Beyond the Labels: Defining Transgender

Editor's Note: This article is the second in a DyeStat series about transgender athletes in track and field and the issues that surround their participation in the sport. In this second installment, we take a look at what it means to be transgender and seek to answer some basic questions with the help of experts.

By Mary Albl of DyeStat 

Terry Miller mulls over the question a moment. 

What is it she feels people don't understand about her? 

“I feel like they don’t understand us as people, and they don't understand the term transgender as well,” Miller said. 

Miller is a 17-year-old transgender girl who competes for the track and field team at Bloomfield High in Connecticut. 

Seventeen states, Connecticut included, allow transgender high school athletes to compete without restrictions. 

According to the Connecticut Interscholastic Athletic Conference Handbook, the non-profit organization is “committed to providing transgender student-athletes with equal opportunities to participate in CIAC athletic programs consistent with their gender identity.” 

A pair of transgender athletes from Connecticut, Miller and Andraya Yearwood from Cromwell High, have been the subject of scrutiny and debate since they began competing and winning girls races. 

Many believe it is simply not fair for biologically born males to compete against females even though they identify as girls, especially without any medical intervention to lower the male hormone testosterone. 

In order to understand the issues better, DyeStat spoke with Christy Olezeski, PhD, Child and Adolescent Clinical Psychology, Director of the Yale Gender Program, and Susan D. Boulware, M.D., Pediatric Endocrinology, Medical Director of the Yale Gender Program.

They helped explain what a child goes through when they start to explore their gender identity. In addition, they explained some of the stigma surrounding the vocabulary and offered definitions for some key words and phrases.  

What is the Yale Gender Program and how does it work?

The Yale Gender Program opened in October of 2015 and is one of several programs across the United States that provides medical and mental healthcare evaluation and therapy for children experiencing gender identity issues. 

The program sees individuals as young as 3 years old and up to about 25 years old.

“Children at two-and-a-half can be able to report on their own gender,” Dr. Olezeski said.

On a first visit to the Yale Gender Program, the child and family meet with a team of individuals – a mental healthcare provider, a pediatric endocrinologist and the pediatric nurse coordinator.

“First of all, we want the children and their parents to feel welcomed, safe and comfortable, because this is typically a very stressful appointment,” Dr. Olezeski said. “A lot of times these kids have been thinking about this and have understood who they are for a very long time before bringing it up to their parents and then coming into a provider’s office.

“After the initial appointment, which usually lasts 60-90 minutes, a full-day interview is scheduled for a later date. At the interview, the child and family speak to the team separately so they can each speak openly about the child’s gender (and life) journey. We try to get a comprehensive look at their home and school life, their gender dysphoria, and supports, or lack thereof, that may make the child more or less vulnerable.

“The interview can range from 2-4 hours for the children and 1-2 hours for each of the parents, depending on the conversation. We speak more about the child’s gender journey, ask about family, friends and school supports, what’s happening in classes, what’s happening with bathrooms and locker rooms, what’s happening in sports, religion, culture. We really try to understand who are the supporters for this kid? Do they have online friends? In-person friends?”

Olezeski and her team then meet to discuss the information they’ve gathered. They talk to the family about any legal and mental health issues, and make sure everyone is on the same page with a clear understanding of the proposed treatment options, support offered and any other concerns. 

“Are they ready? We make sure they understand the risks and the benefits,” Dr. Olezeski said. “By the time they start medical treatment, we feel confident that they understand.”

Dr. Boulware said a major component of the process is addressing mental health, and making sure the right steps are taken to assist a child the best way possible. 

“We know that not doing anything carries huge risks,” Dr. Boulware said. “We know that in trans youth, the incidence of anxiety and depression are significantly increased as compared to cis-gender youth. The most alarming figure is that 41 percent of trans individuals have attempted suicide in their lifetime. That’s attempted suicide, not just thought about it. Doing nothing needs to be an active decision for that child at that particular moment in their journey. We don’t make any of these decisions lightly. We fret about children that we think need to slow the pace a little, to be sure they understand and can articulate their needs (so we aren’t assuming) and that they understand the risks and benefits of specific interventions.” 

In what ways are transgender individuals vulnerable? 

A 2012 journal article entitled, “A Conceptual Framework for Clinical Work With Transgender and Gender Nonconforming Clients: An Adaptation of the Minority Stress Model” written by Michael L. Hendricks, Washington Psychological Center, P.C., Washington, D.C., and Rylan J. Testa of Palo Alto University, offered explanation of The Interpersonal Theory of Suicide, developed by Thomas Joiner, an American academic psychologist and leading expert on suicide. 

The Interpersonal Theory of Suicide explains that suicide risk is “predicted by the confluence of thwarted belongingness, perceived burdensomeness and the capability to kill oneself.” 

The article states: “Trans people, like the general population, have general life stressors that may result in a wide range of reasons for presenting to a psychologist for care. However, on top of general life stressors, trans people are subjected to alarmingly high rates of discrimination, violence, and rejection related to their gender identity or expression.” 

“Self-blame and low self-esteem may develop as a result of gender-related victimization, such as childhood bullying, rejection by one’s family, employment or housing discrimination, or intimate partner violence based on one’s gender identity or expression. 

“With this connection severed, the individual also experiences a decrease in the sense of belongingness. This loss of self-worth, combined with the need for community resources that results from the victimization, may lead to thoughts that simply being transgender presents as a burden to society.” 

A Glossary Of Terms 

Terms explained by Boulware and Olezeski, unless otherwise stated. 

Cross-hormone therapy: For identified females, it is treating with estrogen; for identified males, it is treating with testosterone.

Estrogen: According to medicinenet.com, “A female steroid hormone that is produced by the ovaries and, in lesser amounts, by the adrenal cortex, placenta, and male testes.” Estrogen induces secondary sexual characteristics including breast development (and if the individual has a uterus, estrogen will stimulate growth of the lining of the uterus and eventually will lead to periods).

Gender dysphoria: From the American Psychiatric Association, gender dysphoria involves a conflict between a person's physical or assigned gender and the gender with which he/she/they identify. It is important to note, not all transgender individuals suffer from gender dysphoria.

Natal females: Individuals who are born with genitals that appear female (labia, clitoris, vagina).

Natal males: Individuals who are born with genitals that look male (penis, scrotum, testes).

Onset of puberty: For natal females, the first sign of puberty is breast development which occurs at an average age of ~ 10.  The average age of starting periods is about 12 1/2 years.  For natal males, the first sign of puberty is early testicular enlargement (to a volume of 4 mL or more) which occurs at an average age of ~ 11 1/2 years. For many children, the onset of puberty induces a significant increase in gender dysphoria as they see their body developing along the lines of the natal sex and not the affirmed gender.

Puberty Blockers: Medications that inhibit the secretion of sex hormones (testosterone from the testicles; estrogen from the ovaries) and thereby inhibit development of the secondary sexual characteristics. Options for these medications include an intramuscular injection once every 1-6 months, or an implant that is inserted just under the skin in the inner/medial surface of the upper arm. Natal puberty will restart and progress if the blockers are stopped. As it relates to athletics, a blocker will cause the testosterone level to fall into the range of a natal female. Any possible advantage she might have from having higher than average female testosterone levels (prior to the blocker) will dissipate.

Testosterone: A sex hormone produced by the testes as well as lesser amounts from the adrenal glands and ovaries. Testosterone stimulates development of male secondary sexual characteristics including enlargement of the penis, deepening of the voice, increase in body hair and development of facial hair. Testosterone increases muscle mass as well as bone mass.

Transgender: Transgender is an adjective that describes an individual whose genitalia does not match their inner sense of self (this could be an individual with a penis, testes and scrotum who does not feel male [they have the internal sense of being female or non-binary, ie. neither fully female or fully male]).

WPATH: The World Professional Association for Transgender Health. For more info, click HERE

Additional Questions  

What Is The Appropriate Age To Begin Cross-Hormone Therapy?  “WPATH Guidelines state cross-hormone therapy can begin at 16 years of age, but that there might be compelling reasons to start earlier,” Dr. Boulware explained. “Most cisgender children have nearly completed pubertal development by 14-16 years of age. By delaying the initiation of cross-hormone therapy until an adolescent is 16 years old, we are further marginalizing an already marginalized individual by keeping his/her body in a prepubertal state several years beyond that of his/her peers.” 

What Is The Appropriate Age To Start Puberty Blockers? “At Tanner stage 2-3 of pubertal development (average 10-12 years old). It can also be used in sexually mature individuals to block natal sex hormone secretion.”    

How Does Testosterone Give Someone An Athletic Advantage? “You can build more muscle mass with testosterone, but that is dependent on training. Being stronger does not translate into being faster. That is where technique, practice and training (good coaching) are necessary to improve one’s running.”