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?


4 thoughts on “A Psychoanalytic Take on the Ethics of Puberty Suppression

  1. I really like the notion of “currently adaptive gender self.” That seems like a really logical and useful concept. It points out correctly that the “nonconforming” behavior and self-image is somehow “adaptive” (i.e. useful) to the person. And it points out that the adaptation may be mutable (since “currently” does not always equal “permanently”).

    Permanent body modifications for those who cannot truly give “informed consent” because their brains’ executive functions are not fully developed are not a good, safe, or proven response. May the time come swiftly when professionals can express these opinions without risking their livelihoods.

    Liked by 2 people

  2. You are completely ignoring the hard science from myriad sources on ‘gender identity’ that shows it to be innate and determined before birth. No question about this anymore. Psychoanalysis and Freudian thinking are pseudoscience. Learn physiology if you really want to understand behavior.


    1. Would you kindly link here to one robust research study that “proves” that gender identity is innate and determined before birth? I have not to date seen any evidence to this effect.

      In fact, this study


      and this study


      failed to find any biological etiology for transsexualism.

      This is in fact quite an open question and skepticism about claims for innate gender identity are warranted given the permanent nature of medical transition.

      Even if it is innate for some number of people, there is a lot of research showing that a large majority of gender dysphoric children will desist, and so far there is no way to know in advance which children will desist and which will persist. Therefore, again, caution is warranted.

      Liked by 1 person

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