What Can You Do To Help My Transgender Child?

You are an elementary school counselor.  Towards the end of the school year, the parents of a 2nd grade student named Trevor ask to meet with you.  When you are in the cafeteria during some of the lunch periods, you have noticed that Trevor is always sitting amongst girls, never amongst the boys.  While you see him come to school wearing typical male attire (t-shirts, jeans), you often see him in the halls with barrettes or pink ribbons in his hair--his female friends give them to him during the school day to wear.  His teacher has remarked that Trevor often refers to himself as a "she." As you sit down with Trevor's parents, they tell you that at home, Trevor has been dressing as a girl for the last year-and-a-half.  They have been working with a child psychologist for several years who has diagnosed Trevor with Gender Identity Disorder.  As a team, Trevor, his parents, and the psychologist have decided that starting with the next school year, Trevor will be known as "Tammy," and that he will be attending school as a girl.  They want to know how you and the school can support Tammy and their family in this transition and help to insure that Tammy will be safe.  What is your response?

You are a high-school counselor.  One of your female students, Mirabela, has been out as gay since she was 14 years-old (she is now 16), and while it was a struggle at first, her family has come to accept her.  Mirabela has always dressed in traditional "male" clothing--concert t-shirts, baggy jeans, and steel-toed boots.  She has always had short, cropped hair and speaks with a low voice.  During one of your discussions with her, she states that she feels that she may not be gay so much as that she is really a boy, and wants to know what you would think about her changing her name to "Max" and having her teachers and the school community refer to her by that name.  She also wants to know what other things the school has in place to assist transgender students.  She has not yet discussed this with her parents.  What might be some ways that you would respond?

My guess is that these were probably not scenarios you had to answer on any of your exams as you were preparing to be a school counselor in your graduate programs, nor were these likely interview questions as you were searching for a job.  Yet, these could very well be situations that suddenly appear at your door.  The more time you spend learning about and considering the issue, as well as consulting with other personnel in your building and district, the better you will be able to step into action when the time comes.

The cover story on this Sunday's Washington Post was about a transgender child and the struggles that both he (the gender the child and family have chosen) and his family have gone through as he has journeyed from being a girl to a boy.  'Tyler' expressed early on that something had gone wrong in his mother's belly.  He told his parents that he was born a girl, but was meant to be a boy:


This is one of many stories that are springing up in families and schools around the country.  A few weeks ago, one of our are high-schools featured a transgender female student in their school newspaper, where she openly discussed the challenges of going to school as the opposite gender she was born into, and about some of the harassment she faced as a result.  It should be noted that as you go through this post, I will typically refer to the "gender a child was born into" when talking about the gender that matches the sex organs a child was born with.  I have done this in an attempt to simplify things.  There are some who might dispute this terminology stating that gender should only refer to the construct a child prefers and that "sex" should refer to the gender that matches the sex organs.  In doing this, I hope to have cleared versus muddied the waters.  Time will tell.

So, what is Gender Identity Disorder?  According to the DSM-IV-TR, the criteria for Gender Identity Disorder are:

• Strong and persistent cross-gender identification.  In children, this shows up as a repeated desire to be or a strong insistence that they are the opposite sex, strong preferences for dressing as the opposite gender, strong preferences for opposite gender roles in play, strong preferences for stereotypical games of the opposite gender, and a strong preference for playmates of the other sex. 
• Persistent discomfort with gender and strong belief that their gender is wrong, often with a focus on what is wrong with their bodies in the assigned gender.  
• It is not concurrent with a physical intersex condition.
• The issue causes significant distress or impairment in social, occupational, or other areas of the person's life. (APA, 2007)

This diagnosis is not without controversy.  As the Post article points out, there are those who feel that "disorder" should be replaced with "incongruence" due to the harsh connotation of the former.  (source: www.washingtonpost.com)  Some feel strongly that to pathologize gender identity is wrong when one is born with it.  There is also concern about over-using the diagnosis of GID for any child who shows gender-variant behaviors in order to justify the use of therapies that attempt to "repair" these behaviors.  However, as noted in the same article, without a diagnosis oftentimes they cannot receive treatments later in life, such as sexual reassignment surgeries.

As counselors, we know that identity and gender association and behaviors are ever evolving and changing things, both for children and adolescents but even with adults.  It is very normal for kids to experiment and try on different roles and activities.  Boys will play with dolls.  Girls will play with trucks.  There are those boys who feel more comfortable in the company of girls, and vice-versa.  I am not referring to those children.  What tends to separate normal experimentation and gender variance from transgender children is the pervasive belief and insistence that they were born "wrong" and that they want to be or are the opposite gender, to the point that it becomes extremely disruptive in the child's life and the life of the family.  Thus, this is a male child who doesn't just prefer to play with girls, they believe with every fiber of their being they are a girl and that somehow their body is wrong.  This is a female child who not only wants to ride motorbikes and play baseball with the neighborhood boys, they believe they are a boy and exhibit a great deal of anxiety and worry about what will happen when puberty begins.  This disruption tends to go on over a lengthy period of time, and there are usually many steps involved before a family decides to move forward with a diagnosis and a possible transition into the preferred gender of the child or adolescent.

But doesn't this just mean they are gay?  This is a pretty common question amongst adults.  There is a difference, though, between sexual orientation and gender identity.  Sexual orientation refers to sexual attraction, and while lesbian, gay, bisexual, and questioning children often have a feeling that there is something "different" about them their whole lives, it is not typically an identity that will manifest itself until adolescence--late elementary or middle school at the earliest.  Gender identity has nothing to do with sexual attraction.  Rather, it is about one's perception about their own gender--male or female, or anything in between along the continuum.  Further, the concept of gender manifests itself in children much earlier, oftentimes between the ages of 3 and 6 (source: www.washingtonpost.com).  It is important that we, as school counselors, know the differences between the two concepts of sexual orientation and gender identity.  A student who is transgender is not automatically "gay," and a student who is "gay" is not automatically "transgender."  A gay boy does not necessarily want to be a girl.  A biological female who identifies as a male is not necessarily homosexual.  Sexual orientation and gender identity are two different constructs.  In this video excerpt, you meet Hailey, a child identified as a transgender female:



So how does one treat gender identity disorder in children and adolescents?  You may be aware from the multitudes of television specials, news reports, and talk shows about adults who are often treated with transitions into the opposite gender and oftentimes sexual reassignment surgery.  However, the treatment of children is very different.  NPR did a 2-part story a few years ago that looked at the two major schools of thought with regards to treating transgender children.  In this first installment, we meet two families.  Bradley only wanted to play with girls, with girls' toys, and adored the color pink.  An altercation between Bradley and some of the boys in the school-yard took his parents to see a psychologist in Toronto.  Treatment for Bradley involved forbidding him to play with girls, with girls' toys, or to have anything with "feminine" colors such as pink.  All this in an effort to get him to conform to the gender that he was born with.  At the end of this section of the story, his mother voices some concerns that Bradley is living two lives--his true life where he plays with girls at school, and the life he has at home where he tells his family what he believes they want to hear from him.  The second part of the story follows Jona, originally born Jonah.  Her mother tells the story of how Jonah begged her to let him buy dresses when she was a toddler, and when she finally gave in, how much joy she had.  She never took them off.  Her parents took her to a therapist in California who encouraged them to let Jona be whatever gender she wanted to be at that time.  As the story goes on to tell, while the therapist did not often suggest to parents that children transition into their preferred gender, she did recommend it for Jona.  Jona began kindergarten as a girl and has flourished.  These stories illustrate the two main schools of thought amongst clinicians--either try to make the children conform to the gender they were born into, or allow them to explore their gender identity freely, with a small percentage of those children actually transition, either for a time or permanently, into the opposite gender.

As children get older, there are other modes of treatment.  As the Post article discusses, there are hormone blockers that can delay the onset of puberty.  This is further discussed in the second part of the NPR series.  Here we meet 'Violet,' a transgender female who is about to begin the hormone blockers, allowing her to avoid, at least for a time, the development of male characteristics such as a "larger hands and feet, a pronounced brow, and facial and body hair that will need to be removed." (source: www.npr.org).  This can allow children and families more time to determine if this will ultimately be a permanent choice for the child.  As the child matures, a decision does have to be made as to whether to suspend the hormone blockers and either develop into an adult as the gender they were born into, or whether to begin hormone treatments for the opposite gender.  As the NPR story listed above and this story discuss, if a child begins taking hormones of the opposite gender at the beginning of puberty, they can then more accurately develop into the opposite gender, and limit the amount and cost of surgeries in the future.  However, this will be irreversible, and will render the child sterile for life.  Thus, it is a huge step and a large decision for children and their families to make.  Yet, according to the doctor interviewed in the last story, it can offer children who are truly transgender quite a bit of peace of mind.

I offer all of this information not as an endorsement of one treatment over another.  All of the treatments mentioned above, from therapies that attempt to make the child comfortable with the gender they were born into to the hormones and hormone blockers can be controversial.  These are all decisions that the children, adolescents, and their respective families will be making, and every family, child, and situation is different. Yet, as school counselors, it is important to be aware of what all is out there, as you may be able to help connect the families and their various plans to the school staff.  You may have children who ultimately go the route of the various hormones and hormone blockers, but you are just as likely to have teenagers who are just beginning to grapple with their gender identity and who desire to be called a different name by their teachers and other staff.  Wherever that student is with their gender identity, according to this report from the Gay, Lesbian, and Straight Education Network (GLSEN):

• Nearly 1/2 of transgender students regularly skips school because of concern for their safety
• Nearly 15% of transgender students face harassment that is so severe that it forces them to leave school entirely
• Transgender students who face harassment have lower grade point averages than other students and are less likely to go to college
• Ultimately, transgendered adults who were harassed in school are at a higher risk for depression, suicide ideation, and STDs/HIV. (source: www.glsen.org)

Thus, if students are missing school and not performing as well as their peers, it becomes an academic concern, not just a personal/social issue.  As I discussed in another recent blog post, LGBT issues are not typically a part of training for school counselors.  Yet, as I also discussed in that blog post, it is an ethical mandate from the American School Counselor Association that school counselors have training and an understanding of the issues facing lesbian, gay, bisexual, and transgender students so that we can remove the barriers to their academic success.  So, where do you go from here?

• Do some soul searching.  How do you feel about transgender people and children?  One of the things that good school counseling graduate programs do is help you to confront your own personal biases and norms to determine if and how they may effect your work with students and clients.  Might your personal beliefs and values prevent you from fully assisting transgender students and their families, wherever they might be on the journey?  As counselors, we are tasked with helping others make decisions that are right for them, not necessarily to make the decisions that would be right for us.  Further, our professional mission is to remove any barriers to academic success to students--if making a transgender transition smoother and more nurturing allows that child to continue to do well academically, then, in my mind, we are fulfilling that mission.
• Take the temperature in your school and educate as needed--yourself included.  Unfortunately, even if we, as school counselors, are the most loving and supportive people in the world, children cannot stay with us all day long.  It is important to feel out how much support there would be in your building and in your district for a transgender student, and then to educate others and have conversations as you go along.  I like to think that for most people in education, there is a desire for children to do well and be successful, and that on this topic there is simply a lack of exposure and understanding.  If this is the case, then conversations and the sharing of facts with other school personnel will go a long way.  If, however, there are other school and district personnel who are resistant to even broaching this topic, it might be time to seek out some allies to do some professional development.  It is important for everyone to note that there could be legal ramifications for schools that do not support transgender students.  If school personnel condone and even engage in harassment, that could be an issue.  If schools enforce a different set of rules for transgender students than other students, that could be an issue.  Here in the DC metro area there has been a recent story of a Maryland teenager who identifies as a bisexual male and who was suspended for wearing a skirt to school.  The family asserts that his skirt was no less a dress code violation than the skirts of other girls.  The school states that it was too short. In a 2000 court case, Doe v Yunits, a middle school student won a case against a Massachusetts school district where she had been suspended repeatedly for wearing women's clothing because she was born a male but identified as female.
• Remain open to every individual situation.  Gender identity, like sexual orientation, moves along a continuum, and you can expect that one transgender student situation will not be like the next.  One student and family may be ready to transition into the opposite gender yesterday, while another may only be wanting a change of nickname in the classroom.  It is important to do a lot of listening to determine what a student and their family is looking for from you and from the school.  It may simply be that they want to know there is a resource in the school where they can go if they have further questions or feel they need to make an additional transition in the future.  It is important to let students know they have options, but to allow them to make the choice that is best for them.
• Know what you can do, and what you can't.  Official school records that include birth name and gender are more than likely out of your purview, as well as that of the school.  However, as the GLSEN Model Policy on Transgender and Gender-Non-Conforming Students discusses, students are typically allowed to go by whatever nickname they prefer.  You can ask teachers to label students with their preferred gender and use the preferred pronouns.  Students can be allowed to use designated faculty or clinic bathrooms.  Students can be given a neutral space to change for physical education classes.  Students can be allowed to wear clothing in their preferred gender, as long as it conforms to the dress-code policy for the entire student body and is enforced as such.  Some things may be more difficult--field trips that involve hotel stays, or athletic participation.  Always check into local and state policies and governing bodies for answers to more complex questions.  Chances are high that at this point, you will not be the first person to have asked.  It may be that you can work with your school and district on developing a set of policies with regards to transgender children, using the GLSEN policy above as a template.  Regardless, though, of whether it is in an official policy or not, as a counselor you want to develop a set of "best practices" that include many of the items that I just discussed (name, pronouns, bathrooms, changing facilities, etc.).
• Be honest with students and families.  If a family wants to begin a transition, it is going to be difficult in school, especially the older the child is.  We and the community can do a lot to support the child and family, but there will likely be some rocky moments with peers and situations as everyone becomes used to the new identity.  As with students who are contemplating sharing the fact that they are gay or lesbian, it is important to discuss both the possible positive and negative consequences to any plan.  Ultimately the decision is up to the child and their family, but it is best if everyone has gone through all the anticipated outcomes so that it can be an informed choice.  It is important for you to ask questions when you are unsure--what would the student like you to call them?  What pronoun would they prefer?  It is okay to admit you are not familiar with a specific situation or circumstance and ask them for more information.  Timing is also a consideration.  If you have a senior in high-school who is talking about transitioning two months before the end of school, it might be worth having a discussion about whether it might make more sense to wait until starting college. 
• Nothing should ever be done in a vacuum.  Always seek out support, whether from other school counselors, school personnel, online networks (like Twitter at #scchat), groups such as GLSEN, the National Center for Transgender Equality, Gender Spectrum, or other experts and clinicians in your area.  If the family has been working with someone, ask if you can have a release to speak to them to gather more information not only to help their child, but to further your education.  Check out any presentations or conference sessions on transgender children or transgender policy in schools.  There is a book that is recommended in the Washington Post article, The Transgender Child: A Handbook for Families and Professionals that could also give you some guidance. 

This is a complex and foreign topic for many, I understand.  However, it seems to be coming to the front more and more based on anecdotal experiences here in my area as well as in the national media.  Hopefully, through this post and the information contained within, you will be able to go back to the beginning, read the two scenarios, and have some ideas of how you might approach them should they ever happen to walk into your office someday.

The following work was cited within this post:
American Psychiatric Association.  (2007).  Diagnostic and Statistics Manual, 4th edition,Text Revision.  American Psychiatric Association: Washington, DC.