An RN & mum of a trans-identified young adult on perils of off-label cross-hormones as first-line treatment for gender dysphoria

Mumtears is a registered nurse, a wife, and mum of two daughters, currently aged 23 and 20 years old. She lives with her husband of 27 years, the father of her two daughters. She says: “Because of my currently unpopular thoughts, and because of not wanting to cause harm to my family, I feel I need to remain anonymous. I also started a blog a while ago, but- frankly- I haven’t kept it up. I am not very technologically sophisticated. If you want to read what there is in my blog, you can find it at” She can be found on Twitter @Mumtears1 and is available to interact in the comments section of this post.

by Mumtears

I have been a registered nurse for 30 years. From childhood, I always wanted to be a nurse. I really feel like being in the nursing profession was a “calling” for me.

While going through my post-secondary studies, studying for my Bachelor of Nursing degree, I recall being taught that, in all conditions, medical and nursing treatments should always begin with the least invasive way to treat that condition. I was taught that this was best practice care for the human body.

I have had many years’ experience working in Acute Care Pediatrics at our local children’s hospital. It was there that I learned that children are not simply “little adults”. Pediatric patients require specific attention and care, due to their rapidly developing minds and bodies. Their bodies and minds function very differently from adults. Medications and treatments are all prescribed based on the child’s body weight. They also cross different developmental stages at different rates on their way to becoming adults.

For the past 7 years, I have been working at a very busy family practice, caring for all types of patients with all types of concerns, from birth to the very elderly. I work with a family physician who also specializes in transgender care and sexual health. I have seen, assessed and cared for countless adult transgender patients. They comprise a combination of male-to-transgender and female-to-transgender patients.

Almost 5 years ago, my youngest (then 16) daughter expressed to her dad and me that she “thought she should be a boy”. That was the day our family life changed in ways we never anticipated. Throughout childhood, our daughter never presented as stereotypically “masculine”. She never outwardly expressed to us any kind of discomfort. She appeared to be mostly happy. A bright spark. She loved to play outside: doodle with chalk on sidewalks, sandbox play, climb trees, ride bikes. She smiled often. She loved building with Lego, playing Polly Pockets and with tiny toy horses. She enjoyed making tiny crafts, including models of people and animals made of Sculpey clay.

She was also very academically smart, reading beginner short novels before entering Grade 1. She taught herself how to tie her shoes and how to ride a bike. With the help of her father, when she was about 8 years old, she built one amazing bicycle from two used bikes purchased at a garage sale. In Grade 4 she challenged a Math unit about fractions and passed the final exam with flying colours, even before the unit began. She was musically advanced, playing beautiful piano tunes at age six, wonderful tenor saxophone solos in junior high. We had her tested for giftedness by a school psychologist. He told us that she was “just below” the gifted category.

We parents did begin to notice some general, social discomfort in late junior high, but we assumed that this was normal teen awkwardness, which can happen during puberty, so we were not concerned about it. We were absolutely blindsided by her proclamation that she thought she would be a boy.

My older daughter never had a temper tantrum when she was a toddler. I thought it was down to good parenting. How wrong I was. When our younger daughter was born, she behaved quite differently from her sister. Different personalities, which was not surprising to us because my husband and I are also very different from each other. Our youngest daughter started having temper tantrums at 18 months of age, which lasted 4 long years. Then, it was like a light switch turned on. Suddenly she realized she could settle her emotions down by reading quietly, alone on her bed. After just over 4 years of a frequently chaotic time, our house and family seemed to be at peace again. It was lovely.

Thinking back to this time in early childhood, I thought my daughter’s gender discomfort might be a similar phase for her. I still think it might be. I pray that, with time and life experience, she will develop an acceptance and comfort about her female body, and a knowledge that being the female sex does not have to place limits on her happiness and what she can accomplish in life.

drawing-testosterone-injectionBefore daughter told us she thought she should be a boy, I had already seen and assessed countless adult transgender patients. They comprised a combination of male-to-transgender and female-to-transgender patients who ranged in age from late 20s to early 50s. I admit that I when I first started working in family practice, I was very naïve about what “transgender” means. I noticed that all of the adult transgender patients I met also had comorbid mental health issues, which had not been fully resolved and, in some cases were severe/debilitating. My professional duty was (and still is) to provide excellent, compassionate nursing care to these patients. My personality is compassionate, empathetic and caring. I learned some of the transgender lingo; for example, “top” and “bottom” surgery. I’ve administered countless testosterone injections. I’ve changed the dressing on the donor arm of a young 20-something female-to-transgender patient who had recently undergone phalloplasty surgery. And now, after I administer these injections, I’ve found myself in the staff washroom, trying to compose myself for my next patient. Watching female erasure (in particular) causes me much sadness, partly due to what is going on with my own daughter. But mostly due to the fact that I am an adult female-born woman.

As I already said—but it’s worth saying again–I was taught that, in all conditions, medical and nursing treatments should always begin with the least invasive way to treat that condition. I was also clearly taught that pediatric patients have smaller, ever changing and rapidly developing bodies and minds, and need to be treated differently from adult patients. I was taught that physical, mental, and emotional development in children is ongoing, well into the early to mid 20s. Because of my knowledge about child development, both body and mind, I don’t understand why the medication Lupron is being given to healthy-bodied children. This medication is approved for use to treat adults with advanced prostate cancer and endometriosis. In children it’s used to slow down precocious (early-onset) puberty. It’s only in the past few years that it’s being prescribed for children who have gender dysphoria. This is an off-label use for this drug and it’s being given to healthy-bodied children even though there has been no research done to determine its safety or efficacy regarding gender dysphoria.

And we know that puberty blockers lead in most cases to cross-sex hormones. Why is the current first-line treatment for gender dysphoria in young, healthy bodies off-label, unstudied cross-hormone prescriptions? Young adult females can go into a family doctor’s office, state “I’m transgender”, and be handed a Rx for Androgel. This is what happened with my daughter, over a year ago. She never filled that particular prescription. However, last week she notified her father and me that she plans to start taking testosterone. She’s in a lengthy queue to be seen by our city’s gender specialist/psychiatrist and is impatient. She gave us no concrete reasons for wanting to start taking testosterone. She demonstrates little outward discomfort when she is in our home or when interacting with extended family.

She had one visit with the same family doctor who gave her the previous Androgel Rx. She told us that he told her what side effects could occur (while reading from a computer screen). She told us that he did not discuss reproductive planning with her, and that he gave her no written information about any of the side effects. She told us that he gave her the prescription and some bloodwork requisitions. This family doctor did not take a multidisciplinary team approach; he acted on his own. He did not refer her to an endocrinologist to check her hormone levels. He did not send her to any mental health professional, who could have assessed her for the source of her discomfort and possibly provided her with other less-invasive treatment options, such as cognitive behavioural therapy. How is the way in which this family doctor gave my daughter this off-label cross-hormone prescription medically ethical? In my province, family physicians can be the primary prescriber of cross-hormones. While using a multidisciplinary approach might be a good practice, it is not mandated. I’m currently trying to find answers via our provincial and national medical associations. The answers I’m looking for aren’t forthcoming.

I know that in no other medical or other health-related case would something like this happen, with regard to the prescription of off-label medications. I’d like to give you another home-based, common-sense example: Young adult child says to parent: “I have a really bad headache.” Think about this. Would it make any sense for the parent’s first response to be, “Your dad has some leftover oxycodone from his recent surgery, which he no longer needs to take- here, have some!”? Of course not. What would make medical/practical sense would be to first check that the young adult isn’t dehydrated. It is known that dehydration can cause headaches. “Try drinking some water and see if you feel better”. That would be the least invasive thing to try at first. If drinking water didn’t help the headache and if the young adult child had no know allergies or health conditions, it would be appropriate to next offer them acetaminophen, dosed per the package instructions. It is known that acetaminophen is a very effective analgesic, with a low incidence of side effects. If the headache persisted, perhaps it would be appropriate to then try a non-steroidal anti-inflammatory, such as Advil. There might be some inflammation in the neck or jaw muscles, causing the headache, which, if reduced, could relieve the headache. It is known that Advil is a mostly safe anti-inflammatory medication, with low potential side effects.

Recently I attended a Medical Education Session, which was held at a recent clinic retreat. The session was about low testosterone levels in adult males and testosterone replacement therapy. What I learned is, that for male bodied patients, the recommendation is that if the testosterone bloodwork result is low, it is important to clearly understand the patients’ symptoms concerns and general health. If the patient’s symptoms are low and the patient is not concerned, then giving the patient a prescription for testosterone is not advised. This is because there are also many side effects that can happen from taking testosterone, which can cause negative symptoms/concerns for the patient–especially if these male-bodied patients also have other health concerns. I learned that this is appropriate safe medical care for male-bodied patients.

I’ve done my own learning about testosterone. The pharmacy companies’ printed drug information about testosterone products states that this medication should not be given to women. It has never been studied in female bodies. Also, there are no long-term studies which indicate safety or a positive result for females who take this medication. Physicians are prescribing it “off label”.

I have been trying to learn as much as I can about gender dysphoria and its treatment. I have read many studies, documents, medical association websites, etc., and continue to do so.

When I learned about the newly recognized “rapid onset gender dysphoria”, I realized that much of its description matched what we were/are witnessing in our youngest daughter. Currently there is little known regarding care or treatments for young people presenting with rapid onset gender dysphoria. And few physicians are even aware of this phenomenon. There has been a dramatic increase, over a short period of time, in the number of teens and young adults who are seeking care for being transgender. And the demographic for which sex is declaring transgender has also changed. There are now more natal females than males with this concern.

With all that I have learned about rapid onset gender dysphoria and current treatments for it, I have more questions: Why are these off-label testosterone prescriptions being given to young healthy-bodied female patients as a first-line treatment for gender dysphoria? Especially since it is known that testosterone causes permanent body changes in female bodies, making it an invasive and irreversible treatment. Why are physicians prescribing these off-label cross-hormones without doing further assessments to ensure that this is the best treatment for their patients? I believe these are reasonable questions to ask. I believe these are prudent questions to consider. It is not transphobic to ask these questions. Many parents are asking questions like these. If you’re a parent wanting to learn more and connect with other parents, you can check out:


I have recently learned that my daughter has likely started her testosterone prescription already. I found the receipt for it in her room at home, for low dose Androgel, from a pharmacy our family never uses, so I know that she has purchased it. She is currently living away for university, in a city which is a 2-hour drive from our home, studying in an arts program there. She has never told any of our close extended family anything about her gender dysphoria. We all live in the same city and see each other fairly frequently. Our older daughter (a graduate with a degree in Cultural Anthropology) knows and supports her sister’s claims, but that is all.

androgelOur younger daughter had the opportunity over Christmas (two Christmas dinners actually), to tell anyone in her extended family about her plan to start testosterone. She hasn’t said anything to any of them. Nothing about her gender dysphoria. I’m sure that it will be upsetting to many of them. My daughter and I text back and forth. We text about her activities (theatre, parkour). About her classes (she studies hard and gets excellent grades). About her saxophone practice (she recently was accepted into the university’s wind orchestra). I am proud of the person she is. I see so much potential for her to become an amazing woman and I am sad that she wishes to erase her female body. Frankly, I believe that “gender” is a crap concept, which is why I don’t discuss this with her. Ever since she first told us her thoughts, we have been clear in telling her our concerns. It’s up to her to think about what we have told her. We hope that she will undergo some work to understand the source of her discomfort, but we know that the decision will be hers to make. She tells us that she loves us. We have clearly told her that we love her and always will. We financially help support her post-secondary education. We want her to have many good job opportunities. We want her to have a good life and be happy and healthy. I dread her voice changing. I dread seeing her beautiful face change. And I find myself wondering if she actually needs to go through all of this, in order for her to “find herself” and come out the other side. The birth name we gave our youngest daughter means “strong”. I thought this would serve her well. We continue to use her birth name because we have not given up hope. As parents, we were never prepared for any of this. And as a registered nurse, I am very disturbed by all of it.


Baptised in Fire: A relieved desister’s story

by Sam

Sam (not her real name), 22, identified as trans between the ages of 16-19. A relieved desister, she enjoys tidying, writing, and watching the weather. She lives in the United Kingdom. Sam can be found on Twitter @rainiest_day and is available to interact in the comments section of her article.

Sam joins several other desisters on 4thWaveNow who, along with their parents, have shared their experiences of rapid onset of gender dysphoria (ROGD) in adolescence.

I was not a trans child. I was a gender-conforming little girl, as far as children are ever completely gender-conforming.  I liked pretty clothes but I also jumped in the occasional mud-pit. I didn’t play with Lego very much, because I wasn’t particularly good at it, but who cares? Not I. I felt no discomfort with being a girl. I felt little discomfort with anything, really; I was a bossy, blunt, stubborn little girl with very important opinions about everything.

I was not overjoyed about puberty. I don’t think I’m alone in that! Bras–miserably restrictive. Periods–horrible. Men followed me home from school even when I was twelve and thirteen; I in my uniform was not a very pretty child, but that didn’t seem to be the point. I didn’t like high school because I didn’t understand how I was supposed to act. Being overtly smart, because I was, made people dislike me, so I tried being stupider, but even then, I was still doing it all wrong. I thought I wasn’t on the same wavelength as everyone else, which, of course, is what loads of people feel like. But I didn’t know that. My relationship with my parents wasn’t perfect, but it was good, and we all got on.

When I was in my teens, I got into a disaster of a relationship with a girl. I was no longer in control of myself, of my body, of when I slept and when I ate and where I could be when. Things got very difficult. As the situation became increasingly unhealthy, over a very short space of time I became deeply dysphoric. Suddenly I loathed my female body and its nauseating shapes and its catastrophic frailties with a vehemence I had never known before. I stood in the bathroom and knew I needed to wash but I couldn’t take off my shirt, I couldn’t, because of what was underneath it, so I went out foul. I lost a lot of weight–partly from stress and partly to prove I could still control one aspect of my body. The new flatness of my chest only relieved me, it felt good like nothing else in my life felt good. As my legs got scrawny and the line of my figure straighter I felt only relief. I dressed only in masculine clothing, chopped my hair very short, felt like it made me tough, mean, safe. I still remember the exact moment a man said, “Excuse me, mate” to me as he passed me. It felt so much better than being hit on, even if nothing felt very good anymore.

God, everything hurt. I was desperate, unspeakably desperate to be in control of my own body, in the middle of a situation in which I wasn’t. I wanted to be strong, but I wanted even more to disappear. I wanted everyone in the world to go away. If my body was different, I knew I would have power, to walk away, to STOP IT.

I knew a little about what this was that I was feeling, I’d looked it up online –oh, I’m trans.  I tried to tell my girlfriend that I was trans, that I wasn’t a girl. She carried on as if I had said nothing, wouldn’t humour me by using my new name. I was stung, confused. A friend gave me a binder. I got thinner. I was “he”, or maybe “they”, yes, that was nice, like a cool drink of water; just anyone not called “she”. The “she” I was walking around in felt disgusting to me. “She” was all wrong. Skinny male me, pleasantly mistaken for a boy, felt like a port in the storm, if still not enough. I wanted control, control, of my body, of my life, but not to be me as I had been, because whoever that was far away, getting further away all the time, waiting for all of this to be over. I wanted like hell to be everything I wasn’t, and I didn’t know that other people felt that way too, not just transgender, but apocalyptic, so I was all alone.

The relationship ended. I was in a bad way. I’d made a Tumblr blog, looking, really, for a space that I could have to myself to vent, and I found myself on it a lot more. There is good stuff on that website. But the nasty stuff is so easy to find and so hard to wriggle free of if you’re like I was: lonely, miserable, hollow, and utterly lost, uneasy about everything, because now that she was gone I wasn’t quite so sure about being a boy, but I knew very definitely I couldn’t be a girl. Everything was still all wrong.

It’s difficult to explain what the “nasty stuff” is if you haven’t spent time on there yourself, exactly how pervasive and focused the brainwashing is, how perverse and suffocating and addictive it can be. The convoluted and illogical discourse, the constant shifting of goalposts so you are always on your toes to know what can I say? What am I allowed to think? What does this word mean today? So many lies were told to me about gender, sex, oppression, people, love, health, and happiness. I didn’t get better, and neither did anyone else I spoke to, but we were assured that this way–with our made-up pronouns and our made-up genders and our self-diagnosed illnesses–was the right way. It was a real crabs-in-a-bucket mentality, where any criticism, even of downright abusive behaviour, was transphobic and/or ableist and/or racist. To suggest improving oneself, sorting out your life, was cruelty of the highest order; we were perfect as we were, they  cooed, and anyone saying otherwise hated us and everyone like us. Narcissism ruled supreme.

We copied the writing style everyone else used, and we copied what they said too. They said and then we said we were beautiful. They and then we said we were against the world, the cis world, the hateful world, the world that wasn’t ideologically pure like we were ideologically pure. Nobody suffered like us. We were martyrs, floating high above reproach and deserving, more than anyone, of every good thing in the world: comfort, other people’s money. We deserved to have every rule bent for us, because we were right and they were wrong.

I could go on, describing every argument they used to justify this attitude, but I doubt they’d work on you. A lot of us were young teens, vulnerable in some way, whether abused or ostracised from society or just weak-willed. They gave us a new self, and all the power in the world. We thought so ruthlessly, that people against us didn’t deserve to live, reasoned it out in our mad non-reason –horrible, horrible, icy, inhumanly mechanical thinking that I have never encountered anywhere else since. We didn’t think about what we said, we just repeated what we knew we were supposed to say, and really, truly thought we were expressing our own thoughts.

They told us that we could choose a gender, any gender, out of countless, that we could make up our own and they would be taken seriously; they were, but only ever by others on there. Words on Tumblr ceased to mean the same as in the real world. Words were made up. They said if we wanted to wear make-up, or pink, or feminine clothes, we had to have a label for that, and if we wanted to have short hair, and wear masculine clothes, we had to have a label for that too.

I am not even touching the language around sexual orientation, because that is a whole other article. If we liked to switch how we “presented”, we would have a label to describe that we switched, and we could also change our labels and our pronouns day-to-day to describe how we felt (FELT! That is the crux of all of this nonsense) each day. It is so, so exhausting to be constantly examining every desire, thought, inclination of your shifting, constantly changing adolescent self, trying to find a word to fit, only to question yourself again the next week, or day, or hour. We adjusted our entire sense of self once, again, again, again. Every time, distancing ourselves a bit more from the person we used to be, that we couldn’t bear to be anymore. (I think we knew the old us would be ashamed, so we hid our faces from them.)

The time I wasted! Years on this! The energy! They say “agender” means I don’t have a gender. Do I feel like that? How do I know? How can you “feel” that? They said this was freeing for us, to finally know what to call ourselves, but the boxes they said we had to choose from were so tiny we couldn’t fit, unless we had a hundred, and even then we didn’t feel satisfied. We were forcing ourselves apart into splinters until we weren’t people any more, just words, and words that didn’t mean anything.

Why on earth weren’t we happy? We were children who knew so little about the world, and we believed everything everyone on Tumblr said. They–and then we–all spoke with such perfect arrogance, like we knew everything. We knew we did. There was also an awareness we had–although never, ever voiced, even to ourselves –that if we were just a white, normal, “cis” kid, we couldn’t be part of this club. We were part of it because we were special, and we were special because we were part of the club.

I questioned nothing. I didn’t have one original thought. And I didn’t really feel a thing.

I never looked at myself and thought: girl. That wasn’t right, and what’s more, it was vile. I was something else. I knew it.

Well: my parents knew I was sad. All that I told you about above didn’t fulfil me, although I knew it had to, because I had nothing else. My misery was obvious. One day, I stopped being able to smile. I was so emotionally numb, and that frightened me. I just couldn’t make my face smile. As I spiralled deeper into the trans-cult, my parents & I had arguments over everything. I was snappy, I was mean, I was acting recklessly, I was telling them off for using language that the trans-cult said was bad, I was ignoring all of their eminently sensible and kind advice. I tried to tell them I wasn’t a girl, to use different pronouns when they referred to me.

baptised in fireWhile they weren’t angry, just bemused, and while they really did try, I never felt my parents’ efforts were good enough. It was horribly unfair of me to treat them this way when I myself was always unsure. Even when someone in the real world “validated” me, it didn’t feel as nice as it was supposed to. Why not? I didn’t know. Were they lying? Did they really get it? Why didn’t I feel happy for more than a few minutes, did it mean I was using the wrong words? I crawled back onto my online spaces for further fruitless introspection. Over time, I lost contact with virtually all my old real-life friends – I was no longer invited to anything. I must have been annoying as all hell.

One tiny event in particular– my poor parents, poor me, poor all of us– sticks in my head and makes me feel sick whenever I think of it:

I was in the car. They were driving me to a college lesson because I hadn’t got up in time, because I wasn’t sleeping. I hadn’t washed. Before I got out of the car, my mother gave me a five-pound note.

“It’s the “cheering-up Sam” fund,” she said.

I suppose it sounds silly. But it burns. I’m looking down at that five-pound-note in my hand, and it’s breaking my heart. They knew I was so sad, but what could they do? They loved me so much, but what could they do? What were they supposed to do? How could they possibly help me? I couldn’t hold a civil conversation with them. I was mad, wildly irrational. I knew I was in the wrong but my pride was searing me full of holes. I lost my temper when the conversation became stressful, I walked out of the house and wandered around, alone, sick to my stomach with anger.

I became convinced that T was what I needed. I felt sick at the thought sometimes, but other times I would feel giddily sure, so eventually I summoned up the courage and called a clinic to make an appointment to start testosterone. But before the clinic called me back, something strange happened.

My dysphoria went away. It just went! Why or where it went I can’t say. I was 19 by this time, still clinging to my “trans identity”, insistent I wasn’t “cis”, but the feeling of wrongness about the sex of my body was gone and has stayed gone since. I didn’t love my body in the slightest, but I no longer hated it and think it completely, fundamentally wrong like I had before. I struggled with my weight for a long time then and after, but I began to realise I was female.

My close brush with acquiring testosterone shook me back into my senses somewhat. I was conscious as I came back into my body that I had almost made a huge mistake. The fear of what could have been stayed with me, that as my dysphoria passed I might have been trapped in a body more foreign to me than the original, a body like a boy that my brain no longer actually needed. The irreversible changes that would have occurred weighed on my mind:  the voice no longer mine, the man-face, the dark, thick hair. So anxiously, I thought – that’s not me…

I very slowly, not quite realising it, was distancing myself from the trans-cult and its thinking.

Well, this and that happened, I struggled on, I had a few setbacks, I struggled on a bit more. I got a proper job. This was the kick in the backside, the firework up the arse that I had needed. I was busy. I was tired. I was called “she” – I was too embarrassed to ask for special pronouns. I had to wear work clothes like everyone else. I took my work seriously, but I had to listen to people chatting in such a heretical way! Saying things that I hadn’t dared to even think, for so long! Talking about men being men, and women being women, so casually using language I had forgotten I could use. At some point, I started to agree with them. The hours I worked kept me off Tumblr and Twitter. The real world beamed blinding, hot sunlight into the dark and cold and dusty parts of my world. And one day, I simply deleted all of my social media. I can’t remember why – I just knew I had to. I didn’t stay to say goodbye to anybody I knew, I just wiped it all. I have never missed it since.

My relationship with my parents recovered. It’s a lot better now than it was before, somehow. They know I’m myself– a real, human woman who knows it– again. I started tentatively using the words daughter, woman, girl, sister to describe myself in conversation. Even now when I say those words I feel them in my mouth. I worked, shopped, ate, and I was doing weird things I did before; laughing like a horse, telling off-colour jokes to make my parents snort.

I had spent a lot of time at home, and perhaps the loveliest thing is that I ended up spending much time with my mother, while I was unemployed and recovering. We talked and we argued. But we talked far more than we argued. Sometimes I fell asleep while she was talking; she has a very soothing voice. Sometimes she fell asleep while I was talking – maybe my voice is soothing too. I loved my mother before, but I didn’t know how much I could love her, because I had never tried to understand her. I wonder, if I had breezed through my teens and headed out, unhesitating, into the great beyond, would I talk to her so fondly and treat her so kindly as I do now? Every cloud.

For a long time, I was a shell of myself. But the bossy, blunt, stubborn girl wasn’t all gone. The trauma I went through took time to fade to something I could manage, but I forgave her and I forgave myself. If I met her in the street I really think I could chat with her. I go stretches of days without thinking about it for more than a few seconds. At first my views on, well, everything, flip-flopped wildly. I went to a much wider variety of websites, I read books, I learned about things happening that I had missed, or worse, things where I had believed completely untrue versions of events.

The world had been such a hostile place when everyone was supposedly out to get me, and the only safe space was my Tumblr, where people only ever told me I was right. I learned that people thought a lot of things, had a lot of opinions, and get this: that some people could think one thing I agreed with, as well as another thing I disagreed with. I had been divorced from humanity in the trans-cult, and I was shocked at the empathy I found in myself for people, shocked at all these people, walking around, all with their lives and their feelings and their hearts. The “privileged” people actually suffered; I had believed they couldn’t. There was so much more suffering than I’d known there to be, but there was also so much more goodness. Every morning I realised my horizons were broader than the morning before, only to discover by the evening there was still so much more I hadn’t the faintest clue about.

Turns out, being a woman? You can wear anything you want, and you’re still a woman. You can do what you want, and you’re still a woman. Reality never needs to be validated.

My ability to think critically returned bit by tiny bit. It took time for me to get used to asking questions, checking sources, not believing every little thing I saw or read. I had been taught to believe unquestioningly and I had to wrestle myself out of the habit. Even now, I remind myself I can have opinions and I can disagree with someone, and they can disagree with me, and it doesn’t mean I’m a bad person; it just means that people are people, and I’m a person, and I have to deal with them being people just as they deal with me, because we have a great deal more in common than not. Through it all I have had the support of my parents – we can talk now.

I’m here now. I’ve slowly, quietly rejoined the human race as a woman, knowing it a miracle, holding both the stubborn determination of my childhood and the grateful joy of my young adulthood. The old me I was once so ashamed to face is here, and we are one again, baptised in fire and back fighting.


Who’s gaslighting whom? Susan Bradley, youth gender dysphoria expert, weighs in

Child psychiatrist Susan Bradley, MD, FRCP(C), founded the Child and Adolescent Gender Identity clinic at the Toronto Center for Addiction and Mental Health (CAMH), originally the Clarke Institute of Psychiatry, in 1975. She continued to direct that clinic until 1982, when Dr. Kenneth Zucker took over as head of the clinic after joining as a student in 1977. Dr. Bradley was subsequently employed at Toronto Sick Kids Hospital, where she was chief of the department of child psychiatry. She was also head of child and adolescent psychiatry at the University  of Toronto from 1989 until 1999. She is currently professor emerita at University of Toronto, and is writing a book about supporting youth with high functioning Autism Spectrum Disorder.

Dr. Bradley recently wrote an article for the Post-Millennial about the current political and clinical climate surrounding issues of childhood and adolescent gender dysphoria; highly recommended.

We will be posting a lengthy 4thWaveNow interview with Dr. Bradley in the near future. Stay tuned.

Below, Dr. Bradley responds to a recent paper by Damien Riggs (associate professor of social work) and Clare Bartholomaeus (research associate) of Flinders University, Adelaide, Australia entitled “Gaslighting in the context of clinical interactions with parents of transgender children.”

gaslighting author screen cap

The piece is, in essence, an attack on skeptical parents of trans-identified children, in the form of three “fictionalized case studies.” Riggs and Bartholomaeus characterize parents who do not fully affirm their child as transgender as engaging in “identity-related abuse”; they use the term over 30 times in their paper. According to the authors, “abuse” and “gaslighting” include such transgressions as not using preferred pronouns; cancelling appointments; and not agreeing to medical transition on the timetable preferred by Riggs and other providers engaged in pediatric transition.

The authors counsel therapists to try to see a child privately when parents are not sufficiently obsequious. They even refer to non-compliant parents as abuse “perpetrators”:

gaslighting article 5

Authors suggest therapists should find “creative ways” to make private contact with the child

We have included more screen captures from the Riggs article in Dr. Bradley’s response below. However, we will not be deconstructing the entire paper in detail. We strongly encourage readers to examine it closely.


by Susan Bradley, MD, FRCP(C), Consultant Child Psychiatrist

 Where is Damien Riggs coming from?

That’s what I had to ask myself when I read his diatribe against parents of youth who have recently expressed their feelings of gender dysphoria. His position seems to be this: Parents who are reluctant to simply buy into his belief that anyone who expresses feelings of gender dysphoria must be “trans” and supported in their transition with no questions asked, are not being adequately supportive of their child; further, he terms this parental skepticism “identity-related abuse.” But it’s natural for any parent of a youth expressing such feelings, particularly if they are of recent onset, to wonder “why?” or “how come now?” Such sudden changes in identity would make anyone question what is really going on inside that person.

gaslighting article 1

Parents are “gaslighters” if they question hormone blockers or want to slow down medical intervention

To be a parent of a child undergoing such a radical change in identity is a very stressful experience, with conflicting feelings of wanting to support their child, but also wanting to be sure that what they want really makes sense. If this child has a previous history of feeling rejected by peers, many parents will be aware of the damage that has been done to their self-esteem, and rightly see them as vulnerable to those who offer acceptance, at whatever cost.

But Damien Riggs, the therapist advising us, seems to see things in black and white terms: if they voice any feelings of being “trans” they must be “trans”. What about those individuals who change their minds? Does the therapist know for sure that my daughter is not going to change her mind? How do we know that this sudden, intense interest is different from other intense interests the child may have had in the past? How do we know what impact interventions such as puberty blockers will have on her future, especially if she changes her mind?

gaslighting article 2

“Cisgenderist” parents who misgender their kids should not be allowed to apologize

These are just some of the questions that would go through the minds of any caring parent in that situation. If the therapist does not address these concerns in a straightforward manner, most parents would then begin to wonder if they are in the right place to help their child. Failing to engage wholeheartedly in the “therapy” would be one way of trying to deal with their uncertainty when they sense that the therapist is not open to a discussion about their concerns.

This hardly qualifies  as “gaslighting,” a term defined in the dictionary as “behavior intended to manipulate someone by psychological means into questioning their own sanity” or behavior that “seeks to sow seeds of doubt” about their reality or beliefs. To the contrary, those parents are behaving as most parents would in a situation where they do not feel heard.

From the description of the process of therapy engaged in by Damien Riggs, there appears to be no attempt to help parents be understood in terms of what most would regard as very normal worries about a process that seems to be moving forward with little thought for the persons involved. There is no evidence of intent to deceive by these parents; only a lack of faith in the person directing their child’s treatment, who after all, has very little prior knowledge of that child, their issues, their vulnerability, or their ability to make a competent decision about life-altering interventions.

I would argue that Damien Riggs’ accusations about the parents “gaslighting” is unethical and lacking in understanding of the relationship between child and parent. Amongst other things it is the parents’ job to protect the interests of their children until they reach an age when they are capable of doing so by themselves.  Riggs appears not to understand the importance of this relationship when he mislabels the rather normal reactions of parents with a rapid onset dysphoric child as “gaslighting”.

gaslighting article 4

Parents who ask for a diagnosis for their trans-identified children are gaslighters.

If Damien Riggs had done a careful assessment of the youth, particularly, the girls with rapid onset gender dysphoria (ROGD), he would have understood that most of these young women had begun to have homoerotic feelings as they moved into adolescence. Experiencing crushes on same-sex peers is not unusual both in individuals who later become lesbian, but also in heterosexual women.

However, if you are a teen who has had social difficulties, it is easy to feel that having these feelings will make you feel more “weird” than you may already feel. Homophobic slurs are common amongst teens, further increasing anxiety about acceptance in these young girls. The process is easy to uncover if you—as a therapist—ask the right questions, in that these young women desperately want friends and someone who accepts them. The internet sites for “trans” individuals are very welcoming of anyone who expresses interest. Because many of these young women are not really skilled at self-reflection, finding a simple solution (“I’m trans!”) that makes them feel accepted seems perfect. Unfortunately, as we all know, life is more complicated and what seems like a simple way of feeling good may not be a good long term solution.

Caring parents take time to understand and accept mental health issues even when they are more common than the belief that one is in the wrong body. Recent onset gender dysphoria is a rather sudden change in how the youth sees herself, and although some of these individuals may eventually decide that transitioning is best for them, many will realize that they are lesbian and can explore that and find acceptance in a same-sex relationship without having to change their bodies. They need time to understand their feelings and explore ways of finding the best solutions for them. Parents can usually participate in being supportive when they understand what their child is struggling with and how they can help.  For Riggs to blame parents for not accepting his approach wholeheartedly is not what those of us in mental health are trained to do.

WPATH & The Advocate aim to suppress new research on adolescent gender dysphoria

by Brie Jontry

Brie is public spokesperson for 4thWaveNow. For more about her, see this interview. For more about Brie’s formerly trans-identified daughter, Noor, see here.

On February 20, The Advocate, one of the leading LGBT publications in the US, ran an article which attempted to invalidate data collected by physician and researcher Lisa Littman from parents whose children experienced Rapid Onset Gender Dysphoria (ROGD). The author, Brynn Tannehill, immediately posted the article to the WPATH Facebook page.

Tannehill ROGD WPATH post

In the thread,  Tannehill (along with Jo Hirst, author of the Gender Fairy), suggested The Journal of Adolescent Health should be asked to retract and/or apologize for publication of Littman’s preliminary findings. UCSF’s Dan Karasic, MD (moderator of the Facebook page and WPATH official) agreed.

Littman’s abstract had been accepted for poster presentation and the poster was presented at the March 2017 Annual Meeting. (The full paper has not been published yet, and we look forward to its availability).

karasic retract poster

Note: Interestingly, as of this writing, four days after they were written, the last three comments have been deleted from the original thread.

The dismissal of Littman’s work, and the move to suppress it, is unconscionable. For one thing, some young people (like my daughter)  who experienced ROGD have already desisted. Others, who were supported in procuring medical intervention, have already experienced regret. Many more desisters and detransitioners are sure to follow.

This trend has not gone unnoticed by at least some in WPATH. For example, veteran WPATH clinician Rachael St. Claire, in a Facebook post on January 5 of this year, made this comment (notice that commenting was turned off immediately after St.Claire posted):

WPATH jan 5 2018 detrans therapist

This concern is echoed by UCSF clinical psychologist Erica Anderson, herself a transgender woman, in a recent Washington Post article:

“I think a fair number of kids are getting into it because it’s trendy,” said Anderson, who was married for 30 years and fathered two children before transitioning seven years ago.

I’m often the naysayer at our meetings. I’m not sure it’s always really trans. I think in our haste to be supportive, we’re missing that element. Kids are all about being accepted by their peers. It’s trendy for professionals, too.”

In addition, clinics around the world have noted a sharp increase in the number of girls presenting for treatment in the last few years.

increase in girls

A once-rare condition is now increasingly common. It is surely in the interest of all people who care about gender dysphoric youth to investigate the reasons for the increase, and Littman’s work is an early contribution to this effort.

The ostensible reason given for Karasic et al’s desire to have Littman’s abstract retracted is that the data comes from a self-selected group of parents, culled from websites where such parents gather, in an anonymous survey format, and is thus deemed to be worthless. Yet advocates for pediatric transition constantly promote other survey studies, also culled from “self selected” groups (such as the Williams Institute suicidality survey), as well as research conducted by investigators who only recruit subjects from pro-early transition organizations (such as Kristina Olson’s two studies), with no attempt to broaden their samples to children who are not socially or medically transitioned.

In fact, Littman’s work is the first to study this new presentation of gender dysphoria, and she collected information from the people who know these children and teens better than any transgender advocate, endocrinologist, psychologist, or therapist ever could — their parents.

But you’re not listening to us.

Littman’s study, according to its critics, is contentious for a few reasons, but most notably for using the term “Rapid Onset Gender Dysphoria” as a descriptor for a new kind of trans-identifying youth, primarily natal females, who during or after puberty, begin to feel intense unhappiness about their sexed bodies and what it means to feel/be/present as a woman.

Let me emphasize: What is “rapid onset” in this population is the dysphoria, not the gender atypicality. What distinguishes these young people from the early-onset populations studied previously is that they may have been happily gender nonconforming throughout childhood (though some were more gender typical), but they were not unhappy (which is all “dysphoric” really means), nor did they claim or wish to be the opposite sex. The unhappiness set in suddenly, in nearly every case only after heavy peer influence, either on- or offline.

This phenomenon has only recently been noted by clinicians directly involved in treating gender dysphoric youth, as well as other mental health professionals. While there is no lack of evidence for adolescent emotional and behavioral social “contagions,” Littman’s research is the first to collect data on this phenomenon as it relates to identifying as transgender.

Even though rapid onset gender dysphoria has been noted by other researchers and clinicians who work with these populations, The Advocate and WPATH’s Dan Karasic consider the descriptor “junk science.” In a swift attempt at censorship, Karasic deleted all but one of my comments on the public WPATH Facebook page and then banned me from the group when I asked him to please consider the experiences of young people, like my daughter, for whom gender dysphoria set in hard and fast after being exposed to the idea that her gender nonconformity was in fact a sign of being transgender.

Interestingly, after I was purged, Karasic posted links to both my and my daughter’s stories on 4thWaveNow, and unfounded accusations were leveled against me and 4thWaveNow; since I was banned, I was not able to respond to them.

Interested readers may refer to these Twitter threads should you want more blow-by-blow details:

It is concerning, given Karasic’s reaction to Littman’s research, that he and others evidently leave no room for a teenager to be incorrect about how they are interpreting their feelings, no room for a clinician to be incorrect when recommending transition, and no room for a parent to understand what is going on with their own child. It is narrow minded and short-sighted, especially considering there is no long-term data supporting the benefits of early medical transition for gender dysphoria or consensus from the medical community about best treatment methods.

This lack of consensus, while well known and acknowledged by the international medical community, has been ignored by many transgender advocates, along with the “gender affirmative” recipients of a $5.7 million NIH grant, who, with the help of the mainstream media, have manipulated the public into believing early social transition, pubertal blockade, and early cross-hormone treatment constitute settled science.

To be clear, in “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study,” a 17-clinic international study published in The Journal of Adolescent Health, the authors explain that:

As still little is known about the etiology of GD and long-term treatment consequences in children and adolescents, there is great need for more systematic interdisciplinary and (world- wide) multicenter research and debate. As long as there are only limited long-term data in support of the guidelines, there will be no true consensus on treatment. To advance the ethical debate, we need to continue to discuss the diverse themes based on research data as an addition to merely opinions. Otherwise ideas, assumptions, and theories on GD treatment will diverge even more, which will lead to (even more) inconsistencies between the approaches recommended by health care professionals across different countries. (372)

I am sure some WPATH members, like the treatment teams in Lieke et al., “feel pressure from parents and adolescents to start with treatment at earlier ages.” I know there are others, besides those reported in Lieke et al. who:

[…] wondered in what way the increasing media attention affects the way gender-variant behavior is perceived by the child or adolescent with GD and by the society he or she lives in. They speculated that television shows and information on the Internet may have a negative effect and, for example, lead to medicalization of gender-variant behavior.

“They [adolescents] are living in their rooms, on the Internet during night-time, and thinking about this [gender dysphoria]. Then they come to the clinic and they are convinced that this [gender dysphoria] explains all their problems and now they have to be made a boy. I think these kinds of adolescents also take the idea from the media. But of course you cannot prevent this in the current area of free information spreading.” –Psychiatrist

It is unconscionable that transgender advocates, and the leading international body concerned with transgender medicine, would seek to quash data that address unsettled and mostly unexplored areas of concern. It is incredibly important that ROGD be included as a research point because the main studies used to justify the use of puberty blockers, cross-sex hormones and surgery in adolescents required “persistent gender dysphoria since childhood” and “no serious comorbid psychiatric disorders that may interfere with the diagnostic assessment” before the patients were eligible for medical intervention. In other words, none of the participants in these treatment studies had adolescent-onset of their gender dysphoria and none of the participants had serious psychiatric issues.

It is a huge leap to assume that an entirely different population of adolescents with a different presentation of symptoms will have the same results as the adolescents in the Amsterdam cohort.  An additional gap in the research is that because all the desistence and persistence studies are about adolescents who had childhood onset of gender dysphoria, the persistence and desistence rates for adolescent-onset gender dysphoria are unknown.

In all areas of medicine, best practices come from intense discussion and research into indications and contraindications, and into risks, benefits, and alternatives. Yet, WPATH’s Karasic, along with the trans advocates who have prominent roles in the organization, appear to believe it is in their community’s best interest to shut down all discussion about contraindications, risks and alternatives. This is inappropriate and undermines the very concept of informed consent.

Furthermore, The Advocate article suggests that Littman’s sample is biased because it gathered data from “unsupportive” parents. This framing is both fallacious and dangerous to gender nonconforming and dysphoric youth. It suggests that the only path for gender dysphoric youth, even those with a rapid onset, is full affirmation including fulfillment of requested medical interventions. It also implies that parents aren’t able to be both supportive and cautious.

I have spoken to some of the parents who participated in the study. Few could be described as “unsupportive.” In fact, almost overwhelmingly, these parents supported their children in thinking about their gender identity and helped facilitate their preferences for atypical gender presentation and interests (taking them for haircuts, new clothing, and so forth). Many sought professional mental health consultations and treatment for their children. But what many of these parents did not support for their underage teenagers were hormonal and surgical interventions. This is an important distinction: Littman’s sample were supportive parents who were unsupportive of a particular medical treatment option.

It is entirely possible to be supportive parents invested in our child’s well-being and not agree to unproven medical procedures for which there is no consensus from the medical community of long-term safety or benefit to the majority of dysphoric youth. However, the loudest voices in pediatric transgender medicine often cite Kristina Olson’s descriptive research about early social transition for children which relies on the methods that they decry as “junk” when used in Littman’s research (targeted recruitment and the collection of data from parents). Kristina Olson recruited her sample from support groups and conferences to find parents who have socially transitioned their children, which might consist only of parents who are supportive of early social and medical transition. So is it an acceptable method for both studies, junk for both studies, or are the WPATH activists simply going by whether they like or dislike the findings?

As all parents know, we can tell when our children are suffering. To remain credible, advocates for gender dysphoric youth and the international organization which claims to be concerned with generating best practices in the field of transgender medicine must acknowledge that ROGD exists and there are some trans-identifying youth who arrive at their identity from external social pressures, and at times, internalized homophobia.

Related to this last point, the WPATH Facebook page wasn’t the only place my respectful questions were deleted. In a comment on The Advocate article itself, I asked Tannehill and Advocate readers to consider the recent research into how homophobic name-calling influences (hint: greatly) children’s perceptions of their gender identity.

brie advocate comment

My comment was swiftly scrubbed from existence. For those interested in reading “The Influence of Peers During Adolescence: Does Homophobic Name Calling by Peers Change Gender Identity?” the full text is here.

Finally, the fact that ROGD is being discussed by the conservative media is not, no matter how many “incriminating” links Tannehill dropped in the Advocate piece, a legitimate reason to discredit the data. The irony is not lost on many 4thWaveNow parents that our stories are covered by media outlets we typically avoid. In this politically charged climate, it is important for researchers, clinicians, and parents to work together to “first do no harm” even when those we otherwise disagree with call for the same cautions.

Clearly, Brynn Tannehill and Dan Karasic do not speak for all members of WPATH. I know for certain that they do not speak for many professionals currently working with gender dysphoric youth who see in their own practices what can only be described as “rapid onset gender dysphoria” in an increasing number of adolescents, particularly girls. Clinicians are aware of the rapidly growing numbers of young people requesting services and the possibility of social contagion; there are those among you who are concerned by the potential for misdiagnosis and the subsequent harm that will come to some of your patients as a result.

It is time for those with concerns to speak out. Please do not allow your ethical and professional concerns to be held hostage by ideology.

The Tide Pod Challenge: How a teenage self-harm fad ought to be handled

by Overwhelmed

If you haven’t heard, the Tide Pod Challenge is all the rage with teens and young adults. Unfortunately, many of them have bitten into, ingested, and accidentally inhaled the liquid laundry detergent packets, leading to serious medical consequences. Several young people have even died.

Tide bottleWhy has the challenge become so popular? Well, this age group is not known for risk aversion or for considering the consequences of their actions. And many of them have a social media presence and strive to accrue “likes” and gain new followers. So when #TidePodChallenge started trending, some of them just couldn’t resist. They recorded themselves biting into laundry pods and uploaded it to various social media platforms. This in turn inspired more to join in the dare.

I’m sure 4thWaveNow readers can appreciate the parallels between the Tide Pod Challenge and Rapid Onset Gender Dysphoria.  The same age group is involved. Both are spread by social contagion, which is greatly amplified by social media. And both cause medical harms.

Dr. Susan Bradley, longtime expert in childhood gender dysphoria, as well as autism, had this to say about Rapid Onset Gender Dysphoria (ROGD) in a recent article in the Canadian journal Post-Millennial:

In my own practice, I have seen a good many young women displaying the phenomenon known as “rapid onset gender dysphoria,” or ROGD, which overwhelmingly affects girls.

Typically, the ROGD teenage girls I see have, wittingly or not, begun to experience homoerotic feelings about which they are conflicted. They tend to be socially isolated, and somewhere “on the spectrum.” They may have histories of eating or self-harm disorders.

They have found companions with the same attributes on Internet sites, which diminishes such adolescents’ sadness over their social isolation, but which can also lead to foreclosure of reflective thinking about their own feelings and situation. Some of these girls are depressed, afflicted with suicidal ideation. Because of the initial euphoria they experience in finally “belonging” to a well-defined kinship group, they tend to embrace the idea of transitioning wholeheartedly as the solution to their other problems.

I’ve been impressed with the actions being taken to stem the Tide Pod Challenge (which I list below). It gives me hope that when the serious ramifications of Rapid Onset Gender Dysphoria are eventually acknowledged, steps will be taken to curb it as well.

So, how have responsible adults acted to reduce the number of young people being harmed by the Tide Pod Challenge?

  1. Many journalists are reporting about it. The public is being informed of this trend, including the serious medical implications—seizures, chemical burns to the eyes which can cause temporary blindness, fluid in the lungs, respiratory arrest, coma, death.
  1. YouTube (owned by Google) has removed videos that show people taking bites of laundry detergent packets. According to a spokesperson: “YouTube’s Community Guidelines prohibit content that’s intended to encourage dangerous activities that have an inherent risk of physical harm. We work to quickly remove flagged videos that violate our policies.”
  1. Facebook has followed suit, deleting content off its platforms (including Instagram), stating “we don’t allow the promotion of self-injury and will remove it when we’re made aware of it.”
  1. Procter and Gamble, which owns Tide, is trying to turn the tide (sorry, I couldn’t resist) of this social contagion. According to a company representative, “We are deeply concerned about conversations related to intentional and improper use of liquid laundry pacs and have been working with leading social media networks to remove harmful content that is not consistent with their policies.” Tide has even enlisted a celebrity, NFL star Rob Gronkowski, to appear in a Twitter video informing people that Tide Pods are for washing, not eating. It has already garnered millions of views.

tide podsThis is exactly how a socially contagious craze that is impacting young people SHOULD be handled. I dream of more journalists honestly covering Rapid Onset Gender Dysphoria and its associated often-irreversible medical consequences. I wish pharmaceutical companies would speak up and condemn the inappropriate, non-FDA approved, off-label use of their products. I hope social media platforms will restrict content that glorifies tweens, teens, and young adults altering their bodies via binding, cross-sex hormones, double mastectomies, and genital surgeries. It could easily be interpreted that cheering on medical transition already qualifies as a violation of YouTube’s policy of encouraging “dangerous activities that have an inherent risk of physical harm” and Facebook’s “promotion of self-injury.”

But unfortunately, the transgender rights movement is overshadowing this epidemic. I think the majority of the public is totally unaware that kids are being influenced, especially by social media, to believe that they are transgender. They become convinced their bodies are wrong and in need of drastic life-long medical interventions. The adults who are aware of this contagion are often afraid to raise concerns because they will be labeled transphobic (and potentially lose their jobs). Of course, this seriously dampens the opportunity for rational discussion on this topic. Mainstream journalists, particularly in the United States, have been extremely hesitant to cover it.

I have no doubt that Rapid Onset Gender Dysphoria will eventually become widely known as a disastrous medical fad. Steps will be taken to curtail the damages. It’s just a question of when. In the meantime, parents of ROGD kids and their allies will keep speaking out. They’re doing what they can to reduce the number of young people who may eventually regret how easy it was to medically transition.

Unlike the Tide Pod Challenge, the spread of Rapid Onset Gender Dysphoria has gone unchecked for several years now. Thousands of young people and their families have been impacted. It has gotten so out of control that serious efforts need to be undertaken to counteract the nearly insurmountable amounts of misinformation, and help control this social contagion. This effort needs to be more than parents speaking out. Medical organizations need to review the science (not rely on trans activist ideology), reevaluate their stance on pediatric medical transition, and rein in rogue practitioners. If we have any chance at stemming this, it will have to be done on a grand scale from multiple fronts.

Wanting to protect my daughter’s health does not make me a bigot

By Susan Nagel

Susan Nagel is the mom of a 17-year-old girl who identifies as transgender. Nagel wrote this essay as a way to educate people who assume she is transphobic because she is unsupportive of her daughter’s desire to medically transition. She hopes others may find this essay helpful if they are trying to educate friends, family members, teachers, doctors, therapists, or journalists. Nagel is using a pseudonym to protect the identity of her daughter, and is available to interact in the comments section of this post.

A PDF version of this article is available here.

About a year ago my then 16-year–old daughter told us she believes she is transgender. Soon after, she began begging to take testosterone, to wear a breast binder, to have others call her by male pronouns, and to legally change her name. Nothing about her childhood prepared us for this; she always had stereotypically feminine interests and tastes. She loved stuffed animals, preferred skirts over pants for school, chose bright pink paint for her room, and experimented with makeup and curling her hair. When she was little. I joked that I had to add a pink load to laundry day in addition to lights and darks. Over the course of a month or two after coming out, she changed from a generally cheerful person to a morose one who spent hours crying and who told me to hide the knives.

Before I go further, I think you should know the lens through which I view things. I am a liberal, and I fully support equal access to housing, employment, education, and healthcare for all marginalized people, including transgender people. I do not think being transgender is immoral or that gender diversity is disturbing. Still after spending many sleepless nights researching the transgender movement, I have come to be very afraid for my daughter. My fears are about the rush to turn physically healthy teenage girls and young women into permanent medical patients and to do so before their brains are fully developed and with almost no oversight by mental health professionals.

bigot circleI encounter many well-meaning people who believe the transgender movement is simply a civil rights movement. They do not understand my concerns and assume I am ignorant or a bigot. I think it is because most people’s knowledge of the transgender movement is limited to mass media accounts focusing on discrimination against transgender people or on an individual’s struggle to be true to his or her self. Below are some things I wish people understood about how the transgender movement is impacting the health of children and young people along with some questions I would like people to ponder.

  1. Few children who experience gender dysphoria grow up to be transgender.

Gender dysphoria, a feeling of discomfort or distress with a person’s own biological sex, is a temporary issue for a sizeable majority of the children who experience it. Studies show that only between 6% and 27% of children who experience gender dysphoria will grow up to be transgender.  These statistics do not come from a conservative source. They are from the World Professional Association for Transgender Health Standards of Care.

  1. The drug regimen used to treat pre-pubescent children with gender dysphoria causes permanent sterility.

Some parents whose young children experience gender dysphoria place their children on drugs called puberty blockers to stop the onset of puberty. The rationale: postponing puberty will give a child time to decide which gender the child is. If the child later decides to transition, the child will more easily pass as a member of the opposite sex because the normal development of secondary sex characteristics was blocked. If the child decides not to transition, the child stops the puberty blockers, and normal puberty occurs.  Those wishing to complete medical transition, must follow puberty blockers with the hormones of the opposite sex. When puberty blockers are followed by cross sex hormones, the child never undergoes puberty for his/her birth sex and will be unable to produce viable ova or sperm as an adult.

Sterility is not the only problem caused by the typical treatment route of puberty blockers plus cross-sex hormones . The drugs being used to block puberty are being used off-label; i.e. they have not been approved for this use by the Food and Drug Administration. According to Eli Coleman, a psychologist who heads the human-sexuality program at the University of Minnesota Medical School quoted in The New Yorker, “We still don’t know the subtle or potential long-term effects (of puberty blockers) on brain function or bone development. Many people recognize it’s not a benign treatment.”

Puberty blockers have been used for a number of years to treat precocious puberty and to allow short kids more time to grow.  The FDA is currently conducting a review of nervous system and psychiatric events as well as deadly seizures among pediatric patients using GnRH agonists including one of the most common puberty blockers, Lupron. Over 10,000 adverse event reports in relation to Lupron usage have been filed with the FDA.  According to Kaiser Health News, “…thousands of women have joined Facebook groups or internet forums in recent years claiming that Lupron ruined their lives or left them crippled.”  Complaints include osteoporosis, degenerative disk disease, and deteriorating joints.

My questions are: How can it possibly be ethical to sterilize children before they are old enough to give informed consent? If your child had a medical condition with a 73 to 94 percent chance of remitting without treatment, would you agree to experimental therapies with known serious side effects? What parent can predict whether his/her child will prefer to be fertile or to pass as the opposite sex as an adult?

3. Not every person who medically transitions stays transitioned.

Although trans activists claim otherwise, it is not uncommon for transgender people who have transitioned, medically and/or socially (social transition includes adopting the dress, hairstyles, names, and pronouns of the opposite sex) to eventually change their minds and detransition. For example, a 2016 survey on detransitioning that was posted online for only 10 days collected over 200 responses from detransitioned women. Blogs and videos of detransitioners are easy to find online.

  1. There is little research on the safety of the long-term use of cross-sex hormones for the purposes of sexual transition.

Using testosterone for the purposes of sexual transition is an off-label use of the drug. One observational study of the immediate impact of testosterone treatment on females transitioning to male showed that testosterone impaired mitochondrial function and created a state of oxidative stress in the subjects’ white blood cells.  Oxidative stress is associated with neurodegenerative diseases, gene mutations, cancers, heart and blood disorders, and inflammatory diseases among other pathologies. Research on the long-term effects of using testosterone for transition is sparse.  Given the effect testosterone has on the white blood cells of women, it seems reckless to me to prescribe this drug without further studies of its long-term effects.

Below are just a few items from a consent form that girls and women wishing to take testosterone must sign:

  • “I understand that it is not known exactly what the effects of testosterone are on fertility…,”
  • “I understand that brain structures are affected by testosterone and estrogen. The long term effects of changing the levels of one’s natal estrogen through the use of testosterone therapy have not been scientifically studied and are impossible to predict. These effects may be beneficial, damaging, or both.”
  • “I have been informed that using testosterone may increase my risk of developing diabetes in the future because of changes in my ovaries.”
  • “I understand that the endometrium (lining of the uterus) is able to turn testosterone into estrogen and may increase the risk of cancer of the endometrium.”
  • “I understand fatty tissue in the breasts and body is able to turn excess testosterone into estrogen, which may increase my risk of breast cancer and decrease or impede the desired effects of testosterone therapy.”
  • “I have been informed that testosterone may lead to liver inflammation and damage. I have been informed that I will be monitored for liver problems before starting testosterone therapy and periodically during therapy.”

My daughter sees nothing scary about this list. She is a teenager, and teenagers believe they are invincible. She reassures me that she would receive the treatments from a doctor, so in her mind, nothing could go wrong. She lacks the life experience that has taught me all medical treatments entail risks and side effects, many drugs are withdrawn from the market when they are later found unsafe, some medical professionals are motivated by profit, and that doctors make mistakes.  In the study of detransitioned women mentioned above, the average age of transition was 17, and the average age of detransition was 22. I suspect the timing of detransition had something to do with young women reaching sufficient maturity to calculate risks versus benefits.

In addition to the health risks, testosterone causes irreversible cosmetic changes. Male pattern baldness, facial hair, and a deepened voice follow transmen who detransition to reclaim womanhood.

I am shocked by how readily some friends accept the idea of using synthetic hormones for the purpose of transitioning teenagers. Some of these people avoid drinking milk from cows treated with bovine growth hormone and avoid eating inorganic vegetables or food tainted by genetically modified organisms. If teenagers ingest risky chemicals for politically correct reasons, is the harm is somehow reduced? 

  1. A thorough evaluation and therapy from a mental health professional are not required before a young adult medically transitions.

Several people have told me not to worry that my daughter might transition unnecessarily because a person must have a thorough evaluation by a therapist to assure he/she is truly transgender before receiving medical treatments. That may have been universally true at one time, but unfortunately it is no longer the case.  In the survey of detransitioned women mentioned above, 117 of the surveyed women had medically transitioned. Only 41 (35%) of those women had received any therapy beforehand. The vast majority (68%) felt they had not received adequate counseling and accurate information about transition before transitioning.

Some trans advocates say evaluation by a therapist should not be required for medical transition because they say being transgender is not a mental illness. Consequently, there has been a move toward informed-consent clinics. Under this scenario, any adult claiming to be transgender is allowed to receive medical transition treatments with a letter from a therapist stating they have been informed of the risks involved in transition and are capable of giving consent.

The website of RECLAIM, a St. Paul, Minnesota mental-health center for transgender youth ages 13 through 25, explains that the informed-consent process may take as little as two sessions to 10 or more. It also explains that the resulting letter to medical providers “…does not involve the evaluation of readiness…” for medical transition by the therapist. Call me old-fashioned, but I think most 18-year-olds could benefit from an evaluation of readiness.

The website of a St. Paul therapist specializing in gender issues, Bystrom Counseling and Consultation, tells potential clients that a number of Minnesota physicians “…are now comfortable prescribing hormones without written documentation of completion of (the) Global Review of risks and benefits from a therapist.” The website goes on to list the medical clinics most often accessed for this purpose.

University of Michigan Professor of Social Work Kathleen Levinstein wrote about her autistic daughter’s medical transition for 4thWaveNow. Her daughter was a special-education student, who as an adult, qualifies for disability payments and is not capable of managing her own finances. She functions at such a level, that her mother had to explain to her that women who take testosterone do not grow penises. The day after her 18th birthday, the daughter‘s gender therapist approved a double mastectomy for the daughter after only two sessions together. The daughter began testosterone treatments several months later. The daughter who also suffers from Crohn’s Disease has been hospitalized three times due to adverse reactions to the hormone.

If transgender people are not ill, doesn’t that make their treatments elective and therefore ineligible for insurance coverage? If transgender people are ill, don’t they deserve a thorough evaluation and a diagnosis before undergoing medical treatments? 

  1. When children and teens experience gender dysphoria, they are often allowed to diagnose themselves as transgender.

Parents who convince a child to seek therapy before pursuing transition should know that many mental-health professionals especially those calling themselves gender therapists use an identity approach to treating gender dysphoria, also called the gender affirmative approach. Lisa Marchiano, a Philadelphia social worker, wrote an essay contrasting the identity model of therapy to the traditional mental-health model. Under the identity model, gender dysphoria can mean only one thing: that someone is transgender. Therapists are not allowed to use their own clinical judgement to analyze whether there might be other reasons people are feeling uncomfortable with their bodies. Marchiano states, “Our role as therapists becomes limited to enthusiastic affirmation only.”

I witnessed the prevalence of this model in my own search for a therapist to help my daughter. I interviewed approximately ten therapists by phone before finding one who understood that teenagers experiment with identities and that teenagers’ beliefs about who they are may change over time, something that used to be common sense and common knowledge.

In contrast to the gender-identity model of therapy, Marchiano says the mental-health model sees gender dysphoria as a symptom. The therapist’s job is to help the client “…explore the symptoms without making assumptions about what the symptoms mean. In fact, while identity therapy knows what gender dysphoria means – i.e. that the client is trans – mental health therapy will start with the assumption that we have no idea what the symptom means. We must be open to the meaning that emerges for patients as we explore their experience with them.”

What besides being transgender could cause gender dysphoria? In a letter to the American Psychological Association, Marchiano says the survey of detransitioned women in addition to the online writings and videos of detransitioners indicate “…that many who underwent transition feel that they were doing so as a maladaptive coping mechanism to deal with trauma, anxiety, social difficulties, or other issues. The majority of detransitioners speaking out online now identify as lesbian, and many of them feel that internalized homophobia played a part in their believing that they were men.”

As a woman, I fully understand the impulse to transition to stay safe and sane in a misogynistic world. But please, let’s not view women attaining better camouflage through transition as progressive. Progress occurs when women no longer feel a need to hide.

Studies show most children no longer feel gender dysphoria as adults. It is easy to find examples of people detransitioning. So why do gender therapists assume that every instance of gender dysphoria indicates that a person is transgender? We used to require people to have advanced degrees and licenses to make mental-health diagnoses. Why are we, in effect, allowing children and teenagers to diagnose themselves?  

  1. There is no persuasive evidence that gender transition reduces suicidality in children with gender dysphoria.

One of the scariest things a parent in my position encounters is the widely reported increased risk of suicide among transgender people. Many people believe transition is the only way to prevent suicides among transgender youth. A common sentiment is, “Would you rather have a dead daughter or a live son?” I encourage anyone with this concern to read a recent essay by Michael Bailey and Ray Blanchard. Their key take-away is, “There is no persuasive evidence that gender transition reduces gender dysphoric children’s likelihood of killing themselves. The idea that mental health problems–including suicidality–are caused by gender dysphoria rather than the other way around (i.e., mental health and personality issues cause a vulnerability to experience gender dysphoria) is currently popular and politically correct. It is, however, unproven and as likely to be false as true.” There are, in fact, some studies that show higher suicide rates for transgender people who have transitioned compared to those who have not.

While there is no proof that transition reduces suicidality, teenagers are coached by others on sites such as reddit and Tumblr about how to use suicide threats as a bargaining chip.  In one of the more chilling reddit exchanges reposted on the website Transgender Reality, an 18-year-old whose father is concerned about the wisdom of hormone therapy is asked by a commenter, “Are you ready to talk to him (the father) about the possibility of suicide? Or do you want to couch it more gently, and say you ‘can’t go on living like this’ etc.?” In another post, a 14-year-old is told, “…communicate to your parents that this is not optional. It is either this or depression, isolation, suicide.” Finally, a 13-year-old is told to tell his parents, “If you don’t help me like you need to as the parents who made me, I’ll wind up bitter, miserable or dead.”

  1. Some psychologists and mental health professionals believe teenage girls and young women are experiencing a new type of gender dysphoria caught from peers and through exposure to the concept online.

aitken-sex-ratio-graphUp until about 7 years ago, more boys than girls presented with gender dysphoria at gender clinics in western countries. Around 2010, the number of girls started to exceed the number of boys and began to increase significantly. Many girls experiencing gender dysphoria in the past decade have a different profile than they did in earlier years. In the past, girls with gender dysphoria began expressing discomfort with feminine clothes, interests and toys during preschool. Most would eventually become comfortable with their biological sex while dysphoria would persist into adulthood for some. Now many girls are first experiencing gender dysphoria suddenly in adolescence. Some researchers are calling this phenomenon rapid onset gender dysphoria (ROGD) and theorize it may be a kind of social contagion spread among friends and through the internet.

A 2016 survey of 164 parents of transgender adolescents and young adults demonstrates the current contagious nature of gender dysphoria among young women. Eighty-five percent of the parents surveyed had transgender youth who were biologically female with an average age of 15. In the general population, less than one percent of young adults would be expected to be transgender, however, many of the parents in this survey said that multiple members of their child’s pre-existing friend group were also declaring themselves transgender. To be exact, 50 percent of a youth’s pre-existing friend group became transgender in close to 40 percent of the friend groups described in the study. The average number of friends becoming transgender was 3.5.

Psychologists Ray Blanchard and Michael Bailey recently reported that young people with ROGD (primarily girls) falsely come to believe that all their problems are due gender dysphoria. Girls with ROGD often become obsessed with the idea of transition, and their mental health and social relationships deteriorate. The subculture surrounding ROGD includes attributes found in cults including an “… expectation of absolute ideological agreement …and encouragement to cut off ties with family and friends…” who do not agree with them.” Since ROGD is “…based on a false belief acquired through social means,” Bailey and Blanchard believe transition will not help youth with this condition. They pull no punches: “If knowledge is power, then lack of knowledge is malpractice. The ignorance of some leading gender clinicians regarding all scientific aspects of gender dysphoria is scandalous.”

My own daughter’s experience of gender dysphoria matches the description of ROGD closely. She first began experiencing gender dysphoria as a teenager. Four member of her pre-existing friend group also began identifying as transgender in their teens. Because I have expressed doubts about her transgender identity and voiced opposition to medical transition, she refuses to talk to me about those subjects much as a cult member refuses to listen to anything that contradicts his/her beliefs. Her mental health and relationships with family have suffered.

  1. Many people stand to gain financially by the boom in children, teens and young adults seeking medical transition.

Quite an industry has built up around the treatment of transgender people. In 2007, there was one transgender clinic that served children in the United States; now there are 40 . Transgender people who medically transition become permanent medical patients. To maintain their transitions, they must take hormones and have regular blood tests for the rest of their lives. Puberty blockers, hormone treatments, blood tests, genital electrolysis, facial electrolysis, laser body hair reduction, breast augmentation, facial feminization surgery, orchiectomies, vaginoplasties, colovaginoplasties, metoidioplasties, phalloplasties, and double mastectomies are some of the expensive treatments that may be pursued by transgender people.

Additional treatments may be needed to address complications resulting from medical transition treatments. The Truth About Transition Tumblr blog has compiled posts by female to male transitioners who have experienced difficulties. One trans man posts a video about multiple doctor visits he made recently to correct his testosterone levels and stop bleeding, leading him to 1) increase his testosterone dosage, 2) start taking progesterone, and 3) to go on Lupron, usually used as a puberty blocker. Another young trans man expresses his weariness anticipating his 20th transition-related surgery. The latest surgery is a third attempt to treat an abscess that developed during his surgical pursuit of a penis.

Revenue from testosterone sales has increased dramatically in recent years. Testosterone sales generated $2.4 billion in revenue in the United States in 2013. The projection for 2018 sales is $3.8 billion, a 58 percent increase.  While testosterone is used for purposes other than sexual transition, the increase in revenue correlates with the proliferation of gender clinics.

In addition to risky medical treatments, many girls and women use binders to compress their breasts and make their chests appear flatter. Binders have side effects such as back pain, shortness of breath, and rib fractures. When I Googled the term, “binder risks,” the first site that popped up was a plastic surgery clinic that does “top surgeries” for girls/women who want to transition to male. Yes, the folks who will profit by cutting off girls’ healthy breasts want to make very sure girls and their families understand the risks of binders.

What other civil rights movement has involved supporting body modifications for minors and young adults?

I have never felt so alone. People who would normally be allies for parents of a troubled child including therapists, doctors, teachers, and friends support this madness. I can only assume it is because they believe some or all of the following:

  • Only transgender people experience gender dysphoria.
  • Being transgender is always an innate and permanent condition.
  • People with gender dysphoria receive careful evaluation and therapy before being allowed to medically modify their bodies.
  • Transgender minors are not being allowed to make permanent changes to their bodies.
  • Transition-related medical treatments are well-tested and proven safe.
  • Children, youth and adults always fully understand why they are feeling dysphoric.
  • Physicians and drug companies would never experiment on children or put profit ahead of patients’ best interests.
  • Research has proven that transition prevents suicide.


None of it is true.

A friend told me recently that I have nothing to gain by resisting my daughter’s desire to transition. I strongly disagree. If resistance means my daughter postpones medical treatments until she can weigh the risks versus the benefits with more maturity, I gain plenty. If I can buy more time for her to discern whether her dysphoria really means she is transgender or whether something else precipitates her discomfort, I gain plenty.

I feel genuine rage toward the therapists and doctors who are complicit in the pursuit of medical transitions for kids, teenagers and young adults. You swore you would first do no harm. You should be ashamed!

If anyone working in the malpractice insurance industry happens to read this story, I have one final question specifically for you. Is it wise to cover the therapists and doctors involved in the transition of children and youth? When the lawsuits begin, I hope the settlements are breathtaking.

Gender dysphoria is not one thing

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

This is the second in a series of articles authored by Drs. Bailey and Blanchard; see here for their first piece.

Many parents who are part of the 4thWaveNow community have daughters who fit the profile of a sudden onset of gender dysphoria in adolescence. This phenomenon is discussed in detail by the authors after the first two types, in the section “Rapid-onset Gender Dysphoria (Mostly Adolescent and Young Adult Females).” Some 4thWave parents will also find the section “Two Rarer Types of Gender Dysphoria” of particular interest (near the end of the article).

We recognize that regular readers and members of 4thWaveNow will not agree with all of what Bailey and Blanchard have to say, but as always, if you wish to challenge the authors, your comments will be more likely to be published if they are delivered respectfully.

As their time permits, Drs. Bailey and Blanchard will be available to interact in the comments section of this post.

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

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

One problem with the current mainstream narrative regarding gender dysphoria is that it makes no distinctions among apparently very different kinds of persons. For example, Bruce Jenner appeared to be a very masculine man, an Olympic athlete who was married to three different women and had six children with them, before becoming Caitlyn Jenner. In contrast, Jazz Jennings, a natal male, was so feminine that she earned a diagnosis of gender identity disorder at the age of four. She is attracted to males. Jenner and Jennings are so different in their presentation and history that it is surprising to us that anyone thinks they have the same condition. Jenner and Jennings are examples of two very different kinds of gender dysphoria that have been scientifically well studied, and have fundamentally different motivations, clinical presentations, and likely causes.

The failure of so many therapists and activists to acknowledge this distinction is disturbing for at least two reasons. First, it suggests they are either ignorant of relevant scientific evidence or are purposefully ignoring it. Second, failure to make scientifically valid and fundamental distinctions among different kinds of gender dysphoric persons can only prevent progress toward finding the best approach to helping each. Measles, influenza, and strep throat are all associated with fever. But if we had merely lumped them together as “fever,” we would not have effective treatments for them.

 Types of Gender Dysphoria

Gender dysphoria isn’t common. But there are at least three distinct types of gender dysphoria that, presently, regularly occur in children and adolescents. We summarize these at length here. Two other kinds of gender dysphoria are much less common in these age groups, and so we address them less fully near the end of this essay. The main three types differ in their age of onset (childhood, adolescence, or adulthood), their speed of onset (gradual or sudden), their associated sexual orientations (members of the same sex or the fantasy of belonging to the opposite sex), and their sex ratio (equally or unequally likely in males and females).

The first type—childhood-onset gender dysphoria—definitely occurs in both biological boys and girls. It is highly correlated with homosexuality–the sexual preference for one’s own biological sex–especially in natal males. (Sexual orientation is usually not apparent until a child reaches adolescence or adulthood, however.) This is the type that Jazz Jennings had before her gender transition. The second type—autogynephilic gender dysphoria—occurs only in males. It is associated with a tendency to be sexually aroused by the thought or image of oneself as a female. This type of gender dysphoria sometimes starts during adolescence and sometimes during adulthood, and its onset is typically gradual. (Onset may appear sudden to family members, however.) Although Caitlyn Jenner has not discussed her feelings openly, we strongly suspect she is autogynephilic. The third type—rapid-onset gender dysphoria—mostly occurs in adolescent girls. This type is primarily characterized by the age and speed of onset rather than the associated sexual orientation, and it may not be limited to one sex, as the second type is. Our impression is that rapid-onset gender dysphoria is especially common among daughters of parents who read 4thWaveNow as well as those who post on the support board at

The first two types (childhood-onset gender dysphoria and autogynephilic gender dysphoria) have been well studied, although autogynephilic gender dysphoria has primarily been studied in adults. The third (rapid-onset gender dysphoria) has only recently been noticed, and it is possible that it didn’t occur much until recently.

How do you know which type of gender dysphoria your child has? If there were clear signs well before puberty that your child was gender dysphoric, s/he has child-onset gender dysphoria. (You would certainly have noticed signs at the time; at the very least you would have coded your child as extremely gender nonconforming.) If your child showed signs of gender dysphoria for the first time during adolescence, s/he has one of the other types. Remember, autogynephilic gender dysphoria occurs only in natal males, and it starts either during adolescence or adulthood. (And to a parent, it usually seems sudden.) We describe the three types more thoroughly below.

Childhood-onset Gender Dysphoria (Boys and Girls)

The most obvious feature that distinguishes childhood-onset gender dysphoria from the other types is early appearance of gender nonconformity. Gender nonconformity is a persistent tendency to behave like the other sex in a variety of ways, including preferences of dress and appearance, play style, playmate preferences, and interests and goals. A very gender nonconforming boy may dress up as a girl, play with dolls, dislike rough play, show indifference to team sports or contact sports, prefer girl playmates, try to be around adult women rather than adult men, and be known by other children as a “sissy” (a term generally used to ridicule and shame feminine boys). A very gender nonconforming girl shows an opposite pattern, with the less derogatory word “tomboy” replacing sissy.

Onset of gender nonconformity is childhood cases is very early, typically about as early as gendered behavior can be noticed.

It is important to understand that not all gender nonconforming children (even very gender nonconforming children) have gender dysphoria. Probably most don’t, in fact. But we know of no cases of childhood-onset gender dysphoria without gender nonconformity.

Gender dysphoria in the childhood cases requires that children are unhappy with their birth sex. Furthermore, they typically yearn to be–or even assert that they are–the other sex.

What do we know about childhood-onset gender dysphoria?

Childhood-onset gender dysphoria has been systematically studied by two high quality international research centers (one in Toronto, which was led by Kenneth Zucker, and one in the Netherlands, which was led by Peggy Cohen-Kettenis). Both centers have assessed and followed representative samples of gender dysphoric children seen at their clinics. Reassuringly, results are fairly similar across the two sites. Furthermore, their results are similar to less representative samples studied earlier in the United States.

The published literature shows that at least in the past, 60-90% of children whose gender dysphoria began before puberty adjusted to their birth sex without requiring gender transition. That may be changing, however, due to changes in clinical practice that encourage gender transition. (See below.)

It is important to realize that childhood-onset gender dysphoria is the only kind of gender dysphoria that has been well-studied in children and adolescents. This means, for example, that the persistence and desistance figures we have provided apply only to that type. We do not know comparable figures about autogynephilic or rapid-onset gender dysphoria. Furthermore, most people, when they think of “transgender children and adolescents” have childhood-onset gender dysphoria in mind. (And they think of happy Jazz more than they think of Jazz’s serious medical surgeries and hormonal treatment for life.) But this association is misleading for all cases of gender dysphoria that are not childhood-onset. Autogynephilic and rapid-onset gender dysphoria have very different causes and presentations than childhood-onset gender dysphoria.


Children with childhood-onset gender dysphoria have a much higher likelihood of non-heterosexual (i.e., homosexual or bisexual) adult outcomes compared with typical children. Childhood-onset gender dysphoric boys who desist usually become nonheterosexual men. A smaller percentage have reported that they are heterosexual at follow up. Those who transition become transwomen attracted to men.

Although most childhood-onset gender dysphoric girls who have been followed identify as heterosexual, those who desist have a much higher rate of nonheterosexuality compared with the general population. Among those who transition, most are attracted to women.

We repeat: there is no evidence that parents can change their children’s eventual sexual orientation, and we don’t think they should try.

Risk Factors for Persistence of Childhood-onset Gender Dysphoria

Which childhood-onset gender dysphoric children will persist, and which will desist? Evidence suggests that we can’t distinguish these two groups with high confidence, although we can distinguish them better than chance.

There is some evidence that the severity of gender dysphoria distinguishes these two groups, although it is far from a perfect predictor. Children who not only say they want to be the other sex but who assert that they are the other sex may be especially likely to persist. The reasons why a child’s expressed belief that s/he is the other sex predicts persistence remain unclear, and this variable does not allow even near-perfect prediction. The idea that it is the essential test of “true trans” is an overstatement.

Other empirically supported risk factors include being of lower socioeconomic status and having autistic traits, both of which predict persistence. Why should these factors matter? Researchers have speculated that socioeconomically disadvantaged families are more likely to have problems that prevent them from providing the consistent supportive social environment that may be most likely to help the gender dysphoric child desist. Autistic traits include perseverative and obsessional thinking, both of which may make desistance more difficult. Furthermore, parents of children with autistic traits may be so concerned about other problems that they are permissive about things likely to foster gender transition.

One powerful predictor of persistence is social transition, or a child’s living as the other sex. Until recently this was practically unheard of. Increasingly, however, it is not only known but encouraged by many gender therapists. (Watch an episode of “I am Jazz.”) In the Netherlands social transition has been common longer than in the United States. A recent study found that social transition was the most powerful predictor of persistence among natal males. That is, gender dysphoric boys allowed to live as girls strongly tended to want to become adult women. (The same trend occurred for natal females, but it was less robust.) This is not surprising. If a gender dysphoric child is allowed to live as the other sex, what will change his/her mind? No one disputes that gender dysphoric children really, really would like to change sex.

What should you do?

The necessary studies have not been conducted to be certain. But based on the overall picture, we suggest:

If you want your childhood-onset gender dysphoric child to desist, and if your child is still well below the age of puberty (which varies, but let’s say, younger than 11 years), you should firmly (but kindly and patiently) insist that your child is a member of his/her birth sex. You should consider finding a therapist if this is difficult for you and your child. You should not allow your child to engage in behaviors such as cross dressing and fantasy play as the other sex. Above all else, you should not let your child socially transition to the other sex.

At the same time, you should recognize that despite your best efforts, your child may ultimately need to transition to be happy. If your child’s gender dysphoria persists well into adolescence (again, the ages vary by child, but let’s say age 14 or so), s/he is much more likely to transition. At that point, in our opinion, parents should consider supporting transition.

Autogynephilic Gender Dysphoria (Adolescent Boys and Men)

From a parent’s perspective, autogynephilic gender dysphoria (which occurs only in natal males) often seems to come out of the blue. This is likely to be true whether the onset is during adolescence or adulthood. A teenage boy may suddenly announce that he is actually a woman trapped in a man’s body, or that he is transgender, or that he wants gender transition. Typically, this revelation follows his intensive internet research and participation in internet transgender forums. Importantly, the adolescent showed no clear, consistent signs of either gender nonconformity or gender dysphoria during childhood (that is, before puberty).

There is an important distinction between rapid-onset gender dysphoria and autogynephilic gender dysphoria that happens to have an adolescent onset. Rapid-onset gender dysphoria is suddenly acquired, whereas autogynephilic gender dysphoria may be suddenly revealed, after having grown in secret for a number of years. We will talk more about this later.

Where does autogynephilic gender dysphoria come from? We know a lot about the motivation of this kind of gender dysphoria. Most of our knowledge comes from studies of adults born male who transitioned during adulthood. Some of these adults had gender dysphoria during adolescence, but all of them had the root cause of their condition: autogynephilia.

(Warning: Autogynephilia is about sex. We understand that it is awkward and uncomfortable for any parent to consider their children’s sexual fantasies. But you can’t understand your son with this kind of gender dysphoria without doing so.)

Autogynephilia is a male’s sexual arousal by the fantasy of being a woman. That is, autogynephilic males are turned on by thinking about themselves as women, or behaving like women. The typical heterosexual adolescent boy has sexual fantasies about attractive girls or women. The autogynephilic adolescent boy’s may also have such fantasies, but in addition he fantasizes that he is an attractive, sexy woman. The most common behavior associated with autogynephilia during adolescence is fetishistic cross dressing. In this behavior, the adolescent male wears female clothing (typically, lingerie) in private, looks at himself in the mirror, and masturbates. Some autogynephilic males are not only sexually aroused by cross dressing, but also by the idea of having female body parts. These body-related fantasies are especially likely to be associated with gender dysphoria.

It is important to distinguish between autogynephilia and autogynephilic gender dysphoria. Autogynephilia is basically a sexual orientation, and once present does not go away, although its intensity may wax and wane. Autogynephilic gender dysphoria sometimes follows autogynephilia, and is the strong wish to transition from male to female. A male must have autogynephilia to have autogynephilic gender dysphoria, but just because he is autogynephilic doesn’t mean he will be gender dysphoric. Many autogynephilic males live their lives contented to remain male. Furthermore, sometimes autogynephilic gender dysphoria remits so that a male who wanted to change sex no longer does so.

In general, adolescent boys are unlikely to divulge their sexual fantasies to their parents. This is likely especially true of boys with autogynephilia. Furthermore, many boys who engage in cross dressing feel ashamed for doing so. The fact that autogynephilic fantasies and behaviors are largely private is one reason why autogynephilic gender dysphoria usually seems to emerge from nowhere. Another reason is that autogynephilic males are not naturally very feminine. An adolescent boy with autogynephilia does not give off obvious signals of gender nonconformity or gender dysphoria.

It is likely that most autogynephilic males do not pursue gender reassignment, but this is difficult to know. (We would need to conduct a representative survey of all persons born male, asking about both autogynephilia and gender transition. This has not been done and won’t be done anytime soon.) Many males with autogynephilia are content to cross dress occasionally. Some get married to women and many also have children. Family formation is no guarantee against later transition, although that may slow it up somewhat. In past decades, when autogynephilic males have transitioned, they have most often done so during the ages 30-50, after having married women and fathered children. It is possible that autogynephilic males have recently been attempting transition at younger ages, including adolescence.

The relationship between autogynephilia and (autogynephilic-type) gender dysphoria is uncertain. One view is that gender dysphoria may arise as a complication of autogynephilia, depending perhaps on chance events or environmental factors. Another view is that autogynephiles who become progressively gender dysphoric were somewhat different from simple autogynephiles from the beginning (for example, more obsessional). Because we do not actually know the causes of autogynephilia, it is quite difficult to sort out these various interpretations at present.

Autogynephilia—the central motivation of autogynephilic gender dysphoria—can be considered an unusual sexual orientation. As with other kinds of male sexual orientation, we do not know how to change it, and we shouldn’t try. The dilemma is how to live with autogynephilia in a way that allows the most happiness. For some with autogynephilia, this will mean staying male. For others, it will mean transitioning to female.

What do we know about autogynephilic gender dysphoria?

Much of what we know about autogynephilic gender dysphoria comes from research conducted on adults. Most of the early research was conducted by the scientist who developed the theory of autogynephilia, Ray Blanchard. This work was subsequently confirmed and extended by other researchers, especially Anne Lawrence, Michael Bailey, and Bailey’s students.

Blanchard’s research identified two distinct subtypes of gender dysphoria among adult male gender patients. One type, which he called “homosexual gender dysphoria” is identical to childhood onset male gender dysphoria. Males with this condition are homosexual, in the sense that they are attracted to other biological males. Blanchard provided persuasive evidence that the other male gender patients were autogynephilic. We currently favor the theory that there are only two well established kinds of gender dysphoria among males, because no convincing evidence for any other types has been offered. This could change­–we are committed to a scientific open-mindedness. In particular, it is possible that some cases of adolescent-onset gender dysphoria among males are essentially the same as Rapid-onset Gender Dysphoria that occurs among natal females. This will require more research to establish, however.

Autogynephilia is a probably rare, although it is difficult to know for certain. Among males who seek gender transition, however, it is common. In fact, in Western countries in recent years, including the United States, autogynephilia has accounted for at least 75% of cases of male-to-female transsexualism.

Given how important autogynephilia is for understanding gender dysphoria, it may surprise you that you had never heard of it. Autogynephilia remains a largely hidden idea because most people–including journalists, families, and many males with autogynephilia–strongly prefer the standard, though false, narrative: “Transsexualism is about having the mind of one sex in the body of the other sex.” Many people find this narrative both easier to understand and less disturbing than the idea that some males want a sex change because they find that idea strongly erotic.

Although many autogynephilic males find discovery of the idea of autogynephilia to be a positive revelation–autogynephilia has been as puzzling to them as it is to you–some others are enraged at the idea. There are two main reasons why some autogynephilic males are in denial. First, they correctly believe that many people find a sexual explanation of gender dysphoria unappealing–discomfort with sexuality is rampant. Second, they find this explanation of their own feelings less satisfying than the standard “woman trapped in man’s body” explanation. This is because autogynephilia is a male trait, and autogynephilia is about wanting to be female.

It is good to be aware of autogynephilia’s controversial status, because transgender activists are often hostile to the idea. You will not learn more about it from the activists. And if your son has frequented internet discussions, he may also resent the idea. We emphasize that autogynephilia is controversial for social reasons, not for scientific ones. No scientific data have seriously challenged it.


Males with autogynephilia can have a variety of autogynephilic fantasies and interests, from cross dressing to fantasizing about having female bodies to enjoying (for erotic reasons) stereotypical female activities such as knitting to fantasizing about being pregnant or menstruating. One study found that autogynephilic males who fantasize about having female genitalia also tended to be those with the greatest gender dysphoria.

Autogynephilic males sometimes identify as heterosexual (i.e., attracted exclusively to women); sometimes as bisexual (attracted to both men and women), and sometimes as asexual (i.e., attracted to no individuals). Blanchard’s work has shown that autogynephilia can be thought of as a type of male heterosexuality, one that is inwardly directed. Autogynephilia often coexists with outward-directed heterosexuality, and so autogynephilic males usually say they are also attracted to women. Some autogynephilic males enjoy the idea that they are attractive, as women, to other men. They may have sexual fantasies about having sex with men (in the female role); some may even act on these fantasies. This accounts for the bisexual identification among some autogynephilic males. In some others, the intensity of the autogynephilia–which is attraction to an imagined “inner woman”–is so great that there are no erotic feelings left for other people. This accounts for asexual identification. (Asexual autogynephilic males have plenty of sexual fantasies, but these fantasies tend not to involve other people.)

When autogynephilic males receive female hormones as part of their gender transition, they typically experience a noticeable decrease in their sex drive. Some have reported that this has diminished their desire for gender transition as well. Others, however, have reported no change in their desire for transition. (In any case, hormonal therapy is a medical intervention with serious potential side effects, and we do not recommend it as a way to treat gender dysphoria, except in cases in which after very careful consideration, gender transition is pursued.)

Autogynephilia is a paraphilia, meaning an unusual sexual interest nearly exclusively found in males.

We repeat: Autogynephilia is a sexual orientation–to be sure, an unusual orientation that is difficult to understand. There is no evidence that parents can change their children’s sexual orientations. And we don’t think they should try.

What should you do?

Consistent with our values, knowledge, and common sense, we believe that males with autogynephilic gender dysphoria should not pursue gender transition right away, as soon as they first have the idea. Transition ultimately requires serious medical procedures with irreversible consequences. But we are unsure what the right approach to autogynephilic gender dysphoria is. In part, this is because there has been too little outcome research conducted by scientists knowledgeable and open about autogynephilia.

First, we recommend that your son be informed about autogynephilia. The best way to do this is up to you. There is probably no non-awkward way. Consider showing them this blog. People should make important life decisions based upon facts, and for males autogynephilic gender dysphoria, autogynephilia is a fact. The standard “female mind/brain in male body” is a fiction.

Some males become less motivated to pursue gender change when they understand their autogynephilia. However, some do not become less motivated. We know far less about patterns of persistence and desistance of autogynephilic gender dysphoria than we do about childhood onset gender dysphoria.

If an autogynephilic male has become familiar with the scientific evidence, has patiently considered the potential consequences of gender transition over a non-trivial time period, and still wishes to transition, we do not oppose this decision. It is possible that many autogynephilic males are happier after gender transition. But there is no rush for any adolescent to decide.

Rapid-onset Gender Dysphoria (Mostly Adolescent and Young Adult Females)

Rapid-onset gender dysphoria (ROGD) seems to come out of the blue. We think this is because ROGD does come out of the blue. This is not to say that all adolescents with ROGD were happy and mentally healthy before their ROGD began. But importantly, they had no sign of gender dysphoria as young children (before puberty).

The typical case of ROGD involves an adolescent or young adult female whose social world outside the family glorifies transgender phenomena and exaggerates their prevalence. Furthermore, it likely includes a heavy dose of internet involvement. The adolescent female acquires the conviction that she is transgender. (Not uncommonly, others in her peer group acquire the same conviction.) These peer groups encouraged each other to believe that all unhappiness, anxiety, and life problems are likely due to their being transgender, and that gender transition is the only solution. Subsequently, there may be a rush towards gender transition, including hormones. Parental opposition to gender transition often leads to family discord, even estrangement. Suicidal threats are common.*

We believe that ROGD is a socially contagious phenomenon in which a young person–typically a natal female–comes to believe that she has a condition that she does not have. ROGD is not about discovering gender dysphoria that was there all along; rather, it is about falsely coming to believe that one’s problems have been due to gender dysphoria previously hidden (from the self and others). Let us be clear: People with ROGD do have a kind of gender dysphoria, but it is gender dysphoria due to persuasion of those especially vulnerable to a false idea. It is not gender dysphoria due to anything like having the mind/brain of one sex trapped in the body of the other. Those with ROGD do, of course, wish to gender transition, and they often obsess over this prospect.

The subculture that fosters ROGD appears to share aspects with cults. These aspects include expectation of absolute ideological agreement, use of very specific jargon, thinking of the world as “us” versus “them” (even more than typical adolescents do), and encouragement to cut off ties with family and friends who are not “with the program.” It also has uncanny similarities to a very harmful epidemic that occurred a generation ago: the epidemic of false “recovered memories” of childhood sexual abuse and the associated epidemic of multiple personality disorder. We discuss these more below. First, however, we review what little we know about ROGD.

What About Natal Males?

Why do we keep emphasizing natal females versus natal males? There are three reasons. First, the single study that has been conducted on ROGD found substantially higher numbers of females than males (more than 80% female cases). Second, there has been a striking surge in the number of adolescent females identifying as transgender and presenting at gender clinics. Third, there is a different kind of gender dysphoria–Autogynephilic Gender Dysphoria–that likely accounts for most or all of the apparent cases of ROGD in natal males. However, we cannot be completely sure that the smallish number of ROGD cases in natal males are due to autogynephilia. It’s possible, therefore, that what we discuss here applies to some natal males as well.

What Do We Know?

ROGD is such a recent phenomenon that we know little for certain. We have four sources of data. First, an important study of ROGD has been presented by Lisa Littman at the annual meeting of the International Academy of Sex Research. (It has not yet been published, but we suspect it will be soon.) This is the only systematic empirical study to date. Second, we have had numerous conversations with mothers of girls with ROGD. Third, we have read several case studies of the phenomenon. Fourth, we have been in touch with clinicians who work (either as therapists or consultants) with children with ROGD, or their families. Fortunately, the sources have provided convergent findings. We are fairly confident about the following generalizations:

–The large majority of persons with ROGD are female, and the most typical age of onset ranges from high school to college ages.

–Persons with ROGD have a high rate of non-heterosexual identities before the onset of their ROGD.

–Signs of extreme social contagion are typical. For example, this includes multiple peer group members who all began to identify as transgender. Sometimes this occurs after school-sponsored transgender educational programs.

–Persons with ROGD have high rates of certain psychiatric problems, especially aspects related to borderline personality disorder (e.g., non-suicidal self-harm) and mild forms of autism (that used to be called “Asperger Syndrome).

–In general, the mental health and social relationships of children with ROGD get much worse once they adopt transgender identities.

–Parents resisting their children’s ROGD are not “transphobic” or socially intolerant. These are parents who, for example, usually approve of gay marriage and equal rights for transgender persons.

Our Current Take on ROGD

Rapid-onset Gender Dysphoria (ROGD) occurs when a young person (generally an adolescent female) is persuaded that she is transgender, despite strong evidence that the young person had few or no signs associated with established forms of transgender. How and why does this happen?

Despite the very limited available research to date, we have strong intuitions and hunches about what is going on, based on its similarity to similar phenomena in the past: the recovered memories and multiple personality epidemics. We spend considerable effort in this section both explaining these past epidemics and drawing the parallels to the current one that concerns us now: Rapid-onset Gender Dysphoria. We believe that she who forgets (or ignores) the past is doomed to repeat it.

During the 1990s there was an explosion of cases in which women came to believe that they had been sexually molested, usually by their fathers and often repeatedly and brutally. They believed these things even though prior to “recovering” these “memories”–most often during psychotherapy–they did not remember anything like them. They believed in the memories even though the memories were often highly implausible (for example, family members would have noticed). Many women with recovered memories cut off relationships with their families. Some developed symptoms of multiple personality disorder. We know now that the recovered memories were false. And multiple personality disorder doesn’t exist, at least in the way those affected and their therapists believed. We refer to recovered memories and multiple personality disorder, which have similar causes–and also some similar causes to ROGD–as RM/MPD

Here are the main similarities between ROGD and RM/MPD:

  1. Cases consistent with RM/MPD were very rare prior to the 1980s but became an epidemic. The same appears to be happening with ROGD.
  2. Both have primarily affected young females, although RM/MPD began substantially later (on average, age 32) than ROGD (typically during adolescence). (Another destructive epidemic of social contagion–witch accusations in colonial Salem–primarily involved adolescent girls.)
  3. The explanations of both RM/MPD and ROGD by “true believers” are contradicted by past experience, common sense, and science. Memory and personality integration did not work the way that therapists treating RM/MPD believed they did. For example, children and adults who experienced trauma can’t repress them–they remember them despite their best attempts. And gender dysphoria in natal females does not begin after childhood–unless it is the acquired condition that is ROGD.
  4. Both show ample evidence of social contagion of false, harmful beliefs. In RM/MPD, the “infection route” usually went from therapists who strongly believed in RM/MPD to their suggestible patients, who acquired a similar belief, applied it to their own lives, and manufactured false and monstrous accusations against previously loved ones. (A harmful result of therapy or medical treatment is called iatrogenic,) In ROGD, the infection route appears to be primarily directly from youngster to youngster. To be sure, therapists get into the act after the person with ROGD acquires the belief that she is transgender, and then they are complicit in tremendous harm. But it seems rarely to occur (yet) for a youngster to be talked into ROGD by a therapist.
  5. Both are associated with sociopolitical ideologies. (Interestingly, both ideologies still find comfortable homes in Gender Studies programs in many universities.) For RM/MPD, the ideological system was that men’s sexual abuse of children has not only been too common (true), but that it has been rampant, even the rule (false). Couple this ideology with a belief in Freudian theory and methods (like hypnosis), and what could go wrong? Plenty, it turned out. For ROGD, the relevant ideology is less coherent, but includes the seemingly contradictory ideas that gender is “fluid” (here meaning that not everyone fits into a male-female dichotomy); that forcing people into rigid gender categories is a common cause of societal and personal anguish; but that gender transition is an underused way of helping people.
  6. Both RM/MPD and ROGD are associated with mental health issues, generally, and especially a personality profile consistent with borderline personality disorder (BPD). This is not to say that all persons with either RM/MPD or ROGD have BPD; simply that evidence suggests that it is common in these groups. For example, the high rate of non-suicidal self-injury we have noticed from the aforementioned sources is striking. Such behavior is strongly associated with BPD. (For a discussion of BPD among those with RM/MPD, see this article, pages 510ff.)
  7. Adopting the belief that one has either RM/MPD or ROGD has been associated with a marked decline in functioning and mental health.

Some of the factors that seem to be common in ROGD–and some that are similar between ROGD and RM/MPD–likely encourage the adoption of false beliefs and identities. These include a fragile sense of self (BPD), attention seeking (BPD), social difficulties (BPD and autistic traits), social malleability (BPD, and adolescence), social pressure (adolescence), and strongly held (if irrational and poorly supported) beliefs that make embracing false conclusions especially likely (sociopolitical indoctrination). Adolescents with an actual history of gender nonconformity, or whose sexual orientations are non-heterosexual, may be especially vulnerable to believing that these are signs they have always been transgender. Adolescents whose lives have not been going well may be especially looking for an explanation and may be especially receptive to drastic change.

Based on the aforementioned data sources with which we are familiar, and on our informed hunches, we suspect that many persons with ROGD were usually troubled before they decided they were gender dysphoric and many will lead somewhat troubled lives even after their ROGD (hopefully) dissipates. Of course, ROGD can only make things worse, both for the affected person and her family.

What to do

Because ROGD is such a recent phenomenon, there is very little guidance about helping affected persons. Lisa Marchiano has written two excellent essays abounding with good sense, and we recommend starting with those.

Second, set aside, for now, rapid-onset gender dysphoria. Identify your child’s problems that existed before ROGD and that may have contributed to it. Attending to these problems will be useful for everybody, and perhaps your child will even agree.

Third, with respect to ROGD, do what you can to delay any consideration of gender transition. Of the different kinds of gender dysphoria, ROGD is the type for which gender transition is least justifiable and least researched. Remember, ROGD is based on a false belief acquired through social means. None of the aforementioned factors that have caused your child to embrace this false belief will be corrected by allowing her to transition.

Two Rarer Types of Gender Dysphoria

For the sake of completeness, we include two other kinds of gender dysphoria. We suspect that both are rare, even among persons with gender dysphoria. One of us (Blanchard) has seen cases of the first type, autohomoerotic gender dysphoria, which appears to be an erotically motivated gender dysphoria. In this case, sexually mature natal females (i.e., not biologically still children) become sexually preoccupied with the idea of becoming a gay man and interacting with other gay men. Neither of us has seen someone clearly fitting the second type, gender dysphoria resulting from psychosis. (Our inclusion of this type was motivated in large part by the argument of Dr. Anne Lawrence, an important scholar we both respect.) In this type, a person (either male or female by birth) acquires the delusion that s/he is the other sex, because s/he is suffering from gross thinking deficiencies.

Superficially, both of these conditions have some similarities to some other kinds of gender dysphoria. For example, a female with rapid onset gender dysphoria may be sexually attracted to males and thus strive to become a gay man, similar to autohomoerotic gender dysphoria. The important difference is that the female with rapid onset gender dysphoria is not primarily motivated by an erotic desire to be a gay man. Instead, having the prospect of having sex with gay men is a by-product of her condition, not the main point of it. The female with rapid onset gender dysphoria acquires it via social contagion, broadly speaking (i.e., including cultural signals that gender dysphoria is in some crucial ways desirable). With respect to the other rare subtype, we have both known gender dysphoric persons with psychosis. However, in these cases, the psychosis was not the cause of the gender dysphoria. It was simply an additional problem that the gender dysphoric person had. In the case of gender dysphoria resulting from psychosis, the belief that one is transgender (or the other sex) is clearly a delusion resulting from disordered thinking–and not, for example, from social contagion or autogynephilia.

Autohomoerotic Gender Dysphoria

This rare type of gender dysphoria is limited to females. Published cases have consisted of women whose gender dysphoria began in late adolescence or adulthood. (It is conceivable that it might begin earlier in some cases.) It occurs in (heterosexual) females who are sexually attracted to men, but who wish to undergo sex reassignment so that they can have “homosexual” relations with other men. These females appear to be sexually aroused by the thought or image of themselves as gay men. We have created the label autohomoerotic gender dysphoria to denote this sexual orientation. There are little systematic data on this type of gender dysphoria, although clinical mentions of heterosexual women with strong masculine traits, who say that they feel as if they were homosexual men, and who feel strongly attracted to effeminate men go back over 100 years.

It is well documented that at least a few autohomoerotic gender dysphorics have undergone surgical sex reassignment and were satisfied with their decision to do so. There is no compelling reason to question such self-reports of postoperative satisfaction, although current surgical techniques do not produce fully convincing or functional artificial penises, and it is difficult to imagine that autohomoerotics find it easy to attract gay male partners who can overlook this.

This type of gender dysphoria does not appear to be the female counterpart of autogynephilic gender dysphoria, although the differences might appear subtle. Autogynephilic (male) gender dysphorics are attracted to the idea of having a woman’s body; autohomoerotic (female) gender dysphorics are attracted to the idea of participating in gay male sex. For autogynephiles, becoming a lesbian woman is a secondary goal—the logical consequence of being attracted to women and wanting to become a woman. For autohomoerotics, becoming a gay man appears to be the primary goal or very close to it.

The few available case reports suggest that autohomoerotic gender dysphoria may have ideational or behavioral antecedents in childhood. However, these females are not as conspicuously masculine as girls with (pre-homosexual) Childhood Onset Gender Dysphoria. For this reason, and because it is rare to start with, it is unlikely that many parents will detect this syndrome in daughters. It is conceivable, however, that when they occur, cases of autohomoerotic gender dysphoria may be perceived by others as Rapid Onset Gender Dysphoria. This is not because their gender dysphoria arose suddenly, but rather because their early, atypical erotic fantasies were invisible to their parents.

Gender Dysphoria Caused by Psychotic Delusions

The idea that gender dysphoria can sometimes reflect psychotic delusions is certainly plausible. Delusions in schizophrenia, for example, are often bizarre but compelling to the person who has them. Unfortunately, neither of us (Ray Blanchard or Michael Bailey) has had direct contact with a person clearly meeting this profile, and so we have less confidence in this gender dysphoria category than in the others. Our lack of direct familiarity doesn’t necessarily mean that much. Even if gender dysphoria due to psychosis were fairly common (compared with other forms of gender dysphoria), we wouldn’t have expected to come across it. Persons with severe mental illness have generally been treated for their mental illness and not for gender dysphoria. Until recently, clinics treating persons with gender dysphoria would have screened out patients with severe mental illness, because of concerns that their diagnosis and treatment might be compromised. But we are hesitant to embrace this kind of gender dysphoria as “definitely existing,” because we worry that psychiatrists who have claimed to see it may have been insufficiently trained to notice other kinds of gender dysphoria, such as autogynephilia. Thus, they may have concluded that psychosis caused the gender dysphoria, when in fact, psychosis may have simply occurred with autogynephilia within the same person. One of us (Bailey) has recently been in touch with a mother of a young man who appears to have the profile we would expect for gender dysphoria due to psychotic delusions, and there was no evidence that this young man was autogynephilic. Still, we are least sure about the existence–much less the prevalence–of this kind of gender dysphoria.

Not Just One Type of Gender Dysphoria: Some Implications

It should be clear by now that “gender dysphoria” is not a precise enough term. Parents of gender dysphoric children should know which type of gender dysphoria their child has. To do so it is necessary to learn about all three of the most common types. That is, in order to understand why one’s child is Type X, it is necessary to know why s/he is not Type Y or Type Z. This is not simply academic. There are essential differences between the different types of gender dysphoria.

If knowledge is power, then lack of knowledge is malpractice. The ignorance of some leading gender clinicians regarding all scientific aspects of gender dysphoria is scandalous. To do better, they should start here. We recommend against hiring gender clinicians who are hostile to our typology. Ideally, they would agree with it.

Knowing there are very distinct kinds of gender dysphoria also raises questions–and concerns–about transgender persons of one type using their own experiences to make recommendations for children/adolescents of other types. Nothing in Caitlyn Jenner’s experience allows her to understand what it was like to be Jazz Jennings–and vice versa. Yet a number of vocal transgender activists who have histories typical of autogynephilic gender dysphorics do not hesitate to pressure parents, legislators, and clinicians for acquiescence, laws, and therapies that do not distinguish among types of gender dysphoric children. Moreover, they not infrequently claim inside knowledge based on their own experiences. Yet their experiences are irrelevant to the two types of gender dysphoria that they don’t have. And even with respect to autogynephilia, these transgender activists are nearly all in denial. This means that their public recollections of their experiences are either distorted or outright lies. A notable exception is Dr. Anne Lawrence, who has become an important researcher of gender dysphoria, and who has been honest and open about her autogynephilia. Dr. Lawrence has taken the time to learn the scientific literature regarding different types of gender dysphoria and does not insist that her personal experiences apply to non-autogynephilic gender dysphorics. The biggest victims in the attempts by autogynephiles-in-denial to steer the narrative towards sameness are, in fact, other persons with autogynephilia. These include honest autogynephiles, who frequently contact us but are fearful of public attacks by those in denial. Most relevant to this blog as potential victims are autogynephilic youngsters, who are at risk of being swayed toward decisions they would not otherwise make, on the basis of inaccurate fantasies embraced by those who cannot face the truth of their own condition.

To us, the most tragic group, along with their families, includes those who have acquired rapid-onset gender dysphoria. That condition appears to be the tragic interaction of the current transgender zeitgeist (“It’s everywhere, and it’s great!”) and social media with the vulnerability of troubled adolescents, especially adolescent girls. They are at risk for unnecessary, disfiguring, and unhealthy medical interventions.

*Note. Suicide is tragic and awful, and because of this, we recommend taking seriously your child’s suicidal ideas, threats, and gestures. We have written elsewhere about the risk of suicide among gender dysphoric persons, and we think that this risk is elevated compared with non-gender-dysphoric persons, but still unlikely.