Suicidality in trans-identified youth & the question of media ethics: a roundtable discussion

A few weeks ago, the Washington Post published a story about last year’s tragic suicide of a 14-year-old trans-identified teen named Kyler. Although the Post refers to Kyler by male pronouns, according to earlier reports, Kyler identified at other times as genderqueer and nonbinary, preferring they/them as well as he/him pronouns.

By all accounts, Kyler (a natal female) was fully supported by family, support groups, gender specialists, and friends to identify as and embark upon social and medical transition. The reports also indicate that Kyler had a history of self harm and mental health problems, as well as gender dysphoria, which worsened during puberty. Kyler’s death was one of a cluster of three other similarly supported young teens who died by suicide within 5 months of each other in San Diego, CA in 2015. Kyler and two of the other young people attended the same support group for trans youth. The ongoing emotional devastation experienced by parents, families, and friends of these young people is unimaginable.

This terrible cluster of suicides, including Kyler’s, was widely reported last year. Why did the Post publish another story about Kyler more than 18 months later?

The apparent rationale for the new coverage is that Kyler’s mother has brought suit against San Diego’s Rady Children’s hospital where Kyler was admitted as an inpatient under observation for 24 hours due to suicidality. This brief hospitalization occurred 6 weeks prior to Kyler’s suicide.

The suit alleges that some hospital staff discriminated against Kyler by repeatedly referring to Kyler as female. Although Kyler’s mother stated for the record in the Post story that she is not holding the hospital directly responsible for her child’s death, she makes clear that she believes some staff at the hospital caused serious harm by referring to Kyler as a girl and with female pronouns. She stated that Kyler went into a “spiral” after the events at the hospital.

The Washington Post story was picked up very quickly by Pink News and Gay Star News with headlines asserting that Kyler committed suicide “after hospital staff called him a girl.” (Again, Kyler’s death occurred some six weeks after the 24-hour hospitalization.)

One concern raised by the Post article (and the headlines chosen by the news outlets which re-ran the story) is potential suicide contagion, and how this reporting conflicts with well-established ethical guidelines recommended for news organizations. While these guidelines have been in existence for decades, online blogs and social media, along with the relatively recent phenomenon of stories going “viral,” add a layer of complexity to the longstanding ethical dilemma faced by media who report on suicides. Adolescents, who are most vulnerable to suicide contagion, are almost universally denizens of the Internet, and sensationalized accounts of troubled teens killing themselves are all too easy to find nowadays.

Over 20 years ago, the US Centers for Disease Control and Prevention (CDC) published guidelines for responsible reporting about suicide. These guidelines—still relevant decades after they were written–mirror those released in other countries and by other health care and suicide-prevention organizations.

The CDC guidelines make special mention of the vulnerability of young people to suicide contagion:

 One risk factor that has emerged from this research is suicide “contagion,” a process by which exposure to the suicide or suicidal behavior of one or more persons influences others to commit or attempt suicide. Evidence suggests that the effect of contagion is not confined to suicides occurring in discrete geographic areas. In particular, nonfictional newspaper and television coverage of suicide has been associated with a statistically significant excess of suicides. The effect of contagion appears to be strongest among adolescents, and several well publicized “clusters” among young persons have occurred.

The CDC guidelines list a number of things that news organizations should avoid in their reporting of youth suicide. Among them:

…the likelihood of suicide contagion may be increased by the following actions:

  • Presenting simplistic explanations for suicide.

Suicide is never the result of a single factor or event, but rather results from a complex interaction of many factors and usually involves a history of psychosocial problems. Public officials and the media should carefully explain that the final precipitating event was not the only cause of a given suicide. Most persons who have committed suicide have had a history of problems that may not have been acknowledged during the acute aftermath of the suicide. Cataloguing the problems that could have played a causative role in a suicide is not necessary, but acknowledgment of these problems is recommended.

  • Engaging in repetitive, ongoing, or excessive reporting of suicide in the news.

Repetitive and ongoing coverage, or prominent coverage, of a suicide tends to promote and maintain a preoccupation with suicide among at-risk persons, especially among persons 15-24 years of age. This preoccupation appears to be associated with suicide contagion.

Whether intentional or not, the Post (and the other outlets who republished the story), by their choice of headlines as well as their coverage of the mother’s lawsuit, give the implicit message that it was the hospital’s misgendering that was a leading contributor to Kyler’s suicide 6 weeks after the 24-hour hospital stay. (The Post story diverges from a different account published shortly after Kyler’s death, in May 2015, by the Daily Dot, which, quoting friends and Kyler’s mother, explicitly blamed social media online bullying for Kyler’s death. Other reports last year mentioned the online bullying along with the death of family pets as contributing to Kyler’s deep unhappiness.)

The CDC’s ethical-reporting guidelines emphasize that suicide is always the result of many factors, most prominently a history of mental health concerns; and that news stories focusing on a single cause for a suicide could contribute to suicide contagion in young people. In the case of Kyler’s untimely death and the other young people in the San Diego suicide cluster last year, the Washington Post and other news outlets which revived the story this month focused on gender dysphoria and related “misgendering” in their reporting. But there is broad consensus amongst suicide prevention organizations and researchers that the primary factor consistently tied to a desire to take one’s own life is underlying poor mental health.

Even the often-cited Williams Institute survey study of self harming behaviors in gender nonconforming and trans-identified adults notes that a history of mental health problems is the most frequent underlying cause for suicidality; and that the reported rate of suicidal and self-harming behaviors in their survey did not adequately take into account the well-established link between poor mental health and self-harm:

Second, the survey did not directly explore mental health status and history, which have been identified as important risk factors for both attempted and completed suicide in the general population. Further, research has shown that the impact of adverse life events, such as being attacked or raped, is most severe among people with co-existing mood, anxiety and other mental disordersThe lack of systematic mental health information in the NTDS data significantly limited our ability to identify the pathways to suicidal behavior among the respondents.

Many parents who contribute to 4thWaveNow have felt pressured into agreeing to medically transition their children, due in part to the frequent assertion of a direct causal relationship between gender dysphoria and suicidality, and an underlying assumption that medical transition will halt self-harming behaviors. The terrible story of Kyler’s suicide, revived by the Washington Post, has generated a new discussion among us.

We asked three professionals who work with children and families to respond to the Post article. Their responses, in the form of a roundtable discussion, are presented below, and Stephanie, Lisa, and Lane are available to interact with readers in the comments section of this post.


Stephanie Davies-Arai is a parenting consultant and author of Communicating with Kids. She writes a blog for parents at www.stephaniedaviesarai.com and also runs the website Transgender Trend www.transgendertrend.com, a research-based site for parents and anyone seeking information about the current situation in the UK.

Lisa Marchiano is a licensed clinical social worker and a Jungian analyst. She blogs at www.theJungSoul.com and can be found on Twitter @LisaMarchiano.

Lane Anderson (a pseudonym) is a licensed clinical social worker. Currently in private practice, she previously worked in a clinic serving trans-identified youth. Lane is the author of “Exiles in their own Flesh,” in which she chronicles her experience in the adolescent clinic, and her reasons for reluctantly resigning from her position. 


Stephanie: This is a devastating case and difficult to talk about. The suicide of a child is an awful tragedy and a private grief for the parents that you don’t want to step on. We have to talk about suicide, though, if we want to gain more understanding about how to prevent the same tragedy from happening in other families; and I think there are factors in this case which really need examination.

We don’t know all the details of the case, but what we do know is that this child is part of a wider picture of the sudden, unprecedented increase in the number of girls identifying as transgender at puberty/adolescence, many of whom exhibit the same suicidal ideation and similar self-harming behaviours. We also know that one factor discussed as a key risk to transgender youngsters– lack of family support—is absent here: Kyler was fully supported by mom, family, and a support group.

What is striking in this case is the child’s need for validation not only from family and friends, but from adults and the wider society (not normally a concern for teenagers). This begs the question of what messages the child has received about the necessity of having a fragile identity affirmed by strangers in order to construct a healthy sense of self. The dependence on outside confirmation creates a very shaky foundation on which to build the self, and puts a troubled child in a further disempowered and vulnerable position.

The way this case has been reported only reinforces the message to young people (and their parents) from transgender advocacy groups: that being “misgendered” is a devastating attack from which it is hard to recover. The common narrative of “affirmation or suicide” needs to be strongly challenged if we hope to truly support vulnerable young people in building a strong inner sense of self and identity. In transferring the power to outsiders, a child is left helpless and dependent on the whims of other people, on what they are led to believe is a life or death issue.

Lane: Stephanie, yes. Whether or not a prohibition on misgendering becomes the law of the land, it is always a bad idea to teach over-reliance upon the opinions of others, particularly when one’s opinions require the suspension of disbelief within others. We should encourage trans-identified youth to understand that most people will probably have some trouble digesting the whole transgender concept. While it may appear as if people are fully onboard with affirming a person’s self-proclaimed identity, this may be due to fear of being called transphobic. Also, many youth who are hurting for absolutely legitimate reasons may also be deeply attracted or unwittingly drawn to live inside new social categories that mirror their own preexisting inner states of deprivation/alienation–inner states that are enlarged and/or embodied in collective narratives of oppression.

Stephanie: We don’t know the initial causes of this child’s desperate unhappiness, but it seems to me that “gender reassignment” is fast becoming an instant panacea for all the underlying problems an adolescent may be experiencing, which means they are denied the normal level of care and support from professionals to explore and manage these issues. When a condition comes with as devastating a prognosis as “affirmation or die” we really need to be looking at how helpful the sole diagnosis of “gender dysphoria” really is for young people. Otherwise, we will just keep reinforcing the same narrative that many more troubled young people will grow up to believe as truth.

Lisa: You make an excellent point here, Stephanie. The narrative available to gender dysphoric children is one that offers only the direst of consequences – transition or die. Research does not support transition as a panacea for mental health concerns. Indeed, some research suggests that suicide rates remain very high after transition. As a society, we ought to be very focused on finding a range of treatment alternatives to offer to dysphoric young people.

I was deeply saddened to read the story of Kyler’s suicide in the Washington Post. There is no pain more unbearable than losing a child, and losing a child to suicide is unimaginably awful. From the article, we learn that Kyler was experiencing anxiety and depression and was engaging in self-harming behaviors. Kyler killed himself in spite of being accepted by his friends, and having a family fully supportive of transition. The article states that Kyler “went into a spiral” after hospital employees referred to Kyler as a girl. “They were completely traumatizing him,” his mother is reported to have said.

Hospitals have a duty of care for patients in a way that takes into account their needs and psychological state and to act in a way that isn’t detrimental to the patient’s well-being. However, I was disappointed to see the lack of critical thought presented in the Post’s coverage of the lawsuit brought against Rady Children’s Hospital by Kyler’s family. The Post presented only the superficial story, and did not look deeper into the circumstances that caused Kyler to be so vulnerable.

When transgender activists and the media give kids the message that being misgendered is equal to an act of violence, it sets them up for inevitable wounding and disappointment. We cannot control how others perceive us or what they call us. Hospital staff certainly ought to be as gentle and humane as possible with patients in their care. But if kids are taught that they have a right to expect others to address them according to their wishes at all times, they are being given unrealistic expectations about the world.

The Post’s focus on misgendering obfuscates the complexity of teen suicide in general, and Kyler’s situation in particular. There is much we do not yet know about teen suicide, suicide clusters, suicidality, and poor mental health in those who identify as transgender. Approaching the subject in open-minded spirit of inquiry is the only way to begin to unravel these important topics. The Post’s article gives the impression that we know the answers before we have even asked all the questions.

What a frightening vision of the world trans-identifying must teens must have! They are told that that their choices are “transition or die.” Transgender activists online warn them to be perpetually on guard for being misgendered or “dead named,” and fuel fear and unhappiness by stating that these are both “actual violence.” No wonder trans-identifying teens are scared. Yes, scared. In recent weeks, a handful of trans-identifying teens have contacted me, and this has been the common denominator. They are frightened and confused, and want a place to talk about their feelings where these won’t be shamed or disallowed based upon someone’s rigid ideology. At first, I was so surprised to hear how frightened these young people are, but when I thought about it, it made a lot of sense. Transgender ideology has indeed made the world a frightening place, with few options for young people with gender dysphoria.

Lane: Lisa, this is extremely encouraging that the kids were able to talk to you about their fear. Their anxiety is most likely coming from a natural sense that they are being pulled into something much greater than themselves. From my own clinical practice with trans-identified youth, I often had the feeling that many were partially aware of this loss of control. But to acknowledge what is happening would create a cognitive dissonance they are ill-prepared to tolerate. There are no easy answers to the struggles of living, but the trans-narrative that has sprung up from our liquefying culture like some kind of multi-headed hydra is, in fact, presenting itself in a rather threatening way as The Answer. Of course, it is anything but. The fear the children are expressing is actually healthy, because it reveals their ambivalence about—on the one hand–wanting to believe in the infallibility of the trans solution, yet at the same time knowing in some emergent and liminal part of their psyche that such a threatening narrative will require from them personal sacrifices they may not be willing or able to make.

Lisa: The following is a quote from a recent blog post by a “guy called Helen” entitled “A Culture of Fragility,” excerpted with the author’s generous permission. In this piece, Helen astutely points out how transgender ideology results in a self-concept that is volatile, unstable, and fragile. As Helen knows, it is possible to deal with dysphoria and even live as the other sex without subscribing to a harmful delusion that leaves one at the mercy of others’ perceptions of us.


I’m often told that “Dead-naming and misgendering are literally responsible for the deaths of trans people” and I’ve personally known trans people who have committed suicide. I nearly did so myself a few years ago. I know how much these things can hurt. I used to feel devastated, crushed, invalidated and ashamed.

I was lucky though because something changed for me. I started to see gender as being socially constructed and to see how society conflates femininity with being female and masculinity with being male. I came to accept that it’s ok for me to be a male who looks and acts like I do. How there should be no need for anyone to think I’m *actually* female to be a perfectly valid and worthy person as I am. Accepting this meant I no longer had to live with the cognitive dissonance of believing that I’m female whilst knowing that females don’t father children. It meant I was able to let go of the volatile, unstable belief system that, despite objective reality, I have a female brain and that made me female. So now I’m fortunate that I don’t get too upset, or damaged by somebody using my old name or misgendering me because it doesn’t burst my bubble.

People don’t just self-harm or commit suicide because they are dead named. It might be their final straw, but they commit suicide because they are already volatile and unstable. Their self-worth is fragile because it’s based on a view of the world that relies on everybody else seeing you the way you see self and doesn’t provide any coping mechanisms for when people don’t choose to validate your self-perception. This is what transgenderism does to transgender people. I’m not saying it’s OK to dead-name someone or to misgender them on purpose. It’s rude and inconsiderate at best and dangerous at worst. Doing this might indeed be the final straw that pushes someone over the edge and that’s totally not OK. Of course, it’s always important to be aware of the potential repercussions of our actions and be aware that people are fragile. But I truly believe that identity based politics causes as many problems as it solves and the hypersensitivity to dead-naming and misgendering is one of these things. The trans community actively promotes the view that dead-naming is an act of violence and I can’t help but think that this only exacerbates the negative impact on somebody when they hear this.

Whilst we are still fighting for acceptance, we need to survive the battle. Enough people have died, and we, the trans community, need to think about how we instill a culture of strength and pride rather than a culture of fragility.


Lane: The layers of tragedy in Kyler’s story make it extraordinarily treacherous to discuss. Clearly, the loss of a child to suicide is a catastrophe beyond all comparison. I don’t know how anyone’s heart, if it is still beating, wouldn’t leap to console those survivors remaining in the wake of such a devastating loss. Life will never again be the same for the ones who knew and loved this young person, now gone My heart seizes when I consider the child’s pain. For these reasons alone, social discussions of suicide generally do submit to the authority of those who have been most impacted by its effects. To consider the causes of such tragedy through the lens of reason, which would mandate a level of detachment, could be viewed as callous. A child is gone.

Unfortunately, it is likely the extraordinarily sensitive and traumatic nature of the subject may hinder a more thorough investigation of the conditions surrounding it. But absent the permission to honestly explore possible causes of transgender suicide, we will be hard-pressed to reduce its prevalence. Obviously this isn’t a good thing. We certainly need to increase our understanding of the relationship between those who identify as transgender and their rate of suicide. Though research shows a higher prevalence of suicidality in those identifying as a gender other than their biological sex, we don’t conclusively know why.

As effective, evidenced-based solutions to the problem remain frustratingly at large, naturally we cast about for ways to improve the dire situation. Because nobody wants a child to hurt so badly, we may find ourselves rushing to conclusions, and we might hold firmly to what is at best a working hypothesis on grounds of urgency. But the truth is, until we gather more facts, we should be careful not to close the door on deeper investigation. We must also be careful that any conclusions drawn remain free of political and/or ideological motivations.

Stephanie: I think you’ve said it there, Lane: “nobody wants a child to hurt so badly,” and I would add to that (although it goes without saying really), “especially the parents.” If your own child is suffering depression or anxiety, your biggest fear as a parent is that your child could commit suicide; it’s an automatic reaction to go straight to the worst outcome in your head. The problem is that if we react from that fear we can set in stone for the child the seriousness of the condition and compound the helplessness a child feels. We lose our ability to step back and help them find a way to manage their feelings and find their inner strength, because we become too emotionally involved. My first advice to parents about responding to any emotional problems a child is suffering is “don’t catastrophise it” (and my second point is always “I know that’s really difficult”). The problem is, parents of trans-identified kids try to find information about a subject they know little or nothing about, and inevitably come across the suicide narrative which confirms their deepest fears. How hard does that make it for a parent to communicate trust and confidence in their child, how much harder does it make it for them to try to equip the child with tools to manage their feelings and find different, more self-empowering ways of thinking about their problems?

I’d also say that the message that being misgendered can destroy you is the exact opposite of the message parents try to give their kids in any other area of social difficulty, like being called names, left out or bullied for example. In these cases, we want our child to understand that other people’s actions can’t destroy them, they are stronger than that, they will survive, that they can find ways to protect themselves from people who are mean to them. We acknowledge our child’s feelings, but also try to empower them to be resilient and robust in the face of unkind treatment from others, because we know they will inevitably have to deal with these kinds of situations as they grow up in the world. We might also inform the child’s teachers and do our best to stop any bullying, but we don’t give a child the message “this will destroy you” which I think is the message kids are getting from the trans lobby.

Lane: Some would say that it is society’s lack of acceptance of trans people (signified, partially, in the act of misgendering) which fuels the increase in their rates of suicide. But the assumption that oppression or discrimination is entirely to blame for increased suicidal ideation—which, on the surface may seem compassionate–is not necessarily the best way to actually help those identifying as transgender. Attributing the lion’s share of one’s emotional distress to less than optimal conditions in the social environment is not always an effective means of achieving consistent emotional equilibrium.  Believing one can change the world outside the self, in lieu of finding ways to meaningfully or reasonably adapt to a given environment, is a seductive idea. However, problems invariably arise with this tactic, mostly because the social realms/cultures in which we are deeply embedded are designed to provide relative consistency to their inhabitants; they are not designed to change swiftly. Targeting a slow-to-change external realm as the primary means of altering one’s internal state isn’t generally regarded as the most effective intervention for managing mental unrest.

I fear we may be witnessing the unfortunate convergence of a kind of radical activism with mental health treatment. It doesn’t take a rocket scientist to see the potential problems resulting from the collision course of these two disparate paradigms — one focusing on the environment and the other the individual. Social justice activism, the sort seeking to raise awareness and/or fundamentally alter or deconstruct deeply embedded (and often cherished) beliefs about shared reality (such as the existence of biological sex differences), is mentally taxing in the extreme. Such prolonged and dramatic clashing over the nature of our reality is exhausting for adults; it orients them to a life of battle. Without proper reinforcements, engaging in culture wars can fatigue even the heartiest of souls. Imagine such a call to duty and how it is experienced inside the chaotic mind of your average teen, let alone one whose level of internal chaos may be dangerously elevated.

Lisa: This is a good point, Lane. We need to clarify that we are addressing mental health symptoms, i.e., dysphoria, depression, and anxiety. A transgender identity is not the presenting problem. Rather, it is a self-identification whose significance is determined by activism. As clinicians, we need to be careful that we are assessing and treating symptoms according to a mental health model, and not allow treatment to become ruled by concerns that belong in the realm of social justice and activism.

Lane: Consider such a suddenly gender-dysphoric teen wading into the turbulent battlefield of identity politics, just as they embark on the journey of figuring out who they are. They’ve got serious struggles of their own, but instead of dealing with them on a personal level, in a contained manner, on a private stage tailored to their unique needs, these kids now get corralled into the trans narrative and essentially receive their treatment en masse. Instead of sensitive treatment, they get social-justice activism. From a clinical standpoint, this is appalling. This level of activism puts our youth in harm’s way when they are least prepared to withstand the force of such a cataclysm. They are still children. They are too young and inexperienced to see this is a war for which their bodies, their passions, their hopes, their fears and uncertainties have sometimes been exploited for another’s gain.

The Washington Post article emphasizes the origin of transgender angst as issuing from the outside world, as opposed to being localized within the individual. In this way, it also subtly and perhaps inadvertently relocates the transgender individual’s locus of control outside herself rather than within. Much has been written in the psychological literature about the concept of human agency, and its role in healthy emotional development. Encouraging treatments that inhibit individuals from focusing on ways they can manage in the world, such as increasing their tolerance for distress, or not placing undue reliance upon garnering the proper responses from others to maintain emotional equilibrium, is a better way to keep people from sinking into despair. Overdependence upon changing the world instead of growing the self stunts and inhibits the development of self-awareness (one of the foundations of sound mental health). Activism can blind these young people to alternative solutions that don’t serve the mission of the “cause.” Activism encourages the youth to hunt for and then accentuate problems in the external environment that support the activist narrative. In turn, these youth may become increasingly disturbed by viewing their culture in a negative and punitive light.

Teaching impressionable young people that their psychic safety in this world is absolutely predicated upon whether or not others can or will perceive, as well as actively validate, the profound and idiosyncratic fullness of all that they are, is corrupt pedagogy. It is also a devious form of cruelty.  Those who indoctrinate children with these impossible-to-achieve standards spoil a child’s chance of trusting others, for all the child will likely encounter in such a falsely constructed reality are either lies (from the fearful capitulators) or reactive-anger brought on by feelings of defensiveness from those unable to offer anything less than total validation of the activist narrative. Many people do not appreciate being forced by law and public opinion to so swiftly alter their perceptions of reality. Unfortunately, when these people try to defend their reality, they wind up badly injuring transgender children. The life of a child turned poster child/activist is swirling with fear and deception, all the while most everyone on the sidelines, both supporters and detractors, feel they are defending their version of the good.

Stephanie: It’s frightening how we have been manipulated into believing that “affirmation” is the only caring way to respond to a child confused about gender, that it’s what nice people do. People want to be nice and caring. But of course the issues inherent in medical transition—such as sterilization–are not covered much by the media, so people are being given false and misleading information on which to base their views. And no matter how people try, trans people will always be misgendered because when we meet an adult, the first thing we do is distinguish which sex they are. It’s the most ingrained unconscious response from the primitive brain: “Do I want to mate with this person or should I run from them?” These instinctive responses are there for a reason and of course it’s especially crucial for females to make the distinction. We’re very good at immediately quashing those instincts for fear of appearing rude or unfriendly but is it healthy for us to do so? Is it healthy for children to be brought up to immediately suppress instinctive knowledge because that knowledge is “transphobic”? And of course it’s the opposite of the message we give to our teenage daughters, which we hope will keep them safe. We tell them “trust your instincts, they’re often right. If you feel uncomfortable or threatened by someone, go with that feeling and don’t be afraid of looking unfriendly.” This is a very different issue to teaching children about transgender people and the importance of not discriminating against them. It’s teaching children to re-order reality according to a new subjective belief system which they are obliged to believe in, or at least pretend to.

Lane: The implications of what you say here, Stephanie, are huge. It seems we are teaching children to be fearful of their own instinctive responses. This is what is accomplished when we focus children’s attention on how their instinctive responses could hurt someone else’s feelings. This is quite problematic, as our instincts exist precisely to guide us, as well as provide us with a sense of safety in the world. People who do not know how to listen to themselves, who view their own perceptions as mere static and interference to the greater emerging socially-prescribed “truth” are in serious danger of being exploited.

Stephanie: Yes Lane, and I think that’s especially true for girls who are socialised to be nice and think about others’ feelings first; they really don’t want to appear “rude.” It’s a bigger issue for girls and women, who are often treated as if their perceptions are “wrong” so they may have already learned to doubt them – and that’s part of the reason, I think, that we see that the most vocal support for trans people comes from young women — the group, ironically, who are most at risk of being exploited.

Lane: Now that transgenderism has become so visible in the culture people have feelings and opinions about it they need to express — but these questions and concerns are explicitly forbidden.  How can we discuss this topic when our concerns are equated with invalidating another’s reality, even linked to the transgender person’s urge to die? Who wants to bring out that demon or be branded as responsible for the suicide of another?  So we remain silent, even though a paradigm shift this big cannot be truly integrated into the hearts and minds of others if they are deprived of the right to turn the new ideas around a million times in their head. Additionally, besides being actively silenced in this discussion, our healthy skepticism is also elevated due to the sudden and insistent prevalence of transgender issues in the culture. The trans movement’s debut as the new civil rights movement has felt suspiciously orchestrated from without. Those who take note of this are hardly transphobic; our caution more likely indicates we sense something highly unusual is unfolding within our culture; for from the moment we learned of the transgender narrative, it seemed to already be written in stone. How peculiar. Our kids deserve so much more than this new orthodoxy.  Because activism has supplanted true clinical treatment our most vulnerable youth remain bound in this, the latest installment of received wisdom, before which we all seem to have all lost our inalienable right to question.

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.

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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?