“The Battle Over Gender Therapy”: A Worthy Read
Guest Blogger and 1995 ABAP Diplomate, Jonathan Bauman, M.D.
In a recently published article by Emily Bazelon in the New York Times, “The Battle Over Gender Therapy”, Ms. Bazelon lays out the issues, questions, and struggles adolescent and young-adult psychiatrists have been dealing with increasingly over at least the last 20 years. Back in the early 2000’s the hospital at which I was CMO began admitting an occasional child or adolescent who identified as transgender or was in the process of “coming out”. Our limited experience with such patients and the paucity of coherent standards of care led to some interesting discussions among staff about how to approach these patients and their families, from very basic to more complex issues.
Several child and adolescent units comprised most of our hospital, and these units were divided into male and female wings, mostly two patients to a room. As for basic issues, we suddenly had to consider the previous relatively simple question of where the patient should sleep, as well has how other patients might react. Not surprisingly the adults in the room tended to underestimate the accepting nature of teens that were sharing all kinds of troubling and “unacceptable” thoughts, feelings, and behaviors. Since our patient units had one or two single rooms, we agreed that the trans-female or trans-male child or adolescents would be assigned to a single room on the side of the unit with which they identified (we did not have so many transgender patients that we could not accommodate this solution). Whether this solution was for the kids’ comfort, their parents’ comfort, or our comfort is hard to say.
Of course the more complex issue was what the clinical approach to treatment should be. Though we were dealing with a problem new to us, it became apparent that our approach should be no different from what we had always been doing: conducting a comprehensive bio-psycho-social assessment, gathering an understanding of family dynamics, and maintaining a non-judgmental approach to treatment. Of course “The Devil is in the details”, and we had to tailor treatment to each patient’s particular need.
To confess, I was puzzled by what such transgender “pathology” meant. Was gender dysphoria simply a result of a toxic family environment or some genetic predilection? Were teenage patients just going through their search for identity in a novel way that would correct itself in time? My questions were answered, in part, when an elementary school child was admitted for suicidal ideation. A trans female who strongly identified as a girl since early childhood, she was in outpatient individual and family treatment, and her family appeared to be supportive and non-toxic. This made me consider that there really were people who are born in the wrong skin.
Back in the early twenty-first century, as an acute inpatient setting, we weren’t yet dealing with issues around hormone blockers to delay puberty or gender-reaffirming surgery. The rare adolescent who was on gender-affirming medication as an outpatient would stay on their medication while they were with us. Our focus was on dealing with an individual and family in crisis. In this regard, we were dealing with issues with which we were familiar: feelings, defenses against feelings, motivations, anger, disappointment, family conflict, social issues, etc.
As psychiatrists our current role in transgender care is to provide assessment of a youngsters overall mental health and motivations to inform other medical providers about what medical or surgical interventions to pursue, or not, and also to provide psychotherapeutic intervention and family support when necessary. Bazelon’s article in the Times points out that “more teenagers than ever are seeking transitions”, but that “the medical community is deeply divided about why and what to do to help them.” She mentions a recent estimate that about 300,000 kids nationally identify as transgender, and national data in Britain and the Netherlands estimate that in 13-to17-year-olds those seeking treatment for gender identity issues have increased over the last decade from dozens to hundreds of thousands. Many of these cases are teens around 14 or 15 who haven’t yet “come out” to their parents. Also, unlike in the past when most patients coming out were male at birth, they are now about two-thirds female at birth, identifying at trans boys or non-binary.
Bazelon writes that experts in the field of transgender care, who provide treatment at the more than 60 transgender clinics in the nation, have been having a big debate on how to respond to the thousands of teenagers seeking care, often around puberty-suppressing medications or hormone-replacement therapy. As noted in a draft chapter of transgender standards of care that is being prepared, many of these adolescents have been influenced by the increased visibility of transgender people in the media as well as peer-to-peer online social influence. To complicate matters, many of these youngsters at gender clinics have high rates of depression, anxiety, eating disorders, ADHD, and autism spectrum disorders. The draft raises difficult question. For instance, are the teenagers coming out today different from those is past generations, for whom the benefits are well established and the rate of regret is very low, and how many of these youngsters have serious mental health issues and want to shed discordant aspects of their developing identity.
The Times article goes on to describe the current debate in society about whether even to provide gender-affirming treatment, as well as the debate within the field about what the standards of care, particularly with regard to adolescents, should be. As is often the case in such matters, i.e. differing opinions along a liberal/conservative fault line, the debate is between those providers who advocate for comprehensive psychodiagnostic evaluation to select appropriate candidates for medical and surgical treatment and those providers who feel that demanding mental health evaluation and treatment promotes stigmatization of transgender people. As one might expect, disagreement, uncertainty, and lack of data in the field fuels the radical rights’ attacks on providing gender-affirming treatment, social or medical, at all.
Bazelon goes on to provide an interesting history of transgender care since the 1970’s, citing examples of different approaches and their outcomes across the Western world. She also goes on to describe stories of trans patients and their families in our current climate of controversy and polarization. This is too long to summarize here, but the essay in its entirety is well worth reading (New York Times, June 16th, 2022). The new treatment guidelines for transgender care are expected to come out this summer.
Editor’s Note: For it’s 2019 Annual Meeting, The American Society for Adolescent Psychiatry devoted it’s entire program to current issues in Transgender Mental Health. Knowledge of these issues is unique to the field of Adolescent and Young Adult Psychiatry and is one of many reasons why Board Certification in Adolescent and Young Adult Psychiatry is more relevant now than ever!
To review the 2019 Annual Meeting Syllabus, please go to: https://www.adolescentpsychiatry.org/_files/ugd/0808bc_4ea786407f84485c8248a10c1dbf432d.pdf