The Same but Different: Convergent Pathways of Gender Dysphoria

A few decades ago childhood gender dysphoria was exceedingly rare and it’s cause was not well understood. There have been several revisions to diagnostic terms and criteria attempting to describe this condition. Today most mental health professionals would define gender dysphoria as an incongruence between a person’s biological sex and the “gender” they feel themselves to be. Gender identity is the term used for the subjective, stated inner sense of “gender.” I prefer the clarity of calling this a cross-sex identity. Prior to the early 2000s, researchers documented a much higher percentage of males than females with cross-sex identity.  In the ultra-rare case when a girl or woman felt herself to be a male, she almost always had same-sex romantic attractions towards other women. Many clinicians and researchers dedicated their careers to understanding and treating gender identity conditions, however since gender dysphoria only affected a very small number of children until mid-2010s, the issue remained largely outside of public interest.

Around 2013, however, something shifted dramatically. Gender clinics began documenting soaring numbers of teens, mostly girls, seeking help for gender-related distress. Rightfully, more scientific, clinical, and public attention has been garnered towards this explosion of gender dysphoric children. A close look at this emerging population reveals that adolescents claiming gender dysphoria today are demographically and etiologically different from the population on which we have the most research. First, the sex ratio has been flipped, and now girls vastly outnumber boys in the waiting rooms of gender clinics across the globe. Second, while many dysphoric girls report same-sex attraction, there are also far more than we would expect who only feel attractions to boys. Thirdly, and perhaps most importantly, these girls were not dysphoric as children, instead developing this cross-sex identity only after beginning adolescence. These teen girls often arrive at the therapist’s office in great distress, hoping for a quick path towards medical interventions that will transform them into boys. In my experience with such children, they believe this is the only way to become their “true selves” and already know exactly what medical procedures they want: first testosterone, then top surgery, and maybe one day, phalloplasty. Despite the urgency and sophisticated terminology in a young girl’s gender narrative, any clinician tasked with assisting her must first grapple with how little we really know about this condition or how to treat it safely with favorable long-term results. The demographics of dysphoric children has shifted dramatically. Therefore, even controversial treatments which might have provided some short term relief to dysphoric teens in the past may be completely inappropriate for this new population. We are now forced to confront, again, some questions about gender dysphoria which may require a fresh look.

At this point, some readers may scoff at my invitation to revisit concepts which contemporary clinicians assure us are well-understood. Many gender therapists assert that rising numbers of dysphoric girls simply point to greater societal acceptance of transgender identities and better access to treatment. Anyone expressing curiosity or skepticism about the increasing number of “trans kids” is often accused of bigotry. But this inquiry is required to ensure that adolescent gender dysphoria be investigated thoroughly so professionals can provide young people the most appropriate treatment, rather than the most readily administered. Certainly, it would be expedient to literalize the teen’s narrative, write letters releasing them for medical intervention, and move onto the next client on the exponentially growing list of patients. But when dysphoric young people are rushed or encouraged down the transition pathway, we are in danger of making a type I error. What if this young person won’t actually benefit from medical transition? What if doctors and clinicians are setting kids up for grueling and unnecessary interventions which ultimately fail to ameliorate their distress in the long run? When a dysphoric person, who was on the medical pathway, choses to stop transition and re-identify with their birth sex, it is called detransition. And there is an ever-growing number of detransitioners whose sheer existence has prompted renewed interest in how we should understand this boom of youth gender dysphoria.

Now to begin, we must revisit the question, “what is gender dysphoria?” Today, the American Psychiatric Association says it “involves a conflict between a person's physical or assigned gender and the gender with which he/she/they identify.” Ostensibly, “identify with,” in the counseling room, means the gender a client claims to be. This definition is already quite fuzzy. For example, if a young person thinks it might be better to be a boy, she may simply state that she is one. But for the sake of argument, let’s assume her claims of being a “boy on the inside,” perfectly reflect how she feels at the deepest core of her being. This is truly how she experiences and sees herself. Now this definition of “gender dysphoria” asks us to orient towards identity and self-definitions, more broadly. How do we distinguish identity from fantasy or imagination, and how do we account for the socio-cultural context? Furthermore, the formation of identity is known to be complex and especially malleable in adolescence.

Some activist-organizations have described the incongruence of gender dysphoria as a natural variance in human expression - variance that need not be pathologized¹ or corrected (except for the use of hormones and surgery, apparently). Indeed, if “gender variance” means that individuals have greater freedom to pursue and express interests across stereotypical gender categories, I am in support. If young people hope to better integrate all aspects of themselves, both masculine or feminine, this is good news. We should all want children to feel more whole and experience a deeper sense of embodiment. Yet when a child believes he or she was supposed to have been born into the other biological sex category, this moves us beyond self-expression or personality integration and into the realm of the metaphysical. Even this esoteric domain need not be a reason for ridicule. Like adopting a spiritual or mystical belief system, perceiving an internal gendered soul could prove a meaningful framework for a metaphorical exploration of one’s unseen and unexpressed personality dimensions. On the other hand, if the “wrong body” conception catalyzes a dissociative or self-destructive coping mechanism, it could derail a young person’s healthy development. Failing to assess what, precisely, is taking place, could lead to a misdiagnosis and tragic outcomes for dysphoric patients.

Unfortunately for both the dysphoric child and clinician entrusted with their care, gender dysphoria can be debilitating.  Whether it will persist is not something clinicians can determine with any comforting degree of certainty. Like other nebulous psychological diagnoses, it lacks clear biological indicators and is based on an individual’s subjective inner experience and self-report. For these reasons, gender dysphoria may never become a condition with excellent outcome predictability or undisputed diagnostic and treatment protocols. The DSM 5 is one of the best tools mental health professionals can use to diagnose the condition. It seems, however that gender clinics are often failing to use the diagnostic criteria at all. Even when a careful diagnosis is made using the DSM 5, this has some major limitations. The DSM can help us identify gender dysphoric symptoms at one brief span of time. The diagnosis requires that two of the criteria have been present for at least 6 months. But the DSM fails to account for how symptoms developed. This shortcoming makes assessment especially thorny when a condition, like gender dysphoria, increasingly presents in a demographic that has remained almost completely unaffected for all of history: children. Compounding these challenges is the fact that many characteristics of today’s gender dysphoria closely resemble ubiquitous adolescent experiences during puberty: disliking one’s body, feeling ambivalent about one’s appearance, struggling with peer influence, and searching for personal identity.

I have worked with over 350 families whose child experiences adolescent-onset gender dysphoria and I see full caseload of teen clients. I’ve listened closely to the parental accounts, sometimes with skepticism. I know that some parents might be reluctant to acknowledge childhood signs of dysphoria. Could they be prone to minimize indicators of gender non-conformity or cross-sex behavior in childhood because they fear having a transgender child? Certainly, this is sometimes the case. However, what I’ve found more often are parents actively looking to the past for explanations. Rather than minimizing gender-atypical behavior, they often seem to sift through their child’s early years with a fine-tooth comb, searching for “gender dysphoria.” They often inflate minor instances of normal childhood gender-play, trying to understand their child’s recent gender questioning.  Even more intriguing are the admissions from my teen clients themselves. After establishing trust and a sense of safety, teens openly report that they adopted the transgender identity first, then looked for minor gender-bending behaviors in childhood to justify their “transness” to themselves and to their parents.  And more importantly, regarding symptom development, many kids have told me, “the dysphoria came after I started identifying as trans.” This crucial fact goes undetected when making an assessment using DSM 5 criteria. Clinicians can easily misinterpret a vital aspect of the transgender identity if they fail to develop a timeline for the course and development of the child’s gender dysphoria.

In this piece I’ll lay out two cases of gender dysphoria which look near identical at the time of presenting in the clinician's office. However, one case of gender dysphoria develops endogenously, before the transgender identity, and the other exogenously, after adopting the transgender identity.

To look at the first case, we’ll need to go back in time.

Imagine it’s December in 1989. Rain Man has just won best picture, and comedy fans are mourning the recent loss of Lucile Ball. Gloria Estefan and Phil Collins play on top 40 radio stations. Milli Vanilli are lip syncing their way towards an embarrassing downfall, but they don’t know that yet. Somewhere in US suburbia, a therapist adjusts substantial shoulder pads on her striped skirt-suit as she prepares for the next client to walk into her cozy office. It’s a new intake appointment. The young female client knocks politely on the open door and walks in, but at first glance, the therapist mistakes her for a man. Cindy is in her mid-20s, wearing an oversized button-down short sleeved shirt and pleated acid-washed jeans that appear to have come from the men’s section. She has a leather bomber jacket draped across her forearm and looks handsome in a short but tousled haircut, ala Zack Morris. She gives the therapist a firm handshake and a nearly imperceptible smile. As Cindy settles into the chaise, she adopts a hunched-over position. She appears to be hiding her breasts and fidgets with her shirt frequently.

Juxtaposed against her restrained posture, Cindy’s personality is warm and pleasant, and she is eager to talk. As she answers the therapist’s intake questions, a picture of her story begins to take shape. Cindy had a masculine demeanor ever since childhood, insisting that she was one of the boys in elementary school. Despite her parents’ efforts, which often included critical diatribes and “you’d-be-so-pretty-if” comments, her masculine appearance, mannerisms, and interests remained stable into adulthood. She frequently insisted to her parents that she was a boy, but they either ignored those comments or snapped back harshly and doubled down on their criticisms. She went through a brief phase of trying to copy the popular girls in middle school, but she felt terribly awkward and unnatural in dresses and makeup.

When puberty hit, she felt like her world was flipped upside down. She struggled to deal with the way her body was changing and alienating her from her male friends. As she developed more feminine physical features, she worked hard to keep up her masculine aesthetic, wearing minimizing bras and keeping her hair even shorter. She’d stand in front of the mirror and push her breasts down, wishing they’d just go away. No matter how hard she tried to keep things “the same” with her peers, long-time male playmates started teasing and excluding her from their games. She felt betrayed by her body and her friends.

She also kept her attraction to girls hidden for as long as she could. A clandestine relationship with a female high school classmate developed in complete secrecy. Cindy fell deeply in love with Abigail and they dated for almost a year. One night as Cindy was dropping her off, Abigail’s parents caught them kissing in the car. The romance had been discovered. Abigail’s parents forbid their daughter from having any contact with Cindy and the relationship was abruptly severed. Cindy was heartbroken and ashamed. This painful instance felt like a nail in the coffin, she explained to the therapist. Since then she had become firmly convinced that she was “born wrong.” Berating herself for not being a “normal girl” further fueled the feelings of incongruency and the hatred of her inescapable femaleness.   

Cindy graduated high school with decent grades, has maintained a job in a distribution warehouse, and has a few casual friends. Often, people do take Cindy for a man. She’d gotten a few dates with women this way, but upon discovering Cindy’s sex, many of the straight girls she pursued rejected her and ignored her phone calls. Eventually her parents stopped hounding her about her appearance or finding a boyfriend. The family remains fairly close but they never discuss her sexuality or identity. Cindy has no history of abuse or trauma, and doesn’t struggle with any other major psychological problems, though she did seem depressed by the time she made it to therapy. Her fantasy of becoming physically male had continued to grow and was starting to take over her thoughts. She’d been drinking too much and rarely returned friends’ phone calls. Lately she’d been spending hours at the library reading the few books she could find about female-to-male transexualism, hiding in the back of the building so she wouldn’t run into anyone she knew. Cindy had come to therapy to talk about her gender identity issue and possibly embark on the process of “sex change.”

At this point I feel it’s necessary to add a few caveats. First, I’ve been generous to Cindy by portraying her history as free of serious trauma. More likely, Cindy would have experienced some severe relational trauma or abuse in childhood. Research indicates that gender dysphoria presentation in females, even prior to the current boom, was often correlated with serious childhood trauma. Even gender-affirmative clinicians have suspected that the male-identity in dysphoric females operates as a dissociative coping mechanism. Next, even with Cindy’s more classic presentation of gender dysphoria, recommending a medical transition would certainly not be my first line of treatment. Instead, therapy could give Cindy space to work through the rejection and criticism she experienced in her family and peer groups. Embodiment exercises could help her relate more gently to her body. And with the therapist modeling curiosity and support, she might explore what masculinity means to her. It’s also likely that engagement in a community of women with similar experiences might alleviate her dysphoria without requiring medical intervention. Cindy may ultimately embrace her sexuality and perhaps identify as a “butch” lesbian.

Now back to Cindy’s diagnosis. What’s worth highlighting is that her gender dysphoria is what I often call “organic and spontaneous.” Organic, because the sex-incongruency developed independently, from within Cindy’s subjective inner-world. Cindy’s outward expression of non-conformity and her reported mental anguish reflect that internal incongruence. And spontaneous, because the sex-related distress occurs in the absence of social, environmental, cultural, or temporal catalysts. She didn’t learn the idea of gender dysphoria first, she began feeling gender dysphoria first.

Now let’s contrast Cindy with an example of a young gender dysphoric girl circa 2019. Another fictional character, Adrianne is a composite patient who resembles hundreds of young women from families I’ve met. Her story also draws upon the experiences of female therapy clients I work with on an ongoing basis in my private practice. We’ll look very closely at details of her gender dysphoria and transgender identity and see how each developed.

The therapist introduces herself by first name and Adrianne timidly extends her hand. She stiffens up mid-way through the shake, remembering that guys are to shake women’s hands firmly, but not too hard.  The therapist notices her strange walk: Adrianne takes wide, awkward steps, like she’s straddling an invisible puddle. The 15-year-old speaks with a voice that is forcibly lowered and unnatural. Despite the mimicry, Adrianne still reads quite feminine in her mannerisms. She also looks uncomfortable and self-conscious.

Light aqua streaks punctuate her brown hair, which she wears in a short side-sweep covering her left eye. Haircuts had been a major point of contention with her mother when she first came out. Mom had refused to take her to her brother’s barber despite how much Adrianne begged. Mom would instruct the stylist to give her a “feminine girl’s cut” but Adrianne would pull up a picture of Shawn Mendes or some other male celebrity on her phone. The final look was usually the result of a begrudging compromise between parent and child.  In the last year, though, Mom’s stopped trying to govern her hairstyles.

Adrianne was initially hesitant about this therapist, especially since her parents had strongly encouraged her to “discuss [her] gender problems.” Adrianne didn’t see her identity as a problem, and it “wouldn’t be if they’d only let [her] take ‘T’.”  It felt absolutely devastating that her parents, who she’d rarely fought with before, were now “rejecting” her. She explained, “they’re denying my existence, you know? My parents think it’s a choice, but why would anyone choose to be trans?”

The therapist asked Adrianne what it would be like if she fell asleep and woke up the next day with no gender dysphoria. She asked, “you mean if I woke up with a guy’s body?” The therapist replied, “well, sure you can answer it that way. But also imagine waking up with your body and no dysphoria.” The latter prospect was not appealing to Adrianne. She couldn’t stand herself and couldn’t imagine possibly being happy in her “disgusting body.”

With time, Adrianne became more and more forthcoming in therapy, and even looked forward to the appointments, according to Mom. When exploring her earlier childhood, she admits that she was not thinking much about gender then. She confesses to wearing dresses, having long hair, and that she was fine with her appearance at the time. She reflects, “I was young and dumb and didn’t know anything back then. Simple things made me happy.” She’d spent hours drawing fan fiction and writing play scripts for her stuffed animals. She was a gifted musician and being home schooled allowed her the flexibility to pursue her many creative talents. Her parents put her in a local soccer club, but she struggled to make any close friends. Meeting new kids made her feel self-conscious. But as a child, she recounts being perfectly happy going to the science museum with her parents or watching “nerdy animal documentaries” on YouTube in her room. She rarely got in trouble or fought with her parents at all before the “gender stuff”.

She did want her therapist to know about a few specific memories from her childhood, which she explained, were “signs of early gender dysphoria.”

• One time she was hit hard with a ball during soccer. She wasn’t very athletic and the boys had honed in on her as an easy target. They taunted and cheered, “aiming for Adrianne, aiming for Adrianne.” This left her feeling humiliated and out of place. She added, “oh, and that’s when I really started hating my ‘birth name and I hate when people ‘deadname’ me now.”
• Another time she developed an infatuation with a girl from a community center drawing class. This girl had short hair and never wore dresses. She was confident and funny and carefree. Adrianne wished she could be like that. That girl moved to a different city, but as it turns out, now identifies as a trans guy (she follows “him” on Instagram).
• Last of the memories was an account of jealousy she felt towards her older brother. He got to play baseball with their dad every Saturday morning and she really wanted to go, though she admits she isn’t into baseball. She idolizes her dad and was jealous of the intimate moments her brother got to share with him. One time when she was 12, she built up the courage to protest and asked to join their baseball practice. Her brother grumbled, clearly not thrilled about the prospect of his sister encroaching on his sacred weekend ritual. Her parents reminded her that she and mom would have their own special “girl time” going shopping or getting their nails done. The next weekend (she guessed there was parental intervention from dad) her brother invited her to play baseball with them. She refused bitterly. She also started resenting the nail salon outings with her mother.

She started going to a local middle school in 6th grade, which was a difficult change for Adrianne. Eventually though, she settled into the new routine and made a few friends. In hindsight, she finds more proof that she “has a guy brain,’’ by remembering her first period. She was disgusted even though Mom had prepared her for the “joy of becoming a woman,” she recounted sarcastically. Some of her female peers were excited about getting their periods and that made her feel even more strange. She wanted to fit in desperately, so during much of 6th grade she worked hard to emulate popular, pretty girls at school. She followed Instagram celebrities for beauty and fashion tips. She put her beloved graphic tees in the bottom drawer and asked her mom to stop buying clothes that made her “look like such a loser.” Ultimately, though, competing with models and pretty girls at school was exhausting. She said, “it was just not me.” She’s since deleted all those old social media accounts. She says she wants to erase all traces of that “embarrassing time of life.”

The therapists asks Adrianne when she first started thinking about gender. “First, I was being an ally to my friend, Aiden. The more I helped him and researched gender stuff, the more I figured out that I was trans too.”

“Can you tell me more about the ‘Aiden’ story? Start from the beginning.”

“Aiden,” then Emily, was one of few kids in her small group of girlfriends at school. They all liked the same anime characters, writing fan fiction, and they had marching band together. They kept in touch outside of school using Instagram, snapchat, and Deviant Art, etc.

In February of 6^th grade, Emily changed her Instagram handle to “Illustrating_Boi_He/Him”. Emily’s new profile picture was a grainy image taken from below. She wore a stoic look on her face. In the top right corner was a small pink, white, and blue trans-pride flag. Adrianne recalls seeing this and getting a sinking feeling in her chest. She felt waves of conflicting emotions: confusion, curiosity, dread, excitement.

Emily, now going by “Aiden” started talking about transgender-related things with Adrianne every day at lunch. Sometimes “Aiden” spoke in a whisper so other kids couldn’t hear. “He” confided in Adrianne because she’d always been so kind and sensitive. Adrianne felt a great sense of responsibility for being trusted with this big secret. She was also someone’s “best friend” for the first time in her life. She started spending all her free time researching trans online - she wanted to support “Aiden” and be a good ally. On Reddit, Tumblr, Instagram, and Discord she read everything she could find about gender identity, especially over spring break at home. She learned about transphobia and was very careful not to say, ask, or do anything that could be transphobic. This included asking the wrong questions or thinking of “Aiden” as a girl. “He” was a guy now. Period. “Honestly, I was kind of obsessed with researching stuff at first, but now I don’t really look at those sites anymore.”

“Aiden” soon came out to peers and teachers and joined the school LGBT & Allies club. Adrianne joined too so “he” wouldn’t be alone. They met Josh, a 7th grader (biological male) who had been attending club meetings for a couple of months. He held a leadership role as treasurer. Though he befriended all the new club members with enthusiasm, he soon struck up a closer friendship with Adrianne. She started texting him even more than she texted “Aiden.” Her mom even picked Josh up from school a few times so they could hang out at Adrianne’s house and play video games or work on cosplay costumes. Adrianne concedes to having “sort of liked him at one point,” but her parents report that she was completely infatuated and talked about Josh incessantly.

For Adrianne, the friendship continued to intensify until one day in May during a club meeting when Josh came out as a gay demi-boy. In a text that night, he excitedly revealed to Adrianne that he had a new boyfriend from a neighboring school district. They’d met online and he was so happy. Josh started to become more distant from her and eventually stopped replying to her texts. He even said some hurtful words to Adrianne one day when she tried to sit with him at lunch.

Adrianne stopped going to club meetings and struggled getting through the rest of the academic school year. That summer, she withdrew from “Aiden” and her other girlfriends. She spent most of the summer in her room on the computer, usually declining invitations from her mom to go out. This is when her self-described “obsession” with FTM trans YouTube stars like Jammidodger and Miles McKenna intensified. Thinking back she joked, “that summer when I was first questioning my gender it was pretty bad. I was online constantly doing research.”

She assures the therapist that she really tried to “experiment” and didn’t just jump into “being trans.” She was even weary of “sketchy” activist websites. Instead she looked to bigger, reputable organizations for information. She learned that “no matter what, your gender identity is valid.” Just to be sure she was “transmasculine,” she experimented. She stood in front of the mirror to examine her body to see what she liked and didn’t like about it. She practiced saying boy-names out loud in the shower. She played video games with male avatars to see how that felt. She reached back out to “Aiden” to talk more about gender identity. “I even thought I was nonbinary for a while,” she remembers. “Now I definitely know I’m a gay guy.”

During that questioning phase, she wanted to be sure before doing anything drastic or talking to her parents - this is the tentative caution that has always characterized Adrianne. The more she questioned and read information about different gender identities, the more “puzzle pieces started to fit together.” She had always known she felt different, and eventually when Adrianne “realized” she was a transgender guy, it felt like the most important discovery she’d ever made in her life. The soccer ball incident, the infatuation with a tomboy, the jealousy of her brother, the horrible feelings about her period: it all made sense now that she “has the language.”

That’s when the dysphoria started to get intense, she remembers. It has gotten worse over the last few years, and now when she looks in the mirror, she knows she’s not right. She feels ashamed and disgusted with her body because it doesn’t fit with how she sees herself “on the inside. It’s hard to explain and her parents don’t get it, she reports. Still, she “stays motivated” by looking at transition videos and imagining the “progress” she’ll make once she starts medical transition. If so many trans guys are happy after a few years on T, she has something amazing to look forward to. In the meantime, though, tolerating her female body had become more and more difficult.

The parents provided their version of events to the therapist before intake. Mom and dad remembered the summer after 6th grade being difficult for everyone. It became impossible to overlook the changes in Adrianne’s mood, but they initially attributed the transformation to teenage hormones and heartbreak over Josh. Adrianne asked for a haircut in June. They agreed, thinking she’d get a boost of confidence from a new look. Soon she was wearing huge sweaters in 100-degree weather and eventually refusing to leave the house altogether. When the therapist asked Adrianne about this apparent decline in mood, she confessed, “I didn’t really have gender dysphoria before I realized I was trans, but now I have it really bad. And besides, you don’t have to have dysphoria to be a valid trans person.”

Her parents, deeply concerned, had tried to ask her what was going on. Adrianne wouldn’t say much. That summer, they started researching local mental health professionals and signed her up with a CBT counselor specializing in depression and anxiety. He was an older man whom Adrianne liked, but she kept her identity questions to herself. They worked on coping skills and relaxation techniques, which only marginally lifted her mood.

The therapist asked Adrianne to describe when she first discussed gender with her parents. Two weeks before the start of 7th grade, after watching a few dozen “coming out” videos, Adrianne made the decision to tell her parents she’s a guy. Facing them would be too much, and she feared their reaction would “damage [her] mental health”. So, she wrote them a letter. She had taken pages of notes while looking at other trans guys' coming out stories. She’d written a sincere and heartfelt letter, but also argued her case with a clear sense of urgency. She wrote that she’d always been the same person on the inside and would always be their kid. She knows they have always loved her as their daughter, but now they could learn to love “him” too. She was willing to be patient but insisted that if they love her, they’d need to educate themselves on gender identity and start “supporting their son.” This would need to happen sooner than later, for her “mental health and safety.” She wrote that she wants to start 7th grade as “Kyle” and begin hormone treatments and start “binding.” If not by August, then definitely by spring break. She said she would become severely depressed if developed more of the “wrong secondary sex characteristics.” She informed them that she wants to have top surgery soon too. With eyes puffy from crying, and fingers cramped from typing, she went downstairs at 3:00 am and left the note on the kitchen counter for her parents to find in the morning. She went back to her room to wait till sunlight. Adrianne didn’t sleep at all that night.

She’d heard that lots of trans kids get rejected by their parents, so Adrianne was surprised by mom and dad’s reaction. They said they’d always love her, gave her a hug, and explained they would need time to process everything and do some research. Alone, the couple commiserated in their shock and worry. They never saw this coming. They started combing through memories of her childhood searching for “signs” but deep-down they felt skeptical that Adrianne is a “trans boy.” The coming weeks were full of late nights researching “transgender kids” after Adrianne and her brother had gone to sleep. The more they read from the affirmative websites like PFLAG and Gendered Intelligence, the more nervous they became. These sites repeated suicide statistics which deeply troubled them, especially considering her rapidly declining mood over the last several months. They attended a local meeting for parents of “gender diverse children” (without telling Adrianne) and felt very uneasy about what they experienced there. The information they were given was unscientific. Their questions were dismissed or met with hostility. When they brought up the possibility of depression or body issues contributing to her self-diagnosis, they were arrogantly assured everything would get better after transition. They didn’t go back. Eventually they found some clinicians online who were equally disturbed by the trend of immediate affirmation. When they found the descriptive parent-report data on Rapid Onset Gender Dysphoria, they felt it described Adrianne, especially after having looked at her internet history.

They expected to get help from her current CBT counselor, but when they told him about the “coming out,” he said that wasn’t his area of expertise. He seemed reluctant to keep treating Adrianne and referred the family to a “gender clinic” affiliated with the organization they’d just visited. Suspecting the clinic would just confirm her self-diagnosis and push her towards more social and medical transition, they didn’t take her. They wanted to give her time.

The next few years were a rollercoaster. When her parents tried to explain why her identity as a trans boy didn’t make sense to them or question how she “knows she’s a boy,” things quickly escalated, and Adrianne would shut down. It seemed as if she was allergic to any questions about gender; even the most disarming comments caused explosive emotions. Slammed doors and silent dinners dominated the first few weeks after her “coming out.” Her parents tried to make concessions that were still safe for her growing body. For example, Mom explained that binding can cause injuries, and instead, she brought home a dozen sports bras for Adrianne to try on. They let her shop for clothes from either the girls’ or boys’ section so she could express herself and be comfortable.

At school, however, her teachers, friends, and even the principal used her male name and he/him pronouns. Many adults told her she was brave. This only highlighted the contrast in her parents’ reservations and skepticism and made Adrianne trust them less and less. She vented in online message boards where her resentment towards her parents grew with every sympathetic comment.

Adrianne’s mood decline continued: she stopped going to the pool on weekends. She “held it” when she and her family were out in public, refusing to use the women’s restroom. She glared at her parents when they called her “Adrianne.” They tried to avoid pronouns and use her playful childhood nickname, “Monkey.” Mom would grate her teeth when restaurant servers called Adrianne, “buddy,” but she learned to stay quiet. Within a few months though, going out to eat (or leaving the house at all, aside from school) became a battle. They tried to draw her out of her room with her favorite Netflix shows or the fresh baked sugar cookies she loved as a kid (grandma’s recipe). Sometimes they saw glimmers of the “old Adrianne,” especially over long weekends and summers when anxiety was lower. They eventually settled into a disjointed state of affairs and by mostly avoiding gender, maintained the peace. A lot of the time, life at home felt almost normal. As Adrianne was approaching her 11th grade year, the idea of hormones or mastectomy during college loomed over her parents. She’d also been begging to see a gender therapist, so they decided it was time to find a new clinician who practices traditional talk therapy. They found only one or two clinicians willing to take on patients with gender identity concerns. They signed Adrianne up for weekly sessions.

These two cases couldn’t be more different in etiology and development across time. Yet, the symptomology looks indistinguishable when we take a snapshot at one fixed moment. Let’s look at their clinical presentation during intake:

Discernment regarding symptom onset and development is crucial to ensure proper treatment for young patients. This statement seems straightforward and unremarkable. Yet most girls like Adrianne are not being carefully evaluated. When we compare the stories of Cindy and Adrianne, though they both land on an exploration of transgenderism, their arrival at gender identity originates from divergent pathways. Cindy experiences endogenous gender dysphoria despite her neutral environment, and Adrianne develops exogenous gender dysphoria derived from her environment. Over and over again, I’ve seen children who developed this exogenous form of gender dysphoria after coming to believe they are trans. Yet their presentation upon arrival in the therapist or doctor’s office is taken at face value, and they are immediately reassured, “your identity is valid.” Social transition, puberty suppression, cross-sex hormone administration, and even surgery, are often hastily encouraged by the doctors and clinicians responsible for exercising careful discernment.

How and why has this happened?

In upcoming articles, I’ll aim to provide some answers to this complicated question.

To understand this perplexing and nebulous issue, we will explore a few key features of this “gender dysphoria” explosion in youth. First, I’ll seek to understand historical accounts of mass psychic epidemics and how iatrogenesis operates in the spread of psychological conditions. I’ll review the numerical data indicating this steep rise in children and adolescents identifying as transgender. Can this sharp incline be explained by a decrease in stigma and more awareness of transgenderism, or does the trajectory have common features of a mass hysteria?

Next, we must account for the natural pendulum swing in attitudes from the psychiatric community: previous harsh treatment of gender non-conformity and homosexuality has stained the field. In response, well-meaning professionals aiming to disinfect the past may be overzealous in their desire to embrace the emergent “gender revolution.” This exploration will also touch on the history of transgender medicine, and how evolving medical practices of sex-change got their start.

The next inquiry will take us to the Diagnostic and Statistical Manual, commonly called the “Bible of psychiatry.” How has the gender dysphoria diagnosis changed throughout iterations of the text? What about the Standards of Care laid out by the World Professional Association for Transgender Health? Are these guiding documents crafted with the intent to reduce false positives? Or do the expanding boundaries of gender dysphoria and diagnostic inflation make it possible to commit Type 1 errors on a massive scale?

Is gender-questioning in the digital age similar to opening Pandora’s Box? Here we’ll look at concept creep and how it operates in peer-mediated online circles. We’ll look at other conditions which seem to worsen for some internet-using teens, like depression, and see what they have in common with gender dysphoria. Additionally, what can psychological research tell us about exposure, suggestibility, repetition, frequency, and their impact on adopting a belief? Is belief adoption insulated to youth culture, or do we see shifts happening more broadly?

Lastly, we’ll question whether concerns about detransition are really just dog-whistle to bigotry that should be dismissed. In the absence of comprehensive research and statistics, what can we glean from examining online anecdotal evidence about the number of people reversing their transition? As more clinicians and doctors warn us to adopt a prudent approach to gender dysphoria, what does that mean for affected youth in the digital age?

Inevitably, there are questions that I cannot answer here, though they are of tremendous importance. For example, the innumerable ways that, academic theory, political strategy, radical activism, and legislative changes have contributed to this phenomenon are outside of my scope. My curiosity lies specifically in how the aforementioned factors have converged and set the stage for an epic drama. A look back at history tells us this is a drama we’ve seen many times before, with actors lulled naively into participation they don’t fully understand. In the case of youth gender dysphoria, the key players - teens, psychiatrists, doctors, and clinicians - are unwittingly constructing and advancing an epidemic with grave consequences. I fear many more lives will be disrupted before it reaches completion. Perhaps by grappling with the anesthetizing elements we can more consciously develop a sober solution.