by Dr Stephen Stathis, Child and Adolescent Psychiatrist, Children’s Health Queensland
20 April 2017
Misunderstanding and confusion about being gender diverse or transgender remains one of the biggest challenges facing affected children and their families. It can prevent them from receiving the help, understanding and support they need as they grapple with complex issues of identity. And it can mean they don’t always feel confident and safe in their own body as they find their place in the world.
Having worked as a specialist supporting children and young people who do not conform to society’s expectations for boys and girls for many years, I have seen first-hand the harm, both mental and physical, that confusion and misinformation about gender dysphoria can cause. This can come from the young people’s personal views about gender, as well as those of their family, school, church and wider community.
Fortunately, I have also seen a positive change in attitudes which has resulted in improved support for children and adolescents who may have questions about their gender. But there is still a long way to go before a young boy or girl can openly share their concerns without fear of being judged, questioned or ridiculed.
Some of these children and teenagers are gender expansive which means their expression of gender (for example, through clothing, haircuts, toys and games) does not conform to society’s expectations of the gender they were assigned at birth. This non-conformity is also sometimes referred to as gender variant or gender diverse. Other young people are transgender, which is when someone’s gender identity (internal sense of being male or female) doesn’t match their gender assigned at birth. Neither are pathological or psychiatric conditions, but both may require specialist support.
We don’t have clear answers as to why some children are transgender or gender expansive while others are not but we believe it is likely a complex interplay of factors.
Part of my role as a child and adolescent psychiatrist is to increase understanding of the complex reasons why children and adolescents may experience gender diversity and the importance of providing a thoughtful and thorough assessment to those affected.
So, what is gender dysphoria? The children and young people I see describe and experience varying levels of distress associated with a deep internal, sense that the gender of their body does not fit with the gender they identify with. This distress can range from manageable to debilitating, causing problems with family, friends, school performance, as well as depression, anxiety, self-harm and, in the worst cases, suicide.
It is not ‘just a trend or a phase’. Gender dysphoria is a serious and persistent condition, psychiatrically distinguishable from other issues of gender-expansive expression or confusion, or sexual orientation that may normally occur during childhood or adolescence.
Let’s not forget that growing up is complicated and young people experience a wide array of internal and social pressures that may lead to confusion around sexuality and gender. Gender diversity is distinct from diverse sexuality, described by terms such as gay, lesbian, bisexual, or pansexual.
The reasons why children present with gender-variant behaviours and interests are often unclear and there is not a ‘one size fits all’ approach to treatment.
For example, on one end of the spectrum, there are adolescents who may question their gender and experiment with living as the opposite gender for a period of time. There are many complex social, emotional, environmental and behavioural reasons why this may occur. It’s important that these young people receive specialised assessment and treatment services which enable them to explore and resolve these issues.
Some children and their parents who initially present for a gender assessment may express concerns that any gender-diverse behaviour, such as boys wanting to play with dolls or girls being a ‘bit of a tomboy’, might mean they are transgender.
But by the time they reach puberty, about 75 per cent of children who are gender expansive will identify with their assigned gender at birth. For these children and their parents, appropriate assessment and treatment is needed to support them to continue living in the gender they were assigned at birth during this period.
At the other end of the spectrum, there are children who strongly identify with the opposite gender, either from a very young age or from when puberty began and they became intensely aware of the development of secondary sexual characteristics.
For example, parents will say that from the age of two or three their little boy never behaved as a boy or wanted to dress as a boy, that he wanted to be called a girl’s name, or even that he insisted on being referred to as ‘she’. Over time, some experience such distress that they resort to self-harm. I’ve also seen this response in adolescents, some of whom have never had the opportunity to express these feelings as a child.
In such cases, I sometimes recommend that these children live as their preferred gender (a process referred to as social transition). Many parents have reported that the mental anguish and distress their children experience quickly reduces after social transitioning, provided that the child has support from their family, school and other social networks.
In between the above examples, there is a wide variance in gender expansive behaviour. Some children say to me that they enjoy playing with toys, or wearing clothes, commonly associated with the opposite gender, but do not identify as that gender (e.g., boys who may enjoy playing with dolls and wearing skirts and dresses, but who still see themselves as male). Other children tell me that they deeply wish that they had been born the opposite gender, but have no desire to transition to that gender. Other children or adolescents say they do want to transition, but won’t do so because of current social circumstances (for example, they may be in the final years of high school).
The health risks associated with inadequate care and support for gender-diverse children are well documented. Furthermore, the lack of understanding and acceptance of gender-expansive people in our society leads to transphobia and individuals are at an increased risk of harm because of discrimination, social exclusion, bullying, physical assault and even homicide.
Gender-diverse children and adolescents also have increased rates of mental health issues if not treated early and in accordance with internationally recognised treatment guidelines.
Up to 40 per cent of children and up to 90 per cent of adolescents report symptoms of anxiety, depression, suicidal attempts and substance abuse. Deliberate self-harm to genitals can also occur. Adolescents also increasingly report that they resort to self-treatment with hormones (sometimes purchased online on black markets), which has potentially serious medical consequences.
There’s no question that gender diversity is a complex issue, often with no easy answer or immediate resolution. Positively, though, research tells us that that with the right support these kids can grow up to be transgender adults with the same or better health, social and educational outcomes as same-aged peers.
Ultimately, every gender-variant child is unique and deserves access to expert, comprehensive assessment and timely, appropriate treatment.
They also deserve respect and to be listened to and understood. It is only when this happens that they can get the support that will enable them to live a full and meaningful life as is everyone’s right.
From July 2017, a statewide public Gender Clinic will be begin at the Queensland Children’s Hospital, providing patients and their families with:
- access to mental health clinicians,
- a child and adolescent psychiatrist with expertise in the assessment of gender diversity, and a
- paediatric endocrinologist who is able to manage adolescents diagnosed with gender dysphoria who require medical treatment such as pubertal suppression and hormone replacement.
For more information about the Queensland Children’s Hospital Gender Clinic, email LCCHgender@health.qld.gov.au or phone 3069 7377.