A few weeks ago, I wrote about turmoil in pediatric gender medicine. Nobody, not even leaders of the field, can explain the rapid rise in the prevalence of gender dysphoria. There are plenty of different theories about why GD is occurring at younger ages and among people with more psychiatric problems than in the past. Different countries and different professional leaders have responded to this turmoil in different ways. In the US, sadly, the turmoil has led to outlandish proposals to legally ban certain medically proven treatments. It has also led to bull-headed attempts to simply ignore the phenomena that are causing the turmoil. For a general pediatrician like me, this is terrifying. I see lots of troubled teens. I have no idea what to tell them. It is as absurd to claim that we know what is best as it is to ban gender-affirming treatment. Instead of such dysfunctional, combative, and self-serving responses, we need think creatively about how best to help the children and teens who are struggling.
Two recent books, both by skilled journalists, tug us in different directions. Becoming Nicole, by Amy Ellis Nutt, takes readers inside the struggles of a transgender child and her family. Trans, by Helen Joyce, takes a broader view and examines the implications of the changes we are seeing. The books lead us in different directions. Read them back-to-back and your views, whatever they may be, will be challenged. That’s good.
Nutt tells the story of the Maines family. They adopted twin boys, Jonas and Wyatt. From early childhood, Wyatt was uncomfortable with his gender identity and felt himself to be a girl. He grew his hair long, wore dresses, and told his mother that he hated having a penis. Wyatt’s schools initially worked with the Maines family and supported Wyatt’s social transition. He changed his name to Nicole, identified as a girl, and started using girls’ bathrooms. Some parents objected. The school stopped allowing Nicole to use the girl’s bathroom and set aside a separate bathroom just for her. Some kids started bullying Nicole. She developed anxiety and depression. Eventually, the school environment became so hostile that Nicole and her family had to move to a different city where nobody knew her secret and where she was accepted, as long as she didn’t tell people the truth. The family sued the school and won a landmark case in which the Maine Supreme Court held that it was a violation of human rights to deny transgender students access to the bathrooms designated for their gender. She and her family found their way to the pioneering gender medicine clinic founded by Norman Spack at Harvard. There, she received gender-affirming medical, surgical and psychological treatment. Nicole used the money from the settlement in that case to pay for her gender-affirming surgery. She and her family have gone on to become eloquent defenders of human rights for transgender people.
Nutt concludes, “The problem for kids, for transgender people, isn't within, it's without. Their trouble with their gender identity comes essentially because others view them one way when they view themselves another.” Jennifer Senior, reviewing the book, summed up the take home lesson: “Four ordinary and imperfect human beings had to reckon with an exceptional situation, and in so doing also became, in their own modest ways, exceptional…If you aren’t moved by Becoming Nicole, I’d suggest there’s a lump of dark matter where your heart should be.”
Nicole’s story recalls that of Jan Morris whose groundbreaking book, Conundrum, helped establish one way of thinking about what it means to be trans. Morris described the onset of her gender dysphoria: “I was three or perhaps four years old when I realized I had been born into the wrong body and should really be a girl. I remember the moment well, and it is the earliest memory of my life’ (p. 1).” Morris is clear that transgender identity is a conundrum, “Nobody really knows why some children, boys and girls, discover in themselves the inexpungible belief that, despite all the physical evidence, they are really of the opposite sex.”
But things have changed. Stories like those of Nicole Maines or Jan Morris are no longer typical. About 20 years ago, all over the world, clinics serving the adolescent transgender population started seeing a very different sort of patient struggling with gender identity. There were four key changes. Previously, roughly equal numbers of boys and girls had been referred. Today, many more natal girls than natal boys present with gender dysphoria. Second, rates of mental ill health among referred children used to be about the same as in the general population. Today, there are much higher rates of psychiatric disorders, including autism, in children who present to gender medicine clinics. Third, the age at which people seek medical advice and treatment has fallen dramatically. Finally, many patients have not had long-standing gender-identity issues as Nicole and Jan did. They did not know from early childhood, as Maines and Morris did, that their identity did not match their assigned gender. Instead, they have what has been labeled rapid-onset gender dysphoria. Nobody knows why these changes have occurred or whether the approaches that were used in the past to diagnose and treat are best for such patients.
(Of note, the idea that there is a new syndrome of “rapid onset gender dysphoria” is, itself, quite controversial. Editors of the journal that published the original paper describing and naming the syndrome noted, “…it is unclear, particularly without research about these new populations, whether gender dysphoria in this context has the same outcomes, desistence and persistence rates, and response to treatment as the gender dysphorias that have been previously studied.”
Helen Joyce, in Trans, explores the implications of these changes. Along with discussions of a variety of political and legal controversies, she also describes three patients, Lara, Helena, and Kay, who don’t fit the classic mold but, instead, represent the new type of patient who seeks gender-affirming treatment today. Lara was a 24-year-old European lesbian who had been a “gender non-conforming child.” She came out as same-sex-attracted at age 14. At age 15, she developed bulimia so severe that she was hospitalized repeatedly. She explored whether her problems stemmed from her gender identity and found a therapist who recommended transition. She started testosterone at 18, had a double mastectomy at age 20, and hysterectomy and oophorectomy at 21. She changed her name to Emil and identified as male. But Emil, too, was troubled. He had many of the same psychiatric problems. He reconsidered his gender identity and concluded that he was, in fact, a woman. He changed his name back to Lara and regretted the hormonal treatments and surgeries that he’d had.
Helena also had a troubled adolescence. At age 13, she began exploring Tumblr. She discovered fandoms dedicated to starvation and self-harm. She began cutting herself. She identified as bisexual though she’d never had any sexual experiences of her own. Then she identified as gender-fluid. A few weeks after her eighteenth birthday, she began testosterone injections. She went off to college as a boy, did well for a semester, and then developed severe depression, returned to self-harming behavior, and eventually stopped the testosterone and re-identified as a boy. According to Joyce, she was “grateful she never progressed to surgery.”
Joyce’s final cautionary tale is the story of Kay, an Australian who, as a teenager, began reading about gender identity and began to question her own. Her research led her to the conclusion that she was agender. She started using they/them pronouns and wearing flannel shirts. She considered using men’s toilets but never worked up the courage to do it. Her agender status lasted a few years, until she once again began to identify as a woman.
These cases are very different from those of Maines or Morris and they raise questions about whether the medical or psychological response should be the same. Joyce puzzles over these stories and concludes that trans identification means something different today than it did 10 or 20 years ago. She writes, “Trans identification has moved outwards from the highly gender non-conforming and dysphoric, though the troubled and unhappy, to those who are a little intense and spend a lot of time online.”
Joyce is very much aware that she is writing against the mainstream of professional opinion. She spends time analyzing the outroar that arose when J.K. Rowling made controversial comments about transgender politics. But she thinks that it is important to endorse “open inquiry and robust debate.” That is exactly what seems to have become impossible in the United States where the conundrum of gender identity has become interwoven with an intolerant political climate, a dysfunctional health care system, and a set of regulations governing biomedical and psychological research that place barriers in the way of the careful scientific study that alone can help us understand what is going on.
To do that research, we would need to lower barriers to entry into well-designed studies. We would need to systematically gather data on all children who present to transgender clinics. We would not criminalize treatment. Instead, we would carefully study the medical and psychological outcomes for children and teens who struggle with issues related to gender identity. That sort of research simply isn’t being done today. If nothing else, everybody should be able to agree that the teens experiencing gender dysphoria or other struggles with gender identity face a complex array of medical and psychological options and must make difficult choices. Today, they make those choices in the absence of good evidence about the risks and benefits of treatments. A 2023 meta-analysis entitled, “Psychopharmacological considerations for gender-affirming hormone therapy” concluded, bleakly, that “there are currently no published studies evaluating the risks or efficacy of psychiatric medications for TNG (trans, non-binary, and gender-expansive) patients on gender-affirming hormone treatment (GAHT).” They note these issues are especially complicated in adolescents who “may have psychiatric morbidity that must be addressed, especially when the psychiatric illness impairs the patient’s ability to provide informed consent to initiate or safely continue GAHT.” Another review concluded,“The evidence base for the outcomes of gender dysphoria treatment in adolescents is lacking. It is impossible from the included data to draw definitive conclusions regarding the safety of treatment.”
The bottom line is this: Today, patients, parents and doctors must make life-altering decisions today in the absence of good science. In such circumstances, informed consent must acknowledge uncertainty. Reading these two books helped me understand how to better talk to teens and families about what we know and how much we don't.