Understanding Gender Dysphoria, page 13
The main controversy in intervening to prevent gender dysphoria has to do with a connection between gender dysphoria in childhood and adult homosexuality. Most children who are gender dysphoric find that the dysphoria resolves before adolescence. The DSM-5 offers ranges for persisting at between 2.2 percent and 30 percent of gender dysphoric biological males and at 12 percent and 50 percent of gender dysphoric biological females. Granted, that is a significant range, but those ranges suggest that in most cases the gender dysphoria resolves.
However, most children whose dysphoria resolves report that they have a homosexual or bisexual orientation as they enter their teen years.14 Among those children whose gender dysphoria desisted, a range from 63 percent to 100 percent of biological males and 32 percent to 50 percent of biological females identify as gay, lesbian or bisexual in adulthood. For example, in the Steensma et al. study,15 all of the biological females whose gender dysphoria desisted reported a heterosexual orientation: “All girls felt exclusively attracted to boys. This made them question their ‘masculine’ feelings. It felt like the attractions weakened their cross-gender identification.”16 There was more variation among the biological males whose gender dysphoria desisted: “Two of the boys felt exclusively attracted to boys, three felt attracted to both boys and girls, and one boy reported feeling exclusively attracted to girls. The awareness of being sexually attracted to boys only or to both boys and girls caused some confusion in most of them.”17
I have not spoken much about sexual orientation, but the apparent connection between the resolution of gender dysphoria and a homosexual or bisexual orientation is an interesting association in this line of research. As I mentioned earlier, the association between gender dysphoria and a bisexual or homosexual orientation has contributed to some of the concern about psychosocial intervention to prevent gender incongruence from continuing into adolescence or adulthood. As I mentioned above, the debates center on whether the resolution occurs “naturally,” if you will.
Watchful waiting. One approach with children who exhibit signs of Gender Dysphoria is referred to as “watchful waiting” or a “wait and see” approach in which cross-gender behavior is permitted.18 In that way, it contrasts with psychosocial interventions to reduce cross-gender behavior and identification, as it tries to be neutral in response to such expressions.
The primary difference between watchful waiting and facilitating a transition (which I will discuss below) is that there is not an a priori assumption in place that functions as a goal for the child’s gender identity. Just as the watchful waiting approach is not attempting to reduce cross-gender behavior and identification, it is not intended as a means to reinforce cross-gender behavior and identification. Also, in addition to providing as neutral an environment as possible with respect to cross-gender behavior and identity, watchful waiting as an approach emphasizes helping the family attend to their anxiety about the outcome and to facilitate a positive view of self for the child.
One woman I know who experiences gender dysphoria and did so at a young age sees watchful waiting as “allowing God to do a spiritual, grace-filled work in the life of the child.” From this perspective, allowing a child to explore various gender activities without imposing rigid gender stereotypes allows a child to gravitate toward his or her own interests. The boy who loves to cook is not gender dysphoric, but gender identity questions could arise in a context in which his father and peers ridicule him for his interest and relate to him out of rigid stereotypes that do not make room for his interests. I am not suggesting this causes gender dysphoria, but it can lead to unnecessary questioning of gender identity and potential damage that can come from placing arbitrary pressures on a child that are based more on parental fears than on anything else.
Psychosocial facilitation. The psychosocial facilitation approach facilitates social transition to the other gender.19 While watchful waiting attempts to be neutral and does not hold out an end goal as an expectation for gender identity, psychosocial facilitation is considered “affirming” insofar as it practices out of several assumptions, including that “being transgender is not a mental illness.”20 Another assumption is that of outcome: either a “trans-adult outcome or a benign transition back to the original gender.”21
As Drescher acknowledges, though little research has been conducted on this approach and these outcomes (what does a “benign transition back to the original gender” look like within one’s peer group and community?), the approach reflects a supportive (“affirmative”) posture that many mental health professionals would lean toward today.
According to Olson et al., “Affirmative approaches actively promote exploration of gender identity and assist adolescents and their families in learning about and engaging in appropriate gender transitioning interventions.”22 The social transitions here may or may not involve hormonal treatment, but they facilitate the exploration of the other gender with the intention of transition at some point. The elements involved in psychosocial facilitation could include “adoption of preferred gender hairstyles, clothing, and play, perhaps adopting a new name.”23
When we talk about early social transition, the challenges that arise may be largely related to region of the country and relative support from one’s family, peer group and other institutions, such as schools and religious institutions.
Puberty suppression. A more recent direction with older children and adolescents is the practice of puberty suppression or the use of hormone blockers (gonadotropin-releasing hormone analogs) to delay puberty. This is often connected to psychosocial facilitation of a cross-gender identity, as it would be the “next step” after early affirmation and social transition that would have stopped shy of hormone blocking.
How does it work? Children between the ages of ten and thirteen are prevented from entering puberty by receiving injections of hormone blockers that keep the gonads from making estrogen or testosterone. This, in turn, prevents the expected changes at puberty, such as girls developing breasts, starting their menstrual cycle, and so on. Boys will not grow body and facial hair, nor will their voice deepen. The idea is to then allow time for the child to enter into adolescence and for the teen (at around age sixteen) to eventually decide whether to develop a gender identity in accord with their birth sex or with their preferred/psychological/phenomenal sex.24
The original NPR report included an interview with Norman Spack, an endocrinologist at Children’s Hospital in Boston:
To put off puberty, children—usually between 10 and 13—are injected with hormone blockers once a month. Spack explains that the blockers only affect the gonads, the organs responsible for turning boys into men and girls into women. “If you can block the gonads, that is the ovary [in women] or the testis [in men], from making its sex steroids, that being estrogen or testosterone, then you can literally prevent . . . almost all the physical differences between the genders,” Spack explains.
Without testosterone, boys will not grow facial or body hair. Their voices will not deepen. There will be no Adams apple, and height growth will slow. Without estrogen, girls will not develop breasts, fat at the hip, or menstrual periods. And since most growth happens before puberty, if you block estrogen—and therefore puberty—girls will grow taller, closer to a typical male height.
The hormone blockers are the first stage of the treatment, but there’s a second stage that’s possible. Once children have postponed puberty for three or four years, at around age 16 they can choose to begin maturing sexually into the opposite gender, the gender they want to become. To do this, they begin taking the hormones of the opposite sex. For males, taking estrogen at this point will bring on breast and hip growth—and all the attributes physical and emotional of females. The reverse will happen for girls who take testosterone. Spack says this treatment can help make an adult transgender male almost indistinguishable from a biological male in terms of physical appearance.
Granted, there has been more recent discussion of moving that time up—that perhaps waiting until 16 is unnecessary, but that was the original idea. In any case, if they pursue their phenomenal sex, their preferred gender, they can begin to take the hormone of the opposite sex.
Proponents note that while this does not change a person’s sex, it does provide what they claim is a smoother transition to the other gender insofar as the physical changes and appearance reflects such a transition. That transition, however, does not necessarily equate to improved mental health functioning or resolve comorbid mental health issues.
As I mentioned above, there has been research in support of both psychosocial intervention and puberty suppression. The NPR story cited above noted that researchers in the Netherlands have also been following children who underwent hormone-blocking treatment.25 In their treatment of one hundred patients, all made the decision as adults to live as their phenomenal/felt/psychological gender (rather than their birth sex).26
Criticisms of puberty suppression range from concerns about the effects on bone-mass development to brain development to the concern mentioned previously about comorbid mental health issues not being resolved.27 Sterility is also a concern.28 Critics also express the preference that adolescents complete psychosexual development. Proponents of puberty suppression have pointed to the lack of consensus on what that is and how such advice is a response to the clinical dilemma of gender incongruence.29 They have also admitted that more research is needed on possible effects on brain development, but that each of these concerns must also be weighed against risks associated with delaying intervention. Of course, if a transition were to occur later in life anyway, it is unclear whether delay in treatment would lessen those risks. At the same time, if there is still a possibility that gender dysphoria might abate at age twelve or thirteen, does the decision to use hormone blockers somehow preclude the possibility of natural desisting that might take place?
In Adolescence
Aden came into our first session and made brief eye contact and then stared at the floor most of the time. Aden is a sixteen-year-old biological male whose parents brought him in for a consultation because for the past sixteen months he has insisted that he is female. In our first one-on-one meeting later that day, Aden shared that he would like to transition but that no one believes him. When I ask about “no one,” he shares that he has confided in his parents, who are dismissive (saying things like, “But you’re not a girl; you’re a boy. It’s that simple. You’ve always been a boy and you’ll always be a boy!”). No one else knows. Aden shares that kids at school sometimes tease him for his outfits (which are essentially variations on the theme of black and foreboding) but do not seem to know about his cross-gender identification. Over the course of the next hour or so, we discussed when he first experienced the kind of incongruence he is now reporting, as well as the ebb and flow of various symptoms and how he has understood them in his life up to this point. We also discussed what he would like to see happen now, as well as what he anticipates and what he hopes to see happen in the next chapter of his life. I offered to answer questions he might have about research in this area, especially as he thinks about etiology and care at this point.
When considering treatment for adolescents, it should be noted that there is much less published research available to inform clinical decision making. This is part of what made the conversation with Aden difficult. As a general principle, from the time of assessment on, it is common to provide a place for honest self-disclosure of gender dysphoria and to address any shame associated with the experience of gender incongruence and associated secrecy. It would be common to assess the adolescent’s emotional functioning, social support and related peer-group experiences, school performance, and family dynamics and functioning.30
It is not uncommon for older teens to be fairly familiar with the standards of care associated with gender identity concerns. By the time they come in for a consultation, they may have spent quite a bit of time researching the topic and identifying online communities for education and support. That was true with Aden. Clients may express interest in exploring a range of options now and in the future, including alternatives to the more invasive procedures, such as hormonal replacement therapy and sex-reassignment surgery. Therapy can explore the gender incongruence and dysphoria itself, questions regarding sexual orientation, and any comorbid mental health concerns, such as anxiety or depression, peer group disapproval, bullying, and so on.31
Exploration of the gender dysphoria includes an ongoing reflection of the meaning of the client’s desire for sex-reassignment surgery and whether there are other, viable “lifestyle adaptations” available.32 It is also important to explore whether the dysphoria is a negative response to homosexuality/same-sex sexuality rather than an actual desire to change one’s sex. This is thought to be more often the case among those who express a strong desire for sex change closer to puberty.33 In this case, it can be explored whether a homosexual adaption is possible, although this may not seem like a viable option for some for whom entering into same-sex relationships is also a concern.
As I mentioned above, puberty suppression is a more recent development in the management of gender dysphoria in older childhood and adolescence. I discussed it above as occurring “in childhood” because intervention begins when a child is between the ages of ten and thirteen. To extend that discussion of puberty suppression a little further, Olson and colleagues34 discuss management of gender dysphoria in adolescence in three categories: reversible, partially reversible and irreversible. As I mentioned above, the reversible steps include adopting cross-gender hairstyles, clothing and interests, as well as perhaps use of a preferred name. This would have occurred in older childhood and would continue into adolescence, which is when puberty suppression would occur with gonadotropin-releasing hormone (GnRH) analogues.
The partially reversible step would be cross-gender hormone therapy (testosterone or estrogen depending on the direction of preferred gender identity).
The irreversible steps are surgical, of which there are a range, and I will discuss these under treatment of adults. Currently, most surgeons in the United States will not provide surgery until the adolescent turns eighteen.35
Aden presented with several co-occurring symptoms of distress, including anxiety and depression. Although it can be challenging to parse out what is co-occurring from what is subsequent to gender dysphoria, I felt it would be helpful for him to receive services that addressed several issues, including (1) teaching healthy coping and self-care strategies; (2) treating both anxiety and depression; (3) family therapy to improve the relationship that was at this time quite strained, and (4) helping him navigate gender identity questions in his life until he could be referred to a specialty clinic.
In Adulthood
Bert and Faye had been married some thirty years when they came to my office for a consultation. Each of their three children (two biological and one adopted) had been out of the house now for at least a couple of years, two were married, and one was now expecting their first grandchild. The reason they came for a consultation was Bert’s relatively recent (within the past three years) revelation to Faye that he was a woman. This was really difficult for Faye to process. She would look at me and say, “Does this make any sense to you at all?” In a private meeting, Bert shared with me that he had known about his gender dysphoria for many years before he disclosed to Faye, but he had not known what it was before then. He thought he was losing his mind. He did not have a name for what he experienced, and that lack of understanding only intensified his confusion and distress. He has begun cross-dressing intermittently by wearing female undergarments. He is interested in presenting as female, but he and Faye agree that doing so locally would not be advisable. He has considered doing so on business trips, which he takes about every three to four weeks to larger cities around the country. He believes that this level of cross-gender identification will likely help him manage his dysphoria by helping him express who he experiences himself to be.
As the story of Bert and Faye exemplifies, the challenges in adult experiences of gender dysphoria are numerous and complex. When we look at outcomes for adult experiences of Gender Dysphoria, Carroll notes four typical outcomes: (1) unresolved outcomes, (2) biological sex and gender role, (3) engage in cross-gender behavior intermittently, or (4) adopt cross-gender role through sex reassignment.36
Unresolved outcomes simply reflect that there is a high attrition rate—estimated at up to half of clients who seek services—and this may be due to either personal ambivalence or frustration with what some have felt was a long and involved process (reflected in the current Standards of Care).37 Others might drop out because of the cost of services. Still others may experience second thoughts about the best way to resolve their gender dysphoria. In his discussion of such ambivalence, Carroll writes:
Even though they may have made the initial effort to seek help, they may experience considerable doubt about their identity and, rather than explore these issues in therapy, they may seek to reduce their distress by avoiding the exploration of their internal gender conflicts.38
It is unclear what happens to people who experience this level of doubt or ambivalence. Perhaps they find a way to manage their dysphoria, or perhaps they find a way to compartmentalize gender identity concerns to function in life.
Others come to accept their biological sex and gender role (path 2). They may feel gender dysphoric, but they live as their birth sex and adopt a lifestyle that reflects that.39 In the case of Bert and Faye, Bert shared that he would have liked to have experienced some kind of resolution like this, especially if it meant he and Faye could stay married and avoid predictable social stigma in their rather small and conservative hometown. Faye definitely wanted this resolution. Efforts here are placed on reducing a person’s experience of gender dysphoria. There are published care studies of such psychological resolutions. However, as Carroll observes, “These claims have not been supported by controlled group studies. It appears now that the majority of adults with gender dysphoria cannot, or will not, completely accept their given gender through psychological treatment.”40
