Every June, the LGTBQ+ community and allies celebrate Pride month, which recognizes the Stonewall Riots of 1968, the progress that has been made since then and the work that is still to be done in achieving equality. This year, there is a lot to reflect on. After coming out of remote schooling and social isolation with the COVID pandemic, LGBTQ+ youth had found themselves facing a myriad of attacks on their identity further impacting their mental health.

Recently, there has been an increase in disparaging and invalidating social messaging, political campaigns and even legislation in some states targeting youth who identify as transgender and gender diverse (TGD). They are being prohibited from playing sports, changing their names or gender markers on legal documents, accessing support at school, and obtaining essential, even lifesaving, medical and behavioral health care.

Much of the rhetoric and messaging is based on misconceptions and misinformation. We look to offer accurate information that is essential to countering negativity and fostering family support for LGBTQ+ youth.

What is the difference between sex, gender and sexual orientation?

Sex is a label assigned to a person usually around birth based on their reproductive parts, genetics and biology. Gender is an internal sense of who one is, based on an interaction of biological traits, developmental influences and environmental conditions. The label assigned as one’s sex at birth may not match the label a person asserts as their gender. Self-recognition of gender identity develops over time, much the same way a child’s physical body does.

Sexual orientation is a label used to describe a person’s identity in relation to the gender to which they are sexually and romantically attracted. Being transgender does not imply a sexual orientation, and transgender people still identify as being straight, gay, bisexual, etc.

What is gender dysphoria?

When someone’s gender identity does not match with their physical body or the way they are perceived by others, it can create a sense of discomfort and distress. This can be particularly difficult during puberty with the development of physical characteristics that are very sex-specific. Gender dysphoria is a psychiatric syndrome that can develop when this sense of distress interferes with functioning. A child experiencing gender dysphoria may avoid attending school or engaging in developmentally appropriate activities or relationships.

Just because someone is transgender does not mean that they have a mental health problem. Variations in gender identity and expression are normal aspects of human diversity. However, stigma, discrimination, and negative experiences can contribute to stress that puts transgender at risk for problems like depression and anxiety.

It is important to realize that gender dysphoria and other mental health problems can be prevented or decreased through creating supportive environments, providing behavioral health resources, and assuring access to appropriate medical care.

What is gender affirming care?

Gender and sexuality are important aspects of everyone’s identity that are explored throughout development, especially during adolescence, and with the support of family. Current research suggests that, rather than predict or prevent who a child may become, it is better to value them for who they are now, even at a young age. This fosters secure attachment and resilience.

Gender affirmative care at its foundation is about providing a safe environment, education and access to specialty medical care, drawing upon current evidence-based protocols and the unique needs of each individual child. Gender affirmative care is based on the belief that all children benefit from love and support.

The goal of gender affirmative care is not treatment. It is to listen to the child and, with the help of parents and families, build understanding. Through strong, nonjudgmental partnerships with patients and their families, pediatric providers create an environment of safety in which complicated emotions, questions and concerns related to gender can be appreciated and explored.

Gender affirmative care is most effective in a collaborative system with access to medical care, mental health support, and social services, including specific resources for parents and families.

What is the best way to support gender diverse children?

Research suggests that children who assert a gender-diverse identity know their gender as clearly and consistently as their developmentally matched peers and benefit from the same level of support, love and social acceptance. There is no indication for any medical intervention (blockers, hormones, etc.) prior to the onset of puberty. The best approach for young children is to love and appreciate them as they are in the moment.

Parents and guardians can work with the child’s school and other community leaders to help ensure their child’s safety. Nonbullying policies and curriculum that recognizes and emphasizes the dignity and acceptance of all people has been shown to improve the mental health of not just LGBTQ+ youth, but of all youth.

It used to be the case that for children, gender-diverse assertions were held as “possibly true” and not acknowledged until an age when the child was believed to be old enough to know for sure. This does not serve the child, because it increases discomfort without offering critical support and understanding.

Can a child become transgender or gay due to their friends or things they see online?

Being transgender is not contagious. For many people, they may not have confronted, or may have felt they had to suppress, their gender identity or sexual orientation due to social pressures. Once those people came into nonjudgmental and affirming environments, they felt more free to express themselves. There is a long history of marginalized youth building their own communities, and the internet and visibility of transgender individuals has made that process easier for transgender youth. Often peers can be more understanding initially. Online communities can provide exposure to a wider range of gender and sexual identities and expressions. If this is discovered by parents, or the child works up the courage to disclose such feelings, it may seem sudden and unexpected.

The best thing parents and guardians can do is to explore your children’s feelings, identity and attractions in a way that is supportive and nonjudgmental. You are not expected to be an expert, just to listen and reassure them that they will always have your love and support. It is important to remember that just as social networks can be beneficial, there can also be risks that you should talk about with your child.

Is gender affirming treatment irreversible?

Most of the initial care is fully reversible, including emotional support, social support, and even puberty and menstrual blockers. Some worry about side effects of puberty and menstrual blockers on a child’s bones and other areas of health. However, decades of research have shown that they can be used temporarily and effectively during adolescence. It is not true that all young people who go on blockers will choose to go on hormones. Blockers provide time to explore one’s identity socially and with the support of loving family and behavioral health providers.

Hormonal treatments that may be used in mid-adolescence have some reversible and some irreversible effects. It is important to remember that hormones work slowly and, if they are not doing what is expected, then it is okay to slow down or stop. Gender affirmation can be flexible to the needs of everyone.

Surgical interventions are completely irreversible and are largely reserved for adult populations, but occasionally are explored in late adolescence in specific cases with much input from providers and family.

As a parent or guardian, what if I am struggling to help my transgender child?

Some LGBTQ+ youth expect immediate acceptance, but often family members proceed through a process of becoming more comfortable and understanding of the youth’s gender and sexual orientation. The process often resembles the stages of grieving as it may require letting go of strongly held expectations parents have for their child. Pediatricians can help by promoting open dialogue and perspective taking between the youth and their families.

Some additional supports for parents and guardians:

PFLAG an organization providing peer-to-peer support, publications, toolkits, and other resources to make sure that the family members of people who are LGBTQ+ get the support they need in the way that best serves their needs.

Queer RI a website of specific resources for TGD youth and their families on a variety of services, including emotional support, treatment information, and guidance for families.

Phoenix Rising Centers is a RI-based therapy practice aimed at being a safe, inclusive environment for all clients. They offer a weekly support group called Trans-Forming Families for adults who care for trans, nonbinary and gender diverse youth.

Family Acceptance Project is a national research and advocacy organization providing training on family support and educational materials for families, providers and religious leaders.

TransFamilies provides education and support for families with transgender and gender diverse children. They host national parent support groups and youth leadership groups, along with an annual conference for children, youth and families.

Gender Spectrum is an organization that provides trainings and resources specifically for school, community organizations, and parents to help in advocating with school for gender inclusive policies.

For medical services and support, the Gender and Sexuality Program at Hasbro Children’s Hospital’s Adolescent Health Center provides care for the growing population of children and adolescents who are transgender, gender diverse, or otherwise exploring their gender identity.

We are here to meet the unique health needs of LGBTQ+ youth, and provide education, resources, and support to them and their family as they explore their growing gender and identity. Our goal is to help these children and adolescents be authentic and true to themselves in a safe and healthy way.

Jason R. Rafferty, MD, MEd, MPH

Dr. Jason Rafferty, a pediatrician and child psychiatrist, practices at the gender and sexuality clinic and at the Adolescent Healthcare Center at Hasbro Children’s Hospital