On April 7, 2021, the UC San Francisco Child and Adolescent Gender Center offered a Zoom “training” entitled “Fertility Issues for Transgender and Nonbinary Youth.” Advertised widely on Facebook, the session was led by well-known gender therapist Diane Ehrensaft and a colleague, and was attended by over 100 people via Zoom. A recording of the session was provided to 4thWaveNow by an attendee. This article will draw on a few excerpts from the session, available for viewing here and here.

There’s a lot to unpack in the nearly two-hour long session, and we hope to address it more fully in future writings. For now, this piece will focus on one key theme explored in the session:

Future reproduction is pretty much foreclosed as a possibility for children who have been puberty-blocked and who subsequently continue on (as nearly all do) to cross sex hormones, but the “benefits outweigh risks” to move the child from, as Ehrensaft puts it, “gender dysphoria to gender euphoria.”

The fertility-wrecking aspect of the blockers>cross-sex hormones regimen isn’t new ground for those of us who’ve been closely following the accelerating trajectory of pediatric transition in the last few years. Indeed, gender clinicians themselves have known and talked about it for years. The issue is that biological reproduction depends on full maturation of gametes (sperm and ova), and gamete maturation depends upon a person completing their natal puberty.

But what may be new to our readers is that Ehrensaft–a developmental psychologist by training– herself recognizes a concern that child-transition skeptics have repeatedly pointed out: tweens and young teens undergoing these treatments are not developmentally mature enough to comprehend the full magnitude of irreversible sterilization. (Interestingly, she also discussed this three years ago at the 2018 WPATH conference in Buenos Aires.)

Although Ehrensaft (as you might guess) continues to recommend these treatments, in her Zoom presentation, she explains in detail that clinicians, parents, and other adults involved in the child’s care shouldn’t overburden a child with “TMI” –too much information—too many details– about the momentous decision to undergo interventions that result in permanent chemical sterilization.

Now is as good a time as any to dispense (again) with a typical reaction expressed when anyone talks about fertility and trans kids. Many trans activists routinely pooh-pooh the idea that people should be concerned about the loss of future fertility in medically-transitioned children. “You just think women should be baby machines! Not everyone wants to have babies!” Again we state (as we have previously): The issue is not whether a child should ever want “genetically related” (to use Ehrensaft’s term)  offspring when they reach adulthood. It is that it is a human right to make the decision to reproduce–or not–when one has reached adulthood.  Stated more plainly: Sterilizing children is a human rights violation. Until quite recently, these statements would not have been considered remotely controversial—but here we are.

Before delving further into yesterday’s Zoom session, let’s briefly review some of Ehrensaft’s previous remarks on the sterilization of trans kids.

Regular readers and followers of the 4thWaveNow Twitter account will be aware of Ehrensaft’s now-infamous presentation at a 2016 conference in Santa Cruz, CA, perhaps best known for the segment on barrettes and onesies. Less well known perhaps is her opinion, expressed in the same venue, that parents who might want to protect their children’s foundational human right to decide (yea or nay) about reproduction as adults (as opposed to middle school-age) are wrongly interfering with their children’s “dreams” and only balk because of a selfish desire for “genetically related” grandchildren.

“We have to work with parents on—these aren’t your dreams, we have to focus on your child’s dreams, and what they want.”

It appears Ehrensaft has not changed her views much on this in the last 5 years. In the April 7^th 2021 Zoom session, Ehrensaft again appeared to relegate any worries or ethical concerns about sterilizing an 11- or 12-year-old child to nothing more than a self-centered parental desire for grandchildren.  Note that in the slide reproduced here, the 11-year-old “assigned female at birth” identifies as “genderqueer.”

Back in 2016, Ehrensaft waxed enthusiastic that many of the puberty-blocked trans kids she has worked with are mature beyond their years, capable of choosing adoption over biological offspring, just as a thoughtful adult might do after careful deliberation. (Interestingly, Ehrensaft seems to have moderated her opinion on this somewhat. In last week’s session, she cautioned clinicians that such pronouncements could possibly be “almost a reflexive response” from some young clients who just want to obtain blockers or hormones, an “overblown altruism”.)

But Ehrensaft’s key point back in 2016 was that puberty blockers and cross-sex hormones are directly analogous to fertility-robbing chemotherapy treatments for children with terminal cancer, since both are “life saving” and urgently required interventions. The message is powerful (whether accurate or not) and more than enough to chasten any loving parent: Denying your middle schooler blockers and hormones is tantamount to letting a child with terminal cancer die for lack of treatment.

We have, of course, heard the life-saving claim many times before: that dysphoric tweens require these treatments for survival, despite risks to not only their future fertility, but also potentially to their sexual function. There is no historical evidence for this claim (in fact, child and youth suicide rates have increased since the advent of pediatric medical transition).(A thorough examination of the flaws in the “suicide or transition” orthodoxy would require another 3000-word article, but for those interested, see here, here, and here for some more reading on the subject.)

Now let’s take a closer look at Ehrensaft’s April 7^th Zoom presentation.

You may have heard that puberty blockers are supposed to “buy time” for the dysphoric child to decide whether to proceed further with medical intervention. Indeed, that was the original intent when puberty blockers were first prescribed to gender dysphoric children in the Netherlands.  But there’s a reason why the original Amsterdam clinician-researchers were (and still are) cautious about recommending social transition for younger children: Their goal was to prevent those children who might outgrow their gender dysphoria from embarking on lifelong, unnecessary medicalization; to avoid concretizing what is for some a transient gender confusion. The Dutch engaged in lengthy evaluation and recommended blockers for a carefully assessed cohort of their young patients. Even then, the blockers were meant to buy time.

But Ehrensaft and other “affirmative” clinicians have turned the more cautious “watchful waiting” approach on its head in the last decade or so. No longer is a child encouraged to leave the question open as to whether they will become lifelong medical patients; now they are “affirmed,” often as young as toddlerhood; and at the first sign of puberty, in Ehrensaft’s words, they urgently desire blockers to

 “ward off an unwanted puberty that they’ve been thinking and worrying about for years…These kids who have socially transitioned many years prior, they don’t NEED more time to explore their gender. They’ve known from an early age what their authentic gender was…they’ve been living their affirmed gender for many years by the time they reach puberty.”

For these children, blockers (and the cross-sex hormones which nearly inevitably follow provide “continuity of care in gender affirmation and discontinuity in potential capacity to ever create progeny with their own genetic material.”

So common is social transition (in the US at least), Ehrensaft reported on April 7^th, that US researchers have found upwards of 90% of kids requesting pubertal blockade have already socially transitioned. The full ramifications of this increase in social transition (encouraged by affirmative therapists like Ehrensaft) have never been explored in a controlled study. It’s interesting that affirmative clinicians readily follow the Dutch protocol for the use of puberty blockers, while utterly dismissing their cautions about early social transitions.

So if children “affirmed” (and therefore socially transitioned) since early childhood are now justifiably candidates for blockers and then cross hormones, what is the responsibility of clinicians and parents in consenting to these interventions, given that (in her words) “blocking puberty takes away options for fertility for most?”

Ehrensaft acknowledges that a child at Tanner stage 2 (that is, the earliest sign of puberty— “as early as 8 or 9 years old”) is not emotionally or psychologically equipped to understand sex or reproduction, beyond much more than a simple, concrete description of sperm + egg. What’s more, she says, asking a child to consider the mechanics of sex and reproduction at this age may actually be psychologically harmful!

“Fertility considerations about blockers followed by hormones brings on the storm before the lull is over”… So we now have a child who could be as young as 8, 9 who has to think about sex, babies, and future roles rather than games and game playing, which is where we situate development at this period…it’s a developmental stretch and it can create emotional stress.”

She calls this “the disruption”– the “developmental disarray” which could result from informing a child still interested in games and make-believe (and though she doesn’t say it, at an age when some may still believe in Santa Claus or the Easter Bunny):

“So we’re needing to acquire the child’s assent for medical interventions and that requires asking a child prematurely to take on sex and drugs but no rock and roll.”

So what to do if you don’t want to stress out the child with TMI when they are at the “just the facts” stage of development — when you “may get a lot of squirminess about sex or around sex”?  Do you talk about how the jaunty boy sperm meets the cute girl ovum (like the slide picture shows) but stay silent on the icky stuff about sex? After all, they’re not ready (and may even be disgusted by) the “rock and roll” older adolescents become intensely interested in with full-on puberty and sexual maturation.

Pretty much, says Ehrensaft. Instead of “giving them more information than they need or can handle,”adults should limit themselves to simplistic explanations about reproduction but not sex.

The question arises: If a child as young as 8 or 9 years old “can’t handle” information about sex, how can they handle deciding whether they are OK with losing the right to reproduce (or not) as an adult, when given “just the facts”?

Ehrensaft buttresses her points by highlighting the developmental framework popularized by the late Erik Erikson (one of the 20^th century’s most respected developmental psychologists), which rests on the notion that successful and healthy maturation and adult identity consolidation occurs in stages. She notes that children being asked to decide about their future fertility are “two or three” stages behind the age when they would be better equipped to comprehend the gravity of that choice.

It’s not surprising she would be familiar with the giants in that field; though best known as a gender therapist, Ehrensaft, as mentioned previously, is a PhD developmental psychologist. (It’s much less widely known that in the 1990s, she also had some involvement, as a psychotherapist, in the widely-discredited “satanic ritual abuse” preschool controversy.)

But very unlike Erikson, Ehrensaft’s analyses & recommendations always stem from an untestable confirmation bias: that “gender identity” is a native, fundamental property of the human brain, present from birth (as she said in that 2016 talk, babies “probably know their gender as early as the beginning of the second year of life…they probably know even earlier but they’re really pre-pre verbal”).  In contrast, Erikson’s work made no mention of innate gender. Rather, he emphasized identity development as a long process, involving an essential “crisis” that is often not resolved until one’s 20s. In fact, Erikson posited that a person might not attain healthy adult psychological integration if they did not experience an identity crisis. Another question arises:  Could gender dysphoria, for at least some children and adolescents, be something that needs to be struggled with for successful resolution and maturation, instead of ameliorated (short-circuited?) as Ehrensaft and other affirmative clinicians now do via social transition and hormone blockers?

After warning her audience not to burden tweens with TMI, she rather abruptly notes that

“Those of us who provide this care have been accused of sterilizing children. And what I would say is, we are not sterilizing everybody—[quickly revises] anybody.”

Yet this is precisely what Ehrensaft has told her audience affirming clinicians are doing, just with different words (e.g., “they won’t be able to have a genetically related child”): These treatments WILL permanently take the choice to reproduce away from a child who has been puberty-blocked and then moves to cross-sex hormones. A dictionary definition for that is sterilization.

Not missing a beat, she continues:

“I would encourage us to hold this in mind: That when people—when adults—confront medical infertility it is a very very difficult road and there are certainly and people may go through some really hard times but there’s not a high suicidality rate for infertile people facing medical infertility. But we do know there are alarmingly high rates of self harm and suicidality and suicidal thoughts among both adults and youth who experience extreme gender dysphoria. And I will say that one of the things I’ve read recently while reading a research study it struck me one youth talking about fertility preservation. I have to decide between saving myself and holding the option of someday having a child…to me it’s a choice between that potential child and my life.”

What research study? Who conducted it? And why would children believe (or be encouraged to believe) they must make a “Sophie’s Choice” between their own lives and that of potential future offspring?

“But as we communicate the fertility information to youth, hold in mind, not many people become suicidal about medical infertility, but many do about gender dysphoria.”

Where are the references for this statement? Where are the studies comparing the “not many” infertile adults who never become suicidal, with adults who were sterilized at the dawn of puberty? Where is the NIH-funded research looking at how chemically sterilized trans kids subsequently feel at 20, 35, 40 and later (much later for males) about having their reproductive choices foreclosed when they were 10 or 12 years old?

To her credit, Ehrensaft does acknowledge there are real ethical issues to ponder here. She even poses the same question many pediatric transition skeptics regularly do:

 “Is a child really able to foresee into the future and foreshorten fertility … And how can a child two or three stages behind Erikson’s stage 7 anticipate what they will feel two or three stages later?”

She provides no answer to her own question; in fact, she simply poses more questions, and says it’s “for us to start [emphasis added] finding out. And we are.”

How can this not be seen as an admission that the entire “affirmative” pediatric-transition enterprise is, in fact, an experiment–with unknown future consequences?

Ehrensaft wraps up this part of the Zoom session with an anecdote she says she heard from another gender clinician, Scott Leibowitz, MD:

“I want to mention one intervention I learned from Scott Leibowitz. Which is, in making these decisions with youth about fertility and their future fertility, once they’ve made the decision, he invites them to write a letter to themselves at age 30, and write their present-age self to their 30-year-old self explaining to them what process they went through to make the decision they did that may have implications for future fertility at age 30 or 25.:

What does Ehrensaft (and Leibowitz, assuming she has represented his views accurately) think this letter-writing exercise will accomplish “after [the child has already] made the decision” that they will never reproduce? Is this meant to serve as an apology of sorts to the regretful adult? That 30-year-old future self, with a 30-year-old brain and all its more nuanced and experience-tempered understanding of the world, its fully developed frontal lobes, will see this letter by his or her child-self and feel — what? Does any 30-year-old look upon the writings or thoughts of their 12-year-old self and see wisdom? They will likely “forgive” their 12-year-old self, but …

Ehrensaft presents this anecdote as if it’s some kind of a solution to the question she posed: How can a child at an early stage of emotional, psychological, and intellectual development make a decision several years before they are equipped to fully comprehend it?

To sum up the 4thWaveNow reaction to the main message imparted in this Zoom “training”: Ehrensaft’s use of (accurate) developmental psychology to justify the impossibility of obtaining informed consent from minors, with only the emotional blackmail of suicidality as a rationale, is nothing short of mind-blowing.

But maybe this is all much ado about nothing. After all, as Ehrensaft’s colleague Jen Hastings, MD told her Zoom audience, maybe none of this will matter in a future when reproductive tech and genetic engineering liberate us from our biological constraints:

“Gametes may soon be irrelevant.”

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The complete April 7, 2021 Zoom training can be viewed (in two parts) here and here.