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Guest Editorials

Treating our trans* children

by Rixt Luikenaar

In 2007 my second child was born and until the ultrasound at 18 weeks clearly showed it was a girl, I was convinced I was having another boy.

Growing up, this child resisted wearing dresses and ponytails from the moment he could and at age 2 made it clear he was a boy. At age 5, we donated every piece of clothing with glitter and pink from the girl aisle; in second grade he went to school as a boy, with a boy name and pronoun.

Now I happen to be an obstetrician-gynecologist with a specialty in transgender health care, so I let my child be who he wants to be — a boy — and we take it day by day.

According to the American Academy of Pediatrics, “A child’s awareness of being a boy or girl begins in the first year of life. Their gender identity is stable by age four and they know that they will always be a boy or a girl.” Gender identity is not a learned behavior; it is the sense of who we are from birth and we think that its development starts during pregnancy in the mother’s womb.

Sexual orientation is different than gender identity and does not mean that your child will grow up to identify as gay, lesbian or bisexual. Sexuality develops during adolescence from hormones and physical changes.

In 2012, the Human Rights Campaign did a survey of more than 10,000 LGBT-identified youth ages 13-17. Findings had shown that these kids feel much less happy and do not feel like they fit in. Less than half say they have an adult to talk to; 70 percent are not accepted by family; 40 percent are bullied in school. This confirms findings of significant mental-health issues including depression, suicide, anxiety, body image issues, substance abuse and post-traumatic stress disorder in transgender youth.

As parents we need to know that this is not our fault; we need to accept our child, get informed and be an ally. We need to help them transition if they want to — socially or medically.

Treatment is available. Making informed decisions to medically intervene are essential to our child’s mental health and well-being.

Social transitioning (outward gender presentation, clothes, hair, name and pronoun) is reversible. Many times when a child is allowed to express perceived gender full time, issues like bad behavior, shyness, illness and discomfort improve or rather disappear.

Medicine has made it possible to delay the onset of puberty which can be devastating in transgender children. Making the decision for medical transition is highly individual and may require input from the child and parents, and medical and psychological professionals. Some emotional maturity is needed, especially when it comes to discussing cross hormones — hormones that will change a boy into a girl, or a girl into a boy.

Therapy is recommended to make sure that transgender youth have the support they need and a safe place to explore their identities and process the transitioning experience, not because they are mentally disturbed.

The first step in therapy for transgender adolescents is confirmation of the diagnosis by either a mental health therapist or doctor. The most-used guidelines for the diagnosis and treatment come from the World Professional Association for Transgender Health, the Vancouver Coastal Health, Amsterdam Gender Clinic and Endocrine Society.

It can be difficult to find these services (cost, lack of insurance coverage and lack of research) but research at the Amsterdam Gender Clinic has shown that treatment is safe and, most importantly, leads to happier adolescents, and a decrease in suicide attempts.

The onset of puberty brings increased unhappiness over one’s body and development of depression, anxiety, drug use, high-risk sexual behavior and an  increase in suicide rate.

Suppression of puberty with gonadotropin-releasing hormone (GnRH) analogues blocks puberty of their birth gender. This is reversible and means that more time is “bought” — more opportunity to explore the wish for transitioning and no stress of puberty and irreversible changes that happen with that (deepening of the voice, facial hair, breast development, menses) and also helps prevent bullying.

Therapy is started between the ages of 11 and 15, depending on signs of puberty and blood tests.

Risks and benefits are discussed and a consent form is signed by both parents (if indicated). Blood tests need to confirm the patient is in puberty and liver, kidneys and other tests are normal. Height and weight are measured every three months.

GnRH analogues are given intramuscular. After three months, labs show prepubescence range of hormone levels and confirm that puberty is blocked.

We start cross hormones (testosterone, estrogen or testosterone blockers) between the ages of 14 and 16, depending on the desire of the adolescent and the parents. We then also discuss fertility because hormones are not entirely reversible.

Overall of most importance is that we as parents affirm our child’s gender identity expression to boost their self-esteem, and show them that we accept and support them completely. The difference is not wrong — it just is. Besides that, what’s worse? Accepting your child’s gender identity, or burying them because we couldn’t?

Refuse to be your child’s first bully.


Rixt Luikenaar, M.D. FACOG, is a board-certified obstetrician and gynecologist with 15 years of experience. She has special interest in transgender hormone therapy and GLBTQ healthcare, including pregnancy and preventive care. Her clinic, Rebirth OB/GYN rebirthobgyn.com, provides all-inclusive services to transgender patients, including guided and tailored hormone therapy, preventative, and primary care.

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