Jan-Renee Carlson spent decades constantly stressed out. She would anger easily and admits that she was pretty hard to be around most of the time. She knew something was off, but back in the 1960s, there wasn’t the Internet to turn to for information.
Carlson was born male, and that’s how she was raised. She grew up in Vermont and New Hampshire with four siblings, a nurturing family and a stable home life, but all of that didn’t destine her to behave like a typical boy.
As a pre-adolescent — around 10 or 11 — she remembers trying on her sister’s discarded clothes that were kept in the basement, and later, cross-dressing while in college.
“There still was limited access to information at that time, so it was difficult to really understand what I was going through or if there were others who felt like I did,” Carlson says.
Despite the uncertainties in her life, Carlson graduated college, married a woman, and in 1980, landed a job at NASA Langley in Hampton, Va., as a scientist. But for all her analytical and deductive skills, she still struggled for answers in her personal life.
She tried attending meet-ups and social events with others that were sort of like her in the Hampton Roads area, but she couldn’t connect with anyone in those groups.
“I never really meshed with them,” Carlson says. “They all seemed to be dealing with other issues that just weren’t the issues and problems I was having.”
It wasn’t until the early 90s — and the dawn of the Internet — that Carlson learned of a week-long, yearly conference in Washington state called Esprit that focused “on changing lives for the better and creating pride and self-respect for anyone who is transgender.”
Traveling across the country to attend the conference was a no-brainer for Carlson. Maybe, she thought, this time she’d learn something about herself. There, she had access to psychologists, physicians, speakers and discussion groups.
“I finally found this group of educated professionals, of people who really had their stuff together — but they were trans,” Carlson says. “That’s where the light came on for me.”
What does transgender mean?
Historically speaking, the actual phrase was coined sometime in the 1960s and at the time, referred to people who identified with a gender different than the one assigned to them at birth. Sometimes it’s confused with the word transsexual, which refers to people who have completed a sex-reassignment surgery.
Over the years, the word has grown into more of an umbrella term and doesn’t only refer to those who want to live as the opposite sex, but also includes a wide-ranging, ever-growing number of people with any number of “gender identities.”
Estimates of the number of people who make up the transgender community in the United States have doubled in the past few years — from 700,000 to about 1.4 million — though that amount may not be accurate.
For one thing, the U.S. Census Bureau and other keepers of official records do not ask about gender identity. Also, gender identity can be fluid and hard to define in a multiple-choice list. Facebook, for example, now offers more than 50 gender options on a drop-down list.
Basically, for approximately 1 in every 250 adults, according to a study by the Human Rights Organization, gender is fluid. It’s not as simple as male or female, and with plenty of resources now at their fingertips, more and more people don’t have to wait decades like Jan-Renee Carlson did to understand what they are experiencing.
There’s even a term for what Carlson — who at a young age was wrestling with emotions related to her identify — was going through. Called gender dysphoria, it’s defined as an individual’s persistent discomfort related to their biological sex.
But not all medical communities agree on the issue, especially when it comes to children.
Increase in transgender teens
While there have been several smaller studies done, there is not much data on the number of teens who identify as transgender. A 2016 study of 81,000 Minnesota teens revealed that 2,200 identified as transgender or gender non-conforming, which means not identifying as particularly feminine or masculine.
Despite one’s personal or political feelings about the topic, the fact is that doctors are reporting seeing more and more teenagers for gender-identity issues.
Leah Hedblom, a counselor with Sunrise Counseling in Virginia Beach, Va., said when she first started her residency three years ago, she mostly worked with teenagers dealing with substance abuse and eating disorders. But over time, more of her patients seemed to be transgender teens.
“I’m not quite sure how it happened, but once it began, it was nonstop,” Hedblom says.
As she met with the teenagers, she learned that many of them didn’t know who to turn to or where to go to speak with anyone about what they were feeling. Hedblom did some research and found there was a significant lack of support groups for transgender teens and few counselors with the expertise to help them. She heard stories of some counselors turning teens away, telling them their behavior was “delinquent.”
“I was appalled,” says Hedblom, who started a transgender youth support group for those aged 12-17. “These youth need to feel that they are okay, ‘normal’ and have a safe place to discuss their feelings.… I offer some education, but mainly it is a safe, non-judgmental group for them so they know they aren’t alone.”
Helping youth who are transgender or who are experiencing gender dysphoria early on is of utmost importance, says Dr. Ilana Sherer, a San Francisco, Calif.-based pediatrician and founding member of the American Academy of Pediatric’s Section on Lesbian, Gay, Bisexual, Transgender Health, and Wellness.
“It became really obvious really quickly that the health outcomes and the psychosocial outcomes for transgender people are horrendous,” Sherer says. “The suicide attempt rate is around 40 percent. But, what I found out is that kids who presented early and who were supported by their families and providers didn’t experience the same negative outcome as the adults I was seeing.”
Why the high percentage of suicide ideation? The lesbian, gay, bisexual, transgender and queer (LGBTQ) community are not only targets of harassment, stigma and violence, but also deal with family and social non-acceptance.
In statistics published in Pediatrics, the journal of the American Academy of Pediatrics, among those teenagers who were open about being gay, transgender or questioning, 84 percent reported verbal harassment, 30 percent reported being hit, punched or injured and 28 percent dropped out of school because of harassment.
How to approach the topic of gender identity
There are differing schools of thought on how to approach children who may be dealing with stress and anxiety relating to how they feel about their gender identity, but medical professionals do agree on one thing.
“The most important thing a family can do is to take a deep breath and look their kid in the eye and tell them ‘I’m going to love you no matter who you are or especially because of who you are,’ ” Sherer stresses.
Dr. Michelle Cretella, executive director of the American College of Pediatrics, agrees: If children “consistently and persistently insist they are not their biological sex, regardless of their age, parents should first and foremost assure them of their love for them.”
But that’s where the agreement between the two doctors ends.
Cretella is an outspoken opponent of the transgender ideology that suggests people can be born into the wrong body. Her organization — the 15-year-old American College of Pediatrics (ACP) — is considered a socially conservative advocacy group, different than the 64,000-member American Academy of Pediatrics (AAP), a professional association of physicians that has been around since the 1930s.
“All behaviors and beliefs are due to nature and nurture,” Cretella says. “There is no single, family dynamic, social situation, adverse event, or combination thereof that has been found to destine any child to develop gender dysphoria.” In fact, Cretella suggests, some children may be vulnerable to the idea of being GD.
“Studies suggest that social reinforcement (today this includes schools and other public institutions that recognize gender identity over sex), parental psychopathology, family dynamics, abuse, and social conditioning facilitated by the media (books/music/TV/movies/internet/social media), may all contribute to the development and/or persistence of GD in vulnerable children,” Cretella says. “There may be other as yet unrecognized contributing factors as well.”
Cretella says she believes the increase in children and teenagers being seen for GD is due to “widespread social promotion of transgenderism, and the fact that physicians and therapists face professional sanctions if they fail to affirm a child is transgender.” GD, she says, tends to resolve itself in the vast majority of patients by late adolescence.
“There is no rigorous science to support the claim that GD is innate and unchangeable,” Cretella says. “The message parents should convey repeatedly is that our bodies declare our sex, and we are loving and kind to all people, even when they break sex stereotypes or embrace beliefs different from our own.”
Sherer, on the other hand, has a different perspective.
“Transgender is not a new thing or a trend,” she says. “We know this is a part of the diversity of human existence. The fact that there are more people coming forward has a lot to do with the acceptance out there and because there is conversation about it, I think people are coming to care earlier.”
“that’s what’s going on with me”
As transgender has become more the norm in mainstream media (in 2014, for example, actress Laverne Cox was the first openly transgender person to be nominated for an Emmy,) these teens are seeing someone like them and — much like the light turned on for Jan-Renee Carlson — are saying ‘oh, that’s what’s going on with me,’ ” Sherer says.
Because it’s natural for teenagers to try on different identities, she says, it’s important that while they go through that — even if it’s not their permanent path — that they are made to feel accepted. To Sherer, seeking out a physician or counselor who is trained in the gender affirmative model is a big part of that.
Published by the American Psychiatric Association, the Gender Affirmative Model is meant to help educate psychologists and other mental health providers on how to provide “culturally competent” care to transgender and gender- expansive children and their families.
The book was published just this past May, although the idea behind it was first laid out in a paper by eight doctors in 2013. The model is not without criticism — one online support group called Parents of ROGD (Rapid-Onset Gender Dysphoria) Kids calls the increase in transgender young people an epidemic.
Sherer, on the other hand, says it’s an emerging area of science. “With everything in medicine,” she says, “there’s going to be a period in time when we don’t have extensive data.” And just as the transgender community is evolving with different uses of pronouns and terms, so is the medical community.
Transgender: no longer a mental illness
For decades, being transgender was considered a mental illness.
Just this year, the World Health Organization announced that it has changed the designation of transgender from a mental illness to a sexual health issue.
And despite Cretella’s position that transgender is not biological, a recent brain scan study out of Belgium presented at the European Society of Endocrinology this year found that transgender brains more closely resemble brains of the sex they align with, rather than what they were born with.
Other studies note the role hormones play while babies are in utero and how they may affect gender identity.
Regardless of the many positions about the topic, Sherer says she works with many families who are supportive of their children despite their religious, cultural or political beliefs.
“The reality is there’s a kid in front of you, and it’s your kid, and you get to decide how to approach them,” she says. “I’ve been so inspired by families who were able to realize that this isn’t about politics, this is about their child and the health of their child.”
Another major topic of contention amongst some in the health care industry is use of hormone blockers for transgender youth who are approaching puberty.
Cretella says there’s a lot at risk health-wise if teens take puberty blockers and cross-sex hormones. One of those, she says, is permanent sterility. She also doesn’t think transitioning is the answer to preventing gender dysphoric teens from harming themselves.
“There is no evidence that transition prevents depression, anxiety or suicide in the long run,” she says.
Sherer, on the other hand, thinks of puberty blockers and hormones as “life-saving.” The AAP supports their use when necessary.
“We are healers; we are physicians; we have a tool in our arsenal to help children who are in some cases dealing with life-threatening circumstances,” she says. “With use of these medications, we see a dramatic reduction in incidents of depression and suicide. Obviously, the decision whether to use it is a complex one — and not every child needs the same care.”
For parents who have a child with GD or who may be questioning their gender identity, Sherer says that while it’s a good idea to reach out to the child’s pediatrician, it’s also important to realize that unless it’s a crisis situation, being transgender is not a medical emergency. One of the best things to do initially, she says, would be to reach out to an organization like PFLAG (Parents, Families and Friends of Lesbians and Gays) or a local advocacy group.
Love and support is the key
Having a strong support system is vital when it comes to GD. Carlson leaned heavily on friends she met through attending Esprit conferences, her family and her wife Ann, who has remained by her side, even through some challenging times.
In 2004, Carlson traveled to Arizona and had gender reassignment surgery. It was the final step in becoming Jan-Renee Carlson. Her wife, Ann, was supportive.
“Ann stayed with me,” Carlson says. “She’s been a coach, a friend and a companion, and she’s probably why I survived the whole thing.”
Definitions to Be Aware of
Transgender: A person whose gender identity differs from the sex that was assigned at birth.
LGBTQ: Lesbian, gay, bisexual, transgender and queer/questioning.
Gender Dysphoria: Refers to the emotional distress of having a gender identity that is different from sex assigned at birth.
Cisgender: A person whose sense of personal identity and gender corresponds with their birth sex.
Gender Fluid: Having different gender identities at
Gender Identity: A person’s internal sense of self and how they fit into the world, from the perspective of gender.
Sex: Historically has referred to the sex assigned at birth.
Gender expression: The outward manner in which an individual expresses or displays his/her gender. This may include choices in clothing and hairstyle, or speech and mannerisms.
Gender nonconforming: A person whose gender identity differs from that which was assigned at birth, but may be more complex, fluid, multifaceted or otherwise less-clearly defined than a transgender person.
Nonbinary: Transgender or gender-nonconforming person who identifies as neither male nor female.
They/Them/Their: Neutral pronouns used by some who have a nonbinary or nonconforming gender identity. Last year, the Associated Press began permitting journalists to use neutral pronouns.
Sexual orientation: Describes sexual attraction only and is not directly related to gender identity.
Source: University of San Francisco California’s Center of Excellence for Transgender Health