Jason Rafferty, MD, MPH, EdM, FAAP — a Triple Board-certified paediatrician and child psychiatrist at Thundermist Health Centers (a patient-centred medical centre in Rhode Island). He specialises in the treatment of substance use disorders in adolescents and in gender and sexual development, and also works at specialist clinics at Hasbro Children’s Hospital and Emma Pendleton Bradley Hospital.
Dr Rafferty carries out advocacy work at local and national levels in collaboration with the American Academy of Paediatrics on topics including the emotional health of young men, support for LGBTQ youth, and the prevention of child homelessness.
Introduction
Raising a child with a diverse gender identity can raise questions and concerns for parents — particularly regarding the child’s mental wellbeing. Research shows that gender is linked to what we are born with and cannot be ‘changed’ through interventions. Therefore, rather than trying to predict or prevent who the child will become, it is better to see and value them for who they are right now — especially at a young age. This approach strengthens attachment and promotes resilience.
The American Academy of Paediatrics recommends that the home should be a place where a child feels safe and understands that they are loved unconditionally just as they are. Below are some common questions parents have about gender identity.
Will my child grow up to be transgender?
By pre-school age, children begin to recognise gender differences — both physical and social. Their feelings, thoughts and imagination develop, enabling them to explore the topic of gender. It is important to recognise that cross-gender preferences and play are a normal part of this exploratory process, regardless of the child’s future gender identity.
At the same time, research shows that children who express a gender-diverse identity understand their gender just as clearly and consistently as other children. They benefit just as much from support, love and social acceptance.
In the past, children’s gender-diverse statements were often considered ‘possibly true’ and not acknowledged until the child was ‘old enough’. This approach is unhelpful: it increases discomfort and deprives children of vital support and understanding. The best thing parents can do is to love and value their child just as they are right now.
What has caused my child to identify with a different gender?
We do not fully understand why some children feel gender-diverse or transgender. However, research shows that gender identity is linked to biology, development, socialisation and culture.
There is no evidence that parents are ‘to blame’ for a child’s gender identity if it does not match the sex assigned at birth. Childhood trauma does not cause a child to become gender-diverse or transgender, nor does it determine their sexual orientation. Differences in gender identity and self-expression are normal manifestations of human diversity.
If mental health issues arise, they are most often linked to external factors: bullying, discrimination and other negative experiences. Being ‘different from everyone else’ is really not easy, especially in childhood — and it can lead to teasing or bullying. If this happens, discuss the situation with the teaching staff and work together to develop a plan to prevent bullying. And most importantly: support, love and accept your child just as they are.
The child is still exploring their gender identity but is very stressed about puberty. What can be done?
During puberty, hormone blockers can be used to temporarily halt physical development. This is a reversible measure that gives the person more time to explore their gender identity.
Available evidence suggests that delaying puberty in transgender children is usually associated with improved psychological well-being during adolescence and young adulthood.
For children assigned female at birth, periods can be particularly difficult. These can be reduced or stopped using blockers or certain forms of contraception.
What treatment options are available to children who identify as transgender? What does the process involve?
When a person declares their stable gender identity, they may undergo a gender affirmation process (sometimes referred to as ‘gender transition’). This process involves reflection, acceptance and — for some — medical interventions.
There is no single ‘right’ path, sequence of steps or mandatory end point. The process may include:
1) Social affirmation
Reversible changes where a child or teenager expresses their gender identity through hairstyle, clothing, pronouns, name, etc.
2) Legal affirmation
Formalising elements of social affirmation (e.g. name and gender marker) in official documents: birth certificates, passports, school records, etc. Procedures vary by region and often require documentation from medical professionals.
3) Medical affirmation
The use of hormones to allow adolescents, after the onset of puberty, to develop characteristics of the other sex. Some changes may be partially reversible upon discontinuation of hormone therapy, whilst others are not.
4) Surgical confirmation
Surgical procedures are more commonly used in adults, but in some cases in older adolescents to alter certain physical characteristics (such as the chest or genitals). These changes are irreversible.
The decision to begin affirming treatment is a personal one and requires careful consideration of the risks, benefits and factors unique to each child and each family. Ideally, support should be provided by a team comprising: the child/teenager, the family, the primary care doctor, a mental health specialist (preferably with experience working with transgender and gender-diverse young people), social support services, and a paediatric endocrinologist or a specialist in adolescent gender medicine (if available).
Is it possible to arrange a remote consultation with a doctor?
Ask your paediatrician if a remote consultation via telephone or video call is possible. The child may feel more comfortable talking to the doctor from home.
It is important to provide teenagers with as private a space as possible so that they can talk one-on-one. You can agree in advance to discuss matters with the doctor before or after the private part of the conversation.
If the teenager feels more at ease with the camera turned off during a video call, they can ask the doctor for permission to do so. Follow-up appointments to monitor progress can also take place remotely.
If a child says they are ‘gender-fluid’, does that mean they are confused?
No. For some people, gender identity can be fluid: it may feel more ‘masculine’, ‘feminine’, intersex or otherwise — in different contexts or at different times. This can be part of a personal journey or a process of self-discovery.
Can a child become transgender ‘under the influence of friends’ or the internet? What if there were no signs before?
Being transgender is not ‘contagious’. Some children and teenagers may not express or may suppress gender-diverse feelings until they encounter a safe, supportive environment — among peers or in online communities. When support becomes available, coming out may seem sudden and unexpected to parents.
