There is Truly Nothing Wrong with These Children

A Guest Post by
Karen Adams,
a Colorado Mother
Founder, Transgender Youth Education & Support
PFLAG Boulder County

The proposed stigmatizing diagnosis of Gender Incongruence of Childhood should be completely removed from the ICD-11.

Having facilitated a family support group for 7 years, personally worked with over 100 families and connected online with hundreds more, I have a great deal of experience with gender-expansive children. For the past several years, the majority of families have been contacting our group when their children are younger than 10 years old. Most of the children have been on a clear path to transition, and have proceeded into medical transition at a later time. Others have displayed gender-nonconforming behavior, become comfortable with their gender expression for several years, returned to our support group at the onset of puberty, and started their medical transition shortly after. A significant percentage of children work through clarification of their identity and settle into something other than gender conformity or transition. I am only familiar with a small handful of children who have expressed a cross-gender identity who later settled into a comfort level with their assigned birth sex. What stands out most from my experiences is how incredibly unique each child and family can be. I often say that the only thing I know for certain, is that the next time I pick up the support line, I will hear a story that is unlike any other I’ve heard before.

Our families encourage each other to love their child unconditionally and share resources so parents can educate themselves regarding the medical, social, and legal implications of raising a gender-expansive child. The only time outside services are required prior to puberty are when the parents need support to accept and understand their child’s needs, or when the child needs assistance clarifying their gender identity.

Simply based on the extremely wide variation in identities and needs I observe, our prepubescent children, defy any sort of classification system. Services for these children should readily be available under more generic service codes.

Were I to identify any singular thing that would dramatically improve the lives of all gender-expansive children, it would that be that each and every one of them needs to know that there is nothing wrong with them. Even basic parental acceptance dramatically improves the life and mental health of our kids. This is something I have observed in nearly every gender expansive child I know. Children who live in more liberal areas, who are able to more fully integrate their gender identity due to greater community acceptance, thrive. Even with parents who powerfully support their child, it’s amazing to observe the positive changes children experience when they move from a stigmatizing community to one that celebrates them. There is truly nothing wrong with these children. Changing the perspective from an understanding of gender as a binary absolute to more accurately reflect the experiences of humanity is the only category modification that is needed. The proposed stigmatizing diagnosis of Gender Incongruence of Childhood should be completely removed from the ICD-11.

De-pathologising gender difference is probably the most important step that can be taken to dramatically improve the lives of gender-expansive children.  The World Health Organization (WHO) has an opportunity to help gender-expansive children experience their birthright: the love of their family and community.

Gender Troubles: What’s Wrong With the WHO Proposal for Gender Incongruence in Childhood, by Dr. Sam Winter

Guest Post by
Sam Winter, Ph.D.
Faculty of Education,
University of Hong Kong.
Previously a member of the
World Health Organization (WHO)
Working Group on Sexual Disorders and Sexual Health.

[Formatted pdf version of this paper]

As most visitors to the GIDReform Advocates site will know, the World Health Organization (WHO) diagnostic manual (commonly known as the International Classification of Diseases) is currently under revision. The new edition, ICD-11, is slated for approval in 2017. I was a member of the WHO Working Group on Sexual Disorders and Sexual Health (WGSDSH), the eleven-member group which proposed a number of revisions relevant to trans people. The original WHO plans, for all our proposals to be loaded in October 2012 onto a website, for all the world to see (and comment on), never happened. Indeed, the WHO Secretariat running the show have imposed, apparently as it suits them and somewhat inconsistently, fairly onerous confidentiality rules which have prevented WGSDSH members and others from openly sharing what is going on. That said, WHO has shown itself to be comfortable with releasing material from time to time, particularly at academic conferences, as well as in the odd journal article.

One such article, in late 2012, was the one by Jack Drescher, Peggy Cohen-Kettenis and myself (all of us WGSDSH members) in which we reported a key proposal, that current ICD diagnoses commonly used with trans people (the flagship diagnosis for adolescents and adults being transsexualism) should be replaced by one called gender incongruence, and that this diagnosis should be moved out of ICD’s Chapter 5 (Mental and Behavioural Disorders) and into another chapter. Our rationale was that it was important to retain access to gender affirming healthcare for those trans people who needed it, but that the classification as a mental disorder actually undermined that goal, as well as adding to stigma. Our preference was for placement in a stand-alone chapter, but (with this prospect unlikely) an alternative was placement in a broad chapter on sexual and gender-related health.

In a corner of a little table within that article we were able to mention that the proposal was actually for two gender incongruence diagnoses: Gender Incongruence of Adults and Adolescents (GIAA), and Gender Incongruence of Childhood, for children below the age of puberty (GIC).

The appointment to the WGSDSH was for two years. The two years is well and truly over. It has been a long time since WHO Geneva wrote to me about anything. I do not know whether the WGSDSH still exists. If it does I assume I am no longer a member. So now I can talk.

The GIC proposal has been hatched in a small WGSDSH sub-group consisting of three members (in which my voice was a minority). It was never properly discussed in the full WGSDSH. I had misgivings about the proposal. The case for a diagnosis, to be used with gender different children below the age of puberty, seemed uncertain. My misgivings grew as a result of discussions with trans activists. They continued to grow as reports came in from independent reviewers contracted by WHO to look over the WGSDSH proposals. My attempts to have the GIC proposal discussed in the full WGSDSH were stifled by the WHO Secretariat. It became clear to me that WHO was committed to going ahead with the GIC proposal, at least as far as field trials, and that I would have to work against this proposal from the outside.

The arguments for GIC (commonly that it is needed to justify the existence of specialist clinics, for training purposes, to generate research) really don’t stand up to scrutiny. Worse, the GIC case was entirely undermined by the fact that we (WGSDSH and WHO) were making entirely different proposals in regard to young people exploring (and learning to become comfortable expressing) their sexual orientation. The proposal was that disease diagnoses for these individuals should be removed. And yet here we were, proposing a disease diagnosis for young children exploring (and learning to become comfortable expressing) their gender identity. It seemed to me that there was a hypocrisy at play, and a transphobic hypocrisy at that.

Finally, with Cochran et al’s new paper in the WHO Bulletin which makes public for the first time the proposals for the sexual orientation diagnoses, I am able to release a report I wrote last year, first of all for the WPATH ICD Consensus Meeting in San Francisco (the one that split 14:14 on the GIC proposal) and then for the Global Action for Trans* Equality (GATE) Experts’ Meeting in Buenos Aires (the one that produced alternative proposals for meeting the needs of gender different children).

The opposition to the GIC proposal has now become a worldwide chorus. As well as the voices of GATE, and voices within WPATH, there is the International Campaign Stop Trans Pathologisation (STP), which recently focused its campaign on fighting the pathologisation of children. Participants at a recent trans health conference in South Africa are developing a Cape Town Declaration calling on WHO to discard the proposal. Several other community and professional groups are discussing the issue and can be expected to voice their opposition in the future.

In order to facilitate the debate, I offer here on GIDReform a reduced version of the paper I wrote for the earlier two meetings (WPATH Consensus and GATE Experts’). Some of you may have read it as an Appendix to the WPATH ICD Meeting Report (pages 58-67).This paper makes reference to other documents available to participants at the WPATH Consensus Meeting, but not included here. Readers can access some of those documents, cited in the report of that meeting.

Arguments against the proposed Gender Incongruence in Childhood diagnosis.

In this document I present arguments against the draft proposal for a diagnosis of gender incongruence in childhood (‘GIC’).

Briefly, I believe that the proposed GIC diagnosis pathologises patterns of development that should not be pathologised, that the diagnosis is inconsistent with the approach the Working Group proposes for other children and youth (including, importantly, homosexual youth), that the pathologisation carries risks for the gender-different child (and indeed for the broader work of the Working Group), and that there are alternative ways of providing health care services for gender-different children (plus their parents, teachers and others) who may need such services.

In short the argument is for de-pathologising, rather than simply de-psychopathologising, gender difference in childhood.

A few words about my role in this process. I am the member of the WGSDSH1 (the ‘Working Group’) which has worked on developing the draft proposals you have in your papers. I was also in the small subgroup which worked on the draft gender incongruence proposals, again in your papers. With the other two members of that subgroup I am a co-author of the Minding the Body paper,2 which argues for removal of transgender diagnoses from ICD Chapter 5 (Mental and Behavioural Disorders), and which has, in the table on p570, drawn wide attention to a proposed child diagnosis.

I, like others, have misgivings about the GIC proposal; a proposal which focuses on gender incongruent children below the age of puberty. My concerns have grown in recent months, largely as a result of discussions with professionals and scholars working in the field. Letters from the following persons not at the meeting have been made available to participants at this meeting: Dr Elizabeth Riley (counseling psychologist working in Sydney, Australia), Dr Lisa Griffin (clinical psychologist, working in Virginia, USA), Dr Antonia Caretto (clinical psychologist, Michigan, USA), Dr Kelley Winters (author of the book Gender madness in American psychiatry, currently resident in Florida USA), and Dr Arnaud de Villiers, medical clinician and activist on transgender health issues in Africa (Cape Town, South Africa). They all express some sort of misgiving about the child diagnosis, and many argue the sort of strategies I argue for here. Indeed my ideas have in some cases been shaped by their own.

Please note that my own misgivings place me in a minority (of one) in the small subgroup which has worked on the Working Group gender incongruence diagnoses. As you might expect, I am therefore not a co-author of the Background Discussion Document3 (provided by WHO and among your papers), recently prepared (I assume) by the other two subgroup members.

I am comfortable sharing my perspective on the proposed GIC diagnosis. My contribution to this debate is my acquaintance with the broader aspects of health and rights for transgender people, particularly as those things apply in Asia.

Here are my arguments in more detail.4
_________________________________________

1: The view of gender-different children as sick and in need of health care is a culturally-specific one, not only modern but also peculiarly Western in origin.

It is clear that many transgender people worldwide5 live in cultures that are more accepting of gender difference than is the case in much of the West. Many of these cultures have a long history of inclusivity in regard to such persons,6 inclusivity that was anathema to European colonists and missionaries,7 but some of which survives to this day.8 In these cultures there are often a range of identities available to young children who grow up gender-different.9 Many of these roles had (or indeed still have) particular social, cultural, or even spiritual or religious significance.10 Today, in parts of the global south and east, many such children begin to identify in another gender quite early in life, doing so before puberty, and are recognized by others as being members of their affirmed gender group, even if in the modern world there are often, at home and school, limits to the degree to which they can express that identity. Those limits in any case often loosen by the time they approach school-leaving age.

Many individuals growing up in these social environments appear to enjoy (in childhood, adolescence and adulthood) relatively good psychological adjustment (despite sometimes having to endure broader societal stigma).11 Though a gender-different child’s gender identity and expression may not be universally celebrated by parents and teachers, that identity and expression tends to be accepted by them as diversity rather than mental or medical disorder. In thirteen years working in with transgender people in Asia I recall very few informing me that their parents had taken them to see a doctor when they were a child. Asian transgender activists who have written to me since my arrival in San Francisco a couple days ago confirm that it is relatively rare for parents to do so.

The view of gender-different children as sick is therefore a somewhat culture-specific one; not only modern but also peculiarly Western. (And it is a view that may aggravate whatever societal stigma is out there, but I’ll come back to that point later).

Now let’s consider what health care we actually provide to these ‘sick’ children (those who according to this Working Group proposal would be diagnosed as gender incongruent).

2: Gender-different children have no need of hormones or surgery, or any other somatic gender health care. Insofar as they may benefit from any health care services at all (and an indeterminate number may not need it) their needs are focused on accessing counseling and (perhaps) other mental health care.

They may need support and information to help in exploration of their gender issues (for example ‘Who am I?’, ‘What shall I do about it?’), ways of dealing with the challenges arising from gender expression (for example ‘Why won’t people let me be who I want?’, ‘Why do they treat me the way they do?’, ‘How should I handle this?’) and arising from any bodily concerns they may have (for example ‘Why do I feel this way about my body?’, ‘What can I do about it?’, ‘When?’, ‘With what effects?’). Parents, teachers and siblings may also benefit from some support information about gender issues, and from counseling as to how they should respond to their child’s gender issues.

I suggest all this provides no justification for a transgender specific and pathologising diagnosis of the sort the GIC represents. Consider, for comparison, other children with identity issues, or who find themselves confronted by circumstances (either in or out of their control) which bring them pain. An ethnic minority boy may want to explore his ethnic identity, and deal with the difficult or painful challenges of living in a racist society. But we do not diagnose him as having an ethnic disorder. A girl with divorced parents may need to explore difficult or painful family issues, and deal with unkind teasing at school. But we do not diagnose her as having a divorce disorder. A girl and her parents may want her to be top in the class, and she may feel great pain for not achieving this, and experience rejection at home. But we do not give her a diagnosis of educational aspiration disorder. In all these cases the child needs (and a health care provider would hopefully seek to provide) information, support and a more supportive environment that enables the child’s development. But he or she would do this without pathologising the child who finds him/herself in this situation. It is difficult to see why it should be different for gender-different children.

What about those relatively few gender-different children who actually experience clinically significant distress about their situation. They may feel suicidal. They may be on the verge of self harm. For them there are already diagnoses available, the same diagnoses that might be used with a child clinically depressed or anxious in regard to ethnic minority status, parental separation or inadequate achievement. Of course, one would want to ensure that such diagnoses are not used to justify gender reparative care. But this is where Z codes can come in (more on this later)

One does not have to think of the ethnic minority child, the child from a broken family or the child with unmet achievement goals to see an inconsistency in the way the needs of the gender-different child are addressed. A comparison is even closer to home – gay and lesbian youth. And that leads us to the next section.

3: There is a grave inconsistency in the way the Working Group proposes to address the health care needs of (on one hand) gay and lesbian youth and (on the other) gender-different children.

The WHO Working Group has recommended deletion of the entire F66 block (‘psychological and behavioural disorders associated with sexual development and orientation’). Used with youth, F66.0 (sexual maturation disorder) currently pathologises the teenager who is distressed about his uncertain sexual orientation. F66.1 (ego-dystonic sexual orientation) currently pathologises the teenager who, knowing his or her sexual orientation, wishes it were different. The first youth needs support in exploring his or her sexual identity, and the second youth needs help in coming to terms with it, learning to feel comfortable expressing it, and dealing with the stigma and prejudice that comes from expressing it. These are needs that are directly analogous to those of gender-different children.

F66.0 and F66.1 (and a third diagnosis, F66.2 (sexual relationship disorder)) are widely regarded as providing a final repository for the thinking that underpinned the old homosexuality diagnosis (after all, how many youth are distressed by the possibility they may eventually turn out heterosexual, or about the actual fact that they are?). Part of the concern over the F66 block is that it raises possibilities for psychopathologising sexual variation, and for prompting or justifying stigma and human rights abuses, including sexual reparative therapy.

Few reputable clinicians would disagree with the proposed deletion of Block F66, or with the proposal that those with sexual orientation issues who would genuinely benefit from mental health care could be provided access to it by other diagnostic means. Significantly, the Working Group proposes that Z Codes may be used in these cases.

The F66 proposals present a gravely inconsistent approach. The inconsistency is in the way we address the mental health care needs of (on one hand) the gay and lesbian teenager exploring and coming to terms with his or her sexual orientation (and the expression thereof) and (on the other) the gender-different child exploring and coming to terms with his or her gender identity (and expression thereof). For lesbian and gay youth the move is away from diagnosis that pathologises. For gender-different children the Working Group proposes that a pathologising approach continues.

This inconsistency is all the more perplexing in view of the fact that, despite their names, the current sexual maturation disorder and ego-dystonic sexual orientation diagnoses (both proposed for removal) both explicitly incorporate gender identity.12

4: There are important implications for the prospects of removing the proposed gender incongruence diagnoses from Chapter 5.

The GIC diagnosis, a transgender specific diagnosis affording access only to mental health care, may conceivably come at the price of failure in broader moves to remove both diagnoses (GIC and GIAA13) from Chapter 5. Let me explain why I think this.

a. Undermining the case for removal of GIC from Chapter 5. A recommendation for a GIC diagnosis – a diagnosis aimed to facilitate health care that is exclusively mental health care – is fundamentally inconsistent with a recommendation to remove that diagnosis from Chapter 5 (the mental and behavioural disorders chapter). Indeed, with mental health care the only sort of help to be provided to the child, Chapter 5 would appear to be an obvious place for the diagnosis. The case for de-psychopathologisation of childhood gender difference is therefore undermined, and the case for retaining the child diagnosis in Chapter 5 is inevitably left in place for all those who would use it. This carries risks for ( a ) reduced recognition of gender status (e.g. the little transgender girl seen as a mentally disordered boy), ( b ) increased stigma, and ( c ) increased use of gender reparative approaches.

With regard to gender reparative approaches, the removal of F66.0 and F66.1 (diagnoses that have been used, for example in Hong Kong, to justify sexual reparative therapy) may increase the risk that some mental health care providers will resort to child gender reparative approaches, rationalised in terms of attempting to catch incipient homosexuality early and nip it in the bud. I suggest that this risk would be even higher if the proposal to remove the GIC diagnosis from Chapter 5 were to be rejected.14

b. Undermining the case for removal of GIAA. In view of the sibling relationship between GIC and GIAA (a relationship which is noted in the GIC Background Discussion Document) the case for removing the latter from Chapter 5 may also be undermined. The prospect that both diagnoses might stay in Chapter 5 is as alarming for transgender people in the global south and east as it would be for transgender people elsewhere. The idea that transgender people are mentally disordered already has a foothold there, and it appears to contribute to the stigma that sometimes blights transgender people’s lives. A recent research study in five Asian countries, as well as in the UK and USA, indicates that in Asia, as elsewhere, people who believe that transgender people suffer from a mental disorder also tend to harbour prejudiced attitudes towards them– attitudes which, if expressed in discriminatory behavior, would act to push transgender people towards the margins of society (Winter et al, 2009).

Those working in the West (or in countries influenced by the modern Western discourse on psychopathologisation) may sometimes forget that support for removal of the trans diagnoses from Chapter 5 is less than universal; there are plenty of clinicians worldwide who take a different view. Significantly, dissent was evident even among the experts WHO recently invited to review the Working Group proposals. One, from a place other than North America or Western Europe, remarked on the longstanding and broad consensus among health experts in his country that gender incongruence conditions are mental disorders, disorders that obviously involved a distortion of mental processes contributing to the formation of sexual identity.

In May 2015, the World Health Assembly, the governing body of WHO, is due to vote on ICD-11. Some proposals will no doubt prove more contentious than others. Insofar as there are clinicians and scholars internationally who share the views of the above reviewer, and (either as individuals or through their professional associations) have the ear of their governments, there is a risk that the proposal to remove GIC (and by extension GIAA) from Chapter 5 will be undermined.

_________________________________________

With so many problems plaguing the GIC diagnosis, what is the way forward? The rest of this paper presents ideas. They are the product of long discussions (face to face and by e mail, with clinicians, scholars and activists worldwide.

A way forward.

An important way forward is provided by the non-pathologising Z codes.15 As is evident from the introductory material in the Z-Code chapter, these codes are designed for circumstances matching those in which gender-different children are liable to find themselves. 16

Importantly, the Working Group document which provides a rationale for deleting the F66 proposals notes that Z codes are an alternative (and less pathologising) way of providing health care to those with sexual orientation issues who are currently at risk of receiving a F66 diagnoses. Particularly relevant here is a section entitled ‘What is a disorder vs. a perceived need for mental health services?’ I quote:

……the ICD is structured to allow for two possibilities. First, the individual might have a clinically recognizable set of set of symptoms related to particular life circumstances, such as relationship distress, that is not a mental disorder, but it co-occurs with a recognizable mental disorder, such as Major Depression. In this situation, the diagnosis of Major Depression is applied. In the second situation, the individual may have a clinically recognizable set of symptoms, or ’problems’ but no underlying disorder. In this case, a Z category may be selected. The Z categories recognize that individuals can and do seek services, including mental health services, in the absence of a current mental health or behavioural disorder. For example, requesting help for tobacco cessation in the absence of tobacco dependency (Z72.0), or for assistance in developing coping skills when targeted for discrimination (Z62.5) are both types of presenting concerns that could result in classification with a Z category. A health encounter in which the person is requesting information about sexual matters in the absence of a mental disorder could be classified using a Z category as well. In this way, the ICD distinguishes between mental disorders and perceived need for mental health services in the absence of a diagnosable disorder.17

The Working Group then goes on to make three recommendations, as follows:

a) The deletion of the F66 categories in their entirety: As the review above demonstrates, the F66 categories do not meet the requirements for retention in the ICD-11. There is no evidence that they improve clinical utility, and reason to believe they create harm; no evidence of public health surveillance need; no evidence of research needs in order to track mental health morbidity; and the categories themselves raise significant human rights concerns.

b) The revision of several of the Z70 categories to better address sexual health and sexual relationship concerns at a more general level. These changes would focus more clearly on common reasons for seeking services as well as remove unnecessary focus on sexual orientation that currently lacks justification.

c) The revision of the descriptions of the Z60.4 and Z60.5 categories to encompass sexual orientation concerns. These changes would facilitate accurate coding of personal distress resulting from experiences with anti-gay stigma, and may also be useful as a part of public health surveillance to track human rights concerns related to sexual orientation. 18

A similar approach can be taken with those children liable, under current proposals, to be diagnosed with the pathologising GIC category. There are a number of Z codes that could prove relevant to the needs of gender-different children, to document examinations and other health encounters.

At the WPATH Consensus Meeting I presented proposals for ways in which the Z Codes could be used to facilitate appropriate health care for those gender-different children who might benefit from it, as well as to document contact with health care services. I argued that these codes could be used to help children explore and express their gender identities (and to support their efforts to cope with stigma) in the same way that the Working Group is proposing that the Z Codes could be used with gay and lesbian youth exploring and expressing their sexual orientation (and, again, to support their efforts to cope with stigma).

A more detailed proposal for using ICD-11 Z Codes to facilitate access to support services for trans and gender different children was developed at the GATE (Global Action for Trans* Equality) Consensus Meeting in Buenos Aires, April 2013.1920 It recommended revisions to include gender identity, gender expression as well as sexual orientation in codes:

Z60.4- “Exclusion and rejection on the basis of personal characteristics…”

Z60.5- “Persecution or discrimination, perceived or real, on the
basis of membership of some group…”

Z70.4- “Counseling for a child to support gender identity or
expression that differ from birth assignment.”

Z70.2x- “Counseling for families and service providers related to
gender identity or expression of a child.”

Importantly, where a child is genuinely suffering from anxiety and mood disorders associated with gender difference, Z Codes can be used to specify the nature of the distress, thereby enabling appropriate health care for the child involved. Further, when a child reaches puberty and is in need of puberty blockers (where they are available), Z Codes can be used to document a history of gender difference, thereby ensuring a prompt diagnosis of GIAA.21 Finally, when a gender-different child seeks adaptation at school (or elsewhere) to accommodate his or her gender difference, Z Codes can be used to provide a basis for the case being made.

In short, it is clear to me that Z Codes can play an important and appropriate role in provision of health care for gender-different children in their pre-puberty years, covering a wide range of encounters with health care providers, and a variety of health care-related services appropriate to their needs.

It is to be hoped that a Z Code approach with gender-different children will make it more likely that such children do indeed grow up comfortable with their gender; in the words of Jazz, liking who they are.

 

Footnotes:

1 The WHO Working Group on Sexual Health and Sexual Disorders

2 Drescher, Cohen-Kettenis and Winter (2012)

3 Background Discussion Document on Proposed ICD-11 Category of Gender Incongruence of Childhood.

4 Childhood gender diagnoses have been the subject of much criticism. The Background Discussion Document on GIC to which I referred earlier reviewed some of the published critiques in the area, most of them in relation to the old DSM-IV diagnosis, gender identity disorder of childhood. I will not revisit that research here. I will add though, that the above document neglects to mention publications by experienced clinicians advocating gender affirmative approaches in work with these children and critical of less affirmative (and even repressive) approaches (Ehrensaft, 2011). Other recent additions to the literature are three Australian papers examining the views of three groups of stakeholder (parents of gender-different children, professionals, and transgender adults) on the needs of needs of gender-different children and their parents. Together they indicate concurrence on the importance of freedom of expression, acceptance, respect and support for the children, and for information and support for the parents (Riley et al, 2011a,b, 2012).

5 In the Asia-Pacific alone there are an estimated 9 to 9.5 million (UNDP 2012).

6 See for example Coleman et al (1992) and Urbani (2006) in relation to Myanmar; Matzner (2001) discussing Hawai’i; Schmidt (2001) discussing Samoa; Graham (2001, 2002) and Graham-Davies (2007) discussing Sulawesi in Indonesia; Jackson (2003) discussing Thailand; and Nanda (2000a,b,c) discussing Thailand, the Philippines, India and across Polynesia. Also see Peletz (2006, 2009) for a more general discussion of cultures of ‘gender pluralism’ in pre-modern Southeast Asia.

7 See for example Nanda (1990, 2000a), Brewer (1998, 2001).

8 For example Graham-Davies (2007); Vasey and Bartlett (2007).

9 For a (non-exhaustive) list of around 50 identity labels used in the Asia-Pacific by and/or for (those we in the West would call) transgender women see UNDP (2012)

10 A recent WHO Asia-Pacific regional consultation on transgender health, having drawn up a working definition of transgender, was at pains to add in an explanatory note: “Transgender persons in Asia and the Pacific often identify themselves in ways that are locally, socially, culturally, religiously, or spiritually defined.” (WHO 2013, page 18, current author’s emphasis).

11 I should stress that gender-different children in the global south and east don’t always find acceptance at home and school; not even in the most inclusive societies. Nor does it mean broader societal acceptance when the child reaches adulthood. The very real difficulties facing transgender people across the Asia-Pacific, particularly in the least inclusive societies, are very well documented. For a review of much of the research see UNDP (2012).

12 So does sexual relationship disorder, though in this case children with gender identity issues are not included.

13 Gender incongruence of adolescence and adulthood.

14 WPATH deems gender reparative approaches with children as unethical. “Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success [references supplied], particularly in the long term [references supplied]. Such treatment is no longer considered ethical.” (WPATH, 2011, p16).

15 Z00-Z13 Persons encountering health services for examination and investigation; Z20-Z29 Persons with potential health hazards related to communicable diseases; Z30-Z39 Persons encountering health services in circumstances related to reproduction; Z40-Z54 Persons encountering health services for specific procedures and health care; Z55-Z65 Persons with potential health hazards related to socioeconomic and psychosocial circumstances; Z70-Z76 Persons encountering health services in other circumstances; Z80-Z99 Persons with potential health hazards related to family and personal history and certain conditions influencing health status.

16 Categories Z00-Z99 are provided for occasions when circumstances other than a disease, injury or external cause classifiable to categories A00-Y89 are recorded as “diagnoses” or “problems”. This can arise in two main ways:When a person who may or may not be sick encounters the health services for some specific purpose, such as to receive limited care or service for a current condition, to donate an organ or tissue, to receive prophylactic vaccination or to discuss a problem which is in itself not a disease or injury.

When some circumstance or problem is present which influences the person’s health status but is not in itself a current illness or injury. Such factors may be elicited during population surveys, when the person may or may not be currently sick, or be recorded as an additional factor to be borne in mind when the person is receiving care for some illness or injury.

ICD-10 online, at http://apps.who.int/classifications/icd10/browse/2010/en#/XXI

17 Rationale for the Deletion of the F66 Categories in the ICD-11, p3.

18 Ibid. p21.

19 Global Action for Trans* Equality (2013) “Critique and Alternative Proposal to the ‘Gender Incongruence of Childhood’ Category in ICD-11,” GATE Civil Society Expert Working Group, Buenos Aires, April 4. http://globaltransaction.files.wordpress.com/2012/03/critique-and-alternative-proposal-to-the-_gender-incongruence-of-childhood_-category-in-icd-11.pdf

20 Winters, K. (2013) “From Gender Madness to Gender Wellness in the ICD-11,” National Transgender Health Summit, Oakland, CA, May. http://www.slideshare.net/kelleywinters/201305-nth-sb

21 Gender incongruence of adolescence and adulthood.

 

Reference list:

Brewer, C. (1998). Baylan, asog, transvestism, and sodomy: gender, sexuality and the sacred in early colonial Philippines. Intersections: Gender, History and Culture in the Asian Context. Retrieved 15th March 201 from intersections.anu.edu.au/issue2/carolyn2.html.

Brewer, C. (2001). Holy confrontation: religion, gender and sexuality in the Philippines, 1521-1685. Manila: Institute of Women’s Studies, St. Scholastica’s College.

Coleman, E., Colgan, P., & Gooren, L. (1992). Male cross-gender behavior in Myanmar (Burma): A description of the acault. Archives of Sexual Behavior, 21, 3, 313-321.

Drescher,J., Cohen-Kettenis,P. and Winter,S. (2012) Minding the Body. International Review of Psychiatry, December 2012; 24(6): 568–577

Ehrensaft,D. (2011) Gender born, gender made, raising healthy gender non-conforming children. New York: The Experiment Publishing.

Global Action for Trans* Equality (2013) “Critique and Alternative Proposal to the ‘Gender Incongruence of Childhood’ Category in ICD-11,” GATE Civil Society Expert Working Group, Buenos Aires, April 4. http://globaltransaction.files.wordpress.com/2012/03/critique-and-alternative-proposal-to-the-_gender-incongruence-of-childhood_-category-in-icd-11.pdf

Graham, S. (2001). Negotiating gender: ‘Calalai’ in Bugis society. Intersections: Gender, History and Culture in the Asian Context, 6.

Graham, S. (2002). Priests and gender in South Sulawesi, Indonesia Retrieved 14th August, 2011, from http:// web.hku.hk/~sjwinter/TransgenderASIA/paper_priests_and_gender.htm.

Graham-Davies, S. (2007). Challenging gender norms: five genders among Bugis in Indonesia. Belmont: Thomas Wadsworth.

Jackson, P. (2003). Performative genders, perverse desires: a bio history of Thailand’s same-sex and transgender cultures. Intersections: Gender, History and Culture in the Asian Context, 9.Retrieved 30th March 2012 from intersections.anu.edu.au/issue9/jackson.html

Matzner, A. (2001). ‘O au no keia’: voices from Hawaii’s Mahu and transgender communities. Bloomington: Xlibris.

Nanda, S. (1990). Neither man nor woman: the Hijras of India. Belmont, California,

Nanda, S. (2000a). Hijra and Sadhin: neither man nor woman in India. In Nanda, S. (Ed.), Gender diversity: cross- cultural variations. Long Grove, Illinois: Waveland Press.

Nanda, S. (2000b). Transgendered males in Thailand and the Philippines. In Nanda, S. (Ed.), Gender diversity: cross-cultural variations. Long Grove, Illinois: Waveland Press.

Nanda, S. (2000c). Liminal gender roles in Polynesia. In Nanda, S. (Ed.) Gender Diversity: Cross-Cultural Variations. Prospect Heights: Waveland Press.

Peletz, M. G. (2006). Transgenderism and gender pluralism in Southeast Asia since early modern times. Current Anthropology, 47, 2, 309-340.

Peletz, M. G. (2009). Gender pluralism: southeast Asia since early modern times. New York: Routledge.

Riley, E., Gomathi, S., Clemson, L and Diamond D (2011a). The needs of gender-variant children and their parents according to health professionals. International Journal of Transgenderism, 13:54–63, 2011

Riley, E., Gomathi, S., Clemson, L and Diamond D (2011b). The needs of gender variant children and their parents: a parent survey. International Journal of Sexual Health, 23:181–195, 2011

Riley,E., Clemson,L, Sithathan, G. and Diamond,M. (2012). Surviving a gender variant childhood: the views of transgender adults on the needs of gender variant children and their parents. Journal of Sex & Marital Therapy, 00:1–22, 2012

Schmidt, J. (2001). Redefining fa’afafine: Western discourses and the construction of transgenderism in Samoa. Intersections: Gender, History and Culture in the Asian Context, 6. Retrieved March 30th 2012 from intersections. anu.edu.au/issue6/schmidt.html.

UNDP (2012).: Lost in Transition: Transgender People, Rights and HIV Vulnerability in the Asia-Pacific Region. Bangkok: UNDP Asia-Pacific Office.

Urbani, E.R. (2006). Because Buddha was a man: the ambiguousness of spirit mediums in Mandalay. Amsterdam, Netherlands: MA Thesis, Department of Sociology and Anthropology, University of Amsterdam.

Vasey, P. L., & Bartlett, N. H. (2007). What can the Samoan “fa’afafine” teach us about the western concept of gender identity disorder in childhood? Perspectives in Biology and Medicine, 50, 4, 481-490.

WHO (2009), International statistical classification of diseases and related health problems. – 10th revision, 2008 edition. Geneva: WHO

WHO (2013) Consultation on HIV, STI and
other Health Needs of Transgender People in Asia and the Pacific. Report of meeting 11-13 September 2012. Manila: WHO Regional Office for the Western Pacific.

Winters, K. (2008). Gender Madness in American Psychiatry: Essays from the struggle for Dignity, GID Reform Advocates, www.gendermadness.com

Winters, K. (2013) “From Gender Madness to Gender Wellness in the ICD-11,” National Transgender Health Summit, Oakland, CA, May. http://www.slideshare.net/kelleywinters/201305-nth-sb

 

 

Winter,S., Chalungsooth,P., Teh Y.K., Rojanalert,N., Maneerat, K., Wong Y.W., Beaumont, A., Ho, M.W., L., Gomez, F., and Macapagal, R.A. (2009). Transpeople, transprejudice and pathologisation: a seven-country factor analytic study. International Journal of Sexual Health, 21, 2: 96-118.

WPATH (2011). Standards of care for the health of transsexual, transgender, and gender nonconforming people (seventh version). WPATH. http://www.wpath.org

Methodological Questions in Childhood Gender Identity ‘Desistence’ Research

Kelley Winters, Ph.D.
GID Reform Advocates

An expanded presentation to the 23rd World Professional Association for Transgender Health Biennial Symposium, Feb. 16, 2014, Bangkok, Thailand. (Presented remotely, from Loveland, Colorado, USA)

It is frequently repeated in mental health literature and popular media that the vast majority of children whose gender identity differs from their assigned birth-sex, or who are severly distressed by their birth-sex, will “desist” in their gender identities and gender dysphoria by adolescence. As a consequence, gender dysphoric children are pressed to remain in their birth-assigned roles throughout the world. But are gender dysphoria and diverse gender identities just a phase?

This presentation reexamines research in Canada and The Netherlands that underlies the “desistence” axiom, with respect to methodological rigor and validity of claims.

Conclusions

(1) Evidence from these studies suggests that the majority of gender nonconforming children are not gender dysphoric adolescents or adults.

(2) It does not support the stereotype that most children who are actually gender dysphoric will “desist” in their gender identities before adolescence.

(3) These studies do acknowledge that intense anatomic dysphoria in childhood may be associated with persistent gender dysphoria and persistent gender identity through adolescence.

(4) Speculation that allowing childhood social transition traps cisgender youth in roles that are incongruent with their identities is not supported by evidence.

(5) These studies fail to examine the diagnostic value of Real Life Experience in congruent gender roles for gender dysphoric children.

References


American Psychiatric Association (2014). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Byne, W., Bradley, S.J., Coleman, E., Eyler, A.E., Green, R., Menvielle, E.J., Meyer-Bahlburg, H.F.L., Pleak, R.R. & Tompkins, D.A. (2012). Report of the American Psychiatric Association Task Force on Treatment of Gender Identity Disorder. Archives of Sexual Behavior, 41(4):759-796.

Drescher, J. (2013) “Sunday Dialogue: Our Notions of Gender,” New York Times, June 29, http://www.nytimes.com/2013/06/30/opinion/sunday/sunday-dialogue-our-notions-of-gender.html

Drummond, Kelley D.; Bradley, Susan J.; Peterson-Badali, Michele; Zucker, Kenneth J. (2008), “A follow-up study of girls with gender identity disorder,” Developmental Psychology. Vol 44(1), Jan 2008, 34-45.

Kennedy, N. (2012) “Transgender children: more than a theoretical challenge,” Goldsmiths College, University of London, http://academia.edu/2760086/

Reed, B., Rhodes, S., Schofield, P., Wylie, K., (2009) “Gender variance in the UK. Prevalence, incidence, growth and geographic distribution,” GIRES – the Gender Identity Research and Education Society, http://www.gires.org.uk/assets/Medpro-Assets/GenderVarianceUK-report.pdf

Steensma, T.D., Biemond, R., de Boer, F. & Cohen-Kettenis, P.T. (2011). Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology & Psychiatry, 16(4):499-516.

Wallien, M.S.C. & Cohen-Kettenis, P.T. (2008). Psychosexual outcome of gender-dysphoric children. J American Academy Child & Adolescent Psychiatry, 47:1413-1423.

Winters, K. (2013) Response to Dr. Jack Drescher and the NY Times About Childhood Transition, GID Reform Weblog, July 5, http://gidreform.wordpress.com/category/childhood-social-transition/

World Professional Association for Transgender Health (2011), Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People: Author. http://www.wpath.org

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 8, by Karen Adams

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post by
Karen Adams,
a Colorado Mother
Founder, Transgender Youth Education & Support
PFLAG Boulder County

Early in July, the New York Times ran a feature by Dr. Jack Drescher in response to the Coy Mathis case in Colorado. We were disappointed by Dr. Drescher’s lack of understanding of the experiences of families with transgender children. His suggestions, that families are “encouraging” early transition, and that, once transitioned, children are discouraged from transitioning back to their birth roles was outrageous. In the six years that Trans-Youth Educaton & Support of Colorado (TYES) has been in existence, over 70 families have participated in our group in some fashion. Not once have we met a family that encouraged transition.

Our families spend a great deal of time learning about gender identity and expression. They meet other families and ask many questions. This is not an easy decision or a fad for any of them. They worry for their children and work hard to make life as easy as possible for them. Of many untold stories are the parents who give up their personal big dreams in support of their kids. For one family, it was the dream of watching their athletically gifted child from the stands of the Olympics. Instead, it became painfully clear that early transition was a life-saving necessity for their child.

I have not met a parent yet that would not feel great relief and joy, if their child came to them and said they needed to transition back to their birth gender. It would mean that their child would more likely be safe and face less discrimination. Families have come to our group with children who were uncertain of their gender identity. After interacting our transgender and gender creative children, some have realized that they are comfortable in their birth sex. One experimented with transition and then chose to return to his birth gender, though he was still gender nonconforming. Years later, these families have told us their children were comfortable in their experienced gender fluid identities and remained close to their families who supported them in their process.

Dr. Drescher needs to actually spend time with families of transgender children, rather than writing articles based on theory. He would find here some of the most amazing, intelligent, and loving families. Their love is stronger than their fear of the ignorance shown by these psychiatric stereotypes. Their love is unconditional, and I’m proud to call them my friends.

Transgender Youth Education & Support (TYES) is a Colorado-based group supporting children on the gender spectrum and their families. TYES is dedicated to helping parents support their gender-variant children, and to help families find the information, resources, and the understanding that they need. Our meetings offer parents a supportive forum to discuss the social, educational, and medical needs of their youth, and to explore the journey to acceptance and celebration of each child’s unique gender expression. Youth are provided the opportunity to engage in activities with their children across the gender spectrum and their siblings. In addition to group and individual support, we offer guest speakers and educational, mental health & medical resources.

TYES supports all families of gender variant youth, not just those who are transitioning or considering transition. TYES supports families anywhere in the state. If you would like to join us, please email us at TYES.group@gmail.com or call our support line at (720) 443-7708. Please know that we recognize that privacy is critical for our families and we work hard to protect the privacy of everyone in the group.

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 7, by Halle Sheppard

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post by
Halle Sheppard,
a Colorado Mother
Transgender Youth Education & Support
PFLAG Boulder County

A little girl!! My husband and I so wanted this girl. We had a son and all our siblings had sons, and as long as we had decided to adopt, why not have a girl?! All her aunts bought her the cutest girlie clothes, and I loved to dress her in them. But as soon as our daughter was 3 years old and could tell us what she preferred, she wore her brother’s hand me downs, definitely not dresses, and a boy’s bathing suit. Though my husband struggled with this a bit, it made little difference to me. This was a child with some pretty big attachment issues. All I wanted was a happy kid who would sleep at night.

Imagine my surprise, when during a routine follow up 15 minutes at the end of my 6 year old child’s therapy appointment (which she attended to deal with some attachment issues), the therapist mentioned that she suspected that my child was transgender. She said she had no formal training in diagnosing this but did have some experience working with another family.

What does that mean to be transgender?? As a well educated 40 something living in liberal Boulder, CO you’d think I should know. And maybe I knew a bit or heard about it, but not really. Not really what it meant to have a child who didn’t just dress and act like a boy, but who wanted to be a boy.

We did not treat our daughter any differently after the mention of this from his therapist. At first we were definitely in denial. Eventually, after suggestions from the therapist (so we could be more prepared), my husband and I bought some recommended books and started reading. It was certainly possible our “tomboy” was in fact transgender: the boy’s bathing suits and boxer shorts; the toys and play mates; the absolute distress at being told she would have to wear a dress to a friend’s wedding. The therapist was specific that our child would come to us with her feelings, so we followed that advice and did nothing and just waited.

We did not have to wait long. A few weeks after school (1st grade) was over in June, about 3 to 4 months after the first mention from the therapist, my daughter marched into the kitchen and declared “I would like to be a boy. Not just dress as one, but really be one.” (Oh, did I mention when he was almost 4, he asked me “when do I grow up to be a boy, mom?”) It was all coming together now. Because I was so prepared for this day, and my husband and I had read enough and discussed enough to understand where our kiddo was coming from, I was able to look him (from here on as I write I will use male gender pronouns) in the eye and tell him that this was fine. We could find a new name immediately and make the transition. I hugged him and held him, but as a parent what I really wanted to do was cry (which I did often privately) and tell him what a difficult life choice this would be; how I would always worry about him being socially accepted…..but of course, not something to worry your 7 year old with.

Why would a parent choose a difficult path for their child? And not just for that child but for the whole family. Difficult decisions, awkward conversations with parents on the little league field and your child’s older sibling having to face his 10 year old friends with this news. Life was pretty rough for all of us for a while. We face strife all of the time. Each time we travel and have to use our son’s legal name, which is a girls’ name, or walk into a doctor’s office and worry they will call him the wrong name. Often, friends and relatives we do not see regularly still use the old name. My husband and I have spent considerable time and energy learning about medications and hormone treatments. It stresses our marriage and our finances! We have both had to have considerable talks with our family members to help them understand. It is a huge burden and some days I want to cry and say “It isn’t fair!!! Why me?! Why do I have to deal with this?!”

But we have also learned the alternative to not letting your child transition and be who he or she wants is devastating and can be fatal. So if you love your child and want them to be happy, why wouldn’t you let them transition? That is our plan. We will help with this, support him, allow the use of blockers to prolong the time until a more permanent decision has to be made. We will share all the options with our child. When he seems unsure, we remind him that he does not need to make any decision yet and that we are ready to help him either way. And that if he chooses to be a boy we will love him the same as the girl we adopted.

He is now 9 years old and has socially transitioned to being a boy. He uses the boy’s restroom and a family changing room. His school mates and friends have been 100% accepting. We know it will get harder and more challenging when we leave our small, open elementary school, but this is his choice and we, as his parents, are here to support him.

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 6, by Sam Winter

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post from
Sam Winter, Ph.D.
Associate Professor
Faculty of Education, University of Hong Kong

Generation G Paranoia.

Coy Mathis clearly identifies as a girl. It was a matter of continuing pain to her that she was not fully recognized and respected as one. The decision of the Colorado civil rights division that she be allowed to use the girls’ bathroom at school went a long way to providing that recognition and respect.

The child’s perspective is entirely missing in Dr. Drescher’s commentary. What, one may ask, would Coy have preferred her parents and school to do about her female identity? Would she have preferred them to allow her to express her femaleness and to be the person she so deeply felt herself to be? Or would she have preferred them to discourage, even prevent, her from expressing her femaleness and add to her pain.

The Times piece reflects an anxiety that the world is full of trans affirmative parents who, seeing the slightest sign of gender-nonconformity in their children, overzealously egg them on into a full transition. This line of reasoning promotes a fear that we may lose a whole generation of youngsters who, if only they had not been so enthusiastically pressed into transitioning, would have turned out to be happily adjusted ‘cisgender’ (that is to say, NOT transgender) gays and lesbians.

What we have here is the fear of a lost gay generation… Generation ‘G’.

When I see them on television, I wonder what will happen when the little boy who is socially transitioned with the mother’s encouragement at the age of 9 decides that he wants to be a boy after all but that he still likes other little boys.
–E mail from Senior WHO HQ Staff, 5th Jan 12013

As this quote illustrates, fear about a lost Generation ‘G’ influences international medical policymakers, who continue to argue that kids like Coy have a disorder that requires medical intervention to put a brake on “overzealous” parents and ensure that more of these kids will grow up to be cisgender gays or lesbians.

Generation ‘G’ fear has little basis in reality. It is more like a paranoia. First, one wonders where these overzealously trans affirmative parents are. Parents like Coy’s agonise long and hard over what they should do to help their transgender children. They don’t make these decisions lightly. Second, kids like Coy spend years pressing for their identities to be respected. There is no reason to think they would hesitate, if ever there was a need, to express a desire to ‘go back’ to their birth-assigned roles. To prevent Coy from  enjoying, right now, the fullest possible recognition of who she is would have been cruel, inhuman and degrading. To do so, just because of some hypothetical fear that she may later want to live as a boy and mysteriously lose her ability to tell anyone, would have been irresponsible. The Colorado civil rights division made the right decision.

Dr Sam Winter is an Associate Professor at the University of Hong Kong and a member of the board of directors of the World Professional Association for Transgender Health (WPATH) and the World Health Organization (WHO) Working Group on Sexual Disorders and Sexual Health. He has been working in rights and health for transgender people for more than 13 years.

Response to Dr. Jack Drescher and the NY Times About Childhood Transition: Part 5, by Mary van Balen

Coy Mathis

GID Reform Advocates respond to the question, “When a child identifies with the other gender, what to do?” Dr. Jack Drescher’s commentary on the Coy Mathis Civil Rights Case in Colorado appeared in the Sunday Dialogues Feature of the June 29, 2013 New York Times. Here is the discussion that the Times did not publish.

A Guest Post from
Mary van Balen
Mother, Author, Columnist, Speaker

The New York Times publication of Dr. Jack Drescher’s letter in its July 30 print edition under the headline: Sunday Dialogue: Our Notions of Gender, has generated much response in the paper, on websites, and on blogs, including this one. I have followed the conversation, appreciated the clinical expertise, and would like to add my perspective. I am the mother of a transsexual daughter, now an adult, who lived for twenty-five years with her “secret” telling me only when she had to choose between suicide or finally accepting herself as she was. We spent hours in the family room as she summoned the courage to speak the truth she had known for so long but had kept hidden: “I hate my body. I always have. Do you know what gender dysphoria is? Well, that’s what I have.”

The words stunned. I had imagined other possibilities, but not that. My knowledge of GID was rudimentary. Images that came to mind were of make-up slathered characters in movies or television shows, generally sleazy types. And there was a person I had seen singing in Provincetown whose male face and female attire who made me uncomfortable. “Not my quiet son, the bright physicist,” I thought. This didn’t happen to people like “us.” I had a steep learning curve ahead.

That process included long talks with my daughter, who once out to me, was willing to share stories of her growing up years. Many of them broke my heart. I thought of them as I read Dr. Drescher’s letter and the responses.

“If only I had known,” I thought when my now twenty-something daughter told me that she knew she was a girl since she was three and in first grade at a Catholic school dreamed of a “magic uniform” that would change her into one. As she talked I remembered her playing dress-up with her younger sisters and loving to clomp around the house in glittering silver high heels. I didn’t know that she had also been making up ballets wearing a pink tutu. I didn’t know she was suicidal in sixth grade.

But what if I had known? In the early 80’s what kind of advice would have been given to me? What would I have done? I like to think I would have been accepting, encouraging even. At home, we gave dolls and trucks to all the kids. We encouraged our daughters and son to explore the creek, climb the trees and experiment with chemistry sets as well as cookie recipes. But having a child tell you “he” is a girl stretches a parent well beyond those attempts at gender-neutral play. Would I have stood up against the social norms of the day?

As my daughter and I continued sharing, she lamented not having had the chance to grow up as a girl. She missed all that socializing. “It would’ve helped a lot,” she said as she struggled to move into the world of women with a history of trying to fit into the world of men.

Dr. Drescher’s statement that “Currently experts can’t tell apart kids who outgrow gender dysphoria (desisters) from those who don’t (persisters)…” seems strange to me. My transsexual daughter’s feelings and her positive sense of gender identity by the age of three, are not the same as the desires and feelings of a boy who likes to play with girls toys or dress up.

I read the story of Coy Mathis and applaud the Colorado Civil Rights Division for ruling that she be allowed to use the girl’s restroom. California’s move to allow children K-12 to use the bathroom that matches their gender identity is a step in the right direction. We should listen to the children and follow their lead. Perhaps then there will be fewer who will lament not having had the opportunity to grow up as the person they know themselves to be and fewer adult transsexuals who look at life and consider opting out of it a good choice.

Mary van Balen is an author, columnist, and speaker with a B.S.S.W. and M.A. in Theology. She has worked with abused, single mothers in a family literacy program and served as a curriculum director for an afterschool program for at risk students. She speaks on issues of transsexuality from a parent’s perspective and will be presenting on issues of transgender youth at the national convention of the Catholic Association for Lesbian and Gay Ministries in New Orleans. She was a resident scholar the Collegeville Institute for Ecumenical & and Cultural Research where she worked on her current writing project: “Julia All Along: A Mother’s Journey with her Transsexual Daughter.”

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