An Overview of Sexuality

Taylor and Trinity represent different aspects of the gender and sexuality spectrum. Note that gender and sexuality are mentioned as separate, distinct concepts. There can be confusion with terms related to and within both concepts of sexuality and gender, so this section will provide a brief synopsis of key terms. Sexual orientation refers to someone’s emotional and erotic attraction toward another individual (Forcier & Haddad, 2013; Spielman et al., 2020), and this may also be described as someone’s “sexual preference,” though the LGBTQ+ community has moved away from this terminology, as with the phrase “preferred pronouns.” By labeling them as preferences, it implies a choice, rather than a person’s truth or experience. For those with emotional and erotic attraction to members of the opposite sex, the term heterosexual is used (Forcier & Haddad, 2013). This is the basis for the terms “heteronormativity” or “heterosexism,” which refers to certain cultures’ bias towards heterosexual orientations. Homosexuality refers to emotional and erotic attraction towards an individual of the same sex, though again, many people in the community have moved away from this term due to its use as a diagnosis and consequential stigma. Bisexual people are attracted to people of their own sex and another sex; pansexual people experience attraction without regard to sex, sex identity, or sex expression; asexual people do not experience sexual attraction or have little or no interest in sexual activity (Forcier & Haddad, 2013; Spielman et al., 2020). Intersex refers to people whose bodies are not strictly male or female (Hughes et al., 2006).

Sexuality can be expansive. Research has made clear that sexual orientation is not a choice (Jenkins, 2010), but rather it is a relatively stable characteristic of a person that cannot be changed, despite claims of “conversion” treatments (Spielman et al., 2020). Not only is this type of “therapy” not effective, it is harmful. The position of the American Academy of Child and Adolescent Psychiatry (AACAP, 2018) articulates that such therapies lack scientific credibility, clinical utility, and suitability to the behavioral health treatment of children and adolescents. They instead say that clinicians should operate from a standard of care regarding the open exploration of gender and sexual identity without a predetermined outcome (AACAP, 2018).

An Overview of Gender

Sexual orientation can be confused with gender identity because of stereotypical attitudes that exist about gay and lesbian sexuality, and these issues, while related, are different. Gender identity is one’s experience of their gender, internal to them. This is different from natal sex, or the sex assigned at birth based upon a physician’s observance of particular genitalia/phenotype or through chromosomal testing (Forcier & Haddad, 2013; Spielman et al., 2020). Gender identity can correspond to natal sex, but it is not always the case. Gender identity is psychologically rooted (Forcier & Haddad, 2013), and gender expression is described as the manner in which individuals communicate their gender identity within a given culture. As we saw with the example of Taylor, the development of her gender identity included phenotypic aspects (e.g., wanting breasts, keeping her penis) as well as social transitioning. We will discuss different aspects of transitioning later in the chapter. Taylor can serve as an example of gender nonconformity.

Gender non-conformity is defined by gender role behavior that does not conform to culturally defined norms (Adelson, 2012; Forcier & Haddad, 2013). As mentioned, some people communicate their internal sense of gender identity via gender expression, but this is not always the case. Transgender is an all-inclusive term for people for people who experience or convey gender nonconformity, gender discordance, and/or gender dysphoria. Not all gender-variant or non-conforming individuals identify as male or female, express their gender as exclusively masculine or feminine, or experience gender discordance or dysphoria. We saw this in the example of Trinity, whose gender expression was not confined to one particular identity or role.

Gender non-conformity is different from gender discordance, which is the discrepancy between anatomical sex and gender identity (Adelson, 2012; Forcier & Haddad, 2013). The experiences of folx with gender non-conformity are unique and represent a range of experiences; similarly, those who experience gender discordance have a broad range of experiences with that discordance. For those who experience affective distress, the psychological term gender dysphoria can be used. Not all those with gender discordance will experience affective distress, so gender dysphoria is not synonymous with gender discordance.

Transgender refers to non-conforming gender identities, where someone may identify as genderqueer, gender non-conforming, transgender, or genderfluid. Transexual is considered an outdated term, although this term is used by some to denote a change in their identified sex. This is different from identifying as transgender. When someone identifies as transgender, they can go through physical transitioning such as surgery or hormonal therapy to have the body match the person’s gender expression (Forcier & Haddad, 2013), or they can go through social transitioning (Forcier & Haddad, 2013), in which the person performs and behaves as a way that resembles their expressed gender. These expressions of gender are not mutually exclusive, and it speaks to the overall move beyond a binary gender system.

Transitioning can be emotionally painful due to the external pressures of transphobia as one attempts to navigate social norms and culture and the expression of gender identity. The emotional problem of gender dysphoria occurs when affective distress related to gender discordance and the desire to be affirmed as a gender apart from their current gender identity.

Gender Development

A child has a sense of gender identity by the age of three, with a lifelong identity consistent with their natal sex being formed by age five (Forcier & Haddad, 2013). Gender non-conforming children engage in cross-gender play, activities, and appearances in a way that is described as “consistent, persistent and insistent” (Forcier & Haddad, 2013).

For those experiencing gender dysphoria, the distress can alleviate with developmental progress typically during early adolescence, and oftentimes the affective distress was related to sexual orientation questioning (Adelson, 2012). Gender discordance and the potential for gender dysphoria can be precipitated by the physiological changes and changing phenotypic expressions of puberty (Adelson, 2012). During puberty, an adolescent will need to adjust to their changing body as well as adjust to what that bodily change means for them.

Around this developmental time, a desire to develop physical characteristics related to the other sex or gender can emerge. This desire can lead to seeking out medical interventions like surgeries on different areas of the body, hormonal therapy that can suppress the effects of puberty (Forcier & Haddad, 2013), and this represents only one part of that person’s gender expression. Social transitioning can be another way to present as they desire to be presented through adopting different pronouns or gender-neutral words, changing their name, dressing in particular ways, requesting others to recognize their gender expression (Forcier & Haddad, 2013). Still, others may wish to have affirmation outside of a binary gender model. It is important to note that social transitioning is often the initial means through which individuals assert their gender identity. Gender affirming medical care, via hormone replacement therapy or surgical procedures, can only happen once an individual has an established process of social transitioning.

Across both gender identity development and sexual preferences data, epidemiological information is more readily available in regard to sexual orientation, with studies indicating that homosexuality emerges across cultures in about 10% of adolescents, and the variants of gender identity are less understood (Hill et al., 2012). Zucker (2017) notes that studies show a range of 0.5 to 1.3% of a self-reported transgender identity in children, adolescents, and adults. Rates of gender dysphoria are harder to establish because of the rise of gender clinics that can provide access to gender-affirming services, and there is more robust data for adult populations as opposed to children (Vance et al., 2014).

Developmental Systems Considerations with Sexuality and Gender

We could argue that issues around pathology and sexual and gender identity development reflect the macro pressures of culture and conformity. Culture and conformity play out across representations in mass media, as well as in our institutions. Take an institutional focus when considering the developmental systems approach and inventory these different institutions. What role do schools, employers, and governments play with the cultural reification of gender roles and heteronormative sexual orientations? How can these systems accept and promote non-conforming gender? Much of the distress that a child may feel comes from social norms and perceived expectations. As our interviewee Erica Smith indicated, how can youth feel safe at school, and how can they get their needs met without discrimination? Consider the negative effects of sexual and gender discrimination for children: lost social opportunities, potential development of mental health disorders like depression or anxiety, and lost learning. This may be a chapter where we turn the focus not on the child but on us as part of the systems in a child’s life. What is the role of the behavioral health clinician then in a system of care?

In terms of developmental stages and milestones, it would be appropriate here to mention the Tanner Stages (Tanner, 1962). These stages have become a routine part of the physical exam in pediatrics, with the stages spanning from 1 (no development) to 5 (adult development). Tanner’s stages only capture the external signs of visible secondary sexual characteristics such as the development of breasts or of the genitals, or the appearance of pubic hair growth. Shirtcliff et al. (2009) note that researchers may have difficulty with doing physical examinations in non-clinical settings, so other methods are often used, such as the Pubertal Development Scale (PDS) (Peterson et al, 1988) or the Picture-Based Interview about Puberty (PBIP) (Dorn & Susman, 2002). What is relevant to us here is that these self-report measures were helpful for understanding youth development during puberty (Shirtcliff et al., 2009). These measures were compared against hormonal testing and were seen as adequate (Shirtcliff et al., 2009). In the context of a clinician assessment, these measures may have utility when understanding physical and sexual development. The brief mention of the Tanner Stages and related constructs are meant to be educational in the behavioral health context, not to be diagnostic of anything related to physical health, which is out of our scope of practice.

Gender Diversity in Other Cultures

Non-binary identities and diverse gender roles have existed in various forms across different cultures worldwide. Within these cultures, gender diversity and fluidity have been visible, accepted, and intact (Herdt, 1996; Nanda, 2014). Even with the globalized reinforcement of gender binaries, some cultures continue to honor the traditions and norms of gender diversity within their communities. Although there are many cultures worth mentioning that embrace multiple gender identities, we will describe a few. In some Native American tribes, two-spirited has become an all-encompassing term to describe gender-fluid roles and identities. Two-spirit is a term used to recognize gender diversity with various Native American tribes. In the Mojave (or Mohave) tribe, they accept the gender norms of Hwame (assigned female at birth, identifies as a man) and Alyha (assigned male at birth, identifies as a woman). Within indigenous communities of Mexico’s Oaxaca Peninsula, they recognize Muxe (a person assigned male at birth who exhibits both qualities of a man and woman) as a third gender. Muxes emulate the femininity in their culture but do not identify as women. In the Bugi society within Indonesia, they recognize five genders. The five genders consist of the binary male and female, the Calalai (assigned female at birth, identifies as a man), the Calabai (assigned male at birth, identifies as a woman), and the Bissu (encompasses all gender identities).

Assessment of Emotional Challenges Related to Gender and Sexuality

Sexuality has had a controversial history within the various iterations of the DSM. Homosexuality was considered a mental disorder in the DSM III, then ego dystonic homosexuality was considered to be the source of sexual pathology, with the diagnostic label of disordered gender identity in the DSM-IV (Vance et al., 2014). The current diagnosis of gender dysphoria in the DSM-5 attempts to accept the nuances of sexuality and gender expression and the emotional challenges that accompany gender discordance. There are various criteria for a gender dysphoria diagnosis, but these potential criteria center on a reported marked incongruence between one’s experienced/expressed gender and assigned gender, of at least 6 months’ duration (APA, 2013; Vance et al., 2014).

Vance et al. (2014) note that in the DSM-IV, a cross-gender identity was considered to be pathologic, and with the updated DSM-5, this is no longer the case. The focus in the DSM-5 with gender dysphoria is the distress that arises from incongruence between assigned gender and affirmed gender identity (Vance et al., 2014). Children will express dissatisfaction or affective distress with birth-sex assignments (Vance et al., 2014).

Clinical Features of Gender Dysphoria

To stress the overarching theme of this chapter, there is nothing pathological regarding gender non-conformity or non-heterosexual orientations. In keeping with the current iteration of the DSM-5, there can be significant levels of affective distress that can interfere with the child’s daily functioning, and this falls under the diagnosis of gender dysphoria.

There is some variance in the diagnosis for children versus adolescents (who share similar criteria as adults). Both must have an incongruence between one’s experienced/expressed gender and their assigned gender. Adolescents may want to prevent the development of secondary sex characteristics. For children, criteria must include a “strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)” (APA, 2013). Other criteria span includes strong dislike of one’s sexual anatomy among other behavioral criteria like cross-gendered play and fantasy.

Let’s revisit our case vignette. Would either Taylor or Trinity meet the criteria? At first glance, it is not evident. Taylor felt that breasts would affirm her true gender identity. She didn’t necessarily want to rid herself of her penis. We would need to delve deeper into Taylor’s presentation to see if criteria were present. You may ask, why does that even matter? Sometimes, the diagnosis could be needed in order to receive affirming treatments like hormone therapy or surgical intervention. For the behavioral health clinician, we need to focus on the impact on functioning; what can we do to support quality of life with Taylor? Gender dysphoria varies person to person, and some people may have dysphoria around certain body parts and not others. It may not necessarily be genitalia that’s the source of dysphoria; it could be voice pitch, jawline, or facial hair. Folx from the trans community have cautioned us to move away from focusing on their genitals. In opening a nuanced discussion around this type of bodily dysphoria, it may be worth mentioning that vaginoplasty/phalloplasty, or “bottom surgeries,” are multi-step surgical processes with lengthy recovery times. For some, though dysphoria may be present, the cost/benefit analysis of obtaining that type of surgery and the resources to do so can be a very complex decision.

Intervention with Emotional Challenges Related to Gender and Sexuality

Before speaking about gender dysphoria, clinicians working with issues related to sexuality should be guided by an affirmation approach. Affirmative approaches embrace positive views of sexual and gender minority identities and understand the negative influences that homophobia, transphobia, and heterosexism can have (Leibowitz et al., 2016). This approach recognizes that part of the therapeutic work will be on counseling about the feelings a person has towards their identity and how they relate to and from their identity (Leibowitz et al., 2016).

The affirmative approach is a necessary standard of care (Ehrbar & Gorton, 2011), as it is well-documented that sexual and gender minority persons experience higher rates of bias and discrimination in healthcare settings (Forcier & Haddad, 2013; (Leibowitz et al., 2016)), as well as experience increased risk for bullying, peer nonacceptance, and family rejection. They also experience suicidal ideation, non-suicidal self-injury, suicide attempts, mental health disorders, and health risk behaviors at a higher rate than the general population (Forcier & Haddad, 2013). This approach can come at odds with the systemic challenges related to the gatekeeper model. The gatekeeper model operates in a stepwise approach for medical interventions, in which patients must see a mental health clinician to obtain clearance for the initiation of medical interventions. An alternative model is the informed-consent model, where a mental health evaluation is not necessary for patients with the cognitive capacity to provide informed consent for treatment. Across both of these models and the potential for systems-level limitations, the practitioner should have an affirmative approach.

Evidence-based treatments have not been established specifically for gender dysphoria, but theoretical models indicate that reducing gender dysphoria would focus on targeting the affective distress of gender dysphoria (Leibowitz et al., 2016). For youth with gender nonconformity, intervention can span individual and family work, as well as parent guidance techniques (Malpas, 2011). Interventions can look to process the emotional aspects of the child and family navigating the child’s gender expression, with some interventions focusing on social considerations about passing or not (Malpas, 2011). Behavioral techniques like setting limits on cross-gender behaviors, encouraging gender-normative play and preferences, and promoting same-sex peer relationships can provide important clinical information (Ehrensaft, 2012; Leibowitz et al., 2016). If the child is insistent on cross-gender behaviors, this can be indicative of gender discordance that would make transitional intervention appropriate (Ehrensaft, 2012; Leibowitz et al., 2016). The previously mentioned techniques are not meant to act like conversion therapy, where the heteronormative standards are reinforced; rather, it is meant to see how the child responds to such standards.

There can be less intensive or hands-on approaches, such as a “wait and see” approach to understand how gender identity would unfold after the onset of puberty (Leibowitz et al., 2016; Menvielle, 2012). This is neither encouraging nor discouraging cross-gender expression, and this approach comes from a theoretical assumption that gender identity determination is unreliable in prepubertal children (Menvielle, 2012). Trinity can be an analogous example here, where a clinician can take a non-directive approach, opposed to encouraging the expression of one particular identity (e.g., direct towards Trinity only or towards Clifford only).

The other end of the intervention spectrum is the reinforcement of the opposite gender role through interventions such as prepubertal social gender transition (Ehrensaft, 2012; Leibowitz et al., 2016). This adoption of the affirmed gender can occur through the use of the child’s preferred name and gender pronouns in some or all contexts. This approach builds from the assumption that gender may be fluid and nonbinary, and that acceptance of the child’s gender now will lead to long-term beneficence (Ehrensaft, 2012). Medical intervention can be an option through pubertal suppression in which a child undergoes hormone therapy to suspend endogenous pubertal progression (Leibowitz et al., 2016). By suppressing puberty, the youth have additional time to explore their gender, and it is important to note that this hormonal therapy is “reversible.” The stopping of hormone therapy will allow endogenous pubertal development to resume (Leibowitz et al., 2016). For youth experiencing gender dysphoria, these transitions are not a matter of “sexual rebellion;” these are ways to correct what they feel is a mistake in nature (Spielman et al., 2020)

For the developmental systems guided practitioner, there are few key takeaways. Hold the space for the child to explore and integrate gender identity; address the mental and emotional impacts of minority stress; help the child and family to build a support network; plan for social and legal issues related to transition; help to develop problem-solving skills and flexibility for the child and family to make informed decisions about medical treatment options; increase well-being and quality of life for the caregivers and family members; and cultivate well-being for the child. So, with both Taylor and Trinity, what would affirming their gender expression look like? Given that they both are in the child welfare system, the clinician may need to take the role of advocate to ensure that any future placements are affirming homes, or education may need to be provided to the current group home parents about affirmative care. That home is also the most immediate space for any social transitioning, so then Trinity or Taylor’s clinician would need to consider interpersonal skills development. In summary, the spirit of care is to affirm and not provide treatment for a disorder, and our developmental systems lens can lead to building connections across systems for these youth.

Liberatory Practices

As clinicians, we collaborate with clients to affirm and empower them in their deeply personal journeys of gender and sexuality identity development. While a clinician’s role often focuses on addressing the internal response to stressors—experiences of dysphoria, rejection, internalized shame, and the subsequent impacts on one’s mental health—we must also recognize that trans identities and LGBTQ+ rights have become highly politicized. Contextualizing affective distress within a sociopolitical climate of transphobia and homophobia, compounded by racism, ablism, and classism, is an important component of care and advocacy. Upholding liberatory practices in our clinical work can look like decolonizing our lens and finding space to challenge the heteronormative conceptions of gender and sexuality that permeate our systems and institutions. Trans folx, specifically trans people have color, have historically been at the forefront of LGBTQ+ liberation movements. Supporting activism and organizing efforts led by trans people is an important step in the pathway to liberation (Erickson-Schroth, 2022).

It is easy for anti-trans violence and legislation, as well as the very real struggles that trans people face, to dominate the discourse. People of transgender, non-binary, and gender-expansive experience have highlighted the need to recognize the joy, strength, and diversity within the trans community. The term gender euphoria has been increasingly used to celebrate the ways in which transness can liberating and affirming. Highlighting the positive emotions that trans people have around their gender identity is a necessary balance to the dysphoria that individuals may also experience (Austin et al., 2022). Trans people deserve to have all aspects of their identities and experiences validated in their fullness, with the necessary resources to live and thrive in authenticity and safety, both within the clinical environment and beyond.

Clinical Dialogues: Gender and Sexuality with Erica Smith, MEd

Sean E. Snyder, LCSW: What’s the engagement process like when you work with a child, from when they first get referred to you and first come into your door?

Erica Smith, MEd: The CHOP gender clinic has been open for about six years now, and by the fifth anniversary, we had worked with over 700 children. We get a lot of referrals; oftentimes, there’s a waiting list. During the initial encounter, the parent speaks to one of our intake folks who takes down all of the information about the kid; then they come in for a visit. Unfortunately, there is some wait time because there’s a lot of demand for our services. We are the biggest gender clinic between Boston and Miami.

When a young person comes in, they have a very comprehensive assessment by one of our social workers and clinicians to assess the young person’s situation: what they’re experiencing and what’s going on with them, what’s going on with their family. We try to figure out how long they have expressed their gender dysphoria. That is really where everything starts; there’s no medical stuff or anything. It’s really understanding the many different facets of this child and their family.

Snyder: I wonder, are parents the ones reaching out or do you get physician referrals or other kinds of professional referrals? I wonder about the role that stigma can play with families or providers.

Smith: A lot to cover here. We do have tons of parents who call us and will say, “My child is exhibiting discomfort with their gender,” or “I think my kid is trans” or “My kid came out to me as trans. I need you to help them.” So, plenty of parents call us. The fact that a parent calls us means that they have some measure of acceptance with their child’s gender. It might not mean that they are all the way there, but at least it means they are open to it, if they are bringing their kids to the CHOP gender clinic. We do get plenty of referrals from other doctors, though, but that usually also means the parent is somewhat onboard.

Snyder: What’s it like to work with the parents of the kid in general? How do you work with parents that aren’t really accepting of gender and sexual identity?

Smith: This is a big one. Our team at CHOP is a multidisciplinary team. It is not that we bring your kid into care, and we only address what’s going on with the kid, then send them back out into the world. We have a comprehensive multidisciplinary team that also works with the families, including the siblings. And we also work with school personnel, depending on where your child goes to school. Once your kid is involved in the gender clinic, we are not only addressing their health needs but also their emotional needs and their therapeutic needs.

We are making space for the families, too. For a lot of parents, even parents who accept their child’s gender identity, they kind of have a process that they go through. For some parents that is grief that their child is not the gender they thought they were. We find that it is important to give the parents space to experience and process that grief so that they’re not putting it on their kid.

So, for example, if I had a trans child that was assigned male at birth and then came out as female, I may have feelings because I thought, “Oh, I thought I had a son, and I’m losing my son.” I don’t need to tell my kid all that stuff. I would process that with the clinicians at CHOP’s gender clinic and also seek out my own therapy. We would recommend that the parents are talking to somebody, too, so that everyone in the family has their own process being addressed. That creates a better environment for the young person long term.

The support groups that I coordinate are also for the kids and their families. This massive support group meets once a month, and it’s divided up into transgender children who are nine and under, transgender tweens who are 10 to 13, and young trans people who are 13 and up. We have a support group for parents of each different age group, and we have a support group for siblings of trans youth.

We have a support group for extended families, and we get a lot of grandparents, aunts and uncles, and other people who are caretakers of trans youth who can come and talk to other grandmas about what it’s like to navigate having a trans grandchild and what it’s like for them as grandparents. So, we really do a lot of work with the entire family.

Snyder: Are these groups typically an emotional processing group, or is it more focused on psychoeducation? What typically happens in these groups?

Smith: It’s different, depending on the age of the kids. It is more like a play and social support for a lot of these children, as it’s the only time they have around other trans people. Some of our gender clinic patients come from all over the tri-state area, and some folks drive as far as two hours to come to our group. It might be that in their regular life that they’re the only trans kid in their whole school district who’s out, but when they come to our groups, and they get to play with a whole bunch of other little kids and don’t have to feel weird around their peers or explain themselves. Sometimes with the teens and tweens, they don’t even talk about their gender; they’re just there to be themselves with other kids and talk about things like memes or video games because they really want to be around other people like them.

The parents do a lot of talking about their emotions, and they receive some psychoeducation in the parents’ group. For a lot of the parents, they want practical information like, “How can I change my child’s gender identity marker; how can I change my child’s name; what’s the legal process?” A lot of that practical questioning happens in the parents’ group. Or they want to know, “What’s the process when my child gets prescribed hormones?” and sometimes they do talk just about their feelings.

It’s often hard to get the parents to talk about their feelings because they really like to focus on the practical stuff. That way, they don’t have to feel their feelings, and sometimes this support group coordinators probe with, “So let’s talk about how that makes you feel,” and that’s when we have to tease it out of them. Regardless, there’s space for all of it; it’s a really beautiful group. On any given month, we have like 60 parents that attend, along with about 15 grandparents. 25 teens, 16 tweens, 16 little kids. It’s a massive group of people who come together to seek support from each other.

Snyder: That openness seems like the social work approach of “meeting them where they’re at.” Sometimes all the kids need is just the opportunity to be themselves around other kids.

Some students are wondering about parental support and some of the technical aspects. What is the consent process like in order for kids to seek treatment? What about those kids that are faced with non-acceptance from family members? How can they get support?

Smith: That question brings up a lot of things that I feel like I want to lay out beforehand. The idea of a trans youth or child getting medical care for transition is not something that every single trans person seeks out. I feel that in American culture, there is this idea that if you’re trans, there’s one way to do it: you transition from one binary gender to the other; you use hormones and surgery, and then there’s an end you achieve. In reality, that’s not how it works.

The experience of being trans is different for every single person and not everybody chooses to do the same interventions. There are a bunch of different surgeries that folks can have to affirm their gender and not everyone chooses to have them. For young people who want hormones, hormones are prescribed by their doctors after great consideration and a lot of evaluation that shows that their gender dysphoria has been persistent and over a long period of time and consistent.

When you’re a tween, the first thing that can happen is being prescribed hormone blockers that block your natural puberty from happening. You do have to get the consent of at least one parent for that. When you are a teen, you may be prescribed either estrogen or testosterone depending on how you’re transitioning. You need a parent’s signature for that as well.

Surgical stuff is very different. The only surgery that is usually available to anyone under 18 to affirm their gender would be chest surgery. Very often, you have people who have breasts that want to remove their breasts via chest reconstruction, which we call top surgery. The youngest person we’ve had top surgery approved by insurance for was a 15-year-old. You can have top surgery when you’re under 18; you do need approval. Each surgeon has a different approval process, and most of the time, the surgeon will require at least one parent’s permission. Occasionally, a young person under 18 will get breast implants, but again, that depends on the surgeon’s consent process.

I wanted to address the kind of method that there’s one way to transition and that it’s available to all people regardless of age, because it’s not that simple. If we do have a young person (and I’ve run into this all the time in the juvenile justice system with you and with the young people we worked with together, Sean), a lot of them are trans youth that don’t have family support. If you’re a transgender person, and you really want to begin testosterone, and your family isn’t supporting you, or maybe you’re not even in contact with your family, or maybe you were in DHS, there are ways to address and bypass that. We’ve had success going to judges and getting a judge’s order for a young person to begin hormone therapy. Hormone therapy can be incredibly important to a trans person that wants it. It can really be a therapeutic intervention. It doesn’t just change your body, but if you’re somebody that has gender dysphoria, getting the hormones that affirm your gender can have a massive impact on your wellbeing, on your mental health, and on your quality of life. So, we would get a letter from the director of our gender clinic that says, “X young person has been prescribed testosterone. It’s our belief that it’s going to give them all these good outcomes, and it’s going to prevent certain negative mental health outcomes.” When the judge approves it, we can then prescribe the kid hormones.

Snyder: And I’m wondering, what about the kids that can be left out for whatever reason (family refusal for consent, lack of resources). Are there open support groups for kids that don’t require a parent’s consent?

Smith: There are, and it depends on where you live. In order to go to the groups that I run, you have to either be a patient of the CHOP gender clinic or of Mazzoni Pediatric Trans Care Clinic. For folks that aren’t familiar with Mazzoni, it’s the LGBTQ+ health center in Philadelphia for general LGBTQ+ wellness. It’s not just trans care, but they do trans care for adults and children. There are other places in the city that have support for trans youth, including the Attic Youth Center, which is an LGBTQ+ center for young people. A lot of the kids that go to the Attic are kids that don’t have family support, and they really form community and form intentional family with each other through the Attic. In Bucks County, PA, there’s a place called the Rainbow Room in Doylestown, PA, which is a great place for LGBTQ+ youth.

You kind of have to hear from word of mouth or from other people in the community about what’s out there. There’s also something called Mainline Youth Alliance, which is a queer kids organization on the mainline. There are resources, but this isn’t going to be the case if you’re a kid growing up in a rural area.

Snyder: Right, informal supports where available are very much connected by word of mouth. A lot of your responses have touched on engagement on a lot of different levels. One last area is the workplace.

One of the students asked about how you approach coworkers who have negative perceptions of gender dysphoria or gender non-conforming youth. How do you deal with those coworkers?

Smith: The lives and well-being of trans children are more important than the discomfort of a non-trans adult. If you’re not familiar with the terms cis-gender, it just means a person that is not trans, a person whose gender identity corresponds with the sex they were assigned at birth. Cis-gender people can be uncomfortable. It’s okay. I don’t worry about offending cis-gender people by being an advocate for transgender youth. I think that there might be some people that need science. And there is science that trans identities are valid. From anthropology, they have existed in the beginning of recorded human history. Currently, we have more language now, so folks can put words to their identities in 2020 in a way they couldn’t in 1920.

I would share with people that just because you don’t understand someone’s gender identity, it doesn’t make it any less valid or real. If a person is telling you they’re trans, they know themselves better than any person outside of them knows them. So, I know it can be a shock to some folks when a trans person comes out, but you can guarantee that the person that comes out has already thought long and hard about their gender identity. It is a real thing. It’s not somebody being confused. It has nothing to do with religion or morality. Advocating for the person who is trans is far more important than like the discomfort of a cis-gender person.

Snyder: Right, and, as you said, it’s probably ignorance with lack of information or lack of comfort. And we have to hold firm with our views as advocates for these youth.

References

Adelson, S. L. (2012). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. Journal of the American academy of child & adolescent psychiatry, 51(9), 957–974.
https://doi.org/10.1016/j.jaac.2012.07.004

American Academy of Child and Adolescent Psychiatry. (2018). Conversion Therapy. https://www.aacap.org/AACAP/Policy_Statements/2018/Conversion_Therapy.aspx

Austin, A., Papciak, R., & Lovins, L. (2022). Gender euphoria: A grounded theory exploration of experiencing gender affirmation. Psychology & sexuality, advance online publication. https://doi.org/10.1080/19419899.2022.20 49632

Dorn, L. D., & Susman, E. J. (2002). Puberty script: Assessment of physical development in boys and girls. Cincinnati, OH: Cincinnati Children’s Hospital Medical Center.

Ehrbar, R. D., & Gorton, R. N. (2011). Exploring provider treatment models in interpreting the Standards of Care. International journal of transgenderism, 12(4), 198–210. https://doi.org/10.1080/15532739.2010.544235

Ehrensaft, D. (2012). From gender identity disorder to gender identity creativity: True gender self child therapy. Journal of homosexuality, 59(3), 337–356.
https://doi.org/10.1080/00918369.2012.653303

Erickson-Schroth, L. (Ed.). (2022). Trans bodies, trans selves. (2nd ed.) Oxford University Press.

Forcier, M. M. & Haddad, E. (2013). Health care for gender variant or gender non-conforming children. Rhode Island medical journal, 7– 21.

Hill, A. K., Dawood, K., & Puts, D. A. (2012). Biological Foundations of Sexual Orientation. Handbook of Psychology and Sexual Orientation (pp. 55–68).
https://doi.org/10.1093/acprof:oso/9780199765218.003.0005

​​Herdt, G. (1996). Third Sex, Third Gender: Beyond Sexual Dimorphism in Culture and History. Cambridge, MA: MIT Press.

Hughes, I. A., Houk, C., Ahmed, S. F., Lee, P. A., LWPES Consensus Group, & ESPE Consensus Group. (2006). Consensus statement on management of intersex disorders. Archives of disease in childhood, 91, 554–563.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2082839

Jenkins, W. J. (2010). Can anyone tell me why I’m gay? What research suggests regarding the origins of sexual orientation. North American journal of psychology, 12, 279–296.

Leibowitz, S. F., & Telingator, C. (2012). Assessing gender identity concerns in children and adolescents: Evaluation, treatments, and outcomes. Current psychiatry reports, 14(2), 111–120. https://doi.org/10.1007/s11920-012-0259-x

Leibowitz, S., Chen, D., & Hidalgo, M. A. (2016). Gender dysphoria and nonconformity. In M. K. Dulcan (Ed.), Dulcan’s textbook of child and adolescent psychiatry (pp. 585–602). American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9781615370306.md28

Malpas, J. (2011). Between pink and blue: A multi-dimensional family approach to gender nonconforming children and their families. Family process, 50(4), 453–470. https://doi.org /10.1111/j.1545-5300.2011.01371.x

Menvielle, E. (2012). A comprehensive program for children with gender variant behaviors and gender identity disorders. Journal of homosexuality, 59(3), 357–368.  https://doi.org/10.1080/00918369.2012.653305

Nanda, S. (2014). Gender diversity: Crosscultural variations. Waveland Press.

Petersen, A. C., Crockett, L., Richards, M., & Boxer, A. (1988). A self-report measure of pubertal status: Reliability, validity, and initial norms. Journal of youth and adolescence, 17(2), 117–133. https://doi.org/10.1007/BF01537962

Shirtcliff, E. A., Dahl, R. E., & Pollak, S. D. (2009). Pubertal development: Correspondence between hormonal and physical development. Child development, 80(2), 327–337. https://doi.org/10.1111/j.1467-8624.2009.01263.x

Spielman, R., Jenkins, W., & Lovett, M. (2020). Psychology (2nd ed.). OpenStax.
https://openstax.org/books/psychology-2e/

Tanner, J. M. (1962). Growth at adolescence. (2nd ed.). Springfield, IL: Thomas.

Vance, S. R. & Ehrensaft, D. & Rosenthal, S.M. (2014). Psychological and medical care of gender nonconforming youth. Pediatrics, 134, 1184–1192

Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual health, 14(5), 404–411. https://doi.org/10.1071/SH17067