Not a Parent’s Guide to Transgender Children

Not a Parent’s Guide to Transgender Children

I sprained my knee. That’s how I found out my 14-year-old daughter was struggling with her gender identity. I was combing the house for an ace wrap and found it in the dirty clothes basket in Karen’s room. It looked like it had been through a war. No elastic left. Karen had always been a tomboy. She wanted to mow the lawn, play with bugs, play sports…she was always moving and had zero interest in “girl stuff.” I took her to Claire’s in the mall a few times and she looked totally lost as I picked out headbands, earrings, and miscellaneous froufrou. I guess she was sending signals for years, but I wasn’t picking up the phone.

I don’t know how it dawned on me that she was binding her breasts. It just came to me and so I asked her, “Are you binding your breasts?” She started crying.

“I was born in the wrong body!” She said between racking sobs.

I’m ashamed to say it, but my first thought was, “Why me?” I took her to the pediatrician. She told me that this is just a phase. Karen is hanging out with the wrong people. Monitor her closely. Watch her friends. Ignore it and it will go away.

I was already pretty obsessive about who she hung out with. On play dates I would make sure I went in the house and met everyone involved. When I took her and her friends to the mall, I quizzed the friends about their home life and their grades. I thought I was doing everything right. Over the next year, our relationship deteriorated. I found marijuana, vape pens, bongs…she became a stranger to me. It was all yelling and grounding and taking the phone away. She didn’t do homework. She hated me. So much for the pediatrician’s advice.

I reached out to one of the pediatricians I had worked with and respected and asked him to recommend a doctor who worked with transgender teens. I made an appointment. Dr. Mitch spent an hour with Karen…without me in the room. When Karen came out of the appointment, a weight seemed to have lifted from her shoulders. Later, Karen told me the nurse had given her a shot to “make my period go away.”  I was beside myself. I called the office and demanded to speak with the doctor. My rights as a parent had been violated. How dare he give my child something without discussing it with me first. I wasn’t against the shot so much as being cut out of the decision.

Dr. Mitch called me back that afternoon and spent an hour on the phone with me. Can you imagine? An hour. He patiently discussed what Karen was going through and informed me that children over 12 can get birth control without parental consent. I had no idea. He explained that Karen had gender dysphoria: The constant feeling that her body was the wrong sex.  Karen had anxiety, anger, feelings of hopelessness, and diminished self-worth. My child was in pain. Thus, started my education in transgender children. I knew by now that it wasn’t a phase but, I have to admit, I was still hoping that it would go away.  My own feelings of self-worth had taken a hit, honestly. What kind of a parent was I? How could I let this happen?

WPATH (www.wpath.org) is the World Professional Association for Transgender Health and they write the standards of care for transgender health care. Dr. Mitch suggested I look over the information on the website and I did. It answered a lot of questions. Dr. Mitch assured me that there was nothing wrong with me and that Karen was always going to be my child. He suggested that if Karen wants to dress like a boy, it’s not permanent. He suggested I just back off and let her do what makes her comfortable. Of course, I was terrified that she would start taking hormones and have permanent changes that she would regret later. Dr. Mitch told me that Karen needs to live as a boy for a year and see a therapist every week to discuss her journey to make sure it’s the right thing. He wouldn’t prescribe hormones until Karen has been living as a boy for a year and his therapist signed off on the treatment.

Karen started seeing therapists who specialized in transgender teens. Insurance was a constant battle. The quality of the therapists was spotty. Karen, now Tony, was angry and impatient. He wanted testosterone now, now, now. He went to group meetings with other transgender teens and I think he saw how many of them struggled with no parental support. I remember seeing a young boy with long lanky hair and a defeated demeanor at a couple of his pizza party groups. I saw him, or her I should say, walking there and walking home. I really felt sad for this kid who wanted to be a girl so much. Tony told me the girl was grinding up DVDs and eating them because she heard the plastic works like estrogen. I really felt terrible for her. I determined that I was not going to be like her parents. However, I was not going to let Tony make any irrevocable decisions until we both were sure this was the way forward.

That year was a bit of a blur. Lots of appointments, Tony being angry. Kids and teachers at his school wouldn’t get with his name change and preferred pronoun. I blew it myself many times. I was so used to Karen, my daughter…not Tony my son. Problems at school came to a head and Tony pulled out of high school in favor of going to an alternative school. Things got better and worse, better and worse. I was at my wits’ end. All Tony wanted was to be seen by others as he saw himself, as a boy, not a girl. He bought some binders online and that worked, but they were uncomfortable and over time, left him bruised and misshapen. His girlish hips and curvy legs were problematic.

When he finally got the go ahead to start testosterone, he was so excited. Looking back, I think he thought that once he started hormone therapy, he would magically change into another person. It wasn’t like that. He still had problems with his old friends misgendering him. He still was behind in school. He still had all his old problems. That first year was the angry year. From my perspective, things got worse once he started testosterone. The doctor assured me that it wasn’t the hormones, it was just teenage angst. Tony went from twice a month dosing to once a week, halving the dose. I don’t know if that made things better or worse or didn’t do anything. I was scared, Tony was miserable.

Over that first year of testosterone, Tony gradually got more stable. I guess it was probably two years all in all before Tony got the body he wanted…or close enough that he can live with it. He’s 18 now and looks very boyish. He doesn’t bind his breasts anymore, but he does hunch his shoulders and tape his nipples flat when he goes out. We’ve discussed top surgery and I think the conclusion is that he can live with a small chest for now. There’s no talk of bottom surgery. I think Tony is finding a new middle ground between being a boy and being a girl. I tell him he doesn’t have to be binary, either/or. He can just be himself and I’m cool with whatever that self is. He is OK with being a boy with breasts. I know that given a choice he would choose not to have them. However, for now, the discomfort and risks of surgery are not worth the benefit.

Being a teenager is difficult in the best of circumstances. Tony is an adopted immigrant from Vietnam with a white single gay parent and born in the wrong body. Is it a surprise that his teen years were stormy? Not really. Tony worked all summer long at Chipotle and saved up his money. He bought his own car. He works two jobs. He’s smart and responsible. He’s good with money. He’s still afraid of school. He was tormented in high school and I think he has a lot of anxiety about going to college. I gently nudge him, but there is no hurry. He’s just about as perfect a person as I’ve ever seen. The trauma of those years of his transitioning is with us both, but gradually fading. I’d say he is a success story. He’s my son.

Understanding Patient Sexual Orientation, Gender Identity, and Expression (SOGIE)

Understanding Patient Sexual Orientation, Gender Identity, and Expression (SOGIE)

How often should a man get breast and cervical cancer screenings? Should a woman get screened for prostate cancer? The answer to these questions and more depends on knowing if your patient is transgender.

The Williams Institute estimated the transgender population in the United States to be 1.4 million in 2016. A recent study in Minnesota of 9th and 11th graders found nearly 3% of students identify as transgender or gender non-conforming. When it comes to health care, are we ready to meet these patients’ needs? Several cases where a transgender or gender expansive person was not properly identified or their provider simply was not aware of issues regarding transgender individuals have been in the news lately.

My county hospital is rolling out changes to our HIMS to try to capture this complete information on all of our patients, including transgender and gender expansive patients. These questions are called SOGIE, which stands for Sexual Orientation, Gender Identity, and Expression, and we ask them at intake:

  • What is the sex listed on your original birth certificate?
  • What is your gender identity?
  • What is your sexual orientation?
SOGIE

Source: Benny O’Hara, Office of LGBTQ Affairs, County of Santa Clara

Our initial goal is to capture 10% of our patient population with rolling increases as we move forward. In the hopes of meeting all of our patients’ needs we will ask these questions just one time over the patient’s lifetime. However, the patient can initiate changes at any time in the future.

Our LGBTQ patients can have health issues that are occult if we don’t have correct data. A female-to-male, or FTM, person with residual breast cancer did not know he needed breast cancer screenings. By the time it was diagnosed, the cancer was advanced. Another patient, male to female, or MTF, did not discover her prostate cancer until it metastasized to her bones.

What are the barriers to care for transgender patients? The first is the patient’s comfort with disclosing information about their sex assigned at birth and current gender identity. For a variety of reasons, transgender and gender expansive patients might not trust their caregiver or the health care system in general. A person who has transitioned has spent a great amount of personal capitol to live the life they need to live. It’s not a lifestyle change. It is the core of a person’s being.

A 16-year-old patient who has made the transition from female to male tells me, “I’m not transgender. I’m a boy.” He does not identify as transgender. Practitioners find this a common outlook in their transgender patients. Some transgender individuals may feel that they have always known their gender, and that it was society and other persons who incorrectly assigned or perpetuated a gender identity on their behalf – one that did not ring true for them.  Sharing of this information with a caregiver who is not familiar with the patient might not happen if the patient is not trusting or believes the information is not germane to the situation. For a primary care provider not in the know, this creates problems with preventative care with serious consequences. The SOGIE questions start a conversation that might not otherwise have occurred.

Another barrier is on our side of the street. Are we comfortable asking a patient if they are gay and/or transgender? While rolling out our new SOGIE questions, we find push back in unlikely places. Care providers and nurses at our in-service had these objections:

“My patients will be insulted.”

“Patients of some cultures will be offended if I ask that.”

“Some patients will not understand the difference between sexual orientation and gender identity.”

“This will take too much time.”

For some, a supposed patient objection is a mirror of their own feelings. “I would be offended if someone asked me if I’m gay.” For others, cultural taboos of their own might get in the way. Are we projecting our issues onto our patients? Personally, I’m excited to see my patients’ reactions to the questions and I look forward to educating them on the meaning of the terms. It’s a valuable tool to identify health care needs and an opportunity to destigmatize a subject that might seem uncomfortable.

You can’t tell if a patient is gay, straight, or anything else just by looking. The original birth certificate does not indicate the patient’s current sexual orientation. Often, a transgender person will legally change their birth certificate to reflect their correct gender identity. We just don’t know by looking at a person or their documents what gender identity or sexual orientation they are. Health issues can’t be addressed if we don’t know.

Annette Smith, a nurse at Santa Clara Valley Medical Center in San Jose with 35 years of experience, has insight into changes in practice like the new SOGIE questions: “At the beginning, there is a lot of push-back. ‘The sky is falling! The sky is falling!’ But after a while, the process becomes normalized and it’s not a big deal. We end up wondering what all the fuss was about!”

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