Updated: Oct 13
In a country where access to gender affirming care is constantly at risk and at the forefront of political debate, the medical providers who actively speak up and take care of the trans community - especially our kids - ought to be spot lit and celebrated.
Enter Dr. Ilana Sherer, a San Francisco bay based pediatrician and parent of two young children with expertise and decades of experience supporting trans kids and their families.
In the two hours we talked on the phone, one message was abundantly clear: the best practice in health care for trans youth is one that is community focused, collaborative, and continuous.
When Dr. Sherer came to UC San Francisco for her residency in 2004, organized trans health care for youth didn’t exist in the bay. Gender Spectrum - a heavy hitter in the gender resource space to this day - saw many young folks looking for community building opportunities and medical care, but had nowhere to go.
Today’s gender affirming care resources only exist because of the collaborative and fearless efforts of, among others:
Dr. Stephen Rosenthal, Medical Director at the Child and Adolescent and Gender Center at UCSF
Dr. Diane Ehrensaft, Mental Health Director, Child and Adolescent and Gender Center at UCSF
Dimensions Clinic for Trans and Queer Youth in the Castro, San Francisco - within the San Francisco Department of Public Health
Activist and author Jamison Green
And Dr. Sherer herself
Bay Area locals are likely familiar with the programs at UCSF and the gender clinic at Kaiser, though some health care for trans youth may begin at your primary care office. Establishing pediatric care early is the best thing a family can do - regardless if your child is gender expansive or cis.
Camp Indigo knows that a lot goes into finding a pediatrician and engaging with the healthcare industrial complex. The anxiety and questions can often pile up, so we asked Dr. Sherer to shed some light on what to expect - especially for our youth knocking on the door of puberty.
So, what are the signs of puberty?
Dr. Sherer: For a person with ovaries the first sign of puberty is breast development, and that can happen any time between 8-12. Initially this might feel a little marble or hard sensitive area developing just under the nipple. If you feel that development on your chest, tell your parents and you can come see me.
If a person has testicles I'll start meeting with them at about 10. The first sign we look for is testicular enlargement, but it’s really subtle. Note that instead of measuring testicular growth or looking at breast tissue we can do bloodwork to measure hormone levels.
What are some considerations related to hormone blockers?
Dr. Sherer: I think we should present blockers as one tool, but not something that is an inevitable next step. We need to create space for kids to feel empowered in different types of gender presentation.
If a hormone blocker is the direction the patient is going, we’ll talk about fertility preservation. Naturally, this can be a really stressful time. Most kids aren’t thinking about fertility at this age in very early puberty. Currently the technology for fertility preservation prior to completing puberty is in its infancy (pun intended) and so blocking puberty followed by affirming hormone treatment may mean loss of future fertility. Though I haven’t had any of my trans masculine patients harvest eggs, some of my trans feminine patients have undergone experimental testicular tissue preservation. While it’s important to start talking about this early on, the blockers in and of themselves don’t affect puberty long term. This choice becomes more important to consider prior to starting estrogen or testosterone. At that point, if a child wants to come off blockers and experience their body’s own puberty (and its irreversible changes), fertility should not be affected.
In contrast, If a child has already mostly completed puberty prior to starting gender affirming hormones (and experienced changes such as deepened voice/increased body hair or breast development/periods), it is quite common for transfeminine youth to elect for sperm preservation and less common for transmasculine youth to attempt egg preservation, due to cost, complexity, invasiveness, and the likelihood that transmasculine youth may retain fertility even after starting testosterone.
What about non-binary kids who just don’t want to go through puberty of any kind?
Dr. Sherer: I really struggle between medical paternalism and self actualization of my own patients. You are who you say you are. I cannot tell you who you are. The medical reality is that If you don't go through puberty (with your own hormones or by taking estrogen/testosterone), you’ll experience lifelong problems with low bone density, cardiovascular issues, and sexual health. There is going to be a point where the risk of prolonged use of blockers will outweigh the anxiety of making the wrong choice. I often joke with my patients that I wish we had a non-binary puberty option, so they should grow up and go into medical research and develop it for us. But right now, they have to choose–testosterone or estrogen.
As a pediatrician and a parent I have my own sense of ethics. Sometimes I’ll help parents make a choice for their child but then wonder how I would feel or what I would do if it were my own child. I have to both honor my own experiences and feelings and make sure that I’m not relying on my own perspective to make a decision for another family or patient. There are risks and benefits to every choice we make as parents and sometimes it's hard to see at the point in time we need to make the decisions.
I just know that I have a deep desire to do right by them.
- Camp Indigo, Fall 2023