Helping Pediatricians Care for Transgender Children

Not pure research, but an interesting article in the The New York Times on caring for trans youth.

"But the research shows, he said, that if the children are accepted, they do much better. Dr. Breuner agreed: It’s the environment that endangers the child, she said, not the gender issues; if the child’s family and school and health care system are supportive, she said, the child should not be at higher risk than the general population."

https://www.nytimes.com/2018/10/15/well/family/helping-pediatricians-care-for-transgender-children.html

Suicide risk in the UK Trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt

Published in: Mental Health Review Journal. · December 2014.  Authors: Louis Bailey, Jay McNeil, Sonja J. Ellis.

“The findings reported here indicate that there are extremely high rates of suicidal ideation and suicide attempt within this non-random sample of the UK trans population. However, gender transition – for those that wanted it – was shown to drastically reduce instances of suicidal ideation and suicide attempt, highlighting the important role played by social transition and gender reassignment in improving quality of life and overall well-being amongst respondents…”

“A key finding to emerge from the study was the importance of timely access to gender reassignment treatment for those who required it. Transition was shown to have a positive impact on trans people’s mental health and well-being; the processes of gender reassignment and social transition serving to significantly reduce rates of suicidal ideation and suicide attempt. The majority of participants cited the significant benefits of gender reassignment in terms of aligning their physical body with their internal sense of self, and the knock-on effects of being recognised as the gender that they felt themselves to be…”

“Despite the clear advantages of gender reassignment, some respondents reported significant issues whilst trying to obtain treatment. As has been reported elsewhere, funding delays or refusals were common within this sample and respondents alluded to having gender reassignment treatment stopped or postponed altogether. These issues may, in some cases, contribute to suicide risk within this population…”

“It is crucial that those experiencing gender dysphoria have access to gender reassignment treatment with minimal delays or disruption and that they receive relevant information and support both from medical professionals as well as more informal sources – such as family, friends and support organisations – in order to build resilience and bolster health and well-being during this particularly difficult time.”

https://www.researchgate.net/publication/281441727

Recognising the needs of gender variant children and their parents

Recognising the needs of gender variant children and their parents

Published in: Sex Education: Sexuality, Society and Learning.  2013.  Authors: Elizabeth A. Riley, Gomathi Sitharthan, Lindy Clemson & Milton Diamond

“The data in the present study suggest that even when gender-variant children actively endeavour to conform, their efforts are often thwarted by individuals who seek to marginalise and victimise them for their difference. Children therefore suffer from an invisibility and lack of recognition of their needs, on the one hand, and (in some cases) a violation of their personal boundaries that can foster a general anxiety, on the other. The well-documented need of all children for acceptance and affirmation places even more responsibility on adults to be compassionate and make provisions for gender-variant children.” 

http://dx.doi.org/10.1080/14681811.2013.796287

The role of gender affirmation in psychological well-being among transgender women

No surprise that validating someone’s sense of self decreases depression and improves self esteem.

Published in: Psychology of Sexual Orientation and Gender Diversity. September 2016. Authors Tiffany R. Glynn, Kristi E. Gamarel, Christopher W. Kahler, Mariko Iwamoto, Don Operario, Tooru Nemoto.

“… we found that social, psychological, and medical gender affirmation were significant predictors of lower depression and higher self-esteem... Findings support the need for accessible and affordable transitioning resources for transgender women in order to promote better quality of life among an already vulnerable population.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5061456/

Suicide risk in the UK trans population and the role of gender transition in decreasing suicidal ideation and suicide attempt

It is well known that trans and gender nonbinary people have high rates of suicidality… studies consistently show that affirming treatments decrease risk.

Published in: Mental Health Review Journal.  December 2014.  Authors: Louis Bailey, Sonja J. Ellis, Jay McNeil.

“A supportive environment for social transition and timely access to gender reassignment, for those who required it, emerged as key protective factors… The paper highlights the devastating impact that delaying or denying gender reassignment treatment can have and urges commissioners and practitioners to prioritisetimely intervention and support.”

“The findings reported here indicate that there are extremely high rates of suicidal ideation and suicide attempt within this non-random sample of the UK trans population. However, gender transition – for those that wanted it – was shown to drastically reduce instances of suicidal ideation and suicide attempt, highlighting the important role played by social transition and gender reassignment in improving quality of life and overall well-being amongst respondents…”

“A key finding to emerge from the study was the importance of timely access to gender reassignment treatment for those who required it. Transition was shown to have a positive impact on trans people’s mental health and well-being; the processes of gender reassignment and social transition serving to significantly reduce rates of suicidal ideation and suicide attempt. The majority of participants cited the significant benefits of gender reassignment in terms of aligning their physical body with their internal sense of self, and the knock-on effects of being recognised as the gender that they felt themselves to be…”

“Despite the clear advantages of gender reassignment, some respondents reported significant issues whilst trying to obtain treatment. As has been reported elsewhere, funding delays or refusals were common within this sample and respondents alluded to having gender reassignment treatment stopped or postponed altogether. These issues may, in some cases, contribute to suicide risk within this population…”

“It is crucial that those experiencing gender dysphoria have access to gender reassignment treatment with minimal delays or disruption and that they receive relevant information and support both from medical professionals as well as more informal sources – such as family, friends and support organisations – in order to build resilience and bolster health and well-being during this particularly difficult time.”

https://www.researchgate.net/publication/281441727_Suicide_risk_in_the_UK_Trans_population_and_the_role_of_gender_transition_in_decreasing_suicidal_ideation_and_suicide_attempt

The Needs of Gender-Variant Children and Their Parents According to Health Professionals

Another article outlining that more supportive, nurturing, and affirming perspectives on a youth’s self-reported gender identity are needed to support both the youth and their parents.

 

Published in: International Journal of Transgenderism.  March 4, 2013.  Authors: Elizabeth Anne Riley, Gomathi Sitharthan, Lindy Clemson & Milton Diamond

“The issues that gender-variant children face highlight consistent deficits and negativity in the children’s lives and focus our attention to the extraordinary burden placed on gender-variant children in their formative years. A report by Grant et al. (2010) describes in detail the extraordinary levels of harassment, physical assault, and sexual violence experienced by transgender children in years during primary and high school. These issues, if unable to be alleviated, are likely to present ongoing and accumulative difficulties that then impact their lives as adults.”

“… The needs of parents overwhelmingly feature the various types of support that would help parents become informed, be able to cope, and make the best decisions for their child. Societal and community support appear to be crucial factors for parents to comfortably engage with the tasks required of them to support their child.”

“… The needs of gender-variant children identified from the professionals’ responses revealed a lack of respect for the rights of children who experience gender variance. The most frequently mentioned needs were to be accepted and supported; to be heard, respected, and loved; to have professional support and recognition; to be allowed to express their gender; to feel safe and protected; to live a normal life; to have peer contact; to have school support and; to have access to puberty-delaying hormones. The needs of the parents focused primarily on areas of support and professional assistance, namely, the need for emotional support and guidance; education and information; support from society, local community, friends, and family; competent knowledgeable professionals; diagnosis, treatment, and beneficial outcomes for their children; peer support; support, understanding, and acceptance from schools; and research.”

“Together, these findings call for education programs to provide knowledge and exposure to the issues that transgender people face, across such sectors as medicine, mental health, and teaching in schools. The targeted education of medical and counseling professionals, the inclusion of printed materials in doctors’ surgeries, and the distribution of best practice guidelines and training in schools would signal a major change across the professional and community sectors that the needs of transgender children are being taken seriously.”

http://www.hawaii.edu/PCSS/biblio/articles/2010to2014/2011-needs-of-gender-variant-children.html

Social Support Networks for LGBT Young Adults: Low Cost Strategies for Positive Adjustment

A study demonstrating that family support is essential in the wellbeing of LGBTQ+ youth.

Published in: Family Relations.  July, 2015.  Authors: Shannon D. Snapp, Ryan J. Watson, Stephen T. Russell, Rafael M. Diaz, Caitlin Ryan.

“Our study adds to the growing body of evidence that family support, both general and sexuality specific, is a crucial factor in LGBT youth’s health and well-being…”

“Two variables were most relevant in predicting adjustment: (a) the percentage of friends who knew about participants’ sexual or gender identity and (b) support related to being LGBT from friends. The presence of a network of friends to whom youth can be out has been linked to measures of health and well-being…”

“Although friendship support is clearly associated with positive well-being in young adulthood, it appears that family acceptance has a stronger overall influence when other forms of support are considered jointly.”

 

https://www.tandfonline.com/doi/full/10.1080/01612840.2017.1398283

Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population

Family and peer support, key components of affirmative approaches for gender variant youth, are all protective factors. This study also clearly refutes the notion among some proponents of "Rapid Onset Gender Dysphoria" that disaffirming approaches and limiting access to peers is beneficial. 

Published in: American Journal of Public Health.  May, 2013. Authors: Walter O. Bockting, PhD, Michael H. Miner, PhD, Rebecca E. Swinburne Romine, PhD, Autumn Hamilton, HSD, and Eli Coleman, PhD.

 “… family support, peer support, and identity pride all were negatively associated with psychological distress, confirming that these assets are protective factors. Moreover, peer support significantly moderated the relationship between enacted stigma and psychological distress, thus emerging as a demonstrated factor of resilience in the face of actual experiences of discrimination. Only at high (but not low or medium) levels of peer support was enacted stigma not associated with psychological distress, which suggests that the negative impact of enacted stigma on mental health is pervasive and that regular contact with peers is necessary to ameliorate it.”

“Together, these results offer support for the value of transgender individuals connecting with similar others, possibly providing the opportunity to question stigma from the majority culture and reappraise their experiences in a self-affirmative way, which is consistent with what has been postulated and observed among gay and lesbian individuals. This finding is particularly pertinent because previous research found that transgender people have higher levels of depression and lower levels of peer and family support than their gay, lesbian, and bisexual counterparts. These results support a need to promote resilience by facilitating ample peer support.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698807/

Surviving a Gender Variant Childhood: The Views of Transgender Adults on the Needs of Gender Variant Children and Their Parents

Published in: Journal of Sex & Marital Therapy. 2012. Authors: Elizabeth Anne Riley, Lindy Clemson, Gomathi Sitharthan, Milton Diamond.

“… the needs of children that emerged were most notably, for parents, school staff and other authority figures to be educated so that children do not need to ‘hide’ themselves and their gender expression for fear of adversity. The participants also expressed their need as children to be able to speak about their feelings, to have their gender expression accepted, to be recognised, to be protected, to be given the opportunity to know others with similar feelings and for their parents to be open-minded, able and willing to accept their gender variant children. This study identified that the participants’ parents primarily needed access to information and educated professionals, particularly in schools, counselling and medical contexts. Exposure to successful transgender people and access to parent support groups was also seen as a need to help parents become more accepting of their children's diversity. The need for family and wider support was mentioned as a need for both the gender variant children and the parents as some participants felt that even though support of their parents was necessary, it was not enough for them to live happily and safely within the broader society.”

“The need for ‘health literacy’ was highlighted as tool to empower individuals, in this case, parents, to respond effectively in addressing the issues with regard to their gender variant children. In particular, allowing confidence to approach professionals for support with their own and their child's emotional, physical and social well-being….”

“… it appears that living in a society where punishment is customary for lack of conformity to gender stereotypes creates a lifelong struggle and sometimes ‘withdrawal’ that caused some participants great distress and impacts on their self-esteem and ability to thrive.”

https://www.semanticscholar.org/paper/Surviving-a-gender-variant-childhood%3A-the-views-of-Riley-Clemson/20d1168cecafe4aa6c633e4691b60e88ed31c901

The Needs of Gender-Variant Children and Their Parents: A Parent Survey

The Needs of Gender-Variant Children and Their Parents: A Parent Survey

Published in: International Journal of Sexual Health. 2011. Authors: Elizabeth Anne Riley, Gomathi Sitharthan, Lindy Clemson, Milton Diamond.

“The results of this study support the development of affirmative approaches in supporting gender-variant children and their parents. This is particularly evidenced by the parents’ own approaches to supporting their children where parents experimented with different ways of responding to various scenarios and realized that acceptance of their child was the only option as they learned that their child’s need for expression was not changed by their attitude or management of the behavior.”

http://www.hawaii.edu/PCSS/biblio/articles/2010to2014/2011-gender-variant-children.html

Mental Health and Self-Worth in Socially Transitioned Transgender Youth

Socially transitioned youth do better than those who do not transition, and do not show higher level of depression or anxiety than their peers or siblings.

Published in the Journal of the American Academy of Child and Adolescent Psychiatry. February 10, 2017. Authors: Lily Durwood, Katie A. McLaughlin, Kristina R. Olson.

“We found remarkably good mental health outcomes in socially transitioned transgender children in the present study. Transgender children reported normative rates of depression and slightly increased rates of anxiety. Rates of depression in transgender children did not differ significantly from those in siblings of transgender children or from those in age- and gender-matched controls, although rates of anxiety were marginally higher. Parents’ reports of their children’s depression and anxiety largely mirrored the children’s reports, although parents of transgender children reported slightly higher anxiety in their children than the children did…”

“Our findings of normative levels of depression, slightly higher rates of anxiety, and high self-worth in socially transitioned transgender children stand in marked contrast with previous work with gender-nonconforming children who had not socially transitioned. Those studies overwhelmingly reported markedly higher rates of anxiety and depression and lower self-worth, with disproportionate numbers of children in the clinical range.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5302003/

High School Gay-Straight Alliances (GSAs) and Young Adult Well-Being: An Examination of GSA Presence, Participation, and Perceived Effectiveness

Yet one more study outlining the importance of LGBTQ+ youth having the opportunity to associate with each other. Rather than making youth LGBTQ+ through ‘social contagion’, contact with other LGBTQ+ youth is protective and aids with development and health.

Published in: Applied Developmental Science. 2011. Authors: Russell B. Toomey, Caitlin Ryan, Rafael M. Diaz & Stephen T. Russell.

“… there appear to be positive associations between GSAs and well-being and educational attainment. Our finding that students who were in schools with GSAs were more likely to obtain a college education underscores the potential impact on educational achievement and socioeconomic and occupational status as an adult. In addition, given the heightened attention to suicides of young males who were known or perceived to be gay and bisexual that have been linked to anti-gay harassment at school (e.g., Katz, 2010), our findings point to GSAs as a potential context for reducing this risk – at least at low levels of LGBT school victimization - given the significant interaction between GSA participation and LGBT school victimization on lifetime suicide attempts.”

“In sum, our findings suggest that school administrators and personnel should be supportive in helping students to form and facilitate GSAs in schools as a potential source of promoting positive development for this underserved population. “

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217265/

Stigma, Mental Health, and Resilience in an Online Sample of the US Transgender Population

Continuing on the theme of the need for peer support: While proponents of “Rapid Onset Gender Dysphoria” might argue that exposure to other youth is what spreads the ‘social contagion’, connections to peers is a key in these youth being resilient.

Published in: American Journal of Public Health. May, 2013. Authors: Walter O. Bokting, PhD, Michael H. Miner, PhD, Rebecca E. Swinburne Romine, PhD, Autumn Hamilton, HSD, and Eli Coleman, PhD.

“… family support, peer support, and identity pride all were negatively associated with psychological distress, confirming that these assets are protective factors. Moreover, peer support significantly moderated the relationship between enacted stigma and psychological distress, thus emerging as a demonstrated factor of resilience in the face of actual experiences of discrimination.”

“Together, these results offer support for the value of transgender individuals connecting with similar others, possibly providing the opportunity to question stigma from the majority culture and reappraise their experiences in a self-affirmative way… This finding is particularly pertinent because previous research found that transgender people have higher levels of depression and lower levels of peer and family support than their gay, lesbian, and bisexual counterparts. These results support a need to promote resilience by facilitating ample peer support.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698807/

Describing Roles that Gay-Straight Alliances Play in Schools

Yet another study making clear the link between supporting LGBT youth and better mental health outcomes...

Published in: Addictive Behaviors. April 2014. Authors: Nicholas Heck, Nicholas Liivngston, Annesa Fletne, Katherine Oost, Brandon Steward, Bryan Cochran

"After controlling for demographic variables and risk factors associated with illicit drug use, the results of 12 logistic regression analyses revealed that LGBT youth attending a high school without a GSA evidenced increased risk for using cocaine... hallucinogens... and marijuana... relative to peers attending a high school with a GSA. Youth without a GSA also evidenced increased risk for the misuse of ADHD medication... and prescription pain medication. The present findings underscore the importance of providing LGBT youth with school-based support groups and highlight the potential damaging effects of not having these resources in our nation's schools."

“Highlights:

  • "Assessed association between high school gay-straight alliances (GSA) and illicit drug use."

  • "LGBT youth evidence lower risk for illicit substance use when their school has a GSA."

  • " Inclusive school-based programs may be protective factors for LGBT youth."

"These findings extend the research base related to GSAs and further demonstrate the importance of providing LGBT youth with opportunities for socialization and support within the school setting."

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4066611/

Demographic and Psychosocial Factors Associated With Psychological Distress and Resilience Among Transgender Individuals

Published in: The American Journal of Public Health. October, 2015. Authors: Emily Bariola, BA, Anthony Lyons, PhD, William Leonard, BSc, BA, Marian Pitts, PhD, Paul Badcock, PhD, and Murray Couch, BA.

“The findings indicated that, relative to other sources, family of origin may have the most influence in protecting against psychological distress… our findings support a need to encourage family members to be open and receptive sources of support.”

“…frequent contact with LGBT peers was revealed as a significant [protective] factor… for transgender individuals, frequent peer contact may be particularly important for developing individual resilience, as gender transitioning can be a complex and challenging process and having peers who share similar experiences may provide not only a sense of support and understanding, but also a sense of belonging.”

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4566567/

Why Parents of Trans Kids Are A Special Kind of Tired

Not research, but a really lovely piece on being a parent to a trans or nonbinary youth. Hopefully this helps some of the parents who might need some support.

Why Parents of Trans Kids Are A Special Kind of Tired

Yes. All parents walking the earth are tired.

We are all absolutely in solidarity with that fact.

We could all use about a week on a deserted island without any children, technology, or responsibilities of any kind.

But I feel the need to tell you about the special kind of tired that parents of transgender kids are experiencing.

It’s different than most versions of tired.

And this isn’t to “one-up”. And this certainly isn’t to take away from an LGBTQIA child themselves, their own struggles and hardships. This isn’t to take away from, or distract from… anyone.

This isn’t a competition.

This is just to simply explain and shed light on how we’re feeling, since it’s of my belief that we, the parents of trans youth, are living in our own marginalized community.

Read the rest:

https://vanessaleenic.com/2018/09/21/why-parents-of-trans-kids-are-a-special-kind-of-tired/

Access to GSAs Yields Happier, Better Adjusted Youth...

Contrary to current research, proponents of “Rapid Onset Gender Dysphoria” have argued that the trans identity in some youth could possibly be due to “social contagion” (ie being around youth who identify as trans and taking on the identity themselves though it is not authentic) and thereby urge parents be cautious when around allowing trans youth access to their peers via friends, GSAs, and online resources, so as to limit their exposure to the “contagion”.

There is extensive literature to document that social supports - these same friends, GSAs, and online resources - actually improve the lives and outcomes for these youth. Below is a piece from the publication of the American Federation of Teachers.

Gay-Straight Alliances

Promoting Student Resilience and Safer School Climates

Published in: American Educator. Winter 2016-2017. Author: V. Paul Poteat.

“Students in schools with GSAs report lower mental and physical health concerns, greater overall well-being, less drug use, less truancy, and greater perceived school safety than students in schools without GSAs. These findings now have been documented across a range of studies at local and national levels. Other studies have recorded feedback from GSA members who attribute instances of personal growth and empowerment, as well as a range of other positive experiences, to their GSA involvement.”

https://www.aft.org/sites/default/files/ae-winter2016poteat.pdf

Three Studies for our French Speaking Friends...

« Pour des intervention anti-oppressives auprès des jeunes trans : nécessités sociales, évidences scientifiques et recommendations issues de la pratique».

Médico, D. et Pullen Sansfaçon. (2017) Service social. Volume 63, Numéro 2, 2017, p. 21–34 

"Les pistes d’intervention doivent donc non seulement soutenir les jeunes, mais également leur famille et leur entourage. Elles doivent s’inscrire dans une vision plus structurelle et politique en facilitant les changements nécessaires pour rendre la société plus inclusive.” 

https://www.erudit.org/en/journals/ss/2017-v63-n2-ss03713/1046497ar/ 


« Parentalité et jeunes transgenres : une exploration des enjeux vécus et des interventions à privilégier »

Pullen Sansfaçon, A. Santé mentale au Québec, 2016, Vol. 40 (3) pp 93-197 

"Bien que certains débats sur ces questions perdurent, on observe que les associations professionnelles, de plus en plus, reconnaissent l’importance des approches transaffirmatives visant l’autodétermination de la personne, d’une part, et le soutien du jeune et de sa famille dans le processus d’acceptation, d’autre part.”

https://www.erudit.org/en/journals/smq/2015-v40-n3-smq02336/1034913ar/ 


« L’éthique de la reconnaissance comme posture pour travailler avec les jeunes trans »

Pullen Sansfaçon, A. et Bellot C. (2017). Nouvelles pratiques sociales, Vol 28(2) pp 38- 53 

"L’approche transaffirmative devient alors un cadre d’intervention par lequel les professionnels, et notamment les travailleurs sociaux, pourraient soutenir à la fois l’accompagnement des jeunes dans leur affirmation de genre, soutenir leurs familles et les institutions et milieux qu’ils fréquentent, mais aussi de manière collective, soutenir la lutte pour la reconnaissance de la fluidité des identités de genre, ainsi que les enjeux de tolérance et de respect des individus pour soutenir la promotion d’une société plus juste.” 

https://www.erudit.org/fr/revues/nps/2016-v28-n2-nps03207/1041178ar/ 

Trans Youth: Digging Beneath the Surface: Factors That Facilitate Or Impede Trans Youth Well-being in Quebec

“Quebec has one of the leading identity-affirming clinics for trans kids, the Gender Variance Clinic of the Mon- treal Children’s Hospital. This fact sheet aims at presenting oppressive factors and structures that negatively influence the well-being of trans youth as well as aspects that contribute to it…”

  • “Experiences and Dynamics in the Healthcare System: Healthcare system is a primary contributor to participants’ well-being (gender specific or general care), yet, resources in this system are not trans affirmative. Indeed, because of their gender identity, even when the services they are seeking are not transition-related, barriers to access and fear of negative treatment from healthcare professionals are an issue…”

  • “Other Institutional Spaces: Schools, Child Protection Services, Justice System - Participants feel that those institutions are positive in their lives as long as they are affirming of their identity…”

  • “Family relations and Other Social circles: Family support, in the form of feeling loved, accepted, and supported by immediate and extended family, is a significant resource to help participants cope with difficulties in other spheres of their lives. However, family can also be a source of fear and anxiety (when being rejected, or kicked out). Explicit lack of parental support is detrimental to participants’ well-being…” 

  • “Community spaces: Trans youth identified trans and LGBTQ+ non-governmental organizations (NGOs), support agencies, and other community spaces as an important source of support and information (student unions for example). Online spaces (social medias and web) were also identified as important to affirm their identity…”

https://img1.wsimg.com/blobby/go/8547e446-90ba-4bfb-9351-591f088e59a1/downloads/1cnmpjs2e_3073.pdf

Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.

Published By: The American Academy of Pediatrics. September 17, 2018.

“Supportive involvement of parents and family is associated with better mental and physical health outcomes. Gender affirmation among adolescents with gender dysphoria often reduces the emphasis on gender in their lives, allowing them to attend to other developmental tasks, such as academic success, relationship building, and future-oriented planning. Most protocols for gender-affirming interventions incorporate World Professional Association of Transgender Health and Endocrine Society recommendations and include ≥1 of the following elements:

“Social Affirmation: This is a reversible intervention in which children and adolescents express partially or completely in their asserted gender identity by adapting hairstyle, clothing, pronouns, name, etc. Children who identify as transgender and socially affirm and are supported in their asserted gender show no increase in depression and only minimal (clinically insignificant) increases in anxiety compared with age-matched averages…

“Legal Affirmation: Elements of a social affirmation, such as a name and gender marker, become official on legal documents, such as birth certificates, passports, identification cards, school documents, etc…

“Medical Affirmation: This is the process of using cross-sex hormones to allow adolescents who have initiated puberty to develop secondary sex characteristics of the opposite biological sex…

“Surgical Affirmation: Surgical approaches may be used to feminize or masculinize features… These changes are irreversible. Although current protocols typically reserve surgical interventions for adults, they are occasionally pursued during adolescence on a case-by-case basis, considering the necessity and benefit to the adolescent’s overall health…”

http://pediatrics.aappublications.org/…/09/13/peds.2018-2162