Protecting Our Future Leaders: Two Doctors on Gender-Affirming Care
On November 24th, the Washington Post published a Perspective Article entitled The mental health establishment is failing trans kids, by Drs. Erica Anderson and Laura Edwards-Leeper. The post comes on the heels of Anderson’s recent substack interview with Abigail Shrier, author of Irreversible Damage: The Transgender Craze Seducing Our Daughters, a book openly hostile to the trans community. The article by Anderson and Edwards-Leeper contains errors, false claims, and creates a crisis that will siphon resources from reducing the pressing crisis of serving trans youth.
It is important for the public, especially those in proximity to gender diverse youth, to realize there is a wide array of perspectives on what respectful and integrative care means. Thus, one of the providers mentioned in the Washington Post article and a colleague have joined voices here to provide a response.
Dr. Eckert is one of two medical doctors identified in the op-ed who support and practice the gender affirmative model of care for trans youth and whose words were misrepresented and taken out of context. They are the Medical Director of the Gender and Life Affirming Medicine (GLAM) Program at Anchor Health Initiative, and, in their role, see trans youth and adults in their clinic for primary care and gender-affirming hormones and puberty blockers. Dr. Goldenberg is a Licensed Psychologist with extensive experience in gender affirmative care for clients across the life span. He has been an activist and trainer focusing on gender equity for twenty years.
By publishing this article, Anderson and Edwards-Leeper, who both identified a past or current association with The World Professional Association for Transgender Health, or WPATH, willfully ignored the recent combined statement released by USPATH and WPATH stating, “USPATH and WPATH oppose the use of the lay press, either impartial or of any political slant or viewpoint, as a forum for the scientific debate of these issues, or the politicization of these issues in any way.” We should be able to expect that leaders from our top associations will at a minimum respect the policies and positions of which their respective associations created.
Anderson and Edwards-Leeper construct a narrative in which the increasing rates of youth accessing gender-affirming care have led to affirmation without question, medical and surgical regret, and detransition. They report poorly handled “gender dysphoria cases” and “sloppy, dangerous care.” These are concerning and alarmist statements which both discredit the wise experience of others in the field and are not guided by any data. Anderson and Edwards-Leeper build a case for a “conscientious” assessment process by appealing to the WPATH Standards of Care, internationally accepted guidelines (that) are designed to promote the health and welfare of transgender, transsexual and gender variant persons in all cultural settings. However, the WPATH SOC 7 are misrepresented throughout the article. In this piece, we seek to clarify the WPATH SOC 7 and to articulate what gender affirming care can look like.
Doubting Trans Youth I: Gender Dysphoria Claims
Anderson and Edwards-Leeper open with an anecdote about 13-year-old youth Patricia telling her parents that she is trans. (Note: since presumably P. currently identifies as cisgender, we will use she/her pronouns.) Patricia reported no experiences of gender dysphoria but had recently been sexually assaulted, started using drugs, and was depressed and anxious.
The authors mention an absence of gender dysphoria as a warning sign that this youth is not trans; however, not all trans people experience gender dysphoria. The belief that a diagnosis is clinically required to access gender- affirming care, known as transmedicalism, can contribute to stigma and discrimination toward transgender individuals because centering a mental health diagnosis suggests that all gender diverse people are inherently mentally ill. Another consequence of centering gender dysphoria as an essential trans experience is that it fails to consider that gender diversity is natural and a vital aspect of all societies, not a narrowly defined American pathology. Simply stated, an experience of gender dysphoria is not a requirement to be considered part of the trans community. (Note: we use “trans” throughout this article to include both transgender and gender nonconforming people). Further, one would postulate that if lengthy exploration of gender identity is as critical as the authors suggest, then we should persist in this method for all youth, no matter how they self-identify. Note that gender exploration for all youth is not an explicit recommendation from the article; that intervention is only considered vital for gender diverse youth.
Later in their post, Anderson and Edwards-Leeper assert that there is no evidence that treating gender dysphoria improves other mental health issues in trans youth. However, studies show that trans children supported in their gender identity by their families have rates of depression comparable to their cisgender peers. Studies suggest that improved body satisfaction and self-esteem following the receipt of gender-affirming care is protective against poorer mental health and supports healthy relationships with parents and peers. Research consistently demonstrates that trans youth who are affirmed in their gender identity by their families have significantly better health outcomes. There is a need for larger-scale studies that include questions about gender identity, notably absent in prior research, recruitment in rural areas as well as metropolitan, inclusion of intersectional minorities overlooked and ignored by the system, and analysis of the specific factors that predict rejecting family behaviors and those that contribute to positive climates. It is also known is that social and medical gender affirmation are inversely related to mental health problems in trans people. Research overwhelmingly supports an affirmative approach, but where there is a lot of diversity of thought is what is considered to be affirmative, and by whom.
Doubting Trans Youth II: It’s Actually Mental Illness
Anderson and Edwards-Leeper imply that an adolescent’s mental health issues and “confusion” may express as a newly asserted trans identity. There is no evidence that mental concerns lead to identifying as trans, though this is a common argument perpetuated by those who oppose gender-affirming care, such as William Malone, Paul McHugh, Lisa Marchiano, and others. Instead, research finds that as many as 41.5% of trans people have a mental health diagnosis or substance use disorder. This is widely accepted to be a consequence of minority stress, the chronic stress from societal stigma and discrimination experienced by trans people due to their identity and expression. Certainly, there are trans individuals who experience mental illness, just as there are trans individuals who live through a number of additional marginalized identities.
Doubting Trans Youth III: Questioning Suicide Rates
In Anderson and Edwards-Leeper’s anecdote about Patricia, a gender-affirming therapist tells the parents to support their child’s identity or their child may die by suicide. “41 percent of unsupported children commit suicide, they were told. Would Patricia’s parents rather have a dead child or a trans one?”
Anderson and Edwards-Leeper report a lack of evidence for the alarmingly high suicide rate in trans youth. However, there are statistics reported by several research studies. Because these statistics are based on self-report, some have speculated that the percentages are inflated, a statement not endorsed by any of the studies. It is more likely that suicidal ideation and attempts are underreported; students may not disclose their gender identity for fear of discrimination and bullying, and there is a lack of systematic gender identity data collection. A recent meta-analytic review of worldwide (death by) suicide rates in youth only included binary male/female categories of gender identity. Only recently have large-scale, national studies begun to consider including trans demographics on death by suicide. A limitation there is that autopsy datasets can only collect what is known about an individual’s gender identity postmortem. A secondary analysis of National Violent Death Reporting System (NVDRS) found that 24% of 12–14 year-olds who died by suicide were LGBT; these young ages had the greatest suicide disparity between LGBT and non-LGBT youth. Many potential variables lead to an increased suicide rate for trans youth; inflation of statistics by faking suicidal ideation in order to access gender-affirming care is not one of them.
Doubting Trans Youth IV: There Are Now More Trans Youth than Ever
Yes, the number of adolescents requesting gender affirming medical care is higher than ever. This is due to greater social acceptance and visibility and, despite barriers, overall improved access to healthcare. The reason for higher percentages of people under 18 identifying as trans can be tied to many changes in culture; the statistics were going to grow regardless. For instance, access to terminology has increased tremendously and folks are learning new ways to articulate their experiences with the power and authenticity of language. Those of us in the community are aware that individuals have always been here, surviving and making our way through. We may just be more recognizable to others now that it is easier for us to find each other.
Doubting Trans Youth V: Detransitioners and Desistance
Opening their post with the story of a (possible, since we do not know the end outcome of this youth’s gender journey) detransitioner is disingenuous, given the low rates of detransition, despite what the authors may claim. Perhaps one of the most common narratives of those who oppose gender-affirming care is the one centered around “detransitioners.” The media consensus: “Trans healthcare is dangerous and harmful! Look at all these people who regret this giant mistake.”
Many psychologists continue to falsely rely on the “desistance myth,” the widely accepted idea that most trans children will desist, a presumption that raises questions around whether we should support the gender identities of trans children in the first place. Transition regret attributed to doubt about gender identity is expressed by 0.09% of people in one study, 0.3% in another, a rate of less than 1% in a third, and 2.4% in a fourth. The medical research on gender affirming care yields very low rates of regret. Official statistics are difficult to obtain, however. The appeal may be to distance oneself from the experience of queer and trans people, to pretend as if trans and queer people haven’t always existed and will continue to exist, and to suggest that assimilating into a gender binary is a matter of maturity. We presume based on what the Pew research center has found so far about those born after 1996 that suggesting gender normativity is a cultural goal will be a hard sell.
The rhetoric around “detransitioners” is not dissimilar to that of the “ex-gay” movement, both insisting sexual or gender minorities are a “treatable disease.” These debates, naturally, often center on children. This comparison is useful in that conversion therapists have created no standardized treatment manuals, thus when people speak of conversion therapies, what is meant is any effort to change, manipulate, or distance a person from their authentic self to achieve perceived dominance in the social sphere. Open-ended exploratory therapy, when it is initiated and facilitated by the therapist without desire to participate from the client is a profit-making model. Similar to conversion therapy, non-nuanced exploratory therapy is not evidence-based and likely can result in clients performing participation to satisfy the power struggle from the therapist while creating no positive therapeutic effect. Clients can have questions about gender identity and especially about their belonging, their chances of finding family and love, and economic anxiety. Deep exploration about the generational resiliency within LGBTQI communities can be therapeutic, as can finding language and community resources and many other tasks that can be called ‘exploratory.’ However, these are not questions that all clients have, nor do they need to be imposed.
There is another consequence to the ideas about desistance in gender diverse youth which is important to name here. That is the erasure of gender bending, gender shaping, nonbinary identities in adults. Nonbinary adults know the reality of not being taken seriously or being seen as purposefully challenging or unclear. They are aware of how gendered expressions are seen as childish and unprofessional when done in a beyond-a-binary way. When youth are not held and affirmed in all their gender expressions and we do not celebrate their authenticity and creativity, we are setting them up for an adult world of gender panic, scapegoating, and failed feminist movements. The catastrophic discrimination against the existence of gender diverse people is one of our most expensive and unnecessary errands.
Doubting Trans Youth V: Sourcing Pseudoscience
The authors support their claim that trans youth do not have clarity around their gender identities and their claims of high desistance rates by quoting Lisa Littman’s recent detransitioners study. Littman is the originator of ROGD, or Rapid Onset Gender Dysphoria, a concept that is not a medical diagnosis recognized by any major professional association and has no good evidence to support its existence. In fact, the consensus of major healthcare associations, including the WPATH, is that ROGD use be eliminated from clinical and diagnostic application. Littman’s most recent study, just like the original, skewed results by drawing from blogs openly hostile to transgender youth, the same blogs where Littman developed the concept of ROGD in the first place. Disaffirming approaches to care, such as those advocated by proponents of ROGD, have been shown to lead to high rates of depression, anxiety, substance use, and poor school performance. Depression, anxiety, substance use, and poor school performance primarily manifest in those youth living in unsupportive environments.
Anderson and Edwards-Leeper also source Genspect, an organization closely associated with SEGM. The Society for Evidence Based Gender Medicine, or SEGM, is a transphobic group frequently sourced by mainstream media despite pushing flawed science. There are familiar names that come up in association with these and similar organizations, among them Stella O’Malley, described as “an expert on Rapid Onset Gender Dysphoria,” and Sasha Ayad, an LPC who “questions the practice of medical transition for children and teenagers.” Ayad is sourced by Anderson and Edwards-Leeper as well, in an article defending non-affirming psychotherapy. Anderson and Edwards-Leeper also cite known concern troll Jesse Singal.
Misrepresenting the Standards of Care I: Non-Affirming Therapy
Edwards-Leeper and Anderson mischaracterize the WPATH Standards of Care (SoC v.7) throughout their article. They contradict themselves from one paragraph to the next, describing trans healthcare as having “strict guidelines” only to then address the standards of care recommendations. Recommendations are not strict guidelines, which the WPATH makes clear.
Let’s turn back to the article’s opening anecdote about 13-year-old Patricia. Anderson and Edwards-Leeper report that Patricia’s parents took her to two mental health professionals. Therapist #1 was gender-affirming and supports the youth in their identity, biding the parents to support their child as well. The authors state, “on first meeting, the therapist simply affirmed her new identity, a step that can lead to hormonal and eventually surgical treatments.” Therapist #2 was “more curious and less certain” and, as a result of seeing #2, the youth “no longer felt” they were trans. The anecdote ends here, presumably concluding that Patricia is not trans and just needed to talk to someone who would not unquestionably support her gender identity.
Therapist #2 is the authors’ preferred choice. They, however, neglect to mention that all therapy involves being curious and listening. There is a difference between gender exploration and disaffirmation. The authors’ favoritism of Therapist #2 directly contradicts the WPATH SoC which clearly states in its guidelines:
“1. Mental health professionals should help families to have an accepting and nurturing response to the concerns of their gender dysphoric child or adolescent…
2. Psychotherapy should focus on reducing a child’s or adolescent’s distress related to the gender dysphoria and on ameliorating any other psychosocial difficulties. Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success (Gelder & Marks, 1969; Greenson, 1964), particularly in the long term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical.”
Misrepresenting the Standards of Care II: The “Conscientious” Assessment Process
Anderson and Edwards-Leeper claim that the “conscientious” assessment process (a process they endorse without empirical evidence for its benefits) takes a few months-but only if the trans youth has no underlying mental health issues. Mental illness is an intersection on the bar of ability. The phenomenology of treating other mental illness first tells gender diverse clients to perform to be sick enough for a diagnosis but well enough for a treatment. The narrow space that is offered then is more likely to be filled by those with means.
Asserting that the evaluation process can take up to a few years fully contradicts the WPATH Standards of Care. The WPATH SoC state, “Early use of puberty-suppressing hormones may avert negative social and emotional consequences of gender dysphoria more effectively than their later use would. Intervention in early adolescence should be managed with pediatric endocrinological advice, when available.”
The comprehensive assessment that the writers suggest is not evidence-based, and certainly not in the reality of the modern American healthcare system. The American Psychological Association which accredits doctoral programs in Psychology includes diversity requirements in core curriculum. However, the majority of clinicians will not receive gender inclusive training and many will report that if they did have gender inclusive training, it was because they had LGBTQI professors. If there is one point of agreement between scholars, it is likely that the lack of gender inclusive education especially in professional training has had immeasurable devastation on communities. But becoming absolute with a uniform approach is not the way to liberation. There is abundant data which proves that access to mental health in this country is inadequate. The Washington Post has written extensively about the mental health crisis as it relates to policing, affordability, and culturally aware care. This is the truer crisis to which we all must attend.
Misrepresenting the Standards of Care III: Compulsory Psychotherapy
When discussing Dr. Eckert and similar providers, the authors write, “These providers do not always realize they’ve confessed to ignoring the standards of care.” This is false, given that compulsory psychotherapy is no longer the standard of care, as much as the authors would have their readers believe. They seem to be laboring under the presumption that trans youth are mentally ill cis youth until they jump through several hoops to prove otherwise. The Standards of Care acknowledge the damaging and irreversible consequences of an incongruent puberty, reject the stereotype of trans psychopathology, and include harm reduction strategies.
The Gender Affirmative Approach
Anderson and Edwards-Leeper state that the gender-affirming approach “almost always means no mental health involvement and sometimes no parent input, either.” This is inaccurate. Gender-affirming care is nuanced, complex, and comprehensive. In the gender affirmative approach, both parental and/or medical guardian input and mental health are crucial elements to care. Elevation of careful scientific approaches does not need to disrespect or misrepresent alternative viewpoints; it simply creates greater clarification and progress. Anderson and Edwards-Leeper chose to misrepresent the work of their colleagues with no concern about how this could be deleterious to the individuals named and do not show compassion for how their rhetoric is both palatable and nutritious to the efforts to end affirmative care, thus signifying that this article is about expanding their own privilege.
The gender affirmative approach places significance on a child’s understanding of their own gender and supports trans children in gender affirmation, reassuring them that there is nothing wrong with their gender identity or expression. This approach can alleviate mental health and behavioral concerns in a trans child. Family support is vital to a child’s well-being, and in a gender affirmative approach, healthcare professionals collaborate with children and their families to create individualized affirmative frameworks wherever possible. In the case of medical treatments, physicians provide patients and their families with information about treatment, addresses questions and concerns, and make sure that they have all the information needed to make an informed decision. Therapy is not a requirement in this approach because being trans is not a pathology nor is a therapist in a better position than a medical doctor to detail information about endocrine or surgical options.
Barriers to Gender-Affirming Care
The idea that trans youth are being “rushed” through the gender affirmation process is preposterous. A 2019 study that followed a cohort of over 300 trans children aged 3–12 noted that trans children identify with their gender just as strongly as cis children (those whose gender aligns with the sex they were assigned at birth). The researchers note that this was especially surprising since the transgender children were, prior to social affirmation, treated as a gender other than the one they currently identify as. Most cis and trans children know their gender around age 2 or 3. According to a 2020 research study by Cedar Sinai, most trans children with gender dysphoria experience dysphoria around age 7. Given this information, gender dysphoria often persists for years before patients take any steps toward gender affirmation. The Trevor Project has also contributed to the research about the lack of available mental health care and what some of the nuanced factors are. For example, the 2021 National Survey on LGBTQ Youth Mental Health found that nearly half of youth who wanted counseling did not receive it, and they documented that those risks increased for BIPOC youth.
By the time Dr. Eckert sees patients in their clinic, trans youth have started puberty. No medical or surgical interventions are provided to anyone who has not started puberty. In most states, no one under 18 years old can start gender affirming hormones and/or puberty blockers without parental or other medical guardian consent. Trans youth depend on their families for medical decision-making. Given that youth often need both parents’ permission to make legal or medical changes, this can create the need for a holistic approach that educates and supports all members of a family.
Another obvious error in the assertion that trans youth are rushed through treatment is the wait times for most providers are very long, especially during the pandemic. In spaces where Dr. Goldenberg works, a typical wait to get into care can be a year. Once in care, an individualized treatment plan that is efficient with resources (such as being aware of financial costs to the family) and that is guided in transparency, respect towards autonomy, and collaboration is created. For youth in high conflict families or post-divorce families where each is parent is given medical authority in a parenting plan, it can sometimes take many months to achieve cohesive consent. In cases that Dr. Goldenberg has seen, consent from all parties does not always occur.
Trans youth face both individual and systemic barriers to health care. Trans youth may be unable to access treatment due to anti-trans medical care bans, harassment, refusal of care, lack of support, spotty insurance coverage, fear of doctor attitudes, lack of options, and long clinic waiting periods, leading to delays in timely care. This is an especially hectic reality for foster youth, incarcerated youth, undocumented youth, disabled youth, and unaccompanied or street dependent youth. Access is disproportionately limited for low-income trans people and communities of color. Nonbinary youth face the additional challenge of accessing trans healthcare that follows the traditional binary model. Even making legal changes such as a name change can become a major barrier due to the legal process to do so. Creating a narrative that youth are being rushed through changes ignores the logistical and legal bureaucracy involved in gender transition. Some states have no LGBT community health centers. Electronic medical records often fail to identify trans patients. The cost of gender affirmative care is another reason that achieving gender congruency in youth can take quite some time.
The vast majority of trans youth in the U.S. lack access to competent, responsible, and affordable care. Obtaining competent health services is historically challenging for trans youth and not much has changed.
Only 20 states in the United States have laws banning conversion therapy for minors. 4 states partially ban conversion therapy. 23 states and 4 territories have no state law or policy on conversion therapy. This year, legislatures in 20 states proposed banning health care providers from delivering medically necessary gender-affirming care to transgender and gender-diverse minors. In April, Arkansas became the first state to outlaw any gender-affirming medical treatments for trans youth, overriding a veto from the governor. In November 2021, the GENder Education and Care, Interdisciplinary Support program, GENECIS, the Southwest’s only gender-affirming healthcare clinic for youth, was closed down after a weeks-long campaign by Texas conservatives.
Extensive therapy often delays gender affirming medical interventions that can be literally lifesaving. Puberty does not stop; throwing up roadblocks to healthcare access means an uncertain waiting time during which secondary sexual characteristics develop, which frequently exacerbate gender dysphoria and lead to higher rates of depression, anxiety, and suicidality. Clients are not responsible for managing or shoring up the anxiety of clinicians. Trans youth are not responsible to bring well-worn scripts to a therapist so the therapist can feel pleased and complete in their believability of content. Therapists are responsible to remember the multiple ways we can have power over others, most fundamentally that we can be adults looking down onto youth.
Silencing the Opposition
The authors endorse the common talking point around trans activists silencing those who dare to speak out against gender affirming care. Meanwhile, it is people such as the authors, Lisa Littman, Joe Rogan, Abigail Shrier and others promoting pseudoscientific transphobic views who garner the largest platforms. The trans community today faces an extreme amount of violence and opposition. Trans advocates speaking out for those stigmatized, marginalized, and ignored are often accused of silencing those who “oppose trans ideology.” Trans people are not a threat to free speech; instead, transphobic ideas often inform decisions around basic rights.
In the gender-affirming framework of health care, gender diversity is depathologized, and being transgender is not considered a “disorder” that needs to be reversed. This model follows our current understanding of gender identity and has been derived from decades of scientific research and clinical experience, leading to its endorsement by every major medical association. Over 49 professional associations oppose attempts to change gender identity and/or discourage trans outcomes. Further, gender affirmative models do not ignore the racism which fuels erasure of gender diverse bodies and gender affirmative models acknowledge the stripping of gender diversity as a way to promote white supremacy. Studies note better mental health in trans children supported in their gender identities. The field is resourced with extensive guides that can teach the appropriate models for clinicians to learn how to deliver more inclusive healthcare for all.
While therapy is often an important and helpful aspect of gender affirming care, it is not required. Those of us involved in transgender healthcare agree that guidelines should meet the same high-quality standards followed by other fields of medicine. For this to happen, we need resources and funding for trans healthcare research, regular and consistent data collection on gender identity, and destigmatization of the trans community. Trans children deserve love, support, and thoughtful medical care as much as cis children do. Caretakers of all children need specific, accessible, and culturally relevant frameworks to raise up the resilient and creative generation we need. Trans children are targets in the current political and culture wars; but what the gender culture wars are really about is who has rights to exist in their own body, and whose body we consider credible, autonomous, and worthy.
Licensed Clinical Psychologist
Assistant Clinical Professor of Family Medicine, Frank H. Netter MD School of Medicine at Quinnipiac University