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, or newly out, transgender person.

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

The PRONOUN CORRECTOR!!!

Someone in the early stages of disclosing their authentic gender or social transitioning often experiences a lot of anxiety about how they are being “read” and if they are being seen as their authentic 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/former 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 transgender people will be seeing family members and disclosing their authentic gender 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 correct, or authentic, pronouns. Sadly, holidays can bring an extra dose of anxiety to someone going through gender transition or trying to help others understand who they really are.

If you are the loved one of a newly disclosed 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”. Someone said “he” or “she” in reference to a nonbinary individual? Correct to “they”, or whatever the individual’s pronouns are.

If you are the parent of a newly disclosed or 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 the appropriate 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  pronouns that reflect the individual’s authentic gender, 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.

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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”?  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.” Although this obstacle has been removed, “12 continuous months of living in a gender role that is congruent with their gender identity” is still recommended prior to “bottom surgery”.

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

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.

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.

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