Understanding Gender Non-conforming/Transgender Youth

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What if a young person tells you that they’re “in the wrong body," that their inner sense of who they are as male or female, doesn’t match their body?  An increasing number of youth, identifying as “gender non-conforming” or “transgender” are seeking medical and mental health services to enable development of physical characteristics consistent with their affirmed, true gender selves.  Compelling evidence in recent years has begun to shed light on the biologic underpinnings of gender, supporting the concept that gender is not simply a “psychosocial construct," and that being transgender may be considered a normal variation of gender identity.  Dr. Stephen M. Rosenthal, Professor of Pediatrics, Program Director for Pediatric Endocrinology, and Medical Director of the Child and Adolescent Gender Center at UCSF Benioff Children’s Hospital, explains some of the work and research that goes on at his center to address pre-adolescent and adolescent gender concerns.  

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Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Well, I'm a parent of three children, two boys and a girl, and both boys played with trucks and dinosaurs. And my daughter played with dolls and wore dresses, and their gender seemed to be something they were very comfortable with.  The girl felt female, and the boys felt male.  But what if you as a parent noticed that your child didn't seem comfortable in that, and you had real concerns?  Where do you turn?  Well, there aren't many places in the country where you can get expert guidance when it comes to gender and really having that child grow up and feel together, feel complete in their gender for their whole life. 

Pretty controversial, pretty leading edge, but at UCSF Medical Center in San Francisco they actually have a center that deals with that, and it's called the Child and Adolescent Gender Center, or the CAGC. And the director of that is Dr. Stephen Rosenthal who joins us now.  Dr. Rosenthal, welcome to Patient Power. 

Dr. Rosenthal:

Well, that's a great question, and there are no clear data on this.  The data that are most commonly cited historically—but now about 20 years old—come out of the Netherlands, so it was published in 1993.  They basically reported that the incidence of male to female transgenderism is approximately one in 12,000.  Interestingly, they reported that the incidence of female to male transgenderism is about one?third that, and that in itself is rather controversial.  I would say that certainly in our experience we have seen much more of a one?to?one in our clinical services, and I know that's certainly true in many other centers in the United States. 

But in addition, a study that came out just in the last year, an epidemiologic study out of Boston, basically suggested that the incidence of transgender may be as common as about 0.5 percent of the population.  This was in a survey of adults.  So if it's 0.5 percent, that would be one in 200.  So that's obviously quite a range, one in 12,000 to one in 200, so it's probably somewhere in between.  It certainly, perhaps—well, if it's as common as one in 200, but certainly even one in 12,000 is not rare. 

And sexual orientation is also another construct that is part of being human—and undoubtedly also has a spectrum.  For people that are let's say at the adolescent age range or older, some people have somewhat tongue-in-cheek suggested that the difference between gender identity and sexual identity would be as follows: that sexual identity or sexual identification would inform who you might be going to bed with, whereas gender identity might be who you're going to bed as. 

Now, I somewhat shudder when I even give that particular example because you very correctly cited the example of a 3?year?old child who had very strong sense that—and I would refer to that child, that male?bodied child but with what appeared to be a female identity as she—she had very severe gender dysphoria. But I would think it would probably be a safe bet that that 3?year?old really didn't have any sense of sexual orientation at that point in life.  So gender identity and sexual identity are different constructs in the human experience. 

And just to be sure everyone understands, transgender, or the diagnosis, you referred to it as gender dysphoria, that is the current term that is used in the mental health arena.  And basically the core for that diagnosis is a very strong belief that he or she is of the other gender and typically associated with a significant amount of anxiety and distress.  What the Amsterdam group showed is that the majority of those kids who have gender dysphoria prepubertally, that this essentially dissipates—or they use the words desists—by the time that physical puberty begins.  And many of those kids will not, in fact, be transgender but maybe turn out—may turn out to be gay or just simply not—may not be gay, may be heterosexual but just not stereotypically male or female but certainly still not transgender. 

But for that 10 to 15 percent that still meets the mental health criteria for gender dysphoria at the physical onset of puberty, their studies have shown that the overwhelming likelihood is that they will be transgender for life.  And one of their pediatric endocrinologists, Henriette Delemarre working with Peggy Cohen?Kettenis and Annelou de Vries—they're mental health colleagues. Basically, they had a very clever idea which was knowing that many of the physical changes of puberty are irreversible, such as the deepened male voice or breasts in the female or the relative shorter stature—adult height in a female versus an adult male—that many of these changes that ensue with completion of puberty are irreversible, knowing that the goal here is to really improve the quality of life for these kids and their families, suggested putting their puberty on hold with a class of drugs that we as pediatric endocrinologists have used already for decades in a completely different context, that is, in the treatment of precocious puberty, to take these very same drugs which interestingly have a very good safety profile and are very specific to regulating the onset of puberty and are completely reversible, to take these kids that have transitioned into early puberty and still have gender dysphoria, to basically flip off the switch, put their puberty back—turn it back off before it gets very progressed and allow them more time to really figure out who they are. 

And this really points to the importance of working with a multidisciplinary team, in particular, mental health professionals who really are knowledgeable in gender, and working together with primary care physicians and pediatric endocrinologists knowledgeable in the use of these hormonal interventions.  And then if it is determined with additional passage of time that this person still is on the path of being transgender, that you can keep that person's preprogrammed puberty suppressed with these same medications and then add in the cross?gender sex hormones at a later point. 

There are some official guidelines, and there are some people that are pushing the envelope on that, but in general many of the more progressive centers are using these cross?gender hormones in these young people as early as 14 and maybe even on a case?by?case basis if there are compelling reasons to do this, at an earlier age.  Clearly, there is a tremendous need for outcomes data to look at the safety and efficacy of these approaches, but there appears to be a great interest on the part of funding agencies, and we very much hope to be a part of the efforts to achieve that information and to help move the field forward. 

And I want to make it clear that we very much believe that gender dysphoria despite its presence in a manual of mental health disorders, we do not believe that this is a mental illness.  We do believe that this is simply a biologic variation, and we believe very much in a gender?affirming approach.  It's very, very clear from recent studies, in particular that have come out of Toronto and earlier studies that came out of San Francisco, that the level of support that such a child receives, be it in particular from the parents, has a tremendous impact on the things as basic as that child's risk for suicide.  So it just seems like something really important to do. 

And it's such a privilege to actually see these kids have this—and these families have an incredible sense of relief.  And I just want to make it clear, our center, we have some great people.  Our mental health person is an internationally known figure, Dr. Diane Ehrensaft.  Our medical team is not just pediatric endocrinology, but we also have a primary care person, Dr. Ilana Sherer, and we have a new person who is in training, Dr. Stanley Vance, adolescent medicine.  So we're bringing together multiple dimensions of the medical experience. 

And then it’s so important we have social work and nurse practitioner support, and, especially, we have this advocacy group and legal support as well.  The advocacy group is called Gender Spectrum.  There's a link to that on our website.  They are an incredible group that provides such valuable services to these kids and families, and they are internationally known as well. 

So I feel so happy and proud because I've been able to bring the people I think are the best of the best all together in one location so that when kids and families come to our center they get medical, mental health, advocacy, social work and even access to legal support all in one clinic setting. 

I'm Andrew Schorr.  Thank you for joining us.  Remember, knowledge can be the best medicine of all. 

Please remember the opinions expressed on Patient Power are not necessarily the views of UCSF Medical Center, its medical staff or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on March 26, 2014