Raising a Transgender Child

After having a girl first, Ellen, a mom in Southern California, was excited to learn her second child would be a boy. She went on a shopping spree for baby boy clothes and painted the whole nursery blue, including the ceiling, which she dotted with puffy white clouds. When her baby arrived, Ellen and her husband, John, chose the name, Ryan.

But from toddlerhood, Ryan gravitated to "girl" things, playing with dolls, pretending to host tea parties, and insisting family members use the names, Sarah or Ashley. Each day at the small Christian preschool, Ryan headed directly to the dramatic-play area and put on a dress. At home, Ryan used a red superhero cape to imitate flowing locks of hair. When Ryan asked for a doll, Ellen got a G.I. Joe action figure. Disappointed, Ryan broke off its head.

One day at 3 years old, Ryan said something to Ellen that struck her as particularly confusing. "'I'm a girl. Don't you know I'm a girl?'" says Ellen. Ryan asked Ellen why he was a boy on the outside, adding, "'I'm a girl inside. My blood is pink.'"

When Ryan began to pray to God at night, asking to wake up in the morning as a girl, Ellen consulted a therapist, who said Ryan was going through a phase. Another therapist Ellen and John saw suggested Ryan might have an anxiety disorder or be bipolar. (Ellen, John, and their children's names have been changed at the family's request.)

One afternoon while Ellen was driving, Ryan, then in kindergarten, gazed out the window from the backseat and said sadly, "I wish I could be hit by lightning." Shaken, Ellen made an appointment with yet another therapist, who said she couldn't help but suggest seeking a gender therapist who would be more experienced in addressing gender identity issues.

Social Transition

After an evaluation, Ellen and John finally learned that Ryan was transgender, meaning Ryan's internal sense of gender didn't match the one assigned at birth. They consulted a second gender therapist, who confirmed what the first one had told them and suggested they help Ryan make a "social transition" to her true gender.

Social transition does not include medical interventions; instead, according to the American Academy of Pediatrics (AAP), it involves adapting certain things to align with a child's affirmed gender, such as:

• Name
• Hairstyle
• Clothing
• Pronouns

In Ryan's case, it meant using a girl's name, dressing in the feminine clothes she wanted instead of hiding her sister's dresses under her bed as she had begun to do, and using the pronouns "she" and "her."

John was ready to put the gender therapists' recommendations into action to help Ryan. Ellen, however, was grieving. "My husband was so much more on board with this as something real and more gung-ho that we had to do what was right for Ryan," says Ellen.

For Ellen, though, it was harder. Ellen says she accepted that her child was transgender but took a year to make Ryan's transition public. Because they worried about the reaction from their local community, Ellen and John decided that after Ryan completed first grade, she would change schools and enroll as a girl.

Today, Ryan, now known as Rylie, is a happy fourth-grader. "My husband and I wanted to stay with something similar to the name we had, and I felt like, 'I'm the mom—I get to name my daughter,'" explains Ellen, laughing. So she compromised with her daughter on the middle name since Rylie wanted to be named after her favorite singer, Nicki Minaj. Her name is now Rylie Nicole.

The family also moved around that time, and Rylie's new neighbors and classmates are unaware she's transgender. At the school Rylie attends now, only the principal, teacher, and nurse know.

No Regrets

For Ellen and John, there has been no downside to Rylie's transition. There was no more pretending or leading a double life: Ellen no longer had to remind Rylie to replace the frilly girl underwear she preferred with boy underwear before she went to school. And Rylie, whose sadness and anxiety disappeared, was elated. "She said over and over, 'Thank you so much! It's my wish finally come true!'" says Ellen.

While they can reverse course any time, Ellen feels that's unlikely. "Since the transition, Rylie looks back at those years as Ryan as depressing. She now feels happy and free. She doesn't want to look at old photos of herself as Ryan," says Ellen, who keeps the upsetting pictures out of sight in a box under her bed.

At the suggestion of the gender therapist the family continues to work with, Ellen asks Rylie occasionally if she's ever wanted to return to dressing as a boy. "But Rylie gets so mad at me. She says, 'What? Do you miss your son?'" says Ellen.

So far, Ellen's only regret is not having helped Rylie transition sooner and having let her spend most of the first grade living as Ryan. "I don't know why I dragged my feet so much, but I was totally uneducated. I worried about what other people would think. I've lost that—if Rylie's given me anything as a mom or a person, she's made me brave," says Ellen.

"We're just your average next-door-neighbor family. We chose to make life better for our child." Ellen sees Rylie as 100% girl. "In my mind, and my husband's, if we hadn't done this, she would have become a suicidal teenager," she says.

The Political Landscape for Trans Kids

In many ways, it's a watershed time for transgender people. In 2013, the American Psychological Association (APA) eliminated from its Diagnostic and Statistical Manual of Mental Disorders (DSM) the term "gender identity disorder" and introduced the term "gender dysphoria" to clarify that people who have an incongruence between their experienced gender and their assigned gender do not, in fact, have a "disorder."

No one knows for sure how many people in the U.S. are transgender, although the UCLA School of Law William's Institute conservatively estimates 1.3 million adults and 300,000 youth. Awareness of transgender issues continues to grow thanks partly to high-profile celebrities who've come publicly come out as trans, like Elliot Page and Orange Is the New Black star Laverne Cox.

Social and political resistance

Despite these strides, though, there remains strong resistance to transgender children. "Things have definitely improved. Yet many people are still much less comfortable with transgender children than they are with adults," says Kim Pearson, mother of a grown transgender son and the training director and cofounder of TransYouth Family Allies in Holland, Michigan, which has an active online support group.

"They get sexuality confused with identity, and they feel that kids are too young to make these life-changing decisions." (According to the APA, gender identity is about identifying as male, female—or for some, neither, both, or something else. It has nothing to do with sexual orientation: the gender someone's attracted to.)

In the U.S., support for transgender kids is under political attack. In the first month and a half of 2023, the Human Rights Campaign tracked more than 150 bills targeting transgender people, the largest number of any year.

Some bills target transgender children's ability to access gender-affirming health care, play sports, or use a bathroom that aligns with their gender. And proponents of these bills use the guise of "protecting children" as reasons to limit transgender rights, even though major medical organizations and research support gender-affirming care as life-saving for transgender kids.

Grave threats to trans kids

A staggering 40% of transgender adults have attempted suicide (eight times the rate of the general U.S. population), according to a 2015 National Transgender Discrimination Survey. Further, trans adults reported suicidal ideation at a rate of 82%—that's 12 times that of the general U.S. population.

Researchers suspect the following experiences are unique risk factors that trans people face that likely contribute to the high rate:

• Discrimination
• Family, partner, and friend rejection
• Religious persecution, such as conversion therapy
• Violence
• Fear of being outed
• The cumulative effect of minority stress

"It's important for parents to understand that with early intervention and family support, those statistics can plummet," says Darlene Tando, a gender therapist in private practice in San Diego. "These statistics are typically based on people who have transitioned later in life, after years of societal and family rejection."

Medical Transition

Now, there's more help available than ever for transgender kids, including the option to avoid once-inevitable physical changes. "Puberty is a precarious time for trans kids. It's the development of this adult body they don't identify with for many reasons," explains Johanna Olson-Kennedy, M.D., medical director of the Center for Transyouth Health and Development at Children's Hospital Los Angeles.

Puberty blockers

Puberty blockers, or hormone-suppressing medications delivered via injections or implants, do just as their name implies: they delay the onset of puberty and the physical changes accompanying it. According to the American College of Obstetricians and Gynecologists (ACOG), puberty blockers may result in the following:

• Regression of early breast-bud tissue
• Prevent menstruation
• Prevent the onset of facial hair
• Prevent developing a deep voice
• Prevent the formation of an Adam's apple

Aside from blocking these puberty-related changes, children continue to grow typically otherwise. And the effects are reversible: If children cease taking medication, puberty progresses as it regularly would.

According to the Endocrine Society's clinical practice guidelines for gender dysphoria, starting puberty blockers early in puberty allows for better physical outcomes. That's because developing physical characteristics that are irreversible and incongruent with one's gender creates enormous life-long disadvantages.

"Puberty blockers are incredibly helpful, as children may be able to avoid some surgeries down the road, and they give families time and space," says Dr. Olson-Kennedy. "Children who are distressed about their impending puberty and spending 95% of their time preoccupied with their gender can't concentrate at school or at home. Instead, with puberty put on hold, they can focus and participate meaningfully in family life and activities."

Hormone therapy

In their teens, kids may consider taking cross-sex hormones to masculinize or feminize the body. According to ACOG, these effects may include:

• Deepened voice
• Growing facial hair
• Breast development
• Changing body shape

Most of these changes are permanent. The form of treatment may be a shot, pill, implant, or patch. This type of treatment typically begins when a child is in their mid-teens.

A 2022 JAMA study on health outcomes in trans and nonbinary youth found that youth who initiated puberty blockers or gender-affirming hormones had 60% lower odds of depression and 73% lower odds of suicidality compared to youth who did not receive these interventions.

Surgery

The final step is sex-reassignment surgery. However, not all transgender people have surgery. Plus, surgery is not a standard form of medical transition for children under 18. Except in rare situations, gender confirmation surgery is almost exclusively used for adults.

According to the Office of Population Affairs, gender-affirming surgery may include:

• "Top surgery" to reconstruct the chest
• "Bottom surgery" to modify the genitals
• Facial feminization surgery

Again, importantly, these surgeries are not routine for children.

In addition, a 2021 Surgery review found that gender affirmation surgery is safe with low complication rates. Further, surgery decreases rates of gender dysphoria, depression, suicidality, and improves quality of life.

Dealing With Disapproval

While transgender issues are gaining more attention now than ever, America has a long way to go. Ellen recalls the hurt she felt after she told a close, longtime friend that she would be helping Rylie transition. "She said, 'This is too much for me,'" says Ellen. The friend with whom Ellen had once shared playdates, birthday parties, and a family vacation now avoids her completely.

While Ellen's family started over in a new community, Shannon, a former OB-GYN and mom of a transgender boy, Sam (not his real name), now 9, had the experience of helping him transition between the first and second grade in the same school.

"I went in unannounced to meet the principal in August, and he was frazzled with class assignments. I said our child had the courage to tell us he was a boy in his heart and that we were calling him by his new boy name, Sam, now, and using male pronouns, and we wanted him to be called a boy in school as he is at home," says Shannon, who lives in the Midwest. "And the principal just paused and said, 'All right!'" ("Way to drop a bomb on him," Shannon's husband teased her later.)

Shannon got great support from the school administration and staff, and the kids quickly accepted Sam on his first day back to school, where he simply told people, "My name is Sam now." But then his classmates went home and told their parents, some of whom started avoiding Sam and Shannon as they walked by.

It was hurtful, Shannon says, though one day, not long after Sam's social transition, she got an unexpected boost from a stranger. She was out with Sam and her two other sons, and a man said, "Three boys! You've got your hands full!" For Shannon, who'd spent nights awake worrying about the future, it was welcome reassurance that Sam, who now had the clothes and hair he'd wanted ("short, like Dad's"), would be OK.

Three years ago, mom Debi Jackson, a self-described Southern Baptist conservative, helped her child Avery transition to her true gender, female, at age 4. Debi was interviewed for a story by her local big-city newspaper and became the target of hateful comments online. "People said if our child wanted to be a dog, we'd probably allow that too," says Debi. "My husband and I were also accused of being homophobic—that we have a feminine gay boy but must have wanted a daughter so badly we convinced him that he's a girl."

Debi wishes people who are uninformed and scared would ask parents about their transgender kids. "It's OK to have questions and not understand this," she says. "That's where we were a few years ago too." Slowly, she's tiptoed into advocacy for transgender children and their parents, many of whom are afraid, having received threats of harm, and even death, to their families.

Bathroom Battles

Many transgender kids find themselves in the position of being accidental pioneers at their school, which often doesn't have a policy in place. That leaves parents waging a fight for their kids' rights to use the bathroom.

Lawmakers in several states have proposed "bathroom bills" restricting transgender students' access to bathrooms that align with their gender. "Unfortunately, the bathroom has been made into a much bigger issue than it needs to be," Pearson says. Parents and schools "go nuts" over it, she notes, with unfounded fears of children being exposed to transgender kids' private parts or Peeping-Tom trans children spying into stalls (meanwhile, no such instance has ever been documented).

"These are the most private children in the world," says Pearson. "As worried as you are about people seeing their genitals, they're more worried. The last thing a transgender child wants someone to know is what's in their pants."

While school administrators may feel it's reasonable to propose transgender kids use teacher bathrooms at school but not girls' or boys' rooms, Pearson explains why it isn't: "Schools often impress that children are to be treated equally." Yet, she says when a transgender child cannot use the bathroom that aligns with their gender, their identity is discounted several times a day. "It wears down their self-esteem, and it just doesn't work," she says.

It's also been ruled discrimination: In 2013, a 6-year-old first-grader in Colorado, Coy Mathis, a transgender girl, won a civil-rights case after her school had allowed her to use the boys' bathroom or a single-user staff restroom, but not the girls' room. A similar victory followed in Maine, with monetary damages awarded.

How Siblings Adjust

Transitioning is a big event for the entire family, including the siblings. "For the most part, the younger siblings are, the easier it is for them to adapt to the idea that they now have a brother instead of a sister, or vice versa," says Tando. "The older they are, the longer it may take to adjust. Still, it's a pretty short period, and they typically become their sibling's biggest advocates and the pronoun correctors."

Most of the work gender therapists do with families of transgender youth, says Tando, is in support of parents. She helps them understand that grieving is normal and not uncommon as parents adjust to changes, including letting go of some of the gender-specific expectations they'd had for their child.

"I don't want to minimize it, but the anticipatory grieving is often worse than the grieving that actually happens," says Tando. "Parents come to realize their child is still here, and they are very much enjoying their child, just differently." A gender therapist can also help parents navigate communication with school administrators and extended family and make a referral to endocrinologists who are knowledgeable about transgender kids.

A gender therapist also works with the child, of course, but in Tando's experience, it's the parents who need more guidance. She says, "One child wrote me a note that I thought was so poignant: 'Thank you for helping my mom and dad!'"

Ellen, Rylie's mom, still has the G.I. Joe action figure that Rylie broke apart in anger. "It's symbolic to me, and it reminds me: Do not try to make your child conform. She knew what she wanted and knew who she was, and we don't try to change it," says Ellen.

When Ellen and Rylie went through Rylie's bedroom together at the end of first grade and packed away all her boy clothes for good, Ellen came upon their first family photo together, when Rylie was a baby, before any of them knew what lay ahead. "The words around the frame say, 'Love bears all things, love endures all things, and love helps all things," says Ellen now. "And I reread them, knowing they were true, and I just started to cry."

To learn more about how to support transgender youth, visit these sites:

• GLAAD Media Reference Guide - Transgender Issues
• Stand With Trans
• PFLAG