Fellow’s Corner: Asking 1 Question Made All the Difference
Published on in Children's Doctor
Published on in Children's Doctor
It was during a week on inpatient service that I met L. Information I received said L was a “13-year-old girl who presented 3 days ago with weight loss, complaints of dysphagia, poor appetite, and leg weakness.” L had a history of anxiety and depression, having been on multiple psychotropic medications over the past few years. Over the past few days, L had undergone an extensive workup, including a swallow study, endoscopy, head imaging, and myriad labs, all of which were unremarkable.
L was wearing pink glasses and floral pajamas when we met, and had long hair and a markedly flat affect. After talking together with L’s mom, I asked her to step out for a bit so that L and I could talk one-on-one. We began chatting about L’s interests—soccer and electronics—and L began to open up a bit. Eventually I asked a question I’ve gotten in the habit of asking all my adolescent patients as part of a confidential history: “Do you feel more like a girl, more like a boy, somewhere in between, or something else?”
L suddenly became very serious and looked down. “I feel like … a boy,” L whispered. “Thank you so much for sharing that with me,” I said. “Can you tell me more about that?”
It turned out that L identified as a male and would prefer to be referred to with male pronouns. L explained that for the past couple years, he felt like something wasn’t right. “I don’t feel like a girl at all. I’m a boy, trapped in a girl’s body.” His parents didn’t know about this, and he worried it might upset them. “But I can’t make the feeling go away. It’s always there; there’s nothing I can do about it. I’m trapped.” He began to sob.
After he composed himself, L requested my help in talking with his mother. After getting L’s input on what he wanted me to say (and not say), and making sure this was something he wanted to tell his mother about, the next day L and I met with his mom. There were tears, laughter, more tears, and hugs. Thankfully, while L’s mom was quite surprised, she voiced her unconditional love for L and a commitment to learning more about how to best support him.
L’s mood brightened dramatically after this disclosure. Over the next 48 hours his appetite improved, his dysphagia cleared, his strength returned, and he was discharged home. He’s been connected with our Gender and Sexuality Development Clinic, where we have been able to offer a full psychosocial evaluation and support for L and his family. Following professional guidelines for care of transgender youth, we have provided menstrual suppression, and are beginning to discuss possible testosterone therapy. Though L has continued to struggle with anxiety, he has not had recurrence of his somatic symptoms, and his affect remains brighter.
L’s case illustrates a few points.
Hembree, W.C., et al. Endocrine treatment of gender-dysphoric/gender incongruent persons: An Endocrine Society clinical practice guideline. Endocr Pract. 2017;23(12):1437.
World Professional Organization for Transgender Health (WPATH) standards of care for the health of transsexual, transgender, and gender nonconforming people, 7th Version. WPATH website. https://www.wpath.org/publications/soc. Accessed October 12, 2018.
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Categories: Children’s Doctor Fall 2018, Fellow's Corner, Adolescent Medicine