(2018-07-31) Singal When Children Say They're Trans

Jesse Singal: When Children Say They’re Trans (Sex and Gender). Claire, who was 12 at the time, also felt uncomfortable in her body in a way she couldn’t quite describe. She acknowledged that part of it had to do with puberty, but she felt it was more than the usual preteen woes. “At first, I started eating less,” she said, “but that didn’t really help.”

Claire had discovered the videos by accident, or rather by algorithm: They’d showed up in her “recommended” stream

I just wanted to stop feeling bad, so I was like, I should just transition,” she said

They told Claire that they loved and supported her; they thanked her for telling them what she was feeling. But they stopped short of encouraging her to transition. “We let her completely explore this on her own,” Heather told me.

They were concerned that what their daughter had self-diagnosed as dysphoria was simply the travails of puberty.

The therapist referred the family to some nearby gender-identity clinics that offered transition services for young people.

Claire’s parents were wary of starting that process. Heather, who has a doctorate in pharmacology, had begun researching youth gender dysphoria for herself.

Heather questioned whether these criteria, or much of the information she found online, told the whole story. “Psychologists know that adolescence is fraught with uncertainty and identity searching, and this isn’t even acknowledged,” she told me.

We also took away her ability to search online but gave her Instagram as a consolation

They asked her to start keeping a journal, hoping it would help her explore those feelings.

she traced her realization that she wasn’t a boy to one key moment. Looking in the mirror at a time when she was trying to present in a very male way—at “my baggy, uncomfortable clothes; my damaged, short hair; and my depressed-looking face”—she found that “it didn’t make me feel any better. I was still miserable, and I still hated myself.”

She hadn’t seen herself in the other girls in her middle-school class, who were breaking into cliques and growing more gossipy.

The number of self-identifying trans people in the United States is on the rise.

The current era of gender-identity awareness has undoubtedly made life easier for many young people who feel constricted by the sometimes-oppressive nature of gender expectations

But when it comes to the question of physical interventions, this era has also brought fraught new challenges to many parents. Where is the line between not “feeling like” a girl because society makes it difficult to be a girl and needing hormones to alleviate dysphoria that otherwise won’t go away? How can parents tell?

If you read the bible of medical and psychiatric care for transgender people—the Standards of Care issued by the World Professional Association for Transgender Health (Wpath)—you’ll find an 11-page section called “Assessment and Treatment of Children and Adolescents With Gender Dysphoria.” It states that while some teenagers should go on hormones, that decision should be made with deliberation

The American Psychological Association’s guidelines sound a similar note, explaining the benefits of hormones but also noting that “adolescents can become intensely focused on their immediate desires.”

But some clinicians are moving toward a faster process.

HRC, glaad, and like-minded advocacy groups emphasize the acceptance of trans kids for understandable reasons

Accounts of successful transitions can help families envision a happy outcome for a suffering child. And some young people clearly experience something like what these caterpillar-to-butterfly narratives depict. They have persistent, intense gender dysphoria from a very young age, and transitioning alleviates it.

the transition process for a persistently dysphoric child typically looks something like the following

First, allow your child to transition socially: to adopt the pronouns and style of dress of their authentic gender, and to change their name if they wish

As your child approaches adolescence, get them puberty-blocking drugs, because developing the secondary sex characteristics of their assigned sex could exacerbate their gender dysphoria. When they reach their teen years, help them gain access to the cross-sex hormones that will allow them to develop secondary sex characteristics in line with their gender identity. (Until recently, hormones were typically not prescribed until age 16; it’s now more common for 15- and 14-year-olds, and sometimes even younger kids, to begin hormone therapy.)

University of Washington researcher named Kristina Olson. Olson is the founder of the TransYouth Project, which is following a cohort of about 300 children for 20 years—the longest such longitudinal study based in the U.S. The kids she is tracking appear to be doing well

At the prestigious Center of Expertise on Gender Dysphoria, at Vrije Universiteit University Medical Center, in Amsterdam—often referred to simply as “the Dutch clinic”—an older cohort of kids who went through the puberty-blockers-and-cross-sex-hormones protocol was also found to be doing well

These early results, while promising, can tell us only so much. Olson’s findings come from a group of trans kids whose parents are relatively wealthy and are active in trans-support communities; they volunteered their children for the study. There are limits to how much we can extrapolate from the Dutch study as well: That group went through a comprehensive diagnostic process prior to transitioning

Ignoring the diversity of these experiences and focusing only on those who were effectively “born in the wrong body” could cause harm. That is the argument of a small but vocal group of men and women who have transitioned, only to return to their assigned sex. Many of these so-called detransitioners argue that their dysphoria was caused not by a deep-seated mismatch between their gender identity and their body but rather by mental-health problems, trauma, societal misogyny, or some combination

Some of these interventions are irreversible

The concerns of the detransitioners are echoed by a number of clinicians who work in this field, most of whom are psychologists and psychiatrists. They very much support so-called affirming care, which entails accepting and exploring a child’s statements about their gender identity in a compassionate manner. But they worry that, in an otherwise laudable effort to get TGNC young people the care they need, some members of their field are ignoring the complexity, and fluidity, of gender-identity development in young people

caution comes from the concerns inherent in working with young people. Adolescents change significantly and rapidly; they may view themselves and their place in the world differently at 15 than they did at 12

clinicians practice affirming care instead. They listen to their young patients, take their statements about their gender seriously, and often help facilitate social and physical transition. Affirming care has quickly become a professional imperative: Don’t question who your clients are—let them tell you who they are, and accept their identity in a nurturing, encouraging manner. The affirming approach is far more humane than older ones, but it conflicts, at least a little, with what we know about gender-identity fluidity in young people

When Max Robinson was 17, getting a double mastectomy made perfect sense to her.

I met Max, now 22

When she was 13, she had sex with an older man she was seeing; at the time, it felt consensual, but she has since realized that a 13-year-old can’t consent to sex with an 18-year-old. At 14, she witnessed a friend get molested by an adult man at a church slumber party.

The endocrinologist was skeptical, Max said. “I think what she was seeing was a lesbian teenager,” not a trans one

When she was 17, Max, who was still dealing with major mental-health issues, was scheduled for surgery.

Max was initially happy with the results of her physical transformation.

But that feeling didn’t last.

Today, Max identifies as a woman

Because of the hormone therapy, she still has facial hair and is frequently mistaken for male as a result

Though Max’s therapist had tried to work on other issues with her, Max now believes she was encouraged to rush into physical transition by clinicians operating within a framework that saw it as the only way someone like her could experience relief.

Transitioning offered a “level of control over how I was being perceived.”

Cari Stella is the author of a blog called Guide on Raging Stars. Stella, now 24, socially transitioned at 15, started hormones at 17, got a double mastectomy at 20, and detransitioned at 22

The detransitioners who have spoken out thus far are mostly people who were assigned female at birth. Traditionally, most new arrivals at youth gender clinics were assigned male; today, many clinics are reporting that new patients are mostly assigned female. There is no consensus explanation for the change

I saw and knew so many people who were cutting themselves, starving themselves, never leaving their apartments. That made me doubt the narrative that if you make it all the way to medical transition, then it’s probably going to work out well for you

Carey Callahan is a 36-year-old woman living in Ohio who detransitioned after identifying as trans for four years and spending nine months on male hormones.

Carey’s time at the clinic made her realize that testosterone hadn’t made her feel better in a sustained way either.

“When I look at what the SOC describes, and then I look at my own experience and my friends’ experiences of pursuing hormones and surgery, there’s hardly any overlap between the directives of the SOC and the reality of care patients get,”

No one knows how common detransitioning is.

clinicians who have logged thousands of hours working with transgender and gender-nonconforming young people are raising the same concerns.

Today, Laura Edwards-Leeper oversees a collaboration between Pacific University and Oregon’s Transgender Clinic, within the nonprofit Legacy Health system. At Pacific, she is training clinical-psychology doctoral students to conduct “readiness assessments” for young people seeking physical-transition services.

This so-called desistance research has been attacked on various methodological grounds. The most-credible critiques center on the claim that some kids who were merely gender nonconforming—that is, they preferred stereotypically cross-sex activities or styles of dress—but not dysphoric may have been counted as desisters because the studies relied on outdated diagnostic criteria, artificially pushing the percentage upward.

there remains a paucity of big, rigorous studies that might deliver a more reliable figure.

Edwards-Leeper worries that treatment practices are trending toward an interpretation of affirming care that entails nodding along with children and adolescents who say they want physical interventions rather than evaluating whether they are likely to benefit from them. A decade ago, the opposite was true. “I was constantly having to justify why we should be offering puberty-blocking medication, why we should be supporting these trans youth to get the services they need,” Edwards-Leeper recalled. “People thought this was just crazy, and thought the four-hour evaluations I was doing were, too—how could that possibly be enough

At one conference a few years ago, she recalled, a co-panelist who was a well-respected clinician in her field said that Edwards-Leeper’s comprehensive assessments required kids to “jump through more fiery hoops” and were “retraumatizing.” This prompted a standing ovation from the audience, mostly families of TGNC young people

Even some of the clinicians who have emphasized the need to be deferential to young people acknowledge the complexities at play here. A psychologist with decades of experience working with TGNC young people, Diane Ehrensaft is perhaps the most frequently quoted youth-gender clinician in the country.

Sometimes, she said, she suspects that a kid who wants hormones right now is simply reciting something he found on the internet. “It just feels wooden, is the only thing I can say,” she told me.

At the end of our interview, Ehrensaft showed me a slide from a talk she was preparing about what it means to be an affirming clinician: “REALITY: WE ARE NEITHER RUBBER STAMPERS NOR PUSHERS; WE ARE FACILITATORS.” This isn’t so far off from the definition of the clinician’s role expressed by Edwards-Leeper’s students.

This is not to say that talk therapy can cure serious gender dysphoria. Edwards-Leeper worked to introduce the Dutch protocol of blockers and hormones in the United States precisely because she believes that it alleviates dysphoria in cases where there would otherwise be prolonged suffering

Scott Leibowitz... medical director of behavioral health for the thrive program at Nationwide Children’s Hospital, in Columbus.

how Leibowitz and Edwards-Leeper view their approach. Yes, they want to discern whether a patient actually has gender dysphoria. But comprehensive assessments and ongoing mental-health work are also means of ensuring that transitioning—which can be a physically and emotionally taxing process for adolescents even under the best of circumstances—goes smoothly.

Scott Padberg, one of Edwards-Leeper’s patients

he said he understood that Edwards-Leeper was making certain he had considered a range of questions—from how he would feel about possibly not being able to have biological kids to whether he was comfortable with certain hormonal effects, such as a deeper voice. Scott told Edwards-Leeper that he was pretty certain about what he wanted.

Scott’s assessment process centered mostly on the basic readiness questions Edwards-Leeper and Leibowitz are convinced should be asked of any young person considering hormones. But his was a relatively clear-cut case: He’d had unwavering gender dysphoria since early childhood, a lack of serious mental-health concerns, and a generally supportive family.

He was granted all the freedom he needed to express himself in a gender-nonconforming manner, from getting short haircuts to playing with stereotypically male toys like dinosaurs and Transformers. But the freedom didn’t last. When he was 7

Orion Foss... As a teenager, he identified as a lesbian and became involved in the local LGBTQ scene. He says that in 2014, when he was 14 years old and trans narratives were starting to show up more frequently on social media, he realized he was trans. He was also suffering from severe depression and anxiety at the time, which had led to self-harm issues, as well as what may have been an undiagnosed eating disorder. Orion believed that additional weight went straight to his hips and chest, accentuating his feminine features. At one point, he dipped down to 70 pounds.

Looking back, Orion sees the value of this process. “If I had been put on hormone therapy when I didn’t have my identity settled, and who I was settled, and my emotions settled, it would have been crazy. ’Cause when I did start hormone therapy, hormones shoot your mood all around, and it’s not exactly safe to just shoot hormones into someone that’s not stable.”

When he was finally able to begin the hormone treatments, Orion said, he “immediately felt this weight off my shoulders.” His dosage was gradually increased and then, in May 2017, he got a double mastectomy. Orion’s transition has clearly had a profoundly beneficial effect

But progressive-minded parents can sometimes be a problem for their kids as well. Several of the clinicians I spoke with, including Nate Sharon, Laura Edwards-Leeper, and Scott Leibowitz, recounted new patients’ arriving at their clinics, their parents having already developed detailed plans for them to transition. “I’ve actually had patients with parents pressuring me to recommend their kids start hormones,” Sharon said.

2014, found that 41 percent of trans respondents had attempted suicide; 4.6 percent of the overall U.S. population report having attempted suicide at least once

But the clinicians I interviewed said they rarely encounter situations in which immediate access to hormones is the difference between suicide and survival.

Leibowitz noted that a relationship with a caring therapist may itself be an important prophylactic against suicidal ideation for TGNC youth: “Often for the first time having a medical or mental-health professional tell them that they are going to take them seriously and really listen to them and hear their story often helps them feel better than they’ve ever felt.”

When parents discuss the reasons they question their children’s desire to transition, whether in online forums or in response to a journalist’s questions, many mention “social contagion.” These parents are worried that their kids are influenced by the gender-identity exploration they’re seeing online and perhaps at school or in other social settings, rather than experiencing gender dysphoria.

“I’ve been seeing this more frequently,” Laura Edwards-Leeper wrote in an email

I heard a similar story from a quirky 16-year-old theater kid who was going by the nickname Delta when we spoke. She lives outside Portland, Oregon, with her mother and father. A wave of gender-identity experimentation hit her social circle in 2013. Suddenly, it seemed, no one was cisgender anymore

Edwards-Leeper advised her to wait until she was a bit older to take steps toward a physical transition—as Delta recalled, she said something like “I acknowledge that you feel a certain way, but I think we should work on other stuff first, and then if you still feel this way later on in life, then I will help you with that.” “Other stuff” mostly meant her problems with anxiety and depression.

“At the time I was not happy that she told me that I should go and deal with mental stuff first,” Delta said, “but I’m glad that she said that, because too many people are so gung ho

Not everyone agrees about the importance of comprehensive assessments for transgender and gender-nonconforming youth

Johanna Olson-Kennedy... In “Mental Health Disparities Among Transgender Youth: Rethinking the Role of Professionals,” a 2016 jama Pediatrics article, she wrote that “establishing a therapeutic relationship entails honesty and a sense of safety that can be compromised if young people believe that what they need and deserve (potentially blockers, hormones, or surgery) can be denied them according to the information they provide to the therapist.”

One recent study co-authored by Olson-Kennedy, published in the Journal of Adolescent Health, showed that her clinic is giving cross-sex hormones to kids as young as 12.

keeping several seemingly conflicting claims in mind. Some teenagers, in the years ahead, are going to rush into physically transitioning and may regret it. Other teens will be prevented from accessing hormones and will suffer great anguish as a result. Along the way, a heartbreaking number of trans and gender-nonconforming teens will be bullied and ostracized and will even end their own lives.