I was sixteen the first time I heard my mother curse.
She was worn and weary—stretched beyond her maternal limits. From delirious dreams, I sat up, mumbling that I felt sick. From her own crumpled position in a bedside chair, Mom scrambled for the emesis bowl too late, triggering her exasperated expletive. Who could blame her, after our late-night trip to the ER and the projectile vomiting that began as soon as I walked through the hospital’s sliding doors?
I felt so bad about the mess I was making. I apologized profusely in between heaves, reaching out and cupping my hands to try to catch it, as if that would somehow help. Soon a thin tube was up my nose and down my throat, liquid charcoal slowly descending, making its way to my stomach to absorb the numerous prescriptions I consumed in my first major suicide attempt. Most of what had been in our downstairs bathroom medicine chest was now in me.
After sexual abuse at age ten, my subsequent years had been filled with suicidal ideation. I hated myself, and I hated my female body, scorning it as the source of my vulnerability and betrayal. As I developed, I sought an androgynous appearance, which for me was both a style and a shield. I could tie a man’s necktie as deftly and neatly as my father, I wore one so often.
At sixteen, I could not envision a healthy self, an “untainted” body free from shame. Suicide had long been a false siren in my imaginings, offering relief and a way of escape. I didn’t really want to die, but I needed help, and this attempt was my desperate cry for it.
Suicide obviously wasn’t the right answer, but were pharmaceuticals the solution? I immediately became attached to Dr. Richards, the soft-spoken, fatherly psychiatrist who was on call that night. I continued for several years under his care, but the main thing I got out of our sessions was his kind attention. I remember Transactional Analysis circles, Ids, Egos, and arrows, and very little else. Most interestingly, I was being treated for a “chemical imbalance.” My showing up at the hospital full of pills led to my being put on more pills, as if my problem primarily were somehow in my brain.
But as Robert Whitaker, a Pulitzer Prize finalist for his investigative journalism on psychiatric medicine, observes, “our mental health arises in environments, not just the inside of our head.” As I progressed from one medication to another to see what might help, Dr. Richards and I did not talk about the sexual abuse. Curiously, he insisted to my mother that my despair was so deep, there had to be an earlier trauma, something that happened before the age of two. My mother responded as insistently that nothing had happened before that fateful summer of abuse.
I can only shake my head now at this erudite physician’s puzzling over me. I am adopted, yet no thought of any effects from that primal wound ever crossed his or my mother’s mind. I realize now that my ER apologies have been operating in some form for most of my life: I’m sorry for being here, sorry for the trouble, sorry for the mess I am making. . . .
Adoptees happen to be overrepresented among those presenting at clinics with gender dysphoria. I can see my mother’s haggard face and imagine her plight had my 1980s gender-bending taken the form of “coming out as trans,” as it does today. Mom was already under so much pressure—vulnerable, afraid, and desperate to help. I imagine white-coated professionals telling her what parents hear today: to affirm my trans identity right away or prepare for a completed suicide. Are those really the only two options? For a movement that decries the binary, its commitment to this discrete dichotomy is relentless.
The “rush to treat” is a recipe for irreversible damage and regret. The brave detransitioned woman Keira Bell, who was put on puberty blockers after three one-hour sessions, knows this all too well. Her successful legal efforts to protect other young people from similar harms were overturned on appeal in the U.K. just a few weeks ago. Thus, the medicalized gender pathway has been reopened to children and distressed teens once again, with no oversight outside the questionable clinic required.
Alternatives to Affirmation
In acute situations of crisis, parents and young people need immediate help, as well as support to slow down and aim for the best long-term outcomes. This is similar to the wisdom of not making major decisions after a significant loss or in a time of grief. But that is not what is happening. Instead, parents are led astray by a rogue and en vogue “trans-affirmative” medical establishment, in which financial and ideological motivations override good clinical practice. As with Keira Bell, clinicians now often begin with suppressing puberty instead of dealing with suppressed problems.
In an excellent recent article, distinguished psychiatrist Stephen Levine reminds us that good clinical practice entails addressing any new symptom with the question, “Why is this occurring now?” When affirmative clinicians have patients presenting with gender identity conflicts, they may not even pose this question, thinking it irrelevant and in conflict with their concerns for “patient autonomy.” But Levine reminds us that “today’s passion can be tomorrow’s regret. Making a diagnosis of gender dysphoria is easy. Thinking about what it is a response to is not.”
Responsible clinicians who do want to explore and address the trauma that is quite common among trans-identified youth may be rebuffed by young people conditioned to look for the solution in a pill. Describing their own clinic experiences, a group of Australian professionals reported that “a large subgroup of children equated affirmation with medical intervention and appeared to believe that their distress would be completely alleviated if they pursued the pathway of medical treatment.” These magic-bullet beliefs were the product of peer influence, social media, and previous encounters with other healthcare workers.
The authors lamented that their efforts to explain the risks and engage in authentic therapeutic exploration “fell on deaf ears.” They also note that the “same overall dynamic also put many parents . . . in a difficult and untenable situation.” Parents almost always desire to be supportive and relieve distress, but they have a responsibility to seek out how best to achieve these goals while avoiding unnecessary risks and potential long-term harms. As recent legislation and court rulings show, concerned parents aren’t empowered. Medicalized affirmation is.
Finding the “Courage to Suffer”
Elsewhere Levine describes what true informed consent looks like. It involves pointed questions, such as, “What have you considered the nature of your life will be in ten to twenty years?”
At sixteen, I couldn’t begin to answer that question, as I could not envision a long-term future. After my overdose, I resisted what became a two-month in-patient stay because I didn’t want to get behind in school. When Dr. Richards pointed out I had just tried to kill myself, I assured him that since that had failed, I was back to my other plan—escaping the pain of my current situation through early graduation. I harbored hopes that perhaps if I accelerated a move to the next stage of life, it would be different somehow. Finishing high school was as far as my envisioning went.
What would my life look like in ten or twenty years? At twenty-six, I was in graduate school, seeing yet another therapist, crying uncontrollably and saying it was finally time for me to deal with the sexual abuse. The best advice Dr. Richards, my gentle Jewish psychiatrist, had given me was to read Viktor Frankl. Perhaps my tears, so long suppressed, were finally bearing witness: I was facing things I could not change and finding “the courage to suffer.”
At thirty-six, I became engaged to the man who is now my husband and the father of my two children. The thought of making decisions at sixteen that would have precluded these outcomes, my two children most of all, makes me shudder.
Today, I calculate the odds of my making it whole-bodied through the age of Instagram and social media engineering as small. A double mastectomy would have been my chosen fate, as if my breasts were the thing that was wrong, and not what was done to them. I could easily have chased the next stage of transition rather than matriculation in hopes it would cure what ailed me. But successive graduations didn’t heal me any more than successive surgeries would have.
Advocates of “gender affirming care” congratulate themselves for helping kids “live their best lives.” Yet, as the leaders at the Society for Evidence-based Gender Medicine recently reminded us, in the original Dutch study of seventy kids who took puberty blockers between 2000 and 2008, subjective ratings of their depression levels improved by only three points out of sixty-three after receiving the treatment. On a scale of zero to one hundred, the children’s overall functioning improved only four points. Other measures revealed no gains at all. All of the children then proceeded to cross-sex hormones. Fifty-six children went on to have surgery, one of whom died from post-surgical complications.
These are drastic interventions, leading to “improvements” that are minimal at best. There are worlds of difference between a few points on a psychological inventory checklist and robust future life outcomes such as marrying, having children, education, employment, and intact family relations. Overall well-being, both physical and mental, and authentic human flourishing should be the measure of success.
In the past, patients who were rejected for sex reassignment surgery seemed less apt to be upset, and no dire threats of impending suicide were given. In one study, eleven out of fourteen such patients expressed no regrets over not having transitioned upon follow-up. What happened instead? The majority “found other ways of dealing with their gender problem to the point that they actually reported having less gender dysphoria.” Even the study’s authors—themselves supporters of transitions—admitted at the time that such a resolution was preferable to more invasive treatment methods. But that study is twenty years old now, and such wisdom and caution have long been cast off.
Clear and Present Harm
Before that fateful Halloween night in 1986, the only other time my mother had kept a harrowed vigil at my hospital bedside was when I was seven. What doctors feared was a brain tumor from my sudden loss of ability to walk straight or read turned out to be acute brain inflammation. Mom had followed the doctor’s orders and given me aspirin for comfort during my recent case of chicken pox, and now my parents were waiting to see if I would survive the Reye’s Syndrome that resulted. In a strange coincidence with my teenage future, I missed two months of school while convalescing. The medical establishment didn’t know back then, and no one is to blame. Doctors are humans—doing their best with limited knowledge.
With experimental gender medicine in children, we can no longer claim this is the case. While the long-term outcomes are still unknown, there is abundant evidence of clear and present harm. Trans-affirmative doctors can no longer say to parents and children, “We’re sorry. We did not know.” They know. And they do it anyway. When “best clinical practices” are shaped by politically influenced beliefs and willfully blind optimism, clinicians become “cheerleaders for transition.” Parents are then misled about the “scientific certainty” of transition and bullied for being concerned. Worst of all, children are prescribed a dark future different from the one I couldn’t picture at sixteen but have been blessed to enjoy.