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Hope amid the madness
Therapy may help put gender distress in true perspective
Miriam Grossman, M.D.
An extract from her new book Lost in Trans Nation: A Child Psychiatrist’s Guide Out of the Madness
James is sporting a scruffy beard. Sarah wears skirts and doesn’t care about pronouns. Taylor wants to talk about college, not testosterone.
These small changes—all seen or reported to me recently by patients or their parents—are big.
In my book I’ve described monumental struggles and grief, but I want you to know there’s hope. Young people and their families can be helped with therapy.
They can slow their pace on the assembly line that leads to harm; some even step off. They can accept, even enjoy their bodies. It’s far from guaranteed and not always an easy road, but it’s possible.
How do I treat my gender-distressed patients? The same way I treat any other: with respect, empathy, curiosity, honesty, and with their lifelong happiness and well-being foremost in my mind.
I begin with, Tell me about yourself. I want to know who you are.
My patients have been led to believe they face a simple issue with a simple solution. I explain that it isn’t so. They are, like all people, a huge, complex tapestry, of which gender occupies just a small corner. The entire tapestry interests me, not only the one corner.
We’ll talk about gender, of course, but instead of automatic affirmation, we will look deeper.
“There has been a substantive increase in the number of young people presenting with so-called gender dysphoria in recent years. This has been caused, in all likelihood, by the same mechanisms operative when other psychogenic epidemics have spread through the population: that is, by the marshalling of social forces, for oft-political reasons, to shape the manifestation of an underlying non-specific proclivity to anxiety, depression, and hopelessness among a vulnerable subset of children and adolescents”—Dr. Jordan B. Peterson, forward to Lost in Trans Nation: A Child Psychiatrist’s Guide Out of the Madness
We will try to determine what living as the opposite sex accomplishes. How will it make life better or easier? Is the new identity about becoming someone new, or fleeing who they are? Granted, some of my questions may make patients uncomfortable, but this is the biggest decision of their lives, and it deserves a close, careful look.
I look at my patient’s family. Is there conflict in her home, an ill parent or sibling? I determine if she has a psychiatric condition such as anxiety, depression, OCD, ADD, psychosis, or if she’s on the autism spectrum or has some other form of neurodiversity.
Is there a history of adoption, trauma or abuse? Social awkwardness or bullying? Attraction to the same sex? Is the trans identity a way of exploring themselves separate from their family, a normal task of adolescence, taken to an extreme?
There may be stereotypical beliefs about men and women that are mistaken. He may think he’s not “manly” and won’t find love or acceptance as he is. Maybe she or someone she loves was harmed, she feels helpless against male aggression, and for that reason seeks to flee femininity. Perhaps he or she fears growing up.
The point is: being “trans” is a solution—a coping mechanism—but to which problem? That’s the mystery we solve together.
One of my primary responsibilities is education. I am older and wiser, and that benefits my patients. One line that’s effective with know-it-all-adolescents: “Your sixteen? I’m 116.” Over my decades of practice, I learned many things, one of which is that people change. A leftist turns around and votes conservative. Couples once madly in love, certain about marriage, now are at each other’s throats. A woman who couldn’t have been more certain about aborting, twenty years later she’s childless and rethinking that decision.
People change, I tell my patients. You’re going to change too.
Another wisdom I share is that being human means struggling. It means living with limitations and weaknesses. You’re not the first person to hate your body, feel disconnected from your parents, and lack a place of belonging. You’re not the first human being to experience confusion, pain and loneliness.
Under some circumstances I might share a hardship of my own. Even more important is to reveal difficulties to a patient, at the moment. In doing so, she or he learns I have tough moments too, but they can be managed.
For example, if I fear a patient’s response, I might say: “I must tell you something, but I have mixed feelings about it, because of how you may react.” The patient learns I too have fear of conflict; I feel unsure just like she does. I’ve demonstrated how I tolerate those emotions.
A patient needs to feel safe and understood. It’s in that trusting and honest space between us that healing begins.
I try to model thoughtfulness, humility, and especially compassion. We must have compassion for ourselves and others—including our parents. They too are human, with limitations and struggles. They’re doing, or did the best they could, and it wasn’t all bad.
Ultimately the choice is theirs, I tell my patients, their identity is in their hands. At the same time, whether they’re requesting new pronouns or surgery, there are risks. I’m obligated to point out what they are doing has massive implications. What will their lives be like in ten, twenty, fifty years? There may be a high price to pay.
Video: Dr. Grossman charts Europe’s shift to caution on youth gender medicine
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Red flags aflutter
I remind patients that as a physician, I have a profound appreciation for the body’s wisdom. They may think they have all the information they need, they may be convinced they’re knowledgeable about social and medical interventions, but I know they don’t and they’re not. From new names to mastectomies and vaginoplasties, they must understand the risks and the controversy.
If I neglect to delineate those risks and the current debate, I’m not doing my job. What if he or she comes back crying, Look what I’ve done to myself, why didn’t you warn me? Speaking of risks, that’s one I am unwilling to take.
I strongly encourage gender-distressed patients to at some point read detransitioners’ stories or watch their videos. When patients are unwilling to do so, or are unable to hear about the dangers of medicalizing, or if they claim to be unconcerned and confident, those are red flags. All of us have some degree of doubt when we face major decisions. Every decision has plusses and minuses. To be confident and wrong is dangerous.
It’s also my job to gently challenge and plant seeds. Being from an older generation, I ask my young patients to define the new language and explain their beliefs. I am curious. I want to learn from them. If their definitions or explanations don’t satisfy me, I’ll say so.
The goal is to recognise everyone is a mosaic of male and female. Honour the mosaic and leave the body alone. And to parents: You must respect your child’s mosaic, too. He or she may not match your ideas about masculinity and femininity.
When I said earlier my approach to transgender-identifying patients is just like with any other patient, I omitted a salient point. There is one huge difference. After their brief weekly sessions, my patients return to their friends, schools, and social media—a world bound to the Articles of Faith, which enshrine Gender Identity as sacred and forbid any questioning.
It’s daunting, to say the least, to build a connection with heavily indoctrinated patients. They’ve heard over and over there’s one answer to their predicament—transition. They cannot tolerate the doubts I plant.
The hurdle may be insurmountable. Zoe was an eleventh grader attending a Boston school where the cost of tuition was higher than the median yearly household income. Her mother informed me that in middle school, Zoe and her friends all declared themselves LGBT, they just hadn’t decided which letter.
Once I tried to inform Zoe that due to safety concerns, a minor like herself living in Sweden or Finland would not have access to puberty blockers. She placed her hands over her ears and hollered: “Don’t tell me about trans kids who can’t get medical care! Don’t you know fifty per cent of us try to commit suicide?”
To her accusation of being transphobic, I responded “I’m anti-suffering, not anti-trans.” I could almost sense her friends and influencers in the room with us, scowling at me. She refused to meet again.
In my many years as a physician, I’ve had patients with severe schizophrenia, untreatable cancer, and other serious conditions. No one ever fired me. Do you see why I say fighting dangerous ideas has been harder than fighting dangerous diseases?
When the young person has pledged allegiance to the Articles of Faith, the challenge facing parents and therapists is brutal. Parents who’ve yet to face the predicament, please listen to the mothers and fathers of kids with Rapid-Onset Gender Dysphoria.
Many of them say flat-out: they are living in hell, and they want to warn and teach you before you’re in their shoes. They are reaching out to save you from the impossible position they’re in—a child announcing that in order for me to stay in this family, you must support my self-harm.
These are the parents who—when they catch a glimpse of you at a park or shopping mall holding the hands of your toddler or school-age sons and daughters who are still attached to you, still trusting you—feel a stab in their hearts: If only you knew what may be ahead.
Your children are like a sponge, ready to absorb whatever comes their way. They are a work in progress, and you are their scaffolding, providing support and structure. If you don’t provide a belief system, a compass, or some meaningful foundation from which to understand the world, identify truth and lies, and know right and wrong, trust me—others are waiting eagerly to do just that. Before you know it, your child is a pawn, a foot soldier in a foreign crusade of dark and dangerous ideas, and you’re the toxic parent with a home that’s unsafe.
This is an edited extract from the upcoming book Lost in Trans Nation: A Child Psychiatrist’s Guide Out of the Madness by Miriam Grossman, M.D., with a forward by Dr. Jordan B. Peterson, Skyhorse Publishing Inc. Dr. Grossman’s website is here. Her Twitter handle is @Miriam_Grossman