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Gender Transition in Children: A Dialogue Continued

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I had a very poignant experience in May when I taught Penn Med students during their first course on trans health, touching because 38 years earlier I had sat where they were sitting in the John Morgan building and had been lectured that I was mentally ill due to a sexual perversion. Now I was the one doing the lecturing, transmitting the science and lived reality of the trans experience of the past 38 years.

Since my medical school years, not only have the numbers of successful social and medical transitions skyrocketed in America and around the globe, but our understanding of human sexual development has exploded as well. Today all our medical associations, from the broad-based American Medical Association (AMA) to the brain-related mental health organizations, such as the American Psychological Association (APA) and the American Psychiatric Association (APA), recognize the trans experience as a normal human variation and no longer characterize it in pathologizing terms. The process isn't complete yet, even with the reconceptualization of the transgender experience in the DSM 5, the manual developed by the American Psychiatric Association and used widely throughout the medical and legal professions. It won't be complete until there is no category of gender identity variance left in the DSM, just as gay people were not completely liberated until homosexuality was completely removed several decades ago.

So today we have professional medical acceptance of adult trans persons and increasing acceptance of trans adolescents. Gender clinics are flourishing in Boston (including the Gender Management Service Clinic, which was founded by Dr. Norman Spack), Los Angeles and Chicago, with new ones in development in Pittsburgh, Philadelphia and elsewhere. The controversy in the profession is now focused on children, particularly gender-variant children assigned male at birth who desire to socially transition. Let me make it clear: There is no surgical intervention done in this country before the age of consent, at 18. And hormonal treatment, with puberty-blocking hormones, a completely reversible process, is not prescribed until the onset of puberty. The controversy relates fully to the social aspects of gender transition.

This past Sunday The New York Times published a letter from Dr. Jack Drescher, a renowned psychiatrist and specialist in gender issues, who served on the DSM 5 Workgroup on Sexual and Gender Identity Disorders, relating to the case of Coy Mathis, an 8-year-old trans girl in Colorado. Coy's case related to her use of the girl's bathroom, which the school had banned out of fear that some parents would be concerned about her doing so. Steven Chavez, the division director of the Colorado Civil Rights Division, ruled, quite emphatically, that telling Coy "that she must disregard her identity while performing one of the most essential human functions constitutes severe and pervasive treatment, and creates an environment that is objectively and subjectively hostile, intimidating or offensive."

Dr. Drescher's letter was the kickoff to a "dialogue" in the Sunday Times and includes an abbreviated letter from me. This is my unedited response:

Calling this issue "controversial" is very much like health insurance companies calling genital reconstruction surgery "experimental" 40 years after they began to be routinely performed, and with a 97-percent satisfaction rate.



Dr. Drescher is correct: There are no valid, consistent research studies evaluating these children to provide the empirical data to drive clinician's practice. Follow-up, in particular, is generally very poor, so assumptions about desistance are made. But there has been a wealth of clinical experience over the past 50 years, and the knowledge that social and medical transition results in a 97-percent success rate in most studies of adult transition was first ignored, and then argued about, for decades. Ninety-seven percent of cataract surgeries are successful, and no one campaigns against them.



Those who demand of parents that they reject their children's demands to be seen for who they are have often been the ones most resistant to allowing adults to transition, instead offering all sorts of reparative therapy to prevent transition.



Bias against trans and gender-nonconforming people is profound. It is the nature of bias that those who are biased are oblivious to their prejudice, even when the prejudice is subtle or genteel. We don't demand of anyone with any other condition that they jump through the hoops we impose for a gender transition.



The primary medical dictum is, "First, do no harm." A half-century of lived and clinical experience has proven that trans persons, including children, should have the right to self-determination. We were all children ourselves. Denying that right is ethically wrong. And if a child grows up and decides to de-transition, then what of it? The harm done is minimal compared with denying a child the love and affection associated with encouragement of self-determination.



I keep coming back to the issue to which I referred in the last paragraph. We are not discussing trans children in a vacuum but in the context of first overt and then covert hostility of the mainstream mental health professions for most of our lives. Only in the past decade has the profession awakened to the reality and humanity of trans persons and, to its credit, gone on a tear to learn about human sexuality and culturally competent ways of treating the community.

In his thoughtful letter, Dr. Ken Zucker of the Toronto Center for Addiction and Mental Health (known in the trans community as "Jurassic Clarke," as it had previously been called the Clarke Institute), the bête noire of the trans community for his practice of reparative therapy over the past several decades, remarks that "in the past decade, children and adolescents with gender dysphoria have come out of the closet at a rate that is rather astonishing." And there's the rub. There are probably many reasons for the increase in prevalence, including the increased dumping of environmental pollutants known as endocrine disruptors, but surely the rapid rise in the number of competent, caring therapists and medical providers must play a very large part. Parents are usually very concerned about the lives that their children will lead when grown, and their vision of such life was very constrained just a decade ago. When we were sexualized by both society and the medical profession, parents thought their children would be lucky to become hairdressers and florists, if they didn't end up as sex workers. This was the belief of a leading scientific researcher of the gay community, J. Michael Bailey, chair of the psychology department of Northwestern University, evident in his book The Man Who Would Be Queen, published in 2003. That this piece of pseudoscientific trash was published by the National Academies Press, an arm of the elite National Academy of Sciences -- "where the nation turns for independent, expert advice" -- tells you all you need to know about attitudes toward the trans community a decade ago.

Yet as is often the case (the passage of Prop 8 in 2008, while extremely dispiriting at the time, was the catalyst that mobilized a new generation of activists with gutsy ideas that led last week to marriage equality returning to California and federal recognition of same-sex marriages nationally), the Bailey affair catalyzed a new generation of trans activists, including me, and has brought us today to a revamped DSM, Title VII and other federal recognition and protections, along with nearly 50 percent of the trans population being covered by state and local anti-discrimination laws.

We are left with a mental health profession that has made great strides but is still blind to the pain of gender incongruence, which they exacerbate when they deny transition. That reality is not "up in the air," as Dr. Zucker implies, nor is a "wait and see" approach anything more than a more gentle form of torture for trans children. When the (psychiatric) APA published its guidelines for treatment of gender dysphoria last year and laid out the three courses of action touched upon by Dr. Drescher, it was clear that the first of the three was driven by empirical ignorance, and the second learned helplessness, or fear of the impact of cultural hostility. Let's act with hope and faith in our better angels, as more loving parents are doing, and let our children be themselves and thrive.