Put yourself in the shoes of teenagers who feel different from their birth genders—like two of my patients. One, a young adult, has not identified as male or female, and prefers to be referred to by the pronouns "they, them and their." Another whose gender at birth was female, has told me that he never thought of himself as a female. He wears a chest binder to minimize his breasts and wants medical help to stop menstruation.
I can tell you the path isn't easy for these teens as they navigate their identities. On top of this, the Trump administration recently announced it is considering narrowly defining gender as a biological, immutable condition determined by genitalia at birth. This move would roll back recognition and protections of transgender people under federal civil rights law.
Pronouns matter, as do definitions. "Gender identity" refers to one's internal sense of who one is, based on an interaction of biological traits, developmental influences and environmental conditions, according to Human Rights Campaign. Gender identity can't be changed by any intervention.
This identity may be male, female, somewhere in between, both or neither. Gender identity develops over time. "Gender diverse" refers to a person whose gender identity, expression or perception does not conform to the norms and stereotypes others expect. "Transgender" is usually used when gender-diverse traits remain over time. "Sexual orientation" refers to the gender someone is attracted to.
How common is gender diversity, and is it a disorder? Up to 1.3 percent of adolescents and young adults identify themselves as transgender. That makes it as common as the percentage of people who have obsessive compulsive disorder and inflammatory bowel disease. But is being transgender a psychiatric diagnosis or a medical diagnosis?
In my opinion, the answer is "no," but with a caveat. According to the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the diagnosis of "gender dysphoria" is given to someone who has at least two of six criteria for at least six months. This includes:
A strong desire to be of a gender other than one's gender assigned at birth
A strong desire to be treated as a gender other than one's assigned gender
A significant incongruence between one's experienced or expressed gender and one's sexual characteristics
In addition, the condition must be associated with "clinically significant distress or impairment." It's this part of the diagnostic criteria that makes gender dysphoria part of the DSM-5, and it highlights the hardships that individuals with gender dysphoria experience. I feel that gender diversity is not a mental disorder, but these individuals experience high rates of depression, anxiety and other mental health issues.
LGBTQ youth in distress. I recently attended a workshop led by Erica Smith, M.Ed., a support group coordinator and sexuality educator for the Adolescent Initiative at the Philadelphia Juvenile Justice Services Center and Gender and Sexuality Development Clinic at the Children's Hospital of Philadelphia. Here are a few alarming statistics she mentioned about LGBTQ youth:
Nine out of 10 students reported being harassed at school.
At least 40 percent of the homeless youth population nationwide, and a higher percentage in Philadelphia, are LGBTQ.
They are three times more likely to be in the juvenile justice system.
Smith also talked about Leelah Alcorn, a transgender girl who committed suicide in 2014. She reportedly planned for her suicide note to be posted on social media after her death. Here are excerpts from her note:
"Please don't be sad, it's for the better. The life I would've lived isn't worth living in…because I'm transgender…I feel like a girl trapped in a boy's body, and I've felt that way ever since I was 4…The only way I will rest in peace is if one day transgender people aren't treated the way I was, they're treated like humans, with valid feelings and human rights. Gender needs to be taught about in schools, the earlier the better.…Fix society. Please. Goodbye, (Leelah) Josh Alcorn"
What can parents do if their child is transgender? The American Academy of Pediatrics recommendations include:
Respond with support
Connect your child with LGBTQ organizations, resources and events.
Stand up for your child: do not minimize social pressure or bullying.
Recognize the danger signs including anxiety, depression and low self-esteem, and seek mental health support.
As a physician and parent, I agree and I urge all of us to support children's rights—for every child. Here are a few local and national resources for LGBTQ youth: Gender and Sexuality Development Clinic at CHOP; Resources for LGBTQ Youth By State from Lambda Legal; Philadelphia magazine's Top LGBT Youth Resources in Philadelphia; The Trevor Project and the Centers for Disease Control and Prevention's LGBT Youth Resources.