Part two in a series about LGBTQIA+ youth. Read part one.

How do I know if and when medical intervention is appropriate? Luckily, I have guidelines from trusted organizations. They have deep knowledge about the development, mental health, and medical well-being of adolescents. In my assessments, I’ll reference the specific criteria outlined for a diagnosis of Gender Incongruence from the World Health Organization) and Gender Dysphoria from the Diagnostic and Statistical Manual-5-TR) as well as the guidelines set forth by the World Professional Association of Transgender Health) and the American Psychological Association.

Rates of gender expansive identities grew recently. But, they have leveled off and even shrunk in some studies. This is like when we stopped telling left-handed people that they were not normal.

A term that we hear a lot about in the media when it comes to transgender youth is “Rapid Onset Gender Dysphoria.” This is presented as a phenomenon where a teen suddenly, unexpectedly becomes transgender. This is not a term used in the broader medical community. It does not describe a known mental health condition. A researcher coined the term. They interviewed parents about their perception of their child’s gender journey. We like to think we know our children well - and we do. But, they don’t tell us everything. The phenomenon described by this term has not been replicated or seen in data from interviews with trans youth.

I live and work in New York City. We have many resources available. The wait to see a doctor is long. It's usually an adolescent endocrinologist who specializes in this field. The wait for an initial consultation can be several months (or years depending on the particular doctor). Usually, my patients will keep seeing me for therapy. They will also have a series of appointments for consultations and assessments with a medical doctor. I’ll also write a letter to the doctor. I'll also write to the insurance company. I'll explain why I think the patient needs medical intervention (hormone blockers, hormone therapy, or surgery) now. I’ll include all the assessment information I’ve gathered about the patient’s history and their current functioning. I'll also include my assessment of the teenager’s ability to provide informed assent/consent. This assessment is based on their decision making and cognitive maturity. The letter will also discuss other mental health or intervening factors. These include co-occurring diagnoses, such as anxiety, ADHD, and Autism Spectrum Disorder. Finally, the letter will outline the plan for the patient’s ongoing treatment and care. It will cover their social and familial supports. If needed, it will cover recovery from surgery.

At this point, the doctor will review the information I’ve shared. They will also review the data they have gathered from several meetings with the patient and their family. They'll then meet again to review all the consent materials with the teen and their family. This means reviewing how procedures and drugs work. It includes what side effects can occur, what changes to expect, and addressing any patient concerns or questions. This is the earliest point for medical intervention. It means hormone suppression for those who have not started or are early in puberty. And hormone replacement therapy (testosterone or estrogen) for teens who are 14 or older.

Hormone suppression medication, or puberty blockers, have been used for decades (since the 1980s!). They have traditionally been used to treat precocious puberty, or puberty that begins before the age of 8 for girls and 9 for boys, by stopping the body from producing the hormones associated with puberty development. They are fully reversible. When you stop taking them, your body goes back to making its old hormones. There are some side effects like there are with most medications that we take. This is why this medication is taken while working with a mental health and medical care team to assess, guide, and monitor the process. Puberty blockers are most likely to be useful if the teen and their team (family and medical and mental health) believe that an incongruent puberty would harm the teen.

Surgical procedures have more rules. The rules vary based on the medical provider, insurance companies, and the procedure's location. Some requirements include a minimum age of 18. The person must have had hormone therapy for at least 12 months. They must have lived full-time as their gender for at least 12 months. In rare cases, a patient may be eligible for surgical intervention at the age of 16 or 17. From 2016 to 2020, 7% of gender affirming surgeries were for patients 18 and under. There were about 3,000 procedures over those 4 years, or about 800 per year. For comparison, in a given year, about 3,000 patients ages 19 and under will have Gynecomastia Surgery (Male Breast Reduction). Another 3,000 patients ages 18 and under will have breast augmentations.

Even the most loving parents and other caring adults can struggle. They can struggle to understand the complexity of gender. They wonder how it could be. There were no signs. They can’t understand how your gender and your biological sex can differ. Parents may feel sure that this is a phase, a result of the discomfort of puberty or just one of the passing identity explorations of adolescence. Parents may fear what this means for their child in the world. They may worry about what will happen if their child changes their mind. Parents may feel that this identity means they don’t know their child as well as they thought. This may not be the future they imagined and dreamt of for their child. This is frightening and overwhelming stuff. This is advanced level parenting.

I want to reassure you. I want to reassure you. If you support your curious child in exploring their gender, you won't turn a cisgender child into a transgender one. I want to reassure you that our children, and yes our teengers too, benefit from and appreciate when we join them with our curiosity and love. A teenager who is experimenting and exploring while in dialogue and connection with a caring adult, is a teenager who is going to grow and learn safely.

Learn more about the alchemy of gender in part three to be published next week!

Don’t feel like you know a lot about gender identity? Confused about gender fluid, non binary, cis, trans? Not sure about the difference between gender identity and sexual orientation?

The Gender Unicorn (https://transstudent.org/gender/) is a great place to start familiarizing yourself with new vocabulary and a new non-binary way of thinking!

The National Center for Transgender Equality (https://transequality.org/about-transgender) has a lot of great resources! GLAAD (https://www.glaad.org/transgender/allies) also has tips for allies.

Look into finding a local chapter of PFLAG (https://pflag.org/), an organization that supports queer and trans folks, as well as their parents, families, and allies.