Challenging Misconceptions Around Transgender Youth
Jun 06, 2022 Victoria Pelham
By the time a transgender teenager comes out or begins to transition, they likely have lived in a body that doesn't match their sense of self for years.
Known as gender dysphoria, the psychological distress caused by a misalignment between the gender a person was assigned at birth based on genitalia and their true gender identity can be devastating.
A lack of acceptance of one's gender identity also can be devasting. Compared to non-transgender youth, transgender youth who are not supported by their families are three times more likely to attempt suicide, according to the Centers for Disease Control and Prevention, and have much higher rates of anxiety and depression.
Robust medical and social support—offered as early as possible—are lifesaving for this vulnerable population, says Dr. Paria Hassouri, who heads the Pediatric and Adolescent Gender Wellness Clinic at Cedars-Sinai.
While major healthcare organizations support gender-affirming care for youth, misinformation and a slew of legislative efforts to block this care in some states continue to undermine it.
We asked Dr. Hassouri to break down these misconceptions and share how providers actually treat gender dysphoria in transgender, nonbinary and gender-variant children and teens:
"Most of the time, transgender youth actually have a delay in accessing care because they share this information with their parents, and the parents think it might be a phase or their child may be confused."
1. When do transgender and gender-diverse kids typically first feel uneasy with their assigned gender?
A 2020 Cedars-Sinai study of transgender adults—those whose experienced gender did not correspond with their biological sex—found most cases of gender dysphoria had set in by 7 years old, with transgender women (assigned male at birth) first encountering dysphoria at around 6.7 years and transgender men (assigned female at birth) first encountering dysphoria at around 6.2 years.
About half of transgender and gender-diverse youth present in earlier childhood, says Dr. Hassouri, while the rest present around puberty or later into adulthood.
There's a sharp uptick around puberty, she adds.
"It's a time where somebody who may not have felt tremendous discomfort with how people perceive their gender—or they may not have been aware of it—may really feel a mismatch between how their body is changing and how they feel on the inside," she explains.
2. How do providers ensure a patient is an appropriate candidate for medical interventions?
Some people incorrectly assume that parents immediately take a child who is questioning their gender to a doctor to transition. But there are many clinical guidelines and ongoing evaluation steps medical providers use when treating these patients, Dr. Hassouri explains. Cedars-Sinai follows standards of care from the World Professional Association for Transgender Health.
"Most of the time, these youth actually have a delay in accessing care because they share this information with their parents, and the parents think it might be a phase or their child may be confused," she says.
Parents often wait to seek support until after they see their child's mental health worsen.
3. What does gender-affirming care involve for children and teens?
At its root, affirmative care is "believing and validating the gender identity someone tells you they have and seeing if there's anything you need to do to help affirm who they are," Dr. Hassouri says.
It can include a range of physical health, mental health and support services, depending on the patient and their age. Care providers also often guide patients and families, connecting them with literature, community resources, support groups and gender therapists.
For young children, the focus is on social transition and self-esteem. They may identify with a new name and pronoun, change their hairstyle and clothes, and use bathrooms that align with their gender identity. Pediatricians affirm their identifiers and offer support for any social issues with school, family or the transition.
When youth reach early puberty, they can take puberty blockers to delay puberty while they continue to explore their gender identity. As teens get older, providers may prescribe hormones for transition, including:
- Testosterone for transmasculine youth (assigned female at birth)
- Estrogen and progesterone for transfeminine youth (assigned male at birth)
4. Do transgender youth undergo gender-affirming surgeries?
Gender-affirming surgery is not conducted on children before they start puberty.
Gender-affirming procedures to either remove or enhance breasts, reconstruct or remove genitals and reproductive organs, and feminize facial features can allow gender-diverse people to align their physical presentation with their gender identity.
The vast majority of gender-affirming procedures are performed on adults, Dr. Hassouri stresses. Cedars-Sinai's Transgender Surgery and Health Program is geared toward this older demographic.
5. Do pediatric gender-affirming therapies actually help?
Studies show these therapies have mental health benefits. One study among transgender and nonbinary youth ages 13 to 20 found puberty blockers and hormone therapy reduced their risk of moderate or severe depression by 60% and suicide by 73% over the first year.
Earlier access to these therapies can ease worsening dysphoria and prevent the need for more invasive surgical interventions down the line. Transgender boys can avoid breast development altogether, while transgender girls can halt vocal changes and the growth of traditionally masculine characteristics, such as an Adam's apple, facial and body hair, and squaring of the jaw.
6. Are pediatric gender-affirming therapies reversible?
Puberty blockers are completely safe and reversible. Pediatric endocrinologists have used them for more than 30 years in children who enter puberty too early, Dr. Hassouri says.
Cross-hormone therapy is partially reversible but can cause some permanent effects, such as breast tissue growth in transfeminine girls. Hormones are generally used on older adolescents, she adds.
When a person identifies their gender at puberty or later, it's almost always a stable, lasting identity. Patients who come off hormone therapy tend to stop because of barriers to care—such as lack of family or financial support—not because they changed their mind, she says.
Groundbreaking research confirmed that the overwhelming majority of transgender youth maintain their identity five years after social transition.
7. Can parents or teachers persuade children to change their gender identity?
"There's a fear that talking about the diversity of the gender spectrum is going to make somebody who is not transgender or gender-diverse want to be," Dr. Hassouri notes.
But gender identity is not a choice, she says.
"Nobody can make somebody else transgender, just as nobody can make somebody else cisgender," she emphasizes.