Body and The Gender (Updated): I had to update this post because most of the media I tried to use got deleted so I made some changes to continue to reference the main points and add some additional information with DSM:
Gender and similar topics are just an overall sensitive subject. However, Gender Dysphoria (GD) is important because treatment can be somewhat drastic. Long story short, target the mood and with kids, target the mood and learning skills. Body and gender issues can exacerbate many other mental disorders such as anxiety and depression.
I will try to be fair but the culture has changed dramatically even within the last 5 years and sometimes it’s hard to decipher the fads, gimmicks, and trends, versus what’s real. This is my disclaimer about how some things I write could be wrong or harsh but I’m trying to be practical. We have to stay focused on the main problem, which is addressing the MOOD and possibly learning issues with kids.
…Let’s Start with Birth
The child is born with either XY or XX chromosomes. Maybe some have an extra chromosome, maybe others are missing a few, or the genotype is not the phenotype and the baby is just simply but adorably “different”. That’s it. Nothing more, nothing less. The baby is not born with a sexual preference, social constructs, or opinions. It just wants to sleep, eat, and be loved. The moral of this story is a person is not born with a “sexuality” and bursting with unicorns as opposed to amniotic fluids and parts.
Toddlers
The family still assumes the baby has no preferences, rightfully so because most toddlers are babbling and playing around until the sun goes down. However, since the toddler is a girl, she may play with dolls or if the child is a boy, he may play with trucks and dinosaurs. Could the male toddler pick up a doll or play with make-up and still be innocent? Yes! I get parents concerned about it, but I tell them to put the objects up that you don’t want them playing with and I guarantee that the child will forget about it the next day. Remember humans are a product of their environment, if they only have dolls to play with, then they are simply going to keep wanting to play with pretty things. It doesn’t mean that they want to be of a different biological gender.
School-Age (Before Puberty)
The mother reports “Jack” is getting older but has noticed that at home, he wants to wear a dress and play with dolls more often. The parents are questioning what to do and are getting worried. This is for most of my (before puberty) kids, I emphasize learning NOT sexuality. Kids this age want to be Spiderman, Cinderella, or whatever is cool and pretty. I tell parents, let’s continue to focus on EDUCATION/LEARNING.
I want the kid to continue to learn how to appropriately express themselves so that if they do get bullied (due to being different, for example) or anything else unfortunate, they can communicate their needs instead of shutting down or physically acting out. In other words, it’s hard to confirm a GD diagnosis when DSM-5 suggests the symptoms have to be significant and greater than 6 months but the child is NOT communicating well (the criteria is at the bottom).
We also don’t want to assume. The kid is still trying to understand the reality and doesn’t need more pressure to fit into these norms that may or may not really be an issue in the first place. What if the parents inquire about puberty blockers? Professionally I wouldn’t prescribe it and I’m personally against anything affecting one’s fertility. I try to explain to people that you cannot block those secondary sex hormones and no matter what you do, there is a DIFFERENCE and encourage therapy. Plus, before puberty, it’s easy for a child to be androgynous so we can’t give them this huge credit for looking like a male or a female, but I understand that others may not agree…
Here’s Another Disclaimer
I was following Jazz Jennings because of her inspirational personality and stumbled on this YouTuber, TT Exulansic (her account got banned but she still does media/interviews on other platforms). She has been doing analyses on gender surgeries and their complications. She’s quirky, sarcastic, and funny but truly the only person discussing the reality of these procedures and care that are normally not talked about or known.
Warning some of the videos can be triggering (people are despairing, breaking down, and using difficult language to describe their situations) but they are eye-opening! Anyway, TT Exulansic recently did a video about Jazz Jennings and I agree with her that I had to stop watching because the show was becoming heartbreaking: (video got banned)
I originally followed the Jazz series to learn about her journey but walked away feeling even stronger about not putting a child on any of these treatments. I’m truly worried if Jazz is dealing with major comorbidities and she’s only 21! I’m not sure if “puberty blockers” can stunt emotional and mental development as TT Exulansic videos suggested but I do know that having more ESTROGEN is HELL (like roid rage) and these treatments are mainly experimental. Be mindful that there are no long-term studies or statistics because most of these treatments are relatively new and many things like complications are unforeseen. Jazz reports a binge-eating disorder, which may be true but hormone/organ imbalances can also cause serious unanticipated damages.
School-Age (After Puberty)
Jack continues to want to be a female and changes her name to Jackie, and now the parents are concerned about bullying. The mother wants to know how to support her needs because the father is completely against the kid changing her gender. Again, I’m going to continue focusing on education and mood, I expressed to the mother that I can find some resources and maybe some support groups but I can’t make any promises due to the pandemic.
Basically, in community mental health, nothing specialized is guaranteed, and be mindful that most people don’t have the $$$$ or resources like Jazz so even referring may be difficult…Honestly, most families are just trying to survive and are usually not aware of how costly these treatments are because they’re not aware that it’s NOT a quick fix. However, Jack’s mother called the following week and said he no longer wanted to change his gender and is now thriving and doing better in school.
I’ve had several teenage patients who would literally change their minds about their gender and name within weeks or would affirm different genders just to go back to the biological gender. In general, frequently changing the name/gender is a red flag that’s like attention-seeking versus wanting to change science. However, if the person didn’t change their mind, I would speak with the patient ALONE to truly assess these emotions.
Changing your gender does require more of an assessment because the treatment may be permanent or irreversible. I myself as a psych provider, am not assessing if they should get a sex change, because that should truly be done with a gender specialist. I’m assessing additional thoughts, issues, or risks. Also note how some “specialists” may influence a person to change their gender, regardless if it’s not in the patient’s best interest.
The lady from YouTube goes VERY in-depth with these videos and I also mentioned her because her account may very well get disabled lol. She does have a backup channel (also deleted). YouTube is not tolerating too much of anything…
Full Adults
So you have a transgender male or female in your office. We are unsure if they had any gender-affirming procedures (because some trans populations do not believe in getting top/bottom surgery to change gender) but in general, we still have to ask about any surgical history. Transgender females may have complications or other surgeries that can affect their mental/physical health. There are transgender males, who can still get pregnant, have kids, menopausing, get hysterectomies, or have many other hormones or body issues.
Child-bearing/females with menses still need a pregnancy test for surgical procedures, before starting certain medications, and we don’t want to change the standard of practice (or be held liable) if a fetus is involved. There are certain risks and considerations with treatment that are just based on your gender or if there’s a pregnancy. However, if you keep things respectful the patient should truly know, that the provider is simply trying to avoid further difficulties.
In Conclusion with Kids
Regardless, of the patient’s sexuality, I try to remain objective with their mental health and with kids, focusing on their mood and learning. I want the child to be able to communicate as much as possible because sometimes peculiar behaviors will occur as a form of getting attention.
If a child continues to have an obsession with certain things that aren’t normal and in general, providers always have to r/o abuse. This is another reason why I want the child to communicate and may ask the parents if I can talk to them alone.
Be careful with the questioning and not feeding the answers e.g. Is it okay if a little boy wants to play in a dress, right? No. Asked them very open-ended questions and then narrowed them down if there was anything unusual.
This can be time-consuming and the provider may not have time for all this, but depending on the seriousness, I will prioritize. This is where it gets political and controversial, you may have to advocate against puberty blockers or the parent’s wishes. I don’t want to put this in a Munchausen syndrome category but truly assess the intentions. However, children changing their gender is overall rare and another reason why it should be prioritized. The family should at least know the care and the demands of trans-treatments are VERY costly with MAJOR permanent physical and psychological side-effects and risks.
In Jazz’s case, some people believe that the motives are financial but her family although FAR from perfect, it seemed like they wanted to give her the best support. I do think some people exploit their children on YouTube/television but Jazz sincerely looked happy before her mental health, the surgeries, and weight became more difficult, especially after puberty… In Munchausen Syndrome, the kid usually doesn’t look or appear happy or healthy due to the abuse.
Some parents assume doing whatever a kid wants them to do, will make things better, when it actually shows a lack of insight and coping skills. Blurring the parental/family boundaries, which is clear in Jazz’s case, will exacerbate psych symptoms.
Plus, it’s technically NEVER fair to let a child make major life decisions. It’s why drinking, gambling, video content, voting, etc. have age restrictions. Thus, medical and mental treatment/procedures on minors deserve a more rigorous evaluation.
Final Words
In general, try to promote mental stability as often as possible and if you have to schedule another appointment the following week just to speak with the child alone, then please do it! Many children have poor role models, emotional trauma may be involved, society is falling apart, difficult upbringings, and the provider may be the only sensible person in the child’s life. If the family and everyone want to proceed, definitely consider referring to a specialist or encourage the family to get a second opinion, mainly due to the side effects and the demands of care.
Lastly, this lady, Samantha Lux is beautiful! and I wanted to show an example of how you don’t have to put a young kid on puberty blockers, to have great results as an adult …although she’s dealing with a separate difficult issue with her Adam’s apple (video also got deleted). The difference here and with Jazz is that you can tell that Samantha has more maturity and a better ability to cope and she’s only a few years older than Jazz. I’m also mindful that people would still wish to start the treatment of changing their gender earlier regardless of the risks…
DSM-5 Criteria
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides for one overarching diagnosis of gender dysphoria with separate specific criteria for children for adolescents and adults.
The DSM-5 defines gender dysphoria in adolescents and adults as a marked incongruence between one’s experienced/expressed gender and their assigned gender, lasting at least 6 months, as manifested by at least two of the following:
- A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics)
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
- A strong desire for the primary and/or secondary sex characteristics of the other gender
- A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
- A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
- A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)
In order to meet the criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Time to Rant,
Dear psych providers look at the criteria for gender dysmorphia, it’s NOT good! Again DSM is vague and subjective, in which many people think they can just do a DSM checklist or go to Google and diagnose themselves. Also, note how DSM doesn’t define gender when some people don’t even believe in that anymore or want to be non-binary.
As I usually mention, DSM needs some form of objectivity but since they refuse, we have to come up with our own measures, which should include literacy, what’s age-appropriate, and clear exclusion factors like you can’t just be another race or turn into an animal. If the child is struggling to read/write or academically -advocate for the parents to mainly focus on learning.
The child/adolescent and gender-process changes are very demanding and the child (or a person) honestly has to factor in being more alone and isolated due to the treatment/therapy. I believe Jazz mentioned that she has to take >10 pills a day just for her mental health and hormone therapy. So I’ll be honest, even I wasn’t aware of these processes i.e. using a vaginal dilator, grafting the arm to form a penis, or using pieces of the mouth to form a urethra?!? because there’s truly no standard of care for this… I’m soo disappointed that YouTube took TT Exulansic videos down, you can’t find this stuff in textbooks, and there are no studies or evidence-based practice (bc most of the treatment is new/rare/horrific). And most people are overall are against experimenting on kids, thus no real experts.
I understand various success stories but no study has confirmed how these gender changes at such a young age, have decreased the chances of SI. If anything it can make it worse due to the lack of coping skills and learning abilities (which also means it will be difficult to obtain gainful employment/progress in life). I also don’t want to hear how surgeons were able to recreate the body part because people already have this notion that doctors are really just profit-driven and don’t care about the after-effects/complications.
One of the reasons why I’m mentioning all of this is because we (psych providers) have to advocate for our profession. The general population already thinks mental health is a joke, taboo, and it’s usually stigmatized… We need to show the public that there are some objectivity and measures instead of just winging it and hoping for the best.
To the gender specialists and people who want to go in that direction, please keep the same energy if not more with making sure the child is comprehending and functioning well at the appropriate age. The pandemic has made many kids horribly BEHIND educationally. Most of my patients who have transitioned or had gender issues usually have a hx of emotional/sexual trauma, which causes learning delays as well. I inherited a few trans teenagers and they’re doing better but you can tell that they’re not performing as well as their peers despite receiving gender treatment.
There’s nothing we can do about teenagers because they’ll continue to do whatever they want, but the main purpose of my rant is this is why you want a small child to thrive as much as possible. You don’t want to start experimenting or risk making the mood and behaviors worse by SOLEY focusing on gender. Clearly, DSM only partially understands…
