«Children who are trans often know this very early on»
Ms Pauli, what concerns do young people come to you with at the gender identity consultation at the Psychiatric University Hospital Zurich?
This varies depending on age. When it comes to younger children, it is often only the parents who come for counselling. Not necessarily because their child has problems related to their gender or is expressing distress, but because they are worried themselves. For example, the parents are worried because their child is not behaving in a gender-typical way.
That means?
The son wants to wear skirts, perhaps he has already said he is a girl or wants a vagina. Then the parents ask themselves: How should we deal with this? Is this just a phase or is our child possibly trans? The latter would mean that his psychological gender does not match his physical gender: The child identifies as a boy but has a girl's body, or vice versa. Then we speak of gender incongruence.
What do you tell the parents?
Let's reassure them first: at the so-called magical age of four to seven, gender categorisations are not yet final for children. Anything is possible, and dressing up means transformation: if you put on a girl's dress, you become a girl. As long as the son or daughter is happy and developing well, parents can look forward to an interested child who is keen to experiment. They don't need to worry about whether this is a phase just yet. But they can question the ideas that cause them to worry about the child.
What do you mean by that?
What we understand by masculine or feminine is primarily the result of social moulding through role models. In the past, parents used to worry if their daughter was interested in books or appeared too self-confident, as such characteristics were not desired in women. Today, we are happy about clever, wild and strong girls.
It is important for healthy development that children are allowed to be who they are.
Unfortunately, it is less successful in freeing the male role from stereotypes. When a boy wants to paint his fingernails, the head cinema starts. For healthy development, it is important that children are allowed to be who they are - that parents signal to their son that he can also make himself pretty as a boy or paint his nails.
This is also less irritating than if the son wants a vagina.
I advise parents to react to such comments as calmly as possible. You can ask your son why he wants a vagina. Perhaps he is thinking about whether he wants to be like mum or dad, or he thinks that only those with a vagina are allowed to wear make-up. When parents show interest and listen, they are signalling to the child that they can talk about anything that concerns them. The important thing is how the child is feeling: does it seem content or actually trapped in a role that doesn't suit it?
When do children develop their definitive gender identity?
Usually up to seven years, depending on the child's stage of development. By then, most children are deeply convinced that they belong to one of the two gender categories that exist in our society. However, gender identity can also change and develop later and is not stable for all people. A minority do not feel comfortable in their assigned category. These children feel that they do not fit into the predetermined mould - which does not necessarily mean that they are trans, i.e. that there is gender incongruence.
But what?
Even children who are in harmony with their physical gender can experience incongruence, i.e. the feeling of a lack of conformity. For example, they may not feel like a «real girl» because they deviate from the predetermined role expectations.
Children who are trans often know this very early on, some suffer as early as kindergarten age.
When do people realise that they are trans?
Children who are trans often realise this very early on. Some suffer openly and share their feelings as early as kindergarten age, others keep their feelings to themselves - or hardly feel any pressure to suffer during their childhood years, perhaps because they grow up in a very tolerant environment. For them, the suffering only comes with the physical development of puberty. In our consultation hours, we most frequently deal with adolescents between the ages of 12 and 17.
What problems do they face?
Gender incongruence often causes great suffering during puberty. Adolescents feel misunderstood, misclassified and forced into a mould. Many develop severe body dysphoria - a feeling of suffering that arises because their physical characteristics do not match their gender identity. For example, a trans boy may have hardly any problems with his girl's body as long as it doesn't take on a female form, and may feel like a boisterous tomboy or so-called «tomboy» with «boyish» characteristics. But when the breasts start to grow - or trans girls' beards sprout and their voices break - it plunges young people into despair: Their bodies show ever stronger manifestations of a gender with which they cannot identify.
Apparently, there are more and more young people who do not identify with their birth gender. Enquiries in specialised centres have increased by up to 2000 percent. How can that be?
In 2009, when we started our counselling service for young people, a good five young people a year sought our help. There are now around one hundred a year. You could say that this represents an increase of 2000 per cent. However, it would make more sense to put this figure into its overall context.
Namely?
Our catchment area covers the whole of German-speaking Switzerland. We are dealing with an absolute minority of the total young population living there - I'm talking about a good 0.001 per cent. Yes, the number of enquiries has increased. But this is also due to the fact that there used to be no contact points for trans young people. Most trans people who come out as adults report that they already felt they were in the wrong body as a child, but were unable to express this. We have to assume that these young people already existed before. So we don't really know whether the number of cases has actually increased. However, there are also social reasons for the increased need for counselling.
What are you thinking about?
Today we think about all sorts of questions that no-one used to ask, we grapple with life plans, family forms and role models: What should a man or a woman be like? Young people today are also asking themselves: Am I really a man, a woman? Or perhaps not binary? That's a bit part of it. Not all of these young people are permanently trans.
Non-binary: What does that mean?
The term refers to people who do not feel that they clearly belong to either of the two classic genders. It is not about physical gender, but about psychological, i.e. perceived gender: non-binary people are located somewhere between male and female.
Social media can be positive: Those affected get answers to their questions there.
Gender issues are an ongoing topic online. What role does social media play in the self-diagnosis of trans or non-binary?
An important one. Because the topic is so present, those who are affected come to us earlier. In this respect, social media has a positive effect. Those affected get answers to their questions and can categorise what was inexplicable to them. Interestingly, many adult trans people report that it was a TV documentary that made them realise what was going on with them. However, it is also a fact that young people are impressionable and there is a possibility that they attribute their feelings of incongruence - inner contradictions, inner turmoil - to things they see on social media.
And that they then come up with the idea that they are trans, although they are simply searching for an identity.
That can happen. However, I would urge parents not to simply jump to the conclusion that it is a quirk from the internet when young people express such thoughts. It's not about finding out at that moment whether it's «real» - it's the child's emotions and that's what counts.
How do parents react better?
By recognising that there is a discrepancy between the person the child experiences themselves as and the person they would like to be. This creates insecurity, pressure and doubt. Such feelings are common in adolescence and parents should respect them. If my child suspects gender incongruence, my response as a parent can be that this is one possible explanation, but that there are other possible reasons at this stage of life and that you therefore need to take a very close look and take your time.
As an expert, how do you recognise that there really is a gender incongruence?
There is no reliable method of determining this, such as a blood test for medical diagnoses. We have to take a close look at the development to date and carefully clarify how what the young person describes to us came about. There are more typical signs of a stable, i.e. permanent gender incongruence. However, these signs do not apply to all those affected.
Seven out of ten trans adolescents who remain untreated have suicidal thoughts.
What signs, for example?
If the feeling of not being in harmony with your physical gender was there very early on, around kindergarten age. However, this does not necessarily mean that it was visible to the outside world. Those children who openly expressed it early on usually have the support of their parents when they come to us.
This is a different situation to when a teenager comes out as trans at the age of 15 and this comes out of the blue for their parents. Then they are understandably shocked and caution is called for. Today - for reasons we discussed earlier - we see more minors who are only temporarily trans than in the past. But even then, and especially then, it is important that parents enter into a real dialogue with their child and take them seriously.
What does that mean in concrete terms?
That they are open-minded and ask questions instead of jumping to conclusions. And not cite the fact that their son never played with dolls as a child as proof that he can't possibly be trans.
The more parents try to disprove what young people feel, the more they try to prove that they are right. This hardens the fronts, which ultimately also prevents the child from taking a critical look at their thoughts and the question of whether this is really their way. Precisely: coming out later does not automatically mean that it is a temporary phenomenon. It does, however, require a longer period of observation.
That means?
This is followed by at least several months of counselling, during which any mental illnesses are also identified. Very young sufferers usually only receive psychological treatment at first. We have to be careful with medical measures. At the same time, we can't simply say to young people who are suffering badly because of their external sexual characteristics: let's wait until you're 18, maybe you're wrong. Because seven out of ten trans adolescents who go untreated have suicidal thoughts.
Which medical measures are at the centre of attention?
As a rule, puberty blockers are used first. These are not hormone preparations, they simply cause the body to reduce the production of sex hormones: Puberty is temporarily interrupted. This type of treatment has been around for a long time. Puberty blockers give adolescents who feel strongly and persistently uncomfortable in their birth gender more time to consider their next steps without external sexual characteristics such as beard, voice break or breast growth developing further. The effect is reversible: puberty continues as normal as soon as the medication is discontinued.
How often are puberty blockers used?
Based on an accompanying evaluation, we found that of the adolescents who attended our consultation between 2015 and 2020, 27 were prescribed puberty blockers. The blockade should not last longer than two to three years, as a possible side effect can be problems with bone density in old age. Treatment with puberty blockers usually starts in early puberty. It is also rarely used in 14- or 15-year-old adolescents. After puberty blockade, most people continue with a gender reassignment programme.
Which would be?
The most common is hormone therapy to feminise or masculinise the body. Minors do not receive genital surgery in this country, and this is also rare among adults. The most common surgical procedure is breast removal. It is available to older adolescents with severe psychological distress, but only with parental consent. Nowadays, however, we also often see adolescents who stop taking puberty blockers and continue in their birth gender.
How do you interpret this development?
I think it's positive when young people don't make hasty decisions, take time to consider the issue carefully and get the help they need - the administration of puberty blockers goes hand in hand with psychotherapy. It's good when a young person can say: I've been able to reflect and now I'm moving on differently.
Some also come out as non-binary: they still do not necessarily identify with their birth gender, but no longer see it as a problem because they have realised that they do not feel they belong to any gender category permanently. If society accepted this, it would perhaps lead to fewer gender reassignment treatments being required in future.
Recently, your clinic was criticised: in a letter to the Zurich Department of Health, parents complained that their children had been prematurely diagnosed with gender incongruence and that the young people had not been assessed for other psychological problems. According to the parents' impression, immediate action had been urged. What do you think?
Most of the cases in this letter do not concern our clinic. I wish the concerned parents had contacted me or the other institutions. Unfortunately, that didn't happen. The programme on Swiss television that addressed the allegations affected me. I'm open to criticism, it's always possible that parents don't feel they've been properly listened to.
It bothers me when the impression is created that treatments are carried out without reflection. Our work is not about black or white, pro or con, but about taking as differentiated a view as possible.
I cannot know more about this, as I am not personally aware of the cases due to the anonymity of the complaint. However, I can say that no medical treatment was carried out in any of these cases. The parents were involved in every decision - so their concerns were taken seriously. In addition, 35 parents wrote to the Health Directorate to thank us for our careful investigation and support. Unfortunately, they did not get a chance to speak in the programme.
You say you were affected by the programme. Why?
It bothers me when the impression is created that treatments are carried out without reflection. Our work is not about black or white, pro or con, but about taking as differentiated a view as possible. Bans on treatments, which are very important for many people and are also desired by many parents for their children, do not help here. Reporting should not scandalise, but rather show the advantages and disadvantages in a differentiated way.
