I was traveling recently and happened to sit on the airplane next to a “sex-ender.”  I did not know that she was this person until after we exchanged small talk.  When we got to a point of talking about what we did for a living, I learned that she was a sociology professor at a well-known university.  Once she heard what I do for a living, she said, “Oh,” not happily, and an argument ensued.

Her point of view, captured in this dialogue, was not just academic for her—she told me she had a daughter with gender dysphoria.

“Sex enders” tend to be sexodimorphobic:  they have a fear of sexual dimorphism, sex as binary, and male/female.  Out of that place of fear, they argue we must end binary sex in our social conversation.  They often say, as this professor did, that “‘boy’ and ‘girl’ and sexual dimorphism are transphobic, inherently anti-feminist, anti-LGBTQ+, and neurobiologically, medically, physiologically, psychologically, and educationally unnecessary.”  As this sociologist discussed with me how useful social media is in confirming the veracity of her opinions, she suggested that social media (“the new social construction device”) proved that getting rid of “falsely binary male and female from parenting” would become our human future.  “There’s growing popularity for this.  We will end the use of ‘mom’ and ‘dad’ pretty soon,” she said, “or at least we should if we’re an empathic society.”

“Empathic for whom?” I asked.

“For everyone, since the truth is, we are all gender non-binary, gender fluid, and even bisexual.  The science on this is clear.”

This statement about science is untrue, but I didn’t attack it.  I just kept trying to clarify:  “So, we should say a person is feeding a child from their breast and that activity is ‘chest-feeding’?”

She nodded agreement.  “Getting rid of ‘mom’ and ‘dad’ will protect everyone from feeling pressured to be male or female in life.  Getting rid of ‘breast-feeding’ will finally create a healthy, fully diverse society.”

“So, you’re saying, not including the diversity of male and female worldwide would be healthy diversity, even though it excludes most people; but in your mind, it would be healthy inclusion not unhealthy exclusion?”

“To have a diverse society, we have to stop focusing on male and female.  This is what the AMA is trying for by saying we shouldn’t put ‘male’ or ‘female’ on birth certificates anymore.”

“But the AMA did not say that–a small group within the AMA suggested it as an relatively far-out option.  And the brains and bodies of our children are male and female at conception, so how can getting rid of male and female be real diversity?”

“Sexual dimorphism is a myth.  Anyway, even if it did exist, it can potentially harm and shame gender fluid children and adults to use false binaries.  Whether a baby has a penis or vagina does not matter–that child might end up gender nonbinary later in life so we should stop imposing male and female on that child from the beginning.  This step will also help everyone since male and female are just stereotypes, anyway—getting rid of male and female will free everyone up.”

“But your own child—you said she has gender dysphoria.  Doesn’t that likely mean she is female but feels somewhat male?  Isn’t it possible her internal battle is with male and female?  Perhaps she has brain sex dysphoria, not gender dysphoria?”

She had not heard the term before but, “No,” she insisted, the problem was that her daughter was misnamed ‘she’ at birth by her parents because of binary societal pressure.  “I’m ashamed that I gave her a girl’s name and raised her a girl.  If she (they) had been born into a society without male and female, they would never have suffered the depression and discomfort of gender dysphoria.”

That is likely not true, I wanted to say, but this was not the moment for that.

 

Gender Dysphoria or Brain Sex Dysphoria?

 

If you haven’t read blogs 1, 2, and 3 in this series, I hope you will go to the News page of www.gurianinstitute.com.  This blog is fourth in the series and stands on the ground of the first three.  This fourth blog will make more sense with the first three in tow.

What I called “Brain Sex Dysphoria” is not in the Diagnostic and Statistical Manual for Mental Disorders (DSM), the manual we in the psychology field use to understand, diagnose, and propose treatment for mental health issues.  Right now, when doctors, therapists, or others diagnose a disease, disorder, or mood issue related to sex and gender, the DSM provides “gender dysphoria” as the catch-all for LGBTQ+ feelings.

I have been uncomfortable for some time with hyper-use of “gender dysphoria” because it is not inclusive enough, from a hard science perspective, of all children and adults.  As I noted in earlier blogs, sex comes first, gender comes later.  Sex is the house, gender fills the rooms.  To group everything with “gender” means we will continue to have significant social confusion in families, schools, medical clinics, and therapy offices about what we are dealing with when a child presents to us in distress.

Specifically, many of the children and adults who present with gender dysphoria have sex dysphoria, even more accurately, brain sex dysphoria:  their depression and confusion grow from having a brain that is more female in its structure and function than their male body (or vice versa, more male in its structure and function than their female body).  Some, if not all, of these brain-sex dysphoric children may present as gender nonconforming to parents and professionals but are actually trans–the subject of blog 3.  Understanding who is trans and who is not is crucial to psychiatric care, good parenting, and child development.  If a child has brain sex dysphoria and is, therefore, trans, certain medications, like hormone blockers, will likely become necessary.  If a child is not trans, those same medications and procedures may do the child harm.

To distinguish brain sex dysphoria from gender dysphoria, which I will suggest here, depends on our agreeing, professionally and personally, that sex and gender are not the same thing.  This can be difficult because “gender” itself is now used at the catchall in some clinical study reports and in social trends.  Here is an example:  the study authors mean sex (as the first word in the title implies) but then they use gender: “Psychosexual Aspects, Effects of Prenatal Androgen Exposure, and Gender Change in 46,XY Disorders of Sex Development,” https://pubmed.ncbi.nlm.nih.gov/30388241/.   This is a very useful study, but it also adds to our social confusion about what is sex and what is gender.

You can find more on the “sex” part of the sex/gender equation in books like my own Saving Our Sons and The Minds of Girls or the work of others like David Geary, Male, Female: The Evolution of Human Sex Differences, Second Edition.  And in earlier blogs we noted that sex is pre-set in utero in all of us, even children who will later realize they are trans, lesbian/gay/bisexual, gender fluid, or bridge brains.  Brain scan studies of fetal brains (at eight and nine months in utero) show the male/female difference (sexual dimorphism) in brain function already before children are born (Wheelock, et.al., “Sex differences in functional connectivity during fetal brain development,” https://www.sciencedirect.com/science/article/pii/S1878929318301245).

We mentioned, too, that although laws like Title IX protect against “sex” discrimination, which is accurate baseline phrasing, overuse of gender is something we have perhaps all participated in, not realizing where we would end up now, with a situation in which sexodimorphobic people are trying to end sex.  I confess my own sin in this area: my GI team and I use “gender” quite a bit, as in “gender differences” or “learning through a gender lens.”   We use these terms because “learning through a sex lens” implies a sex act, which we do not mean, and “gender differences” is the popular term for differences between women and men, boys and girls.  The word “gender” is useful, no doubt, but it is crucial we all know what we mean by sex and gender.  In talking with the sociologist on the airplane, when I brought up the limitation of “gender” and the fetal scans (and five decades of research) showing robust sexual dimorphism, she denied the brain science altogether—no nuance at all:  “No,” she said, “there is no sex except our organs, everything between our ears is gender.”

 

Defining Brain Sex Dysphoria

 

The confusion of a sociologist about sex/gender is the confusion of our nation and, today, much of the world, despite that sex and sexual dimorphism appear in all races, cultures, nations, and people.  They do so because of the XX and XY chromosome markers are shared by every race and culture.  These two chromosomes set up our bodies and brains in utero for sex-on-the-body, sex-in-the-hormones, sex-in-all-our-molecules, and sex-in-the-brain.  As Louann Brizendine, author of The Female Brain and The Male Brain, has noted, sex is indeed binary (there are only two options) though there is a broad spectrum of what can be known as male and as female.

“Gender” is not sex but, rather, social constructions about sex.  Gender is more amorphous in large part because social constructs are themselves amorphous—they are what people subjectively make them to be.  This is why harmful gender stereotypes exist in various cultures like our own—we make “boy” and “girl” or “woman” or “man” into what we think they should be and project stereotypes to match our assumptions.   I tried to bring this up to the sociologist, but she still would not allow for any sex except reproductive organs “and a few physical differences.”  Her  daughter had gender dysphoria, she said, nothing else.  But when I asked her more questions about her daughter specifically, I thought perhaps the daughter had brain sex dysphoria and, thus, might be trans.  Her daughter had been on brain- and body-changing hormones for 2 and 1/2 years now, so I hoped so.

What is brain sex dysphoria?  We can define it by adapting other definitions.  Here is a definition of “gender dysphoria” combined from Wikipedia and the DSM (Diagnostical and Statistical Manual for Mental Disorders):  “’Gender dysphoria (GD) is a facet of modern human biology which is believed to be derived from the sexual differentiation of the brain.  DSM 5 states, ‘GD involves a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify.’”

Altering this to fit brain sex dysphoria, too, the definition would move in this direction:

“Brain Sex Dysphoria (BSD) is a facet of modern human biology derived from sexual differentiation in the brain. It occurs when the brain of the individual acts significantly more like the brain of the other sex than average or typical.  Further, DSM 5 states, ‘Gender Dysphoria (GD) is the common term used for all BSD and GD when, actually, it does not account for brain sex dysphoria.  Gender dysphoria should be used to measure a conflict between a person’s sex-derived sense of gender and the gender or genders with which he/she/they may later identify.”

To be accurate to existing science, I believe, we should no longer group all sex/gender dysphoric children simply under “gender” categories.  By expanding our diagnostic categories, especially to help us understand who is trans, LGB, bridge brain, and/or gender nonconforming, we would do better for all LGBTQ+ children and every other child, as well.

Brain sex dysphoria is experienced by children and adults who feel that their brains run counter to their bodies.  If diagnosed with BSD, the child should likely enter a timeline protocol (more on this in a moment) and gradually, if the protocols measure it, be diagnosed with brain sex dysphoria instead of gender dysphoria.  Not their gender but their sex feels at stake for them, like Bruce Jenner becoming Caitlyn Jenner; not mainly their social construction of gender, which they may derive to some extent from others around them, but their brain’s sex difference.

In this vein, clinicians should be trained to see if a trans child may in the short term present to us with GD but as a timeline of protocols commence, actually has BSD.  If the child does not–if the child has become emotionally involved with gender questions including those raised by other children and adults around him or her but that child’s brain does not show structure and functioning significantly akin to the other sex’s brain–that child likely does not have brain sex dysphoria but does have gender dysphoria and treatment for GD will be called for.

To look deeper into the work being done with brain scans and trans children and adults, see these two reports:

https://www.scientificamerican.com/article/is-there-something-unique-about-the-transgender-brain/

https://health.clevelandclinic.org/research-on-the-transgender-brain-what-you-should-know/

In these reports “gender,” “transgender,” and “gender dysphoria” are conflated and they are used to include everything, but I hope you can see room, and necessity, to discuss the difference between sex and gender—including the importance of our human culture developing an understanding of brain sex dysphoria as somewhat different from gender dysphoria.

 

Progressing Our Language and Diagnosis Beyond Just Gender

 

Here is another related and very useful article from the National Institute of Mental Health: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139786/.  Let’s work together with it to see the tension between sex and gender, a tension resolving inaccurately, quite often, toward “gender.”   Wade through this language with me, please, despite that this few paragraphs borders on dense semiotics.  It is very important we look carefully at this so that we can correctly diagnose, treat, and help our vulnerable children–with the nuance and specialization they deserve.

“The process of sexual differentiation refers to the development of differences between males and females,” the study notes, “which are widely observed in nature and also concern humans. One of the most sexually dimorphic human traits is gender identity, defined as the inner sense of self as a female, a male or as an alternative gender, different from the male and female ones.”  In this paragraph, the researchers accurately define what is going on internally but feel pressure to place ‘gender identity’ as an inborn trait when they say, “self as a female, a male.”  This is inaccurate: female and male are elements of sex not parallel to “alternative gender.”

The paragraph continues: “In cisgender individuals, gender identity develops in line with the assigned gender at birth and is stable throughout life.”  In this language, sex has become gender in two ways:  first, via the use of the increasingly used, especially in social media, “cisgender” to include all male and female individuals (“cis-sex” would be more accurate, or no “cis” at all, just “male” and “female”); second, via “assigned gender at birth.”  In fact, sex is assigned at birth not gender, and for accuracy, the language should read “assigned sex at birth.”

The paragraph continues:  “On the other hand, transgender individuals may persistently or transiently identify with a gender different from the one assigned at birth.”  For accuracy, this ought to read:  “On the other hand, trans individuals may persistently identify with a brain-sex different from the one seemingly attached to their genital sex.”  Use of “transgender,” now popular in social media, is incorrect–the trans person is experiencing transsexuality in the brain.  The word “transsexual” has a recent negative history, thus I suggest just the use of trans for a person who presents with brain sex dysphoria and thus is trans-sexual.

The study then continues:  “According to the Diagnostic and Statistical Manual of Mental Disorders 5^th version (DSM 5), we refer to Gender Dysphoria when the incongruence between the experienced/expressed gender and the assigned one leads to clinically significant psychological distress and impairment in the main areas of functioning. In some cases, this distress may lead to the desire for a social and/or somatic transition through a gender affirming hormonal treatment and surgery.”  In this language, we come to the crux of what can bring harm to both children and adults–the inaccurate grouping of “gender affirming” is too thin and leads to use of interventions for gender dysphoric children that are dangerous to them but are necessary for trans children–hormone therapy and surgery.

It is crucial to remember:  hormonal treatment and surgery are working on altering sex.  When researchers and physicians talk about “gender affirming surgery” they are actually talking about brain-sex dysphoria (sex re-assigment).  Surgery to affirm “gender” is likely dangerous–surgery to affirm brain sex is less dangerous and likely necessary in many cases.  However, because the Diagnostic Manual only includes “gender dysphoria”, all presenting LGBTQ+ children are supposed to fit under it, a lack of diagnostic complexity that must change if we are to serve 100% of our children.

Between 5 – 10% of human beings and mammals have a same-sex attraction (Lesbian, Gay, Bisexual), and approximately .3% of human beings are Trans.  These LGBT individuals can be identified via brain research (see Saving Our Sons and The Minds of Girls if you would like more depth on this, as well as blogs 1 – 3).   If your child is L G B, his or her sexually dimorphic nucleus (SDN) in the anterior hypothalamus is different than a hetero-child’s SDN, but your child still carries the SDN difference in his male or her female brain.  Simultaneously, his/her brain will likely show some cross-sex functionality on brain scans.  This means that brain may lean in functionality more toward the bridge brain (see this study just published in 2021:  https://www.nature.com/articles/s41598-021-84496-z).

But without diagnostic complexity available to us, your LGB child will often be grouped under “gender dysphoric,” and because little or no distinction is made between LGB and T and Q+, a potential and popular treatment response, propelled to a great extent by social media, is hormone treatment.  But if your child is LGB, she or he likely does not need that invasive treatment; nor does your child likely need body changes or surgery.  If your child is T (trans), however, s/he may well need those treatments.  One way we know how important it is to expand the DSM to accommodate all of these disparate children is this: many who present as “gender dysphoric” under present definitions, and say, further, that they believe they are trans, later realize they are gay (https://gurianinstitute.com/at-what-age-should-a-child-be-confirmed-as-transgender/) not trans.

In a painfully circular way, if we use invasive therapy on someone who is LGB or Q+ but not T, we permanently alter the child’s brain and physiological development of children who may well not need that alteration at all and miss the children who do need it.   Our society has done this Ritalin, misdiagnosing many children, especially boys, with ADD or ADHD and drugging them when some children needed it but millions did not.  We have done it with anti-depression medications, giving them to children as young as 5 or 6 before a safe diagnosis for depressive disorder could be made for many of these young children–safe for hormonally invasive anti-depression medications.  If we are going to medicate and alter children, we need to know exactly what they need.

 

Revising the DSM

 

To come to grips with this, we will have to transcend the sociologist’s concept, somewhat popular in social media, that “You are transphobic, patriarchal, sexist or anti-LGBTQ+ if you argue that sexual dimorphism is important.”  We will need to add brain sex and brain sex dysphoria to our linguistic and diagnostic arsenal and see that these additions are protective of LGBTQ+ children– not abusive or transphobic but empowering and affirming because they lead to tailored and customized treatment based on the child’s actual situation–trans distinguished from gender nonconforming and gay without stigma for any of these.  Were we to change the DSM to include brain sex dysphoria, the study we just analyzed might read this way:

“According to the Diagnostic and Statistical Manual of Mental Disorders 5^th version (DSM 5), we refer to Brain Sex Dysphoria (BSD) when the incongruence between the anatomical and brain sex experienced by the child or adult leads to clinically significant psychological distress and impairment in the main areas of functioning, and we refer to Gender Dysphoria (GD) when child or adult’s gender constructions reveal clinically significant psychological distress and impairment in the main areas of functioning.  In many cases, brain sex dysphoria may require hormonal treatment and surgery; gender dysphoria, however, will likely not be treated with these practices.

Once brain sex dysphoria is available to clinicians, parents, and children, all the tools available to us as clinicians, parents, and children will be seen through four brain-based categories rather than just the one, gender dysphoria:

Gay, Lesbian, Bisexual.  If the child is in pre-puberty or adolescence (around 9 or older), clinicians and parents will work to discover if the presenting dysphoria links mainly to the disconnect of the LGB attraction with the more typical heterosexual attraction of peers and parents.  If so, self-affirming counseling will likely be needed, including family education, but medication, especially hormone blockers and pre-surgical practices, will likely not be needed.

*Brain sex dysphoria.  As the child presents with gender dysphoria, parents and clinicians will work to discover if the child is trans (See blog 3 and below).  If so, hormone therapy in adolescence might begin, then surgery during adulthood might occur.  Because the child is presenting depression (dysphoria), traditional treatments for depression can also occur simultaneously or a priori to invasive treatments.

*Gender dysphoria.  This diagnosis would put the child in a category of sex- and gender-confusion that is concomitant with depression but not trans.  Because gender dysphoria is linked to identity questions that blend sexes and genders, some of the treatment will likely be self-affirmation as gender fluid, some may connect with LGB, and some with treatment for depression, but invasive hormonal therapies and pre-surgery practices will likely not be needed or advisable.

*Bridge Brain.  Some children presenting as gender dysphoric are depressed but not necessarily trans, LGB, or gender fluid; they may be “bridge brains” (see earlier blogs for more on this kind of brain).  Treatment for these children include empowerment as bridge brain with concomitant treatment for depression, as needed.

 

Going Deeper into Q+ (Gender Fluidity)

 

In statistical terms, 1.4 million people may be trans in the U.S., according to University of California, Los Angeles data, however, many of this number are gender nonconforming not trans, thus, in our language in this blog, some of these 1.4 million might fit in the gender fluid or bridge brain categories.  Advocacy agencies have argued that the number of gender fluid people is really 20% of Americans(see, for instance, “The CEO Who Transitioned,” WSJ, Vanessa Fuhrmans, September 14, 2020).   Common sense tells us this number is inflated.  If it were real, 1 in 5 of us would be gender fluid, and we are not seeing that around us.

But one thing is for certain:  gender-fluid, gender nonconforming, gender ambiguous, gender dysphoric, queer, questioning have a lot to offer the rest of us.   Like LGBT and bridge brain people, gender fluid and nonconforming people have existed throughout history.  They dressed like people of the other sex in public (actors, artists, for instance) and/or in private. They created and invented, fought wars, and suffered pain from people who did not understand their alteration of sex-specific social costuming.  Sometimes I hear people say gender fluidity is very new, but it is not.  These are important people, and suicide and depression rates for trans, LGB, and Q+ children are high–these children need our support and protection.

Thus, I hope we will all come together to agree that training parents, clinicians, teachers, children and others in ALL the categories of brain sex dysphoria, gender dysphoria, bridge brains, LGB, trans, and male and female are all important.

And the way the training is done matters.

An example:  a 13-year-old girl recently came home from Biology class reporting to her parents that her teacher taught a lesson on gender fluidity in class, including the fact that pronouns like “he” and “she” are outdated.  “You need to pick your pronouns,” the teacher said.  “He and she may not work for all or most of you.”  The teacher’s comments were gleaned from a workshop the teacher found on social media in which the trainees were told there is no sex, just gender.  Many of the students just looked at the teacher blankly.

The workshop presenter’s and the biology teacher’s mistake appeared, of course, in trying to erase sex–that everyone possesses, including a gender fluid child–to ostensibly help children who are gender fluid.  Not surprisingly, the teacher experienced significant backlash when the kids went home and talked with their families about this class.  Parents who would support gender fluid children if there was a “both sex and gender” approach tore apart the “it’s only about gender” approach.

The teacher’s heart was in the right place, as was, I am guessing, the workshop presenter’s, too.  But trying to force a culture of the exception into the larger culture (pretending that the exception is the rule), and using social media or other resources that lack in-depth scientific backing cannot help but create backlash.  Most parents in hearing about this girl’s Biology class sensed a layered irony:  a biology class and biology teacher that avoided actual biology in favor of sociology and political pressure and the culture of the exception.

Training adolescents in both sex and gender is a better course.  Numerous times I’ve presented scans of male and female brains to teachers, parents, and students in K – 12 schools.  The adults and the students are intrigued as they recognize themselves in the male/female brain scans.  By late elementary school, too, they recognize gender nonconforming students, and they understand them even better from peering into the human brain.  These children, especially in this generation, recognize variety and a brain spectrum, but should they be told they, themselves, as boys and girls, do not really exist?

 

Is There Social Contagion in Gender Fluidity Among Children?

 

Parental and legal backlash we are seeing worldwide to gender nonconforming people (lawsuits filed to block everything from trans bathrooms to the teaching of anything about gender fluidity in schools) grows in part from the overreach of gender politics on at least these two fronts:

1. Training on gender fluidity, like we mentioned in the Biology class, that lacks nuance or scientific accuracy about human nature and thus only includes a few people, not everyone; and
2. Social contagion among tweens and teens who are engaged in normal experimenting with identity via gender fluidity concepts.

Brown University public health professor Lisa Littman has noticed a trend around this second point, and she is joined by many of us in the school systems who see this trend, too, a new prevalence of children telling us they are gender fluid, gender nonconforming, or trans.  One child will say that he or she is trans in a school and this self-diagnosis is accepted by others as an identity, a style, even an ontology (a way of being).  Observing this, Dr. Littman developed the term “rapid onset gender dysphoria” (ROGD).  “Social contagion,” Littman discovered in her research, involved girls especially. (See more here, https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330, and here, Abigail Shrier, “When Your Daughter Defies Biology,” WSJ, January 7, 2019, and October 6, 2021, Abigail Shrier, Top Trans Doctors Blow the Whistle on “Sloppy” Care, https://bariweiss.substack.com/p/top-trans-doctors-blow-the-whistle).

ROGD, which mainly presents in the tween or teen years, presents at a time when children are developing their own sense of identity, but identity is not one thing–it is a Self we build slowly comprised of fragments gathered over many years of adolescence and emerging adulthood.  Being male or female is one of the core elements of pre-teen and teen identity—especially because of the wash of male/female hormones and biochemistry–thus, it is no wonder ROGD would activate in the pre-teen and teen years.

Why should we worry about all of this?  Because we need to help our children look carefully at where the child’s identity process fits with actionable dysphoria, given that:

• Most of the newly gender nonconforming children are not trans, even if they request affirmation as trans, thus, most are not brain sex dysphoric but they may be gender dysphoric, i.e., depressed and questioning; and
• All the children need help that can include affirmation of who they now say they are but also might include challenge and direction to be sure of who they are (“Are you LGB?”  “Are you trans?” “Are you a Bridge Brain?” “Are you gender fluid?”) during the time of treatment for depression and anxiety via medication and individual and family therapy.
• Others around the ROGD children need help understanding how their own children might fit into the new trend in the school.

An example of this third point came to me from parents of a 14 year old girl who was set to go to a dance with a group of friends who had all come out lately as gender questioning.  The parents did not have an objection to this until they learned that another girl who is gay requested that their daughter go to the dance with her separate from the group.  “This feels like a date,” the daughter said, “and it makes me nervous.”  Though the daughter saw herself as gender questioning, she knew she was not lesbian.  The family joined together to tell the other girl that dating is not allowed in the family until 16–which was true–so that the parents took the fall on the no-dating/no couple engagement with the group at the dance.  In the end, all the girls went together.  Knowing about ROGD and knowing that the other girl was gay helped this family without attacking anyone in the social group.

Retired middle school counselor and now Gurian Institute Program Director, Eva Dwight, spoke with me recently about her experience in this domain.  “In my last few years in the school systems, gender fluid expressions had already begun in earnest.  We had 7th and 8th graders sorting through atypical identities, embracing the differences themselves, and also reflecting peer pressure.  Many of them were sorting through things like, ‘I’m friends with kids who might be atypical, so I will be atypical myself, or at least experiment with being atypical, but I really don’t know what I am, but I have to sound like I do, and this is a way to do that.’  These kids in particular did not need a well-meaning adult to say to them, ‘Let’s try hormones on you,’ at least, not yet. Their struggle was adolescent identity experimentation, normal for any teen, and they were choosing sex and gender as part of that.

“I think, to some extent, many people don’t realize the normalcy of all sorts of exploration in any child.  When I worked with kids and parents around this, I saw significant confusion and angst for kids and parents both because neither are taught what you are explaining in your work on this in these blogs.  The parents and the kids in the cases I’m talking about thought ‘LGBTQ+’ is all one category–they didn’t realize there are brain differences between gay, bisexual, trans, gender fluid, etc.  This is why I think it is best for adults to find a professional who can help the presenting teens to understand and define themselves. This process will take time and patience.  These growing and developing children are changing rapidly.  We do them a disservice by going along with whatever they say as children. ”

 

Is It Even Fair for Adults to Play a Guiding Role When a Child Says, “I’m _________”?

 

In no era but our own would this bolded question arise, but Eva is hinting at it, and you’ve probably heard it asked.  Parents, teachers, and mentors have always been responsible for guiding children through their childhood journey, but in our era there is a significant culture of the exception pressuring us to believe we are abusive of our children if we think like Eva thinks.  An example.

I went to a school district to consult on gender issues just before Covid struck.  Part of why I was called in was that the community saw as ROGD, especially among girls.  The superintendent offered his approach to the issue:  “If a seven-year-old says he, she, or they are transgender, we should just say okay, and that is that.  I’d be worried about too much outrage from parents if we did anything else.”

From this school leader’s viewpoint, the school had a legal obligation not only to stay out of medical questions but also stay out of any questions that connect with a child’s identity development.

I understand the position but argued against it, especially as regards the care of younger children.

“A five or seven or ten-year-old can’t know for sure yet if he or she is trans.  Parents and adults are morally and psychologically obligated to study and help this child.”

Part of my consulting during the district visit involved helping to modify the tools in the district’s toolbox.  I suggested this checklist of protocols for professionals and parents of children who present with gender dysphoria and/or gender fluidity:

*Talk with child and parents about all the options noted above, including gay, trans, bridge, nonconforming, and fluid as special categories.

*Utilize brain scans and existing brain research to help determine if a child is trans.

*Utilize biochemical analysis, including blood tests of testosterone and other hormone levels that 1) indicate range of male and female in the child, and 2) provide insight into whether unbalanced hormone levels are partially causing gender dysphoria.

*Utilize personal statements, including patient journals over a multi-year period before confirming trans but, meanwhile, affirm the child as both depressed—thus receiving treatment—and gender fluid as necessary.

*Utilize parental and community member observations of the child from various sources at home, in school, among the child’s friends, among extended family, to help create a treatment and affirmation plan–the child should not go this alone.

*Minimize invasive biological intervention until mid-adolescence if possible, unless it is very clear that the child is trans earlier than that and/or it is clear that hormone treatment is necessary to treat the depression.

Less nuanced protocols, e.g., “affirm the child no matter how young as trans and begin hormone therapy,” may be politically and socially pressure-filled, but do not distinguish well enough between children in need.   Gender nonconforming children often do not get enough treatment for their depression along or protection from invasive biological treatment.  The one size fits all “everyone is gender fluid” or “everyone gender fluid is trans if they say they are” is not clinically smart and leaves too many children and families in distress.

 

A Treatment Timeline

 

For the protocols to be useful, we need to agree that trans, LGB, bridge brain, and gender fluid people are our children, parents, siblings, friends.  They are not alien, inherently defective, or dangerous to us.  They are people of dignity—they are us, in fact, and deserve equal rights.   But gender dysphoria should not get a free pass, either, to avoid all science in treatment.  In calling for changes in the DSM, I am asking professionals to utilize a timeline for treatment that will affirm a child’s search for identity.  Given all the potential gender placements, here is a timeline that respects the possibility that a child is trans, but also respects the fact that many children telling us they are trans, are not.

First, Pursue Psychological and Medical Evaluation for Six Months or More with Simultaneous Treatment for Depression as Warranted.   Psychological assessments of the child take time.  They can involve interviews, conversations, journaling, analysis of genetics, hormonal, physiological and (if possible—if scan equipment exists in your area) neural assessments.  The Cleveland Clinic I mentioned earlier,  https://health.clevelandclinic.org/research-on-the-transgender-brain-what-you-should-know/  looks at the usefulness of brain scans.  Let me pull a paragraph from their report to illustrate.

“When we look at the transgender brain, we see that the brain resembles the gender that the person identifies as,” Dr. Murat Altinay says. “For example, a person who is born with a penis but ends up identifying as a female often actually has some of the structural characteristics of a ‘female’ brain.  And the brain similarities aren’t only structural.  We’re also finding functional similarities between the transgender brain and its identified gender,” Dr. Altinay says.  “In studies that use MRIs to take images of the brain as people perform tasks, the brain activity of transgender people tends to look like that of the gender they identify with.”

For accuracy (and if “brain sex dysphoria” existed in DSM), this second paragraph would  read:  “We’re also finding functional similarities between the trans brain and its identified sex,’ Dr. Altinay says. “In studies that use MRIs to take images of the brain as people perform tasks, the brain activity of trans people tends to look like that of the brain sex they identify with.” (additions and italics are mine).

Of all our present and future treatment tools, brain scans will end up, I believe, the most helpful for determining a trans child or adult, but many cities don’t have them available.  Six months or more of assessment and “watching” time, with simultaneous treatment for depression or anxiety, is, thus, crucial.  During this time, clinicians can work with children and families.  They can say, “You could indeed be a gender nonconforming child but your brain may not be trans, and here’s why.  Let’s look together at this material.”

The family and child can be shown blogs like this one,  https://gurianinstitute.com/at-what-age-should-a-child-be-confirmed-as-transgender/, that reveal how many children think they are trans in the pre-teen years then realize in middle to late adolescence that they are gay, not trans.  “Being gay does not require hormone invasion and surgery,” the clinician and parents may now realize.  “Being trans likely will go in that direction and that direction may include a future of infertility, so let’s be careful with this.”

A moving, anecdotal support for taking time to assess and treat the child appears in this letter to the editor in the Wall Street Journal (January 19, 2021) submitted by an ARNP, Bob Beerman (who uses the popular “gender” but means “sex”):  “In my 37 years of practicing medicine, I have had approximately 25 patients who were unhappy with their birth gender.”  Some of them, the author notes, moved toward surgery.  He describes two who “spent north of $500,000 of insurance money for urogenital surgery, plastic surgery, and hormonal treatment.  Both later asked how to change back to their original, biological gender.”

Both statistically and anecdotally, there are too many people wanting to change back to their original sex to push forward with children’s lives impatiently.  Brain sex dysphoria, which may end up needing surgery to align with the body, and gender dysphoria are still anomalous in human evolution.  When something is anomalous, we assess, affirm, decide if treatment is needed, practice patience, and protect the child.

 

Second, Utilizing Puberty Blockers and/or Hormone Therapy.

 

Over six months or more, we have affirmed the child’s gender exploration, set a treatment plan for the depression, and assessed what comes next.  If puberty blockers can be postponed until the child is old enough to have gone through some of puberty, that would be ideal.  Meanwhile, it would not be uncommon for puberty blockers to be used for trans teens and for some other teens whose gender dysphoria is so acute the puberty blockers assist in treating the neurochemistry of depression.  Puberty blockers and hormone therapy are juggling acts.  Every ball in the air carries risks.  Sometimes we might have saved a suicidal child from suicidal depression with use of puberty blockers; other times, the hormone therapy leads to what Beerman described—a child’s sex is assaulted by the therapy and the child–once an adult–regrets it.

Here is a study that falls on the side of starting hormone therapy earlier to save lives:  Rain Before Rainbows:  The Science of Transgender Flourishing.  https://www.psychologicalscience.org/observer/transgender-flourishing.  Especially if a child is trans, starting puberty blockers early in the treatment process might be lifesaving.  But if the child is gender-dysphoric-but-not-trans, puberty blockers may give some help regarding the depression, but that same help might be achieved via other kinds of hormone balancing depression medications that are not as physiologically invasive.

Some of the possible long term effects of puberty blockers are:

• Delayed growth plate closure
• Lower bone density
• Less development of genital tissue.

Some of the possible short term effects are:

• Headache, fatigue, insomnia, muscle aches.
• Changes in weight, mood, breast tissue.
• Spotting or irregular periods if puberty blockers don’t suppress periods.

Other potential effects from long term use, especially if coupled with surgery, can include potential for infertility, later sexual dysfunction, inability to orgasm, and reproductive health issues.

Sometimes I read or hear on social media that “taking time to see if a child needs puberty blockers is analogous to saying a gay person is choosing to be gay and, thus, gay conversion therapy should be used rather than just letting them be gay.”  Obviously, this is a false claim: being gay does not require medication, and puberty blockers are medication.  If we immediately, without study, target a five or eight or ten-year-old with invasive medication, we might be doing the very thing we have finally stopped doing with LGB kids, invading the child’s natural development with potentially excruciating consequences to that child.

That said, if puberty blockers are used carefully in the care of your child, you may not need to fear their effects, at least in short term use, because they have already been success to treat early puberty and depression and other issues in girls who have significant menstrual issues at onset of menstruation.  Dr. Deborah Gore in the Kaiser Group founded and runs a trans and gender nonconforming clinic; she told me, “If the child does need puberty blocking hormones, they can be like taking meds for depression or like taking puberty blockers as they are often given now for young patients who are starting puberty very early.  Their use can be reassessed by the child, family, and physician after six months.”

 

Third, After Six Months to a Year of Puberty Blockers or Other Treatment, Reassess.

 

Dr. Gore’s point about reassessment cannot be overstated.  It is crucial in treating early puberty, depression, brain-sex dysphoria, gender dysphoria that we constantly reassess.  The latter two are are, at least at the time of presentation, forms of depression and treatment for depression undergoes reassessment as needed.  Simultaneously, early puberty and other hormone flow and balance issues can affect teens in ways that look like–and likely are–dysphoria or depression.  Mood and self-development issues caused by hormonal activity in adolescence may be a piece of the puzzle.

For girls especially, I recommend the family, including the tween or teen, read books like Women’s Moods by Dr. Deborah Sichel.  After six months to a year, reassessment might suggest another year of puberty blockers; or perhaps the child has now decided that s/he is LGB and/or bridge brain but not trans and puberty blockers can cease; or perhaps the child’s depression and dysphoria have been treated and/or lifted in another way; or perhaps the adolescent and team agree that s/he must start to transition via surgery.

Time is crucial–a whole team, including parents, children, and clinicians–need time to assess, treat, and affirm this child’s development of self.  All the possibilities require that parents and caregivers be careful and resilient in helping the individual child without social pressure to take the child in one direction or the other immediately.

 

Protecting All Our Children

 

Our culture is generally a supportive one, and our science, especially, is supportive.  Like our laws, science supports both majorities and minorities, and provides pathways to protect both.  If we can bring to bear a fully scientific approach to LGBTQ+ debates, we will be directly responding to people who pressure us to erase sexual dimorphism and male/female as well as others who pressure us with arguments that denounce LGBTQ+ people as dangerous.

The core of our being—sex–will never be removed from human nature.  Being a woman and being a man are crucial parts of both individual human identity and our progressive and ongoing prosocial growth.  Remember Anna Quindlen’s “friction” that generates healthy culture:  we need boys to become men, and girls to become women, because we need the loving friction that they generate between them.  As an outgrowth of sex, gender, too, is a permanent part of human being.

When I spoke with the sociologist on the plane, I asked her about the possibility of neglecting women’s rights by asserting a culture of the exception in the area of trans and gender rights.  “By trying to erase girl and woman, don’t you set back women’s equality, for instance in Title IX area involving female rights in sports and athletics.”  I gave her some of the legal cases and analysis that appear in blog 3.  She did not see the removal of women and girl as problematic.

To me, she is dead wrong.  If we try to erase sex ostensibly to uplift gender, we set women’s rights back as we noted in blog 3, and we will continue to raise immature men.  Every time we stop people from finding ways to raise boys into mature men, we do harm to our whole culture.  Girls and boys need to and want to become women and men, with all gender exceptions accepted. The majority needs to continue developing toward purpose and the adult goals of sex because societies flourish when sex is part of adulthood.

Meanwhile, if we try to negate gender exploration–the minority–as harmful, we will create divisiveness in our culture that is unnecessary and dangerous to numerous nonconforming children.   The divisiveness will push the extremes into dangers, pushing some LGBTQ+ activists and some physicians to consider all minority children candidates for potentially life-altering treatments, and pushing opponents of gender fluidity conversations to limit the rights of the gender fluid.

Best would be to understand what both sex and gender are, how they work, and how important each of them is to empathy and care of our full diversity of children.   I have argued throughout this blog series that a careful use of medical and psychological science is key to this understanding.  In our Covid era, the phrase “follow the science” is often misused, but when it comes to sex and gender, following the real science means being humane, true to who we are as diverse human beings, and culturally relevant all at once.

 

Copyright © Michael Gurian 2021