The approach I called "therapeutic" seeks to see a child's gender dysphoria evaporate, if at all possible. This typically involves strictly limiting the child's access to gender-atypical activities and trying to help the child adjust to fit a social environment that (supposedly) requires gender divisions. It also often involves family therapy.
Though it would seem to promise to make a child more comfortable with his body, there's very little data that the therapeutic approach "works." Moreover, the proponents of it have tended to be obsessed with measuring outcomes in terms of ultimate gender identity and sexual orientation rather than ultimate well-being, which surely is what should really matter.
By contrast, the approach I called "accommodating" seeks to prepare the gender dysphoric child for a transgendered life - a life that will ultimately involve hormonal and surgical sex change. Though it seems superficially more gender progressive, the problem I have with this approach is that it may end up sending more children down a high-medical-intervention path than is really necessary to maximize well-being in the population of children who go through gender dysphoria.
"You've done a good job of outlining the warring factions," Sarah told me. But, she added, "I think that there is a third, quieter point of view - the perspective that, sure, transgender kids exist, but really, most of these gender-nonconforming kids are just kids who don't fall to the most-masculine or most-feminine ends of the spectrum, and that's okay. They don't need treatment, they don't need sexual reassignment, they just need a supportive home life, schools with anti-bullying protocols, and therapy for any harassment they face for being different."
I felt kind of stupid reading Sarah's message, because I realized that I had, in fact, left out this approach. I had targeted my article to parents who report that their male children are insisting they are girls or that their female children are insisting they are boys. But the truth is, as Sarah was suggesting, that a lot of "gender nonconforming" kids don't have a simple story of being "trapped in the wrong body." They are expressing more subtle, more complex, and more varied messages of self. What they need isn't therapy; what they need is to know that it's okay to be gender nonconforming. It's perfectly okay to be a male who has feminine-typical interests, behaviors, and desires, or a female who has masculine-typical interests, behaviors, and desires.
Take Sarah's son Sam as an example. Starting in toddlerhood and continuing through early elementary school, Sam expressed an interest in wearing a dress. Sarah, being progressive, didn't see Sam's wish as his unruly desire to collapse the social order. She didn't see it as a sign of a profound mental illness. She saw a boy who wanted to wear a dress. And, as she pointed out to me, we don't think so much (anymore) of girls who want to wear cargo pants. So why get so upset about Sam's wish? Why not just recognize that he's gender nonconforming and understand that if he gets bullied for that, the problem is the bullying and the suffering he is made to experience by the bully?
I asked Sarah if we could converse by phone more about this, and we ended up talking for about an hour, and then more in follow-up e-mails. It was quickly obvious to me that Sarah was right: In my essay, I had set my expectations for parents' and schools' abilities to adjust way too low. This was rather disappointing, I have to say, in that I'm constantly criticizing health care professionals for setting their expectations of parents of "different" children too low.
"You basically said in the essay that, in our culture, we don't have a space for boys who are gender nonconforming, that they've got to conform or cross over into girlhood," Sarah told me. "But our culture has, over the years, made space for women: to dress how they want, to vote how they want, to act however they want in the home and as parents, and we continue to make progress for girls and women."
So why not allow our culture the same potential for growth where males are concerned? "We don't have to accept that our culture is unwilling to make a space. I'm not a Pollyanna," Sarah clarified. "I don't think there will be grand acceptance soon. But I think we can begin to make more space for boys to fully express who they are."
I asked Sarah if she thought there was ever a good reason for parents of a child with gender nonconformity to seek out clinical help. She answered sensibly again: "I think that, given the social context, a lot of families could benefit from mental health assistance. Children who are gender nonconforming are often persecuted and their families don't know how to approach that, especially in communities that disallow nonconformity. Some therapists help parents to do the hard work of accepting a child who is different than they expected. Fathers - and, interestingly, the more masculine partner in a lesbian couple - tend to have stronger feelings about this. Parents need time to deal with their own issues, and help learning how to support their kids. And if the kids are being bullied, they need tools for dealing with it."
But, she went on, "there's nothing inherently wrong with these boys," boys who might want to wear dresses or take on a traditionally feminine role. I've actually written about this, about how in some places, like Samoa, there are systems that welcome such children. So why was I expecting so little progress in North America?
It's worth keeping in mind that in North America, some of the advocates of the "therapeutic" approach to childhood gender dysphoria have had a very negative view of sexual minorities, and so they've sought to "cure" children who might otherwise turn out gay, lesbian, bi, or transgender. That's changed to some extent, and thank goodness. But now I really think we are seeing a problem coming in on the other end, namely that strong advocates of the accommodation approach are, I worry, too quick to conclude that a gender nonconforming child is destined to be transgender. The move toward transitioning children early may look progressive, but if you step back, you have to wonder why the Samoan approach isn't the most progressive.
I actually had a (truly) progressive pediatric endocrinologist at one of my talks express just this concern to me a few months ago - the concern that kids are being sent the route of sex-change too quickly. What we know about gender dysphoria in childhood suggests that we don't actually know that much. Outcomes vary wildly, and it isn't clear what effects clinical interventions have, if any.
In case it isn't obvious, sending a child the transgender route is not trivial. Lupron is typically used to delay puberty (to avoid unwanted pubertal changes), but this use of Lupron is off-label and poorly studied. Endocrinologists all over the country have worried to me about the long-term effects of this use. Surgical sex change will render a person infertile, in need of lifelong hormone replacement therapy, and carries significant risk to sexual function and physical health.
Some transgender advocates don't like to hear this. Because sex change saved their lives - and it really does save lives for people who are transgender - they understandably want children like them to have the best possible experience of transition. The problem is, it just isn't clear which children are children like them - the children in whom significant gender dysphoria will persist.
What we know is that, in a large percentage of children, gender dysphoria appears to go away (or maybe to become accepted as part of their personalities, so that the pressure to change stops?). We also know that a significant number of gay men report having had interests in wearing typically-feminine clothes and doing traditionally-feminine activities as children. So how on earth can we know when a boy who wants to wear a dress will need an endocrinologist? Or even a psychologist? It's not that simple.
I'm going to say something incredibly politically incorrect: some pink boys may benefit simply from meeting a swishy gay man - or better yet, two or three such men who can show them you can grow from being a pink boy to a pink man and have (dare I say it?) a fabulous life. I've actually met one therapist who whispered to me at a meeting that when he met a "gender dysphoric" pink boy who seemed to need this kind of "intervention," it's just what he provided (with a consultation by a colleague). The point was to let the boy know that there were even grown-ups like him, men who love "girly" things like beautiful clothes and Martha Stewart (and, um, men), and who are perfectly at home in their bodies and their selves. Why can't you have (and keep) a penis and love sparkles? Lots of men have.
I asked Sarah - who has engaged with many parents in situations similar to hers - about whether she thought some parents seek out the transgender route for their children because it will mean they might end up going from having a gay son to having a straight daughter. Was homophobia motivating these parents?
Sarah observed that what seemed to be motivating many of these parents is what motivates all us parents - the desire for certainty, and maybe some sense that things will feel "normal" somewhere down the line if all goes as planned. Duh again - this is what I wrote about in an essay called "What to Expect When You Have the Child You Weren't Expecting" in a book, Surgically Shaping Children. There I was writing about children born with norm-challenging bodies, but a boy in a dress - same experience of having the child you weren't expecting.
Being a parent of a boy who wants to wear sparkles and grow his hair long - especially when you don't know where it's all going to go - it's hard stuff. I'm not being politically incorrect in acknowledging that, am I? I get that parents want to feel like they're doing what they can to help resolve whatever suffering their child may be feeling, and prevent more suffering in the future. Sometimes they're sold on the idea that a particular clinical approach will do that. The truth - that we're not sure what "works" clinically, that it isn't clear this should even be considered a clinical problem in any conventional sense, but that we are sure that many people still brutalize boys who wear dresses or even just have long hair - is pretty hard to take.
Sarah concluded our conversation this way: "I want to be clear that I believe that people who are truly transgender should have societal support and access to whatever therapeutic care they need. If my own son were transgender, I would love and accept him as I do my gender-normative daughter, just as I will love them whether they are straight, gay, or bisexual. My position does not come out of lack of trans acceptance, it comes from wanting to see broader social acceptance for the entire spectrum of gender expression so that kids can really figure out who they are and not be pushed into a box that doesn't fit."
And I'd add that we should especially avoid pushing children into a box that involves surgery and lifelong hormone treatments if it turns out that's not what they need to be well. Being well needs to be the outcome we measure.
I thank Sarah for helping me through these ideas. I highly recommend Sarah's blog on raising a "pink boy."
My online writings on sex are now collected at Sex Research Honeypot. This essay originally appeared in Bioethics Forum. My thanks go to Susan Gilbert of the Hastings Center for editing this essay.