What of the gender variant child whose social environment both accepts and encourages an early transition but may be unaware that the child, unwilling to disappoint, has had a change of heart ? —Jack Drescher, MD, quoting Cohen-Kettenis, personal communication, in the introduction to this special issue

The Journal of Homosexuality published a 300-page special issue on childhood gender dysphoria in March 2012. It contains articles by several well known “gender specialists,” including Norman Spack, Kenneth Zucker, Jack Drescher, Diane Ehrensaft and others. These providers discuss their own clinical practice and experiences, informed by their viewpoints–and biases–about “trans” kids.

But of most interest to me is a piece by clinical psychologist David Schwartz, PhD., who is not a gender specialist himself, but knowledgeable about child psychology and the dynamics of family therapy. In his aptly named “Listening to Children Imagining Gender: Observing the Inflation of an Idea,” Schwartz critically and compassionately analyzes three of the other articles in the issue, focusing particularly on one written by Laura Edwards-Leeper, PhD., and Norman Spack, MD. Dr. Spack is a leading proponent of childhood medical transition, and heads up the Disorders of Sexual Development (DSD) and Gender Management Service (GeMs) at Boston Children’s Hospital, the first of its kind in the US.

Schwartz has two main points: First, he skillfully clarifies how most of the other clinicians writing in the issue operate from an idea–an inflated idea, unsupported by evidence–that gender is innate from birth. Schwartz terms this “gender essentialism.” And the concerned parents who bring their kids to these specialists imbibe the same biased idea.

Schwartz’s second key point is that the literal acceptance of a “trans” child’s demands and assertions, while completely ignoring underlying motivations typical of all kids, is something new under the clinical sun when it comes to treating children. It’s as if the insights of decades of child psychology are being thrown out in favor of automatically endorsing a narrative—a narrative driven by children, with their necessarily immature understandings and desires. And Schwartz makes it clear that this clinical approach is doing no favors to dysphoric children–nor their parents.

We desperately need more outspoken therapists like Dr. Schwartz, clinicians who have deep clinical insight into developmental psychology and parent-child dynamics–not just “gender dysphoria.”

Because for most readers, the full article (and the rest of the journal issue) will be behind a paywall, I am extensively quoting several of Dr. Schwartz’s key passages. The abstract is here. [Update: “Awesome Cat,” in the comments section below, has a link to the full Schwartz article.]

The writing and language is that of a peer-reviewed journal article–formal and perhaps less accessible to some. But I am allowing Dr. Schwartz’s words to stand on their own merits. It is unusual to see this kind of gender criticism in a recent journal on the subject of gender dysphoria. Please note: The subheadings and boldface emphasis are mine, not Dr. Schwartz’s.

“Liberal psychiatric treatment”: the avoidance of ambiguity, p. 461

I am disquieted and stimulated by my mediated encounter with the children, parents, and clinicians represented in these clinical articles. The children have a deeply felt complaint, expressed explicitly or indirectly through the disruptions they inevitably provoke. They say they are unhappy with being named, classified, and treated in accord with the match between their visible genitalia and the prevalent set of conventions regarding those genitalia. For them, gender has become preoccupying … …The parents seem to be trying to catch up with terribly surprising news, with varying degrees of success. They are frightened, frustrated, freaked out, and, finally, defeated, as they are forced to relinquish a cherished perception. Their particular defensive configurations vary (guilt, despair, anger, embrace), but all face extreme intrapsychic disruption and pain. The clinicians try to make this child/parent/symptom matrix fit into a model of liberal psychiatric treatment. As is common in the medical sciences, most push against ambiguity, preferring to emphasize speculative generalizations (“genetics is likely a factor”) instead of highlighting the lack of data from controlled studies.

Desistance: Most kids with gender dysphoria will change their minds, pp. 467, 470

With respect to the advocacy of intervention, Edwards-Leeper and Spack … say that they “have learned that delaying proper diagnosis can lead to significant psychological consequences”. This warning implies that the reliability of diagnosis and associated prognosis in this area has been established, which is the case only for diagnosis, that is, we cannot say reliably what the course will be for a given child with GID or gender dysphoria. In particular, we cannot reliably say whether he or she will persist with an expressed need to be affirmed in his/her non-natal gender, or not. In fact, the majority do not sustain the diagnosis, that is, they desist.

[This] fact (supported by five research articles going back to 1987)…every clinician and parent of a child who is gender dysphoric needs to keep firmly in mind. … Given this uncertainty of prognosis, it is significant that Edwards-Leeper and Spack’s presentation of the pros and cons of pubertal suppression, a primary intervention in their protocol and their frequent recommendation following diagnosis, is imbalanced. They offer seven physiological benefits to pubertal suppression (for the most part just a list of the physical effects) and no disadvantages. Likewise they tout the psychological advantages, but note no potential disadvantages. Their conclusion is: “Therefore,

it is our clinical impression that preventing these unwanted secondary sex characteristics with puberty blocking medical intervention allows for better long-term quality of life for transgender youth than what they would experience without this intervention.”

Better quality of life? p. 467

The claim of offering “better long-term quality of life” based on clinical impression only, and absent significant longitudinal experience or controlled data collection, is questionable. Considering that Edwards-Leeper and Spack are advocating a pharmacological intervention aimed at prepubertal children and adolescents, a number of whom are likely to desist, it is surprising and of interest that they so minimize the importance and value of alternative interventions, ones that might have fewer unknown consequences, both physiological and psychological. An alternative sort of intervention would of course be some variety of psychological therapy. Most typically this might include support, reality testing, empathic interpretation and psychoeducation offered to both parents and children.

On the psychology of “trans” kids, p. 468

The intransigent style (cognitive and behavioral) of trans children may deter some clinicians from considering that some of their suffering might be helped without rhetorically opposing their desires or trying to persuade them to relinquish their assertions. … The goal of psychotherapy in this situation would be to help the child feel better and offer reality-based guidance for social situations, as well as the prevention of self-harm, in the rare cases where that is an issue. In general, psychotherapy should entail increasing (parents’ and children’s) self-understanding, not coaxing or pressuring them to change their minds. The disturbing demands and claims of trans children, as well as reports of self-harm (untabulated, to my knowledge) may shock and scare both parents and clinicians into expecting less frustration tolerance from them than is realistic. Such an underestimate of the trans family’s resilience may be abetted by the availability of puberty suppressing drugs. Frightened of the onset of puberty, and intimidated by the at times ominous articulations of the children, parents and clinicians are relieved to imagine even a temporary solution.

Anecdotes from adolescents are not data, p. 468

…Edwards-Leeper and Spack’s usage of anecdotal data concerns me. To counter what they describe as the leeriness of parents with respect to the taking on of transgender identities on the part of adolescents with no prior history of gender dysphoria, they say: “However, many of these adolescents report that their friends are not surprised by their declaration of their affirmed gender, often responding that they had suspected it for some time.” We must assume that Edwards-Leeper and Spack are aware that an adolescent’s report of other adolescents’ validation of a gender identity claim is not credible evidence of more than the first adolescent’s desire to persuade. How then are we to understand their inclusion of this anecdotal information? It would seem that natural skepticism has been suspended in favor of literality. Are they trying to highlight the alleged power of essential gender by pointing to its observability by others even before the subject himself or herself has self-awareness? If so, the weakness of an anecdote such as this gives the appearance of a lack of appropriate scientific and psychological skepticism, and inattention to methodology.

Kids aren’t little adults, p. 470

With essential gender in mind [clinicians] are likely to be less psychologically minded and less thorough in their consideration of the cost–benefit ratio of invasive interventions and of research that might militate against their impulses to intervene. To be sure, they are trying to be respectful of and responsive to children’s stated wishes. But it seems that beyond that, when child patients talk about their gender, their belief in its reality seems to distract the clinician from the fact that we cannot listen to children in the same way that we listen to adults. Patients’ communications always need some degree of interpretation; that is especially true for children, who, necessitated by their cognitive limitations, speak more symbolically.

Is a 5-year-old boy “really” a girl–or trying to be like Mommy? p. 473

Ehrensaft tells us that throughout a session to which Brady/Sophie arrived fully dressed as a girl, “[she] kept sucking in her tummy, in an attempt to make herself more girl on top” (p. 351). This child is less than 5 years old. Sucking in her tummy will not make her more girl on top, since little boys and girls are the same on top, which Brady/Sophie surely knows: It will make her more woman, a very different thing. One possible interpretive direction in light of this slip would be that this child is more interested in a ticket to adulthood than a gender change, but for some reason sees being female as a necessary first step… . …At the conclusion of this patient’s treatment, parents and therapist decide that it is best to permit Brady/Sophie to present as a girl at all times. Sophie (still not 5 years old) proclaims: “I’m the happiest I’ve ever felt in my life.” Ehrensaft furnishes a putative expert statement to the parents, which says in part: “To promote her wellbeing and emotional health, it is imperative that Sophie be seen and treated as a female by her parents, her educational settings, and the community surrounding her.” …Such certainty in matters so fraught with unforeseeable possibilities including the welfare of a child surprises me. The certainty of the child about her gender is matched by the clinician’s certainty about the outcome, both of whom, I suggest, are encouraged by the notion of a true gender found at last. Moreover, I wonder if Ehrensaft has not imagined the inner life of this child, who is rather adult-like in her speech (do 4 year olds commonly speak of “in my life?”), as more adult than it is. This could be for many reasons including, of course, the personality of the child. However, I believe it is easier to be distracted from the childishness of a patient’s claims when the terms they use conceptually match the clinician’s ideas.

Gender is power, p. 474

It seems to me that trans children, in response to great psychic pain (and adaptively or not) have engaged the rhetoric of gender and, thus, stumbled upon a communication of such potency that their parents and therapists are detoured from listening to them as children, instead crediting them with adult-like cognition. When we infer that the trans child has a disturbance in an unobservable gender system, based on a claim of gender transformation, we are granting the truth of a child’s self-analysis and proposed self-construction. I doubt that the receipt of such a gratifying abundance … of respect from the clinician is consciously intended by the child. It is more likely that the child longs inchoately for an emotional experience like respect and rapidly gains unconscious awareness of the power of gender complaints to bring such gratification. When the longing is unwittingly satisfied by the parent or clinician who, thinking they understand the child’s problem, validates the terms of the discussion as the child has set them, the child is likely to reiterate the complaint in those terms. For that child, a psychological structure, more or less transient, begins to develop. For the adult, the illusion of understanding begins to perpetuate itself. The most immediate lesson that the trans child has learned, and then enacts, encouraged by these interactions, is that the idea of gender is very powerful, and if you want to get a rise out of people, play with it daringly. The lesson for the parent or clinician should be: Stop talking about gender.

Schwartz goes there: the child who threatens self harm, p. 475

The specter of harm to children—any harm to any children—is surely a powerful influence in all discussions about children, and no doubt it is playing a role, spoken or not, in this one…. I am aware of no controlled data to indicate that the incidence of self harm among trans children is any greater than somewhere between very infrequent and rare. I am aware of no data to suggest that pubertal suppression, cross-sex hormone administration, or genital surgery diminishes the probability of self-harm in trans children. Moreover, there is no reason to believe that the three above-mentioned physical interventions are any better for the welfare of trans children than supportive psychotherapy and psychoeducation for parents. There are anecdotal reports of threats by children and of children dramatizing the possibility of self-mutilation. There are psychiatric protocols for addressing the patient who seems to pose a risk of self-harm that are minimally intrusive and unquestionably reversible. The long-term psychological and physiological consequences of chemogenic pubertal suppression, cross-sex hormone administration, and genital surgery are unknown, and, as is the case with all self-selected populations, very difficult to assess owing to problems of control and limited sample numbers. The palpable misery of an articulate child may distract the empathic clinician or parent from the venerable admonition: First, do no harm.

Conflation of gender skepticism with historical homophobia, p. 470

Edwards-Leeper and Spack take pride in what they see as their avoidance of the mistakes prior generations of mental health professionals made, in particular when the latter refused to accept gay and lesbian people at their word, sans diagnosis. Indeed, the analogy is tempting, but I would argue, deeply flawed, itself an aspect of the conflation of gender and sexual orientation. …

“An artificially vitalized concept”, p. 476

I believe the disquiet and stimulation I initially experienced after reading these articles and watching some videos, was a reaction to my perception of children and adults struggling in the thrall of an artificially vitalized concept that subjugates and empowers each in complementary ways, a phenomenon both intriguing and worrisome. Most of these adults—parents and clinicians—have been persuaded that gender is biologically real, with specific rules for healthy functioning. The children, having unconsciously learned of the adults’ imbuing of gender with particular potencies, that is, with reification, medicalization, and transgressive possibility, try to put it to use in the course of their own self-development. It proves to be a high-risk and high-gain tool. It has the power to command adult attention, to affect adult emotions and thus to alter the position in the family of the child who chooses to deploy it. As well, in the unconsciously operating hands of the child it can also bring enormous pain, which in its compelling resemblance to physical pain further misleads the adults toward the reification of gender. It is disquieting to observe clinicians unconsciously colluding with troubled parents in the inflation of concepts that are inherently psychologically constricting.

Teaching children to be homophobic? p. 476

… Just as racism requires belief in natural races, sexism and homophobia require belief in natural genders. If we organize our responses to children who play or become preoccupied with gendered behavior around the idea that there are natural genders from which they are deviating or toward which they can aspire with medical help (transitioning), then, however indirectly, we are buttressing the very structures upon which the hatred of gay men and lesbians stands. Or put differently: As clinicians responding to trans children, we are responding to a subjectivity, not to the results of a biopsy or blood test. We and parents must choose whether we respond to that subjectivity as the upshot of a hypothesized psychophysiological gender system, on the one hand, or choose to go no further than regarding it as a mutable psychological situation on the other. Choosing the former, the more elaborately and speculatively theorized framework of essential gender, accepts a theoretical structure that has been used to rationalize sexism and homophobia and, therefore, tends to promote them despite good intentions.

We owe more to kids than to take them literally, p. 478

There is much more to children than what they say. We owe to them a deeper listening than a literal one. We will then likely find that their engagement with gender, especially when it is transgressive or countercultural, may reveal a creativity and even a politics that can contribute to the erosion (if not destabilization) of the gender system as it presently operates. If we listen to them literally, interpret their communications and performances through the categories we adults have grown up with, and of course have ourselves failed to transcend, we will miss whatever new story they are telling or protest they are making. If we listen and respond to what they are saying in the mirror of the old system, they will seem to buy it, because it comes with the feeling, although not the reality, of being understood, which they no doubt crave. Thus, stasis is guaranteed for the child and for our culture. I am not naïve enough to imagine an intellectual transcendence of essential gender. But, in the name of equality—of gender and of sexuality—we must avoid promoting its continued entrenchment.