The word “transition” simply means change. A gender diverse person may go through any number of changes to achieve their gender authenticity. These steps are delineated in four primary categories: social, legal, medical, and surgical.
There is no “right” way to transition – each individual will identify what will best work for them. For children, these decisions are best made within a supportive environment with the child’s physical, psychological, and emotional well-being firmly centered as the top priority.
Social transition is the first step for many transgender people, whether they are children, teens, or adults. For some, social transition-related steps are the only steps they’ll need or want to take. For others, it is part of an ongoing process that includes additional steps.
A social transition may include changes in, among other things,
- hair length or style
- clothing or jewelry
- makeup use
- manner of speaking
- name and pronoun usage
It can involve situational changes that can include
- using a different restroom or locker room
- participating in different activities
- sharing identity with others (i.e. announcements to friends, social media circles, etc.)
A person might share this information widely — at home, school, or work — or they might disclose these changes only to family and close friends.
Using the correct pronoun and any new name they may have chosen shows support and acceptance of that person’s identity. It can be challenging to make these changes at first. Understand that, for some, not using the correct name and/or pronoun, beyond invalidating that person’s identity, could place them in danger or subject them to discrimination, harassment, or abuse in some situations. A social transition is most commonly the first (and sometimes only) form of transition youth experience before puberty.
The legal processes related to gender transition can vary widely from state to state, but all states including Washington D.C. allow legal name changes. Birth certificate changes are another story.
Some states outline straightforward steps for changing birth records, some are more complex, some fraught with inequities, and other states have no way to change one’s birth designation. Barriers like these can hinder, complicate, or prevent a person’s legal gender transition. Amending a birth certificate may seem unnecessary at first, yet it can prevent a child from participating in certain sports or activities. For teens or adults, an inability to change documents may prevent them from getting a job because of an I.D. document incongruity. Some states present even more obstacles to amending a birth certificate by insisting on irreversible surgical requirements as part of the approval criteria. Many trans people, for multiple reasons, do not pursue surgical changes and are therefore denied this crucial transition-related document correction. Expecting surgical requirements for young children simply makes no sense.
Over time, more and more states are streamlining I.D. document change procedures and taking into consideration the diverse needs of trans people. While processes still vary state by state, the U.S. Department of State has increasingly affirming policies authorizing gender marker updates to social security records and passports. Passports, for example, may only need a letter from a physician regardless of any particular state’s requirements.
Steps for legal transition might include updating the following:
- Name change
- Social Security card
- Driver’s license or state identification card
- U.S. Passport
- Birth Certificate
- School transcripts, diplomas
- Professional licenses
- Bank Accounts
Not all transgender people use medical intervention, whether because of choice or lack of access. Many parents of young children lose a lot of sleep worrying about medical procedures that their child may or may not want. We gently encourage you to take this journey one day at a time.
The following are three types of medical intervention that may be used.
Healthcare professionals working with pre-adolescent children will often prescribe what is commonly described as “puberty blockers” at the onset of puberty. Puberty blockers (medically known as GnRH analogues) cause the body to temporarily stop releasing hormones associated with puberty. This is like pressing a ‘pause button’ on a child’s pubertal development. Puberty blockade does not cause permanent changes in an adolescent’s body. Instead, it pauses puberty, and any associated physical changes, providing time to determine if a child’s sense of their gender identity is long lasting. It also gives children and their families time to gather information and to think about, or plan for, the psychological, medical, developmental, social and legal issues ahead. If an adolescent child stops taking GnRH analogues, which eventually they all will, puberty will resume.
If puberty blockers are started late in puberty, they are not able to reverse most physical changes that have already occurred. However, puberty blockers can stop any further pubertal changes.
For children who experience body dysphoria in relation to their gender, suppressing puberty can have some positive effects including:
- Improved mental well-being
- Reduced depression and anxiety
- Improved social interactions and integration with other kids
- Eliminate the need for some or all future surgeries
- Reduce thoughts or actions related to self-harm
It is important to note that puberty suppression alone might not completely ease gender dysphoria. The delay of pubertal changes, until the later introduction of gender-affirming hormones, is a low-commitment, reversible intervention that is more and more common in the care of trans and nonbinary youth. It is typically used for an approximate duration of 1 to 3 years and can be used in tandem with gradual hormonal intervention for a gender diverse child’s peer-concordant pubertal progression.
The most known side effect of puberty blockers can be a temporary, minor decrease in bone density. It is recommended that a child’s diet is supplemented with calcium, vitamin D, and bone strength-building exercises like walking, jumping, and running. The bone density issue is naturally resolved once the child quits taking the medication.
Hormones – estrogen or testosterone – are often a later part of any adolescent’s pubertal development including trans or nonbinary youth. Hormones can be introduced while on puberty blockers to achieve a measured, gradual pubertal development. Older teens who have already experienced puberty, may begin their medical transition with hormone therapy that supports the pubertal development that most closely aligns with their gender identity. Medical providers approach this hormonal care with the mantra of “start low and go slow.”
A slow pace allows physical changes to occur in a gradual way that is at the same pace as the pubertal development of their peers. Because this intervention is supervised by a doctor, it also is a controlled way to enter pubertal development, especially if a youth is uncertain about bodily changes in relation to their gender identity. Both medical interventions – puberty delay and/or a slow, gradual introduction of hormones – can be very helpful to youth whose gender identity may be less fixed (i.e. nonbinary, genderfluid, genderqueer, gender expansive, etc.) and might need more time to determine the best pubertal route.
In most states, individuals seeking hormone therapy may need a letter from a mental health professional confirming gender identity treatment and recommendation for hormone therapy. Some professionals take a more intensive approach that involves multiple visits, while others will take a shorter approach commonly referred to as “informed consent.” A discerning provider will take all factors into consideration including level of distress that might require more immediate steps, level of family support, developmental stage of puberty, length of time of gender identification, and other variables.
It is important to note that nonbinary identified individuals are also faced with decisions about hormonal intervention. Human bodies require hormones for optimal health and development. There are only two hormonal options – estrogen or testosterone. Nonbinary and other gender diverse individuals may also experience dysphoria, be misgendered, and/or desire to be perceived in society as a certain gender. Hormone therapy can benefit them in the same way it benefits other trans people.
A Note to Parents
Some youth may be firm in the knowledge that they are transgender and are ready to begin transition. Yet, parents or doctors may still be apprehensive and hesitant, wanting to be certain themselves. We know that waiting can be harmful, and a definitive certainty for everyone can be elusive. Changes that occur in puberty, combined with medical inaction, may induce even deeper dysphoria, having a greater mental health impact.
Trans teens often experience higher levels of depression, substance abuse, anxiety, have a much higher risk of suicide and other risk factors. Medical intervention is recommended by medical and mental health associations such as the American Academy of Pediatrics, the American Medical Association, the American Psychological Association, and many more. Those who are able to access medical intervention often report significant improvement in mental health and emotional well-being.
Gender Confirmation Surgery (GCS)
Gender diverse people may pursue various gender confirming surgical procedures as part of their transition process. Many do not. It is a common misconception that surgical procedures are desired by all trans people. It is also a misconception that every trans person’s end goal is to “pass” (being fully recognizable by all as either male or female) as the “opposite” gender. Additionally, there are oftentimes barriers to accessing these procedures that can prevent those who do want them from being able to have them.
Some surgeries are more involved, perhaps having several stages that make take years to complete while others are less invasive outpatient procedures. Possible surgical options include genital surgeries, removal of gonads, facial feminization surgeries, chest/breast procedures, tracheal shaves, nose shape/size changes, and vocal cord modifications. Researching and selecting a surgeon should be well-thought out and not hurried, as these changes are permanent.
In the past, gender confirming surgeries were not covered by insurance. That has changed significantly. As a result, more people who wish to pursue surgery can, and there are more surgeons vying to reach those “customers.” Surgeons with the most experience and skill may have much longer waiting lists. Do not be in a hurry, do your research, and if at all possible, be willing to travel to the surgeon that you feel will do the best job possible.
Some surgeries are available to minors, but it almost always requires parental or guardian consent. An emancipated minor could be an exception. The primary surgery pursued by families for their minor age teen is chest reconstructive surgery and has been done successfully for youth as young as 13 or 14. Variables impacting a surgeon’s decision for youth under the age of 18 are duration of time living in congruence with their gender identity, degree of parental or guardian support, level of distress with pubertal changes, and other considerations. Many surgeons will require one or more letters of support from a mental health professional and may have additional requirements. Explore these ahead of time so there are no unexpected delays.
Note: Many parents of young children lose a lot of sleep worrying about surgical procedures that their child may or may not want. We gently encourage you to take this journey one day at a time.