Jan. 15, 2020 -- For Michelle Fleisher, the confusion started in sixth or seventh grade.

“I wasn’t really sure what I was,” Fleisher says. “I knew I wasn’t a boy ... I felt really off-put by my own being. I knew trans people existed, but I knew almost nothing about them. I felt more like a monster than that.”

Now 17, Fleisher appears more feminine, though prefers to be referred to by the pronouns “they” and “them” that don’t denote a gender. They’ve taken hormones for about 2 years, and have reached a more comfortable place. Fleisher dreams of going to Yale University, near their Glastonbury, CT, home, and someday becoming a lawyer fighting for the rights of other trans people.

But it isn’t easy being a transgender teenager -- even for someone living in a state generally seen as progressive, at a time when the trans and gender-nonconforming population seems to be exploding.

Fleisher’s pediatrician told the teenager to find a new doctor. Before Fleisher started hormone therapy, family walks through their Glastonbury neighborhood were often disrupted by homophobic slurs. And even with super-understanding parents, Fleisher, 17, still had to educate them about what it means to be trans.

It also isn’t easy being the parent of a child or adolescent who decides that the gender they were assigned maybe even months before birth doesn’t match how they feel. Being identified by the wrong gender -- or even any gender at all -- can be upsetting for these young people, interpreted as being unseen or disrespected, and driving some to self-harm or worse.

Just over half the trans population has considered suicide, compared to 18% of female teens who didn’t question their gender and 10% of non-questioning males, according to the American Association of Pediatrics.

The number of transgender kids is rising. Roughly 1.8% of high school students now identify as trans -- almost twice the rate of adults. The biggest jump appears to be in teenagers born female who want to transition to males.

Changing social views certainly explains some of that number, experts say. Trans kids and those who don’t consider themselves one gender or the other, called nonbinary, used to grow up thinking they were the only ones in the world who felt the way they did. Today’s teens can easily track down others like them via the internet and learn about puberty blockers, hormones, and surgery before having the first discussion with their parents about their wishes.

Fleisher’s father, Adam, says that puts parents at least 2 years behind their transgender kids, in terms of understanding what it means to be transgender and in what ways people transition.

“As a parent, it’s really overwhelming and scary,” Adam says.

There’s a lot of information to process at first, he says, and it’s terrifying not knowing how strangers will react. Although some of Michelle’s caregivers have been fantastic, he says, their pediatrician told the family not to come back.

Michelle was regularly bullied at first; one boy who wouldn’t leave Michelle alone in school was eventually transferred. The threats and challenges can seem daunting at times, says Adam, who strongly suggests that both parents and trans kids find support groups of others going through similar challenges.

Agreement on Transitioning

Today, the medical community generally agrees that children who have not yet gone through puberty and feel they have been assigned the wrong gender should be allowed to socially transition: to call themselves by a different name, and choose their own pronouns and style of dress.

Tony Ferraiolo, a Connecticut-based trans youth advocate, author, and trainer, says there’s no question that children -- even very young children -- can know that the gender they were assigned at birth isn’t right. “Our bodies and our minds start forming gender identity around ages 3 to 5. Trans people aren’t different,” he says. “Trans children are not too young to know that they’re trans.”

He says when a child tells their parent that they are trans or nonbinary, the best thing the parent can do is love them unconditionally. “Please don’t hold them to your agenda,” says Ferraiolo, who began his own transition in 2004. “Just accept the fact that sometimes you have cis kids and sometimes you have a trans or nonbinary kid. Congratulations. I don’t know what else to say.”

As a child reaches puberty, decisions get harder. Some take puberty blockers to delay the choice.

There’s no reason to start hormones until the child begins to go through natural puberty, says Jeremi Carswell, MD, an endocrinologist and director of the Gender Multispecialty Service (GeMS) at Boston Children’s Hospital.

Around age 14, if the adolescent seems ready and -- typically -- if the parents agree, they can start taking testosterone or estrogen to promote one gender or the other. Decisions about surgery are put off until at least age 18 in most cases.

Sometimes it’s OK for parents to ask their kids to slow down, to help the adults understand what’s going on, why the child feels so strongly and what their options are, says Diane Ehrensaft, PhD, the director of mental health at the UCSF Benioff Children’s Hospital Child and Adolescent Gender Center Clinic.

With young kids, the situation is usually simpler, says Ehrensaft, a developmental and clinical psychologist. They often come to the parent saying not that they want to dress up like a child of the opposite sex, but that they are of the opposite sex, she says. After careful exploration, perhaps with the help of a trained gender specialist, it’s possible to find out if the child is expressing their gender identity or saying something else.

Teenagers are more complicated. “You want to make sure [transitioning] is not the solution to another life problem,” says Ehrensaft, author of The Gender Creative Child. “You want to make sure they have the emotional maturity to be able to step along that path.”

It can be a challenge for the teenager to figure out what they want -- and for adults to hear those desires, Ehrensaft says. “At any particular moment in time, they might not know who they are, or they might know full well, they’re just trying to get people to listen to them,” she says.

Different leading medical programs take slightly different approaches. Boston Children’s Hospital requires an extensive psychological evaluation before proceeding with any medical treatment. Programs like Ehrensaft’s in San Francisco place somewhat less emphasis on such evaluations.

Occasionally, there’s one parent who does not feel comfortable consenting to hormone therapy, says Carswell at Boston Children’s. “We will not precede when that happens,” she says. “You don’t want to drive a wedge in the family.” In cases like that, she says, with continued education and patience, the family member will generally give consent eventually. “Often it turns out just fine in the end.”

Most of the effects seen from hormone therapy are expected, such as breast development from estrogen and more body and facial hair from testosterone. These effects likely include longer-term issues such as higher rates of heart disease for those taking testosterone, although long-term data are sparse, Carswell says. According to one large 2018 study, risks of blood clots for trans females appears to be elevated, compared to biological females who identify as women, known as cis-females, although again more research is needed. Fertility remains possible, and there are several reports of transgender people using their own egg or sperm for procreation, she says.

Once the process of taking hormones begins, it’s rare but possible for the trans person to change their mind. Joshua Safer, an endocrinologist and executive director of the Center for Transgender Medicine and Surgery at Mount Sinai Health System in New York City, says he’s treated about 350 people with what he describes as gender-affirming hormones. He can think of only three people who have come to him saying they wanted to stop. None of the three had any regrets, he says, but they didn’t want more hormones -- either because the gender shift wasn’t helping or because they had mental health issues that complicated their situation. Because of the small numbers, not much is known about whether there are health consequences for people who change their minds after taking hormones, Safer says.

Not a Fad or a Stage

Although the vast majority of people don’t regret their decision to begin gender-affirming hormones, Safer says the challenge is that there’s no objective measure of who should take them and who shouldn’t.

“We don’t have a blood test and we don’t have a scan,” he says. “We’re very much depending on patient self-report in order to figure out what to do next.” The one thing gender affirmation is not, he says, is a fad or a stage that people pass through.

Each child who questions their assigned gender has to be treated individually, Carswell says. “Clearly one size does not fit all,” she says. Caregivers must hear their desires and take into account their  age, personal maturity, home environment, family concerns, and other challenges.

Adam Fleisher was able to do that. “This is my child. I love my child no matter what,” he says.

Fleisher teaches social studies to sixth and seventh graders in Hartford, CT, so he’s used to adolescent angst, phases, and lots and lots of hormones. He says he and his wife knew that something was up with their child, but they were still surprised when Michelle used words newly learned on the internet, like “gender dysphoria,” to explain that they weren’t a boy.

Michelle leans toward eventually getting surgery, which would make the gender change irreversible, but they haven’t made a final decision yet.

Adam says he’s OK with whatever his child decides to do. “I want Michelle to look in the mirror and be happy.”

Show Sources

Michelle Fleisher, Glastonbury, CT.

Pediatrics: “Transgender Adolescent Suicide Behavior.”

Adam Fleischer, Glastonbury, CT.

Tony Ferraiolo, trans youth advocate, Connecticut.

Jeremi Carswell, MD, endocrinologist and director, Gender Multispecialty Service (GeMS), Boston Children’s Hospital.

Diane Ehrensaft, PhD, director of mental health,  UCSF Benioff Children’s Hospital Child and Adolescent Gender Center Clinic, San Francisco.

Annals of Internal Medicine: “Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study.”

Joshua Safer, MD, endocrinologist, executive director, Center for Transgender Medicine and Surgery, Mount Sinai Health System, New York City.

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