Support of the Gender Nonconforming Child and Family the Top Priority

Case

Patty and Joe have a healthy and happy daughter, Maeve, who has been part of your primary care since she was born. At the 4-year-old well child visit, Patty shares with you that it has been a battle for the last several months to get Maeve to wear dresses, have her hair brushed, and go to sleep. Recently, Maeve has started declaring that she is not a girl and wants her parents to call her Mark. Patty reminds you when Maeve was 3 she wanted to be referred to as a kitten, which passed after a few months. Patty is worried now that if she uses Mark as a name, it will confuse Maeve and cause her to become a boy.

The family is now back for the 5-year-old well visit, and Maeve is now going by M, a compromise the family made, and dressing in more male-typical clothing. M is now having stomachaches before kindergarten and says she doesn’t want to go to school anymore.

Discussion

M shows signs of gender dysphoria and should be followed by providers who respect and support the child—as well as support and educate the child’s family members.

When a young person is identified as transgender or has gender dysphoria, withholding support and treatment is not an option. We know transgender individuals are at high risk of suicide, not due to their identity, but due to the stigma, shame, and discrimination they face. Conversely, we know when youth are supported in their identity by parents and medical providers, they have improved outcomes similar to their cisgender peers.

Appropriate treatment depends on a variety of factors that our multidisciplinary team at the CHOP Gender and Sexuality Development Clinic carefully consider together with the patient and family. Treatment is developed to best fit the needs of each individual, because every child, youth, and family is unique.

For a young child exploring gender, no medical treatment is recommended. Instead, we prescribe love and support. This can include social transition when feasible and appropriate, which means wearing clothes and hair as they prefer and being called by name and pronoun they feel fits them best. These may prove to be opportunities for gender exploration, which may result in a change in requests, or may be a way for a child to share they don’t feel they align with their sex assigned at birth.

Dealing with puberty

Once a child begins puberty and has shown a stable gender identity over time, they will be seen by one of our adolescent medicine specialists or endocrinologists. At that time, we begin GnRH agonists or puberty blockers to alleviate distress associated with the changes of puberty that don’t match a young person’s gender identity. For example, many youth born assigned female sex who identify as male will experience significant distress with breast development and menarche. By blocking puberty as early as Tanner stage 2, we also can prevent the need for future surgeries. Puberty blockers are also completely reversible, allowing time for further cognitive development of the youth and family acceptance before making more permanent decisions.

The next step in treatment will usually be to start gender-affirming hormones such as estrogen or testosterone, which will have some permanent effects. Therefore patient, family, and providers work together to decide whether this is the best next step in the treatment plan and determine the most appropriate timing.

Beyond transgender

Many children and youth identify as gender nonbinary or gender nonconforming, which can mean they feel both male and female, neither male nor female, or somewhere in between. For these young people, we work to create an individualized treatment plan that supports their gender identity and helps to achieve their goals.

As a national leader in supporting transgender children, youth, and their families, our center has prioritized research to assure we are providing the best care possible while also sharing this work with others. Our current studies focus on patients’ health and well-being, including fertility preservation prior to medical treatment, impacts of parental support, HIV prevention, and access to recommended medical and mental health care.

Finally, in order to assure the care we provide in the clinic transfers out to the places our patients spend the majority of their time, we provide trainings for schools, churches, community groups, as well as medical and mental health care providers.