^{CHAPTER FIVE}

It Takes a Gender Creative Parent to Negotiate the Gender Maze

SINCE THE PUBLICATION OF Gender Born, Gender Made, stories of parents describing their journeys with their gender creative children have been cropping up all over the world—in the press, on TV and radio, on the Internet, in articles and books, in school auditoriums, on campaign trails. And each of the stories seems to finish on a note of pride and support. On February 19, 2015, the San Jose Mercury reported that US representative Mike Honda of California had announced that Malisa, his eight-year-old grandchild, was transgender. Most moving in the story was his request, following Malisa’s social transition from male to female, that the family retake its family photo to be used in his reelection campaign brochure, for, as he explained to Malisa, “We need you to be who you are in the campaign photos.” Michelle, Malisa’s mother and Mike’s daughter, described Malisa as “incredibly touched.”[44] Two days later, the story of Zay and her parents, Jason Crawford, a pilot, and Chasilee Crawford, a nurse, from Yellow Springs, Ohio, was published in the Cincinnati newspaper the Enquirer. Like Malisa, Zay knew early in her childhood that she was not the boy people thought she was. Jason, her father, described his experience as her dad: “I am really happy that Zay is with us because we are going to try and protect her. There is hurt in everybody’s life. There’s hurt in the world… but that hurt of not being accepted by your family is not going to be something she has to deal with.”[45] Four months before that, the St. Louis Post-Dispatch published the story of Max, a fourth grader who had transitioned from female to male. Max’s mother was fully aware that life might get more difficult for Max as he got older: “There’s a loss of some ‘normalcy.’ Lots of stuff will be harder. What we’ve done now is create a base of security and love to weather those times. He feels safe and secure with our family. Max has taught us so much, just by being himself.”[46]

That same year, the camera was on Angelina Jolie and Brad Pitt, not because they were making a new movie, but because of their eight-year-old child, John Jolie-Pitt, née Shiloh. The photo-op was not Brad or Angelina but John, striding across the red carpet at the premiere of Jolie’s movie Unbroken. Donning a suit and tie, John looked like a carbon copy of his father. Everyone thought that John had come into the world as a girl, but John let Jolie and Pitt know through both word and action that someone had gotten it wrong and Shiloh was not their daughter but, rather, their son. Both parents listened to Shiloh, who had by all reports been insistent, consistent, and persistent since early childhood that “male” would be getting it right—and helped Shiloh transition to John. In an interview several years earlier, Jolie reported, “She wants to be a boy. So we had to cut her hair. She likes to wear boys’ everything. She thinks she’s one of the brothers.”[47] Not too many years before that, another child of a celebrity, Cher, also made front page news: Cher’s daughter, Chastity, now an adult, had come out as her son Chaz. Chaz has become a spokesperson and supporter of transgender issues across the globe, with his mother’s blessings: “I admire my son Chaz’s courage for sharing his personal journey. Most important to me is that he is very happy. That’s what I care about the most. He has my love and support.”[48] Politicians, movie stars, ordinary citizens—mothers, fathers, and grandparents are coming out in support of their gender creative children and grandchildren. Yet, truth be told, it is still easier said than done.

Remember the story of Stuart Little, born to a human couple? The Little family doctor “was delighted with Stuart and said that it was very unusual for an American family to have a mouse.” The situation was, however, not always so delightful for Stuart’s parents, such as when Mr. Little banned references to mice in all family conversations and ordered Stuart’s mother to tear out the nursery rhyme page with “Three Blind Mice” on it, for “I should feel badly to have my son grow up fearing that a farmer’s wife was going to cut off his tail with a carving knife.”[49]

Who knew what an allegory this would turn out to be for twenty-first-century parents stretching to creatively raise their gender creative children. At first, the realization of having a child who doesn’t conform to social gender expectations or to the sex listed on the child’s birth certificate can be quite a surprise. The only difference between the Littles and the parents of a gender creative child is that the Littles knew from the get-go, from Stuart’s first breaths, that their child was a mouse. Not so for the parents of a gender creative child. They will have no idea at first—they might discover early on, they might discover much, much later that the child they have is not the child they thought they were bringing into the world—it could be the boy who is a girl, the girl who is a boy, a gender hybrid, a gender-ambidextrous child, a gender fluid child, an agender child, and so forth. And yet, when families come to learn that their child’s gender is not the one matching the sex marker inscribed on the birth certificate, or that the child is not complying with the gender norms of their culture, it can be no less shocking than discovering your child is a mouse. Like Mr. Little, parents may fear for their gender creative child’s safety, not at the hand of a farmer’s wife, but in the grips of an unaccepting, hostile world. The real question is how they will absorb the shock and take their child in stride over time—again, a task easier said than done.

Basic ground rule for raising children: If we recognize the child we have, rather than the one we wished we had, and if we help our children build resilience to face the challenges before them, we put them in good stead to live a healthy and productive life. Now let’s apply that ground rule to children’s gender and their parents’ role in gender health. Recognizing the child we do have rather than the child we thought we were going to have, coupled with fortifying our child to face life’s challenges, become the two key ingredients in the nurture threads of the child’s gender web. With the benefit of Caitlin Ryan’s work at the Family Acceptance Project, it has become almost a scout motto: If you support your children’s gender creativity, your children will do better, both psychologically and physically; if you fail to support their gender creativity, they will not do so well, both psychologically and physically.

Why write more? Because, again, it is easier said than done. Because support is a rubbery concept—what’s support to one family is neglect to another. So, what does it take for parents to bring that motto of support to life? How do parents succeed in fortifying their children’s gender resilience, in facilitating their children’s ability to live in their true gender self with all the accompanying coping skills that will allow them to maintain confidence and good feeling about themselves even in the face of a world who may think otherwise?

From Thorny Paths to Gender Mazes

Chapter 2 of Gender Born, Gender Made is titled “The Family’s Path Is Covered with Roses and Thorns.” I wrote that parents find themselves on a road of thorns as they try to carve a pathway for their children who do not abide by the culture’s gender proclamations—whether they are boys who are girls, girls who are boys, or young people who defy rules and regulations for how you’re supposed to “do” gender. Sometimes parents are called on to police their children’s gender, telling them they can’t go outside dressed like they are, it’s not safe; sometimes they are called on to play God, to be the ones to decide whether the children should socially transition from one gender to another or take hormones with partially irreversible effects. And all the while, parents still travel through a world that blames parents for their children’s gender “oddities,” albeit far less so than in the past as the public grows more educated and more accepting. But I’ve learned something profound since finishing Gender Born, Gender Made—how quickly the road can morph into a maze, with seemingly endless routes and innumerable dead ends. This is not necessarily bad news. With a half-decade of new knowledge under our belts and an international movement addressing the needs and rights of gender-nonconforming people—a movement nothing less than phenomenal in its emergence and growth—I think we’re actually ready to move from traversing thorny paths to finding our way through gender mazes. If you like to solve mazes, you can understand how the experience of negotiating gender mazes can prove no less challenging than carving a path through thorny terrain, but far more pleasurable.

What can gender mazes look like? There are the two mothers who send their gender-nonconforming little boy to a progressive school where it’s absolutely fine for him to wear girls’ clothes. It’s fine for the mothers, too. Yet he flatly refuses and only wears them in the comfort of his own house, even though he lives in one of the most progressive communities in the country. There are the mother and father who have to decide whether they should let their gender-nonconforming (natal female) child-prodigy teen go to a highly coveted summer program for gifted high school students as a boy because the gender-segregated living halls and activities find this teen insisting that the boys’ unit is a far better fit than the girls’, even though this youth does not identify as transgender but agender.

Let’s zoom in on another family caught in the midst of a gender maze. Alice and Morton have a three-year-old girl, Mirabel; at least that’s what they think. One day Mirabel announces to her parents, “I’m a boy.” What does this mean? As far as they can tell, it means that Mirabel will only wear boys’ clothes. A visit to Mirabel’s grandparents is coming up. Her grandparents are quite conservative and live in a small town several miles away. Alice knows only too well how her parents will react to Mirabel showing up in boys’ clothes—not a pretty picture. The day of the visit arrives. Alice pulls out a dress that has been collecting dust in Mirabel’s closet and announces, “Honey, we’re going to visit Grandpa Joe and Grandma Jane. So, you’ll be wearing a dress today.” Mirabel continues happily playing with her dolls, piping up in a cheery voice, “Okay, Mommy, as long as it’s a boy dress.” The problem of attire for the grandparent visit is solved, but the meaning of Mirabel’s pronouncement is not. Is Mirabel telling Alice that she’s a boy who wears dresses, a boy-girl, or a girl who is creatively de-gendering all clothes? Alice and Morton have read all kinds of books about boys wearing dresses, but never one about a girl wearing a boy dress. This “boy dress” passageway of the gender maze might take them to a dead end; it might lead them down the path to a transgender outcome for their child; it might require going back to the maze entrance and rethinking what Mirabel has been trying to tell them all this time about Mirabel’s gender.

If we go back to the apples, oranges, and fruit salads, the apples—the transgender children—are in some ways the easiest children to traverse the maze with. They are clear about who they are and, if given the chance, they let everyone know. Yes, there is stress, heartache, and grief as a parent comes to terms with the reality that the child they thought they had is not the one they do have—their boy is actually a girl, their girl is actually a boy. But there is also clarity. When it comes to negotiating the maze, the oranges and the fruit salads may prove far more challenging for parents. Who are these children and what are they trying to tell us? How can you be neither gender—or every gender? “Is my child gay? I just want to know.” And sometimes it is so hard not to know—especially about something as basic as gender. And the problem with all these questions is that we can’t know until the children know, and that could be a long way down the road. But the parents have to negotiate the maze right now, because it is their job to shepherd their child through childhood. So, how does a parent find the way out of these complicated gender mazes? Answer: by developing and strengthening a solid gender GPS for traversing the maze while simultaneously cutting new paths so their child can move forward in unique gender creative ways. Let me invite you to think with me about developing a parental GPS for traversing such mazes.

Learning to De-Center

I have discovered that there are many things I learned in my training to become a developmental psychologist that have proved invaluable to me in mapping out the strategies and criteria for becoming a gender creative parent. A central one is the concept of de-centering. To de-center as a parent is to learn how to remove yourself from your own wishes, needs, and desires and instead focus on the wishes, needs, and desires of your child. In the vernacular, it means, in any interpersonal situation, putting yourself in the other person’s shoes to understand their experience. It means being able to empathize with what it means to be them, without getting overwhelmed with how their way of being may be so different from your own or for your wishes for them. With our children, it means having the ability to put them first (which is not the same as letting them be the boss of everything). It requires maturity and imagination—imagining what it is like to be their age; imagining what they are feeling; imagining how they are experiencing the world; imagining what they are trying to tell us in word and deed; imagining what they hope for from us.

De-centering is not always so easy to do. Even in the best of circumstances, we as parents will inevitably view our children through our own lenses, projecting our hopes and dreams onto them. We’re particularly ripe for these fantasies and projections before a baby is even born, when, in Western culture, all we really have to tell us about who they are is the copy of the fetal sonogram pasted on our Facebook page or stuck on the refrigerator with a magnet, the ebbs and flows of the baby’s movements in the uterus—and the sex of the baby, if we have the opportunity to or care to know it. For parents of a baby adopted later than birth, often all we have at first is a photograph. These reveries about the baby who has not yet come to us are all fine and good, because, from our side, it gets the bonding process in gear. Sigmund Freud first alerted us to this natural and healthy phenomenon for new mothers and fathers, and it is what I, in my earlier work, have dubbed “expectable parental narcissism.”[50] But once the baby arrives and begins to have a mind of its own, we have to learn how to shift away from our own hopes and dreams and instead nurture our child’s. Otherwise, we might end up the truly narcissistic parent, not a good thing.

Leaving gender aside for a moment, what happens when parents have a child who is just so different from them that they can’t find a way to de-center and get in their child’s shoes and imagine what it is like to be them? Think about it for a moment: We don’t value genetic connections just to carry on our blood lines—passing on our genes is believed, sometimes naively, to be an insurance policy that our children will be enough like us that we’ll be able to love them. We could say that sameness/likeness seems to function as bonding cement in parent-child relationships. We can find this sameness/likeness as cement in nongenetic family building as well when parents-to-be will make every effort to pick a baby who will match their race, ethnicity, looks, or personality, by making the right match either with a donor, with a birth family, or with a baby or child waiting to be adopted. But it doesn’t always work out that way. A child can still end up very, very different from you, even when half of that child’s genes are yours. So, what happens when parents end up with a child who is very different from them?

They can feel off-kilter or disoriented and confused, not knowing how to secure a connection or make sense of this very foreign creature. In Far from the Tree, Andrew Solomon explores in depth the parental experience in these situations and devotes an entire chapter to parents of transgender or gender-nonconforming children. He introduces us to the idea of horizontal identity—that means a child who will have a lot in common with other children like themselves, but not so much with their own parents. Horizontal identity could apply to the deaf child, to the child prodigy, to the autistic child, and yes, to the transgender or gender-nonconforming child. Dr. Solomon offers us words of wisdom as to what parents can do in those situations—look deep into your child’s eyes, see in your child both yourself and something utterly strange, and zealously attach to every aspect of your child. If you can do that, you have arrived at “parenthood’s self-regarding, yet unselfish, abandon.”[51] That very abandon is the essence of de-centering.

Let’s bring parental de-centering into the gender maze. Let’s take a family that may come to me for support. You may recognize yourself in this family, you may not, so I just invite you to de-center for a moment. Susanna and Sam are a mom and dad who each identify as cisgender. Both have always comfortably identified with the sex assigned at their birth, and both have been pretty gender conforming, living in accordance with their assigned gender and the social guidelines for that gender. They always wanted a little girl, and then their wishes came true—they got one, at least they thought so. For now, Amanda is their only child. She’s four. Ever since she was two and a half, she threw anything pink on the floor and cried out, “Hate pink.” The only colors she will wear are orange and dark blue. While the other girls run to the doll corner at preschool, Amanda runs outside to play King of the Climbing Structure with the boys. She has begun to tell her preschool teacher, “When I grow up to be a man like my daddy, I’m going to be a rock climber like the guy I saw on TV.” Susanna and Sam are flummoxed—what happened to the baby they once dreamed about—the girl in frills? That’s how Susanna was when she was growing up. What isn’t she doing to help Amanda be the same—to be like her? They’re both girls, after all. And Sam feels no affinity for the Annie Get Your Gun kind of females; that’s why he chose Susanna, in all her femininity, for a partner. He wants to make sure that Amanda knows that she is a girl, and a beautiful one at that, just like he knows he’s a guy and Susanna knows she’s a woman. And isn’t gender bedrock, set as soon as you find out the sex of your baby? How could two cisgender parents have anything but a cisgender child? Sam and Susanna assumed Amanda would be just like them. But she isn’t.

Truth be told, at that moment it might be easier to learn your child is deaf than gender creative. Deafness in a child is an immutable difference in hearing that hearing parents have to accept, painful as it might be. They can try to correct the deafness, but it still will not erase the difference between them and their child. Gender creativity, on the other hand, is a difference that is harder to wrap your head around, especially if you believe that you might have caused it, as some experts might tell you. Especially if you are not gender nonconforming. Especially if you believe that with the right efforts you can redirect your child toward more sameness with you and away from this gender difference that may seem so unfathomable to two loving cisgender, gender-conforming parents (remember that sameness functions as bonding cement). But whatever the nature of your child’s difference from you, the work will be the same—for Susanna and Sam it will involve de-centering off themselves and trying to get into Amanda’s experience and learn about Amanda’s gender web and gender creativity, as Amanda lays it out to them. It also means allowing space for the difficult feelings that may accompany the realization of difference, for either Susanna, Sam, or both of them together.

Let’s move from deafness to blindness—in this instance, not the child’s but the parents’. I’m not talking about actual blindness but, rather, blind spots. Parents may suffer from gender blind spots and have no conscious awareness that they even have them. If de-centering means getting your child in focus as a separate person rather than viewing your child as a mirror of yourself, gender blind spots can only work against that clear vision. Gender blind spots can be caused by lack of knowledge or by resistance to seeing what is there to be seen. Blind spots won’t get revealed in an eye exam, only in self-examination and with the help of both the child and a circle of adult support to gently (or perhaps not so gently) point them out.

A gender blind spot shows up most poignantly when a parent insists, “I truly never saw this coming and I can’t even see it now.” Then the child walks in and another person’s first reaction might be, “Wow, you don’t see it? That’s amazing.” I’m thinking of a youth I saw whose parents had on the initial visit described to me their teenage daughter who loved fashion and was stunningly beautiful—how could she possibly be a boy, which she kept insisting she was? The next week I went out to the waiting room looking for that girl, and all I could see was a handsome young man—their daughter. The first thing this youth said to me, with tears streaming down his face, was “Can you believe it? Look at me. What more could I do to get my parents to take their blinders off and see who I am?” The story has a happy ending—the parents, totally committed to the well-being of their child, eventually came to see their child for who he was. This occurred only after they felt safe enough to remove those gender blinders and de-center off their own wishes and hopes for their beautiful, fashion-conscious daughter and get their actual child, a son, in focus. This vision correction was not just an option, but a painful and necessary process to prevent their child from going down the path of self-harm and deep depression, which is where he might have been headed if something wasn’t done to acknowledge his affirmed male identity.

It is certainly possible that a parent may be blind to their child’s gender because their child has done such a magnificent job of hiding it, constructing a false gender self so airtight that the child’s inner desires and sensibilities are masked if not totally opaque, even to their loving parents, maybe even to themselves. This often happens as a result of implicit or explicit negative messages from the social environment that force a child to go underground with their true gender self. Sometimes there are no such messages. Rather, a child’s own sensitive temperament, as laid out in the last chapter, will be the driving force behind the masquerade—a child may be so exquisitely self-conscious that they just can’t bear to have anyone, even their own parents, peer in on such a vulnerable, core part of themselves. It would be like asking the child to run naked through the streets. So, the parents remain blind to the situation, never given a chance to de-center and discover the child who is so different, unless the child can no longer tolerate hiding the truth and steps out of the masquerade.

I will say from my own observations that it is more common for the parents to be the ones who render themselves blind, with no traces of opaqueness or masking on the part of their child, like in the story of the boy in my waiting room. The parents may fear the worst, given their own gender histories and gender sensibilities. They may want desperately to hold on to the belief that their child is just like them, rather than very different. Often with no conscious awareness, they may operate from the tenet “Hear no evil, see no evil, speak no evil,” rendering them unable to recognize the gender creative child clearly standing before them.

To remove gender blinders or gender blind spots so that we can get the children in focus, we need to embark on the process of examining our own gender ghosts and gender angels. I introduced this idea of gender ghosts and gender angels in Gender Born, Gender Made, and now I want to bring them back on the scene to see how they can help with or hinder de-centering. In short, gender ghosts are the internalized thoughts, attitudes, feelings, beliefs, and experiences that draw us toward culturally defined binary gender boxes and make us anxious when we or anyone else strays from them. Our gender ghosts may show up in our conscious minds. They may remain deeply embedded in the unconscious chambers of our psyches. Every time a parent walks around with gender blinders or suffers from gender blind spots, we can assume that gender ghosts are in play. Then, we have our gender angels. Those are the internalized thoughts, attitudes, feelings, beliefs, and experiences that allow us to be gender creative and live or accept others living outside of the culturally defined binary gender boxes. Just like gender ghosts, our gender angels may show up consciously, or curl up in our unconscious. Gender angels are what allow us to take our gender blinders off, erase our blind spots, or never have to struggle with them in the first place. And they work marvelously in helping us de-center off ourselves and accept a child who may be gender-different from us.

How do we examine our gender ghosts and gender angels? Starting with gender ghosts: If we want our gender creative children to feel as if they are the fruit of our tree rather than far from it, we begin by challenging our own socialized beliefs about gender. Just like the adoptive Caucasian parents of an African American child who learn about or take part in the black community that their child may identify with, we make a concerted effort to immerse ourselves in a world where expanded gender possibilities are accepted and celebrated. We learn about the risks to our gender-nonconforming child’s physical and psychological well-being should we not do this. These efforts will metabolize into the nutrients that feed our gender angels and allow them to come to the light of day. For some of us this process seems to happen rather seamlessly; for others it is a struggle; and for every parent the process will be bolstered by the very presence of our own gender creative child—because I truly believe that love conquers all. It is during this process that mourning may come to the fore—we take the time to mourn the child we thought we had, to make room to embrace the child we do have. It is important to acknowledge this mourning process as a critical component of de-centering. It may seem contradictory to be focusing on ourselves if our task is to focus instead on our child, but not if we understand the mourning process metaphorically as the shoveling that allows us to clear the path so that de-centering on our child’s authentic gender is possible.

Then come the gender angels: When the gender angels surface, we call on them to help us de-center off our own desires, hopes, and expectations and offer our children the freedom to weave their own gender web. We get in touch with our good feelings, if we have them, about gender expansiveness and apply them not just to our children’s lives but to our own. For many parents, this will involve a major paradigm shift. Others may find they are simply walking in the footprint of a life they have already lived for many years. Whether it’s a paradigm shift or a walk in the park, we still have to remain on the watch for our gender ghosts (our internalized genderism, so to speak), who are whisperers, warning us to stay put in those binary boxes and accompanying proscriptions and prescriptions where gender is knowable, predictable, and acceptable. If the going gets rough, it helps to remember that a good predictor of a child’s gender health will be the ability of the adults in the child’s life to bring both their gender ghosts and angels into the light of day and allow the voices of the gender angels to triumph.

In My Daughter, He, Candace Waldron’s poignant account of her journey through the gender maze with her child, she quotes from her transgender son’s journal, written by Kai at age twenty-three: “I knew I had disappointed her [Mom] by coming out as trans those years ago, but I knew she’d be okay in time.” Kai is sharing his own realization of his mother’s earlier difficulties in de-centering and focusing on his own gender affirmation rather than her own need or wish for him not to be trans. To disappoint your parents is not the same as making your parents sad. It’s about letting them down, not meeting their expectations, getting their hopes dashed. Through his words we have a portal into the ways Kai bore witness to his mother’s gender ghosts at work. Indeed, throughout the book Candace is courageously transparent in revealing them herself, as when she wrote about Kai (then Kendra):

But at the end of the day Kai reveals his belief in the ascendance of his mother’s gender angels: “I knew she’d be okay in time.” And Candace certainly was okay enough to write a moving book about her gender journey with Kai, a book with the subtitle Transitioning with Our Transgender Children,[52] a profound testimonial of gender angels prevailing over gender ghosts.

Microaggressions

I’ve pulled from my child development training; now I want to draw from my education in sociology. I want to zoom in on the concept of microaggressions. I first learned this concept in the context of US black-white race relations. Microaggressions are not the dramatic violent and sometimes fatal atrocities waged against minority groups, but the everyday oversights, innuendos, slights, disrespectful comments, or actions that a person might endure, based on another’s lack of understanding, antipathy, or fear of difference. It was Derald Wing Sue’s book Microaggressions in Everyday Life that sensitized me to this phenomenon, as he delineated the everyday verbal or nonverbal communications, not necessarily delivered with hostile intent, insinuating to a person of a particular marginalized group that who they are is not acceptable.[53] Microaggressions embody subtle, often unintentional biases. We can think of each one of them as a ping, but when they start to build up, they can morph into a resounding blow. Regrettably, gender-nonconforming children count as one of those marginalized groups, and even more regrettably, the microaggressions can come their way not just from the outside world, but directly from home, even by the most well-intended parents. This may be very different from the experience of children from racial or ethnic minorities whose families share that minority status, because they can at least count on their own family members to watch their backs. Not so for the gender-nonconforming child, who as we can see, can feel far from the parents’ tree.

Although this is not about parenting, I want to share my own recent experience as an unwitting perpetrator of a gender microaggression, just to make the point that it happens all the time to gender-nonconforming children, even when we don’t mean to and even when we believe we are the most sensitive of gender souls. I was standing on the BART platform waiting to catch a train. Near me was an African American mother with her son, who I would guess was around nine. Large for his age, with a trailing tendril of curls down the back of his head, I noticed he was holding something in his hand, gently stroking it with his other hand, with a contented, dreamy look on his face. His mother had a loving hand on his shoulder. When I looked closer, I saw that he was fingering a small action figure, a girl, which he had dressed up in a homemade cape crafted from a scrap of deep red velvet. He continued to stroke the little figure as we all got on the train. As the train took off, I looked over at him with a smile on my face, catching his eye. Rather than smiling back, he flinched and swiftly threw his arm into his jacket, emerging with an empty hand and no action girl. The figure in the cape never appeared again for the entire ride into San Francisco. I wanted to go over and tell him it was okay and that I would love to see what he had been playing with, but I thought that might make it even worse and perhaps leave him even more defensive and self-conscious in the face of a world that had sent out previous messages, “No action girls for boys.” So, I did nothing, except to keep sending smiles in his direction, with the naive notion that he would read my smiles as affirmation and acceptance. Indeed, he was closed up and wanted nothing to do with me. And I wondered how much grief he had already gotten for his doll play, certainly not from his loving mother, but from the kids at school, other people in the family, in his neighborhood, and so forth. Maybe this was going to be a day he was going to get to be free of that, anonymously riding with his mom on the train. So, that, my friends, was a gender microaggression—me, an older white woman, unwittingly but perceptibly infusing discomfort and angst into this child’s train ride with his mother, his action girl hidden deep in his coat rather than enjoying her ride in his hand.

What would home-based gender microagressions look like? Let’s start with the father who tells his son, “You don’t want that Barbie doll; it’s for girls.” Actually, his son does want that Barbie doll. In telling his son that he really doesn’t, the dad might be trying to help his son fit in and fare well in their community, where boys playing with Barbies just isn’t the norm. But if we delve a little further, maybe it’s not the kids on the street, but the dad who feels queasy about his son playing with Barbies. Actually, his son’s friends might be just fine with it. They might even want to play, too. In that simple, brief message—“You don’t want that Barbie doll”—his son has just been the recipient of a microaggression, like the boy on the train feeling shame for wanting what boys shouldn’t want, according to the gender rules. Ping. Surely this cannot be in this little boy’s best interests if he gets the message that who he is will never be worthy in his father’s eyes.

This particular gender microaggression, “You don’t want that Barbie,” is pretty obvious. Let’s move to a subtler one. A little boy announces to his mother, “I like playing with Barbies, and I want to be a girl.” His mother, schooled as a child herself on Free to Be You and Me and William Has a Doll, responds with love and affection, “Honey, you know boys can play with Barbies, too. You don’t have to be a girl to play with Barbies.” She’s proud of herself and counts her response as a supportive parenting moment, breaking the gender barriers of Barbies for girls but not for boys. Except that her son was trying to tell her something very different, which, if she listened carefully, was, “Mommy, I want to be a girl who plays with Barbies.” At that moment her son could explode and yell, “Mommy, I know, I know that boys can play with Barbies. But that’s not what I said. I said I’m a girl who wants to play with Barbies.” Or he could retreat to his room and never bring it up again, keeping his thoughts and feelings about himself as a girl buried deep inside him where no one will try to correct him. Whatever his response, you have just witnessed a potential microaggression, a subtle unintentional message from his mother that who he is as a girl won’t be okay with her. This loving, well-meaning mother only intended to support her child by offering a more expansive world of gender expression, but, unbeknownst to her, she missed her son’s need to be acknowledged for the gender he is coming to know himself to be. Instead of feeling cared for by his mother, he may slink away feeling frustrated, putting all his efforts into calming a bruised psyche, all by himself. Ping.

Now let’s move to the most macro of microaggressions. Do you recall Leelah Alcorn, the transgender teen who left behind a painful but poignant suicide note? After her death, her mother is quoted as saying, “We loved him no matter what. I loved my son…. He was a good kid, a good boy.”[54] I’m sure she did love Leelah, and I can only imagine the grief she must be going through. The only problem is that Leelah was a good girl, not a good boy. Leelah might even be alive today if someone could simply have recognized Leelah for the girl she was and not let her be taken to therapists who tried to make her the boy she wasn’t. Even in Leelah’s death the microaggressions persist, and in Leelah’s case, added up to the biggest of blows.

To negotiate the gender maze is to monitor all incoming microaggressions coming your child’s way, not just out in the world, but right at home. So, when a fifteen-year-old transgender boy of divorced parents tells me that his nineteen-year-old brother moved out of the house to go live with his father because he found his younger sibling disgusting, that’s a pretty resounding ping. And I wondered, sadly, where his parents were in stopping the brother from delivering such a damning message.

Pediatricians will tell parents not to worry—their child’s gender nonconformity is just a phase. In general, whenever “just a phase” is delivered to a parent’s ears, we can anticipate the parent’s reaction close behind: “Oh, thank God, this too shall pass.” Think about tantrums. Think about terrible twos. Think about toileting regressions. Think about grabbing toys from other children at preschool. Think about clinging to Mommy when the babysitter arrives. “Just a phase” = something you hope against hope your child will outgrow. So, the parent comes home from the visit to the pediatrician and reports to the other parent, “We shouldn’t worry about Tommy’s wearing only dresses. The doctor says it’s just a phase. Lots of three-year-olds like to do that.” The other parent lets out a sigh of relief. Tommy looks like he’s over in the corner preoccupied with his puppets. But he’s heard every word exchanged between his parents. He’s too young to understand the exact meaning but old enough to pick up the nuance. His parents are waiting for him to stop being who he is. That’s a microaggression. Ping.

Priscilla plays only with boys. Her parents worry about that. She should have some girlfriends, too. Maybe that will help her be more comfortable at school, because she clearly isn’t at the moment. So, the next time she asks for a playdate with Jasper, one of her mothers says, “Honey, let’s invite a girl over today.” They’ve already gone to see a therapist about Priscilla’s anxiety every morning about going to school. When the therapist heard that Priscilla plays only with boys and likes to wear boxer shorts under her jeans, the therapist connected the dots, or thought they were connectable, and said to the moms, “You need to help Priscilla be more comfortable with being a girl. Buy her some girl underpants she’ll like and find some girls for her to play with.” And the therapist may be thinking to himself, “There’s no man in this house. No wonder Priscilla is trying to be one.” So, Priscilla is now being sent a subtle message that her playmates are really not ideal because they’re boys, and her underwear is a poor choice, too, and she’s missing a father to boot. That’s a microaggression. Ping.

Katy has been gender nonconforming since she was very little. When she got to middle school, she decided she must be a lesbian. But as the school year progressed, she realized that was wrong. She was a boy. She went to see a therapist, she talked to her parents, and they all agreed that it made sense for her to socially transition to her affirmed male identity. Katy became Kat and asked that everyone use male pronouns. Kat’s parents were on board but continued to refer to Kat as their daughter and as “she.” Kat would grow agitated, and Kat’s parents would say, “Look, you have to give us some time to get used to this. You’ve always been Katy, daughter, she.” Fair enough, but weeks passed, months passed, even a year went by, and still Kat heard, “She, daughter, and Katy.” This form of misgendering and misnomering from one’s own parents is not just one microaggression, but a series of them, a chronic slight happening over and over again, definitely risking becoming something bigger than a ping and more like a cumulative assault on one’s self. So, what’s in a name? A whole lot.

I painfully bore witness to such misgendering at a visit with a family at the gender clinic where I work. Len, Nadine, and their twelve-year-old child, Emory, showed up for their initial visit. Six months earlier Emory had come out to his parents as transgender, female to male. Emory requested that everyone start using male pronouns. Len is in a lot of pain about this and having difficulty accepting that his daughter is now asserting that he is their son. During the clinic visit, Len uses she and her to refer to Emory. Every time he does, Emory flinches. Len doesn’t notice this at all. Instead, Len begins to cry, explaining how distraught he is, because he was always so close to Emory, but Emory doesn’t want to have anything to do with him anymore, and Len doesn’t know why. Only meeting this family for the first time, it still seemed to me that each of the pings that Emory endured from his dad just in this one visit to the clinic might be the simple answer to Len’s question, “Why?” So, this was a moment when I hoped I could blow the trumpet for the gender angels to come out. It seemed clear to me that Len loved Emory very much and didn’t want to lose the love of his child. I asked Len whether he had noticed how Emory visibly flinched every time he said she or her. Len seemed surprised and admitted that he hadn’t. I asked Emory whether he could tell his dad how it felt inside when his dad said she, her, or my daughter. Now it was Emory’s turn to cry: “Every time he does that, it feels like my dad has a slingshot and keeps aiming stones at me. And I sink a little lower every time he calls me she. And it makes me mad.” I explained to Len that for Emory, this was not a little deal, but a big deal, and could get even bigger if the slingshot hits kept coming Emory’s way. From that day on Len made every effort to put an end to the pings, doing his best to use he, him, and son. And Emory started talking to his dad again.

The moral of the story is pretty straightforward: If you see a microaggression or are the agent of one, stop it. Anytime you feel an inclination to tweak your child’s playmates or tamper with their toy choices, reassure yourself it’s just a phase, or edit or correct their gender messages to you, that’s a “stop it” moment. Like charity, freedom from microaggressions must start in the home. And it’s good to always keep in mind that although any small action might seem like no big deal, gender microagressions pile up, kind of like the way minor air pollution, if chronic, can add up to serious allergies or asthma. Only instead of breathing problems we’ll have anxiety, depression, self-harm—nothing loving parents would want for their child.

Parents’ Best Insurance Policy: Acceptance

Children do best when they get their parents’ support. Obvious. The vast majority of parents bring their children into the world or into their family with the intent of supporting them. Assumed. Yet what form that support takes is not obvious nor should it be assumed. What is support in one culture might be considered neglect in another. The same difference may hold true from one household to another on the same block. So, let’s talk about the kind of support gender-nonconforming children will need from their family to have a good go of it in life. The secret of navigating the gender maze, with all its potential dead ends and multiple pathways, lies in finding the right ingredients that will constitute true support of gender creative children in spinning their own unique gender web and discovering their true gender self.

Let’s stray for a moment from the arena of gender to other aspects of child rearing. Take parents who value education and very much want their children to succeed. To that end they will push their children hard and will tell you this is the best way to support their children’s academic success. In certain cultures, placing high academic demands on children is the status quo, and everyone accepts this parental practice, including the children. Yet even within those cultures, some children do not experience this practice as support at all but, rather, as undue pressure, and the result is failure rather than success—the children feel neither seen nor heard and buckle under the load created by their parents’ so-called support. How about the parents who want to support their children in being autonomous, confident, and assertive, three traits that may definitely help you succeed in life, at least in Western culture? Such efforts often translate into giving their children an equal voice in family affairs; in other words, every person’s vote counts, even when it comes to setting a bedtime or brushing teeth. Part of that package deal: Whenever possible, avoid two words when talking to your children: stop and no. Such “supports” are rarely in children’s best interests, leaving them in a state of perpetual anxiety. They’re too young for such participatory democracy and decision-making responsibilities; they will end up desperately seeking some form of leadership from their parents, who are not supposed to renege on their duty as benign authorities who will shepherd the children until they are ready to be self-guiding. In each of these examples, parents’ efforts to support their children do not necessarily translate into best practices that will help those children grow healthy and strong.

In like fashion, the support parents may believe they are providing to their children in their gender development may prove to be anything but. The most egregious error in this regard is when parents believe they are the sculptors of their children’s gender self, telling rather than listening, enforcing rather than facilitating, imposing their own picture of their children over the children’s repeated attempts to paint their own gender self-portrait. But if you ask those parents why they are doing this, with love in their hearts and good intent in their minds they will explain that they are helping their children embrace the gender that was either God’s will or nature’s way or culture’s norms, rather than the children’s individual right or choice.

A stands for apple, our young transgender children. A also stands for acceptance, the key ingredient of successful support of the gender creative child, the support that will prove to be parents’ best insurance policy in promoting their children’s gender health. So, from here on in I would invite us all to dispense with the language of support and stay more strictly with the language of acceptance. Here’s the riff: All parents negotiating the gender maze have an obligation to scrutinize parenting practices that they consider supportive of their gender creative children. If the contours of that support aren’t centrally located around acceptance of the children for who those children are, rather than who the parents want them to be, it’s time for the parents to take a look at their own gender ghosts and blow the trumpet for their gender angels to show up. Gender-nonconforming children don’t just want to be seen; more than anything and most urgently, gender-nonconforming children want to be accepted by the people closest to them—their parents or caregivers and family members.

Bart is the single father of Jeremy, a sixteen-year-old high school boy who really wants to wear dresses—at home, at the mall, at weekend social events. Bart calls and asks me for a consultation to sort this all out. In our visit he says to me, “When he’s eighteen, he can do anything he wants. But as long as he lives in my house, that’s never going to happen.” I knew the community Bart and Jeremy lived in, and I wondered with Bart whether he was afraid for Jeremy’s safety if Jeremy sashayed out of the house in a dress. That would be a reasonable concern for any parent, one that might force parents to limit their child’s gender expressions in the name of safety and well-being. But Bart said, “Nope, I’m not that worried about his safety. He’s a big kid and won’t let people mess with him. I just think it’s plain wrong. So, it’s not going to happen on my watch.”

Is Bart de-centering and getting Jeremy in focus? Not so much. Is he stepping forward in support of his son, rather than just covering for himself? Yes, I absolutely believe that was his intention. I didn’t think there would be any point in arguing with Bart about whether it was right or wrong for high school boys to wear dresses. I had another goal in mind: to invite Bart to accept his son, with his dresses. So, I said something like this: “I certainly understand your position, and absolutely, until your son is eighteen he should abide by the rules of your household. But I just wanted to share some other information with you, about what the studies show and the statistics say. A lot of kids whose parents tell them they’ll have to wait until later, when they’re on their own watch, to wear their dress or do whatever they’re thinking about their gender—well, they may be at risk for a whole lot of things that aren’t so good, psychological turbulence, if you will. Some get anxious and withdraw from the world, some turn to drugs, some to alcohol, some become depressed, some stop doing their schoolwork, some start getting into unsafe or dangerous sex, some start harming themselves, some even become suicidal. I’m not saying this will happen to your son; I mean, I haven’t even met him. I just think you should be aware of the risk factors. You know your son best—do you think any of these could happen to him? Or maybe are already happening?” I didn’t wish to alarm Bart; I just wanted to invite him to start thinking about whether his dress-code monitoring was supportive of his son. So, now Bart is faced with a dilemma: “I thought I was setting reasonable parental limits for my son by stopping him from wearing dresses” pitted against “Oh, maybe instead it’s going to harm him.” In my field this is called a situation of cognitive dissonance, where two competing thoughts, beliefs, or feelings contradict each other. To resolve this contradiction, a person has to relinquish one set of beliefs in favor of the other. In this case, my greatest hope was that love would conquer all, leading Bart, a father who truly loved his son, to replace prohibition with acceptance in the matter of Jeremy’s dress-wearing and all that dress-wearing signifies about Jeremy’s true gender self.

I saw Bart for only one consultation, but he left saying, “I guess I’ve got a lot to think about.” A few months later Bart called to let me know that he and Jeremy had been talking more openly about how each of them felt about men wearing dresses, and though Bart couldn’t in all honesty give Jeremy his blessings, he was able to tell Jeremy that he would accept whatever decision Jeremy made about where and when he wanted to wear dresses and that for the time being they would have to respect their differences on this issue. It was a far cry from total acceptance of his son, but a large step in the right direction.

One last cautionary message: Beware going overboard on acceptance. How could there be too much acceptance of a child’s gender? Answer: when it comes from parents’ needs rather than their child’s. This happens most often when parents want to be acknowledged by the world for embracing their gender-nonconforming children with love and compassion, or when they have their own personal investment or political agenda in promoting their children as the public poster child for the transgender movement, or when they’re just too eager to have their children love them for what supportive parents they are. I can usually recognize the surfacing of this hyperactive acceptance when I observe a child squirming rather than beaming as their parents speak of their full-fledged endorsement of their child. As one youth said to me, in considerable distress, after his parents encouraged him to post a video of his coming-out at school, with his parents at his side, on the Internet, “They really don’t care about me. They just wanted the video to go viral for the world to see what incredible parents they are. So, me being trans is just their ticket.” The lesson to be learned: Go back to the basics. De-center; listen to what your child is saying, not what you want; make sure that your support is about not just who they are but also what they need from you, including respect for their privacy and acknowledgment of their desire to keep exploring their gender rather than being pushed into a gender category. Then you come full circle back to true acceptance, a cornerstone of your child’s gender health. And what parents of gender creative children have taught us all: They are doing a superb job of doing just this.

Acceptance = A Form of Protection

I’m hearing a chorus of voices right now: “Well, it’s okay for you to promote boys wearing dresses to the mall, because you live in the crazy Bay Area. But we live in a really conservative part of the country, and there’s no way we can accept our boys trotting out in skirts. They’ll get killed—literally.”

All parents, no matter what their culture, are saddled with the identical set of child-rearing tasks, just by the fact that they are responsible for bringing up offspring who start out very little and very dependent. Task Number 1: keeping their children safe. Task Number 2: helping their children grow into thriving adults who can function in the culture they live in. What counts for “safe” and what counts for “thriving” can vary enormously from one culture to another. But the two variables are a constant, and the biggest challenges come when “keeping them safe” is at odds with “thriving.” For example, the children who were separated from their parents and sent to the country to avoid the bombing that shattered London during World War II did not necessarily thrive in their temporary foster placements, but at least they were safe. Truth be told, though, the children who remained in London with their parents actually thrived better psychologically, as long as their parents could provide them with comfort and assurance, even when huddled in a bomb shelter.[55]

If you are a parent of a gender-nonconforming child, you may identify with the feelings of London parents during World War II: How do I keep my child safe from bombings? In this case, the bombings take the form of rejection, malice, even violence that might come children’s way because of their gender nonconformity. So, if support = acceptance, but acceptance of who children are saying they are might put their very lives in danger, you’re faced with another dilemma: safety versus authenticity: “I want my child to be the most gender creative child possible. I don’t want anyone to hurt my child.” Let me quote from a parent grappling with this very dilemma—“Look, it’s okay for my son to wear his sister’s clothes while we’re here in Canada, but when we go back to India, where we are from, he’ll be attacked in our village if he shows up looking like a girl. I just can’t let him do that.”[56]

Many years ago Abraham Maslow introduced us to the hierarchy of needs. If you think of it as a pyramid, we build from the bottom up: from physical survival to safety to love and belonging to esteem to self-actualization.[57] Without survival, we’ll never get to actualization. That said, it would be reasonable for parents to put reins on their children’s full gender creativity if its open expression was perceived as putting the children in danger. I’ve already pointed out in Gender Born, Gender Made that in those situations we want to make sure that the children get the message that if they have to put a cloak on their true gender self to hide it from others, it’s not because there is anything wrong with them. We need to say, “The problem is the world out there—a lot of people out there haven’t learned yet that gender comes in an infinite variety of packages. So, they need to learn. And we’re all working on it. But in the meantime, we have to keep your true gender self safe, because sometimes people aren’t always so nice to people they don’t understand. And while we’re working on it, we’ll create safe spaces for you where people do understand and you can feel free to be who you are.” And so that little boy traveling to India may pack his girls’ clothes in his suitcase, to be worn freely in his hotel room, and go in “drag” in his boys’ clothes when visiting the village with the relatives who don’t know about such things. As long as he knows it’s because there is something wrong not with him, but with the world, and his parents really mean it that they are working to change it, right now, he can maintain his gender resilience and feel both accepted and protected. I have seen children as young as four years old begin to be able to maintain this differentiation and develop their own creative strategies to meet up with the “unfair” world while maintaining their positive sense of self. As those same children grow older, the parents will best loosen the cords of protection and let the children determine for themselves where they want to express their authentic gender.

This strategy works only if the children feel they will eventually have authorship over throwing these cloaks on and off, which in turn will happen only if they feel totally accepted by the people who love them most. If these factors aren’t in place and the unfairness of the outside world is being used only as an excuse to pass the buck from the parents’ own discomfort with their children’s gender, the children will most definitely smell a rat and lose the protective circle of true acceptance. And even if the parents are not passing the buck but are measuring real signs of potential danger for their children, it will become their obligation to follow through on their promise to become advocates for their children’s acceptance in that unfair world, so those dangers can disappear. This is exactly what I have witnessed parents doing, so movingly, with all the courage and risks that takes, and my hat goes off to all of them, because they, along with their children, are our most critical community leaders in the push toward a gender-accepting world.

But the story doesn’t stop there. Now I want to flip both acceptance and protection on their head. Sometimes full acceptance, with no censorship or limits, can be the strongest form of protection a family can offer its gender creative child. Its strength comes from building psychological muscles. By telling children, “Go for it. Be the person you are,” the children get the message that their parents have confidence that they can stand up to anyone who does not yet understand that they have the right, just like everyone else, to be who they are—everywhere.

Amy is a single mom who explained to me that there was no way she was going to accept her daughter Lucia’s insistent demand that she be allowed to change her name to Luke and go to school as “he.” It was bad enough that Amy was criticized for raising her daughter without a father. Lucia attended a very conservative school where she would no doubt be shunned as a “freak” if she returned to school after the summer as a boy. Amy had her own grief about potentially losing the little girl whom she treasured so dearly. She assured me that she herself could handle the transition; it was just that she would be “throwing Lucia to the wolves” if she indulged Lucia’s wishes. So, here I am again, listening to and totally understanding Amy’s worries, but feeling it my professional obligation to weigh in on the other side of the scales: What if Lucia is at risk for anxiety, depression, anger outbursts, self-harm, or something even worse if we hold her back from expressing her true gender, all because of a school that is less than accepting? If Lucia is truly Luke, are we actually harming rather than protecting her by saying she is not allowed to be the boy she knows herself to be? Might not the best protection be to let her be who she is, which is a “he,” and build her strengths to live with pride in the world she is growing up in?

Suppose Amy moves in another direction: working through her own issues about being a single mother, so that she could derive pride rather than fear of condemnation from that; putting effort into her own and others’ acceptance of the gender Lucia is discovering she is, rather than the gender others are telling her she has to be so as to be safe? Those interventions may very well be the most protective factors Amy could introduce into Lucia’s life, lowering the possibilities of anxiety, depression, and/or self-harm, while building gender resilience, so that Lucia, now Luke, would be ready to meet the challenges ahead and promote his right to be the person he is.

Let’s revisit Bart and Jeremy. Jeremy wanted to wear dresses outside the house. Bart wanted to stop him. Even though it wasn’t clear how much protection from rejection informed Bart’s inclination to say no, for the moment assume Bart’s prohibition of dresses is intended to be a supportive move, but one that was not necessarily in Jeremy’s best interests, given the risk factors I cited. By accepting Jeremy’s desire to wear dresses, even if it wasn’t necessarily something Bart could approve of, Bart was still offering Jeremy a layer of protection: “I am accepting who you want to be and letting you be that person.” As long as Bart doesn’t roll his eyes or make derogatory comments when Jeremy leaves the house decked out in his dress for a Saturday night at the mall, Jeremy can feel fortified that his father has his back, or at least accepts what he wears on his back. Ergo, acceptance becomes protection—not through shielding but by building or reinforcing gender resilience and confidence. On the other hand, if Bart were prohibiting dresses to prevent Jeremy from being harassed, that could backfire—instilling fear and contributing to potential shame, anxiety, social withdrawal, or low self-esteem, nothing we would want for our children. So, Bart’s permitting the dresses would end up on the side not just of acceptance but of another form of protection: sheltering Jeremy from undesired emotional consequences while simultaneously giving his son the opportunity to enhance his psychological well-being by giving him the freedom and confidence to be the gender that is “me.”

Through the Maze: Ally, Advocate, Ambassador

As parents negotiate the maze with a gender creative child, they will encounter a whole lot of people along the paths—their other children, if they have them, their own parents, their extended family, their school, their places of worship, and so forth. This inevitably puts them in the position of ally, advocate, and ambassador.

To be a gender-accepting parent is to watch your child’s back, both out in the world and at home. Becoming ally, advocate, and ambassador means being able to take a position of authority. So, it is time for us to amend our dictum, “It is not for us to say, but for the children to tell.” What I have learned as a gender specialist: Yes, it is important to listen to the children, but their parents are also our best experts. When parents have questions, concerns, doubts, maybe even flat-out objections to the gender path their child is embarking on, I do not dismiss these as evidence of their gender ghosts at work. These parents may have something very important to tell me, and I want to listen to them, too. For example, recently I reviewed a letter of support from a community therapist endorsing hormone replacement therapy for her teen patient. But I noticed in the letter that reference was made to the mother’s having some concerns about the permanence of her teen’s cross-gender identity. That, along with other information in the letter that concerned me, led me to recommend that we slow down and do some further assessment and consultation. I asked the parents to call me about my recommendation. When I spoke to the mother, she was immensely relieved and felt her voice was finally being heard. The therapist who had written the letter had not paid heed. This was the first step in this mother’s being given authorship and recognized as an ally for her child; and at the end of the day, the additional assessment proved her right. Her daughter was still in the throes of exploration rather than affirmation, and now her mother could advocate for her as such.

Parenting can easily become a delicate affair. We want to do our best. We worry we aren’t. To rear a gender creative child in a less-than-gender-accepting world stretches the role of the parent: That parent will need fortifications to go out and be the child’s ally, advocate, and ambassador. I learned this one day at our gender clinic when I wondered with the parents of a young child how we could be of help to them. They seemed to have a healthy, happy gender fluid child, and they both impressed me with their empathic and joyful relationship with Gwendolyn, their child, who was way too young to be considered for puberty blockers or hormones. I couldn’t think of what we could have to offer this family at that time that it didn’t already possess. Yet the parents were quick on the uptake: “We came here because of our parents.” “Your parents?” I queried. “Yes, our parents. They’re always questioning what we’re doing. They think it’s so wrong and that we’re making a freak out of our kid by encouraging it. So, we figured if we told them that the doctors at UCSF said what we were doing is the right thing and our child is all right, they’ll back off.” And indeed they did. So, I now recognized a new component of our clinic service: Good Housekeeping Seal of Approval for Gender Creative Parenting Practices. With that endorsement in hand, Gwendolyn’s parents gained the strength to advocate for Gwendolyn’s gender creative self to both sets of grandparents and then later to her school as well.

Sometimes the role of ally, advocate, and ambassador happens right at home. Arianna is filling out a college application, just as Arianna’s brother walks into the room. On the application, an applicant could check Male, Female, or Other. Arianna, who has been exploring her gender and questioning her gender identity, wonders out loud, “Maybe I should check Other.” Arianna is pretty distraught about what to do in this moment. Thomas, Arianna’s brother, blurts out, “That is so disgusting. What’s ‘other’ even supposed to mean? Sick, that’s what it is.” Arianna bursts out crying and runs to her room, slamming the door behind her. Arianna’s mother hears the commotion and catches the interchange. Before going to Arianna’s room to try to comfort her, she admonishes Thomas, “Knock it off. There’ll be no disrespecting people in this house.” No doubt Thomas needs some help and support in sorting out his own negative or anxious feelings about nonbinary gender and a sister who may be that, but in the meantime Arianna has been empowered by a mother who stood up for her and made it clear that in their house there will be no gender-bashing.

In all areas of life, siblings can be either a child’s best ally or worst adversary, roles that can reverse on a moment’s notice. But when it comes to gender, the peaks are particularly high and the valleys low. Siblings as allies can be a most important buttress for a gender creative child, particularly at school or out in the neighborhood where parents need not apply and therefore aren’t present to protect their child. Alternatively, siblings can be the worst of enemies if they oppress rather than protect, by rejecting or harassing their gender creative sibling. All of that is a roundabout way of saying that parents as allies necessarily includes overseeing the coaching of siblings to be the same.

Sometimes parents, in an effort to protect all their children, and with gender ghosts as whisperers, will be heard to say something like: “We can’t just think about Jennifer. We have to think about our other two girls, too. Do you know what it’s like to have to go to school and have everyone saying, ‘What’s with your sister and the dude clothes? Weird.’ Jennifer’s going to have to stop being so selfish and think of her sisters and what this is doing to them and just stop with the crazy dressing.” Let’s think about this for a moment. The message is that Jennifer should hide her true gender self to keep her sisters comfortable. To become an ally for Jennifer, her mom has to come to recognize the greater harm done to Jennifer if asked to feel guilt and shame and keep her gender fluid self under wraps for the sake of her gender-conforming sisters’ comfort. Indeed, both sisters need empathic attention to their own difficulties in accompanying Jennifer along the gender maze, and Jennifer’s mother needs help talking about her own angst so that she can be an ally to all her daughters while protecting the rights of Jennifer to be her own gender creative self. And part of her work as ambassador and advocate will be working with the school so that Jennifer’s sisters and Jennifer will not have to dodge or be grazed by flying gender bullets. From that work, hopefully new policies and new curriculum will be put in place to help students and faculty alike be respectful and embracing of gender in all its iterations.

Sometimes parents will need to monitor siblings’ honest efforts to be allies, which can unwittingly do the opposite by rewriting their gender creative siblings’ stories. Alicia was thirteen when she finally came to realize that she could no longer live the lie of being a girl. She had known for some time that she was transgender but hadn’t been ready to either admit it to herself or come out to her family. But now she was. And she did. Her parents were understanding, but her mother in particular said she needed time to mourn the loss of the daughter she had. At this point Alicia’s older sister, Tracy, who herself was immersed in the genderqueer community at her college, exploded at her mother: “Get over it. You never had a daughter; you always had a son. Alicia’s always been a boy, and now Alicia’s just letting you know.” A good story, but it wasn’t Alicia’s. Alicia did not feel that she had always been a boy. Her life experience was as both girl and boy, and her journey was an unfolding one—from being a girl who was now going through a metamorphosis, emerging as a boy. To abide by her sister’s story would be like telling a butterfly that it had always been a butterfly without having been a caterpillar. Story correction: The butterfly part came later; the caterpillar was as real as real could be. The son came later; before that, the daughter had been as real as real could be. Alicia felt overpowered by Tracy’s passionate outcry. Alicia’s mother was stewing in her own confusion and mourning but was able to right herself, focus on Alicia, and ask her directly, “Is that true? Have you always felt like a boy?” Alicia mumbled, “No, Mom, not so much,” and Mom turned to Tracy, and reminded her that it was Alicia’s story to tell and not Tracy’s to dictate. So, here we have a sister with every intention of being an ally yet needing a mother to step in as an advocate for Alicia so she could speak her own story and truly be supported. And yes, Mom had more work ahead of her to address her sadness about losing her daughter to make room for the joy of having her son, which indeed she did.

Parents usually don’t sign up for being warriors when they decide to have children. But they may find themselves in that very position as they shepherd their gender creative children through the gender maze, with the rest of the family in tow. Sometimes, parents will need to ask other family members to step aside if they are rejecting or unaccepting of their gender creative child; sometimes they will need to let other family members lead the way if those are the ones with the greater facility to accept and embrace. It’s a lot of work, but the fruits of the efforts are well worth it—a robust and healthy apple, orange, or fruit salad.

The Gender Badge of Courage—Awarded to Every Gender Creative Parent

I have not minced words about the dead ends or hazardous side paths parents can take as they journey with their children through the gender maze. But I also can’t highlight enough the tremendous courage and fortitude exhibited by all the parents who smooth out the bumps, pave new paths, and find just the right end point for children who are not the gender everyone thought they were or who don’t do gender the way everyone thought they would. Parents accomplish this by inventing their own GPS device to guide them. In the process, they give a whole new definition to parental gender creativity: It is not simply parents’ ability to stretch to new gender horizons, but also their acumen to call on their own wisdom and vulnerability so they can learn from their children while simultaneously teaching them what they themselves are relearning about gender. As any artist will tell you, creativity is not just about having fun; it is also filled with pathos, questioning, and allowing yourself to get lost before you are found. That would be the journey of all gender creative parents as they negotiate the gender maze.

^{CHAPTER SIX}

If Gender Is Expansive, Wherefore a Shrink?

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness.

—Charles Dickens, A Tale of Two Cities

WHEN IT COMES TO the field of mental health and its relationship to the trans community, Dickens about summed it up. We have been responsible for harm if not atrocities in the name of mental health; we have been responsible for pouring tons of resources into making sure that gender creative people get all the supports they need. You’ve got to love us, you’ve got to hate us. And we are not all one.

On December 15, 2015, my email inbox was flooded with messages from friends and colleagues with links to an article: CAMH TO “WIND DOWN” CONTROVERSIAL GENDER IDENTITY CLINIC SERVICES.[58] I learned that Toronto’s Centre for Addiction and Mental Health had made an administrative decision to phase out its gender identity services for children and youth. That would be Dr. Ken Zucker’s clinic (first discussed in Chapter 1), which engaged in therapeutic practices to help young children accept the gender that matched the sex assigned to them at birth. The hospital had initiated an external review process because of complaints, particularly from local mental health gender specialists and the trans community, that the program, offered to youth ages three to eighteen, performed a type of reparative therapy that was disrespectful of patients’ gender identity. The review found the clinic’s approach was out of step with currently accepted practice and engaged in techniques that were antithetical to supporting gender creative children and promoting their gender health. Now, not only is our model ascending, we have at least in one instance successfully participated in actions to eliminate potentially harmful child therapy practices.

This has not been a cricket match with a winner and a loser. This is a matter of fighting for what we think is the right and only way to support children’s gender creativity, and doing our best to stop harm being done to both the children and their families. And I can breathe a sigh of relief that our model of honoring children’s gender narratives and helping them be the gender that they know themselves to be is growing and ascendant. As mentioned in the opening chapter, new gender affirmative clinics are showing up all the time, and we have even established an international consortium of gender affirmative practitioners working to develop and apply the model in our own countries. Yet ascendant does not mean arrived—we’ve expended a lot of elbow grease, running just to keep up, and we know there is still much work to be done. But every moment is worth it. In fact, this is the best and most exciting journey I have ever been on. And the people who have joined me along the road are some of the most wonderful I have ever encountered, nothing less than heroic in their firm support for our children of all genders. So, I open this chapter with that sense of exhilaration. And, borrowing from the famous quote of the late President Kennedy, I am putting out a call to myself and my fellow mental health professionals: “Ask not what the families can do for us, but what we can do for the families.”

A Road Map for Mental Health Services

Since Gender Born, Gender Made was published, the gender atoms have dynamically shifted and then coalesced into what are now three constellations of mental health practices for gender-nonconforming children and their families. All parents negotiating the mental health system should be aware of the three, so they can make informed choices, know what they are getting back from their investment, and avoid minefields that could harm their children or themselves.

MODEL #1: LEARNING TO LIVE IN YOUR OWN SKIN

I borrow the term “learning to live in your own skin” from Ken Zucker, as he describes his own philosophy and practice for treating children with gender dysphoria, but I also want to say that there are more extreme models than his, usually endorsed by right-wing religious groups, whose goal is to stamp out gender nonconformity altogether. So, let me start with the “learning to live in your own skin” model, the one whose practice was under investigation in 2015 at the Centre for Addiction and Mental Health in Toronto resulting in the closing of his clinic in December of that year. This approach applies only to children below the age of puberty. The model is adapted from the program directed by Dr. Richard Green at UCLA in the 1960s, a program targeting effeminate boys and treating them to become “boys’ boys,” which equated with becoming straight boys. Overall, the UCLA program proved a colossal failure, as most of the boys went on to be gay in spite of Dr. Green and his associates’ best efforts. One, tragically, committed suicide in his adulthood, with family members and friends blaming the suicide on the harm done to him by the purportedly reparative treatment.

In the “living comfortably in your own skin” model, the underlying assumption is that young children are malleable in both their gender identity and expressions; in other words, there is still plasticity to the gender brain. By this way of thinking, if a child exhibits signs of gender dysphoria and if you catch the child early enough, you can help them learn to “live more comfortably in their own skin,” or, simply put, to “accept the sex assigned to them at birth.” The help comes in the form of: (1) psychotherapy for the child; (2) psychotherapy or counseling for the parents; (3) behavior modification techniques, including removal of “gender-inappropriate” toys and substitution of “gender-appropriate” toys at home, prohibition of cross-dressing, positive reinforcement for “gender-appropriate” activities, extinction of “gender-inappropriate” activities; (4) social engineering of playmate choices, replacing same-sex playmates for opposite-sex playmates; (5) family systems/relational interventions: bringing the same-sex parent closer in, while asking the opposite-sex parent to step back.

The behavior modification interventions are introduced only if that is what the parents want for their child. The goal of the interventions is to ward off/avoid/prevent a transgender outcome. The rationale is that being transgender is a harder way to live your life, so why not offer the child an easier life, with no harm done, given the plasticity of a young child’s gender brain?[59] In a 2015 interview with the National Post, Dr. Zucker explained the “learning to live in your own skin” approach this way: “You are lowering the odds that as such a [gender-nonconforming] kid gets older, he or she will move into adolescence feeling so uncomfortable about their gender identity that they think that it would be better to live as the other gender and require treatment with hormones and sex-reassignment surgery.”[60] In this model, lowering the odds = good outcome, one that ensures better acceptance in the social world and avoidance of medical interventions to alter one’s body. However, if you should begin treatment of a child who has already entered puberty and is clear about their transgender identity, it’s too late. The train has already left the station. No more gender brain plasticity. In those cases, the recommended treatment is to support the youth in their cross-gender identity and help them receive the services, including social transitions, puberty blockers, and hormones, that will better align their affirmed gender identity with their bodies.

Statistics citing the number of children who benefited from this model, accepting the sex assigned to them at birth and going on to live contented lives as cisgender individuals, are used to support this model. The problem with these statistics is twofold. First comes the apples and oranges issue. Many of the youth treated in gender clinics such as Dr. Zucker’s were never destined to be transgender children in the first place. They are more likely our protogay youth. The therapy applied was for treatment of a “condition” that did not exist. These children’s gender identity was never in question; they only wanted the freedom of gender expressions. So, it is inaccurate to assess the outcomes for these children as a warding-off of a transgender outcome. They were never headed in that direction in the first place and the success lies in their own persistence in who they were, rather than treatment interventions to make them that way. Second, it appears, regrettably, that such treatment may not ward off but rather drive underground a child’s transgender identity. Some of the comments that appeared online in response to the article about the 2015 investigation of the CAMH gender clinic point to such a result:

It’s easy to imagine that his methods—steering parents toward removing pink crayons from the box, extolling a patriarchy no one believes in—could instill in some children a sense of shame and a double life. A 2008 study of 25 girls who had been seen in Zucker’s clinic showed positive results; 22 were no longer gender-dysphoric, meaning they were comfortable living as girls. But that doesn’t mean they were happy. I spoke to the mother of one Zucker patient in her late 20s, who said her daughter was repulsed by the thought of a sex change but was still suffering—she’d become an alcoholic, and was cutting herself. “I’d be surprised if she outlived me,” her mother said. This is a success?????

“Repulsed by a sex change” yes, but at what cost?

i was there in 1983-84 they did me no good it has taken me years to be able to deal with what was done to me.

“What was done to me” is antithetical to what we want to hear about the patient’s experience of our mental health services, and cutting and alcoholism are never what we want to see as outcomes.

Dr. Zucker has adamantly insisted that the model he employs is not reparative therapy, and I agree with him if we define reparative or conversion therapy as a comprehensive method for expunging pathological sexual or gender “disorders,” targeting both homosexual and transsexual “conditions.” We know of these methods most often in the context of practitioners, usually associated with the religious right, who have had no compunctions about using draconian punitive measures, going so far as employing electroshock, to purge the patient of untoward desires, thoughts, or actions, in the name of making them either straight or cis, or both. Yet the “living in your own skin” model, in its employment of behavior modification techniques and social engineering to alter a child’s gender identity or expressions, does qualify as reparative. This is exactly why the model is objected to so adamantly by the transgender community and its allies for being at its best ineffective, at its worst engendering great harm to gender-nonconforming children and youth. A further complication is that although Dr. Zucker states very clearly that he will employ these methods only if it is the parents’ wish to do so, parents who decline services after hearing the treatment options have been known to be labeled as resistant. And at the end of the day, even if parents want a particular treatment for their child, it does not mean that we mental health professionals go ahead and implement it if it is not in the best interests of the child, an assessment I would say applies to the methods of this model. Two of my colleagues from Toronto, Robert Wallace and Hershel Russell, coming from an attachment theory model (which looks at development from the lens of the relationship and bonds that develop between parent and child), evaluated the “live in your own skin” approach as practiced at the CAMH clinic and published the following conclusion: “We are concerned that this treatment approach may tend to increase shame in both parent and child, thus potentially impacting negatively on successful attachment and increasing the risk of depression.”[61] Neither of these outcomes could ever be counted as healthy. My recommendation, therefore: Stay away from “learning to live in your own skin” treatment as defined in this intervention package.

MODEL #2: WATCHFUL WAITING

We have the members of the Amsterdam clinic, spearheaded by Peggy Cohen-Kettenis, to gratefully thank for this model. They alerted the mental health and medical community that young children’s gender creativity is not to be squashed but to be observed over time, with the possible follow-up of puberty blockers (this clinic was the first to introduce this procedure as an intervention to put a pause on puberty for youth who are questioning their gender) and then hormones to bring the subjects’ body in alignment with their gender identity. Throughout, the children receive mental health services from a therapist trained as a gender specialist. This model has been researched carefully by the highly respected group of practitioners at the Amsterdam Center of Expertise on Gender Dysphoria, VU University Medical Center, and has taught all of us who work as gender specialists so much about gender-nonconforming children and their psychological needs.

But where does “watchful waiting” come in? Because so many of the young children who came through the Amsterdam program did not persist in their gender dysphoria by the time they reached puberty, it was thought that it would be best to let the prepubertal children be gender expansive but not gender changing, the latter meaning socially transitioning from male to female or female to male. The clinic team saw no harm in asking a child to wait, facilitated by living in the social context of a country that was quite flexible and nonbinary in its gender expression norms, particularly for children below the age of seven. This way a child would not be gender-pigeonholed prematurely, and this would also avoid the discomfort if not psychological harm of changing genders again if the child later proved to be comfortable with their natal sex. During the waiting period, the children would be followed carefully by the clinic team, with the support of outside therapists in the community (which is required before a child can receive medical services), to ensure that the children were growing well and getting their emotional needs met, and in preparation for later transitioning and medical interventions if they proved to be good candidates. In this model, the children going through the program also receive a full battery of psychological tests, documenting not only their gender status but also their cognitive, social, and emotional functioning. Some of these instruments are delivered to the children directly, some to their parents or teachers.

I learned a great deal from studying this model, but I also had some questions. First, I wondered about the contradiction between releasing gender nonconformity from the stigma of pathology and yet at the same time running children through a thorough battery of tests just because they show up as gender creative. Do we really need all these measuring rods—for depression, for anxiety, for behavioral problems, for intellectual functioning, and so forth? I wondered what messages we send to the children when we put them under the microscope in this way. At the same time, if we’re thinking about medical interventions that affect the course of a youth’s life, both physically and psychologically, we do need some indicators that this will be in a child’s best interests. Do these measures provide us with that?

It was through perusing the summary of the data amassed on the children going through the Amsterdam clinic that I got my idea about apples and oranges. In going over the data on persisters and desisters, I began to get the feeling that we were talking about two groups of children who were different from the get-go. In delving into my own clinical work with gender-nonconforming children, I noticed that a repeated set of experiences showed up in a certain subset of the younger children—if they said they were a girl, for example, rather than they wished they were a girl; if the early signs of a cross-gender self were truly very early—such as in the second year of life; if they showed significant distress about their bodies; if all of this already seemed insistent, persistent, and consistent in their young lives. To me it seemed that we could already identify well before puberty that these were our youngest transgender youth.

I had been going on about this for a while when, in June 2013, Thomas Steensma and his colleagues at the Amsterdam clinic published new findings based on a review of the data from their clinic research that corroborated my observations, indeed suggesting that a subgroup of young children could be identified early on as persisters.[62] Yet my Dutch colleagues still held to the watchful waiting approach, arguing that we might otherwise paint children into a cognitive corner where they would get to know themselves as their socially transitioned gender and not know how to get out of that spot if it wasn’t right. Moreover, they reasoned, if the children transitioned too young, they might not be able to hold on to a realistic perception of the bodies they were born with, perhaps with no conscious memory of the opposite sex they once were. I should say that to date I have not yet met any young socially transitioned children who weren’t all too aware of the bodies they came into the world with—they just might hold some illusions about where those bodies might go in the future. And while I certainly understand the concerns about prematurely fixing a self-label on children that they won’t know how to shake off later, (1) I have not had occasion to see that happen; instead, I have watched a small handful of children fluidly moving back into the identity matching their original sex assignment, providing they have social supports to do so; and (2) when I weigh that small potential risk against the higher risks that accompany holding children back from living in the gender they know themselves to be, I’d take a chance on letting them live in their present affirmed gender with no prohibitions. The chances of early transitions being successful will no doubt rise significantly if we work to expand the social environment beyond binary male-female boxes, whether they be cis or trans, to an understanding that our gender may change over the course of our lifetime and may be any-and-all rather than either/or. On the other hand, I will say that watchful waiting is an insurance policy against runaway trains, where families leap forward with social transitions for their young children well before they have time to reflect on what the children are actually telling them.

Ironically, when I was surfing the Internet recently to look for images of “apples,” I came across a picture of a young trans girl, whimsically staring into the camera in her pink tutu and long wispy hair, exactly the image I wanted to use for my presentation. Then, lo and behold, when I researched the source of the photograph, I discovered that this very young transgender child was from none other than the Netherlands. Word has it that young children are beginning to show up at the Amsterdam clinic already transitioned, with their parents’ support, before any green lights are given by the clinic team. In fact, soon after I wrote this last sentence, I received an email from a mother in the Netherlands that read as follows:

Dear Mrs. Ehrensaft,

You do not know me at all, and your time is precious, but as a mother of 3 wonderful children of which our Bia, born as a boy, with twin brother Sven, 6 years old, I cannot do otherwise than reach out even across the borders of our country… all for Bia’s well-being.

Last month she told me: “Mumy, until I was 3 years old, I really thought I WAS a girl… now I know I am not.” And then I explain that how you feel inside is just as real as my oldest daughter knows she is a girl, beyond doubt. In our opinion, Bia is not confused. But the specialist team we consulted tell all parents of children with gender dysphoria: “Do not give too much room, he or she will probably outgrow it…” “It is not so hard to dress neutrally…” But after a year of struggling, crying of Bia, “Why can’t I dress the way I want to, Mom?” We felt we had to give more space…

What do you think of our way of responding?

Thank you so much for your time.

A mother with tears in her heart…

I think her way of responding is just right, and I wish she could wipe the tears from her heart and just feel the love for Bia running through. All these signs lead in one direction: It appears that the waves of historical change may be overriding the norms of the watchful waiting model. For some twenty-first-century families of gender creative children who are hooked into ever growing local, national, and international networks that support children of all ages living in their authentic gender, like the mother with tears in her heart, action seems to have transcended waiting.

MODEL #3: LISTEN AND ACT

I’ve already laid out the gender affirmative model in its general dimensions, but now let’s consider this third model, “listen and act,” from the perspective of mental health care. The “listen and act” model promotes allowing children to live in their authentic gender, whatever their age. This includes the possibility of facilitating social transitions early in life, as young as the preschool years, providing a child’s gender identity is clearly in focus at that time. And yet it does not presume that a young child will necessarily hold that gender for the rest of their lives, although most will. The “listen and act” approach does not assume that the professionals will know best. Instead there is a collaborative support or treatment team, if you will, a team that includes the child, the family, and any professionals involved in the child’s life. At the same time, each of the professionals on the team has a responsibility to apply their expertise to ensure that the child gets the best care they can.

Now, let’s turn to the mental health member of that team. Traditionally, the mental health professional serving the trans community, whether it be little ones or adults, bore the reputation of “gatekeeper.” They were the people who wrote the letter to say whether a person was eligible for medical services (actually, they still are those people). They were the people who looked for “comorbid” conditions that might put a halt on forward movement toward gender affirmation. So, how is that different in the gender affirmative model? Simple: We have expertise, but we don’t consider ourselves the primary experts. The main expert is the child. Alongside the child is the family. The parents are going to know this child far better than we do, even when they have blind spots.

In the gender affirmative model, the mental health people are essentially the translators—taking in information from the child and family to reflect back what we see as the child’s gender web. We don’t assume therapy is mandatory for every child who goes against the gender grain. But we do recognize the value of therapeutic supports in helping a child undo knots as they spin their web and in helping parents align with each other and mirror back to their child the child they know themselves to be. Therapeutic goals nclude building gender resilience, soothing the strains of gender stresses or healing the wounds of gender distress, solidifying and expanding the circle of gender acceptance surrounding the child, and helping the child consolidate their true gender self. Sometimes parent consultation is all that is needed, in which case we spend time only with the parents and never meet the child. Sometimes we do family or sibling therapy. Sometimes we create groups—for the children, for the parents, or both. Sometimes we see a child alone, either briefly or in very long-term therapy, depending on the child’s needs.

We’ve been bothered by the binary nature of the psychological measures that exist to assess a child’s gender, and we have searched to develop alternative assessment packets, which we are successfully accomplishing.[63] We know that the children’s gender well-being will not be ensured by the work we do in our offices unless it is accompanied by the work we do in the community to offer new paradigms for thinking about gender, promote gender expansiveness, and protest against harm when we see it being done. And we struggle to figure out the puzzle about diagnosis: If gender pathology lies in the culture rather than in the children, we ask ourselves why we have a psychiatric gender diagnosis for children at all. At the moment, there is actually no consensus among us on the answer to this question.

If not primary experts, who are we mental health professionals other than translators? From the start, we abide by the principle “If you want to know a child’s gender, ask the child; it’s not for us to tell, but for the child to say.” At one level, that makes it easy for us, because it calls on the basic listening skills we learned a long time ago in Becoming a Mental Health Professional 101. The challenge comes in the translation—making sense of what we are listening to. How do we know what children are saying? They don’t always do it in full or coherent sentences. Much of the communication will come not in words, but in actions, as when a gender-distressed child, natal male, buries a boy figure in the sand tray and firmly plants the girl figure on his grave (that’s an easy one to figure out, but we’re usually not so lucky). We learn to stay suspended in a state of not knowing, training ourselves to be patient as the story unfolds while simultaneously being at the ready to shift gears quickly if a sudden urgency emerges in a child’s gender signals. If we have been trained psychoanalytically, as I have, we put every effort into culling the good and extracting the bad from our training. From my own training I have discovered, in my efforts to promote gender health, that I possess the gift of wonderful social capital, thanks to my psychoanalytic training—a cache that includes listening skills, interpretation, attention to the unconscious, suspension of judgment, knowledge of the interrelationship between outer and inner worlds, and the use of play as a means of discovery.

Our biggest surprise as child therapists is our new role in the medical world—learning to make sense of the appropriateness or a youth’s readiness for puberty blockers, hormones, top surgery, bottom surgery, hysterectomies, and so forth. We have had to educate ourselves in physiology, stages of puberty, bone development, and so forth. In the age of attention to body-psyche linkages and availability of new medical interventions, we find ourselves right in the belly of that beast—how do we help gender creative children make adjustments or create harmony between the bodies they were born with and the gender they know themselves to be? Would there be any harm in doing so? Are we too caught up in the microcosm of body adjustments, rather than working at the macro level to confront the gender-binary social mores that make such adjustments feel so essential to some of our youth? We have had to get over our qualms, and there have been many, about weighing in on medical decisions that may have permanent effects on a child’s future life, all the while with gender ghosts whispering in our ear, “Don’t mess with Mother Nature.” Many of us, save the psychiatrists, may have chosen the field of mental health over the field of medicine with the intent of avoiding just such involvement in children’s medical issues. And here we are, right in the vortex of those very issues; there’s no escaping it if we are to be gender experts. We’re the ones who are asked to write the letters of support or do the psychological assessments to determine whether a specific youth is a good candidate for any number of gender-affirming medical interventions. This is no small burden, and a task we must take very seriously if we are to do well by the youth.

Coming full circle, the proponents of the “listen and act” model are in total agreement with Model #1’s goal of helping children feel comfortable living in their own skin. But our definition of “living in your own skin” is diametrically opposed to the one outlined by Dr. Zucker. We consider a child’s gender skin to be determined not by either chromosomes or genitalia but, rather, by the brain, mind, and experience. It is what is called in my psychoanalytic circles “the ego rind,” the psychological outer covering that envelops the self. So, yes, we very much want to help children live comfortably in their own skin, if that means living comfortably with their true gender self.

I know I do not hide my biases well. In my estimation, the gender affirmative “listen and act” model is the one that makes the most sense to me in promoting children’s gender health. I can suspend judgment about the worth of the “watchful waiting” model, as I always tip my hat to thoughtful, cautious, well-researched approaches, even if I have my differences with the idea of holding children back when they know they are ready. What I can say with no qualifications is that the original “live comfortably in your own skin” model that attempts to get young “apples” to accept the gender that matches the sex assigned to them at birth makes no sense to me. Children going through the multifaceted interventions in this model are at risk for repeated microaggressions, if not outright trauma, if they feel coerced into relinquishing their gender desires, inclinations, and identifications and burying their true gender self so as to become a gender-acceptable human being by other people’s standards, rather than their own self-knowledge. It is no accident that there is a move afoot to outlaw this therapeutic practice with children and youth. To do otherwise would be to abandon our oath—to do no harm.

Putting Out Fires

For those of us who are gender affirmative practitioners, even though we are committed to our model of care and look forward to the time when we have completed the longitudinal research that will validate this approach, we also know we cannot wait for those results to appear. There are fires burning all around us, fires we must put out now—the fires of transphobia and genderism that bear down on the children’s gender health. For myself, I have been accused of being in consort with the devil or the actual devil incarnate, straying from good Christian values, and even worse. My crime: advocating the gender affirmative model. So be it.

I hear about patients who have experienced a course of therapy aimed at altering their gender creative journey, leaving them feeling so much shame about the treatment and about themselves that they retreat into silence rather than speak up. I have heard about a recent situation of a young transgender child living two thirds around the world from me who was removed from her mother’s care by the local social service agency, on the advice of child psychiatrists, because her mother had been bringing her up as a girl. Sometime later, after attempting to cut off her penis because of the distress of being denied who she was, she ended up in an inpatient psychiatric ward where she was put in the seclusion room if she did not behave like a boy, part of the unit’s behavioral program to try and discourage any “atypical” gender behavior. A member of our international gender affirmative community, a psychiatrist, had been doing his best to intervene in this tragic situation, but with only limited success. I myself have had to pick up the pieces in my own work with a young adult who had the same thing happen several years ago, right in my own country, removed from his mother’s care by the courts and forced to return to living as a boy in his father’s care after the estranged father accused the mother of child abuse for her acceptance and support of their child’s transgender female self. This youth was abusing drugs, expelled from his school, and in trouble with the law, exhibiting almost every one of the risk factors faced by youth who are thwarted in their gender journey. My colleague’s efforts across the globe and mine right at home are emblematic of the “firefighter” work that becomes part of our daily life as gender affirmative mental health clinicians. We not only struggle to put out fires; we also take on the cleanup work of undoing the harm that has already been done and replacing it with an accepting, supportive therapeutic environment.

We mental health professionals need to expend an inordinate amount of energy on pushing back whenever we see harm being done. The perpetrator might be an ill-informed mental health professional; it could be an individual, such as Laura Ingraham (see page 10), whose lack of knowledge, surfeit of prejudice, and access to a bully pulpit tap into the media to infuse fear and hatred in people’s hearts—toward the children, toward the parents, and toward the gender-affirming professionals who serve them.

Opening the Gates

Recently a beloved patient of mine sat in my office very distressed. I have worked with this patient, Remy, for many years. Remy was now in young adulthood and wanted to pursue surgeries to better align Remy’s body and gender identity. The facility where Remy sought services has a good reputation as a gender-sensitive program. In accepting a patient for gender affirmative surgeries, the staff requests that the attending mental health provider fill out a mental health summary form and then have a phone interview with one of the mental health specialists on the facility’s team. Then the patient meets with the team for an interview. I was very supportive of this young person receiving the surgeries and spoke to that effect. But in the interview at the program, my patient revealed some recent recreational activities that alarmed two members of the medical team. Remy was told to wait for six months and then be reevaluated. Distressed, Remy pleaded with the team to please contact me again before making that decision. The team agreed. I spoke with the mental health liaison for a second time, and the final outcome was that “the verdict was overturned.” My patient was relieved and grateful, but also quite angry. To paraphrase, “They say they’re not gatekeepers. But they are. And I was just trying to be honest. I should have just kept my mouth shut and told them nothing. And they didn’t listen when I tried to explain. So let’s just call it for what it is—gatekeeping.”

This wasn’t the first time I had pondered the question about gatekeeping myself, but my patient’s tirade propelled me to think about it a lot more. We mental health professionals who practice from the gender affirmative model pride ourselves on being something other than gatekeepers. We think of ourselves as participating in a collaborative process with the youth and families we work with. But are we just fooling ourselves? Especially when it comes to gender affirming medical interventions for minors? Even though the parents have the last word in deciding whether to consent or not consent to treatment for their child, if a mental health professional recommends against any of those procedures, parents will never even get a chance to have that final word.

At the UCSF gender clinic, we, like the program my frustrated patient went to, ask for reports from attending mental health professionals. We have rejected the notion of letters of readiness, disparaged by so many in the trans community as the hoop they were forced to jump through for the price of admission into the hallowed halls of sex-reassignment surgeries. In its stead, we have asked for letters of support, in which the mental health professional writes a narrative answering questions along several dimensions, including present gender status and stresses, gender history, nature of the relationship with the mental health professional, family support system, general social and emotional functioning, and cultural issues that might be relevant. And we certainly request that the mental health professionals make a recommendation, if they feel they can, as to whether it would be in the youth’s best interest to receive puberty blockers or hormones (which are the two main medical interventions we offer at the clinic). We invite input from the parents and child and give the parents access to the letters submitted. Some other clinics engage in more extensive and formal mental health evaluations to get a reading of a youth, assess the appropriateness of various interventions, and collect aggregate data on the children who attend their clinic. But whether we use letters of support or test batteries, I have to ask myself, “Are we just deceiving ourselves, convincing ourselves we’re not the bad guys? At the end of the day, are we mental health professionals, no matter what our persuasion or what techniques we endorse, the toll takers who decide who can pass through and who can’t?”

So, here are my answers to these questions, definitely a work in progress. If we were to say that whatever we write in either a letter or a more formal evaluation is the last word, then we are nothing more than toll takers or gatekeepers. But if we are willing to see our evaluations and letters as plastic rather than rigid, process rather than product, available for discussion and reflection in a collaborative process with the parents and the child, perhaps we can strike the balance between inserting our expertise and professional opinions and simultaneously leaving room for the perceptions, sensibilities, and self-knowledge of both the child and the family.

Ironically, the most difficult situation is when two parents are in conflict and one parent is actually imploring us to be a gatekeeper who says no, while the other parent is imploring us to provide a green light for going forward. For example, a mother and a father, divorced and fighting in court, were in total disagreement about the appropriate way to raise their young gender creative child, Addie, who, by my estimation, completely qualified as one of our apples. The mother, Sheridan, was advocating for full acceptance of her child’s transition from female to male, because, as she saw it, that was who their child truly was. The father, Richard, accused Sheridan of unduly influencing Addie by permitting and even encouraging Addie to act like a boy (indeed, he was attending school as a boy that year). Richard endorsed a “neutral zone,” not pushing or encouraging one way or another, because who knew which direction their child would end up going in? Richard didn’t make up this strategy—it was recommended by the first therapist the family saw when they began seeking help for their gender-nonconforming child, which both parents agreed they had.

By my estimation the train had already left the station, and the direction was clear. When asked if he could have three wishes, what they would be, here was Addie’s first: “That I could be a boy all the time.” As Addie sat listening to Richard and Sheridan talk, or should I say argue, Addie kept busy drawing pictures on a sketch pad—multiple stick figures of boys. But as soon as Addie’s father started talking about the neutral zone, expressing hope that Addie would understand that Addie was female because Addie was born a girl, Addie suddenly switched the subject matter of his artwork and began frantically drawing something quite different and bold—an ominous black gun, smoke pouring out of the barrel, aimed directly at his father, who was sitting next to him. After listening to Sheridan, who, I must say, looked as if she was going to leap across the room and throttle Richard, Richard turned to me and said, attempting to remain calm, but not very successfully: “So, Dr. Ehrensaft, it seems like we need to think of something that would be somewhere in the middle of where we [he and Sheridan] are.”

In that moment I felt pressure from Richard to exercise my authority as a gatekeeper, asserting that Sheridan must stop letting Addie present as a boy, substituting instead a gender compromise, so to speak. I am indeed a trained mediator, taught to help divorced or divorcing parents iron out their differences and come to common agreements they can both live with. But this was not a mediation moment. My response, paraphrased, was: “Well, no, Richard. You sought me out as a gender specialist. My responsibility is not to find a middle ground but to learn about your child and determine what would be in your child’s best interests to keep your child happy and healthy, which is what both you and your ex-wife have shared as being a common goal. If I did anything else, it would be like saying to two parents who disagreed about the worth of antibiotics for treating an infection that I had just diagnosed, ‘Well, how about meeting in the middle and giving the antibiotics only every other day?’ I would never do that, because that could harm your child. You’ve asked me to provide a professional opinion, and I will. You and Sheridan are definitely part of the team, and as Addie’s parents, you will be the ones making the final decisions. But at the end of the day, my job is to offer my professional assessment of who your child is and what will be best practices for your child. I can do no less.”

Richard had implored me to be a gatekeeper. I said no. In other situations, parents or a youth have insisted that I simply sign on the dotted line, giving them what they want. I say no. If I’m going to be part of the team, I have to have an opportunity and the necessary time it takes to bring my brain and mind (and my heart as well) to the table. I’m thinking of another situation experienced by a colleague, in which a parent hurled at the clinician, “My child says if you don’t give her a vagina by the time she’s nine, she’s going to kill herself. So, what are you going to do?” That was an easy no. Are we gatekeepers there? No, I think we’re benevolent overseers, listening to the children, allying with parents when we can, and foremost infusing our own expertise to guide these children, who are not yet old enough, mature enough, or legally able to make independent medical or legal decisions toward their gender health.

Building Dams and Slowing Currents

Being gender creative comes with excitement. It comes with confusion. It comes with challenges. The story of the nine-year-old’s insisting on a vagina—now—reminds me that a child’s gender creativity can also come to a therapist with a sense of urgency or insistence. A book I wrote several years ago, Spoiling Childhood, targeted two words that seemed to have dropped out of some modern-day parents’ vocabulary: stop and no. Now link that to the rubric of the gender affirmative model: Listen to the children. To give our children a chance to assert their true gender, we want them to be both seen and heard. Now link that to the fear many parents carry that if they don’t listen and if they don’t act immediately, their children may be at grave risk—for all those ills that come from being thwarted in affirming their gender, the worst being suicide. Parents might be culpable of inducing trauma if they miss the boat and don’t get the children the medical interventions they need in a timely manner—puberty blockers to stem the flow of an unwanted puberty, hormones to bring a body in sync with an identity. Now link all that to the psychology of children and youth, for whom waiting is anathema; patience, an acquired taste; and the longest the future should be is the day after tomorrow. Add all that up and what do we get? Possibly a feeling of urgency ringing out no less shrilly than a hurricane siren. So, we mental health professionals are not only firefighters. We also build levees and dams to protect against the flood of gender angst.

Distressed parents who demand a vagina for their child by age nine to avoid her threatened suicide will need some help taking a deep breath and slowing down. Another divorced parent I was working with, Samuel, had come around to acknowledging his fourteen-year-old’s legitimate pleas to be recognized as the boy he was. Samuel contacted me after one of their heart-to-heart talks. During this conversation Samuel lovingly gave his child, Ren, the green light to fully transition from female to male, which by almost all means the youth already seemed to have done anyway—except for name and pronoun change. Dad was now on board for both name and pronoun change, although he wondered with his child why he couldn’t keep his present name, as it was a gender-neutral one. Ren, angry at both of his parents not just because they hadn’t been listening to him but because of their acrimonious divorce, threw a curve ball—he wanted to change not only his first but also his last name, the latter to a name that would be neither his father’s nor his mother’s.

At that point I was meeting with Dad regularly to sort out his own feelings about his daughter who was showing him that she was his son. In his high-powered professional life, Samuel was a force to be reckoned with. Not so when it came to parenting—in every respect, he was quite wobbly on his feet. After providing me with all the information that transpired during the name-change conversation, he added, “I’m inclined to ask Ren to accept us continuing to use his last name for a while longer, but I’d love your view of it.” This was a new one for me, but every day I always anticipate a new one. I gave myself a little time to think before I responded to the dad in an email: “Last name should be off limits regarding a change. Has nothing to do with gender. Issue of gender should be separated from issue of wanting to shed one’s entire identity.” Samuel thanked me and said, “I thought so, but I just wanted to check.”

One of our assigned tasks as mental health professionals is to slow things down. We try to dredge out other issues that get tangled up with gender issues so we can concentrate on the latter without getting distracted by the former, or understand how the two are getting woven together, or explore whether the gender issues are actually symptoms of another underlying trouble having nothing to do with gender. In this youth’s case, for good reason he would have an adolescent fantasy of purging himself of any identifiable ties with either of his parents. But do we want to endorse putting those fantasies into action as teens work out their separation issues with their parents? If we did, the registrars at the high schools would go out of their minds trying to track all the daily last-name changes. And would changing his last name facilitate his gender authenticity? Not so much, especially as he was about to enter a school where no one would be there from his past. But we do want to make sure that youth feel affirmed and recognized in the gender that fits them most comfortably, and if that involves changing their given name, that’s where we don’t put up a dam but open up the locks. In this case, even if the given name was gender neutral, for this youth it might be associated with his female self, which no longer felt like a good fit. In the English language, gender is marked not by a surname but by a given name, and here is where the mental health professional can play a hand in injecting a bit of common sense into an otherwise fraught situation.

We’ve all learned that living with ambiguity about gender in a world that has heretofore perceived gender as bedrock (at least in Western culture) is perhaps one of the hardest challenges both for parents and for mental health professionals, and sometimes for children and youth themselves. We speak of the gender journey but have to remind ourselves that it is a walk, not a race. A mother came to me for a parenting consultation about her five-year-old gender-exploring child. She challenged me: “If my child is going to be or is transgendered, isn’t it better to know early?” She had heard about the concept of “consistent, persistent, and insistent,” and also the ex post facto test, that kids calm down once allowed to transition. Unfortunately, partial information can lead to lopsided equations: The word on the street about the ex post facto benefits of early transition gets morphed into the myth that early transition is always better, so let’s just find out and get things moving. One problem—there’s an overriding variable: What’s best for the children is to let the children unfold at their own pace, driven by their own quest rather than our need to know. So, the dam building involves helping whoever on the team can’t tolerate not knowing—to slow the current of their fears and anxieties, remembering always what it feels like to move from gender as bedrock to gender as moving boulders—that it’s destabilizing, if not terrifying. Such dam building is effective only if accompanied by a soothing reminder: “What we all need to do is let children unfold at their own pace, and then make space for them to live their gender as they have discovered it to be.”

But now let’s go back to firefighting. Sometimes the fire alarms are set off not by the actions of the transphobic world, but by an explosion erupting within a child or youth. So the real finesse for the gender affirmative mental health specialist is to recognize when to switch gears—to drop the dam-building equipment and run for the fire truck and hoses. What I’m trying to say is that mental health gender intervention sometimes requires swift and dramatic responses, particularly when a child is rapidly moving toward heavily troubled waters of distress, depression, and self-destruction. Let me give an example. I have been consulting with Tory and her parents about Tory’s gender needs. Tory is just leaving grade school and has been on puberty blockers for two years. She has been living in her female identity for three years. Tory is desperate to go on hormones so she can enter high school with an onset of puberty that will fortify her female presentation and put her in sync with her peers. If she has to go on experiencing herself or being seen as a prepubertal child of nebulous gender, she doesn’t know whether she can keep going. She already has a history of self-destructive behaviors, including one suicide gesture. What is delaying getting hormones? Not her young age, but her phobic fear of needles. She has tried every form of therapy to reduce her needle phobia. Nothing has worked. Medication could—short-acting antianxiety medication to get her through the medical procedures. At first one of her parents doesn’t want to do this, preferring to wait it out until she can overcome the phobia and handle the shots. After all, aren’t we not supposed to rush forward? So, here is where I switch from my dam-building hard hat to my fire hat. Spending time with Tory, my reading is that overcoming her needle phobia may not happen for a very long time, if ever, maybe when hell freezes over. I hear an SOS—I think we need to act fast, and this is what I have told the parents. Unlike the nine-year-old screaming for a vagina, Tory has been crying in my office, both in anger and distress, convinced that she’s doomed to be a gender freak because now she’ll never be able to get hormones, ever. In general, I am not a promoter of psychotropic drugs for youth, unless absolutely essential. In Tory’s case, I assessed the administration of antianxiety medications as absolutely essential, with a high risk of suicidality if we keep slowing down this youth who knows who she is, knows how she will finally feel comfortable in her own skin, and may drown behind the dam if they don’t open the locks and let her move to where she needs to go. So, the lesson to be learned is: Slow down until you need to hurry.

Fast or Slow, Do Gender Diagnoses Help?

In 2013 the Diagnostic and Statistical Manual of Mental Disorders issued the newest edition of the manual. Gender identity disorder was removed as a diagnosis, replaced by gender dysphoria, in which there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign to the person; in children, the desire to be of the other gender must be present and verbalized; and there must be evidence that the incongruence causes clinically significant distress or impairment. In other words, the diagnosis of gender dysphoria signifies that a child has gender concerns and is stressed out by them. The new gender diagnosis is definitely a step up from the gender identity disorder classification, the latter with its implications of pathology and enforcement of culturally dictated binary norms of gender acceptability. Yet the new diagnosis has not quieted the turbulence of an ongoing debate among mental health professionals—should there be a diagnosis at all? When it comes to the diagnosis for prepubertal children, a recent survey of WPATH members at the end of 2014 indicated that the membership was split right down the middle—half were in favor of a childhood diagnosis, half wanted it eliminated.

Those who are in favor of the diagnosis argue that it is necessary because (1) it captures a particular form of psychiatric stress that certain children experience related to their gender, particularly those who feel anguish about being delivered the wrong chromosomes and genitalia; (2) it provides access to services—without the diagnosis, children would not receive needed psychosocial interventions or be able to get insurance coverage for them; (3) it alerts parents to a condition that they had best attend to in their children; and (4) it allows us to aggregate clinical data about the children who come to us, creating a pool of children diagnosed with gender dysphoria, necessary for both research and public health purposes.

Those who are against the diagnosis argue that it should be thrown out because: (1) it continues to cast gender nonconformity as a psychiatric condition rather than a healthy variation in development, and for that reason alone should be eliminated just as homosexuality was struck down as a psychiatric diagnosis in the 1970s; (2) children suffering from the effects of gender nonconformity in an unaccepting world can receive relevant diagnoses, such as adjustment disorder or generalized anxiety, just as children of divorce receive just such diagnoses in light of their divorce experience, rather than a psychiatric diagnosis of childhood divorce syndrome or some such thing; (3) when homosexuality was taken off the books, gays did not stop receiving mental health supports; in fact, such services have increased since that time; (4) yes, the diagnosis may alert parents to the need for their children to get help, but couching it as a psychiatric problem may lead to just the wrong kind of help—trying to “fix” children through reparative forms of therapy; (5) insurance companies and state-run subsidies for mental health should not be dictating what is a mental disorder and what is not; rather, we should be dictating it to them, along with the demand that they provide medical gender affirmation services when needed without a mental health diagnosis but rather with a clear need for gender integration; (6) there are plenty of ways to collect data about gender-nonconforming children who are receiving mental health services without giving them a psychiatric diagnosis; and (7) the pathology lies in the culture, not the child.

My own bias: Down with the diagnosis. Why? Because gender nonconformity is not a disorder of childhood but, rather, a healthy variation of gender possibilities that may show up over the course of a child’s life with good effect if social supports are in place. Difficulties, if faced at all by gender-nonconforming children, are psychosocial, rather than psychiatric, and typically come in one of two forms: (1) a discrepancy between the norms and expectations of gender within the children’s social environment or culture and how these children identify and hope to express their gender; and (2) a discrepancy between the perceived sex assigned to the children on the birth certificate and the gender those children identify as being. Neither of these in itself qualifies as a disorder. Instead, we could say that gender dysphoria is a social condition, not a psychiatric one. As long as penis = male and vagina = female, we will induce gender dysphoria, particularly body dysphoria, in our gender creative children. When we can move the social order to think in terms of a penis-bodied or vagina-bodied person, the boy with the vagina and the girl with the penis will be less of a socially startling phenomenon. It is the anxiety, depression, and distress surrounding this externally induced problem that are expectable psychological responses to the social imposition of gender rigidity, both regarding bodies and roles, that should be of our concern.

Comparing the gender dysphoria diagnosis to the now-defunct DSM classification of homosexuality as a disorder, I have yet to encounter gay people who long for the return of homosexuality as a designated psychiatric disorder; instead, they report that they felt affirmed and liberated by its removal from the DSM. They still find ways to get the supportive mental health services they might want or need, as early as their childhood years, and researchers are still able to locate them for the purpose of conducting psychological studies. Regarding the present requirements of insurance companies and funding agencies to provide their organizations with diagnoses in order to get gender-related services—if we have to live with that for now to ensure our patients get the services they need, so be it, but we shouldn’t leave it there. We should work to change it.

Of most concern to me are effects of a mental health gender diagnosis on the child. The obvious one is the stigmatization of the child. As with gay individuals, I have yet to meet a child or youth who embraces a diagnosis of gender dysphoria as a healthy attribution of self—maybe a ticket to care, but not a proud self-label. Receiving this diagnosis is especially risky in the context of social environments that are hostile to or condemning of both children and adults who do not conform to the culture’s gender norms. For example, one public school refused admission to a transgender child because that child had a diagnosis of gender identity disorder (pre–DSM V), which qualified as an emotional disturbance for which the staff claimed their school could not provide adequate services. Beyond stigmatizing children in the outside world, bad effects of mental health labeling can also show up in the inside world. For a child, the gender dysphoria diagnosis runs the risk of leading the child to think that “there must be something wrong with me,” when there is no scientific evidence that there is, perhaps even causing the child to repress, suppress, or go into secrecy about gender desires and feelings, lest they be seen as “sick.” And then there is the danger that the parents will take the diagnosis and run with it—in the wrong direction, indeed believing that their child is sick and needs to be cured or brought back in line with culturally acceptable gender behaviors and presentations. After all, their child has just received a psychiatric diagnosis. The same danger goes for mental health professionals of a certain type, who might take the diagnosis of gender dysphoria as a green light to proceed with therapeutic interventions that attempt to realign a child’s gender identity or expressions with gender conformity so as to rid the child of the “disorder.” So, the diagnosis runs the risk of imposing unneeded or harmful health services when, with the provision of family and social supports, a child may have needed none.

I would liken the risks of the childhood gender dysphoria diagnosis to the situation for left-handed people. Historically and in certain cultures today, left-handedness is perceived as deviant, disordered, or even sinister. A child observed to prefer the left hand in such cultures is “counseled” away from using that hand and steered toward the right hand, with the goal of eradicating the left-handedness and avoiding social stigma or even punishment. The treatments have proved to be successful at the surface—the child uses the right hand; however, the underlying “condition” of left-handedness remains intact; it is simply suppressed, with subsequent risks for stuttering, learning problems, anxiety, or other psychological difficulties. In cultures in which left-handedness is accepted as a normal variation of handedness, albeit appearing in only a small minority of the population (approximately 10 percent worldwide), the children are left alone to embrace their left-handedness, show no such psychological stresses, and are even reputed to be overrepresented in the highest echelons of the arts and sciences. Isn’t that just like the varying experience of gender-nonconforming children, depending on whether they find their place in an unaccepting social environment that perceives them as ill versus an accepting social environment that perceives them as healthy?

One last thing about gender diagnoses. Increasingly, I have come to see gender as cure rather than disease. It came to me the day after I saw our little patient at the clinic who was both autistic and gender nonconforming and who then returned to the clinic, nine months after being put on puberty blockers and allowed to do a social transition, seemingly remarkably cured of his autistic symptoms. Then I began to think about all the ex post facto tests—if we got it right about a child’s authentic gender and allowed the child to live in that gender, previous psychological symptoms dissipated, if not disappeared altogether. So, how about thinking of gender, or more precisely, gender affirmation, as the cure, rather than the problem? I leave you with that to ponder, and simply alert you to be mindful about the effects, both good and bad, of a gender diagnosis.

Psychiatric Help 5 Cents—The Doctor Is In

Why would a family of a gender creative child seek us out for help? Put another way, what good are we mental health professionals to families? I have said before that for the most part I like to meet with parents and do what I call “behind the scenes” work, in this case working with parents and other caregivers or family members to think about their children’s gender web and create a space and put in place supports so their children can freely traverse all the paths along their gender journey. Sometimes children need a room of their own to sort out their conundrums. Sometimes their siblings do, too. Sometimes the children need a forum with their whole family present. There’s space for that, too.

I am happy to say that “blame the parents” is dying out. “Support parents in supporting the child” is on the upswing. A new form of gender policing is in—instead of policing the children, we are beginning to police the mental health professionals who are doing harm to our gender-nonconforming children and youth. I’m all for that, but my best hope is that we can reeducate rather than subjugate the offending parties, so they can begin to do some good.

Parents and caregivers: If we give you a chance to bring all your feelings about your children’s gender to us, the good, the bad, and the ugly, keep us. If we give your children a chance to say who they are, rather than dictate who they must be, keep us. If we pay attention to your whole family, keep us. If we use our expertise wisely, never withholding, never imposing, keep us. If we recognize you as an expert and work as a team in mapping out a gender support plan, keep us. If we are willing to leave our offices and advocate for gender rights, keep us. If we fail to deliver on any of those things, let us go.

^{CHAPTER SEVEN}

Do We Want a Doctor in the House?

I will remember that there is art to medicine as well as science…, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug…. I will not be ashamed to say “I know not.”… I will respect the privacy of my patients…. Above all, I must not play at God…. I will remember that I remain a member of society, with special obligations to all my fellow human beings…. If I do not violate this oath, may I enjoy life and art, respected while I live and remembered with affection thereafter.

—Excerpts from a modern version of the Hippocratic oath written by Louis Lasagna, dean of the School of Medicine at Tufts University (1964)

IF YOU ARE a parent of a gender-nonconforming child, you will benefit from the care of a medical doctor who holds paramount the oath taken by all health professionals—above all, “Do no harm.” Until recently, we saw no need to go to the doctor to learn how to deal with our children’s gender. The lessons were simply passed on from generation to generation, to be either accepted or rejected by the next. There were basically three gender issues that called for a doctor in the house: If there was some question about our children’s genitalia—they were ambiguous or confusing; if our children didn’t seem to be going through puberty like all the other youth of the same gender—either too early or too late; if our children weren’t doing gender “right” or were saying such things as “I’m not a boy, I’m a girl” or “I’m not a girl, I’m a boy” when everyone knew that was obviously not true. The point person was typically the family doctor or pediatrician who sounded the alarms, possibly preceded by the ob-gyn specialist who may have detected a problem of ambiguous genitalia at the baby’s birth. From there, other specialists may have been brought in to fix the problem, including a surgeon, a pediatric endocrinologist, and a psychiatrist: one to fix the genitalia so they were either male or female, one to study genetic and hormone anomalies to see if they could be fixed, one to help children accept the gender that they were expected to be.

I grew up during that era and ended up having the most familiarity with the doctors in the last category—psychiatric gender fixers. When I was going through my graduate school training as a developmental psychologist beginning in the late 1960s, with gender development as my main field of study, Dr. Robert Stoller was considered one of the top experts in the field. I continued to keep up in the field after leaving graduate school, and here is what I learned as late as 1985 from Dr. Stoller:

I have presented a hypothesis that I believe is being confirmed plus a guess that is beyond confirmation… a mother who tries to create a limitless and unending blissful merging between herself and her yearned-for beautiful son will put him at great risk for becoming feminine if his father does not interrupt the process. The guess is that this malignant process is… the result of a developmental arrest that prevented the otherwise expected unfolding of masculinity.[64]

The implication was that this little boy needed to be treated for his gender malignancy and the parents needed guidance to undo their toxic influences on their child. That is not the kind of doctor I would want to send anyone to today, although sadly, such doctors are still in practice in the twenty-first century.

The world I grew up in is changing dramatically. Today, in the United States, we recognize that intersex children have a right to the bodies they were born with, that children can assert a gender that does not conform with the sex marker on their birth certificate with no question about their sanity, and that parents create not malignancy but positive growth in their nurturing interactions with their gender-nonconforming children. So, why would we need a doctor in the house? Well, to track our children’s gender development over time (that would be the family doctor or pediatrician who might follow our children from birth to maturity), to track our children’s puberty development (that would be the family doctor, pediatrician, or the pediatric endocrinologist), to administer puberty blockers and hormones where appropriate (that would be the pediatric endocrinologist or pediatric gender specialist), to provide surgical interventions where appropriate (that would be the surgeon trained to do gender affirmative surgeries).

Pediatric Point Person

Like mental health professionals, your pediatrician or primary care provider can offer either the best of times or the worst of times when it comes to the care of a gender-nonconforming child. For the medical doctor, training about gender will typically fall within old-school models, if there is any training at all. And not uncommonly, whether well- or ill-trained, the child’s primary care provider may be the first person who hears from parents of a very young child, “There’s something about my child’s gender that I’ve been noticing.” And for the parents of the gender-nonconforming child, their child’s pediatrician may be their only point person in the helping professions. The communication “There’s something about my child’s gender that I’ve been noticing” can be spoken in a tone of pure curiosity; it can also come with a cry of utter panic. It may be a spontaneous offering from the parents or, more rarely, follow a query from the doctor’s general protocol that includes questions about gender development. Alternatively, without such a standard protocol, the doctor may notice something that seems “different” about the child and be the one to bring it up to the parent. However it enters the room, the manner in which the doctor responds can have profound effects on the unfolding of the child and family’s gender journey, either opening up smooth pavement or heading the family toward the bumpiest of roads.

I have had the good fortune of working with the most wonderful of pediatricians who will make every effort to ensure that their gender-nonconforming and transgender young patients get the care and attention they need to grow up healthy. I would encourage the parents of any gender-nonconforming child to search high and low for just such a doctor, which sometimes means having to leave the pediatrician who has up until then served all the children in the family. But in some communities there are no such gender affirmative doctors, and in other situations, a family does not have much choice in its doctor or may not even consistently have the same doctor from one visit to another. In those cases, as if parents did not already have enough work, yet another task for gender creative parents is the guidance of their child’s medical provider in the direction of gender-sensitive care.

When that is the case, there are three simple sentences to watch out for: “It’s just a phase,” “Let me give you a referral to a psychiatrist,” and “I don’t know anything about this.” Let’s start with “It’s just a phase.” Embedded in this communication is the subtext “Don’t worry,” because in child development and pediatrics, phases are typically childhood phenomena that we count on children’s outgrowing—such as terrible twos or adolescent rebellion. And buried in that subtext is yet another subliminal message—that gender nonconformity is not something we celebrate, but something we hope shall pass. Indeed, sometimes gender nonconformity is a phase along the child’s gender journey as they spin their gender web, a way of being that may look very different in its future iterations. But most commonly a child’s gender nonconformity is not a status that they outgrow. Saying “It’s just a phase” gives false hope to parents who are not yet at the place where they can accept and celebrate their child’s gender creativity but, rather, hope it will just go away. So, in one fell swoop, “It’s just a phase” is one of those microaggressions against the smallest members of a minority group and simultaneously a child development inaccuracy. Therefore, beware of pediatricians who bear such gifts, and invite them to dispense with this assessment, replacing it with an open curiosity about what the child is showing people about their gender, both now and in the past.

As for “Let me refer you to a child psychiatrist,” I do not think much needs to be said about the doctor who immediately jumps to the conclusion that a gender identity disorder has just walked through the door, one that needs to be fixed ASAP. In those situations, if at all possible, changing doctors would be the best course of action. Yet that doctor may be a good fit in every other way and may be following another of your child’s medical needs as an expert in that area. In that case, or in the case of the doctor who is assigned and for whom a parent has limited choice, inviting the pediatrician to read literature that offers a different perspective on gender nonconformity, such as publications written for medical professionals by our interdisciplinary team at the UCSF Benioff Children’s Hospital Child and Adolescent Center clinic,[65] can actually lead to enlightenment and change. Recall the Hippocratic oath. All we ask in those situations is that medical providers abide by the oath by reeducating themselves or perhaps for the first time exposing themselves to education and training about gender. This is where we, professionals who do trainings, come in—sometimes I think of us as ghost busters and itinerant teachers all in one: moving across the country from institution to institution to rid the buildings of gender ghosts and replace them with gender angels, by providing coherent and cogent trainings on the gender affirmative model and its application to pediatric practice.

We also write about gender from a pediatric perspective. Here is a sample of a written invitation to pediatricians to implement a gender affirmative pediatric practice:

The first step is to examine our own feelings, attitudes, and beliefs about gender and consider how these affect our work with youth. Equally important is educating ourselves on the diversity of gender in our patients and the corresponding interventions available for supporting them. Adopting supportive, affirming practices, such as intake forms that allow for the patient’s preferred name and pronouns (and using them accordingly), is another critically important step for helping young persons feel comfortable.[66]

Some of these tasks are easy, others are easier said than done, but all are achievable in the context of a supportive and informed teaching environment and a commitment by pediatric professionals to ensure a gender affirmative experience for their young patients and their families.

Now we come to the last of the three sentences, “I don’t know anything about this.” I would say, “See above,” but I also want to add that it is far better to admit ignorance than to operate with conviction informed by misconceptions and biased attitudes. As long as a provider is willing to move from not knowing to knowing, there is hope for gender-sensitive care. And as long as there are interdisciplinary teams of trainers providing the education, there is a good chance that there will be a growing cadre of such sensitive providers. But if the statement “I don’t know anything about this” is really a euphemism for “I think it would be better for you to go elsewhere,” I’d take the provider up on that offer and find a new doctor for your child. I have found that the role of primary providers has been invaluable in the ongoing supportive care of the gender-nonconforming children and youth I have worked with. I know I could not do the work without them, so it’s best that they be the right ones.

The last thing I want to say about gender affirmative care and pediatricians (and I should say all medical doctors) is that most medical doctors have been trained in a model in which practice is informed by data and results, in the form of research studies, be they clinical or in a lab. Providers are often hesitant to proceed until the studies have come in validating a particular form of intervention and its outcomes. I, too, have been raised in a profession that turns to such studies to inform our practices, and I honor that tradition. But I am also a clinical psychologist who honors a different way of knowing—and that is the knowing that comes from spending day after day with children and youth who are going against the gender grain. We are scrambling to get the studies of our gender affirmative interventions under way so that we can document whether our model indeed works, but in the meantime, we already know just by watching. And we also know that the studies about gender-nonconforming children that exist to date have many flaws and need to be reanalyzed with a critical eye. So, I would invite pediatricians to pay attention not just to the reports in the medical journals, but also to the lived experience of the children and families and the clinicians working with those children, to get a full picture of the lives of gender-nonconforming and transgender children.

At some point, there may come a time when the pediatrician will want to make a referral, and that would be to the pediatric endocrinologist or trained gender specialist who is in the business of providing medical interventions to gender-nonconforming and transgender youth, in the form of puberty blockers and hormones. So, let’s wander over to their offices now.

Medical 101

One of the challenges we mental health providers have encountered is our new involvement in medical practices and decision making. Gender is no longer just a psychological phenomenon. For gender-nonconforming youth arriving at puberty, it is a state of being that may be enhanced by medical interventions. And we mental health providers are now asked to weigh in on these medical interventions, through assessments of a child’s gender status and observations of their readiness to receive either puberty blockers or hormones, and then later, gender affirmative surgeries. Since the publication of Gender Born, Gender Made, I have studied hard to hone my medical knowledge, as basic as it might be. As the attending psychologist at the Child and Adolescent Gender Center clinic at UCSF Benioff Children’s Hospital Department of Pediatrics, I have had the opportunity to have a close-up look at the youth and their parents as they contemplate the youth taking puberty blockers and/or hormones. Let me start with what I’ve learned about puberty blockers.

PUBERTY BLOCKERS: THE PAUSE BUTTON THAT GIVES US PAUSE

I am now adept at explaining to parents and youth that puberty blockers, also known as GnRH inhibitors (full name: gonadotropin-releasing hormone inhibitors), coming in the form of either agonists or antagonists, are a substance that, if released in the brain, will decrease the gonadal secretions that set off the beginning of puberty and all the sex-related body changes that go with that. A child can receive puberty blockers in the form of either injections throughout the year or a yearly implant just under the skin, a procedure that can happen in the doctor’s office with a local anesthesia. The best time to maximize the effects of puberty blockers is in Tanner stage II of puberty, when children show the first signs of pubertal development. They are not administered before a child enters puberty. The procedure is fully reversible. If the child chooses to discontinue the blockers, the puberty that had begun to take its course will proceed forward within a short time period (within six months). To get puberty blockers, as one of my patients explained to me, “You have to go to the blocker doctor.” That would be the pediatric endocrinologist, particularly one who is trained in gender care. If there is no such person in a family’s community, it may be necessary to travel a distance to work with a specialist or else to locate a pediatrician or family doctor in the community who is willing and able to administer the blockers. The functions of puberty blockers are twofold: (1) to staunch the flow of an unwanted puberty that at its most extreme could prove traumatic to the child (it should be noted that suicidal feelings and thoughts often spike at the onset of puberty for youth who are troubled, if not horrified, by the onset of pubertal body changes that don’t fit who they know themselves to be); and (2) to buy the youth some more time to explore their gender if their true gender self is still not in focus.

In the United States, the two main problems with puberty blockers is that they can be exorbitantly expensive and, as of this writing, are not yet FDA-approved for puberty suppression related to gender. And some children hate shots—to the extreme. I don’t know how many times a patient of mine has asked, hopefully, “Did they discover a pill yet?” Leaving needle phobias aside, what we know is that puberty blockers have been used successfully for precocious puberty for nearly forty years with no ill effects. The only caveat there is that we do not know whether stopping a precocious puberty that came too early is exactly parallel to stopping puberty in children who were going forward at a normal rate in their pubertal development. We will have to wait for future studies to answer that question, but what we do have as reassuring evidence is that since the 1990s puberty blockers have been administered to hundreds of youth in the Netherlands, youth who have been studied over time into adulthood. No untoward effects have been identified. There has been some concern that the puberty blockers interfere with healthy bone development, particularly bone mineral density. However, studies to date indicate that bone density does not change or simply remains at its prepubertal rate of change during the course of puberty blockers, and once adult hormones are introduced in the form of either cross-sex hormones/hormone replacement therapy or the child’s natal hormones, the bone mineral density picks up again to normal levels. There has been some concern expressed, by both professionals and parents, that puberty blockers might interfere with forward brain development in early adolescent youth, either temporarily or permanently. To date, we have no evidence to indicate that this is the case, so we can only state that every effort is being made to engage in research to determine whether any effects exist. What we do know is that a twenty-two-year follow-up of a youth treated at the Amsterdam clinic with puberty blockers followed by hormones showed perfectly fine brain functioning.[67]

For both puberty blockers and hormones, the gender affirmative mode of practice is moving away from ages to stages as the guideline for when to introduce either blockers or later hormones. With puberty blockers, that’s a simple procedure: When the child arrives at Tanner stage II of puberty, that is the time to start, whether the child is ten years old or fifteen. The real problem for the children who start on the early side is the length of years they might be staying on puberty blockers before the time when it would be appropriate to start hormones, if that seems like the treatment of choice. To date, we do not have any documentation of harm being done to the body by staying on puberty blockers for an extended time, but, erring on the cautious side, it remains a concern.

CROSS-SEX HORMONES/HORMONE REPLACEMENT THERAPY: YOU CAN’T GO BACK, AT LEAST NOT ALL THE WAY

Cross-sex hormones/hormone replacement therapy allow youth to bring their bodies more in line with their affirmed gender. We often think of them in binary terms—through the hormonal effects on the body, we can take a natal female and, with testosterone, affirm the boy; we can take the natal male and, with estrogen, affirm the girl. More recently, genderqueer youth have seen the myriad other possibilities—for example, a touch of testosterone, but not too much. Through their demands and requests, these youth push for us to open our horizons to understand medical interventions not just to achieve gender reversal, but also to afford the opportunity for gender in the middle or in unique iterations.

We do know that there are long-term medical risks to estrogen and testosterone treatments, albeit small, but we also know that cross-sex hormones/hormone replacement therapy have saved the lives of many youth and adults, transforming suicidal ideation into glorious dreams of a gender affirmative future.

For an affirmed male, taking testosterone will result in “masculinization” of his body, including a more buff body (increased lean muscle mass), fewer layers of fat, and facial and body hair, all of which are reversible effects if the youth should decide to discontinue the hormones. If an affirmed male goes straight from puberty blockers to testosterone and started taking puberty blockers before the closure of growth plates, there is a chance he will grow to a normal male height (this is a big, if not a tremendous plus for many young transgender men, who might otherwise always be the shortest guy—another sometimes unwanted visible tag of being a trans rather than a cismale). If a transgender boy has already developed breast tissue, the testosterone may cause some atrophy of the tissue but not make it disappear completely. Some of the effects of testosterone, however, are irreversible, and this is what gives many parents pause when it comes to signing off on this intervention for a child who is still a minor. These include the deepening of the voice and the enlargement of the clitoris. The biggest price tag for many transgender youth who go on testosterone is acne, sometimes fairly acute. But this is only temporary and goes away, just as acne shows up and then dissipates or disappears in cisgender youth as they move through adolescence. The biggest primary health concern is later development of polycystic ovarian syndrome, and this, among other things, is why many transgender young men are eager to remove their ovaries (and usually their uterus) as part of their care.

What about transgender girls and hormones? They will be taking estrogen. If they had been taking puberty blockers, they can continue to do so, to keep their testosterone levels low, making room for the estrogen to have its full effect. If they never took puberty blockers or cannot afford them, they can also take another drug to suppress testosterone, most commonly spironolactone, used in combination with the estrogen. Once on estrogen, a transgender girl will notice decreased facial and body hair, if she ever had it, a redistribution of her fat creating a more “feminine” presentation, a decrease in spontaneous erections, and softer skin, all of which are reversible to some extent. Estrogen can also make breasts grow and might have the effect of closing the growth plate and reducing the possibility of a “too tall” woman (the complementary angst to the short boy syndrome in transgender males). These two changes are irreversible. Unfortunately, estrogen cannot whisk away some male features if they were already there. Body hair and facial hair will not disappear completely, and a low voice will stay low, leading many transgender young women, either on hormones or not, to seek out electrolysis or laser hair removal along with voice therapy or vocal cord surgery.

All of these interventions should be monitored carefully and consistently by a trained medical professional. Blockers, hormone suppressants, estrogen, and testosterone are all prescription drugs and should be respected as such. Many youth seek out hormones on the street or on the Internet, because of either necessity or desire and no other access. We do not want to deny them the hormones they so sorely need, but we do want to make sure they can get the same quality of medical care that is the right of every youth, which means, of course, that we have a lot of work ahead of us to make sure this happens.

One thing needs to be highlighted if a youth has chosen a course of puberty blockers beginning at Tanner stage II, followed directly by cross-sex hormones/hormone replacement therapy: the implications for fertility. At this moment in history, those youth will not produce mature eggs or sperm of their own, meaning they will forgo the possibility of conceiving a genetically related child. These are important considerations that need to be shared with both parents and the youth, which is tricky business. In our culture, youth of that age have typically not reached the stage of family building, making it challenging for them to project into the future as to whether conceiving or bearing their own children or having children at all will be critical to them or not, and parents in these situations are catapulted into the position of signing off on their child’s medically induced infertility. On the other hand, if a youth has already gone through the puberty of their natal sex before starting a course of hormone therapy, they can choose, before starting their course of hormones, to preserve the gametes they already have, with egg extraction and freezing for the XX youth, and ejaculation and sperm collection and freezing for the XY youth. Gamete preservation will afford them the opportunity to use those gametes in the future if they desire genetically related children, albeit through assisted reproductive technology techniques. Egg extraction is a more complicated and invasive procedure than sperm collection, placing an added medical burden on transgender male youth. On the other hand, many transgender females have reported to me how awkward it is to go to a fertility clinic or medical office and ejaculate into a bottle on their way to becoming girls, especially if their sexuality has been put on hold as they consolidate their gender, putting on them an added psychological burden.

SURGERIES: NO GOING BACK

Surgeries are the most permanent of gender affirming medical interventions, which is why so many people are nervous about performing them on youth before they’ve reached the age of majority. In fact, a prominent hospital in the San Francisco Bay Area recently put a stop to just such surgeries, questioning the ethics of these procedures for minors, but also concerned about the perceived liabilities for their institution, leaving a whole group of youth and their doctors temporarily medically homeless as they searched for other hospitals to take them in, which fortunately did happen.

Since completing Gender Born, Gender Made, I have seen an increasing number of youth who are requesting and being granted surgeries over the course of their adolescence, before the age of eighteen. As children are socially transitioning at younger and younger ages, by the time they reach adolescence they have already been waiting for years to benefit from the medical interventions that will align their bodies with their affirmed gender self. Although the WPATH standards of care set sixteen years as the minimum age for such interventions, common practice has led to the amendment of those guidelines in accordance with the stage, rather than age, measure of readiness. The most common form of surgery is chest surgery for transgender males or for some genderqueer youth, followed by hysterectomy (partial or radical), and genital surgeries. Later might also come tracheal shaves, vocal cord surgeries, and facial adjustments. Some youth also request electrolysis or laser removal of gender-discordant body hair. These are definitively irreversible interventions, and, except for electrolysis or laser removal of body hair, performing these procedures on minors can really make people nervous, because there’s no turning back, and the majority of the surgeries target the most fundamental body icons of the gender binary—genitals, breasts, and internal reproductive organs. However, this angst may be soothed by the realization of the increased sense of well-being and mind-body harmony in a youth who is given the opportunity to affirm their gender through their body.

If a child has started puberty blockers by Tanner stage II of puberty and then proceeded directly to hormones, some of these gender affirming surgeries can be avoided. A transgender male in those circumstances will never grow breasts. A transgender female will never grow an Adam’s apple or have facial and chest and back hair. Genitals, on the other hand, are another story. A clitoris may enlarge and count as a micropenis in a transgender male on testosterone, but it won’t be a fully functioning penis. A functioning penis or vagina will come only with surgical intervention. More and more youth are requesting such surgeries, while others are happy with staying with the apparatus they have, challenging the notion that penis = boy and vagina = girl.[68]

On June 17, 2015, an article appeared on the front page of The New York Times, NEW GIRL IN SCHOOL: TRANSGENDER SURGERY AT 18. The subhead: “A Debate over How Young Is Too Young.”[69] The story features Katherine Boone, an eighteen-year-old transgender high school student who completed vaginoplasty surgery in April of her senior year. The surgery was not without medical complications, but Katherine, who likes to be called Kat, also had a gender history not without complications, including self-harm and suicidal thoughts, due to gender distress. At age eighteen, Kat reported that even with the postsurgery complications, she had no regrets and looked forward to entering college fully affirmed in her female identity, with a vagina in place. Yet the article also expresses the doubts of both professionals and the general public—teenagers are in flux, so how could one know this is a stable identity? If so many young children are desisters, how could we know whether a youth who is requesting surgery will end up being one of those desisters? Dr. Paul McHugh, professor of psychiatry at Johns Hopkins Medical School and former psychiatrist in chief of the hospital there, looks askance at the use of surgeries to treat a “psychological” condition, both for adults and especially with children. To quote him directly, referring to the coming out of Caitlyn Jenner, formerly Bruce Jenner, the Olympic champion:

Bruce Jenner—who cares? He’s a wonderfully successful person. He’s got all kinds of social networks. He’s got plenty of money. No one’s objecting to him if he wants to live as a woman. This is America, be my guest. But we are talking about children with a future ahead of them.[70]

Actually, we are talking about children who may not have a future ahead of them, given the rate of suicidality among transgender people who do not receive supports and acceptance, including the ability to access medical interventions now available to bring their bodies in sync with their psyches. And we are talking about a situation that is not just psychological, but biological as well.[71] Dr. McHugh played a part in closing down the transgender surgery program at John Hopkins in the 1980s. I’m imagining he sees this as an accomplishment in his career. One wonders what has happened to all those transgender individuals who found the doors to potential gender affirmative surgeries closed to them.

There is no doubt that surgeries, which are irreversible and involve moderate to extensive medical interventions and aftercare, are to be done only with careful forethought and collaboration to determine whether any one of the surgeries would be in a youth’s best interests. We have already established that one indeed can differentiate the persisters from the desisters, and that a clearly identified transgender identity that is present from puberty and beyond is typically a stable one, into adulthood. The reactive sentiment that youth are just too young to make such irreversible life-changing decisions, in terms of both their gender status and their maturity, leads us into the psychological manifestations of the new medical interventions, to which I would like to turn now.

Psychology 202

Let’s start with puberty blockers, and the story of a youth who has been on them. Tex, now age fourteen, started puberty blockers when he was ten. At that time, Tex was still Tess, a girl who was going on puberty blockers to buy more time to explore her gender while heading full-on into puberty. By age eleven, Tess had finished her exploring—she was clear that she was male and requested a full social transition, changing her name to Tex and her pronouns to he, him, and his. Tex presented as a handsome young boy at the new middle school he entered that fall. But by the end of middle school, all his male friends had voices that were cracking, faces that were showing the early signs of acne, and peach fuzz tickling their top lips. By freshman year of high school, some of his friends were full-out shaving. The endocrinologist treating Tex had a policy that no one under the age of sixteen could receive cross-sex hormones, and even that seemed a bit too young to the doctor. This left Tex in a suspended prepubertal state, out of sync with his same-age peers, and anxious that this suspension would flag him as the transgender boy he was, which he had chosen to keep private.

All right, Tex was simply put in a position no different than any other youth who starts puberty at a late age, known in medical terms as delayed puberty, defined as anyone who has not shown signs of puberty by age thirteen. Let me pause for a moment to give a personal account. I was what my mother called “a late bloomer.” I did not show even the first signs of puberty until age fourteen. By the time I reached high school I was an “A” kind of girl—A’s in my grades and AAA in my bra size, and even that was filled with some padding. I did not get my period until I was approaching fifteen. While all the other girls were filling out bodily and getting excused from gym class because of menstrual cramps, I still looked like a ten-year-old string bean. And I never had a good excuse to get out of gym. I wondered whether someone, maybe God, had forgotten to give me a uterus and ovaries. I wondered whether maybe I really wasn’t female—after all, I was good in math and sports, and wasn’t that supposed to be the domain of boys and men? Ergo—maybe I was actually male. At a time when Marilyn Monroe was the icon of beauty and Audrey Hepburn had not yet made her debut in Breakfast at Tiffany’s as the elegant, skinny girl, this was no easy journey for me. As with many of the strains of adolescence, this, too, did pass. My period came, I stopped being the shortest girl in class, I got some shape, I dropped my doubts about my sex and gender, and life went on.

Nobody and no medical intervention had put a stop to my puberty; its natural onset was just a long time in coming. And finally it did, but not without leaving traces of that discomfort and painful knowledge that I was out of sync with all my peers. I can still feel it today. As hard as it was for me to be a flat-chested skinny girl who looked ten when everyone else my age looked sixteen, I can only imagine, and indeed have witnessed, how much harder it is for a teen who is artificially suspended in a state of prolonged prepuberty precisely because they are indeed not the gender inscribed on their birth certificate. They wait because the doctors or their parents either prohibit or express hesitancy about their taking the next step, which would be hormones to align their bodies with their affirmed gender identity. They are asked to be patient and to keep waiting for the puberty that will not only affirm their true gender but also protect them from being the one kid who stands out in the crowd. Propelled by my late puberty, the ensuing angst about my gender left some psychological stains, but that only pales in comparison to worrying that your gender is being withheld from you. Conclusion: It behooves us not to leave a transgender teen in a suspended prepubertal state, watching all their peers pass them by into their adolescent bodies with all the secondary sex characteristics (breasts or beards, and so forth) accompanying that, if we can avoid it. Waiting until age sixteen makes no sense if a youth shows up firm about their gender, typically already having lived in it for several years, and simply ready to take the next step in consolidating their stable adolescent gender identity. And yet setting an arbitrary minimum age for estrogen or testosterone treatment, which is the prerogative of any practitioner in the United States, is standard practice among many medical professionals and clinics. Why would we want to withhold hormones if a teen is clear about their gender identity and anxious to get to do what all their peers are doing or already have done—to go through the pubertal physical manifestations that establish to themselves and to all around them the gender they know themselves to be, whether that be cis or trans? If hormones could help transgender teens do that, it seems cruel to withhold them due to an age requirement rather than a more flexible stage readiness, which might be as young as age twelve or thirteen. Setting an arbitrary minimum age for hormones, without considering it case by case, is one of those situations where doing nothing is actually doing something: in this instance, putting youth at risk for undue psychological stress and social tension.

To make that point, I’m thinking of another transgender youth I was working with, Omar. Omar had been on puberty blockers since he was eleven years old, the age at which he fully transitioned from female to male. Now he was attending a high school not known for its gender sensitivity. One day Omar came into my office and began sobbing as soon as I closed the door: “I can’t stand walking around my high school looking like an eleven-year-old boy. I’m a freak.” Not only was it exquisitely painful, as it had been for me looking like a ten-year-old girl in high school and for Tex feeling forced into a suspended Peter Pan state, but it flagged Omar as different. He might as well wear a target on his back—a horrifying thought, given that he was not disclosing at his new not-so-friendly high school that he was a natal female. His prolonged prepubertal state stood a good chance of outing him, made much worse because Omar was a very shy, introverted guy. There was a solution for him—he could start testosterone and catch up with his peers. But only if the doctors would give him the medicine. His parents had a limited income and didn’t have a lot of choice in the doctors available to them, due to their stringent insurance plan. The first doctor they found met with Omar and told him, “Sorry. You have to wait until you’re eighteen. That’s the way it works. You’re too young now.” Given what the doctor said, Omar thought that was the rule he had to live with. Through his sobs, Omar was able to tell me that he didn’t think he could make it that long, living in a frozen state looking like an eleven-year-old boy. He might not even want to live any more.

I first listened to Omar with great concern (keeping to myself my frustration with the endocrinologist he had seen) and told him not to worry: I would help him and his parents find another doctor who would be able to see him, one who wouldn’t make him wait until he was eighteen. I assured him that waiting until eighteen was just this particular doctor’s practice, one that made no sense to me. I was appalled that the doctor Omar had first seen hadn’t done his math to calculate that asking him to wait until age eighteen meant that Omar would be suspended in a prepubertal state for seven years after reaching the natural age of puberty, with a prolonged use of puberty blockers that conceivably could affect his health, and certainly his psyche. He would graduate from high school looking like a child prodigy, which was not one of Omar’s aspirations. Or, in desperation, he might not even make it to graduation, were he to follow through on ending his life to put an end to the misery.

With a transfer to a gender affirmative endocrinologist, Omar finally got his hormones at age fifteen, so we could say that all’s well that ends well. In Omar’s case, this was not without some scarring along the way. Omar had been catapulted unnecessarily into a state of gender distress after the first doctor informed him that he would have no choice but to wait until he left high school to enter puberty. Withholding testosterone, the next step in his gender journey, had he taken that advice, would have been nothing short of harmful practice. Perhaps if all pediatric endocrinologists went through either a prolonged prepuberty or a delayed puberty themselves, as Tex, Omar, and I did, because of either natural or medically induced causes, they would be more sympathetic to the problem and more willing to substitute stages for ages in their standards of care for transgender youth.

The use of puberty blockers and then hormones to allow youth to further explore and/or consolidate their affirmed gender identity has been nothing less than manna falling from the sky when we consider the possibilities for enhancing gender health among our adolescent gender creative children. At the same time, these interventions are not always magic bullets (a drug or treatment that cures a disease quickly and easily without producing bad effects). Following the Boy Scouts’ motto “Be prepared,” I think it is helpful to know in advance some of the shadow sides that may follow in the wake of the interventions, especially after a teen starts a course of hormones. It begins with a story of hope—“If I’ve just started puberty blockers, I might just have put a stop to an unwanted puberty that doesn’t match my gender identity and could range from somewhere between horrific and traumatic if it were to occur. If it’s hormones we’re talking about, either I’ve successfully dodged an unwanted puberty or I didn’t, but now I’m going to be getting hormones that will provide me some body features that will validate and solidify my gender identity. If I’m an affirmed female, I’ll grow breasts, my skin will soften, my hips will spread, my muscles won’t bulge, I won’t have to worry about unwelcomed and embarrassing erections. If I’m an affirmed male, my voice will deepen, body hair will grow (I just hope I don’t go bald later), my hips will be slim, my muscles will get bigger. If I already grew breasts, they might shrink in size. If I already started menstruating, I won’t have to worry about that anymore. And so forth.” And yet…

Nicco is thirteen. His assigned sex at birth: female. By age seven he knew he didn’t feel like other girls; by age twelve he figured out that was because he was a boy. Nicco continued to present himself as a girl at school, but this was becoming increasingly stressful to him, as it just didn’t feel right. So, in his eighth grade year, he decided to transition from female to male. His parents were okay with this but wanted him to wait until he went through puberty before considering any medical interventions, as they wanted him to keep the option open of having genetically related children through egg preservation once he started menstruating. At first, Nicco was in agreement with this, carrying the inter-generational weight of a history of genocide in his family’s country of origin, in which many family members had perished, and thus recognizing how important regenerating their family lines was for both of his parents, and for himself as well. But then something exploded inside him. As he watched his breast buds begin to grow, he panicked, to the point that he felt like killing himself, which he revealed to his parents. They definitely took notice, as they certainly did not want to lose yet another beloved family member. In consultation with their therapist (that would be me), Nicco and his parents recognized that asking Nicco to wait until he had gone through puberty was causing Nicco great distress and was not at all what he wanted. So, Nicco’s parents took him to see a pediatric endocrinologist, who started him on a course of puberty blockers, just in time, because he was just at the end of Tanner stage II of puberty. Initially, Nicco was ecstatic and came out to his peers in a moving community event at his school. His friends all hugged and held him, and he was flying high on the newly felt euphoria that was enveloping him. The clouds had lifted and the sun was shining brightly.

But the euphoria soon wore off and storm clouds appeared on the horizon. Relieved of the angst of ever having to menstruate, Nicco discovered that on the school camping trip, he still couldn’t go out in the woods and pee against a tree like all his male friends. Instead, he had to go hide in the bushes and squat. His friends, although accepting, were not as welcoming as he would have liked them to be. He had a crush on a girl, but she showed not the least bit of interest in him, and he wondered whether it was because he wasn’t a “real” boy. He grew increasingly agitated. Coming from a religious family, he railed at having been skipped over when God was giving all the other boys penises and XY chromosomes. In despair, he blurted out that he would never be able to be the boy he wanted to be. He started cutting to express his level of despair and deflation. Obviously, his parents were very worried about him and wondered whether the puberty blockers and the coming out might not have been a terrible mistake, because he had never openly expressed such distress before.

It was not the puberty blockers that were a mistake, but the lack of preparation regarding what to expect once he was on them. Given Nicco’s personality, taking more time to forecast the events to come, incorporating what would change with what wouldn’t, might have helped him be better prepared for life on puberty blockers. Stopping to pay attention to his fantasies and aspirations for life as a boy, and specifically life as a boy on puberty blockers, would have facilitated that work. On the other hand, sometimes we can’t foresee what is ahead of us, and in Nicco’s case, the work came after the crash, when through therapy he could articulate his gender deflation and its causes, have an opportunity to mourn and vent against what couldn’t be, then open up the part of him that was now ready for him to explore, realistically, what could be.

The same euphoria followed by dysphoria can show up even more poignantly in youth who have started hormones, particularly if they have been preceded by puberty blockers. I am specifically talking about body dysphoria—angst about the body one has in contrast to the gender one knows oneself to be. Hormones are supposed to remedy that, at least partially, allowing the youth to develop the secondary sex characteristics of the gender they identify as. But hormone treatment cannot turn a vagina into a penis or a penis into a vagina. The best it can do for a transgender male is to create a micropenis in the form of an elongated clitoris. Estrogen treatment cannot grow a uterus, fallopian tubes, and ovaries in a transgender girl and cannot eliminate them in a transgender boy. The hormones might help with desired height, if timed appropriately, but they might not. So, it makes sense that the dysphoria attached to puberty blockers and hormones would be a body dysphoria. The medical interventions offer promise to the body, but when they fall short of their mark, it is the body that remains the problem.

I’m thinking about Rachel, a transgender girl who fully transitioned from male to female when she entered sixth grade. As soon as she hit Tanner stage II of puberty, her endocrinologist started her on puberty blockers. Right before she entered high school, she requested estrogen so she could begin growing breasts and be on a par with her high school friends. Her endocrinologist agreed, and she was ecstatic. She became much more outgoing, joined clubs at school, and was doing well in all her academic classes. It was a pleasure to watch her blossom. But then one year later, she was showing signs of wilting. Yes, she had breasts now, yes, she had a tall, slender build that gave her a graceful, doelike appearance. But she was still a girl with a penis, and how weird was that? she asked. She, like Nicco, came from a religious family, but now she didn’t want to go to church anymore and she was having real doubts about God, because if God really loved her, God would never have done this to her, and so she was really angry at God. And, for the first time, she was depressed. Even though Rachel had spent many, many hours exploring her feelings about being female and her desire to have the opportunity to take puberty blockers and then hormones to fortify her female self, she still had the feeling that she had been sold a false bill of goods.

As with Nicco, the medical interventions—this time, hormones—failed as a magic bullet. Rachel’s symptoms of body dysphoria resurfaced, perhaps more strongly than ever before. When I think about the stage of adolescence, I think about the resurfacing of the magical thinking of early childhood—the soaring belief that anything is possible. But on the other side of those exhilarating fantasies is the crash—the risk of disappointment and feelings of betrayal in the face of the sobering reality that there is no such magic and not all is possible… and perhaps some agitated accusations: “But you promised.”

I was present at our clinic to witness Rachel’s expressions of angst and frustration upon realizing that she could never be the whole girl she wanted to be, even with estrogen treatment. I watched one of the medical members of the team, in an effort to soothe her distress, offering words of encouragement, pointing out how much better her life was than before and itemizing all the good things estrogen had provided her with. Another member of the team chimed in, assuring her in calming tones that she wouldn’t always feel this way, to the tune of “It gets better.” I felt a need to stop them, and to give Rachel the opportunity to stay with the upset feelings she was having. Anything else was like cheerleading at a funeral. I left that meeting with a heavy heart but with the realization that just as we always talk about giving parents the room to mourn the child they thought they had, to clear the way to embrace the child they discovered they did have, we need to give the youth the same opportunity: not to mourn the gender they’ve left behind, but to mourn the loss of the affirmed gender they will never have the way they wish they could—as a cisgender person. They need space to confront the reality that all the hormones in the world, and surgeries as well, will not make that possible and there’s nothing we can do to change that. All we can do is facilitate their being the truest transgender person they can be.

Will Nicco and Rachel’s future look better when they have the opportunity to choose gender-affirming surgical interventions that could allow Nicco to have a penis and Rachel to have a vagina, if they so desire? Perhaps yes, as the final stage in gender affirming medical intervention, but actually, I would say that Nicco and Rachel’s future will look better far before that, whether they go on to have surgeries or not. They both just need the time and space to metabolize the letdown feelings they are having now, without anyone trying to cheer them on to victory. They also do not benefit at such a time from “Uh-oh, did we get it wrong about you being transgender?” messages from the world around them.

Not just the youth themselves, but we, too, need to be prepared for these potential psychological tumbles and turbulence that these youth may confront. I will say that I’ve noticed deflations, like Nicco and Rachel’s, showing up more in youth who come to their gender identity later in comparison to children who socially transitioned at an early age and thus have consistently lived their lives in their affirmed gender from early childhood through puberty and beyond. The early transitioners have had years to assimilate their bodied self with their gender mind, afforded many years of adjustment to being a girl with a penis or a boy with a vagina. That very experience equips them with shock absorbers for the medical ride ahead, if they should choose to go in that direction. It is the latecomers, those who become aware of their transgender identity only later in childhood, often with puberty as the wake-up call, who are more at risk for the downward slope from euphoria to dysphoria following the introduction of medical interventions in adolescence. They have not had the advantage of years to prepare. But suffice it to say that no child is exempt from the risks of such deflation; some are just more protected from it, and we should be at the ready to receive painful feelings with enveloping arms, without being alarmed by it, wherever and whenever we see it.

Another psychological side to highlight is the experience for youth who did not take puberty blockers, went through the puberty of their assigned sex, and then later began a course of hormones. This means that these youth will go through not just one puberty, but two. Actually, this is true for a transgender person of any age, but we’re sticking to youth for the moment. I don’t know about you, but for myself, once was quite sufficient. Tackling puberty for a second round can be a challenge and quite draining psychologically. With the influx of new hormones, you can feel off-kilter, your emotions may feel as if they’re lacking a surge protector, your sexual energy may shift, your skin might start to break out, parts of your body are morphing into something quite unfamiliar. I’m recalling an eye-witness report from the college-age siblings of a younger high school–age transgender sib who had recently started on estrogen. Returning from a year at college, it was the older siblings, all three of them, who lost the surge protector on their emotions as they expressed their feelings. They were furious—their sister was not only absorbing all the attention in the family, she was hell on wheels, a PMS nightmare with no respite of a menstrual flow to alleviate the symptoms. The three sibs had only one thing to say, in unison: “You try living with that shrew for a day.” How about trying to be that shrew for a day? For an older teen, it is not easy to be catapulted back into an earlier developmental stage, in this case puberty, one that many await with eagerness before they enter but are totally relieved to exit. Psychologically, this is what we are asking all youth who have already gone through puberty to do before starting a course of estrogen or testosterone to align their bodies with their psyches. Let’s have sympathy for that.

An ongoing point of dissent regarding medical interventions for youth under the age of eighteen is that psychologically they do not have the wherewithal to make such heavy decisions that, excepting puberty blockers, are partially to completely irreversible. Further, they are not typically steadfast in how they define themselves—that’s what adolescence is all about. That is, what they feel today may vary drastically from how they will perceive themselves later, once they mature and enter adulthood, or even before that. Which means that they could grow to regret these medical decisions later in life, with potential accompanying serious psychological distress, questioning what they had wrought and why their parents did not stop them when they could. What I would say about that is that we would never want to move forward cavalierly with such interventions in adolescence; they require careful forethought. But the data to date indicate that regrets are quite low; in fact, a study of youth going through the Boston Gender Management Service (GeMS) program and another of youth going through the gender program in Amsterdam revealed that with their clinical population, regrets were actually nonexistent.[72] What we know on the other side is that transgender youth who remain in a state of gender dysphoria with no access to medical interventions have their own set of regrets, and those regrets are many: that they are prevented from living a life that feels most real and integrated to them, or that they have been barred access to surgical interventions for what seem like no good reasons. Such regrets may interfere with their ability to live a fulfilling life, or have any life at all. I don’t think we want that for our children.

We need to advocate for the ability of youth to make informed medical decisions about their gender affirmations and to give them a voice in their own gender care, acknowledging the goodness of these decisions for their gender health. I have come to realize that in doing so, we are simultaneously doing something much broader—challenging our cultural understandings of adolescent development. We need to accept that sixteen-year-olds have the maturity to do long-term planning for themselves, the foresight to project into the future and envision where they will be across time, and the stableness of self required to make informed medical decisions with permanent effects. In other words, we must give teens in our culture more credit than they often receive for sanguinity and level-headedness, and reconfigure their adolescent stage from an emotional platform of Sturm und Drang to a place of wisdom and self-reflection.

Parents’ Gender Creativity at Its Weightiest

Sixteen may be the new thirty, but sixteen-year-olds in the United States, unless emancipated minors, have not reached the age of legal majority. Although we require that they give assent to their medical care, only their parents or guardians have the legal authority to consent to any medical intervention, be it puberty blockers, hormones, or surgeries. This means that for parents or guardians, the gender journey is not just about what you call your children and how you signify their gender marker, the latitude you give them to express their gender as they see fit, the steps you take to make sure they get the support they need at school, in your extended families, and so forth. You also carry on your shoulders the inordinate weight of making medical decisions for your children—some reversible, some only partially reversible, some irreversible—because your children are not old enough to medically sign off for themselves. As some parents have put it, “We’ve left the world of playing policeman to our children’s gender and are now in the position of having to play God.” And while they’re put in the position of playing God, a lot of people are looking over their shoulders with a critical eye, even going so far as to accuse them of child abuse for consenting to these medical procedures.

If you are a parent of a youth who has reached the age of legal majority in the country in which you reside and is seeking a medical intervention to affirm their gender, you may be on the opposite side of the fence: now left in the situation of holding your breath and hoping against hope that your child, barely an adult, can make wise medical decisions, decisions over which you now have no legal control. You may feel helpless to stop them if you feel that they are headed down the wrong path and might make a decision about an irreversible medical intervention that can’t be undone and that they’ll deeply regret later. If you should find yourself in this situation, you can call on your bond with your child to open up a discussion, to express your concerns and listen to theirs. If you are paying for their medical care, you can elect to not cover the cost. But what you cannot do, legally, is stop a youth of legal majority from moving forward with a medical gender intervention.

In your child’s early years, you may also bear the weight of watching your child be burdened with information and decisions that they shouldn’t have to be dealing with at such a young age. Why should a twelve-year-old have to grapple with assenting to a procedure that might render them infertile? Why should they have to make informed decisions about their own future fertility, or lack of it, at an age when their friends only have to think about the latest Facebook postings? Aren’t we robbing them of their age of innocence by forcing them to create an avatar of themselves at age thirty? Why should a child have to make the decision to undergo a second puberty if gender affirmation using either testosterone or estrogen comes only after that child went through the puberty of their natal sex? Wasn’t one puberty quite enough?

In your darkest moments, you as a parent might feel guilty for not having given your child the chromosomes and biological accoutrements that would have made all these medical interventions irrelevant. I’m recalling when my young adult daughter, who was dancing professionally at the time, discovered that she had a torn meniscus flap in both her knees that required surgery to repair. Her doctor informed us that the condition was not caused by Rebecca’s dancing but was a congenital condition, present at birth and only later aggravated by her intense dance regimen. All these years it was a surgery just waiting to happen. I sat with Rebecca in the doctor’s office listening to the news, and what did I think?—It’s all my fault. I made her that way. I should have done better in making her. And now she has to suffer through surgery and take a leave from her dance career. This was not a passing thought; it took me a while to shake the feeling. You can imagine how much more profound that same “blame thyself” feeling can be when it’s not just a knee but your child’s whole gender self at stake.

You might not take it to that extreme, but it is not uncommon to feel the pangs of a gender ghost pulling at your heartstrings—maybe there really was something you did that made your child unhappy with the sex assignment on their birth certificate. Maybe if you had gotten your child early enough to a therapist like the one in Toronto who could have helped them live comfortably in their own skin (that would be a cisgender skin), these medical burdens could have been lifted. And now you have to worry about the potential side effects of the hormones your child will be taking, already fretting about whether your trans son should have his uterus, ovaries, and fallopian tubes taken out or, if it’s your trans daughter, about whether she should have her gonads removed, to prevent in either case the risks of cancer.

And what about the burden of making medical decisions on your child’s behalf that your child might regret later? A scenario pops up on your mind’s eye of your child coming back some day and throwing it in your face, accusing you of being a negligent parent for letting them go forward, when just a kid, with a medical intervention that has no backsies. What if your child hates you forever, or you’ve spoiled their life?

With all these images potentially dancing in your head, you are faced, as a layperson, with the daunting task of sorting out the controversies in the field about whether and when a youth should receive medical interventions to enhance their gender health. We know that parents hold the right to veto a medical intervention requested by their child, a request often accompanied by a recommendation from a medical or mental health professional. Some parents are opposed to any medical interventions or don’t want these decisions done on their watch, and so they take the stance, “When they’re eighteen, they can do anything they want.” That is certainly a parent’s prerogative. The problem with that approach is, their child may be one sorry mess by the time they’re of legal age to make their own medical choices. It therefore behooves parents who are leaning in the “You can do anything you want once you’re a legal adult” direction to remember the adage “Doing nothing can equate with doing something,” in this case something that will not be in their child’s best interests and could cause their child unnecessary pain and suffering, either now or in the future.

Circling back to the fertility issues, this angst about parents’ decision making on their children’s behalf comes up most poignantly around reproductive choices to be made. At this moment in history, we are on the brink but have not yet mastered the art of turning nongamete tissue into reproductive material. Therefore, if you don’t have viable mature eggs, you cannot reproduce. Likewise, if you don’t have viable mature sperm, you can’t reproduce. So, parents learn from the doctor what we have already discussed: that a child who goes on puberty blockers prior to the onset of menses or the production of mature sperm ejaculate and then goes straight to hormones has foreclosed the possibility of having genetically related children in the future. This prospect may lead some parents to shy away from consenting to a medical intervention that forecloses those fertility options. They might refuse puberty blockers until their child is menstruating or producing sperm, so that even if they go on hormones later, they have the options of going off their hormones and having their reproductive system kick in again. Or if their child has already gone through natal puberty but now wants hormones, before consenting to hormones the parents may insist on creating a security deposit box of gametes for the future by collecting and then freezing eggs or sperm. It should be mentioned that this option, especially egg extraction and preservation, is quite costly, available only to those with the financial means. Furthermore, right now the shelf life of frozen eggs is only about ten years. Of course, these procedures cannot proceed without the youth’s assent as well, but the youth may feel pressured into assenting to fertility preservation procedures so as to get the parents to sign off on the hormones.

Here is where the shadow of a grandparent shows up before its time. Many parents are focused on their children’s future fertility not so that their children can become parents, but so that they will have grandchildren. This is the moment where the parents might need some help: “Let’s think about who you’re really doing this for, you or your child.” I’m reminded of another family I worked with, similar to Nicco’s. Their thirteen-year-old daughter, Karyn, began to question her gender identity. She wondered whether she might be trans. They were exploring together as a family whether it would make sense for Karyn to go on puberty blockers. Her parents were very clear that this would be fine, but only after Karyn started menstruating. Karyn’s parents had no other living relatives, so keeping the family going was very important to them. Karyn, with what seemed like an inordinate level of maturity for a thirteen-year-old, appeared to agree, saying, “Yes, I will wait until I menstruate so that I may have an opportunity to have my own kids someday, which has always been important to me.” Yet somehow the words did not ring true to me. As time went on and Karyn and I began to meet individually, it didn’t take long for her to break down and sob, “I don’t want to have periods. And I sure don’t want boobs. And I don’t care if I adopt children. I can’t do this.” Karyn was acceding to her parents because she was a compassionate child and empathized with her parents’ desires. But Karyn couldn’t be the receptacle for her parents’ longing for grandchildren; the weight was too much for her. And she knew, beyond a doubt, that if she grew breasts she would want surgery later, and if she got periods she would be horrified, experiencing the flow of menstrual blood as a betrayal of her burgeoning male self. Fortunately, Karyn’s parents were as compassionate as she was, and after recognizing that she was in agony, they made sure Karyn got the puberty blockers she urgently requested, to help her go forward more securely and authentically in her gender journey.

I hope Karyn’s story will be a helpful message to parents. Time and again I watch youth weigh keeping their fertility options open against postponing obtaining their true gender identity, and time and again I watch the decision to affirm their gender and forgo fertility win out. Can a thirteen-year-old truly know that? Yes, I think so, in the same way that a thirteen-year-old is capable of making a choice that will save their life even if it means losing a limb or living with only one kidney. We could say, “Well, yes, but that’s a matter of life and death.” So is this for many gender creative youth—to affirm their gender or face crushing despair.

Oh, the Doctor and the Therapist Should Be Friends

I would like to bring this chapter to a close by endorsing a model that is being discovered all across the continent, certainly at our gender clinic at UCSF. The best medical decisions for gender-nonconforming and transgender youth are made when the circle opens up to include the doctor, the therapist, the educator, and even the lawyer… and of course, the youth along with their parents or caregivers. We all put our heads together so we can see every side of the elephant.

In the midst of writing Gender Born, Gender Made, I helped give birth to the Child and Adolescent Gender Center. It was not fully born by the time the book was published, but now it is. And the birthrate has been phenomenal in the past half-decade for other programs like ours. Many of us have reached our hands across the continent and beyond to share what we’ve learned and establish ourselves as an international gender affirmative consortium of medical professionals, mental health professionals, attorneys, educators, academics, researchers, community advocates. Each month I hear about another program that has popped up to offer services and supports to gender creative children and their families. And those who are the children and parents have been our greatest teachers in alerting us to what we are doing right, what we are doing wrong, and what needs to be tweaked. So, I want to share what we are all learning together. It sounds so trite to say it takes a village, but that is the simple truth when it comes to promoting gender health. We are learning that the best way to help gender creative children’s garden grow and make sure they get the medical and mental health care they need is to populate that garden with professionals and parents working together as a collaborative team to fertilize the children’s gender creativity and affirm their true gender self. We couldn’t do it without a doctor in the house.

^{CHAPTER EIGHT}

Into the Streets/Onto the Screens

I have always pinned my faith to that spirit which is slowly coming into its own in America.

—Emma Goldman

IN THE BURGEONING OF community psychology in the late 1960s, we who were training to become psychologists were urged to think of psychological services as a storefront operation. The personal was both social and political, and many of us were trained that if we just stayed in our offices or up in our ivory towers, no real change would ever happen. Little did I know then what fine preparation this was to be for working with our gender creative children and their families as we clear the path for their gender journey. And to create those pathways, I am definitely pinning my faith on the spirit coming to its own in America, and beyond.

When it comes to what makes a child’s gender, I adhere to the model of the feedback loop: The child influences the parents who in turn influence the child. Now let’s create a series of concentric loops around the parent-child loop. The world around the gender creative child and family influences the child’s gender, while the gender creative child and family and their allies influence the surrounding world’s sensibilities about gender—the world of extended family, the world of the neighborhood, the world of school, the world of the local community, the world of religious institutions, the world of media—entertainment, news, print, and social; the world of academic studies and research science; the world of medical practice; the world of local and national social mores, action, and advocacy; the world of government law, legislation, and policies; the global world. John Donne was already hinting of these loops four centuries ago when he wrote “No man is an island / Entire of itself,”[73] poetically signifying the ways we are connected to all around us. But I think he missed the two-way street of that connection: Each of us is strongly influenced by the world around us, just as we influence that world.

It is that two-way street that represents the quintessential equation of action for gender creative children and their families. Andrew Solomon in Far from the Tree couldn’t have put it better, “A tolerant society softens parents and facilitates self-esteem but that tolerance has evolved because individuals with good self-esteem have exposed the flawed nature of prejudice.”[74] In that spirit, substituting the word acceptance for tolerance, all of those who are part of such families live within a set of concentric circles that have an influence on their child’s gender opportunities; whoever lives in those families will inevitably enter those circles and alter them, by either stretching them or breaking them open where necessary, whether by conscious intent or simply by being present in the world.

This chapter is all about the inside/out of gender. We’ll zoom in on two specific subsets of social forces—(1) schools, and (2) social, entertainment, and news media—each in its own way strongly influencing the directions of our twenty-first-century children’s gender journey. Then we’ll reverse directions and highlight the incredible force field of the child and family that, in unison with the activism and advocacy of themselves and/or their allies, have come to be the movers and shakers catapulting us into a new world of gender, in schools, on screens, and beyond.

Just five days before I embarked on writing this chapter, the US Supreme Court declared marriage a constitutional right of every American. If you had asked me five years ago while I was in the final stages of writing Gender Born, Gender Made, whether marriage equality for all people in the United States could be possible in the very near future, I would have said, “Only when pigs can fly.” But flew they did, at incredible speed. In a remarkable combustion of community advocacy and shifts in attitude, gay and lesbian individuals have been secured rights to a central arena of life in which they can finally be recognized as full human beings who fall in love, marry, and have children, if they desire, just like anyone else. And although I have said repeatedly that sexual identity and gender identity/expressions are two separate tracks, they do sometimes cross. Right now the victory for marriage equality in the United States gives us tremendous hope that the next terrain of gender victories is close at hand and already in evidence. It now seems imminently possible that the gender force field in place will pay off from the inside out and then back to the inside: There will be a universal end to conversion therapies for gender-nonconforming youth; our children will be granted full protection at school and in their communities—to be acknowledged with appropriate names and pronouns, ensured their rights to engage in activities and use the facilities that match their affirmed gender rather than the sex originally listed on their birth certificate, and so forth. It has already begun. Let’s test it out by looking at schools, screens, and streets.

Schools

All that I have to say about schools I have primarily learned from Gender Spectrum and particularly from Joel Baum, senior director of Gender Spectrum, director of education of the Child and Adolescent Gender Center, and my close colleague and friend. Gender Spectrum has set a mission: to help create gender sensitive and inclusive environments for all children and teens. One of its major targeted environments: schools. What the speakers do when they get there—I call them the gender ghost busters, but, borrowing the words from their Web site:

In a simple, straightforward manner, we provide consultation, training and events designed to help families, educators, professionals, and organizations understand and address the concepts of gender identity and expression. Our accessible, practical approach is based on research and experience, enabling our clients to gain a deeper understanding of gender all along the spectrum.

We present an overview of how society currently defines gender and how these restrictive definitions can be detrimental to those who do not fit neatly into these categories. We then help you identify and remove the obstacles so all are free to be their authentic selves.[75]

In the United States, children as young as two years of age begin to spend a good proportion of their waking hours in school or day care. They learn their colors; their letters and numbers; to read; math and science; new languages; about the world around them; to think; the rules of society and how to get along with others; and to trust their teachers (or not). It is within those last two modules that things can either go belly up or blossom beautifully when it comes to “gender learning.” As soon as a teacher asks all the girls to line up on the left side of the room and all the boys on the right, every child in the class has been taught an important gender lesson: there are only two choices, boy or girl, and you have to fit into one or the other, and it’s the teacher’s choice, not yours. Too bad for children who think they may be both or haven’t yet broken the news that they’re not the gender everyone thinks they are, but the other or another one altogether. Too bad for children who get along better with the people in the other line because their gender expressions are a better fit with those little folks. The lesson to the young children: Gender is a very narrow path with only two tracks within it. Anyone who doesn’t fit is an oddball or a rule-breaker.

Now switch to an alternative method of lining up: Everyone with birthdays from January to June line up over here; everyone with birthdays July to December, over there. Presto: No more gender-boxing; no more stopping in your tracks if you don’t know where to line up; no more lessons about just two tracks. You might be embarrassed that you don’t know what month you were born in and have to ask the teacher, but that’s a far less daunting task than having to hide behind a gender mask to suit the teacher’s line-up rules. The former—an awkward moment; the latter—a marker of many more gender microaggressions to come. And this alternative nongendered line-up routine comes with the perk of a learning moment—you can learn the months of the year, you can memorize your birth date if you haven’t already. What you won’t learn is that gender is only boy or girl, and the teacher, not you, decides who you are. And that is a good thing.

I won’t belabor the point about schools and bathrooms. Similar to the hysteria that erupted in the late twentieth century about the dangers of gay men teaching young children and either molesting or converting them, the apoplectic mania about bathroom use for transgender and gender fluid youth is amazing in its reactive emotionality: It will open up the doors for boys to break into girls’ bathrooms posing as girls and molest them; expose children to private parts different from their own; freak out our cisgender, gender-conforming children; and so forth. All these gender creative children want to do is relieve themselves throughout the day in a milieu that feels most comfortable to them, like any other child. California has mandated that all public schools in the state allow the children to do just that. But other states do not have such statutes, and private schools that do not receive public funds are not bound by those directives in states where such statutes exist. So, we have children who end up with urinary tract infections because they avoid school bathrooms altogether, or who sneak into the bathroom matching their affirmed gender when they’re sure no one is looking, as if they were either committing a crime or entering a potential war zone. I’m thinking of an eleven-year-old I met with who was in the throes of sorting out gender. Assigned female at birth, at the end of the first session this youth whispered to me, furtively looking around to make sure nobody was listening, “Sometimes I go into the boys’ bathroom and it feels so good. But promise, promise you won’t tell anyone.” Our toileting functions are definitely private affairs in Western culture, but they shouldn’t have to be dark secrets.

Yet children do not spend most of their school day in the bathroom, unless they’re hiding out altogether from the stresses in the hallways, classroom, or playgrounds. Moving to the classroom and to the schoolyard, we also know the potentially disastrous psychological effects when gender creative children and youth are teased, harassed, or even physically attacked because of the gender they are. Studies repeatedly indicate that gender-nonconforming children and youth may encounter such abuse on a regular basis in the course of their school day. This puts them at risk for anxiety; depression; drug and alcohol abuse; self-harm; and suicidal thoughts, attempts, or successes.[76] And we know that children do not learn as effectively when they are not accepted for who they are or feel they have to hide who they are.

In the last five years, there have been tremendous efforts, led by parents, community activists, outside professionals, and school personnel themselves to free their schools from transphobic fear or thoughtless actions and replace them with gender-expansive practices. Advancements have included asking all children what pronouns they like used for themselves at school and what names they like to go by, and making sure this information is communicated to all school personnel, if the children so desire, as well as eliminating gender divisions in activities and programs and providing reading materials that represent children of all genders rather than just two. In August 2015, Schools in Transition: A Guide for Supporting Transgender Students in K–12 Schools was released online.[77] It is a joint project of the ACLU, Gender Spectrum, the Human Rights Campaign, the National Center for Lesbian Rights, and the National Education Association. In my view, this was an act of activism and an act of love by the heavy hitters in our field. We could call them a concentric circle around the families; I’d prefer to call them a halo. In the foreword to the guide, Janice Adams, superintendent of the Benicia Unified School District in California, sums up the guide very succinctly:

This guide to supporting transgender students builds on the experiences of educators like myself and the advocates who have supported us along the way. Moreover, it ensures that the knowledge we have gained as we worked to support these students can serve as a model for other educators, parents, counselors and students. In doing so, we hope to provide a foundation so that schools and classrooms become more accepting of gender diversity and where all students can feel supported and safe.[78]

The opening chapter puts out a call to all educators: “Instead of ‘putting out fires’ by treating the needs of each transgender student as an issue to resolve, schools should engage in ‘fire prevention’ by fostering a school environment that celebrates gender diversity.”[79]

Increasingly, schools are doing just that. Scout is a six-year-old attending public school in a large urban area. Scout is in the midst of gender exploring. Scout is gender-ambidextrous—on some days exercising a girl self, on other days, a boy self. Scout just completed kindergarten. The kindergarten had its own bathroom attached to the classroom, available to all children—girl, boy, or other. It also had its own outside play area, separate from the older grades. Scout, a somewhat shy and withdrawn child by temperament, did fairly well in kindergarten, although sometimes thrown off by classmates’ questions—“So, are you a boy or a girl?” But first grade was coming up, which required children to leave their classroom in search of either the boys’ or the girls’ bathroom in the hallways, throwing the first grade children into the melee of all the older students in the school. Arlene, Scout’s mother, was extremely anxious about first grade: not just the bathrooms, but the exposure to older children who might bully and harass Scout for Scout’s gender creative presentation. And then along came Scout’s new first grade teacher: a young gay man. The first thing this teacher did before the start of the school year was to push the school to create a school-wide gender-neutral bathroom for any who would want to use it. He made sure there were books in the classroom demonstrating gender in all its diversity, next to the books about the rainbow spectrum of families. Then he called in Scout’s parents, having heard from the kindergarten teacher about Scout’s gender ambidexterity, and asked them how he could help make sure Scout had a positive first grade year, given Scout’s gender creativity. Arlene burst out crying in the meeting and expressed her fears about Scout, a gentle child, being teased or even beaten up because of Scout’s gender presentation, concerned that since Scout was also not a very verbal child, she would never find out if he was being harassed. The teacher assured her that he would (1) provide a learning curriculum for gender acceptance for his classroom and push other teachers to do the same in theirs; (2) set up a team of adult allies for Scout, especially having one of those team members available during schoolyard time, so Scout would know who to go to and so the team could also monitor for any gender-rejecting/harassing behaviors; and (3) contact Scout’s parents immediately if there was an incident at school, so they could all work as a team to both support Scout and ensure Scout’s gender resilience. Au contraire to the irrational homophobic fears of gay teachers’ being allowed to teach young children, it was this teacher’s own early history of teasing and harassment, not for his sexual identity but for his early gender-nonconforming expressions, that both informed and bolstered his dedication to making his classroom, and the school beyond his classroom, a gender-safe and gender-expansive environment for all students, with a special eye on Scout.

Scout lucked out with this amazing teacher, but I would like to say that more and more schools, individual teachers, and educational organizations around the country have been contacting gender specialists and gender organizations to ask, “How can we do it better?” Understandably, not all schools are on board, and it is a work in progress, but progressing it is, and the more this concentric circle around gender creative children and their families fortifies their school-based gender-expansive practices, the more the psychological risks to gender-nonconforming children will go down, along with the worries of their parents. Caitlin Ryan and her colleagues poignantly demonstrated the positive mental health effects when LGBT youth are supported by their families. I would argue that schools, where children spend most of their day and build the bulk of their peer relationships, are the second in line to provide this same good effect.

Screens

A book about gender in the second decade of the twenty-first century would not be complete without addressing the relationship between gender creativity and screens, and print media as well. Since I wrote Gender Born, Gender Made, there has been nothing short of a media explosion on the topic of transgender and gender creative children and youth, not to mention adults (witness Caitlyn Jenner on the cover of Vanity Fair in July 2015). Also in 2015, within just a few months of each other, three significant documentaries were released featuring gender creative children and youth: Three to Infinity: Beyond Two Genders, by Lonny Shavelson; Growing Up Trans by Miri Navasky and Karen O’Connor, broadcast on PBS’s Frontline; and Louis Theroux: Transgender Kids, broadcast by the BBC. Each of these films had a unifying three-pronged message: Children and youth come in a variety of genders; the journey, for both parents and child, can be a challenging but rewarding one; there are professionals out there supporting the children to be who they are.

Documentaries are not the only show in town. The character Billy Elliott danced across both stage and screen, sending the message to youth across the globe that working-class English boys can be ballet dancers and they and their male friends can wear dresses in happy celebration, rather than dark closets. Before that, the character Ludovic in the film Ma Vie en Rose brought to life the poignant story of a child in Belgium struggling to affirm his gender creativity against great odds. Kids all over the world have been watching I Am Jazz, a young girl’s happy and confident account of her gender journey from male to female, as well as reading the acclaimed children’s book of the same name, coauthored by Jessica Herthel. Transgender actor Tom Phelan plays a transgender boy on The Fosters, which airs on the ABC Family network. Alex Newell has become a regular actor on the TV series Glee, playing a transgender teen girl, Unique Adams, at McKinley High. Moving into adulthood, Laverne Cox plays the vibrant character of Sophia Burset, a transgender woman valiantly struggling with life in prison, while Jeffrey Tambor plays the compelling role of a father discovering he is a woman and transitioning from Morton to Maura in the acclaimed TV miniseries Transparent, which received a Golden Globe Award in 2015.

A major tool of oppression in any society is to render people invisible. The oppression lifts when people are seen and acknowledged, but also when they can find themselves reflected back in the community and society in which they they live—when there is a positive social mirror for them, not one marred by distortions, but an accurately reflecting one. When they can find nobody like them, they are indeed an island, if not stranded on one. We are seeing the proliferation of such social mirrors as more and more gender creative children find themselves in movies, television shows, on billboards, on YouTube, in tweets, on Tumblr, on Web sites, in front-page newspaper articles. Far from a freak show (although this might be how the far right would prefer to have it), what we are finding are positive images of children and their families as they carve out a gender path for themselves. These new social mirrors both reflect and effect attitude changes among the populace viewing these images of children, their families, and their allies, but the mirrors also do something critically important for the children themselves. The images allow them to find themselves and to celebrate their visibility. Moving beyond the direct mirroring from family and friends, these positive media representations provide one more mirror in which to discover themselves and be able to say to other people—“Look everyone, this is who I am, too, just like the kids in the movie.”

Some years ago a youth that I was seeing in therapy, prior to seeking me out as his therapist, had just by chance turned on the radio to the NPR radio program “Two Families Grapple with Sons’ Gender Preferences,” in which I had been interviewed alongside Dr. Ken Zucker. On the show, I had given a description of transgender children in positive terms. In shock, my patient, listening to me talk, turned to his mother and blurted out, “Mom, that’s me! I want to find that woman and go see her.” A determined young person, he did seek me out and was able to come see me, since we both lived in the larger Bay Area, although he came from a very small town nearby, while I was a big city girl. One of the transgender teens showcased in the 2015 Frontline film Growing Up Trans, reported an identical experience to my patient’s. He said he never knew who he was until he read about someone on the Internet, and then he shouted out, “That’s me!”

These are not rare incidents, and not just the youth but their parents or caretakers may also have the same “Aha” moment, as a result of exposure to media accounts. Let me illustrate with an excerpt from a story written by a foster parent about her gender journey with her then eight-year-old foster child:

When he was between six and a half and seven years old, we were at Disneyland in our hotel room, when our daughter-in-law (staying in another room) opened the door and said, “You need to come and watch this.” It was a talk show on TV where they were talking to a family with a transgender child. We couldn’t believe what we were hearing! It was as if they were telling our child’s story, even to the obsession with princesses, mermaids, and fairies!

One year later, this family, with the support of educational and mental health professionals, had facilitated their foster child’s social transition from male to female, and she is now a beaming transgender girl. Would that have happened without the mirror provided by that TV talk show? No doubt eventually, but because of the opportunity to view the show this family more quickly discovered a clear reflection of the child they had, which translated into that child’s finally being seen for who she was, rather than remaining invisible. So, the mirror can benefit the child both directly or indirectly, as illustrated in each of these stories.

Now let’s turn to the Internet and social media. Before the advent of Web sites, YouTube, and smartphones, youth who were questioning or exploring their gender might easily experience themselves as the only one in the world with this “problem.” “Trans” was the issue of which we did not speak and also the image that we could find nowhere. Now, with a click of a button, you can connect to people just like you all over the globe—trans people, agender people, genderqueer people, gender fluid people, and so forth. No longer are you stranded on a desert island with just yourself. And this time, with access to interactive chatrooms, instant messaging, Skype, FaceTime, and so forth, the mirrors are two-way rather than one-way—they are you viewing someone else as someone else is viewing you. And then you can actually step inside the mirror and make contact with the image you are seeing. Unlike passively viewing a documentary, you can talk, see each other on-screen or perhaps later in person, and share experiences with another gender creative person like yourself. And you can connect to a whole lot of people at the same time. This is a boon to all gender creative youth, but especially to those from isolated areas in which gender diversity is hardly celebrated but instead rejected or maligned. It is also a boost to shy and introverted youth who would be hard-pressed to reach out in person in their own community, yet feel safe having virtual interactions via Internet and smartphones. This distance-connecting may also be the most comfortable means for gender creative youth who are somewhere on the autism spectrum, reducing the elements of social anxiety through virtual rather than in-person interactions. Friendships and support groups are built through just such mediums. When you are of minority status and/or when you live in an area of the world where you cannot find anyone else like yourself, meeting up with other gender creative youth through the Internet and social media not only can be a perk, it can be a lifesaver. And for some who would otherwise feel desolate in their gender journeys, by hearing other people’s stories and connecting with those people, it makes a tremendous difference to know that indeed “it gets better.”

The only caveat here is that when “virtual” friends substitute for real-life friendships, it can make for a very “as-if” life and also leaves youth at risk for connecting with made-up characters rather than true gender creative friends. For example, Sonia tells me about her wealth of transgender friends, including her best friend. As we explore further, I discover that she has never been in the same room with any of them. They are, to a person, online friendships. On the positive side, Sonia has been able to test the waters of friendships as a newly transitioned transgender girl, without having to worry about people entrapping her in her previous ill-fitting male persona. But her virtual connections are also getting in the way of reaching out to real people in her community, supportive or like-her people she could hang out with, go to movies with, or meet for dinner. In retreating from a world that did not treat her well, Sonia, by clinging to her online friends, has at the same time insulated herself further in a virtual world, albeit a safe world, but one in which she is suspending herself rather than overcoming the inhibitions and fears about being herself in the “real” world. Real genders need real worlds to live in. There is a risk to them if they exist only in virtual reality. In situations like Sonia’s, best to rely on the Internet as an adjunct or stepping stone whenever possible, not as the central venue of relating. And just like parents of any other teen, parents of gender creative youth reaching for connection through the Internet will need to be on board to monitor contacts and coach their children on Internet safety to make sure that they are not falling under the influence of individuals posing on the Internet with less-than-friendly intentions in making contact with the youth seeking them out.

Moving back to the positive attributes of online connections, everything I have just said about gender creative youth applies to their parents as well. The journey can be equally as isolating for parents, and discovering families throughout the country and beyond through Internet support groups may be as life-saving for them as Internet connections are for their gender creative children. I would like to take a moment to pay tribute to Edgardo Menvielle and Catherine Tuerk for setting up the first of such parent support networks in the United States through the Children’s Gender and Sexuality Advocacy and Education Program based in Washington, DC, a network that continues to this day. In the words of Menvielle and his colleague Darryl Hill, through such support networks:

Gender unconventional children and parents increase their self-esteem and protect it from future attacks. Supportive communities offer alternative relationships in which to feel included, valued, and respected.[80]

If the Internet can provide just that for both the gender creative children and their families across the country and beyond, we should be all for it.

But just as it is the best of times and the worst of times when it comes to mental health and gender creative children, so it is for screens. There is no doubt that a media explosion has occurred in the coverage of transgender/gender-nonconforming children, their families, and the professionals who serve them. Regarding exposure, mirroring, and education, this has been a very good thing. Yet there are some drawbacks in the media explosion of which we all need to take heed. Some of the media presentations, particularly the TV talk shows, have turned a child’s personal story into a dog-and-pony show for the voyeuristic interest of the audience. Right-wing pundits have jumped on the bandwagon to create a platform for their own histrionic and hostile defamations of gender creative children and their families. And then gender affirmative experts have to spend an undue amount of time confronting these misconceptions and setting the record straight about the care of gender creative children—no, six-year-old children are not receiving genital surgeries; no, puberty blockers are not a form of child abuse; and so forth. Recall that gender is no longer bedrock but, rather, moving boulders. This can kick up some pretty thick dust. And those who are threatened or outraged by the dismantling of the binary gender system have the opportunity to use screens to broadcast hurtful messages. Stay tuned to Fox News and you will see it happen. Exposure to such vitriol can never be in any child’s best interests. Hopefully, these negative and harmful tropes will be eclipsed by the increasing number of gender affirmative messages available, on-screen and in print, but know that these hellfire-and-brimstone narratives still remain toxic pollutants for gender creative children and their families, not to mention for the society at large.

Many youth will come to see me and dictate scientific facts about their gender, about medical interventions, and so forth. Increasingly, they are coming in as their own experts. I have said that we learn from the children, but they are also learning from the Internet. They not only find themselves reflected in the Web sites they seek out; they educate themselves—about gender categories, puberty blockers, hormones and surgeries, legal name and gender marker changes, social networks available to them, medical providers, support groups, binders, voice-training apps, stand-to-pee devices, packing, coming out… about anything they want to know along their gender journey.

Self-education is a tool of empowerment, a tool that can only serve gender creative youth well—unless they are getting inaccurate information. And herein lies the underside of an Internet knowledge base for gender creative youth, particularly one that then gets passed on by word of mouth. We all know the old game of Telephone—you whisper something to one person who whispers it to the next person, and by the time it gets to the last person, it bears little resemblance to the original message. Such is the fate of some of the information that comes across the Internet into the mind of eager learners—including gender creative youth. Fifteen-year-old Celine came for a visit with me and explained that even though she had already gone through male puberty and had to shave every morning, as soon as she started taking estrogen, which she hoped would be any day now, her whiskers would disappear and her voice would become feminine and her Adam’s apple would just fade away. A friend of hers on Facebook assured her of that and said that’s exactly what happened for her. Celine was temporarily crushed when she found out this was myth, not truth, and that to eliminate her facial hair she could pursue laser treatment or electrolysis, and to feminize her voice she could pursue voice training, and she may have to think of a tracheal shaving further down the line, but estrogen would not do the trick. Celine recouped fairly quickly, but only after getting angry and accusing me of being outdated and ill-informed, and only after shedding many tears upon the realization that estrogen was not a silver bullet and was going to be able to do only so much for her. Youth itself is a bundle of fact and fancy, as it should be, and so it is for the Internet education of gender creative youth. The residue of misinformation can easily be removed through dialogue with a trusted person who possesses the accurate information, but keep in mind that not all youth have access to such an individual and so are left to the vagaries of the Internet to build their repertoire of gender knowledge. To that end, it behooves all who are experts in the field to publish material for youth that is accessible, readable, and accurate, such as Trans Bodies, Trans Selves,[81] for knowledge is powerful only if it is accurately informed.

Then there is the problem of “scripting,” made available through the eloquent personal stories showing up daily on the Internet. Remember the dictum “It is not for us to say, but for the children to tell.” Our job is to listen. So I do. Occasionally I will hear a narrative from a teen that sounds like an audition for a play—that is, a memorized script. Here’s how it might typically unfold: A youth comes in and reports to me their newfound discovery that they are transgender. As I listen, I notice flatness in the account, almost like that of a younger child reciting aloud from a reader in class. And then I begin to think that I’ve heard the words before, as if maybe I read from the same reader. It is not from a reader but from the Internet that I recognize the words. This youth is borrowing someone else’s narrative. I can’t tell yet whether it’s really who this youth is, or whether they are borrowing someone else’s clothes. It doesn’t mean that the story isn’t the youth’s own, just that the words aren’t. What I have to figure out is whether the borrowed words are expressing a true gender self that matches those words, or if this is a posing of sorts, perhaps trying on someone else’s identity for size.

Why are youth pulling scripts off the Internet to describe their gender self or gender identity? For many reasons, including: They borrow the words of others because they fit perfectly and are articulated so much better than they could say themselves; they are still searching or perhaps floundering and, to right themselves, appropriate someone else’s story as their own; they have an agenda in coming for a visit and use a set script to accomplish their goal (e.g., getting a letter of support for cross-sex hormones); it is safer to tell someone else’s story than their own. Regardless of the motivation, the Internet-recited script, so available to our youth, presents a conundrum for parents and providers alike. How do we sort out the authentic words of a gender creative child from words adapted from a narrative so readily found online—a narrative that may turn out to be a real story, but perhaps not that child’s story?

We’ve already established the challenge of finding the children in translation. Youth’s access to both the Internet and social/popular media only complicates the tasks of interpretation. The child may have borrowed an Internet script because it’s a perfect fit; the child may be suffering from TMI—flooded by too much Internet data—and simply grabbing on to one piece of it as a life raft; through adapting an Internet script, the child may be hiding behind a false gender self while struggling to let the authentic one come out. All of this becomes grist for the mill in the gender journey—brought on by the Internet, one more element to consider when bringing children’s authentic gender into focus and helping them discard what is either inaccurate or inauthentic.

Sometimes it’s not a script but a label that is borrowed. In Chapter 2 we talked about all the possible categories of gender available to children today. Popular and social media play their part in broadcasting gender in all its rainbow of colors. This can potentially influence children toward one self-label or another. So, how do we know when a label is borrowed rather than hatched from within? The answer: with time and exploration. Sooner, or perhaps later, the “real me” will emerge. And are children being bombarded with too many possibilities? Perhaps, but better too many than not enough. In no way does borrowing scripts or adapting self-labels cancel out the virtues of the Internet as a nurturing concentric circle surrounding the family with feedback loop possibilities, for we must remember that not only does the Internet influence the children, but the children (and their families) are also responsible for the postings, YouTube videos, and blogs that are appearing daily and influencing others. In essence, the gender creative children and their families are speaking to themselves from themselves.

One last cautionary reminder about social media—it is a way of connecting, but it is also a means for “outing.” Youth who thought they confided something in confidence may find their newly discovered gender self broadcast across the globe on Facebook before they were ever ready to go public. Parents who have no idea about their child’s gender explorations may suffer gender shock if they unexpectedly and by happenstance receive the message through social media. When we say, “If we listen, the children will tell us who they are,” we also have to provide a space where it is safe to speak and the listeners have the supports they need to hear. Social media has the capacity to provide that safe space, but it also runs the risk of robbing children and their families of safety and privacy, instead leaving them at sea knocked about by the jetsam and flotsam created by gender outing or gender shock.

Yet, on balance, the ability of gender creative children and their families to learn, to connect, to seek support, and to tell their stories through social media, and see their own stories told in positive terms through popular media is one of the most gender-expansive phenomena that has occurred in the first part of the twenty-first century. Could we say that it reflects the spirit that is (not so) slowly coming into its own in America (and beyond)? Indeed.

Into the Streets

When Abe finally gets up the nerve to dance down the street in his favorite red velvet dress, that’s taking to the streets. When Julie’s parents politely but firmly correct the local shopkeeper who keeps misgendering Julie, because, even though told that Julian has transitioned to Julie and prefers the pronoun she, he keeps using “he” because he thinks this “trans stuff” is nonsense, that’s taking to the streets. When Melinda appears at least once a week in the principal’s office to bring up an incident or a policy that has been less than supportive to Franklin, her transgender little boy, and ask that it be remedied, that’s taking to the streets. When a father calls to make an appointment for his child at our gender clinic, seeking out professional support for his child’s gender creativity, that’s taking to the streets. In other words, every time a gender creative child and their family moves through the community, confident in who they are, social change in happening.

Another way to think about the families is as snowballs. A family works to support the gender creative child they have. Each time another family does that, it is like a snowflake being added to a snowball. The snowball gets bigger and bigger. Soon it rolls down the street and grows into a snowman, or snowwoman, or snowperson. You don’t even have to leave your house to get the ball rolling. But when you do leave the house to advocate for your child at school, attend a Gender Spectrum or Gender Odyssey or Transhealth or Gender Infinity or True Colors conference, or solicit your local legislator to support a gender affirmative initiative, the snowball grows even bigger and the forces for change toward a gender-expansive world grow even stronger.

Yet it is not up to families alone to make that change, and it will take more than skipping down the sidewalk, walking to the corner store, showing up in the principal’s office, or making an appointment at a gender clinic. Others need to contribute to the gender affirmative snowball as well. It appears this message is getting across. In August 2015 the American Psychological Association released its first set of guidelines for transgender care. Going through them, it warmed my heart to read:

In educational settings, psychologists may advocate for TGNC [transgender and gender-nonconforming] youth…. Psychologists may consult with administrators, teachers, and school counselors to provide resources and trainings on anti-trans prejudice and developing safer school environments for TGNC students…. [P]sychologists may consider and develop peer-based interventions to facilitate greater understanding and respectful treatment of TGNC youth by cisgender peers…. Psychologists may work with TGNC youth and their families to identify relevant resources, such as school policies that protect gender identity and gender expression…, referrals to TGNC affirmative organizations, and on-line resources, which may be especially helpful for TGNC youth in rural settings.[82]

The American Psychological Association has never been known for street protests, rabble-rousing, or formal demonstrations, so when a fairly conventional professional organization sends a missive to its members to infuse themselves in the community in the name of promoting gender health in youth, we have a social movement that’s both deepening its roots and spreading its wings.

We would expect as much and far more from such an organization as the Transgender Law Center, based in Oakland, California, and indeed, it has far exceeded anyone’s expectations in what it has delivered, taking to the streets and to the halls of justice in advocating for the rights and protection of gender creative children. In the center’s own words:

Things are changing, and momentum is on our side. Countless students and their families have courageously come out in town halls, school board meetings, on social media, and in mainstream news stories to build visibility and support for transgender youth. And across the country we are seeing schools, communities, towns, and states update and change their policies and laws to make sure all students have a chance to thrive.[83]

The Transgender Law Center has invited the youth to lead the way, and the youth have turned to the center as their guiding light and to its staff as the folks they can count on to watch their backs. And the Transgender Law Center is definitely coming through. The same is true for other gender advocacy programs throughout the country, with new ones continually popping up—our own legal director at the Child and Adolescent Gender Center, Asaf Orr, helping to lead the way.

All of these actions have the effect of stirring up our feisty and our creative juices. For example, at a recent monthly meeting of Mind the Gap, our mental health group at the Child and Adolescent Gender Center, one of our members cited the story of a transgender teen who was given an endless amount of grief simply for requesting access to a gender-neutral bathroom at their school. The principal was resistant. First he said it wasn’t possible, then he explained that it would take at least a year, then he said the only way it could happen sooner would be to allow this student to use the staff bathroom, and that would be unfair to the other students and give this student preferential treatment. Then the principal compromised and said, “Okay, you can use the staff bathroom, but you’ll have to come to me and request that a key be made for you for that bathroom [which was kept locked] and then you’ll have to wait until the key is made before you can get access to the bathroom.” This solution was something close to mortifying for this student—he was quite shy and didn’t want the whole office staring at him if he had to come in with this request. But this was still a better situation than having to go into the misgendering student bathroom. So, our group came up with a transgressive solution: Organize the student body to rally around their transgender classmate by having each and every one of them appear in the office requesting that a key be made for them to be able to use the staff bathroom—for their own comfort. After all, the principal made it very clear that he did not want to give preferential treatment to any one student, so the other students would be asking for the same treatment to which they were entitled. Even if only ten or fifteen students showed up, that would be enough to send a message. And if two hundred showed up, well, I guess the principal would have gotten his just due for being so insensitive to a transgender teen’s needs. And maybe it would be a learning opportunity for him—wouldn’t it be a lot easier to have an unlocked gender neutral bathroom for everyone, rather than have to make two hundred copies of a key and have all the students storming the single-stall staff bathroom?

As our creative juices flow, we also have to keep in mind that the streets are filled with many kinds of gender-nonconforming and transgender children and youth. They will be of different races, ethnicities, and religions. Some will come from nice homes; some will have no home at all. Some will live with a parent or parents; some will have guardians other than their parents. Some will be rich; some will be poor. So, we have to pay special attention to the specific needs of the children and youth walking or marching alongside us. CeCe McDonald, a twenty-six-year-old African American trans woman, reflects on her life as black and trans and its relation to social action:

As I figure out who I am as a person, it is hard not to consider my black and trans identities. There is so much misogyny, racism, sexism… I navigate this world knowing that I’m in this world, in this body, and that is challenging. I can get harassed, I can get stopped by police, I can get harassed for being black, I can get heckled for being trans… I have to know that’s not my fault. I’m doing nothing wrong—this is about other people’s ignorance.

It will be a struggle… But there’s nothing worthwhile that’s not worth fighting for. For myself, my community, for change in our society. I’m going to have to fight for it. And, that’s my mindset.[84]

CeCe’s community is all of our community, her society is our society. Her fight is our fight. As CeCe points out, there are a lot of sharp nails tossed right in the middle of the street, so when we take to the streets, we’re going to need the soles of our shoes to be tough enough to march right over those nails. As far as I can tell, the best way to fortify those soles is by linking arms and working together to make this a place where gender health—the freedom to live one’s authentic gender protected from harassment or violence and surrounded by love and acceptance—is available to a child of any age, race, religion, ethnicity, or class, along with their elders.

Before I leave the streets, I want to say that not all marching is done with our feet. As the old saying goes, the pen is mightier than the sword. We who are writers have an obligation to advocate for gender health in written words—in the books and articles we write; the blog entries we post; the stories we document about gender creative children’s lives; the research we conduct about gender creative children, their needs, and the methods for meeting their needs. We who are not writers but have a story to tell, like so many parents of transgender and gender creative children, can also make use of the written word to get out the message—the children are all right, even though the journey may be challenging. I would refer you to Raising My Rainbow: Adventures in Raising a Fabulous, Gender Creative Son by Lori Duron, a book Lori generated from the blog posts she had been writing under the same title. Her book stands as a superb example of one mother’s eloquently written story making a tremendous difference in the social fabric of gender beyond her own household.

We also have to fight back with our pens (or more precisely, our computers). We fully expected to meet the wrath of right-wing conservatives and religious fanatics, but when it is our fellow professionals—research scientists, academics, clinicians—who we discover in print vilifying the gender affirmative approach and the concept of a world beyond the gender binary with an infusion of inaccuracies and misinformation, many of us feel compelled to take action and fight back by writing back, setting the records straight. For example, in 2015 Eric Vilain and J. Michael Bailey published an op-ed piece in the Los Angeles Times titled “What Should You Do If Your Son Says He’s a Girl?” and then they answer in the text, “As scientists who study gender and sexuality, we can tell you confidently: At this point no one knows what is better for your son.”[85] Really? I couldn’t get to my computer fast enough to write a response, which was published in the Los Angeles Times the next day. Instead of paraphrasing, let me present to you my letter to the editor in full:

“What should you do if your son says he’s a girl” (May 21, 2015) only highlighted for me the work to be done in counteracting the arguments made in the guise of scientific evidence that is in itself faulty and in its implications alarmingly damaging to the number of children who need to be heard about what their gender is. If either of the authors has ever spent an hour with a young child sobbing in their office, “Why did they get it wrong? I’m not the boy you think I am” and if either of them has ever witnessed the remarkable transformation from distress and anxiety to happiness and well-being when these children are listened to and allowed to transition to the gender they know themselves to be, they might think twice about putting the decision in the parents’ hands rather than in the child’s affirmations. There are different ways of knowing, not just from numbers in boxes in research studies but from clinical experience documented day after day in our offices. And as for the research statistics about the number of children who by adolescence “desist” from their early diagnosis of gender dysphoria, I would ask the authors, “Don’t you know the difference between an apple and an orange?” As reviewed by the team of researchers who originally collected the data on desisters and persisters in the Netherlands,[86] from early on the persisters are not the same group of children as the desisters and should never be lumped together. The apples, the persisters, are our youngest cohort of transgender folks, showing up early in childhood, saying “I am a girl” rather than “I wish I was a girl” and being insistent, persistent, and consistent in their declarations. We can find them if we look for them, and the worst thing we could do for them is deny who they are and try to force them to be someone else. If we don’t do that, and continue to promote approaches that attempt to twist a child’s gender to parents’ or professionals’ demands, we will end up with more Leelah Alcorns ending their lives in despair. This is never what we would want for our children.

This is just a sample of how many of us are spending our days as allies and advocates of gender creative children and their families.

Schools, Screens, Streets

As I came to the close of writing this chapter, I picked up my New York Times to discover that the present (conservative) mayor of Venice, Italy, Luigi Brugnaro, is attempting to ban forty-nine children’s books from the city’s preschool libraries. Included in the list: a story of the male dog who aspired to be a ballerina; the tale of a little boy who wanted to be a princess; and a book about a princess who wanted to be a soccer player.[87] No gender diversity in his city, at least among the youngest set, not if Mayor Brugnaro can help it. So, yes, I know that we have miles and miles ahead of us before we are done with our work of instilling in the minds of people the notion that when applied to gender, rainbows are good; boxes, not so much. But I do believe that in the course of negotiating the moving boulders that gender has become, we are making tremendous inroads—at school, on-screen, and in the streets—advances that can only make it a safer and more expansive journey for our gender creative children.

In Gender Born, Gender Made I underscored that gender creative children would never be totally free to exercise their creativity until we also laid the path of a gender-accepting world for them. I can say with great excitement and good feeling that in the past five years, one pathway after another has been paved for the children and their families, all by the love, sweat, and labor of parents, providers, educators, attorneys, community activists, and most important, the children themselves bonding together to both educate and demand change. There are trainers ready to go into any school and help them set up a gender-expansive environment—for all the children. There are attorneys who are entering the halls of justice to fight for the rights of transgender and gender-nonconforming children. Parent support groups, both local and virtual, have proliferated—and generated larger social movements advocating for gender diversity. PFLAG, originally established to support the friends and family members of gay and lesbian individuals, has now opened its arms to the transgender community. I might even go so far as to say that we have finally created a civil rights movement—to promote gender acceptance for all children and youth and to stop the oppression that continues to stifle them in their growth and development. And we can never forget that it is the children who are leading the way—they are out in the world making change and raising consciousness just by growing up and shaping gender in their own creative ways that we never could have imagined.

^{CHAPTER NINE}

What’s Left to Learn?

I have come to view gender less as a riddle that should be solved and more as a collage, which we each assemble in our fashion.

—Deborah Rudacille, The Riddle of Gender

I’VE COME TO the very same conclusion as Deborah Rudacille, and my greatest hope is that this book can provide not a puzzle to be solved but a map to guide you along the pathways of an infinite variety of gender journeys. Before I sign off, I thought I would do something unorthodox (for isn’t that what this is all about?) and admit to you that I know things now that I didn’t know when I began Chapter 1 of this book, which of course opens the door to exploring what I still don’t know at all. I am going to label these new nuggets of information, knowledge, and reflection my epiphanies, and run them by you one by one. Theoretically, I could take all these epiphanies and edit them into the earlier chapters to give you the impression that I’ve known these things all along. But that wouldn’t be the truth. Instead, I wanted to be transparent and show you how much I’ve learned just in the process of writing this book, so you can experience my own evolutionary gender journey from Chapter 1 to this concluding chapter.

Epiphany #1: Time as a Fourth Dimension

With the help of a close friend who attended one of my talks at a local hospital,[88] I came to realize that I had forgotten the fourth dimension of the gender web—time. Each child’s unique gender web is an interweaving of nature, nurture, and culture (three of the dimensions) over time (the fourth dimension). By factoring in time, we clear up the misconception that authentic or true means permanent, never-changing. On the contrary, what is true today may not be as true tomorrow. Some people reading these words might grow squeamish about young children being given the green light to declare their gender before they’re even old enough to actually cross the street on their own. You might feel compelled to say, “If children are going to change over time, how can you let them jump forward into a new gender so prematurely?” We are not talking about leapfrog when we speak of the dimension of time and the potential of a child’s gender web to change over the course of their childhood or beyond. Think molasses, not raging flood waters. Think evolutionary rather than revolutionary time. Yes, we are struggling to comprehend the intricacies of brain functioning and gender messages from that brain. We observe a strong constitutional component to gender identity, but that does not equate with absolute permanence of that identity. Thus we factor in time as the fourth dimension of the gender web. In doing so, we tip our hats to the growing realization that gender is mapped out in an ever-expanding playground, a space that reflects the circle between our inner selves and our outer lives as they dance together around the mulberry bush—over time. To quote Jody Norton, the author of “The Boy Who Grew Up to Be a Woman”:

That paradox—that one can stay, moving—stands for me as a metaphor for transgender. May we all stay where we love to be, moving as much as we need to.[89]

Epiphany #2: Stable Gender Identity by Age Six: You Can’t Have It Both Ways

How can a child know their gender? That is the question raised again and again in response to what is seen as our careless practice of allowing young children to transition from one gender to another “prematurely,” words seemingly expressed as a query but typically lodged as a formal complaint.

Can a young child know their gender? Traditional developmental theories say they can, will, and should, by age six, for normal development to unfold. But that dictum, by conservative standards, applies only to cisgender children. If they are transgender children, they can’t and they shouldn’t, and they are not normal if they insist they do. I don’t think you can have it both ways—you can know your gender by age six if you’re cisgender, but you can’t if you’re transgender. Common sense would tell us that there is a contradiction in theory if cisgender children are expected to know without a doubt their stable gender identity by age six, but transgender children are considered pathological, confused, or in need of intervention and redirection if they are equally clear.

Epiphany: How about if we put it this way instead? Developmentally, at age six or before, all children are quite capable of knowing their gender. That does not mean this self-identity will remain stable throughout their entire lifetime, but it does mean that on average, children by that age will exhibit a core consistency and cohesion of self, whether cis-, trans-, or everygender. And it does not mean that the gender they know themselves to be, by age six, will match the sex listed on their birth certificate.

Epiphany #3: Girl Brains and Boy Brains?

Many people hear us talk about the strong constitutional component of transgender identity and listen to tropes about being born in the wrong body and come to the conclusion that we who promote the gender affirmative model are essentialists who believe gender is innate and inborn. Nothing could be further from the truth. We recognize the intricate interplay of nature, nurture, and culture that goes into the making of each child’s gender web. It’s just that some threads have a stronger pull for certain children. By our and parents’ observations, we locate a small cadre of children who are experiencing a disjuncture between the sex assigned to them at birth and the gender they know themselves to be. We recognize that they just show up very early in life, rather than being shaped by their environment. Put differently, gender lies in our brains and minds, rather than in the formation of our genitalia and our chromosomal makeup. The latter obviously play an important part but are not deterministic. Here comes my epiphany: Gender lying in the brain does not mean there is a female brain and a male brain. Instead, it alerts us to the phenomenon that a small minority of people receive messages from their brain telling them that the gender they are is not in congruence with the F or M marked in their birth records or the body part showing up between their legs. It is those brain signals that are not malleable and should never be tampered with by adults hell-bent on getting the children to accept the sex assigned to them at birth as the gender they must be. I suppose another way of saying it is that we are talking about brain waves, not brain functions, when we talk about gender emanating from between our ears rather than from between our legs. And that brain is not a binary one—male or female—but, rather, a gender-expansive one.

Epiphany #4: Gender as Cure

Gender as a cure was a lightbulb going on for me when I observed with wonder the autistic features receding in our little clinic patient once he received hormone blockers and once he was allowed to socially transition to the boy he kept trying to communicate he was. Having worked with autistic children for many years, I had never in all those years witnessed such a radical transformation. That got me to thinking about gender as a cure rather than a disease.

I thought about the worries people have about regrets—youth, still in the throes of development, will make decisions about medical interventions (hormones, top surgery, bottom surgery) that they may be really sorry for later. After they mature, they might look back with dismay, lamenting, “What was I thinking?” followed by an accusation hurled at their parents: “Why did you let me do this? I was just a kid.” We cannot rule out the possibility of this ever happening, but if we weigh the tiny odds of such a lament occurring against the assuredly higher risks for psychological upheaval and psychiatric symptoms if we withhold from youth the opportunity to align their bodies with their psyches in gender consolidation, that seems like a no-brainer of an equation to solve. And if we consider further that such youth may assuredly discover greater happiness and better life satisfaction if afforded the opportunity to receive gender affirmative treatments, then we can say that we have provided gender as a cure for angst. In which case, if gender is a cure, how could it also be a disease? If the answer is “No, it can’t be both,” then we are led to the logical conclusion: dispense with psychiatric diagnoses of gender pathology, because gender is the cure, not the disease.

One more piece of gender as cure is gender as a protection against trauma, such as my earlier example of girls in Afghanistan who found safety and freedom in assuming a male identity. In their case, gender became a cure for women’s oppression, socially induced but internally embraced.

My epiphany of gender as cure reinforces the notion that all three dimensions of the gender web—nature, nurture, and culture—hold the threads of gender authenticity. Therefore there is no reason why a youth couldn’t weave together an authentic genderqueer or transgender self to cure the disease that stems, for example, from a foster child’s traumatic history of repeated molestation in their birth family only to be repeated in their foster family, or in the example of the Afghani FtM youth, to cure the disease of repeated oppression, repression, and violence against females. So, I leave you to muse on the concept of gender as cure as a replacement for gender as disease.

Epiphany #5: “I Hate the Word Trans”

In recent months I’ve been repeatedly meeting up with frustrated, downtrodden, or protesting preteens and young teens who transitioned earlier in life and have been living consistently in their affirmed gender for several years. Many of them are on puberty blockers; some have just started hormones. What they have in common: They hate, and I mean hate, the word trans. As far as I can tell, this is not internalized transphobia. It is a loud objection to a word that just doesn’t feel like a fit—“Trans is not me.” In other words, they were always the gender they know themselves to be; they were never anything else. In conscious memory, this may actually be true. They can no longer remember their youngest years living in another gender. That loss of memory is exactly why the “watchful waiting” folks get nervous about early transitions, worried that such early switches might create a delusional mind-set in the children about their bodied self. But let’s see it from the youth’s perspective. They insist that they never transferred over into another gender. Instead, by their own narrative, they just made it clear to everyone else, once they got it clear in themselves, that they are “just a boy” or “just a girl,” and always have been. They resent being seen as the transgender girl or the transgender boy in town. They just want to be left alone to live as the girl or the boy they are.

I’m thinking of Larkin, a child I have been working with for several years. Larkin socially transitioned at age eight, but for all practical purposes she was 99 percent transitioned many years before that. She was twelve when she came into my office furious that her mother had dragged her to the Gender Spectrum conference (Note: In years past she loved going to that conference and couldn’t wait until the day came for it to start). Larkin sat curled up on my couch, her toenails painted a beautiful shade of blue, her long blond hair cascading down the front of her plaid flannel shirt, and blurted out, “I just want to be home with my girlfriends, the ones I especially chose because they don’t like to do girly things. And all the girls at the conference—well, they were just frou-frou. Stupid, stupid conference.”

I can almost hear the red flags going up—Are Larkin and her cohort in denial about their history and about their early life living as the other gender? Maybe, and we definitely need to pay attention to any fault lines of delusional thinking or poor reality testing on the part of our early (or even later) transitioning youth. But that’s me talking as a developmental psychologist and an old fogy. Now let’s consider it from their point of view. If we are going to do a shake-up of sex and gender so that we can have penis-bodied girls and vagina-bodied boys, or just vagina- or penis-bodied people, why shouldn’t these children, who enter their affirmed gender early in life, protest against being pegged as a girl who becomes a boy or a boy who becomes a girl? They are a girl, they are a boy, or they are some other gender creative identity of their own making not by our standards but by theirs, standards created soon after we offered them the possibility that girl does not equal vagina and boy does not equal penis. So, in their eyes—down with trans. From our own adult view, we understand that, no matter how they define themselves, the outside world may still see these youth as trans and treat them accordingly. To that end, we must balance hearing their call for “trans transcendence” while promoting the gender resilience these youth will continue to need as they meet with a world that will still see them as trans, rather than just as a boy or girl. And as we listen to their declarations, we must also make sure that this trans transcendence is not a thinly veiled defense against the aspersion of being trans in a transphobic world, for pride in gender in all its iterations is what we are about.

I’ve said that if we want to know the children’s gender, we should listen to them, rather than tell them. We also need to listen to them when they tell us we’re passé, behind the times, or oppressing them with what to them is experienced as our outmoded sensibilities about gender. My epiphany: You never graduate from gender school.

Epiphany #6: The Rise of the Fruit Salads

It was in the last weeks of writing The Gender Creative Child that the film Three to Infinity was released. The content was about as fruit-salady and gender creative as you could get—gender revolutionaries of all ages challenging the concept of masculine-feminine dualities and constructing lives and selves that are truly gender mosaics, often leaving others wondering about their gender. They do this with their clothes, their own creative use of medical interventions, and their insistence on being referred to in gender-neutral terms. To say that they live in the middle would be adhering to a binary model—point a, point b, and the space in between. Better to say that they live in the space between finite and infinite, if we can get our head around that.

Soon after the release of Three to Infinity, The Gender Quest Workbook by Rylan Testa, Deborah Coolhart, and Jayme Peta came out.[90] The workbook follows in the same vein as the film—gender lies within an infinite space. The authors invite teens and young adults to explore the full range of who they are and how they like to be that person—in both their gender identity and expressions— with plenty of room for apples, oranges, and fruit salads.

But what about the younger folks? Recently I met with a mother whose six-year-old child, an assigned male at birth, wears dresses, asks everyone to use the child’s given name as a pronoun, and explains, “I’m not a boy, I’m not a girl.” As we talked, this mother expressed frustration that there were no books for a child like hers. She’s right. And that got me to thinking—given the rise of the fruit salads, why aren’t they showing up in books so that our youngest fruit salads can find themselves reflected? We have books, films, and videos about boys who want to wear dresses or be princesses, girls who are boys and boys who are girls, but what about the gender-ambidextrous, gender fluid, gender-hybrid child, the one who lets us know, in word and action, “I’m neither one nor the other, but both, and maybe something else altogether”? My epiphany here is that we talk a good line about gender expansiveness, but we have to get the rubber to hit the road and do better in highlighting the pathways for our children who enter their gender journeys early as our fruit salads. Who knows, maybe that will be my next volume on gender.

Epiphany #7: I Want It Now: Spoiling Childhood and the Gender Creative Child

For weeks I mulled over the story of the parents who appeared at a gender clinic announcing that their transgender daughter had proclaimed that if she didn’t get a vagina by the time she was nine, she was going to kill herself. Following this announcement, the father leaned toward the medical director with a piercing look understood to mean, “So-o-o, what are you going to do about it?” It brought me back to the years writing my book Spoiling Childhood, in which I investigated the tremors modern-day parents felt when they had to say no to their child and the entitlement children felt to demand what they wanted and get it now—or else. So, why wouldn’t that pattern extend to children’s feelings about gender—a sense that everything happens instantaneously, waiting is an obsolete concept, and if no immediate gratification is forthcoming, threaten death by suicide or homicide? Now I am exaggerating, but the trend has been in that direction since the late twentieth century, and it is not unheard of to see this sensibility, which I labeled “Your Majesty, the Baby,” embedded in children’s expressions of gender dysphoria, when such dysphoria exists: “I want boobs now!” “I absolutely refuse to wait until I’m older to start hormones. I have to be like everyone else and have my puberty now. So what if I’m only eleven?” I think you get the gist. For some children and youth, there indeed is an impending crisis that requires immediate attention to avoid gender trauma and possible self-harm. But for other children, crisis is not the operating variable. Instead, patience and reflection are foreign concepts, and, for their parents, keeping their children happy by acceding to all their wishes becomes the dominating force in child rearing, particularly when they imagine the stresses their child may have to face within an unaccepting genderist world.

When my own children were growing up, we called on the unsavory character of Veruca Salt from Charlie and the Chocolate Factory—“Daddy, I want it now”—to remind them (and us) that we were veering in the direction of Your Majesty, the Baby. Those five words were typically enough to stop Jesse or Rebecca short. (Who would ever want to become Veruca Salt, the most unpleasant of children?) Since gender is not an area exempt from the Veruca Salt syndrome, I have learned the necessity of sorting out true gender urgency from indulgent parents/child royalty conundrums, where no and stop become verboten words.

Eurocentric Western culture does not receive high scores for helping our children build frustration tolerance and accept delayed rather than immediate gratification. Now couple that with an electronic world in which if you want to order something online, you can have it by tomorrow. That’s where the gender path can become a speed raceway. I’ve emphasized repeatedly that we need to listen to the children. My epiphany, which sounds so basic, is that our gender creative children also need a guiding hand. For example, in growing up, cross-sex-hormone-induced puberty through the administration of estrogen or testosterone is really not that different from naturally induced puberty—it doesn’t always come exactly when you would want it to (ask any late bloomer), and sometimes you just have to wait. You, the parents of the gender creative children, may never want to be a gatekeeper, but you will sometimes need to be the engineer driving that train, pulling on the brakes or slowing things down along the gender journey when need be.

Epiphany #8: The New Love Affair with Adoption

For many, many years I have worked in the areas of foster care, adoption, and assisted reproductive technology. I have witnessed so many parents exploring alternative means of building their families, adoption being one of them, and I have sat with them through their journeys, experiences sometimes filled with joy, sometimes laden with pain. Those among them who have embraced adoption as the means to become parents now have a young cohort joining them—transgender teens. Never have I experienced a group of people as positive about having a child through adoption. They don’t come to this through support groups. They don’t come to it by direct instruction. Instead, one by one, as we have sat with youth at our gender clinic and explained to them the reproductive outcomes of the various gender paths they might choose, we hear a repeated story: “Oh, I’ll just adopt. There’s too many children in the world anyway, so that’s the best way to go.” This is typically in response to learning that if they should go directly from taking puberty blockers (starting them before they begin producing viable eggs or sperm) to taking hormones, they will not be able to have a genetically related child of their own (at least at this moment in history).

We already know that parents may carry a lot of angst about signing off on these interventions at an age when their children couldn’t possibly know exactly how they’ll feel about being a parent when they’re twenty-five, thirty, or thirty-five. The youth are clearly feeling something very different. They have no worries about being infertile. Could it be that they’re all riffing off the same Internet site about transgender parenting (or not-parenting)? I don’t think so. Could it be that their impressively altruistic sentiments about adoption are really a psychological defense against the opposite feeling that they will forever be robbed of childbearing choices because someone dealt them the wrong hand a long time ago? Potentially, but I would say not likely. My epiphany is that this expressed love affair with adoption, repeated by one child after another in the privacy of the clinic meeting room, is an authentic individual psychological response telling us a social story. And the story goes like this: “More important than anything in the world is getting the opportunity to live the gender that is me. If medical supports can help me do that, that’s front and center for me. How I become a parent, if I become a parent at all, is back seat, if in the car at all.” What am I learning? That gender authenticity trumps desires for genetic parenthood. Epiphany #8.

So, Where Are We Going?

From the beginning to the end of writing The Gender Creative Child, I have watched the continuing transformation of gender from bedrock to moving boulders. As a hiker, I know full well that trekking across bedrock is far less of a challenge than traversing moving boulders, but never as exciting. So, I exit The Gender Creative Child balanced on the moving boulders of gender, wondering where they are taking us and whether they will ever stop moving so fast. Periodically I ask myself, “In one hundred years, will people be looking back and saying, ‘Really, they got hung up on all that stuff about gender and genders. That’s just so quaint. I wonder what it was like to be not beyond gender’?” Forget about the next century. What about our gender creative children today? Where will they be at age fifty? The early transitioners—will they look back at their lives with gratitude, the gratitude that their older cohort of transgender adults imagined they would have felt if only their own elders had known enough to let these transgender people live their authentic gender lives as young children, when they already knew but couldn’t say? The children who chose to use puberty blockers—will they indeed be healthier as adults, or will we discover some yet unknown health risks to these interventions that might have made us pause rather than confidently pressing the pause button on their puberty? Youth who chose cross-sex hormones/hormone replacement therapy—will hormones fortify their gender resilience over the course of their life? How will these youth feel later if they bump into medical side-effects or life-threatening conditions that might be related to their very long-term use of hormone therapy? The children who go straight from puberty blockers to hormones—despite their love affair with adoption, could I be wrong and will they later regret having given up the opportunity to have their own genetic offspring? Was it worth the trade-off—to live a life that feels authentic and real and find alternative means to build a family? The gender fluid youth who may change their self-affirmations of gender over time—do we want to try to discourage too many turns in the road, or do we want to make room for all-terrain gender vehicles that can go forward, back, and sideways over the course of the life journey?

I embrace the concept of gender infinity, but let’s get real. Complexity is rarely easier than simplicity, and ever-growing iterations of gender definitely count for being complex. With gender expansiveness, might we possibly suffer from gender overload, or will we bathe ourselves in the sparkling waters of never-ending gender flow? So, I leave us all with two questions: “Where are our gender creative children taking us?” and “Are we ready for the ride?”

And I leave us with an answer as well. The gift of the gender creative child is this: Because of them, we know so much more about gender than we ever knew before. Because of them, gender still remains a mystery. That is what makes the gender journey, with all its pathways, so exciting. So, where do we go from here? Dial back to 2003. Picture my granddaughter, Satya, then age three, elatedly dressed from head to toe as her favorite character, Buzz Lightyear. Listen to her as she raises her hand to the sky, and calls out, in her loudest voice, “To infinity and beyond.”

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ACKNOWLEDGMENTS

First and foremost, I want to thank all of the gender creative children and families who have entered my life over these many years—in my private practice, at the UCSF Benioff Children’s Hospital Child and Adolescent Gender Center Clinic, at workshops and conferences throughout the world, and in my personal life. You have been my guiding light and my mentors in helping me understand just exactly what it means to be a gender creative child, sibling, parent, caregiver, grandparent, aunt, uncle, or cousin.

And next come the people at The Experiment, who have made this book a reality. A very special thanks to Matthew Lore, cofounder and president of The Experiment, for meeting with me for coffee one day in 2008 at Oliveto’s Café in Oakland, California, and putting his faith in me to morph into print my ideas and my passion about gender creative children. And without the incredible support of Allie Bochicchio, editor; Jeanne Tao, managing editor; Iris Bass, external editor; Jennifer Hergenroeder, publicity and marketing manager; and Elizabeth Johnson, events manager, those ideas would have remained just that.

I now come to my village of gender specialist colleagues, my midwives in giving birth to The Gender Creative Child. Without a doubt, Stephen Rosenthal has been my closest colleague, friend, and muse in founding the Child and Adolescent Gender Center, making our pediatric gender clinic at UCSF Benioff Children’s Hospital a reality, and just being there. Right alongside him are my other team members at CAGC and the clinic—Asaf Orr, Joel Baum, Meredith Russell, Molly Koren, Stanley Vance, Ilana Sherer. And then there is each and every member of Mind the Gap, the ever-growing mental health subgroup of the Child and Adolescent Gender Center. Without you and our monthly Sunday meetings at my house, I would never know what I know today. To Lisa Kenney and Pam Wool at Gender Spectrum, deep gratitude for all that you do and all the support you have given me. And special thanks to some particular colleagues who have come along with me on this gender journey for many years, if not decades—Herb Schreier, Stephanie Brill, Caitlin Ryan, Karisa Barrow, Susanna Moore, Susan Bernstein, Dan Karasic, Jamison Green, Lin Fraser, Susanne Watson, Shawn Giammattei, Lisette Lahana, Joy Johnson, Michelle Jurkewicz. And reaching across the continent: to my close friends and colleagues in the South, that would be Santa Cruz, California—Jennifer Hastings, Shane Hill, and Ben Geilhufe; Los Angeles—Joanna Olson and Aydin Kennedy; Texas—Colt Meier; New Mexico—Nate Sharon. In the Midwest—Marco Hidalgo, Diane Chen, Scott Leibowitz, Rob Garafolo. In the East—Amy Tishelman, Norm Spack, Randi Kaufman, Francie Mandel, Edgardo Menvielle, Catherine Tuerk, Jean Malpas, Aron Janssen, Cathy Renna. North of the border—Jake Pyne. And across the globe—Sam Winter, Thomas Steensma, Annelou de Vries, and Simon Pickstone-Taylor.

A few people, close friends and colleagues, have simply been grounding poles for my whole professional life, not just for my gender explorations, and to them I want to express my deepest gratitude for helping me be the best psychologist, writer, and feminist I could be. That would be Gloria Lawrence, with special thanks for every one of our Thursday lunches for almost twenty-five years now; Toni Heineman for reading, writing, thinking, working, and playing with me and for her endless dedication to children in foster care; my decades-running child consultation group—Eileen Keller, Bonnie Rottier, and Stephen Walrod—without which I could never be the therapist I am today; Marcy Whitebook, for her dedication to the lives of young children and keeping me on track with mine; Nancy Chodorow, for thinking, walking, sharing her mind with me; Barbara Waterman, who has showed undying enthusiasm for my work and has always generously lent me her critical and insightful eye as both a thinker and commenter on my writing.

A person does not live by work alone, and this book could have died on the vine if I had not had the warmth and love of close friends around me. From far away—Elli and Robby Meeropol, Mindy Werner-Crohn and Joel Crohn, Stephanie Riger and Dan Lewis, and Cathey Billian. Closer to home—Alan Heineman, Matt Ross. To my communal eating group, I would like to extend the heartiest of thanks, not just for the food we eat but for the years of friendship, intellectual sharing, talking politics, raising families together, and offering the love that feed both my mind and my soul—Joanna Levine and Marc Stickgold, Joan Skolnick and Randy Reiter, Nancy Hollander and Stephen Portuges, Anne Bernstein and Ringo Hallinan, Noree Lee and Ron Elson, Yana and Len Goldfine. Everyone should be as lucky as I am to have a chosen family like you.

And last, I want to acknowledge my family, both close in and miles away: my mother and father, Edith and Morris Ehrensaft, for being my role models for living a very long and full life and giving me all the educational opportunities they did not have so I could be here writing these acknowledgements right now; to my brothers, Phil and Rick Ehrensaft, for lovingly showing me about gender across the aisle—that would be the world of boys and their toys; to my children, Rebecca Hawley and Jesse Ehrensaft-Hawley—words can’t even begin to describe the depth of my gratitude to them for all they have taught me and all they give me; the same goes for my granddaughter, Satya Hawley, who could sing her way into anybody’s heart. And always, and forever, I will thank my husband, Jim Hawley, for being the wonderful husband, father, and grandfather he is, for putting up with a sometimes write-aholic partner, for giving me the bandwidth to talk endlessly about gender, and for helping me come up for air, with a glass of wine and a smile on his face.

INDEX

Numbers in parentheses beginning with “n” refer to notes.

acceptance

about

as form of protection

hyperactive

Adams, Janice

adolescence, ref. 2

adoption

advocate, parents as

Afghanistan

agender youth

“Ain’t I a Woman?” (Truth)

Alcorn, Leelah, ref. 2

ally/advocate/ambassador, parents as

American Psychological Association

Amsterdam Center of Expertise on Gender Dysphoria, VU University Medical Center, ref. 2, ref. 3

angels, gender, ref. 2, ref. 3

apples

about

body dysphoria

early onset

example

ex post facto test

gender expressions

gender maze and

“I am a …” statements

knowing, early sense of

parents and, ref. 2

“watchful waiting” model and

See also persisters

Asperger’s syndrome, ref. 2

See also autism spectrum disorder (ASD)

assessment packet, gender affirmative (n63)

authenticity versus safety

autism spectrum disorder (ASD)

about

case study

explanations for

gender affirmation as cure, ref. 2, ref. 3

misdiagnosis of

research on

as sensory issue

social cues, inability to read

thinking outside of boxes and

Bailey, J. Michael

bathrooms, gender-neutral, ref. 2

bedtimes

Beemyn, Genny, ref. 2

biology of gender, ref. 2, ref. 3

Birch, Herbert G.

birthdays, lining up by

blacks

blind spots, gender

body, feelings about

body dysphoria, ref. 2

bone mineral density

Bono, Chaz

books, banning

Boone, Katherine

borrowed labels

borrowed scripts

boxes, thinking outside of

brain as gender-expansive

brain development, ref. 2

Brugnaro, Luigi

CAMH (Centre for Addiction and Mental Health), ref. 2, ref. 3, ref. 4, ref. 5

CAH (congenital adrenal hyperplasia), ref. 2

case studies

autism spectrum disorder

gender spread

Centre for Addiction and Mental Health (CAMH), ref. 2, ref. 3, ref. 4, ref. 5

Charlie and the Chocolate Factory

Cher

Chess, Stella

child psychiatrists, referral to

child rearing, basic ground rule for

cognitive dissonance

cognitive-emotional development

Cohen-Kettenis, Peggy, ref. 2, ref. 3, ref. 4

community psychology

comorbid psychiatric conditions

congenital adrenal hyperplasia (CAH), ref. 2

conversion therapy, ref. 2, ref. 3

Coolhart, Deborah

Cox, Laverne

Crawford, Chasilee

Crawford, Jason

Crawford, Zay

cross-sex hormones/hormone replacement therapy

arbitrary minimum age for

fertility implications of

gamete preservation and

Ingraham, Laura, on

as medical intervention

misinformation about

psychological aspects, ref. 2, ref. 3

puberty blockers and

readiness for

terminology (n12)

culture

fruit salads and, ref. 2

in gender web, ref. 2

cure, gender as, ref. 2, ref. 3

dam builders, mental health professionals as

deafness

de-centering

about

gender angels and, ref. 2, ref. 3

gender blind spots and

gender ghosts and, ref. 2

gender maze and

delayed puberty, ref. 2

desisters, ref. 2, ref. 3

See also oranges

diagnoses, gender

Diagnostic and Statistical Manual of Mental Disorders (DSM), ref. 2

doctors

mental health professionals and

pediatricians

as psychiatric gender fixers

documentaries

doll play

Donne, John

DSM (Diagnostic and Statistical Manual of Mental Disorders), ref. 2

Duron, Lori

early onset, ref. 2

easy children (temperament type), ref. 2

editor, letters to the

environmentalists, ref. 2

Erikson, Erik, ref. 2, ref. 3

essentialists, ref. 2

estrogen

See also cross-sex hormones/hormone replacement therapy

“expectable parental narcissism”

experience versus research studies

ex post facto test

Facebook gender options, ref. 2

factitious disorder

false gender self

Far from the Tree (Solomon), ref. 2, ref. 3

fashion

feedback loops

feminism, radical

fertility issues, ref. 2, ref. 3

fiction, gender as

films

firefighters, mental health professionals as, ref. 2

Freud, Sigmund, ref. 2

friendships, online versus real-life

“fruit,” as term (n33)

fruit salads

about

adolescence

body, feelings about

culture and, ref. 2

gender maze and

rise of

gamete preservation

gatekeepers, mental health professionals as, ref. 2

gender

biology of, ref. 2, ref. 3

as cure, ref. 2, ref. 3

as fiction

lining up by

sea change in

as social opportunity

as solution

as symptom, ref. 2

See also specific topics

gender affirmative model

See also “listen and act” model

gender-ambidextrous children

gender angels, ref. 2, ref. 3

gender-bedrock

gender blind spots

Gender Born, Gender Made (Ehrensaft), ref. 2, ref. 3, ref. 4, ref. 5, ref. 6, ref. 7

gender-by-location children

gender-by-season children

gender categories, ref. 2

See also specific categories

gender creativity, defined

See also specific topics

gender diagnoses

gender dysphoria, as diagnosis

gender expressions, ref. 2

gender fluid children, ref. 2

See also oranges

gender gap, new

gender ghosts, ref. 2

gender health, ref. 2

gender hybrids

gender identity by age 6

gender identity disorder, as diagnosis

gender infinity

gender maze

gender minotaurs

“gender offensive,” oranges as

gender Priuses

GenderQueer Revolution, ref. 2

genderqueer youth, ref. 2

Gender Quest Workbook, The (Testa, Coolhart, and Peta)

gender smoothies, ref. 2

Gender Spectrum, ref. 2, ref. 3

gender spread

about

apples

case study

fruit salads

future of

oranges

gender Teslas

gender Tootsie Roll Pops

gender web, ref. 2

genetics

genitalia, ambiguous, ref. 2

ghosts, gender, ref. 2

GnRH inhibitors. See puberty blockers

Goldberg, Michelle

gonadotropin-releasing hormone inhibitors. See puberty blockers

grandparents, ref. 2

gratification, immediate versus delayed

Green, Richard, ref. 2

grief, ref. 2, ref. 3

guilty feelings

health, gender, ref. 2

hierarchy of needs

Hill, Darryl

Hippocratic oath, ref. 2

homosexuality, DSM classification of

Honda, Mike

Honda-Phillips, Michelle

horizontal identity

hormone blockers. See puberty blockers

hormone exposure/absorption

hormone replacement therapy. See cross-sex hormones/hormone replacement therapy

hybrids, gender

hyperactive acceptance

“I am a …” statements

“I don’t know anything about this” statements

India, ref. 2, ref. 3 (n56)

infinity, gender

information, inaccurate

Ingraham, Laura, ref. 2

Internet and social media

Facebook gender options, ref. 2

friendships, online versus real-life

information, inaccurate

labels, borrowed

outing

scripting

support networks

Italy, ref. 2, ref. 3

“It’s just a phase” statements, ref. 2

“I wish I were a …” statements

Jenner, Caitlyn

Jolie, Angelina

Jolie-Pitt, John

Jorgensen, Christine

knowing, early sense of

knowledge, doctor lack of

labels, borrowed

“learning to live in your own skin” model, ref. 2

left-handedness, ref. 2

legal authority for medical interventions

“Let me refer you to a child psychiatrist” statements

letters to the editor

likeness as bonding agent

lining up in schools

“listen and act” model

Lives of Transgender People, The (Beemyn and Rankin), ref. 2

“living in your own skin” model, ref. 2

Los Angeles Times

marriage equality

Maslow, Abraham

maze, gender

McDonald, CeCe

McHugh, Paul

media. See screens

Menachem, Seth, ref. 2

mental health professionals

attributes, desired

as dam builders

doctors and

as firefighters, ref. 2

as gatekeepers, ref. 2

medical world, role in

as translators

mental health services models

“learning to live in your own skin” model, ref. 2

“listen and act” model

“watchful waiting” model, ref. 2

Menvielle, Edgardo

microaggressions

about

home-based

society-based

Mills College

minorities

minotaurs, gender

misinformation

Mock, Janet, ref. 2

mourning, ref. 2, ref. 3

Munchausen syndrome, ref. 2

My Daughter, He (Waldron), ref. 2

names, last

National Public Radio (NPR), ref. 2

nature, in gender web, ref. 2

needle phobia, ref. 2, ref. 3, ref. 4, ref. 5, ref. 6

needs, hierarchy of

Netherlands, ref. 2

“New Girl in School: Transgender Surgery at 18”

New Yorker, The

New York Times, The, ref. 2

New York Times Magazine, The

Norton, Jody

NPR (National Public Radio), ref. 2

nurture, in gender web, ref. 2

onset, early, ref. 2

oranges

about

confusion about

early onset of

example

gender expressions

gender maze and

as “gender offensive”

“I wish I were a …” statements

protogay children as

See also desisters

outing

parental acceptance

about

as form of protection

hyperactive

parental support

parents

as ally, advocate, ambassador

apples and, ref. 2

in conflict

guilty feelings

medical interventions and

motivations and psychological issues

support networks for

pediatricians

persisters, ref. 2, ref. 3

See also apples

Peta, Jayme

“phase,” gender exploration described as, ref. 2

Pickert, Nils

pink boys

Pitt, Brad

possibility, ref. 2

Priuses, gender

pronouns, gender-neutral (n3)

protection, acceptance as form of

protogay children, ref. 2

prototransgender youth

psychiatric conditions, comorbid

psychiatric gender fixers, doctors as

psychiatrists, referral to

puberty, delayed, ref. 2

puberty blockers

bone mineral density and

brain development and

cross-sex hormones/hormone replacement therapy and

Ingraham, Laura, on

as medical intervention

psychological aspects, ref. 2, ref. 3, ref. 4

readiness for

surgeries and

use of

radical feminism

radio, ref. 2

Raising My Rainbow (Duron)

Rankin, Susan, ref. 2

regrets, ref. 2

reparative therapy, ref. 2, ref. 3

research studies versus experience

risk, ref. 2

Rosenthal, Stephen, ref. 2

Rudacille, Deborah

Russell, Hershel

Ryan, Caitlin, ref. 2

safety versus thriving

sameness/likeness as bonding agent

San Francisco Arts and Lectures series

San Francisco Chronicle

schools

bathrooms, gender-neutral, ref. 2

gender-expansive practices in

Gender Spectrum and

lining up in

Schools in Transition: A Guide for Supporting Transgender Students in K Schools

screens

documentaries

films

Internet and social media

radio, ref. 2

as social mirrors

television, ref. 2, ref. 3

scripting

self-labels

sensory issue, autism spectrum disorder as

sexual abuse

siblings

Singer, Isaac Bashevis

“Sissy Boy Syndrome” and the Development of Homosexuality, The (Green)

“Sisterhood Is Complicated”

slow-to-warm-up children (temperament type), ref. 2

smoothies, gender, ref. 2

snowballs, families as

social action. See streets (social action)

social constructivists, ref. 2

social cues, inability to read

social media. See Internet and social media

social mirrors, screens as

social opportunity, gender as

social transition

Solomon, Andrew, ref. 2, ref. 3

solution, gender as

Spiegel, Alix

Spoiling Childhood (Ehrensaft), ref. 2, ref. 3

Stocker, David

Stoller, Robert

streets (social action)

advances

American Psychological Association

bathrooms, gender-neutral

minorities

snowballs, families as

Transgender Law Center

written words

Stuart Little (White), ref. 2

support, parental

support networks

Supreme Court (India)

surgeries

symptom, gender as, ref. 2

television, ref. 2, ref. 3

temperament

about

behavior categories reflecting

easy children, ref. 2

as “how” of behavior

slow-to-warm-up children, ref. 2

Teslas, gender

Testa, Rylan

testosterone

See also cross-sex hormones/hormone replacement therapy

“they,” as gender-neutral pronoun (n3)

thinking outside of boxes

Thomas, Alexander

Three to Infinity (film)

thriving versus safety

time, as gender web dimension

Tootsie Roll Pops, gender

“trans,” as term

transactionalists, ref. 2

transgender children, defined

See also apples; specific topics

Transgender Law Center

translators, mental health professionals as

trauma

treatment, gender as, ref. 2, ref. 3

true gender self

Truth, Sojourner

T: The New York Times Style Magazine

Tuerk, Catherine

“Two Families Grapple with Sons’ Gender Preferences” (radio program), ref. 2

University of California, Los Angeles

University of California, San Francisco, Benioff Children’s Hospital Child and Adolescent Gender Center Clinic, ref. 2, ref. 3, ref. 4, ref. 5

Venice, Italy

Vilain, Eric

Waldron, Candace, ref. 2

Wallace, Robert

“watchful waiting” model, ref. 2

Wellesley College

“What Is a Woman?” (Goldberg)

“What Should You Do If Your Son Says He’s a Girl?” (Vilain and Bailey)

White, E. B.

Winnicott, D. W.

Witterick, Kathy, ref. 2

World Professional Association for Transgender Health (WPATH), ref. 2

written words, for social action

“Yentl the Yeshiva Boy” (Singer)

“Your Majesty, the Baby” sensibility

Zucker, Ken, ref. 2, ref. 3, ref. 4, ref. 5, ref. 6

ABOUT THE AUTHOR

DIANE EHRENSAFT, PHD, is a developmental and clinical psychologist who for over thirty years has worked with gender-nonconforming children and their families. Dr. Ehrensaft is the author of numerous books and articles on child development, gender, and parenting. Her previous books include Gender Born, Gender Made; Parenting Together; Spoiling Childhood; Mommies, Daddies, Donors, Surrogates; and Building a Home Within (with Toni Vaughn Heineman). Dr. Ehrensaft is an associate professor of pediatrics at the University of California, San Francisco, and the attending psychologist at the UCSF Benioff Children’s Hospital Child and Adolescent Gender Center Clinic. She is a founding member of the Child and Adolescent Gender Center and serves as its director of mental health. She speaks in the United States and abroad on the subject of gender-nonconforming children at both community and professional conferences and is cited frequently in the media. She has appeared in The New York Times and many other media outlets and was featured in National Public Radio’s landmark 2008 two-part series on gender-nonconforming children. Dr. Ehrensaft is a founding member of A Home Within, a national project focused on the emotional needs of children and youth in foster care, and holds leadership positions with Gender Spectrum, a national organization offering education, training, and advocacy services to promote gender acceptance. She is a mother, a grandmother, and a proud member of PFLAG. Dr. Ehrensaft lives and practices in Oakland, California.

dianeehrensaft.com

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PRAISE FOR

The Gender Creative Child

“The Gender Creative Child is an invaluable resource for families and practitioners wanting to understand the complexity and beauty of gender development and the value of affirmative care. I’m struck that Dr. Ehrensaft’s most revolutionary idea is also her most straightforward—if we really learn how to listen to our children, they will tell us what they need.”

—Aron Janssen, MD, director and founder of the Gender and Sexuality Service, NYU Langone Medical Center

“Dr. Ehrensaft has achieved the impossible: an easy-to-read, but hard-to-forget, handbook that speaks to parents, teachers, medical doctors, counselors, and policymakers alike. In an accessible and conversational manner, Ehrensaft tackles tough challenges such as how to help gender creative children who also struggle with autism; why some youth intentionally choose the middle of the gender spectrum instead of the binary; how to navigate the legal and financial barriers to cross-sex hormone treatments; and why we must analyze traditional gender-based research studies with a critical eye and the wisdom of experience. This book urges us to abandon the fantasy that gender is a simple either/or proposition, and embrace the reality that there are infinite manifestations of a person’s identity. If we allow children to blaze the trail, however, then their path to self-actualization becomes clearer. A must-have for any professional who works with youth.”

—Jessica Herthel, coauthor of I Am Jazz

“The Gender Creative Child should be required reading for all therapists, pediatricians, and K–12 educators and for parents whose children express their gender differently from societal expectations. Diane Ehrensaft deftly shows that many trans and gender-nonconforming children can be identified from a young age and how critical it is to provide support to them.”

—Genny Beemyn, PHD, trans educator and coauthor of The Lives of Transgender People

“Diane Ehrensaft has written an exceptional book—smart, accessible, and beautifully written. Her work is fueled by empathy and compassion, apparent on each page, and informed by her unparalleled expertise as a gender expert, as well as her characteristic thoughtful intelligence. Her first book, Gender Born, Gender Made, presaged the more widespread recognition of gender diversity in children. In The Gender Creative Child, she elaborates on the forces that shape gender development, drawing on years of work with children and families. She entwines her dual clinical and scholarly perspectives into a clear and coherent framework of understanding. This book will serve as an education for those who are naive about gender diversity and as a refuge for individuals and families who are attempting to raise gender creative children on their developmental odyssey with sensitivity and love.”

—Amy C. Tishelman, PHD, director of clinical research and senior staff psychologist, Gender Management Service, Boston Children’s Hospital and Harvard Medical School

“The Gender Creative Child is a must-read for parents of transgender and gender-expansive children and the professionals who work with them. Dr. Ehrensaft, a leading authority on gender development, uses an inviting, engaging, and humble style to present the gender affirmative model and provide insight into achieving gender health for all people. Dr. Ehrensaft’s concepts of gender webs, gender smoothies, gender ghosts, and gender angels, and her methods of distinguishing ‘apples,’ ‘oranges,’ and ‘fruit salads,’ are illuminated by her use of multiple real-life stories of families with gender creative children. There is no other resource like The Gender Creative Child and I am thrilled to recommend it to my clients.”

—Colt Keo-Meier, PHD, licensed psychologist and cofounder of Gender Infinity in Houston, Texas

“This book offers an accessible, engaging, and informative guide for families and therapists supporting transgender and gender creative youth. Dr. Ehrensaft’s commitment to and empathy for the young people with whom she works as well as for their families is clear throughout the book.”

—Heather Killelea McEntarfer, PHD, author of Navigating Gender and Sexuality in the Classroom

“The Gender Creative Child lays out what we now know—or think we know—about gender and points out how much we still have to learn. Dr. Ehrensaft deftly illustrates that, despite our tenaciously held view to the contrary, gender never has been binary; we just couldn’t or wouldn’t see that clearly. She uses a multitude of case vignettes to help remove the blinders to gender complexity. Dr. Ehrensaft’s young patients are wonderful guides on this journey—often pointing out things that we would rather not see, but also showing us the limitless vistas that lie ahead. This is essential reading for the mental health community.”

—Toni Heineman, DMH, executive director and founder of A Home Within and author of Relational Treatment of Trauma

“An amazing book! It is a must-read for anyone whose daily life involves children, from parents and pediatricians to mental health providers and family court judges. The Gender Creative Child is a comprehensive, thorough, and accessible resource written by the preeminent expert in the field. The book holds the reader’s hand as it takes them through basic concepts and complex issues, answering common questions and concerns.”

—Asaf Orr, Esq., Transgender Youth Project Staff Attorney, National Center for Lesbian Rights

“Dr. Ehrensaft explains gender and children like no one can. She equips adults to understand and support gender-expansive children the way they deserve to be. This book is the newest must-have for every LGBTQ library and a must-read for every adult with a child in their life.”

—Lori Duron, author of Raising My Rainbow

“In The Gender Creative Child, Diane Ehrensaft illuminates the tremendous variation in gender identity and expression that we find in children. With a depth of understanding that comes from years of experience, she shows parents, professionals, and the culture at large how to foster authenticity and psychological health. Dr. Ehrensaft’s emphasis on the uniqueness of each child reminds us to be thoughtful, keep an open mind, and listen carefully. I highly recommend this book!”

—Irwin Krieger, author of Helping Your Transgender Teen

“Finally a book that appropriately reflects the great spectrum of gender diversity that young children and teens embody and envision. Dr. Ehrensaft has, once again, moved beyond the challenges of identity politics and academic controversies and meets parents, families, and young people where they live—exploring the edges of gender expression in rapidly changing times.”

—Arlene Istar Lev, LCSW-R, CASAC, family therapist, gender specialist, and founder of Choices Counseling and Consulting

“The Gender Creative Child is a critical resource for anyone who loves or works with gender-nonconforming children and youth. In addition to providing an insightful overview of the medical and social context in which our misperceptions of gender have been passed down and the efforts underway to correct them, the author of Gender Born, Gender Made once again brings us into the room with a wide array of gender-nonconforming children to hear their struggles and wisdom as they communicate their experience of gender. True to her word as listener and translator, the author articulates what she has learned and faithfully guides families, professionals, educators, and communities to create safe, accepting environments that foster the full development of all.”

—Candace Waldron, author of My Daughter He: Transitioning with Our Transgender Children, trans parent coach, and speaker

“Diane Ehrensaft’s new book is a timely treatise on the ways families can best support the journeys of their gender creative children. As a pioneer in the care of transgender and gender-nonconforming kids, Dr. Ehrensaft continues to teach us important new concepts in the ever-evolving gender landscape. Parents, teachers, therapists, and medical practitioners, sit up and take note! Although society may still be riddled with the outdated gender ghosts of times past, Dr. Ehrensaft is here to safely steer us toward a day when all children will feel safe and assured in their authentic, affirmed gender.”

—Rachel Pepper, LMFT, coauthor of The Transgender Child: A Handbook for Families and Professionals

“This exciting book from the author of Gender Born, Gender Made is an essential guide for any parent whose child goes against the grain of society’s expectations about gender. Diane Ehrensaft has delved deeply into the hearts and minds of gender-nonconforming and transgender children and adolescents to bust a multitude of myths. In simple language, The Gender Creative Child explores and explains new ways of thinking about gender-nonconformity. It’s an invaluable handbook, providing sensitive wisdom, helpful messages, and constructive advice for confused or anxious parents challenged by their child’s gender creativity and complexity. It’s a must for all parents, teachers, and pediatricians and should be in every public library. Riding the crest of the sea change of gender she describes, Dr. Ehrensaft is indeed a ‘gender angel.’ I only wish I’d had this book when my son was a toddler in the early ’90s.”

—Julie Tarney, author of My Son Wears Heels

“Diane Ehrensaft’s timely book offers parents, practitioners, and community members an invaluable road map for supporting children who are transgender or gender-nonconforming. Highly accessible, Dr. Ehrensaft offers the adults in the lives of transgender children a compelling analysis of the dangers of trying to change a child’s gender expression and/or identity. Dr. Ehrensaft draws on her vast clinical experience and an emerging body of research to argue that we should instead strive to cultivate a child’s gender health by ‘listening and acting.’ The Gender Creative Child should be required reading for anyone wanting to support the well-being of transgender and gender-nonconforming children.”

—Kimberley Ens Manning, founding board member of Gender Creative Kids Canada, and principal at the Simone de Beauvoir Institute, Concordia University

“Without Dr. Ehrensaft’s willingness to share her knowledge, our family’s journey would have been unimaginable. Dr. Ehrensaft has crafted yet another remarkable tool for the world to understand gender creative children. Using her own professional experience with countless gender-nonconforming individuals, this book will undoubtedly guide more parents to see gender is not as simple as checking a box.”

—Hillary Whittington, author of Raising Ryland: Our Story of Parenting a Transgender Child with No Strings Attached

“Insightful.”

—Vox

ALSO BY DIANE EHRENSAFT, PhD

Gender Born, Gender Made: Raising Healthy Gender-Nonconforming Children

Parenting Together: Men and Women Sharing the Care of Their Children

Spoiling Childhood: How Well-Meaning Parents Are Giving Children Too Much—But Not What They Need

Mommies, Daddies, Donors, Surrogates: Answering Tough Questions and Building Strong Families

WITH TONI VAUGHN HEINEMAN

Building a Home Within: Meeting the Emotional Needs of Children and Youth in Foster Care

Copyright

Copyright © 2016 by Diane Ehrensaft, PhD

Foreword copyright © 2016 by Norman Spack, MD

All rights reserved. Except for brief passages quoted in newspaper, magazine, radio, television, or online reviews, no portion of this book may be reproduced, distributed, or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or information storage or retrieval system, without the prior written permission of the publisher.

The Experiment, LLC

220 East 23rd Street, Suite 301

New York, NY 10010-4674

www.theexperimentpublishing.com

This book contains the opinions and ideas of its author. It is intended to provide helpful and informative material on the subjects addressed in the book. It is sold with the understanding that the author and publisher are not engaged in rendering medical, health, or any other kind of personal professional services in the book. The author and publisher specifically disclaim all responsibility for any liability, loss, or risk—personal or otherwise—that is incurred as a consequence, directly or indirectly, of the use and application of any of the contents of this book.

Many of the designations used by manufacturers and sellers to distinguish their products are claimed as trademarks. Where those designations appear in this book and The Experiment was aware of a trademark claim, the designations have been capitalized.

The Experiment’s books are available at special discounts when purchased in bulk for premiums and sales promotions as well as for fund-raising or educational use. For details, contact us at info@theexperimentpublishing.com.

Library of Congress Cataloging-in-Publication Data

Names: Ehrensaft, Diane, author.

Title: The gender creative child : pathways for nurturing and supporting children who live outside gender boxes / Diane Ehrensaft, PhD ; foreword by Norman Spack, MD.

Description: New York, NY : Experiment, 2016. | Includes bibliographical references and index.

Identifiers: LCCN 2015041549| ISBN 9781615193066 (pbk.) | ISBN 9781615193073

(ebook)

Subjects: LCSH: Transgender children. | Transgender youth. | Gender identity--Psychological aspects. | Child rearing.

Classification: LCC HQ1075 .E363 2016 | DDC 649.1--dc23

LC record available at http://lccn.loc.gov/2015041549

ISBN 978-1-61519-306-6

Ebook ISBN 978-1-61519-307-3

Cover design by Sarah Smith

Cover photograph by Lindsay Morris/INSTITUTE

Author photograph by Jim Hawley

Text design by Sarah Schneider

Manufactured in the United States of America

Distributed by Workman Publishing Company, Inc.

Distributed simultaneously in Canada by Thomas Allen & Son Ltd.

First printing April 2016

10 9 8 7 6 5 4 3 2 1

Note message

Cheryl Kilodavis,

Jayme Poisson, “Parents Kee

Part of the gender revolution initiated by the young is the insistence on using gender neutral

Katy Steinmetz, “America’s Transition,”

Pi

Seth Menachem, “My Son Wears Dresses, and That’s OK with Me,”

em

em

em

em

For a thorough, scientific descri

The term

Nanette Asimov, “Mills College S

Michelle Goldberg, “What Is a Woman?,” American Chronicles,

Ruth Padawer, “Sisterhood Is Com

See Ste

BBC News India, “India Court Recognises Transgender Peo

D. W. Winnicott,

See Genny Beemyn and Susan Rankin,

V. Pasterski et al., “Increased Cross-Gender Identification Inde

Two major articles about androgens and gender: P. T. Cohen-Kettenis, “Gender Change in 46,XY Persons with 5al

Ste

As a sam

The World Professional Association for Transgender Health (WPATH),

The Brothers Grimm, “The Frog Prince,” in

Candace Waldron,

E. B. White,

Genny Beemyn and Susan Rankin,

Thomas D. Steensma et al., “Factors Associated with Desistence and Persistence of Childhood Gender Dys

Hoffman and Hoffman,

Richard Green,

GenderQueer Revolution, “About,” facebook.com.

Some

Wiki

Suzanne Leigh, “Getting Beyond Male and Female,”

GenderQueer Revolution.

Eric Erikson,

Jennifer Carr,

39. Mx. Nathan Tamar Pautz, “On Not Judging a Book by Its Cover,” in

WPATH,

For more information, see Alexander Thomas, Stella Chess, and Herbert G. Birch,

See Annelou L. C. de Vries et al., “Autism S

See Avgi Saketo

As quoted in Julia Prodis Sulek, “Transgender Grandchild: Re

As quoted in Anne Saker, “Raising Zay: A Family’s Journey with a Transgender Child,”

Colleen Schra

As quoted in Hayden Manders, “Angelina Jolie and Brad Pitt Su

As quoted in KC Baker, “Cher: I Admire Chaz’s Courage,”

White,

For a com

Andrew Solomon,

Waldron,

See Derald Wing Sue,

Leelah Alcorn’s mother’s statement was quoted in Mikey Prizmich, “Acce

See Anna Freud and Dorothy Burlingham,

Even though India has given legal recognition to third genders, in everyday life those individuals are often

See Abraham H. Maslow, “A Theory of Human Motivation,”

Sheryl Ubelacker, “CAMH to ‘Wind Down’ Controversial Gender Identity Clinic Services,”

See Kenneth Zucker and Susan J. Bradley,

As re

Robert Wallace and Hershel Russell, “Attachment and Shame in Gender-Nonconforming Children and Their Families: Toward a Theoretical Framework for Evaluating Clinical Interventions,”

See T. D. Steensma et al., “Factors Associated with Desistence and Persistence of Childhood Gender Dys

The Child and Adolescent Gender Center mental health grou

Robert Stoller,

See S. R. Vance, D. Ehrensaft, and S. M. Rosenthal, “Psychological and Medical Care of Gender Nonconforming Youth,”

As quoted in Sherer et al., “Gender Nonconforming

P. T. Cohen-Kettenis et al., “Puberty Su

See Vance et al., “Psychological and Medical Care of Gender Nonconforming Youth” for a fuller discussion of medical interventions.

Anemona Hartocollis, “The New Girl in School: Transgender Surgery at 18,”

Quoted in Hartocollis, “The New Girl in School,” A20.

I would refer the reader to an article written by the medical director of our Child and Adolescent Gender Center, Dr. Ste

Norman P. S

John Donne, “No Man Is an Island,” Meditation XVII, Devotions u

Solomon,

genders

See R. B. Toomey et al., “Gender-Nonconforming Lesbian, Gay, Bisexual, and Transgender Youth: School Victimization and Young Adult Psychosocial Adjustment,”

Asaf Orr and Joel Baum,

Foreword by Janice Adams, in Orr and Baum,

Orr and Baum,

E. Menvielle and D. B. Hill, “An Affirmative Intervention for Families with Gender-Variant Children: A Process Evaluation,”

Laura Erickson-Schroth, ed.,

American Psychological Association,

Transgender Law Center, “Creating a Safe and Fair Climate to Learn and Thrive: Trans Youth Leading Change,”

CeCe McDonald, “On Fashion, Fierceness, and Fighting Revolutions,”

Eric Vilain and J. Michael Bailey, “What Should You Do If Your Son Says He’s a Girl?,” O

See T. D. Steensma et al., “Factors Associated with Desistence and Persistence of Childhood Gender Dys

Elizabeth Povoledo, “Book Ban in Venice Ignites Gay Rights Battle,”

Personal communication from Ronald Elson, MD.

Jody Norton, “The Boy Who Grew U

Rylan Jay Testa, Deborah Coolhart, and Jayme Peta,