Psychotherapist Lisa Marchiano sent the following letter to the APA in support of Justine Kreher of thehomorarchy.com. For months, Justine has been tirelessly sending letters to LGBT organizations on this topic.
Lisa blogs on parenting at https://blogs.psychcentral.com/big-picture-parenting/ and blogs on Jungian topics at http://www.theJungSoul.com. She can be found on Twitter at @LisaMarchiano.
March 6, 2017
Dear Members of APA Division 44:
I am writing this letter in support of my colleague Justine Kreher of thehomoarchy.com. (Her letter can be found here.) I am a licensed clinical social worker and Jungian analyst who has consulted with dozens of families who have a transgender identified teen. My experience with these families has shown me that parents want to protect their child from drastic and potentially harmful medical intervention that may not be necessary.
I have many concerns about the role of psychologists and other mental health professionals in affirming a young person’s self-diagnosis as transgender, and encouraging immediate social and/or medical transition. For the sake of brevity, I will focus on the following four areas:
Potential Harm to Gay, Lesbian, and Bi Children
I am aware of the APA’s position on sexual orientation conversion therapy (i.e. therapy intended to ‘convert’ gay individuals into heterosexual individuals). The first strong position came out in 1997: http://psychology.ucdavis.edu/rainbow/html/resolution97_text.html and then a stronger position later: http://www.apa.org/about/policy/sexual-orientation.aspx
The APA has taken an unequivocal stance against conversion therapy. Gender reassignment evaluation and treatment, without strong guidelines and oversight in place, amounts to the same outcome as conversion therapy – implementing a treatment for a problem that hasn’t been scientifically established to exist, with the intent of creating a change that hasn’t been proven to be therapeutic (or is only therapeutic in some cases). I encourage the APA to take a strong position against pediatric transition practiced without careful oversight.
There is plenty of anecdotal evidence reported by clinicians who see families with gender nonforming children that parents are uncomfortable with the thought of having a gay or lesbian child. Many of these parents feel more comfortable having a transgender child. One example appeared in this article in The Atlantic.
Catherine Tuerk, who runs the support group for parents in Washington, D.C., started out as an advocate for gay rights after her son came out, in his 20s. She has a theory about why some parents have become so comfortable with the transgender label:
“Parents have told me it’s almost easier to tell others, ‘My kid was born in the wrong body,’ rather than explaining that he might be gay, which is in the back of everyone’s mind. When people think about being gay, they think about sex—and thinking about sex and kids is taboo.”
In the recent BBC documentary “Transgender Children: Who Knows Best?” Dr. Ken Zucker shared that he had had families say of their trans kids, “Well, at least they’re not gay.”
Kimberly Shappley, whose transgender daughter was featured in the March, 2017 HBO special Vice was clearly disturbed by the thought that her little boy was exhibiting pre-gay behavior. The following quote is from this news article.
“I am a devout and conservative Christian and an ordained minister,” she said and explained that she tried to force Kai into being a boy when she was a toddler. “I knew my kid was different before the age of 2,” Shappley said. “My child was very feminine, flamboyant and dramatic. No matter how I tried to punish, reshape or discipline her, she continued being very feminine.”
In this news article, Shappley admits that friends and family were questioning whether Kai was gay before Shappley allowed her child to transition. Says Shappley:
“I was very concerned, because at the time I was leading a small ministry at my church and teaching Bible study, and here I have this kid who people in my family were flat asking me if this kid was gay.”
While Shappley’s story may be an especially clear cut case where a parent appears to be more comfortable having a gender conforming “straight” trans child than a gay or lesbian child, tales such as this are not uncommon.
Keeping this in mind, consider the recent longitudinal study that found high rates of gender nonconforming behavior among gays and lesbian in early childhood.
Abstract. Lesbian and gay individuals have been reported to show more interest in other-sex, and/or less interest in same-sex, toys, playmates, and activities in childhood than heterosexual counterparts. Yet, most of the relevant evidence comes from retrospective studies or from prospective studies of clinically-referred, extremely gender nonconforming children. In addition, findings are mixed regarding the relationship between childhood gender-typed behavior and the later sexual orientation spectrum from exclusively heterosexual to exclusively lesbian/gay. The current study drew a sample (2,428 girls and 2,169 boys) from a population-based longitudinal study, and found that the levels of gender-typed behavior at ages 3.50 and 4.75 years, although less so at age 2.50 years, significantly and consistently predicted adolescents’ sexual orientation at age 15 years, both when sexual orientation was conceptualized as two groups or as a spectrum. In addition, within-individual change in gender-typed behavior during the preschool years significantly related to adolescent sexual orientation, especially in boys. These results suggest that the factors contributing to the link between childhood gender-typed behavior and sexual orientation emerge during early development. Some of those factors are likely to be nonsocial, because nonheterosexual individuals appear to diverge from gender norms regardless of social encouragement to conform to gender roles.
Given the high rates of gender nonconforming behavior in gay and lesbian children; the high desistance rates of gender dysphoria; that as yet there is no reliable way to determine which dysphoric kids will desist and grow up to be well-adjusted lesbian, gay, or bi adults; given that puberty blockers followed by cross sex hormones lead to permanent sterility 100% of the time, it is crucial that careful clinical guidelines be developed that will help to prevent gay and lesbian children being lead down a path that leads to permanent sterilization and other medicalized intervention. Since the APA has taken a strong stand against conversion therapy, the organization should also speak out against what is in practice a form of medical gay conversion therapy.
Lack of Evidence Regarding Outcomes
Currently, the evidence related to transition outcomes is relatively poor. In June of 2016, the Centers for Medicare and Medicaid Services (CMS) denied coverage for gender reassignment surgery after a year-long review determined that there was not sufficient evidence that these treatments were therapeutic. From the report:
Based on a thorough review of the clinical evidence available at this time, there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria. There were conflicting (inconsistent) study results – of the best designed studies, some reported benefits while others reported harms.
The overwhelming majority of the evidence about transition was derived from studies done on adult transitioners. There are only a few studies that look at outcomes among those who transitioned prior to age 18. De Vries et al. noted positive outcomes among pediatric transitioners. However, the sample size of 55 was relatively small. In addition, it seems worth pointing out that the original group being studied consisted of 70 young people. One of these was not included in the study because the individual died from postsurgical necrotizing fasciitis after vaginoplasty. In addition, these young people were assessed for the final time at approximately one year post surgery.
In contrast, consider the study conducted by a young female detransitioner. Though not peer reviewed research, this study offers one of the few glimpses into the experience of those who transitioned and then went on to re-identify as female. (Honestly, I find it sad and telling that the only research being done on this growing group is being conducted by the young women themselves.) Cari Stella’s study was open for two weeks. During that time, more than 200 detransitioned women responded. The results are enlightening. Most chose to detransition because they found other ways to deal with their dysphoria. While participants in the De Vries study were assessed for a final time at least one year post operation, the women who answered Cari’s survey reported that the average time they spent transitioning was four years. It seems possible that some individuals in the De Vries study may become less happy over time with their outcome.
It is also important to point out that those individuals in the De Vries study were carefully screened, assessed, and followed. In today’s climate of immediate affirmation, young people are receiving hormones after only a handful of therapy sessions. This of course may make it more likely that they may come to regret these interventions. From Cari’s survey:
117 of the individuals surveyed had medically transitioned. Of these, only 41 received therapy beforehand. The average length of counseling for those who did attend was 9 months, with a median and mode of 3, minimum of 1, and a maximum of 60. I’d like to have something cool to say here, but I’m honestly just stunned at the fact that 65% of these women had no therapy at all before transition.
Cari’s findings corroborate what I am hearing from parents and seeing online. With good intentions, gender therapists are quickly affirming a trans teen’s self-diagnosed identity. However, this may mean that other factors get overlooked.
Cari’s survey and the writings and videos of detransitioners around the web make it clear that many who underwent transition feel that they were doing so as a maladaptive coping mechanism to deal with trauma, anxiety, social difficulties, or other issues. The majority of detransitioners speaking out online now identify as lesbian, and many of them feel that internalized homophobia played a part in their believing that they were men. Many express having been harmed by their transition, and some refer to it as “medically assisted self-harm.” Here is just one excerpt from the writings of a detransitioner discussing how she was harmed by transition:
I transitioned FTM at 16, was on testosterone and had a double mastectomy by 17. I’m 20 now and back to understanding myself as a lesbian, like I was before I found out about transition and latched onto it as a way to “fix” body issues created by the challenges of growing up in a deeply misogynistic and lesbian-hating world.
I absolutely am traumatized by what happened to me, and I’m not the only one. I’m a part of support networks for women who stopped transition that have over 100 members, and that’s just the individuals who have gone looking for others with this experience and found us. I’ve met more than a dozen of these ladies in person at different times… we’re definitely real.
Plenty of others who transition, whether they continue or not, live with complicated feelings about what happened. Not all of us name those experiences the same way, search for community to process that pain, or ever “go public” to any degree. This is trauma.
Hormone therapy really wasn’t that safe, in my experience. I remember being 17 and watching my pediatric endocrinologist literally Google dosing information right in front of me. Didn’t inspire confidence. The doctors controlling my HRT had no idea what they were doing, at least with patients like me. They were all just as confused about how to treat me medically as they were about how to interact with me as a human being. When I was on testosterone and taking Adderal for ADD, I got heart palpitations, chest pain, and shortness of breath. I didn’t tell anyone because I didn’t want to have to choose between a psych med that was making a huge difference in my ability to function in the workplace and hormone therapy, and I didn’t want to acknowledge that what I was doing was dangerous.
Early in my transition, I went through menopause. This caused vaginal atrophy and drip incontinence that has persisted for years. I piss myself slowly all day now; it’s really not cute or fun. I refused to acknowledge it was connected to the HRT-caused vaginal atrophy that immediately preceded its onset until months after going off testosterone. Yeah, I signed a paper saying I knew that could happen. I also thought this treatment was my only hope for coping with the intense feelings of alienation/disgust with my femaleness. I was wrong. Transition didn’t help. It did harm, harm that I now have to learn how to live with on top of all the shit I thought transition would fix.
Practice norms in this area are alarmingly based more on activist agendas than evidence. Take for example Diane Ehrensaft, PhD. She is a thought leader in pediatric transition, and the Director of Mental Health and founding member of the Child and Adolescent Gender Center at UCSF. She has written and published widely, and is often cited as an expert. She writes about helping children find their “true gender self,” and states that the clinician needs to go through a careful process to differentiate between the persisters, desisters, and the genderfluid – or the “apples,” “oranges,” and “fruit salad,” as she names them. However, she cites almost no research to help us understand how she makes these determinations. As stated earlier, we do not currently have criteria that can definitively identify which children will persist. In this short video clip, Ehrensaft reveals her casual disregard for the fact that the treatment path towards which she leads families will permanently sterilize the child.
Until recently, the evidence for social contagion among transgender identified teens was strong, but anecdotal. For example, a therapist wrote a blog post in which she described whole friend groups coming out together. Fortunately, there is some research currently being conducted that is attempting to document social contagion among transgender identified teens.
This transgender trend looks strikingly like other social contagions to which adolescents are known to be prone. There is considerable research on suicide contagion among teenagers. There is also a great deal of research on social contagion in eating disorders. To take just one example, Paxton et al. demonstrated that a teen girl’s use of extreme weight-loss behaviors is closely linked with whether her friends use them. From the study:
This study explored friendship variables in relation to body image, dietary restraint, extreme weight-loss behaviors (EWLBs), and binge eating in adolescent girls. From 523 girls, 79 friendship cliques were identified using social network analysis. Participants completed questionnaires that assessed body image concerns, eating, friendship relations, and psychological, family, and media variables. Similarity was greater for within than for between friendship cliques for body image concerns, dietary restraint, and EWLBs, but not for binge eating. Cliques high in body image concerns and dieting manifested these concerns in ways consistent with a high weight/shape-preoccupied subculture. Friendship attitudes contributed significantly to the prediction of individual body image concern and eating behaviors. Use of EWLBs by friends predicted an individual’s own level of use.
Paxton, S. J., Schutz, H. K., Wertheim, E. H., & Muir, S. L. (1999). Friendship clique and peer influences on body image concerns, dietary restraint, extreme weight-loss behaviors, and binge eating in adolescent girls. Journal of Abnormal Psychology,108(2), 255-266. doi:10.1037//0021-843x.108.2.255
Social contagion among teens is a rich area of literature for which many examples could be cited. This 2014 study found that teens who adopt an “alternative” identity such as “emo” or “Goth” were more likely to self-harm. This was true even after controlling for other factors. The authors point out that engaging in self-harm aids in reinforcing group identity among teens.
It is likely that we do not yet fully understand the enormously powerful role that social media can play in spreading social contagion. Many transgender identified teens report extensive time online on social media sites such as Reddit or Tumblr. On YouTube, there are tens of thousands of videos made by trans young people, documenting their transitions in a way that valorizes taking testosterone and estrogen, or getting a double mastectomy.
Consider this account from a young man found here:
So you have all these young men who don’t understand their sexuality, watching sissy porn. Eventually they are going try and find out what it all means.
This is where the trans ideology plays its part. The trans narrative sucks these confused young men like myself in with all the “answers.” You see many confused fetishists posting in places like reddit/asktransgender asking if they are trans. Whatever their questions are, the usual reply from these places is something like “if you could press a magic button that would give you a female body would you press it? If you thought about it, then you may be trans, because a “straight” guy wouldn’t hesitate for a moment.” They try to equate the masochistic thrill with a desire to be a woman. And once you fall for that they have you.
They create a very intricate web of bullshit that is very hard to see out of once inside. It is very cult like. Any non-kool-aid drinking source of information is deemed “transphobic.” Any therapist that doesn’t tow the line is a “gate keeper.”
Lastly, in discussing teen transgender identification and social contagion, it is crucial to keep in mind that teens are presenting with gender dysphoria in a way that was exceedingly rare even a short time ago. Until recently, most cases of pediatric gender dysphoria began in early childhood. With the onset of puberty, most children desisted, but some persisted into late adolescence. Research confirmed that cases of gender dysphoria that began in early childhood and persisted into late adolescence were extremely unlikely to resolve. In these cases, it made sense to assist the young person in transitioning. Now what we are seeing is significant numbers of young people coming out as transgender in adolescence (the most common age appears to be 14 or 15) without having had any prior history of gender dysphoria or even gender nonconforming behavior in many cases.
The major studies on using puberty blockers had very strict criteria of early onset of gender dysphoria and life-long gender dysphoria. Specifically- the studies did not include kids who had no gender issues in childhood and had the onset of gender dysphoria happening as a teen. It is quite an overreach to apply those studies to defend treatment for kids who have an out-of-the-blue onset of GD as a teen (often in the context of mental illness or social struggle) as if they are exactly the same thing. This rapid onset gender dysphoria appears to be an entirely new clinical presentation that may well indicate significant social contagion.
Misuse of Suicide Statistics
In nearly every media article that discusses transgender children, a mention is made of high rates of self-harm and attempted suicide. Gender therapists often cite suicide statistics in attempting to convince parents to affirm their child’s trans identity and allow them to transition. The Williams Institute found that 41% of transgender people reported having made a suicide attempt at some point, and this statistic is frequently cited. The study’s authors admit that, because of the way the survey was conducted, the 41% number may be somewhat inflated. Taking this into consideration, we see that suicidality among transgender teens appears to be roughly similar in incidence to suicidality among gay and lesbian teens.
Most relevant to the discussion here is the complete lack of evidence that transition alleviates suicidality. The Williams Study, for example, does not indicate when the attempts took place – whether before or after transition. In fact, it may be the case that suicidality is higher among those who have transitioned.
Studies such as this one found that suicide rates were higher for those who transitioned. From the study:
“Those who have medically transitioned (45%) and surgically transitioned (43%) have higher rates of attempted suicide than those who have not (34% and 39% respectively).”
A long-term follow up study conducted in Sweden and published in 2011 found that suicide rates were significantly higher for those who had transitioned.
“Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.”
A 2015 suicide cluster of transgender teens in San Diego included three adolescents who had been fully supported in transitioning by their families.
It bears repeating: There is no evidence that transition reduces suicidality among transgender teens. Suicidal young people ought to be treated for suicidality, not given body altering drugs. Nevertheless, gender therapists continue to use the threat of suicide to convince parents to allow their children to undertake irreversible medical interventions of dubious therapeutic benefit.
Thank you for taking the time to read my letter. I hope you will give the issues I have raised here careful thought.
Lisa Marchiano, LSCW, NCPsyA