More About Children and Gender

In a previous blog post I discussed two particular parenting styles, which seem especially unusual concerning children and gender. The first was (what was probably) a fa'afafine, a boy raised as a girl in a culturally sanctioned third sex, a practice which occurs in several of the Pacific Islands. The second was about Kathy Witterick and David Stalker, who have refused to reveal the sex of their third child, Storm, with the intention of allowing Storm to discover his or her own gender identity, free of societal expectations.

Storm with brothers Jazz (left) and Kio (right)

As I write this, Storm is now three years old, and still of unrevealed sex. There is a more recent interview with the family here. It seems quite clear that Storm's parents love their three children very much. They seem able to stand aside from any expectation of what their children will be, and just watch what happens. As a parent myself, I find it extremely difficult not to project onto my children some sort of expectation about what sort of adults they will eventually become. In addition, gender-neutral parenting is extremely difficult to achieve, for even the most well-informed and well-intentioned parents.

Witterick and Stocker have (perhaps understandably) provoked a fair bit of outrage. While I admire the unconditional nature of their love, I ultimately think their idea is misguided. Children are not simply free to decide for themselves how the world works. I believe that responsible parents attempt to equip children with both cognitive and moral structures which help them to make sense of the world. (If they don’t, then sure as eggs someone else will: via the TV or the Internet or popular music; even their peers). Therefore, it is inevitable that some parental biases and ideas (and neuroses and hangups) will be communicated to their children. I believe it is an essential part of growing up to weigh those parental structures and decide to keep some and abandon others.

One might, for example, discover that one's child had a penchant for cruelty or mischief. I don't think a responsible parent would simply stand by and admire that ("Aww, bless, there's the kid setting fire to the cat again. Isn't it cute?") but would actually intervene.

Both of those situations are where the parents have decided how they are going to raise the children in a certain way. What happens when the child has other ideas from the parents?

In this powerful and thought-provoking article, Eric Adler of the Kansas City Star describes the situation of "A.J.". Born an apparently normal boy, A.J., now six years old, knows he is a girl.

Then around Christmas, A.J. said it. He took his mom's breath away. They were in a store, walking hand in hand.
"'Mom,'" she recalled him saying. "'Do you know that I'm a girl? I'm really a girl on the inside.'"
It was not a question. It was a statement.
"My child did not say, 'I want to be a girl.' He said, 'I am a girl. How can you not see it? Don't you know?'"
The room went out of focus. She tried to respond.
"I said, 'No. No. I didn't know. The doctors told us you were a boy, so that's what I thought.'"
"OK," her son replied. They kept walking. Her mind spun.
"You cannot be prepared for this as a parent," she said. "It's not in any of the What to Expect When You're Expecting books."
Back home, she phoned her husband. "We have big stuff going on here," she said.

A.J., has one older brother, who seems to be an "ordinary" boy, into trucks and sports and the like.

"We were just parents going to work, sending our kids to day care, and this happened to us," the mother said. "I had never even heard the term 'transgender.'"

Read more here: http://www.kansascity.com/2014/02/26/4850042/i-am-a-girl-transgender-children.html#storylink=cpy

A.J. in her bedroom

The article goes into considerable detail about the parents' reaction. For reasons of confidentiality, they are not named. As comparatively conservative people, they supported their child the best they could, and sought professional advice.

They called Children's Mercy [Hospital] and then Gibbs [Caroline Gibbs, gender counsellor]. They remained cautious and skeptical, wondering whether someone who ran a place called the Transgender Institute might be too apt to diagnose a child as transgender. They sat down with A.J., watching Gibbs for signs of leading questions. Gibbs, as A.J.'s mother recalled, began talking to A.J.
"Can you tell me something about yourself? Are you a boy or a girl?"
"I'm a girl," A.J. said.
"What makes you think you're a girl?"
"I just am," she said.
"Is it what you wear or what you play with?"
"No. I just am," she said.
"Your parents say 'my son' and 'him.' How does that make you feel?"
"I'm really a she," A.J. responded, "'cause I'm a girl. I'm a daughter."
"But they don't call you that."
"Yeah, I know," A.J. said.
Her mother could see her sadness.
The eventual diagnosis: gender dysphoria, which led to weekly counselling.

Both parents were supportive of A.J.'s change in gender and role, and both the school and the other schoolchildren were accepting. However, the parents of the other children were a different matter. Sadly, many of them turned their backs.

In the pickup line after school, parents stopped making eye contact. Invitations disappeared. Some parents said they would call, but they never did.

"It is not something that I expected," said A.J.'s father, "but as a parent you want to do what is in the best interest of your child. Your job is to shepherd them into the world. And if your own family can't be accepting of who they are, how is the rest of the world going to accept them, or how are they going to accept themselves?"

A.J.'s mother wrote a follow-up article, which you can read in full here. This article attempts to deflect potential criticism of her and her husband's approach to their transgender child. From my perspective, A.J.'s parents come across as sensible, concerned, loving and right-thinking people, and therefore this article does a great job. But doubtless other people may hold different views.

I absolutely admire A.J.'s parents for their standpoint. What they have done, in openly supporting their child in this difficult time, is both painful and courageous. It's quite clear this situation is not of their choosing; nonetheless they both seem determined to make the very best of it.

Adler's article goes into some discussion about what therapists do when faced with gender dysphoric children.

Treating and guiding young children identified as transgender remains a thorny issue. Some therapists discourage the transitions. Some remain neutral and allow free gender expression to see what evolves. And some actively support and guide children with their new identities.

Read more here: http://www.kansascity.com/2014/02/26/4850042/i-am-a-girl-transgender-children.html#storylink=cpy

The problem is that nobody knows how these children are going to turn out. Some children, known as "desisters" eventually change their minds and return to their birth gender. Again, nobody knows how common desisters are. The experts quoted in the article consider desisters to be few, but studies from other countries report that desisters are quite common. (Even adults occasionally detransition, as described in my blog post here).

Autism: getting commoner (US figures)

A generation ago, autism was very rare. Then suddenly it seems to be everywhere. Is that because we are facing an epidemic of autism? Maybe. On the other hand, maybe we are just getting better at recognising it. Autistic genius Daniel Tammet describes in his extraordinary autobiography, Born on a Blue Day, that his parents struggled to deal with his stereotyped behaviours and incessant wailing as a child, but labelled him "sensitive".

I wonder if something similar isn't happening with transgender children. A generation or more ago, most parents would just not have listened or sympathised (unless the child were a tomboy!). "It's just a phase, son. Here's a toy gun. Go and shoot something". I know that something akin to this happened in my own upbringing. My boyish behaviours were encouraged, and my non-boyish behaviours discouraged, and my family was educated, kind and enlightened. (And I believe, to a great extent, parenting of the kind I had is still very prevalent).

On the other hand, transgender children seem to be becoming more common. (Now you can even get picture books for children about it). The problem is, how common are they? Nobody knows for sure. There are no clear terms of reference, or agreed standards of diagnosis. In other words, we can't even be sure that the numbers they count in the Netherlands are directly comparable with the numbers in the US, or the UK, or anywhere else. I tend to think that, as with autism, the apparent rise in prevalence is not due to a sudden rise in actual numbers of gender-non-conforming children, but an increase in recognition and tolerance of them.

How should they be treated? Nobody knows for sure, and I can say this with absolute certainty. In scientific terms, it is an evidence-free zone. No amount of professional expertise (so-called "eminence-based medicine") can substitute for good scientific studies-- and there are none.

A generation ago, children with ambiguous genitalia were arbitrarily assigned their most likely sex at birth. This was done, with the very best of intention, by doctors, and supported by parents. It was believed at the time that surgical assignment of sex, together with hormonal and psychological treatment, would be all that was necessary to ensure the child would grow up happy and well-adjusted in their assigned sex. Unfortunately, this was often a disaster.

As they became adolescents and eventually adults, some of those people rebelled against the arbitrary assignment of sex at birth, and transitioned to the other sex. One particularly tragic case concerns David Reimer, born a normal male, whose penis was accidentally destroyed during circumcision. His parents were persuaded he should be raised as a girl, but despite orchidectomy and female hormone treatments, Reimer never accepted his assigned sex. He underwent surgical transition to a man, married a woman and became a stepfather to her children. He took his own life at the age of 38.

Reimer's case is pretty extreme, and the psychologist involved, John Money, seems in retrospect to have been profoundly misguided-- if not an unmitigated quack. Nonetheless, Money reported Reimer's habituation as a girl to have been successful, leading to this becoming the template for the care of many other children in similar circumstances.

Boy: dress

The warning signs are all there. Assuming Money was acting with good intentions (which is questionable), we have a case where a prestigious doctor decides on a course of treatment without doing any sort of studies first. Money brushed aside any evidence that went against his belief: that Reimer was doing fine as a girl. Unquestioning acceptance of Money's technique led to it becoming an accepted, standard treatment. I believe that most of the doctors who performed surgery on intersex children were doing it with the very best of intentions, believing they were doing the right thing. But we now know they were wrong.

Likewise I do not doubt that the clinicians caring for A.J. believe they are acting in her best interests, using the latest medical knowledge. Unfortunately, the latest medical knowledge just isn't up to much. All we have are case series; in effect, anecdote and eminence. There is absolutely no way to be sure that what we are doing now is not going to lead to further problems a generation hence.

What do we actually need? First, we need agreed definitions of what we are studying. Next we need numbers; as many as we can get. Next, we need randomisation into two arms: a treatment arm (say, hormones), and a non-treatment arm. Next we need double-blinding: the non-treatment group should receive placebo tablets instead of real hormones, and the researchers recording the results should be blinded as to which subjects have had which treatment. Next, we need clear, clinically-relevant endpoints. Finally we need time, lots and lots of time, since these outcomes can't be measured in six months or a year but over a decade or more.

There are plenty of good reasons why research like this is cumbersome, time-consuming, expensive, uncomfortable for the participants and difficult to conduct easily. Nonetheless, without it, clinicians treating transgender children are doing no better than informed guesswork. We do have the opportunity not to make the same mistakes as John Money, but do we have the will?

===

My thanks to Randy for drawing my attention to the Kansas City Star article. Thanks to Una for pointing out a factual error which I have now corrected.

===

Addendum 13th April 2014

My thanks to Heather Colleen for drawing my attention to this interesting article in the New York Times written by the mother of a non-girly girl. What I hear in the article is the perplexity, the uncertainty, but also the love and acceptance, and the lack of hand-wringing or catastrophising. Well worth a look.

My thanks also to JJ Saphir for drawing my attention to this article from the New Zealand Herald, which strikes a very opposite view, and is highly critical of allowing children free gender expression. The author unfortunately trots out some fairly obsolete views in support of his very hardline position.