#I think dualism can be non-binary in the sense of: a spectrum between two things which are NOT mutually exclusive

[king0fcrows]

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[therapy101]

(1/2) With a rise in young children expressing gender nonconformity being sent to gender clinics, being taught about gender dysphoria and being ‘born in the wrong body’ in schools, being guided towards pubertal blockers and medical transition, I was wondering if I could ask for your more knowledgeable input please. When treating such children and adolescents, why is the underlying assumption that the dysphoric feelings are valid and the body is what needs fixing? Why is APA/psychologists

(”2/2) allowing medical decisions to be made based on outdated mind-body dualism? We don’t affirm anorexia and offer liposuction, or the delusions of schizophrenia for instance, so why is this the only mind-body incongruence that’s treated this way? Does GD in a developing child really warrant medicalizing them for the rest of their lives? Since we’ve scientifically concluded gender is a spectrum, shouldn’t we instead be promoting gender diversity no matter what sexed body we’re born in?”

There are a lot of things to unpack and understand here. 

1. The underlying assumption is not that “the body needs fixing.” Medical transition is not the first step for children, adolescents, or adults with gender dysphoria. From 2004-2016, only 92 total children and adolescents out of six million total patients younger than 19 seen in the sample received a hormone blocker for a transgender-related diagnosis. Even among adults, current estimates for the United States are that between 25-35% of trans and non-binary adults complete any kind of gender affirming surgery (this means, even enough those who have surgery, it may only be one type of surgery and may not impact all relevant body parts). Getting access to trans-affirming medical care is very difficult, and structural inequalities like racism impact access to care, leading some trans people, especially Black trans women, to have to buy hormones from non-medical sources. That’s one of the reasons why the APA has come out to support trans folks and gender affirming care: because otherwise, these folks don’t get any care, or they get mistreated. The point here is to ensure that everyone gets equitable access to high quality medical and mental health care. That includes hormones, hormone blockers, and/or surgery for some people, but not everyone. 

2. All feelings are valid- dysphoric or otherwise. Sometimes feelings don’t fit the facts, or acting upon them doesn’t make sense, but that doesn’t take away from their validity. The question is not whether the feelings are valid for kids with gender dysphoria, the question is how to understand that dysphoria better and how to identify what to do about it, both in terms of gender identity and in terms of coping, support and improving overall mental health. This is a great place for a therapist with expertise to step in and help the child and their family figure it out. 

Sometimes the child or adolescent has known literally or essentially their whole life, and that may mean no dysphoria (which is great!). From Katz-Wise et al., 2017: 

For some youth, primarily but not exclusively those ages 7–12 years, indication of transgender identification occurred early and was described as “immediate.” One father of an 18-year-old trans boy from the Northeast noted, “It was so immediate that it was just, you know, it wasn’t like he was seven and he said, ‘Oh my god he thinks of himself as a boy.’ It was just kinda always like that with him.”

For other youth, it is a more gradual process, and may take some time to sort out. Some youth also don’t have dysphoria while they are doing that so there may not be a reason to seek out therapy unless there is some other mental health issue they are facing. But if they do have dysphoria, or are otherwise experiencing mental health symptoms related to their gender identity, then seeing a therapist can help. 

3. Supporting a child to identify as trans or nonbinary or some other non-cis gender is not “medicalizing them for the rest of their lives.” Hormone blockers can be removed, and hormones can be stopped- but I disagree that these are “medicalizing” in any case. A person cannot be reduced down to the medications they take or the treatments they receive. Is a woman with cancer “medicalized” because she undergoes a hysterectomy? Are the children on puberty blockers for medical reasons “medicalized” (>2000 of them in the study I cited above, but no one seems concerned about them)? What about those people with delusions who are put on antipsychotics, which are known to have severe side effects including higher risk of diabetes and heart disease, seizures, tardive dyskinesia, overwhelming sleepiness impacting ability to work or drive, weight gain (I’ve seen clients gain >70 lbs in 3 months), and more? 

I would encourage you to read either of these great studies by Katz-Wise et al: 1 or 2 to understand this better. When you ask trans youth about themselves, the medical aspect is such a small part- they are talking about their whole selves, their hopes for the future, their families and friends, and their wishes to be able to be loved and accepted for who they really are. Some of it is about their bodies, sure, and that can mean that some decide to use hormones and/or hormone blockers or undergo surgery (although we’ve seen that those rates aren’t super higher ). But they’re also just talking about being called the right name and pronoun, getting to wear the clothes that make them feel authentic, getting to date and marry and have sex, and: getting to live. Not being ostracized and assaulted and killed. Like this 8 year old who identifies as a girlish boy worrying he’ll never be able to get married AND be his true self (from the second Katz-Wise et al):

An 8-year-old youth participant who identified as a “girlish boy” similarly worried about other people's reactions related to gender norms in the long-term future, as told by his mother,

He said [to me], ‘But I'm not going to get married, because if I married a boy I'd want to be the bride...I would want to wear a dress and people would laugh at me because I'm marrying a boy and I'd be wearing a dress.

He is 8 years old and these are his worries. As a mental health professional, my immediate thought is that he deserves any and all support that makes sense to him and his family so that he doesn’t have to worry like this. So that he can be 8. 

4. Finally, and probably most importantly: gender dysphoria is different because treating it with hormone blockers, hormones, and surgery is literally life saving. 

As high as 42% of trans people have attempted suicide at least once. For comparison, the lifetime prevalence of suicide attempts in the general population is 3%.  

Study after study has shown that there are three primary factors that reduce suicide risk: 1. Timely medical and legal transition for those who want it; 2. Family acceptance and general support from friends and loved ones; 3. Reduced transphobia and internalized transphobia. (1 2 3 4 5). 

Psychologists want to help people live, and live well. Living well means having a life you enjoy and find meaningful. If medical transition means someone’s suicide risk decreases and their mental health improves, then they can pursue the life they want. Being affirmed in their gender means they can have that part of the life they want. It might also help them get to other things they want (like having the marriage and wedding they envision, like that example). These are things we as psychologists prioritize. Period. 

It’s not the same as anorexia because providing a liposuction for two reasons. One: It would not resolve the dysphoria. People with anorexia who lose weight do not feel better about themselves and their bodies. That’s the dysphoria: people with anorexia (and other eating disorders, sometimes) often cannot see their bodies as they really are. Changing the body won’t help. Unlike in gender dysphoria, where changing the body- either in presentation or actually medically -actually does help. Two: Liposuction for an underweight person with anorexia could kill them. As we’ve discussed, gender affirming surgeries for trans people can save their lives. These are not comparable. 

The comparison to delusions doesn’t work very well because there isn’t really a “medical” intervention you would do to affirm someone’s delusion. But, since you may not know this: we sometimes do affirm people’s delusions, and it’s not necessarily psychologically helpful to try to change someone’s mind about a delusion. Delusions are not bad all on their own, and: sometimes things we think are delusional, actually aren’t, so it’s super important not to assume we know someone’s life and experiences better than they do. (Just recently a nurse assumed a patient was delusional, but actually they were quite rich and owned several expensive cars. People can be rich and have a significant mental illness.) So anyway- I don’t know how that applies. 

Overall: we as a field are still understanding the full spectrum of gender identities and how to do good treatment and good science in relationship with that. But what’s clear is that medical transition is sometimes a part of a good treatment plan for both youth and adults, and that it can save people’s lives. It can make their lives better. I am 100% about saving people’s lives, so I am 100% about a medical transition when appropriate and gender affirming care in general. 

References: 1 2 3 4 5 6 7 8 9 10

(email me at academic.consultant101 gmail.com if you need full texts)

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