Photography by Gara Dyson
Jessica, one of the center’s patients, with Dr. Christopher Lewis
Four months ago, St. Louis Children’s Hospital opened The Transgender Center, the first of its kind in the region. Kids who are deeply distressed by their gender identity can swiftly receive care, education, counsel, and referrals. There are no months-long delays, waiting for an appointment while hormone levels build and anxiety and depression increase apace.
But neither is there irrevocable treatment of kids who are just exploring or experimenting, trying on identities like outfits in a changing room.
The word “distressed” is the key.
“During adolescence, it’s common for teens to gender-bend or explore different gender expressions—but that does not cause them to be in distress,” explains the center’s cofounder, Dr. Sarah Garwood, who specializes in adolescent medicine. “The definition of gender dysphoria is the distress that occurs when a person’s gender identity differs from the gender assigned at birth.” Biologic sex and gender identity are usually aligned—but not always.
And when they’re not, emotions get complicated.
“The role of a mental health provider is important in treatment of gender dysphoria," continues Garwood. “Most of our patients have a mental health provider who’s part of the assessment and makes recommendations for treatment.”
The center refers to mental health providers in the community, and its team also includes a nurse-practitioner, a nurse-educator, and a social worker, expanding the care offered by Garwood and Dr. Christopher Lewis, a pediatric endocrinologist.
“We have been seeing kids in our clinics who are gender-nonconforming or transgender for several years,” says Garwood, “but now we’ve created a multidisciplinary team.” More expertise is available faster, with more scope for assessment and education.
Sometimes it’s parents who need the information: “It’s a process for them, too,” says Garwood. “They might not understand the consequences of gender dysphoria,” which can include anxiety, depression, and eating disorders, and even lead to suicide. “Teens with gender dysphoria have high rates of anxiety and depression, partly because of the social stigma and the rejection and also just not feeling like they’re in the right body.
“Parents also might not realize how damaging it can be if they’re not supportive,” she continues. “The number-one thing that makes a difference in how kids do is whether they have their parents’ support.”
Other parents have made their peace with their child’s explorations of gender identity, but they’re not ready to approve hormone treatment because they’re afraid of long-term side effects, such as infertility.
A hormonal blockade can be used to stop puberty, but it resumes as soon as the block stops, so fertility is not damaged, Garwood explains. “However, taking cross-gender hormones in either direction will likely affect future fertility.”
Is there concern about taking clinical action too early in a child’s life?
“There are published guidelines by both the Pediatric Endocrine Society and the World Professional Association for Transgender Health,” she says. “You’re eligible for a pubertal blockade when you have started puberty, which can be measured by hormone levels as well as a physical exam.”
Isn’t that waiting too long, though, if puberty has already begun, and you’re hoping to steer development in a different direction?
“The blockade basically puts the brakes on before secondary sexual characteristics develop,” Garwood says. “There might be breast buds, but they won’t continue to grow. Waiting for the onset of puberty is important diagnostically, because some kids will actually—we use the word ‘desist’—and accept their natal sex. But if you reach the beginning of puberty and you’re still proclaiming a transgender identity, you’re very likely to have a transgender identity as an adult.”
For gender-affirming hormones or cross-gender hormones, the recommended age is 16. “But there is clinical discretion,” Garwood says, “and there’s a lot of discussion in the field about starting younger, because it makes sense to match an adolescent child’s development to their peers’ development. Most adolescent females begin puberty before 16. So it’s a case-by-case decision made by Dr. Lewis, the pediatric endocrinologist.”
If surgery’s considered, the center partners with Washington University plastic surgeons. The center also helps with the transition of care to adult medicine. “We’ll see new patients up to age 21 and existing patients to age 24,” Garwood says. “But after age 24, they’ll need to see a provider who can prescribe gender-affirming hormones.” Theoretically, that doesn’t require a specialist—“but it’s not mainstream yet. We have a long way to go in terms of educating medical students and residents.”
Given that this is still a fairly new treatment area, has the center gotten any flak since opening?
“Some, yeah,” Garwood says. “I received a very heated voicemail from a nun, saying that altering the body is not a role humans should be taking.”
Hospital spokesperson Jacqueline Ferman-Grothe notes “a few isolated comments on our social media channels from people who do not share our philosophy on supporting the transgender population. But for the most part, the community response has been very positive.”
Garwood sees a dramatic increase in acceptance by other young people, even though “there’s still some bullying, ostracism, and harassment. She pauses. “It’s really a cultural phenomenon. If you look around the world, there are hundreds of cultures that historically accepted more than two genders. Native American people often called transgender people ‘two-spirits.’ In Bangladesh, people who were male at birth but lived as females were given positions of respect—until Bangladesh was colonized by the British. Then they were shunned and marginalized.”
She knows the issue’s hard for a lot of people to wrap their heads around, “but transgender people have been present in our societies forever. It’s just a variation of human experience.”
