Monique (The patient’s name has been changed for privacy purposes.) is an African-American 16-year-old youth from a small city in Southern California who lives with her foster parents. She was referred to a community-based mental health provider because of significant depression and anxiety. In working with her, the therapist discovers that gender worries are at the core of her psychiatric distress.

Assigned male at birth, Monique has felt for several years that she is not male, but female. The therapist, recognizing that she has not been trained as a gender specialist, continues to treat Monique but makes a referral to a specialized gender clinic, where Monique gains access to a clinician who can better understand her core gender issues in the context of her other psychological symptoms.

The young woman in the case was referred to our clinic, the University of California San Francisco Benioff Children’s Hospital Child and Adolescent Gender Center Clinic, an interdisciplinary program serving the needs of gender-nonconforming children since 2011. Similar clinics are opening across the country. Why the proliferation of these programs within the past decade? Because there has been a need for them. More and more children are expressing to their parents questions, worries, or declarations about their gender. At our clinic, we are referred approximately 20 new patients per month.

Approach to assessment and diagnosis

Our experience is that medical, mental health, educational, and legal expertise all contribute to optimal care of gender patients. Gender clinics typically use a team approach; patients are cared for by a large interdisciplinary team that includes psychologists, psychiatrists, social workers, pediatricians, pediatric endocrinologists, nurse practitioners, educational specialists, and legal advisors.

Let us circle back to Monique. If the gender clinic provider had gone into the assessment equipped only with teaching received in medical or graduate school about gender development, she might have walked out of the session with deep concerns about Monique’s mental health. Monique told the provider that, although born a boy, she knew from the time she was 1 year old that “boy” did not feel right. By the time she was 3, she, then a child named Samuel, was borrowing her sister’s toys and clothes. By seventh grade, she could no longer live as a boy and announced that she was a girl. She had identified as a girl ever since—not as a transgender girl, but as just a girl. She was sure she had never been male; she had a body with a penis but had a girl self.

The mental health provider’s early training might have suggested that Monique was delusional, that she had failed to receive the gender socialization that would have allowed her to accept her boy body and her male sex ­assignment, and that the traumas and attachment disruptions in her early life had set her askew in her—or rather, his—normative gender development.

Instead, the assessment uncovered the following: Monique had a very early history of female gender identification; it had never wavered; it went far beyond just wanting to do girl things and extended to the very core of her being. Corroborated by her foster parents’ report, she had not said, “I want to be a girl” but rather, “I am a girl”—this certainty is one of the signifiers that differentiates transgender children from children who are simply exploring their gender identity. From an early age, Monique had been distressed about having a penis (another signifier). Puberty was highly stressful for her, if not traumatic, as her body betrayed her by sprouting male secondary sex characteristics.

The mental health team member’s retraining as a gender specialist assured her that there was nothing delusional about Monique. She suffered from gender stress, distress, and dysphoria. More importantly, she met all the criteria indicating that she was a transgender girl, including the signifiers listed above and a persistent, consistent, and insistent declaration of her female gender identity from an early age. The cure for Monique’s gender stress (a stress that met all the requirements for a DSM-5 diagnosis of gender dysphoria), along with treatment for her generalized anxiety, was to facilitate her full transition to her eloquently articulated and authentic gender self—and that would be a female self.

Given all the information about Monique’s history and a letter of support from her current therapist—a requirement of the clinic before a youth can be approved for any kind of medical treatment in gender care—the mental health provider recommends that Monique would benefit from receiving estrogen at this time to better align her body with her psyche.

The gender-affirmative model

In order to improve our understanding of transgender issues, the NIH funded a four-site longitudinal study of the physical and mental health effects of puberty blockers and cross-sex hormones. One concrete product of that collaborative effort has been to outline the parameters of the gender-affirmative model, which informs best practices for serving these nonconforming children and adolescents (Hidalgo MA et al, Human Development 2013;56(5):285–290).

Using the gender-affirmative model (see accompanying list on page 8), we define gender health as a youth’s opportunity to live in the gender that feels most real and/or comfortable; or, alternatively, a youth’s ability to express gender with freedom from restriction, aspersion, or rejection. To that end, interdisciplinary treatment goals are as follows: 1) facilitating an authentic gender self, 2) alleviating gender stress or distress, 3) building gender resilience, and 4) securing social supports (Ehrensaft D. The Gender Creative Child. New York, NY: The Experiment; 2016). We also recognize that to think clinically is to first think developmentally. For example, at age 4, the child exploring gender is in the stage of magical thinking where frogs can become princes (or princesses) and old genitals can be easily traded for new ones at the pharmacy. This situation is very different than the teenage patient who is in the throes of identity ­consolidation vs. confusion, and who now has gender as one more aspect of identity to negotiate.

Treatment

When it comes to treatment, a single guiding light pertains: Discovering a child’s authentic gender is not for us to say but for the child to tell. The major challenge is to decipher what the child is showing us in word, affect, and action about two aspects of gender: gender identity and gender expression. Gender identity is quite basic: Who am I—male, female, or other? Gender expression refers to how I present my gender to the world—the toys I like to play with, the children I like to have as friends, the activities I like to do, the clothes I like to wear, and so forth. This is not to be confused with a child’s sexual development, which is a separate although sometimes criss-crossing developmental track—a confusion that typically takes the form of, “He likes to wear makeup and jewelry, so he’s going to be gay.” That may be true, but there are other potential meanings of that behavior. He may be trying to communicate that he is not the boy we think he is, and that he is in fact a girl who likes makeup and jewelry. Or, he may be a boy who simply likes jewelry and makeup, period. Nature, nurture, and culture all come together to create the core of the child’s authentic gender self. We must keep all this in mind as we sharpen our translation skills to better understand the messages children deliver to us about their gender.

How can we as clinicians better understand and treat these gender-nonconforming children? In general, the clinical tools needed are no different from the ones we learned to use with any child: listening, mirroring, play, interpretation, suspension in a state of not knowing, monitoring our countertransference feelings, applying cultural sensitivity, and collaborating with parents and other professionals. But two of those tools, mirroring and suspension in a state of not knowing, have proven to be the most critical in this population. Mirroring helps because the greatest assault on a gender-nonconforming child’s psyche is the distorted gender image reflected back to the child based on the other person’s perceptions, needs, or beliefs rather than the child’s inner knowing of the self. Suspension in a state of not knowing is important because it shows the child that you are not being judgmental, and that you are willing to let the child take the lead as you help in understanding the child’s gender identity.

Basic Premises of the Gender-Affirmative Model

1. Gender variations are not disorders


2. Gender presentations are diverse and varied across cultures, requiring cultural sensitivity


3. Gender involves an interweaving, over time, of biology; development and socialization; and culture and context


4. Gender may be fluid; it is not always binary


5. If present, individual psychological/psychiatric problems are more often than not secondary to negative interpersonal and cultural reactions to a child


6. Gender pathology lies more in the culture than in the child

CCPR Verdict: Whether you are a general practitioner or a gender specialist, your gender-nonconforming child or adolescent patient will rely on you to use the two primary skills well—mirroring and the ability to remain suspended in a state of not knowing. If you do, you will find a child blossoming in gender discoveries, protected from the risks of anxiety, depression, self-harm, and suicidality that might develop in the absence of robust gender supports (Grossman AH and D’Augelli AR, Suicide and Life Threatening Behavior 2007;37(5):527–537; Roberts AL et al, Pediatrics 2012;129(3):410–417). Isn’t that what we would want for all our patients?