Hi, I'm Dr.
Jessica Bernacki, clinicalpsychologist for UCLA's Gender Health Program.
And I'm Dr.
Amy Weimer, themedical director and co-director for UCLA's Gender Health Program.
And today, we're going to talk about gender identity development and medical optionsfor youth with gender dysphoria.
During this talk, you can ask questions ontwitter using the hashtag #UCLAMDChat or comment via YouTube.
Okay, and ourgoals for today are to provide an overview of gender identity developmentin youth, discuss the options available for managing gender dysphoria– we like to start off with distinguishingbetween gender identity, sex assigned at birth, and sexual orientation.
So, sexassigned at birth is typically someone being labeled as male or female at birth, commonly based on genitalia.
And gender identity is a person's internal sense ofsex assigned at birth, or may have a gender identity that's different than their sexassigned at birth, which is what we're going to be focusing on today.
And thensexual orientation is its own experience entirely, which has to do more with howsomeone is romantically or emotionally attracted to other people.
And what'simportant to note here is that someone may feel a little bit feminine and a lotmasculine, it's not necessarily one or another.
So, we often get askedabout when does gender identity develop, when can we start to know if there's adifference between how they identify and how they're being labeled by otherpeople, typically based on their sex assigned at birth? And we know thataround one year of age youth can show gender preferences for type of play, andbetween a year and a half and two years of age, youth start to often labelthemselves as either a boy or a girl.
You may see that around age two years, a kidmight start to express some dislike or discomfort with the label that they arebeing given by other people, so you may start to hear youthsay, you know, "I'm not a boy, I'm a girl, " and then typically, youth have a stablesense to their gender identity between age 4 to 5, although we know that thismay be different for gender diverse youth or youth who have gender dysphoria.
And we know adolescence is another key time point in which we may start to seesome evidence of individuals kind of thinking about their genderidentity and maybe noticing that there's a difference between how they are beinglabeled and how they identify-we'll talk a little bit more about that in a minute–so it's important to highlight different things that you may observe in a kidwith gender dysphoria.
There's kind of gender non-conforming behavior, which, again, is a behavioral phenomenon, so these are youth who are showingbehaviors that are different than what we would say we expect a youth todisplay based on their sex assigned at birth, and then there is gender dysphoria, which is really an identity phenomenon, so youth who really describe adifference between how they're being kind of labeled by other people and howthey truly identify themselves to be in terms of like male or female orsomething else, and we're really going to focus on gender dysphoria.
Although youth who have gender dysphoria will often show gendernon-conforming behaviors, and again, we typically see signs of gender dysphoria, or kids coming to us talking about gender dysphoria, at kind of two main agepoints.
So, there are early pre-pubertal youth, around, you know, early childhood, who are starting to show signs, again, coinciding with that identitydevelopment around age, you know, say, four, who are having that discomfort withhow they're being identified, and kind of talking about that, and then there'sadolescents who are often coming to gender clinics like ours and talkingabout the sense that their gender is not how they are identified at birth andstarting to talk about distress, and that's often coinciding withthe changes that happen with puberty and the feminization or masculinization ofthe body that's happening at that time and not aligning with how theyidentified.
So, we often also get asked, you know, how do we know that my child, who has this difference in their gender identity, or this incongruence intheir gender identity with their sex assigned at birth, how do we know if thatwill persist for them into adolescence and into adulthood? And there are somesome ways in which we can feel this is more likely to persist.
So, the moreinsistent, consistent, and persistent a youth might be, the more likely that thiswill persist for that person in the long term.
We know that for youth whoexperience an onset of this dysphoria, or an intensification of this dysphoriain adolescence, that that's a strong predictor.
So, again, when bodies are changing with puberty, if that is not aligning with howa person identifies, again, that's a strong predictor that that distresswould persist if they were to continue in that puberty.
And then bodydissatisfaction–so, youth who have gender dysphoria are more likely to talk aboutdissatisfaction with specific parts of their body and typically the parts oftheir body that are more gendered, so typically relating to the chestor their genitals, and then often we're hearing things about a person's identity, so for youth, it's telling you "I am a boy" or "I am a girl"rather than talking about "Well, I want to get to do the boy activities.
" That may bea sign that it is more likely to persist.
It's more about their kind of core senseof who they are.
So I mentioned we were going to talkabout family support today, and the reason we are going to focus so much onfamily support is because we know it is kind of a strong predictor of well-beingfor LGBTQ youth broadly, and there's a couple graphics that I thinkare really kind of powerful to show you what the research hasdemonstrated about the importance of youth having supportive familymembers or supportive people in their lives.
So, we know that youth who identify as LGBTQ, who come from extremely acceptingfamilies, that a majority of them–over 90%–will describe seeing the future forthemselves as being–that they see themselves as a happy adult, whereasyouth who come from completely unaccepting families–only 1/3 envision a positive future for themselves.
Then we also know that LGBTQ youth who come from highlyrejecting families also experienced an eight times greater risk of a lifetimesuicide attempts than youth who come from very accepting families or familieswith low rejection.
So, we often get asked, you know, what is the best way to supportour child as a parent? And, you know, many parents come to us believing that thebest thing for their kid would be to help them to kind of fit in with theircisgender or non-transgender peers, so they encourage their kids for a periodof time to conform, so play with the toys that are stereotypical for, you know, their assigned sex at birth, play with those types, you know, those peers, but mostparents often find that this does not go well, and many youth described this asfeeling quite negative and experiencing rejection with this, and andthis experience of reduction can be associated with some of those kind ofnegative results that I alluded to before, which was poor outlookfor their ability to be a happy person in the future and increased risksfor things like anxiety and depression and suicide risk.
So, what we want to, youknow, spend the rest of the time of our talk doing, what Dr.
Reimer willtake over with now, is talking about what are the options for supportingtransgender youth, what are the best ways to support them, options available to usto support them.
So, since we spent a little bit of time talking aboutgender identity development, how to determine somebody's stability ofgender identity, and the importance of family support and acceptance, now wewant to talk about how does that apply to you and to your child.
And the mostimportant thing to recognize is that every person's experience is going to bedifferent, and every child's needs are going to be different, so the mostimportant thing that we can do is really listen to that child, what it is that'scausing them discomfort, and in what way can we best support them.
And socialtransition is the process by which a person changes how they present to theworld to live in their affirmed gender role, so this might mean changing theirhairstyle, changing their style of dress, changing their name and pronouns, andeven making legal document changes with name and gender marker, so that thesematch their affirmed gender role.
And social transitioning can be a very, verypowerful intervention, particularly in youth.
There was one wonderful study thatwas published a few years ago that showed that young people–so these werechildren before puberty who were allowed to socially transition and live in theiraffirmed gender role–when they were evaluated in later adolescence, hadsimilar rates of depression and only slightly higher rates of anxiety thantheir same aged non-transgender peers, so it can be a very powerful intervention.
Aside from social transitioning, there are a number of other ways to help aperson live in their affirmed gender, and these have more to do with aligningtheir body so that their body reflects their affirmed gender, and when we'retalking about pursuing this in young people, the first question that we needto answer is where are they in puberty? And we use a stage called the Tannerstage, or scale called the Tanner scale, that divides puberty into fivedifferent stages, with Tanner stage 1 being a child who hasn't started pubertyat all and Tanner stage 5 being a child who has completed puberty, and this is based on a physical exam.
When we do the physical exam forchildren with gender dysphoria, it can be a very emotionally challenging timebecause they may have a tremendous amount of discomfort with their bodies, so we really need to approach this in a sensitive way.
In addition, we supportthis staging with lab tests that look at where hormone levels are at, so oncewe've determined the Tanner stage that a child is in, then we can start to makedecisions about what options are available.
So, a child who's Tanner stage1, who hasn't yet had any puberty changes, there's no medical treatmentthat's indicated at this point, and this is for a couple of reasons.
One is thatwe don't want to start any medications that aren't necessary to start, and ifthe body isn't developing in a way that doesn't align with the gender identity, it's not necessary to start medications yet.
But we also know that those earlypubertal times are very important for helping us clarify whether this child islikely to have persistent gender dysphoria, so if their discomfort abouttheir body intensifies around the time of puberty onset, that's a strongpredictor, and if we start interventions very early in puberty, then we reallyhaven't lost any ground in helping this child.
So a Tanner stage 1, really whatwe're looking at is supporting this child in socially transitioning if thatwould be something that might alleviate their discomfort.
For kids who are Tannerstage 2, 3, or 4–so these are children who have started puberty but have not yetcompleted puberty–then we can use what are often referred to as blockers ormedications to suppress puberty, and these medications are fully reversibleand essentially put a pause button on puberty so that it stays where it's at.
And they can be used for months to years alone without any other interventionsand are fully reversible, so they're a very useful tool for a number of reasons.
One is that it can give the child and family and providers more time to havediscussions and clarify what the best path is going to be for this individualchild and help the child to reach an age where their decision-makingmight be a little bit more mature and future-oriented, and they also can prevent changes that might come from allowing puberty tocontinue that would necessitate surgeries in later life.
But we know thatpuberty is important–it's important for our general health and our braindevelopment, and so at some point we need to make a decision to move forward withpuberty.
So if that child, after reflecting on this, decides that theyactually want to resume their own puberty, then we can stop the blockers, and puberty will proceed where it left off.
In reality, this doesn't happen veryoften.
Most kids who are put on puberty blockers are put on puberty blockersbecause they have significant gender dysphoria, and we know that that usuallydoes not resolve on its own with time, so the other option is for kids who desireto continue their gender transition.
Then we actually continue the blockers sothat changes from the body's own program to puberty don't proceed, and we starthormone therapy.
So, hormone therapy is–we either do this in kids who have been puton the blockers and are at Tanner stage 2 to 4 or kids who have completedpuberty and are at Tanner Stage 5, and essentially, we use these hormones toinduce changes in the body that are more in line with the person's genderidentity, so for trans-feminine people, people who were assigned male at birthand have a more female gender identity, we use a form of estrogen calledestradiol, and then we pair that with another medication to either block orbring down testosterone levels.
For kids who are already on puberty blockers, thepuberty blockers will serve that latter role.
And for trans-masculine people–so, people assigned female at birth who are transitioning to a more male genderexpression–we use testosterone, and generally, we don't need to pair thiswith another medication to bring down estrogen levels, but, again, if somebody'salready on blockers, we do continue the blockers.
And in children, we gradually increase these doses of hormones to sort of mimicthe experience of puberty.
If a child is at an older age when they start, then wemay do that dose escalation a bit faster, but in this way we're trying to helpthese children have an experience that's more in line with their peers.
Aside from hormone therapy, there are a number of surgeries that people mightseek in order to align their bodies more with their gender identity, and I've puthere the common terms that are often used.
Top surgery refers to chestreconstruction, and it's more commonly pursued in people who are trans-masculine, where they have the removal of most of their breast tissue and areconstruction of the chest to a more masculine appearance.
It can also be pursued in trans- feminine people, where it's more of aclassic breast augmentation surgery.
Bottom surgery refers to genitalreconstruction, or really any surgeries that are done on the reproductive tract, and that can be done just for hormone management by removing sort of thehormone making factories of the body or to get the genitals more in line withone's gender identity.
Facial feminization is facial reconstruction tofeminize what may be seen as very masculine facial features, and thenthe tracheal shave refers to a reduction in the size of the Adam's apple, andthese latter two surgeries are a great example of surgeries that could beavoided if we put a child on blockers before they reach about Tanner stage4, which is where we start to see a lot of the bony changes that come alongwith testosterone-based puberty.
So what do we know about the outcomes ofall of these interventions? We have a number of studies that really supportpositive health outcomes in people who have access to hormones and to surgeries, and specific to children.
When studies have been done on adults who were givenpubertal suppression in adolescence followed by hormones and surgeries, thosestudies show that the adults have significant improvements in their genderdysphoria as well as their general psychological functioning.
And this is reallyimportant because we know that rates of depression, anxiety, and suicidality areall markedly increased in the transgender population, so interventionswhere we can reduce those particular conditions are very powerfulinterventions, so very good and effective interventions.
Many patients and familiesask us how much will all of these treatments cost, and will my insurancecover it, and the short answer is it varies depending on where you live andwhat your insurance plan is.
The Affordable Care Act does have anon-discrimination clause, which includes a prohibition on discrimination on thebasis of sex, but whether that term sex refers to gender identity is oftendebated, and in fact, the Supreme Court is currently considering three cases wherethey're trying to make a determination about just that question, and that rulingis expected out next year, which hopefully will clarify things, but fornow, some states have a specific non-discrimination clause within theirstate, and other states do not.
So, some health plans will cover these services, and some will not.
The insurances that do cover it typically use a document calledthe Standards of Care from the World Professional Association for TransgenderHealth as the basis for authorizing certain procedures, and these guidelinesgive some recommendations for readiness criteria that a person shouldmeet before proceeding with certain interventions, and it's important to beaware of this because it is so often referred to by insurance companies.
If aservice gets denied by insurance company, the patient can appeal, the provider canappeal, patients can actually file complaints with the Department of Healthand Human Services Office for civil rights on the basis of discrimination, and we have seen a number of denials overturned when patients have taken thisstep.
Patients can engage a legal advocate, which can be avery, very useful tool, and there are advocacy organizations that may offerthese services free of charge, and there's a great summary of how toapproach this process online at TransgenderLawCenter.
org, which is inand of itself a very, very helpful resource.
In the state of California, which is where we practice, there is indeed an Insurance GenderNon-Discrimination Act in place, which mandates that services that are providedfor other medical indications are also provided as part of gender transition ifthey're medically indicated, so there's some wonderful protections in place inCalifornia.
And I think it's important to note that this is part of a largerGender Non-Discrimination Act in this state that also providesprotections in a variety of different settings, including schools–so ifchildren are having difficulty accessing specific things in schools, for instance, safe bathroom access, they should know that there is legislation in place thatshould give them those protections.
So, we just wanted to take a moment recognizinghow important parental and family support is for the outcomes for thesechildren, just to thank everybody who's watching this webinar because you aretaking a very, very powerful step to help your kids have a happy and healthy life.
And this is our contact information.
Feel free to reach out with any questions, andI think we might have some questions available to us.
So, one question is, "What are thelong-term health risks of hormone therapy?" This is a very common questionthat we get, especially from parents who are really looking out for theirchildren's long-term health, and generally, hormone therapy is actuallyvery safe.
With estrogen, the one medical concern that we really keep an eye on isthat it can increase the risk for dangerous blood clot formation, and thisis strongly associated with smoking, so staying away from smoking is veryimportant for anyone who's on estrogen for any reason.
But aside from that, long-term studies have shown there's no increased risk in cancer of any kind, noincreased risk in heart attack, no increased risk in diabetes, and then, intrans-masculine patients, no increased risk in stroke.
In trans-femininepatients, there is a slight increased risk of stroke related to thatpredisposition to blood clot formation.
Here's another question.
"What is requiredbefore an adolescent can have top surgery? Do they need to be on hormonesor to see a psychologist?" So, most gender affirming surgeriespeople don't pursue before the age of 18, and the one notable exception is topsurgery in adolescent trans-masculine patients because it can be verychallenging to go through life as a teenage guy with breasts, and it can bevery tricky because many insurances will not cover it, so this is a place where wereally do a lot of appeals work for readiness for top surgery.
It is notmandatory that people be on hormones because the breastdevelopment isn't really affected by being on hormones.
It's not medicallynecessary.
However, a number of surgeons that I've spoken with will say that theyfeel like if somebody is on testosterone for perhaps about a year and does somework on building the muscles of the chest, this can help them with theirsurgical technique, really align the scars with a person's anatomy, and helpmake their result perhaps a little bit better.
But there are peoplewho want to pursue top surgery and never start hormones, andthat is also an option.
And then in regards to working with a psychologist, I'll pass that to Dr.
Yeah, so, currently in our program–and Ithink many other programs that we have seen patients participate in–therapy is not necessarily a requirement in terms of someone having been intherapy for a certain amount of time, but there is a role for a behavioral healthprovider, usually, in this care, in that it is currently–as part of the Standard ofCare Guidelines–a requirement that individuals for insurance coverage havea statement of support, typically from a behavioral health provider.
So, you know, youth who are interested in pursuing trans-masculine top surgery will oftenhave to provide a statement of support written by a therapist or psychiatristor other mental health provider documenting that readiness for surgery, so, often, that is where we'll become involved, is to help do thatdocumentation to help pursue insurance coverage.
And then this question, "Aftersurgery, how long do I need to continue hormone therapy, and how does that affectsexual activities?" And so this, I think, would be specific to probably bottomsurgery.
We ideally want a person to be on some sort of hormone for most oftheir life, again, for general health.
It probably–definitely impacts bone health, and probably cardiovascular and brain health as well, and so ideally, we don'twant to remove a person's own gonads, which is where we make hormones, unlessthey feel very committed to continuing the hormones that they're taking, so inthis question, "How long do I need to continue hormone therapy?", the answerwould be indefinitely.
We don't really know the best guidelinesfor people who reach an older age, where naturally the hormone levels woulddecline in our bodies, and at this point, that's a veryindividualized discussion with each patient.
But we do often reduce thehormone doses in later life, and as far as sexual activities–sex is affectedtremendously by everything that we do, and that's probably multifactorial.
Someof it is coming as a direct result of hormones–for instance, testosteronedefinitely makes sex drive go up, but some of it also is related to a personfeeling more comfortable in their own body as their body changes to align withtheir gender identity, and so our goal is, as we go through these treatments and aswe go through genital surgeries, that people have very full and functional sexlives.
So, all of these steps that we take ideally would only be enhancing sexualfunction.
Thank you again for being here today, and if there are any ongoingquestions you may have or anything else you feel like we may be able to help youwith, we do hope you reach out and contact our program, and thank you verymuch.