Suicide or transition: The only options for gender dysphoric kids?

by J. Michael Bailey, Ph.D  and Ray Blanchard, Ph.D

This is the first in a series of articles authored by Drs. Bailey and Blanchard. As their time permits, they will be available to interact in the comments section of this post. Please note: As always on 4thWaveNow, if you disagree with the content of this article, your comments will be more likely to be published if they are delivered respectfully. Hateful or trollish comments will be deleted.


Michael Bailey is Professor of Psychology at Northwestern University. His book The Man Who Would Be Queen provides a readable scientific account of two kinds of gender dysphoria among natal males, and is available as a free download here.

Ray Blanchard received his A.B. in psychology from the University of Pennsylvania in 1967 and his Ph.D. from the University of Illinois in 1973. He was the psychologist in the Adult Gender Identity Clinic of Toronto’s Centre for Addiction and Mental Health (CAMH) from 1980–1995 and the Head of CAMH’s Clinical Sexology Services from 1995–2010.


It is increasingly common for gender dysphoric adolescents and mental health professionals to claim that transition is necessary to prevent suicide. The tragic case of Leelah Alcorn is often cited as the rallying cry: “transition or else!” Leelah (originally Joshua) was a gender dysphoric natal male who committed suicide at age 17, blaming her parents for failing to support her gender transition and forcing her into Christian reparative therapy. Subsequently, various “Leelah’s Laws” banning “conversion therapy” for gender dysphoria (among other things) have been passed or are being considered across the United States.

The suicide of one’s child is every parent’s nightmare. Given the choice for our child between gender transition and suicide, we would certainly choose transition. But the best scientific evidence suggests that gender transition is not necessary to prevent suicide.

We provide a more detailed essay below, but here’s the bottom line:

  1. Children (most commonly, adolescents) who threaten to commit suicide rarely do so, although they are more likely to kill themselves than children who do not threaten suicide.
  2. Mental health problems, including suicide, are associated with some forms of gender dysphoria. But suicide is rare even among gender dysphoric persons.
  3. There is no persuasive evidence that gender transition reduces gender dysphoric children’s likelihood of killing themselves.
  4. The idea that mental health problems–including suicidality–are caused by gender dysphoria rather than the other way around (i.e., mental health and personality issues cause a vulnerability to experience gender dysphoria) is currently popular and politically correct. It is, however, unproven and as likely to be false as true.

Suicide vs Suicidality vs Non-suicidal Self-injury

Suicide is a rare event. In the United States in 2014, about 13 out of every 100,000 persons committed suicide. Suicide was most common among middle aged white males, who accounted for about 7 out of 10 known suicides.

It is helpful to distinguish at least four different things: Completed suicide means death by suicide. Suicidality means either thinking about committing suicide or attempting suicide. Non-suicidal self-injury means injuring oneself (most often by cutting one’s skin) without intending to die. Finally, mental illness includes a variety of conditions, from depression to conduct disorder to personality disorders (such as borderline personality disorder) to schizophrenia–some of which are especially strongly associated with completed suicide and suicidality, others of which are more strongly associated with non-suicidal self-injury.

Obviously, completed suicide is what we are most worried about. Because it is so rare, however, and because it is often difficult to know about the dead person’s motivations for suicide, it has been especially difficult to study. There are fewer studies focusing on gender dysphoria and completed suicide than on gender dysphoria and either suicidality or non-suicidal self-injury. Studies of suicidality must rely on self-report (for example, someone must report that they are, or have been, thinking about committing suicide), and this complicates interpretations of results. (Maybe some people, some times, are especially likely to say they have been suicidal, even if they haven’t been.) Also there is more than one kind of gender dysphoria–we think there are three (this is a topic for another day)–and we should not expect risks to be identical for all types.

The Scientific Literature

Our aim here is not to review every available study, but to focus on the best evidence. Larger, more representative studies–and most importantly, studies of completed suicide–are most informative.

Studies of Completed Suicides

 Two large systematic studies of completed suicide and gender dysphoria have been published, one from the Netherlands, the other from Sweden. Notably, both countries are socially liberal, and both studies were conducted fairly recently (1997 and 2011). Both studies focused on patients who had been treated medically at national gender clinics. These patients all either began or completed medical gender transition, and we refer to them as “transsexuals.” (We don’t know how many of the patients there were from each of the three types we believe exist.)

The Dutch study’s suicide data were of male-to-female transsexuals (natal males transitioned to females) treated with cross-sex hormones (and many also with surgery). Of 816 male-to-female transsexuals, 13 (1.6%) completed suicide. This was 9 times higher than expected. Still, suicide was rare in the sample. The Swedish study found an even larger increase in the rate of suicide, 19 times higher among the transsexuals than among a non-transsexual control group. Still, only 10 out of 324 transsexuals (i.e., 3.1% of the group) committed suicide. Again, still rare. Note that both studies were of gender dysphoric persons who transitioned. As such, their results hardly support the curative effects of transition.

The Dutch and Swedish studies were of adults whose gender dysphoria may or may not have begun in childhood. No published study has focused only on childhood onset cases. However, psychologist Kenneth Zucker has tracked the outcome of more than 150 childhood onset cases treated at the Centre for Addiction and Mental Health into adolescence and young adulthood. He has generously shared with us (in a personal communication) his outcome data for suicide. Out of those more than 150 cases followed, only one had committed suicide. Furthermore, Dr. Zucker’s understanding (based on parent report) is that this suicide was not due to gender dysphoria, but rather to an unrelated psychiatric illness. On the one hand, one suicide out of 150 cases is more than we’d expect by chance. On the other hand, it is a rare outcome among gender dysphoric children and adults.

Studies of Suicidality and Non-suicidal Self-injury

People who commit suicide were suicidal before they did so. But most people who are suicidal do not commit suicide. “Suicidal” is necessarily a vague word, encompassing “intends to commit suicide” and “thinks about suicide,” both in a wide range of intensity. Furthermore, most studies would include as “suicidal” someone who falsely reports a past or present intention to commit suicide.

Why would anyone falsely report being suicidal? One reason is to influence the behavior of others. Saying that one is suicidal usually gets attention–sympathy, for example. It can be a way of impressing others with the seriousness of one’s feelings or needs. Although this possibility has not been directly studied, reporting suicidality may sometimes be a strategy for advancing a social cause.

According to data from the Centers for Disease Control (CDC), the rates of intentional but non-fatal self-injury peak during adolescence at about 450 per 100,000 girls and a bit fewer than 250 per 100,000 boys. These rates are much higher than the 13 per 100,000 American completed suicides per year (and remember that suicide is more common among adults than adolescents). So it is reasonable to assume that most adolescent self-injury is not intended to end one’s life. We are not suggesting that parents ignore children’s self-injury. We simply mean that self-injury often has motives besides genuinely suicidal intent.

 Not surprisingly, given the increased rates of suicide among gender dysphoric adults, suicidality (i.e., self-reported suicidal thoughts and past “suicide attempts”) is also higher among the transgendered. One recent survey statistically analyzed by the Williams Institute reported that 41% of transgender adults had ever made a suicide attempt, compared with a rate of 4.6% for controls. This survey recruited respondents using convenience sampling, however, and this may have inflated the rate of suicidal reports. Additionally, the authors of the survey included the following (admirable) disclaimer):

Data from the U.S. population at large, however, show clear demographic differences between suicide attempters and those who die by suicide. While almost 80 percent of all suicide deaths occur among males, about 75 percent of suicide attempts are made by females. Adolescents, who overall have a relatively low suicide rate of about 7 per 100,000 people, account for a substantial proportion of suicide attempts, making perhaps 100 or more attempts for every suicide death. By contrast, the elderly have a much higher suicide rate of about 15 per 100,000, but make only four attempts for every completed suicide. Although making a suicide attempt generally increases the risk of subsequent suicidal behavior, six separate studies that have followed suicide attempters for periods of five to 37 years found death by suicide to occur in 7 to 13 percent of the samples (Tidemalm et al., 2008). We do not know whether these general population patterns hold true for transgender people but in the absence of supporting data, we should be especially careful not to extrapolate findings about suicide attempts among transgender adults to imply conclusions about completed suicide in this population.

That is, importantly, the authors realize that suicidality and completed suicide are very different things, and it is suicidality that they have studied. Completed suicides in their group will be much, much lower.

Increased suicidality for gender dysphoric children was also reported by parents in a recent study by Kenneth Zucker’s research group.

A systematic review of non-suicidal self-injurious behavior in “trans people” found a higher rate, especially for trans men (i.e., natal females who have transitioned to males). The most common method mentioned was self-cutting. (Self-cutting is a common symptom of borderline personality disorder, which is also far more common among non-transgender natal females than among natal males.)

Is Transition the Answer, After All?

In a very recent study psychologist Kristina Olson reported that parents who supported their gender dysphoric children’s social transition rated them just as mentally healthy as their non-gender-dysphoric siblings. Furthermore, parents’ reports suggested that the socially transitioned gender dysphoric children were not less mentally healthy than a random sample would be expected to be.

This research falls far short of negating or explaining the findings we have reviewed above. First, it was relatively small, including only 73 gender dysphoric children. Second, families were recruited via convenience sampling, increasing the likelihood of various selection biases. For example, it is possible that especially mentally healthy families volunteer for this kind of research. Third, the assessment was a brief snapshot; we would expect socially transitioned gender dysphoric children to be faring better at that snapshot compared with children struggling with their gender dysphoria. (There is little doubt that at first, gender dysphoric children are happier if allowed to socially transition.) Young gender dysphoric children do not show that many psychological or behavior problems, aside from their gender issues. The aforementioned study by Kenneth Zucker’s research group showed that mental health problems, including suicidality, increased with age. Perhaps this won’t happen with Olson’s participants, but it’s too soon to know.

Why Is Gender Dysphoria Associated with Mental Problems, Including Suicidality?

 We don’t know.

The current conventional wisdom is that gender dysphoria creates a need for gender transition that, if frustrated, causes all the problems. That is a convenient position for pro-transition clinicians and activists. But they simply don’t know that this is true. Furthermore, both our past experience studying mental illness scientifically and specific findings related to gender dysphoria suggests the conventional wisdom is unlikely to be correct.

As an example, Leelah Alcorn’s suicide (like most suicides) was tragic, but she appears to have had problems that were not obviously caused by her gender dysphoria. She posted as Joshua (her male identity) on Tumblr:

“I’m literally such a bitch. shit happens in my life that isn’t even really that bad and all I do is complain about it to everyone around me and threaten to commit suicide and make them feel sorry for me, then they view me as sub-human and someone they have to take care of like a child. then when they don’t meet my each and every single expectation I lash out at them and make them feel like shit and like they weren’t good enough to take care of me. since I can only find imperfections in myself I try my hardest to find imperfections in everyone around me and use them as a way to one up myself and make others feel bad to make myself look better.”

Sophisticated causal analysis of mental illness and life experiences has invariably shown that things are more complex than previously assumed. For example, although depression is certainly caused by adverse life experiences, those vulnerable to depression have a tendency to generate their own stressful life experiences. So it’s not as simple as depression being caused by life experiences alone. Also, depression has a considerable genetic influence. Similarly, women with borderline personality disorder (BPD) report that they have experienced disproportionate childhood sexual abuse (CSA), and many clinicians and researchers have assumed that CSA causes BPD. But one just can’t assume the causal direction goes that way–one must eliminate alternative possibilities. Recent sophisticated studies suggest that, in fact, CSA does not cause BPD.

Research to understand the link between gender dysphoria, various mental problems (including suicidality), and completed suicides will take time. There is already plenty of reason, however, to doubt the conventional wisdom that all the trouble is caused by delaying gender transition of gender dysphoric persons. We have already mentioned the fact that transitioned adults who had been gender dysphoric (i.e., “transsexuals”) have increased rates of completed suicide. Their transition did not prevent this, evidently. Suicide (and threats to commit suicide) can be socially contagious. Thus, social contagion may play an important role in both suicidality and gender dysphoria itself. Autism is a risk factor for both gender dysphoria and suicidality. No one, to our knowledge, believes that gender dysphoria causes autism.

Conclusions

Parents with gender dysphoric children almost always want the best for them, but many of these parents do not immediately conclude that instant gender transition is the best solution. It serves these parents poorly to exaggerate the likelihood of their children’s suicide, or to assert that suicide or suicidality would be the parents’ fault.


References

Aitken, M., VanderLaan, D. P., Wasserman, L., Stojanovski, S., & Zucker, K. J. (2016). Self-harm and suicidality in children referred for gender dysphoria. Journal of the American Academy of Child & Adolescent Psychiatry55(6), 513-520.

Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one6(2), e16885.

Marshall, E., Claes, L., Bouman, W. P., Witcomb, G. L., & Arcelus, J. (2016). Non-suicidal self-injury and suicidality in trans people: a systematic review of the literature. International review of psychiatry28(1), 58-69.

Nock, M. K., Borges, G., Bromet, E. J., Cha, C. B., Kessler, R. C., & Lee, S. (2008). Suicide and suicidal behavior. Epidemiologic reviews30(1), 133-154.

Van Kesteren, P. J., Asscheman, H., Megens, J. A., & Gooren, L. J. (1997). Mortality and morbidity in transsexual subjects treated with cross‐sex hormones. Clinical endocrinology47(3), 337-343.

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Could social transition increase persistence rates in “trans” kids?

The trend of “socially transitioning” children as young as 2 or 3 years old to endorse the notion they are “born in the wrong body” is a very new phenomenon. But to read about it in the press, you’d think this was a settled area of clinical practice, with proven results and few doubts about its efficacy.

It is no such thing.

In a 2011 journal article,  Dutch clinician-researchers who first pioneered the use of puberty blockers cautioned that early social transitions can be difficult to reverse:

 As for the clinical management in children before the age of 10, we suggest a cautious attitude towards the moment of transitioning. Given our findings that some girls, who were almost (but not even entirely) living as boys in their childhood years, experienced great trouble when they wanted to return to the female gender role, we believe that parents and caregivers should fully realize the unpredictability of their child’s psychosexual outcome. They may help the child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse.

Even the Endocrine Society, which actively promotes puberty blockers and cross-sex hormones for pubescent children, counseled against social transition in its practice guideline:

endocrine-society

As recently as last year, a 17-clinic qualitative study reported on doubts some clinicans have about aspects of “affirmative” treatments for children:

As long as debate remains … and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.

But among many clinicians and activists, social transition (which usually leads to puberty blocking and then to cross sex hormones) is now being actively promoted as completely harmless and “fully reversible.” Not only that: it is being shamelessly peddled as the only way to prevent suicide amongst children and teenagers.

What evidence do we have for these assertions? There is no historical record of desperately dysphoric “trans children” who demanded sex change lest they commit suicide.  The constant media and activist drumbeat that very young children must be socially transitioned ASAP; must be called by the correct pronouns; must have their “wrong bodies” fixed prior to the “wrong puberty”– or they will kill themselves–is the most irresponsible thing the mass media and medical profession could possibly do. It is a form of emotional blackmail which has terrorized countless parents into handing their kids over to gender clinics and activist-run “charities” for transition to the opposite sex. And the media, by running breathless stories implying that the only way to support gender-defiant and gender dysphoric children is to  “transition” them, may be contributing to suicide contagion, a phenomenon that has been well known for decades.

As far as evidence that social transition is “reversible,” which of these children is actually “reversing”? Certainly, the ones who have continued on to puberty blockers are not:

spack-100-persist

Imagine the pressures on any of the myriad trans-kid YouTube stars, or the children who are the subjects of the too-many-to-count fawning media portrayals we see in every major newspaper and magazine. Can a Jazz Jennings really change course?

None of the children who have been identified as “truly transgender” by clinicians like Norman Spack and Johanna Olson are going to get the chance to find out if they would have been just as happy not being socially transitioned. We won’t learn in any systematic way whether social transition and media validation could be creating persistence in children who might otherwise have grown up without medical and psychiatric tampering.  We can’t know, because researchers aren’t studying them; they don’t have control groups of children who claim to be the opposite sex but who are not socially transitioned and subsequently puberty blocked.

What is a truly transgender child? According to activists and some clinicians, the key trait (along with being generally “gender nonconforming” and preferring the clothes, activities, and appearance more typical of the opposite sex) is that these children are more “persistent, consistent, and insistent” in saying they are the opposite sex (vs simply wanting to be, or wishing they were).

But what is the meaning of “persistent, consistent, and insistent” with children who have only been on the planet a short time, as are the many toddlers, preschoolers, and grade schoolers now being labeled as “trans kids”?  Especially when a rather large percentage of these children also exhibit traits of autism—a disorder known to be characterized by rigid thinking, gender nonconformity, and obsessive/restricted patterns of behaviors?

Activists don’t seem troubled by any of this, nor by the decades of research showing most dysphoric children desist and grow up to be lesbian or gay adults.

korte

The recent study most often cited by trans activists is one by Kristina Olson at the University of Washington, which essentially proved that children who preferred the activities and appearance of the opposite sex weren’t just pretending; they  really meant what they said! (Why would anyone question that?)

But even Dr. Olson, whose confirmation-bias-riddled study includes no control group of non-socially transitioned children, admits that no one can know the outcome for this new generation of experimental patients. kristina-olson-does-not-know

These kids are, by any measure, guinea pigs being subjected to social engineering and then (in most cases) experimental medical procedures, the results of which won’t be known for decades. Researchers like Kristina Olson are fully aware of this, but they think it’s worth the cost of some regrets, some detransitions. Because hey–it’s science.

kristina-olson-admits-kids-are-guinea-pigs

A commenter on the above article aptly points out the elephant in the room:

comment-on-olson-article-persistence-caused-by-social-transition

Fortunately, there is reliable data from other clinician-researchers which suggest a more cautious approach is still in order. We have a 2012 study by Devita Singh, which demonstrated that a very high proportion of kids—some 88%–happily desisted from a trans identification as adults.  It’s worth noting that several of these children were “persistent, insistent and consistent” in their formerly intense gender dysphoria.

Dr. Singh shared her views about early transition in a recent, unusually balanced article in The Walrus magazine:

Singh is frustrated that, despite the findings of her study and others like it, there’s now more pressure than ever for doctors and families to affirm a young child’s stated gender. She doesn’t recommend immediate affirmation and instead suggests an approach that involves neither affirming nor denying, but starting with an exploration of how very young children are feeling. Affirmation, she argues, should be a last resort.

These days there can be a high price to pay for treating gender affirmation as a last resort. Dr. Ken Zucker, a  renowned gender dysphoria expert, has approved puberty blockers and cross-sex hormones for many adolescents. Nevertheless, he recognizes that children often change their minds, and takes a careful approach in his clinical practice. For this heresy, he was hounded from his position at CAMH in Toronto by trans activists hellbent on preventing any kind of therapy for dysphoric kids besides “affirmation.”

But Dr. Zucker is still actively publishing,  having co-authored several scholarly journal articles in 2016 alone, and he continues to work with families and young people in his private practice.

In an age when too many believe that children, no matter how young, should be affirmed in their gender identities with no further investigation, clinicians like Zucker are very much needed. Desistance, despite trans activist protestations to the contrary, is a real thing. It’s just not as newsworthy as the latest trans kindergartener coming out story.

This places a heavy burden on parents who aren’t sure who their children are, or who don’t accept the notion that a 5-year-old, even an insistent and strong-willed one, has a set identity in the same way adults do. The current politics leave them behind, because their stories don’t fit neatly into the binary in which trans identities are either accepted or rejected, full stop. There’s no natural political grouping for parents of desisters, because desisting isn’t an identity-politics lodestone in the way persisting is. “We’re quieter,” said Amanda of parents of kids whose gender dysphoria desists. “There are a bunch of us scattered around, and we’re not acting collectively.” As Merry put it, “I feel like sometimes there’s no middle ground. You’re either trans or you’re not, and you can’t be this kid who is just kind of exploring.”

 

The adolescent trans trend: 10 influences

The below post is written by Overwhelmed,  4thWaveNow contributor and the mother of a teen daughter who insisted she was transgender, but who subsequently changed her mind. Other parents in the same situation have shared their experiences on 4thWaveNow, and a new research study (currently recruiting) is the first to systematically examine the phenomenon of “trans trending” amongst tweens and teens.

Trans activists and gender specialists constantly assure us that puberty blockers are harmless and “fully reversible.” They claim these drugs “buy time” for a young person to decide if they really are trans. But given that social transition + puberty blockers are followed in 100% of reported cases by cross-sex hormones (see here and here),  the “buying time” assertion deserves a lot more scrutiny. If there weren’t other forces at work (like social contagion and the conditioning effect of being validated in the idea that you are “really” the opposite sex if you prefer the appearance and lifestyle of that sex), a 100% persistence rate in trans-identification simply wouldn’t be happening.

And when it comes to teens who experience onset of gender dysphoria in adolescence, parents like Overwhelmed, Penny White, and the founder of this website–who have personally observed their teens voluntarily desisting from a trans identity–are the ones who have actually bought time for their kids: precious time to realize that becoming a lifelong patient haunting the offices of endocrinologists and plastic surgeons is not the only way to live a gender-defiant life.


by Overwhelmed

Earlier this year, a Nature article reported on the May 2016 launch of a study aimed at documenting the psychological and medical impacts of delaying the puberty of trans youth:

 Funded by the US National Institutes of Health (NIH), the US $5.7-million project will be not only the largest-ever study of transgender youth, but also only the second to track the psychological effects of delaying puberty — and the first to track its medical impacts. It comes as the NIH and others have begun to spend heavily on research related to the health of transgender people, says Robert Garofalo, a paediatrician at Ann and Robert H. Lurie Children’s Hospital of Chicago, Illinois, and a leader of the study. “We seem to really be at a tipping point,” he adds.

Garofalo and his colleagues aim to recruit 280 adolescents who identify as transgender, and to follow them for at least five years. One group will receive puberty blockers at the beginning of adolescence, and another, older group will receive cross-sex hormones. Their findings could help clinicians to judge how best to help adolescents who are seeking a transition.

Despite the fact that puberty blockers–followed in nearly every case by cross-sex hormones–have been prescribed for many years for “trans kids,” this study will be the FIRST in the United States to track the impacts of medical transition on this population. It has become increasingly popular for gender doctors to start trans-identified children on puberty blockers. The rationale is to avoid the potential psychological distress and the physical development of secondary sex characteristics associated with the “wrong puberty.” Based on the constant onslaught of celebratory articles about “trans kids” in the media, the public is likely unaware that puberty blockers and cross-sex hormones are not approved by the FDA for this purpose. These drugs are being used off-label and the science isn’t settled by any means. Even the gender doctors confess there is no medical consensus.

I appreciate that the Nature piece is not just another one-sided article touting pro-transition dogma. Although the journalist failed to mention that children who pause their natal puberty, and then directly proceed to cross-sex hormones, have the not-so-insignificant consequence of permanent sterility, she did include viewpoints not often seen in the mainstream media:

 “But some scientists worry that putting off puberty in older children may disrupt bone and brain development, reducing bone density and leading to cognitive problems.”


 “Because most children who question their gender do not do so past adolescence, many psychologists discourage “socially transitioning” until the teenage years.”


The debate is so heated — and evidence so sparse — that the authors of the American Psychiatric Association’s 2013 Diagnostic and Statistical Manual of Mental Disorders (DSM-5) were unable to reach a consensus. “People are making declarations of knowledge that are their belief systems, that aren’t also backed up by empirical research,” says Jack Drescher, a psychiatrist at the William Alanson White Institute in New York City.”

 But there is one assertion in the article–touted as settled science—that raises a huge red flag:

 “But those who identify as transgender in adolescence almost always do so permanently.”

Many parents who read 4thWaveNow are VERY familiar with this assumption. When their child, out of the blue, with no prior history of gender dysphoria, claims to be transgender, most parents resort to internet searches to become more knowledgeable. They read articles like this one by Irwin Krieger, LCSW, which tells parents it’s pretty much inevitable their teen or young adult child will remain transgender:

 …I do acknowledge that most teens who have come out to parents and others as transsexual are truly transsexual so as not to give them any false sense of the likelihood of their child having a change of heart.

Parents are encouraged to just start “supporting” their child by using the correct pronouns, buying new clothes and aiding their child with social (and possibly medical) transition.

Historically (prior to the year 2000), the research data did show that many kids who consistently believed they were the opposite sex during and after puberty held onto this belief into adulthood. But in the last few years, something new has emerged: a wave of post-pubertal, self-diagnosed trans teens.  These youth may not fit the historical profile due to relatively recent influences like:

  1. The social contagion phenomenon. Many confused teens and young adults (and increasingly, tweens) seek out answers from strangers online. They say they don’t “fit in,” that they prefer clothing and activities usually associated with the opposite sex. They ask, “Does this mean I’m transgender?” The answers they receive frequently affirm they are and urge them to “Transition NOW!” Places like Tumblr, Reddit, and YouTube (MTF and FTM transition videos) are full of this “wisdom.” The blog Transgender Reality documents some of these conversations.

Sometimes it isn’t an online influence that sparks a newly realized transgender status. There are more students socially and medically transitioning in high schools and universities. On some campuses there are entire friend groups claiming to be transgender, and an impressionable child who is befriended by this group may suddenly decide he/she is trans as well.

  1. The ability to achieve an instant “special” status. There is an appeal for some to identify as transgender in order to receive extra attention or boost their social standing.

If a student announces to school administration that they’re transgender, it’s becoming taboo to question them. More schools are enacting guidelines (like this one co-authored by the National Education Association) that enable children to be treated as the opposite sex, regardless of maturity level or mental health status. And parents don’t need to be in agreement, or even informed, about these accommodations.

Additionally, some children and/or their parents may be enticed by the potential to become celebrities. After all, Jazz Jennings and Caitlyn Jenner have their own TV shows strictly based on their transgender identities.

  1. The reduction in gatekeeping. The current train of thought among gender doctors and therapists is that gender identity is innate, unchangeable, and is often realized at a very young age. If you follow this line of thinking (and assume that no one could possibly be confused or misled into believing they are transgender), then you likely feel it is unjust, and even harmful, to make a child jump through gatekeeping hoops before medical treatment.

As an example of this logic, Dr. Johanna Olson-Kennedy, the medical director of the Center for Transyouth Health and Development at Children’s Hospital in Los Angeles, was recently quoted in this article about Sam who was given puberty blockers, then began testosterone injections and had a double mastectomy all by the age of 14:

 “It is pretty well proven that people know their gender by the age of 5,” said the Center for Transyouth Health and Development’s Olson. “If we accept and believe that people know their gender by the age of 5, why not accept that trans kids know their authentic gender?”

Treating young people with gender dysphoria is critical, Olson said, as puberty increases the chances they will harm themselves.

“One of the things that puts trans kids at higher risk is this period of time when they are going through puberty,” she said. “Their body is becoming the adult or permanent version of this body they are not comfortable with.”

  1. The push for transgender identities to be seen as a normal variation of human existence (like homosexuality). It has become more common for doctors and therapists to avoid labeling people who think they are the opposite sex as having a mental disorder. An example from Jack Drescher is in this article about the World Health Organization classification system:

When ICD-11 is published, being transgender will be listed in a different part of the document, potentially under conditions related to sexual health, said Drescher, who is a New York psychiatrist and a professor of psychiatry at New York Medical College. “So they’ll be diagnoses, but they won’t be mental disorder diagnoses.”

The medical community’s process of de-stigmatizing being transgender was also reflected in the last round of updates to the Diagnostic and Statistical Manual of Mental Disorders in 2013.  The DSM, which is used by clinicians, replaced the diagnosis of “gender identity disorder” with “gender dysphoria.” The diagnostic class was also separated from sexual dysfunctions.

Identifying as transgender shares some similarities with anorexia nervosa  and body dysmorphic disorder for which treatment consists primarily of therapy and possibly medication. But the regimen for gender dysphoric patients often includes medical interventions to physically alter their bodies to better align with their feelings, making this condition treated like no other mind/body disconnect.

  1. The popularity of early social transition. It’s becoming increasingly common to socially transition prepubescent children, to encourage them to live as the gender with which they identify. In the Nature article cited above, psychologist Diane Ehrensaft (a proponent of the gender affirmative model) and transgender rights attorney Asaf Orr comment on this approach:

But encouraging children to live as the gender they identify with is an increasingly popular choice. “There’s been a real sea change,” says Diane Ehrensaft, a psychologist at UCSF. She reports seeing more prepubescent patients recently who have already transitioned socially.

Many transgender-rights activists support this model, and liken any other approach to gay-conversion therapy. “You’re telling a kid, ‘I don’t believe you’,” says Asaf Orr, staff attorney at the National Center for Lesbian Rights in San Francisco. The best strategy, he says, is “to affirm a child’s gender exploration, regardless of what the end result is going to be”.

The gender affirmative model encourages children to “explore” their gender identity through social transition. It is often stated that it’s harmless to do so since no hormones or surgeries are involved. But this doesn’t take into account that children who are treated as the opposite sex are being conditioned to continue in their belief, potentially leading to future medical interventions. Even the Dutch researchers who pioneered the use of puberty blockers to treat transgender youth, do not recommend social transitioning in prepubescent children due to the “high rate of remission.”

dutch anti social transition

6. Transactivism. There is a burgeoning group of people who are out to educate the world about the importance of accepting transgenderism. Their pleas are often presented as anti-bullying or anti-discrimination campaigns. They tend to cite high suicide rates and imply that misgendering someone or questioning their gender identity may contribute to these statistics. Many of these activists are transgender themselves and feel they are the most knowledgeable about their condition. They pass themselves off as experts. Many conduct training sessions in schools, police departments, hospitals, etc. They write books, media articles, blog posts. Host conferences. Just one activist can have considerable influence. And there are so many voices shouting this philosophy that it drowns out opposing viewpoints.

7. Framing transgender acceptance as the new civil rights movement. Personally, I was elated when the US Supreme Court declared same-sex marriage legal. But, after that triumph, organizations like the Human Rights Campaign (HRC), the American Civil Liberties Union (ACLU) and the National Center for Lesbian Rights (NCLR) seem to be focusing more intensely on the transgender rights movement.

It is admirable to oppose discrimination against transgender people in employment, housing and appropriate health care. And I very much condemn violence against them. But there needs to be a balance. It should be acknowledged that some impressionable children, teens and young adults are confused and erroneously self-diagnose as transgender. This vulnerable population needs protection from unnecessary medical interventions. But since these organizations promote the “born this way” dogma, anyone who doesn’t blindly accept and support them as the opposite sex, is called misinformed or even abusive and bigoted.

In a short period of time, the transgender rights movement has made substantial gains. There have been laws passed in the United States and Canada that could be interpreted to mean any therapy that doesn’t affirm a youth’s gender identity is illegal. US schools are being pressured to allow transgender-identifying students into opposite sex bathrooms, locker rooms, and even bedroom assignments on overnight field trips. Overall, there has been a tendency in recent guidelines, legislation and court cases to prioritize gender identity over sex.

  1. The significant growth of the gender industry. There has been a rise in demand for gender clinics, doctors, therapists, endocrinologists, surgeons (and even “packers”—penile prostheses) due to the rapid increase in gender dysphoric children.

Back in January 2016, this pro-transition Cosmopolitan article stated that the first US transgender youth clinic opened in Boston in 2007. And since then 40 more have begun catering—exclusively to children—in the United States.

Surgeons are finding their services are increasingly sought after as well. Dr. Curtis Crane (who performs mastectomies on minors) has commented on how he cannot keep up with the demand for phalloplasties, even though he keeps training more surgeons in the technique:

 Crane says he’s one of only a few surgeons in the U.S. performing a high volume of phalloplasties — a booming surgical niche fueled by an increasing number of transgender men seeking to complete their anatomical transition. Even after hiring and training two colleagues to perform the eight-hour surgery, Crane’s patients must wait a year to have it done.

I frequently come across statements from doctors and therapists saying their transgender-based business is flourishing, often with a significant backlog. Due to their expertise, these are the professionals that I wish would speak out about potential over-diagnosis and over-treatment of trans-claiming youth. You have to wonder if they truly see the massive increase in patients as a positive (“more people are finally being treated because they are better informed and there is less stigma”). Or do they see trouble on the horizon (“I’m pretending everything is peachy, but I’m really concerned this may be a disastrous medical trend”)?

  1. Selective media coverage. Many media outlets portray positive “trans kids” stories, but choose to omit information not favorable to the transgender rights movement. Usually there is no discussion of the high desistence rates, or of the significant risks associated with medical treatments. And when facts like these are not included, the public is misinformed.

US media is chock-full of pro-pediatric-transition stories, many of which have been discussed on this site. You can also click on the Transgender Trend blog links below for examples and excellent analysis of biased programming from the UK’s BBC:

  1. The silencing of skeptics. Unfortunately, it is taboo to voice concerns that children, teens and young adults may be at risk of unnecessary medical transitions. This blog is one of the ONLY places online that parents and their allies can speak out, although most choose to do so anonymously to maintain their privacy.

Unfortunately, there are some trans activists, deeply offended by anyone contradicting the transgender narrative, who work to discredit anyone who dares to express opposing viewpoints. To these activists, it is fair game to try to get someone fired from their job or to post pictures of their children with sexually explicit captions (see the Michael Bailey link). Alice Dreger, Michael Bailey and Kenneth Zucker have been recipients of this treatment.

On a positive note, I’ve heard there are a growing number of professionals—doctors, nurses, teachers, journalists—whispering their concerns to each other. But due to the current environment, they’re afraid to speak publicly. Afraid they’ll be called bigots. Afraid they’ll lose their jobs.

We are living in a time when the number of gender dysphoric children is rising exponentially with no sign of a leveling off.

Guardian increase in peds transition graph

Kids are being medically transitioned regardless of the fact that there’s no medical consensus of what the best treatment options are. No one knows the long term consequences of puberty blockers, cross-sex hormones and surgeries in this population. This may very well be a disastrous fad similar to the false memory and ritual abuse scares of the ‘80s and ‘90s. And to top it all off, there’s significant pressure not to publicly express skepticism.

Mainstream media involvement would be welcome, along with brave professionals speaking up about their concerns. It is essential that the public be informed not only of the pros, but also the cons, of transitioning children.

Instead of focusing solely on treating the burgeoning number of gender dysphoric children, professionals ought to investigate the reasons for the radical shift in this population. Why are so many presenting to gender clinics? Why are there currently so many females vs. males seeking treatment (historically it was the opposite)? Why do so many have co-morbid mental health issues—autism spectrum disorders, OCD, ADHD/ADD, depression, etc.? These are important questions in need of answers. Especially because of the often irreversible nature of medical interventions, and that the patients are children with the rest of their lives ahead of them.

Today’s children are exposed to all kinds of influences that weren’t present until relatively recently. It would make sense to now reject the statement “those who identify as transgender in adolescence almost always do so permanently.” And to re-evaluate treatment protocols so that children, teens and young adults receive the thorough mental health care they need, and avoid any unnecessary medical interventions.