Frances B. Lim-Liberty, MD, of New London is a pediatric endocrinologist and practices adolescent transgender medicine.

I have many trans people in my life. I am cisgender and I provide gender-affirming care. I have had the honor of being part of people’s medical affirmations. These clinic days are my favorite.

I walk into the first room and am struck by how many people have come to this new visit. All his parents are here, uplifting their child. I introduce myself, sit down, and listen. Simon is loved and supported at home but bullied at school. He does not use the bathroom all day because of fear of harassment. Yet Simon finds other avenues to relate to the world (theater) and he’s good.

My next patient, Taylor, is here for a follow-up visit. We have been trying to get her on a puberty blocker and the window of time to halt it and prevent further masculinization narrows waiting for insurance to approve the medication. We know that transgender individuals who received gender-affirming hormone therapy earlier, rather than waiting until completion of puberty, were able to make age-appropriate developmental transitions while living their affirmed gender, and had better outcomes in adulthood.

My next patient wants to transition from weekly testosterone injections to topical. We discuss the pros and cons of the two formulations, and he decides. I am late for the next family. I knew before I walked in that it would be a difficult visit. I had seen Nick a couple of months ago, and the family was ready to start gender-affirming hormone therapy at that visit. Today, they were no longer on the same page, and anger and disappointment erupt during the visit. I place my hand on my patient’s shoulder and let him heave. His parent is worried about Nick changing his mind.

Two recently published studies showed low rates of adolescents choosing to stop gender affirming hormone therapy. A study published in Pediatrics last year also showed very low rates of retransition. We have little data on this still, but the data suggests that even those who changed their minds do not regret having started gender-affirming hormone therapy. I ask Nick’s parent, “but what if he doesn’t change his mind? Then what have we done?”

My afternoon is also full. I see a patient whose parent has been refusing to sign consent for gender-affirming hormone therapy for the past three years. It had been a painful journey, and she climbed deeper into depression with each visit. Harper didn’t want to socially transition because she was afraid of rejection from others. “How can I expect to feel accepted by others, if my own [parent] won’t look at me?” she had asked at one visit. She is beyond sad or angry today — she is despondent. My biggest fear manifested, would she make it to her 18th birthday, just three months away? I worry I won’t see her again.

We know that mental health incrementally improves with more acceptance and affirmation across more settings, including home, school, work, friends, but the rejection from her parent had kept her frozen in space. I worried about the damage done from these years of being rejected. I promise her we will start medical affirmation as soon as she turns 18. I watch her shuffle out, face down and hidden behind her hair. I swallow the lump in my throat and knock on the next door.

The patient is with her parent and transgender sibling. They are both on gender affirming hormone therapy, doing well. I ask about school. The question, “how is school going?” takes on special meaning here. Rejection, through deadnaming, bullying, use of wrong pronouns, and verbal and physical abuse, is strongly linked to anxiety, depression, suicidal ideation and attempts, and substance use, continuing into adulthood. I probe to see if my patients are feeling safe, using the bathrooms of their choosing, and are supported at school.

My patients live in a world that has been trying to erase them for decades. Their existence threatens people’s perceptions of society’s norms. They are singled out by transphobic policies, ostracized by families and communities, and told that who they are is wrong. But they are not asking for people to understand or agree. They are looking for compassion.

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