Parents of trans and non-binary kids often think the best option is to “wait until the teen is 18 before making choices with permanent consequences.” But this is actually making a choice, not postponing it, and is often based on inaccurate beliefs.

I met with a 13-year-old girl and her mom today. The daughter, who I will refer to as Sam, is transgender - meaning that she was designated as male when she was born, but feels that the identity of female feels most congruent, most like her. Sam and her mom, Anna (also a pseudonym), came to talk to me about Sam’s identity and Sam’s desire to medically transition (meaning to alter one’s secondary sex characteristics through medication and/or surgery).

The men in Sam’s family are very masculine appearing - lots of facial and body hair; thick, angular faces; booming voices. Sam is terrified about the possibility of looking like them when she grows up. The thought makes her feel panicky, like she wants to cry. If she thinks about it hard enough, she told me, she thinks she would rather be dead. Anna is like so many parents I talk to. She loves her child - there is no doubt of that - and wants what is best for her. But, like many parents I see, she is deeply skeptical of medical interventions. She might be willing to consider medications that would suppress puberty, but is very opposed to estrogen therapy.

I believe that parents need space and time to come to terms with their child’s gender, just like the child needed time in their discovery process. I would like Anna to meet with me, without her child. I tell parents that, with their child, they need to show their love and their commitment to trying to understand what is happening. The parents can feel grief, anger, doubt and more, but these thoughts and feelings are best expressed outside of their child’s awareness.

But today, Anna made it clear she wasn’t going to do this. She is sure that she knows what’s right. Here is her rationale - and what I wish she knew.

Sam is too young to know that she is a girl. Funny how we only doubt the identity of gender expansive kids, and not of cisgender kids. I don’t think Anna would say that Sam’s younger cisgender sister doesn’t know she is a girl.

Sam just came out as trans 6 months ago and already wants hormones! Usually, kids have been aware of feeling something incongruent about their gender - something that doesn’t quite fit. It is very common for kids to go through an obsessive period of researching gender identity online, and thinking about it. Many kids will start choosing ways to explore their identity, such as creating an online identity and avatar that represents their true selves. They also often come out to friends, especially other gender expansive friends, early on in their process. For many kids, coming out to parents is the scariest - and therefore, final - step in coming out. While Anna has only known that Sam is a girl for 6 months, Sam has known for over a year. This situation is very frustrating and confusing for both parents and kids. From the kids’ perspective, this has been bubbling up for a long time. Telling their parents was a huge hurdle. Now that they have crossed it, they are elated and can’t wait to start living the life they have been imagining! At the same time, parents are in a state of shock, feeling all of the fear and uncertainty that their child has been feeling, unbeknownst to the parents, for months or years.

Sam changes their mind about things all the time - they will change their mind about this, too. First, none of us have a crystal ball about any decisions we make for our kids. And I don’t mean to be glib about transition regret - that will be a future blog post. But, while Sam might have changed her mind about piano lessons or a horse obsession, identity is different. We do a marvelous job of communicating to children that not conforming, especially in areas of gender, is very dangerous. Even if kids are too young to realize how violent that danger can be, they see the way that Joey is bullied for “walking like a girl.” They see the behind-the-back mocking of that gender non-conforming character on TV. The stakes are high, and I have never, ever seen a kid casually decide they want medical treatment for their gender incongruence. I have, however, seen many kids and adults stay in or return to the closet because the social price of living authentically is too high.

This is a fad. Sam is only “trans” because everyone at school is. Are more and more kids identifying as trans, non-binary, demi…something? It certainly seems that way anecdotally, and in a few years we will have data. I would argue that this is because it is easier for kids to get information about normal gender variance in people. And treatment is so much easier to get. And, while there is still a crushing amount of transphobia in our society, more kids are finding pockets of safety. Even in liberal Portland, Oregon where I am, I would still (anecdotally, while waiting for actual data) bet that the majority of kids still identify as cisgender.

Hormone therapy has permanent consequences. Sam can just wait until she is 18 to decide. I sympathize with parents, because when it comes to puberty, someone has to pick a path, and either path has permanent consequences. (Note that this is not true for puberty blockers). If Anna and Sam decide to pursue estrogen therapy, Sam might ultimately have breasts that will not go away if she stops estrogen. But without intervention, Sam will complete a testosterone puberty. This might result in facial and body hair, a deep voice and possibly an Adam’s apple, more height, and masculine facial features. Some of these - like the height and voice - are permanent. The other changes require surgery and possibly extensive hair removal. And here is the thing: I try to avoid hitting parents with the worst outcomes. It feels unnecessarily harsh. But the reality is that, without medical intervention, gender diverse youth and teenagers are at higher risk for depression, substance abuse, and suicide. And in Sam’s case - for people assigned male at birth who have to complete a testosterone puberty - it is much more likely that they will be perceived as a trans woman, rather than a ciswoman, and therefore they may be at higher risk of violence and becoming victims of murder. People who are assigned female at birth are more fortunate in this regard - they are more likely to be seen as cisgender, even if they completed an estrogen puberty in their youth. One of the hardest things for parents to understand is that refusing hormone treatment until the child is an adult is not merely postponing a decision, it is making a decision with equally serious consequences