I learned about working with transgender individuals by doing it.
Why did I have to learn by doing? Because the existing research before the mid-2000s was both scant and suspect. Suspect, because research from the 1970s through the early 2000s focused on how people with gender dysphoria could be “fixed’ and what type of pathological environments “created” a transgender person.
From Scientific American:
There still isn’t enough research, but fortunately the most recent valid research doesn’t consider transgender children as coming from a place of pathology or from pathological environments.
In this article, I’ll be sharing about my experiences as a clinician as well as some recent research that’s informed my practice, in the hopes it may be useful to other parents and caregivers of transgender pre-teens and teens.
. . .
In my experience with young adults who’ve transitioned (or are planning to), they’ve already made the decision about transitioning. They haven’t come to me for validation of their transitioning. Our work therefore focuses on the same things I work on with all clients: Depression, anxiety, relationships, and moving safely and confidently through the world.
Working with tweens and younger teens is more nuanced. In general, their parents send them to therapy to address depression, anxiety, and/or acting out, and the clients then open up to me about gender dysphoria. Sometimes when that happens, the parents aren’t open to their child’s feelings or the possibility of them having gender dysphoria.
The work is further nuanced because body dysmorphia comes in different forms and often arises in adolescence. I work to help adolescents discover what their body dysmorphia, which is body hatred, means.
In the early days of my practice, I needed to uncover what my patients’ thoughts and feelings meant in terms of transitioning so I would know how to proceed. I hoped to find research with more definitive answers. That type of research wasn’t available until recently.
I had questions. Do all transgender teens realize it when they’re four or five-years-old? Do they all hate the bodies they are in? When teens hate their bodies, is it because they’re transgender? If not, how, as a therapist, could I help them determine if their body dysmorphia was in fact gender dysphoria?
I previously worked with many adolescent cisgender girls who hated their bodies, largely due to our culture’s obsession with weight and attractiveness. Some had mothers who obsessed about their own bodies and that of their child’s.
In addition to enduring cultural and societal pressure about female bodies, many cisgender girls I had as clients were sexually abused. The development of female secondary characteristics during puberty, especially breasts, brought attention from cisgender boys, which was triggering for them. I also saw how even for girls who weren’t sexually abused, the unwanted male attention alone — if it was disrespectful and harmful —was also abuse that could cause the development of body hatred.
How, as a therapist, could I help them determine if their body dysmorphia was in fact gender dysphoria?
Initially, I relied on anecdotal reports from adult transgender people, who mostly recalled they’d felt like the opposite gender as early as four- or five-years-old.
My first transgender client supported this criteria. I began seeing her in 2011, when she was 16 and just starting to live as female. She said she knew from age four that she was different from other boys, but didn’t understand why. She assumed her penis would simply fall off one day. She told me she doesn’t hate her penis — she considers it a “birth defect” until she can afford to have surgery.
. . .
But this wasn’t always what I heard from my adolescent assigned female at birth clients who had gender dysphoria. Some came to therapy and didn’t remember feeling transgender when they were very young. This 2020 research by The Medical College of Georgia at Augusta University has some insight into why:
According to this study, not all trans individuals have those early memories.
For those who don’t report or remember experiencing gender incongruent feelings as very young children, it may be that they didn’t relate to gender at all until puberty. In other cases, they simply don’t remember early feelings one way or the other due to trauma.
As a therapist hoping for answers, this was frustrating — though not nearly as frustrating as it was for my clients.
It was also confusing for the parents. Some parents believed in “rapid onset gender dysphoria,” the idea that blames social media and peers for their child’s desire for gender transition. I wondered the same at first.
A survey study in 2018 popularized this notion of rapid onset gender dysphoria, but the study was deeply flawed. The sample size was small, and it was made up of only parents. The survey did not poll transgender youth.
In contrast, a separate study released by Pediatrics in 2022 showed that transgender identification by teens assigned female in birth decreased from 2017 to 2019, which refutes the concept of social contagion.
The sample for the 2022 Pediatrics study was 91,000 adolescents in 2017, and 105,437 adolescents in 2019. In research, the larger the sample the more valid the results.
What does this mean? It indicates that, ultimately, social contagion does not influence transgender identity.
Puberty and the resulting body development may be the first time transgender youth experience feeling they are in the wrong body, explaining what some people think of as “rapid onset gender dysphoria.”
. . .
When puberty awakens these feelings is when the real work begins. Through therapy, I can help my younger clients discover how much, if any, of their body dysmorphia is a result of gender dysphoria. I can help them determine how committed they are to transition, and — when they are fully committed — when are the best times to take each step in transitioning.
My advice to parents is to listen to your pre-teen or teen with an open heart and mind. Think back through their childhood. Did you notice gender fluidity more pronounced than with other children? If not, then maybe they didn’t fully experience their gender dysphoria until puberty. Ask them about their pubescent feelings. Read the current research on possible brain differences influenced by genetic variants. Read the large-sample, two-year study of transgender youth, if you’re worried about social contagion.
Transition means change, and change is never easy. You can smooth the way for you and your child, though, by accessing good information from the recent research.
As for me, as a therapist, I help cisgender adolescents rule out body dysmorphia unrelated to gender dysphoria. Once adolescents determine their body dysphoria is gender dysphoria, I provide unconditional support for them in coming out to their parents and others, along with guidance during transition.
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This post was previously published on Pink Hair & Pronouns.
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