“When is a good time to start a medical transition? My 12-year-old had two suicide attempts in November and in January. He came out as trans and is now living as a boy, and his happiness has drastically gone up. I don’t know if it’s worth the risk of not being able to backpedal or the risk of nearly losing my baby again. He mentions wanting to start hormones and I just don’t know what to do. As recent as a year ago I had a pastel wearing girly girl, but I’ve always allowed my kids to be who they are and express themselves.”
Question Submitted Anonymously
Answered by Irwin Krieger, LCSW
I am sorry to hear about your child’s despair and so glad to know he is feeling better now. We often see a dramatic improvement in well-being once a young person affirms their transgender identity and is supported by family. I strongly recommend meeting with a psychotherapist who specializes in gender identity if you have not already done so. You can look at the “Find a Provider” tab on wpath.org (which stands for World Professional Association for Transgender Health) to find someone near you. A gender identity specialist working with your child will provide you with an additional measure of safety, and help you and your child arrive at a full understanding of his gender identity and helpful transition steps. As he has already made a social transition (living as a boy) and is happy in his affirmed gender, I understand why you are considering medical interventions.
In regards to starting hormones for a medical transition, there are a couple different paths to consider and understand, including puberty-blockers and cross-sex hormones. Puberty blockers provide relief for trans youth who are in distress about pubertal changes that don’t fit with who they know themselves to be. For example, youth who begin blockers prior to breast development are relieved of the need for top surgery (breast removal with male chest reconstruction) in the future if they continue on the path of gender transition. Even an interruption of breast development that has already begun can be helpful, since less intrusive surgical techniques are possible for those with smaller breasts. Blockers will also stop menstruation, which for some trans masculine youth is a painful monthly reminder of the discordance between body and gender identity. If the young person later decides that their innate biological puberty is the right one for them, blockers are stopped and their puberty proceeds as it would have, just delayed. The impact of these medications is considered fully reversible.
Cross-sex hormones, such as estrogen and testosterone, provide feminization or masculinization of the body in accordance with a teen’s affirmed gender identity, and prevent further changes in the direction that does not fit for the youth. These include irreversible changes, which some parents worry about, understandably, for someone so young. For that reason, your child’s therapist will refer you to a knowledgeable medical provider. You, your child, the therapist, and the medical provider will together come up with the treatment plan that is best for your child. Depending on your child’s level of pubertal development, hormone treatment may involve cross-sex hormones. But for many 12-year-olds who are ready to begin medical intervention for gender transition, their hormone treatment at first will be only puberty-blocking hormones, or puberty blockers in combination with low-dose cross-sex hormones. When low-dose cross-sex hormones are used, changes occur at a slow pace, allowing everyone time to assess whether going ahead with these changes is in the best interests of the child. Historically guidelines recommended waiting until the age of 16 to start cross-sex hormones. Sixteen is the age of consent in Holland, where puberty blockers were first used. Experienced practitioners are now moving toward individual assessment and timing for hormones.
You can find medical providers specializing in hormone treatment for gender transition at the ‘Find a Provider’ tab on wpath.org. You may want to schedule an appointment to get information about hormone treatment even before your child’s therapist is ready to make a referral. I discuss hormone treatments in more detail in my new book, Counseling Transgender and Non-Binary Youth.
With a history of two suicide attempts, it is especially important to be aware of any harassment or rejection that could lead to a resurgence of despair. Be alert to any negative responses your child is receiving from his friends and neighbors, from peers and adults at school, on social media, or from family members and family friends. Share any concerns you have with your child’s therapist. Be prepared to advocate for your child at school and with any disapproving family members. Act quickly to address any setbacks that occur. If you remain open-minded and supportive of your child’s gender exploration he is more likely to let you know about any difficulties he encounters.
People often wonder how someone can be sure he is a boy when a year ago he seemed to be living comfortably as a girl. Keep in mind that many transgender people try hard to fit in with their birth-assigned sex, since that seems to be what society expects of them. It is not uncommon to see a young person go from embracing being the girl or boy others expect them to be, to feeling despair because inside they know that’s not who they are, followed by expressing their authentic gender identity and feeling much better as a result. For parents this can seem to come “out of the blue,” making it difficult for many parents to fully accept their child’s affirmed gender. Take time to ask a lot of questions in a spirit of curiosity, without judgment. Ask him how his awareness and feelings have developed over the past few years, what his feelings about gender were when he was much younger, what his distress has been over this period of time, what he needs from you now, and what his hopes are for the future.
I would also like to recommend that you seek out support groups, both for you and your child. If there are no transgender youth and family support groups in your area, some online supports are available, as well as wonderful conferences for transgender youth and their families if you are able to travel. For information about these and many other supports see my webpage: www.HelpingYourTransgenderTeen.com.
Thanks to Jennifer Hastings, MD of the Center of Excellence for Transgender Health at UCSF for your help with the information on hormone treatments for transgender youth.
Irwin Krieger, LCSW, is a clinical social worker who provided psychotherapy in a private practice setting for LGBT individuals, couples and families for over 30 years. A graduate of Yale with an MSW from UConn, Irwin has worked extensively with transgender teens and adults and their families. He was a 2013 recipient of the New Haven Pride Center’s Dorothy Award for his service to the LGBT community in New Haven.
With the goal of expanding the base of knowledgeable providers for transgender individuals and their families, Irwin provides training for mental health and health care professionals, as well as school personnel. Irwin Krieger is the author of Helping Your Transgender Teen: A Guide for Parents and Counseling Transgender and Non-Binary Youth: The Essential Guide. For additional information see www.IKriegerTraining.com.