by Joan Allison
The extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex (Institute of Medicine, 2011).
Discomfort or distress that is caused by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the associated gender role and/or primary and secondary sex characteristics) (Fisk, 1974; Knudson, De Cuypere, & Bockting, 2010b).
*Only some gender nonconforming people experience gender dysphoria at some point in their lives.
Natal, felt or authentic gender
The gender assigned to a child at birth based on factors such as the child’s anatomy, hormones, and chromosomes.
In childhood, we begin to learn the answer to this question. For some children as young as kindergarten, the answer, to them, is not so easy. Are these children truly transgender? Should parents wait till the child is older and let them decide? There is some risk in allowing a child to go through puberty when their natal gender does not match their chosen one. For many, puberty blockers have given families much-needed time before those permanent changes happen to help their child decide.
Young children who identify with the opposite sex can usually navigate life between genders, gliding along the gender spectrum until their natal hormones demand expression. It’s at around
age 9 that the hormonal and physical cascade of changes makes their decisions about gender expression more urgent. Girls who identify as male are faced with developing breasts, and males who identify as female begin to develop Adam’s apples and facial hair.
About 75% of children who are left untreated through puberty will eventually decide to express as their natal gender. For the other 25%, their cross-sex gender will persist. There’s no way to know which children will go in which direction. What is known is that if a child reaches adolescence and persists in cross-sex identity, most will pursue a gender non- conforming role and/or go on to transition physically.
Based on the self-harm and abuse statistics for gender non-conforming children, many psychologists have adopted the ‘affirm’ method of treatment. They let the child decide which gender to express, then affirm how the child wants to live in that role. If a child is pre-pubertal, medical treatment can be used that creates time for more exploration of gender. These medicines are called puberty blockers.
Puberty blockers are just that, they stop the onset of puberty and the progression of secondary sex characteristics like breasts in girls, and deepening of the voice in boys. These drugs have been around for many years and were traditionally given to children experiencing precocious puberty (e.g. menstruation in girls before age 9).
When used therapeutically in gender non-conforming children, they can sort of ‘stop the clock.’ Some doctors and psychologists argue that this in itself is detrimental because it doesn’t allow a child to have the same puberty experiences of their peers. They say that puberty itself can help answer some of their questions around gender.
Other professionals argue that the blockers stop the irreversible physical changes that come during puberty, and for children who will persist in their gender non-conforming identity, it prevents the development of the secondary sex characteristics. This is crucial, they say, because an outward appearance that is in opposition to the child’s identity leads to higher rates of depression, anxiety, and suicide. Bullying and abuse of children who do not ‘look’ like their chosen gender is higher than for those children who do look like their chosen gender.
In such a complicated process of discovery, where can Mid-South parents with concerns for their child begin to get help? In Memphis, there are at least a couple of options. Focus was able to confirm that Dr. Jerry Heston with Child and Adolescent Psychological Associates and Dr. K.T. Hiestand of Hiestand Psychological Services work with children who have gender issues. They can provide the mental health services that are a required part of the overall process of blocking puberty (and for adolescents, using cross-sex hormone therapy to begin transitioning).
Children must also see an endocrinologist for a medical solution. In the Memphis area, three practitioners at The Endocrine Clinic provide the medical portion of puberty blocking. They are Drs. Karabell and Cohen, and Nurse Practitioner Sally Humphrey.
In the region, Nashville’s Vanderbilt Program for LGBTQ Health connects patients with comprehensive services including mental health and medical providers who offer puberty blockers. The program is also opening a gender clinic this fall, which will provide comprehensive gender-affirming services to best serve transgender patients. In Alabama, a similar, comprehensive practice, Pediatric Endocrinology, serves the needs of children. All the practices mentioned here also treat adult transgender persons as does Choices Memphis.
Puberty blocking medicines are expensive (several thousand dollars per month). A spokesperson at the Endocrine Clinic said that they have had some success working with insurers to get the expense covered, but emphasized that insurance benefits vary greatly and coverage is not a guarantee of approval.
The World Professional Association for Transgender Health (WPATH) is an international, multidisciplinary, professional association whose mission is to promote evidence-based care, education, research, advocacy, public policy, and respect for transgender health. The vision of WPATH is to bring together diverse professionals dedicated to developing best practices and supportive policies worldwide that promote health, research, education, respect, dignity, and equality for transsexual, transgender, and gender nonconforming people in all cultural settings.
One of the main functions of WPATH is to promote the highest standards of health care for individuals through the articulation of Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming People… This assistance may include primary care, gynecologic and urologic care, reproductive options, voice and communication therapy, mental health services (e.g., assessment, counseling, psychotherapy), and hormonal and surgical treatments.
Visit their website, wpath.org, for extensive information for transgender persons of all ages. For a copy of the Standards of Care document, go to the ‘publications’ tab at the top of the WPATH page. In the pull-down menu, you will see ‘standards of care.’ The downloadable pdf document is available in 18 languages.