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The NHS defines gender dysphoria as "a sense of unease that a person may have because of a mismatch between their biological sex and their gender identity. This sense of unease or dissatisfaction may be so intense it can lead to depression and anxiety and have a harmful impact on daily life."
The cases of GD in children and adolescents is rising though it is still a fairly low number: 0.6%, or over 1.6 million of those aged 13 and older in the U.S. identify as transgender; among 13 to 17 year olds, just over 300,000, or 1.43%, identify this way.
At Vator's Future of Behavioral and Mental Health last month, a panel of CEOs and experts discussed gender dysphoria in children, what may be leading to that increase, and whether or not the data around potential treatments has been thoroughly vetted.
The panel was moderated by Bambi Francisco, Vator's founder and CEO, and Dr. Archana Dubey, Chief Medical Officer at HP, with panelists Rebecca Egger, co-founder and CEO of Little Otter; Divya Shah, Director of Consumer Privacy at Meta; Ed Gaussen, founder and CEO of Mantra Health; Catherine Saxbe, Child & Adolescent Psychiatrist; and Helen Joyce, Director of Advocacy at Sex Matters.
Francisco kicked off this part of the conversation by saying, "there is a fear that is revolving around little children these days, that their voices aren't heard and their identities aren't heard and it is a big, huge problem. Some people might even say it's a social contagion."
"I want to legitimize the fact that there is a certain population of children who do have gender dysphoria, so I want to recognize that they exist out there. The problem is, how do you identify, how do you find these children?" she asked.
Creating gender-confused children
Joyce answered that, rather than wondering how we find them, she believes the better question is, "are we unfortunately, and accidentally, creating them?"
"We know that there's been a huge rise in the number of children who experience some gender distress and that's the question you want to ask first. What are we doing as a society that we're making children feel so ill at ease in the body that they have or the identity that they have? I don't think that's by any means a settled question; it's something that people are looking at in different countries," she said.
"I'm not a specialist, as people here are in these spaces, or indeed in child psychology, but our new specifications for the NHS for gender care for children very much acknowledge that there can be a contagious aspect to this, that there can be a passing phase to it, for the children for whom gender becomes uncomfortable and an issue. So, absolutely a serious issue, a genuine issue, and they also have other issues a lot of the time, and that the best way to treat these children is holistically to look right across all of these issues that they have and not just put a child in the gender bucket as soon as they say ‘gender.’"
She then brought the conversation back to the first topic discussed during the panel, the impact of social media. Specifically, how it allows children to learn from each other, away from adults, who aren't a part of those spaces.
"That's one of the reasons why we see so many things moving so fast through children, because children are still developing, they're changing, they're inexperienced about the world, they don't have supervision the way that they used to," she said.
"And so, they feed each other ideas about how things work. Suddenly everybody's worried about climate change, and everybody's got to do this, that, and the other. These things run through these groups in ways that are not necessarily healthy and that we're not even seeing that as adults, because we're not there. We're not there with them onTikTok, we're not there with them on their fanfic websites, or whatever."
The other thing that's happened, Joyce mentioned, is that, we've legitimized the talking about mental health by non-professionals over the last 10 or 20 years, including the expectation that teachers will deal with mental health issues.
"Now, everybody talks in mental health terms, including children; I talked to a therapist the other day, who said that she was amazed at how insightful the kids she was seeing were, and they had all these ideas about what was happening to them. And then, after a while, she realized that it was just talk, but they're picking these things up from each other as well and almost diagnosing themselves and each other in basically child only spaces. I don't think that's very healthy."
Dubey mentioned an article from NHS that talked about gender identity among children and the need to pause before jumping into therapeutics because of long term side effects, to which Joyce responded that, "The risk is that you're concretizing something that's maybe an exploratory phase."
"A skilled therapist will say, ‘what is this child trying to say to me?’ That's always what they say to themselves. Like, if a child comes in who's cutting or is expressing something, ‘what is this child trying to express?’ Unfortunately, we've started in many cases to just concretize this identity, rather than say, ‘what is this child communicating?’"
Dubey then asked Saxbe to weight in, and asked her if we need to take the individual more into account when discussing things like sex education.
"Kids are getting sex ed at a certain age, which is totally fine and it needs to happen, it's just that not every kid is at that maturity level at that age. A kid could be on the lower side of the spectrum, so some of this education, which is complex and then does have the mental health issues that they're tying in now early on. They need to be almost catered to that that maturity level of that individual, because of what you mentioned, Helen, they're just reciting what they are hearing from their teachers," Dubey said, to which Saxbe agreed.
"I see that on social media, I also see that in the schools. Sometimes kids will come and talk to me and they will have these phrases that are instantly recognizable as a prepackaged gender identity. It will be a girl who will say, ‘I feel that I'm really a boy,’ or vice versa. The question is, ‘well, how do what it feels like to be a girl?’ or, ‘how do what it feels like to be a boy?’ and then that stumps a lot of the kids because what they may be saying is, ‘Oh, I see that the opposite sex maybe has certain privileges that I am envious of. Where I see that something is easier for them or I see that my peer who identifies as non binary or transgender is getting a lot of attention from the counselor and the teacher and the neighborhood, changing names and changing pronouns.’ And there's like this big celebration about this," she said.
"The word ‘authenticity’ is used a lot to designate that a child who professes themselves to be of the opposite gender. And it's interesting because, on the one hand, we're supposed to be non binary but it's also impossible to talk about this without saying the opposite gender, which reveals that, really, we can't get away from the binary. But, I see that the word ‘authenticity’ is used when, in fact, I find that a truly much more authentic way to help a child with dysphoria or distress or depression, or any of the other things that go along with gender dysphoria diagnosis, is to help that person accept themselves in their actual, physical, authentic form. So, we're calling something authentic, which actually then requires a lot of pretending."
She acknowledged that gender dysphoria does exist, and that a child may express a desire to be the opposite sex, and can feel sad that they're not the opposite sex; even for those therapists who are interested in exploratory therapy, rather than immediate gender affirmation, it always begins with acknowledging and compassionately respecting that somebody is dysphoric.
"But the approach is, where is this dysphoria truly coming from? Is this a proxy for some other feeling of self-loathing? Or some other feeling of self rejection? What is it that it looks better maybe on the other side of the gender fence?"
Francisco chimed in to say that it is similar to how mental health disorders were once treated in children, that everyone was quickly labeled as depressive or bipolar or so on. She also brought up a study from Alex Keuroghlian, Director of Education and Training Programs at The Fenway Institute, who was supposed to be on the panel to defend the view that gender transitioning surgery helps mental health but decided not to participate in the debate.
"He did do a pretty large study on looking at gender dysphoric children, and it showed that there is a link, this is his conclusion, between positive mental health and putting your children on puberty blockers or hormones, etc. There are a number of people out there who are listening who would probably say that this is a good direction for the kids," she said, though she counted that the study didn't not look five years down the line at the effects of these treatments.
"There's a lot of kids who are now sitting uncomfortably in their unfortunate decision that they made when they were probably too young to make that," said Francisco. "So, what's the downside of getting this wrong? We're not just talking about pills and having somebody addicted to pills, we're talking about sitting in an entirely different body. What's the downside?"
Saxbe responded that children who go to gender clinics with their parents, have a clinician, have a counselor, there's a lot of attention also being paid to the child at that time, and that child feels like they're being seen and listened to and cared for.
High suicide for post-transition adults
"I don't think that that has a negligible effect on that immediate, what's being called 'euphoria.' That has a lot to do with attention and being seen. And as Bambi just said, it's important to know what happens years and years down the line and we do have some results in adults. In a very large study at a clinic in Sweden who looked at what we're talking about: suicidality, and really found that, actually, there was an incredibly high rate of suicide post-transition in those people's adult lives. So, that needs a lot of attention to figure out why that's happening," she said.
Dubey asked if we identifying that what came first: was is a mental health issue that led to the gender dysphoria, or was it the gender dysphoria that led to not being seen and led to a mental health issue?
"I feel like we're aligning towards the fact that there has to be a clinical level assessment, a holistic assessment, that allows for that kid to be better attended to in a more clinical way than being attended to in that what they think is a safe space, could be groups that are unmoderated in a social setting media setting and things like that," she said.
Joyce then said that we've been here before with mental health issues and the way that society has shaped them. For example, there's a lot known about the way that psychosomatic diseases are expressed and experienced, and the way that that expression is shaped in the clinical setting.
"In different countries, the details of how you would feel in your body, how depression feels or how anxiety feels, they vary, and they vary because there's a cultural template for how that experience is, in its essence, experienced. So, we know that we're not just diagnosing, we're also shaping when we enter into a clinical relationship with somebody, and this is on any ailments that isn't just really entirely biological and physical. All of them, we shape them," she said, citing a book written about the history of psychosomatic illnesses by Edward Shorter, who is a historian of medicine, where he said that, the media at the time, like newspapers and television, were taking over from doctors, as the people and the place where psychosomatic illnesses were being shaped.
"Now, 20 years later, it's social media that are doing a lot of that. And this is a very broad point, this is really nothing to do just with gender, it's to do with all of it. Like, it's the first thing we all do: we go online to see how to explain what we feel. The thought of children coming in expressing distress about climate change was really interesting. Like, where did that come from? It came from what they're seeing and the culture around them. And it's almost created a new disease, like maybe it's not named as that, but that's how it's being expressed and how it's then being seen in the clinic and then we react to that, and that feeds back. It's just an extraordinarily complex environment. And we can't just say, ‘Oh, we just need to get our diagnoses right.'' The way that we're treating these children, or the way that we're diagnosing things, is actually shaping their experience of their disease."
Later on, there was a comment from a member of audience that read, “many of us physicians on this call are deeply concerned about the level of confidence being placed in weak data around treating gender distressed youth medications and surgery. I was disappointed not to be able to ask questions to Dr. Keuroghlian about his interpretation of short term mental health data, and where he sees things going given the current direction of our European medical colleagues.”
Francisco asked Egger and Gaussen to respond about their level of confidence in the types of treatment protocols currently being prescribed for children with gender dysmorphia, and Egger responded that she "interpreted that comment a little differently," and that, "We're making a lot of large assumptions on all sides without really having a conversation about the data."
"There's still a lot to be discovered and known, as we've talked about, and I'm definitely not an expert here, so should not be speaking about it; I can only talk about what I've seen anecdotally, and what I know from my community and friends, because I do think that people should get the type of care that they want and deserve," she said.
Gaussen seemed to agree, noting that his company tried to build a provider group that is diverse by nature.
"I don't want to narrow the conversation down, even though I know that's the core of the question, talking about treating gender distressed youth; whether we're talking about gender distressed youth, the LGBTQ+ community, or any other community that's presenting to us in abundance on college campuses, we have to build a provider group that resembles some of the issues that we see on college campuses, and we have to provide our providers as well with the type of training and supervision that allows them to deliver a culturally competent care," he said.
"I would abstract the issue and say that we're monitoring the evolution of the presenting issues and making sure that we're looking at the latest data."
Data should be questioned
Saxbe, on the other hand, took the opposite view: that the data is weak and should be questioned.
"A lot of the gender affirming surgeries and hormones do not have a long history in children and adolescents. However, we do know from other endocrine studies that long term use of hormone replacement therapy does lead to problems with organ systems and puberty is not only the development of secondary sex characteristics, it's something that affects you neurologically, it's something that affects you metabolically, it is something that affects every cell in your body. And so, the studies that we do have, when they are examined by other biostatisticians and not just the peer reviewers who are also the contributors and editors of the couple of journals that seem to publish a lot of related things, the evidence and the methods are not very rigorous," she said.
What happened a lot of the time is that it becomes a political situation, Saxy said, meaning clinicians are not allowed to question the data.
"When this concern is raised by clinicians, because we're taught in medical school not just to read the abstract and the conclusion, but also to look at how the data is collected, how it's interpreted, what were the methods used, when any concern has been brought up, letters to the editor or in other academic rebuttals, there is so much political and social pressure put on those clinicians that I've never seen any other clinical diagnosis get this response. It's very emotional," she said.
"When we go to medical conferences, we debate back and forth. ‘Is this treatment better? Is that treatment better? Yeah, but look at the study, it's not that hot.’ In this case, there seems to be a real taboo against questioning any of these studies that show that gender affirming care is anything other than positive. And these are surgeries that can never be reversed, the puberty blockers and then together with the cross sex hormones, cause permanent infertility. So, we need to be debating these things without fear of causing offense, or being canceled or alienating one another. We need to talk and think like clinicians who don't have a political agenda, but we all must respect each other as people who want the best for somebody who's in distress."
(Image source: aleteia.org)
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