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Happy Pride month! To kick it off, I spoke with Dr. Ariel Frey-Vogel, director of child and adolescent services at Mass General’s Transgender Health Program (and, full disclosure, a high school friend).

Understanding the nuances and fluidity surrounding gender identity is essential. Research from the American Academy of Pediatrics states that between 30 and 51 percent of transgender adolescents reported attempting suicide during their lifetimes. According to a 2019 study from suicide-prevention organization the Trevor Project, nearly 1 in 3 transgender or nonbinary youth have attempted suicide. The risk increases if kids have unsupportive families, Frey-Vogel says.

Meanwhile, anti-transgender legislation is on the upswing nationwide, especially surrounding participation in youth sports. On Tuesday, Florida Governor Ron DeSantis signed a bill barring transgender girls and women from playing on public school teams intended for student athletes identified as girls at birth.

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Meanwhile, in 2020, at least 44 transgender or gender nonconforming people were shot or killed by other violent means, according to the Human Rights Campaign. (Frey-Vogel says that the term “gender nonconforming” is falling out of fashion. “It’s seen as a more stigmatizing term, as if there’s something one should ‘conform’ to,” she says. Gender diversity is a more expansive way to describe people without referencing cultural norms.)

If you’re a parent contemplating gender issues with your child — or just someone who wants to be supportive — here’s a primer.

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Sign up for our parenting newsletter, In the Family Way.Heather Hopp-Bruce

Understand the terms. They can be confusing, even for the most well-meaning person.

Cisgender describes someone whose gender identity aligns with their sex assigned at birth.

Transgender is a broader term referring to someone whose gender identity or expression is different than cultural expectations.

Nonbinary describes a person who doesn’t identify exclusively as male or female. They could identify as both or fall someplace in the middle.

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“They might go back and forth or feel a little of both — or feel something else entirely,” Frey-Vogel says. “I think that’s hard for people who haven’t experienced it. It’s one of those things where we have to listen to people and believe them, even if we don’t completely understand how they feel.”

Know the timelines. Gender awareness unfolds on a fairly predictable timeline.

At around 18 months, kids can identify males or females. At around 3, they recognize their own gender. At around 4, they realize their sex assigned at birth is permanent. At around 6, “magical thinking stops — such as, ‘Maybe Santa will bring me the right body part,’” Frey-Vogel says.

This awareness typically coincides with elementary school, which is inherently gendered, Frey-Vogel says.

“There’s the boys’ bathroom and the girls’ bathroom; boys’ and girls’ birthday parties, Boy Scouts and Girl Scouts. Everything is gendered, so you see dysphoria come out around then,” she says. Dysphoria refers to the feeling of discomfort that might happen when an emerging gender identity differs from a child’s assigned sex.

She recommends the Gender Unicorn as a visual way to conceptualize gender.

Is it a phase or an identity? Many kids go through phases of gender play and experimentation — boys who try on skirts, for example.

“The difference is, kids who are trans end up being insistent, consistent, and persistent about their gender,” Frey-Vogel says. “It’s not, ‘I wish I were a boy.’ It’s: ‘I am a boy. This is who I am.’”

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When this insistence, consistence, and persistence carries through puberty, the chance that a child will later change their mind is minimal, she says. This can be extremely hard for a parent who wonders if a child they thought they knew is actually someone different, and every kid’s journey and process is unique. Gender identity is expansive, and timelines aren’t always linear.

“What we know from the research is the very best thing is to listen, support, and affirm them as they are now, even though you have to embrace the uncertainty. From a mental health perspective, a child does better if their parents supported them the whole time,” she says.

She recommends PFLAG as a support resource for parents and allies.

Getting medical support isn’t a commitment. Frey-Vogel says that some families are reluctant to see a physician because they “don’t want to be on a conveyor belt,” she says — as though receiving medical guidance might hasten or finalize an irreversible transformation process.

“But I would much rather see kids really early, when there’s nothing to do medically. That way, a parent and child can feel comfortable with me. We can talk about resources and giving 360-degree support without having to worry about hormones. I’d rather see people once a year as soon as it’s an issue, rather than: ‘This is an emergency, my child is starting puberty, and I need something right now,’” she says.

Medical intervention, if needed, doesn’t happen until puberty. At this point, families can opt for a pubertal blocker, which “puts a reversible pause button on puberty,” she says. “It gives everyone in the family time to decide on the right next step.”

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Families can decide if they should let natural puberty unfold or receive hormones to affirm a new gender identity, usually within a two- to three-year window. During this time, Frey-Vogel says, she can help direct families toward therapists who are expert in gender identity and offer support group resources for kids and adults.

Gender isn’t an “on-off” switch. Frey-Vogel wants parents to know that, at this stage, “You’re not making a decision for the rest of your life. It’s about, ‘What feels right for you, right now?’ People think of gender as an on-off switch, but it’s a continuous discussion,” she says.

Grieving doesn’t make you a bad parent or ally. “This is an overwhelming process. A child is going through a journey, and each parent is, too, and there may be some grieving, as you say goodbye to the child you thought you had and welcome the child you do have. All of that is OK,” she says.

Some parents might be reluctant to offer full-fledged support out of fear for their child’s safety, though.

“I think parents are often wary of doing things to affirm their child’s gender because they’re worried about stigma. There are two things we worry about: one is the mental health of the child on their own, and the other is, how is the world going to treat the child? What we know is that, when parents are supportive and affirming, kids do so much better from a mental health perspective,” she says.

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We can control our immediate family’s response. We can’t control the outside world, but we can “help advocate for changes in our society, helping our kids to build resilience and allow them to live authentically and create supportive environments in our own small communities,” she says.

Look for allies. She recommends BAGLY, the Boston Alliance of LGBTQ+ Youth, a social justice advocacy group.

Share on your own terms and timeframe. There’s no script or deadline for sharing your family’s experience with the outside world. (Frey-Vogel says PFLAG offers helpful tips from those who’ve navigated the process.) It’s more about deciding what feels more stressful — opening up or not.

“It’s very individual. I try to check in with patients: If something is feeling too scary, then don’t do it right now. But if it’s too stressful if you’re not out, let’s think about how to help you to be out. It’s about reducing the stress,” she says.

On the hopeful side, “What has become clear to me in this work is that what is normalized has changed for the better, such that kids at a much younger age recognize there are many ways to be and that those ways are normal. Once, a lot of people who may have been trans and not felt it was a normal thing to be suppressed it, whereas now, I think a lot of kids are coming out as trans and non-binary,” she says.

Today, “The stigma I worry about is more from other adults in the child’s life,” she says.

And so, remember: A child’s identity is internal and integral. What we can control is their environment, whether it’s supportive, affirming, and loving — or punishing, shaming, and judging.

“This is what influences how a child acts in the world and expresses themselves,” she says.

Their lives, quite literally, depend on it.


Kara Baskin can be reached at kara.baskin@globe.com. Follow her on Twitter @kcbaskin.