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Secret #41: Gender Affirming Care with Steve Graybar
161 Plays5 months ago
In this episode we are joined by Dr. Steve Graybar, a clinical psychologist from the University of Arizona.
They delve into the complex and sensitive topic of gender affirming care for minors. Dr. Graybar provides a nuanced analysis, advocating for a more comprehensive and research-based approach to gender affirming care. He emphasizes the need to reimagine the current model to include thorough psychological evaluation and family therapy while cautioning against the politically charged atmosphere surrounding the issue.
The discussion also explores the risks of medical transitioning and the importance of empirical support and informed consent in making these significant decisions.
Topics Discussed:
- Evolution of gender reassignment and need for long-term follow-up studies
- Social pressures and vulnerabilities during adolescence
- Emphasis on family therapy to prevent parental alienation
- Societal Approach and Policy Recommendations
About Steve Graybar
Clinical Psychologist, Associate Clinical Professor University of Arizona, Tucson, AZ, all around nice guy.
Follow us on Facebook @lifesdirtylittlesecretspodcast and on Instagram @lifesdirtylittlesecrets
Reach out and let us know you are listening and what you would like to hear on the show - email:lifesdirtylittlesecretspodcast@gmail.com
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Transcript
Introduction to the Podcast
00:00:02
Speaker
We are all very human and fallible, and yet we live in a society that rewards pretending we're not fallible, or the range of acceptable fallibility is narrow. We are constantly comparing our insides to other people's outsides and feeling inadequate and guilty, even ashamed. Trying to blend in means parts of ourselves will disappear, and we must then live in fear that we will be found out. Here, together, we will create a space where we can laugh, cry, and carry our suffering and hurts lightly in the service of being deeply human. This is Life's Dirty Little Secrets. Welcome to Life's Dirty Little Secrets. I'm Emma Waddington. And I'm Chris McCurry.
Introducing Dr. Steve Graybar
00:00:48
Speaker
Our guest today has been a dear friend of mine for almost 40 years. Dr. Steve Graybar received his PhD from the University of Nevada, Reno, where he was a year ahead of me in the program, but light years ahead of me in wisdom and dedication to the field. It was a great pleasure to know him as we endured graduate school together, and then watched our professional and family lives blossom over the years.
00:01:14
Speaker
After graduation, Steve spent some years affiliated with the Department of Psychiatry at the UNR School of Medicine. He currently splits his time between Reno and Tucson, where he has a private practice. I'm going to take the unusual step of giving a little disclaimer as it were at the beginning.
What is the Stance on Gender-Affirming Care?
00:01:33
Speaker
We're going to talk about gender-affirming care for minors. This is obviously a very hot topic. And in doing a podcast on this important topic, we are in no way, and I mean no way, meaning to give to support aid or comfort to the bigots out there who are using this complex, nuanced, and sensitive topic as a political cudgel. And you know who you are.
00:01:59
Speaker
you know, the politicians and others who would demean and dehumanize young people whose lives are difficult enough as it is. And so we want people who are struggling with gender and identity issues to get the compassionate support they need. And as we've done for a long time on this podcast, we want any person seeking help to be supported by good science.
00:02:23
Speaker
And I think that pretty much sums things up. So thanks for joining us, Steve. It's been a pleasure. That's been our podcast for the day. Just kidding. We're actually going to talk about this, but if this is a hot topic. So Steve, thank you
Rethinking Gender-Affirming Care
00:02:37
Speaker
for joining us. no You talked about reimagining gender affirming care. Why do we need to reimagine gender affirming care? You know, it's gender. Who can argue with gender affirming care?
00:02:51
Speaker
That's like arguing you know against hot lunches for orphans. But that's only in the title and my concern has been as I read about it and learned about it and actually tried to learn more about it and it was it it actually became more and more diffuse and less clear to me what gender affirming care meant other than, and this is probably going to be a very controversial thing to say, other than it seemed to start functioning as a funnel toward medical transitioning, which is not the same as gender-affirming care in my mind, at least the way I would have understood it.
00:03:32
Speaker
And so gender-affirming care has as its fundamental tenants, even in, I believe it was the APA monitor here in the States, American Psychological Association publication. And it really, its fundamental or its foundation is taking kids' claims at face value, believing what kids are saying, and assuming that kids know exactly what they want and what they're talking about and are even intellectually as well as emotionally capable of articulating other thoughts and feelings in ways that I know adults struggle to do and I struggle to do.
Informed Consent vs. Mental Health Care
00:04:14
Speaker
around conflictual or complex or difficult topics. And it seemed, I know it sounds stereotypic, that you know but I am worried that gender affirming care has functioned of late. And there's been a a lot of discussion in some articles and some whistle blowing and now lawsuits about how it has functioned to bypass mental health care, mental health providers, and really is sort of streamlining many young people.
00:04:49
Speaker
into the process of medical transitioning. So reimagining gender-affirming care, I don't want to reimagine affirming. Also, i would like it i'd like I would like gender-affirming care to fall under the auspices of psychotherapy as an empirically supported treatment that is grounded in informed consent. So if you're making a recommendation to someone, what is the basis of that recommendation?
00:05:16
Speaker
And if you're sitting across from someone, a child and or their family or parents, What are your responsibilities to inform consent, to sharing where this pathway leads? And trans identification doesn't necessarily have to lead anywhere. And I think in a psychotherapeutic relationship, that's exactly what can happen. A potential for that to happen seems greater to me and there might be greater confidence if they do choose to medically transition.
Gatekeepers or Guides in Transitioning?
00:05:50
Speaker
But right now, I think that mental health people are being viewed by many in in the trans community and community as gatekeepers, as letting some people in and keeping a lot of people out.
00:06:05
Speaker
and And that's an affront to the patient's autonomy. I think in some ways it's a recognition of children's vulnerability and family's vulnerability to and around this issue. Does that help? Does that make sense? Or is that confusing? No, it's a good statement of the position that you know you've you're taking in this paper that you've written that I do hope it gets published. Did you say it was accepted somewhere? It was accepted and then upon being accepted, it was unaccepted.
00:06:45
Speaker
And that's really, it's it's striking because there's a little section in this paper about how the controversy surrounding this topic is influencing clinicians as well as researchers, as well as what people are willing to to publish, what other people are willing to research or to even talk about.
00:07:05
Speaker
So you would your preamble to our meeting today is necessary and is important to sort of clarify where you stand. And hopefully I'll be able to convey to people where I stand, which is not against medical transitioning, where I stand is for empirical support, research-based support for these most powerful and at times irreversible interventions. And that's really where I stand on all of this.
00:07:33
Speaker
is I'm willing to, if the research supports it, I'm in. If the research research shows that gender dysphoria is addressed, who would argue with that? If the research shows that social and emotional functioning of these people who are going through medical transitioning is effective, <unk> i don't I'm sure there are some people who would stand in the way of that. I'm not one of them.
Historical Context and Evidence of Care
00:07:56
Speaker
Does that help? him Yes, and you mentioned the Dutch protocols, which it seems from my reading of your paper, kind of got everybody started down this path. Is that an accurate description?
00:08:12
Speaker
I don't know that they got everyone started, but they, I don't know, Chris, you and I are old enough to remember, remember this used to be about transsexuals and gender reassignment surgeries. And that was way back, Christine Jorgensen, I think was the patient in the 50s and 60s. And it was happening in the 60s and Johns Hopkins was a big part of it. And even in the 70s,
00:08:37
Speaker
And then it stopped. And it sort of, or it certainly quieted down. But Johns Hopkins, as I recall, just pulled out of it and said, we're done, we're out. And my recollection is because of the dubious nature of their outcomes. And there's one study that's just disastrous. It basically was a 20-year follow-up of those patients who who's whose attempted suicide rate was 19 times higher than that of the general public.
00:09:07
Speaker
which is catastrophic. so at very long term and and you know One of the calls that I'm a part of is we need long-term follow-ups, not six months, certainly not six weeks, but five and 10 and 15 years. When you're intervening with someone who's 15,
00:09:27
Speaker
how they're feeling it about it at 17, I don't find as compelling as at 27. You can't push time, and if I'm hoping these studies are underway, but we are acting as if they're already underway and they've provided us with answers. but Then there was paths in Great Britain.
00:09:47
Speaker
Yes. Yeah. Hilary Cass is a very well-known pediatrician and was asked by the NHS in in Great Britain to look into this. And so so she cobbled together a ah research team who to gather all the studies internationally that they could get their hands on. And then from that, they tried to pull out those studies that were not so methodologically flawed. And this is a difficult issue because they are.
00:10:17
Speaker
They have small sample sizes, they have very low follow-ups, heavy attrition rates, all kinds of no control groups, confounding interventions. There's a lot of people in psychotherapy who had but trend the medical transitioning done, what role did that play, et cetera, et cetera. And so they pulled out the best studies they could find.
00:10:43
Speaker
that would not be methodologically dismissed by your average master's thesis committee, if that makes sense to your viewers. And from those studies, she came out with an incredibly powerful, not at all edgy, I mean, I talk about compassionate and kind, in a very kind and compassionate way, she stepped on a lot of toes.
00:11:08
Speaker
And it wasn't with a gleam in her eye, not when I saw her interviewed, not when I read this, it's about a 400 page report. She said with a gravity, and I'm very sorry, but we don't have the evidence.
00:11:23
Speaker
that we need to support these dramatic interventions. We just don't. It's not there worldwide. it's we We have no long-term solutions for gender dysphoria, no gains significant gains that we can document in social and emotional well-being and functioning for these patients.
00:11:42
Speaker
I mean, it's really quite incredible. what And she's also talking, she talks about it while a great deal of research has been published in this area, it's been of poor quality, and that's true. I basically you did the Cass study on my own, and then she trumps me and publishes first.
Politics, Social Pressure, and Research Gaps
00:12:01
Speaker
How rude is that?
00:12:03
Speaker
So anyway, aside from her bad manners, but I was really impressed with myself because I came up with many of the same things like this is not so good. How did we get here? But she talks about there's no solid evidence for transgender patients, their families or clinicians to draw from in their personal and professional decision-making.
00:12:24
Speaker
That's pretty powerful stuff. And she has other conclusions about how research has been misrepresented as being more effective than it actually has been.
00:12:36
Speaker
that political social and political controversy has affected clinical decision-making. I think it's intimidated mental mental health professionals right out of the arena. Would you want to be a therapist who gets in the way of this train? Well, many therapists aren't. Many have just sort of abdicated, many deeply. And there is and we were talking briefly before we got on about good and evil.
00:13:03
Speaker
I don't think this is about good and evil. I don't think it's that simple. I think people deeply want to help and want to intervene with young people's suffering. And if I may unconsciously, want to somehow reverse what mental health has done to the ah gay community.
00:13:22
Speaker
by diagnosing them as having a mental illness in the 50s, 60s and 70s and doing all the damage we did through conversion therapy. And so I'm not going to be on the wrong side of that. I'm not going to be on the wrong side of history again.
00:13:38
Speaker
And I think that has pushed a lot of mental health folk. My reflex was to accept this, and I think it was grounded in that. Again, I'm old enough to remember when it was pulled out of the DSM for of homosexuality.
00:13:53
Speaker
Well, and I think too, I can't say enough about it, but it's powerful. I believe that she was impartial. I really do. I know she's being just savaged in Great Britain. And you you have to, I'd recommend anyone watch a YouTube video of her if there's like the least most savageable person on the planet, it looks like this lady. I mean, she's kind, she's thoughtful, she's caring, and she's almost apologetic for our lack of data. So I just, I find her ah very compelling. Well, i I think, you know, this has become so politicized. And I would make a gross overgeneralization and say that a lot of people who are
00:14:38
Speaker
in the mental health field are probably leaning a bit more toward liberal views. And so they feel they need to take a stand against, you know, again, black and white, good and evil. They need to take a stand against all the stuff that we're seeing that is going on. and And, you know, particularly here in the United States, it's become so politicized and you have, you know, certain states that are passing you know really draconian laws, you know not just in this area, but for you know reproductive rights and everything else. And so everything gets lumped together. There is no more discussion at that point. It's you're either for or against.
00:15:23
Speaker
yeah Well, yes, that's sort of the black and white thinking. and In psychoanalytic parlance, it's splitted to the very primitive defense against reality. And as far as you know the politicalization of this, I don't know the governor of Texas, but I'm certain that he and I have... This is the first time we may have agreed on anything. And I don't think we agree on this either because I think I'm willing to wait for the data and to support the data whichever way it falls. And of course, I think he's unburdened by science as are many of the folks. I don't want to paint too broadly ah with this brushstroke, but you know, if if this is in your heart, this just feels wrong to you. There's no amount of data that's going to convince you. On either side then.
Complexities of Mental Health and Consent
00:16:16
Speaker
what Well, right now that's how I'm feeling when I am attacked by I'm just waiting till this podcast drops. I can't, I can hardly wait. I mean, I mean, if you look at my voting record, I mean, you know, I voted for Michael Dukakis, it's John Kerry, a series of losing democratic candidates. Uh, but I hope not this time as I'm listening to you and having done a bit of reading around this, I am struck by, um,
00:16:46
Speaker
I guess before before we started this conversation or before we decided to have you on, I wasn't very well read in this area. Obviously it's all come about since I graduated, so it's all relatively new. but So reading your paper and doing my own research, I came to realize that the data isn't there. And that was a surprise given yeah given the force with which the argument has been made.
00:17:18
Speaker
in certain communities and certain countries ah around what gender-affirming care should look like. It's quite striking. I'm curious as to how that happened. How did we come to be having this conversation in as much as the, you know the like you said in your paper, how is it that intervention has preceded the data?
00:17:47
Speaker
you know And that's the first thing that really got me rolling was that somehow treatments and interventions have preceded data. And that ha that I think that's very common in in psychology and in medicine. People in the field, people on the front lines see some things and try some things and make some connections that aren't available to people purely in a laboratory setting. And so they get out in front of it. And then they start, well, I wonder if this is a real thing. and there's only And many people say, well, it feels right. And we stop there. But that's not our charge, not as professionals. It's to take it back.
00:18:32
Speaker
to a research setting and and to weed out. you know That's what the scientific method is. It's to weed out our biases. It's to literally control for our biases and our blind spots and our wishes. The biggest defense against that is the null hypothesis. And so let's go back.
00:18:52
Speaker
and do what we were trained to do. And I'm really speaking to mental health types. We've abdicated. I mean, come on now. You can't be a student of human psychology or understand or grasp childhood development.
00:19:07
Speaker
cognitive development, emotional development, and really believe some of the things that are being said and or done. One of the things in the paper I really talked about, things that I didn't talk about, one of them was can children ever give informed consent? Can people who are profoundly emotionally disturbed, yeah I think your listeners, your viewers, I'm not sure which they are or if they're both, would be shocked at the mental health diagnoses of ah young people who are going through medical transitioning, including thought disorder. I mean, I hope and pray that's rare, but I'll tell you what isn't, especially in the UK.
00:19:47
Speaker
Autism and autism spectrum disorder kids are being medically transitioned. And then for the rest of of the folks out there, kids with, we have to be very careful with personality disorder diagnoses in general, but in particular with children. But there is a place for almost a, a, a pro-dromal borderline personality process for minors.
00:20:12
Speaker
and And none of these things are going to shock you, kids who are cutting, kids who have chronic suicidal ideation, impulsivity, other types of self-injury, yadda yadda yadda, suicide attempts, you name it, impulsivity, whatever, anxiety, panic, mood disorders. Oh, then they have, and they also have gender dysphoria. How does gender dysphoria trump those multiple diagnoses?
00:20:41
Speaker
how do we presume that those pre-existing emotional difficulties are caused by gender dysphoria or being a minority person, a person with gender dysphoria who's been discriminated against when they have preceded, in many instances, the gender dysphoria? And then people will say, well, there's other causes of gender dysphoria. And It's, that's also frequently not the case for what, there's another classification out there for rapid onset gender dysphoria, which is sort of interesting, but it's just, yes, I'm assuming that having gender dysphoria can lead to great emotional upset and distress
00:21:28
Speaker
but it doesn't lead to trauma necessarily. I mean, the trauma has preceded many of these kids' ah experience of gender dysphoria. So we're looking at that gender dysphoria may be a cause of emotional disturbance, but it may also be in effect. And that has not been teased out. That has not been answered yet. Does that Did I remotely answer your question, Emma? Can we talk baseball? I'm much better. I think that's really interesting. Not in Seattle with the way the Mariners have been doing.
00:22:04
Speaker
I think what's interesting with you but and in my reading, preparing for this, I think I was of the assumption that my understanding was that gender dysphoria, because of the stigma, the discrimination, the bullying, leads to many mental health issues. And that therefore, there's the argument, right? The issue is the gender dysphoria, because of the context that it creates, and that the mental health issues that come, come about afterwards. But reading the Cass,
00:22:35
Speaker
work and reading your work, I came to realize that actually it's much more contextual. The gender of dysphoria doesn't happen in and of its own. It happens in the context often of many other mental health issues that sometimes proceed. Gender dysphoria is actually, I think in some cases, I fear that I might be right, but I'm certainly willing to be wrong.
00:22:57
Speaker
is a problem solving approach to kids with some profound emotional disturbances. It's a way to try and explain. There's a lot of discussion and research that many of these children, if not socially transitioned, and that's another topic that should get the three of us tar and feathered, it is if they're not socially transitioned, if they're loved and supported and allowed to be who they are,
00:23:28
Speaker
will naturally accept their natal sex, their birth sex, by the time puberty, which is so dreaded and feared, like so many things that we dread and fear, that once we start to move through it,
00:23:42
Speaker
It's actually strengthening. It's cohering. It helps us make sense of so many things going into it. It's, I don't know, I don't know what kind of car washes they have around the world, but if, you know, those multi-purpose car washes. Well, I'm always a little anxious right at the beginning, right at the mouth of that thing.
The Role and Risks of Puberty Blockers
00:24:03
Speaker
i mean Tight and But all of a sudden, i I'm feeling pretty good about myself when I'm three quarters of the way through and I can see that there's light at the end of the tunnel. I can still escape my car if it gets stuck in there. Well, that's how it is for so many things that are anchored in anxiety is exposure. And I hate to sound so... banal, but exposure-based living is the way to live. It involves healthy risk-taking. It involves approaching those things that we fear. And what we are doing with puberty blocking is probably one of the most high-tech avoidance strategies one can imagine. For kids who, in many research, the range is, well, there's a number of studies that say it's 80% will desist
00:24:52
Speaker
with their trans identification. That's a brutal number if we are transitioning a significant number of those. and I talk about social transitioning, that social transitioning is very effective. If kids are socially transitioned between the ages of six and seven by age 12... Can you define that quickly? ah yeah It's using a different name, using a different pronoun, different dress, and sort of being allowed to move in the world.
00:25:28
Speaker
as if I were allowed when I was a boy to move in the in the world as a girl. And this is at school and at home and other places. And so it is very much very reinforcing, very positive and very powerful experience. And in this one study I read 60% of those kids by the time they turned 12 had already had remained Trans identified and had begun purely blockers so you can see how the numbers don't fit up they don't matter that we and one of the most important. Findings in the cast report is that we cannot distinguish transitory from enduring. Trans identification and the more i read that gender discontent in this.
00:26:21
Speaker
is almost development and especially so for girls. And it's striking to me that girls in the study of detransitioners by Littman were most likely to report feeling forced or pushed into transitioning. yeah I don't want to say forced, but pressured was the word, was the actual word. I'm sorry. yeah By whom?
00:26:47
Speaker
Well, by therapists that they were in there, parents and healthcare care practitioners and different types. Well, also friends. Social media, no doubt. I don't know what tumbler is, but it sure sounds malignant to me because it's in, it's in almost every one of these studies as where kids first started learning about and hearing about, then they jumped on YouTube, et cetera, et cetera. But i i didn't i don't I still don't know what Tumblr is, but it even sounds evil to me. I tried to destroy anyone's livelihood here. I'm just saying it it just seems to be implicated.
00:27:31
Speaker
as offering this kind of information and peer groups, huge. So it's multiple sources. I'm struck by, yeah if we have a ah young person who's got you know significant gender dysphoria and you know is is reporting a lot of anxiety, suicidality is very high in the community, suicide attempts are very high too.
00:27:58
Speaker
and My understanding was that puberty blockers were a way, like you said, to sort of ah slow the process down to help them make a decision, to buy time exactly, to help them make a decision as to what they want to do. But listening to you and having read your work, it does it seems to do more than that. It doesn't just buy them time. It actually seems to make a decision for them.
00:28:24
Speaker
Well, that's what social transitioning does, in my opinion. Puberty blocking doubles down on that. And then, Chris, I'm sure you can wax eloquently about cognitive dissonance. You know, in for a penny, in for a pound. You've come this far. You've advertised your entire life that I'm not really a boy, I'm a girl. And the whole school worked with you on that. And now you started puberty blockers.
00:28:50
Speaker
And puberty blockers bring with it all kinds of different feelings and experiences. And all of a sudden you are now being passed by. You're not growing. There's growth hormone in there. and And so the world has moved on from you, or if I were the case in point, has moved on from me as a boy, my friends are now becoming young men. So it's not as passive, it's a propellant.
00:29:18
Speaker
just like the social transitioning. And I have to make something clear because someone pointed this out to me and it feels like a fair criticism. And then it it also seems bizarre. They said, you seem to be saying that it's it's preferable or it's a superior outcome for someone to be non-trans over trans.
00:29:41
Speaker
Do you understand what I'm saying? yeah but you You seem to be saying it's it's it's it's bad to be trans and it's it's good to be non-trans.
The Gravity of Surgical Interventions
00:29:49
Speaker
And I think you have to work ah to hear me say that.
00:29:54
Speaker
but But if that's what anyone's hearing, that's not my issue. my My issue is what are the risks and benefits of medical interventions versus psychosocial intervention? And what is the data supporting each? And it's and one carries with it tremendous implications, including aspects of irreversible interventions. So if if I have a bias, ah the bias in my life,
00:30:23
Speaker
I have the best orthopedic surgeon in the world because he's mostly an orthopedic consultant. Because he said to me when this is, you know, I immediately threw myself at his feet and worshiped at the the altar when he said there's nothing that surgery can't make worse. And we're talking about this old man's potential knee replacement. Well, he knows that I have a bias towards I'll do anything not to have surgery. I've had many surgeries.
00:30:49
Speaker
They're hard and they're never, is it's never quite the same. And I respect surgeries because I think my life has been saved by a couple, but there's always been consequences.
00:31:00
Speaker
And so when he says, well, you can do this or you can do six weeks in physical therapy, I have a deep and meaningful and ongoing relationship with my physical therapist because I'll do anything to avoid surgery. And I'm not being cavalier about this. I'm just saying surgery is a big damn deal. And so we better really be able to identify, can you imagine having a huge surgery that you, and here's more of some of the semantical concerns I have. They're calling the transitioning regret.
00:31:30
Speaker
Regret? Having your reproductive organs removed and then thinking you made a mistake? Regret doesn't quite capture it. I regret backing up into the light pole in my parking lot. Don't regret initiating a revolution upon my body.
00:31:47
Speaker
that I'm going to have to live with the rest of my life. And if I decide to detransition, even detransitioning in many cases a misnomer, you're not going to get your breasts back if you've had a mastectomy. You're not going to get your ovaries back if you've had a hysterectomy or your genitals or all kinds of things. And so regret doesn't capture what happens, at least from the kids that I've been exposed to in almost exclusively online, what they're dealing with is not regret, it's horror. They're haunted by this decision and they're asking all of us as adults and as clinicians, where were you?
Research Gaps and Social Influences
00:32:29
Speaker
And that's a damn reasonable question in my opinion.
00:32:32
Speaker
Where are we on this? Especially if we do the data, as Emma, as you pointed out, you've read the data. It's not there. Not yet. It's a long story, not yet. It seems like reading your work and it's like a Because my understanding was puberty blockers, like you said, bias time, but it actually initiates a process, doesn't it? and It creates a cascade, potentially. That's quite scary. It's not targeting.
00:33:02
Speaker
we don't you know when you yeah We're not just blocking aspects of certain hormones and what they're doing. We're blocking what hormones do during puberty, which is why one of the big issues right now is about bone density concerns and young women having stress factor fractures in their 20s because their bones are not calcifying because that's a part of what puberty does.
00:33:26
Speaker
for young women also. And Chris, I know you could speak to this in ways that I can't. Puberty is involved in neuropsychological development until our mid 20s. And that is stopped. That's stopped there. The research is not clear how much is lost, but there's some suggestions.
00:33:49
Speaker
about what is missing neuropsychologically or cognitively when we initiate this. It's not solid yet, but it's a significant concern, which I think is reasonable that we would want answered. The same is true with cross-sex hormones. There are some serious concerns by some serious researchers about cardiovascular risks. And then the surgeries certainly are going to bring sterility if you have the entire surgery.
00:34:17
Speaker
and sexual dysfunction, two very common outcomes of the full process. And and how do you talk about, will you miss orgasm to a i ah child when you're about to put them on puberty blockers? How can we, you know even those, I don't know if you've heard of the WPATH files. Yes, I read them. There's a special place in hell when someone's joking about talking to a little girl about having children and alludes to, it's like talking to a rock. Well, then God damn it, don't do it. What you are talking about, what are you doing? and and And this isn't, they're not coming in, this is elective. I know children don't understand when they're going through chemo, but it is for their parents to understand. So why would someone pretend to explain something that is outside the grasp of a child? Is it for their conscience?
00:35:12
Speaker
Is it for the child's benefit? What exactly what were they doing? And I know that may have been an isolated example, and I could possibly certainly be taking it out of context. But what I saw, and it may have been presented to me out of context, but what I saw was pretty terrible. And I don't think that's modal. i Don't get me started. I don't think this is about good and evil, but that was a damn rotten thing to joke about. And the person was joking about it.
00:35:39
Speaker
And again, out of context, not knowing that they're being taped, we all say crazy stuff. I get it. But damn, that sort of stung. Sorry, I don't mean to. No. And that's the, like feeding through that piece of work. I think it's the SOC 8 is the latest version of their work is informing a lot of the care in the US.
00:36:05
Speaker
from what I was reading and other countries too. I think not in Europe so much. I think what's, yeah, what's just striking me is thinking that we all want to do the best for these young people and these children. I mean, nobody's denying that.
00:36:22
Speaker
You know, we want to take care of them and it's really scary because some of them are really distressed and very unwell. And yet it feels like we've been pushed into a direction because of some of the severity of their presentation. I mean, some, you know, very high rates of suicidality and attempts has pushed us into the urgency of doing something about it.
00:36:50
Speaker
And concerns are, in this conversation, that what we're doing is moving quicker than the research. And potentially, I'm struck, I keep going back to these puberty blockers, but I found it very difficult to find the research, but I had read it, where if children, and you've alluded to it, you know, with young people that are allowed to go through puberty, the majority of the gender dysphoria gets resolved. I found that unbelievable.
00:37:21
Speaker
Yeah, that's what the data says, but it's not easy to find as in you have to do the work to find the data. I think the that's where Cass comes in. She's you know helped us with this, but you need to do your research because that's quite reassuring as a parent. You have your child, like you said, you know your child is going through this and your work will support them as they go through this period but the process of puberty is paramount to helping them potentially resolve or come to a clearer understanding as to what they want to do moving forward. That's kind of the flip side of informed consent because in the same way that you it's hard to talk to an eight year old about, you know,
00:38:07
Speaker
not having orgasms, you know, for in for the rest of their life. It's also hard to say, oh, this will get better in 10 years. That's, you know, kids are so much in the moment and they're suffering now and they're going to let their parents know that they're suffering and the parents are going to suffer for their kids suffering. And so they're in a bind.
00:38:27
Speaker
parents are are in hell on every side of this issue. But one of the things I want to, I don't know if clarify is the word, but comment on is that the trans kids, the data is that they are no more likely to commit suicide than any other mental health patient, kid in mental health treatment.
00:38:46
Speaker
So there used to be this big threat, which was your kid will kill themselves if you don't do this. That was a part of the informed consent process, by the way, that's been reported wildly by whistleblowers. So, so then that sort of urban legend by now, but I believe it has happened. But the Chris, you've also just described, you know, the paradox of parenting. I mean, kids want a lot of things now and it's our job to endure.
00:39:13
Speaker
alongside them, those things that are and are not possible. And the issue is they live in a milieu in which they're being told, we can transform a Ken doll into a Barbie doll, and you'll live happily ever after. Who doesn't want a piece of that action when you're 13. We're taking the most vulnerable, emotionally vulnerable phase of human development. I hesitate to say this, but we're preying upon it. And as opposed to helping people wade through these multiple life changes and emotional waves, we're medicating it. We're intervening with it chemically.
00:39:52
Speaker
by blocking the natural processes of the body, and then we're surgically getting involved. And as ah it it just doesn't make sense to me to do that without an abundance of solid, high-quality research saying, yes, this is the right path.
The Emotional Journey of Parents
00:40:09
Speaker
And I think that's what's happening. And my one thought, and it's and it's This is not going to help any of the three of us if you don't cut this out. My one thought is I am old enough to remember the nineties and the false memory syndrome and the implanting of false memories by therapists and the spike in reports of child sexual abuse by women, young women, middle-aged women, older women, by their father. Satanic abuse, satanic abuse, paternal abuse.
00:40:42
Speaker
And then the corollary to all of that was the proliferation of multiple personality disorder. This is a true story. I have people who identified themselves as therapists and saying, you know, boy, but this is a hard week. You know, I've got 17 multiples on my caseload.
00:41:00
Speaker
So, it's just, yeah I actually think, you know, the hockey stick, the the data, but you know, we're cruising along like this and all of a sudden, 2008, it's skyrocketing and just, that's a phenomenon. And it looks a lot like a social contagion. And I... Yeah, well, I mean, people argue that, you know, left-handedness skyrocketed when we stopped making kids use their right hands, you know, in school. So, you know, people say, well, it's just, we're no longer, you know, suppressing or repressing this stuff. But, you know, I do think there is a great deal of social pressure and
00:41:43
Speaker
in the same way that there are websites for you know anorexia, pro anorexia websites. And I was hearing recently about websites encouraging kids to be estranged from their parents if they feel, you know,
00:41:59
Speaker
victimize to many websites and many platforms parents are being vilified as the enemy. To your freedom and to your transitioning into your happiness and to your true self and to that extent. Hate to sound too crazy but that's how cold for the server those times.
00:42:21
Speaker
in which there's going to be a semblance of reality and truth. And there's just also a sense of historicity that can wade through this with kids. And yet parents are, they're being vilified. That's where most of my clinical experiences is really in this area, is with parents, what do I do not to lose my kid? And what they're doing is they're exchanging surgeries and and medical interventions.
00:42:51
Speaker
for holding on and having a relationship with their kid. I mean, they're hostages. So if we do reimagine gender-affirming care, what would that look like? Of course, I have my bias. I think that family therapy is crucial to make sure that this parental alienation doesn't occur, that ah psychotherapy and empirically supported psychotherapy and empirically supported interventions start being developed.
00:43:24
Speaker
that this needs to be the beginning. some We've allowed ourselves, I think, out of fear and intimidation and also heartfelt beliefs, perhaps, to be pushed aside in theorizing, in researching, and in intervening with these patients. And so gender affirming care affirms the gender dysphoric experience and how difficult that is.
00:43:52
Speaker
But it generates additional solutions, possibilities, and develops a level of relatedness where one can challenge the all and all or nothing thinking, the black and white thinking, the splitting that goes on, and the intensity of these experiences. It's not, it's holding the line for reality. And it's not just stepping back and sort of saying, you know, believing kids.
00:44:21
Speaker
They have this feeling. None of us, none of the three of us believe our feelings. Our totally and completely accurate representations of reality all the time. We have to step back from our feelings.
00:44:34
Speaker
Most good therapy helps us accept our feelings, observe, and be curious in order to understand our feelings, not to be slaves to them. It's a very different process than this is what you're feeling, this must be true. Or people who have similar feelings are trans. You know, that's the this sort of helpful advice that kids are giving other kids. And denying the social contagion to this when there's five girls in the same friend group presenting, that's not the lifting of a prohibition against a oppressed minority. That's a ah social psychological process that is affecting oftentimes vulnerable kids and kids who want to belong. And at the same time, there's a part of me, this is where I began, I believe there are truly trans kids, but I think it's a fraction of what we're seeing. That's my fear.
00:45:33
Speaker
is that we're we are we are way off in those numbers. So I guess in a way, what I mean, it sounds like a ah compassionate stance in that it's a journey with your but the parents, with the young person, with the therapist to make sense of what's happening before making a decision whether to transition or not. And I guess this idea of buying time is
00:46:05
Speaker
It's not about buying time. It's actually about let's do some interventions socially and emotionally to see what's happening, how they can function to the best of their ability given yes the different complexities. like It's much more nuanced and complicated. but I don't want to meet with meet oversimplification with oversimplification.
00:46:28
Speaker
i think I think this is very complex. I think it's very difficult work. I think it'll be very challenging. And one of the things that we could do, in my opinion, as a culture or as ah in our society, is what they've done in Europe, which is no medical transitioning before the age of 18. That takes it out of the parents' hands. yes And it takes the pressure off parents that this is the way it is. This is the law.
00:46:58
Speaker
We're going to support you through this with all the love, understanding and acceptance that we can muster and we're going to get help doing that. The last thing I would like to throw out is also I would like to see whatever medical transitioning that is occurring and social transitioning that is occurring in the States.
00:47:16
Speaker
be under the auspices of research. Because if this does not have empirical support, a scientific base, then it's experimental. So then it should be truly occurring in an experimental and research context. Well, again, you know you've got yeah when they pass laws in certain states in the United States prohibiting you know these treatments for minors, it's an an incredible political you know pushback.
00:47:46
Speaker
And I think that's where all the things that you're describing get drowned out. yeah Well, right. You don't do this, you know, with a gleam in your eye. Like you just won something. This is our failing. We haven't done the research. The research has to catch up to and surpass the interventions.
00:48:07
Speaker
which is why we should be preventing this outside of a research context, not because we want to stick it to some liberals or we want to gain political advantage. That's just terrible. That's the bottom of cynicism of behaving in that way.
00:48:25
Speaker
Well, any final thoughts? I mean, I just, I do hope you get the paper published. I hope somebody has the courage to do that. And I hope people will come away from this being a little more curious about the science and feeling empowered to not be swept along.
00:48:48
Speaker
by you know emotion or political agendas. you know People can look at this in the best interest of these vulnerable young people. Yes. and I think that you know as clinicians, many steer away because they don't believe they know enough. and I think that is wise. But perhaps when we think about what do we know and what don't we know, we need to but do better research ourselves.
00:49:17
Speaker
and be mindful because I think that there is a lot of intimidation. There's a lot of fear of doing, there is fear of doing harm and understandably not being able to support young people the way they deserve. and Maybe what you know one takeaway from me is that as a clinician, as a psychologist, I can support the family and the young person in many ways, that I can really create these this environment where we can explore and support the process of understanding.
00:49:55
Speaker
of connection. The relational piece with the families is incredibly important and we see it all the time with the young people that they get alienated and that's incredibly painful for everybody that's involved. So not to underestimate really the impact clinicians can have because I think potentially that's been one of the dangerous messages. If you'll not meet a more tortured group of people than the parents, yeah they they are just suffering because they don't want to lose their child and there there is a pull.
00:50:33
Speaker
that parents are in some ways the enemy. And so they're supporting and doing everything they can, even things they just do not believe in, to maintain a relationship with their... I can't talk to my son. I can't talk to my daughter. I feel I'm losing them. I don't recognize them. Something's wrong.
Towards a Compassionate, Evidence-Based Approach
00:50:54
Speaker
If you can imagine. And then there are other adults in their lives, medical professionals,
00:51:00
Speaker
or pulling them in at a at of pace that is unnecessary, in my opinion. I know their hair is on fire for these children, these young people. I know this and promise something, and they're convinced that the sooner I get this done, the better.
00:51:17
Speaker
And nobody wants, I mean, you know, if you've got cancer, and someone's got an experimental drug, who's not going to get in line? This feels terrible to an adolescent, again, the most vulnerable time in their lives. And the key to my suffering is over there, and you're preventing me from doing it.
00:51:36
Speaker
oh yeah Well, thank you both very much for having me. Thank you, Steve Grabar. Wow. I'm sure we'll get some feedback on this one, but it was it was a great conversation and I really appreciate you willing to... I have this terrible sense that the three of us are all depressed.
00:51:55
Speaker
but yeah no but i mean I've learned a lot. I've loved a lot and um you know my compassion for the families that are going through this and the young people remains and I feel more hopeful. Things are actually turning ever so so it's ever so slightly.
00:52:15
Speaker
and in the direction of of oh people are concerned with being nice and kind to to to people who are in difficult situations. What's not to love about that? And this generation, you know, we pummel them with our judgments.
00:52:32
Speaker
But more than anything, they're the least judgmental generation that I've been exposed to. And I've been on college campuses for about three generations now. And they're good young people. They really are.
Fostering Curiosity and Community Feedback
00:52:44
Speaker
And they want if they're going to make a mistake, they want to make they want to err on the side of kindness. I have no argument with that. I really don't. So I just agree with you, Emma, so much. Thank you. Thank you.
00:52:58
Speaker
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00:53:19
Speaker
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00:53:37
Speaker
We're all very human and fallible, and yet we live in a society that rewards pretending we're not fallible, or the range of acceptable fallibility is narrow. We are constantly comparing our insides to other people's outsides and feeling inadequate and guilty, even ashamed. Trying to blend in means parts of ourselves will disappear, and we must then live in fear that we will be found out. Here, together, we will create a space where we can laugh, cry, and carry our suffering and hurts lightly in the service of being deeply human. This is life's dirty little secrets.