This piece was originally posted here, on The Jung Soul, the blog of Lisa Marchiano, LCSW. Lisa is a clinical social worker and Jungian analyst in private practice. She offers consultations to families of trans identified teens and young people looking to support their child without immediately rushing to permanent medical intervention.
Parents whose teens or tweens suddenly come to identify as transgender “out of the blue” without a significant history of gender dysphoria or even nonconformity have few places to turn. The professional response to gender dysphoria has not caught up with this new presentation, and parents are often told that they need to affirm their child’s self-diagnosis, and sometimes are encouraged to allow medical transition right away. In reality, there is a paucity of research about transition outcomes for young people. The trend to affirm and transition children and teens with rapid onset dysphoria is not supported by science at this time, however professionals are not offering much in the way of alternative treatment options. Having a teen with rapid onset gender dysphoria can feel like being lost without a map.
If a family feels that transition may not be right for their child, what can be done? Here are suggestions based on my work with parents of teens with rapid onset dysphoria. Please note that every family is different, and every child has individual needs. In the end, it is up to parents to decide if any of these suggestions feel right for them and their child, and to adapt these to their particular situation.
- Listen to your child, but share your concerns as well.
Arguing with your child or dismissing his concerns will likely only alienate him from you. Whatever the underlying cause of your child’s gender preoccupation, remember that these feelings are very important to him. Expressing genuine interest may be difficult when we are feeling anxious and upset, but it communicates caring and warmth, and lets our child know that he is safe with us. Asking questions about your child’s experience of dysphoria and listening attentively to the answers may also give you crucial information about what he is going through so that you can get him the help that he needs.
In addition, encouraging your child to talk about her dysphoria in an open-ended way may give her an opportunity to sort out some of her thoughts and feelings. The ideology of innate gender identity doesn’t make much sense of a lot of the time, and many young people seem to sense this and struggle with resolving cognitive dissonance inherent in believing, for example, that because you never liked dresses, you must in actuality be a boy. I have engaged with trans identified youth who have shared that they don’t have many places to take these doubts and questions, since the culture around gender identity online, in peer groups, and unfortunately in some therapeutic environments such as support groups requires strict adherence to the ideology. Just like dropping a pebble into a still lake, your thoughtful questions may have far-reaching ripples. “So what lets you know you are in fact a boy?” for example. Really listen to your child’s answer, and perhaps follow it up with another question if your child is amenable. Cultivate genuine curiosity. It is impossible to be judgmental and curious at the same time. Letting your child know that she can discuss these matters with you without fear of judgment is likely to be much more beneficial than a lecture.
On the other hand, don’t shy away from parsimoniously and calmly expressing your beliefs or concerns. Your child needs to hear your thoughts and worries. Side effects, sterilization, and the possibility of regret are all very real issues that she is likely not hearing about elsewhere. A teen may roll her eyes or protest when we share that we are worried about the health consequences of long-term testosterone use, for example, but kids usually hear us even when we think they aren’t listening.
- Express support for your child, though perhaps not for the identity.
No child should ever be shamed, rejected or punished for expressing an alternative identity. It is always appropriate to let children know that we love and support them. This does not have to mean affirming their self-diagnosis as transgender, and it certainly doesn’t mean that we must accept their desire to transition, either socially or medically.
If a child is particularly young, if the child seems to have begun experimenting with the idea of being transgender only very recently, or if you sense that the gender identity exploration is an unconscious attempt to avoid a developmental challenge or to otherwise manage stress or anxiety, it may be right to calmly and compassionately refuse to engage the possibility that the child is trans for the time being. I have seen it happen where parents intervened early on in a child’s gender exploration, communicating that a self-diagnosis of transgender would not be indulged. In quite a few of these cases, the child dropped the fascination with gender readily, and moved on to other interests.
Certainly, deciding not to engage a child’s gender exploration is not right in every case. There are some children who are genuinely suffering from acute dysphoria. There are others who are so invested in their own self-diagnosis that any lack of engagement may be experienced as unsupportive or rejecting. These are decisions that only parents, who know their child best, can intuit. However, parents need to hear that it might be okay to simply put a loving foot down without rancor, without making a big deal of it. No. We are not doing that in this house. You can wear your hair however you like. You can pick your own clothes. We want you to follow your interests. But we don’t accept that you are born in the wrong body.
Conversely, I am aware of numerous families who cautiously embraced a child’s self-diagnosis in an effort to be as supportive as possible. They responded to the announcement with openness, allowing changes of names or hairstyle, for example, without fully committing either to transition or to demanding that the child wait. Several of these parents regretted that they met the initial announcement with such tolerance and openness, as partial acceptance of the child’s self-diagnosis put them on a slippery slope, wherein the parents felt held hostage to the child’s continued demands.
Children recognize the great power they have over parents in a situation in which they announce they are transgender. No matter what our ideological beliefs in this area, we all want what is best for our children. Hearing our child declare that he or she is trans awakens anxiety and the fervent desire to respond in the right way. Our children sense this, of course, and it gives them a great deal of leverage. If they get the feeling that we will accede to their demands for accommodation out of fear for their safety and happiness, we can get into a pattern where the child has too much power.
Coming out as transgender is without question a provocative thing to do. Sometimes people do provocative things because they authentically need to do them. And sometimes they do provocative things for secondary gain, such as to signal distress about something else, or to avoid another problem. A parent’s job is to try to sense whether there is a genuine emergency, or whether the child is engaging in emotional flame throwing. In the latter case, a more neutral, matter-of-fact approach may help to de-escalate the situation. This might mean choosing to focus on gender and related topics as little as possible.
I have known families who have decided not to indulge a child’s desire to change names and pronouns. Other families feel that these are supportive concessions. Each family must chart the course that feels right for them. The goal is to avoid unnecessary power struggles while continuing to offer warmth and support. Teens that get caught up in this trend tend to get a lot of positive reinforcement from peers both online and in real-life. It is important that parents remain a place of acceptance and love.
- Express support for gender nonconformity.
Adolescence is a particularly difficult time for any child who doesn’t quite fit in. Lesbian, gay, bisexual, or even just gender nonconforming kids (“feminine” boys or “masculine” girls) often have it particularly rough. I have heard from several transgender adults that they might not have chosen to transition if they had faced less prejudice. Make sure your kid knows you support her no matter how she dresses or wears her hair, no matter whom she dates.
- Don’t be afraid to set limits.
Setting limits is a primary responsibility of parents. Teens are too young to be making major decisions on their own. It is age appropriate for teens to experiment and take risks. It is our job as parents to take measures where we can to ensure that these risks and experiments don’t carry long-term consequences.
Obviously, the ability to set limits will depend on the age of the child, and whether he or she is still living under your roof. For tweens and younger teens especially, don’t be afraid to limit screen use. Parents should feel empowered to set limits on inappropriate behavior. Tantrums, outbursts, physical or verbal aggression need not be tolerated without compassionate consequences. Teens who threaten or engage in self-harm ought to be treated for suicidality. Although any threat of suicide needs to be taken extremely seriously, using threats of suicide to demand parents accede to transition can be a form of emotional manipulation. Parents should make sure their child is safe and receiving appropriate treatment for their suicidal feelings while they continue to consider how best to approach the dysphoria. Parents ought not to be blackmailed into agreeing to transition by threats of self-harm.
It is okay to ask your dysphoric teen to continue to function at home and at school to the extent that they are able. Staying busy with chores, extracurriculars, and academics can remind a child that he or she is more than just a gender identity, and can be an alternative source of self-esteem and affirmation.
Remember that tweens and teens feel cared for and grateful when we set and enforce appropriate boundaries. Don’t expect them to admit this! They may scream and spew hate and vitriol. But we can withstand these outbursts better if we remind ourselves that some part of them is relieved that we are willing to do the hard work of limit setting in order to keep them safe and on track toward their futures.
- If possible, get both parents on the same page.
All parenting works best when both partners agree substantially and are enforcing the same rules. Having a trans identified teen can be divisive. Parents may disagree on what they believe about transgenderism, what they think is best for their child, and how to move forward in helping their child deal with dysphoria. If there are any pre-existing fault lines in a couple, having a trans identified teen may well exacerbate them. As with many things in parenting, consistency is key here. Outcomes are likely to be better if both parents agree on the plan and are enforcing it. While couples counseling could theoretically be helpful here, parents ought to screen carefully when selecting a clinician to make sure that the counselor will support the parents’ wishes as regards their child.
- Treat underlying mental health issues.
Appropriate treatment for depression and anxiety has completely resolved dysphoria in a number of cases of which I am aware. There is considerable research that points to a high rate of comorbidity in trans identifying teens. Conditions that may co-exist along with dysphoria include bipolar disorder, Aspergers or autism spectrum disorder, PTSD, anxiety, depression, as well as others. In most cases, the mental health diagnosis precedes the preoccupation with gender according to the literature. Although some in the pediatric transition business will insist that transition will address the other issues, there is no evidence that this is indeed the case. Even if transition does prove right for your child in the long run, it is much better to make that decision with a clear head, without confounding issues.
Unfortunately, therapists and psychiatrists engaged to treat these other issues will have to be carefully screened. Many will have imbibed the “born in the wrong body” narrative, and may see gender as the root cause of the other issues. Interview therapists beforehand and be prepared to do some education about alternative approaches to dysphoria.
- Limit internet use by filling their time with other activities.
If your child is under 18 and lives under your roof, you can use your parental authority to limit when, where, and how much time your child uses screens. There is a wealth of evidence that too much screen time negatively effects both academic performance as well as mental health among young people. If possible, get your child off the internet by engaging her in other activities. Take weekend trips as a family and leave the phones at home. Sign your child up for any activity that she enjoys. Don’t allow cell phones or computers in bedrooms. During summer break, make sure your child is occupied with employment or camp, preferably one that restricts technology.
Even teens still need their parents. Make an effort to stay connected with your child where you can. Spend time with her doing something that she enjoys. Plan fun activities as a family. The more time your child spends doing real things in the real world, the more chance that he or she will gain valuable perspective.
Trans identifying teens have often come to inhabit a small echo chamber of peers obsessed with gender. Like most teens, they lack the sense of where they fit in the larger world. The self-preoccupation of adolescence breeds myopia. Connecting kids with the wider world – through travel, employment, time in nature, time spent with relatives, extracurricular activities, etc. is a powerful corrective to the natural self-absorption of adolescence. A month or so in nature or on an overseas trip that dramatically widens their worldview can serve as a “hard reset,” reminding them of different facets of their personality they may have lost touch with.
- Is early transition ever appropriate?
In general, natal males who transition in late adolescence will have better cosmetic outcomes than those who wait. Transitioning in late adolescence may be right for some natal males. However, it must be said that we don’t yet understand transsexualism well. There are likely complex biological, social, and psychological factors that contribute to a desire to live as the opposite sex. Moreover, gender dysphoria is not the symptom of a single condition with only one root cause. While some natal males may have better outcomes from transitioning in late adolescence or young adulthood, I know of cases where young natal males who seemed to be good candidates for early transition later came to question this decision. At this point in time, there are no good diagnostic guidelines to help determine who will likely benefit from early transition, and who may not. Parents of natal males wishing to transition are urged to read as much evidence-based information as possible about transsexualism in natal males. A good place to start is “The Man Who Would Be Queen,” a lively, warm, and readable overview of current research.
Cosmetic outcomes for natal females who transition when they are older are not significantly impacted by waiting. The recent dramatic increase in teens and tweens coming out as trans without a prior history of significant prior dysphoria and/or nonconformity in childhood may be influenced by social contagion, especially among natal females. Psychologists have noted the potential for teen girls to engage in “co-rumination” about problems or concerns. According to a New York Times report, such co-rumination can “spin into a potentially contagious and unhealthy emotional angst.” It appears that a similar process may be going on in person as well as online friendships with teens exploring their gender identity.
We are seeing significant numbers of young people coming to identify as transgender after increased social media use and/or having members of their peer group self-identifying as trans. In recent years, there has been an unprecedented and unexplained rise in the number of natal females presenting as transgender. There is concern that identifying as transgender and transitioning by binding, taking hormones, or undergoing “top surgery” may be a the newest culturally mediated way that female adolescents are giving expression to and coping with the intense discomfort that most young women feel with their bodies.
The psychotherapeutic community has done a poor job of developing alternative treatments for gender dysphoria, but evidence suggests that there may be several effective approaches. Somatic therapies can lessen one’s discomfort in one’s body. Dialectical behavior therapy can teach affect regulation skills. Psychodynamic psychotherapy can explore the unconscious dynamics that underlie one’s feelings about one’s gender. Given the permanence of medical transition, the unknown nature of its long-term consequences for teens, and the possibility of a high incidence of regret, it is my belief that transition should be a last choice option after other treatments have been exhausted.
When choosing whether to let a teen transition, parents must make the difficult choice between possible psychological and social pain during adolescence, as opposed to potentially serious side effects of medical intervention and lifelong dependence on synthetic hormones. This is not an easy choice to weigh. If we decide to encourage them to wait until adulthood to transition, we may have to bear watching them experience pain. Each family must make their own decisions, and ought to receive support to make the choice that feels best to them based on their knowledge of their child.