Peter T. Daniolos, MD, DFAACAP.
Faculty member, Harvard Medical School; child and adolescent psychiatrist, Cambridge Health Alliance/Cambridge Hospital, Cambridge, MA; clinical professor, University of Iowa Carver College of Medicine, Iowa City, IA.
Dr. Daniolos has no financial relationships with companies related to this material.
CCPR: Let’s talk about working with families, starting with how you connect with kids and teens about gender and gender identity.
Dr. Daniolos: Gender is more complex than chromosomes and genitalia. Dr. Ann Fausto-Sterling states that sex and gender—like nature and nurture—are interwoven and begin in utero (Fausto-Sterling A. Sex/Gender: Biology in a Social World. New York, NY: Routledge; 2012). Powerful cultural and biological factors shape gender, which can shift. A person may identify as female, male, nonbinary, gender expansive, gender fluid, etc. Don’t lead with questions about gender identity and pronouns, which can force a patient to talk before they’re ready. Allow patients to share their experiences and concept of gender over time. I have no agenda regarding who a patient is or will be. Teens might absolutely know their gender identity, or say that it’s shifted, or say that no labels capture their experience (Editor’s note: See our “Gender Affirming Terminology” table for a glossary of terms).
CCPR: What is the range of experiences you hear about regarding gender identity?
Dr. Daniolos: I’ve had patients who realize they’ve been struggling with their sexual orientation rather than their gender identity or what society expects of their gender roles, and then conclude that they do not need gender affirming care (GAC). Others are equally clear that until their physical form better matches their gender identity, their sense of self remains incomplete and deeply flawed, driving dysphoria.
CCPR: How would you define gender dysphoria?
Dr. Daniolos: According to the DSM-5, gender dysphoria is the distress people experience when their body is different from their self-concept of their gender identity. This self-concept is shaped in part by societal attitudes, including family culture. If your family members, especially your parents, do not accept your sense of gender, not only do you lack support, but your internal self-concept may be plunged into turmoil. Psychologist Irving Goffman wrote in the 1950s about how we tend to reduce people, including ourselves, to our most stigmatized aspects—we internalize homophobia, racism, sexism, and misogyny. If you are a trans person with internalized transphobia and you believe that being trans is wrong, then your depression skyrockets. Some trans individuals present as cisgender at incredible cost to their sense of self, similar to Goffman’s studies of light-skinned Black individuals passing as White. Those patients enjoyed majority privilege and escaped stigma, but at the price of estrangement from their community and the stress of living a double life (Goffman E. Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice-Hall; 1963).
CCPR: Are there any specific considerations or approaches for certain populations?
Dr. Daniolos: Autistic individuals may experience more gender dysphoria, perhaps due to biological, developmental, or social factors. For example, autistic kids often feel outside of typical society, which may broaden their thinking about gender and/or sexuality. Another population to consider involves trauma. Trauma can complicate identity consolidation. You can be both a trans person and traumatized (sexually, emotionally, or physically). I’ve had traumatized patients in therapy identify as trans who realized over time that although they enjoyed shifting their gender expression, at their core they were cisgender and no longer desired to medically transition. I have also worked with traumatized teens suffering from PTSD with identity diffusion, clearly trans, and benefitting from a medical gender transition. This underscores the value of careful, nuanced therapy over immediate intervention for gender identity.
CCPR: How do you conceptualize therapy for patients with gender dysphoria and their families?
Dr. Daniolos: I start with gender expression—how people present themselves to the world: male, female, androgynous, or expansive/fluid/alternating kinds of gender expression. As the patient changes their gender expression, family, peers, and others have reactions that we can sort through in therapy. Some patients have mixed feelings. For example, a patient’s breasts might bother them beyond the usual feelings of adapting to a changing body during puberty, and so they might consider a chest masculinization procedure, yet they might also have no interest in testosterone. Therapy helps them sort through these conflicting feelings. A trans medical student I worked with used therapy to navigate coming out to their loving evangelical Southern family and medical school peers and dealing with painful transphobic comments from attending physicians.
CCPR: Is therapy the standard of care for patients and families receiving GAC?
Dr. Daniolos: The latest World Professional Association for Transgender Health (WPATH) guidelines dismiss the therapy requirement for trans adults. However, for adolescents, WPATH has strengthened the language recommending therapy before irreversible treatments. I see wisdom in that stance. Shifting how one presents to the world in terms of gender expression and/or identity often comes with turbulence! Therapy can help people develop an affirming identity that might change how others see and respond to them. That said, I have respected colleagues who argue that we shouldn’t be gatekeepers to potentially lifesaving GAC. Both arguments are important. Some in the trans community assert: “Who are you to say I need therapy to prove that I’m trans?”
CCPR: How do parents respond to their child experiencing gender dysphoria?
Dr. Daniolos: Society clings to gendered categories and struggles with those who shift. Parents struggle even when they are comfortable with gender fluidity. When the doctor declares “it’s a boy/it’s a girl,” parents develop gendered hopes and dreams for that child. Later, when the child tells parents they don’t identify with their assigned gender, parents may feel their foundation buckling or grieve for the child they thought they had. This can irritate the child, who is more than their gender, and who was previously treasured. Help parents by clarifying what is happening and supporting them to accept their child. When parents do not accept their LGBTQ+ kids, those kids have higher rates of depression, anxiety, and suicidal ideation (Katz-Wise SL et al, Pediatr Clin North Am 2016;63(6):1011–1025). LGBTQ+ kids who feel accepted and loved by their parents do not have higher rates of psychopathology than the general public.
CCPR: Can you give us an example of how you’ve helped parents accept their trans child?
Dr. Daniolos: I worked with a parent who was a devout Christian. He adored his trans child but held religious beliefs that being trans was wrong. We discussed that Christianity is supposed to create spaces of belonging and acceptance for all, without judgment and without reducing a child to a stigmatized part of their identity. This language resonated with him enough to make him cry. He told me that he never intended to reduce his child to what he considered a sin. I could not comment on what he or his church considered sin, but as a physician, I could attest that gender identity is very complex and woven into the biological framework of every child. With time, he reconnected with his child and found a more supportive church.
CCPR: How did you help the child with their parent’s process of acceptance?
Dr. Daniolos: I helped them to understand their parent’s perspectives, reminding them that their self-acceptance also took time, that their parent had just learned this information, and that it might take time for the parent to understand and accept their child’s gender identity. Caitlyn Ryan’s free, evidence-based Family Acceptance Project works with multiple faith traditions, offering paths forward for parents and children (https://familyproject.sfsu.edu/about).
CCPR: How do you help a child who wants GAC but worries about approaching their parents?
Dr. Daniolos: I talk with the child or teen about the possible responses their parents might have and think about what words might help their parents to better understand their hope to make that transition. For instance, “Can we let me live for a while the way I feel about myself? That can help us see what to do next.”
CCPR: How do you talk with parents about a child’s gender expression?
Dr. Daniolos: Gender expression is fluid, influenced by factors like the child’s preferences, parental approval, and peer acceptance. Even if a teen rejects medical treatment for gender affirmation, their gender identity may be expressed fluidly (eg, defying traditional gender norms in clothing). I recall a trans man who, despite starting testosterone, occasionally wore feminine attire, causing distress for his mother. I helped the mother understand that gender expression differs from gender identity and gave examples of historical and cultural variations. Men in this country once wore hose, heels, and wigs; men in the Greek National Guard still wear pleated skirts, to name a few.
CCPR: This is hard on parents.
Dr. Daniolos: Yes. We need to gently help them see that gender expression—the way we dress in the world—is different from gender identity. And we have to help them see that a person’s gender expression can change! A child who wore dresses when they were younger might not want to wear dresses now, but in the future might choose to wear them again. When we allow children to express themselves as they wish, many parents are stunned at how happy their kid is.
CCPR: How are family responses to their child’s transgender identity different than responses to, say, ADHD or OCD?
Dr. Daniolos: With ADHD and OCD, parents usually understand that treatment is necessary. Families who support their child’s transgender identity usually address the emotional needs and support GAC if the child requests it. However, families who view being transgender as a sin, disorder, phase, or choice influenced by peers may withhold support to the child, and the child may look for support elsewhere. What can we say to parents who reject their child’s identity but still love them? I view the child through their parents’ eyes and work with parents to focus their attention on their child’s well-being and happiness rather than stigmatizing their identity.
CCPR: So how should we approach families in these conversations?
Dr. Daniolos: Start at the level of understanding and acceptance of the family members involved. Different family members may have varying responses, ranging from support to hesitation. Avoid making assumptions or prejudgments about their beliefs. Some religious families do not view being transgender as sin or pathology. However, parents may become upset if they think that clinicians are influencing their child in a particular direction. Use open-ended questions: “Tell me what you think about your child’s ideas about their gender.” Ask about their hopes, dreams, and fears for their child. They often worry about their child’s safety and happiness or how others will perceive the child. Spend time listening and talking with parents. This can help them become less rejecting, with significant impact on their child’s well-being (www.tinyurl.com/3ruhswdr). I once worked with a family that slowly shifted from being very rejecting to just a little rejecting, and the child’s response was remarkable. Their dysphoria decreased, they became happier, and their grades improved, which the parents noticed, reinforcing the family’s acceptance even further.
CCPR: Do you use information about the risk of depression or suicide for kids whose families do not accept their gender identity?
Dr. Daniolos: LGBTQ+ youth living in rejecting communities and families have higher rates of depression and suicide, which are distressing statistics. But if you use this information to shame parents, it may push them away. Instead, I weave the information into a positive conversation, highlighting the benefits of growing up in an accepting and loving community. Most religious parents want their child to draw nourishment, not judgment, from their faith tradition. If a family is Catholic, I remind them what the Pope said about homosexuality: “Whom am I to judge? It is time the church concern itself with other graver matters such as poverty and violence rather than wasting time on such matters.” I’ve paraphrased, of course!
CCPR: How do families respond when people change their mind during GAC?
Dr. Daniolos: For patients and families, this is their gender journey. Some people de-transition, even after surgery, and are fine, maintaining that they needed to take the path they did. A better word is re-transitioning. It can be confusing, and some patients and families have pursued lawsuits (Turban JL et al, LGBT Health 2021;8(4):273–280). They felt rushed by the clinician when the issue wasn’t about gender, but rather core self or sexuality. This is not the norm, and it is tragic to restrict GAC for all just because it’s the wrong choice for some patients. Most young people remain happily affirmed in their gender identity, including those who re-transition. Being a good Greek, I note that the original Hippocratic Oath declared: “…and I will take care that they suffer not hurt nor damage.”
CCPR: Thank you for your time, Dr. Daniolos.
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