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The Phony Debate about Transgender and Gender-Nonconforming Youth

newspapers sitting on garbage canI’m noticing with increasing alarm and annoyance articles aimed at at the general public that trumpet alarm about the hazards of medical treatment and/or social transitioning for transgender kids under the age of 18. The experts quoted urge caution, and wonder publicly whether these kids might “change their minds” if not “allowed” to ever express themselves in their affirmed gender. There is often a suggestion that the explosion of TGNC (trans and gender-nonconforming) kids in the past 20 years is the result of overly permissive parents and militant transgender activists who want to “recruit” young people.

So I’m feeling a need to address this so-called debate.

The World Professional Association for Transgender Health is the universally recognized authority on transgender care since the 1950s, when it was called the Harry Benjamin International Gender Dysphoria Association. Since WPATH’s beginnings it has developed and promulgated standards of care (SOC) for medical and mental health people involved in transgender health care. In 2012, WPATH published new standards of care that were a radical departure from the past. Among the changes were recommendations that pubertal transgender young people should be allowed some medical treatments, most reversible, and should be allowed to transition. Social transitioning for prepubertal children was not recommended, but acknowledged to be the only viable alternative for some children.

The SOC also specifically called treatment that forced TGNC kids to dress, play, and express themselves as the gender of their birth “unethical” as well as ineffective.

In most of the world, the WPATH standards of care have been welcomed and adopted. But the United States and Canada are home to some of the most conservative therapists working with transgender people. And it is these people who are generating this press.

A commentary by Jack Drescher in the The New York Times Sunday Dialogue section last year, and a recent article by Margaret Wente in The Globe and Mail, have framed an imaginary “debate” about the wisdom of treatments for transgender and gender-nonconforming children and adolescents. I’m feeling a need to address the misinformation because it is essentially directed at parents of TGNC kids, to give advice and, quite frankly, to alarm parents and the general public. The authorities involved—Dr. Drescher, Dr. Ken Zucker, and Dr. Alice Dreger—appear in these pieces to be highly credible even though Drescher’s piece is not an unbiased commentary, and Zucker and Dreger have long been seen as holding up the conservative rear guard of professionals working with TGNC youth.

Drescher and Wente, in their own ways, characterize as “reckless” a type of gender-affirming treatment that occasionally supports early social transition, and may include puberty-blocking hormones and cross-gender hormones for TGNC adolescents. At the same time, both writers legitimize an outmoded form of treatment that has been deemed unethical by WPATH. Dr. Drescher assumes an air of neutrality when he presents three different treatment options as though they were distinct and equally desirable: 1) encouraging early transition, 2) discouraging cross-gender behavior and expression, and 3) taking a wait-and-see approach. Wente interviewed only Zucker and Dreger, both advocates of the discourage-the-child approach, sometimes called the “throw away the Barbies” treatment.

This treatment is called unethical for a good reason. Substantial research by Brian Mustanski and others has indicated that failure to support a child’s expressed gender identity correlates strongly with depression, suicidality, and other mental health issues in the child. So it’s a treatment that causes harm.

Furthermore, Dreger’s claims in the Wente article are both wrong and misleading. There is a substantial body of outcome research in this country and in Europe (Norman Spack in Boston, Peggy Cohen-Kettenis in Holland) that indicates that children who embrace a transgender identity at puberty or later retain this identity over time, and that puberty blockers are a godsend to these children. Dreger also mentions a “dirty little secret” she claims clinicians tell her “over a beer.” According to Dreger, the parents of TGNC kids tend to have mental health issues and be dysfunctional.

This comment is not only cruel but untrue. There is no evidence to support Dreger’s snarky remark. Indeed, at my agency, the Institute for Personal Growth, where we have more than two dozen clinicians who work with TGNC kids, we’ve noticed that most parents with gender-variant children are highly educated and responsible—that’s why they are seeking help for their children instead of taking a punitive attitude or ignoring the issue. No parent is eager to declare his or her child transgender, and the suggestion that any parent comes to this conclusion capriciously, impulsively, or for pathology-related reasons is insulting.

Experts such as Arlene Istar Lev and Jean Malpas represent what is rapidly becoming the mainstream approach in treatment for transgender people that conforms to the standards of care. Progressive gender therapists such as Lev, Malpas, and the clinicians at IPG are well aware of the research, and never present early social transition as a first-line treatment. However, neither do we attempt to convince the child that their affirmed gender is “wrong.” When possible, we try to help parents and kids construct an environment where there is maximum ability to self-express authentically, where there is support for the child’s identity, and where when a child must “present” as the birth gender the child understands that this is for safety reasons only. Our goals are to protect the child from social discrimination, bullying, and peer rejection while affirming the child’s identity and building family and community support. Much of the time, this can be accomplished without socially transitioning a prepubertal child.

In my experience, when young children are socially transitioned it is a highly deliberated and debated decision, not the rash and naive act implied by Zucker, Dreger, and to an extent Drescher. If there is one misimpression I’d like to correct about therapy with TGNC youth, it is the ludicrous idea that trans identities are arrived at lightly—by parents or children. Yes, the Internet has made it easier for young people to find others like them and to read about experiences like theirs. But being transgender is not a fad—any more than it is a tragedy. If a young person tells you they are transgender, the appropriate reaction is to believe them.

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  • Melinda

    March 6th, 2014 at 12:53 PM

    While I Know that it would be hard if one of my kids cane to me and told me that they really felt like they were something other than what their gender dictates, I would hope that if put in that situation I would stick up for them and support them in what they are feeling and experiencing. It can’t be any easier for them than it would be for me and I think that this woul be a journey that the whole family would have to commit to taking together. The kids feeling this way are going to need all of the love and support that they can get and this would not be the time at all to turn away from them and act as if they should just stamp out what they are feeling. You know already that they are going to experience hate and cruelty in society- I don’t think that any parent whould want to add to that by piling on even more.

  • craig

    March 7th, 2014 at 3:44 AM

    Militant activists?
    Have we stopped to think that the only thing that they could be militant about is protecting these children?

  • Jack Drescher

    March 8th, 2014 at 10:07 PM

    If Dr. Nichols had actually read WPATH’s most recent Standards of Care, she might have learned that nothing I wrote about is at odds with them. Page 17 reads:

    See the “Social Transition in Early Childhood” section of this page (section 6.8):,_Transgender,_and_Gender_Nonconforming_People#Social_Transition_in_Early_Childhood

  • Jonah

    March 9th, 2014 at 4:57 AM

    It’s not that I am not an open minded person because I like to think that I am, but surely you have to realize that most of us still have some pretty basic ideas about how a boy should behave and how a girl will. How a boy should dress and the same thing for a girl. I know that before both of my boys were born, I didn’t imagine them all decked out in pink and playing with Barbies. You know that there aren’t that many parents who would think that way! Now I’m not saying that if the kids came to me and said they were feeling this way or that way that I wouldn’t try to help them. Of course I would, they’re my kids. But you also have to understand that I still have ideas about things that are feminin and masculine and this new way of thinking really does challenge me to think outside of my comfort zone.

  • paula sitton

    March 10th, 2014 at 2:48 AM

    while I would have problems with this for really young people, if there are adults who have thought this through and know that the move to transition to the other sex is the best choice for them, then who am I to stop them or say that’s wrong? I am sure that they are educated and informed, so that’s their choice, not mine

  • Margaret Nichols, Ph.D.

    March 10th, 2014 at 12:08 PM

    Dr. Drescher has completely misunderstood my critique. My biggest problem with his article in the Times is that he suggests that one viable treatment option for TGNC kids is discouraging cross-gender behavior and expression, the ‘throw away the Barbies’ approach advocated for years by Dr. Ken Zucker and others. As I’m sure Dr. Drescher will recall from HIS reading of the WPATH SOC, p. 175,
    “Treatment aimed at trying to change a
    person’s gender identity and expression to
    become more congruent with sex assigned
    at birth has been attempted in the past
    without success (Gelder & Marks, 1969;
    Greenson, 1964), particularly in the long
    term (Cohen-Kettenis & Kuiper, 1984;
    Pauly, 1965). Such treatment is no longer
    considered ethical.”
    So Dr. Drescher is recommending – and legitimizing – a treatment the SOC considers unethical. It’s time we starting calling out this treatment for what it is: a form of ‘reparative therapy’ for young TGNC children.

  • ConcernedParent

    March 11th, 2014 at 3:52 AM

    Why would I ever take my child to a therapist who was more intent on telling me the things that are wrong with my kid instead of helping me find the good and showing me the things that are good? It might not be what I would choose, but maybe it isn’t what he would choose either but that instead he just IS and has to learn to live in a way that inspires such hatred in others. I don’t want a therapist for him that is always throwing up red flags and telling us the ways that he can change. I want to know how we can learn to love who he is and have others see the same.

  • Russ Healy, MSW

    April 3rd, 2014 at 9:01 PM

    I attended the recent WPATH conference in Bangkok. I fully agree with Dr. Nichols. I have an interest in biomedical ethics stemming from my doctoral level studies in Drew University’s Medical Humanities program. I began seeing transgender adolescents in my practice about six years ago. In my experience, puberty blockers have been of great utility because of their “reversibility.” They prevent the traumatic impact of puberty on TGNC young people while allowing them to understand their experience. But I have been looking for an ethical argument that can supersede the age of majority standard. At WPATH I learned about the “mature minor doctrine.” In many Western societies an ethical exception is made for minors 14 years and older who can demonstrate a sophisticated understanding of their experience. Case studies were presented of such adolescents and it was clear to me that these youth can “know” their gender identity. When their cerebral knowledge is at odds with their genitalia a profound dysphoria results. Those of us whose gender is congruent cannot fully grasp how much these kids struggle. If the parents are on board I have no problem referring minors for hormone replacement therapy (HRT). I have been struck by how dramatically the gender dysphoria desists once HRT begins. Likewise, I have been struck by the power of simple parental acceptance. As Dr. Nichols points out not all gender dysphoric youth require medical intervention. Parental acceptance is an established protective factor these kids. Simple acceptance buys them time during which they can work on understanding themselves. Finally, as a South African child psychiatrist pointed out at the WPATH conference, pathology is not located in children. It is located in societies that are not curious about – or accepting of – differences in gender expressions.

  • Pat

    April 11th, 2015 at 4:47 AM

    Hormone replacement therapy does not resolve anything for transgendered people, adult or child. In boys lowering the level of testerone reduces the dysphoric feelings and quite often leads them to feel more comfortable in their birth sex. Others like the new face of Clean And Clear, 14 year old Jazz Jennings, quite clearly suffer from Dissociative Identity Disorder.

    Jennings frequently refers to himself in the third person as if He is actually removed from Jazz. This kind of condition has its genesis in childhood trauma, generally emotional, and is not genuine gender dysphoria.

    Gender dysphoria is most often a case of identifying strongly with the object one is most strongly attracted to. In other words overwhelming attraction is expressed in the desire to be the object of one’s most intense desires.

    Subjecting children to puberty blockers is not good medicine. Despite opinions to the contrary it is not safe and can lead to endocrinological problems and consequent auto immune diseases like Arthritis and Lupus.

  • Margaret Nichols, Ph.D.

    April 8th, 2014 at 10:13 AM

    Russ, thanks for contributing to this discussion. The points you made are critically important, and you articulated them expertly.

  • Missy

    October 27th, 2014 at 6:03 PM

    I am a mom who has a child with gender issues. I would only hope there would be support from medical professionals that would only help my child emotionally and not hurt him. I think it is so hard for many to understand unless they themselves have seen a child go through something like this.
    My son is 6 and I have know since he was 2 or 3 that he wasn’t a typical boy. It saddens me to think of the life he may have because of the opinions of others and lack of understanding.
    However I am glad there are people ready to defend these children and adults who have had to fight since since the beginning to have fulfilling life as everyone else.

  • Margie Nichols

    October 28th, 2014 at 11:18 AM

    Missy, thanks for posting this. The good news is that attitudes are changing, school policies are as well….and by the time they hit high school, many of these kids have the support of their peers too.

  • Julie N.

    January 17th, 2015 at 11:02 PM

    I find the comments here completely misrepresent Dr. Dreger’s work. She has never said to young boys to ‘throw away the Barbies’–to the contrary her work is about the fact that barbies are not uniquely the domain of girls and tractors of boys. I am pretty appalled by the ad hominem attacks here at a professional who is able to shed some light on the problems surrounding transgenderism. The assumption that parents are somehow not part of the child’s self-perception is just wrong-minded. We are seeing more and more of these parents who parade their child before television cameras proclaiming that their 5 year old is now a girl. I do not think that Dr Dreger is off in proclaiming such behavior as indicative of mental issues. Nor is questioning the mental stability of a parent who forces gender onto a child, assuming a child to be a girl because he likes barbies.

    The article is badly researched as well and refers only to a very rigid and not at all agreed on list of criteria about transgenderism.

  • margaret nichols

    January 20th, 2015 at 10:25 AM

    To Julie N.

    Are you confusing my comments about Ken Zucker, Alice Dreger, and Jack Drescher? At any rate, your biases are clear when you talk about parents who ‘parade their children before TV cameras.’ You are making a lot of assumptions about the parents of trans and gender nonconforming kids that our thirty clinicians have not found in our work with over 200 children like this. We find the parents to be heroes, people who certainly did not WANT to have a gender variant child, but who, when faced with reality, accept, support, and validate their children. Maybe there are some crazy parents who ‘push’ their kids into this, but we haven’t seen them, and Dreger’s public comments about parents – if she was quoted correctly – are rude, insulting, and just plain wrong.

  • Mike F

    January 5th, 2016 at 9:42 AM

    I question the title of this blog post particularly with the word ‘phony’ being used to describe a debate. If a debate exists, then it exists and anything that exists isn’t phony, it’s real in at least some sense to some people. Or am I just stating the obvious that isn’t always so obvious?

  • common sense

    January 13th, 2016 at 4:37 PM

    I was always told I was a boy when younger. My grazed knees and elbows, ripped jeans and short hair plus a boyish attitude, always gave that impression. I so desperately wanted to be male…

    Thanks to mum and dad for neither encouragimg or discouraging me, I grew out of it and now appreciate being a woman.

    The problem with Phd holders is they are hamstringed by their own prior knowledge based on other people’s prior knowledge. Most of it is gained in a clinical setting and not the real world. Also,they can never be told they’re wrong.Very dangerous.

    Even at 47 people tell me I am very male-minded, and they are right, it gives me a wonderful spin on life, rather than spin my life around

    Transgender are only personality disorders, nothing more and nothing less. I have examples? Would you like them, or do all psychologists want to limp through life on that dodgy hamstring?

  • Mike

    February 25th, 2017 at 10:31 AM

    There’s no need to even read the whole article. At the beginning of your argument you go skip right to an “argument from authority” by citing an organization that will obviously contain inherent bias. This is the most often used and quickest means to a logical fallacy. It’s the easy way out, the path of least resistance, the intellectual easy button.
    Opinions are subjective, but facts are facts. Facts are the only foundation for a quality opinion and the strongest means of formulating a durable argument. The fact of the matter, is that gender is biologically determined. “Feeling” like a boy when you were born a girl is a feeling, not a fact.
    The true problem is one of sociological acceptance for varying expression of gender characteristics. It should be ok to be a guy that is more into fashion or other traditionally female things and it’s also perfectly fine for women to enjoy sports or racing cars etc. As a society, we should be tolerant and accepting of who people are, not make them feel that they have to attempt (because you can’t) to change something as fundamental as gender to fit in.

  • Colin R.

    August 14th, 2017 at 7:26 AM

    The title of your article tells me that you’re frightened of debate. Maybe you should ask yourself why?

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