The 8-year-old boy came to the doctor’s office with complaints of anxiety and problems going to the bathroom. The boy refused to use public restrooms and would visit them in the company of his mom.

Traditionally, these symptoms might point a medical professional to investigate a potential painful urinary tract infection, or perhaps undisclosed sexual abuse that had caused the boy to “hold it” rather than visit a restroom where he might be in danger.

But on further investigation, gender identity proved to be at the root of this boy’s problems, said Dr. Jennifer Winter, a physical with Internal Medicine and Pediatrics, Fort HealthCare’s Family Care Clinic.

Questioned further, the boy revealed that he felt uncomfortable in men’s restrooms because he identified as a girl, and, in fact, he always pretty much had felt this way.

Winter spoke about gender identity at the Fort Memorial Hospital Thursday, keynoting a luncheon of Women Who Care, a group of female professionals from throughout the area.

Failure to take into account gender identity issues, and failure to recognize people as they identify, can lead to poor medical outcomes, she noted.

In fact, Winter said, people who identify as transgender have a 41-percent rate of suicide attempts. Compare that to a rate of 4 percent for the general population.

If those people are supported in their gender identity, however, that heightened suicide risk falls back down to that of the general population, although anxiety rates remain a little higher than the norm, Winter said.

The health-care professional said that 1.4 million people across the United States identify as transgender, and as people become more comfortable talking about the topic, she feels that number will go up.

Of this population, she said, 65 percent report experiencing discrimination due to their gender identity. Some 20 percent say they have postponed health care due to prior mistreatment.

She reiterated that 41 percent report having actually attempted suicide — not just having suicidal thoughts.

“And the ones who succeeded aren’t being counted,” Winter noted.

Of transgender individuals, 62 percent report having experienced depression. Some 14 percent are unemployed and 15 percent live in poverty.

“A lot of that comes from just misunderstanding,” Winter said.

“One of the things I did when I started researching this was to ask myself, ‘How do I know I’m a girl?’” Apart from the genitals with which one is born, this is difficult to quantify, she said.

But modern research has shed light on an entire spectrum of the human experience and has found that it does not always fit neatly into the “binary” system of female versus male as defined in Western culture.

“We need to step away from the idea that gender equals biological sex,” the doctor said. “What you look like on the outside does not necessarily tally with how you feel on the inside.”

Gender concepts always have been heavily influenced by culture, she noted, using an advertisement from the 1950s to point out how the definition of femininity has changed in just a few decades.

The ad, with the slogan, “Show her it’s a man’s world,” depicts a man being served coffee by a kneeling woman. He’s leaning back in his chair, his feet up, a smirk on his face that would engender anger in a modern feminist, while her posture is one of supplication.

Winter noted that modern society has moved past the idea that it’s inappropriate for boys to play with dolls and girls to play with trucks.

She defined gender identity as an individual’s personal, internal, deeply-felt sense of being feminine, masculine, both or neither.

“It’s not necessarily aligned with what you look like,” she said.

Winter said this might occur because as young people develop — first inside the womb and then after they’re born — different parts of them develop at different times. While the physical structure of the body that gives a person a particular set of genitals develops very early, the portion of the brain dedicated to gender identity develops at a different time and might not match.

Winter defined several terms that have come into use as more studies have been done on transgender issues.

“Binary” is the belief that there are only two genders.

Looking at modern research, Winter said, this is “not a good assessment of gender.”

A trans male is a female-born person with a masculine gender identity, and the opposite is true for a trans female.

“Non-binary” is an umbrella term for someone who does not identify specifically as male or female.

This term includes other subcategories, such as “gender-fluid,” which defines a person who experiences a changing gender. Some days they feel like a female and some days like a male, and sometimes it can be neither.

“That’s probably the hardest for most of us to understand,” Winter said.

As this field of study has progressed, a term was needed for a person whose gender identity does match his or her sex at birth. This term is “cisgender.” Most people fit into this category.

Winter cautioned that people should keep in mind that gender identity has nothing to do with sexual orientation. The two are separate.

Sexual orientation, to put it simply is “who you like,” whereas gender identity is “who you feel like.”

“It’s not something you can really control,” Winter said. “The distress is intense. (Being transgender) is not something anyone’s going to voluntarily want to be part of,” she said.

She defined dysphoria as an intense feeling of not fitting one’s own body. For example, it’s not uncommon for a trans male to feel extreme anxiety, or even suicidal thoughts, on looking down at his feminine-appearing chest.

This individual might not be able to sleep without wearing a binder, which is a garment worn to flatten breasts.

That can become its own health issue, as it’s best not to wear a binder for more than eight hours at a time, Winter noted, as this can lead to rashes or infections.

Addressing one of the “frequently asked questions,” the doctor said that occasionally, there are people who identify as transgender while young who return to a cisgender identity later.

“Not all kids who explore gender end up transgender,” she said. “Studies suggest many won’t.”

However, they might not settle on a cisgender identity either, but might define themselves as somewhere in-between.

She said it’s important for parents and health professionals to show support for children wherever they are in their journey.

“Value them for themselves,” she said.

She went on to define a couple more terms which have become more common now that transgender issues are “coming out of the closet.”

Gender expression is how a person expresses themselves. They might have a male or non-binary gender identity, but adopt a more traditional female appearance, for example.

The term “transsexual,” which used to be used to describe a person who has undergone surgery to repair one’s gender identity, is no longer in common use. She noted that this is really a person’s own business and does not need to be delineated in public.

The term “transgender” covers both individuals who have been surgically altered to fit their gender identity and individuals who have not undergone this drastic measure, but whose gender identity does not match their sex at birth.

Two new terms have come into use recently which address this phenomenon: “assigned female at birth” and “assigned male at birth.”

An “intersex” individual is one born with indeterminate genitals or characteristics of both genders. It is rare, but it does happen.

Additionally, the term “gender-nonconforming” often refers to someone like the traditional “tomboy,” who enjoys activities and/or clothing that is traditionally associated with the opposite gender, but who still feels they fit the gender they were assigned at birth.

“People are varied,” Winter said “It is appropriate and medically necessary to treat people as they identify.”

She said that being transgender is not a mental illness — just a variation in the human condition. And while transgender people experience depression and anxiety at greater rates than the general population, this can be traced to the discrimination, misunderstanding and lack of acceptance this population still experiences in everyday life.

While traditional Western culture has not recognized transgender individuals, the phenomenon has existed around the world for millennia and is recognized by numerous non-Western cultures, Winter said.

For example, the Polynesians recognize “mahu” as half-female, half-male people. Native Americans call this group “two-spirit people.” Meanwhile, in India, male-to-female transgender individuals constitute an entire religious sect.

Winter emphasized that the more research is done on transgender people, the more scientists have come to understand that the phenomenon has a neurological and biological basis. In other words, it is not a choice.

Recognizing that transgender people were born that way and are measurably different than other people, Winter said, medical professionals must change their practices to accommodate this not-so-rare condition in order to assure the best medical outcomes for people in this group.

When treating a transgender person, she urged health-care providers to avoid pressuring these individuals or telling them to suppress, hide or reject their gender identity. Rather, allow people to be who they are.

“It’s not as easy as it sounds,” Winter said, acknowledging that for affected individuals and families, this often involves changing a person’s name, going through lots of paperwork, and working closely with schools and institutions to make sure individuals can access the correct restroom for their gender identity.

And of course, while society is changing as transgender people are better understood, there is still a significant risk or censure, discrimination or even violence for those who “come out” as transgender.

“School is a critical place,” Winter said. “Students need to know they are accepted and valued.”

In terms of medical treatment for young people going through this process, what is done depends strongly on the individual and the family.

If a child thinks they are transgender, they can go on puberty blockers to give them a little more time as they make that decision. This causes no permanent change or damage, Winter said.

When they’re a little older, perhaps in the early teen years, cross-hormones may be given. This leads to some irreversible or only partially reversible changes.

Surgery is an extreme measure that some transgender people undergo and many do not.

In terms of transitioning, everyone does it in their own way, Winter said.

One of the first and easiest steps a medical provider or other person can take to show their support of a transgender individual is to use the pronouns that person prefers: such as “she,” “he,” or in the cases of many non-binary individuals, “they.”

“Even if you don’t understand it, don’t like or or don’t feel comfortable with it, it’s one thing you can do to support that 41 percent of transgender people who are likely to attempt suicide if they don’t have that support,” the doctor said.

She said it’s as simple as asking what pronouns that person prefers.

Winter then ran through a list of points that trans people most want the public to know:

• This is not a choice.

• This is not a mental illness.

• Just because I am transgender, don’t assume I have co-morbid mental health issues like depression.

• Be aware of triggers which can remind me of past trauma and put me in a bad place.

• Use my preferred name and pronouns.

For those in the medical profession, Winter recommended they pass along the patient’s preferred name and pronoun to others caring for that individual so they don’t have to repeatedly explain themselves.

She also reminded her fellow health-care professionals that they shouldn’t assume all of the patient’s problems are related to a patient’s gender identity.

“Strep throat is just strep throat,” she said, with humor.

Finally, she reminded her audience of the Hippocratic Oath, which calls on doctors to “First, do no harm.”

Moving forward, Winter said health-care professionals can help this vulnerable population by teaching and modeling tolerance, helping to educate the public on the realities of and misconceptions about gender identity, and especially to “watch their words.”

For example, don’t refer to the general population as “normal,” as in “Normal kids don’t do this.”

She encouraged medical professionals to employ cultural humility, understanding that their experience is not the same as everyone else’s.

As more is learned about transgender individuals, hospitals and clinics need to become more welcoming, Winter said, with more gender-neutral restrooms; welcoming waiting rooms; publicly available information about gender identity, and a non-judgmental atmosphere.

Winter said her own office is working to make its forms more inclusive by eliminating the need for patients to check just one box, either “male” or “female,” when this dichotomy does not fit everyone.

Winter finished up by returning to the case scenario she opened her talk with, disclosing what happened to the young boy who didn’t want to use male restrooms.

Once they determined the child was transgender, the child entered counseling to address gender identity and anxiety issues.

The parents met with school officials, who were thankfully very supportive, Winter said, to develop a safety plan for the student.

The child transitioned from male to female gender expression over the summer and entered school the next year as a girl.

“She was no longer as anxious and turned into more of an extrovert,” Winter said. “She was relieved to meet other trans kids, as she had felt very alone before. Now she helps to educate others.”

That child is her own, Winter said: born Patrick and now a happy Patricia.

“It has been a journey,” the doctor said, noting that she was apprehensive about how some members of her husband’s Catholic and fairly conservative family would take this change. They surprised her with their acceptance, however.

Winter said she figured she wouldn’t even tell the 93-year-old grandmother. As the senior citizen couldn’t see very well, Winter acknowledged she thought the grandma might not even notice.

When Patricia came close for a hug, the grandma simply said, “Patrick? ... I really like your dress. It’s quite a change.”

Wrapping up the meeting, Carol Burrows, co-chair for Women Who Care, said that hearing this story will help the health-care professionals in the room provide better care and everyone have a better understanding about gender identity.

“I am at an age where a lot of these things weren’t discussed,” Burrows said. “But there’s nothing worse than not talking about something that’s right in front of you.”

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