Before Rafferty

Where the medical affirmation model really came from

Photo by Marek Studzinski on Unsplash

In 2013, The New York Times published story about a young trans girl in Colorado, Coy Mathis, whose parents sued the school district for not allowing her to use the girls’ bathroom.

“It became really clear that it wasn’t just about liking pink or feminine things,” Coy’s mother Kathryn told the Times. “It was that she was trying so hard to show us that she was a girl.”

In response, Dr. Jack Drescher, a psychiatrist who’d been part of the American Psychiatric Association’s DSM-5 Workgroup on Sexual and Gender Identity Disorders, wrote a letter to the editor, which the Times published: “Currently experts can't tell apart kids who outgrow gender dysphoria (desisters) from those who do not (persisters), and how to treat them is controversial,” he wrote.

That prompted several clinicians who’d been working with trans youth to publish an editorial in the journal Human Development: “The Gender Affirmative Model: What We Know and What We Aim to Learn.”

The 2013 editorial acknowledged the controversy over kids like Coy, but expressed that these clinicians, as “members of a four-site child gender clinic group,” took issue with his characterization that they couldn’t discern whose dysphoria would remain. “Research and our clinical experience suggest that many children develop a strong sense of gender identity at a young age,” they wrote.

The clinicians noted that all children must “live in the gender that feels most real or comfortable,” or else they “are at later risk for developing a downward cascade of psychosocial adversities including depressive symptoms, low life satisfaction, self-harm, isolation, homelessness, incarceration, posttraumatic stress, and suicide ideation and attempts.” 

And yet, this notion is immediately followed by an admission: “the developmental impact of our approach has yet to be rigorously studied.” 

This editorial marks the introduction of the affirmative model to the scientific community, a “third way” which rejected both the “normalizing therapies” of earlier eras—which shocked and shamed gender nonconforming children into behaving “appropriately”—and the “gatekeeping” approach of the Dutch.

These professionals were deeply informed by the emerging notion that transgender and transsexual people were not disordered; there was no disease to be cured, but rather a gender incongruence that may or may not require medical intervention to align. And they took to heart the importance of family and societal acceptance in order to maintain or achieve mental health—the onus for gender health was no longer on the child, but spread out across institutions, and the culture. Just as gay people, and those who tried to “fix” them, had eventually realized “that one was collectively oppressed rather than individually disturbed,” gender-diverse people and their “fixers” began to adopt that mentality, too.

The piece addresses what the authors say are two myths that had already been established about their new approach:

Myth No. 1: Gender-affirming approaches conflate gender identity and gender expression; therefore, any child who exhibits gender nonconformity is believed to be transgender.

Myth No. 2: The gender affirmative model asserts that gender identity and gender expression are immutable and removed from social context or influence.

The authors define gender identity “as the gender the child articulates as being - male, female, or something else,” and establish gender identity as the north star of the treatment. If previously, the goal of medical intervention was to cure or reduce gender dysphoria, under the affirmative model the goal was to help a child’s body match their identity.

Gender identity, they asserted, was not to be confused with gender expression, which was about a child’s appearance or behaviors, who and what they played with. The category of “gender nonconforming children” was vast, and included those with a gender identity that didn’t match their natal sex. But not all GNC kids were transgender. “…we dispute the notion that any child who exhibits nonconforming gender expression be considered transgender. Our stance, as gender-affirming practitioners, is that children should be helped to live as they are most comfortable.” Much the way American parenting was shifting to child-led, gender medicine and psychology became child-led, too.

Key to this model was insisting that sexual orientation and gender identity were separate, and that the kinds of gender-atypical behaviors observed in gay youth, which commonly resolve with puberty, were fundamentally different than having an identity that conflicted with sex, and which caused persistent dysphoric feelings. Gender nonconformity, and sometimes with accompanying gender dysphoria, had previously been linked with homosexuality in the “desistance literature”—long-term follow-ups of such kids. A body of research begun in the 1960s established a correlation between childhood gender nonconformity and adult homosexuality.

But that research was dismissed in the new approach. “We have worked to dispel the myth that gender identity formation is synonymous with sexual identity formation (i.e., sexual orientation),” they wrote. One is who you like, the other who you are. They admitted that “many young boys explore the margins of gender identity on the way to later discovering their gay sexual identities,” and that these boys will be “desisters.” The affirming clinicians acknowledged that “the majority of gender-nonconforming children presenting for clinical care related to gender dysphoria are desisters unlikely to mature into transgender individuals.”

Even those kids, they wrote, were vulnerable to familial rejection and peer bullying. They, too, must “express that gender with freedom from restriction, aspersion, or rejection.”

Essentially, all kids have a gender identity—instead of some having a gender identity disorder—and must be all affirmed, whatever their gender identity. Those for whom the identity causes distress will reveal themselves as different from those who simply must have the freedom to behave differently. This model of affirmation, which can lead to very concrete medical interventions, was built on the fuzzy and mystical gendered soul, an interpretation of the contested idea of gender identity. The approach affirmed an identity rather than treating gender dysphoria.

As such, the authors admitted that there were more questions than answers. Those included:

• “[W]hat are the comparative developmental outcomes of the various approaches for treating gender-nonconforming children and youth?

• Can we provide a fuller, accurate developmental picture distinguishing gender-nonconforming children who are transgender from gender-nonconforming children who may not be transgender?

• Is there any psychological harm done if a child transitions from one gender to another and then transitions back?

• What are the outcomes of receiving (or not receiving) psychosocial or medical interventions characteristic of gender-affirming support, which may include reversible pubertal suppression therapy and irreversible cross-sex hormone therapy?

• Can we identify resilience factors and psychosocial risk factors in gender-nonconforming children and their families?

• What are the effects, both positive and negative, of the family, peer, socio-economic, and socio-cultural systems in which gender-nonconforming children develop?

• Are there instances in which a child's beliefs about gender identity can become confused by family and social forces, and how can we help to account for and counter such forces?”

They were curious to know the answers, and “eminently guided by the oath of our professions: to ‘do no harm.’”

Their statement about the lack of rigorous study is still true more than a decade later. The only American long-term, prospective research—research that came from this four-site group—suggested improved psychological functioning but an alarmingly high suicide rate among young people who’d medically transitioned, and didn’t report on many of the factors they set out to reserach. A study in England found no improvement in psychological function after puberty blockers. The original Dutch study, on which youth medical gender transition is based, did show drastic improvement, but the quality of the study is so low that across the Western world, many are now skeptical of it; a Dutch media company just released an exposé of it.

Still, this model was codified in 2018 by the American Academy of Pediatrics in a policy statement, which in many ways goes further than the 2013 statement, conflating gender nonconformity and trans identity, sealing their connection when originally it was imperative to maintain a division between them. As Colin Wright reported, “transgender” as an umbrella term covered just about everything.

By the time Rafferty put out the 2018 statement, the term TGD, for “transgender and gender-diverse,” was used to describe children in this cohort. The statement insisted “that youth who identify as TGD have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space.” Baked in is the assumption that gender diversity requires medical care.

As such, per the statement, medical records should reflect gender identity; insurance plans should cover gender medicine interventions; schools should accommodate children according to gender identity—and pediatricians should serve as advocates to make that happen; medical students should be in this model; and gender-based DEI of sorts proliferate in healthcare—among many other suggestions.

All those changes had long been under way. We’d passed the transgender tipping point. We’d watch Jazz Jennings transition on TV. Trans-identified students had sued schools, and a new wave of policy guidelines washed over education, spurred on by Obama’s government.

The 2018 AAP statement is essentially a road map to letting gender identity reign, to valuing gender identity over sex or gendered behavior or stereotypes, and to institutionalize child-led gender medicine. That statement and its author, Dr. Jason Rafferty, and the AAP, are now the subject of a lawsuit by a detransitioner, one of those young people allowed to direct their own care based on their internal sense of gender.

In other installments: where the idea of “affirmation” really came from, and what changed between 2013 and 2018.