Every kid is different and thus has different needs. Some kids want to run around outside all day; others want to sit indoors with a book. Some have an easy time making lots of friends; others struggle. Some kids are entirely comfortable with the gender they were assigned at birth, and others don't conform quite so neatly to expectations.
Parenting any kid is a challenge. But one challenge parents of gender-non-conforming kids — that is, those whose gender expression is different from conventional expectations of masculinity and femininity — face is that it can be hard to get good information about the sort of support their kids need. (Not all gender-non-conforming people identify as transgender — a term that describes people whose gender identity or gender expression differs from what's typically associated with the gender they were assigned at birth — and vice versa, according to GLAAD.) A Google search on care for gender-non-conforming or transgender kids turns up a lot of misinformation, including about what good support for trans kids really looks like.
Live Science spoke with pediatricians who responsibly affirm and support gender-non-conforming and trans kids about the facts and myths of medical care for these young individuals. They answered questions about what parents can do to support their gender-non-conforming children and how they can ensure their children receive the best possible care. [25 Scientific Tips for Raising Happy (& Healthy) Kids]
The first step is always a conversation, led by the patient.
Dr. Daniel Summers, a Boston-area general-practice pediatrician, said he makes an effort to understand his young patients' gender expression on their terms — particularly when they tell him that they're not comfortable with the gender they were assigned at birth or that they belong to a different gender.
"I find out: 'Well, what does that mean to you?'" he said. "'Does that mean that this is how you've been able to live? Is this how you're wanting to live? Is this something you've been able to tell other people about?'"
Summers and two other pediatricians told Live Science that their goal is never to encourage patients to express a particular identity. Rather, he tries to create a space where they're comfortable frankly discussing their own feelings on the matter.
Dr. Andrew Cronyn, a pediatrician in Tucson, Arizona, who has seen more than 70 gender-non-conforming patients as a routine part of his general practice, said some kids state a clear gender preference from a very young age.
"For some of these kids," he said, "it means that when they were 3 years old, they started asking their parents questions like, 'When am I going to grow a penis? Why do I have to wear these boy clothes all the time? Why can't I wear a dress? I'm not a boy. I'm a girl.'"
Other kids' gender expressions are more ambiguous, he said.
Dr. Olivia Danforth — who sees young patients in Corvallis, Oregon, and helps run a clinic for trans adults — said that, in those cases, her role is to provide parents and kids with information, reassure them that their situation is normal and let them know about resources they can access if the kids' gender identities become a source of distress.
Cronyn said he often connects parents with local support groups and summer camps for families with gender-non-conforming kids.
The goal there, he said, is "giving people a chance to meet these other families. And sometimes, they will go … then talk to their kid, and they'll realize that this isn't really the route they're on — it's a little boy who wants to wear nail polish, but he's not transgender," Cronyn said. "And he's perfectly happy with his body and his gender right now."
But sometimes, he said, a child will express that they do want to transition — meaning to affirm publicly the gender they know themselves to belong to. The best thing parents and healthcare providers can do for those kids, he said, is to follow their lead.
Kids, not doctors, lead the way when they transition.
The first step in transitioning, Cronyn said, isn't medical. It's social.
That's especially true in kids who haven't yet entered puberty and whose bodies don't yet bear many obvious markers of sex, he said. Kids will let their friends at school, teachers and wider families know about their genders. That can often involve taking a new name, and it almost always involves letting people know the correct pronouns to use with them.
Often, kids who transition will also make changes to the way they dress to clearly mark their genders — though Danforth said it's important to understand that (just like their cisgender, or non-transgender, peers) not all trans kids will want to dress in ways stereotypical of their genders. [Why Is Pink Associated with Girls and Blue with Boys?]
Cronyn said he often sees a difference between how trans boys and trans girls handle transitions.
"Some of the boys will immediately socially transition," he said. "They will cut their hair short, wear boy clothes. They might wear binders; they might wear a packer."
Girls can be a little more cautious, he said. "A lot of times, they realize the safety issues related to someone seen as masculine presenting as a woman," Cronyn said.
Trans girls in his practice often take the process of coming out more slowly, he said, but they tend to be just as consistent in their intent to transition as trans boys are. The most important thing parents, family and friends can do when a child socially transitions, Danforth said, is to respect and affirm the gender that the child expresses.
Prepubescent kids don't take hormones, and minors never get genital surgery.
A lot of scaremongering about health care for trans kids falsely suggests that doctors push kids into making permanent changes to their bodies. Every pediatrician who spoke with Live Science for this story emphasized that this isn't true and that they don't know of any doctors who would do that.
Kids who haven't yet reached the stage of puberty in which physical changes begin don't receive medication of any kind, Cronyn said. For kids who want them, those treatments don't begin until puberty begins in earnest. And the first stage of treatment isn't hormones. Instead, doctors prescribe kids puberty blockers, which can safely put those changes on "pause." That's the standard of care endorsed by both the Pediatric Endocrine Society (PES) and the World Professional Association for Transgender Health (WPATH). (A representative for the American Academy of Pediatrics told Live Science that it has an official policy statement on the subject in the works, which it will publish later this year.)
There is some limited evidence that puberty blockers can impact height and bone density, but Cronyn said those risks are low enough that he's never encountered issues in his practice. More recent research has cast doubt on the idea of bone density issues.
In his clinic, Cronyn said, no child ever receives any medication related to transitioning unless they've been demonstrably "insistent, consistent and persistent" about their gender for at least six months. (Again, this in keeping with PES and WPATH guidelines.)
At the same time, Danforth said, parents should be aware that there are some doctors who take that idea too far.
"The big caution I think — that may be hard for parents who are nervous to resist — is to pay attention to what kind of terms and conditions a provider wants to attach to care," she said. "There has been a historical tradition of making patients jump through hoops and sort of perform in these arbitrary ways."
For example, she said, trans girls might be expected to always wear a dress and paint their fingernails to "prove" their genders, even though there are plenty of cisgender girls who don't do either of those things. Acting overtly, stereotypically masculine or feminine, she said, isn't a condition a responsible doctor sets before pausing puberty.
Why pause puberty? There's a real risk, Danforth said, that kids might hurt themselves or even attempt suicide if their bodies start to develop in ways that trigger debilitating dysphoria (a sense of conflict between one's gender identity and physical or social presentation).
There's evidence for the idea that supporting trans kids in their transitions can protect their mental health. A 2015 study published in The Journal of Adolescent Health showed that trans kids in general are at much higher risk of suicide, but a 2016 study in the journal Pediatrics showed that teenagers who are supported in their transition seem to be no more depressed and only slightly more anxious than their cisgender peers.
Adolescent mental health isn't the only reason for puberty blockers though, Cronyn said. Even trans kids who don't go through self-harm during unchecked puberty are at risk of developing unwanted physical traits that are difficult or impossible to reverse. Puberty blockers, he said, are a safe and effective way to ward off life-altering physical problems without starting kids on hormones before they're ready — or before most doctors are comfortable prescribing them. The point, Danforth said, is to protect kids from having to go through a puberty that isn't right for them.
"If you never fully develop breasts, you're never going to have to have chest reconstruction," Cronyn said. "If you never develop an Adam's apple, you're never going to have to have your Adam's apple shaved."
In addition, kids, with medical guidance, can decide to stop taking these puberty blockers so that puberty will begin on its own.
A lot of discussion of transitioning focuses not on puberty blockers or hormones, but on the idea of surgery. However, Cronyn, Danforth and Summers said, the notion of trans kids getting surgery is largely a myth.
Clinics simply don't offer "bottom" surgery of any kind — meaning surgery to change a person's genitals — to children under the age of 18. And while the World Professional Association for Transgender Health (WPATH) guidelines do allow "top" surgery — surgery to remove breasts and reconstruct the chest — for certain adolescent boys "after ample time of living in the desired gender role and after one year of testosterone treatment," that course of treatment isn't common.
Hormones don't start until much later in the transition process.
The point of trans kids receiving hormones is to enable their bodies to develop in line with their genders, Cronyn said. And kids never receive them unless they've reached puberty and have expressed consistently and persistently that they want to receive them.
Once kids do begin to take hormones, Cronyn said, they'll go through puberties that are, in most respects, indistinguishable from those of their cisgender peers. Boys' voices deepen more than girls'; they develop Adam's apples and facial hair; and they develop testosterone-driven facial structures. Girls develop breasts; their voices don't deepen as much as boys'; and they develop estrogen-driven facial structures.
Typically, Cronyn said, trans girls remain on puberty blockers for as long as their bodies still produce high levels of testosterone, while trans boys can stop taking them as soon as they begin taking hormones, because "testosterone is a bulldozer."
Hormones do change the kinds of medical risks these kids face, he said — trans boys on hormones are at increased risk of baldness, for example, and trans girls on hormones are at increased risk of blood clots — but those risks aren't that different from their cisgender peers'.
The most significant difference between puberty on hormones and most non-drug-induced puberties, Cronyn said, is fertility. Hormones can make it difficult for trans people to have biological children. Some patients and their families elect to store eggs and sperm before hormones begin, he said, though that can be an expensive and sometimes difficult process.
"The thing that we also have to look at, though, is the risk of not treating [gender-non-conforming kids]," he said.
Kids who have treatment withheld, or who are pushed to suppress their genders, are at significant risk of self-harm and other mental-health issues.
"Doing nothing is not a benign action," Danforth said. "It's not neutral, because [the kids] aren't getting a choice in what's happening to their bodies."
Forcing a trans kid to go through puberty without blockers or hormones, perhaps with the idea that they can transition as adults, does a lot of harm and no good, she said.
"We know for a fact that whether these kids are accepted or rejected, it's never going to affect whether they are trans or not, or whether they are the gender that they are or not," Danforth said. "But it is a life-or-death thing. There are potentially lives being lost in failing to be supportive and compassionate about this stuff."
The most significant debate among responsible doctors, Danforth and Cronyn said, isn't about providing hormones to kids but about when to start. Current standards, based on the age of consent in the Netherlands, instruct doctors to wait until a kid turns 16 to start them on hormones.
Cronyn and Danforth argued that, in some cases, the long wait can be irresponsible, putting the child in the position of remaining prepubescent until their sophomore year of high school. Some doctors, they said, are starting to seriously consider offering hormones earlier to kids who want them.
Originally published on Live Science.