A different take on affirmation

by Brie J

 Brie J is the mother of a teen who temporarily believed she was a trans boy.


We appear to be living in an age of heightened ideological dualism and false dichotomies. Nowhere is this more obvious than if you’re the parent of a gender-engrossed young person, and you’re desperate for objective information about how to best support your loved one. But parents who turn to the Internet to learn about the seemingly sudden distress that’s gripped their children are likely to find only one response: “affirmation.”

What does “affirmation” mean in this context? If you thought it meant affirming (as in acknowledging the reality of) a child’s distress and other assorted negative feelings surrounding their expected adherence to sex-rooted gender norms, you’d be mistaken. Increasingly, affirmation means confirming a child’s belief that there is something incongruent between their body and their mind and the belief that their body is afflicted by a kind of birth defect that only appears around puberty. To hear many trans advocates and certain clinicians tell it, the natural development of a sexed body is traumatic, dangerous, and possibly even deadly.

Like just about every other social and political issue currently being debated, the approach to helping kids uncomfortable in their born bodies could be drawn on a spectrum with a wide field of grey between the two opposing ends: blanket affirmation of born-in-the wrong-body rhetoric on one side, and wholesale invalidation of a young person’s feelings and beliefs on the other.

I want to encourage all those concerned with this issue to take a deep breath and try their hardest to assume positive intent on behalf of all parents struggling to help their children. Claims of “child abuse” from both sides against obviously caring parents need to stop. A little empathy will go a long way toward encouraging more productive and meaningful conversations. Most parents, regardless of where they stand on the affirm-or-not spectrum, want the same thing: healthy, actualized, contented children.

For my part, I want to widen the scope of what it means to offer “affirmation” and encourage those who are skeptical of medical interventions to embrace validating their children’s discomfort. At the same time, I want to encourage those researching and caring for dysphoric youth to recognize that a large percentage of parents are already doing that: affirming their children’s distress, fully in support of their gender atypicality, and also, when needed, seeking out specialized mental health care for underlying issues prior to agreeing to hormonal and surgical interventions.

When my now teen daughter was four years old, I happened upon a philosophy of parenting that at once sounded both ludicrous and wonderful. “Radical unschooling,” I read, was practiced by parenting according to principles, not rules, and by nourishing a rich relationship built on trust between parent and child. I decided to forgo punishments in favor of seeing my child’s behavior as communication, which at that age, was often grounded in an unmet need or frustration. I prioritized not only supporting her interests, no matter how odd (road kill), or silly (The Wiggles), or redundant (The Wiggles), but also tried my hardest to understand what was interesting about the things my daughter chose to pursue.

Unschooling is often misunderstood as being “child-led.” It isn’t. According to Pam Sorooshian, one of my parenting and unschooling mentors:

The term, “child-led learning,” does emphasize something very important – that the child is the learner! I couldn’t agree more. However, it also disregards the significant role played by the parent in helping and supporting and, yes, quite often taking the lead, in the investigation and exploration of the world that is unschooling.

So when my 11-year-old daughter revealed to me that she thought she was a boy inside, I approached the news from the framework of partnered exploration. I supported her by listening, by learning about her interest, by doing research she couldn’t do for herself, by talking to others and talking about all kinds of things with others while she was near, by finding specialists who could help, and also by asking:

Why…?

Where do you think that comes from?

What does that mean to you?

How else could this be different?

What can I do?

I had always (already) accepted my kind, curious, creative, quirky, stereotype-bending child. There was never a second when I considered not walking beside her as she struggled with feeling wrong in her developing body. As she sorted through trauma and grief and went through the stages of forming her unique identity, our parental support was critical to keeping her safe.

I told her I would love her no matter what and help her however I could and that I would always have her back. I told her I didn’t care who she loved, how she dressed, or what name she chose to use.

I told her I didn’t think she was really a boy but I understood she wanted to be one. I told her I wasn’t convinced there was enough evidence that hormonal interventions would serve her well long-term.

question markI asked her what boys could do that she couldn’t? Why being a boy would be better? I listened. I affirmed her distress, her confusion, and her desire as valid emotions. I empathized as much as I could. I helped her find ways to feel stronger, to BE stronger, to feel safer, more secure, and better able to manage discomfort and ambiguity. Because I had spent her childhood up to this point prioritizing our relationship and not my position of authority, she trusted me to help her get what she wanted, which was to feel better about herself and her place in the world. I was lucky in one way: My child was still young enough that we both had the luxury of ample time to work on this together (unlike some rapid-onset older teens and their parents).

The vast majority of parents who read and contribute to 4thwavenow may not be radical unschoolers, but they still unconditionally love and accept their children. In fact, it is precisely because they unconditionally love and accept their children that they want more than anything to help them find ways to be at peace with themselves. No parent is perfect; all of us make mistakes, get frustrated, say or do the wrong thing at times. But despite (or even because of) our blunders, we can grow along with our children. We can model empathy, open-minded curiosity, a willingness to apologize when we get it wrong, and acceptance of ambiguity. In other words, we can and we do model a different kind of affirmation.

James Cantor shreds American Academy of Peds gender-affirmative policy statement

Anyone who is paying attention knows the US holds the dubious distinction of being the world’s incubator for the “gender affirmative” approach. This treatment pathway–increasingly, the only pathway available in the United States–frequently consists of:

  • full social transition for children, starting as young as toddlerhood;
  • cross-sex hormones and even “top” and “bottom” surgeries for young teens, some of whom showed no childhood gender discomfort and only announced a trans identity in adolescence; and
  • affirmation of a child’s trans identity at any age, regardless of other possible causative/related factors (such as autism, social contagion, or same-sex attraction). Some of the more fervent US clinicians eschew careful psychological assessment before they prescribe full social and/or medical transition, asserting that such thorough evaluation is unnecessarily onerous or “triggering” to the young patient.

The American Academy of Pediatrics recently released a policy statement  which essentially rubber-stamps the affirmative approach. (While the Academy itself has tens of thousands of members, a recent article pointed out that the policy document was the work of a very small, activist-inspired subgroup). The AAP document creates the impression that affirmative treatment is a matter of settled clinical consensus.

Nothing could be further from the truth.

The AAP policy has a number of glaring flaws. To take just one example, it omits a significant body of research evidence that is inconvenient to the AAP’s affirmation-only doctrine. Worse: the research the AAP document does cite ironically substantiates the very “watchful waiting” approach dismissed by the AAP. The truth is, this more cautious approach is the most commonly used and evidence-based treatment for childhood gender dysphoria recognized by clinicians around the world.

There’s a lot more to pick apart in the AAP’s policy statement, and James Cantor, PhD., a Toronto-based sexologist, researcher, and clinical psychologist, did just that today. His long (but worth it) fact-checking article is required reading for anyone interested in the topic of pediatric transition.

Please read and share Dr. Cantor’s piece widely. You can read the whole thing here.

Cantor sex today lead aap

Gender-affirmative therapist: Baby who hates barrettes = trans boy; questioning sterilization of 11-year olds same as denying cancer treatment

Note: 4thWaveNow frequently features posts (like this one) that focus, often unflatteringly, on the activists and providers involved in pediatric transition. These people aren’t ogres who intend to bring harm to the young people and families under their care and influence. They undoubtedly sincerely believe they are doing the right thing. The purpose here, as ever, is not to demonize, but to shed light on the potential and actual damage done by the practice and ideology of “gender affirmation.”  Harms done not only to children and their families, but to the decades of progress achieved by the women’s and LGB liberation movements.


A well known subscriber to the “gender affirmative” approach to trans-identified children is Diane Ehrensaft, PhD., a clinical and developmental psychologist. Dr. Ehrensaft, author of The Gender Creative Child, plays a powerful role in the burgeoning field of pediatric transgenderism. She is director and chief psychologist for the University of California-San Francisco children’s hospital gender clinic, and is also an associate professor of pediatrics at UCSF. She sits on the Board of Directors of Gender Spectrum, a San Francisco Bay area organization which is heavily involved in matters pertaining to trans-identified children and youth.

In February, Dr. Ehrensaft, along with other pediatric transition specialists, including Joel Baum, MS (senior director of professional development and family services at Gender Spectrum), presented at a conference and continuing education event in Santa Cruz, California.  The all-day event, attended by over 400 people, was recorded and video is available here.

The 5.5-hour video is well worth watching in its entirety for anyone interested in the current state of “gender affirmative” therapy. This post will touch on only a few highlights from the conference. There is much, much more.  (Numbers in square brackets give approximate hour:minute time stamps for each video excerpt.)compare-models

Dr. Ehrensaft [1:31] tells the audience that “gender affirmation” differs from the more cautious approach of learning to “live in your own skin” provided by Dr. Ken Zucker in Toronto. Zucker’s clinic was shut down by trans activists a few months ago—reported by Ehrensaft with obvious glee and to the applause of her audience. Gender affirmation also parts company with the “watchful waiting” protocol pioneered by clinician-researchers in the well known Amsterdam gender identity clinic founded by Peggy Cohen-Kettenis. The Dutch have repeatedly counseled caution in social transition and early intervention for gender dysphoric children, given the high rate of desistance and the fact that early social transition has made it more difficult for some young people to change their minds later—and might even increase the likelihood that a child will persist in a trans identity.

kid-tells

Ehrensaft labels “gender affirmative” therapy as “listen and act,” i.e., essentially follow the child’s lead in whether or not to proceed with early interventions like social transition and puberty blockers.  According to Ehrensaft, this boils down to whether the child says they ARE (vs. “want to be”) the opposite sex, and how “persistent, insistent, and consistent” they are in asserting their cross-sex identification and gender “expression.”

Ehrensaft denies that gender-affirmative therapists simply “rubber stamp” a child’s gender identity, yet despite her protestations to the contrary, she constantly reifies the idea that gender identity is innate and recognizable even in pre-verbal babies and toddlers (more on that later in the post).

rubber-stamp

To be fair, in her presentation Ehrensaft does acknowledge the replicated research showing that a large majority of gender dysphoric kids will grow out of it. Yet she strongly believes that she and others like her can reliably distinguish between the “apples” who are truly transgender and the “oranges” who are only exploring.

Even if you believe there is such a thing as a truly transgender child, what is the justification—the evidence— for her hubris, her certainty that she and others like her who peddle the “gender affirmative” approach can predict which children might be happy, decades later, as sterilized, surgically and chemically altered adults? There really isn’t any. Even so, at one point, she claims science is on her side, pointing (without directly citing it) to “research” out of the University of Washington that proves—gender-defiant children really, really, really mean it when they say they prefer the clothes, toys, and lifestyle more typical of the opposite sex.

Let’s take a closer look at the “insistent, consistent, persistent” mantra—droned incessantly by gender experts, with this conference being no exception. While Ehrensaft and Baum take great pains to say they support and even celebrate gender “nonconformity,” when the young trans-identified people (present at the event and on video) talk about their experiences and how they “know” they are trans, we hear the same rationale we always do: they eschew sex-stereotyped behaviors and appearance.

How does Ehrensaft directly instruct us in what it means to be “consistent, persistent, and insistent”? She plays a video clip of a young FtoM who has this to say about why s/he is and has always been trans: [47:00]

 We [trans kids] don’t know about much but we know about gender. We know that girls are the ones supposed to be in skirts and dresses and guys in jeans and fight all the time…I think what should have been a sign to my parents was um…I was a quiet child. I didn’t fuss or anything. But whenever my mom would try to dress me up and put lipstick on me and get me all pretty for pictures I would throw a tantrum, I would scream … that should have definitely been a big sign to her that I was not trying to fit into the girl role… The most feminine thing I did as a child was paint my nails—black.

There is knowing laughter from the audience at this last point—as if choosing black (instead of pink or purple?) fingernail polish were a sure sign that this child was, in fact, a boy.  A child who was, yes, persistent, consistent, INSISTENT…that she didn’t want to act like a stereotypical girl in a dress wearing lipstick.

persistent-teen

If Ehrensaft could respond here, I imagine she might say something like, “oh but it’s more than gender expression!” If it’s more than that, why is the one video excerpt provided to teach us about who is really trans all about stereotypes? Could it be that conforming to stereotypes is the very basis of the definition of a “trans child”?

We hear from another trans-identified teen during the panel discussion, Jordan, a 17-year-old FtoM. We also hear from Jordan’s mom, Heidi, who leads a local support group for trans-identified youth and their families.

Heidi—who at several points mentions her strong church affiliation–talks about some of the childhood experiences that convinced her that her daughter was actually her son, including this [4:37]:

 When Jordan was about 2 it became clear to me that Jordan liked boy things—you know trucks, video games, violence…when he was about between 2 and 4 I noticed he would rip off the pretty little dresses I would put on him. Would go screaming through the house and would not leave the house until he had on his brother’s big, holey T-shirts. I just thought he was a tomboy and that it was a phase.  He was driving me nuts but it was a phase. During this time I worked for a very large church… We are Christians… We were told by everyone around us to make that kid wear a dress.

Another kid screaming in a dress.

Mom tried to force her kid to wear dresses: check. The kid liked trucks: check. A girl not wanting to wear dresses is ”a phase”: check. Mom didn’t like this (it drove her nuts): check. Mom was involved with a church, whose members wanted her to “make” her child wear a dress.

Could this stuff be any more obvious?

Jordan seems to agree that an aversion to wearing dresses is a key sign of one’s innate gender identity [4:44].

 My mom put me in a dress at Easter.  [But I] went to church in dirty jeans and a big T-shirt. That was kind of a big signal.

A big signal of what? That Jordan didn’t like dresses, preferred to wear jeans? What is this obsession with dresses that we see in each and every media story about girls who are “really boys?” When did we step into this time machine, returning to the turn of the 20th century? Even Katherine Hepburn wore pants and eschewed dresses in the 1940s.

Then there’s this from Heidi [4:40]:

[During the elementary school years] I was [putting up] posters of really strong women. You know, like the singer Pink? Oh, this is a real kick-ass girl, you can be like her… when he had a crush on her. It was things like that.

Things like… not wanting a lesbian daughter? This conference took place in 2016, in the San Francisco Bay Area–for decades considered one of the most gay-friendly places in the USA, and the audience tittered at this revelation of Jordan’s same-sex attraction—as if that were a sign Jordan was actually a boy!

Mom goes on to describe how Jordan was diagnosed with a whole “plethora” of mental health issues, from ADD to bipolar to mood disorders, and concludes that it was being trans that was the root of all these other problems; once Jordan transitioned, everything else cleared up: the self hatred, the self harm, the unhappiness.

This is an increasingly common refrain, and in fact, Ehrensaft at several points in her presentation asserts that “gender is the cure” for an array of other mental health issues. What we don’t see, from Ehrensaft or anyone else, is actual evidence that allowing children to “transition” results in improvements in mental health over the long haul. What we are beginning to see in accounts from some people who have detransitioned is that transition essentially put their other issues on hold for a while—only to re-arise when the initial transition exhilaration began to dissipate.

We have evidence from several studies that gender dysphoria often co-presents with other mental health issues. Ehrensaft and others like her are now turning such research on its head, positing that the cause of comorbid mental health problems is a child being somehow thwarted in their gender identity.

Returning to the conference, although Jordan’s “gender expression” is not assumed to be the real reason for transition, it is telling that, as always, it is examples of how a person does or does not conform to sex-stereotyped behaviors that are presented as the evidence for being transgender.

And that goes even for babies, according to Ehrensaft. During the audience Q&A, a man asks how one might tell if a pre-verbal one or two-year-old is transgender. Ehrensaft’s answer, delivered with a knowing and confident smile [Clip for this excerpt is here, starting at approx. 2:05-2:06 in main video]:

 [Preverbal children] are very action oriented. This is where mirroring is really important. And listening to actions. So let me give you an example.

I have a colleague who is transgender. There is a video of him as a toddler–he was assigned female at birth–tearing barrettes out of then-her hair. And throwing them on the ground. And sobbing. That’s a gender message.

barrettes

Ehrensaft miming a significant “gender message:” a toddler ripping barrettes out of her hair

Ehrensaft is a developmental psychologist, and the only reason she can think of that a 2-year-old girl might detest the feel of barrettes in her hair is that the child is really a boy?

Again, I imagine Ehrensaft’s retort: Oh, that was just one thing–there were lots of other signs. Then why does Ehrensaft use this as a seminal example when responding to a question from the audience? And according to Ehrensaft, if the child (consistently, insistently, and persistently?) tore the barrettes from her hair “not once, but twice, three times,” that is the clincher.

Ehrensaft elaborates:

Sometimes kids between 1 and 2, with beginning language, will say, “I BOY!” when you say “girl.” That’s an early verbal message! And sometimes there’s a tendency to say “Well, honey, no you’re a girl because little girls have vaginas, and you have a vagina so you’re a girl…Then when they get a little older [the child] says, “Did you not listen to me? I said I’m a boy with a vagina!

Believers in gender identity accuse gender skeptics like me of “reducing people to their genitals.” But here we have a developmental psychologist saying in so many words that the only thing that makes a girl a girl….is her vagina. I don’t know about the other parents reading this, but I can say my response to my two-year-old in that scenario would not have been a reference to (one aspect of) her genitals.

What else does Ehrensaft advise for parents who are so concerned about their baby’s “gender identity”?

They can show you about what they want to play with…and if they feel uncomfortable about how you are responding to them and their gender… if you’re misgendering them. So you look for those kinds of actions….like tearing a skirt off. …There was one on that Barbara Walters special, this child  wore the little onesie with the snap-ups between the legs. And at age one would unsnap them to make a dress, so the dress would flow. This is a child who was assigned male. That’s a communication, a pre-verbal communication about gender.

Ehrensaft then counsels parents not to try to squelch non-sex-stereotyped behaviors (good advice), but ruins it with a faith-based assertion of innate gender identity:

And children will know [they are transgender] by the second year of lifethey probably know before that but that’s pre-pre verbal.

Not to put too fine a point on it but…this is a PhD. developmental psychologist talking here. What is her evidence base for saying babies “know” their gender identity?

…Especially since, at other points in her presentation, Ehrensaft acknowledges that gender identity can be fluid.

So which is it? A baby innately “knows” their gender identity, or it’s mutable?   To be logically consistent, Ehrensaft ought to also say that some infants are born (innately) “gender fluid”—an assertion that would be much closer to the truth, given the fact of lifelong neuroplasticity.  I wonder when the NIH will fund a study to determine which babies are born “binary” and which “genderqueer”?

What if gender-fluid children transition but change their minds? No harm done, according to Ehrensaft. She breezily asserts [1:50] that there is “no data” that it harms kids to switch back and forth between identities, as long as we “support” them in their “journey”—presumably even if that journey takes them down the road to hormones and surgeries which will alter them forever. She even touts “nonbinary transition” [3:57] as if it is something to be celebrated when youth who define themselves as “agender,” “nonbinary,” or any of the other “genders” (better known as “personalities”) might choose irreversible medical interventions.

Is Ehrensaft aware of cases like this? Would she just chalk it up to this detransitioned woman being “gender fluid” instead of “binary” and the permanent damage done to her body just part of her “gender journey” for which we have “no evidence” of any harm?

My double mastectomy was severely traumatizing. I paid a guy, a guy who does this every day for cash, to drug me to sleep and cut away healthy tissue. I did this because I believed it would heal all of the emotional issues I was blaming on my female body. It didn’t work. Now I’m still all fucked up and I’m missing body parts, too.

Ehrensaft also thinks social media has “been a godsend” [2:08] and a “tremendous boon” for young people to find others like them, with the only real ill effect being the online bullying of trans-identified kids. To be fair, she does throw a bone later to the fact that some kids presenting to clinics may be using a “script” and it’s important to look deeper to see whether it’s “their script”—which is something;  although if Ehrensaft was trained in child/adolescent developmental psychology, her cheerleading for nothing but the positive effects of social media is stunning. Has she never heard about online “communities” of teen anorexics and cutters?

Now to touch upon one final topic covered by Ehrensaft and others in the conference: permanent sterilization caused by prepubescent hormone treatment. This “side effect” is rarely mentioned in the countless media stories celebrating trans kids. One usually has to hunt for obscure literature references to find any mention. But during the conference, several providers do  acknowledge—repeatedly–that puberty blockers followed by cross-sex hormones always result in permanent infertility. They do so at least three times in the conference: [3:53], [4:18], and [5:06].

During the closing panel discussion, Ehrensaft and Baum devote several minutes to the topic of sterilizing trans kids—but explain it away with a twofer: By equating it to treatments for children with life-threatening cancers, and by stating that parents reluctant to sterilize their 11-year-olds are only concerned because they selfishly want grandchildren.

Actually, it’s a three-fer, because Ehrensaft and Baum manage to squeeze in the usual emotional blackmail: children who have to go through their natal puberty might commit suicide. [5:06].

Ehrensaft:

Another thing that’s a show-stopper around [parents] giving consent is the fertility issue. That if the child goes directly from puberty blockers to cross- sex hormones they are pretty much forfeiting their fertility and won’t be able to have a genetically related child.

There’s a lot of parents who have dreams of becoming grandparents. It’s very hard for them not to imagine those genetically related grandchildren. So we have to work with parents around, these aren’t your dreams. [she laughs]. You have to focus on your child’s dreams. What they want.

Let’s be very clear here:  Ehrensaft laughingly implies that parents concerned about their child’s human right to choose or not to choose to reproduce, a decision heretofore seen as inalienable and reserved for mature adults, are really only concerned about future grandchildren, not the bodily integrity or cognitive wherewithal of their prepubescent child. These egocentric parents are denying their children “their dreams.” These thoughtless parents need to be “worked with” by gender specialists.

And that’s not all: Ehrensaft goes on to shame these recalcitrant parents with the implication that puberty-blocked, 11-year-old trans tweens are more socially responsible than their clueless parents:

 And what I will say about many of the youth who want puberty blockers is: I have never met such an altruistic group of kids around adoption! Never! “I will adopt because there are so many children who need good homes.” And I think that’s both heartfelt but also they’re trying to tell us the most important thing to me right now is being able to have every opportunity to have my gender affirmation be as complete as possible. Anything else is secondary.

Do we need a PhD in developmental psychology to tell us this? You bet an 11-year-old thinks anything but what they want RIGHT NOW is secondary.  I want it, and I want it right now: the motto of youth, of children who are a decade or more away from full development of their reasoning, judgment, and awareness of future consequences.

But wait—perhaps there’s hope. Asks Ehrensaft:

The question is, can an 11-year-old, 12-year-old at that level of development, be really thinking and know what they want at age 30 around infertility?

Can they? Might it be ok to wait and allow this child to mature to adulthood before making such momentous decisions?

The answer to that is: We don’t think twice about instituting treatments for cancers for children that will compromise their fertility. We don’t say, we’re not going to give them the treatment for cancer because it’s going to compromise their fertility.

So here we have a woman who is directly responsible for sterilizing 11 and 12 year old children equating simply waiting–allowing a child to grow up to make their own decisions—with denying cancer treatment. And of course, we know what’s coming next: Transition or suicide.

For some of the youth, having the gender affirmation interventions is as life-saving as the oncology services for children who have cancer.

And they must have these interventions right now!

I wonder: Do Ehrensaft or any of the others here, so very certain of their moral superiority, ever lie awake at night wondering whether these children in their care could just as easily be supported in waiting?

baum-threat

Joel Baum instructs parents to transition their kids–or else.

Joel Baum, head of education for Gender Spectrum doubles down [5:09] to deliver the coupdegrâce to any parents who might still be hesitating:

I’ll just add one thing here. When we’re working with families, what is the leverage point for that family?…The fact of the matter is at the end of the day, it is their decision and we just hope they’re going to make an informed decision. Just make sure you have all the information you need. Which includes:

Here comes the punchline—the ultimate “leverage point”:

You can either have grandchildren or not have a kid anymore because they’ve ended the relationship with you or in some cases because they’ve chosen a more dangerous path for themselves.

Here, I’ll just let one of my lovely, unpublished commenters translate Joel Baum’s so-very-subtle veiled threat into plain language:

You are a horrible mother and you are abusing your son. You’re the reason trans people kill themselves. I hope one day he escapes from you and your transphobic abuse and never has to see you again.

Never mind that my daughter desisted from trans identity; never mind that our family remains intact despite my “transphobic abuse” i.e., refusal to pay for hormones and top surgery. And never mind, Joel Baum, that there is no evidence that troubled youth will desist from self harm if their parents are terrified into paying for irreversible medical interventions.

At this juncture, let me repeat what I’ve said many times before: A concern about sterilizing children is not a statement about whether a person ought to reproduce or not.  It’s about respecting the right of children to mature to adulthood to make the decision for themselves. It’s a basic moral tenet, respected in every other area of human rights law: you don’t sterilize children.

And this, too: There is no evidence, historical or otherwise, that a child prevented from medically transitioning will kill themselves before making their own medical decisions as an adult. That activist-clinicians feel justified in holding this threat over the heads of loving parents—and that journalists, politicians, and pediatric specialists who should know better abet them in wielding this weapon—is deeply shameful and should be exposed to the intense, disinfecting light of public scrutiny as long as necessary; until the purveyors of this immoral strategy are finally forced to answer the difficult questions they have been avoiding for the better part of a decade.

This conference is worth studying for anyone who wants to fully understand how a formerly rare diagnosis, with medical treatment only available for legal adults, has morphed into a pediatric specialty area where doctors, psychologists, and psychiatrists wave away the sterilization, drugging, and permanent medical alteration of children with nary a peep of dissent. And they do it by shamelessly scaring the bejesus out of everyone, by shaming parents into believing that unless they permanently sterilize little Judy or Billy at age 11, unless they agree to irreversible medical interventions for their teenager, they will be colluding in their child’s demise.

Watch the entire 5-hour presentation, even if you have to do it over several sessions. What you’ll be observing is how key movers and shakers on the cutting edge of pediatric transition in the United States are moving inexorably forward. Understand their tactics. Understand their ideology.

Because despite its steady progress so far, the “gender affirmative” pediatric transition juggernaut is only beginning to pick up speed.

[Meanwhile, if you haven’t already, be sure to read this post by a therapist who is skeptical of the “identity model” for trans-identified youth.]

Layers of meaning: A Jungian analyst questions the identity model for trans-identified youth

Lisa Marchiano, LCSW, is a Jungian analyst. She blogs at theJungSoul.com (Facebook: https://m.facebook.com/thejungsoul), and can also be found on Twitter @LisaMarchiano.

Lisa’s thoughtful essay stands in stark contrast to the simplistic advice we see from self-declared gender therapists like this one. For the perspective of another therapist skeptical of the “gender affirmative” approach, see this post by Lane Anderson, a former therapist for trans-identified teens who quit her job last year due to ethical concerns.

Lisa would like to thank Miranda Yardley, ThirdWayTrans, and Carey Callahan for their contributions to this post. Though these three individuals were generous in sharing their time and expertise, the views expressed here are Lisa’s own.

Lisa is available to respond to your remarks and questions in the comments section of this post. In addition, Lisa is interested in being in contact with other therapists who share her concerns about the identity therapy model:

If there are other therapists reading this and wanting support to question or work outside of the identity model, please be in touch. Contact me privately on Facebook or Twitter, or ask this blog to put you in touch with me via email. There are lots of us out there. Let’s start talking.


by Lisa Marchiano 

As a social worker and a Jungian analyst, I have become increasingly concerned about the rush to affirm children’s and young people’s transgender self-diagnosis, and then transition them to the opposite sex. I am particularly worried about social and medical transition among teens whose transgender diagnosis arose “out of the blue,” without a significant history of early childhood dysphoria. I fear that, via their well-meaning desire to validate young people in pain, therapists are discarding basic principles of psychotherapeutic care.

My views have been informed by my work with detransitioners, as well as with parents of trans-identifying teens. I have also sought to educate myself further by listening to trans people, parents, clinicians, academics, lesbians, feminists, educators, gays, and others who are writing and speaking about gender. I believe that transition may be a viable and even necessary option for some people. I support the right of adults to choose this option with appropriate therapeutic care and support. I certainly believe that trans people deserve human rights, legal protection, humane care, and respect. However, there are potential physical and psychological dangers of transition, and we need to exercise astute clinical judgment and caution when working with young people who are seeking transition.

I have often seen trans activists and gender specialists promote “social transition” of trans-identifying youth as a positive and “fully reversible” intervention. Social transition refers to a number of steps one can take to present as the opposite sex. These might include making changes to one’s hair style, make-up, name, pronouns, and dress. One might also begin binding breasts or wearing a packer to “present” more convincingly as the opposite sex. Social transition is sometimes described as something that has few if any long-term consequences, and therefore can be recommended with minimal concerns,  even for young children. However, in some significant percentage of cases, social transition leads to medical transition. It appears likely that being conditioned to believe you are the opposite sex creates ever greater pressure to continue to present in this way. Once one has made the investment of coming out to friends and family, having teachers refer to you by a new name and pronouns, will it really be so easy to change back? Children who socially transition at a young age may have little experience living as their natal gender. How easy will it be for them to desist?

At least some of the time, each step taken toward transition creates pressure to continue. Numerous blog posts from detransitioners explore how transition made dysphoria worse, often because the young person became increasingly preoccupied with passing. This further discomfort created pressure to take more steps toward transition in order to present more convincingly as the opposite sex. To take just one example, breast binding may bring relief to some natal females who experience discomfort with their breasts, but binding in itself can be quite painful, restricting breathing and movement—thus creating an incentive to take the next step—“top surgery”/double mastectomy. I have heard one mother of a FtM young person stating that this natal female “got his lungs back” after getting a double mastectomy because he no longer needed to bind. Additionally, anecdotal evidence indicates that it is not uncommon for teens who socially transition to move on to hormones and/or surgery shortly after their 18th birthday. So it’s clear that social transition must be viewed as a treatment that carries with it a significant risk of progressing to medical transition.

Medical transition refers to a number of interventions undertaken to alter one’s body. These can include administration of hormone blockers to children and teens; administration of cross sex hormones; mastectomy; phalloplasty; hysterectomy; body masculinization; orchiectomy; vaginoplasty; facial feminization surgery; and others. All of these procedures can have permanent effects, and most of them carry significant risks. It is unusual (though not unheard of) for minors to have these surgeries. However, it is not uncommon for minors to take hormone blockers and cross sex hormones. And in 100% of the cases reported in the literature, children on puberty blockers went on to cross sex hormones. Top gender clinician Johanna Olson reports that no puberty-blocked children at her clinic in LA Children’s Hospital have ever failed to continue hormone treatment. Therefore, the claim that blockers are “100% reversible” is not accurate in practice. In fact, being on blockers appears to consolidate an investment in a cross sex identification. And although one rarely sees this “side effect” reported in the mainstream media, because gametes do not develop when an adolescent does not undergo natal puberty, hormone blockers followed by cross sex hormones results in permanent, life-long sterility 100% of the time.

Hormone blockers and cross sex hormones are being used off label (that is, they are not FDA-approved for this purpose). We have almost no knowledge about the long-term effects of taking these drugs over the course of decades, as anyone beginning transition as a young person will likely do. According to Madeline Deutsch, clinical director at University of California, San Francisco’s Center of Excellence for Transgender Health, “it scientifically makes sense that if someone is on hormones for decades, it’s highly likely that they’re going to be at higher risk [for certain health issues] than someone who started taking hormones at age 40 or 50.” Even the top pediatric gender doctors admit that there’s a dearth of good data on the long-term health outcomes of transition.

Certainly, there are risks. Cross sex hormones change bodies fairly quickly. Some of these changes are irreversible, such as a deepened voice, facial hair, and baldness for testosterone, and breast growth and, potentially, infertility for estrogen. In addition, use of cross-sex hormones carries with it potential negative side effects. Girls who take testosterone will be at increased risk for developing diabetes, cancer of the endometrium, liver damage, breast cancer, heart attack, and stroke. There may be other adverse effects of which we are not aware at this time, since long-term testosterone use in natal females is a relatively new phenomenon that has not been adequately studied.

I fear that there are young people transitioning – with the ready help of therapists, doctors, and others – who may regret these interventions and need to come to terms with permanent and in some cases drastic changes to their bodies. In fact, I know this is already happening. I have had considerable contact with the growing community of detransitioners. In many cases, the hatred for and disconnection from their bodies that these young people experienced was due to sexual trauma, internalized homophobia, or bullying. In videos and blogs, young women speak about their sadness over their lost voices and breasts. Male detransitioners mourn the loss of their testicles, the loss of their ability to orgasm, in some cases the loss of their fertility. Many have had complications from hormones such as vaginal atrophy, nerve damage, or chronic pain. You can hear some of these stories for yourself here, here, and here, among other places.

I have also spoken with many parents. Their stories are just as heartbreaking. These usually involve a teen who was anxious, depressed, socially isolated, or suffering from PTSD coming to identify as trans after internet binges on social media sites. These parents report that mental health professionals are validating the self-diagnosis of transgender after a handful of therapy sessions, without any exploration of prior mental health issues, trauma, sexual orientation, or history of gender nonconforming behavior. This clearly violates APA recommendations, which urge special caution in treating adolescents who present with sudden onset dysphoria.

All of this comes down to an essential question: When treating someone with gender dysphoria, do we do so using a mental health model, or an identity model?

An identity model is founded on the belief that we ought to be able to define our own experiences for ourselves. It proclaims that each of us has a right to assign our own meaning to our lives, our feelings, and our bodies. We get to decide who we are, and no one has authority over our self-perception. An identity model offers respect and self-determination for every person to define themselves as they would like.

An identity model has a place in psychotherapy. As people, we all self-identify aspects of our personality, values, and experiences in ways that are often very important to us. We might identify as Catholic, or as a Democrat. We might identify as an artist, an introvert, or a lesbian. As therapists, accepting and affirming our clients’ self-identification is important and empowering. As therapists, we can accept and empathize with a client’s story about his or her life experience. We can hold this story as valuable and important whether or not we objectively agree with it. As long as the client’s story does not lead to maladaptive behaviors, we do not need to challenge or attempt to discredit or disprove such a self-identification.

However, an identity model of working with transgender people goes further. An identity model stipulates that it is wrong to explore or question a client’s self-determined identity. Gender dysphoria is seen as evidence that someone is transgender, and merely wondering about underlying psychological reasons for dysphoria or alternative explanations for symptoms is seen as synonymous with denying a person’s identity. Applying our own clinical judgment to someone’s proclaimed self-diagnosis is seen as bigoted and wrong. Our role as therapists becomes limited to enthusiastic affirmation only.

In contrast, when we are working in a mental health model, we understand that clients come to us with symptoms that cause distress, and may interfere with a person’s day-to-day functioning. As therapists, we ought to be interested both in helping to alleviate or manage symptoms, as well as helping to understand the underlying cause of the symptom. If we are psychodynamically oriented, a basic assumption of our work is that every symptom has a meaning beyond its superficial presentation, and a major part of our work is to help our clients gain insight about this meaning.

In opposition to an identity model, then, the main task in mental health therapy with a client experiencing gender dysphoria would be to deeply explore the symptoms without making assumptions about what the symptoms mean. In fact, while identity therapy knows what gender dysphoria means – i.e. that the client is trans – mental health therapy will start with the assumption that we have no idea what the symptom means. We must be open to the meaning that emerges for patients as we explore their experience with them.

Seeking to understand deeply the nature, quality, and etiology of the dysphoria is not at all the same thing as denying the reality or importance of the symptom. When I explore a client’s anxiety – when did it start? What tends to trigger it? How does it feel? – I am not implying that I do not feel that the anxiety is unimportant or illusory. As we come to understand more about a client’s unique experience of a symptom, we may unwrap the meaning behind the suffering so that the problem resolves in a surprising, unexpected way. Or we may simply gain better information about the best course of treatment to alleviate the symptom for that particular person.

An identity model is not an appropriate basis on which to prescribe drastic, permanent medical intervention.

An identity model does not leave room for a therapist to exercise his or her clinical judgment. It disallows the possibility of a thorough assessment and differential diagnosis. According to the identity model, a client’s self-diagnosis is not to be questioned or explored. Therefore, alternative causes of dysphoria cannot be sought. As with many other mental health issues, the symptoms of gender dysphoria can be caused by many different things. Feeling uncomfortable with or disconnected from one’s body can go along with being on the autism spectrum; having experienced trauma; having bipolar disorder; having an eating disorder; or experiencing internalized homophobia. And sadly, it is a normal experience for teen girls, 90% of whom express dissatisfaction with their bodies.

An identity model subverts the normal diagnostic paradigm in which a patient presents with symptoms, and the clinician makes a diagnosis. In an identity model, the diagnosis is the identity. This occludes the focus on symptom resolution and management because the priority becomes affirming the identity. When symptoms are seen as validation of an identity, clinical judgment becomes irrelevant.

Before determining that a young person ought to undergo drastic treatments that may permanently alter their bodies and lead to permanent sterilization, a thorough assessment should be conducted that explores all potential factors contributing to the dysphoria. Unfortunately, because exploration of gender dysphoria is construed by some to be tantamount to “conversion therapy,” this kind of extensive assessment is frequently not performed. Though data is sparse, I personally have had contact with dozens of young people and/or their families who received a transgender diagnosis and a prescription for hormones after one to three appointments with a therapist.  According to this survey of more than 200 detransitioned women, 65% of those who transitioned received no therapy at all, either because they were referred for treatment at their first visit, transitioned through an informed consent clinic, or bought hormones through unofficial sources. (The median age for beginning transition in this survey was 17.) Only 6% of respondents felt they had received adequate counseling about transition. In fact, according to the ideology of gender identity, thorough assessment is seen as inappropriate “gatekeeping.”

An identity model does not allow us to rule out cases of transgenderism where social contagion might be at play. It appears quite likely that the striking increase in trans-identifying teens in recent years is due at least in part to social contagion. There has been a sudden sharp rise in the number of children and teens presenting at gender clinics. The first transgender youth clinic opened in Boston in 2007. Since then, 40 other clinics that cater exclusively to children have opened. Inexplicably, the ratio of natal males to natal females has flipped sharply, with many more natal female teens now presenting. Many of these young people have been presenting with dysphoria “out of the blue” as teens or tweens after extensive social media use without ever having expressed any gender variance before. This now-common presentation was virtually unheard of even a handful of years ago. Thousands of home-made videos on sites such as YouTube chronicle the gender transitions of teenagers. These teens show off their new-found muscles or facial hair. The Tumblr blog Fuck Yeah FTMs  features photo after photo of young FtMs celebrating the changes wrought by testosterone. “I finally have freedom!” posters boast under photographs of their scarred chests post mastectomy. “I’m no longer pre-T!” boasts another under a video of someone injecting testosterone. Almost all of these posters are under 25 years of age. According to Jen Jack Gieseking, a New York academic and researcher who was interviewed by BBC Radio 4 last May, “There really isn’t a trans person I’ve met under the age of 30 who hasn’t been on Tumblr.” There are multiple credible online reports of whole friend groups coming out together as trans.

But correlation isn’t causation. As this brilliant blog post explores, the contagion factor only speaks to the particular way that young people choose to deal with distress. It isn’t that the internet is “causing” the rise in transgenderism. It’s that many young people – particularly young females – are feeling alienated from their bodies due to trauma, porn culture, societal standards of beauty, oppressive gender roles, sexism, homophobia, and so forth. Self-diagnosing as transgender becomes an attractive way to deal with the alienation because it is so validated and even lionized in the culture and the mainstream media. For therapists, an identity therapy model does not allow us to acknowledge the role of social contagion, though contagion has been well-documented in contributing to suicide clusters and other behaviors.

An identity therapy model encourages us not to put safeguards in place to prevent young people from undertaking treatments they may later regret. According to an identity model, self-diagnosis as trans should never be questioned. To do so implies a lack of support and even bigotry. Therefore, the clinician must not stand in the way of transition to the person’s “authentic self.” Because of this, an increasing number of minors are going on hormones and even undergoing surgery that will permanently alter their bodies. Even 18 is probably too young to make such major medical decisions. In cases where the 18-year-old is making medical decisions based on a social transition that she or he began years earlier, it is possibly even more likely that that young person has not carefully considered the consequence of transition. Top gender doctors are hoping to see the recommended age for “bottom surgery” lowered.

In sharp contrast, it’s not easy for non-trans patients to be sterilized before adulthood. For instance, in Massachusetts, a patient must be at least 21 years of age to qualify for sterilizing surgeries under the state’s public health scheme. When such a surgery is undertaken, patients are carefully counseled and must sign a form stating that they understand the permanent nature of the procedure, and that they do not wish to bear or father children. Patients must then wait a minimum of 30 days after signing the form before having the surgery. This procedure has been put in place because surgical sterilization has been shown to come with a high incidence of regret. Why are there not similar safeguards in place for those transgender identifying young people wishing to amputate healthy organs and/or sterilize themselves?

There is a wealth of research about cognitive and emotional development in adolescence. The upshot of it is that teens and young adults are more likely to act impulsively, are unable to assess risks well, and are more emotionally reactive. It is partly for these reasons that we do not allow teens to drink, get tattoos, or use tanning beds without adult consent.

An identity model does not allow us to examine the homophobia that drives some – possibly many — transitions. According to extensive research on desistance, a significant majority of children who identify as the opposite sex will not continue to do so into adulthood. The majority of those who desist will come to identify as lesbian or gay. “Feminine” boys are actually many times more likely to grow up to be gay men rather than transgender women. The same is true for “masculine” girls. Many lesbian bloggers (such as this one and and this one) are very concerned that the current trend to transition young people is disproportionately hurting lesbians and gays, and their fears appear to be well founded. This conservative Christian Texas mother was bothered by her son’s “flamboyant, feminine” behavior. Rather than accepting her son’s gender-defiant presentation, she has decided he is transgender. She now has a very pretty, gender conforming “daughter.”

There is widespread concern in the lesbian community that many young would-be lesbian or bisexual women are finding it easier to become “straight men” due to internalized homophobia. In this article, fourteen-year-old Mason describes how he knew he was transgender. “I’ve always known something was up about how I felt about myself,” says Mason, who as Madelyn had refused to wear pink, or to dress in stereotypically feminine attire. “I thought I was gay or bisexual or something.” In years past, Madelyn most likely would have grown up to be a lesbian or bisexual woman. To paraphrase psychiatrist Ray Blanchard, surely it’s preferable to have an outcome of a reasonably well adjusted lesbian woman, rather than someone who identifies as a trans man who has had many irreversible surgeries and a lifetime of drugs.

An identity model makes us unable to tease out other mental health concerns that may be impacting the desire to transition. There is considerable research that points to a high likelihood of co-occurring disorders in young people who wish to transition. For example, this study from 2015 noted that “severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.” In this study, 68% of the population had first had contact with psychiatric service for reasons other than gender dysphoria. Thirteen percent were being treated for psychotic symptoms.

This study from 2004 found high rates of “comorbidity” in those with gender dysphoria, and noted that this was often not taken into consideration when treatment planning for these patients. “Results: Twenty-nine percent of the patients had no current or lifetime Axis I disorder; 39% fulfilled the criteria for current and 71% for current and/or lifetime Axis I diagnosis. Forty-two percent of the patients were diagnosed with one or more personality disorders. Conclusions: Lifetime psychiatric comorbidity in GID patients is high, and this should be taken into account in the assessment and treatment planning of GID patients.”

This 2015 study found a link between gender dysphoria and dissociative symptoms secondary to trauma. According to this blogger, trauma and dissociation were a big part of her desire to transition. This was also true for this blogger here. Similar stories from detransitioners with histories of unaddressed trauma abound.

An identity model does not allow us to take into account reports from parents or previous therapists who may not agree with the patient’s self-diagnosis. I have received dozens of distraught emails from parents trying in vain to get gender therapists to listen to them when they share information about their child’s mental health history that ought to be taken into consideration while assessing and treating gender dysphoria. While I cannot share the contents of these emails without violating people’s privacy, I can point to quite a few places online where frustrated parents have shared similar stories. For example, this social work professor states that the gender therapist did not review her daughter’s special education records or speak with the previous therapist before recommending hormones and surgery for this young autistic teen.

Parents I have had contact with have told me about their child having a history of anxiety, panic attacks, depression, trauma, loss, bipolar disorder, anorexia, cutting, borderline personality disorder, and psychosis. In these cases, as soon as the young person brought up their transgender self-diagnosis, the focus of the therapy shifted to this alone. The parents’ fears, concerns, and information about past treatments were disregarded as obstructionist and transphobic. I am not alleging that this is happening in every case. However, it certainly is happening with some degree of regularity.

An identity model does not allow us to question the incoherence of gender identity ideology. While gender dysphoria appears to be a meaningful diagnostic term that describes a set of symptoms – namely intense discomfort with one’s sexed body – it does not follow from this that one is “trapped in the wrong body,” has a “female” or “male” brain, or even a “gender identity” that doesn’t match one’s body. Though the concept of gender identity is currently being enshrined into law, the truth is that we have no meaningful definition of the term. (For an excellent analysis of the incoherence of the term, take a look at Rebecca Reilly Cooper’s work.) When a trans-identified person is asked how they know they are transgender, they are usually unable to answer the questions without reference to sex role stereotypes. For example, a physician who prescribed cross sex hormones to a 12-year-old natal female stated that the child had “never worn a dress.” This was offered as evidence of the child’s being “truly trans,” and therefore needing these hormones. I would strenuously argue that one’s clothing preferences should not be a reason to permanently sterilize a child.

It doesn’t make sense to say that one’s sex organs don’t matter, but then assert a primary, essential difference based on a sexed brain. Sexed brains do not exist. It is absurd to posit that one’s chromosomal sex, genitals, and entire reproductive system are meaningless and irrelevant or a social construct, and then assert that a subjective feeling of being the opposite gender is determinative. There is no robust science behind the notion of gender identity. Journalists have been quick to report on studies that seem to prove brain differences among those who are transgender. However, as the sexology researcher James Cantor has pointed out, these studies actually seem to be documenting brain differences among those who are homosexual.

If you want to see a review of some of the literature out there in support of a biological basis for gender dysphoria, this blog post does a good job. There are some solid studies that seem to indicate that genetics or pre-natal hormone exposure may play some role in the development of gender dysphoria. That isn’t really surprising. Pretty much every diagnosis in the DSM – from depression, to anorexia, to borderline personality disorder – has some genetic component. Gender dysphoria is real. As with other mental health diagnoses, its causes are likely complex and involve genetic, biological, environmental, and psychological factors. But it doesn’t follow from any of this that the sufferer has an inborn “gender identity” that ought to supersede any consideration of one’s objective biological sex. Body dysmorphic disorder is associated with brain differences and appears to have a genetic component, and yet the biological component of the condition does not dictate that we understand the patient’s suffering to reflect objective reality.

Transgender activists assert that “gender is between the ears, not between the legs.” However, this is an ideological, faith-based statement that cannot be scientifically validated. What is “between our ears” — meaning our inner experience of ourselves as a gendered person — is purely subjective. Within this context, asserting that one is transgender is an unfalsifiable statement of belief. In reality, feeling like the other sex does not in any way mean that you are the other sex. Identity is an important aspect of one’s experience. We get to define ourselves subjectively, and I would argue that full-fledged adults ought to be able to modify their bodies in accordance with their sense of themselves. However, subjective identity should not dictate a necessity for medical treatment of any kind, especially body-altering treatments with highly significant side effect profiles for minors or young people

An identity model does not allow us to consider treatment outcomes critically. The research on outcomes post transition is mixed at best. It is well-known that one study showed that 41% of transgender people had experienced suicidal ideation or self harm. It is less well-known that the study gives no indication whether the attempt was before or after receiving transition care. Several large studies show astonishingly high rates of suicide among transgender people who have medically transitioned (see here and here). It has been argued that suicide rates continue to be high after transition due to societal prejudice. While this likely is true some of the time, post-transition transsexuals are more likely to “pass” as the target gender, and therefore ought to be less subject to discrimination. Given the undeniably high rates of suicide in post-transition transsexuals, it is disingenuous to claim that transition is a panacea that will prevent suicide.

While this study showed positive outcomes for early transition, there were only 55 subjects included. Perhaps more importantly, they were last assessed at one-year post sex reassignment surgery. In the survey of detransitioned women, the average length of transition was four years. It seems possible that some of the 55 individuals followed in the first study might go on to have regrets if they were followed for longer. Worryingly, one of the 70 individuals invited to participate in the study was unable to do so because the person died as a result of postsurgical necrotizing fasciitis after undergoing vaginoplasty.

While the media is full of stories of young people becoming happier and more confident after being allowed to transition, there is some evidence that this is not always the case. In addition to the research that documents high suicide rates post transition, I am aware of anecdotal evidence of continued or even increased anxiety and depression, social isolation, psychiatric hospitalization, and poor academic outcomes for those who have transitioned.

An identity model does not allow us to explore other options for dealing with dysphoria. Transition – social and medical — is currently the only treatment commonly prescribed for gender dysphoria. If what we are treating is an acute discomfort with one’s body, it would seem reasonable to offer a range of different treatments before prescribing transition, including anti-depressants, talk therapy, and emotion-regulation skills to help patients manage their distress. However, none of these treatments is routinely prescribed for gender dysphoria. In the survey of 200 detransitioned women, some significant percentage of them stated that they found alternative ways of dealing with dysphoria other than transition. Detransitioner and therapist in training Carey Callahan offers several specific techniques that she has found helpful on her blog. Clinicians and researchers ought to be mining these experiences to find other effective treatments for dysphoria in addition to transition.

whitman-quote-2

An identity model makes some questionable assumptions about the nature of identity and our ability to know ourselves. An identity model is predicated on the notion that identity is immutable, essential, and knowable. This is not my experience of human nature. Identities are useful for approximating something about ourselves. They are constructs that allow us to talk about our experience. But they are not absolute truths, and they rarely say something about our most essential, mysterious, and ultimately unknowable essence. To quote Whitman, “do I contradict myself? Very well, then, I contradict myself. I am large. I contain multitudes.” I have had the good fortune to contradict myself many times in my life – contradict myself on things that at one time felt utterly essential and absolutely true. I believe this is a universal human experience, and yet another reason why making permanent changes to one’s body at a young age ought to be approached with extreme caution.

An identity model makes it impossible for us to acknowledge or discuss the varied reasons why a person might want to transition. The desire to transition likely has many varied causes. Seeing all transitions as an expression of innate gender identity obscures the very real differences between one person’s situation and another, making it impossible to assess and treat people in an individualized way. A late transitioning MtT autogynephile has an experience of gender dysphoria that is vastly different than that of a fifteen-year old lesbian, and the former’s experience ought not in any way to dictate how we understand or treat the latter.

An identity model creates a false dichotomy between affirmation and bigotry. According to the current narrative, the only supportive response to a teen who has self-identified as transgender is to affirm this identity and begin transition immediately. Any other response is quickly labeled transphobic. In reality, there is a huge range between assisting a child in transitioning immediately and affirming that they are and in fact always have been the opposite sex, and denigrating or shaming them for their desire to transition or coercively trying to get them to conform to rigid gender expectations. Parents can communicate their unconditional love and support. Parents can offer solace and warmth as the child struggles with distressing feelings. Parents can seek legitimate psychotherapeutic help to offer space for the young person to explore and understand the desire to transition. Teenagers often develop strong beliefs about what they must do or have, and it is well known that these beliefs and demands are not always sound or rational. Never before have parents of teens been told that they have to accede to the demands of their teenager or risk doing irreparable harm. Parents of teens have always had to step in and set loving limits on behavior that may not be in the young person’s long-term best interest. When dealing with a child who has diagnosed themselves as transgender, parents can do what parents of teenagers always do – set sensible limits and help a child to reflect on the potential consequences of his or her actions. Parents can assure the child of their ongoing love and acceptance if he or she does eventually decide, as a full-fledged adult, to transition.

An identity model offers an inferior kind of therapy to those who identify as transgender. As the blogger Third Way Trans has pointed out, “if someone is a member of a dominant class they receive regular psychotherapy but if they aren’t they receive a special kind of social justice therapy.” Those who come into treatment with gender dysphoria are not given the opportunity to explore deeply their experience, but instead have their self-diagnoses affirmed. There are people who will need to live as the opposite sex in order to have the happiest, fullest life possible. These individuals may need to consider taking hormones or having surgery. Surely these people deserve to have a place to explore these consequential decisions without prejudice in favor of a specific outcome so that a process of careful discernment can take place. If therapists are only cheerleaders for transition, how can someone in this situation get help to make the best decision?

I believe we should offer clients with gender dysphoria high quality mental health therapy. In a guest post on this blog, a woman who considered transitioning several times during her life shared a moment from her own therapy that proved important to her.

“When I started therapy in my early twenties, I revealed to my therapist that I had been raped at 18. It had been four years and I had never told anyone. In the process of uncovering that rape and telling her about it, I stated, during a session, that I wanted to become a man. She nodded, she said she understood, and that it was something we could explore, but in the meantime, we really needed to talk about the rape. I appreciated her approach. She wasn’t directive, judgmental, or reactive, she simply stated it was something to keep talking about, but encouraged me to focus on my experience of being raped and other traumas.”

In providing high quality mental health therapy to all patients, we would communicate unconditional positive regard to our gender dysphoric patients, just as we would with anyone else, and as the therapist in this blog post did. We would greet their announcement that they feel as though they may need to transition with acceptance and curiosity, communicating that we are willing to go there with them, to explore this desire in all of its intricacy, without prematurely coming to a fixed notion of what is right for our patient. We would see the person in front of us in all of their miraculous complexity, and not just as a “gender identity.”

As therapists, we have been trained in assessment. We have been trained to wonder about layers of meaning that may not be visible at first glance. We have been trained in how to recognize and work with trauma. We have been trained to help out clients explore their labyrinthine inner lives. When clients come to me wondering whether to end a relationship with a boyfriend or change careers, we typically spend months considering all of the different facets of such a decision. Don’t we owe at least as considered a process to someone contemplating making permanent changes to his or her body, especially when that person is a teen or young adult?