Receipts: NYT Magazine Pitch, July 22, 2021

Turned down, became the Bazelon piece instead

Photo by Lena Balk on Unsplash

Melissa watched as her 17-year-old son was hooked up to a feeding tube, the long snake of pale plastic inserted into his nose, a patch of fraying white tape splotched over his delicate skin. The look of terror that had crystalized in his eyes subsided, and Melissa, too, found herself letting go of the guilt and fear, allowing one small seed of hope to germinate. He had been hospitalized for anorexia at a well-respected residential facility for kids with eating disorders, where they promised to make her son well.

The next day, Melissa (not her real name) received a call from the therapist making the rounds on the ward—not about her son, but about her daughter. “Your child is transgender,” the therapist said. “She needs to start hormones right away.”

Melissa was flabbergasted. Her son had not only never come out to her, but he’d shown no signs of gender nonconformity throughout his childhood, other than recently having long hair, nor a single sign of gender dysphoria (GD)—distress at a perceived mismatch between your body and your sense of self as boy, girl, or neither. He was bright but socially awkward, quirky, desperate to be liked by his peers, who often shunned him. She suspected he was on the spectrum. But Melissa had hardly found a moment to shepherd him through the trials of puberty, because her entire life had been dedicated to helping his older sister, whose debilitating autoimmune disease had at times left the child paralyzed.

Melissa wanted him to stabilize first, to get the anorexia under control and deal with their underlying family trauma. Then they could investigate the gender issues. But the therapist, who had talked to her son for less than an hour, insisted it was the other way around.

“They said gender dysphoria can cause the eating disorder, so if he does not transition right away, he will not get better,” Melissa told me. No one discussed, with Melissa or her son, any possible health complications from cross-sex hormones, that he might be sterilized or a life-long medical patient if he started them. Another psychiatrist told her, in front of her son, that if she didn’t give them to him, he would kill himself. When she said she needed more time, a staff member later told her, the team discussed calling child protective services, suspecting she was transphobic.

Until recently, having other mental health conditions would make therapists hesitant to medically transition someone with puberty blockers, cross-sex hormones and possibly surgeries, because of the emotionally stressful and physically intense process. Now transition is often presented both as a panacea for those other conditions and the only path forward. Some gender clinics are reporting a 4,000 percent increase in referrals for GD over a 10-year period. Almost all push the affirmative model of care, which may involve socially transitioning a prepubertal child and allowing a pubertal child to physically transition, often in the name of preventing suicide.

In fact, there is almost no research on this model of care, and the research that exists doesn’t support it. The World Professional Association of Transgender Health (WPATH) Standards of Care suggest that mental health providers “assess and treat any co-existing mental health concerns of children or adolescents,” and “educate clients and their families about therapeutic options.” Revised standards, to be released in the fall, will highlight the importance of thorough clinical assessment, but few clinics follow the standards.

The little data about suicide attempts among transgender people doesn’t support the transition-or-death scenario often repeated in the media and among activists and clinicians. One oft-cited but heavily criticized study on puberty blockers said they alleviated dysphoria, yet a major review of the literature found that any evidence of blockers’ effectiveness was of very low quality. Some research found that gender-affirming surgeries didn’t improve mental health.

There is almost no research on teens like Melissa’s. Until about 15 years ago, teens with no history of GD had rarely presented at clinics. The medical protocol was designed for kids with persistent, insistent and consistent cross-sex identities since early childhood, who engaged in exploratory therapy and were not socially transitioned as kids. Around 80 percent saw their gender dysphoria alleviate, usually around puberty, and the bulk of these kids later came out as gay. But a small number did medically transition later, after careful assessment, and their mental health had improved. The Dutch pioneered this protocol, called “watchful waiting,” but they have expressed concern about the new influx of gender dysphoric kids, because the research is not applicable to them.

Almost all the cases are in this new, unstudied cohort consistof awkward, shy, bright kids, often with other mental health problems, who have suddenly latched onto the idea that they’re transgender and demand immediate, invasive medical treatment, like hormones, mastectomies or penectomies. “The cases used to be so straightforward,” said Laura Edwards-Leeper, the psychologist who in 2007 helped open the first pediatric gender clinic in the U.S. and brought the Dutch protocol here; she has facilitated hundreds of successful medical youth transitions. “Now they are so complicated.”

Many parents and providers report feeling pressured into affirming children and sending them down the medical path immediately and without question. As one mother, whose autistic son also came out suddenly at 17, told me, “If gender is on a spectrum, how come there isn’t a way to treat this on a spectrum?”

Around the country, support groups for parents have formed, safe spaces where they can share research, trade stories and openly express concern about the medical protocol, without fear of losing jobs, social standing, or even their own children, if schools or hospitals call Child Protective Services when they want to pause and investigate. Many meet in secret, sometimes in person or on Discord, where almost everyone has adopted pseudonyms. It’s part of an underground resistance that demands evidence-based, ethical treatment of youth with gender dysphoria, including organizations like Genspect, Society for Evidence-Based Medicine or Rethink Identity Medicine.

“They want the treatment to be less invasive and to go slower,” said Stella O’Malley, a therapist who works with gender-questioning youth. The founder of Genspect, which has connected parents of gender-questioning kids around the world, O’Malley suffered from gender dysphoria as a child and lived much of her childhood as a boy; it resolved, as the research says it often does, around puberty.

It’s well known that not all transgender kids are gender dysphoric. But what if some of the many thousands of patients suddenly overcome with gender dysphoria aren’t trans, and are getting the wrong treatment? After all, some medical centers in Sweden no longer provide the medical protocol to children; Finland has tightened its guidelines; kids in western Australia will now have to get a court order for medical treatment, due to the rising number of detransioners, who had late-onset gender dysphoria but should not have been medicalized. This underground movement says the political environment in the States is making it impossible for anyone—even the therapists and doctors treating—to even ask questions. People may have to quit their jobs if they want to speak openly.

There are hundreds of variations on Melissa’s story. I’ve spent the last three months cataloguing them: stories about a healthcare protocol gone awry; the culture of fear and shame, the intolerance of questioning and dissent that has prevented people from speaking out; and the politicization of science, leaving families in the lurch, and preventing kids from getting the therapeutic help they need. Even many trans adults, like psychologist Erica Anderson, who works with trans youth, feel this blindly affirming model is the worst thing for trans people, because the pushback comes in the form of legislative bans, rather than guidelines from within the healthcare world, which harm those who would genuinely benefit from medicine.