One psychologist who gets it: “Trans” kids and their parents deserve better

What of the gender variant child whose social environment both accepts and encourages an early transition but may be unaware that the child, unwilling to disappoint, has had a change of heart ?Jack Drescher, MD, quoting Cohen-Kettenis, personal communication, in the introduction to this special issue

The Journal of Homosexuality published a 300-page special issue on childhood gender dysphoria in March 2012. It contains articles by several well known “gender specialists,” including Norman Spack, Kenneth Zucker, Jack Drescher, Diane Ehrensaft and others. These providers discuss their own clinical practice and experiences, informed by their viewpoints–and biases–about “trans” kids.

But of most interest to me is a piece by clinical psychologist David Schwartz, PhD., who is not a gender specialist himself, but knowledgeable about child psychology and the dynamics of family therapy. In his aptly named “Listening to Children Imagining Gender: Observing the Inflation of an Idea,” Schwartz critically and compassionately analyzes three of the other articles in the issue, focusing particularly on one written by Laura Edwards-Leeper, PhD., and Norman Spack, MD. Dr. Spack is a leading proponent of childhood medical transition, and heads up the Disorders of Sexual Development (DSD) and Gender Management Service (GeMs) at Boston Children’s Hospital, the first of its kind in the US.

Schwartz has two main points: First, he skillfully clarifies how most of the other clinicians writing in the issue operate from an idea–an inflated idea, unsupported by evidence–that gender is innate from birth. Schwartz terms this “gender essentialism.” And the concerned parents who bring their kids to these specialists imbibe the same biased idea.

Schwartz’s second key point is that the literal acceptance of a “trans” child’s demands and assertions, while completely ignoring underlying motivations typical of all kids, is something new under the clinical sun when it comes to treating children. It’s as if the insights of decades of child psychology are being thrown out in favor of automatically endorsing a narrative—a narrative driven by children, with their necessarily immature understandings and desires.  And Schwartz makes it clear that this clinical approach is doing no favors to dysphoric children–nor their parents.

We desperately need more outspoken therapists like Dr. Schwartz, clinicians who have deep clinical insight into developmental psychology and parent-child dynamics–not just “gender dysphoria.”

Because for most readers, the full article (and the rest of the journal issue) will be behind a paywall,  I am extensively quoting several of Dr. Schwartz’s key passages. The abstract is here. [Update:  “Awesome Cat,” in the comments section below, has a link to the full Schwartz article.]

The writing and language is that of a peer-reviewed journal article–formal and perhaps less accessible to some. But I am allowing Dr. Schwartz’s words to stand on their own merits. It is unusual to see this kind of gender criticism in a recent journal on the subject of gender dysphoria. Please note: The subheadings and boldface emphasis are mine, not Dr. Schwartz’s.

“Liberal psychiatric treatment”: the avoidance of ambiguity, p. 461

I am disquieted and stimulated by my mediated encounter with the children, parents, and clinicians represented in these clinical articles.

The children have a deeply felt complaint, expressed  explicitly or indirectly through the disruptions they inevitably provoke. They say they are unhappy with being named, classified, and treated in accord with the match between their visible genitalia and the prevalent set of conventions regarding those genitalia. For them, gender has become preoccupying …

…The parents seem to be trying to catch up with terribly surprising news, with varying degrees of success. They are frightened, frustrated, freaked out, and, finally, defeated, as they are forced to relinquish a cherished perception. Their particular defensive configurations vary (guilt, despair, anger, embrace), but all face extreme intrapsychic disruption and pain. The clinicians try to make this child/parent/symptom matrix fit into a model of liberal psychiatric treatment. As is common in the medical sciences, most push against ambiguity, preferring to emphasize speculative generalizations (“genetics is likely a factor”) instead of highlighting the lack of data from controlled studies.

Desistance: Most kids with gender dysphoria will change their minds, pp. 467, 470

With respect to the advocacy of intervention, Edwards-Leeper and Spack … say that they “have learned that delaying proper diagnosis can lead to significant psychological consequences”.  This warning implies that the reliability of diagnosis and associated prognosis in this area has been established, which is the case only for diagnosis, that is, we cannot say reliably what the course will be for a given child with GID or gender dysphoria. In particular, we cannot reliably say whether he or she will persist with an expressed need to be affirmed in his/her non-natal gender, or not. In fact, the majority do not sustain the diagnosis, that is, they desist.

[This] fact (supported by five research articles going back to 1987)…every clinician and parent of a child who is gender dysphoric needs to keep firmly in mind. …

Given this uncertainty of prognosis, it is significant that Edwards-Leeper and Spack’s presentation of the pros and cons of pubertal suppression, a primary intervention in their protocol and their frequent recommendation following diagnosis, is imbalanced.  They offer seven physiological benefits to pubertal suppression (for the most part just a list of the physical effects) and no disadvantages. Likewise they tout the psychological advantages, but note no potential disadvantages. Their conclusion is: “Therefore,
it is our clinical impression that preventing these unwanted secondary sex characteristics with puberty blocking medical intervention allows for better long-term quality of life for transgender youth than what they would experience without this intervention.”

Better quality of life? p. 467

The claim of offering “better long-term  quality of life” based on clinical impression only, and absent significant longitudinal experience or controlled data collection, is questionable. Considering that Edwards-Leeper and Spack are advocating a pharmacological intervention aimed at prepubertal children and adolescents, a number of whom are likely to desist, it is surprising and of interest that they so minimize the importance and value of alternative interventions, ones that might have fewer unknown consequences, both physiological and psychological. An alternative sort of intervention would of course be some variety of psychological therapy. Most typically this might include support, reality testing, empathic interpretation and psychoeducation offered to both parents and children.

On the psychology of “trans” kids, p. 468

The intransigent style (cognitive and behavioral) of trans children may deter some clinicians from considering that some of their suffering might be helped without rhetorically opposing their desires or trying to persuade them to relinquish their assertions.

… The goal of psychotherapy in this situation would be to help the child feel better and offer reality-based guidance for social situations, as well as the prevention of self-harm, in the rare cases where that is an issue. In general, psychotherapy should entail increasing (parents’ and children’s) self-understanding, not coaxing or pressuring them to change their minds. The disturbing demands and claims of trans children, as well as reports of self-harm (untabulated, to my knowledge) may shock and scare both parents and clinicians into expecting less frustration tolerance from them than is realistic. Such an underestimate of the trans family’s resilience may be abetted by the availability of puberty suppressing drugs. Frightened of the onset of puberty, and intimidated by the at times ominous articulations of the children, parents and clinicians are relieved to imagine even a temporary solution.

Anecdotes from adolescents are not data, p. 468

…Edwards-Leeper and Spack’s  usage of anecdotal data concerns me. To counter what they describe as the leeriness of parents with respect to the taking on of transgender identities on the part of adolescents with no prior history of gender dysphoria, they say: “However, many of these adolescents report that their friends are not surprised by their declaration of their affirmed gender, often responding that they had suspected it for some time.” We must assume that Edwards-Leeper and Spack are aware that an adolescent’s report of other adolescents’ validation of a gender identity claim is not credible evidence of more than the first adolescent’s desire to persuade. How then are we to understand their inclusion of this anecdotal information? It would seem that natural skepticism has been suspended in favor of literality. Are they trying to highlight the alleged power of essential gender by pointing to its observability by others even before the subject himself or herself has self-awareness? If so, the weakness of an anecdote such as this gives the appearance of a lack of appropriate scientific and psychological skepticism, and inattention to methodology.

Kids aren’t little adults, p. 470

With essential gender in mind [clinicians] are likely to be less psychologically minded and less thorough in their consideration of the cost–benefit ratio of invasive interventions and of research that might militate against their impulses to intervene. To be sure, they are trying to be respectful of and responsive to children’s stated wishes. But it seems that beyond that, when child patients talk about their gender, their belief in its reality seems to distract the clinician from the fact that we cannot listen to children in the same way that we listen to adults. Patients’ communications always need some degree of interpretation; that is especially true for children, who, necessitated by their cognitive limitations, speak more symbolically.

Is a 5-year-old boy “really” a girl–or trying to be like Mommy? p. 473

Ehrensaft tells us that throughout a session to which Brady/Sophie arrived fully dressed as a girl, “[she] kept sucking in her tummy, in an attempt to make herself more girl on top” (p. 351). This child is less than 5 years old. Sucking in her tummy will not make her more girl on top, since little boys and girls are the same on top, which Brady/Sophie surely knows: It will make her more woman, a very different thing. One possible interpretive direction in light of this slip would be that this child is more interested in a ticket to adulthood than a gender change, but for some reason sees being female as a necessary first step…

.  …At the conclusion of this patient’s treatment, parents and therapist decide that it is best to permit Brady/Sophie to present as a girl at all times.  Sophie (still not 5 years old) proclaims: “I’m the happiest I’ve ever felt in my life.” Ehrensaft furnishes a putative expert statement to the parents, which says in part: “To promote her wellbeing and emotional health, it is imperative that Sophie be seen and treated as a female by her parents, her educational settings, and the community surrounding her.” …Such certainty in matters so fraught with unforeseeable possibilities including the welfare of a child surprises me. The certainty of the child about her gender is matched by the clinician’s certainty about the outcome, both of whom, I suggest, are encouraged by the notion of a true gender found at last. Moreover, I wonder if Ehrensaft has not imagined the inner life of this child, who is rather adult-like in her speech (do 4 year olds commonly speak of “in my life?”), as more adult than it is. This could be for many reasons including, of course, the personality of the child. However, I believe it is easier to be distracted from the childishness of a patient’s claims when the terms they use conceptually match the clinician’s ideas. 

Gender is power, p. 474

 It seems to me that trans children, in response to great psychic pain (and adaptively or not) have engaged the rhetoric of gender and, thus, stumbled upon a communication of such potency that their parents and therapists are detoured from listening to them as children, instead crediting them with adult-like cognition. When we infer that the trans child has a disturbance in an unobservable gender system, based on a claim of gender transformation, we are granting the truth of a child’s self-analysis and proposed self-construction. I doubt that the receipt of such a gratifying abundance … of respect from the clinician is consciously intended by the child. It is more likely that the child longs inchoately for an emotional experience like respect and rapidly gains unconscious awareness of the power of gender complaints to bring such gratification. When the longing is unwittingly satisfied by the parent or clinician who, thinking they understand the child’s problem, validates the terms of the discussion as the child has set them, the child is likely to reiterate the complaint in those terms.

  For that child, a psychological structure, more or less transient, begins to develop. For the adult, the illusion of understanding begins to perpetuate itself. The most immediate lesson that the trans child has learned, and then enacts, encouraged by these interactions, is that the idea of gender is very powerful, and if you want to get a rise out of people, play with it daringly. The lesson for the parent or clinician should be: Stop talking about gender. 

Schwartz goes there: the child who threatens self harm, p. 475

The specter of harm to children—any harm to any children—is surely a powerful influence in all discussions about children, and no doubt it is playing a role, spoken or not, in this one…. I am aware of no controlled data to indicate that the incidence of self harm among trans children is any greater than somewhere between very infrequent and rare. I am aware of no data to suggest that pubertal suppression, cross-sex hormone administration, or genital surgery diminishes the probability of self-harm in trans children. Moreover, there is no reason to believe that the three above-mentioned physical interventions are any better for the welfare of trans children than supportive psychotherapy and psychoeducation for parents. There are anecdotal reports of threats by children and of children dramatizing the possibility of self-mutilation. There are psychiatric protocols for addressing the patient who seems to pose a risk of self-harm that are minimally intrusive and unquestionably reversible. The long-term psychological and physiological consequences of chemogenic pubertal suppression, cross-sex hormone administration, and genital surgery are unknown, and, as is the case with all self-selected populations, very difficult to assess owing to problems of control and limited sample numbers. The palpable misery of an articulate child may distract the empathic clinician or parent from the venerable admonition: First, do no harm.

Conflation of gender skepticism with historical homophobia, p. 470

 Edwards-Leeper and Spack take pride in what they see as their avoidance of the mistakes prior generations of mental health professionals made, in particular when the latter refused to accept gay and lesbian people at their word, sans diagnosis. Indeed, the analogy is tempting, but I would argue, deeply flawed, itself an aspect of the conflation of gender and sexual orientation. …

“An artificially vitalized concept”,  p. 476

I believe the disquiet and stimulation I initially experienced after reading these articles and watching some videos, was a reaction to my perception of children and adults struggling in the thrall of an artificially vitalized concept that subjugates and empowers each in complementary ways, a phenomenon both intriguing and worrisome. Most of these adults—parents and clinicians—have been persuaded that gender is biologically real, with specific rules for healthy functioning. The children, having unconsciously learned of the adults’ imbuing of gender with particular potencies, that is, with reification, medicalization, and transgressive possibility, try to put it to use in the course of their own self-development. It proves to be a high-risk and high-gain tool. It has the power to command adult attention, to affect adult emotions and thus to alter the position in the family of the child who chooses to deploy it. As well, in the unconsciously operating hands of the child it can also bring enormous pain, which in its compelling resemblance to physical pain further misleads the adults toward the reification of gender.  It is disquieting to observe clinicians unconsciously colluding with troubled parents in the inflation of concepts that are inherently psychologically constricting.

Teaching children to be homophobic? p. 476

… Just as racism requires belief in natural races, sexism and homophobia require belief in natural genders. If we organize our responses to children who play or become preoccupied with gendered behavior around the idea that there are natural genders from which they are deviating or toward which they can aspire with medical help (transitioning), then, however indirectly, we are buttressing the very structures upon which the hatred of gay men and lesbians stands. Or put differently: As clinicians responding to trans children, we are responding to a subjectivity, not to the results of a biopsy or blood test. We and parents must choose whether we respond to that subjectivity as the upshot of a hypothesized psychophysiological gender system, on the one hand, or choose to go no further than regarding it as a mutable psychological situation on the other. Choosing the former, the more elaborately and speculatively theorized framework of essential gender, accepts a theoretical structure that has been used to rationalize sexism and homophobia and, therefore, tends to promote them despite good intentions.

We owe more to kids than to take them literally, p. 478

There is much more to children than what they say. We owe to them a deeper listening than a literal one. We will then likely find that their engagement with gender, especially when it is transgressive or countercultural, may reveal a creativity and even a politics that can contribute to the erosion (if not destabilization) of the gender system as it presently operates. If we listen to them literally, interpret their communications and performances through the categories we adults have grown up with, and of course have ourselves failed to transcend, we will miss whatever new story they are telling or protest they are making. If we listen and respond to what they are saying in the mirror of the old system, they will seem to buy it, because it comes with the feeling, although not the reality, of being understood, which they no doubt crave. Thus, stasis is guaranteed for the child and for our culture. I am not naïve enough to imagine an intellectual transcendence of essential gender. But, in the name of equality—of gender and of sexuality—we must avoid promoting its continued entrenchment.

Two recent survey studies by Dr. Johanna Olson: Biases, assumptions, and the medical transitioning of young people

“Confirmation bias, as the term is typically used in the psychological literature, connotes the seeking or interpreting of evidence in ways that are partial to existing beliefs, expectations, or a hypothesis in hand.”

Confirmation Bias: A Ubiquitous Phenomenon in Many Guises, by Raymond S. Nickerson,  Tufts University

In this post, I will look at two recent survey studies (i.e., patient questionnaires and demographic data culled from medical records) conducted by Dr. Johanna Olson and colleagues at the The Center for Transyouth Health and Development at Children’s Hospital, Los Angeles. These studies do not look at the medical effects or potential harms of hormone treatments and/or sterilization of prepubescent children and adolescents. Rather, they consist of self-reported characteristics and demographic data, with no questioning of the key “hypothesis in hand”: that medical transition is the treatment of choice for self-identified “transgender youth.”

A hypothesis in hand also can bias the interpretation of subsequently acquired data, either because one selectively looks for data that are supportive of the hypothesis and neglects to look for disconfirmatory data or because one interprets data to be confirmatory that really are not.

In looking at the work and public statements of Dr. Olson, there are a number of biases and assumptions that can be easily seen:

  • Children and adolescents who label themselves as “transgender,” or who claim to be the opposite sex, are a priori “transgender,” even though there is no hard scientific data that a “transgender child” actually exists.
  • The reason for depression and suicidal ideation in youth who identify as transgender is lack of access to medical transition (i.e., hormones and/or surgery) and/or lack of parental support for such treatments.
  • Comorbid mental health issues are not explored as possible causes for gender dysphoria or suicidal ideation.
  • Parental, clinician, internalized, or societal homophobia is not mentioned as a possible contributing factor in the diagnosis of “transgender youth.”
  • It is a foregone conclusion that the psychological stress experienced by a young person believing they are “actually” a member of the opposite sex cannot be addressed via supportive psychotherapy to help resolve such feelings.
  • Permanent adult sterility, the usual consequence of puberty blockers followed directly by cross-sex hormones, is an acceptable and tolerable outcome for prepubescent “transgender children.”
  • Further, despite overwhelming scientific consensus that judgment, decision-making, and awareness of future risks and rewards does not reach maturity in the human brain until the early 20s, prepubescent children facing irreversible sterility are capable of understanding and choosing this consequence.
  • The possibility of future patient regret (a completely unknown factor at this time) is insignificant in comparison with the urgent need to treat children NOW with hormones and (possibly) plastic surgeries.

Now to the two survey studies. First, let’s look at “Parental Support and Mental Health Among Transgender Adolescents” by Simons et al, examining the impact of parental support on the mental health of 66 self-identifying “transgender” youth ages 12-24. What’s the main conclusion?

 Parental support is associated with higher quality of life and is protective against depression in transgender adolescents.

What is meant by “parental support” in the context of the 66 youths included in the survey? The “limitations” section of the study tells us it wasn’t well defined:

The parental support measure did not delineate whether the subject was referring to one or more parents, differentiate between parents and other guardians or caregivers, or explore the impact of other sources of support on mental health. Also, it did not distinguish between general parental support versus support specifically for gender identity, or assess particular parental qualities or actions constituting support.

Readers who have been with me for awhile know that my idea of “support” for my erstwhile trans-identifying  teenager did not include agreeing to hormone or surgical treatments. Judging by the vague criteria in the survey, my daughter and I might have presented to Olson’s clinic, with my teen rating me as “supportive” even if, in the end, we left without a prescription for testosterone or a recommendation for “top surgery” (two interventions my teen, at the time, insisted she wanted).

Here is how the study defined parental “support.” The 66 patients

completed a survey assessing parental support (defined as help, advice, and confidante support)

Help, advice, and confidante support? You better believe I provided that to my kid.

Regarding the young people who were surveyed in the study:

Before meeting with medical staff, participants underwent mental health assessment by a provider with knowledge of gender nonconformity in youth to identify major mental health concerns and provide a recommendation that hormone therapy would benefit the participant in their transition process.

But the paper doesn’t provide any hint whether “identify[ing] major mental health concerns” might have included psychotherapy or some other exploration of how these concerns might contribute to the young person identifying as transgender. Nor do we know specifics of what these concerns might be.  All we know is that “hormone therapy” was recommended, and it is assumed that a “transition process” was a desirable outcome. In my own personal family case, finding a supportive therapist who was willing to explore other thorny psychological concerns was extremely important and led to a reduction in my child’s desire to medically transition.

Moving on, another limitation noted by the authors is

Findings were based on self-report and may be open to self-presentational biases.

In other words: Like the diagnosis of “transgender” itself, the survey data is based on subjective thoughts and emotions. While the researchers acknowledge this as a “limitation” of their study, why don’t they acknowledge that the “self report” of being the opposite sex (in contravention to objective biological reality) is itself a “limitation” of the entire enterprise of the medical transition of minors? The diagnosis of “transgender children”  as opposed to just letting kids be kids, however they “identify,” is the mother of all confirmation biases.

Dr. Olson is listed as the first author of the 2nd study, still in press: Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria. The subjects were 101 youth (approximately 50/50 male and female), ages 12-24, who had indicated the “desire to undergo puberty suppression or phenotypic gender transition” at Olson’s clinic from 2011-2013.

What were some key psychological findings these young people self-reported? (Of note, physiological characteristics did not differ from other similar-aged youth.)

  • suicidal ideation: 50%
  • suicide attempt: “nearly 1/3”
  • depression: mild-moderate 35%, severe 11%
  • drug use: alcohol (75.5%), tobacco (58%), cannabis (61.5%,), other drugs (43%)
  • gender dysphoria experienced since approximately age 8
  • revealed their transgender identification to family at a mean age of 17.1 years [Remember this one]

What do Olson et al conclude from their survey?

…transgender youth are aware of the incongruence between their internal gender identity and their assigned sex at early ages. Prevalence of depression and suicidality demonstrates that youth may benefit from timely and appropriate intervention. All participants expressed a desire to begin hormonal intervention to assist in bringing their physical bodies into better alignment with their internal gender identity.

Seems to me there are several assumptions and confirmation biases in operation here:

  • “Timely and appropriate intervention” apparently does not include anything other than “bringing their physical bodies into alignment” with internal identity. No suggestion is made that psychological treatement aimed at helping youth feel comfortable in their bodies should even by considered.
  • The assumption appears to be that depression and suicidality are caused by gender dysphoria–or at the very least, the correlation of  suicidal ideation with gender dysphoria–can only be solved through medical transition.
  • Suicidality rates for other psychological problems (apart from gender dysphoria)  are not mentioned or compared in this study, only those of “normal” adolescents  (6.7% for ages 12-17, 10.9% ages 18-24), even though there is research (see here, and here for examples) indicating that some disorders may occur at higher rates in people with gender dysphoria. Nothing in the survey or study design indicates any knowledge of these comorbidities, whether there was an attempt to control for them, or the fact that increased suicidality is associated with some of them.
  • And again, the key assumption: “Identifying” as transgender is a priori a reliable diagnosis, as opposed to a psychological problem that could possibly be exacerbated by some combination of peer pressure, societal trends,  or online social media.

But enough of my criticisms. What limitations do the authors of this study see?

…these data describe those who are able to access care related to gender dysphoria and desire medical intervention for gender transition. These results may not be generalizable to transgender youth who are not receiving care or to those who do not desire a phenotypic transition with cross-sex hormones…

…Lastly, data collected about early childhood gender nonconforming feelings or behaviors are subject to potential recall bias. Ideally, this information could be collected in a cohort of younger children currently experiencing gender nonconformity.

“Recall bias” means the adolescent or young adult may not be remembering his or her childhood experiences accurately. Also, and even more to the point: if most of the youth in this study “knew” they were trans at 8-years old, but didn’t “come out to family” until about age 17, how are they “truly transgender?”  The phenomenon of young kids insisting they are the opposite sex is often touted as proof of some innate brain-based gender. And as anyone who has raised a child knows, 8-year-old children don’t generally hide their true feelings from their parents. If these young people profess to have “known” they were the opposite sex as 8-year-olds, why didn’t they voice this realization earlier? Why did they wait until they were 17?

I have to wonder: given that the patients who completed the survey for this study had managed to secure hormone treatments at Olson’s clinic; and given the ready availability on the Internet of the list of requirements to qualify for hormone therapy, it’s not much of a stretch to think that many likely knew that reporting a long history of identifying as transgender would be helpful in actually qualifying for treatment.

And here comes the final caveat:

Although there are guidelines and recommendations for the treatment of transgender-identified youth with puberty suppression in early adolescence followed by appropriate hormone therapy, there remain fundamental questions about when to start puberty suppression with gonadotropin-releasing hormone analogues, when to add cross-sex hormones, and how young is too young for gender confirmation surgery.

Dr. Olson has repeatedly  gone on record as promoting early cross-sex hormones, stating in a recent NPR interview that it is “ridiculous” to make an adolescent wait until age 16, as the current WPATH standards prescribe. (Some might counter that it’s more absurd to permanently destroy a child’s fertility.) Interestingly, Olson et al seem to almost concede that point in their last-but-not least limitation to the current study:

Finally, the trajectory of gender nonconformity among peripubertal youth is still difficult to predict, creating serious concerns for providers and families about the possibility of future regret in response to more permanent aspects of hormone therapy, such as breast development and voice deepening. The data we have begun to collect are an attempt to understand the transgender youth population and follow them over time, tracking the safety and efficacy of medical intervention as well as the impact of intervention on quality of life, high-risk behaviors, suicidality, depression indices, gender dysphoria, and potential regret in response to early medical intervention. We will continue to publish our follow-up data as they are collected,

So once again, as I chronicled in an earlier post, providers of medical transition tell us, “We just don’t know.” The implications of this cannot be overstated.  These providers are, by their own admission, essentially experimenting on children and adolescents with treatments that have permanent consequences, and they have no idea what the rate of future regret will be. Let’s listen again:

“… the trajectory of gender nonconformity among peripubertal youth is still difficult to predict, creating serious concerns… about …future regret…in response to early medical intervention.”

There it is, folks, in black and white, in a peer reviewed journal. We don’t know, but we’re going to find out–after it’s too late to take any of it back.

It is not my intention to demonize Dr. Olson. In fact, to give Dr. Olson a heaping helping of Benefit of the Doubt, it’s quite possible she is operating from compassion for the suffering of the youth and families who visit her clinic. (I realize more cynical observers might say she and her fellow “gender specialists” are only in this field for profit, but I am not prepared to assign sociopathic greed at this juncture).

Might Dr. Olson be suffering from pathological altruism—a particular brand of confirmation bias?

A working definition of a pathological altruist then might be a person who sincerely engages in what he or she intends to be altruistic acts but who (in a fashion that can be reasonably anticipated) harms the very person or group he or she is trying to help

…such as the substantial percentage of her young patients who, without her intervention, would have been allowed to grow up to be gay, lesbian, or simply “gender nonconforming” adults, their fertility fully intact, without the need for an expensive lifelong medical condition treated by endocrinologists and surgeons.

or a person who, in the course of helping one person or group, inflicts reasonably foreseeable harm to others beyond the person or group being helped

That might be, in the case of the steadily increasing numbers of young women being transitioned, the harm to the lesbian community, particularly the “butch” and “gender nonconforming” lesbian community. And then there is the damage to families–parents, siblings, other relatives–whose doubts and concerns are dismissed as “transphobic.” Their prior knowledge of their loved one; their possibly correct hunch that the young person is not actually in need of such extreme intervention. Their opinions are never considered or legitimized in any research or media story I’ve seen, but brushed aside,  as they watch their loved one step on the conveyer belt of puberty blockers-cross-sex hormones-surgery, to be changed forever.

Dr. Olson and the other purveyors of pediatric medical transition are certainly reasonably intelligent human beings; obtaining an MD or PhD is no mean feat. But (again from the above linked article, Concepts and implications of altruism bias and pathological altruism by Barbara A. Oakley)

 Intelligence is no safeguard regarding these confirmation bias-related issues. Highly intelligent people, for example, do not reason more even-handedly and thoroughly; they simply are able to present more arguments supporting their own beliefs.

A hunt through Who is recruiting puberty-blocked kids for research studies?

When gender critics and gender advocates spar, the more thoughtful opponents at some point usually attack and parry with links to published research. There is sparse conclusive evidence regarding transsexual or transgender adults, but at least you can link to what little there is when making your points.

When it comes to systematic studies of the growing number of children and adolescents undergoing medical “transition” via hormones and surgeries? Not so much. In fact, pretty much nothing. Zilch. Nada.

As I discussed in this post, pediatric gender specialists—endocrinologists, pediatricians, psychiatrists— openly acknowledge that there is essentially no research about the effects and outcomes of childhood medical transition.

So what generally happens when more data is needed about an accelerating and urgent medical problem, one for which experimental treatments are being prescribed? Teams of doctors and/or academic researchers write grants to fund rigorous studies. In the US, important medical research is often funded through the National Institutes of Health or other government-funded agencies. Given the increase in gender dysphoric kids popping up for treatment*, it seems likely the NIH would be quite amenable to funding well-designed studies. Particularly since the medical treatments for childhood gender dysphoria are so extreme that they can result in the permanent sterilization of minors.

There are plenty of potential research subjects being seen in gender clinics right now. While the practice is relatively new, hormone treatment for gender dysphoric kids has been ongoing in the US since 2007 (first cases at Boston’s Children’s hospital) and for over 20 years in the Netherlands. There has been ample time for researchers to apply for and receive funding.

What could be studied in these children who are having natural puberty arrested? I can think of a few interesting lines of research:

  • The physiological and psychological effects of GnRH agonists (“puberty blockers”) on gender dysphoric children and adolescents
  • The physiological and psychological effects on adolescents who have gone directly from GnRH agonists to cross-sex hormones
  • Brain activity and neurological effects on adolescents who have delayed puberty; such studies could include noninvasive MRI and fMRI brain scans, coupled with behavioral observations
  • Attitudes and opinions of gender dysphoric children and adolescents vis-à-vis permanent loss of fertility and how these attitudes and opinions change (or don’t change) over time
  • Executive function development in prepubescent children who are under treatment vs. a control group of children who are not treated
  • Long term outcome studies comparing gender dysphoric children who undergo hormone and surgical treatments vs. those who do not

There are many other avenues research could take. And these studies, to be meaningful, ought to be longitudinal (over the longest time span possible), and start as soon as possible after the child begins treatment.

So given the desperate need for research being called for by all the experts in the field, surely some studies have been funded and are actively recruiting subjects?

The place to find current research studies is (The database also lists recently closed studies that are no longer recruiting). indexes all studies in the world—not just the US—which are seeking subjects.

Here’s a sample of what I found—more to the point, what I didn’t find. I tried many permutations of keyword searches and came up essentially empty. I encourage readers to do their own searches and tell us your results in the comments section.

  • Puberty blocker: 0
  • GnRH agonist: Hundreds—but all for either cancer patients or for precocious puberty
  • GnRH agonist gender dysphoria: 0
  • GnRH agonist child gender: 0
  • GnRH agonist fertility: 99, all about adult cancer patients
  • MRI gender dysphoria: 0
  • Child (or adolescent) transgender: 4, all about HIV prevention
  • Gender dysphoria: 3, all about HIV risk
  • Adolescent transgender: 2, both about HIV prevention
  • Leuprolide [generic name for Lupron, a puberty  blocker]: Hundreds—but all for either cancer patients or for precocious puberty
  • Leuprolide transgender: 0

When it comes to medicine, if there are no current studies recruiting new subjects, it typically indicates that the research questions have been more or less settled. A clinical problem or hypothesis has been thoroughly explored, studies have been conducted, the results have been replicated, and evidence-based clinical practice follows from there.

But the use of off-label GnRH agonists followed by cross-sex hormones on prepubescent children is new. We don’t have the data.  And unless someone collects that data in a systematic way, we will never know the outcome of this grand experiment on young people.

What we have now are anecdotes, personal testimonies, and shrill voices demanding medical transition for children NOW.  The usual reason given is suicide prevention. But if innate gender is real, this means there have been “transgender” children and adolescents since the dawn of human history. Yet there is no prior record of nor claim of suicidal children claiming to be “in the wrong body” before the modern age, when pharmaceutical and surgical solutions have become de rigeur.

Surely we can all agree that any treatment meant to prevent suicide; any treatment resulting in possible sterilization of minors deserves serious and wide-ranging study. Someone needs to get moving.

But the evidence suggests—no one is.

As one detransitioned woman has said, “We aren’t even lab rats.”

*A cursory Internet search reveals many stories about the steady increase in kids referred to gender clinics throughout the Western world

False positives: How many 12-year-olds is it acceptable to mistakenly sterilize?

As anyone who has spent time reading my blog well knows, I am highly skeptical of the scant existing research which purports to show a binary, static “male” or “female” brain. To my knowledge, there is no research in existence that proves a gendered brain is present from birth; and that that gendered brain is unchanging and persistent throughout the lifespan, regardless of lived experience. ** (see note, bottom of post)

But for the purposes of this post, and despite this dearth of evidence for “brain sex,” let’s just assume that the strident proponents of childhood transition are correct: there is an immutable male and female brain, set in stone and impervious to change via life experience. (Of course, this flies in the face of the settled science of neuroplasticity—but we’ll ignore that for the time being). Further, we will assume that, for a small percentage of people who experience gender dysphoria in childhood (no more than  about 20%, the number generally agreed upon even by the most zealous transgender advocates), this gendered brain is mistakenly lodged in the skull of the “wrong” body. It follows that there is such a thing as a truly transgender child. These kids really do have a mismatch between brain and body, and the most humane and medically responsible thing that can be done for them is to let them “transition” to the opposite sex, post haste. As young as possible.

Case closed? Not quite.

First, let’s be very clear what we are talking about here, in terms of pediatric medical treatment. The current protocol for children identified as transgender is puberty blockers  (GnRH agonists) administered at the onset of puberty (Tanner Stage 2). The child is then monitored for several years, and if they continue to believe they are the opposite sex, cross-sex hormones are started, so as to prevent natural puberty occurring in the “wrong” gender (i.e., the biological sex of the child). In the case of a natal girl with two x chromosomes and a biologically female body, she will not go through maturation of the ovaries, menstruation, breast development, nor other primary and secondary sexual characteristics. Cross-sex hormones (testosterone for a girl) will cause her to develop more in line with the sexual characteristics of a male: a slightly enlarged clitoris, increased body and facial hair, and an enlarged larynx resulting in a deepened voice. She will thus avoid the assumed trauma of going through the “wrong” puberty, with shrinkage and no maturation of her internal reproductive organs. She will appear more or less as the gender (male) she (now he) identifies with. These changes are permanent. They cannot be undone.

And one of these permanent changes is of special import: In nearly every case, this treatment protocol will result in irreversible sterility. This child will never be able to produce their own biological children. However, the gender experts believe this outcome is worth it and justified for “truly transgender” children. The puberty-blocked girl (who still has the brain of a prepubescent child, not that of a maturing adolescent) agrees that transitioning is far more important than future fertility, and the adults in charge make the monumental decision to destroy the child’s future reproductive capacity.

Fair enough? Maybe, if we continue to assume that there is such a thing as a “truly transgender” person with an immutable, innate gender identity; if we treat this condition as a sort of birth defect that will never change, even later in life; and that the young person in question will be forever miserable to the point of suicide if they do not chemically and surgically alter and thereby sterilize their hated and mistaken body.

The problem is, these gender experts—from the most certain to the most cautious—agree that they don’t reliably know which of these children really will be transgender for life. And what that means is there are going to be some false positives: kids who will mistakenly go through extreme medical and pharmaceutical treatments—not just in childhood and adolescence, but for life, since hormones must constantly be administered to suppress the “wrong” body from reverting to the characteristics normal for the genetic makeup of the person. Some number of these kids will have been misdiagnosed. It’s inevitable. Even the most careful clinician, who believes they have narrowed their treatment cohort to only those children who are most “persistent, consistent, and insistent” cannot prevent this, because the research simply isn’t there to tell clinicians who will or won’t grow up to be truly transgendered.

Let’s agree, for the sake of discussion, that these gender clinicians—and the parents who are authorizing the treatments—truly believe they are doing the right thing. They believe that these puberty-blocked children who continue to insist they are the opposite sex are correct. It’s worth repeating that these children’s brains, and thus their critical thinking, reasoning, judgment, and other aspects of executive function, have also not been allowed to mature; because puberty is about brain development, not just secondary sex characteristics. No matter how careful these clinicians and parents are, they are still going to catch a few wrong fish in the transition net they are casting.

Does this matter? How many misdiagnosed kids are acceptable? How many sterilized children (many of whom might otherwise have grown up to be gay or lesbian adults with a desire for their own biological children) are ok? 100? 50? 20? 2? 1?

Put it this way: If there were any other treatment, for any other disorder, which resulted in sterilizing prepubescent children, and which caused irreversible, permanent changes with as-yet-unknown side effects, you’d better believe that treatment would be limited to only the most extreme cases—and even then, only after extensive clinical trials. These clinical trials would span years of rigorous peer review, with successful completion of many replicated and corroborating studies, involving thousands of subjects. These human trials would have to look at physical and psychological side effects and risks of this extreme and lifelong treatment.

Rigorous study, with several phases of clinical trials, is the norm for modern evidence-based medicine, even for life-threatening medical conditions. To take but one contemporary example, there has recently been a successful drug treatment protocol released for the treatment of chronic hepatitis C, which with prior treatments, had a rather dismal cure rate. Despite the promise of the ongoing clinical trials for the new hepatitis C drugs (over 90% cure rate), which took place over many years, the general public was not allowed access to these life-saving drugs. Many people died waiting for the drugs to be approved. If the side effects of these drugs had included sterility—for adult patients—it is highly unlikely the treatments would have been approved by the FDA. Even though the drugs might have saved many lives.

We don’t remove organs and body parts, we don’t give children powerful drugs for any other disorder based on what currently amounts to clinical guesswork. We don’t remove organs or administer chemotherapy because someone might go on to develop cancer later. We don’t prescribe poorly studied, off-label drugs or perform surgery on children to relieve them from psychological distress in any other case apart from “gender dysphoria.” Surgeries and lifelong drug treatment are rightly seen as last resorts, not the first line of treatment for a problem that might turn out to be transient.

The media and trans activists are constantly telling us how important it is to transition children—as young as possible. But what about the kids who might be wrongly diagnosed? Why does no one talk about them? Why is their future happiness not a subject for media exploration? What about the suicide rates of adults who realize with horror later in life that they actually don’t want hormones and surgeries?  That it was all a big mistake? That they don’t want to have to routinely stretch or pump up their artificially constructed sexual organs to keep them in some sort of working order? What about the adults who will mourn the children they were never allowed to bear because of decisions made by parents and doctors decades earlier?

If we care about all children, including the 80-95% of kids who in fact are only “gender nonconforming”;  if only a small number of “truly transgender” children exist, why not allow those few to transition as adults, when they have the cognitive wherewithal to decide for themselves? Why not simply help them cope with their feelings of dysphoria in childhood, instead of stunting their intellectual, emotional, and physical development, and risking the huge mistake of proactively sterilizing even one non-transgender child for life?

Would it really be so terrible for parents to simply let their kids wear what they want, pursue activities they want, heck, “identify” as they want, without the medical piece?

It only takes one person to file a malpractice lawsuit. There is no minimum number for a class action suit, but given the increasing numbers of children undergoing these early transition protocols, the typical 20-50 plaintiffs is not an unlikely number for future adults willing to litigate; a fraction of the people who will wish their parents and doctors had simply allowed them to dress and behave as they wished as children, without making permanent decisions that could not be undone.

So I ask the gender specialists, the parents, the activists, the journalists celebrating the medical transition of children: Granting you for the moment that your fervent belief in immutable, innate gender corresponds to reality, what concern do you have for the children who will be wrongly sterilized, drugged, and surgically altered? Do those children matter to you at all?

Is it acceptable to wrongly sterilize even ONE child?

** Such studies would be difficult to conduct. To come close to proving significant differences between male and female brains that result in innate transgenderism, researchers would necessarily have to scan large numbers of identical twins at birth. These twins would then have to be separated and raised in different environments, then be followed into adulthood. (Genetically identical twins are necessary to prove innate brain physiology, and the twins must be raised separately to control for the effects of life experience and influence, which would need to differ to prove that nature trumps nurture). A statistically significant number of those pairs of twins would then have to both be transgender-identified to prove that transgenderism is an essential and innate trait of the human brain.

The Advocate publishes hit piece aimed at gender critics

Today, Dawn Ennis of The Advocate posted a long piece attempting to take down critics of pediatric medical transition. My blog is linked on page 2, with an excerpt from an email thread that took place between Ennis and me:

“Yes, I DO support Mark’s efforts to shine a light on the current trend to transition kids. Please read my blog, because I’ve written extensively about it. I don’t particularly agree with his approach sometimes, which too often ends up in vicious Facebook wars. But his heart is in the right place — and you can quote me on that.

You really have no idea how much people who question the dominant trans paradigm are vilified and harassed. … We have to protect our CHILDREN’s anonymity. We can’t afford to have their identities exposed — unlike the parents who are making tons of money parading the children they are sterilizing before the fawning media. Jazz Jennings comes to mind.”

For any Advocate reader who might be reading this right now because of that referring link, I have this question for you:

Are you aware that The Advocate, initially a strong voice for gay and lesbian people, has in recent years been mostly trumpeting a one-sided meme about the positive effects of transition? More importantly: Do you know that there is a body of research going back decades indicating that 80-96% of “gender nonconforming” children grow up to be gay or lesbian if left alone and not interfered with by “gender specialists?” 

Please read these posts for an introduction.

Into the Heart of the Homophobic Beast

Parental Homophobia is Never Examined in Triumphant Transition Stories

Research evidence: Most Gender Dysphoric Children Grow Up to be Gay or Lesbian

Update: And before you write to me screaming about suicide, see my August 3 post on the often-cited 41% suicide attempt rate.

“Transition or die” is promoted to young people on Reddit and Tumblr. For more, see the excellent blog Transgender Reality for this: When Suicide is Presented as the Logical Alternative

I wrote earlier this year on suicide as well. “Transition or Die” should never be promoted by any responsible medical provider or media figure. Yet it is used constantly as a way to end reasoned discussion and force frightened parents into submission:

Teen Suicide and the Chilling Effect on Dialogue

And finally: Do you think it is rational to conflate anti-gay conversion therapy with psychotherapy that might allow a “gender nonconforming” child to become comfortable in their own body? Do you really think it is “transphobic” to attempt to help a possibly gay or lesbian young person avoid lifelong hormone treatments, plastic surgeries, and (in the case of puberty blockers followed immediately by cross-sex hormones) permanent sterility?

Anyone who truly supports gay and lesbian people owes it to themselves to read widely and understand the arguments of gender critics like me. Simply dismissing us as “transphobes” and TERFs is not worthy of any thoughtful progressive who cares about human rights and dignity.

For the record: Contrary to Dawn Ennis’ attempt to paint all gender critics as mindless followers, I began blogging well before Mark and Lynna Cummings posted their video criticizing puberty blockers and childhood transition. The blog GenderTrender, also mentioned by Ennis, has been extant for years.

Far from “parroting,” parents like me are finding their own voices by exploring the research base going back decades–and even by scrutinizing the words of “gender specialists” themselves:

Kingpins of pediatric transition confess: We have no idea what we’re doing


Some FTM peer counseling on breast binding injuries

This is Part 3 in a series about breast binding. Part 1 here, Part 2 here. The purpose of this series is to educate parents and caregivers about breast binders: their easy availability to girls and young women, and their potential dangers. 

Truth-about-transition has a new reblog up with peer advice for girls and women who have sustained an injury from breast binding. Like most of what truth-about-transition ferrets out, the post pretty much speaks for itself: breast binding can be dangerous–in rare cases, life-threatening.

As I noted in a prior post,  adolescents seek advice primarily from others their own age, with Tumblr, YouTube, and Instagram serving as peer counseling hubs for kids discussing dysphoria, surgeries, binding, hormones and everything else trans.

To their credit, the original poster offers advice to stay safe and avoid further injury. Which is a good thing. Adolescents aren’t exactly known for good judgment, foresight, or awareness of danger. Most teens seem to think they’re immortal, preferring to follow their own impulses and desires. They also tend to think adults (particularly their parents) are clueless morons.

The post (excerpted below) is interesting not so much for its pragmatic advice, but for the underlying and very typical messaging. It begins with commonsense advice for those with injuries:

1. Take the binder off. I don’t care how dysphoric you are, I don’t care how bad you feel, I don’t care who is around. DO NOT PUT IT BACK ON.

2. Go to the doctor. Or to a nurse. When I broke my ribs, I went to the nurse at my school because that was free and that worked fine.

Clearly, we are talking about kids here. The fact that the original poster went to the school nurse indicates that they handled this likely without parental knowledge or support. We are talking about broken bones here.

3. Accept that there isn’t anything you can do to heal faster. The most likely thing that doc is going to tell you is that you have some bruised ribs, and you need to let them heal. Sometimes broken ribs can break lungs, which is potentially fatal, so no matter what, you still need to do step two, but that’s probably not going to be the case.

Yes, a broken rib could puncture a lung. At least the original poster mentions the possibility, hopefully scaring the bejesus out of some of their readers. Some of these girls might actually talk to a caring parent (vs. a stranger on the Internet) the next time they have a chest injury, given the potential danger.

Later in the post, we receive the pièce de résistance:

6. Don’t reflect too hard on it. The first thing you are going to think is not “oh I have an injury so I better take care of myself” it’s going to be “this is the physical manifestation of my dysphoria and why does being trans always ruin my life”. Try to refrain from that particular thought. You have an injury. Treat it like any other injury or illness you could get.

Don’t even let the thought enter your mind that doing this to your body is maybe a bad idea. If your ribs are bruised or broken, if being trans ruins your life, is there any possibility you could see this another way? Maybe try to find a way to accept your healthy body, the only one you will ever have?

No. The original poster instructs you to “refrain from that particular thought.” It’s just an injury like any other. Nothing to see here. Move along. (Or maybe it’s time to contemplate a double mastectomy?)

The post finishes by reiterating the message to leave the binder off until the injury heals, with a mention of yet another danger–a warped ribcage:

What not to do.

1. Put that damn binder back on. Don’t. I see you tempted. Don’t.


3. You could end up with a warped ribcage if you don’t allow yourself to heal. Don’t put it back on.

4. Really. Don’t.

This post is but one of many in the Tumblr FTM blogosphere on the same subject. YouTube–the go-to place for FTM transition stories–has this video from 6 years ago which presents a similar cautionary tale.

Why are more girls than boys presenting to gender clinics?

For decades, more young men than young women presented to doctors and psychiatrists with gender dysphoria.  But that has all changed in recent years.

As reported in a 2015 article in the Journal of Sexual Medicineresearchers in Canada and the Netherlands examined data from 748 total clinic referrals in the two countries across several decades. The flip-flop in the boy-girl ratio is obvious, as seen in the  below graph from this quantitative study. As always, a picture is worth at least 1000 words.

Aitken sex ratio graph

The dramatic uptick in girls and women presenting to gender clinics from 2006-13 is abundantly clear–and there seems to be no end in sight.

Starting in 2006, we noted that the number of  referred female adolescents with GD was now  exceeding the number of referred male adolescents with GD in the Toronto clinic. Thus, there appears to be an emerging inversion in the sex ratio of adolescents with GD which, to our knowledge, has not been documented formally in the empirical literature.

The sex ratio of adolescents from two specialized gender identity clinics was examined as a function of two cohort periods (2006–2013 vs. prior years). Study 1 was conducted on patients from a clinic in Toronto, and Study 2 was conducted on patients from a  clinic in Amsterdam.

Results. Across both clinics, the total sample size was 748. In both clinics, there was a significant change in the sex ratio of referred adolescents between the two cohort periods: between 2006 and 2013, the sex ratio favored natal females, but in the prior years, the sex ratio favored natal males.

This reversal of the boy-girl ratio seems to be the case in other Western countries as well. Two other studies, one from Germany, the other from Finland, corroborate the findings from the Toronto and Amsterdam clinics.

In the German study (2014)

Between 2006 and 2010, 45 gender variant children and adolescents were seen by clinicians; 88.9% (n = 40) of these were diagnosed with gender identity disorder (ICD-10). Within this group, the referral rates for girls were higher than for boys (1:1.5). Gender dysphoric girls were on average older than the boys and a higher percentage of girls was referred to the clinic at the beginning of adolescence (> 12 years of age). At the same time, more girls reported an early onset age. More girls made statements about their (same-sex) sexual orientation during adolescence and wishes for gender confirming medical interventions. More girls than boys revealed self-mutilation in the past or present as well as suicidal thoughts and/or attempts.

And in the Finnish study (2015), which looked at referrals from 2011-2013:

The number of referrals exceeded expectations in light of epidemiological knowledge. Natal girls were markedly overrepresented among applicants. Severe psychopathology preceding onset of gender dysphoria was common. Autism spectrum problems were very common.

…The natal girl:boy ratio among the adolescent SR applicants was very high. In prepubertal children referred to gender identity services, boy:girl ratio is reportedly 3–6:1, with some variation across countries presumably due to cultural reasons [5,13]. Previously a more even boy:girl ratio has been suggested in adolescents seeking sex reassignment than among child samples [13]…

What could be causing this undeniable increase in referrals of girls with gender dysphoria?

The German and Finnish studies offer no explanation, other than to say “cultural factors” likely play a part. In the larger Toronto-Amsterdam paper, Aitken et al posit

It is well-known that cross-gender behavior in children is subject to more social stigma (e.g., peer rejection and peer teasing) in males than in females, in both clinic-referred adolescents with GD and in the general population [26–30]. Thus, it could be argued that it is easier for adolescent females to “come out” as transgendered than it is for adolescent males to come out as transgendered because masculine behavior is subject to less social sanction than feminine behavior. … Given that a transgendered identity as an “identity option” has become much more visible over the past decade, it is conceivable, therefore, that such an identity option is easier for females to declare than it is for males because it does not elicit as much of a negative
response. .. there are greater costs for a male to adopt a female gender identity in adolescence than it is for a female to adopt a male gender identity.

I find the authors’ explanation lacking for several reasons. One, this is nothing new. Girls who are “tomboys” are more socially acceptable than “sissy” or effeminate boys. This didn’t start in 2006. But more to the point, I think the authors’ reasoning is exactly backwards. If it is more acceptable for girls to be tomboys, why would those tomboys think they need to change their gender? It would seem that boys who are effeminate would feel a much greater sense of urgency about changing their sex, because they would face constant disapproval about their behavior from parents, schoolmates, and anyone else they encountered, especially in more conservative families and regions. Girls, on the other hand, would presumably feel more comfortable continuing to present as “gender nonconforming” or “tomboyish.”

I am not the first blogger to contemplate this question. GenderTrender, for one, has been blogging for years about the phenomenon of young, primarily lesbian young women “transitioning.”  Others have written in elegaic terms about the near eradication of less conventionally “feminine” lesbians, with so many now choosing “transition” instead of the fomerly proud and celebrated butch identity as in the bygone Second Wave era. The loss of womens’ bookstores, support groups, and other spaces, as well as role models (both in real life, and in movies, TV, and other media consumed so much by young people) is also key. Homophobia/lesbophobia is most certainly a factor. I have written several posts pointing out the influence of social media in glamorizing transition, with video logs and journals chronicling the FTM transition and the profound (and partially permanent) changes wrought by testosterone.

And what of the straight girls who transition to then become gay men? What motivates these young women to abandon the relatively easier path of heterosexuality? The current cultural expectation seems to be that girls look, act and dress like–to put it bluntly–porn stars, so a girl who eschews makeup and the other accoutrements  of “femininity” could be drawn to the relative freedom of a man’s life.

None of this fully explains the inversion in the ratio of girls to boys. But whatever the reason (and please share your own thoughts and theories in the comments), the increasing number of girls dis-idenitifying with their own bodies is an undeniable and growing trend–and to observers like me, an emergency.

I am haunted by the the words of a detransitioned woman, who recently wrote that when she was active in transgender circles, the only voices to be heard amongst both MTFs and FTMs were testosterone-deepened. Women’s voices were gone.

The voices of too many young women are being lost. Figuratively, as these young women no longer identify with their natal gender and join the chorus of male opinion. And literally: their female voices silenced and transformed by testosterone.

Peer pressure to transition

This is a guest post from another concerned mom. It’s not our imagination, this “teen transition wave” our kids are riding.

Philomena says:
I am relieved to find this site. We are a progressive family caught in the teenage transgender wave. It’s so scary. I can’t even put it into words.

What we are seeing are pockets of teens in different towns who are declaring themselves either non-binary or transgender. In many cases, these are teens who showed no gender variance at all, and then they get connected with a group in their high school, and suddenly a large percentage of them are identifying this way.

The information they find on the internet convinces them that physical transitioning via hormones and surgery is not only the only way to go but should also be available to them right now, as soon as they want it.

I am very concerned that the medical community is not looking at the sheer number of teens, post-puberty, who are making these kinds of declarations and asking whether this can be genuine or a temporary stop on the process of figuring out one’s identity as a teenager. Peer influence is just so huge in these kids.

As soon as they turn 18, they are seeking medical intervention, and the model now is informed consent, so we have lots of teenagers and young adults making permanent changes to their bodies when their brains have not yet reached adulthood.

Very, very scary.

Kingpins of pediatric transition confess: We have no idea what we’re doing

How many ways are there to say: “We just don’t know?”

On June 30, 2015, PBS Frontline aired a story about “transgender kids.” The program presented a more balanced view than the usual pro-transition media coverage, with doctors actually admitting that there is much that remains unknown about dosing kids with hormones and performing surgery at younger and younger ages.

Frontline posted a companion article about pediatric transition on their website. In this post, I will excerpt from the PBS piece, along with several other sources, highlighting quotes from well-known gender specialists.

There’s a lot of redundancy in what I’m about to share, and that’s the point. It turns out that the top dogs of pediatric transition agree: we just don’t know whether puberty blockers, cross-sex hormones, “social” transition, and the other “treatments” being foisted on our “gender nonconforming” youth can be justified—because we don’t have the evidence.

Some phrases you’ll see:

  • There is no objective test
  • We still don’t know
  • Someone will figure it out
  • There are so many unanswered questions
  • Hopefully there will be research to begin to answer these questions
  • Unknown consequences
  • What’s lacking are specific studies
  • Risk is unknown
  • We don’t know the long-term effects
  • We’re in unknown territory
  • There is no medical consensus

Oh, but the gender doctors do bemoan the unfortunate lack of evidence. They wring their hands, claim to be “worried” and “troubled.” They say they sincerely “hope” that “someone” will do the necessary research. Funny how none of them mention how or whether they themselves will spearhead these desperately needed studies, or apply for research grants.

There is no mention of slowing down or stopping the medical transition of children. No suggestion that maybe it would be prudent to halt what they’re doing until there is some actual evidence that they are not doing irreparable harm. To CHILDREN.

Nope, lack of evidence isn’t stopping any of these “gender specialists” from plowing full speed ahead,  continuing to diagnose and treat “gender nonconforming” toddlers, elementary-school children, and adolescents as transgender-until-proven-otherwise.

It’s as if they think they can be absolved of responsibility for future negative consequences, just by confessing in the Church of Public Opinion that they are operating in the dark. 

From the PBS Frontline article:

“What makes [puberty blocker] treatment tricky is that there is no test that can tell whether a child experiencing distress about their gender will grow up to be transgender. The handful of studies that do exist suggest that gender dysphoria persists in a minority of children, but they involved very few children and were done mostly abroad.

… the use of puberty blockers to treat transgender children is what’s considered an “off label” use of the medication — something that hasn’t been approved by the Food and Drug Administration. And doctors say their biggest concern is about how long children stay on the medication, because there isn’t enough research into the effects of stalling puberty at the age when children normally go through it.

… However, doctors caution that estrogen and testosterone, the hormones that are blocked by these medications, also play a role in a child’s neurological development and bone growth.

“We do know that there is some decrease in bone density during treatment with pubertal suppression,” Finlayson said, adding that initial studies have shown that starting estrogen and testosterone can help regain the bone density.

…Finlayson said there isn’t enough research on whether someone who was on puberty blockers will regain all their bone strength, or if they might be at risk for osteoporosis in the future.

Another area where doctors say there isn’t enough research is the impact that suppressing puberty has on brain development.

The bottom line is we don’t really know how sex hormones impact any adolescent’s brain development,” Dr. Lisa Simons, a pediatrician at Lurie Children’s, told FRONTLINE. “We know that there’s a lot of brain development between childhood and adulthood, but it’s not clear what’s behind that.” What’s lacking, she said, are specific studies that look at the neurocognitive effects of puberty blockers.

…The physical changes that hormones bring about are irreversible, making the decision more weighty than taking puberty blockers. Some of the known side effects of hormones include things that might sound familiar: acne and changes in mood. Patients are also warned that they may be at higher risk for heart disease or diabetes later in life. The risk of blood clots increases for those who start estrogen. And the risk for cancer is an unknown, but it is included in the warnings doctors give their patients.

…Another potential dilemma facing transgender children, their families and their doctors is this: Taking cross hormones can reduce fertility. And there isn’t enough research to find out of it is reversible or not. So when children make the decision to start taking hormones, they have to consider whether they ever want to have biological children.

 [Take a breath and ponder the above sentence: CHILDREN have to consider whether they ever want their own biological CHILDREN.]

“I think it’s really important to talk to these children and families about fertility,” Finlayson says. “I do worry that at that stage in life many of them may not be able to realize how important that would be to them someday.”

 [But you’re not THAT worried, are you Dr. Finlayson? You’re not bothered by this enough to put the brakes on these “treatments” are you?]

…It’s an ethical question that each family has to deal with in their own way, because if a child goes from taking puberty blockers to taking hormones, they may no longer have viable eggs or sperm at the age when they decide they would like to have children. They do have the option to start their puberty and delay their treatment in order to store eggs or sperm, but some of them may not want to.

While transgender adults have taken hormones sometimes for years, the generation growing up now is among the first to start taking hormones so young. Since most people who start hormones take them for life, doctors say there also isn’t enough research into the long-term impact of taking estrogen or testosterone for what could end up being 50 to 70 years.

There are so many unanswered questions around the long-term consequences, and whether your health risk profile really becomes that of a male or female,” Garofalo says. “If we start testosterone today, will you have the cardiac risk profile of a male or female as you grow older? Will you develop breast cancer because we’re administering estrogen?

“I think those are the unanswered questions that really trouble me, and can only be answered with long-term follow-up studies.”

[Excuse me, Dr. Garafalo,  but if these unanswered questions “really troubled you” that much, you wouldn’t be experimenting on kids, now would you?]

…Ultimately, the doctors working in clinics like the one at Lurie Children’s hope to spare transgender children some of the anguish and societal isolation that earlier generations of transgender people went through. But they too would like the answers to the unknown consequences of these medications.

[Just who exactly do you think is going to give you these answers, doctors?]

“The stakes are super high, and we don’t have all the answers,” Garofalo says. “Hopefully, there’s going to be more research and some of those unanswered questions, hopefully, will begin to be answered.”

The Frontline piece is only one source of confessions by “troubled,” “worried” gender doctors.  Here is a sampler of quotable quotes from some of the other big guns in the pediatric transgender world.

Dr. Ximena Lopez is founder and head of GENder Education and Care, Interdisciplinary Support (GENECIS), one of the newer gender clinics in the US, and the first in the Southwest.

Dr. Lopez tells us:

There is a strong need for research in this field to improve the outcomes of our patients,” explains Dr. Lopez. “For example, it is still unclear which very young patients with gender dysphoria will persist as transgender individuals through adulthood. There is no objective diagnostic test available that can predict this.”

In a 2013 New Yorker piece, we have this:

Eli Coleman, a psychologist who heads the human-sexuality program at the University of Minnesota Medical School, chaired the committee that, in November, 2011, drafted the latest guidelines of the World Professional Association for Transgender Health, the leading organization of doctors and other health-care workers who assist trans patients. The committee endorsed the use of puberty blockers for some children, but Coleman told me that caution was warranted: “We still don’t know the subtle or potential long-term effects on brain function or bone development. Many people recognize it’s not a benign treatment.”

 And this:

Alice Dreger, the bioethicist, said, of cross-gender hormones and surgery, “These are not trivial medical interventions. You’re taking away fertility, in most cases. And how do you really know who you are before you’re sexual? No child, with gender dysphoria or not, should have to decide who they are that early in life.”

 Dr. Johanna Olson, Medical Director of the Center for Transyouth Health and Development at Los Angeles Children’s Hospital is one of the better known pediatric transition proponents. She has even argued for skipping puberty blockers and going straight to cross-sex hormones for “transgender” pre-adolescents. Olson said this in a 2012 NBC Dateline broadcast I wrote about last month:

 What’s missing in the data right now is: these exact characteristics mean for sure this person is going to be a trans adolescent and adult. We don’t have that data.

 More mea-culpa redundancy from Houstonia magazine, in “What do Transgender Children Need” published in 2014:

There is no medical consensus on the best course of treatment for gender-dysphoric prepubescent children, mainly because it’s almost impossible to tell which kids will continue to experience the condition as adolescents and adults. Citing informal studies, Drescher and Meyer estimate that only about 20 percent of prepubescent children who exhibit cross-gender behavior continue that behavior into adolescence.

You’re in unknown territory, where the experts disagree,” says Dr. Jack Drescher, a New York–based psychiatrist who, along with Dr. Kenneth J. Zucker of the University of Toronto’s Gender Identity Service, helped write the entry for gender dysphoria in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. “If most of these kids won’t grow up to be transgender,” says Drescher, “[socially transitioning] could be harmful,” never mind hormone therapy.

And finally, this treasury of quotes would not be complete without some words of wisdom from Dr. Norman Spack, head of the Disorders of Sexual Development (DSD) and Gender Management Service (GeMs) at Boston Children’s Hospital, whose pediatric gender clinic is  the “first of its kind in the nation.”

Dr. Spack holds forth in an interview/blog post in April 2015. Notice his use of future tense. “Someone” else is eventually going to solve the problem.

Question: GeMS was the first transgender treatment clinic in the U.S., and there are now over 40 programs across the country. You’re reaching more and more kids and at a younger age. What’s next for this field of medicine?

Dr. Spack: I think that there is an absolutely tremendous need for tools with which to discern which of the kids are really among the 20 percent who are definitely going to be transgender. With these tools, people could far more freely encourage their kids to act and dress as the gender they identify with, and kids will have a much easier time in school.

…These tools are going to be based on analysis from the neck up, not blood levels of anything I can think of—unless it’s maybe a genetic test, but I doubt it. My theory is that we just don’t know enough about the brain… I’m convinced that sooner rather than later, someone’s going to figure something out related to the brains of the 20 percent transgender kids.

Sooner or later….we just don’t know enough….there is a tremendous need…

But meanwhile: Carry on! with administering off-label puberty blockers followed by cross-sex hormones. Keep  sterilizing our guinea  pi–  um, kids.

“Someone” will figure it out—sooner or later.