Monday, November 11, 2013

Gender Non-conformity in Children and Adolescents

Hi Everyone,

I attended a really interesting conference on Saturday about gender non-conformity in kids. It was geared more towards doctors and psychologists than teachers, but I still felt I took a lot of important information away from the day. Below are my notes and a few handouts I picked up there. There will be a similar conference for educators this spring - I'll let everyone know when they announce the date. I would highly recommend the spring conference.


  • Terminology defined 
  • Health Imperatives - Putting into place the Massachusetts Department of Elementary and Secondary Education Guidance for Massachusetts Public Schools: Nondiscrimination on the Basis of Gender Identity
  • Resources for youth
  • OutHealth School Safety Assessment Tool

Irwin Krueger, LCSW of Connecticut author of "Helping your Transgender Teen: a Guide for Parents"
What has changed since 2004 when he started working in this area - major change in the pace of transition steps. More sympathetic media portrayal. Increased acceptance. Access to information via the web. Kids come in very well informed. Teens can feel increased pressure to start medical transition earlier. They can feel hurt if they are not able to progress with medical transition as quickly as they would like, because they are aware of kids who are progressing more quickly. Can feel like parents are holding them back. Parents are more well informed and sometimes more accepting. Professionals recognizing that transition during puberty in parallel with peers is best. Increased availability of insurance coverage. Laws and educational policies to protect trans kids. 

Educators/clinicians: Keep an open mind - kids won't always present as gender non-conforming. Listen to them. Be empathetic. Think about something important about you that you know some people won't approve of, how hard it was to be true to that. Handle any discomfort that you have with colleagues, etc. but don't let it affect the relationship with the child.

Intersex is not the same thing as trans - very small number of individuals with ambiguous genitalia at birth or external and internal genitalia that are incongruous. 

Transgender- people whose gender identity is discordant with biological sex. Cisgender- having a gender identity congruent with biological sex. Genderqueer now used by many teens and young adults to express not fitting into usual binary gender identity in some distinct way.

Best Practices for Clinicians 

Help trans youth sort out their identity.
  • Sense of self (how do they feel and for how long)
  • Sense of group affiliation (what group do they feel like they belong with)
  • How do they feel about their body especially gendered parts of the body? (not usually an issue until puberty)
  • How do they feel about how others see them? Happy when "mistaken" for gender they are, not sex they were assigned at birth. Feel dismissed when parents or other adults correct.
  • Who have they talked to? How have they tried to express who they are?
  • What are their hopes and expectations for the future?
Help parents understand and support their child. 
  • Feels as though for youth under 21, hope to engage the family at some point.
  • Parents concerned with child's safety. Sometimes react with disbelief. 
  • Parents want to know if it is real? Often little discussion between child and parent. Often need separate conversations with parents and kid to see where everyone is. In their understanding of the issues at hand. 
  • Sometimes parents worry if it is s reaction to trauma or loss. Talk to the kids and understand their reactions to those traumas or losses. Often the kids think the connection is ridiculous. Elements of being trans were there earlier and parents need to look at that timeline. 
  • Worried about the child's future. Not the case, at least in New England. Parents need to know trans adults who are living successful and fulfilling lives. There are challenges, but need to see that distress of not transitioning is worse than those challenges. 
  • Parents need to deal with their own shame and grief. This is not for the child to solve. Parents need to deal with these feelings with their supports. Parents need to be absolve of guilt about making their child trans, but should see how they may have hurt their kid though shaming them for gender non-conformity. Offer them opportunity to make up for it with support. 

Help them to be as authentic as possible. Doesn't need to be fully passing at first, but need to show that support and respect.
  • Name and pronouns
  • Clothing and grooming (can sometimes be tried out in different safe settings before being universal)
  • Group affiliation and bathroom use
  • Attention to safety 
  • Change school rosters - can be tricky but required to affirm gender at school but not in communication with parents if parents are resistant (legal requirement for public schools)
  • Legal name change
  • License or state ID change
How do you balance parents' need to talk about issues with child's need for privacy? Separate meetings and no sharing of information shared during separate meetings. Mostly sharing info about trans teens in general with parents. 

How do you advocate for the kids who do not have the parental and family support? Try to offer that support through school. Social workers, school mental health professionals. DCF can be supportive. Reassure them of options for once they are 18. 

What about starting a kid at a new school with a new gender? Sometime coming out as trans decreases harassment, when there is a group of friends to support and transition is clear. Going stealth dangerous because of connections online, etc. People might find out. Dating can be an issue. When do you disclose? Are you at risk of violence when you disclose?

Hormones: chemicals made by cells that affect other cells in the body
Trans people have the wrong organs, thus they are making the wrong hormones and changing their bodies in the wrong ways for their gender

Genetic sex established at fertilization. First six weeks of development organs undifferentiated. After six weeks sex determination happens and the testes and ovaries are defined and making testosterone or estrogen in different amounts. Female sort of the default, more testosterone and anti-Müllerian change to make structures. How do these hormones in fetal life affect things like the brain and gender identity formation? During childhood (pre-puberty) there are no sex hormones to worry about so focus can be on psychological and social issues and transition. 

Puberty: gonads make hormones in huge quantities. Kisspeptin in hypothalamus, GnRH released by cells in hypothalamus, affects the pituitary which then stimulates the gonads. Testosterone increases muscle, bone mass, vocal cords, shape of skeleton, larger hands and feet, decreased body fat percentage, facial and body hair. Slower fusion of growth plates increases height. Estrogen, increased fat in hips and breast development, menstruation. 
DSM V defines Gender Dysphoria as marked incongruence between assigned and perceived gender. Distress as a result.
Percocious puberty and delayed puberty already studied and treated. Gender Dysphoria can be treated as precocious puberty of the unwanted gender and delayed puberty of the desired gender. Amsterdam Study - Block undesired puberty entirely and then at 16 initiate the desired puberty. Never exposed to unwanted hormones, go through desired puberty only a little later, increase passability, prevent dysphoria. GnRH in a steady dose instead of natural pulses actually prevents puberty. Leuprolide suppresses. Runs 30,000$ a year if not covered. Histrelin implant in inner arm. Replace annually. Type approved for precocious puberty is called Supprelin (20,000$) plus surgery cost. Vantas for prostate cancer (4,000$) works (off label) and cheaper due to increased competition in prostate cancer market. Cross sex hormones more straightforward when puberty has been suppressed. Testosterone or estrogen, subcutaneous and oral respectively. Higher dosages required if puberty hasn't been suppressed, which increases chances of side effects, for example, blood clots with estrogen. 

How does transgender identity and sexual orientation develop? Hormonal, learned, genetic?
Probably not one right answer. 

Brain organization theory. Exposure to gonadal hormones prenatally permanently alter brain organization including behavior, sexual orientation, etc. Studies in rats do show brain changes and behavior changes resulting from exposure to different levels of hormones. Can't do these studies in humans. Can look at humans exposed to different levels of hormones for other reasons. Congenital adrenal hyperplasia, in infant girls causes masculinization of genitalia. Altered play behaviors and increased preference for boys as playmates. Increased chance that they will not be exclusively heterosexual. Correlation between severity of case and homosexual identification. Doss not seem to correlate with transgender identity. 

Transgender at 11: Jazz (Barbara Walters interviews )
Available on YouTube. 

Psychological Evaluation
Intake. Ask about legal and preferred name, ask about sex and preferred gender. Ask about pronouns. Make no assumptions. Have resources available. 

Goals are to determine the degree of gender dysphoria and cross gender identification. 
Talk to parents about how to support the child. Deal with parental grief and loss. 
Help the child explore their identity. 
Help the family make decisions about various transitions. 
Provide a record to support future medical interventions. 
  1. Strong and persistent cross gender identification
  2. No major underlying and untreated psychiatric disorders 
  3. Family support
Puberty blockers: easier transition, buys time, less psychologically distressing.

Complex cases: suicidal ideation or attempts, self-harming behavior, psychotic, homicidal ideation, anxiety, depression, eating disorders. Must be stable within reasons. Difficult because some of the issues they have are a result of the dysphoria. Transition can be helpful but can also be destabilizing. Tricky balance. Mood shift as a result of hormones can happen, but often calming. Late onset can be complex. Asperger spectrum can complicate, is this a way to try to fit in? Need to figure that out. Another challenge is parents who aren't on board or want to wait. Parents who disagree. Parental anxiety. Parental trouble with gender fluidity, need to know. Parents annoyed by time and cost of process. Cultural and religious issues. Not conflating sexual orientation and gender identity.  WPATH can help. 

Issues to consider: do young people who want hormone treatments get it if they are genderqueer? What about young children who are very concrete who may later in life identify more as fluid? See these as one of the differentiations that psychologists can help them make. 

Medical Q and A Session
What if there is lack of persistence or ambivalence? Blockers or just psychotherapy? Case dependent. Breast development? Self harming behavior? Therapy is a must, make that a condition of blockers. 

Hormones don't change who these kids are. Studies with kids who are not trans but can't make their own hormones have shown that. 

Legal Protections for Transgender Youth with GLAD
Yellow booklets with info about legal issues for trans people available with Caitlin or Daisy.
Successfully litigated a case where a trans girl was told she had to wear boys clothing to school. Maine Supreme Court hearing a case about a fifth grade girl who was told she couldn't use the girls restroom. Schools and judges have a hard time understanding what it means to be trans. Think of a trans girl as somehow less than a girl. A key argument they have to make is that these girls are girls and boys are boys, not somehow less than. 

Antidiscrimition - in MA only public schools prohibited from discrimination on the basis or gender identity. Language of the law is important. Public school law MGLC 76 section 5: no person shall be discriminated against in obtaining privileges and advantages in courses of study on account of race, religion...gender identity. Covers sports and extra curricular activities. Covers bathroom use.  Consistent and uniform assertion or evidence that gender identity is sincerely held, and not asserted for an improper purpose. This is the no flinch moment. Then you just need to deal with the social discomfort. Student must be allowed to use whichever restroom they feel most comfortable in and IF THEY NEED a separate bathroom they must be given access to that as well (but can't be forced). Public accommodations are not covered. Can argue that it is sex discrimination when there is a gap in the TG law. Discrimination is based on sex stereotypes. Discrimination because someone is changing their sex is sex discrimination. Used as protection. Department of Justice can use title IX to go after public schools in states with TG law gaps. Letter from a provider to a school outlining what kids need. Refer to medical and mental health standards and use clear and unequivocal language. Make it about the student and be clear about the harm to the student when needs aren't met. Sports in MA kids must be allowed to join teams and extracurricular activities consistent with gender identity. Harassment actually difficult to litigate, but threat of litigation is a useful tool. 

Interfacing with Schools GLBT Youth Support Project of Health Imperatives
Make a plan with the student re: what, who and when
Records changed to preferred name. Don't need name to be changed legally to change school records.
Parents involved if child is under 14. Is it safe for parents to know? If not, what do we say to parents?
Family Acceptance Project
As part of initial meeting plan for future check-ins
There should be no threshold that students need to meet to be treated as they wish to be treated. 
No threshold for identity to be valid. 
Use the gender checkbox only when necessary and if necessary have an other or blank to fill in. 
Gender neutral bathrooms available but should not be the only option. Stories of some kids avoiding using the bathroom at school altogether when it doesn't feel safe. (There is an iPhone app for all gender neutral bathrooms in public places.) Cisgender kids discomfort with trans kids can't be cited as a reason to deny trans kids rights. Do we really need things like graduation robes to be gendered? Should not have two dress codes for boys and girls. Even for events like prom. Have trainings and professional development! Missy Sturtevant or
Schools want to make these changes and need to know that the law backs them up. Connect with aglys and pflag as resources. 
Can make all bathrooms one in at a time. Don't need to talk about any particular student to other students parents. About anything. Welcoming schools has lessons about teaching gender. 

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