Being transgender isn’t about a boy dressing up as a princess or a girl who wants short hair.

When working with transgender youth, doctors at the Gender Clinic at Maine Medical Center in Portland start with counseling to determine if the patient is transgender.

Psychiatrists look for three factors – the child’s insistence, persistence and consistence – to determine gender.

“It’s not ‘I want to be a girl’ or ‘I wish I was a girl.’ It’s ‘I am a girl,’ ” said Dr. Erin Belfort, a child psychiatrist. “Gender identity is such a core part of who we are and it’s established in toddlerhood. It’s not a choice. It’s not a lifestyle.”

It has nothing to do with sexual identity, but with the gender one feels internally.

Medically speaking, being transgender is called “gender dysphoria.” Patients have a strong sense they are the “wrong” gender and have the wrong body parts.

According to the diagnostic definition, transgender patients must have a “marked difference” in their identified gender and their biological gender. That sense must continue for at least six months and can manifest itself in various ways, including “strong desires to be treated as the other gender or to be rid of one’s sex characteristics, or a strong conviction that one has feelings and reactions typical of the other gender.”

“For some kids, it’s a no-brainer,” said pediatric endocrinologist Jerry Olshan, the medical director of the Gender Clinic and Lucy Tidd’s doctor. “I haven’t seen any kids like Lucy change back.”

DIFFERENT THAN SEXUAL IDENTITY

Olshan notes that gender identity is not sexual identity: Within a gender identity, a person may be gay, lesbian, straight or asexual.

The range of experiences, and possible medical treatments, can make talking about transgender issues confusing and complicated.

Being prepubescent can actually be an advantage because children do not have an established sense of what is expected, or even what is considered “normal,” said Dr. Jeremi Carswell, a pediatric endocrinologist at Boston’s Children’s Hospital, home to the first clinic for pediatric transgender patients.

“When you introduce these things to youth, they are a lot more accepting,” Carswell said.

For child psychiatrists, the primary mission is to be supportive, a far cry from previous treatments in past decades, Belfort said.

Some doctors used to do “reparative” therapy, telling patients that they simply weren’t gay, or weren’t transgender. Then there was a school of thought with young transgender patients to take a wait-and-see approach.

“But even wait-and-see is damaging because it doesn’t support the child,” Belfort said. “Now treatment is much more affirming.”

Belfort also emphasized that while some families want and need mental health support, many families do not because they are not struggling with the decision.

“We don’t want to send the message that it’s an illness,” she said.

The children themselves will face different issues around their gender identity as they age.

As prepubescents, there is no medical treatment, just a decision about how and whether to present their gender identity.

Once a child hits puberty, medical interventions can be considered.

First comes hormone blockers, which suppress secondary sex characteristics such as vocal changes, facial hair or breast development.

Medical experts note that blocking physical development can make a big difference in a patient’s future body: Once a male goes through puberty, the size and shape of hands, feet, jaw and greater height cannot be changed, nor the narrow width of the pelvis. For a woman, lower height and broader hips cannot be changed.

To actively develop the traits of the identified sex, older patients can take cross-sex hormones.

Carswell said that treatment can start at about 15 years old, but noted that it can be difficult for transgender teens to go through puberty after all their peers have already gone through it. Hormones are introduced slowly, over a year or so, to allow for proper development. Hormones can be transdermal, like an estrogen patch, or shots. Newer treatments can include pellet implants.

Cost is a factor in choosing treatment. Hormone implants – which only last a year – and associated surgery can cost more than $30,000, Carswell said.

Testosterone, a more powerful hormone, does not have similar costs, she said.

Finally, there is sex reassignment surgery, which is not reversible and can cover a range of procedures.

Increasingly, medical costs for transgender patients, including gender reassignment surgery, are covered by insurance and Medicare. Some states, such as Massachusetts, have anti-discrimination statutes that prevent health insurance companies from barring coverage for transgender patients.

NAVIGATING THROUGH ADOLESCENCE

For young transgender patients, however, counseling and mental health professionals can help navigate the added complexity of going through adolescence as a transgender person, with the usual teenage questions revolving around sexuality, safety and social issues. Even basic issues, like asking someone out on a date, can be fraught for a transgender teen, particularly if others don’t know the person is transgender.

The most important thing for transgender children, Belfort said, is family acceptance. Many of the worst outcomes, such as suicide, self-harm, addiction or running away, are related to not being accepted as their chosen gender.

“Family acceptance is really related to kids’ sense of happiness and well-being,” Belfort said.

Olshan said some families have come to the Gender Clinic convinced that their child is transgender, and the professional diagnosis is that the child is not transgender, but instead has another issue such as depression or mental illness that is the underlying medical condition. In those cases, the desire to be transgender can be a way of finding a group where the child is welcomed and feels supported in being different.

That is one reason the Gender Clinic makes sure all patients get counseling.

“To be transgender gets you hooked up in a community right now that is very supportive,” Olshan said. “We do have to be careful we’re doing the right thing.”

No cross-sex hormones are administered in the first six months of treatment, he said. Sometimes puberty blockers will be prescribed as early as a first visit, because they are reversible.

“It gives us a chance to figure out what’s going on,” he said.

Carswell said she sees how much treatment can help struggling young people.

“It’s been so hard for these kids,” she said. “We’ve had some kids take selfies with their first prescription.”

Send questions/comments to the editors.