Not plural-phobic: USPATH psychiatrist promotes transition for multiple personalities

This is another in a series of posts examining statements made by top gender specialists at the inaugural USPATH conference in Los Angeles in February 2017. (See here, here, and here for more.)

Note: The audio recordings linked in this post, as well as the presentation slides, were provided by an attendee at Dr. Karasic’s USPATH presentation.

Dan Karasic, MD, plays an important role in the area of transgender health care.  He is clinical Professor of Psychiatry at University of California, San Francisco, and a practicing psychiatrist for the Transgender Life Care Program at Castro Mission Health Center, as well as at his faculty practice at UCSF. He is also the co-chair of the recently formed USPATH, on the Board of Directors of WPATH,  and, as such, has been instrumental in the ongoing development of WPATH policies and standards.

With so much experience, as both a clinician and trans advocate, Karasic’s statements and clinical judgment carry a lot of weight. So it’s of particular interest that his presentation at a mini-symposium entitled DEVELOPMENT OF GENDER VARIATIONS: FEATURES AND FACTORS at the inaugural USPATH conference last February should focus on a topic as controversial as this: medical transition for one or more “alters” of people with multiple personalities (MPD)—also known as dissociative identity disorder (DID).

MPD/DID had its diagnostic heyday in the late 20th century, peaking in the 1990s. The public was fascinated by the idea that one human being could comprise more than one identity or personality, and novels, films, and breathless media coverage proliferated. The disorder was thought to be the result of trauma or abuse, but has since that time been subjected to the same skeptical reassessment as the now widely debunked recovered memories and satanic abuse diagnoses (MPD/DID was, in fact, often associated with/comorbid with both).

There is something eerily familiar in this excerpt from a 1999 book by Joanne Acocella about the rise and fall of the MPD diagnosis . 

Another important circumstance in Carlson’s case, as in other MPD histories, was the media. During the period of Carlson’s therapy, magazines and newspapers were retailing utterly unskeptical stories about MPD. So was the evening news. MPD experts went on TV with their patients in tow. Bennett Braun, of the nine-hour abreactions, appeared on the Chicago evening news with his star patient. At his bidding she “switched” on camera—now she was “Sarah,” now “Pete”—thus providing early training for prospective MPs in the television audience.

More important than the news were the talk shows. Phil Donahue was apparently the first talk-show host to present a program on MPD; he was followed by Sally Jessy Raphael, Larry King, Leeza Gibbons, and Oprah Winfrey. Meanwhile, celebrities were coming forward with their tales of childhood sexual abuse: Roseanne Barr, La Toya Jackson, Oprah herself. Some of them claimed to be multiples as well. Roseanne, who had unearthed twenty-one personalities within herself—Piggy, Bambi, and Fucker, among others—made the rounds. Again and again on the talk shows it was stressed that MPD was not rare; it was common, and becoming more so. “This could be someone you know,” said Sally Jessy Raphael. Oprah’s program was called “MPD: The Syndrome of the ’90s.” Today, as people are sifting through the wreckage created by the MPD movement, many therapists are blaming the media for spreading the epidemic. They are passing the buck, but still they have a point.

In the late ’90s and into the present day, a number of critical papers appeared in the clinical literature, and the verdict from many clinicians and researchers was that often cases were at least partly iatrogenic:

Although the relative paucity of data on the role of iatrogenic factors in DID renders a definitive verdict premature, several lines of evidence converge upon the conclusion that iatrogenesis plays an important, although not exclusive, role in the etiology of DID:

(a) The number of patients with diagnosed DID has increased dramatically over the past several decades (Elzinga et al., 1998); (b) the number of alters per DID case has increased over the same time period (North et al., 1993), although the number of alters at the time of initial diagnosis appears to have remained constant (Ross, Norton, & Wozney, 1989); (c) both of these increases coincide with dramatically increased therapist awareness of the diagnostic features of DID (Fahy, 1988); (d) a large proportion or majority of DID patients show few or no clear-cut signs of this condition, including multiple identity enactments, prior to therapy (Kluft, 1984); (e) mainstream treatment practices for DID patients appear to verbally reinforce patients’ displays of multiplicity and often encourage patients to establish further contact with alters (Ross, 1997); (f) the number of alters per DID case tends to increase over the course of DID-oriented therapy (Piper, 1997); (g) therapists who use hypnosis appear to have more DID patients in their caseloads than do therapists who do not use hypnosis (Powell & Gee, in press); (h) the majority of DID diagnoses derive from a relatively small number of therapists (Mai, 1995); and (i) laboratory studies demonstrate that nonclinical participants provided with appropriate cues can successfully reproduce many of the overt features of DID (Spanos et al., 1985). Given the high rates of preexisting mental conditions among DID patients (Spanos, 1996), however, it seems likely that iatrogenic factors do not typically create DID in vacua but instead operate in many cases on a preexisting substrate of psychopathology, such as BPD.

As the authors of this article attest, some patients diagnosed with MPD got worse instead of better as they underwent treatment, and not a few came to realize that their deepening troubles were at least partly the result of the misguided efforts of their psychotherapists. Some high-profile cases ended up in court, like this suit brought by Pat Burgus, who settled for $10.6 million against her psychiatrist, Bennett Braun. Burgus had once believed she had 300 different “alters,” and she “recovered” memories under hypnosis that she had eaten human flesh and–among many other horrors–sexually abused her two sons.  She blamed her therapist for convincing her these memories and personalities were real.

Pat burgus.jpg

Before her ordeal was over, Pat would develop 300 personalities, attempt suicide twice, cut ties with her family in Iowa, and go to court to regain custody of her children. She would spend more than two years in the hospital; her children would spend three. And her insurance company would pay $3 million for a treatment regi­men that today seems utterly fantastic….

… Since 1993, more than 100 patients nationwide have sued therapists over treatment for MPD, which was diagnosed in explosive numbers throughout the eighties. “In many of these cases, we see a situation in which the poor training and instability of the therapist, coupled with the vulnerability of the patient, creates a situation fraught with the potential for a folie à deux”—that is, a delusion shared by therapist and patient, says R. Christopher Barden, a lawyer and psychologist who served on the Burgus legal team.

MPD/DID remains today a controversial diagnosis. In a 2004 review paper, “The Persistence of Folly: Critical Examination of DID. Part II. The Defence and Decline of Multiple Personality or DID,” authors Piper and Mersky, make the crucial points bluntly.

piper and mersky highlightsConcerns about the validity of MPD/DID raised by skeptics in the psych literature seem to coalesce around the following: only a small group of therapists have been involved in diagnosing it; the condition often worsens and more identities/personalities arise after treatment has commenced; and its close association with the widely debunked notion of “recovered memories” of childhood abuse further undermines its validity.

Given the precarious legitimacy of the MPD/DID diagnosis, it seems clear that–if it’s going to be made at all–it should be done with extreme caution and, above all, with an awareness of the potential for iatrogenic conditions that might exacerbate it—most importantly, the influence of the treating clinician.

Yet MPD/DID is apparently very much alive in WPATH circles. Returning to Dr. Karasic’s presentation about “trans plurals” at USPATH, he offered several case studies, all of which involved medical transition of all or some of the “alters”:

EF case 7 alters

In the case of this 20-year-old “AMAB,” as seems to be typical with gender affirmative practitioners, medical transition is reported as curative (or at least palliative) for a host of other problems apart from gender dysphoria; in this instance, the patient’s Bipolar Disorder 2 and Alcohol Use Disorder were “treated simultaneously” with the T-blocker spironolactone and cross-sex estrogen. The patient “did well,” and the 7 alters (including 3 in “co-conciousness,” 2 agender, 1 female) seem to have reached consensus about gender surgery later on–presumably the requested “genital nullification” .


Then there is the 27-year-old who identifies as a genderqueer “system.” Diagnosed with autism in childhood, this “AMAB” with a primary “front” female alter, has undergone hormone therapy and presently has 85 “headmates” that include alters, tulpas, and fictives.

Headmates, tulpas, “fronting,” co-consciousness: Dr. Karasic seems well versed in the insider jargon used by the trans plural community.

“So I’ve had several patients who identify as trans and plural

and I guess I had a reputation as a psychiatrist who was not plural phobic.” 

After discussing several cases of successful medical transition of alter identities, Karasic reported on an online survey of 250 self-identified “trans and plural” subjects conducted by three self-described members of the trans plural community, over a one-month period. From the data gathered, there seems to have been a plethora of different alter types reported by survey respondents.

Trans plural survey

Did these alters include “furries,” an audience member wanted to know?

Q: “…What are “damiens?” [sic] The other thing is, were all the alters human, or were there some alters that took on another form?

Karasic: …I think there are people who have alters that take different forms. And I have had somebody with a wolf, you know, and sometimes fictional characters who might not be human, who can become a headmate, basically.

Q: Separate from furries? We’re not talking about furries..

Karasic: No, no no, this doesn’t have anything to do with that. This is just different people’s identities, but there are people who may have within this a system with headmates. There can be kind of a variety of …headmates.

Last August, 6 months after the USPATH symposium, Dr. Karasic discussed his experiences with transitioning multiple personalities in a thread on the public WPATH Facebook page.karasic wpath DID aug 21 2017 part 2

Dr. Karasic does acknowledge here the importance of mental health care for people with multiple issues, but per the informed consent model that Dr. Karasic subscribes to (evidenced by his many public statements, as well as the fact that his trans health clinics operate on the informed consent model), comorbid mental health problems are not seen as a barrier to medical transition instituted before treating other comorbid issues.

karasic WPATH DID aug 21 2017 alter egos fronting

In the era before informed consent became the preferred approach , particularly in the United States, clinicians were often reluctant to initiate hormonal or surgical intervention in patients with comorbid, severe mental health issues. But in the age of gender affirmation, withholding medical transition is seen as restrictive—even immoral– “gatekeeping”—even if one runs the risk of one alter ego disagreeing with medical treatment and suing the provider in court for “violating the rights of one or more personalities“, as a commenter on the same thread hypothesized.

karasic wpath DID aug 21 2017 commenter on court case different personalities

Taking this a step further, might one trans-plural headmate sue not only the surgeon or gender therapist, but one of the other headmates for forcing medical transition (or not) on the others?

Time will tell if the spectacular court cases brought by aggrieved clients who were diagnosed with DID/MPD in the 1990s will play out in a similar fashion within the labyrinthine world of trans plurals.

Meanwhile, the reader may find the concluding paragraphs of the previously cited Piper and Mersky paper relevant when weighing the plight of “trans plurals” and the clinical approach taken by at least one prominent WPATH clinician:

Wherever we look—whether at the posttraumatic model; at theories of repression; at the epidemiologic uncertainties and aggrandizements of the disorder; at the persistent proliferation of personalities; at the elusive data that attempt to sustain the claims of exceptional abuse; at the bland presentation of breathtaking assumptions such as cross-sex, cross-species, or cross-ethnic alters; or at the impossibility of proving almost any of the basic claims of the disorder—we encounter propositions that appear to be founded on beliefs and not on facts or logic. That such beliefs could prosper in a society or a discipline represents an embarrassing weakness of the academic and professional establishment of psychiatry.

Perhaps the closest example of another culture-bound movement that resembles the modern DID–MPD movement occurred in the late 19th and early 20th centuries, when mediums and spiritist practices were popular. Hacking notes that “multiple personality has long had close links with spiritism and reincarnation. Some alters, it has been thought, may be spirits who find a home in a multiple; mediums may be multiples who are hosts to spirits” (79, p 48). Much of the best turn-of-the-century English-language research on multiple personality was published by the London- or Boston-based societies for psychical research. However, After 30-odd years of high times around the turn of the century, mediumship, spiritism and psychical research went into radical decline. A zone of deviancy that was hospitable to multiple personality severely contracted (79, p 48).

When it becomes suspect to recommend MPD as part of psychiatric evaluation or treatment, the condition is diagnosed less frequently. For example, Pope and colleagues (80,81) and others (82) have shown that North American psychiatrists and psychologists are abandoning the notion of MPD–DID as an acceptable diagnosis. In these circumstances, we expect that the condition will revive momentarily and die several times before it finally ceases to be a ripple on the surface of the psychiatric universe. In the end, it is likely to become about as credible as spirits are today. Having attempted to rationally analyze the claims of MPD–DID, we trust that we have shown sufficient evidence to predict a steep decline in the condition’s status over the next 10 years and a gradual fall into near oblivion thereafter.

The boy with no penis: David Reimer & the question of what is innate

Carrie-Anne is a thirtysomething historical novelist, historian, and lover of many things from bygone eras (except for the sexism, racism, and homophobia). She can be found at Welcome to My Magick Theatre, where she primarily blogs about writing, historical topics, names, silent and early sound cinema, and classic rock and pop; and at Onomastics Outside the Box, where she blogs about names and naming-related issues. Her only child, a 17-year-old spider plant named Kalanit, has thankfully never had any issues with her gender identity!

Carrie-Anne can be found on Twitter @Anyechka and is available to interact in the comments section of this post. Her previous article for 4thWaveNow was “Transing the Dead: The erasure of gender-defiant role models from history.”

by Carrie-Anne Brownian

Though many people today have wholeheartedly accepted the theory claiming “gender identity” is innate, such an idea developed very recently in the grand span of human history. The word “gender” itself also only came to be used in reference to the state of being male or female (or some new-fangled “identity” such as “agender” or “femme demiboy”) very recently. A predominant reason for this sharp shift in language is the work of Dr. John Money (8 July 1921–7 July 2006). But before I embark on a discussion of the most infamous exemplar of Money’s legacy—the case of David Reimer–some etymological explanations are in order.

The word “gender” entered the English language in the year 1300, by way of the Old French gendre and genre, meaning “kind, species; character.” In English, the word had almost the exact same meaning, “kind, class, sort, a class or kind of persons or things sharing certain traits.” The Old French word in turn comes from the Latin genus (genitive form generis), “race, stock, family; kind, rank, order; species.” Its ultimate etymological root is the Proto–Indo–European *gene- (give birth, beget). Other words formed from this ancient root related to familial and tribal groups, as well as procreation.

Though “gender” is attested as referring to biological sex in English as early as the 15th century, this wasn’t the most common usage of the word. Even the Victorians, cast in the modern imagination as extremely prudish, and, well—Victorian–used the word “sex” when referring to the state of being female or male. It was only in the last few decades of the 20th century, after the word “sex” came to be the common parlance to refer to sexual relations, that the switch began. (On an interesting side note, the phrase “making love,” now seen as a softer, romantic way to refer to sexual relations, only referred to sweet-talking or other attempted wooing until the earlier decades of the 20th century.)

Instead, the word “gender” was by and large used to refer to grammar. Though English isn’t a particularly gendered language, many other languages are. Nouns, adjectives, definite articles, and pronouns are all feminine, masculine, or neuter. Some words in some languages will always maintain their grammatical gender, while others are modified based upon whether, for example, a cat, teacher, or baby is female or male. Not just the nouns and pronouns themselves, but also the accompanying adjectives and definite articles, are subsequently gendered to agree with the main object. Some languages, most famously many of the Slavic languages, gender surnames and patronymics based upon the sex of the bearer. Grammatical gender also includes verb forms. The example most readers will probably be familiar with is the French née/né (she was born/he was born), used to refer to a birth name.

All this changed with the appearance of Dr. John Money in the mid-20th century.


John Money

John Money was born in Morrinsville, New Zealand, to an English mother and Australian father.  He had quite a dysfunctional childhood.

Money was raised in a very strict, religious home, where anything related to sex was repressed and portrayed as dirty and sinful.  From his first day of school at age five, he was marked by bullies not only as someone who didn’t fight back, but who took shelter in the girls’ play-shed.  Later in life, he wrote about his father “with barely controlled venom,” describing him as an extremely cruel man who shot birds in his fruit garden and administered a brutal, abusive whipping and interrogation to his son on account of a broken window.  At age eight, his father died, and he wasn’t told for three days [Colapinto, John, As Nature Made Him:  The Boy Who Was Raised As a Girl, 2000; also see Colapinto, John, “The True Story of John/Joan,” Rolling Stone, 11 December 1997, pgs. 54–97)].

After his father’s death, Money was raised in a house full of women, whom he believed despised all things male and viewed him as wearing “the mark of man’s vile sexuality” (i.e., the penis and testes).  In the 1997 anthology How I Got into Sex, in an essay entitled “Serendipities on the Sexological Pathway to Research in Gender Identity and Sex Reassignment,” Money described how this led him to reject the role of “man of the household,” and “wondered if the world might really be a better place for women if not only farm animals but human males also were gelded at birth.”  (This is also related in Colapinto’s book.)

After graduating from high school early, he attended Victoria University in Wellington. In 1944, he earned a double master’s in philosophy/psychology and education, as well as a teaching certificate. Because New Zealand didn’t grant doctorates in psychology in that era, Money immigrated to North America in 1947.

Money worked at the Psychiatric Institute at the University of Pittsburgh for awhile, and was later accepted into Harvard’s PhD program in the Department of Social Relations. In 1952, he earned his doctorate, with a thesis entitled “Hermaphroditism: An Inquiry into the Nature of a Human Paradox.”

During the 1950s, Money began studying intersex people, who were then referred to as hermaphrodites. Most famously, in a 1955 paper, he expounded upon six variables which he believed defined biological sex. Though all these variables are identical in the average person (as all are either male or female), things aren’t so cut and dried with the intersex.

Money identified these variables as:

  1. Assigned sex and sex of rearing.
  2. External genital morphology.
  3. Internal reproductive structures.
  4. Hormonal and secondary sex characteristics.
  5. Gonadal sex.
  6. Chromosomal sex.

He also added a seventh factor applying to people for whom there were mismatched combinations and permutations of the above-mentioned six factors: Gender role and orientation as male or female, which he posited were established while growing up [Money, John; Hampson, Joan G.; Hampson, John, “An Examination of Some Basic Sexual Concepts: The Evidence of Human Hermaphroditism,” Oct. 1955].

Money defined “gender role” as:

[A]ll those things that a person says or does to disclose himself or herself as having the status of boy or man, girl or woman, respectively. It includes, but is not restricted to sexuality in the sense of eroticism. Gender role is appraised in relation to the following: general mannerisms, deportment and demeanor; play preferences and recreational interests; spontaneous topics of talk in unprompted conversation and casual comment; content of dreams, daydreams and fantasies; replies to oblique inquiries and projective tests; evidence of erotic practices, and, finally, the person’s own replies to direct inquiry. [Ibid.]

As compared to the earlier definition of gender as referring to the state of being female or male (usually in a grammatical sense), Money expanded it to refer to personality, self-definition, behavior, social role, and cultural role. He believed gender is something one learns, irrespective of reproductive biology. Money further distinguished between “gender identity” (the internal experience of one’s sex) and “gender role” (social expectations of female and male behavior).

Money’s research on the intersex led him to researching transsexualism. From 1964–67, he was part of a research team led by famous sexologist and endocrinologist Dr. Harry Benjamin. Because of the team’s research, the Johns Hopkins Gender Identity Clinic was founded in July 1966. At the time, almost no one else offered so-called “sex reassignment surgery.”

Into all this stepped Janet and Ronald Reimer of Winnipeg, Canada, desperate for someone to help their young son Bruce.

On 27 April 1966, eight-month-old twins Bruce and Brian Reimer were scheduled for a medically-necessary circumcision to correct their phimosis. The first twin to undergo the procedure was Bruce.


David Reimer

Because the attending general practitioner (not the usual urologist) elected to use a Bovie cautery machine (an electrical needle) instead of a more traditional method, very serious complications were visited upon Bruce. His penis was severely burnt, and the urologist who was called couldn’t insert a catheter in the urethra. The catheter had to be inserted through the abdomen and into the bladder, in an emergency suprapubic cystotomy. Over the next few days, Bruce’s penis dried up and broke off in pieces, with only the urethra left like a dangling piece of string [Colapinto, John, As Nature Made Him: The Boy Who Was Raised As a Girl, 2000].

After the Reimers realized the damage was irreversible, and that Bruce wouldn’t just have a tiny penis but none at all, they were desperate for something, anything, to help their son live a somewhat normal life. All the doctors had told them Bruce would never have a sex life or be part of society without a working penis. The Reimers felt a new wave of hope when they saw Dr. Money on the TV program Tis Hour Has Seven Days in February 1967, being interviewed with Diane (né Richard) Baransky, a male-to-female transsexual whose reassignment surgery he’d performed [Ibid.].

The Reimers brought Bruce to Johns Hopkins, and Dr. Money told them he could live a happy, normal life if he were surgically altered and raised as a girl. At the age of twenty-two months, Bruce received an orchiectomy (castration) and rudimentary vaginoplasty. He was also renamed Brenda. This was the same course of action Dr. Money recommended for all intersex children, with the parents being the ones to decide which sex it would supposedly be easier for their child to be raised as.

Dr. Money saw in these young twins the potential to test and prove his theories about gender identity. Brian, the other twin, hadn’t been maimed, and so was still an anatomically normal male. He would be socially and culturally raised as a boy, while his pretend sister would have no memory of having been a boy, and also had no intersex abnormalities. “She” was still young enough to develop a gender identity as a girl, if she were strictly raised as one. With the right environment, gender identity could successfully change, with the child none the wiser. Identical twins provided the perfect paired test subjects, with a built-in control subject (Brian).

Janet Reimer began putting the renamed Brenda in “girls’ clothes” such as skirts, dresses, and blouses, studiously avoiding pants. Though Winnipeg has some of the most frigid winters in North America, Dr. Money didn’t want Brenda to wear pants like her other female classmates. Any deviation from the strict gender roles he insisted upon would ruin his experiment.

Dr. Money also insisted the Reimers not let Brenda play with “boys’ toys,” and ordered them to treat her “like a girl” (e.g., gently, sweetly, softly). Brian meanwhile was raised exactly the opposite, in the stereotypical gender role of a boy.

reimer twins

The Reimer twins

The twins regularly came to see Dr. Money, so he could see how the experiment was working out. During these visits, according to several sources, the children were forced to take their clothes off, engage in sex play as he took pictures, view pornographic films and photographs, inspect one another’s genitals, and many other things which were beyond inappropriate and unethical. Dr. Money also interviewed them to see how secure they were in their respective gender identities. The twins routinely gave him the answers they knew he wanted to hear, just so they could get out of his office as soon as possible. These interviews also included very graphic, inappropriate questions. At home, he ordered their parents to walk around naked in front of them, so they could see the differences in biological sex illustrated in real life. Another aspect of his experiment involved having sex in front of their children, which they wisely refused to do. (Sources bearing this out include Colapinto’s book, the 2004 BBC Horizon documentary Dr. Money and the Boy with No Penis, and the 2000 BBC Horizon documentary The Boy Who Was Turned into a Girl. As adults, the twins also stated that they firmly believed this information is in files which Dr. Money donated to the Kinsey Institute, files which the institute refuses to release to the public.)

Money believed his experiment was a success, and he published several papers on what he called the “John/Joan case.” In particular, he publicized these findings in his 1972 textbook Man & Woman, Boy & Girl. These findings were used, for many years, to support surgical sex reassignment for intersex children, and children with conditions such as micropenis and an enlarged clitoris.

But behind the scenes, the experiment was never a success. Brenda always had an unexplainable feeling something wasn’t right, not least because her genitals didn’t look like those of other girls. She often fought with her brother at home and boys at school; found it very difficult to be friends with other girls, even the so-called tomboys; wanted to play with “boys’ toys,” like cars, and do “boys’ things,” like pretend to shave; didn’t like the stereotypical trappings of femininity; and urinated standing up. Brenda also repeatedly refused to undergo surgery for a more detailed vaginoplasty, and fought against taking estrogen pills. Both she and Brian were terrified of having to see Dr. Money ever again, and Brenda in particular experienced a suicidal depression [Colapinto, ibid].

When the truth came out when she was about 14, Brenda immediately reclaimed her natal male sex and took the name David, inspired by the warrior spirit of King David. Even though he couldn’t fully understand what his pull towards maleness meant, he instinctively understood something wasn’t right, and that he wasn’t like other girls, even the most tomboyish. This went far beyond merely being a very stereotypically masculine girl. The fact that his body had been surgically altered added to his sense of not being normal, and not belonging to the female sex class.

Though he wasn’t socialized as male, he knew who he was. Whatever the relative contributions of nature and nurture to stereotypical “male” pursuits—toy trucks, sports, rough-housing, and tool sets—David felt called towards the physical, biological aspects of maleness, and fought against the attempts to pretend he was a girl. He never felt female.

Unfortunately, modern-day transactivists regularly use his story to try to prove gender identity is innate, when it truly proves the opposite. David was born a normal male, suffered a freak accident, and was unsuccessfully raised as a girl. He wasn’t a natal female who always felt male, nor was he a boy who was able to adopt the stereotypical persona of a girl and never consider himself male in any way.

Dr. Money was still pretending the John/Joan experiment was a success as late as 1997, and using his pretended findings to recommend the same course of action to intersex children and children with genital abnormalities. It was then, in a 2000 interview with the CBC program The Fifth Estate, that the twins finally went public about the unethical experiment and counseling sessions they’d been subjected to. Their story was also told on a 2001 episode of NOVA, Sex: Unknown. They wanted to save other children from suffering the same fate, which had already been visited upon thousands.

For his part, Dr. Money believed the experiment had failed only because of the delay in Brenda receiving an orchiectomy and rudimentary vaginoplasty; Brenda’s knowledge of being an identical twin, and having this twin with whom to compare her genital self; various post-traumatic stresses; parental ignorance; intrusive outsiders threatening to give away the secret; having a trust fund while her twin didn’t; and not presenting lesbianism as a viable possibility.

Sadly, the childhood traumas never left either of the twins, and they had serious psychological problems as a result, including depression and a strained relationship both with one another and with their parents. Brian, who’d developed schizophrenia, died from an overdose of antidepressants in 2002, and in 2004, David committed suicide a few days after his wife told him she wanted a separation.

In spite of how Money has, in recent years, been rather clearly brought to light as someone who wasn’t exactly the world’s most ethical doctor, many people continue to sing his praises and tout his studies as proof positive of gender either being innate or able to be taught. On the contrary, if his research proves anything, it’s that biological sex is the only thing which is innate.

For those who claim David’s lifelong gravitation towards stereotypically male things means gender roles and expected interests are inborn, another explanation is that David, instinctively sensing he was first different from the others and then coming to realize he was male, was also influenced by society’s stereotypical gender roles. In another era or culture, he may have gravitated towards things considered feminine in the modern West.

David also knew something wasn’t right about his body. When he was living as Brenda, he realized his genitals didn’t look like those of other girls, and his own parents acknowledged this. They told her Dr. Money was pressuring her into a more detailed vaginoplasty because, when she was a baby, “a doctor made a mistake down there,” and it had to be corrected. Brenda then asked her father if he’d beaten the doctor up [Colapinto, ibid].

In addition to abnormal genitals, Brenda never menstruated, and had to be forced to take estrogen in order to grow breasts. Other abnormalities about her supposed female body were that she developed an Adam’s apple, never had a very feminine voice (not even the type of husky voice some women naturally have), and didn’t have a female bone structure or muscle mass. All these strange things about her body led her to feeling a disconnect from the gender role she was being raised as. This was far more than merely preferring certain toys and being rough-and-tumble [Colapinto, ibid.].

People nowadays who believe no lasting harm can come from socially transitioning a child, or a teen or twentysomething embarking upon that path oneself, need to take a long, hard look at what the true moral of this story is. Even if the child or young adult realizes it was a mistake, fueled by a myriad of underlying causes, and returns to living as the natal sex, there may be great confusion, a sense of betrayal, or deep-seated psychological damage, which can’t completely be undone. At best, it can be minimized, but certainly not overnight.

Today, Money’s legacy takes the form of transitioning children, or claiming a trans identity, because one’s personality and interests don’t match what society has decided is acceptable for members of one’s biological sex. Instead of surgically altering babies because of a micropenis, botched circumcision, or enlarged clitoris, gender-atypical children are socially transitioned, told their bodies are wrong but their brains are right, and given sterilizing drugs and irreversible surgeries by their teens or early twenties.

Though Money styled himself as a progressive, his theory of gender identity is anything but. It’s built around the idea that girls must always wear dresses, be spoken to softly, and play with dolls, while boys are the ones who play sports, wear pants, and study science.

One’s interests and chosen appearance (hairstyles and clothing) really amount to one’s personality—however atypical for one’s sex. Biology doesn’t dictate whether one likes a certain hair length, color, or item of clothing. In fact, many people have gender-atypical interests and personalities, particularly lesbians and gay men.

Even aside from gender roles, what person has never developed any interest independently of socialization and parental influence (whatever population norms may be for male/female typicality)? For example, my own passion for silent film didn’t come from anyone in my family or earliest circles of peers. It’s just something I’ve always been deeply enamored of, since my first exposure to it as a preteen.

Wouldn’t it be nice to return to the society we enjoyed all too briefly a few decades ago, when children of both sexes experienced far less pressure to pick between the blue and pink boxes, and when people realized biological sex was purely about biology instead of a collection of stereotypes?

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

By Susan Nagel

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

A PDF version of this article is available here.

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

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

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

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

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

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

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

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

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

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

3. Not every person who medically transitions stays transitioned.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


None of it is true.

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

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

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

Gender dysphoria is not one thing

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

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

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

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

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

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

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

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

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

 Types of Gender Dysphoria

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

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

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

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

Childhood-onset Gender Dysphoria (Boys and Girls)

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

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

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

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

What do we know about childhood-onset gender dysphoria?

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

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

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


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

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

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

Risk Factors for Persistence of Childhood-onset Gender Dysphoria

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

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

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

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

What should you do?

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

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

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

Autogynephilic Gender Dysphoria (Adolescent Boys and Men)

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

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

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

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

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

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

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

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

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

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

What do we know about autogynephilic gender dysphoria?

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

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

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

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

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

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


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

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

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

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

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

What should you do?

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

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

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

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

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

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

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

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

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

What About Natal Males?

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

What Do We Know?

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

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

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

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

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

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

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

Our Current Take on ROGD

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

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

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

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

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

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

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

What to do

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

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

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

Two Rarer Types of Gender Dysphoria

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

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

Autohomoerotic Gender Dysphoria

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

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

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

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

Gender Dysphoria Caused by Psychotic Delusions

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

Not Just One Type of Gender Dysphoria: Some Implications

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

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

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

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

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


Call the Police! Mom questions transgender treatment model, gets banned from support group

If liberty means anything at all, it means the right to tell people what they do not want to hear.    ~ George Orwell, from the original preface to Animal Farm 

 by Linda MacDonald

Linda is a left-leaning Canadian mom, believer in science and common sense, who is navigating life with her 19-year-old trans-identified biological daughter. She hopes that her daughter will opt out of medical transition and eventually come to a more genuine understanding of who she really is.

The events described in this article recently took place in a support group jointly sponsored by Family Services Ottawa  and Children’s Hospital of Eastern Ontario  for “parents & caregivers of gender creative, trans, transgender children, youth or young adults.”

It was my turn to introduce myself. “Oh God,” I thought nervously, “here it goes!”

I glanced around at the others in the circle.  Like me, they were all parents of children who had decided they were transgender. They were smiling politely, looking at me expectantly. I gripped the top of the spiral-bound notebook in my lap with both hands and, ignoring the group leader’s request to “state your name and preferred pronouns,” I began.

“Hi, my name is Linda and I am the mother of a 19-year-old girl who thinks she’s transgender. Well, she thinks she’s a boy, but really, she’s a girl. I mean, you can’t change your sex, right? It’s scientifically impossible.” 

I paused and looked around. The friendly smiles froze in place. People shifted uncomfortably in their seats.

I had attended this support group sporadically since my daughter announced she was a boy three and a half years ago. The 25-30 parents who regularly attended all appeared to accept their child’s self-declaration without question, and seemed happy to follow their doctors’ recommendation that they “affirm” their children.

Of the 18-20 children represented by these parents, all but approximately three were teenage girls, including my own. Yet, none of the parents seemed bothered by this wildly skewed statistic. They all unquestioningly, even enthusiastically, supported their children’s wish to transition—fighting for better, faster access to medical transitioning services, cheering when they heard our Children’s Hospital was about to start offering mastectomies to children under the age of 18.

I found it disheartening. To me, the group seemed like little more than a cheering section, where each parent proudly announced their child’s latest achievement—their first Lupron shot! their mastectomy, finally! And they were roundly congratulated by the other parents. These days, I attended only now and then, hoping to find someone else who was as skeptical as I was.

Once I had started talking, there was no going back. I had come here to tell them something important, and I was determined to finish. The words came tumbling out now.

“I think she has something called rapid-onset gender dysphoria. It’s new. Something scientists are only beginning to notice. It happens to kids—mostly teenage girls—who are really bright, but have trouble fitting in—well, my kid had a little trouble, but not a lot. And they spend too much time on the Internet—way too much—on sites like Tumblr and Reddit and YouTube—my kid spent too much time on this site called DeviantArt. I think that’s where it started—anyway they get brainwashed by transgender sites on the Internet. Oh, and another thing, kids with rapid-onset usually have friends who think they’re trans, too.  It’s a social contagion. If one kid transitions, their friends get the idea, too. It spreads.”

This had sounded way better in my head. My nerves were getting the better of me.

suzannah picI had intended to alert the parents to a new type of gender dysphoria that has emerged only within the last ten years or so, and scientists are only now beginning to study. Researchers are calling it Rapid-Onset Gender Dysphoria (ROGD). And it seemed to describe most of the children in this group.

Until about ten years ago, most cases of childhood gender dysphoria began very early, around age three or four. It was extremely rare, occurred predominantly in boys, and usually resolved on its own by the time the child reached adolescence.

This new type of gender dysphoria comes on rather suddenly in adolescence, after an unremarkable childhood in which the child did not display any discomfort with their gender. It typically involves highly intelligent children who have pre-existing emotional issues, and who often have difficulty fitting in with their peers. They also spend far too much time on the Internet, immersing themselves in websites, videos and chat rooms that actively promote the transgender lifestyle as cool, fun and the solution to all of their problems. Most children with ROGD have friends who have also declared themselves transgender, providing evidence of a social contagion at work.

And ROGD predominantly affects girls. It has become so frequent and pervasive that it is turning long-held statistics of transgender children on their head. Today, it is mostly teenage girls who are presenting to gender clinics, and their numbers are exploding.

I pressed on…

“…But I’m not supporting my daughter in her trans identification. I don’t want her to start hormones or have surgery or anything like that. I have made that clear to her. I don’t want her to do anything that might harm her body. I mean, there are no long-term studies to show these things are safe, right?  So I told her I wouldn’t support any medical interventions; that she’ll have to pay for that herself if she wants it. She knows that and is OK with it, I think. At least, I don’t think she has done anything.”

I finished my speech and looked around. The silence was deafening.

Out of the corner of my eye, I saw one woman looking pointedly at the leaders and gesturing towards me, silently mouthing “why is she here?”

After a long, uncomfortable pause, one of the group leaders, a female-to-trans, spoke.

“OK.  I’m going to take a minute to address this issue right now, because some things were said that are starting to make some of the other parents have…feelings.” S/he approached me, bent down and said in a quiet voice, “Why did you come here? This is a support group for parents of transgender kids.”

“I am a parent of a transgender teen,” I protested, “I came here to warn the other parents about rapid-onset gender dysphoria and to find other parents like myself who are skeptical of transitioning their kids, because I know they’re out there—”

“Not here!” called out one parent firmly. “Yeah, not here!” echoed another.

The group leader continued, “We are here to support our children on their transgender journey. You do not support your child. You belong in another group.”

“I asked if there was another group,” I replied. “I was told there wasn’t one.”

I wasn’t kidding. Earlier in the year, I had emailed the group’s administrator, asking if there was a group for parents like me, who wanted to take a more cautious approach and consider alternative ways to treat their child’s gender dysphoria. She politely replied no, this was the only support group available, but I should feel welcome to attend at any time.

I was not feeling welcome. And things were rapidly getting worse.

“Why are you taking notes?” one of the parents demanded. “I was wondering the same thing!” said another, angrily. I showed them my notebook. I had written only the group leader’s email address, some first names, and a tally of boys to girls who thought they were transgender.

“Check her phone. I bet she’s recording us, too!” I held up my phone to show them it wasn’t recording and turned it off for good measure.

“You’re making me feel unsafe!” cried a woman. Sobbing, she rushed from the room, and was quickly followed by another weeping mother.

A security guard appeared. “I’m sorry.  I’m going to have to ask you to leave.”

“This is a group for parents of transgender kids. I am a parent of a transgender kid.  I belong here,” I insisted. “This is a public building and I pay my taxes. I’m not doing anything wrong. You can’t kick me out.”

I was on a roll.  They weren’t going to get rid of me if I could help it.

Suddenly, the room was empty and I found myself sitting alone.  Apparently, the group had decided if I wasn’t going to leave, then they would, and they found another room.

Someone said the police had been called.

I decided this would be a good time to leave.

As I was leaving the building, I encountered the female-to-trans group leader consoling one of the sobbing mothers. I stopped to speak to her, thinking this might be my last chance to explain myself. But as I approached, she pulled out her phone, turned the video camera on, pointed it at me like a cross fending off a vampire, and said in slow, measured words, “I FEEL UNSAFE. YOU MUST LEAVE!”

The next day, I received a phone call from the group administrator.

I had been banned from the group.

Looking back, I feel nothing but sympathy for these parents. I am sure they truly love their children and want to do what’s best for them. And they are doing exactly what their doctors and social workers advise. These parents are simply trusting in the system.

They don’t realize the system has been gamed.

From the politicians, who pass laws forcing us to use “preferred pronouns” and “affirm” our children or risk losing them.

To the schools, who teach children as young as five that they can change their sex, and hide it from their parents at school.

To the media, who normalize transgenderism by featuring transgender characters in movies, television and the news, casting them as victims and presenting them with awards for their “bravery”.

To the Internet, where sites like YouTube, Tumblr and Reddit provide a steady stream of trans-affirming propaganda.

To the universities, where women’s and gender studies departments openly deny science and rewrite history, and where health centres ‘counsel’ students on how to transition and bankroll hormone injections and surgery.

To the medical community, which is dominated by “gender specialists” who espouse The Gender Affirmative Model—a seriously flawed and unethical approach that is little more than political ideology dressed as science, while ethical professionals who speak out are fired or intimidated into silence.

The system has been gamed.

And our children, naïve and trusting, are its pawns.