How do you support a child or young person who is transgender or nonbinary? We asked our resident Medical Director Elaina Tully, MD (she/her) to answer some of the questions you might have. Dr. Elaina started and led one of the largest community-based, gender-affirming care programs for youth in the region at a Federally Qualified Health Center. She received her medical degree from Harvard Medical School and completed a combined residency in Internal Medicine and Pediatrics at the University of Pennsylvania & Children’s Hospital of Philadelphia. This blog shares Dr. Elaina’s responses and points you to additional resources to support trans youth.
If you’re reading this, you might have recently found out that your kid (or nibling, or student, or other child you care for!) is trans or nonbinary. You might be feeling a lot of emotions—pride at their self-expression and self-awareness, fear or anxiety about what this means for their future, relief that you know more about them, or something else entirely. We’re glad you’re here, however you are currently feeling.
Coming out as trans or nonbinary in a world that is not always welcoming to trans people (and to trans youth in particular) is an act of deep courage. As a parent, caregiver, teacher, or mentor of kids, you can have a huge impact on your child’s path. Seeing and loving your child for who they are is the greatest gift you can give. Extensive research shows that trans youth with supportive parents “report higher life satisfaction, higher self-esteem, [and] better mental health including less depression and fewer suicide attempts” than those without strong parental support.
What does it mean that my kid is “trans” or “nonbinary”?
When you hear the word “trans” or “nonbinary,” it means that the gender a person identifies with does not perfectly align with the gender they were assigned at birth and/or the physical body they were born into. For example, someone who is assigned male at birth (AMAB) might identify as a girl, or someone who is assigned female at birth (AFAB) might identify as a boy.
We also know that many, many people do not fit into this “binary” of male or female. Gender can absolutely be experienced on a spectrum, with some people feeling like they identify as both male and female, or neither. How someone identifies on the inside (their gender identity) is not always the same as how someone appears on the outside (their gender expression).
Should my kid go on puberty blockers?
As early as ages 3-4, kids are beginning to develop a sense of their gender identity. While all kids play with gender expression (i.e., try on all types of clothes), it is only when a kid’s gender identity is consistent, over time, that we start to consider they might be trans or gender-expansive. A study of transgender adults found that most of them began to experience feelings of gender dysphoria (a feeling of misalignment of their gender assigned at birth and their gender identity) by age 7. Because there is now more awareness and openness about the spectrum of gender, kids and families are finding the right words to use and the supports to seek at an earlier age.
Puberty blockers are ideally started just as someone is beginning puberty. While the right age to start is different for everyone, the first signs of puberty can begin as early as age 9-10 for kids with ovaries (with development of breast buds) and as early as ages 11-12 for kids with testicles (with enlargement of the testicles). The goal of puberty blockers is to hit pause on the body changes that come with puberty. Puberty blockers are reversible and allow kids and families time to make important decisions around if and when starting hormones makes sense. Starting puberty blockers can improve satisfaction with future physical outcomes, and even prevent the need for future surgery or procedures.
There’s never a time that’s “too early” to start a discussion around gender identity with your pediatrician. Having a conversation doesn’t mean you need to start a medication or treatment plan—it allows you to be more informed and better able to support your kid. If your pediatrician or family doc isn’t savvy with caring for gender-expansive kids, they should refer you to a provider that is.
Other than puberty blockers or hormones, what kind of healthcare needs might my kid have?
I am the biggest proponent of mental health care and encourage all families to look into therapists or counselors that have experience in working with trans youth. This isn’t to say anything is wrong with your kid that needs fixing. They are perfect exactly the way they are. I do think it’s helpful for families (i.e. guardians and even siblings) to have a space to work through their feelings as well; it allows you to be as supportive as you can for your kid. It’s also helpful for your kid to have space to process all that they have encountered or might encounter—with medical treatment, social interactions at school, family relationships, etc.
Otherwise, trans and gender-expansive kids can lead a healthy “normal” life (whatever normal is!). Connection to a pediatrician or primary care provider in both childhood and as they grow into adulthood is always helpful!
What other kinds of resources should I look for, for my kid and myself?
Connection to community is so helpful. When kids, parents, and families can meet other people going through similar circumstances, it reduces the worry, and makes people feel not so alone. One great online resource for parents and kids that I often recommend is Gender Spectrum. PFLAG has local chapters, and is a good place to look for in-person resources near you.
What are the biggest health risks of being transgender? Does being on lifelong hormone therapy come with health risks or impact lifespan?
Before I prescribe any medication with a patient, I have a clear discussion about the risks and benefits of starting. If we decide, after discussion, that the benefits of the medication outweigh the risks, then we start. This is the same for puberty blockers and hormones. We have standard, nationally and internationally recognized guidelines for providing gender-affirming medical care. Before starting, all patients (and parents, for patients under 18) should have a conversation with their medical provider to ensure they have a good understanding of risks and benefits, and that all their questions are answered. As medical providers, we educate on and monitor for any potential risks associated with therapy.
We have very strong evidence that not starting treatment for a young person can lead to negative mental health outcomes; trans youth are far more likely to be depressed, and more likely to attempt suicide than their non-trans peers. We also know that access to gender-affirming medical care (and living within a supportive environment) can dramatically improve mental health outcomes. Our kids can go on to live long, healthy, normal lives (whatever normal is!).
Can my child still have their own children if they want to later?
There are so many ways to have a family, so my initial answer is yes, of course they can have children of their own! I have witnessed many trans patients and colleagues go on to build beautiful families—though how this happens looks different for everyone. It’s important to remember that your wishes as a parent might not be the same wishes of your child. But the question of whether or not your child will be able to have biological children (using their own gametes—sperm or eggs), is not as straightforward.
Using puberty blockers should not cause a long term impact on fertility; however, starting on hormone therapy does. Most pediatric gender clinics recommend that families meet with a fertility specialist to discuss their options for preserving gametes before getting started on hormones (though your body does have to have been through puberty to do this). Even for patients that plan to start hormones after their body has been through puberty, preservation can be cost-prohibitive.
Talking about future fertility isn’t easy. How are kids supposed to know exactly what they’ll want when they’re adults? It’s important for you and your child to understand that starting hormones can reduce the likelihood of being able to have biological kids. It’s also important to weigh the risks and benefits of starting hormones. Often, we find that starting hormones is so critical to a kid’s happiness and future well-being, that a family is willing to accept this side effect of treatment.
How can I best support my transgender child?
This can often feel like a lot for a parent or caregiver to take in. But let’s keep it simple. The single most important thing that can improve a child’s happiness is having a loving, supportive adult in their life. This means listening (truly listening!) to what your kid has to say about their body, their feelings, and what they need for support. This means loving them unconditionally. And this means being their biggest advocate, learning what you can, and helping them navigate this sometimes wild world we live in.
So, you don’t have to know everything—you just have to care. Acceptance, respect, curiosity, and compassion are the secret ingredients for raising healthy kids of any gender. If your child is turning 18 or is already over 18 and you’re interested in supporting them with a Plume membership, you can learn more about our services here!
