Q&A with Dr. Stephen Levine

Written and compiled by Genspect parent Derek Duval.

Clinical Professor of Psychiatry and Genspect advisor Stephen Levine published the prescient Reflections on the Clinician’s Role with Individuals Who Self-identify as Transgender in the Archives of Sexual Behavior in September 2021.  As he states in the abstract, his aim is “to assist clinicians in their initial approach to trans patients of any age. Gender identity is only one aspect of an individual’s multifaceted identity” and “it is relevant and ethical to investigate the forces that may have propelled an individual to create and announce a new identity.”  Levine’s essay provides a sorely needed model for a comprehensive evaluation process using adolescent patients as the example.

Genspect had the opportunity to explore these ideas in a Q&A with Dr. Levine.

Genspect: 

As you powerfully point out, “Making a diagnosis of gender dysphoria is easy. Thinking about what it is a response to is not.”  Why do you believe so many therapists have adopted the “affirmative” model, with the notion that these children need to change their bodies, rather than doing the actual work of therapy to explore what is underlying the distress? 

Levine:

Well, it is much simpler in the short run because it pleases the adolescent or adult and makes the therapist into an ally of the patient’s emerging inner self of gender identity that privileges this over all other considerations.  It also is what they have been taught or indoctrinated to believe by teachers who have not looked into the subject in a scholarly way.  It is also a politically correct “liberal” thing to do to add to the growing sense that this is the new civil rights issue I can be part of by being supportive.  It is the product in part of the idea that the object of intervention is the patient, not the family.  Of course, it is short-sighted and ignores what is well known about the problems of adult trans communities.

Genspect:

Awareness of the shortcomings and resulting dangers of the affirmative model has been burgeoning in recent weeks.  How do you believe the Psychology profession will evolve as a result of the past several years?  If we have indeed funneled vulnerable young people toward medicalization instead of doing what we are trained to do, exploring the true issues underlying the very real pain felt by patients struggling with an identity crisis, what can we learn?  

Levine:

Social movements are not infallible.  Trans medicalization may someday be viewed as a therapeutic misadventure just as the false memory syndrome and brain surgery [lobotomies] for depression has been.  It might ultimately clue the profession and the public how unscientific and irresponsible and unethical professions can prove to be.

Genspect:

You aptly state what many believe should have been obvious all along: “Adolescent onset of gender dysphoria must bear some relationship to puberty when the body is changing, sexual drive appears, and awareness of social interactions and social status are heightened. One cannot discount the pervasive influence of the Internet in influencing current adolescents. Most adolescents undergo psychological strains and stresses that are only partially understandable to them. It may be possible that some adolescents who declare a trans identity are responding to ordinary developmental angst in an extraordinary manner. Some may be attracted to the cause of improving the world through expanding notions of gender.”

As clinicians who recognize the flaws of the affirmative model are increasingly seeking specific guidance, and as the comorbidities accompanying a “trans” identification in young people are becoming better understood, could you provide examples of specific words/phrases you utilize with several of the most common presentations or comorbidities?  Thoughtful practitioners are searching for ways to help patients feel understood and respected rather than pathologized.  In lieu of a case conference on specific individuals, could you provide examples of how you engage with the following cohorts:  autism spectrum; intellectually gifted; prior physical or emotional traumas; internalized homophobia; and those with no discernible comorbidities?

Levine:

Autism spectrum: Kids on the spectrum seem particularly prone to gender change.  The question is why? Does it have to do with intense loneliness, which is a consequence of their social anxiety, habit of not engaging, tendency towards rigid thinking, and getting intensely lost in unusual subjects?  I think the key is the wish to start life over and be more successful in a rebirth.  The trouble with this hypothesis is that I can’t prove it and when I share it, it is often more understandable to the parents than the teen.  So, the answer may be empathy, empathy, empathy for the pain of loneliness and go from there.

Intellectually gifted: I like to say that even bright people can be wrong and give some examples.  One can be a genius in one subject arena and ordinary in others.  

Prior physical or emotional traumas: It seems easier to change one’s gender than to deal with the events or processes that hurt you. I will try to help you appreciate and process what we can identify over time that hurt you so.

Internalized homophobia: I remember a mother who told me that she would rather her son be dead than gay.  This is the most extreme position that I ever encountered; all else has been more subtle but powerful nonetheless.  Many very smart people have thought that most of the trans teens of today would have been at least briefly thinking of themselves as gay a generation or two ago. Now there are two options.  Many have noted that the first sign of what will be a trans identity is the announcement that “I am bisexual.”

No discernable comorbidities: Well you are a rare and refreshing patient for me.  I’m so lucky because usually I have to help young people to face painful past situations whereas with you, we can focus on the hoped-for benefits, risks, and our mutual emerging philosophies on the role of gender in private and public life.

Genspect:

If you were in charge of the APA, how would you attempt to put your proposed assessment process into place?  How can we “pump the brakes” on the affirmation model while educating and re-training (or just reminding?) therapists of the foundational understanding of teenage and early adult development and emphasize the fundamental skills of openness and exploration that underpin our field?  The task of re-vamping our existing infrastructure of mental health professionals in the face of the avalanche of demand from young gender-questioning people feels overwhelming.  Any ideas on how to address this?

Levine:

This is a tough one.  The answer may be a few key concepts such as: Therapy as fashion and fashion leading research versus Science first, then therapy.  Organizations must commit themselves to their ethical obligations to let science lead and to Do No Harm.  Organizations such as the APA need to encourage, not suppress, debate.  More emphasis should be placed on learning about a teen’s development and less on curing their GD, which can’t be done with hormones and surgery.  Education of the public.  Education of the professionals. Focus on lawsuits being adjudicated.

We at Genspect thank Dr. Levine for the generous time he has given and the thought he has put into answering our questions.

Stephen B. Levine, MD is a Clinical Professor of Psychiatry at Case Western Reserve University School of Medicine and a practicing Psychiatrist at Debalzo, Elgudin, Levine, Risen, LLC. Image credit.

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