by Nervous Wreck, SunMum, BornSkeptical, Snowyball, & FightingToGetHerBack

Nervous Wreck (Twitter: @nervouswreckmom) is the mother of a rapid-onset transgender gifted female who “came out” after turning 18, was promptly affirmed on her college campus, and who sought treatment at an off-campus Informed Consent clinic.

SunMum (Twitter: @Mum3Sun) is a UK academic and mother of a son who experienced sudden onset gender dysphoria.

BornSkeptical is the mother of a 15-year-old girl who suddenly began to question her gender at the age of 13, now identifies as a gay boy, and plans to take testosterone and get top surgery when she turns 18. BornSkeptical wants to help her explore other options first.

Snowyball (Twitter: @snowyball2) is trying to make sense of why her otherwise bright and happy teenage daughter is all of a sudden depressed and anxious following the unexpected realization that she is a boy born in the wrong body.

FightingToGetHerBack (Twitter: @FightingToGetHerBack) is the mother of a 16-year-old girl with autism who unexpectedly identified as a boy at age 13. After nearly a year of following the harmful advice of gender specialists, she has realized her daughter’s trans identity is the product of social contagion and autistic thinking. She is seeking therapeutic guidance to help her daughter, and pleading with journalists to expose what she considers the dangerous practices of gender therapists.

The following post is in response to a recent article and online chat in the Washington Post about transgender kids and teens; several 4thWaveNow parents participated in the chat.

On February 24, 2017, Steven Petrow, in his Washington Post “Civilities” column, used an email from a “worried mom” to kick off an article about transgender bathroom use in schools. He called it “ Let’s remember, when we talk transgender law, we’re talking about our kids. ”

Mr. Petrow describes receiving an email from a “worried mom” of a transgender teen. He assumes before he reads it what it is going to say: “I figured that the mom was about to voice her anxiety about what rolling back the school protections could mean for her child.” But because Worried Mom doesn’t respond as Petrow thinks parents should, her email is used as a public example of how not to parent a transgender child.

Petrow forwarded the letter to “several parents of trans and gender-nonconforming kids and teens to get their read” and quotes their exemplary responses. Debi Jackson, mother of 9-year-old Avery, the transgender cover star of National Geographic’s gender issue understands Worried Mom’s concern, but explains that “Showing your child that you’re not going to judge as they go through this process is so important.” (Whether putting your young child on the cover of a magazine is necessarily beneficial to mental health is another question).

Another parent (who requests anonymity to protect her child) is more openly critical: “Every day I try to figure out where the line is supposed to be between supporting a child and encouraging a transition…. It sure sounds as if this particular mom is not trying to figure that out, that she’s decided what ‘side’ she’s on about an issue where there needn’t be sides at all.” Her advice is simple: “Just love your child.” (Worried Mom presumably needs reminding of that.)

For an “expert” perspective, Mr. Petrow reaches out to Diane Ehrensaft, Ph.D., a developmental and clinical psychologist at the University of California at San Francisco and author of “The Gender Creative Child.” Her advice? “We should always listen to parents.” Yet “the parent [should] also listen to their child, as at the end of the day, that child . . . will be the arbiter of their own gender identity.” (Translation, maybe?: we should listen to parents only if they say what we think they should say.)

Mr. Petrow makes it clear that parents should affirm their child’s decision to transition. He advises, “Use the name and pronouns that your kid (or another trans young person) relies on. If you’re not sure, ask — without judgment.” So how about we “listen to parents” without preconceptions, “without judgement”? Mr. Petrow might have done this with the original email sent by Worried Mom, which we reproduce here in full:

Dear Mr. Petrow: I have been reading your column for many years, have learned a lot from your perspectives, and in general, share your political views. I sense that your writing comes from a place of compassion and thoughtful consideration. I am reaching out to you because there is an issue that you have been writing about lately that is of grave concern because it is very personal to me: that is, your reporting on the transgender issue. The reason this is so personal is because my 16-year-old daughter told me she was transgender when she was 13. I was shocked. There had never been any signs of this. However, there were several kids at her school who identified as trans. She is also on the autism spectrum and very susceptible to mimicry and falsely identifying with groups in order to feel like she belongs. What has happened is that therapists that I took her to for help did not question her beliefs but made her think she should transition and that I should blindly accept her assertion. They pushed me to accept hormone treatment, which I refused. As a compromise, I allowed her to wear a binder (which causes physical problems) and let her change her name and pronouns – and yet I know 100% in my heart that this is not real and I live in a constant state of anxiety about the psychological and physical damage this is causing. Mostly I worry about her future plans to fully medical transition as soon as she is legally able. I feel scared and powerless. The medical consequences are significant and irreversible. It is impossible to convince a teenager – especially an autistic teen – of something that is a belief that can neither be proven or disproven. It is especially difficult when the media narrative seems to portray anyone who questions these beliefs as a bigot.

Following publication of Petrow’s article with the truncated version of the above email, many commenters wrote in to point out that he had failed to recognize the validity of Worried Mom’s concerns. And Worried Mom, the author of the email, also left this comment:

Mr. Petrow responded to my letter by stating that he would like to discuss this with me. I provided him with my contact information, but never heard back. It was only by accident that I learned that I had been selectively quoted pushing the very narrative that I had hoped I could get Mr. Petrow to question. Such irony. The reason that I wrote to you, Mr. Petrow, was in the hope that you would see what is going on with our youth. The media seems very afraid to question the sudden increase in transgender identification in our youth. Common sense alone says that social contagion is a factor. And because of the politicization of this topic, parents like me are labeled bigots, told we don’t love our child…or as your “expert” stated, told that our child’s gender journey is “poetic.” I assure you that I am not a bigot, love my child unconditionally, and living with a teenage girl who thinks she is a boy is not a poetic experience.

Worried Mom also raised the issue with Mr. Petrow on Twitter. “I reached out because I trusted you would listen to me as the civil and respectful journalist that you describe yourself as,” she wrote. (Mr. Petrow’s Washington Post column is entitled “Civilities.”)

Commenters on Petrow’s article were overwhelmingly critical of his stance. To his credit, on March 7, 2017, Mr. Petrow returned to the topic in his Civilities online chat. This could have been the perfect opportunity to present various perspectives on this complex and controversial issue, and to consider them in a balanced way.

Instead, Petrow invited only Dr. Michelle Forcier, Assistant Professor of Pediatrics and Adolescent Health at Hasbro Children’s Hospital to answer questions. In 2016, Forcier had 400 patients on a transgender pathway. Rejecting “gate-keeping” or psychological evaluation as out of date, Forcier believes that “kids as young as two, three, four know what their gender is,” and compares gender identity to asthma: “You don’t have to prove to me you’re transgender, just like you don’t have to prove you have asthma.” (Unlike transgender identity, which is based on subjective feelings, there are objective tests of lung capacity in the case of asthma). Forcier, then, is no neutral “expert” but an evangelist for medical transition of kids. Perhaps Petrow’s plan was to allow Forcier to demolish the questions of “bigoted” parents. In any case, he did reach out in the hope of a lively confrontation, tweeting @4thwavenow and alerting his audience that “a sub-Reddit group of “gender critical folks” issued a “call to action” to get folks to join today’s discussion”.

You can find the complete chat via this link: Civilities: Taking all your questions about transgender teens with Brown U. expert Dr. Michelle Forcier and Steven Petrow. In this post, we will highlight a few excerpts. In addition, some of the parents who sent in questions will explain in more detail what they made of Dr. Forcier’s answers.

The issues raised repeatedly in the chat revolved around some common themes: challenging the belief that there is a single “scientific” position on gender identity; asking why gender dysphoria increasingly appears out of the blue in troubled teens and why doctors do not look at existing mental health co-morbidities; and why the warning voices of detransitioners are not heard and not heeded. This question is emblematic:

My daughter certainly never seemed like a son to me, just a very creative intelligent girl who had trouble “fitting in” socially. But to so quickly get a prescription for testosterone for this out of the blue self-diagnosis feels very wrong. Dr. Forcier’s position is that parents of underage transgender kids who hesitate about medical transition could be charged with medical neglect with a report to child protective services. This goes against parental rights. […] Late teens/young adulthood is also the time when many mental health issues first show up…this is well known and documented. For instance, bipolar shows up at that time and it is known to distort the sense of self/identity. There are a growing number of detransitioners speaking up wishing they had been offered other treatment options, including mental health diagnostic testing with time for mental health treatment first. What do you suggest these detransitioners do to help the psychiatric community adjust their “one size fits all” treatment for gender identity issues in teens and young adults?

There are clearly many points to deal with here, but Forcier chose to first focus on the allegation that her “position is that parents of underage transgender kids who hesitate about medical transition could be charged with neglect and be reported to child protective services.” Forcier seemed worried that “the writer seems to know my position and I am trying to figure out how they actually ‘know this.’”

We know Forcier’s position on calling the authorities on some parents via a session on puberty suppression that she co-led at the February 2017 USPATH conference . During the Q&A part of the session, Drs. Johanna Olson-Kennedy and Michelle Forcier explained that they are not afraid to involve the courts when they must to “bring along” “recalcitrant” parents. A psychologist who runs a gender clinic asked whether there is a way to legally “force parents” to go along with the recommendations of a gender therapist to administer puberty blockers. Forcier explained that her team has been busy training family court judges in her region:

FORCIER: Yeah, there’s no precedent but you can again work with the child protection team for medical neglect. Work with one parent…at least to get things started. And again, you can do some education. We did education with judges in Rhode Island. We spent a half day with family court judges, telling them this is what gender and transgender is…

In the WaPo chat, Forcier seemed to deny that she advocated such an approach:

And I do NOT take the position that as the writer suggests ‘that parents with underage kids who suddenly insist they are transgender but as a parent have grave concerns about the only treatment option being medical transition could be charged with medical neglect with a report to child protective services’.

Forcier went on to claim that her approach is evidence-based: “There is reasonable science that supports listening to patients in regard to learning more about their gender identity. It does not mean, not asking questions or asking for more time to explore with a patient–but it is important with any medical issue or developmental concern to start with the patient.” Fair enough, although you hardly need “science” to remind a doctor to listen to their patient. She reassured readers that she is flexible and responsive to individual patients:

We do espouse a very individualized, patient-centered approach to gender as with other types of youth care we provide. There is no one size fits all for gender. So first–it worries me that there is misinformation and mischaracterization of care and our practice. What is the harm of seeing how a child who is “different” explore their gender? Again, there just seems to be interesting bias against gender diversity and helping kids figure out who they are– a generally accepted part of adolescent development. So first and foremost–we want to get to know our kids well and there is not one size fits all…. second, accurate information is helpful for all parties!

But the parent who sent in the question was not reassured. She writes that her “big concern is with informed consent clinics, and the impact on young adults, newly on their own and full of youthful, optimistic self-assurance about their decision to live a transgender life”:

My perspective is as the parent of a transgender college student female who sought treatment after age 18, fulfilling her six months “real life” experience as a transman on a college campus…not exactly a real life experience. My child’s decision to identify as transgender was rapid onset after learning the concept only a year earlier at most, while attending a small high school where she felt a misfit, comparing herself to the other girls, as teen girls do. My child, the extremely smart yet highly anxious misfit who had a very stressful last two years of high school, picked up on the transgender option through online sites, a child who only the previous summer was happily frolicking in her swimsuit on a trip to the beach, not showing any signs of gender dysphoria, at least not beyond any other girl in puberty. However, my child was able, at age 18, to go to an informed consent clinic only two times to get a prescription to start medical transition with testosterone. Two times. This has now become the norm. Teenagers are known for impulsive behaviors, and my child’s behavior is poster-child teen impulsive behavior. But apparently, no “asking for more time to explore with a patient” because this might be considered conversion therapy…simply exploring with a patient about gender expression. Hence, informed consent clinics in at least some states are indeed one size treatment fits all.

Another question took up the frequently reported link between autism and transgender identity: “Dr. Forcier, what is your explanation as to why kids on the autism spectrum are seven times more likely to have gender identity issues (and those at gender clinics 6-15 times more likely to have autism)? Do you believe that an autism diagnosis should be considered before a therapist tries to convince parents to support their child’s transition?”

The gaps in knowledge about autism and gender dysphoria did not translate to Dr. Forcier counseling caution in recommending irreversible treatment:

FORCIER: We don’t know for sure. What we do know there seems to an association … We do know that with other neurologic conditions- there are menstrual and other reproductive health associations (epilepsy for instance). We do also know there is an association for gender and autism as well. For autism spectrum youth- maybe it is that not being as clued into or bound by social messages and constructs allows them a more fluid approach to gender and a greater willingness to express that more openly. For autism spectrum we know there are some differences in brain and neuro function… for persons whose assigned gender and anatomy/physiology is different than their identified gender (brain heart soul personhood gender) … this might be another way or manifestation of different ways brains are built or function in different ways.

This is curiously unscientific: Forcier glosses “identified gender” as “brain heart soul personhood gender.” For the more scientifically minded, there is a growing body of work on the link between transgender and autism. This 2014 paper co-authored by John F. Strang (a pediatric neuropsychologist with the Center for Autism Spectrum Disorders and the Gender and Sexuality Development Program at Children’s National Health System in Washington, D.C.), reports that participants in a study with ASD were 7.59 times more likely to express gender variance. Initial clinical guidelines were published in 2016 by Strang, et al, in an attempt to provide consensus guidelines for the assessment and care of adolescents with co-occurring autism spectrum disorder (ASD) and gender dysphoria (GD). But “why” there is an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD) is not yet known. Noticeably absent from the list of participants of these “consensus” guidelines is Tania Marshall, a specialist in the diagnosis of ASD in females. She states that the “majority of females do not receive a formal diagnosis until well into their adult years,” largely due to their very different coping mechanisms (as compared to males). As reported in this article by Aitken, et al, there has been a significant change in the sex ratio of adolescents referred to gender clinics: natal males outnumbered natal females up till 2006 when the ratio changed. How many of these young females fall within ASD but have fallen through current diagnostic tests that are based primarily on males? Please see this post. 4thWaveNow has previously published several other articles about the issue of ASD and transgenderism; see this and this.

Another parent asked what happens when transition makes a young person feel worse and actually intensifies dysphoria:

Q: Gender clinicians claim that transition dramatically improves the mental health of gender dysphoric teens. If this improvement does not take place, is it right to reconsider either the diagnosis or the treatment? In the case of my child, who experienced sudden onset gender dysphoria aged 20 after a series of traumatic events, without any signs or expressions of gender dysphoria earlier in his life, transition followed by hormone therapy has been followed by a descent into social isolation, altered sleep patterns, anger problems and other symptoms of depression. We live in a socially liberal trans affirmative cultural setting and he attends a trans support group. I suspect other mental health problems and his family and general practitioner suspect that the problem is not gender. But gender clinicians refuse to consider any other diagnosis. In these circumstances, surely, a rush to accept the patient’s self-diagnosis is dangerous. Your thoughts?

Forcier conceded that “yes, many gender patients have other mental health comorbidities…” (thereby tacitly acknowledging that gender dysphoria can be seen as a “morbidity”). But whatever the co-morbidity, gender reassignment can go ahead: “Not sure that depression, anger, sleep issues after trauma negates an exploration of gender,” says Forcier. As this parent told us, “she didn’t address my suggestion that the problem may not be gender at all, a view held by the family doctor and by those who knew my son before he became ill. The fact that other professionals disagree with the transgender diagnosis evidently interfered with her upbeat narrative of brave kids and bigoted parents.”

Another parent wanted Forcier to recognize and respond to the fact that a large majority of gender dysphoric children desist and reconcile with their biological sex:

How is it ethical to put children on a journey of lifetime hormone medication plus to endure the health risks of surgery when if those children are left to work their own life out, 80% will come to accept their biological sex?

Forcier’s reply:

Ethical questions are great when it comes to gender care, as NOT providing care seems to be more unethical and have worse health outcomes than providing care in this population. For example: How ethical is it to negate a person’s identity–to tell them you know them better than they do? How ethical is it to deny a person access to medication that is very safe, effective and proven to help persons with gender nonforming[sic] /diverse brain/identity and body experiences? The bias inherent in the question is interesting and deserves a response!

No evidence is provided for Forcier’s belief that “NOT providing care seems to be more unethical and have worse health outcomes than providing care in this population.” The medications she prescribes are not “very safe, effective” as recent studies on the side effects of puberty blockers make clear. Nor did she explain why it is ethical to medicate non-conformity (what Forcier calls “gender nonconforming/diverse brain/identity and body experiences”). Why should being different require hormones and surgeries?

Forcier then used a comparison between physical and mental disease; a puzzling response, if gender dysphoria is a naturally occurring variation (an assertion frequently made by trans activists and gender clinicians) rather than a disease:

FORCIER: Another good medical example, in trying to help us deal with offering or refusing to offer known safe effective medical care might be to liken this experience to other health concerns. For example, would you also propose letting a diabetic slip into diabetic ketoacidosis and coma before offering them fluids and or insulin if you suspected a high likelihood of diabetes? Would you wait for an asthmatic to collapse unconscious before offering oxygen and albuterol? Gender care has many safe medical options that in many instances are safer than withholding care. Additionally, this question has some other interesting perspectives… Transgender persons are never forced into surgical care- that is something that they need true understanding and consent to be able to engage in….The 80% data is not representative or accurate for the bulk of children who move towards blockers or gender hormones–not sure where that number came from but it is not correct.

Both asthma and diabetes are organic diseases which can be fatal and objectively identified. Gender nonconformity is a rejection of socially defined conventions and is not fatal. It is in no way like “other health concerns.”

And no one claims that 80% of the children “who move towards blockers or gender hormones” desist. In fact, nearer 100% of children “who move towards blockers or gender hormones” persist because social transition (which nearly always precedes medical transition), and blockers themselves, likely make desistance highly unlikely. Indeed, most “affirmative” gender clinicians, including Johanna Olson-Kennedy, Norman Spack, and others report near 100% persistence rates.

Forcier says she doesn’t know where the statistic “came from” that 80 percent of children who wish to be the opposite sex go on to accept their natal sex. This widely cited statistic is based on a multitude of studies—including those with children with severe gender dysphoria, including :

“Only 2.5% to 20% of all cases of GID in childhood and adolescence are the initial manifestation of irreversible transsexualism.” From Deutsches Aertzteblatt International, November 2008. Korte et al published a more recent metastudy in December 2016 with the same results.

“the majority of boys with GID showed desistence of their gender dysphoria when followed into adolescence and adulthood: 87.8% of the boys did not report any distress about their gender identity at follow-up and were happy living as males.” Devita Singh, “A FOLLOW-UP STUDY OF BOYS WITH GENDER IDENTITY DISORDER”, PhD, 2012.

“The exact number varies by study, but roughly 60–90% of trans- kids turn out no longer to be trans by adulthood.” James Cantor, “Do Trans Kids Stay Trans When They Grow Up?” January 2016.

Returning to the chat submissions, another parent who voiced genuine concern for her child was simply mocked as bigoted, and she asked Petrow to have a bit of empathy:

What would you do if your child suddenly, out of the blue, announced they were transgender, wanted to change their name, pronoun, and buy a breast binder? What would you do if you suspected your child might have been influenced by the media? What would you do if you suspected your child had other mental health issues to deal with? Walk in my shoes for one moment. What would you really do if it was your child? What would you do if your gut feeling was that your child was making the biggest mistake of their life? What would you do if everyone around you was telling you to celebrate your child on their brave journey? Please, what would you do?

In reply, Petrow equated transgenderism with homosexuality:

PETROW: Honestly, your question reminds me of those from parents in earlier generations who learned their kids were gay or lesbian. So, here’s what I’d do: I would try to read materials from the most credible experts, speak with other parents of similar kids (which you can find at PFLAG), and, of course, talk with my child. In other words, I would try to keep an open mind and learn as much as I can. Many parents of gay kids caused great harm to their young ones by not accepting them and but not helping them to accept themselves. I hope we’ve learned since then…

To this parent, Petrow’s reply was seriously lacking. She comments: “Despite my obvious concern and anguish you replied with absolutely no compassion. You chose to accuse me of being a bigot and to liken me to ‘earlier generations who learned their kids were gay or lesbian’.” This comparison misses the point. She explains:

My child did indeed inform us she was a lesbian, a few weeks prior to announcing she was transgender. When she told us she was a lesbian, we were happy for her and readily accepted it. I find it hard to believe that you cannot see the difference between a child who announces they are lesbian and a child who announces they are transgender. Being lesbian does not require her to become a lifelong medical patient. Being lesbian doesn’t ask her to chop off her breasts. Being lesbian doesn’t ask her to spend her life in anxiety about whether she will or will not “pass” as a man. Anybody can see that the future for a gay or lesbian child is very different to the future of a transgender child and I think it is an extremely lazy tactic to label any parent who dares to question their child’s transgender declaration as like “earlier generations. I have already read extensively from many credible experts; I have spoken to many other parents of similar kids and of course I have talked with my child. I am keeping an open mind and learning as much as I can. And it is with my mind fully wide open that I am helping my child to make the right choices in life.

Mr. Petrow advises this parent to “seek top notch treatment” for any “other mental health issues” her child might be experiencing. She respond: “You seem to have absolutely no understanding of mental health issues and how these could cloud a child’s judgement.” Oddly, given the comparison with homosexuality, Petrow also appearsto think that a transient transgender identity can be discarded without difficulty: “I’d also note that changing a name or pronouns, even wearing a breast binder, can easily be changed or reversed.” But this parent knows the lasting damage that binders can do:

You mention that changing a name or pronouns or wearing a breast binder are ‘easily changed or reversed’ without any understanding of real life. To think that you have no awareness of the damage done by wearing a breast binder shows that you have done absolutely no research (back pain, chest pain, shortness of breath, bad posture, rib fractures, rib or spine changes, shoulder joint “popping”, muscle wasting, respiratory infections, abdominal pain, breast changes, breast tenderness, scarring, skin infections – in case you were wondering).

Transition as gay conversion was the premise of another question:

How do we encourage kids and adults that being a feminine boy or masculine girl is ok, when trans communities use these stereotypes to determine if a kid is trans? Most homosexual adults didn’t conform to their gender as kids, will this mean the number of homosexuals is going to decrease because of transitioning? Could this be seen as homophobic?

Forcier’s answer is that “We encourage kids to be AUTHENTIC!” But if being “authentic” leads to medication with off label prostate cancer medication and later perhaps to surgery, it is a dangerous course. To truly encourage kids ‘to be AUTHENTIC!’ would involve accepting gender nonconformity and allowing kids to live in their own bodies without medical intervention. In her view

The clinical and research data do not suggest there are overwhelming numbers of parents or providers pushing kids into the trans box as suggested in some of the comments. In fact, historically, it has been hard for folks to access providers who listen and take them seriously or offer to engage in plans that explore gender.

History apparently began around the turn of the 21st century, when the category of ‘transgender kids’ was invented. Before this, kids were rebellious, or unusual, or gender nonconforming. Even in the 20th century, when medical transition started to become available, no one suggested that minors ought to be considered transsexual or in need of medical services.

From the mid-16th through the 19th century, boys were dressed indistinguishably from girls until between the ages of two and eight. ‘Breeching’ was the moment that a boy was put into trousers and had his hair cut. But Forcier asks us to accept current gender stereotypes as evidence of an innate identity. A body of research—including this 2017 longitudinal study of over 4000 young people—has repeatedly found that childhood gender non-conformity is strongly correlated with adult homosexuality.

Transgender suicidality is frequently used to coerce parents into supporting transition, as another questioner suggests:

Parents of transgender teens are often told about the high rates of attempted suicide among the transgender population. However, the studies from which these statistics are drawn do not indicate whether attempts occurred before or after transition. Given that several good quality studies indicate that suicidality continues to be high after transition (the Swedish study by Djhene et al. from 2011), what clinical evidence do we have that transition reduces suicidality?

But Forcier, similar to many trans activists, has no problem leveraging suicide as an argument. This is a “great question!” and she goes on to claim that:

There is both research and anecdotal evidence that both disclosure and appropriate care can offer relief to gender nonconforming youth who are at risk for self-harm and suicide. Data include Amsterdam’s early studies (no suicides and no street drug use) as well as later studies such as: de Vries AL, McGuire JK, Steensma TD, et al. Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics 2014. Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129:418. We have good data that disclosure AND LOVE & ACCEPTANCE by parents and families is protective. See Ryan, See Olson and other Family Acceptance Project studies. Also we would not expect all self-harm or suicidality to “disappear” or resolve completely even with good treatment options as there is still minority stress status effects and other ongoing macro and microaggressions that harm gender nonconforming persons on a daily basis.

Forcier’s answer is both manipulative and misleading. Parents are told that “disclosure AND LOVE & ACCEPTANCE by parents and families is protective.” This is manipulative because it assumes that to love is to uncritically accept whatever your child says. No responsible parent would accept this advice in relation to any other parenting issue.

It is also misleading because there is no reliable evidence that medical transition prevents self harm, which is readily acknowledged in the widely cited 2014 Williams Institute report about suicide in the US transgender population (also cited in Petrow’s original article). According to psychotherapist Lisa Marchiano, “it may in fact be the case that suicidality is higher among those who have transitioned.” Studies such as this one found: “Those who have medically transitioned (45%) and surgically transitioned (43%) have higher rates of attempted suicide than those who have not (34% and 39% respectively).”

Another parent expressed concern that teenage mastectomy is a drastic surgical intervention:

Trans teens in this country now receive drastic surgeries, e.g. mastectomy, as young as age 14. How can such young kids truly give informed consent for such radical measures? There’s a good reason we don’t trust young teens with huge decisions — they are immature, by definition. Their brains have not fully developed.

Forcier did not like this framing:

This “drastic surgery” — again such biased language!–has really changed many trans boys and men’s lives- and has low risks and outcomes for complications and regret. Teens assent to surgery WITH parent consent… we are lucky that many parents understand waiting for arbitrary legal age of 18 for chest surgery for some young teens is cruel and harmful from a physical and psychiatric perspective.

“Drastic” is a term that has been used by more than one clinician who has worked with this population. James Barrett, lead clinician at the UK’s oldest Gender Identity Clinic, writes that “The treatment of disorders of gender identity is drastic and irreversible, so it should only be undertaken in a setting of diagnostic certainty.” By dismissing the parent’s concern about medical transition as “biased,” Forcier minimizes the serious and irreversible treatment she is dispensing. “Diagnostic certainty” cannot be possible in the case of teenage clients. There is a reason why many psychiatric diagnoses (including personality disorders, schizophrenia, and others) are not made until adulthood because it is known that young people are not fully mature and can and do change dramatically. (For a recent article by a professional who does acknowledge the need for more “gatekeeping” for young trans-identified clients, see “Careful Assessment is Not Happening” on the First Do No Harm website.)

Speaking of diagnostic certainty, those who regret medical transition and decide to detransition– whatever their number — present a fundamental challenge to the notion of diagnostic certainty in teens. A parent asked

Given the growing number of people, especially young women, who have detransitioned in recent years, don’t you think it does young women a grave disservice if we don’t help them explore why they might want to transition– especially those young women who never expressed gender dysphoria as a child? Many of the detransitioners have talked about the role that trauma played in their decision to transition. And even though my child experienced a traumatic event shortly before her announcement that she believed she was trans, the therapist was convinced not only that she was trans but that she might need to start testosterone even at the age of 14.

In response, Forcier brands parental worries about regret and detransition as the creation of “alternative facts”:

Forcier: I am unaware of your data–please provide. If you are a gender provider and doing research – please send – it would be important to look at this and incorporate into care. But for clarity’s sake- there is no large number of “detransitioning” kids… It is so important to stick to what is actually going on for the majority of gender care youth- not create “alternative facts” that support our opinions.

“Gender providers” have shown scant interest in studying the population of detransitioners, so some of them have taken it upon themselves to gather data:

These informal surveys demonstrate the need for further research. The first formal survey study of detransitioners opened on March 17. It is being conducted by Lisa Littman, MD, MPH, Adjunct Assistant Professor, Icahn School of Medicine at Mount Sinai.

In addition to looking at these survey studies, Dr. Forcier could visit any of the multitude (and increasing number) of blogs set up by detransitioners such as

The underreported experience of detransition is beginning to appear in the mainstream media: see Experience: I Regret Transitioning and the BBC documentary, Transgender Kids: Who Knows Best? which aired in January 2017 (archived version available to US viewers here). Forcier should also be aware that USPATH, the U.S. branch of the World Professional Association for Transgender Health hosted a panel of detransitioners at the same conference she presented at in February.

Some of the parents’ stories sent in to the chat are harrowing, revealing the frequent association of mental health issues with sudden transgender feelings:

My female child turned 18 and only months after learning the concept transgender, was put on testosterone at an informed consent clinic in the LA area after only 2 visits to the clinic. We have a wealth of mental health issues in our families, including bipolar that is very genetic and shows up in older teens/young adults. My child is 19, technically an adult, now on T, but I very much see signs of bipolar. Do you think gender clinics should add controls back in to take longer time with young patients? brain science says the brain is still adolescent until at least age 25, not in any way an adult brain at age 18. My child never went thru any diagnostic testing for mental health issues or autism spectrum that could be clouding her/his judgement. I think only 2 visits to a clinic is way too fast to start any medical transition. Do you have some advice for what I might tell my child about getting this testing done now before getting too far with the HRT? treatment for bipolar could change how s/he thinks, and counsel for ASD would be needed first since ASD can also cloud judgement about social issues. And how can these gender clinics be made aware of the need for gatekeeping for young adults age 18-25 since they can definitely be impulsive and may be dealing with young adult mental health issues that need treatment first.

“More questions than we can really address here,” says Forcier, but she says that “bipolar and gender are two very different things.” She rejects

some of the very biased terminology…. gatekeeping, as reparative therapy has led to significant harm in the trans community. And recommending “gatekeeping” for consent age adults has an interesting paternalistic, controlling twist. Docs who provide adolescent and young adult care are clear on the literature about the 18-25 years continued brain development. But just as we might listen to a 9 year tell us they have a sore throat, take a history, consider taking a throat swab. Or we might listen to a depressed 16-year-old tell us they are sexually active and need chlamydia testing… we need to listen and incorporate a holistic approach to these youths’ care.

The parent isn’t satisfied with this response, and persists:

Actually there is documented overlap between bipolar and gender identity. There are some cases that have made it into the medical literature. See here and here and here. And you can easily search online and find conversations within the transgender and gender questioning population about how bipolar episodes affect how they feel regarding their gender identity. Indeed, here is an interesting article about how bipolar affects the development of self. For lack of a better word, “gatekeeping” is the due diligence that used to happen to ensure a low probability of regret following medical transition. There are mental health issues that, once properly treated, can resolve the desire for a change of gender identity. It is the slower approach of “Gender Identity Disorder” that has been replaced with the affirming approach that most are now practicing. Yet, how can a young adult struggling with undiagnosed bipolar be expected to accurately know that a change of gender at age 18 won’t be regretted at a later age after they are actually diagnosed and treated? All for the lack of mental health due diligence. This could indeed be the case for my child….mood disorders are prevalent in her father’s family and I’ve documented behaviors that look suspiciously like bipolar disorder. This makes it particularly distressing that you should find “gatekeeping” (again read this as simply “first do no harm” medical due diligence) as “paternalistic and controlling”. A feature of someone with bipolar disorder is that they are highly unlikely to see it in themselves. Diagnosis relies on the observations of family and friends. Helping them seek mental health assistance is certainly not paternalistic and controlling.

The association of gender dysphoria with other psychological problems has been well understood by clinicians and researchers for some time. In recent years, however, activists have worked diligently to prevent that information from being widely discussed. To take just one example, a 2003 survey of 186 Dutch psychiatrists reported on nearly 600 patients with “cross-gender identification” with these results.

In her final remarks, Dr. Forcier dismisses the parents who joined the chat thusly:

There seems to be lots of bias, misinformation, making statements about “data” that are not supported in the actual medical literature. I am also always struck by how many persons without gender expertise or significant experience with a cohort of gender patients have such strong, absolute opinions.

But these questions came from “persons” with first-hand knowledge of their own kids; parents who have read widely (including the “actual medical literature”); parents who care deeply and who view bland reassurances with due skepticism. For these parents, simply “affirming” their kids’ transgender identity is not just a matter of “etiquette” and appropriate language. The decisions made by doctors who prescribe hormones and surgeries have real life implications for the lives of those we love, and it has become evident to many of us that transition is not the best solution for our kids. And as far as “gatekeeping” goes, it’s quite obvious that the easier it becomes to transition, the more transition regret we are going to see.

Speaking of “bias” (the word Forcier used repeatedly to denigrate the parents raising questions in the chat): If one were to go strictly by the comments of Steven Petrow and Michele Forcier, it seems to us that the professionals in the affirm-only gender field and their media handmaidens are the ones with the “strong, absolute opinions.”

And just a reminder: they are talking about our kids.

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