Q&A 1

Gender Changes in Children

It is becoming more common to see gender dysphoric children, or children who believe their biological sex does not match their psychological gender identity, in society. The TLC reality show “I Am Jazz” details the life of Jazz Jennings, a transgender teenage girl, and has helped bring transgender children into mainstream TV. Recently, a viral video surfaced of a mother surprising her daughter with hormones in order to begin her gender transition. The emotional reaction from the daughter depicted the gratitude many transgender individuals have when they are finally able to transition.
However, there is still a lot that is not known about the benefits and drawbacks of allowing prepubescent children to block hormones necessary for puberty when they feel that they are the wrong gender.

Ball Bearings discussed this issue with Teri Schulz, a general practice pediatrician of 26 years at the St. Vincent Medical Group in Anderson, Indiana. Schulz provides her insight on the potential consequences of allowing a child to transition before puberty.

Ball Bearings: What are the purely physical health advantages or disadvantages of transitioning before children begin puberty?

Schulz: With kids that have something called gender dysphoria before puberty, there’s a fairly high percentage of them that do not have gender dysphoria after or during puberty. The studies vary, but only around 20 to 25 percent of kids that state before puberty that they feel like they have gender dysphoria will actually go on to feel that way post-puberty. Kids that feel very strongly that way are more likely to carry it through after puberty.

To me, it’s potentially a little dangerous to use medications or hormonal treatments prior to puberty, especially when there’s such a high percentage of kids just in the few studies that have been done, that no longer have those feelings after puberty and say it’s a transient feeling. To me, unless you had strong evidence from a psychologist, endocrinologist, or a psychiatrist that this is something that’s really going to persist, I think there’s potential danger in doing those type of medications. I know one of the newer kinds of things that they talk about in the literature is actually not doing the whole hormonal transferring, but using things to try to stop them from going into puberty; that’s different from hormonal therapy. A lot of people, if they are thinking that this is something that is going to persist, will start those medications pre-puberty to try to prevent them from going into natural puberty. They’re the same kind we give kids who start early puberty, that is, earlier than we would want them to. That can be used from around 5 to 7 years, and it halts your body from going into natural puberty which would give you a chance to assess whether you think this is really a more permanent feeling or just a transient one. In my opinion, there’s a big risk in giving hormonal treatment to someone pre-puberty unless you’re very convinced that this is not something that’s going to go away.

Now, it if it’s a pubertal child that starts saying they have a gender dysphoria, there’s a really high percentage of those people that say those feelings persist, so that’s a completely different issue.

BB: What are the emotional/social/psychological pros and cons of transitioning before puberty?

Schulz: Transitioning before puberty might help them feel like they’re fitting in better, and would possibly help with other people accepting them as the gender they’re identifying as, so there could be some psychological benefits. On the other hand, they’re not easily reversible decisions, so you have to be very comfortable with what you’re doing. If you felt like they’re going to stay in the gender that they’re identifying with, there could be some psychological advantages to treating them prior to puberty, but that’s a pretty significant decision. It can’t be taken lightly.

The trend now is to try to just delay puberty, and if you do that early enough, there aren’t going to be a lot of physical signs. Prior to puberty, a biological female who feels like she’s a male will not have a lot of breast development so it would be hard to tell when she dressed like a male. So halting puberty is a lot of times the safer route to go.

Clearly all of those kids have psychological issues that need to be looked at in terms of bullying, feeling like they don’t fit in, depression – there’s a very high rate of suicide in transgender kids in general. You do have to look at that and it takes a team approach to decide what the best option is. I’m not sure that taking the step of hormonal therapy is what I would normally recommend, but I would always get someone who has more experience involved.

BB: What kind of options are there, surgically or otherwise, for children wanting to transition? If they don’t want to or aren’t allowed to get any surgery, what else can be done to help a child feel like the gender they want to be?

Schulz: Well, there’s hormonal therapy. A lot of people who could get surgery don’t get it. There’s a lot of transgender people who just do the hormonal therapy and they don’t actually take the more significant step of doing an actual surgical procedure, and that’s totally up to them. But with the hormones, a female who is transitioning to male would take testosterone, for a male transitioning to female, they would take estrogen or progesterone. This is going to affect your body build; estrogen would cause more of the curves that you’d expect with a fairly female body and testosterone would increase facial hair and build up muscle mass. The surgery would be the ultimate step, but not everybody takes that. Some reasons not to do it could be cost, or they just don’t want to. The biggest thing is having their family and friends’ support.

The other issue with that is how does everybody else relate to you? That’s a trickier issue because when you’re talking about bathrooms, changing rooms, or dressing rooms, because it’s not all about one person. Teenage and middle school years are very emotionally upsetting for lots of kids and there’s lots of questions about gender, sexuality, and their bodies. I’m not sure it’s reasonable to expect that 6th, 7th, and 8th grade girls to accept a guy that wants to transition to a girl dressing in their locker room without a special place to dress. That’s kind of one big issue that’s coming up now. Because it’s not just about that one person, you have to consider the feelings of everybody else, too. That’s where our society’s going.

Personally I feel that they need to have gender neutral bathrooms that transgender kids could use. I’m not sure that I would be supportive of the situation in another state where their court ruled that a transgender student, biological male transitioning to female had to be allowed to dress and undress in an open girl’s locker room, and the school could not request that this person go to a gender neutral locker room. I’m not sure that that’s the right answer because then all of the other girls might feel uncomfortable with that. There’s one transgender individual involved but there’s also 20 or 30 other girls involved and that should be taken into account, too. You can try to teach people to be accepting, but you can’t legislate those things. Kids’ emotions are so up and down during that time anyway, it’s a lot to absorb. It’s a lot for kids to accept, it’s even a lot for adults to accept. It’s a very different issue. I don’t think the answer is saying, “Oh you just have to accept everybody – we have to let this guy who biologically looks like a guy dress, undress, and shower with girls in a place with no privacy – that’s not necessarily the right answer. You obviously don’t want those kids bullied, you don’t want them depressed, you need to watch their anxiety, but you also don’t want all of their peers to feel pressured either, because it’s a complicated issue.

BB: So what would you suggest for a school that might not have a gender neutral bathroom?

Schulz: They need to find one. They either need to find one or they need to find a place where they can curtain off an area or something – they need to respect the transgender individual but they do need to respect the privacy of all of the other students that are in that school who might not be able to wrap their heads around an issue that’s even complicated for adults to wrap their heads around. Maybe I feel this way because I’m older, but parents in my practice would not be thrilled if a biological male undressing and dressing in an open locker room with their biological female children. It’s a hard thing to grasp. A lot of people are just uncomfortable undressing and dressing anyway, whether male or female, they have body image issues anyway, and it’s more uncomfortable if it’s in front of someone from the opposite sex.

You always have to respect the rights of a minority of people. I’m not saying that you shouldn’t, and you certainly shouldn’t tolerate bullying, but you certainly need to respect the rights of the majority, too.

BB: How are transgender children different from babies born intersex, and how do you approach the situations differently?

Schulz: People who have genitalia of both sexes or ambiguous genitalia, it’s more of a pure medical problem. They’re typically raised by what they genetically are, chromosomally. Usually they don’t have gender identity issues necessarily; they’re not more likely. Kids with gender dysphoria are generally genetically a male or female, it’s more what their mind thinks they are. Nobody really knows why that is. It does seem to be on the rise, I read. But is it on the rise because people never talked about it before, or is it on the rise because we’re doing something in our society that makes gender more fluid? Gender seems a lot more fluid than it did when I was younger.

There’s a new trend in some places around the country where parents are telling their children that they can be whatever they want to be. It’s not because of what the child is saying. It’s called “raising your child to be gender neutral.” This woman had a 3-or 4-year-old and she says to him every day, do you feel like a boy or a girl today? They’re trying to raise their children so that they can express whatever gender they feel like they want to be. I personally think that’s just completely confusing to a child. Most kids have a sense somewhere between the ages of 2 and 4 whether they think they’re a boy or a girl. That’s one of the questions I always ask 3-year-olds: “What is your name, how old are you, and are you a boy or a girl?” and they know! Very rarely do they actually say the opposite sex, but they seem to have a concept of gender somewhere in that 2-4 range. There’s a percentage in that group who are maybe biologically male and feel female, but not very many of them go on to feel that way. Gender is established relatively early on for most people, in your mind.

BB: Anything else you’d like to add?

Schulz: The key thing is try not to over-question kids. Let kids figure out some of those things on their own. If I were a parent, I wouldn’t get too freaked out if my little boy wanted to play with dolls and said, ‘Oh maybe I want to be a girl.’ Kids can do that and it doesn’t necessarily mean that it’s going to be a permanent feeling. If your child is consistently saying that, those are the times you might need to approach your doctor and get some extra advice and guidance. But I wouldn’t freak out every time they say something; kids think they’re dogs sometimes, too. But if they keep saying it, or develop gender dysphoria, then you need to keep a close eye on how they’re developing emotionally and socially and make sure they’re not becoming depressed. There is a very high rate of that – even in people who have completed the process of gender transformation – there’s still a high rate of suicide, so that’s not the complete answer either.

Although allowing a prepubescent child to start transitioning may come with psychological benefits at the time, there is still the possibility of that child outgrowing their gender dysphoria later on. Not much research has been done on this topic, therefore the benefits and drawbacks of blocking puberty in children are still not entirely known. The few studies that exist suggest that children usually outgrow their dysphoria.

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