July 2008

"Transgendered Youth"

The Schwartz Center Rounds is a series of multidisciplinary forums where caregivers discuss challenging emotional and social issues that arise in caring for patients.  Names and clinical details have been altered to protect confidentiality.

Presenters: (1) Dr. B, Pediatric Endocrinologist/Gender Management Specialist, (2) Dr. G, Psychologist/Facilitator of therapeutic support group for genetic males living as females, (3) Parent of teenager (T) who has completed the gender reassignment process.

Abstract

Panel members discussed their unique perspectives and experiences with transgendered youth. Transgendered youth can find support in the medical community from specialists who enable their gender reassignment transition.  This patient population inspires their health care providers to learn and grow with them.

Clinical Summaries

Parent:  T is a genetically male adolescent who has self-identified as female since age two.  Mood and behavioral challenges led to evaluations by myriad mental health professionals, various psychiatric diagnoses, treatment with multiple psychotropic medications, and special needs education.  As T became more confident in her female identity and appearance, her need for psychotropic medications decreased.  When advised against hormonal treatment by her primary care physician, T was so distressed by masculinizing pubertal changes that she was “out of control” at age 15.   T’s mother brought her for an evaluation by a specialized gender management service and consented to initiation of female hormones.  T and her mother then traveled to Thailand for gender reassignment surgery.  T is now doing well, getting good grades in school and plans to attend college.

Dr. B:  C is a 14-year-old genetic male who affirms a female identity.  After years of counseling and a suicide attempt, C’s mother traveled out of state to have her child evaluated by an experienced gender specialist willing to implement hormonal treatment with the ultimate goal of genital reconstructive surgery.

Issues Raised

Mental Health/Cultural Competency
Dr. B reported that suicide risk is extremely high for transgendered youth: nearly 50% of transgendered youth attempt suicide, with an average of three suicide attempts during adolescence.

Question from Rounds attendee:  I have a genetically female patient who identifies as male.  He has many mental health issues as a result of gender dysphoria.  He has seen several mental health providers, all of whom have rebelled against the notion of reassignment treatment and have expressed doubt about the overlap between mental illness and gender dysphoria, citing mental illness as the primary issue.  Can you comment?

Dr. B:  Once patients begin hormonal treatment, their need for psychiatric medication plummets.  Many transgender individuals are mislabeled with a primary psychiatric diagnosis.  This is historically similar to the way homosexuals were treated years ago.  Homosexual behavior was socially unacceptable and was given a DSM diagnosis.  It is still that way for many transgender patients, particularly if the consulting psychiatrist is not familiar with transgender issues.  My hypothesis is that the DSM diagnosis could disappear in light of a better understanding of transgender issues.

Support/Empowerment
Question:  What feelings have you experienced while managing this issue?

Parent:  It has been a nightmare.  I have compassion for youth whose families have walked away from them and for families who cannot afford hormonal or surgical treatment.  Now T is a typical teenager daughter.  Everyone in our family accepts her; we have had an easier experience than most families.

Dr. B:  The challenge provides an opportunity for personal and professional growth. Helping people blossom from what they look like to what they feel like is very rewarding and feels like assisting with a birth. 

Question: What has been helpful?

Parent:  Access to the medical community, ability to afford medications.

Dr. B:  Although at times the work feels overwhelming, and there are so few of us doing it, it is very rewarding.

Question: Any thoughts of forming a mentorship program to connect your patients with other transgendered youth?

Dr. B:  Treatment of patients under age 18 requires parental consent.  Generally, supportive parents find medical resources via websites and internet chat rooms. There is a support conference every year in Philadelphia and a new program at Children’s Hospital Boston that is drawing attention from patients throughout the U.S.  Parents have been seeking medical care at younger ages for their male and female cross identity children.  Though transgender identity occurs in equal numbers in males and females, a greater proportion of genetic males who identify as females feel the need to seek medical help since it is more socially acceptable in our society for genetic females to live as males.

Parent:  My daughter does not want to be labeled “transgender”.  She is totally female and wants to live as a woman.

Dr. G:  Among the street community, it is rare for transgenders to survive past age 40.  Older women who have survived help youth avoid some of the difficulties they went through.

Spirituality
Question:  What good news has religion brought?

Dr. G’s response:  Many transgender women are very religious and/or spiritual but they cannot go to church because it makes people uncomfortable.  Most church communities believe that G-d made these individuals and did not make an error.  For transgender individuals, prayer is helpful.  When they don’t pray, they may make less desirable decisions.  Support combined with faith can help transgender individuals who are poor and/or from communities of color.

Dr. B’s response:  Parents look for acceptance from religion, which can be very validating and powerful.  Clergy can talk to young adults and their parents.  One of my patients, a recently affirmed male, was able to pray because he was supported by senior clergy in his community.

Patient Centered Care
Question:  Should transgender patients be treated differently by medical professionals?

Dr. B’s response:  Most patients still have their birth name on their medical records and insurance documentation.  It is important to ask the patient “How do you like to be called?” and to inform clinical assistants to be sensitive to this issue.  The health system has been problematic for transgender patients, particularly when they arrive in the emergency room or see a new provider.  Questions arise when these patients are admitted, such as whether to place them in a female or male two bedded room.  I have learned to treat these patients as they want to be treated.  Asking what they want is important.  There are problems with seeing this issue in a binary way, e.g. male vs. female, as “in-betweens” are quite evident.  The focus should be on personhood.

Parent:  It is important to train medical and administrative staff on transgender issues, including receptionists, to increase their sensitivity.

Challenges
Dr. B:  U.S. regulations prohibit reconstructive surgery prior to age 16, so transgendered youth experience full puberty.  The Dutch have developed a protocol which is implemented at the onset of puberty.  Objective data is lacking, more research on outcomes is needed. 

Lessons Learned

Resources

The Children’s Hospital, Boston, Gender Management Service
http://www.childrenshospital.org/clinicalservices/Site2280/mainpageS2280P0.html

Disorders of sexual differentiation (DSD) guidelines for parents:
http://www.dsdguidelines.org/htdocs/parents/index.html

Intersex Society of North America http://www.isna.org/

Parents, Families and Friends of Lesbians and Gays (PFLAG) Transgender Network (TNET)
http://community.pflag.org/NETCOMMUNITY/Page.aspx?pid=380&srcid=400

Mermaids family support group: http://www.mermaids.freeuk.com/