What of the gender variant child whose social environment both accepts and encourages an early transition but may be unaware that the child, unwilling to disappoint, has had a change of heart ? —Jack Drescher, MD, quoting Cohen-Kettenis, personal communication, in the introduction to this special issue

The Journal of Homosexuality published a 300-page special issue on childhood gender dysphoria in March 2012. It contains articles by several well known “gender specialists,” including Norman Spack, Kenneth Zucker, Jack Drescher, Diane Ehrensaft and others. These providers discuss their own clinical practice and experiences, informed by their viewpoints–and biases–about “trans” kids.

But of most interest to me is a piece by clinical psychologist David Schwartz, PhD., who is not a gender specialist himself, but knowledgeable about child psychology and the dynamics of family therapy. In his aptly named “Listening to Children Imagining Gender: Observing the Inflation of an Idea,” Schwartz critically and compassionately analyzes three of the other articles in the issue, focusing particularly on one written by Laura Edwards-Leeper, PhD., and Norman Spack, MD. Dr. Spack is a leading proponent of childhood medical transition, and heads up the Disorders of Sexual Development (DSD) and Gender Management Service (GeMs) at Boston Children’s Hospital, the first of its kind in the US.

Schwartz has two main points: First, he skillfully clarifies how most of the other clinicians writing in the issue operate from an idea–an inflated idea, unsupported by evidence–that gender is innate from birth. Schwartz terms this “gender essentialism.” And the concerned parents who bring their kids to these specialists imbibe the same biased idea.

Schwartz’s second key point is that the literal acceptance of a “trans” child’s demands and assertions, while completely ignoring underlying motivations typical of all kids, is something new under the clinical sun when it comes to treating children. It’s as if the insights of decades of child psychology are being thrown out in favor of automatically endorsing a narrative—a narrative driven by children, with their necessarily immature understandings and desires.  And Schwartz makes it clear that this clinical approach is doing no favors to dysphoric children–nor their parents.

We desperately need more outspoken therapists like Dr. Schwartz, clinicians who have deep clinical insight into developmental psychology and parent-child dynamics–not just “gender dysphoria.”

Because for most readers, the full article (and the rest of the journal issue) will be behind a paywall,  I am extensively quoting several of Dr. Schwartz’s key passages. The abstract is here. [Update:  “Awesome Cat,” in the comments section below, has a link to the full Schwartz article.]

The writing and language is that of a peer-reviewed journal article–formal and perhaps less accessible to some. But I am allowing Dr. Schwartz’s words to stand on their own merits. It is unusual to see this kind of gender criticism in a recent journal on the subject of gender dysphoria. Please note: The subheadings and boldface emphasis are mine, not Dr. Schwartz’s.

“Liberal psychiatric treatment”: the avoidance of ambiguity, p. 461

I am disquieted and stimulated by my mediated encounter with the children, parents, and clinicians represented in these clinical articles.

The children have a deeply felt complaint, expressed  explicitly or indirectly through the disruptions they inevitably provoke. They say they are unhappy with being named, classified, and treated in accord with the match between their visible genitalia and the prevalent set of conventions regarding those genitalia. For them, gender has become preoccupying …

…The parents seem to be trying to catch up with terribly surprising news, with varying degrees of success. They are frightened, frustrated, freaked out, and, finally, defeated, as they are forced to relinquish a cherished perception. Their particular defensive configurations vary (guilt, despair, anger, embrace), but all face extreme intrapsychic disruption and pain. The clinicians try to make this child/parent/symptom matrix fit into a model of liberal psychiatric treatment. As is common in the medical sciences, most push against ambiguity, preferring to emphasize speculative generalizations (“genetics is likely a factor”) instead of highlighting the lack of data from controlled studies.

Desistance: Most kids with gender dysphoria will change their minds, pp. 467, 470

With respect to the advocacy of intervention, Edwards-Leeper and Spack … say that they “have learned that delaying proper diagnosis can lead to significant psychological consequences”.  This warning implies that the reliability of diagnosis and associated prognosis in this area has been established, which is the case only for diagnosis, that is, we cannot say reliably what the course will be for a given child with GID or gender dysphoria. In particular, we cannot reliably say whether he or she will persist with an expressed need to be affirmed in his/her non-natal gender, or not. In fact, the majority do not sustain the diagnosis, that is, they desist.

[This] fact (supported by five research articles going back to 1987)…every clinician and parent of a child who is gender dysphoric needs to keep firmly in mind. …

Given this uncertainty of prognosis, it is significant that Edwards-Leeper and Spack’s presentation of the pros and cons of pubertal suppression, a primary intervention in their protocol and their frequent recommendation following diagnosis, is imbalanced.  They offer seven physiological benefits to pubertal suppression (for the most part just a list of the physical effects) and no disadvantages. Likewise they tout the psychological advantages, but note no potential disadvantages. Their conclusion is: “Therefore,
it is our clinical impression that preventing these unwanted secondary sex characteristics with puberty blocking medical intervention allows for better long-term quality of life for transgender youth than what they would experience without this intervention.”

Better quality of life? p. 467

The claim of offering “better long-term  quality of life” based on clinical impression only, and absent significant longitudinal experience or controlled data collection, is questionable. Considering that Edwards-Leeper and Spack are advocating a pharmacological intervention aimed at prepubertal children and adolescents, a number of whom are likely to desist, it is surprising and of interest that they so minimize the importance and value of alternative interventions, ones that might have fewer unknown consequences, both physiological and psychological. An alternative sort of intervention would of course be some variety of psychological therapy. Most typically this might include support, reality testing, empathic interpretation and psychoeducation offered to both parents and children.

On the psychology of “trans” kids, p. 468

The intransigent style (cognitive and behavioral) of trans children may deter some clinicians from considering that some of their suffering might be helped without rhetorically opposing their desires or trying to persuade them to relinquish their assertions.

… The goal of psychotherapy in this situation would be to help the child feel better and offer reality-based guidance for social situations, as well as the prevention of self-harm, in the rare cases where that is an issue. In general, psychotherapy should entail increasing (parents’ and children’s) self-understanding, not coaxing or pressuring them to change their minds. The disturbing demands and claims of trans children, as well as reports of self-harm (untabulated, to my knowledge) may shock and scare both parents and clinicians into expecting less frustration tolerance from them than is realistic. Such an underestimate of the trans family’s resilience may be abetted by the availability of puberty suppressing drugs. Frightened of the onset of puberty, and intimidated by the at times ominous articulations of the children, parents and clinicians are relieved to imagine even a temporary solution.

Anecdotes from adolescents are not data, p. 468

…Edwards-Leeper and Spack’s  usage of anecdotal data concerns me. To counter what they describe as the leeriness of parents with respect to the taking on of transgender identities on the part of adolescents with no prior history of gender dysphoria, they say: “However, many of these adolescents report that their friends are not surprised by their declaration of their affirmed gender, often responding that they had suspected it for some time.” We must assume that Edwards-Leeper and Spack are aware that an adolescent’s report of other adolescents’ validation of a gender identity claim is not credible evidence of more than the first adolescent’s desire to persuade. How then are we to understand their inclusion of this anecdotal information? It would seem that natural skepticism has been suspended in favor of literality. Are they trying to highlight the alleged power of essential gender by pointing to its observability by others even before the subject himself or herself has self-awareness? If so, the weakness of an anecdote such as this gives the appearance of a lack of appropriate scientific and psychological skepticism, and inattention to methodology.

Kids aren’t little adults, p. 470

With essential gender in mind [clinicians] are likely to be less psychologically minded and less thorough in their consideration of the cost–benefit ratio of invasive interventions and of research that might militate against their impulses to intervene. To be sure, they are trying to be respectful of and responsive to children’s stated wishes. But it seems that beyond that, when child patients talk about their gender, their belief in its reality seems to distract the clinician from the fact that we cannot listen to children in the same way that we listen to adults. Patients’ communications always need some degree of interpretation; that is especially true for children, who, necessitated by their cognitive limitations, speak more symbolically.

Is a 5-year-old boy “really” a girl–or trying to be like Mommy? p. 473

Ehrensaft tells us that throughout a session to which Brady/Sophie arrived fully dressed as a girl, “[she] kept sucking in her tummy, in an attempt to make herself more girl on top” (p. 351). This child is less than 5 years old. Sucking in her tummy will not make her more girl on top, since little boys and girls are the same on top, which Brady/Sophie surely knows: It will make her more woman, a very different thing. One possible interpretive direction in light of this slip would be that this child is more interested in a ticket to adulthood than a gender change, but for some reason sees being female as a necessary first step…

.  …At the conclusion of this patient’s treatment, parents and therapist decide that it is best to permit Brady/Sophie to present as a girl at all times.  Sophie (still not 5 years old) proclaims: “I’m the happiest I’ve ever felt in my life.” Ehrensaft furnishes a putative expert statement to the parents, which says in part: “To promote her wellbeing and emotional health, it is imperative that Sophie be seen and treated as a female by her parents, her educational settings, and the community surrounding her.” …Such certainty in matters so fraught with unforeseeable possibilities including the welfare of a child surprises me. The certainty of the child about her gender is matched by the clinician’s certainty about the outcome, both of whom, I suggest, are encouraged by the notion of a true gender found at last. Moreover, I wonder if Ehrensaft has not imagined the inner life of this child, who is rather adult-like in her speech (do 4 year olds commonly speak of “in my life?”), as more adult than it is. This could be for many reasons including, of course, the personality of the child. However, I believe it is easier to be distracted from the childishness of a patient’s claims when the terms they use conceptually match the clinician’s ideas. 

Gender is power, p. 474

 It seems to me that trans children, in response to great psychic pain (and adaptively or not) have engaged the rhetoric of gender and, thus, stumbled upon a communication of such potency that their parents and therapists are detoured from listening to them as children, instead crediting them with adult-like cognition. When we infer that the trans child has a disturbance in an unobservable gender system, based on a claim of gender transformation, we are granting the truth of a child’s self-analysis and proposed self-construction. I doubt that the receipt of such a gratifying abundance … of respect from the clinician is consciously intended by the child. It is more likely that the child longs inchoately for an emotional experience like respect and rapidly gains unconscious awareness of the power of gender complaints to bring such gratification. When the longing is unwittingly satisfied by the parent or clinician who, thinking they understand the child’s problem, validates the terms of the discussion as the child has set them, the child is likely to reiterate the complaint in those terms.

  For that child, a psychological structure, more or less transient, begins to develop. For the adult, the illusion of understanding begins to perpetuate itself. The most immediate lesson that the trans child has learned, and then enacts, encouraged by these interactions, is that the idea of gender is very powerful, and if you want to get a rise out of people, play with it daringly. The lesson for the parent or clinician should be: Stop talking about gender. 

Schwartz goes there: the child who threatens self harm, p. 475

The specter of harm to children—any harm to any children—is surely a powerful influence in all discussions about children, and no doubt it is playing a role, spoken or not, in this one…. I am aware of no controlled data to indicate that the incidence of self harm among trans children is any greater than somewhere between very infrequent and rare. I am aware of no data to suggest that pubertal suppression, cross-sex hormone administration, or genital surgery diminishes the probability of self-harm in trans children. Moreover, there is no reason to believe that the three above-mentioned physical interventions are any better for the welfare of trans children than supportive psychotherapy and psychoeducation for parents. There are anecdotal reports of threats by children and of children dramatizing the possibility of self-mutilation. There are psychiatric protocols for addressing the patient who seems to pose a risk of self-harm that are minimally intrusive and unquestionably reversible. The long-term psychological and physiological consequences of chemogenic pubertal suppression, cross-sex hormone administration, and genital surgery are unknown, and, as is the case with all self-selected populations, very difficult to assess owing to problems of control and limited sample numbers. The palpable misery of an articulate child may distract the empathic clinician or parent from the venerable admonition: First, do no harm.

Conflation of gender skepticism with historical homophobia, p. 470

 Edwards-Leeper and Spack take pride in what they see as their avoidance of the mistakes prior generations of mental health professionals made, in particular when the latter refused to accept gay and lesbian people at their word, sans diagnosis. Indeed, the analogy is tempting, but I would argue, deeply flawed, itself an aspect of the conflation of gender and sexual orientation. …

“An artificially vitalized concept”,  p. 476

I believe the disquiet and stimulation I initially experienced after reading these articles and watching some videos, was a reaction to my perception of children and adults struggling in the thrall of an artificially vitalized concept that subjugates and empowers each in complementary ways, a phenomenon both intriguing and worrisome. Most of these adults—parents and clinicians—have been persuaded that gender is biologically real, with specific rules for healthy functioning. The children, having unconsciously learned of the adults’ imbuing of gender with particular potencies, that is, with reification, medicalization, and transgressive possibility, try to put it to use in the course of their own self-development. It proves to be a high-risk and high-gain tool. It has the power to command adult attention, to affect adult emotions and thus to alter the position in the family of the child who chooses to deploy it. As well, in the unconsciously operating hands of the child it can also bring enormous pain, which in its compelling resemblance to physical pain further misleads the adults toward the reification of gender.  It is disquieting to observe clinicians unconsciously colluding with troubled parents in the inflation of concepts that are inherently psychologically constricting.

Teaching children to be homophobic? p. 476

… Just as racism requires belief in natural races, sexism and homophobia require belief in natural genders. If we organize our responses to children who play or become preoccupied with gendered behavior around the idea that there are natural genders from which they are deviating or toward which they can aspire with medical help (transitioning), then, however indirectly, we are buttressing the very structures upon which the hatred of gay men and lesbians stands. Or put differently: As clinicians responding to trans children, we are responding to a subjectivity, not to the results of a biopsy or blood test. We and parents must choose whether we respond to that subjectivity as the upshot of a hypothesized psychophysiological gender system, on the one hand, or choose to go no further than regarding it as a mutable psychological situation on the other. Choosing the former, the more elaborately and speculatively theorized framework of essential gender, accepts a theoretical structure that has been used to rationalize sexism and homophobia and, therefore, tends to promote them despite good intentions.

We owe more to kids than to take them literally, p. 478

There is much more to children than what they say. We owe to them a deeper listening than a literal one. We will then likely find that their engagement with gender, especially when it is transgressive or countercultural, may reveal a creativity and even a politics that can contribute to the erosion (if not destabilization) of the gender system as it presently operates. If we listen to them literally, interpret their communications and performances through the categories we adults have grown up with, and of course have ourselves failed to transcend, we will miss whatever new story they are telling or protest they are making. If we listen and respond to what they are saying in the mirror of the old system, they will seem to buy it, because it comes with the feeling, although not the reality, of being understood, which they no doubt crave. Thus, stasis is guaranteed for the child and for our culture. I am not naïve enough to imagine an intellectual transcendence of essential gender. But, in the name of equality—of gender and of sexuality—we must avoid promoting its continued entrenchment.

“Confirmation bias, as the term is typically used in the psychological literature, connotes the seeking or interpreting of evidence in ways that are partial to existing beliefs, expectations, or a hypothesis in hand.”

Confirmation Bias: A Ubiquitous Phenomenon in Many Guises, by Raymond S. Nickerson,  Tufts University

In this post, I will look at two recent survey studies (i.e., patient questionnaires and demographic data culled from medical records) conducted by Dr. Johanna Olson and colleagues at the The Center for Transyouth Health and Development at Children’s Hospital, Los Angeles. These studies do not look at the medical effects or potential harms of hormone treatments and/or sterilization of prepubescent children and adolescents. Rather, they consist of self-reported characteristics and demographic data, with no questioning of the key “hypothesis in hand”: that medical transition is the treatment of choice for self-identified “transgender youth.”

A hypothesis in hand also can bias the interpretation of subsequently acquired data, either because one selectively looks for data that are supportive of the hypothesis and neglects to look for disconfirmatory data or because one interprets data to be confirmatory that really are not.

In looking at the work and public statements of Dr. Olson, there are a number of biases and assumptions that can be easily seen:

• Children and adolescents who label themselves as “transgender,” or who claim to be the opposite sex, are a priori “transgender,” even though there is no hard scientific data that a “transgender child” actually exists.
• The reason for depression and suicidal ideation in youth who identify as transgender is lack of access to medical transition (i.e., hormones and/or surgery) and/or lack of parental support for such treatments.
• Comorbid mental health issues are not explored as possible causes for gender dysphoria or suicidal ideation.
• Parental, clinician, internalized, or societal homophobia is not mentioned as a possible contributing factor in the diagnosis of “transgender youth.”
• It is a foregone conclusion that the psychological stress experienced by a young person believing they are “actually” a member of the opposite sex cannot be addressed via supportive psychotherapy to help resolve such feelings.
• Permanent adult sterility, the usual consequence of puberty blockers followed directly by cross-sex hormones, is an acceptable and tolerable outcome for prepubescent “transgender children.”
• Further, despite overwhelming scientific consensus that judgment, decision-making, and awareness of future risks and rewards does not reach maturity in the human brain until the early 20s, prepubescent children facing irreversible sterility are capable of understanding and choosing this consequence.
• The possibility of future patient regret (a completely unknown factor at this time) is insignificant in comparison with the urgent need to treat children NOW with hormones and (possibly) plastic surgeries.

Now to the two survey studies. First, let’s look at “Parental Support and Mental Health Among Transgender Adolescents” by Simons et al, examining the impact of parental support on the mental health of 66 self-identifying “transgender” youth ages 12-24. What’s the main conclusion?

 Parental support is associated with higher quality of life and is protective against depression in transgender adolescents.

What is meant by “parental support” in the context of the 66 youths included in the survey? The “limitations” section of the study tells us it wasn’t well defined:

The parental support measure did not delineate whether the subject was referring to one or more parents, differentiate between parents and other guardians or caregivers, or explore the impact of other sources of support on mental health. Also, it did not distinguish between general parental support versus support specifically for gender identity, or assess particular parental qualities or actions constituting support.

Readers who have been with me for awhile know that my idea of “support” for my erstwhile trans-identifying  teenager did not include agreeing to hormone or surgical treatments. Judging by the vague criteria in the survey, my daughter and I might have presented to Olson’s clinic, with my teen rating me as “supportive” even if, in the end, we left without a prescription for testosterone or a recommendation for “top surgery” (two interventions my teen, at the time, insisted she wanted).

Here is how the study defined parental “support.” The 66 patients

completed a survey assessing parental support (defined as help, advice, and confidante support)

Help, advice, and confidante support? You better believe I provided that to my kid.

Regarding the young people who were surveyed in the study:

Before meeting with medical staff, participants underwent mental health assessment by a provider with knowledge of gender nonconformity in youth to identify major mental health concerns and provide a recommendation that hormone therapy would benefit the participant in their transition process.

But the paper doesn’t provide any hint whether “identify[ing] major mental health concerns” might have included psychotherapy or some other exploration of how these concerns might contribute to the young person identifying as transgender. Nor do we know specifics of what these concerns might be.  All we know is that “hormone therapy” was recommended, and it is assumed that a “transition process” was a desirable outcome. In my own personal family case, finding a supportive therapist who was willing to explore other thorny psychological concerns was extremely important and led to a reduction in my child’s desire to medically transition.

Moving on, another limitation noted by the authors is

Findings were based on self-report and may be open to self-presentational biases.

In other words: Like the diagnosis of “transgender” itself, the survey data is based on subjective thoughts and emotions. While the researchers acknowledge this as a “limitation” of their study, why don’t they acknowledge that the “self report” of being the opposite sex (in contravention to objective biological reality) is itself a “limitation” of the entire enterprise of the medical transition of minors? The diagnosis of “transgender children”  as opposed to just letting kids be kids, however they “identify,” is the mother of all confirmation biases.

Dr. Olson is listed as the first author of the 2nd study, still in press: Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria. The subjects were 101 youth (approximately 50/50 male and female), ages 12-24, who had indicated the “desire to undergo puberty suppression or phenotypic gender transition” at Olson’s clinic from 2011-2013.

What were some key psychological findings these young people self-reported? (Of note, physiological characteristics did not differ from other similar-aged youth.)

• suicidal ideation: 50%
• suicide attempt: “nearly 1/3”
• depression: mild-moderate 35%, severe 11%
• drug use: alcohol (75.5%), tobacco (58%), cannabis (61.5%,), other drugs (43%)
• gender dysphoria experienced since approximately age 8
• revealed their transgender identification to family at a mean age of 17.1 years [Remember this one]

What do Olson et al conclude from their survey?

…transgender youth are aware of the incongruence between their internal gender identity and their assigned sex at early ages. Prevalence of depression and suicidality demonstrates that youth may benefit from timely and appropriate intervention. All participants expressed a desire to begin hormonal intervention to assist in bringing their physical bodies into better alignment with their internal gender identity.

Seems to me there are several assumptions and confirmation biases in operation here:

• “Timely and appropriate intervention” apparently does not include anything other than “bringing their physical bodies into alignment” with internal identity. No suggestion is made that psychological treatement aimed at helping youth feel comfortable in their bodies should even by considered.
• The assumption appears to be that depression and suicidality are caused by gender dysphoria–or at the very least, the correlation of  suicidal ideation with gender dysphoria–can only be solved through medical transition.
• Suicidality rates for other psychological problems (apart from gender dysphoria)  are not mentioned or compared in this study, only those of “normal” adolescents  (6.7% for ages 12-17, 10.9% ages 18-24), even though there is research (see here, and here for examples) indicating that some disorders may occur at higher rates in people with gender dysphoria. Nothing in the survey or study design indicates any knowledge of these comorbidities, whether there was an attempt to control for them, or the fact that increased suicidality is associated with some of them.
• And again, the key assumption: “Identifying” as transgender is a priori a reliable diagnosis, as opposed to a psychological problem that could possibly be exacerbated by some combination of peer pressure, societal trends,  or online social media.

But enough of my criticisms. What limitations do the authors of this study see?

…these data describe those who are able to access care related to gender dysphoria and desire medical intervention for gender transition. These results may not be generalizable to transgender youth who are not receiving care or to those who do not desire a phenotypic transition with cross-sex hormones…

…Lastly, data collected about early childhood gender nonconforming feelings or behaviors are subject to potential recall bias. Ideally, this information could be collected in a cohort of younger children currently experiencing gender nonconformity.

“Recall bias” means the adolescent or young adult may not be remembering his or her childhood experiences accurately. Also, and even more to the point: if most of the youth in this study “knew” they were trans at 8-years old, but didn’t “come out to family” until about age 17, how are they “truly transgender?”  The phenomenon of young kids insisting they are the opposite sex is often touted as proof of some innate brain-based gender. And as anyone who has raised a child knows, 8-year-old children don’t generally hide their true feelings from their parents. If these young people profess to have “known” they were the opposite sex as 8-year-olds, why didn’t they voice this realization earlier? Why did they wait until they were 17?

I have to wonder: given that the patients who completed the survey for this study had managed to secure hormone treatments at Olson’s clinic; and given the ready availability on the Internet of the list of requirements to qualify for hormone therapy, it’s not much of a stretch to think that many likely knew that reporting a long history of identifying as transgender would be helpful in actually qualifying for treatment.

And here comes the final caveat:

Although there are guidelines and recommendations for the treatment of transgender-identified youth with puberty suppression in early adolescence followed by appropriate hormone therapy, there remain fundamental questions about when to start puberty suppression with gonadotropin-releasing hormone analogues, when to add cross-sex hormones, and how young is too young for gender confirmation surgery.

Dr. Olson has repeatedly  gone on record as promoting early cross-sex hormones, stating in a recent NPR interview that it is “ridiculous” to make an adolescent wait until age 16, as the current WPATH standards prescribe. (Some might counter that it’s more absurd to permanently destroy a child’s fertility.) Interestingly, Olson et al seem to almost concede that point in their last-but-not least limitation to the current study:

Finally, the trajectory of gender nonconformity among peripubertal youth is still difficult to predict, creating serious concerns for providers and families about the possibility of future regret in response to more permanent aspects of hormone therapy, such as breast development and voice deepening. The data we have begun to collect are an attempt to understand the transgender youth population and follow them over time, tracking the safety and efficacy of medical intervention as well as the impact of intervention on quality of life, high-risk behaviors, suicidality, depression indices, gender dysphoria, and potential regret in response to early medical intervention. We will continue to publish our follow-up data as they are collected,

So once again, as I chronicled in an earlier post, providers of medical transition tell us, “We just don’t know.” The implications of this cannot be overstated.  These providers are, by their own admission, essentially experimenting on children and adolescents with treatments that have permanent consequences, and they have no idea what the rate of future regret will be. Let’s listen again:

“… the trajectory of gender nonconformity among peripubertal youth is still difficult to predict, creating serious concerns… about …future regret…in response to early medical intervention.”

There it is, folks, in black and white, in a peer reviewed journal. We don’t know, but we’re going to find out–after it’s too late to take any of it back.

It is not my intention to demonize Dr. Olson. In fact, to give Dr. Olson a heaping helping of Benefit of the Doubt, it’s quite possible she is operating from compassion for the suffering of the youth and families who visit her clinic. (I realize more cynical observers might say she and her fellow “gender specialists” are only in this field for profit, but I am not prepared to assign sociopathic greed at this juncture).

Might Dr. Olson be suffering from pathological altruism—a particular brand of confirmation bias?

A working definition of a pathological altruist then might be a person who sincerely engages in what he or she intends to be altruistic acts but who (in a fashion that can be reasonably anticipated) harms the very person or group he or she is trying to help

…such as the substantial percentage of her young patients who, without her intervention, would have been allowed to grow up to be gay, lesbian, or simply “gender nonconforming” adults, their fertility fully intact, without the need for an expensive lifelong medical condition treated by endocrinologists and surgeons.

or a person who, in the course of helping one person or group, inflicts reasonably foreseeable harm to others beyond the person or group being helped

That might be, in the case of the steadily increasing numbers of young women being transitioned, the harm to the lesbian community, particularly the “butch” and “gender nonconforming” lesbian community. And then there is the damage to families–parents, siblings, other relatives–whose doubts and concerns are dismissed as “transphobic.” Their prior knowledge of their loved one; their possibly correct hunch that the young person is not actually in need of such extreme intervention. Their opinions are never considered or legitimized in any research or media story I’ve seen, but brushed aside,  as they watch their loved one step on the conveyer belt of puberty blockers-cross-sex hormones-surgery, to be changed forever.

Dr. Olson and the other purveyors of pediatric medical transition are certainly reasonably intelligent human beings; obtaining an MD or PhD is no mean feat. But (again from the above linked article, Concepts and implications of altruism bias and pathological altruism by Barbara A. Oakley)

 Intelligence is no safeguard regarding these confirmation bias-related issues. Highly intelligent people, for example, do not reason more even-handedly and thoroughly; they simply are able to present more arguments supporting their own beliefs.

When gender critics and gender advocates spar, the more thoughtful opponents at some point usually attack and parry with links to published research. There is sparse conclusive evidence regarding transsexual or transgender adults, but at least you can link to what little there is when making your points.

When it comes to systematic studies of the growing number of children and adolescents undergoing medical “transition” via hormones and surgeries? Not so much. In fact, pretty much nothing. Zilch. Nada.

As I discussed in this post, pediatric gender specialists—endocrinologists, pediatricians, psychiatrists— openly acknowledge that there is essentially no research about the effects and outcomes of childhood medical transition.

So what generally happens when more data is needed about an accelerating and urgent medical problem, one for which experimental treatments are being prescribed? Teams of doctors and/or academic researchers write grants to fund rigorous studies. In the US, important medical research is often funded through the National Institutes of Health or other government-funded agencies. Given the increase in gender dysphoric kids popping up for treatment*, it seems likely the NIH would be quite amenable to funding well-designed studies. Particularly since the medical treatments for childhood gender dysphoria are so extreme that they can result in the permanent sterilization of minors.

There are plenty of potential research subjects being seen in gender clinics right now. While the practice is relatively new, hormone treatment for gender dysphoric kids has been ongoing in the US since 2007 (first cases at Boston’s Children’s hospital) and for over 20 years in the Netherlands. There has been ample time for researchers to apply for and receive funding.

What could be studied in these children who are having natural puberty arrested? I can think of a few interesting lines of research:

• The physiological and psychological effects of GnRH agonists (“puberty blockers”) on gender dysphoric children and adolescents
• The physiological and psychological effects on adolescents who have gone directly from GnRH agonists to cross-sex hormones
• Brain activity and neurological effects on adolescents who have delayed puberty; such studies could include noninvasive MRI and fMRI brain scans, coupled with behavioral observations
• Attitudes and opinions of gender dysphoric children and adolescents vis-à-vis permanent loss of fertility and how these attitudes and opinions change (or don’t change) over time
• Executive function development in prepubescent children who are under treatment vs. a control group of children who are not treated
• Long term outcome studies comparing gender dysphoric children who undergo hormone and surgical treatments vs. those who do not

There are many other avenues research could take. And these studies, to be meaningful, ought to be longitudinal (over the longest time span possible), and start as soon as possible after the child begins treatment.

So given the desperate need for research being called for by all the experts in the field, surely some studies have been funded and are actively recruiting subjects?

The place to find current research studies is ClinicalTrials.gov. (The database also lists recently closed studies that are no longer recruiting). ClinicalTrials.gov indexes all studies in the world—not just the US—which are seeking subjects.

Here’s a sample of what I found—more to the point, what I didn’t find. I tried many permutations of keyword searches and came up essentially empty. I encourage readers to do their own searches and tell us your results in the comments section.

• Puberty blocker: 0
• GnRH agonist: Hundreds—but all for either cancer patients or for precocious puberty
• GnRH agonist gender dysphoria: 0
• GnRH agonist child gender: 0
• GnRH agonist fertility: 99, all about adult cancer patients
• MRI gender dysphoria: 0
• Child (or adolescent) transgender: 4, all about HIV prevention
• Gender dysphoria: 3, all about HIV risk
• Adolescent transgender: 2, both about HIV prevention
• Leuprolide [generic name for Lupron, a puberty  blocker]: Hundreds—but all for either cancer patients or for precocious puberty
• Leuprolide transgender: 0

When it comes to medicine, if there are no current studies recruiting new subjects, it typically indicates that the research questions have been more or less settled. A clinical problem or hypothesis has been thoroughly explored, studies have been conducted, the results have been replicated, and evidence-based clinical practice follows from there.

But the use of off-label GnRH agonists followed by cross-sex hormones on prepubescent children is new. We don’t have the data.  And unless someone collects that data in a systematic way, we will never know the outcome of this grand experiment on young people.

What we have now are anecdotes, personal testimonies, and shrill voices demanding medical transition for children NOW.  The usual reason given is suicide prevention. But if innate gender is real, this means there have been “transgender” children and adolescents since the dawn of human history. Yet there is no prior record of nor claim of suicidal children claiming to be “in the wrong body” before the modern age, when pharmaceutical and surgical solutions have become de rigeur.

Surely we can all agree that any treatment meant to prevent suicide; any treatment resulting in possible sterilization of minors deserves serious and wide-ranging study. Someone needs to get moving.

But the evidence suggests—no one is.

As one detransitioned woman has said, “We aren’t even lab rats.”

*A cursory Internet search reveals many stories about the steady increase in kids referred to gender clinics throughout the Western world

As anyone who has spent time reading this blog well knows, I am highly skeptical of the existing research which purports to show a static male or female “gender identity” in the brain. Even if there are fundamental differences between typical male and female brains, there are going to be bell-curve outliers; and those outliers are still biologically male or female. Further, to my knowledge, there is no research proving that there is an immutable “gender identity” that is persistent throughout the lifespan, regardless of lived experience and separate/apart from biological sex) . ** (see note, bottom of post)

But for the purposes of this post, let’s just assume that the strident proponents of childhood transition are correct: there is an immutable gender identity, set in stone and impervious to change via life experience. Further, we will assume that, for a small percentage of people who experience gender dysphoria in childhood (no more than  about 20%, the number generally agreed upon even by the most zealous transgender advocates), this gender identity is mistakenly lodged in the skull of the “wrong” body. It follows that there is such a thing as a truly transgender child. These kids really do have a mismatch between brain and body, and the most humane and medically responsible thing that can be done for them is to let them “transition” to the opposite sex, post haste. As young as possible.

Case closed? Not quite.

First, let’s be very clear what we are talking about here, in terms of pediatric medical treatment. The current protocol for children identified as transgender is puberty blockers  (GnRH agonists) administered at the onset of puberty (Tanner Stage 2). The child is then monitored for several years, and if they continue to believe they are the opposite sex, cross-sex hormones are started, so as to prevent natural puberty occurring in the “wrong” gender (i.e., the biological sex of the child). In the case of a natal girl with two x chromosomes and a biologically female body, she will not go through maturation of the ovaries, menstruation, breast development, nor other primary and secondary sexual characteristics. Cross-sex hormones (testosterone for a girl) will cause her to develop more in line with the sexual characteristics of a male: a slightly enlarged clitoris, increased body and facial hair, and an enlarged larynx resulting in a deepened voice. She will thus avoid the assumed trauma of going through the “wrong” puberty, with shrinkage and no maturation of her internal reproductive organs. She will appear more or less as the gender (male) she (now he) identifies with. These changes are permanent. They cannot be undone.

And one of these permanent changes is of special import: In nearly every case, this treatment protocol will result in irreversible sterility. This child will never be able to produce their own biological children. However, the gender experts believe this outcome is worth it and justified for “truly transgender” children. The puberty-blocked girl (who still has the brain of a prepubescent child, not that of a maturing adolescent) agrees that transitioning is far more important than future fertility, and the adults in charge make the monumental decision to destroy the child’s future reproductive capacity.

Fair enough? Maybe, if we continue to assume that there is such a thing as a “truly transgender” person with an immutable, innate gender identity; if we treat this condition as a sort of birth defect that will never change, even later in life; and that the young person in question will be forever miserable to the point of suicide if they do not chemically and surgically alter and thereby sterilize their hated and mistaken body.

The problem is, these gender experts—from the most certain to the most cautious—agree that they don’t reliably know which of these children really will be transgender for life. And what that means is there are going to be some false positives: kids who will mistakenly go through extreme medical and pharmaceutical treatments—not just in childhood and adolescence, but for life, since hormones must constantly be administered to suppress the “wrong” body from reverting to the characteristics normal for the genetic makeup of the person. Some number of these kids will have been misdiagnosed. It’s inevitable. Even the most careful clinician, who believes they have narrowed their treatment cohort to only those children who are most “persistent, consistent, and insistent” cannot prevent this, because the research simply isn’t there to tell clinicians who will or won’t grow up to be truly transgendered.

Let’s agree, for the sake of discussion, that these gender clinicians—and the parents who are authorizing the treatments—truly believe they are doing the right thing. They believe that these puberty-blocked children who continue to insist they are the opposite sex are correct. It’s worth repeating that these children’s brains, and thus their critical thinking, reasoning, judgment, and other aspects of executive function, have also not been allowed to mature; because puberty is about brain development, not just secondary sex characteristics. No matter how careful these clinicians and parents are, they are still going to catch a few wrong fish in the transition net they are casting.

Does this matter? How many misdiagnosed kids are acceptable? How many sterilized children (many of whom might otherwise have grown up to be gay or lesbian adults with a desire for their own biological children) are ok? 100? 50? 20? 2? 1?

Put it this way: If there were any other treatment, for any other disorder, which resulted in sterilizing prepubescent children, and which caused irreversible, permanent changes with as-yet-unknown side effects, you’d better believe that treatment would be limited to only the most extreme cases—and even then, only after extensive clinical trials. These clinical trials would span years of rigorous peer review, with successful completion of many replicated and corroborating studies, involving thousands of subjects. These studies would have to include untreated control groups, and these human trials would have to look at physical and psychological side effects and risks of this extreme and lifelong treatment.

Rigorous study, with several phases of clinical trials, is the norm for modern evidence-based medicine, even for life-threatening medical conditions. To take but one contemporary example, there has recently been a successful drug treatment protocol released for the treatment of chronic hepatitis C, which with prior treatments, had a rather dismal cure rate. Despite the promise of the ongoing clinical trials for the new hepatitis C drugs (over 90% cure rate), which took place over many years, the general public was not allowed access to these life-saving drugs. Many people died waiting for the drugs to be approved. If the side effects of these drugs had included sterility—for adult patients—it is highly unlikely the treatments would have been approved by the FDA. Even though the drugs might have saved many lives.

We don’t remove organs and body parts, we don’t give children powerful drugs for any other disorder based on what currently amounts to clinical guesswork. We don’t remove organs or administer chemotherapy because someone might go on to develop cancer later. We don’t prescribe poorly studied, off-label drugs or perform surgery on children to relieve them from psychological distress in any other case apart from “gender dysphoria.” Surgeries and lifelong drug treatment are rightly seen as last resorts, not the first line of treatment for a problem that might turn out to be transient.

The media and trans activists are constantly telling us how important it is to transition children—as young as possible. But what about the kids who might be wrongly diagnosed? Why does no one talk about them? Why is their future happiness not a subject for media exploration? What about the suicide rates of adults who realize with horror later in life that they actually don’t want hormones and surgeries?  That it was all a big mistake? That they don’t want to have to routinely stretch or pump up their artificially constructed sexual organs to keep them in some sort of working order? What about the adults who will mourn the children they were never allowed to bear because of decisions made by parents and doctors decades earlier?

If we care about all children, including the 80-95% of kids who in fact are only “gender nonconforming”;  if only a small number of “truly transgender” children exist, why not allow those few to transition as adults, when they have the cognitive wherewithal to decide for themselves? Why not simply help them cope with their feelings of dysphoria in childhood, instead of stunting their intellectual, emotional, and physical development, and risking the huge mistake of proactively sterilizing even one non-transgender child for life?

Would it really be so terrible for parents to simply let their kids wear what they want, pursue activities they want, heck, “identify” as they want, without the medical piece?

It only takes one person to file a malpractice lawsuit. There is no minimum number for a class action suit, but given the increasing numbers of children undergoing these early transition protocols, the typical 20-50 plaintiffs is not an unlikely number for future adults willing to litigate; a fraction of the people who will wish their parents and doctors had simply allowed them to dress and behave as they wished as children, without making permanent decisions that could not be undone.

So I ask the gender specialists, the parents, the activists, the journalists celebrating the medical transition of children: Granting you for the moment that your fervent belief in immutable, innate gender corresponds to reality, what concern do you have for the children who will be wrongly sterilized, drugged, and surgically altered? Do those children matter to you at all?

Is it acceptable to wrongly sterilize even ONE child?

** Such studies would be difficult to conduct. To come close to proving an innate “gender identity” separate from biological sex, that results in intractable transgenderism, researchers would necessarily have to scan large numbers of identical twins at birth. These twins would then have to be separated and raised in different environments, then be followed into adulthood. (Genetically identical twins are necessary to prove innate brain physiology, and the twins must be raised separately to control for the effects of life experience and influence, which would need to differ to prove that nature trumps nurture). A statistically significant number of those pairs of twins would then have to both be transgender-identified to prove that transgenderism is an essential and innate trait of the human brain.

Today, Dawn Ennis of The Advocate posted a long piece attempting to take down critics of pediatric medical transition. My blog is linked on page 2, with an excerpt from an email thread that took place between Ennis and me:

“Yes, I DO support Mark’s efforts to shine a light on the current trend to transition kids. Please read my blog, because I’ve written extensively about it. I don’t particularly agree with his approach sometimes, which too often ends up in vicious Facebook wars. But his heart is in the right place — and you can quote me on that.

You really have no idea how much people who question the dominant trans paradigm are vilified and harassed. … We have to protect our CHILDREN’s anonymity. We can’t afford to have their identities exposed — unlike the parents who are making tons of money parading the children they are sterilizing before the fawning media. Jazz Jennings comes to mind.”

For any Advocate reader who might be reading this right now because of that referring link, I have this question for you:

Are you aware that The Advocate, initially a strong voice for gay and lesbian people, has in recent years been mostly trumpeting a one-sided meme about the positive effects of transition? More importantly: Do you know that there is a body of research going back decades indicating that 80-96% of “gender nonconforming” children grow up to be gay or lesbian if left alone and not interfered with by “gender specialists?” 

Please read these posts for an introduction.

Into the Heart of the Homophobic Beast

Parental Homophobia is Never Examined in Triumphant Transition Stories

Research evidence: Most Gender Dysphoric Children Grow Up to be Gay or Lesbian

Update: And before you write to me screaming about suicide, see my August 3 post on the often-cited 41% suicide attempt rate.

“Transition or die” is promoted to young people on Reddit and Tumblr. For more, see the excellent blog Transgender Reality for this: When Suicide is Presented as the Logical Alternative

I wrote earlier this year on suicide as well. “Transition or Die” should never be promoted by any responsible medical provider or media figure. Yet it is used constantly as a way to end reasoned discussion and force frightened parents into submission:

Teen Suicide and the Chilling Effect on Dialogue

And finally: Do you think it is rational to conflate anti-gay conversion therapy with psychotherapy that might allow a “gender nonconforming” child to become comfortable in their own body? Do you really think it is “transphobic” to attempt to help a possibly gay or lesbian young person avoid lifelong hormone treatments, plastic surgeries, and (in the case of puberty blockers followed immediately by cross-sex hormones) permanent sterility?

Anyone who truly supports gay and lesbian people owes it to themselves to read widely and understand the arguments of gender critics like me. Simply dismissing us as “transphobes” and TERFs is not worthy of any thoughtful progressive who cares about human rights and dignity.

For the record: Contrary to Dawn Ennis’ attempt to paint all gender critics as mindless followers, I began blogging well before Mark and Lynna Cummings posted their video criticizing puberty blockers and childhood transition. The blog GenderTrender, also mentioned by Ennis, has been extant for years.

Far from “parroting,” parents like me are finding their own voices by exploring the research base going back decades–and even by scrutinizing the words of “gender specialists” themselves:

Kingpins of pediatric transition confess: We have no idea what we’re doing

This is Part 3 in a series about breast binding. Part 1 here, Part 2 here. The purpose of this series is to educate parents and caregivers about breast binders: their easy availability to girls and young women, and their potential dangers. 

Truth-about-transition has a new reblog up with peer advice for girls and women who have sustained an injury from breast binding. Like most of what truth-about-transition ferrets out, the post pretty much speaks for itself: breast binding can be dangerous–in rare cases, life-threatening.

As I noted in a prior post,  adolescents seek advice primarily from others their own age, with Tumblr, YouTube, and Instagram serving as peer counseling hubs for kids discussing dysphoria, surgeries, binding, hormones and everything else trans.

To their credit, the original poster offers advice to stay safe and avoid further injury. Which is a good thing. Adolescents aren’t exactly known for good judgment, foresight, or awareness of danger. Most teens seem to think they’re immortal, preferring to follow their own impulses and desires. They also tend to think adults (particularly their parents) are clueless morons.

The post (excerpted below) is interesting not so much for its pragmatic advice, but for the underlying and very typical messaging. It begins with commonsense advice for those with injuries:

This post is but one of many in the Tumblr FTM blogosphere on the same subject. YouTube–the go-to place for FTM transition stories–has this video from 6 years ago which presents a similar cautionary tale.

This is a guest post from another concerned mom. It’s not our imagination, this “teen transition wave” our kids are riding.

Philomena says:
I am relieved to find this site. We are a progressive family caught in the teenage transgender wave. It’s so scary. I can’t even put it into words.

What we are seeing are pockets of teens in different towns who are declaring themselves either non-binary or transgender. In many cases, these are teens who showed no gender variance at all, and then they get connected with a group in their high school, and suddenly a large percentage of them are identifying this way.

The information they find on the internet convinces them that physical transitioning via hormones and surgery is not only the only way to go but should also be available to them right now, as soon as they want it.

I am very concerned that the medical community is not looking at the sheer number of teens, post-puberty, who are making these kinds of declarations and asking whether this can be genuine or a temporary stop on the process of figuring out one’s identity as a teenager. Peer influence is just so huge in these kids.

As soon as they turn 18, they are seeking medical intervention, and the model now is informed consent, so we have lots of teenagers and young adults making permanent changes to their bodies when their brains have not yet reached adulthood.

Very, very scary.