AMA Journal of Ethics

Formerly Virtual Mentor

Illuminating the art of medicine

Journal of Ethics Header

AMA Journal of Ethics

Formerly Virtual Mentor

Illuminating the art of medicine

Virtual Mentor. March 2005, Volume 7, Number 3.

Medical Humanities

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Adolescence and Gender Identity

A coming-of-age memoir about one man's journey into womanhood underscores the important role that physicians can play to recognize transgenderism in adolescents and coordinate the care for gender reassignment.

Allison Grady

The memoir She's Not There by Jennifer Finney Boylan explores the little-known and often misunderstood world of transgenderism. In Boylan's book and for the purposes of this discussion, the term transgendered describes individuals with a range of gender issues [1]. What they share is some degree of discomfort with their physically assigned sex. She's Not There allows lay people to better understand the challenges and stigmas attached to this condition, and, for doctors in particular, this story offers both clinical information and personal narration about an illness that many times is first recognized during adolescence. She's Not There sensitively illuminates the human side of an uncomfortable topic in an approachable and entertaining manner.

During the turbulent formative period known as adolescence, many young people struggle with their identity. The struggle entails questions about personality, sexuality, and, sometimes, gender. Because of our society's rigid views of gender roles and behaviors assigned to males and females, young people can find it difficult to voice their doubts and frustrations about a topic so many take for granted. The experience Boylan describes can help doctors who work with adolescents to understand that asking about someone's gender identity is different from asking about sex and sexual activity. By knowing what types of questions to ask and separating gender from a discussion about sexual conduct, doctors can begin a productive conversation. Boylan writes:

My conviction, by the way, had nothing to do with a desire to be feminine, but it had everything to do with being female…It certainly had nothing to do with whether I was attracted to girls or boys…being gay or lesbian is about sexual orientation. Being transgendered is about identity. What it's emphatically not is a "lifestyle," any more than being male or female is a lifestyle [2].

Boylan's story underscores the idea that transgenderism is not about sexuality nor is it about "choice." For many who suffer with what the Diagnostic and Statistical Manual of the American Psychiatry Association calls "gender identity disorder," being transgendered is an unfortunate reality of life [3]. It is important for doctors to provide a place that is safe and sensitive to privacy and discretion. They must be able to speak frankly and honestly with patients without injecting their own prejudices. Primary care physicians can take an active part in the diagnostic phase by making referrals to mental health professionals who can further explore gender questions. Typically, therapists will ask about "sexuality, marginality, culture, and archetype, about the difference between reality and fantasy…medical history, history of abuse or neglect" [4]. Because of the unique nature of the condition, a referral should be made to a therapist who is either a specialist or has relevant experience with the transgendered population. But primary care physicians who are not particularly familiar with treatment for transgenderism can still provide support, trust, and respect for confidentiality when working with teenagers and younger patients, especially.

Transgenderism is about more than just feelings. Some individuals decide that living as one gender, while feeling much more like a member of the other is no longer tenable, and they seek surgical reassignment. Because this is a medical process, doctors are necessarily involved and, depending on the confidence level of the person seeking gender reassignment and his or her family, physical changes can be embarked on during adolescence. She's Not There discusses the medical process of going from being physically male to being physically female (M2F). Boylan noted that the most important clinical document used when proceeding with gender reassignment is the Benjamin's Standards of Care (SOC). The SOC outlines the clinical roles and obligations of doctors and mental health professionals working with transgendered persons. One section of the SOC addresses the ethically and clinically permissible actions for adolescents [5]. To be eligible for gender reassignment surgery a person generally must enroll in therapy, begin to live as a member of the desired sex, be on a continuous hormone regimen for a minimum of 12 months, then live full time as the desired sex for a minimum of 1 year, and receive clearance from at least 2 medical specialists [5]. This process takes several years, and, because of the numerous physical and psychosocial changes that occur, the participation of a doctor is critical throughout.

The SOC allows for the process to begin as early as age 16, but, given the identity issues inherent in this phase of life, the adolescent must be in the care of both a dependable therapist and a doctor who is clear in his or her discussions with the young person, competent on the subject, and able to be in constant communication with the others on the care team. When adolescents both recognize and articulate their desire to begin reassignment, the doctor must respond and work in conjunction with family, other doctors, schools, and all major actors in the "patient's" life. (At this point, the adolescent, though not sick, is being treated with hormones and, perhaps, other drugs and is anticipating surgery. Hence, the designation "patient.") While the most dramatic portions of transition cannot occur until age 18, the doctor must continue to follow younger patients to impress on them the gravity of transition and assure them that, any time prior to surgery, treatment can cease. No matter what the age of the gender reassignment candidate, the doctor should work with him or her and family members, explaining the physical and psychological changes that will occur as transition progresses. With adolescents in particular, physicians must be responsive to the fact that relationships are naturally in flux; many friends and even family are unable to accept the artificially created hormonal and physical changes, and this can cause greater interpersonal instability. Boylan, who actually postponed reassignment surgery until her mid-40s, uses much of She's Not There to describe the changing relationships with her wife and with her best friend—who is a man. Just prior to her surgery, Boylan's wife shares her opinion about the reassignment:

All I've ever said…was Wait, please, stop, slow down, and to that you've responded with all sorts of words about your suffering, about what you've been through, about how you don't have any choice, about how this is mostly a medical issue…You're going where you feel like you need to go. For me, I'm standing here watching [6].

She's Not There demonstrates how radically relationships, world views, and expected "life paths" change for someone who is transgendered and chooses to confront the impulses. For those in high school who may be living as the "opposite" sex, doctors can help by looking out for signs of abuse or bullying, depression, problems at home, slipping of school work or avoidance of classes, and questions or hesitancy surrounding dating. For adolescents embarked on the process of change, mental health experts must work with school officials to make arrangements for locker room and bathroom use, determine how the school will address the student (eg, often a person living as a member of the opposite sex will adopt a new first name), and train staff in a basic understanding of transgenderism and the stereotypes that surround this condition. It is currently estimated that there are 40 000 transgendered people who have undergone male-to-female surgery, making this more common than cleft palate and multiple sclerosis [7].

She's Not There is an untraditional coming-of-age story; it describes one man's journey into womanhood beginning in adolescence. It touches on major themes and explains some misconceptions in an eloquent but still very personal way. Boylan's experience will not act as a mirror for all, but does provide insight and intrigue into a world that is shrouded in privacy, secrecy, and often, shame.


  1. Boylan J. She's Not There: A Life in Two Genders. New York, NY: Broadway Books; 2003:172.
  2. Boylan, 22.
  3. American Psychiatric Association. Diagnostic and Statistical Manual. 4th edition, text revisions. Washington, DC: American Psychiatric Association; 2000:256. The DSM-IV defines those with gender identity disorder as having "a strong and persistent gross-gender identification, which is the desire to be, or the insistence that one is of the other sex…there must also be evidence of persistent discomfort about one's assigned sex or a sense of inappropriateness in the gender role."
  4. Boylan, 121.
  5. Meyer W, Bockting W, Cohen-Kettenis P, et al. The Harry Benjamin International Gender Dysphoria Association's Standards of Care for Gender Identity Disorders. Minneapolis, MN: Harry Benjamin International Gender Dysphoria Association Inc; 2001.
  6. Boylan, 216.
  7. Boylan, 249.
