By Erica Anderson
Special to The Examiner
Through a grant from the San Francisco Department of Public Health, UCSF’s Child and Adolescent Gender Center has for the past five years provided training and consultation on transgender kids to all youth-serving agencies and professionals in The City, including its public schools. The vision has been to make San Francisco a model in caring for its gender creative youth.
I was part of that effort, and for years worked at UCSF’s Gender Center as one of its two psychologists. I provided consultation, taught in the professional schools and wrote about the work. It is well documented that LGBTQ youth are subject to minority stress and higher rates of almost every potential psychological and social problem.
As a trans woman and therapist to trans and gender creative people, I’ve worked hard to advance acceptance of trans identities, including those of trans youth. But increasingly I’m worried that in our zeal to identify and protect these special children and adolescents, we may have strayed from some core principles and we are in danger of losing our way.
In this extraordinary time during a global pandemic, we have all been subject to extra stress to stay vigilant and avoid COVID and all its variants. Young people have pivoted to remote learning and stayed at home for in many cases more than an entire academic year, depriving them of ordinary social experiences. As a result, most adolescents have also depended upon social media and the internet to an extent never before seen.
We are learning some worrisome things about this massive, unplanned social experiment. Even the tech giants have conceded in their own research that there is a new kind of addiction/attraction to certain content and a kind of contagion among select groups, especially adolescent girls. Increased rates of depression and suicide, declines in dating and sexual activity, more reported loneliness and feelings of being left out, lower rates of involvement in extracurricular activities and surprisingly less sleep all characterize the current generation of adolescents. These trends seem to be accelerating in the era of the smartphone.
There is little question that reliance on screens and devices has isolated adolescents who may be most vulnerable and susceptible to peer and other influences, intensifying their usage of and reliance on whatever messages and images they see. I am concerned that our computer-mediated, always online environment is creating isolated echo chambers that can work on adolescents in an insidious way. And I believe that it’s been worse during COVID.
For example, some content on YouTube and TikTok includes “influencers,” who themselves are barely out of puberty. They dispense advice to other young people, specifically encouraging them to explore their gender identity freely.
On the one hand, I’m glad our society has evolved toward greater acceptance of all LGBTQ identities. On the other hand, some of the messaging has landed on vulnerable youth searching not just for keys to their own identity but solutions to other psychological and emotional problems, including serious psychiatric problems.
Here is where things may have gone wrong.
Some influencers are literally encouraging the idea that one’s psychological distress may be because a young person is trans and is suffering from gender dysphoria. The remedy, they say, is to come out as trans or non-binary, which the influencers advise will alleviate their suffering. Welcomed into the company of other trans and gender creative persons, such young people may have found acceptance — though virtual acceptance, since much of this rapport is online.
They also may be coached on how to navigate and/or control these issues with their parents, who they are told may not “get it.” Among the advice from these influencers is to make a quick social and gender transition, which may include a new chosen name and pronoun and access to gender-affirming hormones. Many of these influencers are literally dispensing medical advice.
Increasingly, I am contacted by parents whose child has come out to them as trans in recent weeks. Searching for help, they find me because they want to be affirming. But they report that the newly asserted gender identity occurred during the pandemic, and they cannot recall any significant suggestion of gender creativity by their child prior to recent events, though many parents report previous psychological problems with their child.
For example, I received a recent inquiry from a San Francisco father whose 14 year old came out as trans in late October after a year of therapy for anxiety and depression. “We were pretty surprised by the news, as we’d had no indication that he had thoughts in this area,” the father communicated.
Supportive, open-minded and conscientious parents like these have been contacting me at an accelerating rate in the past year. They also report that their initial contact with therapists leads to affirmation of their child’s asserted trans identity and referral to gender clinics. The numbers of new cases at such clinics have exploded. (A recent Gallup poll found that 1 in 6 members of Gen Z identify as lesbian, gay, bisexual, transgender or queer.)
In some cases, well-meaning psychological and medical providers are allowing themselves to be “triangulated,” pitting a child’s wishes against parents who are reluctant to see their child quickly put on hormone blockers and/or cross-sex hormones. Minors need parental consent for gender-affirming medicines that can pause natal puberty and/or introduce physical changes concordant with the affirmed transgender identity. And minors, especially those between the ages of 12 and 17, often prefer not to heed the advice of their parents.
So instead of forging an alliance between child and parent to evaluate what is needed and drive consensus as the basis for gender affirmation, providers may challenge parents and fuel adolescent rebellion. Of course, virtually all young people need their parents and will for years. Some families experience a rupture from which it may be difficult to recover. In my experience, the vast majority of parents want to support their child whom they love. But they are overwhelmed with shock, grief and legitimate concern for their child’s well-being.
In the hundreds of cases I have seen over the past half decade at UCSF and in my private practice, these types of cases are growing. Often by the time I get involved, there has been set up a pitched battle between a youth whose interest is to hurdle toward life-changing decisions with enduring consequences and parents who are bereft and torn between the acceptance and affirmation they want to give their child and their terror about consenting to medical interventions they fear are not right for their child at this time or at all. Ominously, such parents are worried that the child will later regret such decisions and blame parents for allowing it.
With some colleagues, I have been speaking and writing about these concerns. Unfortunately, we find the research on trans youth has not kept up with what is happening. The pandemic has turbo-charged these dynamic trends. Some deny the reality of peer influence upon identity formation. Others decry the methodological approach necessary and consistent with best practices, namely the World Professional Association for Transgender Health Standards of Care and the Endocrine Society and APA guidelines — which encourage an individualized, comprehensive biopsychosocial evaluation prior to initiation of gender-affirming medications and, of course, surgeries.
Research confirming the benefits of gender-affirming psychological and medical care has been done at university-based gender clinics like UCSF in the U.S. and Europe. The gender creative youth served by these clinics, which offer a careful methodical approach with the support of parents and professionals, go on to do well. In the case of a recently disclosed gender identity, the established clinics and best practices have encouraged gender exploratory therapy. This can be a matter of a few weeks to a year or more.
In my over 40 years as a psychologist, I’ve seen psychotherapeutic phenomena come and go. Eating disorders, multiple personality disorders and repressed memory syndrome have in retrospect spread through subgroups of adolescents and the professionals who have treated them. This spread is like wildfire through vulnerable underbrush, clearly borne in an environment of contagion.
Why is this phenomenon distinctly different from previous ones? How is it possible that gender identity formation constitutes the only area of development in adolescence that is immune from peer influence? Having gone to extraordinary lengths to make San Francisco the best city in the world for trans acceptance and affirmation, let’s not be derailed by zealous disregard for what we see happening in our own back, front and virtual yard.
The COVID pandemic doesn’t appear to be going away anytime soon, nor are online dynamics detrimental to young people. So let’s make sure that every young person questioning their gender gets what they need, not just what they want.
Erica E. Anderson, Ph.D. is the former president of the United States Professional Association for Transgender Health, former board member of WPATH and is writing a book on the evolution of the science, practice and culture dealing with transgender healthcare; she is based in Berkeley.