Lisa Marchiano, LCSW is a psychotherapist and certified Jungian analyst. She blogs on parenting at Big Picture Parenting, and on Jungian topics at www.theJungSoul.com. You can also find her at PSYCHED Magazine and @LisaMarchiano on Twitter. Lisa has contributed previously to 4thWaveNow (see “Layers of Meaning” and “Suicidality in trans-identified youth”).

Lisa is available to interact in the comments section of this post.

In recent years, stories of young children socially transitioning have been increasingly common in the mainstream media.  Frequently, the focus is on the child’s preference for toys, activities, hairstyles, or clothing more typical of the opposite sex. Critics of these articles sometimes insinuate that parents merely need to reinforce that non-stereotypical toy and clothing choices are acceptable, and this will resolve the child’s distress. “Why don’t the parents just buy their son a doll instead of agreeing he is a girl because he doesn’t like trucks?” is a typical critical statement. But it is my belief that in some cases, such criticisms oversimplify the complexity and difficulty of situations in which a young child experiences severe dysphoria.

There are certainly cases where parents hastily infer that a child is transgender and ought to be transitioned based on non-sex-stereotypical choices on the part of the child, and these are troubling indeed. To take but one example, the mom interviewed about her nonbinary child in this BBC story was looking into blockers for her daughter partly on the basis of the child preferring pirates to princesses.

But closer attention to the details in some of these stories reveals a more complicated picture. For example, there are media stories about children who appear to despise their own genitals.  In this account, according to his mother, a little boy attempted to cut off his penis at age 4 with a pair of scissors.

Clearly, a parent facing a situation like this would want to seek out professional help, and might understandably conclude that the child is suffering from intractable dysphoria.  It’s worth noting, though, that the current trend in the US focusing on gender affirmation makes it difficult to consider alternate explanations for such distress in a child, including co-occurring mental health problems—or even more mundane explanations. See, for example, in this piece, the observations of a parent of such a boy, who discovered

…the importance of asking “Why?” Had I asked that when [my son] told me that he wanted to cut off his penis with a pair of scissors, who knows what I would have learned? But I didn’t ask because I thought I knew precisely what he meant. Applying an adult perspective, and my own views on gender, I immediately concluded that that remark was a rejection of his birth gender. But maybe he had a urinary tract infection and his penis was sore. Or maybe he had been wearing a pair of pants that he had outgrown and they were uncomfortable in the crotch. Or maybe having a penis made him feel like he didn’t fit in with his sisters and cousin, and he thought that if he looked more like them then they would all get along better instead of squabbling. Who knows. But we should at least have had the conversation. The same way we would if he had said “I’m sad” or “I’m angry.”

But setting aside for the moment alternative explanations for why a young child might want to mutilate his own genitals, it seems to me that in at least some cases where young children have been transitioned, these kids were experiencing a significant amount of distress over their sex. They may have suffered from a deep feeling of having been born “wrong.” They may have a powerful feeling of really being the other sex. They are likely subjected to significant social stress at school due to not fitting into gender expectations. The pain experienced by these children – and families – is very real and sometimes quite extreme.

I imagine it would be very difficult to be the parent of these children. One would have to bear with so many unknowns. Will the dysphoria resolve itself? If so, when? How? Will my child be subjected to bullying? How can I protect him or her? What if the dysphoria worsens? What will happen at adolescence? What is the right thing to do?

Above all, a parent in this situation would be subjected to the horrible reality of having to watch their child suffer each and every day.

Childhood Transition Solves Some Problems…

Although affirmation and social transition are frequently prescribed in todays’ activist climate, we do not have any good long-term evidence to support social transition among pre-pubertal children. The clinical practice guideline of the Endocrine Society recommends against doing so. The Dutch researchers who developed the use of puberty blockers also recommend against it. Nevertheless, I can certainly understand why social transition would be an attractive option for parents.

First, it would resolve ambiguity. One would know what course their child would be on, and could embrace the new reality and adjust accordingly, rather than have to tolerate the agony of not knowing. Consider for example the following excerpt from a 2013 story from The New Yorker.

One mother in San Francisco, who writes about her family using the pseudonym Sarah Hoffman, told me about her son, “Sam,” a gentle boy who wears his blond hair very long. In preschool, he wore princess dresses—accompanied by a sword. He was now in the later years of elementary school, and had abandoned dresses. He liked Legos and Pokémon, loved opera, and hated sports; his friends were mostly science-nerd girls. He’d never had any trouble calling himself a boy. He was, in short, himself. But Hoffman and her husband—an architect and a children’s-book author who had himself been a fey little boy—felt some pressure to slot their son into the transgender category. Once, when Sam was being harassed by boys at school, the principal told them that Sam needed to choose one gender or the other, because kids could be mean. He could either jettison his pink Crocs and cut his hair or socially transition and come to school as a girl.

Hoffman ignored the principal’s advice. She told me, “Are we going to assume that every boy who doesn’t fit into the gender boxes is trans? Don’t push kids who aren’t going to go there.” Still, as Hoffman’s husband said, “It can be difficult for people to accept a child who is in a place of ambiguity.” A kid with a nameable syndrome who requires a set of specific accommodations at school (recognition of a new name, the right to use the bathroom and locker room he or she wants to) is, in some ways, easier to present to the world than a child who occupies a confusing middle ground.

Above all, it must be extremely compelling as a parent to know that there are simple steps you can take that will resolve your child’s unhappiness in the short term. Many parents in these stories report that their child immediately become happier, more playful, and more joyful as soon as they were allowed to wear dresses full-time, or cut their hair short and choose a new name. It is hard to argue with what looks like success.

…And Creates Others.

While I have a great deal of empathy for parents who, in the face of their child’s overwhelming distress, decide to allow a social transition,  there are serious risks to doing so. As human sexuality researchers point out, every parent in this situation must weigh the immediate suffering that their child is experiencing against potential future suffering of regret or medical complications. There is accumulating evidence that Lupron may have serious side effects. Testosterone and estrogen may increase risks for heart disease, cancer, stroke, and diabetes. And of course, as has been pointed out even by gender specialists themselves, the child will become permanently sterilized if puberty blockers are followed immediately by cross-sex hormones.

What an agonizing choice. Such parents believe they can relieve their children’s distress for at least a while, but there may be real consequences down the road. There is very little evidence to help a parent make this decision. We simply don’t have good criteria for decisively determining which children will persist in a cross sex identification into adulthood. Though some gender therapists claim those who are persistent, insistent, and consistent will benefit from transition, the evidence we do have indicates that this is not a fool-proof criterion.

The second significant risk in facilitating a social transition among pre-pubertal children is that transition almost certainly increases persistence. If a five-year-old boy is “affirmed” that he is the opposite sex, and is addressed by a typically female name and pronouns by the adults around him, it is very likely that the child will be reinforced in his belief that his body is “wrong.”

Moreover, the surge of endogenous hormones at puberty rewires a young person’s brain in complex ways. It is likely these hormones and the changes they bring that in part account for desistance in the roughly 80% of children who grow out of dysphoria and come to feel at home in their natal sex. By blocking these pubertal hormones with Lupron, it is probable that clinicians and parents are setting the child’s cross-sex identification in stone.

The Stories We Tell

Therapists like to remind our clients that there is the thing that happened, then there is the story we tell ourselves about what happened. The stories we tell can make a huge difference in how we feel and respond to events–and the options we have.

For example, if a friend doesn’t call when she said we would, we could tell ourselves any number of stories about that. We might imagine our friend forgot. She’s been busy lately. We might call her instead, or we might move on with other things, intending to catch up with her later.

But what if we tell ourselves a different story? What if we decide that she probably didn’t call because she is angry? Or has decided she doesn’t want to be friends? Then we might find ourselves upset. We may experience a significant amount of unnecessary distress as we react to a situation that is mostly of our imagining. We might even make a choice – such as avoiding or confronting her – that might wind up bringing about the very outcome we feared.

A lot of what therapists do is help people to generate new stories that can maximize the potential for positive outcomes. Roughly speaking, there are two main criteria that make for good, adaptive stories. First, does the story more or less reflect reality? Second, does the story open up new possibilities for response?

Reality

Reality, of course, is sometimes a matter of opinion. It isn’t always possible to judge what is “real.” However, in general, those beliefs that do not line up with objective reality are often not very adaptive. If we believe, for example, that no one ever gets into college without straight A’s, we may feel as though our efforts at obtaining a university education are futile, and we will be more likely to give up.

An exception would be the coping strategy referred to as denial, which can be adaptive if it shields us from realities that are too harsh or painful to tolerate right now. However, even denial can be maladaptive, since it may encourage us to ignore or avoid important realities. Imagine, for example, someone diagnosed with cancer, who decides to forgo the recommended treatment of chemo and use ineffective herbal remedies instead.

Telling—or agreeing with–a child that she is a boy in a girl’s body doesn’t pass the reality test. It may be true that a child strongly feels she is the opposite sex. It may true that she feels very uncomfortable with her body, or the social roles ascribed to her. But to assert that she is really a boy is to deny objective, material reality. It sets a child up to manage massive cognitive dissonance, and to be at odds with her own biology.

We only have one body. Part of being a parent is teaching our children how to accept, love, and care for the one body they will have throughout their life. Believing that there is something fundamentally wrong with our body, such that it might require drugs and/or surgery to be corrected, makes it more difficult to accept and care for ourselves properly.

Options

A good story increases our options. Generally speaking, one story is better than another if it allows us to generate more possible ways to respond. Returning to the example of our friend who doesn’t call, if we believe she didn’t call because she hates us, our one option may be to sit home and feel miserable, sad, and angry. If we believe that she may be busy and perhaps she forgot, we have other options. We can call her right away. We can wait and call her tomorrow. We can decide we are tired of her being forgetful, and decide we aren’t going to call her until she calls us.

Having multiple choices increases our agency, and gives us an internal locus of control. Psychologists believe that developing an internal locus of control is one of the key variables that determines resilience. We experience ourselves as active participants in our lives rather than passive victims.

Affirming that a child is transgender is a story that reduces rather than increases options. If I tell a five-year-old that he is a girl in a boy’s body, then the choices become transition, or be miserable. The internet is quick to tell young people that their choice is to “transition or die.” Many parents who have decided to support social transition report that they believed they would either have “a dead son, or a live daughter.” When there are only two choices and one of those is suicide, then there really is only one choice.

In contrast, if the story we tell our child is that he has gender dysphoria, suddenly a range of possible options becomes available to us. We can support him in managing his distress. We can work to challenge rigid gender expectations. We can try to find him like-minded peers, and adult role models of feminine men. We can teach him self-soothing skills. We can work with the school to reduce bullying. And of course, the option to transition will still be there.

When Pharma Shapes the Story

Influential journalist and author Alan Schwarz convincingly traced the explosion of ADHD diagnoses to Big Pharma’s aggressive marketing of stimulant medications for the condition.

“A.D.H.D. Nation” focuses on an unholy alliance between drug makers, academic psychiatrists, policy makers and celebrity shills like Glenn Beck that Schwarz brands the “A.D.H.D. industrial complex.” The insidious genius of this alliance, he points out, was selling the disorder rather than the drugs, in the guise of promoting A.D.H.D. “awareness.” By bankrolling studies, cultivating mutually beneficial relationships with psychopharmacologists at prestigious universities like Harvard and laundering its marketing messages through trusted agencies like the World Health Organization, the pharmaceutical industry created what Schwarz aptly terms “a self-affirming circle of science, one that quashed all dissent.

Our children look to us, their parents, to help make sense of their experience – to know, in effect, what story they should tell themselves. The marketing messages of pharmaceuticals change the stories we tell ourselves and our children about their suffering.

When our toddler falls and bumps herself, she looks at us to gauge our reaction. If we reassure her that she is okay, she runs off and continues playing. If our face reveals fear and alarm, if we rush to her and ask worriedly whether she is all right, she is likely to burst into loud wails.

Before 2007, when Lupron was first used in the United States to block puberty for gender dysphoric children, kids who experienced even extreme distress over their sex were probably rarely socially transitioned. After all, the physical changes of puberty were inevitable. Before Lupron, there were very few “transgender children.” There were certainly gender dysphoric children, whose parents likely did the best they could to help their child navigate distress.

Lupron is a profitable drug. The drug’s manufacturer AbbVie reported making $826 million on Lupron sales in 2015. New off-label uses for the drug, such as helping kids grow taller or delaying puberty in gender dysphoric kids, have certainly provided new markets. The annual cost for Lupron for a transgender child can be around $15,000. The story that tells us we need to arrest puberty for dysphoric children or risk dire consequences directly benefits the pharmaceutical industry.

The treatments available to us shape how we conceptualize our symptoms. Pharmaceutical companies magnify this influence through marketing and hiring of physicians as consultants. As the image below shows, mentions of the term “transgender children” was nearly nonexistent in published books before 2000 – not long after the Dutch published their studies about using Lupron to block puberty. The mentions rise sharply around 2007 — the year Norman Spack began using Lupron for gender dysphoria at his clinic in Boston. Google’s Ngram had data available only through 2008. We can only imagine what the mentions must be like in recent years.

With the ability to suspend puberty granted by the magic of pharmaceuticals, a whole new treatment pathway has opened. I fear that the temptation to take this route may be strong, even though there is little empirical evidence about where it leads.

Psychotherapists know that often, the answer to dealing with discomfort is to learn to sit with it. It must be excruciating as a parent to watch a child suffer with dysphoria. The temptation to end the suffering with a quick pharmaceutical fix must be immense. But I can’t help but think that at least some of time, it might be better to sit with this discomfort rather than reaching for a drug.

Having a young child with severe dysphoria presents an excruciating dilemma for a parent. I can’t say without any doubt what path I would choose, as I have not been faced with this very difficult decision. I do believe that those supporting these families ought to offer them honest information about what we do and don’t know, both about gender dysphoria, and the effects of transition.