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Pressing the easy button
A Guest Post from a Licensed Psychologist Navigating the Thick Fog of Gender Ideology
This post is an anonymous guest essay. The author, a licensed psychologist, is writing anonymously for one reason and one reason only: for the parents of gender-questioning/dysphoric children who seek out her help, who hope that their child – who might believe that hormones and surgery are *the answer* to their problems – can begin therapy with an open mind.
History will not look kindly on mastectomies being done on 13-year-old girls. Or teenage boys being castrated. Books will be written about this period of time; it already has been compared to the time when lobotomy was *the solution* to severe mental illness.
It also will be compared to the opioid crisis: a couple of decades ago, doctors were encouraged to liberally prescribe opiates for pain relief. Pain is a subjective experience, and doctors were taught that a patient’s pain level was to be believed and treated accordingly. Doctors who resisted the liberal prescription of opioids were derided by their colleagues as “opiophobes”. (Seriously, I can’t make this up.) The notion that opiates were not addictive was based on very little data, but at the time, this notion was allegedly based on the “best available evidence,” despite long-standing evidence showing that chronic pain could be treated in multidisciplinary (e.g., behavioral, psychological) ways.
Enter the Sackler family sociopaths and the creation of Oxycontin by their pharmaceutical company, Purdue Pharma. Corrupt and/or complicit Purdue Pharma board members and employees, probably including some uninformed sales staff just wanting to keep a job, focused solely on Oxycontin sales. We all know what happened next.
In 1692 in Salem, Massachusetts, a group of teen girls… – I don’t need to finish that sentence. We all know how that one ended too. How could it be that everyone, including those in powerful positions, believed and went along with this insanity? we ask.
We have a long history of believing those who suffer and wanting to ease their pain, as quickly as possible, whether by words or actions. I believe that this aspect of human nature is one contributing factor, among many others, in the practice of “gender-affirming” care.
To be sure, we are more rational and sensible than were the citizens of Salem, Massachusetts in 1692; we aren’t burning anyone at the stake. But an aspect of human nature remains constant: it is tempting to agree with the prevailing narrative at the time. It also is tempting to believe that something we cannot see or touch (e.g., a wicked spirit inhabiting a human body) is real and explains a phenomenon we witness.
We will say what needs to be said to (try to) ease suffering and go along with the narrative of the moment. I first started noticing this about 20 years ago.
Let me back up.
During my years in graduate school pursuing a PhD in clinical psychology (2005-2011), I learned that there are certain things one should not say, even if true, so as to reduce the chance that another person will be hurt, especially if what you are talking about pertains to any type of power or privilege (race, religion, sexual orientation, etc.) that you hold. I learned that you should - in the name of empathy - make assumptions and generalizations about people based on their (immutable and other) characteristics. I learned that you should believe someone who is “less privileged” under all circumstances and should not question them, even to clarify things or better understand them, and to do so means you did not "do the work" and are burdening them (to educate you) by asking them questions. I learned that you should verbally acknowledge your privilege in interactions with others but not actually do anything in any practical way to help underprivileged people ("white saviorism"). Lastly, I learned that you should be inclusive but should not expect to develop any real, genuine friendships with anyone who is in a position of lower power or privilege than you, because the power differential is just too large to make this possible.
Of course, there is some truth here: white (and other types of) privilege is, and historically has been, quite consequential in many ways; we, as mental health professionals, absolutely should do our own reading (“work”) to better understand our patients' cultures; it is important to be aware of power differentials and consider their impact on others, especially as a healthcare professional. But, to me, much of what I was learning was not only divisive but also seemed to me to have the effect of reducing one's sense of agency. That is: If my natural inclination is to actually do something for someone else that helps them in some meaningful or tangible way, I was - at that time - very confused about if and how I should do that.
At the time, and for some time after graduating, I was frustrated because I actually want to be able to do something to help others and right wrongs. Words do not put food on the table or pay medical bills. People living in poverty do not gain any tangible benefits from catchy slogans.
But after some time, it hit me: Why am I agonizing over how to justify my desire to help others, when all that seems to matter is what you say? This is easy, really. Just say the “right” thing, not the “wrong” thing.
Fast forward to April 2022, when into my inbox arrived a piece by The Free Press (at that time, Bari Weiss’s “Common Sense” Substack column) about several young women who had undergone “gender-affirming” medical interventions who later realized that these interventions not only did not alleviate the mental anguish as mental and medical professionals had promised, but also, of course, left these these young women with permanent damage to their bodies. At that time, I had heard of Abigail Shrier’s book Irreversible Damage, but (regrettably) did not read it. My understanding of her book was that an increasing number of girls were feeling uncomfortable in their bodies, and some were receiving medical interventions that resulted in permanent changes to their bodies. I thought that perhaps a few girls and/or their parents were aggressively seeking this “gender-affirming” medical treatment against the advice of doctors – because what doctor would do this? – or, perhaps, one or two doctors accounted for the cases described in Shrier’s book. I could not have conceived of (what I later found out in reading that piece by The Free Press) the reality: these girls were being quickly affirmed and encouraged to undergo these medical interventions by mental and medical health professionals.
My first thought was: this is not how we are trained. Given these girls’ reports of the time frame between initially seeking mental health or medical treatment and then undergoing medical intervention, as well as their experiences in treatment, it seemed highly unlikely that a thorough biopsychosocial evaluation that considers differential diagnoses and a variety of treatment plans – not to mention a thorough discussion of medical treatment risks and benefits – could possibly have been done. It seemed pretty obvious that no, or very little, psychotherapy transpired either. That their mental health and medical providers were allowing - even encouraging - such extreme interventions at such a young age and seemingly without a sufficiently thorough assessment and treatment process (so as to justify these interventions) seemed, to me, to be inconsistent with “first, do no harm.”
So, then, I wondered: what is the latest research in this area? What does it say about prompt affirmation and ready access to medical interventions? Maybe there’s an evidence base for this, I thought.
A search of the literature eventually led me to the Society for Evidence Based Gender Medicine (segm.org). On their website, I read that both Finland and Sweden had recently conducted thorough literature reviews and determined that any potential benefit of transition (at least among children) did not outweigh the risks. Florida also had commissioned a literature review, which arrived at the same conclusion. Other countries in Europe have been following suit. It became clear: what is happening now should not be happening. It is not supported by the evidence. Further, it never really was: the notion of providing these “gender-affirming” medical interventions to minors was based on the outcomes of just 70 people in the Netherlands (the “Dutch Protocol”), which began to give puberty blockers to some children with gender dysphoria in the 1990s. This “Dutch Protocol” has since been intensely scrutinized, but two general themes are worth noting. First, the evaluation and treatment process for these 70 Dutch youth was much longer, cautious, and thorough than that which many U.S. providers are enacting; and second, the long-term outcomes of these 70 young people aren’t that stellar anyway.
I felt that I had to do something or I wouldn’t be able to sleep at night. As fate would have it, around this time I happened to listen to a commencement speech in which the speaker quoted philosopher Alasdair MacIntyre: “I can answer ‘What am I to do?’ only if I can answer the prior question, ‘Of what story or stories do I find myself a part?’”
I promptly found and began collaborating with similarly-concerned clinicians who seek to provide their clients an alternative to the gender-affirming model. In therapy with gender-questioning youth, I affirm that I understand that they feel the way they feel about their body and their gender and I empathize with their dysphoria, but I do not collude with their belief that their gender identity is the reality (akin to biological sex), nor encourage them to undergo medical intervention to change their bodies.
In therapy with these youth, I walk a very, very fine line. Establishing rapport is paramount in therapy. It is quite a challenge to establish rapport with these teens and young adults who believe that any person who does not immediately express unbridled enthusiasm for their gender identity and transition plans is a bigot who probably cannot be trusted. Many of them are convinced that medical transition will improve their life and solve their problems. These teens and young adults typically have other psychiatric disorders and/or a history of trauma, but they (at least initially) reject my earnest interpretations and suggestions that – maybe, just maybe – other problems in their life could explain their discomfort about their body or, more broadly, current distress about their lives.
It would be so easy to just affirm their gender identity as the reality that they think it is. That old Staples commercial of the EASY button often pops up in my mind. I could just press it and – presto! My client will beam with joy and immediately deem me one of the “good guys.” Rapport would be established immediately. It has even crossed my mind that affirming their gender – with the immediate rapport that would result – could improve therapeutic progress regarding other aspects of their life, at least in the beginning stages of therapy. So, indeed, it is very tempting to just affirm, to just press the easy button.
But this rapport, ultimately, would be predicated on a lie. Both of us would be pretending to be someone we are not. Pretending is easy - for awhile - and then it isn’t. (Ask any detransitioner.)
In the coming years, we (collectively) will learn the full scale of the damage inflicted on today’s youth because too many adults allowed them to pretend. Too many adults - especially mental health and medical providers - simply pressed the easy button.
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