When doing less is helping more: A more considered approach

Written by Genspect parent Lynn Chadwick.

In Clinical and Ethical Considerations in the Treatment of Gender Dysphoric Children and Adolescents: When Doing Less Is Helping More, his article published in The Journal of Infant, Child, and Adolescent Psychotherapy, Dr. David Schwartz outlines significant concerning observations regarding the current practice of the affirmative-care approach in treating gender-distressed young people. He begins by restating the fact that gender identity is a psychological, not physical, condition. Dr. Schwartz defines it thusly:

“[G]ender identity is psychological, made up of expectations and self perceptions. Gender does not exist in the body or in any bodily structure or process. This is in contrast to sex, which is determined exclusively by bodily data: genitals and chromosomes. Gender exists in the mind, happily or dysphorically.”

He goes on to describe his growing concern:

“I wrote a paper which reflected how troubling I found most of the treatment protocols to be. I was disturbed by what seemed to be a rush to surgical and pharmacological interventions with children and adolescents. I also noticed that in most of these treatment protocols, psychological treatments, i.e., psychotherapy, was very much neglected.

What I seemed to have discovered, I suppose unsurprisingly, was that the treatment protocols on which I had commented in my article, which touted the value of hormones and surgery, were what parents of, trans kids were being offered as standard treatment much of the time. Clinics and some individual therapists, were describing themselves as ‘gender specialists,’ performing assessments that varied widely, but could be quite brief, sometimes a single session, and then declaring that a given child was indeed ‘trans,’ and urging parents to accept this and cooperate with the administration of hormones and plan on surgery. The parents who called me exhibited varying degrees of desperation.

I was also struck by the terrible dilemma these parents were facing: they were being offered a prescription by putative experts for the welfare of their children that went against their deepest instincts.”

Dr Schwartz points out the inherent risks involved with recommendation of puberty blockers:

“First, we do not have certainty about the harmful effects of puberty blockers as we do have for cross-sex hormone administration, because we do not have good longitudinal data on their effects in general. But we do know that puberty blockers adversely affect bone density, can instigate excessive height and adversely affect fertility. It is false to say that we know them to be physiologically benign. And second, what about the psychological consequences of this maneuver? The claim of providing a respite, or pause, suggests that puberty suppression is a benign, non-prejudicial move in the life of a gender dysphoric child. It seems to me that this is extremely misleading. Consider: what is the implicit message we give a child when we offer puberty blockers? We are validating the idea that the advent of puberty is a fearsome thing that calls for a prophylactic medical intervention.”

Dr. Schwartz goes on to cite five studies demonstrating that the vast majority of gender-confused children, if not intervened with, simply stop identifying as the opposite sex by late adolescence, most of them going on to become gay or lesbian adults. Given this, he continues:

“What is surprising is that some adults could not foresee that these children’s outlandish claims and self diagnoses would likely alter and adjust with time. But that many adults failed to anticipate this changeablility also does not surprise those of us who have worked with transgender kids: the earnest emotionality with which these claims are made, sometimes accompanied by threats and dramatizations, especially in the hands of a very intelligent and/or creative child, will move even the most detached adults, not to mention the parents, to a state of very intense distress, possibly impairing their usual ability to anticipate. If only we could be patient. But more on that shortly. Certainly for these children, who will likely change their minds while still young, surgery and hormone administration cannot be justified.

But here is the interesting and important part: I have noticed a disturbing pattern in the literature of the clinical groups that employ surgical and hormonal interventions. Desistence is touched on almost not at all.

How can any clinician fail to encourage the desisting child? Why would they actively exclude it from their interventions? For certainly the child who is no longer pre-occupied with the idea that his or her welfare depends on a non-medical surgery and the ingestion of hormones should be encouraged. He or she has overcome and inhibiting and unhappy preoccupation. In fact we clinicians should try to figure out the mechanism through which desistance happens and to promote it.

An additional moment of thought on this erasure of one of the most significant and established data points in the whole transgender story, that most trans kids will get over it. How can this be left out or minimized in the clinical protocols of those who proffer surgery and hormones? Well, it is said that to someone with a hammer, everything looks like a nail, and perhaps to the physician who just bought a cat scan, everyone’s brain needs examining. Is this a case of technology and a new ‘discipline’ (gender medicine) driving theory and practice? I fear that it may well be. Certainly the less invasive, technology-free options are given very short shrift by these protocols including that of the Boston group, and without explanation. They certainly cannot say that psychotherapy won’t work: they don’t try it.

So, I am recommending psychotherapy, a decidedly low-tech treatment option.”

Dr. Schwartz then offers some advice to parents:

“I gave the emphatic advice to give intense and plentiful attention to their child, but not speak about gender at all. Listen to whatever your child has to say on the subject if they bring it up, be interested, but make no contribution of your own and never initiate it. They have found this surprisingly hard to do. On the question of pronouns and names, my advice was to avoid them as much as possible. I do not favor explicitly agreeing to a trans child’s requests to modify language and naming. Such agreements are usually infested with dishonesty—parents have not really agreed to a name or gender change, they are just succumbing to pressure—and the unconscious meaning behind the linguistic surrender are very hard to disentangle. Punting and honesty are usually better.”

Dr. Schwartz concludes with a discussion of the frequency of underlying serious psychiatric conditions as well as a brief discussion on the frequency of suicidal threats being used to justify hastening the use of hormonal or surgical interventions.

To clinicians, Dr. Schwartz counsels caution:

“I am encountering clinicians, who, confronted with a transgendered or gender dysphoric child and their freaked out family, start to doubt themselves, lose track of their established tools of empathic, psychodynamically informed listening and reasoning, and imagine themselves to be in terra incognita where the usual rules of safety and value no longer apply and extraordinary measures must be taken. I am here to tell you that the psychotherapeutic relationship is still the safest and best of methods even with these seemingly unusual children. The times indeed are a ‘changin’. But humans, not so much.”

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