According to the Centers for Disease Control, LGBT youth are at an increased risk for suicide and a national study found that those in grades 7-12 were twice as likely to attempt suicide as their heterosexual counterparts. LGBT youth are also a disproportionate percentage of homeless youth: According to the Williams Institute, a UCLA Law think tank, “40 percent of the homeless youth served by agencies identify as LGBT — a huge number considering that LGBT youth represent only 7 percent of the youth population.” Once homeless, according to the National Alliance to End Homelessness, LGBT youth experience higher rates of physical and sexual assault.
With this in mind, Jaimie Seaton sat down with Dr. John Turco, director of the new Transgender Clinic at Dartmouth-Hitchcock Medical Center, specializing in endocrinology and metabolism, to discuss gender identification and sexuality, specifically as related to adolescents. DHMC’s Transgender Clinic will be offering an expanding variety of services for the transgender population.
Question: What determines gender?
Answer: Ninety-nine percent of the time it’s determined by the people in the delivery room at birth. They look at the baby’s genitalia, which is only one sign of gender: phenotypic sex (internal and external genitalia). Genetic sex is based on chromosomes (46XX for female and 46XY for male). Most of the time genetic sex determines phenotypic sex, but not always. We are assigned gender at birth and obviously a baby can’t tell you what gender they identify with. So, when is gender identity determined? Many little kids do gender bending, so phenotypic boys will dress in girl’s clothes, but that doesn’t mean they’ll become a transgender adolescent or adult.
I always ask my patients about when they first sensed there was something different about their gender, and many say at the age of 4 or 5. Perhaps a girl was jealous of her brother because he had a penis, or vice versa. The individual may start to feel different at that age, but they also sensed that their parents didn’t want to hear it, so they put it out of their mind.
Others say it was later on, oftentimes puberty — which can be vicious for a kid who’s trans — brings it to a head. They often say, “My body betrayed me.”
There is only one test I know of to determine gender identity, and that is to ask the person.
Q: Let’s move on to transgender teens. We now know that the human brain continues to develop until the age of 26. This fact is oftentimes used to discourage adolescent use of drugs and alcohol. So what would you say to those who question the ability of a teenager to make such a monumental decision about their own gender?
A: It’s a key question. There are certainly kids who are gender bending at the age of 8, 9 and 10. The overwhelming majority doesn’t end up being transgender adolescents or young adults.
If strong transgender feelings persist into early puberty, and the situation isn’t addressed, that can lead to depression. Gender dysphoria arises when a trans individual is getting all these hostile feelings from their parents, friends or society. That only gets worse when they go through puberty. If at the beginning of puberty an individual is still convinced they are in a trans situation, a very high percentage of those individuals will continue with that, and want that. The elephant in the room is suddenly going to become a tiger in the room with the onset of puberty.
With some of my patients, their parents will say, “This doesn’t surprise me. I knew from the time my child could walk and make choices about which toys to play with that, my ‘Alice’ was a boy.” We’re not seeing them as young children; we usually see teens whose parents have done some reading and are convinced their child is transgender. And those parents aren’t the ones who have locked their kid in a room and refused to discuss it; they’re open-minded enough to say, “What should we do here?” What’s being done now is to put them on hormones to suppress puberty, to prevent the pituitary gland from putting the individual into puberty.
Q: How does this address the situation?
A: Let’s say you have a 12-year-old who is not identifying with their assigned gender; there is more and more of a chance that the kid will grow up and choose to be a transgender adult. Now, the problem is, especially if it’s a genetic boy, do you really want that kid to go through puberty, and become a “man”? At the age of 18 or 19 it’s much harder to have that individual transition because there are a lot of secondary sex characteristics that are difficult to reverse. Similarly, someone who identifies as a trans male doesn’t want to grow breasts and start menstruating.
Q: For how long do you suppress puberty?
A: The Endocrine Society guidelines have set 16 for the age that patients can start receiving hormones for their preferred gender. Now, during the period between identifying as trans and 16, we recommend the individual see an experienced counselor to see if there are other issues. It’s possible — but extremely rare — for the kid to have some kind of psychiatric dysmorphic body problem. If a counselor is working with the teen and the family, and at 16 the teen still has a preferred gender different from the assigned gender, that’s when that individual should go through the appropriate puberty.
Q: What is the appropriate age for an individual to have surgery?
A: There are no legal requirements, but I believe it’s a good idea for the patient to be of legal age, so 18. Surgeons usually require that the patient be on hormones for at least a year before performing the surgery.
Q: What would you say to parents who don’t want to address the issue at all?
A: They can do nothing, thinking their child will grow out of it when he/she hits puberty. And some of the time they’ll be right, and most of the time they’ll be devastatingly wrong. That’s why I’m offering middle ground; delay puberty. You’re buying time to see if the kid changes their feelings, and also getting some professional input.
That’s shocking to some parents, but look at the alternative. Most of the patients I’ve seen are very articulate and introspective, even if they don’t have the most refined vocabulary; they’ve figured it out. My fear is that there is a whole other population of kids out there who just aren’t that sophisticated enough or have access to the same resources, or supportive parents, who just can’t figure it out. They often end up on drugs, alcoholics, depressed, even suicidal and homeless. Some of these kids choose to leave home, so we have a huge number of homeless trans kids.
Q: What about the argument that being transgender is simply trendy now?
A: From my experience of how powerful gender dysphoria is, I don’t know why the hell someone would do this to his or her self. It’s not like it’s cool, and there aren’t a lot of benefits from it. Many of my patients will say to me, “I chose to take hormones, but I didn’t choose to be a transgender person.”
One of our problems in society is that we have a very binary view of gender identity, meaning we are either male or female. There are more individuals who would like to hang out in the middle, but our society won’t let them. What I’m saying is that it’s much more of a spectrum.
Maybe there is a genetic male who has a lot of feelings that our society equates with being female, but it doesn’t necessarily mean that the individual wants to live as a female.
Q: Can you explain why some transgender individuals don’t get all the surgery to have complete genitalia?
A: There are myriad reasons. Firstly is that it’s expensive, and often patients don’t have the financial means to have the surgery. Other individuals get to a point where they feel comfortable about their gender identity without having to have further surgery. And most individuals realize that it’s not perfect surgery.
Q: Does gender correspond with sexual preference?
A: We don’t know why somebody’s attracted to a male or female. Gender may not correspond with sexuality. Genetic sex usually predicts phenotypic sex, which often but not always predicts sexual preference. Most of the time in our society people are heterosexual — but not always. When I ask patients who they are attracted to I’ll get one of three answers: male, female or both.
Q: What advice do you have for parents who think their child might be a transgender individual?
A: The best thing would be to discuss it with the child in a non-weighted way. Ask them how they look at their gender. Many of my patients have said to me that they were waiting for a doctor, a parent, for somebody to open up the conversation. I’ve heard from many of my patients that they dropped hints to their parents that were either missed or overlooked.
Parents should be looking for ways for the conversation to occur earlier, which may help avoid gender dysphoria that can occur in adolescence and beyond.
For example, I talk to school nurses who are aware of students who seem to be expressing transgender feelings, so wouldn’t it be nice for school nurses to be empowered to at least bring this up on the radar with parents? I do realize it’s a difficult topic to bring up.
The parents should realize that this is not an incredibly unusual situation. In my experience, of the 6,000 students on Dartmouth’s campus in one academic year, about 1 in 1,000 will identify as a transgender individual.
It’s important for parents to educate themselves, and one good place to start would be a book written by Jackson Schultz of Dartmouth called Trans/Portraits. It gives a great overview, and includes a glossary of terms.
I’ve done this for 25 years and seen maybe 400 patients. When I see a new patient I ask them what they want, and they say, “I want the outside to match the inside.”
My oldest patient was a 76-year-old man who came to me and said, “I’ve known since the age of 7 that this was not my gender.” He was a gifted scholar, an incredibly successful person. He said, “I’ve been living a false life. I’ve got to do one thing before I die.” He added, with a twinkle in his eye, “You better hurry.”