Five Things Child and Adolescent Psychiatrists Should Know about Caring for Trans and Gender Non-Conforming Youth

In just the last five years, public knowledge of transgender issues has expanded significantly. Even though celebrities like Laverne Cox and Caitlyn Jenner have graced magazine covers, and the stars of Transparent have collected Emmys, there are still struggles for recognition and acceptance, particularly among trans and gender-non-conforming (GNC) youth.

Ohio teen Leelah Alcorn’s suicide garnered international attention after it became clear that stigma and mistreatment related to her gender identity was a major factor in her depression and ultimate death. Indeed, trans and GNC youth are at dramatically increased risk of numerous adverse mental and physical health outcomes, from self-injury and eating disorders to substance abuse, STIs and attempted suicide. All of these negative outcomes are associated with exposure to discrimination and victimization based on gender expression. Stigma is a pathogen, and it’s as deadly as any virus or bacterium.

There is good news, however: many of these adverse outcomes can be prevented when trans and GNC youth are supported by their families, schools and communities. That’s where CAPs—always on the front lines, championing children’s health—have the chance to make a major impact. Yet it can feel confusing or overwhelming to incorporate all this new information into practice, even with the very best of intentions.  Following are five simple ideas that hopefully will demystify working with trans and GNC youth:

1. Gender and sex are not the same. And gender identity and sexual orientationaren’t the same thing either. This trips up many astute clinicians, as the two terms often are used interchangeably in common clinical parlance. Remember:

·         Sex is a biological identifier assigned at birth when the baby emerges and the doctor sees either male or female genitalia (it’s actually not even this simple, as someone can be born with female external genitalia yet possess an X and Y chromosome, as in cases of androgen insensitivity syndrome or 5-alpha reductase deficiency, but you get the idea).

·         Gender isn’t dependent on genitalia or chromosomes, but rather on how an individual identifies socially, his/her/their sense of role—man or woman as opposed to male or female.

Le Chevalier D'eon who was born male
in 1728, had an adventurous and courageous
destiny and lived as a female in their last 33 years

2. Gender doesn’t just refer to male or female. Gender binary refers to the common separation of the world into the two buckets of boy and girl. But here are a number of terms in common use, from the simple ‘non-binary’ to more complicated terms like ‘gender fluid’ and ‘neutrois.’ As with most descriptors in psychiatry, it’s useful to ask patients how they identify, and what they mean by the words they use to describe their gender.  

3. Names and pronouns are a big deal. If you’re uncertain which pronoun someone uses, consider using the following script (common already in many high schools and colleges): “You can call me Dr. ___, and I use she/her pronouns. What about you?” Then make sure that your office staff are aware, too. Using the wrong pronoun or name, known as “misgendering” and “deadnaming” respectively, can be incredibly hurtful. When you make a mistake (which you will), apologize, move on and do better.

·         Pro-tip: Yes, some trans and GNC people don’t feel the need for surgery or hormones, and they are still absolutely trans. Actually, “they” as a singular pronoun is not only acceptable, it was declared ‘Word of the Year’ by the American Dialect Society in 2015 for the very reason that it is acceptable and preferred to a pronoun that doesn’t fit.

4. Simple steps to be welcoming make a big difference. This can be as minor as placing “gender” on forms followed by a blank rather than requiring patients to circle “M” or “F.” You also can include preferred names/nicknames in many electronic health records so office staff know the right name/pronoun to use (especially useful when insurance cards and medical records are required to be kept in the patient’s legal name). Train your staff to be sensitive to LGBTQIA+issues. Put some issues of OUT, Teen Vogue and Curve in your waiting room—bonus points if you read a few articles yourself!  

5. Don’t try to change it. Therapy to change a person’s sexual orientation or gender identity is not just ineffective, it is damaging. So-called “conversion therapy” or “reparative therapy” is opposed by numerous professional organizations. By the time patients make their way to you, they’ve already been exposed to discrimination or worse. Go beyond the neutral stance and explicitly celebrate your patients’ identities. Better outcomes are linked directly to willingness to engage in medical and behavioral treatment. The more we can build trust with support, the safer and happier our patients will be.