The stories we tell: Inspiring resilience in dysphoric children

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.

Marchiano ngram

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.

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Insurance requirements are a “ridiculous” speed bump on children’s gender journeys

Yesterday, Johanna Olson-Kennedy, MD, one of the better known US pediatric gender doctors, railed against insurance companies who stand in her way. It seems they have the temerity to demand written evidence that her prepubescent clients are mentally prepared for the chemical blockade of their natural puberty.

The insurance companies also, inexplicably, want to see evidence that the children and their parents have actually agreed to this off-label (not FDA approved) and very expensive drug treatment.

johanna olson april 12 2017 eradicate gatekeepers

Olson-Kennedy wants WPATH, in its next Standards of Care (SOC 8), to “eradicate” the requirement that minors have some sort of psychological evaluation before embarking down the Lupron road (which leads in nearly every case to cross-sex hormones, as Olson-Kennedy well knows):

So, what a lot of people want to understand is, “If I give my child this blocker, can I take it away, if at the end of a certain amount of time they no longer have a trans-gender identity, or they don’t want to continue on to pursue a transition with cross-sex hormones.” The answer to that is, “Yes.” They are reversible. You can take them off without any problems or major medical problems. But it’s very rare that that happens. In my practice, I have never had anyone who was put on blockers, that did not want to pursue cross-sex hormone transition at a later point.

Olson-Kennedy is also no doubt aware of the growing controversy about Lupron and other puberty blockers, but that doesn’t seem to be a concern when it comes to insurance reimbursements.

This isn’t the first time Olson-Kennedy has publicly complained about the foot-dragging of insurance companies. Last September, she posted “unfounded” denial letters from insurance companies on the WPATH Facebook page–mostly having to do with the fact that puberty blockers have never been approved by the US FDA for use in chemically halting the puberty of healthy “trans” kids.

Johanna Olson complaining about blue shield sept 21 2016 cropped

Should insurance companies be in the business of paying for experimental treatments on children–some who (on Olson’s caseload) were actively suicidal? Take a look at these denial letters. Do gender doctors like Olson-Kennedy deserve this level of oversight?

Is my use of “experimental” warranted as an adjective–apart from the fact that, a full ten years after Norman Spack, MD first began to use GnRh agonists in his practice, these drugs are still not approved for this use by US regulatory agencies?

Take a look at these remarks by Rob Garafolo, MD, another top pediatric gender doctor, made in a PBS interview two years ago:

garafolo admits experimenting

Garafolo is referring here to the multimillion dollar NIH grant he, Olson-Kennedy, Spack, and others have received to study “trans kids.” He hopes to have more answers after, as Garafolo admits, the kids have been experimented upon for 5 years–and beyond. As he says, it’s an “imperfect field” and how these children will fare through a lifetime is “entirely unknown.”

 

Lupron: What’s the harm?

Worried Mom and her son, Worried Brother, co-wrote this post.  Worried Mom is an attorney who currently works in the non-profit area, and Worried Brother is employed in the pharmaceutical industry, with a background in chemistry.  This piece is sourced in the scientific literature; click superscripted footnotes to follow links.

For recent mainstream coverage about the potential harms of pubertal suppression, see here and here.


by Worried Mom & Worried Brother

Before we can have a sensible discussion about Lupron and its hormone-suppressing effects, it is important to understand what normal hormonal balance means in a healthy teenager or adult.

Normal body functioning requires a certain latent amount of testosterone and estradiol (estradiol is the major estrogen in humans).  Men and women both have some of these hormones naturally present in their bodies, produced by testes in men and ovaries in women.  Testosterone is involved in the development of muscle bulk and strength, the maintenance of proper bone density, the creation of red blood cells, the sleep cycle, mood regulation, sex drive, hair growth, and cholesterol metabolism.1,2,3  Low testosterone levels can lead to deficiencies in any of these areas.  For example, lack of testosterone can cause fatigue, insomnia, and interference with mood and sleep, together with a host of other impacts on, for instance, a person’s sex drive.

Like testosterone, estradiol is involved in the maintenance of proper bone density, mood regulation, skin health, and reproductive health.4,5,6  Lack of estradiol can lead to adverse impacts in those areas.  Because estradiol is a crucial component in maintaining bone density, individuals who lack sufficient amounts of estradiol will fail to undergo proper bone development, because the growth plates on the ends of the bones will never close.7  This profoundly alters the physical structure of the body.

Lower levels of estrogen are also associated with significantly lower mood.  The primary regulators of mood in the brain, according to our current understanding of neurochemistry, are the systems relating to the neurotransmitter serotonin.  Estrogen receptors are prevalent along the mid-brain’s serotonin systems, and they are believed to play an important role in serotonin-mediated behaviors such as mood, eating, sleeping, temperature control, libido and cognition.  Mice that are bred missing this particular sub-type of estrogen receptor show enhanced anxiety and decreased levels of serotonin and dopamine.8

As noted, both men and women naturally produce testosterone and estradiol in their bodies.  The levels of these hormones fluctuate greatly depending on the person’s stage of life.  At the start of puberty, a child’s body will begin to produce either testosterone or estradiol in much greater quantities than it had previously.  This increased production leads to the development of secondary sexual characteristics.  As men and women age, their levels of testosterone and estradiol also decrease, leading to well-known age-related effects, such as thinning bones and hair in both men and women.

A current focus in the treatment of transgender children and teenagers is to arrest, or delay, the impact of testosterone and/or estradiol in adolescence.  Arresting the impact of these hormones will prevent the development of secondary sexual characteristics.  Moreover, many clinicians recommend–if a child or teen is unsure as to whether he or she wishes to become a transgender adult–that the administration of so-called “blockers” will “delay” puberty and “buy time” for the teen to make a more informed or mature decision.  Theoretically, a teen could always desist from taking blockers and then normal puberty would ensue, although there is very little data in this area.  It is also currently unknown whether, if a teen takes a puberty blocker during what would otherwise have been his or her normal puberty and then stops, whether puberty will proceed entirely as normal or whether there will be some other effects from having delayed it for a period of years.  The “puberty blocker” discussed in this article is leuprolide acetate, better known by its trade name Lupron.

What is Lupron?  Lupron is a gonadotropin-releasing hormone analog.  The primary pharmacological effect of Lupron administration is a decrease in the concentrations of testosterone and estradiol throughout the body.9,10  How does it achieve this decrease?  It does so by tinkering with a hormonal feedback loop between the hypothalamus and the pituitary gland, and interferes in the release of gonadotropins (“Gn”), which is a catchall term for 2 separate hormones, luteinizing hormone (LH) and follicle-stimulating hormone (FSH).  Gn acts as the primary means by which the body controls the release of testosterone and estradiol.  Gn interacts with the tissues that are involved with the release of these two hormones.  It stimulates specialized tissues in the ovaries and the testes to produce testosterone and estradiol.  LH stimulates the Leydig cells in the testes and the theca cells in the ovaries to produce testosterone11.  FSH stimulates the spermatogenic cells in the testes and the granulosa cells in the ovarian follicles (the granulosa develop to produce a layered structure around the egg), as well as stimulating the production of estrogen by the ovaries12,13,14. There are Gn receptors embedded in the cell membranes of these tissues and binding with Gn results in those tissues producing the hormones.  The hormones are released into the bloodstream, and travel to specialized receptors that are located systemically, in most major tissue groups.  The systemic distribution of these receptors is responsible for Lupron’s effect on the entire body.

The hypothalamus releases GnRH (Gn-releasing hormone) which binds with GnRH receptors on the pituitary gland15.  The hypothalamus responds to the concentrations in the blood of testosterone and estrogen, as well as the presence of Gn16,17.  Since Lupron is chemically similar to GnRH, it is essentially repeatedly stimulating the GnRH receptors on the pituitary gland.  This artificially high activation of these receptors desensitizes the pituitary gland to the presence of GnRH18.  There is an initial flare-up of Gn release in response to the presence of the Lupron, but it eventually results in down-regulation or deactivation of these receptors19.  In physical terms, this means that the pituitary, in an effort to restore normal functioning, will cull the number of GnRH receptors.  This results in a significantly lowered response to a given concentration of GnRH in the blood. Why is this?

This is the key point, because the strength of an organ or tissue’s response to any drug is directly proportional to how many receptors are activated by the presence of the drug.  So, using this idea, lower the number of receptors, lower the response, and if there is an absolutely lower number of receptors present, there is an absolutely lower potential response20.  Once the drug is removed from the body, the pituitary is left in a desensitized state, rendering it unable to respond to ‘normal’ activation by GnRH.  This results in decreased production of Gn, which in turn means decreased production of both testosterone and estradiol in the tissues with which Gn would normally interact.

Lupron use in otherwise normal teenagers to delay puberty is both relatively new and off-label.  Lupron does have a history in treating a condition called ‘precocious puberty,’ which is what happens when a child’s body enters puberty too quickly for his or her age.  However, this is a clinical condition typified by concentrations of sex hormones deemed wildly abnormal in the course of normal development.  As such, the usage of this drug may be more appropriate in  these particular individuals, because the marginal benefit of leaving this condition untreated is higher than it would otherwise be. Any competent medical professional would not generalize from outcomes observed in a population of individuals affected by abnormal hormone levels, to individuals with normal hormone levels.

Industry standards21 judge the usage of Lupron in treating gender dysphoria as providing at best no proven benefit and hold that there is an insufficient quantity of published evidence to prove its safety for this purpose.  UnitedHealthcare, the nation’s largest insurer, makes its stance clear on Lupron for usage in treating gender dysphoria on their Drug Policy page:22

‘Hayes compiled a Medical Technology Directory on hormone therapy for the treatment of gender dysphoria dated May 19, 2014.  Hayes assigned a rating of D2, no proven benefit and/or not safe, for pubertal suppression therapy in adolescents. This rating was based upon insufficient published evidence to assess safety and/or impact on health outcomes or patient management.’

A D2 rating is the lowest rating possible on that particular institution’s scale of safety and efficacy.  The Hayes Technology Review is considered to be the industry standard in linking treatments with patient outcomes.

In Lupron’s case, the vast majority of clinical data is found in samples of middle-aged or older men with late-stage prostate cancer.  This means the aggregate of the medical community’s understanding of Lupron’s safety profile relates to its use in this context, in terms of both the condition it is meant to treat and the individuals for whom it is approved.  When using Lupron as a “blocker,” medical professionals are, in both senses, treading untested waters, for the dual reason that it is not approved or recommended to “treat” this particular condition, and clinical studies relating to its long-term or even short-term safety in treatment of gender dysphoria are vanishingly rare.  To further illustrate this second point, the population to whom Lupron is most commonly prescribed on-label, middle-aged and elderly men, has a much shorter life expectancy from the date of administration than do teenagers.  In other words, based on the current state of research, one would not expect to see data collected from groups who are 40, 50 or 60 years “out” from administration.

Putting together what we know about how the body normally reacts and develops during puberty with what we know about how Lupron works, we can conclude the following: administration of Lupron to young people for the purposes of blocking puberty is a disruption of a delicate hormonal balance that has the potential to cause adverse health effects.  The risk is further compounded by the off-label usage of the drug for this purpose, as well as the lack of long-term data related to safety.

 

Shriveled raisins: The bitter harvest of “affirmative” care

by the parents of 4thWaveNow

Note to readers: This is another in an ongoing series of posts which shine a light on the public statements made by gender specialists in various forums. The aim here, as always, is to inform the public, particularly parents, about the actions and self-reported thoughts and plans of individuals who are currently involved in providing hormones and surgeries to minors. All screen captures are from publicly accessible (i.e. not password-protected or otherwise private) websites. We intend to continue to exercise our free-speech right to report on these public statements, as well as publishing our personal opinions on pediatric transition and those who enable and promote it.

To anyone who may object to our work in this area, hear this: The backlash represented by 4thWaveNow, Transgender Trend, Youth Gender Professionals, and the increasing number of individuals and organizations who question the burgeoning increase in child and youth transition is precisely that: a backlash against the decision taken by trans activists and their media handmaidens to relentlessly promote pediatric transition—especially MEDICAL transition.

The final straw, for many of us, has been the shameless and daily attempts by activists, journalists, and some clinicians to misuse self-harm statistics as a weapon to bludgeon parents into submission. A recent article in Spiked Online exposed this immoral and deeply destructive tactic, and we will continue to expose it on 4thWaveNow.


Scattered through the posts on this site, we have discussed the fact that puberty blockers followed by (or used concurrently with) cross-sex hormones to prevent the “wrong puberty” in prepubertal kids results in irreversible sterilization. This is well-recognized fact, openly acknowledged by researchers and top pediatric gender specialists alike [see the bottom of this post for a collection of links on this matter].

rainbow-health

The reason is that gametes (sperm and ova) require natural, biological puberty to mature to the point that they are viable for reproduction. It is not currently possible to freeze immature gametes, as it is for those of adult trans people who have been allowed to go through natal puberty.

Our point is not that anyone and everyone should have biological children or that women are only fit to be baby machines (a red herring “argument” that has been used against us by trans activists). It also has nothing to do with the demographics of who will ultimately decide to bear or father children. (I notice none of these activists cavalierly argue for sterilization of disabled or gay people, both of whom have a lower statistical rate of becoming biological parents). The point is that it is a human rights violation to sterilize minors, who by definition cannot consent nor understand what it means to give up that future right.  And given that the majority of “persisting” trans kids are same-sex attracted, it is not a stretch to see that prepubescent sterilization of “trans kids” amounts in many cases to a form of proactive anti-gay eugenics—even if that is not the conscious intention. What’s more, as many parents know, the decision to reproduce may come later in life, even if we thought in our youth that we wouldn’t have wanted children. Most young people naturally don’t spend their time thinking about having kids of their own; they have other priorities at that stage of life, as well they should.

But does any of this matter if adult trans people aren’t particularly interested in reproduction?

trans-men-want-children

Well, it turns out that several studies have shown that a majority of trans men and trans women desire to have biological children of their own. 

 

But even setting aside research evidence, all you have to do is look at the increasing number of (sometimes sensationalized) media stories about “pregnant men” to know this is “a thing”.

There are a sufficient number of trans men becoming pregnant and giving birth that the premier midwifery organization in the United States has changed all its literature to be “gender neutral” in an ostensible effort to avoid “triggering” its clients with words like “woman” and “breasts.” Planned Parenthood now campaigns on behalf of “menstruators” and the venerable La Leche League has even scrubbed its language of inconvenient mentions of biological reality, to ensure that trans men who want to “chest feed” won’t feel excluded.

la-leche-chestfeeding

But when it comes to the fertility of trans people,  trans activists want to have their cake and eat it too: Celebrate and support adult trans who decide (often unexpectedly) to reproduce, while fiercely lobbying for medical intervention which permanently sterilizes prepubescent children. There is really no way to square this contradiction. They constantly claim that stopping the “wrong puberty” is the only antidote to suicide, yet that “wrong” puberty is the one and only pathway to possible reproduction in the future.

Not to put too fine a point on it, but the very people arguing that the only alternative to these sterilizing pediatric treatments is suicide are very much alive, and quite a fair few of them (notably, several top MTF trans activists) have biological children of their own. “Do as I say, not as I do” is rightly ridiculed as hypocrisy when it comes to any other subject. How on earth did these people survive to adulthood, father children, yet now harangue us that the “wrong” puberty of these children must be stopped?

As to the weaponization of suicidality: There is no record in the history of medicine of children and teenagers killing themselves because they could not medically transition in childhood, or because they were “born in the wrong body.” (Since August when this piece was posted, we’ve been waiting for any evidence to the contrary.) Even the most frequently cited “41%” study of trans adults who have reported suicidal ideation doesn’t assert that medical transition cures suicidality.


So, given that

  • large numbers of adult trans men and women express a desire to have biological children;
  • no child or pre-adolescent can know for certain whether or not they will eventually want to reproduce;
  • it is a universally acknowledged human rights violation to sterilize minors;
  • and there is no evidence that early medical transition will ultimately reduce self harming behaviors,

we must ask: Why do gender specialists continue the reckless practice of promoting sterilizing hormones and surgical interventions on prepubescent children, who, by virtue of their undeveloped powers of reason and judgment, cannot meaningfully consent to such treatments? On what authority does any adult—including these children’s parents—have the right to make a decision for a minor that should solely belong to adults of reproductive age themselves?

Even if it turns out to be true that most of these kids won’t opt for biological reproduction in the future, what of the (already limited) pool of potential life partners they might fall in love with? It’s not at all uncommon for couples to part company over disagreements about whether to have children. And then there’s the issue of what genital surgeries do to sexual response and function. None of this is ever discussed in the glowing portraits of “trans kids” that we see daily in the mainstream media (though it is by the clinicians themselves—as you’ll see shortly).

The gender specialists are fully aware of the irreversible effects of their interventions. Gender clinics detail the risks of infertility and other permanent changes on their consent forms. Research articles, public statements, and news articles capture the admissions by prominent gender specialists (again, see the bottom of this piece for links). Some express reservations (but no accompanying intention to cease and desist or even slow down their caseloads); some mention it in passing. And some, as you’ll see in a moment, appear to lose no sleep at night over what they’re doing, but only express interest in the future market for even more high tech interventions for the young people entrusted to their care.

Last March, Johanna Olson-Kennedy, MD (herself a parent), one of the world’s most successful and best known pediatric gender specialists, posted a call on the publicly accessible WPATH Facebook page for earlier genital surgeries on minors. We wrote about it at the time in this post.

Olson orig post.jpg

The irony is inescapable: By puberty blocking young people, endocrinologists create a situation where these youth naturally yearn for puberty, as they watch their unblocked peers mature and move on. Olson-Kennedy’s solution? More high-tech, expensive medical intervention; earlier cross-sex hormones, earlier sex reassignment surgery. An iatrogenic problem created in the first place by suppressing the perfectly healthy bodies of young people.

Just a few days ago, Olson’s original post was revived via several new comments supporting her radical idea. This one, by Susan Maasch, founder of the Trans Youth Equality Foundation (TYEF) is particularly striking. ( We wrote about TYEF—a purveyor of free breast binders (secretly to girls with “unsupportive” parents) and youth transition propaganda, last year.)

shriveled-raisins

“Shriveled raisins”: The outcome of years of hormone treatment unnatural to the female body.

Other activists and pediatric gender specialists, including Rixt Luikenaar (ironically, an OB-GYN), Kathie Moelig (founder of TransFamily Support Services), and others acknowledge that sterilization (which their clients may someday regret) will result from early surgeries and hormones, but place their faith in high-tech medicine to find a way around it—eventually.

rixt-et-al-on-sterlization

This unquestioning belief that medical technology will solve the problems created by zealous “affirmative” gender specialists is widely shared.  Just a couple of days ago, NPR ran an article acknowledging that immature gametes can’t currently be preserved for future reproduction. But by drawing on fertility preservation research  in cancer survivors treated with sterilizing chemotherapy, the pediatric-transition pushers hope that  puberty-blocked children’s ova and sperm can eventually be coaxed to reproductive viability in a petri dish.

Both groups — young cancer patients and trans kids hoping to transition early — have a demand for fertility preservation at an age where it has not usually been possible. But researchers say they are drawing closer to a solution with new techniques to freeze, or cryopreserve, immature reproductive cells…

… they started to look for ways to grow that tissue in a petri dish, so it can develop into a mature egg. “We’ve had to borrow knowledge from other disciplines and sort of figure out how that applies to trans people … What can be frustrating sometimes is having to adapt and extrapolate all of this information from work that is not done for trans people.” — Zil Goldstein, Mount Sinai

Brave New World. Puts a whole new spin on “test tube babies.” Not to mention a future boost for the surrogacy industry.

No one in the mainstream media—in this case, NPR– seems willing to point out the obvious: If you let these kids simply mature naturally–as their healthy bodies are desperately fighting to be allowed to do–they can preserve their fertility and decide whether they want to choose hormonal or surgical interventions when they reach adulthood,  with mature judgment and reasoning powers. There would be the added benefit of giving kids a chance to desist before it’s too late—as so many were allowed to do before “gender affirmative” treatment was advertised 24 hours a day, 7 days a week.  Only a few years ago, this would have been seen as just common sense caution. Adults-only transition was the norm.

There are other ramifications besides infertility resulting from this reckless rush for earlier and earlier surgeries and hormonal treatments.  Here, Olson-Kennedy and other commenters analyze the impact of surgeries on sexual function—but disagree on how much should be discussed with the kids themselves about their future orgasm potential after their genitalia have been surgically rejiggered.

olson-orgasm

At least one “practitioner” seems not to want concerns about orgasm potential to be a “hindrance” to  a child achieving their “authentic self”:

low-orgasm

Bringing us into 2017, Jenn Burleton, head of Transactive Gender Center, assured the Facebook group on January 18 that orgasm is a discussion topic amongst “caregivers” in Transactive support groups. Good to know parents and other adults feel empowered to make decisions for these kids about their adult sexual function and fertility in their “support groups.”

Burleton orgasm.jpg

(Just a thought: how many of these people publicly pontificating about the sexual function of children consider how they’d have felt as teens if adults had been scheming about their orgasm potential, and the impact thereon from a surgeon’s scalpel?)

In January 2017, nearly a year after Olson-Kennedy’s original post calling for the WPATH Standards of Care 8 to support earlier genital surgeries, many clinicians, activists, and parent leaders of trans youth groups remain keenly interested in lowering age of surgeries for youth. From the sounds of it, “many many” surgeons are eager to oblige.

maasch-et-al-earlier-surgeries

Dan Karasic, MD, director of a gender clinic at UC San Francisco, moderator of the WPATH Facebook page,  and a key player in WPATH and the co-chair of the recently formed USPATH, helpfully informs us  that a discussion on under-18 surgeries will take place at the inaugural USPATH conference February 5 2017. “Advocacy” to pressure insurance companies to get onboard and pay for genital surgeries on minors is also an important part of the discussion.

This isn’t the first time we’ve seen Dr. Karasic advocating for lowering the age for surgeries. In this post, we discussed his public support for a mother obtaining double mastectomy for her 15-year-old and her attempts to get her insurance company to foot the bill for it.

Again: The people advocating for drastic and irreversible medical interventions on minors have enormous power over the future lives of children. The decisions they have taken with their careers and activism will impact a generation of youth for a lifetime. These adults, trans or not, were allowed to mature without medical interference in the era preceding this Age of the Trans Child.

Some of the people weighing in are trans adults, among them MTFs who have fathered children and had successful careers, who were not subjected to tampering and scheming about their most private and personal bodily functions as children. And as much as the trans activists may claim they’d have welcomed such interventions as children, the fact remains: Somehow they made it to adulthood, fertility and sexual function intact, without killing themselves.

Exactly what authority gives these people the right to advocate for and perform medical experiments on children, “trans” or not? This is a question a lot more people need to be asking.

Meanwhile, the USPATH conference  session on surgery in minors is on Sunday, February 5 at 10:15 AM  in Los Angeles.

Readers will undoubtedly recognize some of the names on this panel.

uspath-minor-surgery-1


For more information about the irreversible sterilizing effects of puberty blockers followed by cross-sex hormones on prepubescent children, see below. Readers contributions are welcome and will be added to this list.

Sahar Sadjadi, The Endocrinologist’s Office—Puberty Suppression: Saving Children from a Natural Disaster?

It must be remembered that puberty suppression as the first step to medical transition, if followed by cross-sex hormones, which has been the case for almost all reported cases, leads to infertility due to the permanent immaturity of the gonads and the reproductive tract. The absence of the discussion of sterilization of children as a major ethical challenge in this bioethics article, and many other clinical debates on puberty suppression, is striking. For any other group of children, such an intervention would be discussed extensively with ethics review boards. (What grounds might justify the permanent elimination of the child’s reproductive ability? Should parents be able to make such a decision for the child? Which futures are opened by the treatment and which ones are foreclosed? How might benefits be weighed in relation to the loss of reproductive capacity?) The media would likely react with investigations and questions about the long-term consequences of treatment. These “queer” children’s bodily integrity and reproductive rights should not be any less pressing than other children’s. Needless to say, children are not legally capable of consent, and 9–10 year olds are not capable of understanding all the health consequences of the treatment. Parents are asked to make life decisions on issues as critical as fertility for young children. Can they make an informed decision and evaluate benefits vis a vis risks when confronted with such horrendous forecasts for their children?

 Unique ethical and legal implications of fertility preservation research in the pediatric population

 Norman Spack, MD, founder of first US pediatric gender clinic:

The biggest challenge is the issue of fertility. When young people halt their puberty before their bodies have developed, and then take cross-hormones for a few years, they’ll probably be infertile. You have to explain to the patients that if they go ahead, they may not be able to have children. When you’re talking to a 12-year-old, that’s a heavy-duty conversation. Does a kid that age really think about fertility? But if you don’t start treatment, they will always have trouble fitting in. And my patients always remind me that what’s most important to them is their identity.

Brill & Pepper, The Transgender Child, 2008, p. 216

“The choice to progress from GnRH inhibitors to estrogen without fully experiencing male puberty should be viewed as giving up one’s fertility, and the family and child should be counseled accordingly”. For girls, sterilization is the outcome too, because “eggs do not mature until the body goes through puberty”

Diane Ehrensaft, video clip from conference. Time stamp: 5:06

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

Robert Garofolo, PBS.org:

“It’s an imperfect field with regards to decisions we are asking these families to make,” acknowledged Dr. Robert Garofalo, who co-directs the Center for Gender, Sexuality and HIV Prevention at Chicago’s Lurie Children’s Hospital and is also working on the transgender youth study. Garofalo hopes the team will be able to study patients far beyond the current five-year term to address a host of questions that currently have no answers. Does hormone use in trans youth increase breast cancer risk? How well do adults who have transitioned as teens grapple with their loss of fertility? “These are things that are entirely unknown,” Garofalo said.

 

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.”

 

Brain sex: The jury is still out—but does it matter?

Early this morning, Think Progress (a “progressive” news outlet) posted on Facebook what was meant to be a provocative pull-quote from its latest trans-kid piece by reliable journalist propagandist Zack Ford, “It Takes A Village To Bully A Transgender Kindergartner”:

And what exactly is the “need” of this child? A boy in kindergarten would like to be accepted as “girl”? Well, as a woman, I take offense at any boy who is pretending to share my gender when he quite clearly NEVER can nor ever will. … He is not. He never can be.”

The commenter quoted is, of course, a woman (a bigoted bully, as seen through Ford’s tunnel-vision lens) who questioned the parents’ need to socially transition their 5-year-old child. The child’s transgender status has resulted in a giant kerfuffle as result of the Minnesota school’s dilemma in deciding what to do to accommodate the kindergartner.  Zack Ford paints anyone who questions the wisdom of a 5-year-old boy being assured he is really a girl as an ignorant transphobe, a bigot supported only by right-wing conservative groups.

Zack Ford Facebook
In this post, I’m not going to be writing about the fact that it isn’t just conservatives who question the trans-kid trend (obvious to anyone who reads this blog on a regular basis, or for that matter, the increasing number of blogs by left wing parents, professionals, and feminists. Check out my blogroll). Nor will I be dissecting in detail this “news” article set out as bait on the Think Progress Facebook page to incite the reliable progressive hordes.

Instead, my interest in Ford’s latest bit of Newspeak revolves around the huge number (easily 10-1) of reader comments on that Facebook post, which can be paraphrased as follows:

You stupid bigots! Go read up on the science of gender identity. Gender identity is proven, settled brain science. Little kids KNOW from the time they’re born what sex they are. Plus intersex. No one “chooses” to be transgender, they’re born that way.

 I’ve spent thousands of hours marinating in gender dogma and research studies, both pro- and con-, re: “innate gender identity.” So while it’s no surprise to me to see some people spouting as FACT the totally unproven hypothesis that gender identity is set in stone at birth, what does surprise me is the sheer numbers who have bought what, at best, is a tenuous theory, and who have thereby completely shut down even a modicum of critical thinking.

Of course, who can blame well intentioned progressives? They’re fed bittersweet mouthfuls of Innate Gender Identity gruel every single day not only by the media, but even by the President of the United States, who via his Department of Justice, baldly asserts on line 36 of the complaint against the state of North Carolina:

36. Gender identity is innate and external efforts to change a person’s gender identity can be harmful to a person’s health and well-being.

DOJ complaint

US v. North Carolina

(And it’s not just these few lines. The entire complaint reads like boilerplate trans-activist dogma, and interested readers are urged to take a look at the rest of this document).

This increasingly unchallengeable notion that gender identity, aka “brain sex,” is innate, hard-wired at birth, and thus absolutely unchangeable (despite the efforts of us horrible bigoted parents who are rooting for our kids to commit suicide) means, to the masses who now parrot it like the top graduates of a Maoist Re-Education Camp: Every toddler who claims to be the opposite sex must be agreed with by every adult who comes in contact with the child. Innate gender identity is the ironclad reason why no one is supposed to question the sudden flood of “trans kids” we hear about on a daily basis.

Given the gravity of all this—that little kids are now being ushered aboard a train that will lead inexorably from puberty blockers to cross-sex hormones (with concomitant irreversible changes) in 100% of reported cases–these brain sex/innate gender identity claims can’t just be ignored and dismissed. Not when so many  people—more every day—have swallowed them whole.

Here’s the thing. There is some research that supports a role for biological, genetic, or physiological factors in gender dysphoria. And as much as people on “my side” of this argument (the argument being: should children be “transitioned” to the opposite sex on their own say-so?) would like to simply dismiss any and all evidence for biological aspects of things like gender dysphoria, it’s not that simple.

Shunning entire lines of research because we are made uncomfortable by the findings should not be the way of truth seekers. If opening our minds to their claims changes our position, then so be it. As medical historian and intersex-rights activist Alice Dreger says in her book Galileo’s Middle Finger which chronicles (among other things) the chilling effect of activism on scientific inquiry,

[it is] a rare trait in activists: a belief in evidence even when it challenge[s] our political goals.

Human beings, in general, do not appreciate having their cherished ideas challenged. Political viewpoints tend to be set in stone, with any wavering seen by one’s allies as a dangerous and slippery slope. Evidence contrary to the ideological convictions of either side is taken as an existential threat to the fundamental integrity of the position.

For instance, people (like me) who support a woman’s right to abortion often avoid  acknowledging the fact that a fetus is not just an amorphous mass of cells, but a proto-human being. Conversely, anti-abortion advocates give short shrift to arguments about a pregnant woman’s agency over her body, and the critical importance of a baby coming into the world to a parent who is ready–and can financially afford–to raise the child.

The battle lines dividing those who support the idea that self/parent/activist-identified “trans” kids should be transitioned as young as possible, vs. those who disagree (like me) are drawn across a long-contested and hardened piece of ground: nature vs. nurture. And the opposing combatants are highly reluctant to give even an inch on the matter.

As you’ll see, this post is going to argue not for a détente or concession of territory, but rather, for a willingness of “my side”—the gender critics–to consider the evidence marshaled by our detractors, and then ponder whether it changes your mind. I’m only going to touch on a few areas of research typically used by the trans activist side; if you’re interested, you’ll want to spend some delving time yourself.

Let me cut to the punchline right now: Speaking for myself, weighing the claims (and the research they base it on) of the activists who want to transition children as early as possible has actually strengthened my conviction that medical transition should be an adults-only decision, if made at all. The only thing I can say I might have shifted my opinion on after endless investigation is this: There may be a very small (it’s always been very small) number of people for whom medical intervention is the only way they can live a happy life. I don’t believe we should prohibit these interventions for such people as adults. I still do not believe, weighing up all the evidence, that we should be tampering with the bodies of young people who may very well grow up to be happy without the expensive, drastic, and irreversible meddling of the gender-soaked medical and psychiatric professions. Instead, as I harp on constantly, let’s celebrate and support gender defiance in young people.

So let’s start with the obvious. [Note to regular readers: The information in the next couple of paragraphs is well known to you, but please stick with me, because I’m going to cover some research I haven’t formerly written about]. If gender identity is “innate” how come so many gender dysphoric youngsters change their minds?

4thWaveNow is chock-a-block with posts and research studies—as well as personal narratives from formerly trans-identified people who changed their minds, as well as others who experienced and resolved severe gender dysphoria in childhood—supporting the fact that many children outgrow their dysphoria and grow up to be adults happy to have bodies and brains that have not been tampered with by the medical and psychiatric professions. A 2008 meta-study by Korte et al sums it up:

Multiple longitudinal studies provide evidence that gender-atypical behavior in childhood often leads to a homosexual orientation in adulthood, but only in 2.5% to 20% of cases to a persistent gender identity disorder. Even among children who manifest a major degree of discomfort with their own sex, including an aversion to their own genitalia (GID in the strict sense), only a minority go on to an irreversible development of transsexualism.

Because so many trans activists claim that intensity of discomfort with one’s body parts is some irrefutable sign of “true transgender,” or that prior researchers didn’t adequately differentiate between “true trans kids” and the merely “gender nonconforming,” I’m going to emphasize this bit of the above quote:

even among children who manifest a major degree of discomfort with their own sex, including an aversion to their own genitalia.

Even WPATH—World Professional Association for Transgender Health—whose clinician-activists spend a good deal of time promoting younger and younger ages for “transition,” acknowledges on page 12 of its Standards of Care that most trans-identified kids grow out of it:

In most children, gender dysphoria will disappear before, or early in, puberty.

An earlier online version of  the WPATH SOC-7 cited specific numbers—greater than 80%–and included research citations, but this more specific information, oddly enough, has disappeared. But this 2014 study remembers:

…as the World Professional Association for Transgender Health notes in their latest Standards of Care, gender dysphoria in childhood does not inevitably continue into adulthood, and only 6 to 23 percent of boys and 12 to 27 percent of girls treated in gender clinics showed persistence of their gender dysphoria into adulthood.

Ok. So most kids grow out of gender dysphoria. But that fact doesn’t by itself dispense with biological evidence for gender dysphoria, whether or not it persists.

Traditionally, feminists have staked their claim on the “nurture” side of the “gender identity is innate” argument, with little acknowledgement of the findings in biology and neuroscience that hint at any real difference between male and female brain physiology.  And there is plenty of hard science bolstering this nurture-based stance: recent MRI studies have mostly corroborated the view that male/female brains are more alike than different, which leads to the conclusion that sex-role stereotyped behaviors are primarily the result of socialization, as Cordelia Fine laid out in her “Delusions of Gender.”

Nature_versus_Nurture

Trans activists and the clinicians who (let’s face it) follow their lead obviously point to other studies of adult transgender people which support the idea that their brains are hard-wired to be closer to the sex they “identify” with. Some of these studies do offer some evidence for sex differentiation in the brain. But imaging studies of adult brains are pretty much impossible to control, because all adults have had life experiences and social influences (not to mention possible cross-sex hormone treatments in some cases) which, owing to neuroplasticity, will of course have an impact on brain structure.

But even in the (primarily MRI) studies of adult brains that are better executed and controlled, it turns out the fundamental difference in these studied brains is not so much a matter of the subjects’ gender identity but of their sexual preference, as sexologist James Cantor draws attention to in a blog post surveying research studies frequently cited to prove a transsexual brain:

 In Scientific American Mind, journalist Francine Russo takes on a fascinating research question: “Is there something unique about the transgender brain?” she reviews some of the relevant brain research on transsexuals and concludes that transgenderism is indeed a phenomenon of the brain.  Although I agree with Russo that transgenderism is a phenomenon of the brain, I believe Russo over-focused on gender identity, which led her away from the better explanation of the data:

These brain scans don’t reflect gender identity, they reflect sexual orientation.

Cantor’s post, Russo’s Scientific American piece, and the cited research studies are all well worth reading.

There is some other research I find compelling: studies of prenatal hormone levels—specifically, testosterone—and their influence on sex-stereotyped behaviors and other characteristics in children.

A couple of years ago, Brynn Tannehill, a trans activist-journalist, posted a list of what Tannehill obviously considered to be airtight studies,  many of them revolving around prenatal hormones,  in support of innate gender identity . But are they airtight?

First, Tannehill conveniently neglects to mention that many of the cited studies (surprise, surprise) also show a link between prenatal testosterone levels and rate of homosexuality—in other words, hormone levels may have some impact on same-sex attraction.

But, more importantly, it turns out that several of the researchers linked by Tannehill have shown that the impact of hormones on both sexual identity and gender identity, while existing, is small. For example, Melissa Hines, in a 2006 paper, “Prenatal testosterone and gender-related behaviour, looked at several studies and concluded that

 Levels of prenatal testosterone predict levels of sex-typed postnatal childhood play behavior.

 Like what kinds of play behavior?

Research on girls and women with CAH has provided some support for the hypothesized influence of testosterone on human behavioural development. Girls with CAH show increased male-typical play behaviour, including increased preferences for toys that are usually chosen by boys, such as vehicles and weapons, increased preferences for boys as playmates and increased interest in rough-and-tumble play.

 Does this preference for rough-and-tumble, stereotypical “boy” play mean these kids are transgender?

Although there are fewer studies relating prenatal testosterone levels to postnatal sexual orientation and core gender identity, there is also some evidence, particularly from women with CAH or CAIS, that testosterone influences these psychosexual outcomes as well. However, these influences are substantially smaller than those on childhood play behaviour.

 

 

 

 

Prenatal testosterone levels are only a small factor in later sexual orientation and gender identity. What they are more predictive of is –wait for it—preference for non-sex-stereotyped activities! In other words: gender nonconformity (or my preferred term: gender defiance).

So some children play with stereotypically opposite-sex toys, prefer the hairstyles and activities of the opposite sex, and prefer the company of children of the opposite sex. Is it possible these preferences are at least partially “hard-wired” due to the effect of androgens on their brains? Sure. Does it follow that this means they are the opposite sex? Of course not. Nor does it necessarily mean they will grow up to be same-sex attracted, either (as I’m sure many heterosexual women who were tomboys can attest).

Let’s put a finer point on it: while some studies show that prenatal hormone levels could contribute to sex-stereotyped differences in human behaviors and, yes, sense of self, acknowledging these differences doesn’t lead to the conclusion that trans activists reach: If a child is born with a set of proclivities and tendencies more typical of the opposite sex, this means they ARE the opposite sex and medical and chemical alteration of the body is fully justified and should be pursued as soon as possible. 

What else does biological or genetic research show? In an earlier post, I argued that the only way to even begin to prove an innate male or female brain would be to scan a huge number of identical-twin newborns (before they had a chance to have any “nurture” influence—i.e., no social experiences), separate the twins at birth, then compare those brains later when the children grew up, some of whom would no doubt decide to undergo transition to the opposite sex.

For ethical reasons, this sort of research would be pretty much impossible (you can’t forcibly separate twins at birth and raise them separately, and you can’t control how kids are raised by dictating to parents how to raise them, even if you could). But an international team of researchers has looked at twins and the prevalence of gender dysphoria/transsexualism in a meta-analysis published in 2012, “Gender Identity Disorder in Twins: A Review of the Case Report Literature.”  (The full study is behind a paywall.)

Using a combination of their own clinic records and an exhaustive search of the literature, they examined a total or 44 twins of which at least one twin had gender identity disorder (GID)—the diagnostic term at the time, since replaced with “gender dysphoria” (GD). Of these, 23 were identical (monozygotic/MZ). The remainder were fraternal (dizygotic/DZ).

What were their findings?

 Nine (39.1%) of the 23 MZ [identical] female and male twins were found to be concordant for GID. In contrast, none of the 21 DZ [fraternal] twin pairs were concordant for GID.

This was a statistically significant difference, leading to the conclusion that “there is a role for genetic factors in the development of GID.” That difference in rate of gender dysphoria in identical twins matters. But let’s not lose sight of the fact that it was still a minority (39.1%) of identical twins who were both gender dysphoric.

Twin studies
In their discussion of their findings, the authors (like all truth-seeking scientists who submit their work to peer review) acknowledge that reality is nuanced:

The higher concordance for GID in MZ than in DZ twins is consistent with a genetic influence on its genesis although shared and nonshared environmental factors cannot be ruled out. Indeed, from these case reports, very little is known about the “equal environments assumption,” that is, the assumption that MZ twins are not treated more similarly than DZ twins in ways that might affect their gender identity.

In other words—“nature” appears to be a factor, but we can’t rule out nurture. ”Influence” is not causality.

And of even greater interest: In the penultimate paragraph of the discussion, we find this gem:

In the studies on genetics and sexual orientation, a higher concordance for homosexuality has been found in MZ versus vs. DZ twins. Using family methodology, there is also evidence for genetic influences [38]. In the reviewed case studies of twins with GID, from those whose sexual orientation is known, all, with the exception of Green [25], were attracted to their biological sex and nearly 50% of the non-GID twins were also homosexual, reflecting a higher percentage than found in the general population [39]. In all the cases reported to be concordant for GID, there was also concordance for sexual orientation.

Here we have it again. As Cantor noted, as I have noted, as the Dutch pioneers of pediatric transition have noted, this study finds—as nearly every study over decades has found: Whatever the precise contributions of nature v. nurture that leads to gender dysphoria or opposite-sex identification, a huge majority (if not 100%) of the studied individuals exhibit same-sex attraction by adolescence or adulthood.

I’ll hammer it home again: The constantly repeated refrain by trans activists that gender identity has “nothing to do with sexual orientation” is directly refuted in every study, as well as many of the personal accounts by trans-identified people splattered all over the media.


 So, what have we learned from looking at a few studies aiming to tease apart the nature-nurture question about gender dysphoria/opposite-sex identification?

  • there is sparse evidence of an innate male or female brain, and what differences there may be are mitigated and influenced by later life experiences. If anything, brain differences seem to indicate variations in sexual preference, not intrinsic gender identity; and
  • prenatal hormones—specifically, testosterone—have an effect, on….gender nonconforming behaviors in childhood. They have a contributing, but minor, effect on later homosexuality and gender identity; and
  • in general, there is evidence for both biological and non-biological (environmental-social) contributions to the development of gender dysphoria.

For me, it all boils down to this: Nature v. nurture is a false dichotomy. We are all the result of our genetic inheritance, hormonal influences, and how we were brought up and continue to live—which also includes both post-natal physiological influences (e.g., the various chemicals we imbibe in our hyper-industrialized world in addition to drugs and hormones we deliberately take in), as well as what we learn and experience over the course of our lifetimes.

In the end, the squabbling over nature v. nurture is a non-issue. What matters is protecting kids from the—however well intentioned—meddling of adults in children’s bodily and psychological integrity.  Whatever the relative contributions of nature and nurture to a child’s sense of self and ultimate decisions, adults should protect children from undergoing interventions that close off future possibilities.

Proponents of medical transition for children are not champions of gender nonconformity. If they were, as I’ve said many times, they would be celebrating it in children and instead of agreeing with the magical thinking of a child that this means they are “born in the wrong body,” they’d be helping these kids realize they are wonderful and unique examples of their natal sex. A healthy, fully functioning body attached to a brain is an integrated whole with that brain. It is an existential reality, no more “wrong” than the body of a person who demonstrates more sex-stereotyped typicality. By promoting the view that research evidence pointing to certain sex-stereotyped behaviors as having a biological component (however small) means kids’ bodies can be “wrong,” they are using science to limit the possibilities for children.

Puberty blockers, cross sex hormones, and surgeries for children and young people permanently limit their options. Options like: sexual experiences in an unaltered, non-surgically-tinkered-with body. Options like: Figuring out your sexual orientation, especially if you’re gay or lesbian and won’t, on average, come to terms with that fully until early adulthood. Options like: Being a role model for other kids that boys and girls can be and do or be anything, regardless of whether they fit into sex-stereotyped-typical behaviors and appearances.

Yes, a person who later decides to “transition,” who undergoes hormone treatments or surgeries after puberty may not “pass” as well as a someone who had natural puberty curtailed (and was incidentally permanently sterilized in the process). But the Cult of Passing as the opposite sex should be challenged—especially since those same trans activists who worry so much about “passing” (in perhaps their most obvious self-undermining argument) want us to also believe (for instance) that a “penis can be female.” To play Devil’s Advocate with the trans activists, if a boy’s penis can be female, you have no business promoting medical transition for anyone’s child.

Puberty blocking is not a benign intervention. While I’ll grant that, if stopped in time, GnRh agonists are “reversible” (as in, they will not prevent natural puberty), the psychological and neurological effects of delaying natural puberty cannot be seen by any thinking person as “fully reversible.” Neither is social transition “fully reversible,” for that matter. You can’t “reverse” a childhood spent cementing the idea that biological sex can be changed by a society bent on denying the existential reality of sexual dimorphism. You can’t “reverse” a message, repeated over and over to a child by trusted adults that there is something fundamentally wrong with his or her body that must be corrected.

Regarding nature-v-nurture?  Here’s what I’d say to my fellow kid transition critics:  Don’t dismiss the stuff from the “nature” side because you’ve pre-decided that any science supporting an innate contribution to gender dysphoria is a priori bunk and it’s all nurture/socialization.

In my opinion, taking seriously the dogma of the other side, examining it closely, and then coming to well-thought-out, nuanced conclusions is a much stronger place to operate from than dismissing out of hand any kernel of truth “they” might be obsessing over. That’s not truth seeking; that’s just being close-minded in service of an impenetrable ideology.

Nature-nurture—it’s both. Just like our thought-generating brains are indivisible from the bodies they’re a part of.

Your thoughts?

Do No Harm: An interview with the founder of Youth Trans Critical Professionals

A new organization has formed for therapists, social workers, medical doctors, educators, and other professionals concerned about the rise in transgender diagnoses among children, adolescents, and young adults. Youth Trans Critical Professionals was founded by a psychotherapist and a university professor just a few short weeks ago. The organization has a website (already publishing thought-provoking pieces from professionals), a Facebook page, a Twitter account, and many followers. If you are a professional skeptical of the transgender youth trend, please visit the website and consider contributing to the effort. Your anonymity will be protected at your request.

4thWaveNow recently interviewed one of the founders of Youth Trans Critical Professionals. She is available to respond to your questions and remarks in the comments section below this post.

ytcp logo.png

Why did you start this organization for professionals skeptical of the trans-kid trend? What is your personal interest in this matter?

I’m going to start by saying something that I will probably say several times. Our main concern is with medical intervention in children and young people that leaves their bodies permanently altered and/or sterilized. We don’t have a moral issue with people identifying as transgender, and believe that those who do should be protected from discrimination like any other minority. However, the medical treatments for children who identify as transgender are risky, not approved by the FDA, and permanent. With any other condition, we would be bending over backwards to find other ways to support these children without resorting to major medical intervention, and would turn to puberty blockers, cross-sex hormones, and surgery in only the rarest and most extreme cases. It is very disturbing to the originators of youthtranscriticalprofessionals.org that these treatments, whose long term effects are not well-studied, are being offered very casually for a condition which isn’t even clearly defined.

I have a private practice where I work mostly with adults, although from time to time, I do see adolescents. I first became aware of this issue because parents were coming in describing kids struggling with gender identity. I started to notice a pattern: an anxious, depressed, or socially awkward kid who spent a lot of time on social media would announce that he or she was “trans,” often requesting access to cross-sex hormones shortly after this announcement. Every one of the mothers in my practice who reported this behavior was incredibly supportive of her child. These moms may have shared feelings of confusion or concern with me, but their initial reaction toward their child was always acceptance.

The first time I heard this story, I didn’t make much of it. It sounded like normal teenage experimentation to me, and I admired the mom’s openness to accepting her child. However, as I saw more of these cases – and I saw the cases progress to the point where the child was demanding medical intervention – I became concerned and wanted to learn more.

What I found once I started looking was that more and more young people are identifying as trans, often after bingeing on social media. For some reason that I can’t quite fathom, there is a tremendous feeling of excitement around this issue among many adults. I found out that administrators at private schools were boasting about “several kids transitioning” at their school. I heard this from more than one school while I was researching this. They shared this as evidence, I think, of how truly progressive and accepting their school is. However, I find it really odd that no one blinks an eye when four kids are transitioning in a grade of sixty kids. Given how rare transsexualism is believed to be, doesn’t that alone ring a warning bell?

The more I learned, the more disturbed I became. Where were the critical voices? Where were the adults familiar with child development speaking out for young people who are in danger of being swept along on a current that may carry them towards sterility before they have even finished high school?

I was shocked to realize that many of my fellow therapists appear to have uncritically bought into the narrative about trans children that goes something like this: 1.) gender identity is a legitimate thing. You cannot question it without being bigoted. 2.) Children know their own gender identity. 3.) If you do not immediately and uncritically affirm a child’s professed gender identity, you will be doing that child grave harm, and may even induce suicidal behavior, 4.)  The best and only treatment for a child who professes to have gender dysphoria or claims to have a gender identity other than that associated with his or her sexed body is transition – social, medical, or both. It doesn’t matter whether that child has comorbid mental health issues such as anxiety, depression, trauma, autism, substance abuse or bipolar disorder. 5.) Once a child has professed his or her gender identity, the adults around that child should follow his or her lead, providing whatever treatment and accommodations are requested by that child.

There is nothing about the narrative outlined above that is beyond controversy and shouldn’t be open to questioning. The construct of gender identity is poorly defined and lacks coherence. It surely shouldn’t be the basis for subjecting our kids to irrevocable body changes and sterilization. Assuming that children have some mysterious knowing about their gender identity seems like poor practice. Children are often very sure of things at one moment in time and believe something completely different a week, a month, or a year later. Child development is a fluid process. Refraining from immediately affirming a child’s gender identity brings with it no documented harm. The oft-quoted figure about suicide among transgender youth is a misuse of statistics. Many children (and adults, for that matter) feel significant distress about an aspect of their body or identity. Usually, therapists explore many ways to support a person facing this kind of discomfort. Sometimes medication can bring relief. Sometimes, exploration brings a new understanding. Sometimes, discomfort must be borne as we come to terms with a difficult or disappointing reality. Why the rush to change the body? Permanently?! Of course we as adults should be putting the brakes on a process that is leading toward permanent sterilization. Of course we should. Where were the other professionals who also believed this?

There is such a dearth of professional voices calling for restraint and caution in turning to medical intervention. Pediatricians, social workers, psychologists – most professional groups state that we must affirm a child’s gender identity. While we appreciate the intention here to be supportive of gender non-conforming kids, it seems the greater value ought to be protecting children from unnecessary medical procedures that often result in sterility; a central aim of youthtranscriticalprofessionals.org is to raise awareness of this.

Yes. Where are the child and developmental psychologists on all of this?  Much of what transgender activists promote seems to fly in the face of what we know about child and adolescent developmental psychology. It has been understood for decades that young children confuse fantasy with reality; that adolescents try on and shed different identities;  that children are conditioned by what they experience; that a child or adolescent’s sense of self is anything but rigid. Have you heard from any skeptical child psychs, and what will it take for some of them to start speaking out?

So far, I haven’t heard from any, but I imagine we will. You are right, and you phrase the issues very clearly. Kids do try on different identities. And we as adults don’t do them any service by privileging gender identity as some special, separate category. There is nothing innate or special or sacred about gender.

And kids have very strong feelings about what they want, and they often confuse things they want with things they need. It is so incredibly difficult to watch out child be in psychic pain. It can send us flying into action as we try to make their suffering stop. But part of our job as a parent is to use our discernment as the adult who knows them best to learn when to listen to the manifest story they are telling us about themselves, and when to listen to a deeper story underneath that.

I was talking recently with a friend who has a daughter in college. She was telling me about the awful, awful time she went through when he daughter was 13. The girl was obsessed with getting an iPhone. She cried nightly about how terrible it was for her not to have one, how it was damaging her social life and making her isolated and depressed. She was visibly distraught over this issue being any reasoning. She begged for it literally as if her life depended on it.

Thinking of this issue with trans kids, I said to her, “At least you knew that she wasn’t going to come to any grave harm if you didn’t give her an iPhone.”

My friend surprised me by saying that at the time, she felt confused about whether she was doing great harm to her daughter by not giving her a phone. “Between the peer pressure and the advertising, I was almost convinced that I was doing her grave psychological damage.” Imagine how hard it would be to stand up to a teen’s desperate demands for hormones if you had mental health professionals telling you that you were damaging your child by withholding them!

I suppose the point is that just because our kids want something very, very badly doesn’t mean that we have to capitulate or surrender our adult judgment. Teenagers don’t have a fully developed prefrontal cortex. We can’t abdicate our responsibility as their parent to say no when what they fervently desire may be harmful for them, or at least may have consequences they aren’t capable of fully appreciating.

Do you believe there are truly transgender children? Are they different from the teens who claim to be trans because of social contagion?

What a complicated question! Let me break it into a couple of parts.

First of all, there is no question that there has been a huge increase in kids identifying as trans. Much of this increase is certainly due to social contagion. Kids are getting exposed to this on social media, where they are taught that “if they are asking whether they are trans, they probably are.” Look, most teenagers go through a period of feeling intensely uncomfortable in their own bodies. I think that for many of these kids, this is an expression of that discomfort. Forty years ago, maybe more kids developed eating disorders. Twenty years ago, they were cutting. This is the current way to express that nearly universal adolescent discomfort. We all need to feel that we fit in, and that we stand out. Identifying as trans hits both of those criteria big time. You go to school and announce you are now Joe instead of Jo, and let people know you want to be referred to by a different pronoun, and in many schools, you are met with excited acclimation from peers. You are different in an exciting, trendy way. At the same time, you can feel a part of the other kids who are also embracing different gender identities. It must be very heady.

So I do believe that there is a huge social contagion piece, and this is one of the things that I don’t hear other people talking about much. This matters a great deal, because it has probably happened that some anxious, socially awkward kid has come out as trans as a way of gaining acceptance and belonging, and has gotten so much support and affirmation that she has continued down the road to take hormones. In short order, she had permanently altered her body – a deepened voice, facial hair, baldness, increased risk for certain diseases – and maybe this wasn’t for her, really? Or not for her forever? But now this person has to live with those consequences forever. Testosterone and other cross-sex hormones are not tattoos that carry trivial risks, or can at least be hidden easily. This ought not to be a life-style or fashion decision, and for some kids at least, I am convinced it is. I realize this is an incredibly unpopular stance, but this is what I am seeing from my little perch.

Of course, there are those who identified significant distress with the sex of their body before transgenderism became a cause celebre. I have read the stories about two-year-olds who ask why God made a mistake. Some of these stories are pretty compelling. I am not an expert in this area, and when I read these stories, my strongest reaction is that I am grateful I have never had to be the person responsible for making a decision about such a case. I’m not at all sure what the right thing to do is, but I will say that I could imagine that transitioning might be right in some cases.

There is an Atlantic article about this from 2008 that I found very interesting. It profiled several of these kids who are “persistent, insistent, and consistent” starting at an early age. Some of the Canadian kids were treated by Dr. Kenneth Zucker. The article describes some of the things involved in the treatment such as “taking all the girl toys away.” I admit that made me cringe. Really?! Who would want to do that to their child? However, at the time the article was written, Chris, the child in question, had grown up to be a gay, effeminate man who had a healthy, intervention-free body.

My understanding is that when Zucker’s team assessed a gender dysphoric child, they closely examined the family system, considering carefully different dynamics that were in play, and then crafting an individualized treatment plan that might involve several different kinds of interventions. I believe that enforcing gendered toys was something that was done in some cases, but was accompanied by other therapeutic interventions that took into account the whole family dynamic. The ultimate aim was to help the child feel comfortable identifying with his or her natal sex.

The article also followed an American child who had been affirmed early, and had begun to live as a girl. And it made reference to the social media star Jazz Jennings, who was profiled by Barbara Walters. I found the reaction of the Canadian parents to this practice of early affirmation very compelling, so let me quote from that part of the article. (The bolding is my own.)

The week before I arrived in Toronto, the Barbara Walters special about Jazz had been re-aired, and both sets of parents had seen it. “I was aghast,” said John’s mother. “It really affected us to see this poor little peanut, and her parents just going to the teacher and saying ‘He is a “she” now.’ Why would you assume a 4-year-old would understand the ramifications of that?”

“We were shocked,” Chris’s father said. “They gave up on their kid too early. Regardless of our beliefs and our values, you look at Chris, and you look at these kids, and they have to go through a sex-change operation and they’ll never look right and they’ll never have a normal life. Look at Chris’s chance for a happy, decent life, and look at theirs. Seeing those kids, it just broke our hearts.”

So I think, if I had a little boy who insisted he were a girl, and I could do this terrible thing of enforcing gendered play, or I could do this terrible thing of altering his body and destroying his ability to have his own children, which would I pick? If I knew I would have a healthy, happy, whole gay man at the end of it, if I had a reasonably good guarantee that would be the outcome, I would much rather pack away the Barbies. The personal and social difficulties of back-tracking on a childhood or adolescence spent transitioning will inevitably be immense. If a child has been transitioned from a young age how will they know, or be able to begin to articulate, that a mistake has been made? At a recent at Cambridge University seminar entitled ‘Gender Non-Conforming Children: Treatment Dilemmas In Puberty Suppression‘ it was stated that 100% of children on puberty blockers go on to transition; it’s clear there is absolutely no going back on medical intervention.

In any case, those of us who started youthtranscriticalprofessionals.org would argue that transition is always an option into adulthood. I am familiar with the view that when someone transitions as a child, they have a better chance of “passing” in adulthood, but given the very real risk of later regret, I think we might decide that medical transition is a choice to be made by full-fledged adults only.

How do you answer charges that you are promoting harmful reparative therapy on trans youth? How is this different from trying to turn gay kids straight?

Well, I’m not sure I believe that we should try to “talk kids out” of believing that they are trans, first of all. If a fourteen year old kid came into my office and said, “I’m pretty sure I’m gay,” or “I am gay,” I would say, “Tell me about that! What is that like for you? How long have you known? What lead you to first wonder about your sexual orientation? What is hard for you about knowing this? What kind of support do you need?”

If a fourteen year old kid came into my office and said, “I think I am trans,” or “I am trans,” I would ask similar questions: “Tell me more about that? What does that mean to you? Help me understand your internal experience that leads you to know yourself as trans? What kind of support would be helpful in addressing this? When did you first start to wonder?”

The purpose is both cases would be to do the thing that therapy is meant to do – to explore our experience so that we can understand it more deeply.

There are a couple of differences. First, while I would be interested in hearing from the gay child about his particular way of experiencing his gayness, we all have a pretty clear idea of what that means. A gay boy experiences sexual attraction to other boys, and not so much with girls.

The notion of gender identity, however, is much less clear. If a boy of fourteen were to tell me he is really a girl, I would want to know about that experience. What does that mean? In what way do you experience this inner sense of femaleness? How does this experience manifest for you? What are the different ways of understanding this experience? Is it a consistent experience, or is it subject to variation? How does this experience influence your understanding of yourself?

Sexual orientation and gender identity are actually quite different and these differences justify different approaches. Sexual orientation has shown itself to be quite stable. Most gays and lesbians knew from very early on that something was different. These feelings aren’t dysphoric, although they may cause distress because of homophobia. It isn’t dysphoria, it is just an awareness of who you are. It isn’t a sense of being wrong, or in the wrong body. And it doesn’t tend to change. These feelings are generally stable throughout the life span.

This isn’t the case for gender dysphoric kids. We know that a majority of them will naturally desist. Unlike sexual orientation, gender identification does tend to change for the large majority of dysphoric kids.

The other major difference – and this is the heart of the artichoke – is intervention. Gays and lesbians are not seeking intervention. They just want to love whom they love. My hypothetical gay boy client and I would be free to discuss and explore his experience of being gay and his coming out process without any high stakes medical decisions hanging over our heads. If I knew that my hypothetical trans patient would not have access to medical intervention until she was, say, 25 years old, she and I could spend our therapeutic hours exploring her experience as a trans woman, and I could offer support for the difficulties involved in being different in this way.

My goal for therapy with a trans kid would be to provide a warm, judgment free space in which they could explore their gender identity and what it means for them without a rush to medical intervention. I wouldn’t aim to convert. No. But I wouldn’t want to close in on this being the final answer, since I know that so many gender dysphoric kids will desist of their own accord.

I would hope that no one would ever be shamed or persecuted or made to feel unworthy or respect and love because of these feelings. I would argue that there is another approach in between rejection and affirmation, and possibly the word for that would be acceptance. I accept you as you are. I support you. I am curious about what you are going through. I want to hear more about your experience. And I accept that your sense of your own identity might change, and I will accept you then as well. But in any case, I would hope to delay medical intervention until the person was at least 25 years old.

Maybe the last thing to say about this is the most controversial. It isn’t really clear what exactly “gender identity” even means. It appears to refer to a subjective inner state, but when pressed, those who identify as trans will often resort to gender stereotypes in describing their discomfort. Forgive me, but I am not going to want to send any person down a conveyor belt toward permanent mutilation and sterilization over a self-diagnosis of an inner state.

Gender is a social construct. If gender is the problem, why on earth change the body? Is seems obvious that the right thing to do is to change or even abolish the construct altogether. Changing the body to fit the social constructs we have around gender only serves to further entrench the constructs we are trying to escape – and these are socially, not biologically constructed; there is no evidence that gender identity is innate.

What is your vision for Youth Trans Critical Professionals? What do you ultimately hope to achieve?

Initially, we are hoping to solicit posts from 100 professionals writing on the trans child trend from how they see it. By doing this we aim to assemble the first collection of voices of Youth Trans Critical Professionals to evidence our mutual concern. There is a meeting being planned, and we are also discussing the possibility of co-authoring a book. Ideally, we would like to help move the needle on this conversation, hopefully resulting in clearer standards of care that protect gender dysphoric and nonconforming young people from unnecessary medical intervention and permanent sterilization.

How can a group of anonymous professionals make a difference? Without a public face and voice, who will believe you are who you say you are?

Anonymity certainly limits our credibility at this point. Many of us are contending with constraints of professional institutions which broker no dissenting views. It is our hope to speak out publicly once there are more of us. In the meantime, I hope that we will be judged by how we write and think. I believe that people that read the site will know that we are striving to do this in order to protect children from unnecessary medical procedures and permanent sterilization, not out of hatred or bigotry. In addition, some professionals working with us are also friends and relations of children and young people identifying as trans and need to remain anonymous to protect their loved one’s privacy.

In the few weeks the site has been live, have you heard from other professionals who want to be on-board?

The site has been up for less than two weeks, and it has already been viewed over 2,000 times. The overwhelming majority of the comments have been positive. (I have not deleted any comments, if that tells you anything. One person wrote a critical comment, which I approved.) And yes, professionals are reaching out and asking how they can be involved not just from professions allied to medicine, but teachers, youth workers, practitioners of law, artists and writers and so on.

How can parents find therapists and other medical providers who will resist the current trend to diagnose kids as trans? There are no public directories, while there are tons of  published resource lists of “gender specialists.”

What a good idea! Perhaps we could gather the names of such providers and maintain a directory. This would be a great resource because families are telling us they reluctant to access services because they do not trust service providers to tread a sensitive line between gender confusion and medical intervention.

As a therapist, how would you suggest a parent deal with a child insisting they are trans? The current trend seems to be “affirming” the child’s identity, no matter how old the child is.

Well, this is another complicated question. Obviously, we always want to communicate love and acceptance of our children. We can accept and affirm our child and respect their struggles and personhood without necessarily affirming a professed identity.

Part of what makes this a thorny problem is that there is no neutral stance. If we affirm the kid’s gender identity, we likely tip the scales in favor of a trans identity. If we look for other ways to express our support and empathy for our child, we likely tip the scales the other way. Given that even doing nothing is not a neutral intervention, we have to ask a difficult question. Is desistance a better outcome? If we had to choose which way to tip things, what is the right way? For me, it is clear that, all things being equal, desistance is a better outcome because it avoids invasive medical procedures and sterilization. Whenever a young person is engaged in keeping the conversation about their trans identity open, they may feel comfortable deferring medical intervention which will have the side effects of irreversible sterilization – at least this puts growing maturity on their side.

There is also the very critical issue of social contagion. I believe that many kids identifying as trans for the first time as teens – and perhaps many younger kids as well – have “picked this up” from social media. Parents are not infallible, but we are likely the best judges of whether our kid is truly suffering from deep-seated gender dysphoria, of whether the gender issue is a way to express other issues.

If a parent has a teen who comes out as trans, I would be interested in knowing the following:

  • Has the child been anxious, depressed, or struggling socially?
  • Does the child have other mental health issues, such as PTSD, substance use, or bipolar disorder?
  • Has the child been spending a lot of time on social media? What sites? How much time?
  • Are the child’s peers (or desired peers) coming out as trans as well?
  • Did the announcement come “out of the blue,” without prior indication that the young person has ever struggled with their gender or identity before?

If the answers to these questions are pretty much “yes,” I would actually suggest that the parent state firmly and clearly that they do not support their child’s transition. I realize this is heresy. I would, as David Schwartz suggests, stop talking about gender. Anxious and depressed teenagers may learn that they can get a rise and a reaction out of adults when they mention gender. Addressing only the gender dysphoria instead of the underlying issues does these kids a huge disservice.

We know that social media sites like Tumblr and Reddit are fertile ground for social contagion and that many children start talking trans following immersion in these worlds. We know it’s easier said than done, but disconnecting them from the internet, especially social media, does give space for developing more self-reliant thinking. For some families it may be possible to remove a young person from their environment completely. Three months spent in nature away from screens, or overseas, or volunteering in a challenging environment may serve as a “hard reset,” allowing them to focus on something other than themselves. (After all, gender dysphoria is in essence very solipsistic.) Of course not all families have the networks or necessary resources to broker new horizons for their child in these ways. Parents are telling us it is extremely difficult to work out the best ways to support their child. But we are gaining increased confidence that saying ‘no’ to your child’s trans aspirations can inspire your child’s confidence for reflection. All parents try to keep their children away from dangerous trends sweeping youth culture and the trans trend requires the same vigilance.

I do believe that parents can have an impact. Letting a kid know that you don’t buy the gender identity drama, stating plainly that you love them as they are, but you don’t want to see them destroy their health and sterility can have an impact. They might roll their eyes, but I believe they hear you. At least if they ever look back in regret and despair they will know that you tried to protect them.

How can we support you?

If you know a lawyer, doctor, therapist, academic, nurse, teacher, guidance counselor or other professional who deals with young people and questions this trend and is thoughtful, please send them to our website! We are hoping to solicit 100 professionals to post on the site over the next few months. They can reach us from the site, and can send us material to post – anonymously if they wish.

Send parents, trans youth and their allies to the site too. Our aim is to cohere strength amongst and between us to bring serious, committed and critical attention to the dangers of trans orthodoxy.