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I took my teen to a gender clinic. This is what happened
Last November, the Washington Post published an opinion piece with the provocative title “The mental health establishment is failing trans kids.” In the piece, authors Dr. Laura Edwards-Leeper and Dr. Erica Anderson note that “A study of 10 pediatric gender clinics [in Canada] found that half do not require psychological assessment before initiating puberty blockers or hormones.” This is exactly what happened to my family when my child (I’ll call her “Jane”) sought help in 2016.
I brought Jane to our family doctor when she was sixteen because I was concerned about depressive symptoms and changes in her behavior. Jane had told me she was beginning to realize she "liked it when people thought she was a boy,” and that she thought she would make a better boy than girl. When I asked her why, she told me her head and feet were too big to be a girl’s, among other comments about her appearance. She also told me she was unsure of her sexual orientation. I thought a referral from our family doctor to a psychologist could help her explore these feelings, as this was the first time I had ever heard her express any sentiments like these.
To my shock, our family doctor did not ask her any questions about why she was feeling the way she was, and instead instantly affirmed her trans identity—perfectly echoing the phenomenon Laura Edwards-Leeper and Erica Anderson would later discuss in The Washington Post article. When I explained my concern about possible underlying factors that might be contributing to Jane’s distress—such as her potential autism, her frequent black-and-white thinking regarding gender roles, and uncertainty about her sexual orientation—he told me to look for a licensed psychologist. I was happy to do so. At the time, I was confident that a psychologist would take a holistic approach that would include differential diagnoses and a review of Jane’s social, academic, and family history, and provide her with the attention and care she needed.
Jane has always been a unique child. Since she was a toddler, she had exhibited certain atypical behaviors that suggested to me that she could have autism or attention deficit disorder. She lacked organizational skills, and she always seemed to be somewhat lost in her own world. I explained my concerns to our family doctor, who reassured us we had nothing to worry about as long as she continued to reach linguistic and physical developmental milestones at the expected rate. Similarly, Jane’s teachers didn’t believe that her behavior warranted a formal evaluation. As a result I concluded that it was best to try not to worry and to let Jane keep developing on her own—but as she grew older, it became increasingly clear that she was struggling to keep up with her peers.
After looking at the background of several adolescent psychologists, I was referred to a family therapist with training in the area of adolescent gender dysphoria. Within minutes of that initial consultation, the therapist directed my husband and me to use Jane’s preferred pronouns and new name, and accept that we had a son—otherwise, we were told, Jane’s mental health would worsen. There was no discussion of Jane’s history, family dynamics, or exploration of sexual orientation—as soon as “gender dysphoria” was mentioned, it seemed to not only overshadow other potential factors, but to preclude the possibility of exploring any of them. We did not return after I discovered that this therapist’s training in gender dysphoria consisted of a single weekend workshop.
Throughout this process, Jane appeared content that my husband and I had taken her distress seriously by going to the therapist. She did, however, agree with the affirming approach she had received from the clinicians so far, and had begun to express a need to pursue testosterone and a double mastectomy in the near future. Given her age, Jane did not need our consent in our province in Canada to have those procedures done at an adult clinic. I was still concerned that Jane’s feelings were the result of underlying factors, and that without a comprehensive and thorough professional assessment, I couldn’t be sure that the treatments she wanted were actually what was best for her.
My husband and I decided to contact our provincial Children’s Hospital Gender Clinic, naively expecting a thorough assessment would have to take place there. Jane agreed to this when I explained that since she was still a minor and could be seen at the children's clinic, she might receive better care there. The clinic referred us to yet another psychologist, and after a preliminary consultation, they diagnosed Jane with gender dysphoria. She told me that Jane’s gender dysphoria would never go away, that I had to purchase a binder for her to help her mental health (which I never did because the use of a binder can reduce lung capacity), and concerned relatives would just have to accept Jane’s plan to medicalize. When I asked how severe a person’s gender dysphoria should be and what type of benefit-versus-risk analysis should be conducted prior to medical interventions, she said I had an interesting question but refused to discuss the matter further.
Jane was then placed on the clinic’s six-month waiting list. We attended one appointment there in 2017 where Jane, now seventeen, was handed a consent form to take home and consider. A social worker read aloud the risks of testosterone injections, but neither she nor the endocrinologist asked if Jane truly understood those risks. They never so much as ordered baseline blood work. I voiced my concerns that I believed Jane had another condition that was contributing to her gender dysphoria and had expected further screening. The clinic dismissed my concerns and said all that was needed, given Jane’s age, was the report from the psychologist (who had seen Jane only twice). As a result, the clinic booked Jane’s first appointment for a testosterone injection.
Jane was upset that I was taking a cautious and slower approach to find out more information about the side effects of cross-sex hormones. We had to have very difficult conversations about the reality of what testosterone could or could not do, so that Jane could have realistic and well-informed expectations if she were to go ahead with treatment. Unfortunately, it was clear to me that none of the clinicians or the specialists at the gender clinic had made any such effort to have those conversations with her, to assess her understanding of the risks, or to help her compare the benefits versus those risks.
When I explained to Jane that more information was still needed, she was furious with me. She felt I did not believe her. I tried to explain that she needed to understand the limits and risks of the medical interventions, and I didn’t feel that the professionals we had consulted did a very good job of that. No matter what Jane ultimately decided to do, we told her that we would love and accept her, but as her parents we needed to make sure she was able to make a fully-informed decision.
Another alarming factor in the process was that certain health plans covered, or offered at a nominal rate, both the testosterone injections and the double mastectomy, but no coverage was given for any of the psychological assessments, screenings, counseling, and psychotherapeutic exploratory options prior to medical interventions to determine if Jane’s condition could be treated with less invasive options, or if the distress stemmed from a different root cause. Nor was any therapy offered prior to the medical interventions. Jane might have benefited from counseling to prepare her for the reality of what medical interventions might or might not do, to compare the benefits versus the risks of impairment of cardiovascular, sexual, and reproductive health, and to assess Jane’s actual capacity to provide informed consent.
Many parents may naively assume, as I did, that a comprehensive psychological assessment with therapy would occur before the introduction of irreversible gender-affirming procedures. Unfortunately, in my experience, this is far from reality, and as a result, I feel the affirmative-care model—where professionals defer to a young person’s expressed, but possibly transient, gender desires—is ultimately harmful to individuals whose gender dysphoria may not require medicalization. The lack of screening is also detrimental to those who may benefit from medicalization, since waiting lists increase unnecessarily with the addition of inappropriate candidates, delaying treatment for those whose gender dysphoria is severe enough to warrant the interventions’ risks. Both cohorts suffer as a result of this lack of adequate assessment.
It is true some diligent Canadian clinicians may follow the WPATH guidelines, which include performing differential diagnoses; treating co-occurring conditions such as depression and anxiety first; screening for autism, which often overlaps with gender dysphoria; or exploring sexual orientation, among other recommendations. But these practices are not mandatory, and clinicians are left to follow guidelines at their own discretion. Furthermore, with the federal conversion therapy legislation (Bill C-4) having passed, which conflates gender identity with sexual orientation, these conscientious practitioners may no longer be allowed to continue performing thorough assessments.
Parents have the right to know what type of treatment and assessment their child will really receive, and our media have a duty to inform the public that many clinicians will immediately affirm without a meaningful screening process.
Jane never went back to the clinic, nor did she start testosterone injections. Despite what we were told, her gender dysphoria did resolve itself gradually without medical interventions. As I suspected, it turns out that other conditions had in fact contributed to Jane’s distress, including autism spectrum disorder and polycystic ovary syndrome. Once these were identified and adequately treated, Jane’s overall condition improved.
Today, as an adult, Jane supports gender-affirming interventions for adults, but not for adolescents—and admits that she was actually surprised and disappointed that the clinicians did not ask her more questions and assess her for other conditions when she was experiencing gender dysphoria.
It is important to emphasize that my child’s experience does not negate someone else’s—it is just an example of another possible outcome that sadly goes underreported. If our goal is to truly give all people the care and attention they need, it is crucial for the public to consider the experience of not just those for whom transition was the best response to gender dysphoria, but also that of desisters and detransitioners.
It is only by including all possible outcomes, and by honestly and adequately assessing risks and potential alternatives, that treatment can improve for all patients seeking the highest standards of individualized care.
The opinions expressed here do not necessarily reflect those of the Foundation Against Intolerance & Racism or its employees.
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