New Guidance for Rapid Onset Gender Dysphoria

In 2016, I posted a short blog that gave general guidance for parents with teens who had recently come out as transgender. In the intervening months, I have spoken with a number of families whose teen identified as trans for some period of time, and subsequently desisted, often as a result of parental support for finding alternative ways of managing the feelings that led the young person to identify as trans. This post summarizes what I have learned from speaking with these families.

As background, I have spoken with dozens of parents looking to help their child deal with gender dysphoria without resorting to transition. In virtually every case, these parents were motivated by a desire to help their child avoid unnecessary medical intervention that could compromise fertility and expose their child to potentially serious side effects. These parents were not motivated by transphobia, bigotry, or right wing ideological beliefs. Many consider themselves politically liberal. In quite a few cases, the young person came out as gay or lesbian to full parental support and acceptance before going on to later come out as trans.

If the distress of gender dysphoria can be managed well with less invasive interventions, this is preferable to transitioning. This is because medical transition damages the body, and can lead to lifelong dependence on synthetic hormones. Teens ought to be guided to make choices that are most adaptive – that will leave them able to have loving relationships and community, meaningful work, and long-term mental and physical well-being.

I have spoken with many families who initially supported their child at least partially toward a social transition. They may have allowed changes in names and pronouns, or purchased a binder or new clothing. These families report that they noticed their child’s mental health symptoms worsening after such a transition. It is worth noting that there may be many families who noticed an improvement in their teen’s symptoms after supporting a social transition, but these families are unlikely to seek me out, so of course my experience is limited in this regard and may not be representative. However, my observations are supported by recent research published in the February, 2017 Journal of Adolescent Health that noted that mental well-being and parent child relationship tended to get worse in the majority of cases after an adolescent came out as trans. This is one of the many areas where further research would be helpful.

Who Tends to Desist?

Teens with rapid onset gender dysphoria who have desisted from a trans identity seem to share at least a few of the following traits or experiences:

• They were younger teens when they came out.
• Their parents received early support not to affirm their child’s transgender identity.
• The teens were never fully affirmed at school.
• They were never fully affirmed by another adult authority figure such as a gender therapist.
• Their online time was limited.
• Their overall mental health was relatively stable.

Parents who meet a child’s initial announcement with loving support but without affirmation were more likely to see their child desist in my experience. It appears that the more teens are supported in a belief that they are a member of the opposite sex, the more entrenched this belief becomes, making later desistance more complicated.

Outcomes

Although my sample is small and my observations anecdotal, teens who have stepped away from a trans identity appear to be happier, less anxious, and more flexible in their choices than during the period of time they identified as trans, according to parent report.

Ignoring versus Challenging

When a child identifies as trans, the topic of gender becomes extremely invested with energy, emotion, and significance. If a parent begins to argue with a child on this topic or to police fine points of the young person’s appearance or behavior, gender will only increase in importance as it becomes the battleground on which normal parent-child skirmishes around separation, independence, and control are fought. In general, therefore, ignoring the topic of gender is helpful in de-escalating the situation. Parents can focus instead on other ways to connect, finding enjoyable ways to spend time together, or discussing neutral topics of interest to the teen.

As with every rule, there are some exceptions. Most parents who have had a child who desisted challenged their child’s belief that they were born in the wrong body. This can obviously be a difficult thing to do, and comes with risks. In general, the more entrenched a person is in a trans identification, the more difficult it will be to engage him or her in a discussion about alternative ways to interpret feelings. If a child is particularly fragile or firmly invested in a transgender identity, even gentle questions may lead a child to feel unsupported. Teens and young adults may decide to cut off contact with a parent who expresses anything other than full support. The decision of whether to engage the teen in a discussion that questions his belief clearly needs to be handled with extreme care. Parents know their children best, and ought to be supported in following their instincts in this regard.

If a child has only recently come out as trans, it can be very effective for parents to share their opposing views. Questioning a teen’s self-diagnoses as transgender does appear to be an important intervention that helps lead to desistance. Challenging a child’s beliefs should always be done without anger. As much as possible, it ought to be done respectfully and with genuine empathy for the child’s suffering. Some parents have had good success with carefully timed, short reality-based statements, delivered with authority but not anger. An example might be a well-placed statement such as “liking video games doesn’t make you a boy.” Since the point is to avoid power struggles, there is no need to engage in an argument. Simply make the statement, and then move on.

Setting Limits

In a similar manner, when setting limits around a child’s behavior related to gender, parents ought to be clear, compassionate, and consistent. Rules work best if they are sensible and safety-based. Such limits might include forbidding a child from binding; using male restrooms (for a natal female); having unlimited internet access; routinely staying up late into the night (develops poor sleep hygiene); avoiding physical activity; and becoming isolated. All of these activities pose real health, mental health, or safety risks for teens.

Once these rules have been communicated to the child, parents are advised to enforce them consistently, but not obsessively. This is of course the best way to enforce any limit we set with children. We expect them to step over the line at times. Doing so ought to carry a reasonable consequence, but if we become overly activated when they trespass, we once again invest the action with too much power. A matter of fact response is usually best.

We cannot and should not expect to control every aspect of our child’s life. Experimentation with identity – friends, hairstyles, clothing, belief systems, etc. – is an important and natural part of adolescence, and our kids need some room to do this in a safe and healthy way. Creating safety-based limits that parents feel comfortable with and will be able to enforce, and then ignoring behavior we may not like can be a good way of ensuring our kids stay safe and have some room to explore, and while minimizing conflict and power struggles.

How Do We Know It’s Working?

Encouraging a child to consider other ways of understanding her feelings of distress is often a marathon, not a sprint, especially if the child is in an affirming environment at school. Compassionately refusing to give in to demands for puberty blockers or hormones may bring dramatic displays of anger and upset. When does our child’s distress signal that not affirming is indeed harming our child?

It’s important to remember that adolescence is nearly always a time of increased conflict between parents and children. It is normal for teenagers to experience some degree of distress. The majority of teen girls feel some degree of displeasure or even hatred of their bodies. Limit testing is also a typical feature of the teen years. When we see our dysphoric teenager become angry or upset when we impose a limit around transition, it might help us to place her reaction within the context of normal teen behavior. Just because they express unhappiness does not mean that we ought to give in to their every demand.

It can be helpful to separate the concepts of gender dysphoria from transition. Gender dysphoria is a mental health diagnosis and can result in real suffering, for which we can offer compassion, support, and treatment. Detransitioners are writing and vlogging about alternative ways of managing dysphoria. Asking your teen to wait until adulthood to consider transitioning does not mean that you won’t offer support and care for their dysphoria.

Don’t expect a teenager to tell you that you are right, that they are happy you are imposing limits, or that they are grateful to for you slowing things down. That would be like a toddler waking up and thanking you for making him take a nap! However, you can feel reasonably reassured that things are moving in the right direction if you observe any of the following:

• When you set a limit or refuse to accede to a demand, your teen becomes angry and upset, but recovers quickly. She moves on after a short period of distress and reconnects with you.
• The trans identification becomes more important during periods of stress, such as final exams. Parents have described their daughter’s frequency of binder use as a reliable indicator of academic pressure. When your teen is less tense, she seems generally more content and less interested in asserting a trans identification.
• Although your teen may have periods of significant distress, he also has times where he seems generally content and functions adequately socially and academically. He can participate as part of the family at least some of the time.

If, however, a child disappears into prolonged depression or isolation, it may be a sign that more serious intervention is needed.

What About Suicide?

Any mention of suicidal feelings needs to be taken extremely seriously. Teenagers are highly suggestible, and suicide has long been known to be socially contagious. The transgender narrative that teens learn online tells them that they will become suicidal if they don’t transition, and it is my guess that this belief might have contributed to a number of suicides among teens who were fully supported in their transition.

Regardless of the etiology of suicidal thoughts, such ideation must be addressed with professional support. Teens expressing suicidality ought to be shown support and compassion for their distress. They also ought to be treated for depression and suicidality. In the mental health field, suicidality is treated with therapy, medication, and hospitalization when necessary. Provisions are made to ensure the person’s immediate safety while helping them find more adaptive ways of managing feelings.

Parents Don’t Need to Be Perfect

Although it is important for parents to avoid being overly reactive, parents ought not to berate themselves if they can’t respond with perfect equanimity at all times. Having a child come out as transgender out of the blue can be stressful and frightening, and there are limited supports for families in this situation who would like to explore alternative methods of supporting their dysphoric child. It is important for parents to cultivate compassion for themselves, including forgiving themselves when they lose their temper or otherwise become reactive.

Get Support for Yourself

Parents I spoke with recommended finding something absorbing to do as a way of channeling energy and anxiety. This helps interactions with your child to be less pressured. Finding supportive friends or family members in whom you can confide is also crucial. Parent support can be found online.

Disclaimer: This blog post is not meant to take the place of psychotherapeutic treatment.