Advances in the Treatment of Transgender Children and the Hurdles Yet to be Overcome

As we do more research, and delve into the genetics of a host of intersex conditions, we will be well placed to understand the trans experience as one of many on the spectrum of the human sexual rainbow.
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This past week has seen thepublication of two important research papers dealing with transgender children. Thefirst, from Amsterdam's world famous Center of Expertise on Gender Dysphoria at VU Medical Centre, was published in the leading American pediatrics journal,Pediatrics. This study isdescribed in understandable detail byDr. Jack Drescher, a trans-supportive psychiatrist and Past President and Member of the LGBT Committee of the Group for Advancement of Psychiatry, who played a major role in removing transgender identity being considered a mental illness. Thesecond was written by Dr. Drescher in association with Dr. Jack Pula, and published by the Hastings Center, and considers the ethical issues raised by such treatments and others.

The conclusion of the first study was one we knew anecdotally for several years - that adult trans men and women benefit strongly from the use of puberty-suppressing hormones before being administered cross-gender hormones and undergoing surgical treatment and entering adulthood. They are as happy and well-adjusted as their cisgender counterparts, and there are no obvious side effects from the delay in puberty. 71% called their social transition "easy," a stunning percentage compared to earlier generations for whom "easy" would rarely have been in one's vocabulary. It has also been obvious to the hundreds of thousands of trans women and men who were forced to undergo the wrong puberty. We've long known that there is little in life as miserable as puberty, but the wrong puberty is torture. And I will say here, in response to one of the ethical questions raised by Drs. Drescher and Pula - given the state of the art of medicine today, it is malpractice to force a trans child to undergo what she or he believes to be the wrong puberty. Too many mental health providers, to justify their own discomfort with trans persons, have long demanded adolescents undergo the wrong puberty in an attempt to cure them of their trans feelings. It must stop.

It's fair to say that with the exception of a few religious fundamentalist outliers, the mental health community today accepts the existence of trans adolescents and adults, and is no longer in the business of reparative therapy. The ongoing debate continues, however, with respect to children who either behave in a gender variant manner or express a trans gender identity. As Drs. Drescher and Pula point out, there is little research on the natural history of trans children, though the Europeans are studying this issue across multiple centers, and most children who are gender non-conforming turn out to be cisgender gay men and women. This, too, has long been known from work in hospital clinics, particularly the one at Children's Hospital in DC. It's also been easy to infer, since many gay men and women were gender variant during childhood. Since there are roughly 12 times as many gay adults as trans ones, most gender variant children, just by the numbers, would turn out not to become trans adolescents. However, the vast majority of trans adults were trans children and adolescents, and it's wrong to harm them by denying effective treatment, just to potentially preclude the need for a detransition by some who will grow up to be cisgender gay men and lesbians.

Drs. Drescher and Pula discuss the three different approaches to trans children today - (1) the outdated and harmful approach of Dr. Ken Zucker of Toronto's Center for Addiction and Mental Health (formerly the Clarke Institute), known affectionately by trans persons worldwide as Jurassic Clarke, (2) the laissez-faire approach of the pioneers in Amsterdam, and (3) the more recent proactive support for early transition by Diane Ehrensaft and colleagues at UCSF. I know that it is extremely difficult for people to understand the trauma suffered by children denied their fundamental identities as sexual beings, but no ignorance on the part of health care providers or dearth of research excuses those providers from allowing trans children their right of self determination. Yes, on occasion a child who pushes to transition may "desist" and revert back to the birth gender assignment in a few years, but even so, that detransition does not cause as much harm, or the same type of harm, as the refusal to allow a desired transition in the first place. As Drs. Drescher and Pula point out, the withdrawal of love and approval shown by parents who refuse to assist in a social transition will often be internalized by the child with long-term effects. It's destructive to feel utterly alone as a child; harder even than not being allowed to be yourself.

While we don't know, for sure, which gender variant children will grow up and remain trans, there is a lot of experience in those settings in differentiating the gay boys from the trans girls. There is often a qualitative difference in the child's presentation and play behavior, and as Dr. Ehrensaft says, the real life experience of allowing a child to transition will provide the family and providers ample evidence of whether or not the treatment is working. As I said before, if the child changes her mind and reverts back to being a gay teen dude, it's unlikely there will be much lasting psychological damage. In a world becoming increasingly comfortable with gay men, it's hard for me to believe that their experience of a few childhood years living as girls will permanently scar them or lead to social ostracism. Though, to be fair, with the rootedness of misogyny in our society, and the unfortunate persistence of gay transphobia, it probably won't be easy for another generation or two.

Our underlying problem is the persistence of the belief, as exemplified by Dr. Zucker in Toronto, that being a trans person is a state of being worth preventing. In decades past I would have added, "at all costs." Dr. Zucker is famous for his absurd racial analogy: "Suppose you were a clinician and a 4-year-old black kid came into your office and said he wanted to be white. Would you go with that? . . . I don't think we would," Zucker says. Today the prejudice is fading fast, as are the "religious" beliefs of the Freudians and others that there is something inherently deviant in the trans phenomenon. As we do more research, and delve into the genetics of a host of intersex conditions, we will be well placed to understand the trans experience as one of many on the spectrum of the human sexual rainbow.

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