03 Apr 2018
Transgender children and adolescents face many obstacles in today's society that others do not; however, these obstacles are socially constructed and can be mitigated, and in some cases even negated, when the child or teen is afforded an affirming environment and the appropriate social and medical interventions. These factors are crucial to the welfare of transgender children and ideally would be available to them as early in their lives as possible.
Kohlberg's Theory of Gender Constancy (as cited in Bernal & Coolhart, 2012) states that children begin developing their gender identity in their preschool years. It is therefore unsurprising that the World Professional Association for Transgender Health (WPATH), the organization that is responsible for drafting the standards of care by which all trans people are treated by medical and psychiatric professionals, has found that signs pointing to Gender Dysphoria have been observed in children as young as two years old (2012).
Gender Dysphoria, previously known as Gender Identity Disorder, is the state of feeling dissonance between one's gender assigned at birth and one's self-perceived or experienced gender. The number of children and youth who are being diagnosed and treated for this condition is growing, and according to Bernal & Coolhart (2012), research and treatment protocols are showing that early intervention is effective in improving the lives of these children.
In early childhood, one of the biggest decisions families will have to face is whether or not to allow their gender non-conforming child to begin socially transitioning into their preferred gender. In Kuvalanka, Weiner, and Mahan's (2014) study, in which five mothers of transgender girls between the ages of eight and eleven years old were interviewed, it was shown that all five of the children were happier, more outgoing, and had a more confident demeanor after being allowed to express their self-perceived gender. At the point in her social transition in which she was allowed to express herself as a girl at home but had to pretend to be a boy in public, Lilly, a nine year old at the time, was described by her teacher as being “very quiet and shy (p.363).” Her mother, however, reported that at home she was happy and vibrant (Kuvalanka et al., 2014). Ehrensaft (2012) explains Lilly's behavior at school as being what she calls the “false gender self,” that is, “the face a child puts on for the world [either consciously or subconsciously] based on the expectations of the external environment and the child's interpretations and internalizations of either appropriate or adaptive gender behaviors (p.342).” When the girls in the study were allowed to express their “true gender self,” the positive effects went even further than just changes in attitude; their mothers reported that the children's friendships and participation in school also improved (Kuvalanka et al., 2014). With the support of their families, these girls were able to go on to lead relatively normal childhoods.
However, many children maintain this false gender self for years, sometimes into adulthood, with no parental support and no outlet to express their true self. Parental support has been shown to be extremely important in the quality of life of transgender children and teens. Simons, Schrager, Clark, Belzer, and Olson's (2013) study on the effects of parental support on the mental health of transgender adolescents shows that parental support correlates positively with higher life satisfaction, lower perceived burden of being trans, and fewer depressive symptoms. The study surveyed transgender youth between the ages of 12 and 24, excluding those who had not yet decided to pursue hormone replacement therapy, on their quality of life and the level of parental support they were receiving (Simons et al., 2013). Their quality of life was measured as their life satisfaction and their perceived burden of being trans, and their level of parental support was determined using the family subscale of the Multidimensional Scale of Perceived Social Support (Simons et al., 2013). This includes questions such as, “I get the emotional help and support I need from my [parents]” and “I can talk about my problems with my [parents] (Zimet, Dahlem, Zimet, and Farley, 1988, p. 35).” It was also shown that greater depressive symptoms were associated with a greater perceived burden and that life satisfaction negatively correlated with perceived burden (Simons et al, 2013). What this study shows is that without parental support, transgender youth face a litany of hardships because of their gender identity that most children do not.
Parental support is even more important when we consider the fact that many of the necessary medical and therapeutic interventions transgender children and adolescents need become much more difficult, if not impossible, for them to attain without the resources and support of their parents. Arguably the most important of these, and undoubtedly the most difficult to obtain without parental support, is the medicine used to delay the effects of puberty, known as puberty blockers.
According to Bernal & Coolhart (2012), many transgender people describe puberty as “extremely distressing, as changes in their bodies feel like betrayals to their sense of self (p. 292). ” Puberty blockers allow the child to stall their natal puberty so that they can further explore their gender identity without fear of experiencing this potentially traumatic and permanently life-altering event. Even after being allowed to socially transition, one girl in the Kuvalanka et al. (2014) study, Nicole, experienced suicidal urges and was diagnosed with bipolar disorder when her natal puberty began; however, the diagnosis was removed after she began taking puberty blockers. According to her mother, Nicole is now “doing very well and her issues are only those of a normal middle school girl (Kuvalanka et al., 2014, p. 364).”
A study by Cohen-Kettenis, Schagen, Steensma, de Vries, and Delemarre-van de Waal (2011) that followed a transgender man from age 13 to age 35, who at the age of 13 had received puberty blockers, showed that puberty suppression can be a safe and effective treatment for transgender adolescents. They found that puberty blockers make certain gender affirming surgeries unnecessary, because many of them involve correcting the effects of natal puberty; they also made other surgeries less invasive, should the person decide they are necessary for them in the future (Cohen-Kettenis et al., 2011). According to Cohen-Kettenis et al. (2011), “unfavorable post operative outcomes seem to be associated with a late rather than an early start of gender reassignment (p.844).” One possible side effect, as noted by Bernal & Coolhart (2012) is that cognitive development may be delayed as long as puberty is being delayed, however Cohen-Kettenis et al. (2011) found that the puberty blockers can be stopped at any time and the adolescent's natal puberty, including their cognitive development, will commence.
The research presented shows that with family support and positive, early intervention, transgender children and adolescent's lives can be improved; however, there is a dearth of research on transgender people in general, and on children and adolescents in particular. That is why this paper will propose a study to be performed to learn more about this under served population.
Cohen Kettenis et al. (2011) showed that puberty blockers can be an effective intervention for transgender adolescents, but because their study was longitudinal and limited to one transgender man it was unable to make conclusions that could be generalized to the larger transgender population; also, it was unable to measure the effects of puberty blockers against a control group of transgender adolescents who are not receiving puberty blockers. Therefore, the question this research will be attempting to answer is this: How do puberty blockers affect the quality of life of transgender adolescents? The study will measure quality of life by the subjects reported life satisfaction (to include their satisfaction with their social lives) as well as their academic and/or professional achievement. The hypothesis of this study is that taking puberty blockers will positively correlate with higher quality of life.
Bernal, A. T., & Coolhart, D. (2012). Treatment and Ethical Considerations with Transgender Children and Youth in Family Therapy.Journal of Family Psychotherapy,23(4), 287-303.
Cohen-Kettenis, P. T., Schagen, S. E., Steensma, T. D., de Vries, A. L., & Delemarre-van de Waal, H. A. (2011). Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-year Follow-Up.Archives of sexual behavior,40(4), 843-847.
Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., ... & Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism,13(4), 165-232.
Ehrensaft, D. (2012). From Gender Identity Disorder to Gender Identity Creativity: True Gender Self Child Therapy.Journal of Homosexuality,59(3), 337-356.
Kuvalanka, K. A., Weiner, J. L., & Mahan, D. (2014). Child, Family, and Community Transformations: Findings from Interviews with Mothers of Transgender Girls.Journal of GLBT Family Studies,10(4), 354-379.
Simons, L., Schrager, S. M., Clark, L. F., Belzer, M., & Olson, J. (2013). Parental Support and Mental Health among Transgender Adolescents.Journal of Adolescent Health,53(6), 791-793.
Zimet, G. D., Dahlem, N. W., Zimet, S. G., & Farley, G. K. (1988). The Multidimensional Scale of Perceived Social Support.Journal of personality assessment,52(1), 30-41.
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