Most of us never gave much thought to our gender identity growing up. As we navigated our way through childhood and adolescence, we felt comfortable – for the most part – aligning with the expected behaviors associated with our gender. It was a non-issue. Sadly, however, that’s not the case for some individuals. They never feel comfortable in their bodies. They deeply believe that nature made a terrible mistake, that they’re trapped in the wrong body. This intense “disconnect” with the sex they were assigned at birth can cause significant distress or “dysphoria”, known as gender dysphoria (previously known as gender identity disorder).
Life for teens struggling with gender dysphoria can be extremely challenging. Parents are often baffled and worried, wanting to ease their child’s pain but not sure what to do to help. This brief guide is designed to help you identify the signs of adolescent gender dysphoria and determine the best steps to take to help your teen.
Statistics and Facts about Gender Dysphoria
- Throughout their lifetime, over 70% of individuals with gender dysphoria will have another psychiatric disorder
- Having an unsupportive family greatly increases the risk of suicide (57%) in transgender teens; the suicide rate of those with supportive families is only 4%
- Research suggests suicide risk is high in transgender youth, with 50% attempting suicide before the age of 20 according to a 2011 survey of 6500 transgender individuals
- A 2016 study found that over 40% of transgender youth have engaged in cutting or other forms of non-suicidal self-harm, and 30% have attempted suicide at least once
- An estimated 0.3% of U.S. adults identify as transgender
- Transgender individuals are frequently subjected to significant discrimination (including healthcare and housing), verbal harassment, bullying, violent attacks, and social isolation
- While symptoms of gender dysphoria often appear in early childhood, it’s not uncommon for them to first appear during adolescence or, in some cases, even adulthood. Also, feelings of dysphoria don’t always accompany gender incongruence; in some cases, it may develop years later – or not at all.
Co-Occurring Disorders
Individuals with gender disorder often have another mental health disorder, such as:
- Depression
- Anxiety
- Specific phobia
- Adjustment disorder
- Substance use disorders
- Posttraumatic stress disorder
- Asperger’s syndrome
- Bipolar disorder
- Eating disorders
Looking for and Recognizing the Signs of Gender Dysphoria
Some adolescents with gender dysphoria exhibited gender-nonconforming behaviors as children. However, that’s not always the case. When gender dysphoria emerges during the teens years many parents are caught completely off guard.
Teens may go out of their way to hide their struggles with gender identity. This is often due to their fear of ridicule, judgment, rejection, or condemnation – not only from peers and others, but also – and sometimes especially – from their parents. That’s why it’s so important for you to know what to watch for so you can recognize the signs of gender dysphoria in your teen. Doing so will enable you to get your teen the help he or she needs.
It should be noted that gender dysphoria isn’t the same as being gay or lesbian. Nor should it be confused with “gender nonconformity”, i.e. behaving in ways that don’t align with gender stereotypes or norms associated with one’s gender at birth (“assigned gender”).
Signs to watch for include:
- Conviction that they were born the wrong gender
- Strong, persistent discomfort with their own gender
- Feelings of disgust with their genitals
- Avoiding activities that would require them to touch or see their genitals (e.g. having sex or taking showers)
- Preoccupation with ridding their body of primary and secondary sex characteristics through surgery, hormones, or other medical procedures
- A deep-seated belief that they feel and react in ways typical of the opposite gender
- Expressed desire that others treat them and refer to them as their gender identity
- Dressing and altering their outward appearance to pass as their gender identity
- Expressed desire to live as their gender identity
- Feelings of social isolation
- Distress caused by the conflict between their biological sex (assigned gender) and the gender they identify with
- The internal conflict causes impairment in one or more significant areas of life
- His or her desire to be the opposite gender is not due to social or cultural benefits or advantages associated with the other gender
- The distress is not related to a physical intersex condition
Associated signs of gender dysphoria may include:
- School aversion
- Low self-esteem
- Non-suicidal self-harm (e.g. cutting, burning)
- Depressed mood
- Suicidal thoughts and behaviors*
*Suicidal thoughts or behaviors should never be ignored. Don’t assume your teen is just being “dramatic” or manipulative. The risk of suicide is particularly high for teens suffering from gender dysphoria.
Knowing the First Steps to Take
If your teen is exhibiting signs of gender dysphoria there are several things you can do to help:
1 – Talk to your teen. Discussing your teen’s gender identity with him or her must be handled delicately. Before you broach the topic, it’s imperative that you do your best to set aside any personal judgments and negative feelings you may have about transgender individuals for now.
Let your teen know that you have concerns regarding the behaviors you’ve been noticing, that you want to help in any way you can, and that you’re there if he or she wants to talk – about anything. Be prepared for a defensive response or denial. If your teen opens up to you and confirms your worst fears, stay calm.
2 – Set up an appointment for an evaluation. Your family doctor or teen’s pediatrician can do a preliminary evaluation. However, it’s essential that you have your teen evaluated by a child and adolescent psychologist or psychiatrist, preferably one who either specializes in working with transgender individuals or has experience treating gender dysphoria. It’s in your child’s best interest to find someone, if possible, who understands the unique challenges of teens struggling with gender identity issues. Your family doctor or pediatrician may be able to give you a referral or recommendation.
3 – Get your teen into treatment. Treatment for gender dysphoria in teens often involves a multidisciplinary approach, including both medical and mental health professionals as well as other specialists. One of the toughest decisions facing parents is whether to pursue medical intervention (i.e. puberty suppression, hormone therapy, and / or gender reassignment surgery) in the hopes of alleviating the gender dysphoria. Delaying those treatments can make transition more challenging at a later age, but pursuing them prematurely is also risky.
It’s important to understand that treatment for gender dysphoria isn’t about changing your teen’s gender identity or how your teen feels about his or her identity. Rather, it’s to help your teen cope with the distress accompanying those feelings.
If possible, find treatment providers who are members of the World Professional Association for Transgender Health (WPATH). You can check to see if there are providers in your area via their website at WPATH.org.
Generally, the best approach is to start with therapy before making any decisions regarding transitioning. Initial treatment may include a combination of the following:
- Individual psychotherapy
- Psychiatric medication (if indicated, for symptoms of depression, anxiety, or other comorbid disorders)
- Family therapy
- Individual or couples therapy for parents
- Peer support groups (for the teen with gender dysphoria)
- Parent support groups
Individual psychotherapy, or “talk therapy”, can help your teen sort through and understand his or her struggles with gender identity, weigh the pros and cons of transitioning, and help him or her find healthy ways to cope with the challenges of living as a transgender individual (e.g. feelings of isolation). It will also address any comorbid disorders, such as depression or social anxiety.
Psychiatric medications, such as antidepressants, can help treat symptoms of depression, anxiety, or other comorbid psychiatric disorders.
Peer support groups can help your teen feel less isolated, while allowing the opportunity to talk openly and safely about his or her feelings with other teens experiencing gender dysphoria.
Family therapy can help you and other family members come to terms with personal feelings about transgender individuals. It can also help you find ways to provide a supportive environment for your teen.
As a parent, you (and your spouse or partner) may also benefit from individual or couples therapy or attending a parent support group.
Other forms of treatment for gender dysphoria may include:
- Puberty suppression
- Hormone therapy
- Gender reassignment surgery (GRS)
Puberty suppression – This involves the use of medications known as puberty blockers to delay or suppress the development of secondary sex characteristics. There is limited research regarding the long-term effects of puberty suppression, and side effects and risks must be carefully weighed.
Cross-sex hormone therapy – This involves the use of hormones to alter secondary sex characteristics. Some transgender individuals find hormone therapy sufficient for their needs, while others prefer to eventually undergo surgery to further the transition.
Gender reassignment surgery – Also known as sex reassignment surgery (SRS) or gender confirmation surgery (GCS), this involves reconstructive surgeries that allow for a complete physical transition to the gender they identify with. (It’s important to note that this should not be referred to as a “sex change operation”.)
Puberty suppression, hormone therapy, and gender reassignment surgery all carry risks that must be carefully considered. Also, there is no guarantee that any of these medical interventions will resolve your teen’s feelings of dysphoria.
It’s important to note that some teens with gender dysphoria primarily wish to be supported and recognized as the gender with which they identity, and may not desire to physically alter their body via puberty suppression, hormone treatment, or surgery. Research shows that the risk of emotional distress, depression, anxiety, and suicide is often substantially reduced when they feel truly supported.
Supporting and Encouraging Your Teen
There are many things you can do to support and encourage your teen during his or her struggle with gender dysphoria. Two critical things to remember are 1) your child’s struggle isn’t a sign of weakness and 2) gender dysphoria isn’t something your child can simply “overcome” with sheer determination, nor can your child merely decide to accept his or her assigned gender and be “fine” with it.
Things you can do as a parent include:
- Learn everything you can about gender dysphoria, it’s treatment, the terminology, and the challenges faced by transgender teens
- Educate yourself regarding the risks versus the benefits of puberty suppression, cross-sex hormone therapy, and gender reassignment therapy
- Practice empathy and be compassionate. Don’t expect to understand what your teen is experiencing – it may seem completely foreign to you, but it’s a very real struggle for your teen.
- Don’t judge, shame, or ridicule your teen’s gender identity
- Be supportive of your teen’s gender nonconformity. Refrain from pressuring your teen to dress, look, and behave according to cultural norms (or your own expectations) based on the gender he or she was assigned at birth
- Show your support by addressing your teen by his or her preferred name and use the pronouns that fit his or her gender identity. Also, ask your teen about how he or she would like to be addressed when out in public
- Understand that your support and affirmation of your teen’s gender identity can greatly reduce the emotional distress he or she experiences
- Find a healthy way to manage your own discomfort with your teen’s gender identity
- Make sure your teen gets professional help for underlying issues (e.g. feeling distress about the physical changes that come with adolescence)
- Be willing to set and enforce appropriate boundaries
- Work closely with your spouse or partner to ensure you’re on the same page when it comes to rules and boundaries for your teen
- Nurture your relationship with your teen; make yourself available to talk and listen, and spend quality time with your teen
- Love and accept your child unconditionally
- Focus on helping your teen love and accept his or her body and the reality that he or she may never fit society’s expectations for his or her assigned gender.
- If transition is the goal, you can help by allowing your teen to take initial steps such as voice training, laser hair removal, etc.
What to Do When Things Escalate
The challenges faced by teens with gender dysphoria can be intense, making them especially vulnerable to things escalating quickly. As mentioned above, many individuals with this disorder suffer from depression or other psychiatric disorders. Substance use can quickly make things worse., and the risk of suicidal thoughts and behaviors is significant. Transgender teens are also frequent targets of bullying and violence, both of which can trigger an escalation.
If your teen is becoming increasingly depressed, actively suicidal, engaging in self-harm, or exhibiting any other type of acute emotional distress, take immediate steps to ensure his or her safety and wellbeing. A visit to the nearest ER or a brief hospital stay may be necessary to keep your teen safe from self-harm and / or stabilize symptoms.
Don’t hesitate to reach out for help. You can:
- Contact your teen’s treatment provider asap
- Enlist the help of a close family member or friend for support or assistance
- Call an emergency hotline
- Take your child to the nearest hospital emergency room (if you can do so safely)
- Call 911
When Individual Therapy isn’t Enough
Due to the complexities of gender dysphoria, as well as the frequency of comorbid disorders such as depression or social anxiety, individual therapy often isn’t sufficient. Additional treatment, usually in the form of a more intensive level of treatment, may be necessary for your teen. If he or she is:
- Sabotaging or refusing to cooperate with the therapy process
- Abusing alcohol or drugs
- Experiencing severe depression, anxiety, PTSD, or other psychiatric symptoms that requires a more intensive level of care
- Actively suicidal – threatening or planning suicide, and / or engaging in suicide gestures or attempts
- Frequently engaging in non-suicidal self-harm behaviors
- Is struggling to function at school or in other areas of life then it’s time to consider a more intensive level of treatment. This may involve:
- Intensive outpatient treatment (IOP) / Psychiatric day treatment
- Dual diagnosis treatment (if substance abuse is occurring)
- Residential treatment
- Inpatient psychiatric treatment
Intensive outpatient treatment or psychiatric day treatment can vary in terms of the amount of time spent in treatment and how many times a week your teen is required to go. These programs are often the next step up from regular outpatient treatment.
Dual diagnosis treatment is often necessary if your teen has a substance use disorder in addition to gender dysphoria. Alcohol and / or drug use almost always diminishes the effectiveness of therapy. A dual diagnosis program addresses the substance use issue as well as your teen’s gender dysphoria (and any other psychiatric issues) simultaneously. Dual diagnosis treatment may be part of a residential treatment program or an outpatient program.
Residential treatment requires having your teen live at a non-hospital treatment facility that specializes in treating teens with gender dysphoria and other psychiatric disorders. Residential treatment typically lasts between 30 to 180 days, depending on the severity of symptoms and how well your teen is progressing in treatment.
Inpatient psychiatric treatment in a hospital setting is the highest and most intensive level of treatment for teens with gender dysphoria. Often, this level of treatment is used to treat symptoms of severe depression and / or suicide risk co-occurring with gender dysphoria with a focus on stabilization and safety. Patients are monitored 24/7. Hospitalization is usually relatively brief.
Taking Care of Yourself
Knowing that your child is suffering is very difficult for any parent. Realizing your child may be transgender, and understanding the many challenges they may face as a transgender individual, can elicit a wide range of conflicted emotions, including fear, sadness, and helplessness. Since your struggling teen needs to be able to rely on your strength, love, and guidance, it’s imperative that you take steps to take care of yourself.
A few things you can do include:
- Get support from other parents with teens dealing with similar issues
- If you’re struggling to accept your teen’s gender identity, consider reaching out to PFLAG (Parents, Families, and Friends of Lesbians and Gays – pflag.org) for support
- Talk to a therapist or counselor so you have an objective sounding board to process your feelings
- Find healthy ways to manage your stress, such as yoga and regular exercise
Gender dysphoria can be successfully treated. However, even if the dysphoria resolves your teen’s gender identity may not change. Your unconditional love, support, and acceptance will help and ensure that your teen has a happy, fulfilling life as a transgender individual.
