What if your child is born transgender

Transidentity in children and adolescents: born in the wrong body

Trans identity has long been viewed as a disease-related disorder and delusional idea. Gradually, however, a more comprehensive understanding is gaining ground. If social and intrapsychic problems come together in the adolescents, this can lead to severe psychological stress.

Trans identity is an innate variant of people's gender identity in which the gender identity does not match the assigned gender. Photo: Ekaterina / stock.adobe.com

When girls play with cars and boys with dolls, it is most often seen as a temporary phase and a normal part of child development. The situation is different when girls insist with unequivocal certainty that they are actually male, and boys are unwaveringly convinced that they belong to the female gender, that is, that they were born in the wrong body. In this case, one speaks of trans-identity (see box Terms). It presents the children, but also their parents, relatives, educators and other people in their environment with very special challenges.

Transidentity has long been (and in some cases still is) viewed as a disorder and a delusional idea. Gradually, however, a more comprehensive understanding is gaining ground. According to this, trans-identity is an innate variant of the gender identity of people, in which the gender identity does not match the assigned gender. “The exact causes of different variants of gender identity are not clear. Presumably, hormonal influences during pregnancy and genetic factors play a role, ”say child and adolescent psychotherapists Sabine Maur and Konstantin Shahshahani from Mainz.

Increasing utilization

An estimated two to three percent of all children and adolescents are convinced that they were born in the wrong body. The prevalence may be higher, because experts have been observing an increasing use of special outpatient clinics, for example, for years.

Persistence is relatively low from childhood to adolescence. The transident feeling persists in adolescence only in around two to 20 percent, but in the majority it disappears with increasing age. The persistence from adolescence to adulthood, however, is very high. With regard to persistence in childhood, three groups are distinguished:

  • The majority of children come to terms with their gender-specific body characteristics and develop a homosexual or bisexual orientation later in puberty.
  • A small minority also comes to terms with their gender-specific body characteristics and develops an exclusively heterosexual orientation during puberty.
  • In the other children, the perceived discrepancy persists and increases as the secondary sexual characteristics begin to develop.

In childhood, for example, transidentity manifests itself in the fact that children become increasingly aware of the discrepancy between the assigned and perceived gender (this can already start from the age of two to three years) and distance themselves from their innate gender. For example, they choose a first name that corresponds to their gender and only want to be addressed with this. They are heavily involved in games and activities associated with the opposite sex and prefer playmates of the opposite sex. They reject their sexual characteristics, want them to go away, and instead want the sexual characteristics of the opposite sex. It is also characteristic that they try to hair and dress like the opposite sex and have a pronounced desire to belong to it and to be treated accordingly.

During puberty, not only do the perceived discrepancy and rejection of the assigned gender increase, but also the fear that the assigned gender will become clear due to the development of the secondary sex characteristics. The adolescents therefore try to conceal these characteristics, for example by having girls tie their breasts or boys wearing tight-fitting underwear. At the same time, many young people appear in public as the person of the desired gender.

In addition, the young people increasingly want to know what is wrong with them. They do research on the Internet, get in touch with like-minded people and find out what options there are to create a congruence between their gender identity and their assigned gender. Often they already have a very specific idea about this. "Adolescent patients are increasingly expressing the desire for medical gender-correcting measures such as hormone treatment or mastectomy," writes the specialist in psychiatry and psychotherapy, Dr. med. Bernd Meyenburg at the University Hospital Frankfurt / Main.

Violence and discrimination

Transident children and adolescents are confronted with the most varied of reactions from their fellow human beings. Some fellow human beings are open and tolerant, others are indifferent and many are incomprehensible and negative; The latter can be accompanied by violence, bullying, hostility and discrimination. If, of all things, the family and their peers react negatively, this is particularly stressful for transident children and adolescents.

The children and young people affected not only suffer from their fellow human beings, but also from their situation. They are often desperate because they are unable to live the identity they want. They also find their body so inappropriate that they develop a great hatred for it. If such social and intrapsychic problems come together, this can have an extremely unfavorable effect on psychological well-being and lead to high levels of dissatisfaction, high levels of suffering and poor school performance. There is also an increased risk of depression, self-harm, self-mutilation, anxiety disorders, social isolation and suicidal intentions.

The high levels of stress associated with gender dysphoria can be mitigated by three factors: firstly, by understanding and supportive parents and family members, secondly, by various medical steps to bring the assigned and perceived gender into line, and thirdly, through greater tolerance in society.

Most parents notice when their children do not behave in a gender-compliant manner. However, since they often do not know the reason and have never heard of trans-identity, they cannot explain it to themselves and react to it in their own way: some parents ignore the behavior of their children and consider it a phase that will soon pass. Others stay calm, accompany their children on their way and accept them for who they are. Still other parents cannot deal with this and force their children to behave according to their assigned gender by various means; The latter can increase the level of suffering in children and prevent healthy personal development.

Parents of transident children are confronted partly with the same, partly with different tasks and problems as parents of non-transident children. For example, numerous resistances and prejudices have to be overcome again and again and the children may need to be protected. In addition, parents are accompanied by constant doubts, they have to make decisions that determine the future of their children and trans-identity can become the dominant issue in a family. So that such challenges do not become a constant burden, it is important that parents deal with their problems and feelings, especially fears, reservations and worries, and that they seek professional help if necessary. In addition, they should obtain detailed information about trans identity, network (for example with self-help groups), get expert advice (for example in special consultations and advice centers) and keep looking for a conversation (for example with the staff of kindergartens or schools and with parents ).

The matching of assigned gender and gender identity is graded and age-dependent. The following measures are mainly used: treatment with hormones that block puberty, treatment with opposite-sex hormones and surgical sex reassignment. While the effects of puberty-blocking treatment are reversible, the effects of the other measures are irreversible.

Treatment according to guidelines

There are indications that step-by-step treatment in accordance with guidelines has a positive effect on subjective well-being, psychosocial functional level and the burden of symptoms in adolescents. Even in adults who have undergone gender reassignment man-to-woman surgery, it has been shown that the measure has a positive effect on satisfaction and quality of life. However, there are also adolescents and adults who have been operated on who would like a return operation. In order to avoid disappointment and to achieve the most positive treatment results possible, psychological-psychotherapeutic support during the measures and more research with regard to trans-identical children and adolescents are essential.

Trans identity is no longer as taboo as it used to be and some forms of gender identity even seem to be in vogue (for example metrosexuality). This is due, among other things, to some of the media that portray transident people and offer insights into their worlds. However, there are still numerous hurdles that make it more difficult for transident children and adolescents to show and live their gender identity, for example ignorance, prejudices, certain official and medical requirements as well as a lack of training and specialization opportunities in the area of ​​trans identity among children and adolescents. Associations such as Trans-Kinder-Netz eV (www.trans-kinder-netz.de) or the German Association for Transsexuality and Intersexuality eV (www.dgti.org) have therefore set themselves the task of removing such hurdles, for Example by taking action against stigmatization and exclusion, calling for the depathologization of trans-identity and promoting more tolerance and acceptance of gender diversity.

The gender incongruence of childhood and adolescence does not require any psychotherapeutic treatment per se, as it is not a psychological disorder. However, if it causes relevant suffering in the sense of gender dysphoria, psychotherapeutic treatment may be indicated. Psychotherapeutic support is often experienced as helpful, even if there are no primary, secondary or comorbid disorders. According to Maur and Shahshahani, psychotherapists should accompany the individual experience of gender identity and the rejection of one's own body in a non-judgmental, understanding, devoted and open-minded manner. The goals of the accompaniment can be, for example, to promote psychosocial development and to reduce the problems and difficulties that arise from the particular developmental situation, to clarify the individual internal and external situation and to deal with disappointments. A therapy goal can also be to help those affected feel comfortable with their individual gender identity experience and to deal better with possible stress. In addition, the psychotherapeutic accompaniment serves to advise the caregivers in order to promote their acceptance and support.

In the case of psychotherapeutic support, neither the therapeutic orientation nor the duration of the therapy are decisive, but rather that the person concerned is accompanied on their way for a sufficient period of time, thus ensuring that the desire for gender reassignment is consistent. Marion Sonnenmoser

Terms used

With regard to the perceived incongruence between the assigned gender and the gender identity of a person, various terms are in use, for example trans identity, transgender, gender dysphoria, gender incongruence, gender identity disorder, transsexuality and transsexualism. In the present text, the terms “transidentity” are used in the sense of gender incongruence without psychological stress according to the future ICD-11 and “gender dysphoria”, i.e. gender incongruence with psychological stress, according to DSM-5.

Recommendation of the German Ethics Council

As the number of transgender children and adolescents is steadily increasing, the German Ethics Council adopted an ad hoc recommendation on the subject on February 21. With this, the interdisciplinary committee wants to sensitize the public to the difficult questions of an appropriate social and medical handling of trans-identity.

On the one hand, the general right of personality must be observed, which also includes the right to lead a life according to one's own subjectively perceived gender identity and to be recognized in this identity. In all decision-making processes, the child must be heard and his / her ideas and wishes taken into account according to their maturity and age.

The council emphasizes that the therapeutic interaction with the child must be designed in such a way that it is introduced to the decisions that become more momentous with increasing age. Parents and treating persons should give the child the best possible support. Without the consent of the person concerned or even against his will, it should not be treated.

The experts emphasize that the benefits and harm of the medical-therapeutic measures must be carefully weighed in each individual case. This is particularly true because the measures are in some cases controversial with regard to their risks, side effects and consequences. Like the risks, (side) effects and long-term consequences that the minors would incur as a result of active medical-therapeutic intervention, however, those that are threatened by failure to take measures must also be taken into account. Particularly in view of the dispute about individual options for action, those affected and their parents would have a right to balanced advice and information. In addition, a destigmatizing approach to trans identity in children should be promoted. Appropriate offers of psychosocial counseling should be strengthened.

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Maur S, Shahshahani K: Trans-Identity in Adolescence. Psychotherapy currently 2018; 10 (4): 18-23.
Meyenburg B: Gender dysphoria in childhood and adolescence. Stuttgart: Kohlhammer 2020.
Weinforth G, Fakin R, Giovanoli P, Garcia Nuñez D: Postoperative quality of life after male-to-female gender reassignment surgery. Deutsches Ärzteblatt 2019; 116: 253-60.