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Gender-Transition Decisions Should Be Made by Families, Not the State

· 9 min read
Gender-Transition Decisions Should Be Made by Families, Not the State
Photo by Sharon McCutcheon / Unsplash

This month, the New York Times ran a two-part podcast series titled When Texas Went After Transgender Care, detailing that state’s effort to ban “elective procedures for gender transitioning, including reassignment surgeries that can cause sterilization, mastectomies, removals of otherwise healthy body parts, and administration of puberty-blocking drugs or supraphysiologic doses of testosterone or estrogen.” Even those of us who are concerned about the encroachment of ideology on medicine by activists should be alarmed by what Texas is doing. There are now reports of families of trans children being visited by agents from the state’s Department of Family and Protective Services, on suspicion of what they are deeming child abuse (mostly because of the medical interventions’ potential to cause infertility in these young patients later on). The affected parents are understandably upset and confused: Whatever you may think of their efforts to help transition their children, those efforts were consistent with the advice given by such medical groups as the American Academy of Pediatrics, whose relentless focus on gender “affirmation” has led to the use of puberty blockers, cross-sex hormones and sometimes surgeries for patients as young as 13.

But to my knowledge, no prominent mainstream or liberal media outlets have emphasized that this kind of madness is coming from both sides: In some jurisdictions, child protective service agencies are investigating parents who don’t affirm or medicalize their trans-identified children. The theory here is that such parents’ “gender-critical” attitudes are also somehow tantamount to child abuse.

Because I have written a book about girls who break out of sexist gender norms, and publish a Substack about people who challenge stereotypes more generally, I hear from parents going through this kind of ordeal. In some cases, I interview them to get the facts about how they’ve been treated.

One California couple I’ve spoken with spent three years affirming their daughter, a stereotypically feminine child with no previous history of gender issues who was suddenly exhibiting gender dysphoria and suicidal impulses as she entered puberty. Following on what they were told were best practices, the parents facilitated the child’s social transition, including changing her name and haircut to something boyish. She was binding her breasts and taking puberty blockers. Unfortunately, the mother told me, “What we found was that her mental health, her happiness, faded, and her mental health deteriorated and got worse.” Each intervention only seemed to exacerbate her problems.

By the time the child was in eighth grade, the family was in full crisis-management mode. The mother quit her job at the height of her career to try to manage the daughter’s mental health. And it eventually struck her that the affirmation approach seemed to meet the pop definition of insanity: doing the same thing over and over while expecting a different result. So, on the advice of their child’s mental-health and medical experts, the parents reversed course on the affirmation approach—and this is how they got into trouble: When the daughter told her school counsellor that her parents wouldn’t let her transition, they got a call from the local child-services office.

Even before parents get a call like this, they usually have been gaslit as bad parents, thanks to torqued surveys purporting to show that a family’s failure to provide a trans-identified child with instant affirmation will put that child at risk of suicide. The actual suicide rate, as it happens, is somewhere between 0.3 percent and 0.6 percent, with the latter linked study—titled, Trends in suicide death risk in transgender people: results from the Amsterdam Cohort of Gender Dysphoria study—suggesting that transition doesn’t mitigate that suicide risk. Moreover, these rates are similar to the rates observed among children with other mental health challenges that often are comorbid with gender dysphoria.

The propaganda surrounding medical literature in this area has become shockingly sensationalist, and this propaganda has migrated from Internet subcultures into mainstream civil-liberties activism and even clinical practice. In many cases, parents are told—often with their child present—that they can either have a trans child or a dead child. Small wonder that trans-identified children come to see their gender distress in apocalyptic terms.

Thankfully, the last few years have witnessed stirrings of common-sense pushback from clinicians who are looking anew at the science, and rethinking their approach to treating gender dysphoric children. While it seems unlikely that a single, uniform, international treatment standard will emerge in the short term, one point I hope policymakers of all stripes will agree on is that we shouldn’t be punishing parents for their good-faith decisions either to affirm, or to not affirm, a child’s transgender identity. And I hope they’ll consider how other countries are approaching the science of gender-affirming care.

“The scientific evidence is not sufficient to assess effects on gender dysphoria, psychosocial conditions, cognitive function, body size, body composition, or metabolism of anti-puberty or sex-opposite hormone therapy in children and adolescents with gender dysphoria,” Sweden’s national health board recently announced, adding that it would exercise restraint in providing hormones, because of “uncertain science and new knowledge.” Officials at the country’s Karolinska Hospital admitted that children treated with puberty blockers and hormones “have been exposed to the risk of ‘serious care injury’ and that there is a continued risk of incorrect treatment.”

In the UK, the National Health Service has released an interim report critiquing the “American”-style informed-consent model of gender-affirming care, and noting, “There is lack of consensus and open discussion about the nature of gender dysphoria and therefore about the appropriate clinical response.” And in France, the National Academy of Medicine recently announced that “great medical caution must be taken in children and adolescents” because “there is no test to distinguish a ‘structural’ gender dysphoria from transient dysphoria in adolescence.” The Academy also noted “the many undesirable effects, and even serious complications, that some of the available therapies can cause,” and that “the risk of over-diagnosis is real.” This flatly contradicts the North American medical approach and media narrative of transition as panacea.

The above-described situation involving a California family isn’t an isolated incident. Parents in Indiana whom I’ve spoken to lost custody of their son because they had not affirmed the child’s self-identification. (He had come out earlier as gay, and was battling anorexia; they were trying to help him come to terms with his sexuality and find good medical care for the eating disorder, but did not wish to affirm the child’s belief that the solution to these problems was to identify as a woman or take hormones.) And in Canada, one father was actually sent to jail because he refused to stop speaking out against doctors and educators who were, as he saw it, rushing his child through aggressive transition therapies.

Another California case ended so tragically that it attracted national coverage—though far less than it should have. When she was 13, Abigail Martinez’s daughter Yaeli began struggling with depression. In eighth grade, she tried to overdose on allergy pills, which brought the Department of Children and Family Services (DCFS) into family members’ lives, with a social worker routinely checking in.

By the time Yaeli was set to begin 10th grade, her condition had improved, and she seemed happy and comfortable with herself. But at school, Yaeli began hanging out with an older trans boy; then came out to her mother as bisexual; then as a lesbian; and finally as trans, demanding a new name, new pronouns, and testosterone treatment. Despite the various phases and identities that Yaeli had rapidly cycled through, this teenager was now insisting that she’d always been a boy, notwithstanding her stereotypically feminine childhood appearance and demeanor. Her behavior seemed erratic and strange to her mother; she’d been a happy girl over the summer, but was now suddenly a miserable boy during the school year.

Abigail, an immigrant from El Salvador, didn’t understand why her daughter thought these social and medical interventions would help her. At first, she refused to comply with Yaeli’s demands, though eventually assented to the name change—which she thought would help keep her daughter happy. But she drew the line at cross-sex hormones, believing that this was too radical an intervention to embark on given her daughter’s unsettled mental-health state.

But the DCFS social worker, school psychologist, trans friend, and that friend’s mother, all were allegedly counselling Yaeli otherwise. Yaeli learned that if she were removed from her mother’s home, she could then petition the state to give her the hormones she wanted. According to Abigail, Yaeli, by now 16 years old, falsely accused her mother of physical abuse as part of such a plan. Yaeli was removed from the household, sent to a group home, and got her court order for testosterone. (Her three siblings remained at home with Abigail, which suggests that officials did not actually consider her a threat.)

“I asked the judge to send her to a psych evaluation,” Abigail later told me. “I [knew] as a mom [the transition] was not going to work.” And it didn’t. Her daughter developed relentless physical pains that Abigail believes were caused by the testosterone injections, and she didn’t seem better emotionally. Even though Yaeli was now living outside her home, Abigail tried to address her daughter’s underlying mental-health problems. But it seemed that everyone else in the girl’s orbit was interested only in affirming the child’s trans identity, convinced that her anguish could be addressed with faster and more thorough forms of transition.

Eventually, Yaeli committed suicide by lying down on a set of railroad tracks in front of a train that hit her at high speed and scattered her body parts widely. It was an unusually horrific tragedy. But because the arc of the narrative was ideologically “off-message,” only a few journalists bothered to report it, and these few were from conservative outlets. One is left to wonder how much more attention would have been paid to Yaeli’s fate if the suicide had followed, say, an episode of transphobic bullying at school.

The other (anonymous) California mother, whose case I mentioned earlier in this piece, has been able to push back against the system more forcefully. She educated herself about the lack of long-term research regarding medical-intervention outcomes for young people, such as her daughter, who experience gender distress. She also joined a support group for parents of children experiencing rapid-onset gender dysphoria. With the group’s help, she found a doctor and a psychiatrist who more fully explored the sources of her child’s distress, rather than just rubber stamp what the child had decided about herself from listening to Dr. Tumblr.

“I must have talked to about 10 to 15 different providers,” the mother told me. One, she reports, suggested that if a two-year-old pulls a barrette out of their head, that means that they’re transgender and you should transition them immediately. “We wanted somebody who could take a good look at who our daughter was and tell us what was going on. And if they [ultimately] told us, ‘Your daughter is transgender,’ we were prepared to get behind that and support it.”

The doctor who treated her child examined her comorbid conditions and underlying causes of distress. He considered her eating disorder, her cutting, her sleeplessness, her anxiety, her depression and her suicidal thoughts. He concluded that what the child needed wasn’t cross-sex hormones, but rather a less disruptive approach—one that would allow her to get her various issues under control before committing to medical steps that cause permanent changes.

This made sense to the parents, and they saw their daughter improving as she worked with the psychiatrist. Her eating normalized. She stopped cutting. Her suicidal ideation decreased.

But their daughter was disappointed. She’d been dreaming of the magic elixir of testosterone that would destroy her problems, as so many trans men on the Internet claimed it had done for them. That’s when she told her school counsellor that she wanted to medically transition but that her parents wouldn’t support it. Days later, DCFS showed up at their door.

But unlike Abigail Martinez, these parents were lucky. DCFS officials investigated the family, talked to the doctor, talked to the child and the school counsellor—then closed the investigation.

After that, their daughter desisted—stopped identifying as transgender, stopped asking for medical interventions. It’s a happy ending. But the ordeal left the family distrustful of the school, the government, and the medical establishment, all of which seemed eager to back an ideologically constructed theory about the “true” identity of a child whom these officials barely knew. And there is little accountability for ideologues: According to the mother, the school counsellor, who reportedly touted herself as an expert in “gender-expansive” children, recently got a promotion.

The only way to turn down the heat around this issue is to follow the science and to listen to all sides. Some studies, flawed as they may be, indicate that children can get short-term emotional relief from cross-sex hormones, though we have no high-quality, long-term research in this area. It’s up to medical organizations, not the state, to evaluate the evidence and create a safe and effective treatment protocol. Parents shouldn’t be punished for doing what they think is right.

But there is also plenty of evidence indicating that many trans-presenting children can benefit far more from therapists who treat them as complex human beings instead of simple cases of gender dysphoria, and who scrutinize whether a child’s exhibited gender distress is a cause, or symptom, of other problems. Yes, having supportive families is critical for protecting the mental health of LGBTQ+ children, and helping them flourish. But “support” isn’t synonymous with robotically affirming every passing idea the child asserts, let alone promoting medical interventions with lifelong ramifications. And no parent who insists on this principle should be sanctioned by the state for doing so.

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