The Real Thing in Trans – writers talking

I am at a tiny writer’s retreat in Greece to escape an exhausting round of youth trans critical writing, talking and interviews. Only eight wise and thoughtful people are here, between us from Ireland, Holland, Australia and the UK. At the dinner table, in the middle of relaxing small talk about meditation, blessings and enlightenment, trans appears. Everyone has a view, most people ‘know one’, including knowing parents of children identifying as trans. Even here, on the terrace of a remote peninsula, trans is everywhere. Once again, I find I dare not speak of my experience.

I left the table to try and write out my troubled thoughts but couldn’t think where to begin. No, no. Not again, not saying the same things over and over and over. I had been reading Nelson Algren trying to explain the way of things to a girl who had been out of town[i]. It seemed to me the dialogue could transpose to explaining the youth trans critical perspective to those who have not yet come into town. It’s not original to make a pastiche other people’s work but the youth trans critical youth agenda is unspeakably urgent and I have neither time nor talent to do better. I remembered Algren quoting Simone de Beauvoir saying ‘if one gives time to trivial things, the important matters will never be settled’. So I decided to transpose the piece and post. Just as a way of finding a small way to scatter further some seeds of awareness.


‘Not so long ago, ‘what kind of gender does this child have?’ was never a question for asking in schools. Yet now we have changed all the rules. And in the process of changing all the rules, we have confused questions about gender with questions about sex and sexuality’.

‘Is it not against the rules for people to confuse children about gender, sex and sexuality in schools?’ asks the girl from out of town. ‘Yes it is, but the rules keep changing. It used to be against the rules for people who are not teachers to take the lead on educating children and young people in schools. And questions about a child’s gender, sex and sexuality were not uppermost in every day school life. Teachers were supposed to teach children how to learn and what they would learn was suggested in a curriculum put together by education researchers, policy makers and professors. For young children how and what they learned about sex and gender was left for them to discover quietly along the way, in their own terms and largely with reference to conversations within their own family and community. Questions about sexuality were left for adolescence and for teachers who had training in working sensitively with young people on these things’ I told her. ‘Now people who want to promote transgender have unparalleled access to children in schools and children don’t have to wait for sexual development to become embroiled in conversations concerning their gender and sexual identity. They don’t, in fact, have to know the first thing about gender or sex. All they have to do today is to give adults around them a reason to question the way they are behaving so that those adults can start to claim ‘that child was born in the wrong body’. Adults can do this from when the child is only two or three by using stereotypes to ‘prove’ it. If a male infant says they like to play with pink things, for example, and wants to push dolls around in a pram and to grow up to be a princess that can nowadays give people a reason to say ‘child, you were born in the wrong body’.

‘So wouldn’t it be easy for parents who wanted a girl but have a male baby to persuade their infant that they like pink and are really a girl?’ ‘Yes. That’s a possible outcome of uncritically accepting that children who say they are trans are trans. Once the unknowing child goes along with liking pink (of course this is just an example) their parents could nudge along a process of getting their child first socially, then physically, reassigned as a girl. All that is needed is for enough adults to agree the child is ‘in the wrong body’.’ ‘But surely people wouldn’t do that?’ ‘Well it’s not so simple as that, there are parents for example who are homophobic, you can think of how the situation might unfold if their teenage daughters say they are lesbians. There might be a feeling that it’s better to say those girls are in the wrong body. They are really straight guys in the wrong body’.

‘So trans advocacy can be homophobic?’ she asked me. ‘I hadn’t thought of that’.

‘There is a lot we haven’t thought about. You see so many people have become trans activists and so few people are recognized as trans critical that it is like being in a country run by people with chemical bombs when there is a shortage of people who are worried that the bombs might be dangerous. There are simply not enough critical chemists to slow down the danger posed by those with the chemical bombs. So many rich and powerful people have become persuaded by trans activism that they can stop the media writing copy which tells, for a literal example, how dangerous the chemicals can be. This provides a neat way for the trans activists not only to keep pushing the chemicals, but also to denounce the trans critical people and get rich and famous by doing it at the same time. Trans critical people have become so afraid that someone will catch them not applauding the trans activists that we dare not speak out or write so that all the air is taken up by pro trans voices. Most journalists are afraid to write youth trans critical pieces even when people do try and speak out’.

‘I do not understand these youth trans critical people’ said the girl. ‘Are they parents and professionals with no courage?’ ‘Not exactly. But they don’t want to accidentally push the people with the chemical bombs into getting even more excited about using them. And they certainly don’t want to get penalized or policed more than they already are’.

‘But people who are trans critical yet going along with it, like teachers and doctors, why are they going along with it?’

‘Well teachers and others in schools are going along with it because trans activists have already placed incendiary devices in schools by changing the rules and putting in policies which stop people speaking out. Prevent them from saying anything different – like they don’t believe a child is in the ‘wrong body’. Therapists too aren’t allowed to help a child question any feelings that they might be ‘in the wrong body’. Therapists have been put under strict guidelines not to question a child saying they are trans, just accept it. Helping a child reflect is seen as ‘transphobic’ and against the rules. Teachers don’t mind children changing their names and pronouns with their friends so much as they do being asked to use those names and pronouns themselves. They never used to call their pupils ’Fatso’ or ‘GeekGirl’ when a child was self-identifying in such a way. They also mind a lot because they are never sure what the child’s parents know and want, what with the world and its children and young people changing every day’. ‘You mean a school can turn a girl into a boy by changing their names and pronouns without the parents wanting that?’ ‘Yes. Schools pride themselves on being pro trans and have been given the power to trans a child even if their parents do not know or agree this is happening because the view is that parents who don’t agree are transphobic’.

‘It really sounds better for children and young people if most teachers are trans critical does it not?’

‘It would be if those teachers could be trans critical, but silenced as they are they are the world’s biggest distributors of trans’. ‘I am disgusted with teachers I trusted’ said the father of a girl I met in England, ‘they call my daughter a boy and refer to her as ‘him’. ‘Don’t bother with your disgust’ I have to say, ‘until we can be openly trans critical too’.

‘We are in a bind’ said the girl. ‘Where do we find the courage to speak critically directly?’

‘Ah. I have omitted that I am the mother of a trans identifying teen and busy working on that. I am working with others to try to coordinate the best writers and thinkers in the world to dispatch their analysis and views on this problem. In doing so I endure battle with my child and with the whole world. I am helping coordinate a fast growing US/UK organization to unify youth trans critical professionals and parents from around the world. Many of us take great risks to speak publicly though I cannot myself speak openly yet because I must protect the identity of my child. My friends and I are doing everything we can to bring the necessity for trans critical thinking into light’.

‘What are trans activists doing at the same time?’ the girl wanted to know. ‘An excellent question. They are discovering more and more ways to disrupt the way children have been children and the young have been young since the beginning of time, kicking up a celebrity storm of stereotypes and righteousness and earning good dividends at the same time. They are policing what people say and silencing those with experience of desperately regretting transition or who are trying to detransition. Unfortunately the trans activists omit to say that their preferences for transitioning children and young people involve sterilization, life-long reliance on unlicensed drugs, strokes for children and young people, UTIs, scars, mental health chaos and worse and that the trans promise, that intervention will change your sex, is a lie’.

‘How can this be happening?’

‘I am trying to tell you. It is being done by being very disapproving of the society in which we live and at the same time being very angry at anyone who wants to air a different critical edge. They have got us to the point where you will be dragged to explain oppression to your Equality Committee, subpoenaed by the Human Rights Commission, if you criticize the trans movement or gently ask a child if they are really sure they were ‘born in the wrong body’. They know how to lick a critic into shape.’

‘It sounds very confusing’.

‘On the contrary. Trans activists are very clear headed.’

‘But does not what they are doing have a very worrying effect on the children?’

‘Yes. It leaves the children with no confidence about themselves in relation to others. Unless they change their identity to ‘trans’ to explain why they are not like others. And it makes it necessary to have children and young people take drugs they will need for life and have surgery which will change their bodies so that they can be presented as ‘in a pudding of sameness’ that is ‘normal’. But this is the new normal of butchers and lies. These trans activists think they are God themselves’.

‘The power they are taking leaves parents and others looking on with no choice but to present themselves as supporters of trans. So they are cheer leaders in the tyranny of trans chauvinism?’ she wondered.

‘Yes. And they have made it necessary to applaud castration of little boys and mastectomies for young girls and to celebrate the construction of people who may, for example, have a penis, breasts and a high voice or who will live their adult life with a vagina, no breasts and a beard.’

‘In the pudding of normality’ said the girl – and this was a most thoughtful girl I think.

‘I cannot help wonder at what I am seeing and hearing. People recognized as arbiters of social justice, human rights, compassion and learning are not permitted ordinary grace sufficient to speak for our children on the madness of trans orthodoxy. You can report me if you don’t call that a difficulty’.


[i]Based on The Real Thing in Kitsch by Nelson Algren

Algren At Sea. Who Lost an American? & Notes from a Sea Diary 2008 edition, Seven Stories Press, New York.



“I Was Not Given Options Other Than Transition:” Another Open Letter to Therapists from a Detransitioning Woman

This post is from Cari, who is 22. She began transitioning at 15 and began medically transitioning with testosterone at 17. She eventually had a mastectomy before deciding to begin detransitioning earlier this year. You can read more about her experience on her blog as well as here. Thank you so much for your contribution!


When I try to think about the care I wish I had when I was transitioning, a few different things come to mind, but the single biggest one is the fact that I was simply not given options other than transition.

When it comes to picking apart the reasons for my dysphoria itself, it’s easy to point to something in hindsight, but the truth is I was a stubborn child and am now a stubborn adult, and it’s possible I wouldn’t have been receptive to treatment for these issues anyway, once I had set my mind on transition.

However, why did I think that transition was the solution in the first place? Largely, because I bought into the idea that it is the only cure for dysphoria. This idea seems to be ubiquitous in trans spaces. It’s meant to illustrate why transition care should be prioritized and covered by insurance, but it also has the effect of invalidating any kind of alternative treatments. Suicide is considered a direct outcome of dysphoria by many, as simply what happens when the proper treatment (transition) isn’t given, the same kind of causal relationship as death by diabetic coma might be for untreated hypoglycemia. The application of this idea to a diagnosis that has no objective test, that has many differential diagnoses that can be difficult to pinpoint or treat, that is infrequently questioned or scrutinized in any meaningful way by gender therapists, is very dangerous.

Very soon after coming out as trans, the “reality” that I would have to transition in order to be happy hit me, and I became deeply depressed. Transition became a huge focus of my life, because I believed it needed to be, that I needed to devote my energy to it in order to alleviate my dysphoria, in order to live my life, really. I’ve seen a lot of therapists, including three who specialized in gender therapy. Yet it wasn’t until I began reading the writings of detransitioned women that I had any clue there were other viable ways of dealing with dysphoria.

Another really important thing to me is the need for trauma-informed care. Therapists need to be looking at the histories of people who are seeking transition, to be working through their trauma with them in more ways than just talking about it briefly. When I was in therapy and soon to start hormones, I told my therapist about my trauma history, which seemed to do little more to affect my treatment than having a session or two devoted to talking about it, and then pressing forward with the idea of transition. The idea that trauma could have caused body image issues, dissociation, reality distortions, not wanting to be a woman because of the “target” status it conferred, was never brought up. Nor was there much of an attempt at treating my mental health symptoms other than through transition. This needs to be part of the conversation—even if there are so-called “true transsexuals” whose issues are caused by some kind of neurological difference, (controversial, completely unproven, and supported by highly flawed studies) there are also plenty of people who can recognize their dysphoria as being based in trauma or mental illness, at least once they know where to look.

The third thing I can identify as a cause is the lack of representation of adult women who were gender nonconforming or butch, and the narrowing of “acceptable” gender expression as girls grow up. It’s one thing to be a tomboy, but tomboys are expected to “grow up” (become feminine) eventually. For me, this realization came around the same time as puberty started to make itself known, and the associations I began to make between my female body and the constriction of gender roles I felt was powerful. It does no good to ask a child “could you be happy living as a butch woman?” if she has no idea what that could possibly mean for her as an adult. One of the ways you’re supposed to be able to tell if someone is “really trans” is for them to think about how they can see themselves living in 10, 20, 30 years—as a man, or as a woman? This is a flawed diagnostic for many reasons—how many people, trans or not, can picture their future in a positive light while dealing with depression or trauma? But when there are no models for the type of woman you want to grow up to be, it becomes even more skewed.

Link between gender dysphoria and dissociation found

Since Maria Catt discussed the role of trauma and dissociation in her own experience of dysphoria, I thought I would reblog (with kind permission) this thoughtful post from thirdwaytrans that looks at some research linking trauma, dissociation, and gender dysphoria.

Third Way Trans

Here is an interesting study I just ran across from Collizi, Costa, and Toldarello, entitled “Dissociative symptoms in individuals with gender dysphoria: Is the elevated prevalence real?”, abstract pasted below:

This study evaluated dissociative symptomatology, childhood trauma and body uneasiness in 118 individuals with gender dysphoria, also evaluating dissociative symptoms in follow-up assessments after sex reassignment procedures were performed. We used both clinical interviews (Dissociative Disorders Interview Schedule) and self-reported scales (Dissociative Experiences Scale). A dissociative disorder of any kind seemed to be greatly prevalent (29.6%). Moreover, individuals with gender dysphoria had a high prevalence of lifetime major depressive episode (45.8%), suicide attempts (21.2%) and childhood trauma (45.8%), and all these conditions were more frequent in patients who fulfilled diagnostic criteria for any kind of dissociative disorder. Finally, when treated, patients reported lower dissociative symptoms. Results confirmed previous research about distress in gender dysphoria and improved mental health due to…

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What I Needed: An Open Letter to Therapists from a Detransitioner

Detransitioner and author of this wonderful blog Maria Catt very generously agreed to write a guest post about the mental health care she wished she had received as she was going through her transition. Thank you for your brave words, Maria!

Update: Maria’s letter is getting a huge number of views. Evidently, this is striking a chord. If you are a detransitioned person and would like to submit an open letter to therapists and other professionals, please feel free to contact us. We welcome submissions.

The main thing I wish were different about the therapy I received before and during my transition is I wish my therapists had been trauma competent.

I was in therapy right after my college rape. I was in therapy for the many years I was wondering if I was some kind of trans. I was in therapy when I decided I was trans and needed to get my letters for hormones and surgery.

All three therapists knew about my college rape. All three therapists knew about my stressful childhood in a home with daily violence. The second two therapists knew about me going through an experience of being virally hated on on the internet. Looking back, knowing about dissociative states, it’s crystal clear that was a traumatic experience I had classic trauma reactions to- dissociation, depression, anxiety, avoidance. We talked over my rape. We talked over my childhood. We talked over a pack of strangers hating me on the internet. We talked and talked and talked.

Talking does exactly NOTHING to reset the human body’s stress reactions after trauma. A massage will do more than sitting in a room and talking. The first responders who were traumatized after 9/11 found massage and yoga more effective than talk therapy. I highly recommend the book “The Body Keeps the Score” by Bessel van der Kolk about the limits of talk therapy and the need for embodiment work after trauma.

So why didn’t any of these therapists teach me about cortisol and the other physiological facets of a prolonged stress reaction? Why didn’t we talk about the altered states of consciousness that are part and parcel of untreated trauma? Why didn’t anyone say anything to me about dissociation?

The first time anyone acknowledged that the circumstances I was talking about in therapy- humiliating, coerced sex (otherwise known as rape, my first therapist let me call it “coerced sex” the entire time),a stressful childhood in a violent home, the amorphous threat of a lot of men on the internet calling me terrible names and also knowing where I was performing- constituted trauma, was actually at a medical appointment. I told the doctor I couldn’t concentrate and was crying a lot. I also said I had been raped in college. I was given a prozac prescription and the doctor wrote down on my chart that I had PTSD. My therapists up to that point had not mentioned PTSD to me. Once I had what I took as permission to apply PTSD to myself, a lot of the way my brain worked made more sense. Extreme trouble concentrating. Racing, obsessive thoughts. Lots of crying. Getting triggered at comedy shows by all the rape jokes. Nightmares.

But no one said anything to me about dissociation.

No one said, hey do you ever feel like you’re an outside observer of your thoughts and actions? Do you ever feel like you’re outside your body? Do you ever feel numb for weeks at a time? Do parts of your body feel unreal to you?

This is the best link I could find describing the DSM 5 criteria for depersonalization/derealization disorder.

I believe my experience of constructing a fantasy, non-woman persona was somewhere between a depersonalization/derealization disorder and a dissociative identity disorder. The obsessive thoughts of how my life would be different if people could see the “real,” non-woman, no boobs or butt having me, were all day, every day, for years. I’ve had obsessive thoughts about being really more like a boy since before puberty. There have been points in my life when  I would  catch myself in a window or mirror and see a boy briefly. My breasts and thighs and butt have felt unreal to me for a long time. Since long before my college rape. Pretty much as soon as they came in it’s felt to me like there has got to be a zipper for this exaggeratedly sexual body suit I’m wearing.

Now, let’s be kind to my old therapists and acknowledge differential diagnosis is a tricky skill set.

Here are the criteria for gender dysphoria in the DSM 5:

  • Noticeable incongruence between the gender that the patient sees themselves are, and what their classified gender assignment
  • An intense need to do away with his or her primary or secondary sex features (or, in the case of young teenagers, to avert the maturity of the likely secondary features)
  • An intense desire to have the primary or secondary sex features of the other gender
  • A deep desire to transform into another gender
  • A profound need for society to treat them as another gender
  • A powerful assurance of having the characteristic feelings and responses of the other gender
  • The second necessity is that the condition should be connected with clinically important distress, or affects the individual significantly socially, at work, and in other import areas of life.

To get diagnosed with gender dysphoria you need two of these criteria for at least 6 months. Absolutely I had every one of these criteria for years. I had “an intense need to do away with my primary or secondary sex features” from ages 13 to 31. I had “a noticeable incongruence between the gender that the patient sees themselves as and their classified gender assignment” from ages 13 to 31. I had a “powerful assurance of having the characteristic feelings and responses of the other gender” from 26 to 31- once I was in a queer scene and knew about non-binary identities.

And yet, my “powerful assurance of having the characteristic feelings and responses of the other gender” was an incorrect powerful assurance. I am now powerfully assured if by some medical miracle surgeons actually were able to transform a bottom heavy woman into the David Duchovny lookalike that I obsessed about being since puberty, that transformation would have ended with me profoundly unhappy. (Surgeons can’t do that by the way. I had big delusions about what surgeons would be able to transform my body into. Realizing I was deluded about that resulted in a half a year of profound, suicidal despair.) If you get triggered by rape jokes at comedy shows you will constantly be triggered by how men talk to other men about the women around them. It would cause me significant, clinically important distress, which would affect me socially, at work, and in other important areas of life, to be regarded as a man by other men. My transition was always bound to fall apart, because what I actually have is a body with a stress response that is all bent out of whack from sustained, untreated, repeated trauma.

Ok, so how are mental health providers supposed to parse out who should be labeled with “gender dysphoria” and who should be labeled with a decades long dissociative disorder that is manifesting itself with gendered fantasy?

Good luck answering that. The DSM is a frustrating document because it attempts to categorize human misery along lines of potential treatment. This means that the treatments the psychiatric community and the patient communities like to have happen end up reflexively creating the diagnostic categories. The authors of the DSM 5 acknowledged that leaving the door open for insurance companies to pay for transgender medical interventions was a major consideration in how they reworked the criteria of “gender identity disorder” into “gender dysphoria disorder.” Here’s the fact sheet the APA put out explicitly acknowledging that.

I needed mental health care that would steer me towards constructing a daily life that works with my exaggerated cortisol responses, so that I can ease up off of the obsessive thoughts. Here are the lifestyle changes that have actually helped me with my “intense need to do away with my primary or secondary sex features” and my “profound need to have society treat me as another gender.”

1) Making reducing stress the number one goal of my life- reducing stress about money, reducing stress about bodily safety, reducing stress about accomplishments, reducing stress by separating myself from stressful people

2) Hot yoga

3) Getting enough sleep

4) Reducing use of marijuana and alcohol. Pot absolutely increases my risk of having an episode of dysphoric feelings, both while I’m high and the next day. I relied on marijuana so much while I was trans for stress reduction, and as a result felt like life was unreal, that my body was unreal, that I was living in a creepy movie, for 2 years.

If there was a pill I could take to help me with this dissociation I struggle with, I would take it in a heartbeat. My grasp on my symptoms when life gets stressful is sometimes tenuous. Getting care for dissociation is very challenging. Heck, getting care even for ADHD is really challenging- testosterone was way easier for me to get a prescription for than my ADHD meds.

I wish I had had a therapist talk to me about sustained stress. I wish I had had a therapist talk to me about cortisol. I wish I had had a therapist talk to me about embodiment work. I wish I had had a therapist who talked to me about trauma.

I also wish I had more answers for mental health providers. In the current political climate, responding to a patient who wants a letter for hormones or surgery with a line of questions about trauma symptoms is verboten. I think if MH providers felt ok about talking to each other about the traumatic histories they are seeing walk in with their trans patients, they could come up with better ways to encourage trans-identifying patients to hang out in a discernment period for awhile. Treating trauma symptoms is also something that people who should transition deserve. I believe there are people for whom living as another gender is the best outcome. I believe the people in that category also deserve education about trauma and embodiment. If only so that every decision the patient makes about the medical interventions they pursue are coming from a clear, relaxed, realistic about how their bodies can be transformed state of mind. People deserve to make life changing decisions when they are thinking clearly and are realistic about the future lives they’re constructing. People with untreated trauma are in long term altered states and should not make life changing decisions.

I’ve talked to therapists who specialize in trans care and I know this is already a concern for a lot of them. The political climate makes them nervous to speak openly about it. They need the voices of detransitioned people talking about trauma to create a climate where they can talk about trauma. More transitioned people being willing to speak openly about the role of trauma in their gender dysphoria would help a lot too. We are so constrained by this “brain gender” narrative. The political emphasis on sticking to that story, and editing life stories to affirm that narrative, ends up hurting trans people. At the end of the day, people get to transition because of their human right to autonomy. Part of respecting people’s autonomy is creating therapeutic contexts where they are making these big decisions with their most relaxed, calm, realistic mind. Therapists who treat trans people incorporating trauma education and treatment into their practices is a base level necessity to fulfill the ethical requirement of respecting their patients’ autonomy.


Social work professor speaks out on behalf of her FtM autistic daughter

An important piece by a social worker.


Dr. Kathleen “Kelly” Levinstein, PhD, LCSW, LMSW is a Professor of Social Work at the University of Michigan, Flint.  Among many other accomplishments, Dr. Levinstein was a Heilbein Scholar at the NYU School of Social Work, where she also taught, and has directed and provided clinical services for people with disabilities for many years, primarily in New York and New Jersey. A clinical and research social worker for 40 years, Dr. Levinstein describes herself as “the only out autistic PhD level social worker” in the world. Her research and advocacy work includes human and civil rights violations against the autistic community.

In this post and accompanying short interview, Dr. Levinstein tells us about the ordeal currently being experienced by her daughter who has undergone transgender medical transition. Dr. Levinstein also shares her thoughts about the current increase in young women with autism being diagnosed as transgender.


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A Psychoanalytic Take on the Ethics of Puberty Suppression

In a March 2015 article entitled “Transgender Children: Conundrums and Controversies” in The Psychoanalytic Study of the Child features a discussion about the possible benefits and dangers of puberty suppression in children who identify as transgender. It features an introductory paper by Claudia Lament, PhD, Training and Supervising Analyst at the Institute for Psychoanalytic Education. Her introduction lays out some of the arguments for and against puberty suppression.

Writes Lament, “Despite those advocates and opponents who swarm around both poles, any reliable conclusions as to the long-term safety and psychological effects of puberty suppressants will remain provisional until future studies proffer more definitive answers. While we await further study, the journal sees the necessity to press for dialogue concerning this conundrum.

The paper in the series that anchors the discussion is by Diane Ehrensaft, PhD.  Entitled Listening and Learning from Gender Nonconforming Children, it details Ehrensaft’s method, which she names True Gender Therapy. It is this paper I hope to examine and critique here. To be frank, I find Ehrensaft’s conceptualization of gender to be full of inconsistencies and ideology unsupported by evidence.

For example, Ehrensaft explains that she believes that we are all born with both male and female tendencies.

I situate myself in the school of thinking that conceptualizes gender as fluid rather than dichotomous. In essence, this is an extrapolation of Sigmund Freud’s Three Contributions to the Theory of Sex (S. Freud, 1962) in which he posited, as articulated later by Anna Freud, that our bisexual tendencies, considered part of the inborn constitution, “endow all individuals with psychological characteristics not only of their own but also of the opposite sex” (A. Freud, 1965, p. 195). Whereas Anna and Sigmund Freud were referring to sexuality and erotic object choice, I am proposing that the same paradigm can be applied to our gender: we are not born binary but rather gender inclusive. Beyond birth, gender development becomes an interplay of nature and nurture. Within this conceptual framework, the variations on gender that unfold over the course of development do not constitute abnormality but rather creative differences.

One possible way to understand this construction of gender is that we each have within us both masculine and feminine impulses and ways of being, and that we have a choice to express these fluidly according to what feels most authentic for us. I would agree with this whole-heartedly. But it begs the question – if gender is not determined by biological sex, then why attempt to change one’s biology in order to match an inner experience of gender?

It also begs a further question – If gender is fluidly constructed and we are neither entirely male nor female, why should we have to “pick” one?

Further on, Ehrensaft is specific about how she envisions this fluidity working when she writes that:

“Gender identity and gender expressions, on the other hand, refer to aspects of self that can be established or altered over the course of a lifetime, not just within the earliest years of life.”

Again, I find myself in complete agreement. Our sense of our gendered self is open to change throughout our entire life, and does not become fixed early on. If this is true, as I believe it is, why does Ehrensaft help young children become fixed in a gender identity that they then make a life-long commitment to via puberty suppression and sterilizing cross sex hormones?

Ehrensaft goes on to appeal to anthropological sources that make clear that gender nonconformity has existed in many cultures, including Native American ones.

Since the gender nonconformity was believed to be in the child’s nature, Native American parents did not to try to change the child. Instead, they allowed the child to either cross genders or live as both.”

Sounds great! I’m in favor. Let’s take a page from the Crow tribe, and allow gender nonconforming children to live however they like without forcing them to conform to sex role stereotypes. (Boys have short hair. Girls like pink.) This seems to me the rather obvious answer rather than setting a child on the road to a rigid identification with one gender and its culturally constructed sex role characteristics.

Ehrensaft sees each child as needing to “discover his or her own authentic gender.” According to this belief, our True Gender Self in inherent and immutable (even though she said earlier that it can change over the course of our life) and merely awaits revelation by the child.

“The True Gender Self begins as the kernel of gender identity that is there from birth, residing most importantly in our brain, mind, and body. Once we are born, and even in utero, the True Gender Self is most definitely shaped and channeled through our experience with the external world, but its center always remains our own personal possession.”

This is where I have the biggest problem with Ehrensaft’s True Gender Therapy. She seems to have delicately skipped over the fact that there is no robust evidence for any kind of biological cause for this notion of gender identity. It is NOT settled science that gender identity exists in the brain as some unique and discrete biologically-based property of human identity. As Rebecca Reilly Cooper says, we have a marker for differentiating sex, and it is male versus female biology. Studies such as this one and this one have failed to find any physiological etiology for transsexualism.

So if gender identity isn’t inherent and essential, why the special treatment? If a child of Caucasian parents were to assert that he was in fact South Asian, and that this were his True Ethnic Self, what should we do? Should we seek to facilitate a social transition, allowing the child to dress, speak, and perhaps eat foods according to (stereotyped) expectations of how South Asians behave?

What if the five-year-old daughter of a practicing Catholic couple announced that she was Jewish? Would we encourage the family to embrace their daughter’s Judaism as her True Religious Self? What makes gender identity more inherent than ethnicity, spirituality, or any other aspect of identity? (Note that if this were our child, we might tolerate or even encourage her religious exploration. And hopefully, we would welcome her mature decision to convert to Judaism or any other religion once she were older. We might be inclined, however, to keep bringing her to mass for the time being, simply because that is the norm in our family, and she is still quite young. I don’t think that anyone would accuse us of thwarting her True Religious Self if we did so. Analogy stands.)

As Paul M. Brinich, PhD comments in response to Ehrensaft’s paper:

Ehrensaft writes, “In childhood it is up to the child, not the parent, to spin the gender web.” Does that “hands-off” attitude extend to other crucial areas of biopsychosocial development such as toilet training? I very much doubt it. And yet I cannot see a huge gap between the “self” that must grapple with toileting and that which must grapple with questions of gender identity and gendered behavior. Is the true self a poopy self or a clean self?

In short, gender identity is a construct which may be useful in understanding people’s experience of gender. However, it is just a construct. There is no empirical evidence that it exists per se. Therefore, it is very poor grounds for leading children down a path that will lead to permanent sterilization.

Here again is commentary from Dr. Brinich:

The concept of “True Gender Self” begs the question: How do we decide what is a “true” gender self? Can what is “true” at age three or thirteen or twenty-three become “false” at thirty-three or forty-three or fifty-three? Perhaps we should replace that “true” gender self with a more modest “currently adaptive” gender self. This would, at the very least, emphasize that these matters are not fixed but continue to evolve as long as we are alive.

Ehrensaft goes on to propose that a child’s reluctance to pick a gender is a creative response to a developmental crisis.

“We could say that they are the ultimate antiessentialists, who challenge us to reconsider that gender can be all-and-any, rather than either-or. In that sense they are able to maintain what so many of us have relinquished in our earliest childhoods as we strived to accommodate to a social world in which gender is defined by what is between our legs rather than what is between our ears. Rather than an arrest, we can recognize the children’s persistent gender inclusivity as an accomplishment, one in which they are better able than those who have relinquished gender inclusivity to privilege psyche and social construction over deterministic biological materiality, much to their artistic and creative credit.”

Again, I mostly agree here. The contradiction in her position, however, is hinted at in the word “anti-essentialists.” For without appealing to some kind of essentialism, there can be no good reason to risk the health and fertility of children. If biology (sex) is not essential to gender, then what is? Is nothing essential to gender? I believe that could be true, or largely true. If so, then we certainly shouldn’t be delaying puberty and risking health and fertility over a construct that is so wide open and not nailed down. Is something else essential to gender? Something “between their ears?” What is that? What does what is “between the ears” have to do with gender? What do we know about it? As I said before, there is no good evidence that there is a gendered brain, or that gender identity has a biological basis. In any case, even if there were some evidence of a gendered brain, (and there really, really isn’t), why should that kind of essentialism trump the much more straight-forward and obvious essentialism of biology?

She talks about children needing to live a “gender authentic life,” and I find this term, too, sticks in my craw. Notions of psychological development are many and varied. It seems to me that this idea that there is one authentic way to be – in any realm of our life – is a particularly narrow way of understanding what it means to be human. In a recent Wall Street Journal book review, Michael Puett and Christine Gross-Loh make this point.

According to Confucius and other Chinese philosophers, we shouldn’t be looking for our essential self, let alone seeking to embrace it, because there is no true, unified self to begin with. As Confucius understood, human beings are messy, multidimensional creatures, a jumble of conflicting emotions and capabilities living in a messy, ever-changing world.” (WSJ, April 2-3, 2016, “The College of Chinese Wisdom.”)

Ehrensaft ends her paper with a long case of a prepubertal child with whom she worked who eventually chose to go on puberty blockers. The case was, of course, presented as a tremendous success, with the child presenting more confidently and happily after choosing to live in their affirmed gender.

While I am not doubting Ehresaft’s report, it seems crucial to mention that whenever it has been studied, the administration of puberty blockers has resulted in children going on to take cross sex hormones nearly 100% of the time. Puberty blockers are NOT a neutral intervention. They effect the development of gender identity. A child who takes puberty blockers and then goes on the take cross sex hormones will 100% of the time be permanently sterilized.

Is True Gender Identity really worth permanent sterilization and a lifetime of potentially harmful medical treatments?