Supporting mental health in children with gender issues
Writer: Caroline Miller
Clinical Expert: Paul Mitrani, MD, PhD
The experience of being transgender or gender nonconforming means that a person’s gender at birth (their assigned gender) does not match the gender they feel themselves to be (their affirmed gender). Young people who are transgender feel powerfully that they are not the gender assigned to them at birth. Even young children might say, “No, I’m really a boy” or “No, I’m really a girl.” As they get older, they may feel extremely uncomfortable in their bodies and want to change their gender identity.
Sometimes, the difference between their assigned gender and their affirmed gender causes extreme distress called gender dysphoria. It’s important to note that being transgender is not a mental health disorder, and not all transgender people experience gender dysphoria. But most do. They have a strong dislike of their sexual anatomy, a strong desire to be a different gender, and a strong desire to be treated as that other gender to relieve their discomfort. Many of them have anxiety or depression, which may be made worse by bullying, isolation from their peers or rejection by their families or community.
Treatment for gender dysphoria focuses on treating anxiety or depression, and helping kids reduce their distress about their gender identity. That might mean changing their name getting accepted as a different gender by their family and community. It can also involve guidance around surgery or hormone therapy, which can change a young person’s body to better match their gender identity. Not all transgender kids are interested in those options, so treatment should always be tailored to their specific goals and needs.
For young people who are still deciding whether they want to make a physical transition, hormone treatments to delay puberty are an option. That means that kids don’t develop mature characteristics, like a deeper voice or breasts, which could make them feel worse in their bodies. The treatment buys time to make a decision about further hormone therapy or surgery.
The rights and experiences of transgender people have been very much in the news over the last several years. But parents of kids who raise questions about their gender or come out as transgender may still find themselves at a loss for what to do next. What do kids need from their families as they wrestle with their gender identity?
Kids who question or want to change their gender usually do so because they are experiencing severe distress that they associate with the gender they were assigned at birth. “They know something is not right and it’s felt this way for a long time,” explains says Emma Woodward, PhD, a clinicalpsychologist at the Child Mind Institute.
They are usually struggling to understand and alleviate that distress. “It’s rare that kids just say one day, ‘I was born female and I don’t identify as that, I identify as a male and that’s what I want to be,’ “ says Dr. Woodward. “Usually it’s much more confusing for the child and family.”
This kind of distress is called gender dysphoria, and it is complicated by the fact that kids who don’t feel at home in the body they were born with often also experience rejection, bullying and social isolation. “We see a lot of anxiety and depression,” adds Dr. Woodward. “It’s often affecting every part of their life: in school, in friendships, in family life.”
What does it mean to be transgender or gender nonconforming?
The experience of being gender nonconforming means that a person’s gender at birth (assigned gender) does not match the way they feel about themselves (their affirmed gender).
Gender is expressed through one’s personality, appearance and behavior — typically as either masculine or feminine. Gender nonconformity can appear as young as two or three years of age, when children become aware of the notion of gender and they may assert, “No, I’m a boy,” or “No, I’m a girl.”
Exploring different modes and expressions of gender is a normal part of development during childhood. Young kids often playact favorite characters of a different gender, or enjoy playing dress-up. Most eventually assume the identity of their assigned gender. For some children, gender remains fluid. These kids often identify as non-binary or gender-nonconforming.
Some gender nonconforming kids, when they are young, don’t associate with either male or female gender expression in things like clothing, toys, activities and preferences in friends. They stay neutral, and in some cases never develop a strong identity as male or female.
Others present as typically male or female when they’re younger and surprise their parents when they declare their affirmed gender, explains Paul Mitrani, MD, PhD, a child and adolescent psychiatrist at the Child Mind Institute. “Parents can come to you and say, ‘I don’t understand. She used to love dresses and dolls and all those things, and all of a sudden she’s telling us that she’s a transgender male.’ ”
Young people who are transgender (or trans) feel powerfully that they wish to be — or are — a different gender from the one they were assigned at birth. They not only want to dress and act and be accepted as the other gender, but may feel extremely uncomfortable in their bodies. Some (though not all) transgender people want to change their bodies, through hormone therapy or surgery, to align with their gender identity. Girls who transition to become males are transgender males. Boys who transition to become girls are transgender females.
The terminology around gender nonconformity is rapidly evolving. Terms kids might use include genderqueer, nonbinary, gender fluid, agender, two-spirit, demigirl or demiboy. But the definition of these terms might vary for different people. Dr. Woodward notes that it’s important for parents and clinicians to accept the labels kids choose for themselves, rather than imposing labels of their own, or jumping to conclusions about where the child’s identity will end up. Often the first step kids want to take is a name change that reflects a different gender — or no gender.
What is gender dysphoria?
Being trans or gender nonconforming is not a mental health condition on its own, and not all kids who question or change their gender suffer significant emotional distress.
But for some kids the disconnect between their experienced gender and their assigned gender can result in the acute distress called gender dysphoria. These kids have a strong dislike of their sexual anatomy, a strong desire to be a different gender, and a strong desire to be treated as that other gender.
When they are unable to be accepted as the gender they feel they are, or are bullied or victimized, they are at high risk for depression and anxiety, as well as self-harm and suicidality.
Their mood can be very low, Dr. Woodward notes, and that’s often why families are bringing their child in to see a professional. “Some of them know that the issues are stemming from gender or sexuality, and some have no idea,” she says.
A study of transgender teens found that more than 50 percent of transgender males and almost 30 percent of transgender females reported attempting suicide.
And even when families are supportive, it can be a difficult transition for both the teen and the parents. If your gender nonconforming child is showing significant signs of distress and is struggling in school, with friends, or with other areas of functioning, it can be important to get help from a mental health professional who has experience with trans and gender nonconforming kids.
One family’s story
Melanie is one of those parents who was surprised at her daughter’s gender identity change. Now a transgender male named Kyle, Melanie’s child had never been particularly girly, but Melanie was not aware of any gender issues until she was 12. Her daughter had seemed vaguely uncomfortable, though, and at 11 was diagnosed with social anxiety. A psychiatrist put her on an anti-depressant, which seemed to help. Then, at 12, she told her mother she thought she was gay. And she quickly told the news to everyone at school.
The summer after seventh grade, Kyle told friends he thought he was trans. Melanie and Kyle returned to the psychiatrist they had seen earlier, and she was dismissive of the news. “Oh, all the kids think they’re transgender now,” as Melanie recalls.
“I thought it was really hurtful, Melanie said. “She basically scoffed. I think it taught me something too: I don’t want to be like that, for my kid.”
Kyle went public as a trans male the summer after eighth grade, when he went to sleepaway camp, and he started high school that fall as a male.
Treatment for gender dysphoria
Treatment for gender dysphoria varies, explains Dr. Mitrani, depending on what individual patients need to alleviate their distress. It involves understanding and validating their emotions and working with them to help them get relief. If they are diagnosed with anxiety or depression, the first step is to treat those disorders with therapy and/or medication.
“If we work on reducing those other symptoms and the gender dysphoria is still really strong and present,” says Dr. Woodward, “then it’s time to work on what we can do for that.”
Dealing with the gender disconnect itself can take a number of forms. As Dr. Mitrani puts it: “Let’s see what we can do to shape your responses or your coping skills or your environment to help you be who you want to be.” Dr. Woodward notes that this usually starts with changes to gender expression through things like clothing or grooming.
Further down the line, the child and their family might consider medical interventions. Hormone therapy and surgery are options that many patients desire, but some may not. “Some want to present and be treated as their affirmed gender but may not feel the need to go through all these steps to address the dysphoria,” Dr. Mitrani explains. “You see what their goals are and what their needs are, and you address those.”
For both the individual and the family, transitioning involves a series of decisions and challenges as they move forward. “As providers, we need to help support them through these changes,” he adds.
When trans kids want to change their bodies
The families Dr. Mitrani sees are often coming to get guidance on next steps for transgender children. While holding off hormone treatment or surgery until adulthood might seem the prudent choice, to give teenagers time to make sure this is what they want, there are also reasons to act as soon as possible.
“Once you start going through puberty, the complications from any medical or surgical transitions down the road may be higher,” Dr. Mitrani explains, “and the time living with that dysphoria or that distress is longer, so the risks are higher.”
Hormone treatment that suppresses puberty for as long as several years is one strategy for buying time to be sure. “If you can stop puberty, then you don’t have to worry about those secondary sex characteristics — the deepening of the voice or breast development or even menstruation — and you don’t have to have that added distress of your body acting in a way that isn’t the way you feel inside” he says. “Then, after careful assessment, if you want to move on to hormone therapy, it’s somewhat easier to get the outcome that you want.”
The typical recommended age to start hormone treatment is 16, based on best practice standards set by transgender and endocrinology organizations, but the timing, Dr. Mitrani emphasizes, should always be based on what is best for the individual.
Kyle’s new identity
For Kyle, the issue was whether he would be able to make the transition before he goes to college. At 16, he started on hormones. Melanie acknowledges that her first impulse was to push it off. “Originally, I was like, ‘Well he’s not doing anything until he’s 18, because we don’t want to change his body.’ Now, I’m like, ‘Okay, I’m wrong.’ ”
There were many painful experiences in Kyle’s first year as a transgender male, including the suicide of Kyle’s first trans friend. The family tried hard to support him, struggling at times to keep up with his expectations. “My husband took him to Radio Shack, and they got materials so Kyle could build a buzzer,” Melanie recalled. “Every time someone in the family misgendered him, he would hit the buzzer. Because he was like, ‘People, get in line.’ ”
But as the family came to accept Kyle’s new identity, it became easier on all of them. “Since we started getting onboard, he’s much better. Compared to where he used to be, before any of us knew he was transgender, he’s light-years better. He’s much more at peace. He’s an awesome kid. And I couldn’t be more proud of him.”
This article was last reviewed or updated on June 17, 2022.