TOPICS

For those new to this issue it’s best to know these terms before reading.

5) Mental health & medical professionals have moved from a mental health screening model TO A Dysphoria Affirmative Model

With the “affirmative model,” the child’s gender identity is always affirmed. Efforts to help the young person adapt to the biological reality of their body are viewed as transphobic. Currently therapists and medical providers are rapidly adopting the gender affirmative model which is in essence a “transition as first resort” model, rather than a mental health model, where all other options are explored before the child or teen embarks on a social or medical transition. It is also contrary to the “watchful waiting” or “Dutch model” which acknowledges the possibility of harm enthusiastic social transition may pose to desisters. 

Coping skills beyond social transition, hormone blockers, cross-sex hormones or surgeries are not emphasized by affirmative therapists and doctors. Sometimes these extreme measures are framed as conversion therapy. There are also no attempts made to help the youth delay permanent medical treatments to preserve fertility, avoid stunting penile growth (which complicates vaginoplasty and may affect sexual function) or to make a decision as a more mature person (full maturity is not actually reached until age 25). This model is promoted by most trans activists, Diane Ehrensaft, Stephen Rosenthal, Johanna Olson-Kennedy, Aidyn Olson-Kennedy, Kristina Olson, Michelle Angello, Norman Spack and Michelle Forcier among others. There is not however, a consensus that this is the best approach.

The clinicians in the Netherlands, promote a watchful waiting model where social transition is not necessarily encouraged. Dr. Zucker, Dr. Bradley and others believe the affirmative model is likely to create false positives. This hesitation can be considered serious considering it would result in unnecessary sterilization/castration and otherwise medically altered youth. It does appear childhood gender identity is malleable for some children or resolves on its own over time. Some youths don’t have a changeable gender identity. Without a study with a control group determining influences of therapy or other kinds of support is impossible.

There are some therapists and clinics who do at least employ criteria and screenings for other psychological conditions in minors. But this isn’t always the case in all Western countries, particularly the United States with a private healthcare system. In addition, the criteria for transitioning minors that are employed could be considered lax considering children are making permanent life altering decisions to change their bodies and sterilize themselves. Tavistock, in Britain requires only four appointments before putting a child on blockers or cross-sex hormones. In fact, in Britain many are becoming concerned about what they see as dangerous affirmation protocol.

Pro-early transition advocates view preventing transgender children, who are sure of themselves, from transitioning, as immoral. Concern for them and their rights is valid. As a result of this, clinics in the United States, Canada and other countries are operating on an “informed consent” model. The patient decides treatment, but are informed of the medical risks. There are very valid ethical and libertarian arguments against putting adult people who want to transition under scrutiny and empowering therapists and doctors to dole out treatment. Many in the trans community view this as patronizing, withholding care and emotional abuse. It is an interesting question as to why there should be no gatekeeping for drugs and surgery to treat gender dysphoria but all other requests for drug treatment for even less serious and life altering decisions are not. But issues of personal identity are relevant here.

This goes to the heart of current trans activism, that the need to medically transition is not a mental health issue, but a “normal variation” of the human experience. “Gender confirmation surgery” is merely correcting a minor body issue and there are attempts to remove it from the DSM all together. Therefore, no gatekeeping will be necessary as societal transphobia is blamed for all of the higher rates of suicide, anxiety and depression in trans people, which is debatable as a single cause. Trans people have high rates of comorbid conditions and it is difficult to discern how much is related to the GD and other factors and how much to societal treatment of trans people. 

 A. Statements by therapists & doctors supporting the gender dysphoria affirmation model in children

Margaret Nichols & Laura Jacobs, (Trans Conference Brochure),

Therapy’s old, paternalistic gatekeeping model for working with gender-transitioning clients is out. Today, our job is to provide gender-affirmative care both to adults and the increasing numbers of young people coming out as transgender or nonconforming. This means the average therapist needs to know the basics of diagnosis and be able to identify complex cases where gender dysphoria may not be the relevant psychological issue. In this workshop, you’ll discover: The latest perspectives on gender diversity, including up-to-the-minute research and definitions. The basic principles of gender-affirmative care for adults and children, including supporting a client’s internal sense of their own identity and helping younger clients find a safe space to express their gender. How to best assess gender dysphoria and gender-identity issues across different age groups. The impact of the current political climate on the transgender community and your role as an affirming clinician.

Below are several statements by Dr. Olson-Kennedy Gender Odyssey, 2017:

We do not practice a gatekeeper model in my facility. We do all of the discussion ourselves…If you do practice a gatekeeper model, I strongly advise you to reconsider that. And why you’re doing it...

And that’s an acknowledgement that we persistently, underestimate people’s capacity to know what they need. We do that with trans folks when they are three and we do that with trans folks when they are sixty-five. We just persistently as their gender providers, make decisions about trans life that aren’t appropriate. 

Immediate alleviation of stress in the short-term

…but good conversation and acknowledgement of a young person’s process and meeting them where they are is an essential, possibly most critical part of the work. (WPATH Facebook March 10, 2019)

Let’s think about where you are and how we can help you function best right now.

She feels children and teens are old enough to give to consent.

I’m just gonna say this but people get married when they are under twenty, they choose colleges to go to. Actually, people make LIFE altering decisions in adolescents all the time. And honestly. Most of them are good. It’s just the bad one’s we talk about. Oh my God, the cinnamon challenge.

Here are examples of Diane Ehrensaft stating that other options to transition should not be explored. She discourages working through gender dysphoria in any way or aiding a child to align with their body until they get into puberty. It’s their identity. It should not be challenged.

The next step is to help them live in their authentic gender … We don’t tell them who they are, or try to bend who they are, Ehrensaft said.



Diane Ehrensaft and other affirmative model advocates appear to see no value in aiding youth to perhaps cope with gender dysphoria without drastic body modification. This would be not allowing them to express their “true gender self” even if they are young children. This is contrary to the medical approaches to every other medical condition or psychological conditions where over-medicalization in response to less drastic approaches is considered unethical. 

Let the child lead

The attitude of affirmative model advocates is that adults should not provide structure around gender but the children should lead the society the way to a new “gender revolution,” that now includes dozens of gender identities.

(19:38-20:47):

Now we come to our fruit salads. Now our fruit salad is a tapestry of self that is neither male or female but our own creative understanding of gender both in identities and expressions. These children resist gender boxes. I used to say they were only are older children. We are now seeing them at very early ages. They often live in gender middle grounds. There is no either or but instead all and any. And these are our agender, pangender, genderfluid and genderqueer children youth and child beyond the binary. Now I would say that recently the culture thread of gender web can be very strong. The children are influenced. This is not pressure, this is not a fad, it’s opening up the possibility of difference and gender. And children are often our leaders in revolutions its fascinating to these notions of the gender mosaic. And here we have somebody who identifies as agender who would be one of our fruit salads.

A similar quote (1:51:54):

Listen to the child… Make no attempts to ward off a transgender outcome or gender-non-conforming outcome, including social transitions in prepubertal children.

Not all therapists and psychiatrists believe that this approach is best for youth, who they believe with some structure and time could work through dysphoria. And despite what screening processes and therapeutic support are administered in some specific clinics even the most basic levels of screening or gatekeeping have often fallen by the wayside, particularly in the United States with a private health care system. Parents in some areas of the United States can’t find a therapist who does not instantaneously affirm a minor as trans despite the child’s history or comorbid conditions, including recommendations for permanent medical changes (hormones and surgery) in minors.

B. Pro-early transition doctors & therapists do not want psych. assessment letters or age restrictions for cross-sex hormones or genital surgery for minors

Below are some examples of the unsupportive attitudes affirmative model advocates have towards assessment and mental health screening for medically transitioning minors.

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Arguments around body autonomy are very different when considering minors rather than adults for 3 reasons,

1) The ethics of giving children unlimited access to blockers, cross-sex hormones and surgeries may be unsafe for some children due to the well-established reality that many youths desist from GD. It would be extremely unethical to arrest the develop of these youths at a time when they had a disordered relationship to their bodies as an 11-year-old child, if they in fact would have resolved their gender issues naturally. Any permanent effect on the young person, hirsutism, micro penis, sterility in these cases become medical malpractice, child abuse, and a human rights violation of children to grow up in safety in an environment where adults are obligated to keep them in touch with reality and safe form their own impulsive, immature decisions. Also, doctors are puberty suppressing 11-year-olds, younger in females. Desistance can happen later into puberty. These youths are being given hormone blockers before the age of possibly aligning with their natal sex. Affecting outcomes by drugging a child would be highly unethical. 

2) Even if the youth has intractable gender dysphoria and will want to seek SRS, brain development is not complete until age 25. Children simply cannot absorb the consequences of sterility, impacted sex organs and sexual function, vaginal atrophy, cardiac risks and possible serious side effects from puberty blocker use that an adult would. An example of the reality of how young and immature gender dysphoria patients actually are is demonstrated by Johanna Olson’s advice to parents that their children obtain vaginoplasty before they leave their parents’ house because they are not responsible enough to stick to the necessary “neovagina” dilation schedule, something that has apparently already caused serious problems in the past. But they are mature enough to consent to a surgery many adult MTFs choose not to ever have. An article in Nature discusses the impulsive and risky decision-making process in teenagers here is more evidence in Scientific American of poor decision making by minors.

This suggests that decision-making in adolescence may be particularly modulated by emotion and social factors, for example, when adolescents are with peers or in other affective ('hot') contexts…You don’t need to be a neuroscientist to know that adolescence is also a time of greatly increased impulsivity, sensation-seeking and risk-taking. One aspect of risk behaviour in adolescents appears to be an apparent inability to match their behaviour to the likely rewards (or punishments) that might follow.

A mature brain is quite good at predicting the necessary balance between effort and reward. It does this by using links between the cognitive control systems, found in the highly evolved prefrontal cortex, and the reward circuitry, made up of evolutionarily older sub-cortical structures, which controls motivation and “wanting”. These include the striatum and the anterior cingulate cortex.

3) There is another problematic aspect to the above quote by Olson-Kennedy, that the child “lives are on hold” In regards to developmental psychology this is a maladaptive attitude to take. The youth should not be encouraged by mental health and medical professionals to view their lives as on hold. Especially in light of the reality of shifting dysphoria (meaning even post transition the surgical solutions don’t cure the gender dysphoria). Given shifting dysphoria is a reality children should be raised with as much of a body acceptance model as possible and the false promise that surgery will solve all of these problems justifying the youth’s life considered to be “on hold.” There are cultures that accommodate feminine males. In appears these males don’t experience the intense body dysmorphia that these males experience in western culture.

Here she recommends that some youths need no counseling prior to medical transition as minors.

This view is informed by the fact that Olson-Kennedy is not convinced that mental-health assessments lead to better outcomes. “We don’t actually have data on whether psychological assessments lower regret rates,” she told me. She believes that therapy can be helpful for many TGNC young people, but she opposes mandating mental-health assessments for all kids seeking to transition. As she put it when we talked, “I don’t send someone to a therapist when I’m going to start them on insulin.” Of course, gender dysphoria is listed in the DSM-5; juvenile diabetes is not.

‘You wouldn’t give insulin if you didn’t need to. It would be medical malpractice. And unlike diabetes gender dysphoria can be on a complicated spectrum where proper treatment isn’t easy to determine.’

It has to stop being a mental health issue…This lives in the medical world. –Interview (offline) 

Here Dr. IIana Sherer, a medical doctor who sends her patients to Diane Ehrensaft, decries mental health screenings for minors as unnecessary. This desire for “rubber stamping” seems odd considering the very high rates of mental health problems in MtFs and FtMs coming from Western countries with publicly funded trans health care and permissive societal attitudes. Almost studies on trans adults show higher rates of mental illness and suicide risk.

…or how can we help them get to a person who can help with the gender stuff. Again, what comes out of this is what do we do about the kids who don’t need therapy. I really struggle, there are lots and lots of kids that I see that don’t have dysphoria that really don’t have mental health issues. And so to say to them you have to go get a letter from a mental health provider feels challenging to me. And so what we’ve started to do in our clinics is have someone like Dianne go in and kind of do a brief assessment and give their, I know you don’t say rubber stamp, you know but basically in my mind that’s sort of what it feels like. So that we can say ok “now we can move on and talk about what you are actually here for”…

This statement begs the question, “if a youth isn’t experiencing negative dysphoric feelings, why wouldn’t this doctor wait to transition a youth at age 18 when, bone health won’t be affected, IQ won’t be affected, genital function won’t be destroyed, desistance won’t be prevented and they won’t experience severe effects from Lupron?”

Here is another account regarding a lack of interest in mental health screening letters,

In addition to being a popular presenter at Gender Odyssey, the yearly shindig for all things transgender, Dr. Mangubat is apparently well known as a surgeon who’s an easy touch for those looking for double mastectomies. As recently as six days ago,  underage top surgery seekers on Reddit were recommending him:

Also, the surgeon I went to (Dr. Mangubat) did not require any kind of letter and I don’t think he requires patients to be on T either, but I could be wrong on that. It was as easy as emailing his office to set up a consultation and then I was immediately able to schedule the surgery.

Lowering the age of consent for surgery & hormones

More doctors are admitting to performing genital surgery on minors. In the survey study, “Age is Just a Number” 11 out of 20 surgeons admitted to performing genital surgery on males.

Here is another example of a youth who never even entered puberty (suppressed at age 11) and is “the youngest” person to undergo SRS MTF surgery in the United States. Another interesting aspect of this case is that the genital disfigurement that resulted from Lupron administered at age eleven followed by cross-sex hormones, is now used to justify the underage surgery because the youth now has genitals that don’t resemble anything normal in the adult world.  

The patient’s psychotherapist, Christine Milrod, Ph.D., who referred the teenager for the surgery, stated: “Much like female-affirmed transitioning adults, transgender teenagers who experience puberty with atypical genitals often find the exploration of sexual self-pleasuring, romantic relationships and engaging in physical contact with a romantic partner extremely difficult, if not impossible. The avoidance of any such activities until the age of 18 may cause a delay in healthy age-appropriate emotional development due to dysphoria or discomfort with incongruent genitals. Thus, we believe that harm reduction is a justification for treatment and for recommendation of surgical intervention, particularly since this patient has never experienced puberty in the male gender.

 Below is more discussion on WPATH Facebook:

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At a recent WPATH conference in Brazil apparently all US clinics are disregarding recommendations about age restrictions:

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C. Enthusiastic support for medically transitioning minors with unstudied non-binary identities

While there have always been androgynous people, actual gender dysphoria used to be very rare but is becoming more common, particularly in females. And having people (mostly teenage girls and young women) seek surgical modifications to achieve a spectrum or androgynous appearances to match a myriad of pronouns that can go with these identities is completely new. this is all being embraced as progressive and liberating by LGBT orgs, the APA, WPATH and among the left

Enthusiastic support for these mostly young females permanently modifying their bodies may be premature, as even binary trans individuals still have high rates of suicide risk and mental illness post medical transition. The current societal celebration of medicalized, non-binary identities never explores the identity in depth, but merely affirms it. Anecdotal observations and now some data suggests some non-binary identified individuals have serious mental health issues that should perhaps be explored before medically transitioning minors with this identification. A study out of Germany indicates higher levels of mental illness in this cohort. This study also speaks to the reality that even FtMs and MtFs retain high levels of mental illness even if receiving medical support. 

While mental health was significantly lower in the MtF and FtM group even after hormonal and medical treatment than the general population control group, mental health was even worse for non binaries.

4.3. Nonbinary Trans Persons

Our results show considerably different characteristics within the group of trans participants. While we did not detect significant differences in the QoL between transfeminine and transmasculine participants, persons with a nonbinary gender identity presented the lowest rates of wellbeing. They showed significantly worse values in five of eight QoL domains as well as in the mental component summary (MCS) compared to both binary groups. Moreover, a nonbinary gender identity was associated with significantly more depressive symptoms compared to the transfeminine and transmasculine groups.

The reasons for these clear group differences should be determined on different levels. First, nonbinary persons reported specific needs regarding medical GAI. Thus, approximately half of this group decided not to seek medical treatment. This diversity in terms of the GAI undertaken has been confirmed by other studies [38]. The comparatively worse QoL of the nonbinary participants could therefore be related to the lack of a standardized treatment and accordingly suitable GAI, which cover the specific needs of this group [39]. Second, the nonbinary group most clearly questions the binary gender norm that exists in western societies. As a result, nonbinary individuals are more likely to be confronted with stigmatization experiences, which can lead to higher minority stress levels [26] and increased self-reported disability [28]. This in turn has a negative impact on mental health [28] and especially the emergence of clinically relevant depressive [2] and anxiety disorders [29], which ultimately affects QoL.

It is interesting to note in this quote the investment of the researchers in the “oppressed” narrative. They indicate worse mental health is the result of a binary society deeply oppressive to these individuals who most “challenge” western norms (which are world norms in reality). It seems highly questionable that this is the only explanation or even one reasonable explanation as to why their mental health is worse than MtFs and FtMs who undergo considerable life difficulties themselves. Non-binary identities may be a new dissociative mental illness or a variation of BDD. It’s too early to tell if it is purely GD. The idea that if society just adapts pronoun check ins before college lectures and stated pronouns at the end of email signatures that these individuals will be happy, should be treated with skepticism. There have always been androgynous individuals but a cohort of people (mostly females) who feel compelled to amputate body parts and drug themselves for an “andro” appearance appears totally new, despite these medical procedures being available for decades and that androgynous culture has existed for a long time in the modern gay and lesbian community and was popular even among bi/heterosexuals like David Bowie, Mick Jagger, and Patti Smith in the 1970s.

Quotes are provided here to demonstrate the strong enthusiasm for encouraging medicalized non-binary identities in minors and lack of clear criteria for diagnosing non-binary youth.

Medical doctor Jennifer Hasting (3:56:49-3:57:09):

I really want to do a shout out to the non-binary transition. All of my conversation right now, we are sort of looking at going one direction or another. A lot of youth and adults that don’t want to go into, towards the other box, to be in a non-binary place. I just want to shout out to this website…

An observation in a Medium article critiquing the enthusiasm for medicalizing “non-binary” children:

But she keeps going. Ehrensaft even sees the potential of drugging the ‘non-binary child’:

‘Not only is there no other aspect of adolescent care where the teamwork between medical and mental health provider is critical; there is no other domain of youth services in which a mental health provider is so actively involved in medical decision making. Where this has surfaced most recently is in the recent emergence of youth in gender clinics who present as neither male nor female, but rather gender nonbinary or “in the middle”, adopting the platform of the multiplicity of gender. The challenge is when these youth ask for a particular medical intervention that achieves that goal of a middle ground — perhaps a touch of testosterone, or chest surgery with no other intervention and a chosen pronoun of “they” rather than “he” or “she”. These are new horizons for both medical and mental health professionals today, and there is a mutuality, therefore, in the medical professional training the mental health professional while the mental health professional is in turn training the medical professional in order to integrate the biopsychosocial aspects of care to include the gamut of all the gender nonconforming youth presenting for care.’

Diane Ehrensaft doesn’t worry about youth changing their minds, in an environment where transition is beginning at the dawn of puberty.

(22:25-23:40):

But what about our fruit salads. They’re a mélange. And they give parents and providers a lot of headaches, particularly when they start asking for medical interventions.Some may request or benefit from a gender transition but not necessarily a binary one. Others are fine with the sex assigned on their birth certificate but they redefine what that means. And we need to stretch our thinking to consider pangender agender and 3rd, 4th, and so forth and gender identity that includes our fruit salads. And what if they change their minds? I’m going to change that sentences with a different tone. (happy, relaxed tone)So what if they change their minds? (audience giggles-‘Don don don’ horror movie music joke- audience laughs). We just help them spin together their gender web as they know it now. The gender web changes over time. There is no data to indicate that children who change their gender more than once over time, including switching back from transgender to original gender are at risk for any psychological disturbances as long as we support them in their gender. And that is the key factor. 

1) Given the fact that 3% of Minnesota teenagers identify as trans now in a recent poll (as well as high rates elsewhere), signify’s something that used to be a very rare psychological condition to becoming a common one. It indicates actually that trans identification and viewing one’s personality traits in terms of gender stereotypes is in fact a fad or socially contagious body dysmorphia.

2) Gender clinics now offer a smorgasbord of transition options for young people who want to permanently modify their bodies. It is questionable if in some of these cases it is any different than offering cosmeticsurgery such as breast augmentation and labial reduction surgery (increasing popular with young females). 

3) Gender nonconformity is not new and there have been other cultures (Zapotec, Fijians, Indians) who view very gender nonconforming people as somewhat of a third gender. But Diane Ehrensaft is asserting that the emergence of non-binary ideology in its current form in Western countries, complete with support for breast amputation, hormones, and other body modifications on immature young people is positive, adaptive, and healthy with no long-term data to support this assertion. In fact, serious questions can be raised if genderqueer/non-binary/genderfluid ideology is actually healthy for young people and if surgeries and hormones are the best approach to treating disassociation and dysphoria not just with one’s own gender but with any gender.

4) “So what if they change their minds?”- Unfortunately there are more and more desisters and detransitioners who have been harmed by transitioning too young and being her flippant attitude (as well as the laughter of the audience) appears callous. 

5) She says there is no evidence switching back and forth in gender creates any psychological disturbances. This contradicts a study (Steensma 2013) that says girls had difficulty transitioning back. This is also an appeal to ignorance logical fallacy. Worrying about children living in inconsistent identities is valid if considering child development in extremely formative years. 

Here are some examples from Johanna Olson Kennedy that demonstrates youth do switch back and forth, and that medical interventions are going to be applied to young people who would have in fact evolved in a different direction in the past. These youths in reality have very unstable identities and full access to permanent body modifications as minors

Gender Odyssey, 2017:

Let me tell you a story about a young person, assigned female at birth. 18 months, ‘I a boy.’ This kid was insistent, persistent, consistent to the T. Right? And not that that is the only way you can be trans. But this kid was. This was this kids story. I’m a boy, I’m a boy. I go into my dad’s closet. I get his ties. I put on his shorts. I put on his blah blah blah…kicking screaming 3 years old. No dresses no dresses. So, the mom came in to our program and said…” Ok fix my kid.” And the therapist was like “Oh no we are just going to see you and your husband.” (audience laughs). And so, they are going to help their kid do a social transition…Lived as a boy from three onward…was nondisclosed at school…just before this kid 9thbirthday, this kid was what I call dropping gender bombs. This kid had struggled because, this kid loved, like American girl doll, pink sparkly UGG boots, right? And so, I’m thinking like, "Oh this is going to be like among my myriad of gay trans boys, right?"...But it’s starting to be difficult for this kid…not with the girls, not with the boys, right. This kid never had a place…Ok first of all this kid said, “If I’m a trans boy and I wear girl’s cloths am I a cross dresser?” (audience laughs). And I’m like, “Yeah, I don’t know, are you? (audience laughter)

…Then this kid said I think what I’m going to do is be a boy in elementary school and girl in middle school and by high school I will have a better idea, what works best for me. Sounds pretty profound. So, I said to this kid, “It sounds like you are ready to try on girl.” And this kid said, “Yes, I am.” And I said, “OK let’s do the work we need to do, we went to the school. We said, “This kid’s going by birth name, female pronouns.” So, everyone thought this kid was a trans girl, right? (audience laughs) …I know your secret, you have a penis…” So, two weeks after social transition, living as a girl calls me up, ‘I got a second breast bud, I need a blocker. “Ok, why?” Tells the therapist, “I feel like a little girl dangling a little boy over the” cliff and if I don’t get a blocker he will die. That’s what this nine year old said…So I brought the kid in and the kid said “Tell me about this… “Well, I just don’t know. I just don’t know!” And so, I said “Well, why do we put blockers in.” “So, I don’t get boobs” …So 2 years later the kid says I want the blocker out. I want to go through girl puberty.” “All right come in, let’s talk about it. Do you remember why we put the blocker in?” “Yes.” Why’d we put the blocker in? “So, I didn’t get boobs?” “So, what’s going on with your gender.” “I don’t know? But I want to go through girl puberty.” Ok we’ll what if your gender lands more on boy. (Giggles) This is word for word. “It’s 2015 Jo who said boys can’t have boobs?”

1) The “no check list” approach is understandable because people’s psychology is complex and unique. But instead of using this argument to validate a cautious approach, it is used for the opposite reason, to simply affirm rather than make an effort to support body acceptance or delay chemicals that may have permanent effects. Cases like these appear in danger of over-medicalization.

2) In is debatable if “genderqueer/genderfluid ideology” is actually healthy for the young person or the culture at large. Growing numbers of LGB and even T people feel it is actually doing damage. Taking a look at this information, it is reasonable to ask if perhaps children actually need some structure around identities and biological realities.

3) This case, as well as others, is a refutation of Kristina Olson’s and Diane Ehrensaft’s argument that “I am a boy/girl” is diagnostic. This child clearly said she was a boy and later turned out to have a very unstable identity and a confusing identity. She has been needlessly exposed to a round of hormone blockers, which are now the subject of multiple complaints and even lawsuits.

Olson offers a variety of non-binary medical treatments (below quotes a are from Gender Odyssey, 2017). 

There are a variety of medical interventions for non-binary folks. Creative thinking, thinking out of the box. Trying to figure out what people want. And what people don’t want. It can be challenging but it also can be really exciting and fun in really addressing what are some of the things you want? How can we get them for you? ...There’s sort of a lot of different things people want. I really encourage people if they are going to get hysterectomies, to think about leaving an ovary or 2…you get injection fatigue right, “I really like testosterone, I don’t want to keep injecting myself.” You still want hormone protection…Maybe T for a year. Maybe a central blocker plus low dose T. These are all possibilities. Maybe no medical intervention at all. Non-binary assigned males maybe Spyro(lectin) only. Maybe feminizing hormones for just a short amount of time. Maybe selective estrogen receptor modulators. Like I had a young person who…had autism and couldn’t stand the kinesthetic feel of breasts but liked the way they looked. So, I was like, “What are we going to do here.” But loved the way that estrogen made their brain feel.

Here a parent of a “non-binary” 13-year old female wants to know if she has to choose a binary hormonal pathway for her child.

I know testostrogen (audience laughs).  So, there are some options. I think it’s challenging because you do need a…you need to have sex steroids for bone protection and probably a lot of other things that we are not nearly as clued in as we need to be. But…So certainly there’s going to come a time and for the young people in my practice I hesitate to have people on just blockers in that age range for more than 2 years. Although I think you still can do that and certainly we use blockers in adult populations for longer than 2 years. But I do worry about their bone density.

There are things people can do and it will largely depend on how your child wants to wear their gender. So, a lot of times my non-binary kids…. they preferred to be misgendered as male than female. And some people have chosen testosterone for a year and then stop. Some people have chosen to do very low dose to see how it makes them feel. And make a decision if they want to continue on it or not. Some kids they simply have to come off of blockers and go through some more of their endogenous puberty to say “oh no, I don’t want this.” This is bad. And then some kids are like aaahh, it’s ok…. At some point your kid is going to have to make a choice which is really hard. I imagine that must be really really difficult... It’s probably unlikely that your young person is going to want to be on perpetual blockers. That’s my guess. 

 She has a very pro medication and cosmetic surgery experimentation outlook:

I think what it boils down to for me is this core of fear around gender exploration and I wonder when we are going to get to the point as a society of celebrating gender exploration versus putting so much pressure on young people to make the right decision and be in one box or another.

A reasonable response would be, “because it’s celebrating identities that require invasive surgeries that are dependent on and profitable to the medical industry, with unknown long-term outcomes.

More mix and match non-binary options for minors:

And it’s great. I love this. I don’t like the word “pass” at all. Passing as a member of the other sex is not a criterion for treatment, whereas achievement of personal comfort and well being are. And that is really the crux of what should guide our care, as medical providers, as professionals in the mental health role…So, there are a lot of medical intervention possibilities for folks who have nonbinary identities. And again, this is really not for me to determine. It’s really for me to work with a person to determine what it is they’re interested in...

Some people are like, oh! no menses, no mustache. You know, assigned female at birth, “I really don’t want facial hair, I don’t want [inaudible], I’m super dysphoric about bleeding. So, there’s lots of options, certainly for menstrual suppression. I love—I was so excited to be in one of  the first sessions that I went to, which was gynecologic care for trans-masculine folks, this “leave a gonad” thing. So, it was this idea of, you know, maybe you don’t wanna have bleeding but you still want estrogen, and you want that support from a medical perspective. Or you just don’t want to go on testosterone.

There’s lots of these different things.  Maybe a central blocker and low dose testosterone. I had a young person who went on testosterone for a year, and it was like, that’s enough, I’m fine with it.  I’m masculinized enough, and that’s good for me. Or no medical intervention at all.  That’s absolutely possible…

 So, for nonbinary assigned males, maybe just Spironolactone [an androgen blocker] or using a peripheral blocker only. That might be something that people opt for. I had a young person who really [inaudible] nonbinary identity, but kind of, very very huge fear of a large nipple areola complex. Like, “I just can’t even deal with that... So, we put them on Spironolactone for a while, and then eventually she came back and said I wanna go on estrogen.  So there’s selective estrogen receptor modulators for people who do not want breast development. That could be a possibility. Maybe hormones, no surgery. No medical intervention, another possibility.

Confused non-binary children have trouble making decisions.

The harder piece is when non-binary kids want to be on blockers forever. And you’re like you can’t do that because hormones actually are binary. And there’s no testostrogen (audience laughs). 

And:

That’s what I’ve seen anyway. And I didn’t really talk about non-binary youth in this conference this time. But I do have a whole presentation on non-binary youth. And how the space of non-binary can be strategic for some people. And that it may be a temporal and not a landing space.And so I think it’s just going to be a little bit of time before you know where your kid is.

Michelle Angelo admits these cases are difficult which calls into question the wisdom of medicalized pathway at such a young age (Gender Odyssey, 2017).

I think a nonbinary identity probably is one of the more challenging identities out their. 

Some affirmation model advocates believe females should have access to double mastectomy even if they don’t have dysphoria and still consider themselves female.

dan_karasic_nonbinary_sugery.png
wpath_nonbinary_surgery.png

Similarly, Dr. Johanna Olson (USPATH 2017) provides enthusiastic support for drugs and surgery for individuals who don’t actually have gender dysphoria. A ”my body my choice” attitude is reasonable for adults but is it for 15-year-olds?

There are still people who want to embark on phenotypic gender transition—hormones and surgeries, who don’t meet this criterion [for gender dysphoria]. Well, what are we to do?…And it’s great. I love this. I don’t like the word “pass” at all. Passing as a member of the other sex is not a criterion for treatment, whereas achievement of personal comfort and well-being are. And that is really the crux of what should guide our care, as medical providers, as professionals in the mental health role…So, there are a lot of medical intervention possibilities for folks who have non-binary identities. And again, this is really not for me to determine. It’s really for me to work with a person to determine what it is they’re interested in…

Some people are like, oh! no menses, no mustache. You know, assigned female at birth, “I really don’t want facial hair… I’m super dysphoric about bleeding…So, there’s lots of options, certainly for menstrual suppression. I love—I was so excited to be in one of the first sessions that I went to, which was gynecologic care for trans-masculine folks, this “leave a gonad” thing…So, it was this idea of, you know, maybe you don’t want to have bleeding but you still want estrogen, and you want that support from a medical perspective. Or you just don’t want to go on testosterone…There’s lots of these different things.  Maybe a central blocker and low dose testosterone. I had a young person who went on testosterone for a year, and it was like, that’s enough, I’m fine with it.  I’m masculinized enough, and that’s good for me. Or no medical intervention at all. That’s absolutely possible…So, for non-binary assigned males, maybe just Spironolactone [an androgen blocker] or using a peripheral blocker only. That might be something that people opt for. I had a young person…non-binary identity, but kind of, very very huge fear of a large nipple areola complex. Like, “I just can’t even deal with that…So, we put them on Spironolactone for a while, and then eventually she came back and said I want to go on estrogen.  So, there’s selective estrogen receptor modulators for people who do not want breast development. That could be a possibility.  Maybe hormones, no surgery. No medical intervention, another possibility. 

These very pro-drug and surgery attitudes are not surprising in light of the fact that some in the mental health and medical industry are transitioning delusional individuals (called “plurals”) with multiple identities and are performing full penis amputations for “nullo” identities. A long quote below illuminates the libertarian philosophy behind nullo and non-binary body part removel that is also being applied to tweens and teens.

There are men who wish to become eunuchs in the classical definition. For them, removing the entire penis and testicles can be a remarkably fulfilling, relieving experience, even though they may still identify as male and use male pronouns. In their online enclaves, such people sometimes identify as "eunuchs," "nullos," or "smoothies." In the medical literature, they are referred to as male-to-eunuchs, suffering from their own unique form of gender dysphoria

Because of the scarcity of providers, the expense, and the taboo nature of the procedure, patients who seek penile amputation have few options. Men who are seeking to nullify their sex often go to great lengths to find someone who is willing to help them. "There are very few surgeons in the world who are comfortable with this," says Dr. Curtis Crane,one of the nation's leading experts on penises. "I've done a few [full penectomies]. We get a few requests a year, and I think it's a good service to provide to the community."

For example, Crane says that it is "well accepted" among surgeons who specialize in providing care to trans and gender nonconforming people that there is a subset of assigned-female-at-birth patients who "do not believe in a binary classification." These nonbinary individuals don't identify as men, but they still suffer from gender dysphoria. People in this group commonly "want the absence of female characteristics, such as breasts"—and this procedure is generally accessible for them, even if they don't want to go on Hormone Replacement Therapy, because surgeons who perform trans operations recognize their need.

"It's perfectly acceptable for a lot of us [surgeons] to go, 'OK, let's masculinize your chest even though you aren't fully transitioning,'" Crane says.

"Well, you know, what's good for the goose is good for the gander," he continues. "There are some patients that were born male who don't want to fully convert to becoming female, but they don't identify with their testicles, or they don't identify with their scrotum, or they don't identify with their phallus, but they still feel male; they want masculine pronouns. To me, it's a double standard to accept the gender fluid female, but not the gender fluid male."

nonbinary_genderqueer_symbols.jpg

Affirmation model advocates frequently make comments that they believe hormones and surgery for minors should be accessed without alternative therapy or attempts at alternative coping skills, despite admitting these difficulties in a young person may be transient or their cases may be borderline. They rally for medicalizing these minors while at the same time admit their “true self” who is demanding hormones and surgery may be transient. It seems logical to ask why borderline cases should not receive counseling to try to forgo or delay medical treatment.

D. Enthusiastic support for transitioning autistic youth or developmentally disable youth

There is now a well-established connection between autism and gender dysphoria. There is concern about this because people on the autism spectrum can have rigid ideas about the world around them and gender in particular and can often latch onto ideas and obsess about them. Diane Ehrensaft, Johanna Olson-Kennedy and other pro-early transition therapists and doctors do not believe that the autism should be explored or should be any barrier to immediate affirmation. The idea is that they have rights too and should be able to decide to transition (true but the issue here is should they transition as minors). Diane Ehrensaft talks about their uniqueness and how we should celebrate it by describing them as “double helix rainbow kids.”

This is a story of a 14-year-old female on the spectrum with a below average IQ and other damage from being born to an alcoholic mother, encouraged to transition by Johanna Olson-Kennedy’s spouse, Aidyn Olson-Kennedy. Given that Aidyn also canvased for money for a seriously developmentally disabled female with severe health problems to obtain a double mastectomy, this transition of very young people with mental issues isn’t out of the ordinary.

Diane Ehrensaft does not agree with taking autism into consideration as a comorbid factor that could be creating GD, that could be possibly be improved with therapy.

(2:00:46-2:02:45):

The problem is when it’s gender and something else, doctors, teachers, well it’s just a symptom of the neuro diversity. There’s obsessions, there is like an obsession now with gender and it is a phase. It’s a passing obsession. So, we need not take it seriously. We need to take it very seriously. It is most likely a core part of the person.

Norman Spack believes in the informed consent model but admits autistic cases can be difficult to assess due to magical thinking and obsessiveness in autism spectrum individuals. He states many of his new presenters are on the spectrum. The below quote seems to indicate reason for caution.

(41:40):

 They may have wanted to be a lion 2 years ago, now they want to be a girl.

Some mental health experts advocate for more caution with autistic youth

Other clinicians and mental health experts do not share this enthusiasm for medically transitioning autism spectrum minors. 

Autism expert Tania Marshall is very concerned about the affirmation model and in a video, she covers many issues with transition and autism including rigid thinking, not fitting in socially with other girls (if female), and cases of regret. 

(54:20-54-55):

So those clients that I have seen who regret their transition or retransitoned said that they felt that they were too young. That they were misdiagnosed as being trans rather than being autistic. For parents, teachers, therapists. School counsellors, explore.  

Mental Health experts in the public health system in Britain talk about some of the difficulties in treating autism spectrum individuals. 

(7:45-8:50):

I think having a diagnosis of ASD or features of ASD doesn’t preclude people from coming to our service and having treatment if it is appropriate. I think it probably has more implications in terms of, I suppose sometimes the needs are different. So, a lot of the adolescents that attend our services may be very isolated. Their social lives are in the middle of the night with friends in America rather than in the real world outside. So, what might be directed more towards really thinking about how individuals can be supported to integrate into the world around them. And I think it also has real implications for how one might start to explore gender. I think there may be a tendency to be a bit more concrete and find exploration a bit more challenging. 

From the same video (9:17-9:50) Mike Davies, a neuropsychologist states:

For me it’s not the concrete thinking that’s the problem there, although obviously there is concrete thinking . It’s actually understanding social relationships. Understanding social relationships is a big problem for people on the autism spectrum. When you are talking about sexual relationships and sexual interactions, and dysmorphia, I think that the fact that they’ve got problems with that, social understanding is the bigger problem. Probably the bigger problem you have to face when working with them.

Another therapist in Britain expressive frustration with the limitations of the affirmation model and the risk he feels this poses.

(40:40-41:11):

It’s not at all easy to work with someone who is slightly on the spectrum who feels emotional and social distress in their bodies and then is told, that’s because you are in the wrong body. It is possible to work with those people psychologically. But it’s difficult to translate dysphoric feelings in the body into symbolized emotional relational issues. But it’s not impossible. But it requires long-term psychotherapy, not just 6 sessions assessment. 

Susan Bradley, a psychiatrist from Canada, is alarmed at the way autistic youth are being fast-tracked into medical transition and advocates for a mental health model.

When a sex change seemed the only realistic option, we referred them to an endocrinologist for assessment regarding puberty blockers; if prescribed, we continued monitoring their progress to ensure their ongoing safety. (Even so, we had qualms, given a lack of evidence of long-term impact.)

However, we also felt strongly that irreversible medical intervention such as hormones and surgery should be postponed until we could be certain that the individuals were fully able to understand that there would be no going back. We were quite willing to accept that individuals might change their mind or wish to slow the process down. In short, we did what is considered best practice in the field of ASD and gender discomfort.

Activists would have the public believe that anyone who expresses a wish to be the other gender should be allowed and encouraged to do so. Credulous politicians have translated their demands into law. To date, however, there is no evidence that there is such a thing as a “true” trans, just as there is no marker that would identify a “false” trans. To accept the thinking and wishes of those with ASD at face value, without understanding why they feel the way they do, is not a kindness, and may in fact be extremely damaging.

Autism spectrum individuals who feel transition would have been harmful to them

Here a bisexual identified woman (there seems to be an association with autism and same-sex attraction in females also) on the spectrum who had dysphoria. She discusses how autism spectrum issues affected her thinking and how she overcame them to have a more comfortable relationship to her natural body.

Another bisexual woman on the autism spectrum discusses how the option of medical transition could have been confusing to her as a young person.

But when I read stories about kids — especially girls — who had childhood crushes on the “wrong” people, played with the “wrong” toys, or felt awkward all the time and were isolated because they couldn’t compensate, I relate. And I worry.

Will a mastectomy help self-control in response to sensory overload, either from uncomfortable social situations or intense environmental stimuli? Will a mastectomy help with task organization, completing paperwork, or making appointments?

I very much doubt if these are challenges that any surgical intervention on healthy tissue, or any supplementary sex hormone injections, could even be imagined to help with…

I was not a boy even though I hated it when my breasts grew in. Not even though I thought they were too big, too warm in the summer, too obvious in light clothes, and near impossible to neatly fit into well-fitting buttoned clothes. But who doesn’t complain about theirs? In my experience, almost all women do, eventually. I grew up in Los Angeles, and people talked about plastic surgery often. Breast augmentation became a popular topic, because it seemed obvious that whatever kind you had, there was something wrong with them. Even the women everyone in the media agreed were “beautiful” didn’t like theirs.

Here is an example of a transition of an autism spectrum individual that seems to have gone very badly. The person’s ability to give informed consent is questionable, as they have the maturity and cognitive capacity of a nine-year-old.

Levinstein’s daughter’s double mastectomy took place a year ago and she is now on an aggressive regimen of additional testosterone. When the endocrinologist gave her daughter the first batch of testosterone, it came with 30 pages of warnings and said that the medical profession does not know of the long-term health risks associated with such a regimen. Her daughter also has Crohn’s disease and has been hospitalized several times for what she describes as “absorption issues” related to the testosterone.

E. Not all gender professionals agree that the gender dysphoria affirmative model doesn’t increase persistence & that these concerns should be disregarded

The attitudes of affirmation model therapists and doctors who support the gender affirmative model are not universally supported in the mental health and medical community despite often being presented as if they are by LGBT orgs, schools, therapists themselves, and the media.

In “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study. ”Many mental health and medical professionals express doubts.

The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions. As still little is known about the etiology of GD and long-term treatment consequences in children and adolescents, there is great need for more systematic interdisciplinary and (world-wide) multicenter research and debate. As long as debate remains … and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.

This is a quote from the researchers in Sweden, also experiencing an unexpected rise in GD referrals, particularly among girls. They express that there is a lack of research and understanding in the area of adolescent GD.

More empirical research is needed regarding virtually all aspects of GD in adolescence to create treatment approaches that optimize these young people’s future psychosocial health and well-being. It seems unlikely that all the psychopathology observed in the referred samples is secondary to gender identity issues and would resolve with hormonal and later surgical treatments. There is still no clear consensus regarding hormonal treatment for adolescents because long-term data are unavailable;36 actually, only one long-term follow up has been carried out, with a highly selected intervention group and an at baseline non-comparable comparison group.102

An affirmative approach103 is increasingly implemented in the health care of gender nonconforming children. This includes, based on a comprehensive psychological and psychosocial assessment, work with the children and their families and schools to support the gender-nonconforming minors to express themselves in a way that feels most comfortable for them. With the starting point that gender presentations are fluid and changing over time, gender variant children need to be allowed to freely explore a range of gender identities and expressions. A debate concerns whether or not a prepubertal child should be allowed to completely transition to live in other than birth gender. Concerns include that childhood transition may be forcing adolescents to proceed to biomedical interventions, as stepping back may be psychologically troublesome, even though identity development has taken a new direction.28,104

Dr. Singh is a more cautious gender dysphoria expert who expresses alarm over ignoring the reality of desistance.

Singh is frustrated that, despite the findings of her study and others like it, there’s now more pressure than ever for doctors and families to affirm a young child’s stated gender. She doesn’t recommend immediate affirmation and instead suggests an approach that involves neither affirming nor denying, but starting with an exploration of how very young children are feeling. Affirmation, she argues, should be a last resort.

Debra Soh who holds a PhD in sexual neuroscience is also worried about the overall safety of the gender affirmative model and confronts Ehrensaft’s plea to “let the children lead the gender revolution.”

But by taking children's words at face value, the adults in the room are denying them the help they need. The goal of successful policy and medical treatment should be to improve the lives of those who are struggling, not to pat ourselves on the back for being open-minded and progressive.

Bob Withers is a therapist and Jungian analyst in Britain who believes gender dysphoria is being over-medicalized in young people.

(2:49-6:07):

I think the trans affirmatory lobby has unconsciously and unwittingly channeled this generation into a load of unnecessary surgery and medical treatment. I think my profession; our profession of psychologists has been complicit in that because we’ve wanted to be nice. We don’t want to offend people. We want to virtue signal to each other. And we don’t want to repeat the horrible mistakes that we made with gay people by pathologizing them. But to be gay you don’t need surgery and you don’t need hormones. So, I think we’ve let down, particularly this young generation of trans kids and so I’m concerned to try and understand how that’s happened… My own internalized fear of being transphobic led me to let down one of my patients… I think we are all working under a cultural constraint here which is not helpful for anybody, least of all the trans kids themselves.

Psychiatrist Susan Bradley, is interviewed on the subject in the podcast Wrongspeak where she discusses the complicated issues involved with youth gender dysphoria.

Sasha Ayad is a therapist who has been working with dysphoric teens.

One of the underlying assumptions of the affirmative approach is that “gender dysphoria” is an incongruence between biological sex and “gender identity”, which proponents claim, is innate and fixed throughout life. Advocates of this approach also believe that “gender dysphoria” is qualitatively so different from other forms of suffering, that it requires a radical and unprecedented type of remedy – medical and surgical modification to have the body imitate the opposite sex. For adults, this physical transformation is absolutely their right, if living in the opposite sex-role is something they carefully and freely chose to do. The idea that children can weigh, process, or consent to such drastic intervention, however, is completely unreasonable.

So how do we ethically and morally address these mind-body problems? Typically a least-invasive-first approach is standard, but in the world of gender ideology, politics and propaganda have managed to sweep that option right off the table.

To complicate matters, gender dysphoria is now being self-reported in unprecedented numbers, often by young teens who have declared themselves “gender dysphoric.” THese self-diagnoses are sudden, and often manifest after the teen has read about the condition online. You’d think our first step is to examine how that initial exposure to the “wrong body” schema, combined with personal and individual vulnerabilities, might have lead her to believe she has the “wrong body.” Or, perhaps, we might begin by exploring what it means for a child, symbolically, to adopt a new identity and alienate herself from the body she has always inhabited. We mental health professionals are, instead, being instructed to bypass any case conceptualization or critical examination, and move right along to the next step: treatment. And specifically, one that addresses the body itself as culprit for the patient’s suffering, rather than perceptions of the mind. Rather than “saving lives” or exercising “compassion,” as proponents claim, this literal approach trivializes the gravity of the child’s experience of incongruence. It’s equivalent, in my view, to a doctor prescribing amputation for a patient who complains of arm pain. Or worse, complaining that they don’t “identify” with having an arm, and demanding an amputation – actually, this already happens.

James Caspian is a therapist who worries that enthusiastic affirmation is increasing regret rates and detransition. He wanted to research detransition but his University censored his project due to fear of trans activists.

'I decided to do it, so went to Bath Spa University and signed up for an MA in Counselling and Psychotherapy, and started to do the preliminary research.

'Traditionally, people had always thought the regret rate among those who transition is between 1 and 5 per cent, so the general attitude among people involved in the transgender world was it was so low that it wasn't really important. 

But that was based upon old research from the Eighties and Nineties.

'My preliminary research suggested those percentages were out of date. You just need to look at the increasing numbers of those regretting and reversing their transition on the internet on websites and in blogs.

'Last year, a group of young women in the U.S. who detransitioned had their first ever convention.'

There are many posts on the internet from those who regret changing gender. Each of them makes for desperately sad reading.

Take, for example, the anonymous 30-year-old who transitioned from a female to a male and is now detransitioning, who wrote on a blog recently: 'I don't blame anyone else for my idiocy.

'I just wish I would have learned to love myself before completely turning my life upside down with all of this.

'I've been injecting testosterone for around three and a half years, have had top surgery [a double mastectomy] and a hysterectomy.

'I know I'll be able to have reconstructive surgery on my breasts eventually. I mainly worry about how people will treat me until I can re-feminise my face, body and fix the thinning hair issue.'

In November 2015, James submitted his first proposed Masters Research title, 'An examination of the experiences of people who have undergone reverse gender reassignment surgery', which was accepted.

'I had some people contacting me who said, 'Yes we've reversed our gender reassignment, but we're so traumatised we don't want to talk about it.' It made me realise how very important the research is.

Terry Patterson, a university student counsellor in a paper titled “Unconscious homophobia and the rise of the transgender movement”, worries about the connection between dysphoria and homosexuality and the rush for counselors to affirm irreversible medical changes in young people.

(Patterson et al 2017):

Those who work in the field of psychological therapies are increasingly seen as obstacles to be overcome, enemies to be defeated, rather than benign, helpful professionals trying to facilitate careful consideration of this irreversible and life changing process, with the long-term best interests of the child at the heart of their work. 

I have recently become aware of, and that both speakers referred to, which is in the rise of the transgender movement of the unintended, perhaps unconscious intolerance of diversity that fuels demand for a quick fix to a very complex issue. 

There has been a big increase in my line of work, university counselling, in the numbers of young people accessing services with issues around gender. I have been concerned by what we are being asked to do as counsellors and therapists in terms of unquestioning support for young people to make irreversible changes to their bodies, without exploring what’s happening at an unconscious level. In my service, we have had complaints and accusations, that we are trans-phobic, on the grounds that, rather than automatically accepting that students who present with this issue are ready to start a process of gender reassignment, we take a stance of helping them to think things through and explore what it means to them. What they seem to want is for us to accept that this is the right decision and to provide emotional support as they begin the process. But for some of these young 18 and 19 year olds, this would, I believe, be an ethically irresponsible stance to take. Often they have either not even had a sexual encounter, or have had a same sex partner which they feel has given them confirmation that they are ‘in the wrong body’. 

So what might be happening here? It seems that there is a desire to jump over this quagmire and quickly grab hold of an identity, with a wish that professionals will collude in the avoidance of painful, confusing and potentially destabilising feelings. 

So what might be happening here? It seems that there is a desire to jump over this quagmire and quickly grab hold of an identity, with a wish that professionals will collude in the avoidance of painful, confusing and potentially destabilising feelings...

It seems to me that while parents are trying their best to be supportive in response to the significant dis- tress of their gender non-conforming children, they are inadvertently encouraging a split and I question what unconscious anxieties may be motivating this. It’s as though, if a child has feelings about their sexual identity which don’t fit neatly into masculine male or feminine female, we must help them to change the physical body to accommodate this, rather than allowing a healthy, perhaps more depressive position where varying degrees of feminine male and masculine female can co-exist. To me, this is ‘child-centered’ parenting taken to the extreme. 

Ken Zucker in fact, believes affirmation will groom pre-gay and lesbian children for sex reassignment. It’s the reason he supported a body acceptance and cautious model.  

Alice Dreger expresses alarm of increasing evidence Lupron has serious long-term side effects and its enthusiastic us in pediatric endocrinology,

…the drug is known sometimes to cause serious side effects. As one oncologist quoted in Grady’s article put it, the side effects are serious enough, “you’d better have some decent justification” to use it… 

A 2009 specialist review of the use of gonadotropin-release hormone analogs like Lupron for precocious puberty and for making children taller found “few controlled prospective studies have been performed… and many conclusions rely in part on collective expert opinion.” It now appears increasingly likely that serious bone problems can arise from this use for some pediatric patients—serious enough to cause life-long problems.

This paper, is a response to an uncritical promotion of providing medical transition to large increases of young people. The authors complain about the apathy in the mental health profession around exploring the reasons for huge increases in female teens identifying as trans and expresses concern over lack of gatekeeping, 

However, the article does not question the steep rise in referrals, especially of girls, to gender identity clinics (GICs) nor concern itself with potential harms of self-diagnosis and prescribing, or medical over-diagnosis and over-treatment. Comprehensive services must be commissioned locally before ongoing, costly, life-changing interventions and life-long medications are provided after discharge from specialist clinics, and risk:benefit must be understood…

Medicine needs to be held to regulatory and ethical standards (such as ‘first of all, do no harm’), rather than allowing a system where healthcare professionals simply respond to client expectations.(7) A survey of doctors could helpfully highlight this important issue and describe physicians’ views.

While the proposal to measure outcomes and experience of those receiving interventions is to be welcomed, there is a vital opportunity, and ethical imperative, to create an ongoing cohort study for all those referred, so that outcomes can be measured at a population level over time. We disagree with the campaign group Action for Trans Health’s claim that ‘the continued existence of GICs amounts to wilful abuse of trans people’.(7)  People who are questioning their identity or see themselves as transgender should have access to high quality joined-up and person-centred healthcare based on good evidence. Creating that evidence to inform quality standards is imperative.

The below quote from Jesse Singal’s Atlantic piece indicates some gender therapists who have supported the affirmation model are becoming concerned with the affirmation model,

They very much support so-called affirming care, which entails accepting and exploring a child’s statements about their gender identity in a compassionate manner. But they worry that, in an otherwise laudable effort to get TGNC young people the care they need, some members of their field are ignoring the complexity, and fluidity, of gender-identity development in young people. These colleagues are approving teenagers for hormone therapy, or even top surgery, without fully examining their mental health or the social and family influences that could be shaping their nascent sense of their gender identity... 

 In February, I visited one of her classes at Pacific, just outside Portland. For an hour, she let me pepper her students with questions about their experiences as clinicians-in-training in what is essentially a brand-new field. When the subject of detransitioners came up, Edwards-Leeper chimed in. “I’ve been predicting this for, I don’t know, the last five or more years,” she said. “I anticipate there being more and more and more, because there are so many youth who are now getting services with very limited mental-health assessment and sometimes no mental-health assessment. It’s inevitable, I think.”

…A decade ago, the opposite was true. “I was constantly having to justify why we should be offering puberty-blocking medication, why we should be supporting these trans youth to get the services they need,” Edwards-Leeper recalled. “People thought this was just crazy, and thought the four-hour evaluations I was doing were, too—how could that possibly be enough to decide whether to go forward with the medical intervention? That was 2007, and now the questions I get are ‘Why do you make people go through any kind of evaluation?’ And ‘Why does mental health need to be involved in this?’ And ‘We should just listen to what the kids say and listen to what the adolescents say and basically just treat them like adults.’ 

It seems that regret rates in Ireland may be higher than in other places and one healthcare professional worries.

‘People who have true gender dysphoria from a young age don’t feel the need for psychiatric intervention and feel it’s a heavy-handed [measure], but for every one of those, there is another case where it is not straightforward and it’s not easy, and the transition may not deliver what the individual was hoping for.

‘They’re disappointed, as they thought there would be more of a lightbulb moment, and if you don’t have that input you will have regret and a really bad outcome.

The lack of mental health support and it’s replacement with drugs and surgeries as the immediate solution appears to not be helping youth cope with the reality that medical transition is not a panacea with the power to solve all psychological problems. While Lupron prescribed to dysphoric youth may have some benefits, it is not a fix-all and it comes with possible serious long-term side effects.

Denise Chew at the University of Melbourne and her colleagues identified only thirteen relevant studies, and most of these involved small samples, only two featured a control group, and none involved blinding or randomisation (the gold standard approach for medical trials).

Puberty suppressors appear to be effective at having their intended physical effect – that is, preventing pubertal changes associated with the person’s sex assigned at birth. They also have emotional and behavioural benefits, such as reducing depression. Crucially, however, they do not alleviate gender dysphoria (one study even found a trend in the opposite direction and increased negative body image). The researchers said this is “probably not surprising” given that puberty suppressing drugs “cannot be expected to lessen the dislike of existing physical sex characteristics associated with an individual’s birth-assigned sex nor satisfy their desire for the physical sex characteristics of their preferred gender”.

Meanwhile, gender affirming treatments and cross-hormonal treatments are successful, to a degree, in achieving the intended physical changes in line with the desired gender. However, these often do not match the hopes of the person with gender dysphoria – for instance, oestrogen led to a degree of breast growth that most of those treated found unsatisfactory. There are some cognitive effects to consider – for instance, after taking puberty suppressing drugs, teenagers born male but seeking to transition to female, subsequently showed poorer performance on tests of executive functioning and mental rotation. Perhaps most concerning – especially given the psychological vulnerability of many teens with gender dysphoria – there is simply no data on the psychosocial effects of these treatments.

This lack of data is in the context of a growing concern among some psychologists that the affirmative approach may have gone too far. For example, psychologist Dianne Berg, Co-Director of the National Center for Gender Spectrum Health in the US (which advocates an affirmative approach), told The Atlantic recently “Under the motivation to be supportive and to be affirming and to be nonstigmatizing, I think the pendulum has swung so far that now we’re maybe not looking as critically at the issues as we should be.”

In an interesting quote in a piece critical of sources of trans activism funding, the author explores a possible reason for the push to eliminate gender dysphoria from the DSM,

What this translates to, in other words, is a goal of considering gender dysphoria no longer a mental illness — and to consider gender dysphoria a mental illness as a ground for violating a trans person’s human rights. This could mean that with no diagnosis, doctors cannot be sued for malpractice for prescribing transition. Do you see an issue with that? Other focuses of GATE include “Movement building”, which is described in its 2015 IRS 990 form.

The difference between pro early transition clinicians like Diane Ehrensaft and Johanna Olson-Kennedy and more conservative ones like Dr. Ken Zucker, Drescher, and Bradley, or even clinicians more in the middle such as doctor Dr. Wren, is a tolerance for accepting ambiguity in borderline cases. The prior acknowledge borderline “fruit salad youth” and the latter acknowledge them but disregard the dangers posed to them with early medical treatment. The stricter gatekeepers do not consider inappropriate medical transitions morally acceptable, the dysphoria affirmation model advocates do. 

Increasingly with liberal media, LGBT organizations, and school systems celebrating the affirmative model and promoting it as worth the risk to desisters and settled science, parents are increasingly not hearing any other viewpoints nor are they being informed that this is all actually very controversial.

Strikingly, the guidelines are debated both for being too liberal and for being too limiting…As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required. (Vrouenraets LJ et al 2015)

F. There are already historical examples of harm resulting from lax gatekeeping

Risk of regretters is worth trans affirmative healthcare

Some affirmative model advocates appear to believe affirming children as trans and medically transitioning tweens and teenagers is worth having some youth make mistakes and having regrets, as regret will be rare. Johanna Olson-Kennedy says she has had some regretters (tiny amount) but this should not be a reason to subject others to gatekeeping. She also thinks that teens who get double mastectomies and have regrets can just “go and get” breast implants later if they want them. 

Jack Turban has said parents should not worry about their children making a mistake and having to detransition later in this Vox article.

Sometimes “de-transitioning” is just part of a person’s healthy psychological development.

His assertion that detransition is part of a healthy process is contrary to accounts on sites like Tumblr and elsewhere of people (mostly females) in fact being harmed or even traumatized by their medical transitions. But attaining percentages of detransitionser at this point is very difficult and loss to follow-ups are high in studies.

The narrative coming out of the NHS in Britain is similar, that detransition, even from medical body modifications, aren’t a negative and are part of the youth’s healthy gender exploration.

On the subject of detransition, the concept of regret itself was questioned. We were told that detransition is not necessarily a ‘failure;’ that re-transition may be a better way of looking at it and that many are happy that they transitioned as part of their ‘gender journey’ and have learned about who they are. The NHS does not fund ‘reversal’ of transition although we were told that testosterone-induced facial hair could be removed as part of a ‘second gender dysphoria event’ although it was not clear whether the NHS would fund this. The people who regret medical transition and describe their lives as having been ruined are absent from this picture and without this data the NHS cannot build up an accurate evidence base for medical transition of young people.

Examples of enthusiastic medical transition environments causing enough harm to require governmental intervention

Given the earlier and earlier ages people are medically transitioning, the celebration of young medical transitioners as heroes in the media, and the elimination of a mental health screening process in some cases, it is worth exploring if this kind of environment will increase medical harm to young people. There are already several historical examples of harm resulting from lax standards involving young people or people with mental health problems.

Here is an example in Britain:

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’.[18] 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.

Russel Reid also transitioned a woman who wanted a sex change because she believed she was Jesus Christ and amputated healthy limbs of people with BIID.

There are also accusations of misconduct in Britain of Dr. Richard Curtis.

A woman who alleges that she was inappropriately prescribed sex-changing hormones and then wrongly underwent a double mastectomy is one of several complaints being investigated by the General Medical Council about the doctor who oversaw her aborted gender reassignment, the Guardian has learned.

The allegations include commencing hormone treatment in complex cases without referring the patient for a second opinion or before they had undergone counselling, administering hormone treatment at patients' first appointments, and referring patients for surgery before they had lived in their desired gender role for a year, as international guidelines recommend. One patient allegedly underwent surgery within 12 months of their first appointment. He is also accused of administering hormones to patients aged under 18 without an adequate assessment, and wrongly stating that a patient seeking gender reassignment had changed their name.

Australia also had an issue with an overzealous gender clinic being shut down by the government.

AUSTRALIA'S only sex-change clinic has been temporarily shut down and its controversial director forced to quit amid growing claims that patients with psychiatric problems have been wrongly diagnosed as transsexuals and encouraged to have radical gender reassignment surgery.

The 2004 review, led by Victoria's chief psychiatrist, was never made public, but a copy obtained by The Sunday Age shows the review found that countless patients were given sex changes without proper mental health checks before or after surgery.

A second review in 2006 found half of all patients had significant psychiatric conditions, such as borderline personality disorder and psychotic depression, but many were still operated on. There was no evidence that patients' underlying mental problems were treated or their risk of suicide monitored.

The reviews also found most patients had been prescribed hormones almost immediately and in some cases were referred to a plastic surgeon before being sent for psychiatric assessment.

Despite lax gatekeeping causing harm in Britain in the past British schools are immediately and enthusiastically affirming a young person’s trans identification.  

Bernadette Wren, consultant clinical psychologist at the Gender Identity Development Service (GIDS) clinic in London, said some schools were moving too fast in allowing young girls to be treated as male pupils and vice versa — simply at the child’s request

She said schools were rushing to allow pupils to change their names, uniforms and gender pronouns as soon as they “got a whisper that a child might be querying their identity” and this was not in every child’s best interests.

Overzealous and lax attitude about transgender surgeries caused gay rights activists to successfully raise the age of consent for sex reassignment in Thailand. Activists in western countries are seeking to lower it.

Sex changes are outlawed completely in Thailand before the age of 18, and for men aged 18 to 20 parental consent must be obtained…Thai gay rights campaigner Nathee Teerarojanapong said the greater legal protections are necessary to guard against gender swaps that too often backfire on those who make an irreversible choice. 

"I got so many calls where they said they are so sorry that they did a sex change," says Nathee. "They make a big mistake and they want to come back and be the same. But they cannot!"

A former trans identified female decries lack of gatekeeping. 

I was passionately convinced I was transgender. A belief bolstered by the discovery of words like ‘non-binary’ and ‘genderfluid’. I clung to this new lexicon like my life depended on it; I was convinced I’d finally discovered my true self, and I was hostile to all who suggested otherwise. Whilst I was busy shrouding myself in trans rhetoric, I unnecessarily injected androgens. I damaged my voice and I grew a lot of very dark, coarse hair on my face that I now have to epilate regularly. Now, at the age of 30, I often find my mind wandering to the possibility of children, but I have no idea if I’m still fertile.

Regardless of where you stand on the sex vs gender debate, are you confident that medical interventions for trans children are in their best interests? Given that capacity is decision-specific, are you confident that a child can consent to such treatment? Can you cite a decent number of high quality studies demonstrating trans children persist in their gender identity and that the risks of GnRH analogues and long-term cross sex hormones are ameliorated by the benefits of transition? Are you aware that research on the use of these drugs in trans children is scarce, inconclusive and misused? Data from the long-term safety of puberty blockers comes from children with precocious puberty, NOT trans children, and there is no evidence on the impact of such drugs on a child’s cognitive development...This irreversible and erroneous manipulation of children’s bodies has the potential to be one of greatest medical blunders of the 21st century.

There are many other anecdotal examples that include confused adults, not just minors. 

 The pro medical treatment environment being created in the United States seems certain to do some young people damage given there is precedence for damage in even much less enthusiastic pro medical transition environments.

G. Proper mental health support as a human rights issue

While access to medical transition is framed as a human rights issue, the above examples of historical harm involving young people indicates lack of proper mental health care could be considered a human right as well, especially in regards to tweens and teens whose ability to consent is questionable. These mental health professionals frame proper mental health care for youth at risk for inappropriate medical transition as a human rights issue.

As we have already stated, we believe there is an important human rights issue at stake here in relation to young people receiving appropriate mental health care. This includes developing our understanding of which young people will benefit from transitioning and which young people require other forms of intervention other than gender-affirming care to address their difficulties. We fundamentally disagree with Serano’s implicit critique that Littman’s paper is transphobic. We believe Littman’s paper is supportive of all youth, including trans youth because it attempts to expand our awareness of the diversity and complexity of youth mental health needs…

It is the responsibility of the medical and therapeutic establishment to guard against both under-diagnosis and treatment, as well as over-diagnosis and treatment, either of which can be harmful. Gender dysphoria ought not to be any different simply because it is more politicized.

Detransition is an under studied topic. But a detransitioned women created an interesting survey that demonstrated that many detransitioners had zero therapy. The number was 65% for women who had “no therapy at all.”

65% of those who medically transitioned had no therapy at all.

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.

Some gender clinicians are expressing they have doubts about the safety of the way young people are being transitioned.

However, after a member of staff at the Tavistock flagged concerns that psychosocial factors influencing a person’s decision to transition were not being given adequate weight, the clinic confirmed to the Observer that its staff were being encouraged to share views via an internal review.

This will be welcomed by the parents who met Jenkins. They say they have been contacted by about 400 others who share their worries “that activist pressure may seek to limit the psychosocial assessment which precedes medical involvement, and is aimed at understanding the young person’s development and gender identification in the context of their family background and life experiences”.

They add: “In a zeitgeist which encourages unquestioning affirmation of gender identity statements, we fear that confirmation bias may lead to children being prematurely diagnosed and ‘treated’ as trans, regardless of the complexity of family circumstances, the presence of neurodevelopment disorders or of psychopathology.”

H. Trans people & detransitioners concerned over lack of mental health screening & support

The trans community is not a monolithic place and interestingly some of the most vocal critics of transitioning children or operating under an informed consent model are trans. Buck Angle is an FtM and trans activist who speaks about detransition and regret and its association with the “informed consent” model and his own benefits from mental health counseling,

I want to talk about it. I’ve been wanting to talk about it for years. I’ve been wanting to talk about it for a long time since I saw what was happening in our community. And what was happening in our community is we weren’t talking about people who were detransitioning. And people are transitioning at such a fast rate that it didn’t make sense to me that, wait a minute here, let’s have a discussion here. We’re taking mental health care out of the equation? Really!? We’re taking mental health care out of the equation of transitioning. I personally disagree with that…I will tell you for me, it was the best thing ever. I’m not saying we need gatekeepers. We have plenty of gatekeepers in this community. I’m not saying mental needs to be gatekeeping. So, don’t put words in my mouth because I know that’s what you’re thinking right now. (14:29-15:18)

Detransitioned MtF, psychology PhD student,and blogger Thirdwaytrans, suggests an alternative to “informed consent.”

The movement towards pure informed consent also creates problems and may lead to unnecessary transitions. A possible alternative would be to include a therapy requirement for transition, but allow the client free choice to participate in hormone or surgical treatment after therapy. This would prevent some of the problems with the gatekeeping system. However, even this would be difficult to implement because there really is no more gate as referenced above.

He also expresses concern over social justice activism ideology clouding judgement of mental health and medical health professionals,

A lot of what is currently going on with gender therapy is currently related to “social justice” ideology. The goal of social justice ideology is an admirable one. Its goal is to correct injustices that occur when groups are marginalized in various ways. This is a noble pursuit. Being part of a marginalized group and being subject to discrimination and prejudice is pretty awful, which is something I certainly learned after 20 years of living as a trans women. It is not the goals of social justice ideology that are problematic, but its methods. In fact, its methods sometimes cause harm to the very marginalized groups it purports to protect…

This means that if therapist who has a strong orientation towards social justice and works with trans people they will tend to see their problems as due to oppression, and additionally feel they should not question the client’s narrative which must be taken at face value as they are oppressed people. At first I found it perplexing this practice of engaging in minimal assessment for something as serious as hormonal treatment and surgery. This seemed irresponsible especially given as I am trained as a therapist and understand how much focus is generally placed on assessment for other conditions. Now, I understand it is not so much irresponsibility, as morality. It is not that they consider it unnecessary to do assessment; it is that they actually consider it immoral to do assessment!

A few months ago, I attended a conference about trans health. At this conference, there was a presentation titled something like “assessments for mental health” and I was excited to attend this presentation because I thought I might finally come across some good information on this topic, which every training and conference I attend never seems to have. Unfortunately, I was rather disappointed. The presenters presented a case study of a client who had psychotic symptoms, and issues with dissociation. Surely some caution would be indicated in this case. Of course, the answer was “we found a way to get them enough resources and support to have that surgery” and there was nothing about any kind of evaluation of whether they should do this or not. 

British man who advocates for a more cautious approach to transition

At that time there was no possibility of transitioning during high school, however once I got to college and I was on my own I was free to pursue my goal of transition. At age 19, I saw a gender therapist and in just two sessions I was approved for hormones. There was no exploration of any underlying issues and even the possibility that underlying issues could relate to gender dysphoria was denied.

I went through gender transition and I was happy for me, but had ongoing difficulties with relationships and still feeling unsettled with my gender. Twenty years later I went to therapy, not with the intention of working on gender, but to deal with my other issues. It was a long process, but after 150 sessions of therapy, I came to understand the origins of my gender issues and then returned to living as a man. I feel strongly that these issues should have been explored at the me of my gender transition, and it took working with a skilled professional over a long period of me to resolve them.

 A detransitioned FtM opposes medical treatment for children due to her own experience of desisting even as an adult.

Parents who try to protect their kids from transition are absolutely doing the right thing,” says Carey Callahan, a detransitioned woman who is currently pursuing a master’s degree in family counseling…”Medical transition has significant consequences. I was on testosterone for nine months, and it affected my liver. I know other detransitioners who have tissue damage from binding their breasts, nerve damage from a double mastectomy, and vaginal atrophy from testosterone.

 An MtF wrote an entire article about why gatekeeping with children is wise.

The role of gatekeeping is critical in examining the underlying causes of distress, and such distress may or may not be strictly gender dysphoria. Indeed, at least 70 percent of people with gender dysphoria at some point also experience psychiatric comorbidity, such as anxiety, depression, anorexia, autism spectrum disorder, ADHD, bipolar disorder, PTSD, borderline personality disorder, or dissociative identity disorder. This 70 percent rate complicates the matter at hand, requiring careful differential diagnosis, exploration of trauma, and questions about sexual orientation. Sadly, this common sense approach is making way for the ‘informed consent’ model, where a quick initial consultation at the doctor immediately follows seeing an endocrinologist to start HRT, with nothing in between except for a consent form.

Blaire White (a famous conservative leaning homosexual transsexual YouTuber) is opposed to sterilizing and medically transitioning minors. Miranda Yardley, is another homosexual transsexual who is also adamantly opposed to medically transitioning youth. The term “transsexual” fell out of favor with many trans activist but some trans people are re-embracing the term to differentiate themselves from what they see as some faddish or even fetishistic elements in the trans community which involve multiple gender identities and trans identity without medical transition. Jamie Shupe, a trans activist (since detransitioned) responsible for adding a third gender ID option on Oregon driver’s licenses, is another person who is opposed to the medical transition of children. This is merely to point out not all trans people who experience genuine dysphoria think that early medical transition doesn’t have the potential to harm not just desisters, but trans youth as well.

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Contents

5) Mental health & medical professionals have moved from a mental health screening model to a gender dysphoria affirmative model

A. Statements by therapists & doctors supporting the gender dysphoria validation model in children

-Let the child lead

B. Pro-early transition doctors & therapists do not want psych. assessment letters or age restrictions

-Lowering the age of consent for surgery & hormones

C. Enthusiastic support for medically transitioning minors with unstudied non-binary identities

D. Enthusiastic support for transitioning autistic youth or developmentally disabled youth

-Some mental health experts advocate for more caution with autistic youth

-Autism spectrum individuals who feel transition would have been harmful to them

E. Not all gender professionals agree that the gender dysphoria affirmative model won’t increase persistence

F. There are already historical examples of harm resulting from lax gatekeeping

-Risk of regretters are worth trans affirmative healthcare


-Examples of enthusiastic medical transition environments causing enough harm to require governmental intervention

G. Proper mental health support as a human rights issue

H. Trans people & detransitioners concerned over lack of mental health screening & support

Back to Outline

More

1. Do children outgrow gender dysphoria?

2. Permanent side effects

3. Are children & teens old enough to give consent?

4. Comments safety / desistance unknown

6. Minors transitioned without any psychological assessments

7. Conversion therapy laws

8. Regret rates & long term mental health

9. New World Order

10. Nature versus nurture

11. Why are so many females coming out as trans / nonbinary?

12. Cultural ripple effects

13. Why is gender ideology being prioritized in educational settings?

14. Problems with a politicized climate (censorship, etc)

15. Suicide risk reviewed

16. Trans rights / risks of false positives on minors

17. Moral Dilemmas