This essay was originally posted on the Kelsey Coalition website on March 9, 2020.
Coercive practices associated with sexual orientation and gender identity change efforts that use shame, punishment, or other abusive strategies should be banned. Luckily, these interventions have long-been frowned upon in the psychological community. However, government officials may be unaware of a different type of conversion that will take place if conversion therapy bans extend to cover any investigation of gender identity, especially in children.
As a Licensed Professional Counselor, I provide individualized psychotherapy with gender-questioning teens and consult with parents whose children began experiencing gender dysphoria around the age of puberty. My clinical cases indicate that banning the thoughtful exploration of gender identity can prevent clinicians from properly assessing patients and from developing holistic treatments. I offer this personal testimony to explain how current conversion therapy bans prevent vulnerable patients from receiving appropriate psychological care.
During adolescence, identity is in flux and children explore different ways of being and relating to the world. This developmental process should be respected as a fluid and dynamic. I have met many young people who explore gender as they navigate their teen years. Rather than being a “discovery” with a fixed outcome, cross-gender identity can be one way for a young person to understand the existential conflicts that emerge around puberty and young adulthood, such as independence, romance, sexuality, responsibility, and social belonging.
For example, many of my female clients began noticing their romantic attractions towards other girls in the pre-teen years. Despite having open-minded attitudes towards homosexuality, they felt confused and ambivalent about their emergent sexuality. In these cases, searching online for explanations of their same-sex attraction lead them consider if they may have a “male gender identity.” Though this had never occurred to them before, this suggestion became a powerful explanation for why they were feeling romantically attracted to girls, why they didn’t conform to stereotypes of feminine behavior, or why they felt uncomfortable with their developing bodies. Many also experienced homophobic bullying at school or online, and came to resent their same-sex attractions and nonconformity. These clients began obsessively researching gender transition online, coming to believe it would resolve their distress. In the course of therapy, we held this gender exploration in a non-judgmental way, remaining curious about sexuality, normalizing same-sex attraction, thereby affirming their sexual orientation. When greater self-acceptance was achieved, these clients no longer felt a cross-sex identity was authentic, and these girls came to understand themselves as bisexual or lesbian. Distress and body-hatred that accompanied attempts to be seen as boys (what they called “gender dysphoria”), also resolved once they came to accept their sexual orientation.
If conversion therapy bans include gender identity, therapy will either affirm same-sex attraction or it will affirm gender identity. We can’t simultaneously affirm both, since biological sex is the basis of sexual orientation. A therapist would feel obliged to agree emphatically with a client’s gender self-concept. In the above examples, had therapy prioritized gender affirmation, these young women might now be in the process of making unnecessary and irreversible medical changes to their healthy bodies in an attempt to become boys.
In the last few decades the number of adolescent females, like the ones I described, presenting at gender clinics has increased a few thousand percent. Prior to the 2010s, most children with gender dysphoria were males (M:F ratio approx 6:1), but now girls in gender clinics far outnumber boys. According to research by Dr. Littman at Brown University, these girls presented no indication of gender dysphoria as children. Around puberty, these girls (and some boys) declare a transgender identity after a close friend or peer has also come out as trans – this type of adolescent-onset gender dysphoria has been descriptively termed, Rapid Onset Gender Dysphoria (ROGD).
I can corroborate these findings anecdotally. After consulting with approximately 400 families and working directly with several dozen teens in my practice, it seems that the concept of transition comes before the development of gender dysphoria. This crucial distinction represents another way that this booming population of trans-identifying youth is clinically different from previous populations (gender dysphoria historically developed before the patient discovers the concept of transition). We clearly need more research on what treatments would most benefit these distressed youth. We do know, however, that most ROGD teens were struggling with social isolation, eating disorders, depression, anxiety, autism, or other mental health issues before they discovered transition and subsequently became gender dysphoric. This begs an important chicken-egg question, which a clinician could never ask under a gender identity conversion therapy ban.
As clinicians, when we encounter such distress in our patients, it’s imperative that we take a thoughtful approach to requests for identity change, hormones, or surgery in teenagers. No greater evidence for this need to be cautious exists than in the stories of detransitioning people themselves. Detransitioners are individuals who identified as transgender, began medical transition, and then came to see themselves, once again, as their natal birth sex. Most decide to cease medical transition, though many of the physical changes are irreversible.
I’ve met many such individuals and they often feel deeply harmed by the “affirmative therapy” they received. Affirmative therapy for gender identity refuses to consider if past trauma, eating disorders, family conflicts, autism spectrum disorder, depression, or anxiety may be contributing to a young person’s gender struggles. It’s a true disservice to the integrity of psychological therapy if clinicians blindly support cross-sex hormones, breast removal, hysterectomy or SRS for severely distressed patients. Banning any effort to investigate gender identity is a one-size-fits-all mandate on therapists that will harm vulnerable patients and prevent them from receiving appropriate psychological care.
Sasha Ayad, M.Ed., Licensed Professional Counselor
Further Reading:
Exponential rise in children presenting at gender clinics and identifying as transgender
Rapid Onset Gender Dysphoria
https://www.brown.edu/news/2019-03-19/gender
https://www.tandfonline.com/doi/full/10.1080/00332925.2017.1350804
Detransition
Sexual Orientation Identity Development
The Big Problem with Outlawing Conversion Therapies (interview with “Jess”)
https://www.wired.com/2015/06/big-problem-outlawing-gender-conversion-therapies/
I just stumbled across your work, researching this topic. My husband and I have been trying to make sense of our 16 year old daughter’s sudden problem with Gender Dysphoria after discovering this theory with YouTube Influencers. The few videos she showed me, as a way of helping me understand how she was feeling, reminded me of how I felt at adolescence. Of course, when reading all the material online about how to deal with the situation, we were told to affirm this desire for our daughter to transition so she wouldn’t become suicidal. We let her cut her hair and dress however she felt comfortable but as the transition moved along, she became more distance towards us even almost hostile towards me and any other woman which she interacted. Luckily, I had a friend recommend Abigail Shier”s book because it made a lot of sense to my husband and I, as we recognized our daughter as a textbook case within the pages, for ROGD. Even though we better understand and have been trying to find proper help for her to help with some of the mental health situations that we recognize within her like, anxiety and PTSD. She, of course, thinks we are not being supportive and thinks the full problem is being transgender. We are hoping we found a local therapist who seems pretty onboard with exploring other these matter first but as a sexual therapist says he follows the WPATH outline. I was wondering if you do online therapy or if we should hope for the best with this local therapist? We are just needing some guidance in better helping her move through the teen years safely before deciding as an adult about transitioning.
Rebecca:
I appear to be experiencing precisely what you are with my own daughter re: ROGD. Have you found a local therapist who isn’t going to merely affirm gender. My daughter suddenly dropped this news on me at age 17 1/2 with no signs in early childhood, is on a self-destructive path re: hormones/surgeries she wants to get to be a man, I also got Abigail’s book, but of course, she views the book itself as “transphobic” merely because of the title. And of course, I get labeled transphobic because I’m trying to help her and won’t finance this mutilation of her body through hormones/surgeries on health insurance. I’m so desperate for help to find a therapist to help with other mental health issues that I know exist–anxiety, depression, suicidal tendencies/thoughts, psychological abuse from her father, etc. I’ve been reading detransitioners’ stories, and their experiences are frightening/traumatic and these medically-altering hormones/surgeries never seem to address their underlying issues. I’m so desperate to find a therapist.
Hello. I know you are busy and have a full client load but I desperately need help for my 14 year old daughter. I am in Utah. Do you know any therapist here that use your approach? Every where I look it’s all about affirmation. I listen to your podcast, reading your website and thinking of joining your top tier member site. I just need to find a therapist near me that will help us figure this out. Thank you.
Hello, I am in the same situation as well with my soon to be 15 yr old daughter. We are based in Southern California and looking for a therapist who will explore reasons behind my daughter not wanting to be female. Looking for some guidance on how to move forward.
Hello, Sasha. I was curious as to why you were citing the topic of Rapid Onset Gender Dysphoria (ROGD) is this article, when the study the typology was derived from underwent a revision which undermined its original hypothesis. ROGD has been dismissed by the American Psychological Association and the American Psychiatric Association which both cosigned a letter alongside over 60 expert psychological organizations, in which all of whom consider the typology to be unsupported by academic research (1). In addition to this, follow-up research on this topic has yielded poor credibility to the original typology when analyzing the reports of the transgender youth in question directly, instead of relying on parental reports (2). There were also some notable problems with the sources that Lisa Littman obtained her samples from, which were websites commonly known for strong anti-trans leanings, predominantly visited by people who subscribe to ‘gender critical’ political positions.
I think it is also worth noting that a 1000% increase is not by itself indicative of an underlying rapid onset of gender dysphoria, as similar growths among marginalized demographics throughout history, such as left-handed people and gay and lesbian people. It is quite common to see a sudden spike among a demographic of people that previously had little awareness or acceptance. While there are likely several intersecting factors which play into this, transgender men and nonbinary people has historically not had the same level of media-based awareness that transgender women have, even if the depictions of transgender women have been largely in a negative light. Another factor which might have played into this was the original treatment of this group, which treated gender dysphoria as typical ‘teenage angst’, and that could have potentially resulted in a number of trans men and nonbinary people suppressing their identities as a result. It is also important to note that a 1000% increase is not a particularly large amount when considering the fact that the actual size scale of the group we are talking about is very small to begin with.
Lastly, while I think it is greatly important that we emphasize with the needs and concerns of detransitioners, it is imperative that we do not do so at the expense of transgender people — be they adolescents or adults.
(1) https://www.caaps.co/rogd-statement
(2) https://www.jpeds.com/article/S0022-3476(21)01085-4/fulltext
I think you missed something. In her own clinical experience she has treated trans identifying teens with comorbities who, through the therapy process, have ceased to identify as trans. If they were “affirmed” without exploring their feelings and experiences … they would now be detransitioners. The very important point she is making is that quality deep exploratory therapy and support are in the best interest of every patient.
A common criticism I’ve seen of detransitioners is something like “you were never really trans” or “you didn’t have *real* gender dysphoria” or “well, you were an adult. You chose to do this” And yet, where is the support for a therapeutic process to discover this and prevent further harm? “Affirmation” only healthcare doesn’t serve trans ppl well either. Long term (10ys) studies have shown a 19x higher incidence of suicide in those who do transition. It’s clear that quality mental health care is needed for *all* trans identifying ppl, whether or not they are “true trans”
What name is appropriate for the phenomenon of those who genuinely come to believe they ARE trans, without a prior history of gender dysphoria?
ROGD or adolescent onset gender dysphoria if you prefer is the phenomenon that describes detransitioners and their trans identifying history.
Tjose who push for the affirmative model of care are the ones 100% responsible for causing harm to those who will not be helped by it AND in denying quality metal health support and explorative psychotherapy to those who may be helped by affirmative gender care, but still need help.