity issues, and to become more comfortable with the topic. Additionally, parents tend to be better historians and reporters of behaviors, which can be extremely beneficial to the treatment course.

Sample Questions to Ask a Potential Gender Therapist

  1. What is your opinion about how young a child can understand their gender identity?
  2. What is your general opinion on letting a child express their own gender identity?
  3. What are your thoughts on hormone blockers/therapy for youth?
  4. How long have you worked with children?
  5. Are you experienced in building rapport with children?
  6. Have you been trained in how to talk to and interview children in a non-leading manner?
  7. How involved are the parent(s) in the therapy with the child?

If you are struggling to find a gender therapist that is right for your family, reach out for help. TransYouth Family Allies is a great resource. If you join TYFA Talk, you can chat with other families and get information about what resources are out there. Wishing you all the best on YOUR journeys!

*Special thanks to Kim Pearson of TYFA who requested this piece to present at this year’s Gender Odyssey Family Conference.

**While this post was written specifically for parents finding a gender therapist for their child, many elements can be applied to the gender nonconforming or transgender adult. Go with your gut! Find a therapist who will support you in your journey and help you access resources. If it doesn’t feel right to you, keep looking.

Published in: on August 3, 2012 at 2:52 pm  Comments (3)  
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