Viral Video: Ryland’s Story

A very important video has gone viral with over 4.5 million hits in one week. It’s the story of young Ryland, a transgender boy who was allowed to socially transition at the age of 5. To see the video, click here. As a gender therapist, and a gender therapist who also works with transgender children, I’m thrilled to see this video in mainstream media: Huffington Post, People.com, Upworthy.com. It’s bringing awareness to an extremely important issue: not just that transgender children can transition, but it drives home the point that transgender people are born transgender. The age that one is consciously aware of being transgender or transitions can vary widely, but an individual does not become transgender over the course of their lifetime.

I had the honor of speaking about this issue on Good Morning America. To see the clip, click here. I said a lot more than what was aired, but there’s only so much they could fit into a 4-minute news segment. I’d like to take this opportunity to address some of those things now. These points are in direct response to the questions I was asked by Good Morning America about the video. Regular readers of this blog are probably well-versed in the answers below, but in case this post is read by someone seeking more education or to understand young transgender children, I wanted to be thorough.

Many people were surprised to read that 41% of transgender individuals have attempted suicide, while the rate of the general population is 4.6%. That staggering statistic, I believe, applies to transgender individuals who transition later in life and meet with familial/societal resistance, rejection, or shame. “New analysis of responses to the National Transgender Discrimination Survey (NTDS) shows that transgender respondents who experienced rejection by family and friends, discrimination, victimization, or violence have a higher risk of attempting suicide.” I strongly believe that number will plummet in the coming years with increased awareness, education, and accepting, responsive families like Ryland’s. To read the full report from the Williams Institute, click here.

I was asked questions about what interventions are recommended for transgender children. For a transgender child as young as 5 or 6, the first step is social transition. This means changing pronouns, sometimes name, and some societal markers of gender such as haircut or dress. No medical interventions happen at this stage, contrary to some sensationalistic beliefs. The first medical interventions would be just before the onset of puberty, at which time hormone blockers would be introduced to prevent the body from going through the “wrong” puberty. As the teen ages, cross-sex hormones would be administered to initiate puberty of the preferred sex, which would produce some much-desired “gender markers”.

When a child has been clear about their gender identity and not transitioning causes distress, transitioning young can be incredibly beneficial to the individual. While not all transgender people are focused on “passing”, it is hugely important to many. “Passing” means being read in society as the gender with which you identify in your brain. Going to the grocery store and having the cashier address them with the correct gender pronouns… that is “passing”. Transitioning early and intervening before puberty takes over will allow that individual to pass as his or her “true” gender without question.

One thing I want to say is that I know many people worry that a very young child is too young to make such a big “decision”. I want to remind you that gender identity is not a decision. We all know very early on what gender we are. A transgender child of Ryland’s age is not making a “huge decision” to be a boy. He IS a boy. His parents were faced with a huge decision about allowing him to transition, and they made it based on Ryland’s asserted gender identity.

I thought Good Morning America did a good job of covering this video. I was pleased about the input from ABC’s Chief Health and Medical Editor, Dr. Richard Besser. “The more we’re learning about gender, the more we’re learning that this is really hard-wired. It’s hard-wired in the brain. And from very early, from the first couple years of life, children will recognize gender and then start to identify with gender.” My only feedback would be that he should have used male pronouns when referring to a transgender boy.

One thing that didn’t sit right with me was the way they worded the “teaser” for the upcoming segment on the video. “True Identity: The incredible story being shared coast to coast of one little girl who just wanted to be a boy. Why her parents encouraged her to change gender.”

This statement is misleading at best. First of all, this child is not a little girl. This child did not “want to be a boy”, this child has the brain gender identity of a boy. As the video said, this child did not say “I want to be a boy”, he said “I AM a boy”. Now, I understand those snippets are meant to be short and can’t cover it all, and they are geared to having people tune in to watch the segment. The part that got me the most was the last sentence: “Why her parents encouraged her to change gender.” If you are the parent of a transgender child, you probably understand why that sounds a little silly. Do these parents have some sort of ulterior motive to have a transgender child? Doubt it. Was this in their master plan? Likely not. Many of the parents of young transgender children I work with struggle extensively during the process of understanding their child’s true gender identity. It takes time to accept their child is transgender, and naturally, parents tend to agonize over allowing their child to transition. Supporting and responding appropriately to their child’s gender identity is not encouraging something that wasn’t there; you can’t make a child transgender. However, supporting and encouraging the child to live life as their true selves, that is selfless, unconditional love. For more reflections on how difficult and intense this journey can be for parents, see my blog post “Feelin’ The Love: Watching the Journey of Parents”.

In the video, the song fades from “Hallelujah” by Jeff Buckley to “Good Life” by One Republic as it shows Ryland transitioning. I think it was the perfect song choice. So many parents worry whether or not their transgender child can have a good life. The answer is: ABSOLUTELY. Thank you to Ryland and his family for being selfless and strong enough to share your story so that many more transgender children can have good lives, just like you.

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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?

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”?  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.

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!

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

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.

Physical Transition Options for the Transgender Individual*

In conjunction with my last blog, “What’s in YOUR Pants?”, this blog is about physical transition options for the transgender individual. As stated in the aforementioned blog, many people ask about surgery the first time they hear about a transgender individual’s plans to transition. It may surprise many people to find out the transgender individual has no plans to pursue surgery, specifically genital surgery.

I recently watched a documentary called “Diagnosing Difference” by Annalise Ophelian (excellent; I highly recommend it!).  This quote from that documentary summarizes perfectly what I was trying to say in my last blog, and leads nicely into what I’m going to explain in this blog. “There’s this huge stereotype that trans people all have genital surgery, that we know that someone’s really the new gender because they’ve had genital surgery, and that’s one of the biggest misconceptions about trans people. In reality, the vast majority of trans people will never have any surgery, and many trans people have surgeries that aren’t genital surgeries. [Italics added.]  And some people don’t have surgeries and don’t undergo medical care related to their gender because they don’t want it, it’s not appropriate to them, there’s other ways that they’re expressing their gender, and some people don’t have it because it’s not available to them, it’s not covered by their insurance…and so for both of those reasons, rules that govern are you really trans or have you really transitioned based on genital status or surgical status are very damaging to trans people’s well-being.” –Dean Spade

Hormone Therapy

OK, so before I get to surgery, let me talk a little bit about hormone therapy, or hormone treatment. Hormones are often a huge part of the physical transition process. Transmasculine individuals can opt take Testosterone or “T” (by patch, cream, or injection, most commonly injection). Doses vary depending on the individual and his desire for physical outcomes. Often the first changes that occur from taking Testosterone are the deepening of the voice and facial hair. These are also two irreversible changes that occur from taking T. Other changes include changes in facial features, head shape, clitoral enlargement, and fat redistribution (less on hips/butt/thighs, more to stomach). For more information regarding this type of hormone therapy, visit http://transhealth.vch.ca/resources/library/tcpdocs/consumer/hormones-FTM.pdf or http://www.ohio.edu/lgbt/resources/transoptions.cfm.

Transfeminine individuals may opt to take Estrogen, which can be administered orally or by injection, most commonly in a pill form taken orally. This regimen often includes an anti-androgen such as Spironolactone, which blocks the effects of testosterone.  Results from taking Estrogen include but are not limited to: breast growth, softening of the skin and facial features, lessening of body hair, and changes in fat distribution (less on abdomen, more to hips and bottom). For more information about this type of hormone therapy, visit http://transhealth.vch.ca/resources/library/tcpdocs/consumer/hormones-MTF.pdf, http://www.transgendercare.com/medical/resources/tmf_program/tmf_program_6.asp, or http://www.ohio.edu/lgbt/resources/transoptions.cfm.

Female-to-Male Surgical Options

FTM individuals have the option of two types of surgery, commonly referred to as “top surgery” and “bottom surgery”. Top surgery refers to the removal of breasts, the shaping of a male chest, and re-sizing the nipples. In my experience, this is the most commonly pursued and desired surgery for the FTM individual. A main reason for this is that the removal of breasts eliminates the need to bind (http://www.ftmguide.org/binding.html) and also helps the individual “pass” as male. Many (if not most) FTM individuals pursue this surgery, and those who don’t often cite the obstacle of not having the finances for it. Top surgery commonly costs between $6-10k, out of pocket.  For more information re: FTM “top surgery”, please visit: http://www.ftmguide.org/chest.html.

As for “bottom surgery” (surgery to construct a penis), most FTM individuals do not pursue any genital reconstruction surgery (GRS). You read that right, most DON’T.  Finances are often a major obstacle; GRS costs anywhere from $20k to $70k, depending on the procedure.  Additionally, many FTM individuals are not happy with the options/projected results; techniques have not been perfected enough to deliver optimal results. Additionally, some FTM individuals don’t have a problem with their genitalia or see the need to have it changed. (Remember, one’s genitalia has more to do with one’s anatomy than gender. For a refresher on the difference between Gender and Sex, visit my blog Gender Vs. Sex.)

For those who do pursue “bottom surgery”, there are a few options. These include but are not limited to: a metoidioplasty, which involves cutting the ligament connecting the (now enlarged, thanks to T) clitoris and removing extra skin, resulting in a small phallus. The urinary tract can also be lengthened if the individual wants to be able to urinate while standing. Another surgery called a “phalloplasty” is basically the creation of a penis using skin from a donor site on the individual’s body, most commonly the forearm.  If the trans man desires testicles, the skin from the labia can be used to create a scrotum. At least six months after a phalloplasty, testicular and penile implants can be inserted.  To quote Hudson’s FTM Resource Guide, “Phalloplasty usually involves a urethral lengthening procedure so that the patient can urinate through the penis. Erections are usually achieved with either a malleable rod implanted permanently or inserted temporarily in the penis, or with an implanted pump device.”   For more information regarding GRS for FTM individuals, please visit http://www.ftmguide.org/grs.html or http://www.savaperovic.com/ftm-srs-metoidioplasty-total-phalloplasty.htm.

There are MANY different options for FTM individuals who don’t choose to or who can’t afford bottom surgery. There are all sorts of accoutrements available for purchase that allow the trans man to stand to urinate, wear a penis, and/or to have intercourse. In order to stand to urinate, there are “stand to pee” (STP) devices. (http://www.ftmguide.org/packing.html#stp)  If the trans man prefers to wear a penis, full-time if desired, this is called “packing”. (http://www.ftmguide.org/packing.html) There are a variety of different packers available for purchase.  (http://www.tranzwear.net/store.php?seller=TranZwear&navt1=101317&navt2=101323. For a 15% discount on purchases from tranzwear.com, use discount code “TRANZ” when checking out.)  For sexual intercourse, there are also a variety of options to choose from (http://www.ftmguide.org/packinghard.html).  I should add here that not all trans men choose to pack or wear any kind of prosthesis. As with any group of individuals, there is a spectrum of preferences about this!

Male-to-Female Surgical Options

Facial feminization is a common surgery pursued by MTF individuals. This can include changing the hairline, frontal bone contouring, mandible contouring, chin augmentation or reduction, rhinoplasty, lip augmentation, etc. I don’t know the exact numbers on this, but the cost of this surgery can be upwards of $30k. For more information on facial feminization, visit: http://en.wikipedia.org/wiki/Facial_feminization_surgery. Some trans women opt to undergo breast augmentation surgery. (Estrogen often does not enlarge one’s breasts to more than a “B” cup.) http://marcibowers.com/grs/breastaug.html

As for MTF “bottom surgery”, often referred to as Sexual Reassignment Surgery (SRS) or Genital Reconstruction Surgery (GRS), many transgender women opt to undergo a vaginoplasty, using skin and tissue from the penis to create a vagina, clitoris, clitoral hood and labia.  This is another expensive surgery not covered by insurance; I don’t know the exact figures but what I could find implied a ballpark figure of $20k. Sue Boyd, LCSW, a trusted colleague of mine who works with more MTF individuals than I do, estimates that about half of her MTF clients opt to pursue this surgery “expense and all”. My guess is because the results are more satisfactory to the consumer than the current results of FTM bottom surgery. For more information on MTF GRS, please visit: http://www.thetransgendercenter.com/transgendersurgerymaletofemaleMTF.html or http://en.wikipedia.org/wiki/Sex_reassignment_surgery_(male-to-female)#Genital_surgery.

I should say again that all of the above depends on personal preference. Some individuals believe opting to get any or all of the above surgeries is a way of buying into the gender stereotypes prescribed by society, particularly about how a man or woman “should” look. To quote the film “Diagnosing Difference” again, “I think ‘passing’ is a word to discriminate us immensely. Not everybody can pass. And passing is something that the doctors will tell you to do, you try to pass. Well, no matter how much I pass, I will never be a biological woman. How about empowering me as the transgender woman that I am?” -Adela Vazquez

A moment on my soap box:

After reading all these extensive options a transgender individual confronts, don’t you wish things could be a little bit easier? They can be. By intervening EARLY with a child or pre-adolescent who has yet to start puberty, their future does not have to hold as many medical interventions! For the MTF individual, staring on hormone blockers pre-puberty would prevent facial hair from growing in, thereby preventing HOURS of painful and expensive electrolysis. Hormone blockers would also prevent one’s Adam’s apple from growing and the voice from deepening, which would eliminate the need for a “trach shave”… ouch! Similarly, staring hormone blockers pre-puberty for the FTM individual would prevent breast growth and ultimately prevent an expensive and painful “top surgery”. Additionally, for the transgender individual who desires to “pass” as their true gender, intervening early gives them the best chance at doing exactly that. For more information about hormone blockers and intervening early for transgender children, please visit http://transhealth.ucsf.edu/trans?page=protocol-youth.

*Disclaimer(s):

  • I am a Licensed Clinical Social Worker, not a medical doctor. The information contained in this blog should not be considered a replacement for medical advice or consultation.
  • The websites used in this blog should not be considered as endorsements but rather sources of information.