Expertise with Kids Questioning Their Gender Identity

Consistent. Insistent. Persistent. Those are the characteristics health care professionals seek when it comes to understanding if a child is transgender, meaning the child’s gender identity is different from the one assigned at birth.

Just because a little boy likes to teeter around in his mother’s high heels or try on his big sister’s dresses—or even paint his nails—does not mean parents should begin wondering if their child is transgender.

“It’s completely normal for prepubescent children to explore their gender identity and expression,” says Christy L. Olezeski, PhD, a Yale Medicine clinical psychologist and director of the Pediatric Gender Program, which was created to help children and their families who are grappling with gender identity, expression, and related issues. “The difference can be your daughter saying, ‘I am a boy,’ over and over again.”

Yale Medicine’s program combines mental-health care with medical support, in the form of puberty blockers and hormones, when appropriate. The team also works closely with reproductive endocrinologists, pediatric and adolescent gynecologists, lawyers, and medical ethicists. Before any medical interventions are made, a child, along with parents, first engages in an extensive “readiness” evaluation. 

It’s important to note that Yale Medicine clinicians follow current medical protocols, which do not allow for either surgery or drug therapy for prepubescent children. Social transition is the only medically accepted form of gender-affirming care—and the only form of care they provide—for that age group.

In 2018, the American Academy of Pediatrics issued its first set of guidelines offering advice to pediatricians and parents about how to best support gender-diverse youth. The guidelines recommend taking a “gender-affirming,” nonjudgmental approach, which can help eliminate discrimination and stigma, a common problem among gender-diverse children and adolescents.   

There have been no national surveys to identify how many children are transgender, but some smaller studies throughout the country indicate that it might be 1 to 2 percent of the pediatric population. “That means as many as 1 or 2 in 100 children,” says Susan D. Boulware, MD, a Yale Medicine pediatric endocrinologist and medical director of the Pediatric Gender Program. She believes that transgender children and adults are underserved by the health care community. 

At the first visit, children and parents together meet with a Yale Medicine pediatric endocrinologist and a mental-health caregiver. They obtain a medical history, including the child’s gender identity and any accompanying psychological concerns. Anxiety and depression are very common in trans youth, Dr. Boulware notes. The patient, their family, and the medical experts discuss what physical changes the child might be interested in and possible safety concerns at home and at school.

Next, comes a thorough mental-health, or readiness, assessment, in part to determine if the child has gender dysphoria. This diagnosis means people experience discomfort and distress because of a mismatch between the physical characteristics of their assigned sex at birth and their gender identity.

Addressing mental health is paramount. This is especially true given the high rate of suicide attempts among transgender people. About 40 percent of people in the transgender and gender nonconforming communities report having attempted suicide in their lifetime, according to a 2015 study from the National Center for Transgender Equality. This compares to 4.6 percent of the general population.

“A lot of trans youth internalize societal influences, and some have anxiety and depression that are completely separate from their gender identity,” Olezeski says. “It’s important for us to assess those different factors so that we can adequately refer them to therapy. And if we can help them now, we can counteract the negative outcomes, such as the high suicide attempt rate, later on.”

The Yale Medicine team also assesses how children are supported at school and by friends. “If there is not a lot of support, we try to address that,” Olezeski says. “Plus, we ensure kids understand the risks and benefits of care, including potential effects on puberty.

Families often benefit from help and support, too, Olezeski adds. “They might not know the best way to support their children. They might have grief or they might be questioning their role in supporting their child through discovery and transitioning,” she says.

The readiness evaluation typically takes six to eight hours and is split up into sessions for the child and for the parents. If a family is traveling from far away, sessions can be arranged for one day. Or, they can be spread out over a period of time that works for the family.

“If you understand youth, you know that some of them wanted all of this done yesterday,” Olezeski says.

“But many parents tell us they are grateful that we are taking things slowly,” Dr. Boulware says.

Through the assessment, Yale Medicine can link children and parents with mental-health providers in the community who are specially trained in dealing with not just transgender issues, but other conditions that commonly go along with gender variance, including anxiety, and self-injury, such as cutting and substance abuse.

Additionally, the evaluation explores symptoms of depression and longer-term issues that transgender people face. “We discuss fertility issues and pose questions they might not have answers to. It's a way for us to start a conversation because we will be seeing them long term,” Olezeski adds.

If the evaluation confirms a diagnosis of gender dysphoria, Dr. Boulware and her pediatric endocrinology colleagues, Anisha D. Patel, DO, and Stuart A. Weinzimer, MD, offer a variety of care options:

• Puberty blockers are medications that stop the body's natural production of estrogen or testosterone. They are available as either an intramuscular injection once every three months or as an implant that is effective for a year. These medications are important, Dr. Boulware says, because it can be traumatic for a child who identifies as a boy to have to go through female puberty, and vice versa.

• Cross-hormone therapies—administering estrogen or testosterone—are used to change the balance of circulating hormones so that they are consistent with the individual’s gender identity. These medications, which are usually prescribed between ages 14 and 16, cause changes including the development of breasts, softening of skin, development of facial hair, and increased muscle mass. 

Dr. Boulware points out that many, but not all, of the changes from medications can be reversed if a patient simply stops taking them. As for the safety of cross-hormone therapy, the data for trans adults is “very reassuring,” she says. However, there is little data evaluating its long-term effects for developing adolescents, as it is a new field of medicine. “We discuss these issues with our patients and their parents in great detail before initiating therapy in any individual," she says.“

Most of the children we see identify as transgender, and most have already transitioned socially,” Dr. Boulware says. “But a small subset is gender-fluid and are questioning their identity. Our role is to support them and their parents. It’s not our job to determine their gender identity or insist they fit into the binary alignment of male or female. It’s our job to give the child a supportive environment and manage care if such therapy is needed.”

What makes the Pediatric Gender Program stand out, Olezeski says, is the abundance of resources—for children and adults. The program offers support groups for youth and for parents, and links patients with psychiatrists, fertility experts, a lawyer for name changes and other legal issues, an ethicist, and plastic surgeons, gynecologists, and ear, nose, and throat specialists for voice modifications.

In 2013, Connecticut became the fifth state to require health insurance providers to cover treatments related to gender transition. “This is terrific," says Dr. Boulware, noting, however, that "the vast majority of insurance plans do not cover the costs of fertility preservation."

Long term, Dr. Boulware and Olezeski have a vision of a comprehensive gender center that would include pediatric and adult endocrinologists, mental-health providers and on-site access to all the necessary surgical subspecialists. Ideally, such a center would provide primary medical and mental-health care for the transgender community. That, Dr. Boulware says, would be of great service, because many transgender people avoid seeking medical care, sometimes because they don’t know which doctors are knowledgeable and experienced in trans health care. They may also, she says, have experienced verbal and even physical abuse in a general medical office.

The differences that the Pediatric Gender Program staff members have seen in patients are remarkable. Dr. Patel recalls one transgender patient who—before starting hormone therapy—had been admitted to the hospital several times for suicide attempts. “And then I saw him, after he began treatment, and noticed the scars on his arm and said, ‘How are you doing now?’ And he just smiled and said, ‘I’m so much better now.’”

Olezeski agrees that the transformation can be striking. “They get a little lighter, like a weight has been lifted off of their shoulders,” she says. “Even at their first appointment, you see that they feel better just to know that someone is willing to validate who they are.”

To learn more about the Yale Medicine Pediatric Gender Program, click here.