Youth Month: Transgender youth explosion; early evaluation and support are vital

When he started the Gender Identity Development Service at Red Cross War Memorial Children’s Hospital in 2012, Dr Simon Pickstone-Taylor saw an average of two young transgender patients a year. Eleven years later, he often gets more than three referrals a week.

The surge is worldwide, said the University of Cape Town (UCT) alumnus, and it’s not a fad. Advances in neuroscience are unlocking the causes. But early evaluation and support are essential.

“We used to think the incidence [of transgender or gender dysphoria] was one in every 10 000 for girls and one in every 30 000 for boys,” said Dr Pickstone-Taylor. “Now it’s believed to be one in every 200 children.”

He was speaking at a UCT Summer School Extension Series public lecture on 17 May, titled “Supporting gender-diverse youth”.

Pickstone-Taylor did his undergraduate degree in medicine at Cambridge University and in psychiatry at the University of California, San Francisco where he had a fellowship in child psychiatry. He is an honorary senior lecturer in the Department of Psychiatry at UCT and a member of the World Professional Association of Transgender Health and a founder member of the Professional Association of Transgender Health of South Africa.

Based in UCT’s Division of Child and Adolescent Psychiatry, the Gender Identity Development Service supports children and adolescents up to 18 years old, and their families.

Information and understanding

The information age has played a significant role in numbers of children and adolescents presenting at gender clinics, he said.

But rather than ‘contaminating’ children and youth, as some parents fear and some groups have contended (“It’s not something you catch from internet or media”), the internet and social media have made information more freely available and gender-diverse youth are able to find information to help understand themselves at a much younger age.

The underlying causes of body dysmorphia lie partly in the biology of the brain, as advances in neuroscience have shown.

“These children face enormous prejudice.”

“Psychiatrists used to think it was parental influence; a distant father and an overly close mother,” he explained. “The first 20 years of research was done on ‘what the parents did wrong’ to cause their children to be transgender – essentially how to prevent them from existing – but not on helping them. Not a single study showed any link to parenting, so we know today that parenting has nothing to do with gender identity in a child.”

Help and support are the cornerstones of the Gender Identity Development Service.

“Having a transgender child is not easy,” said Pickstone-Taylor. “These children face enormous prejudice. Most parents become comfortable with their transgender child and even celebrate them, but for most it’s extremely difficult in the beginning.”

Brain development

The first hint doctors got that being transgender might be biological came from babies born with Congenital Adrenal Hyperplasia. These mothers carrying female babies in utero have a higher level of testosterone while pregnant. But a higher proportion of these female babies later identity as male in their gender identity, despite having female bodies. Hormone levels during the different stages of brain development appear to play an important role in gender identity formation, said Pickstone-Taylor.

Research on the sizes of the different parts of the brain show that certain parts of the brain are statistically likely to be bigger or smaller depending on whether subjects are male or female. Similar studies on the sizes of these parts of the brain in transgender people show that they follow the statistical pattern for the gender they identify as rather than their birth assigned sex.

Early indications

Gender-diverse children also usually present with a range of co-exiting psychological problems. Younger children present with somatic problems (headaches or tummy aches) and school avoidance. “They hate being forced, for instance, into dresses or being constantly misgendered,” said Pickstone-Taylor. Older children develop emotional and behavioural problems. Later, these children develop full blown anxiety and depression syndromes.

“If we do nothing, by the time these children are 18, 50% would have tried to kill themselves.”

“If we do nothing, by the time these children are 18, 50% would have tried to kill themselves. This is probably the worst outcome for any group of young people.”   

Talk therapy to change gender identity, or sexual orientation (reparative therapy) has been shown not to work and causes significant, long-lasting damage to children.

“It is crushing for children to have to go to therapy week after week and having to work on something they can’t change,” said Pickstone-Taylor. “That form of therapy causes a far higher suicide rate in young people and certainly a lot of depression and anxiety.

“Some of these transgender children don’t want to be different. They want to fit in and might even pretend to be straight or cisgendered, but five years later they are still homosexual or transgender.”

Trying to change a child’s gender identity is a form of child abuse, he said.

“For many it’s like the rape victim. They’re ashamed to speak about the trauma of reparative therapy for years.”

Evaluation and care strategy

Early help and support completely change a transgender child’s prognosis. The World Professional Association of Transgender Health has produced best evidence-based guidelines on how to support transgender youth. Clinicians in all major gender clinics follow these closely, Pickstone-Taylor said.

Guidelines recommend first that these children are thoroughly evaluated by a mental healthcare practitioner with requisite experience in gender diversity and child development.

“Establishing whether a child is transgender is usually relatively easy, as they have thought about it for years and are abnormally advanced in understanding gender,” he noted.

“It is important that parents understand and support their children in their gender journey.”

The evaluation is also crucial to be able to support the child in the process and treat any co-existing psychopathology.

“It is important that parents understand and support their children in their gender journey, as studies show that transgender children do not do well without their parents’ support.”

A very high proportion of them are also neurodiverse and on the autism spectrum, he said.

“And we need to explain all of that and ensure adequate support is put in place, not only for the transgender aspects.”

Transitioning socially

Guidelines recommend that ideally these children should be allowed to express themselves socially as freely as possible. They should also be allowed to make social transitions, including at school, which is usually a “highly binary and transphobic experience for most gender-diverse children in South Africa”.

“This means changing names and pronouns, toilets, school uniforms and choosing who they play sports with, if the child wants these changes,” he noted.

“It’s like pulling out a thorn.”

In the Western Cape, over 60 schools with learners from all backgrounds have had social transitions, supported by UCT clinical social worker Dr Ron Addinnal, and Pickstone-Taylor. The teachers and staff have also received psychoeducation and guidance on how to communicate to parents and learners on the subject.

In the schools where this advice has been followed, there has not been a single case of significant bullying to the gender-diverse child and the whole process is usually reported as a ‘non-event’.”

He added, “For pre-adolescent gender-diverse children, all their associated psychopathology disappears overnight when they are supported and allowed to socially transition. It’s like pulling out a thorn.”

Physical transitioning

No endocrine or surgical interventions are necessary for pre-adolescent children. However, puberty is especially difficult for children questioning their gender identity, Pickstone-Taylor said.

“Once a person has completely gone through puberty, it’s hard to change the body so that they can pass as male or female.”

Fifty percent of people transitioning as adults do not fully pass as male or female. This results in very poor mental health outcomes and 40% attempt suicide.

“We know that once puberty starts, 90% of children who identify as transgender are never going to stop identifying as transgender. In youth requesting these, and with their parents’ consent, hormone blockers are started at puberty.”

Once puberty has been ‘put on ice’ these individuals’ mental health improves and their suicidality disappears, he noted.

“Hormone blockers are also totally reversible. If a youth wishes to stop them, they can go on to develop normally as their birth-assigned sex. If they continue to identify as the opposite sex, cross-sex hormones can be started at around 15 years old.”

“Their mental health improves dramatically to within normal health levels as for their same aged peers.”

The outcomes are very good, said Pickstone-Taylor. If they start on this protocol early enough, youth pass 100% as the gender they identify as.

“Their mental health improves dramatically to within normal health levels as for their same aged peers and under 1% ever choose to stop taking the hormones or have a change in gender identity.”

‘Top surgery’ to remove breasts is sometimes supported for those under 18 years old. “As being a boy with breasts is extremely distressing and causes poor mental health.”

However, in South Africa, the costs of this surgery are high so very few follow this route before they are 18. ‘Bottom surgery’ is given only after the age of 18.

As he underlined throughout his lecture, parents must be fully informed and supportive of their children on this journey.

“Because at the end of the day it is their choice. It’s not the doctor’s choice. The doctor is there to inform people of their options, not make decisions for families.”