Week 7 Assignment

Social Transition: Supporting Our Youngest Transgender Children Ilana Sherer, MD

Those of us who work with

transgender children frequently face

decisions based on evidence that is

conflicted or lacking and encounter

opponents who are rightfully wary

about what they see as experimental

treatments without well-examined

outcomes. However, in a transgender

population where nearly one half

experience suicidal ideation, the risk

of nonintervention is quite high.1

In this issue of Pediatrics, Olson and colleagues2 provide evidence

in support of social transition, a

completely reversible intervention

associated with lower rates of

depression and anxiety in transgender

prepubescent children. Socially

transitioned children, or those who

have adopted the name, hairstyle,

clothing, and pronoun associated

with their affirmed, rather than

birth gender, have become more

visible in the media over the last

several years. Although to date there

has been no published evidence to

support providers in suggesting social

transition as a beneficial intervention,

many families, often guided by

mental health professionals, make

that decision based on observational

evidence in response to seeing how

suffering can be alleviated by allowing

the child to express their own sense of

gender.

Much of the research that is available

on transgender youth and adults

points to the dismal psychosocial

outcomes faced by this population.

Homelessness, substance abuse, HIV

infection, depression, anxiety, self-

harm, and suicidality are much higher

than in the general population, and

are thought to result from family

and community rejection.3, 4 In the

last decade, we have learned that

medical interventions, including

hormone blockers and later

phenotypic transition with feminizing

or masculinizing hormones, can

improve these outcomes in youth.4, 5

We have also learned the key role that

family acceptance plays in improving

outcomes.6

Olson and colleagues report on

the mental health outcomes of

prepubescent, socially transitioned

transgender children, comparing their

depression and anxiety scores with

those of age-matched controls. They

interpret these scores in light of the

findings of previous studies of children

with the diagnosis of gender identity

disorder (GID; a diagnosis that has now

been replaced by gender dysphoria in

the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) who had not socially transitioned. Children

in the Olson sample who had socially

transitioned had depression scores

equal to their cis-gender peers and

anxiety scores dramatically lower than

the GID study sample (although anxiety

scores were higher than age-matched

peers and siblings). The authors use

social transition as a proxy for family

acceptance. Although families can be

accepting without allowing a social

transition, social transition can be an

incredibly affirming process for the

child, showing the child that their

identity is supported.

The rationale cited by those who

oppose social transition are that

children cannot possibly know their

gender at such an early age and that

social transition could encourage

Palo Alto Medical Foundation, Dublin, California; and Child

and Adolescent Gender Center, Benioff Children's Hospital,

University of California, San Fransisco, California

Opinions expressed in these commentaries are

those of the author and not necessarily those of the

American Academy of Pediatrics or its Committees.

DOI: 10.1542/peds.2015-4358

Accepted for publication Dec 8, 2015

Address correspondence to Ilana Sherer, MD, Palo

Alto Medical Foundation, 4050 Dublin Blvd, 2nd Floor,

Dublin, CA 94568. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,

1098-4275).

Copyright © 2016 by the American Academy of

Pediatrics

FINANCIAL DISCLOSURES: The author has indicated she has no fi nancial relationships relevant to this

article to disclose.

FUNDING: No external funding.

POTENTIAL CONFLICT OF INTEREST: The author has indicated she has no potential confl icts of interest

to report.

COMPANION PAPER: A companion to this article can be found online at www. pediatrics. org/ cgi/ doi/

10. 1542/ peds. 2015- 3223.

PEDIATRICS Volume 137 , number 3 , March 2016 :e 20154358 COMMENTARY

To cite: Sherer I. Social Transition: Supporting Our Youngest Transgender Children. Pediatrics.

2016;137(3):e20154358

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SHERER

children to later seek out treatment

of medical transition.7 A 2013

study by Steensma and colleagues8

looked at factors associated with

“persistence”, that is eventual

pursuance of medical treatment, and

“desistance” of gender dysphoria.

Among the factors associated

with persistence was early social

transition. This set up a “chicken

or egg” question: is it early social

transition that leads to later

transgender identification or are the

children most likely to identify as

transgender later on also more likely

to socially transition? Those most

likely to seek out later transition are

also those with the strongest sense

of dysphoria, an older age at the time

of the study, and those most likely to

describe their identity in declarative,

rather than affective form (ie, “I am

a boy, ” as opposed to “I feel like a

boy.” Thus, the “persisters” may be a

qualitatively different group than the

“desisters, ” and further research may

be able to distinguish them at earlier

ages.

Proponents have argued that social

transition is useful both in improving

function in those children who are

intensely gender dysphoric and

in helping to test the waters so

to speak; that is, giving the child

a completely reversible way to

explore life in the other gender

before committing to any medical

interventions.9 Observational

evidence has shown that once they

have socially transitioned, children

with intense gender dysphoria

often settle down and show marked

improvement in behavior and mood.

If the child or family later realizes the

need to transition back to the birth

gender, that can also happen, with

the appropriate social supports and

without any irreversible changes.9

Olson and colleagues give supporters

of social transition evidence that

shows what we have suspected all

along: that socially transitioned

children are doing fine, or at least as

well as their age-matched peers and

siblings. This finding is truly stunning

in light of the numerous studies

that show depression and anxiety

internalizing psychopathology scores

up to 3 times higher for non–socially

transitioned children; although, as

pointed out by the authors, there

are some differences in the patient

population of those studies and in the

methods used to rate internalizing

psychopathology. Although it does

not establish a causal relationship,

this finding is crucially important to

professionals who work with these

children, as well as their families,

in showing us that they are not

likely to suffer any additional harm

and may benefit from early social

transition. While there is obviously

more research needed to determine

if providers should recommend

social transition as a beneficial

intervention, for families who have

already chosen this avenue for their

children, professionals should have

no concern over supporting the

family’s (or mental health team’s)

decision, and reassuring the parents

that social transition should have

little negative impact on their child’s

mental health.

ACKNOWLEDGMENTS

I thank Drs. Stephen Rosenthal and

Diane Ehrensaft for their review of

this commentary.

ABBREVIATION

GID:  gender identity disorder

REFERENCES

1. Grossman AH, D’Augelli AR.

Transgender youth and life-threatening

behaviors. Suicide Life Threat Behav.

2007;37(5):527–537

2. Olson KR, Durwood L, DeMeules

M, McLaughlin KA. Mental health

of transgender children who are

supported in their identities.

Pediatrics. 2016;137(3):e20153223

3. Grant JM, Mottet LA, Tanis JE, Harrison

J, Herman JL, Keisling M. Injustice at

Every Turn: A Report of the National

Transgender Discrimination Survey.

Washington, D.C.: National Center for

Transgender Equality; 2011

4. Spack NP, Edwards-Leeper L, Feldman

HA, et al. Children and adolescents

with gender identity disorder

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Pediatrics. 2012;129(3):418–425

5. de Vries AL, Steensma TD, Doreleijers

TA, Cohen-Kettenis PT. Puberty

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6. Ryan C, Russell ST, Huebner D, Diaz

R, Sanchez J. Family acceptance in

adolescence and the health of LGBT

young adults. J Child Adolesc Psychiatr

Nurs. 2010;23(4):205–213

7. Vilain E, Bailey JM. What should you

do if your son says he’s a girl? Los

Angeles Times. May 21, 2015. Available

at: www. latimes. com/ opinion/ op- ed/

la- oe- vilain- transgender- parents-

20150521- story. html. Accessed

November 19, 2015

8. Steensma TD, McGuire JK, Kreukels

BP, Beekman AJ, Cohen-Kettenis PT.

Factors associated with desistence

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dysphoria: a quantitative follow-up

study. J Am Acad Child Adolesc

Psychiatry. 2013;52(6):582–590

9. Ehrensaft D. Found in transition: Our

littlest transgender people. Contemp

Psychoanal. 2014;50(4):571–592

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DOI: 10.1542/peds.2015-4358 originally published online February 26, 2016; 2016;137;Pediatrics

Ilana Sherer Social Transition: Supporting Our Youngest Transgender Children

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