By Susan Bradley, MD

Susan Bradley is a Child Psychiatrist. She founded the Toronto Gender Identity Clinic at the Centre for Addiction and Mental Health in 1975 (now closed). She was previously Chief of Psychiatry at the Hospital for Sick Children and Head of the Division of Child Psychiatry at University of Toronto. She is the co-author with KJ Zucker of Gender Identity Disorder and Psychosexual Problems in Children and Youth, 1995, and author of Affect Regulation and the Development of Psychopathology, 2000. She is currently a consultant psychiatrist to Children’s Mental Health Agencies outside of Toronto.

Therapists who are new to seeing children or youth who declare that they are “trans” or exhibit gender dysphoria may not intuitively know what to look for in doing an assessment. It is my experience that there are recurring patterns that can assist in understanding why some children may express such wishes.

When I began the Toronto Clinic in 1975 for children with Gender Identity Disorder (now called gender dysphoria), my initial approach was to look carefully for some physical evidence of intersex or hormonal conditions. This approach yielded nothing and we began to see patterns in the children and families which we felt contributed to the child feeling uncertain or unvalued in their natal sex.

We continued to wonder about the cognitive style of these children, as their solution to their apparent distress was very concrete. After many years of working with these children and their families we began to realize that the concrete thinking was typical of children in the Autism Spectrum who would be considered high functioning. High functioning girls with ASD are often missed by clinicians and so most of these girls had not been identified prior to being seen for their gender dysphoria.

As we explored this more fully we came to the conclusion that many if not all of the children and youth coming to our clinic either had traits or met criteria for Autism Spectrum Disorder High Functioning. This realization made sense in terms of their concrete solution but also in the rigidity of their thinking when challenged about their feelings or solution. When past history was explored more fully, many had patterns of earlier repetitive/narrow interests and most had peer difficulties.

In the young children most of the girls could acknowledge, if asked, that they felt girls were weak and unable to protect themselves or others. They could frequently recall episodes of parental conflict interpreted by them as mother being in danger, this despite mother’s reassurance to us that she never felt threatened. When we explored these issues we realized that this child was prone to misinterpreting situations but genuinely feared for mother’s wellbeing and in some instances felt responsible to protect her. In other situations older male siblings had been aggressive to the girl herself and she felt very vulnerable. Some other girls were, in fact, sexually abused and so traumatized by this and their sense of being weak and powerless as a female that they tried very hard to disguise any evidence of pubertal development in order to feel safe.

Many of these girls did not fit in well with peers and as they matured, especially if their social understanding issues were not identified and ameliorated. They felt rejected and often bullied and seldom had a close confiding same sex peer friend. Those youth who were approaching puberty inevitably had poor self-esteem. Many of these youth who did not self-identify as “trans” until that time longed for a close female friend but felt lost as to how to fit in to this rapidly changing culture. There was a tendency for the longing for a close female friend to be interpreted as being lesbian. This interpretation made this young woman feel “even more weird” and thus the search for a more acceptable solution. The acceptance by the “trans” community was like a powerful elixir, one that took away the pain of rejection and poor self-esteem. Parents were rightly confused at the sudden change but many also realized that their child was distressed and were aware of the social rejection and low self-esteem. Some knew that their child was often rigid when they thought they were right but felt that their solution did not make sense.

I believe that, with enough time to explore their feelings, some youth will understand that there may be better solutions than altering their bodies. However, given the cult-like culture that surrounds many youth who begin to think about being “trans” it can be very hard to imagine letting go of a solution that takes away distress so completely and provides an accepting community of friends.