Sasha Ayad, M. Ed., LPC is a therapist with extensive experience working with teens, and gender defiant teens in particular. When she started to notice her bright, creative gender defiant teen patients feel that they needed to define themselves by picking a label that then sometimes encouraged them to make permanent changes to their bodies, Sasha found herself thinking critically about this trend. She has researched gender identity issues in teens extensively, and has a private practice where she works to support gender questioning youth. In Sasha’s words:
“I use non-judgmental, compassionate, dialogue that focuses on exploration rather than immediately seeking to affirm and transition your child. Together with your teen and family, we consider multiple complex factors that may contribute to their dysphoria, including social, cognitive, environmental, physical, and emotional factors. Treatments may include mindfulness, somatic, and integrative techniques as well as confidence-building, and age-appropriate sexual identity exploration. I also educate parents about the topic of gender identity, break down stereotypes, discuss risks, and encourage parents to become deeply invested in the process so they can best support their child outside of therapy sessions. While transition may be the best option for some kids, many others have had very painful and negative experiences with their transition, and I help families prevent this from happening. I believe I owe it to your child to be thorough and careful in my approach, placing safety, well-being, and happiness above all else.”
The following piece was posted originally on Sasha’s blog. While the current narrative around helping trans identified teens creates a false dichotomy between affirming a teen’s identity and being unsupportive or rejecting, Sasha’s work beautifully illustrates how one can offer unconditional support while helping a teen to navigate the confusing waters of identity.
I was busy working on a behavior plan for a very fidgety 6th grade boy when I heard an assertive knock on my office door. This was the third time this week Sally had left class without permission to come talk to me.
“Ms Ayad, how can I transfer schools? I really don’t think I can get a proper education here and none of the teachers know what they’re doing”, so began our 45 minute conversation. She often got fixated on one or two teachers, who despite their best efforts, could not find a good way to work with Sally. I had a very different relationship with her though, and I was able to help her work through some of her generalizations and logical leaps.
Her hair was always pulled back hastily in a low ponytail, the eczema around her mouth, though visible, wasn’t as noticeable as the smudges that covered her glasses – she pushed them up from the lenses every time. Often a curious little smirk would lift the corner of her mouth, even when she was clearly upset or discussing something serious.
She is one of those kids who teachers were often exacerbated by, but I got to see her in a different light, and I found her endearing, creative, and incredibly interesting.
Once we were able to conclude that switching schools was not the best option, and I taught her some self-regulation skill using a squeeze ball, it seemed she was much more at ease. She took a deep breath and said “Ms Ayad, can we talk about that other thing now?”
“You mean gender?” I replied. She nodded.
Sally and I had been talking for the last several months about her “gender identity”. When she first brought this up to another counselor, they referred her to me, knowing that I am experienced and confident in working with kids around this topic. However, Sally had certainly been exploring this issue online for months she brought it to the attention of her school counselors. Our first conversation on the topic made it clear that she had a broad vocabulary (straight from gender identity theory) which is not typical for most middle-school students.
My approach was patient, inquisitive, and I challenged her… just a bit. When she talked about her parents pressuring her to wear dresses and “act more like a girl”, I made a point of breaking this down, deconstructing what that means, and sharing ways that we all behave outside of gender stereotypes: and that’s a GOOD thing!
When she told me, weeks later, that she was looking for binders online and asked me to stop using the pronouns “her” and “she”, I felt deep pangs of worry, but took it slow. I asked her where some of these ideas were coming from: she was spending hours on tumblr, trans-advocacy sites for teens, and chat groups with other kids who she believed were “just like her”. I treaded very carefully, but told her about the medical dangers of binding and what the long term consequences may be. Our limitations in the school system made it hard to get too deep on these topics, but in every brief interaction with Sally, I found ways to empathize with her struggle, instilling pride in who she is, and still gently challenge her flawed ideas.
I deliberately pointed out all of the ways she doesn’t conform to gender stereotypes, without implying that she’s in the wrong body: her love of manga comics, her cargo pants, her disdain for dresses and “girly” clothes, in my eyes, made her a unique and awesome person. Hearing those compliments always brought that endearing little smile to her face.
Eventually, as her classroom behavior improved, her anxiety lessened, and she started making friends, she relied less and less on me for support that year. Several months passed and before I knew it, the school year was coming to a close. I wanted to follow up with Sally, so I pulled her from her PE class and we talked outside on a particularly nice, sunny afternoon.
I started with, “Sally, I’ve missed you, how are things going? It seems like we haven’t talked in forEVER!” A huge smile emerged on her face, and since her glasses were less smudgy than normal, I could actually see that her eyes were smiling too.
“Doing great! I’m getting along better with Ms Barnay and I haven’t been walking out of class when I feel frustrated”. We talked about the anime club, her plans for summer, and how her other classes were going. She paused, looking ready to tell me something that meant more to her than academics. “Ms Ayad, remember how we used to talk about gender a lot? Well, I’m kinda over it”.
“Ok, tell me what you mean by ‘over it’, Sally”.
“Well before, when I didn’t have any friends at school, I was meeting a lot of people online and I thought they were my friends. Then when I actually started hanging out with people in real life, things felt different. Before, I really wasn’t comfortable with myself so I felt like I needed to change. But now, I’m ok with myself”.
I nearly fell off the bench. This was one of the most profound realizations a therapy client can make – and she, even in her young 13 year-old body and mind, came to this conclusion by herself: “I really wasn’t comfortable with myself, so I felt like I needed to change. But now I’m ok with myself”.
I was grinning from ear to ear by this point. I told her how incredibly proud I was, that I was so happy she was feeling good about herself.
Over the summer I thought often about Sally’s story. While she turned things around largely on her own, I can’t help but wonder how things might have unfolded had I followed the prescribed gender identity model.
What if I had asked about using male pronouns?
What if I had been very supportive of her desire to bind her chest?
What if I had affirmed the idea that because she doesn’t like dresses and feels like she identifies with trans kids online, that she too may be a boy stuck in a girl’s body?
And what if I hadn’t directly (though gently) challenged some of her flawed beliefs – that stereotypes and clothing styles are a good foundation on which to question your biology, to modify your body parts, and to change your entire identity.
These are questions gender therapists HAVE to ask themselves, and it frightens me that most aren’t. Our kids are dynamic, different, and unique. But they also have insecurities, self-doubt, and are vulnerable to finding “solutions” in the wrong places. When a teenager feels isolated and misunderstood, trans-advocacy sites can convince them that hope lies in changing who they are. And isn’t this the opposite of what we’ve always tried to instill in kids: self-love, confidence, and embracing their uniqueness?
Regardless of the misinformation and wayward perspectives currently taking over the mental health field, I will continue to focus on self-acceptance for my clients. Sally’s story, and many others like it, will be our reminder that in counseling, self-loathing should never be promoted over self-love.
*The names in this story have been changed to protect the identities of the people involved.
Marcus lives in the United Kingdom. He can be reached at @LogicalMarcus on Twitter. He has provided an extensive bibliography at the end of this piece.
I’m twenty-four and it is the mid 2000s. I am coming out to my parents. I planned it carefully. They have never made a homophobic remark but I have read accounts of coming outs going poorly, so I have waited till I am an independent adult. I tell them I have a boyfriend called Matt. They take the news with no real rancor. My father tells me to be careful about AIDS and my mother cries because I will not have children. We continue to love one another.
Every gay and lesbian person has a story of how they came to accept themselves. Realizing you are gay can take a long time. It took me at least ten years, much denial, some unhappiness, and lasted until I was a grown man. There was never a moment as though a sign turned on in my head to say “You’re gay.” For a long time I tried to ignore it or bargain it away: I didn’t want to be one of “those” people, who seemed to be on the margins of society. Self acceptance and coming out were gradual, constant negotiations between my feelings and what I felt safe and comfortable saying, to myself and others. But I am just who I am, a gay man, and there is nothing wrong with that. The rest is society’s problem, not mine.
As an adult I hoped growing up gay would be easier for children today. With what’s commonly called LGBT acceptance, gay and lesbian people are full legal citizens in many Western nations, and can marry, and have basic protections from prejudice. We are not yet full social equals – holding hands and kissing as a same sex couple can attract unwanted attention and be dangerous, “gay” is still a playground slur, and we rarely see our lives reflected in the media. But when I see young gay couples walking around, I feel intense pride and happiness that the situation is improving.
Recently I have read many accounts of parents raising so-called “transgender kids”. This is a new thing, specific to wealthy Western nations and in particular the US, that did not exist when I was growing up. These are children who are held to be “female brains in male bodies”, or vice versa. The science does not support this claim: science shows that there are no male or female brains. These “transgender kids” are not diagnosed by scanning their brains. They are boys who prefer, in some way, “girl things”, or the other way around. These children are dysphoric, that is unhappy, specifically with the kind of things they can do as boys or girls. They can be as young as three or four. For example:
For such children, an increasing number go through the following regimen: social transition (dressed as the opposite sex), then subjected to increasingly invasive medical treatment: puberty blockers, then cross-sex hormones, followed by sexual reassignment surgery at adulthood or even mid teenage years. Transgender kids seem to be a trend in the USA and UK, and the numbers reflect that, with steep increases at “gender clinics”. But how is it possible so many children are just now being declared to be in the “wrong bodies”? This looks alarmingly like a kind of conversion therapy. Studies (links below) have found that most children who express “gender identity disorder” did indeed desist and become gay adults in the past.
As a gay man, who also has struggled at times to accept myself in a society that does not always accept me, it is troubling to see children encouraged to think their bodies are wrong for the way they behave or the way they feel. The root of this seems to be a conservative enforcement of the same stereotypes that make gay people suffer. Even when these children are said to declare they are in the wrong body I think it is plausible they are doing so out of an awareness some kinds of bodies are being allowed to do some things, but not others, and if you want to do those other things you had better have the other kind of body. But surely it is better to tell all children that they can do, wear, and enjoy whatever they want without it being “wrong”.
I think there is a fad, or a contagion, going around parents and medical professionals, being pushed by motivated activists and fed by well-meaning liberals and echo chambers on social media, for declaring children to be transgender. Although society recognizes this as real, for example in educational material and school bathroom use, there does not seem to be solid science or evidence behind this condition being more than a cultural issue. I am concerned this fad will harm children through unnecessary medical treatment with permanent effect – sterilization for example, or the irreversible effect of testosterone on the growing female body.
In particular, a trend for transgender kids seems to target those children who do not conform to stereotypes society expects them to obey on account of their sex: who very often grow up to be wonderful, happy, effeminate gay men and butch lesbian or bisexual girls. We need years or decades to grow into ourselves as gay adults and the medicalization of difference through transgender seems like an attack on our personhood, an attack on our right to process being gay, painful and confusing and messy as it can be.
I have known dozens of gay men and lesbian women who might well have been “trans kids” today. Some of these gay men like to paint their nails, or dress up in women’s clothes (drag), and they care very much about clothing, and have some effeminate mannerisms. Some of these lesbians are rough and tough and they like short hair and clothing cut for men. They are happy and comfortable being who they are. I admire these non-conforming gay and lesbian people very much, because most never had the luxury of the closet, like I did. If they had been made into “trans kids” in order to produce humans who conformed better to a standard I think the world would be a poorer place and they would have been harmed. If the prevalent view of transgender is wrong then harm is being done to children and we cannot remain silent.
I have also met transgender people, in real life and online, and I have listened to their pain over their “wrong bodies”. But I also do not understand how transgender can be destined or “real” in the same way that being gay is real. Transgender and gay are not interchangeable. There are profound differences between gay and transgender. The idea of transgender as a biologically destined, permanent, fixed identity should be justified on its own merits, not by a silencing tactic where activists claim their cause is no different from gay rights and scream “Transphobia” at all questions. Gay activists never had to silence, shame or threaten opponents, because our cause is just, cohesive and reasonable, and stands by itself.
Nobody has ever shown being gay can be “cured” but there is evidence that transgender people do sometimes stop being transgender. People do detransition. One way in which gay people have also argued against a notion that being gay was wrong was to point to gay animals. There are gay animals everywhere, and our closest ape relatives the bonobos are thoroughly homosexual, but mammals do not change sex. Nobody has ever seen a transgender sheep, where a ewe becomes a ram. A dominant female hyena can take on a male role but it is still a female that has a different, natural, hormonal balance, not a male hyena.
Most importantly “the mind does not match the body” is the opposite of what being gay is about. At the end of our coming out stories, gay and lesbian people are comfortable being just who we are. There is nothing wrong with us, nothing wrong with the way we were born. Our problem is society’s prejudice, not our minds or bodies. Lesbian, gay and bisexual people have always demanded freedom from persecution and acceptance as the social and legal equals of straight people, which we are.
There is no need for medical intervention, hormones and surgery to be gay. In fact the words transition and conversion are synonyms. There are alarming similarities between the discredited notion of conversion therapy against gay children and so-called gender transition therapy. Reinforcing this, conservative Islamic nations such as Iran, the United Arab Emirates, and Pakistan, all punish homosexuality, but encourage or mandate a conversion of gay men to transgender women via sexual reassignment. It is appalling to contemplate supposedly liberal parents replicating Iran-style erasure of gay people on their own children.
Seen this way transgender could be compared to anorexia, because here too there is great unhappiness about the body. Anorexia is a real and serious condition, and anorexic people must have their human dignity respected, but it would be dangerous to say we should accept anorexia, or tell children anorexia was okay. Magazines that promote anorexic models and celebrities are criticized and there is an attempt to stop the fashion industry from doing this.
I probably would not have been a “trans kid” if I had grown up today. I was not effeminate but bookish and a science geek, and with the trend for medicalized childhoods, I might have been diagnosed with something else. There is a broader and long term trend of over-medicalizing children. A diagnosis like ADHD seems to often reflect an attempt to contain rambunctious childhood personalities. Of course medical treatment is not always bad but it must also be based on the best evidence that it is necessary and not harmful. What kind of evidence should we demand before assigning a child a medicalized identity, setting them down a road that can end in sexual reassignment?
I think parents and children should not always pursue instant gratification even if medicine seems to offer it.
Having a teen with rapid onset gender dysphoria can feel like being lost without a map.
This story comes from “Mother Earthling.” It was originally posted on reddit and is reposted here with the author’s permission.
I was driving my 8 y/o daughter (I’ll call her “A”) to camp today, and we had a slightly terrifying, yet in the end, kind of wonderful conversation about girls who feel “more like boys.”
Her friend “B” (10) was over the other night and the two of them spent most of the evening holed up in A’s room, talking and listening to music. This morning on the long ride out to camp, A wanted to talk about their conversation – about how B had said that she felt like she was a boy inside because she doesn’t giggle and likes boy things better than girl things, but that she was happy to finally have a friend (A) that was like her. B mentioned that A likes math, comics and robots, and that even though she doesn’t like those things too much herself, they were “boy-things” and so knowing that about A made her feel less alone.
A, who is definitely a weird little kid who has already had to fight pretty hard to be her own kind of girl, concluded that because of all of these things, she and B might really be more like boys than girls. She said she was really happy that B was like her, and it was good to have a friend with these thoughts. The rest of the conversation between the two of them apparently centred around their discomfort with impending puberty and a little bit about sexual orientation – these topics were (not surprisingly) initiated by B, who is two years older and entering Grade 5.
Probing a little further, A stated that in spite of her inside-boy-feelings, that “Technically, I am a girl. I have girl sex parts.” Reflecting that back to her, I said, yes, more than “technically”, you’re a girl – you’re a juvenile human female – and thankfully her logic kicked in and she agreed with that.
Next, I asked her about ‘girl’s interests and activities’ – what makes those? And she said, “well, the stereotypicalgirl things…” and then listed some. I asked her about non-stereotypical girl things – what if a girl does those? Are those a girl’s interests and activities?
She lit up, and said, “Yes! If a girl is doing them, they are a girl’s activities – a stereotype is obviously different than a girl herself!” I challenged that a bit, just to make sure she really had it, and asked about whether she thought the stereotypes came from inside our brains or outside in the world, and she said definitely outside, because – AND I QUOTE – “a long time ago, men used to wear high heels in France, and pink used to be the boy-colour – if that stuff came from inside us, these things wouldn’t change so quickly.”
Can we all just share a sigh of relief? This is hours later and I’m still exhaling.
One small note for context – I homeschool A, but B goes to our neighbourhood public school. Our school board has 100% swallowed the Trans agenda, and I’m betting a lot of her confusion and discomfort comes from the new gender identity curriculum / bathroom regulations
by Susan Matthews, UK Academic
The Charing Cross Gender Identity Clinic is the ‘oldest and largest adult clinic’ in the UK. It was founded in 1966, the year that the first sexual reassignment surgery was carried out at Johns Hopkins Gender Identity Clinic, the world’s first GIC founded the previous year by psychiatrist and sexologist John Money (1921-2006). The founding clinician at Charing Cross, Richard Green (1936 -), came with an impressive academic pedigree, having worked with Money, collaborating on research on boys who demonstrated cross-gender behaviour. Money liked to claim (with some justification) that he had invented the modern sense of the word ‘gender’ – andit was Money who named the clinic (specialising in the treatment of intersex and transsexual patients) a ‘Gender Identity Clinic’. (Up until the second half of the twentieth century, the word ‘gender’ referred to grammatical gender, a feature of language not human identity). Money was a psychiatrist by training but working with the new specialism of endocrinology his clinic was able to achieve unprecedentedly convincing results in gender transition.
1966 was the golden age of gender specialists, a period in which Money and Green felt an exhilarating confidence not only in their ability to improve the lives of intersex and transsexual patients through surgery, but also in their ability to understand the mystery of human gender (a concept that they themselves had defined). This was also the year that Money acquired what seemed a perfect test case and one that came with an inbuilt control when Bruce Reimer, one of a pair of identical twins, suffered a medical mistake that destroyed his penis in the course of a routine circumcision. Drawing on his expertise with intersex, Money recommended that the baby should undergo orchidectomy and be raised as a girl. Bruce became Brenda and was subject to yearly consultations with Dr Money. But when Brenda decided to revert to a male identity at 14, took the name David and refused to attend any more annual inspections, Money failed to correct the many publications that he had drawn from this case. In the end it was not so much the ‘failure’ of the gender reassignment, but the fact that Money lied about his findings, continuing to reissue earlier accounts and claiming that Brenda was ‘lost to follow up’ that threatened his reputation. Some remained loyal, not least Richard Green who described Money in a 2010 BBC documentary as a ‘brilliant man, one of the most brilliant men I have ever met’. According to Green, Money did the best he could – given what was then known about gender.
Back in 1966, surgical solutions for psychological problems seemed to offer a breakthrough in patient care and sex reassignment was not the unique procedure it now seems. At the time, there was no hesitation about naming transgender as a ‘disorder’, indeed the term ‘gender identity disorder’ was taken from Green’s work. This was the time when lobotomy was still widely practised: Antonio Egaz Moniz had won a Nobel prize for the procedure in 1949, and although the operation was banned in the US in 1967, lobotomy continued in the UK in reducing numbers until the 1980s. As a child I met a woman who had been my mother’s best friend, who had undergone a lobotomy after a breakdown following an affair by her husband – who as next of kin had authorized the operation on his wife. Seeing her capable of no more than flat small talk left me with a lasting horror of psycho-surgery. What I didn’t realise then was that demand for lobotomy came from patients, enthused by claims made for the procedure.
‘The Death Star’
Back in 1966, the science of gender identity was in its infancy and both Money and Green were highly respected. Money’s professional standing was based on his expertise in the treatment of intersex for which he devised a widely accepted protocol. But intersex was particularly important to Money because he believed that by studying intersex he could gain an unprecedented understanding of human gender identity. In a 1996 introduction to the reissue of his classic 1972 Man & Woman, Boy & Girl: Gender Identity from Conception to Maturity, Money explicitly thanks his intersex patients: ‘The majority of people who contributed to this new meaning of gender were hermaphrodites or intersexes. To them social science and social history overall owe a debt of gratitude.’ What Money did not acknowledge in this introduction was that by 1996 the consensus amongst clinicians about how to treat intersex had been challenged by the patients themselves – many of whom viewed Money’s protocol as invasive. Many felt that their bodies had been subject to unnecessary surgery and believed that they had been lied to: some called Money’s intersex clinic at Johns Hopkins the ‘Death Star’.
The difficulty is to know which elements of the science of gender spawned by the Johns Hopkins Gender Identity Clinic need to be revised and which rejected. For the Reimer case is open to many different readings. Zoe Playdon attributes the failings of UK gender identity clinics to this history, associating them with the ‘falsified research’ of the Reimer case and arguing that they ‘still generally coerce patients into extended psychiatric treatment, often lasting for years, in the absence of any identifiable mental health problems and without informed consent.’ But she is wrong to claim that Money and the Johns Hopkins clinic were ‘conversion therapists’. In the field of transsexualism, they saw themselves as sexual radicals, at the forefront of supporting gender reassignment. If their model of gender roles was conservative that is unsurprising for a rigid model of gender underpins the whole field of gender reassignment with its insistence on matching bodies to socially defined roles. Certainly the psychiatric assessments described by the Reimer twins (both of whom subsequently committed suicide) appear to have been unprofessional and probably traumatic. But for intersex patients, so were the surgical therapies imposed on their bodies. Playdon cannot conceive that the medical and surgical procedures evolved in Money’s clinic might require challenge as much as the particular model of psychiatric assessment that Money used.
The Charing Cross GIC, then, was founded in a very different world from that we now inhabit, a world to which we would not want to return. The science of gender emerged from a tiny group centred on John Money and its findings were ethically compromised. It was a world in which the authority of the clinician was unchallenged, and in which transsexualism was believed to be rare but universal and unchanging. Although Money’s students and followers have gone on to found a series of treatment centres, the numbers of ‘gender’ specialists are relatively few. Echoes of the founding beliefs are still apparent in a 2011 paper by James Barrett, currently lead clinician at Charing Cross GIC. ‘Disorders of gender identity have probably always existed, inside and outside Europe’, Barrett writes, citing a 1975 study (Heiman). Citing a 1996 study, he presents the condition as vanishingly uncommon: ‘It seems that the incidence of transsexualism is very roughly 1 in 60000 males and 1 in 100000 females, and it seems to have remained constant’ Given that ‘Treatment is drastic and irreversible’, Barrett insists that diagnosis must be entrusted to the experts of the gender identity clinic:
The least certain diagnosis is that made by the patient, made as it is without any training or objectivity. This uncertainty is not lessened by the patient’s frequently high degree of conviction. Neither does the support of others with gender dysphoria help, since conviction leads people to associate with the likeminded and to discount or fail to seek out disharmonious views.
For Barrett in 2011, the aim is to ‘pass’ and he reports that ‘At least one patient has been undetected by her general practitioner and by her boyfriend of 9 years. Another was undetected in the course of several lesbian relationships.’
These assumptions do not fit the world that Barrett and his colleagues encounter now when rates of transsexualism are rising sharply – not remaining constant. The incidence of transsexualism in women exceeds that in men. The whole notion of diagnosis is seen as inappropriate: patients self-identify, drawing often on online guidance, and the role of the clinic is simply to accept a diagnosis formed by the patient. For many of those who claim a trans or non-binary identity, passing is no longer the aim. Above all, transsexualism, now redefined as transgenderism, is no longer a disorder. In this changed world, the function and the funding of the Gender Identity Clinic is thrown into doubt. Clinicians do not understand the world they now encounter, nor are their theoretical models adequate to understand their patients.
A mighty taxonomological struggle
It is not surprising, then, that Trans is now a thing like no other, a condition without a theoretical model. Barrett compares it, in a 2016 blog post for the BMJ, to ‘the Australasian Platypus’:
The first specimens were dismissed as a joke of some sort.
But then more came, and alive and kicking at that. There followed a mighty taxonomological struggle. They were reptiles or perhaps some sort of bird, surely, as they were warm blooded, laid eggs and were venomous. On the other hand, the fur argued for mammals, but they didn’t have proper breasts, the defining feature of the mammals, and that business of being venomous is more of a reptile-like thing, is it not? And they do lay eggs…but warm blooded…perhaps a bird of some sort…?
In the end, it was all solved by everyone admitting that the Platypus was real, important, couldn’t be dismissed and didn’t fit any existing category very well. It got its own, special category where it has paddled, very happily, ever since, albeit joined by echidnas and some long-extinct fossilised forebears.
The difference from the Money/Green generation is striking. When Brenda Reimer insisted – despite an upbringing and a family that told her she was a girl – that inside she had never felt female, this high profile (and unique) case seemed to demand a new model of gender identity. For David Reimer as for many now, gender was a strongly felt internal sense of self. Richard Green’s 2010 comment that Money’s model of gender identity was the best that was known at the time was an attempt to overcome the threat to his professional identity as a gender specialist created by the fallout from the Reimer case. Yet there was no model to take its place. Trans clinicians are now unwilling to offer a theoretical model of gender. Doctors are asked to prescribe hormones on the basis that medication reduces distress and leads to an improved quality of life (claims that are hard to support from evidence).
With no theoretical model, analogy is often the next best thing. Those arguing for access to medical intervention frequently invoke – and discard – parallels with gay abandon. But in every case, the differences are as significant as the similarities. A key claim is that the fight for transgender equality mirrors that for homosexual equality in decades gone by. It should not need pointing out that you don’t need to alter your body to be gay. Homosexuality does not depend on medical or surgical intervention – except in countries such as Iran where homosexuality is currently illegal. Attempts to change the bodies of homosexuals are considered some of the most flagrant crimes of the last century. When Alan Turing, the early computer scientist and code breaker, was forced in 1952 to take androgen blockers to control homosexual urges or face imprisonment, we rightly blame doctors for complicity in denying his human rights. But Turing’s treatment was later mimicked in Money’s clinic: in the key year 1966, John Money became the first US doctor to prescribe androgen blockers to a patient dealing with paedophilic urges. The parallels are at the least problematic. Responding to James Barrett’s 2016 piece, a GP writes: ‘I personally and professionally object to Dr Barrett linking the transgender status of a patient to that of being Gay or Black. My Gay and Black patients do not need me to prescribe medication to maintain their status.’
Equally problematic is the comparison with intersex which formed the basis for Money’s theories on gender. Trans activists borrow terms like ‘assigned male (or female) at birth’ from the language of intersex: ‘When a person is born, a doctor assigns a gender by only looking for one thing: the presence or absence of what they consider to be a penis. […] As they grow up, the doctor’s guess can turn out to be wrong, either because the person had an undiagnosed intersex condition, or they are transgender and don’t identify with their assigned gender.’ Yet trans people by definition belong to the 99% of human beings for whom genital, gonadal and gene sex is congruent. For this group sex is not assigned at birth but is a biological fact. To suggest otherwise is to co-opt intersex narratives. 
Trans treatment protocols were established within the academic fields of sexology and psychiatry. Yet trans (it is now claimed) has nothing to do with sexuality or with mental health: Barrett writes in 2016 that ‘My patient interviews are not ‘psychiatric’ just because I come from an originally psychiatric background. They relate specifically to gender dysphoria.’  The body of professional knowledge that Barrett mobilises is the knowledge of gender, a discipline defined and originated in the clinic run by Money and a discipline whose methodology is unique.
Given the lack of any parallel, it is not surprising that the treatment protocol established over the last fifty years has been described as ‘a unique intervention not only in psychiatry but in all of medicine.’ It is also not surprising that it is increasingly difficult to know where gender specialists should be accommodated and who should fund them.
Over a period of fifty years, the Charing Cross Gender Identity Clinic has catered for a large number of patients. But it has also been somewhat accident prone. Perhaps clinicians become blasé as they become accustomed to prescribing irreversible treatments. James Barrett started his career as a sceptic and gatekeeper, joining in 2006 with colleagues Richard Green, Stuart Lorimer and Don Montgomery, to report the leading gender clinician at Charing Cross, Russell Reid to the GMC (General Medical Council) for professional misconduct, a charge of which Reid was found guilty. Colleagues, including Barrett, accused Reid of blurring ‘professional boundaries by calling patients his nephews and nieces’. Past patients claimed that Reid ignored a series of traumatic events in supporting gender transition which they came to regret, and failed to acknowledge co-morbidities such as psychosis. In subsequent years, gender surgeon James Bellringer was eased out of the clinic for undisclosed reasons. And the clinic has found it hard to recruit sufficient psychiatric and surgical staff.
But only a decade since the Russell Reid inquiry, Barrett now presents a very different account of the clinic and of the role of the gender expert. A Freedom of Information request in 2016 by the Guardian newspaper revealed that the ‘number of referrals has almost quadrupled in 10 years, from 498 in 2006-07 to 1,892 in 2015-16.’ James Barrett told the Guardian: “It obviously can’t continue like that forever because we’d be treating everyone in the country, but there isn’t any sign of that levelling off”. (So much for Barrett’s 2011 claim that the incidence of transsexualism is constant and unchanging.) The clinic is currently funded by the West London Mental Health Trust. But funding this new demand places an intolerable strain on underfunded mental health services: the Kings Fund showed in 2015 that ‘Mental health problems account for 23 per cent of the burden of disease in the United Kingdom, but spending on mental health services consumes only 11 per cent of the NHS budget.’ For the mental health trust which funds the Charing Cross GIC, the only answer is to end their contract with NHS England, a solution that paradoxically matches the demands of trans activists who call for the depathologization of trans and the removal of medical gatekeepers. James Barrett is clear that “clinicians have long felt that West London Mental Health Trust is not a good fit for the unique and specific service we provide (the vast majority of those we see are not mentally ill).”
This claim is important, for if trans were a disorder (as in 1966), the work of the clinic would belong in a worrying tradition, one that harks back at the worst to lobotomy and calls up disturbing memories of the treatment of David Reimer. If trans has any links to body dysmorphia, to anorexia, or to self-harm, then it could not be appropriate to medicate or to offer surgery, however acceptable to the patient, however fiercely demanded. Colin Ross identifies the underlying ethical problem:
Gender identity disorder is unique among all DSM-IV-TR diagnoses. It is the only disorder in which treatment is designed to confirm, reinforce, and validate the belief that is the basis of the mental disorder. In all other diagnoses, the symptoms in the diagnostic criteria are viewed as pathological and the goal of treatment is to remove the symptoms. In gender identity disorder, however, the body is altered to match the belief that is said to be a symptom of mental disorder. This is self-contradictory. Either gender identity disorder should be dropped from DSM-V, just as homosexuality was dropped from the diagnostic system, or gender reassignment should be discontinued. The core contradiction in the current approach to gender identity is an ethical problem in the mental health field.
For James Barrett and the Charing Cross GIC, the only way out of the quandary is to separate the GIC from the Mental Health trust. But to do so is to admit that this form of necessary body modification is without parallel. It is unique and specific. Gender is not like anything else.
‘Unique and specific’
In a recent discussion with Jay Stewart, founder of the Gendered Intelligence community support group for trans and non-binary young people, I was struck by the insistence that the young people he works with are not mentally ill. Any distress they might experience comes from people saying ‘unkind things’. Their problems are caused by a society which is slow to accommodate diverse gender identities. Yet Stewart’s claim did not match the picture I saw at a recent visit to the GI parents’ support group where a parent claimed that all the young people have co-morbidities. Stewart dismissed the distress , the self-harm and depression that parents described as ‘an account I do not recognise’. He does not use the term ‘gender dysphoria’ with its acknowledgement of unhappiness. Trans is a movement for health and happiness.
James Barrett by contrast admits that trans people can suffer from mental illness. But mental illness, where it exists, has nothing to do with a trans identity. Writing in 2016 to the London Review of Books, Barrett is proud that co-existing mental illnesses are no bar to accessing the unmitigated good of gender transition services:
Patients have already advanced perfectly satisfactorily through all stages of treatment with coincidental diagnoses of schizophrenia, chronic renal failure, paraplegia, emotionally unstable personality disorder, learning disability and autism. Patients currently being treated in the UK include those unwell enough to be detained under the Mental Health Act in a secure hospital.
The contrast with Barrett’s position in his 2011 paper (or his 2006 action against Russell Reid) is striking and reveals what we already know: that scientific ‘objectivity’ reflects the demands and assumptions of the society it serves. The beliefs of the gender specialist have a history – a starting point and perhaps an end. Barrett’s position now means that gender dysphoria cannot be caused by mental illness (as Reid’s patient accusers believed). If trans is never a pathology, then existing mental illness is nothing to do with trans. Barrett does not offer a psychiatric assessment but a gender assessment to patients at the Charing Cross GIC. A clean bill of mental health from Barrett can coexist with a disability diagnosis from a local mental health trust which has led to Personal Independence Payments (PIP). Yet to qualify for PIP you must have ‘a long-term health condition or disability and face difficulties with ‘daily living’ or getting around.’ It is curious that the onset of the diagnosed disability in the case known to me, coincided with the onset of gender dysphoria. But gender specialists work to a different model of mental health than Mental Health trusts. In the US, blogger, psychologist and detransitioner ‘Third Way’ says that ‘a lot of the treatment now for gender dysphoria just throws out the basic principles of psychology’.  He comments that ‘people who detransition often talk about issues of trauma’ and that ‘these are things that can be worked on psychologically’.
Voices that matter
A belief that trans is never a pathology makes it impossible to recognize evidence of psychological vulnerability and trauma in this population. A 2011 Swedish study into long terms outcomes of transgender patients concludes that this group is liable to suffer from a range of psychological difficulties: ‘Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.’ In this study, sex reassigned patients fared markedly less well than a comparable group matched ‘for premorbid differences regarding psychiatric morbidity’.
Perhaps the most important voices are those of transitioners and detransitioners who are now beginning to explore what they see as a relationship between trans and trauma, challenging the constricting logic which demands that the complexity of human experience must fit the constructs of the gender narrative. Carey Callahan describes how depersonalization both drove her to identify as trans and intensified while taking testosterone. Not only is there a huge rise in teenage girls identifying as trans or gender non-binary but there seems to be a marked overlap with those suffering from eating disorders and self-harm. One blogger writes: ‘I am a female to male transgender with an eating disorder, and this kind of thing is very common among trans men. Gender dysphoria can cause us to have body dysmorphia because our minds and our bodies are not congruent and we hate the bodies that we were born with!’ Jack Monroe, the food writer who now identifies as transgender has described how ‘all through high school’ she ‘struggled with a severe eating disorder.’  In studies, the overlap between trauma and gender dysphoria is striking. How else could we explain the overrepresentation of trans people within US army veterans? A 2013 study shows that Gender Identity Disorder in the Veterans Health Administration is roughly five times higher than in the general US population (22.9 per 100 000 amongst veterans rather than 4.3 in 100 000 persons). Suicide-related events among veterans with gender identity disorder occur 20 times more frequently than in the general US VHA population. Gender identity disorder is increasing amongst US veterans, nearly doubling over ten years.
According to Barrett, the interventions offered at the Charing Cross GIC make for ‘happier and healthier lives’. But if the rise in transsexualism is an expression of the multiple forms of trauma in modern life, then the attempt to de-pathologize trans and to separate trans provision from mental health services may have devastating consequences. It is an understandable response to the dark early history of gender identity study, yet gender clinicians remain fixed within a closed set of assumptions that blind them to the evidence.
 Terry Goldie, The Man who invented Gender: engaging the ideas of John Money (Vancouver: UBC Press, 2014); Lisa Downing, Iain Morland, and Nikki Sullivan, Fuckology: critical essays on John Money’s diagnostic concepts. (Chicago: University of Chicago Press, 2015); John Colapinto, As Nature Made Him: The Boy Who Was Raised as a Girl, p25.
 ‘Money continued to insist to his scientific, academic, and medical colleagues that the case was “lost to follow up”’, John Colapinto, As Nature Made Him, 202.
 BBC Horizon, 2010, ‘Dr Money and the Boy with No Penis’. Currently available at https://vimeo.com/55409956. The BBC team began following the Reimer case and recording interviews in 1979. (Colapinto, 168).
 John Money, Anke A. Ehrhardt, Man & Woman, Boy & Girl: Gender Identity from Conception to Maturity, Northvale N.J.: Jason Aronson Inc, 1973, 1996), xii.
 Alice Dreger, Galileo’s Middle Finger: Heretics, Activists, and one Scholar’s Search for Justice New York, Penguin, 2015, 40.
 A letter to the BMJ from Zoe Playdon claims
 Zoe Playdon, ‘Unequal treatment of transgender people’
BMJ 2016;353:i2329doi: http://dx.doi.org/10.1136/bmj.i2329 (Published 26 April 2016)
 James Barrett, Advances in psychiatric treatment (2011), vol. 17, 381–388 doi: 10.1192/apt.bp.109.007484
 James Barrett, http://www.bmj.com/content/352/bmj.i1694/rapid-responses
 Jeremy Luke, ‘Gender dysphoria: shared care is the answer’
BMJ 2016;353:i2326http://dx.doi.org/10.1136/bmj.i2326 (Published 26 April 2016)
 Daphna Joel, ‘Genetic-gonadal-genitals sex (3G-sex) and the misconception of brain and gender, or, why 3G-males and 3G-females have intersex brain and intersex gender’,
Biology of Sex Differences 2012, 3:27 http://www.bsd-journal.com/content/3/1/27Daphna Joel
 New Narratives 2014 rejects ‘COINing’, or co-opting intersex narratives: ‘we have a strict no-COINing policy (co-opting intersex narratives). That means, if you are a trans woman who “suspects” or wishes you were intersex, but have not been diagnosed, please either see a doctor or cut it with the appropriation.’
 James Barrett, http://www.bmj.com/content/352/bmj.i1694/rapid-responses
 ‘Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden’
Cecilia Dhejne, Paul Lichtenstein, Marcus Boman, Anna L. V. Johansson, Niklas Långström, Mikael Landén
Published: February 22, 2011http://dx.doi.org/10.1371/journal.pone.0016885
 Colin A. Ross, Ethics of Gender Identity Disorder, Ethical Human Psychology and Psychiatry, 11.3, 2009. https://www.questia.com/library/journal/1P3-1923231181/ethics-of-gender-identity-disorder
 Blosnich, John R. et al. “Prevalence of Gender Identity Disorder and Suicide Risk Among Transgender Veterans Utilizing Veterans Health Administration Care.” American Journal of Public Health 103.10 (2013): e27–e32. PMC. Web. 10 Aug. 2015.