[MUSIC] Keeping transgender children healthy across their life span involves a changing set of social considerations and later, medical options. In early childhood, establishing an affirming environment for a transgender child is probably the most important way to protect their health and help them develop to their full potential. This includes allowing them to express themselves by letting them dress in ways that they feel most comfortable. Allowing them to choose a hairstyle that they feel fits their sense of who they are. And listening to them about things like the name and pronouns they want others around them to use. This also often includes working with family, friends, and teachers to honor a child's request. >> Little kids don't really need much treatment, so to speak. I mean, you're not going to give them hormones, they don't have much of their own anyway. But what sometimes people will do is they'll do sort of a social transition. They'll dress in the gender they're comfortable. They might even want you to call them a different nickname. They might cut their hair a certain way. And so that's a way that they can sort of come out and experience that gender to their family and to their friends in school. And of course, those kids really need a lot of support and acceptance. >> The time around puberty is uniquely challenging for transgender children, as they face the prospect of developing physical characteristics that may not match their gender identity. At this time, many transgender children and their parents begin to discuss the option of delaying puberty. This gives the child and the family more time to make decisions together about longer term medical options. It also prevents the child from experiencing distress, as their body develops in a way that doesn't align with their internal sense of who they are. >> Another time when it becomes a little bit more of an issue and distress for the child is when it's about time to go into puberty. And especially if the child is identifying as a different gender than their assigned one at birth, the puberty they're going to go into is going to be different, not the one that they want. And that can be very traumatic. >> The other benefit of delaying puberty is that it prevents the development of some secondary sex characteristics that may be irreversible, or that may only be surgically reversible later on in life including, for example, breast development or voice changes. The onset of puberty is usually triggered by the beginning of fluctuations in a hormone called gonadotropin releasing hormone, or GnRH. Pausing puberty is achieved by administering small amounts of that very same hormone. This levels out the fluctuations and temporarily interrupts the process of puberty by stabilizing the amount of GnRH in the adolescent's body. Puberty blockers are reversible. Once removed, puberty continues as it would have organically. So later on in adolescence or early adulthood, many transgender individuals choose to use cross hormones, so their bodies develop in accordance with their gender identity. Taking puberty blockers before taking cross hormones means that a transgender child will never have to experience a phase of pubertal development that takes them farther way from their gender identity and their desired gender expression. >> Then the next step would be to put in the opposite sex hormones. So in a transgender girl we might start adding in estrogen because the body would've naturally made testosterone. So we stop or put a pause on the male hormones that would've been made, and we add in what's known more as the girl hormones. >> For transgender adolescents taking cross hormones, their physician and family will usually have an informed discussion about their fertility options moving forward. >> And then the other issue that really comes up that we have to check in with patients about is fertility. So a lot of the treatments may, as you imagine, reduce fertility. And so we may talk about banking sperm for use later, or freezing eggs. And so that's a whole other realm of complication that you want to make sure that you're doing the right thing. Again, you don't want to reduce somebody's fertility without some thoughtfulness around that. >> In adulthood, some transgender people may opt for surgical interventions that further align their body with their gender identity. Many physicians who practice in this field have called gender-affirming surgery a life saving intervention for some transgender individuals. But physicians also remind us that some transgender people choose not to have any medical interventions, and that the treatment plan is as unique as each individual person. >> I do want to mention, as an aside, that there are some people that don't do hormones at all, and they consider themselves transgender. They just choose not to do hormone therapy. There are some side effects, potentially, and they choose not to do that. And some people choose not to do surgery. Some people do hormones and surgery. Some people do surgery and not hormones. So just to give you an idea, again, it's not this progression that everybody follows. It's not this cookbook recipe. It's very, very individualized, because everybody's different, we're all unique, and so is our therapy. And we take a lot of our lead from our patients. [MUSIC]