Gender Identity and Neurodiversity in Adolescents with Chronic Pain
Brought to you by Creative Healing for Youth in Pain's Parenting Blog
There has been increasing interest in gender identity vs. biologic sex in adolescents, especially in those with chronic pain.
In my pediatric pain clinic, when I spend time alone with an adolescent -- without parents present -- and ask questions related to adolescence and mental health status, more youth are indicating transgender identity (vs. cisgender). Some have said that one or both parents know, and others have said they haven’t told either parent.
I also notice that many (not all) of these teens have developmental atypical neurobiology. They often have multiple sensory sensitivities, tend to perseverate on thoughts or behaviors, and have difficulty with transitions. Often, they are logical and will “out-argue” anyone if they feel that they are correct.
Many of these kids – especially the bright kids -- have been bullied in elementary and middle school, since most others don’t “get” them. They typically have more online friends with whom they play videogames. The literature labels these kids as having autism spectrum disorder, although more recently, the label “neurodiverse” has come into vogue since it is less stigmatizing.
Reasons are unknown about why there is a relatively high incidence of youth with developmental neurodiversity among transgender youth. One factor that brings these two groups together might possibly be feelings of isolation from peers at school and a connection with unique groups that provide feelings of belonging for neurodiverse youth or transgender youth. We don’t know the answer. We do know that members of each group may feel isolated and lonely.
Gender Identity Issues
We know that adolescence in general is a time for gender identity formation. It is a major task of adolescence. So, questions arise about two issues faced by parents of some adolescents. One relates to the adolescent with developmental neurodiversity and the other to transgender identification.
When I reviewed the literature, two major findings emerged. First, if one looked internationally at adolescents who felt like they were in the wrong body (transgender identification), a significant majority met criteria for neurodiverse development (called autism spectrum disorder in many studies).
Second, in studies that looked at outcomes in youth with gender dysphoria significant enough to qualify for puberty suppression and administration of medication to block puberty, there were overall significantly positive outcomes. These included decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life. (Negative factors associated with puberty blockers were changes in body composition, slow growth, decreased rate of height, decreased bone turnover, the cost of the medications, and lack of insurance coverage.)
Some states have legally assigned age limits for gender affirming treatment. Most adolescent health care specialists suggest that such treatment be individualized rather than using specific age limits. The research on positive outcomes for receipt of gender affirming care during adolescence relates to puberty blockers and not surgical changes specifically. In fact, there was a big story in the British newspapers about the Tavistock Clinic in London performing gender-change surgeries on children as young as 13-14 years of age. The whistle-blower indicated that the gender surgical clinic was the Tavistock Clinic’s biggest source of revenue and that the surgeries were motivated, in part, by financial gain.
Transgender Kids with Chronic Pain
Many studies have shown high rates of depression and suicidality in youth who feel transgender. If they also have the neurobiology associated with autism spectrum disorder, they may experience further isolation and shunning by peers at school. Kids with chronic pain often already feel a sense of isolation because they may be experiencing increased absenteeism associated with their pain.
There is no single answer about what parents of kids who feel transgender and have chronic pain should do. The literature suggests that allowing such kids to have puberty blockers at specific teen gender clinics (most Children’s Hospitals now have this) typically results in good outcomes. These clinics tend to be thorough in psychological evaluations before such gender-affirming treatment is administered.
Many teens withhold critical information about themselves from parents for fear of negative judgment. I recommend that parents encourage their teens to discuss topics such as body image and any feelings of dissatisfaction, including about gender. Time alone with your adolescent to allow talk about feelings of isolation, depression, suicidal thoughts, and other negative feelings – without judgment or instruction from you -- will permit pathways for ongoing good parent/teen communication.
Parent/teen openness and encouragement of communication -- and acceptance of the teen’s feelings -- allow for actions that result in optimal outcomes, including in the area of sexual identity.