Trans kids

[Macareaux]

This is an interesting article in a US publication about trans kids and rapid onset gender dysphoria.

After considering many aspects of the issue and anecdotal reports and data, the writer comes to the the conclusion that the distilled problem is that there is no way of determining which children are truly trans and which are not.

If we are to progress then sooner or later these mainstream writers are going to have to have the courage to say that there is no such thing as a transgender child.

http://nymag.com/intelligencer/2019/11/andrew-sullivan-hard-questions-gender-transitions-for-young.html

A case by case approach has got to be the answer but clinicians have to have the support to not to refer for blockers and cross sex hormones if they don't think it is in the best interests of the child.

Even more so in the case of 18- 25 year olds who don't come under GIDS - from close experience I can state that there is NO therapy or line of questioning offered that might not end inevitably in cross sex hormones for this vulnerable group of young people. Even more so in the case of autistic young adults where international guidance suggests that a much more cautious approach is needed - that didn't happen in our case.

He says that blockers are reversible but I haven't read all the research on this- I imagine he has read a lot more than me

I’ve read a lot more than you

Hormone blockers cause irreversible damage to bone density. They have irreversible side effects

- he thinks that Littman's work isn't robust but that it has become a massively political hot potato;

Where does Zucker say he thinks Littman's work is not robust? He describes other people accusing her of 'bad science' and says,

One well-known clinician in the specialty world of gender dysphoria even went so far as to criticize the method of sampling in Littman’s study as akin to “…recruiting from Klan or alt-right sites to demonstrate that blacks really are an inferior race” (“Why Are So Many Teenage Girls Appearing in Gender Clinics?”, 2018).

I can't see where he agrees with any of the 'methodological critique' though. Maybe I missed it?

Of course further study is needed on ROGD. Littman's is the only study we have so far, and we nearly didn't have even this one, thanks to certain people.

The purpose of this study was to collect data about parents’ observations, experiences, and perspectives about their adolescent and young adult (AYA) children showing signs of an apparent sudden or rapid onset of gender dysphoria that began during or after puberty, and develop hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among this demographic group.

Clearly Littman's aim was to take a first tentative step towards understanding this phenomenon. Zucker says,

In moving forward, what I believe needs to be done is to try and replicate Littman’s observations by documenting, using multiple informants and multiple methods, the core clinical phenomenology. It is not entirely clear to me why some clinician and “armchair” critics have been so skeptical about the possible veridicality of ROGD. Perhaps because Littman (2018) advanced a set of hypotheses about predisposing psychosocial factors in its genesis, the objection is that this disrupts an essentialist model of gender dysphoria and, therefore, has therapeutic implications.

Thank you so much pencils. I have no time at the moment but your work goes to show how people can use these studies, that are often written in language that is not easy to understand, to bend the truth for their own obscure purposes.

It seems that Zucker is not saying what some people say that he is saying.

Zucker has been effectively closed down by trans rights activists and hostile govt. agencies. He seems to have been the only person really trying to take an objective approach and it is sad that he and all other serious researchers are being denied the opportunity to do thorough research that is scientifically and not ideologically based

I mean they’re reversible in that you can stop giving them, I suppose.

They are not reversible in terms of undoing the problems they have caused.

So if someone is writing a study and calling them reversible, I know that they are ill-informed or disingenious or have an agenda.

But of course when patients suffering from longterm harm are roundly dismissed by doctors, it’s unsurprising that so many pretend we do not exist.

Zucker's conclusions on best practice clinical care for children with ROGD are a big 'don't know'. He suggests several different possible approaches:

1. ^For example, one might argue in favor of gender social transition and hormonal suppression along with a course of psychosocial therapy in which the stability of the patient’s gender identity can be explored, just as it is in the case of treatment for early-onset gender dysphoria.^

This is where he describes puberty blockers as 'reversible' and it's clear he is not talking about side effects or long term health issues, he is merely saying that if the blockers are stopped then puberty will resume.

It is less clear to what extent hormonal suppression has completely reversible effects with regard to sex dimorphic neural regions of interest and correlated behavioral parameters

I followed his references to see what he was on about:

www.ncbi.nlm.nih.gov/pubmed/25720349

This one looks at anatomical differences in the brains of male and female adolescents, with and without gender dysphoria.

www.sciencedirect.com/science/article/abs/pii/S0306453015000943

This one measured differences in adolescents' ability to complete an executive functioning task and compared girls, boys, girls with GD, boys with GD, girls with GD on blockers and boys with GD on blockers.

I'm not a neuroscientist and would not know where to begin to evaluate these studies, however we know that there is a massive amount of brain development during adolescence and also that boys on average mature a couple of years later than girls, so it would not surprise me at all if there were observable differences between the brains and functioning of adolescent boys and girls.

In any case, what is clear is that 'sex dimorphic neural regions of interest' means regions of the brain that are of interest to neuroscientists, and is nothing to do with a child's interests - or sexual orientation, come to that. Similarly, 'correlated behavioral parameters' refers to the children's performance on the executive function test and not to sex stereotypical behaviour.

2. Alternatively, one might make the case that since we know so little about ROGD that there should be a period of “watchful waiting” or exploratory psychotherapy, i.e., without biomedical treatment, but, perhaps, with the recommendation that the youth consider living in the felt gender role in order to see whether this confers any reduction in the gender dysphoria and the associated distress.

This is where Zucker suggests taking advantage of long waiting times in lieu of proper 'watchful waiting'. The problem is that the long waiting time can be circumvented by going private or by buying medication online. Also, for children on the list who do not go private or buy online, this approach is all 'waiting' and no 'watchful' - i.e. they are getting no help for the distress they are in. I don't think this is good enough.

3. Lastly, one could consider recommending exploratory psychosocial treatment without social transition and hormonal suppression, particularly if the case formulation is that the gender dysphoria has emerged in the context of other psychosocial factors or as a result of other mental health issues.

So Zucker suggests three possible approaches. He concludes:

^Given the substantial uncertainties about best practice care for these youth, the frontline clinician will have to weigh carefully the benefits and risks of various treatment options
and proceed with caution.^

So my very short summary of this article as a whole is 'ROGD is a thing, we don't know why it's happening and we don't know how best to treat it. Proceed with caution.'

Frack didn't you say that ROGD has been debunked? And now you are linking to all sorts of papers which examine the reasons for it?

76 children in one Brighton school. If that's not ROGD, what is it? 10 girls in one class simultaneously at well-known girls school?

Is it something in the water?

Frack didn't you say that ROGD has been debunked?

Oh yeah.

Thanks for spending time on this Pencils. It’s so helpful to have a translator!

But blimey

This is where he describes puberty blockers as 'reversible' and it's clear he is not talking about side effects or long term health issues, he is merely saying that if the blockers are stopped then puberty will resume

This totally blinkered view where the only affect anyone seems to consider of these drugs is on puberty

It’s bonkers

Thanks for spending time on this Pencils. It’s so helpful to have a translator!

It really is. Its bloody invaluable.

Yes I have learned things as a result of reading the article and @PencilsInSpace 's summary.
Look, he both says it's new and that he's seen it before. I think he means it's new as a clinical question but that he's seen people who would have been labelled with it before.

What he doesn't say though is that one should never give blockers or support transition. And that suicidality is exacerbated by stigma and prejudice.

Ie he doesn't say the first, but does say the second

Frack I'm going back to one of your earlier posts here. You said;

I agree with Zucker that the reduction of stigma has led to more girls thinking about their gender as something they can act on in terms of their bodies.

What do you mean by this? I don't understand what you mean by gender being something that girls can 'act on' in terms of their bodies.

And could you answer my questions in my post at 12.50?

I'm reading the Zucker paper and I've just got to the bit that Frack was referring to about stigma.

For example, perhaps behavioral masculinity (or behavioral “androgyny”) in birth-assigned females is subject to less social ostracism than behavioral femininity in birth-assigned males. If this conjecture is correct, then perhaps fewer birth-assigned males feel comfortable coming out as transgender and, therefore, are less likely to present at specialized gender identity clinics. It is conceivable, therefore, that, with further destigmatization, it will become easier for birth-assigned males to “come out” as transgender and the sex ratio will move closer to parity.

To my mind, he's got this completely the wrong way round. Up until recently the number of males identifying as transgender was far greater than the number of females. I had always assumed that this was because of exactly what he describes as the reason for more girls now presenting at gender clinics - because it is far more acceptable for a girl to be a 'tomboy' or for a woman not to be particularly feminine than it is for a boy or man to be feminine. So men had to become 'transwomen' if they wanted to be feminine, whereas women could just be women.

If there were no stigma at all about being totally gender non-conforming, there would be no need at all for anyone to be transgender. Although sex dysphoria, the revulsion with one's own sexed body, would still exist in a tiny number of people, so transsexuals would still exist.

@OldCrone i agree with this

If there were no stigma at all about being totally gender non-conforming, there would be no need at all for anyone to be transgender. Although sex dysphoria, the revulsion with one's own sexed body, would still exist in a tiny number of people, so transsexuals would still exist.

Although I do still feel that gender is a useful concept

Although I do still feel that gender is a useful concept

that's interesting. Useful for what?

you have said that your 'gender presentation varies'. could you describe how you behave and look when you are presenting as masculine or feminine gender?

On suicidality, Zucker says that adolescents with GD have similar levels of suicidality as those with other mental health issues and that there are several ways to conceptualise this:

1. In some instances, it may be that the gender dysphoria has emerged as secondary to another, more “primary” mental health diagnosis, such as autism spectrum disorder or borderline personality disorder, or as a result of a severe trauma (e.g., sexual abuse).

2. Another explanation is that gender dysphoria is inherently distressing, i.e., the marked incongruence between one’s felt gender and somatic sex—even within psychosocial milieus that are largely “affirming/supportive”— which leads to clinically significant symptoms such as anxiety or depression.

3. A more common explanation (and one that is often favored by “gender-affirming” clinicians and theorists)is that the co-occurring mental health issues are simply secondary to factors such as family rejection or social ostracism within the peer group vis-à-vis the gender dysphoria

He then goes on to discuss the 'intense focus' on concerns around suicide risk:

On the Internet, for example, one might come across the comment made by some parents “I would rather have a trans kid than a dead kid” ... “I’d Rather Have a Living Son Than a Dead Daughter,”

He mentions the intense media scrutiny of cases of completed suicide and says,

Indeed, Karasic and Ehrensaft (2015) asserted that completed suicides are “alarmingly high”—a statement which, in my view, has no formal and systematic empirical basis. In fact, I would argue that the statement itself is alarming.

He then discusses the actual data from studies in gender identity clinics and also in 'non-clinic-based samples of adolescents with gender dysphoria or who self-identify as transgender'. He describes the studies as using fairly crude metrics of suicidality and goes on to point out further methodological issues - the clinic studies had no comparison group and the non-clinical studies, where they used a comparison group, used an inappropriate one:

when a comparison group was used, it was limited to “cisgender” adolescents, but without taking into account the mental health status of these youth.

He then discusses a paper by deGraaf et al from this year (Zucker is a co-author of this one), which addressed the methodological flaws in previous clinic-based studies by using an appropriate comparison group, and again showed that adolescents referred for help with GD have similar rates of suicidality as adolescents referred for help with other mental health issues.

Thus, one could argue that the presence of suicidal ideation or behavior among adolescents with gender dysphoria should contextualize an understanding of it in relation to broader mental health issues that these youth may be struggling with.

He then talks about studies that show pretty much the same factors leading to suicidality in both trans and non-trans youth, including self-reported school-based “victimization” experiences (of various types) but cautions:

However, I would not want to make the argument that the pathways that lead to suicidality are fully identical in both groups of students. In this regard, the concept of equifinality should be considered (Cicchetti & Rogosch, 1996), i.e., that there are several pathways leading to the same outcome, and some of these pathways may be unique to adolescents with gender dysphoria.

Only then, in the final paragraph of this section, does Zucker briefly discuss some of the unique factors which may reduce suicidality in adolescents with GD:

1. for example, it has been argued that (perceived) social support of an adolescent’s transgender identity reduces the risk of suicidality

2. In another community-based study, it was found that the number of social settings in which adolescents felt comfortable in using their preferred name was associated with less suicidal ideation and behavior

3. Lastly, in a clinic-based study, Allen, Watson, Egan, and Moser (2019) reported that commencement of “gender-affirming” hormonal treatment was related to a decrease in self-reported suicidal feelings.

So it's a bit more complicated than saying 'suicidality is exacerbated by stigma and prejudice' Rather, he seems to be saying that these are worth looking at as possible factors among many, in order to reduce what is a very complex risk. I have no problem with this, stigma and prejudice are shit anyway and of course make people feel worse.

My own main takeaway from this section is that despite the fact that suicidality is a massive issue for all children with mental health issues, for some reason there is only intense scrutiny of suicidality when it's associated with GD.

Why is that?

Wouldn't it be great if this amount of effort, interest and money was being given to the whole of child and adolescent mental health?

Although I do still feel that gender is a useful concept

Why?

The thing is we live in a very gendered world. Some people are still trying to keep people sex segregated.
I'm referring to how I'm generally read by others.

The thing is we live in a very gendered world.

Agreed. And I think it's a forlorn hope that things will change at any great rate there. I can see why it seems easier to an adolescent to 'become a boy' or 'transition to a girl' rather than wait for the world to catch up.

Some people are still trying to keep people sex segregated.

I think we're trying to 'keep facilities and sports sex-segregated', actually. Happy for anyone who actively wants mixed-sex to go and join the other willing participants.

And if we're going to discuss stigma and prejudice as factors in suicide risk then they are surely just as important in mental health conditions more broadly.

WHO moved GD (or gender incongruence as they're now calling it) out of the 'Mental disorders' section of the ICD to avoid the stigma associated with mental illness. Thus reinforcing the notion that there is something shameful about being mentally unwell.

The thing is we live in a very gendered world. Some people are still trying to keep people sex segregated.

Frack Do you understand the difference between sex and gender and why sex segregation exists?

The idea that toys and games and clothes can only belong to one sex is nonsense.

The idea that bodies are different isn't, it's fact.

This totally blinkered view where the only affect anyone seems to consider of these drugs is on puberty

Indeed.

For those who want to know more about Lupron, please read this:
rxisk.org/lupron-a-nightmare-produced-in-abbvie/

This is the drug most commonly used as a “puberty blocker” in trans children. This is not the drug I was on, although it’s similar.

The worst part of all this is that I know these children will become adults with the health issues common to so many of us and I know they’ll be told it’s nothing to do with the drug, because we all are. All of us. Perhaps this will trigger much needed research, but I can’t hope for that even if it could help me because the cost is these childrens’ lives. They won’t live the lives they could have done because of this drug. And very few people care. And many more want to shut women like me up. I’ve spent many years being so angry but now I’m just so sad. There’s been no help for me. There never will be. My life is ruined. I’m a shit mother, shit wife, shit friend, shit sister, I was a shit employee when I could work. I’m a waste of oxygen frankly. And it was all completely avoidable.

How anyone can read this and think that this is an acceptable route for their children is beyond me. Many parents have no option but to give these drugs to their children due to precocious puberty, and I can’t imagine how that must feel - at least they are stopped when puberty is due to occur but it must still be so worrying.

Perhaps you could address Tammy's post, Frack

This is where he describes puberty blockers as 'reversible' and it's clear he is not talking about side effects or long term health issues, he is merely saying that if the blockers are stopped then puberty will resume

Yes I think that's what they all mean. It's another thought terminating statement.