Presentation to the CASS Webinar 2 July 2024 SOCIOLOGICAL APPROACHES and PSYCHOLOGICAL THERAPIES for GENDER DYSPHORIC YOUNG PEOPLE: CHALLENGING UNDERLYING ASSUMPTIONS and ATTRIBUTIONS

Nosology is the practice of classification of diseases in the medical sciences, psychiatry, and psychology. To classify behaviours or clinical presentations as dysfunctional requires the making of attributions, defined as automatic causal beliefs about what constitutes normality. We are all socialized into such attributions so seamlessly that they can often be out of our awareness when making critical judgements about “patients” and how they might best be assisted. A review of history shows that attributions are culturally bound, changing with the times like fashions in music and dress. They can also change in response to increasing knowledge.


One major unresolved controversy is the degree to which dysfunctional behaviours are more situationally determined or more due to stable, internal qualities of the individual, and the degree to which external versus internal attributional biases exist in assessors. Differing attributions along this dimension can have profound effects on diagnosis, management, and treatment (Gold & Gold, 2015). Charcot and Freud were the first to conceptualize hysteria as a psychological, not a neurological condition, moving treatment out of the physical domain, up to and including hysterectomies, to the psychological investigation of the cause of the symptoms that had both situational and intrapersonal causalities. Similarly, alcoholism was once thought to be due a reprehensibly weak will and lack of self-control. It is now understood to be a chronic disease of the brain that produces both physical and emotional dependence.


Examples of this dilemma occur in other disciplines, such as the law. A clarifying example is the principle of doli incapax, which in Australian law decrees that a child under the age of 14 is presumed in law to be incapable of bearing criminal responsibility. To counter doli incapax, the prosecution must prove that the child knew that the conduct was morally wrong and chose to proceed with the offence. The Children (Criminal Proceedings) Act 1987 (NSW) provides that no child under the age of 10 years can be guilty of an offence. This statutory presumption is irrebuttable. This is a far cry from practices in England’s Middle Ages in which children were perceived to be “mini adults.” Those older than eight years could be hanged for stealing. Doli incapax is an attempt to determine the developmental and cognitive limits of young minds, which we can see have changed over time.


We are faced with a similar dilemma about whether young people under the age of 18 can give informed consent to what amounts to irreversible changes to their bodies that render them permanent hostages to the medical profession.
Returning to psychiatry and psychology for another cogent example of unconscious attributions driving nosology, the understanding and classification of homosexuality was responsive to increasing scientific understanding and research, which was reflected in iterative editions of the DSM. In DSM 1 (1952), homosexuality was considered a “mental disorder” along with other sexual deviations, such fetishes and pedophilia. In 1973, homosexuality was replaced with “ego dystonic sexual orientation,” recognizing that only the distress, not the orientation per se was pathological. This classification was removed in the 1987 edition (DSM-III-R) and was replaced with a category also noting marked distress about one’s sexual orientation, but under a blander heading of “sexual disorder, not otherwise specified.” All reference to homosexuality as psychiatric condition was removed from the DSM-5 (2013).


Most of these changes were accomplished by gay rights activism that succeeded in changing underlying attributions and hence the law (via decriminalization) and medicine via abandonment of conversion therapy.


Transactivists have modelled their own campaign on the gay rights campaign, with one critical difference—the absence of a scientific basis.
The criteria for diagnosis of GD in children and in adolescents and adults are well known to you and I will not enumerate them here. It may already be self-evident how problematic these criteria are, relying on vague, poorly specified notions of “marked incongruences,” “strong desires,” and “strong convictions,” and assuming that we are all in agreement about “typical” feelings and reactions of the various genders identified in contemporary society. We should inquire as to whether a fear of impending puberty justifies the chemical castration of a developmentally normal biological process.


The criteria for children are even more disturbing, characterizing as they do choices of toys, playmates, games, and clothing as the symptomatic signs of GD in very young children, many of whom do not complete the achievement of gender constancy until seven years of age.


The DSM-5 criteria for diagnosing GD by reference to gender-atypicality is misguided and unsound. This approach ignores the fact that a child may display an expressed gender that is manifested by social or behavioural traits that are incongruent with the child’s biological sex but without identifying as the opposite gender. Indeed, very young children may be observed to engage in such behaviour before they have acquired the cognitive concepts of “gender” or “gender identity.”

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Even if children did identify as the “opposite” gender from their biological sex, it is likely due to other factors such as traumatic experiences during the period of early gender development or difficulties associated with the expectations of prescribed gender roles. Disorders of Sexual Development, particularly intersex conditions can also contribute to gender dysphoria.


DSM does not consider the environmental influences on these choices, such as family constellation, the presence of older siblings of the opposite sex, or the effects of modelling, imitation, and reinforcement on gendered behaviours in young children. Here we have evidence of another failure to interrogate our attributions regarding these behaviours that have the effect of acting on assumption driven criteria that foreclose decisions regarding diagnosis.
Despite the flaws in the DSM 5 (2013) and its text revision (2022) with respect to diagnosis of GD and failing to recognize the inherent tensions in the fundamental conceptualization of gender distress as either a mental health condition or a normal variant of human functioning, clinical assessment of young people with gender dysphoria commences with an examination of the criteria in DSM 5 for diagnosis. Despite arguing that being transgender is not a medical condition to be treated, young people are propelled into medical and surgical interventions.


Studies point to the high prevalence of collateral mental health issues in people identifying as transgender, which may predate or co-date the transgender identification, but these mental health issues frequently remain ignored and untreated in current models of GAT. There is rarely a discussion of whether these comorbidities are causal, collateral, or coincidental to the transgender declaration, yet this is a fundamentally important fork in the decision tree i.e., what condition should be treated first?
Because my cognate discipline is psychology and because I am a clinician, I use a primarily idiographic approach to understanding human behaviour and to formulate my treatment approaches.


There is another lens through which we can view treatment—the sociological, specifically, public health campaigns. However, before we can approach the problem of the transgender pandemic from this perspective, adults need to come their senses and regain their sanity. This includes all the professions involved—the doctors, the legislators, the court system, educationists including teachers, policy makers, and curriculum designers, academics, the journals through which academic work is disseminated, the media, social media, and politicians.


There are many precedents for a public health approach to gender dysphoria. For example, in response to alarming increases in road fatalities in the 1970s, legislators, with the support of government, introduced a series of changes in several areas simultaneously—the mandating of seatbelts, the introduction of airbags in motor vehicles, more stringent licencing requirements for young drivers, reducing speed limits, and improving roads, as well as introducing road safety classes to high school students. Since the implementation of these measures, road fatalities have decreased by 86 percent since their peak in 1970.


There have been many similar successful public health campaigns, including those that have led to a net reduction of 66 percent in cigarette smoking over the past 30 years of Australians aged 14 years and older. This campaign was successful primarily because governments supported health officials’ calls to ban advertising, increase taxes on cigarettes, forbid smoking in restaurants, public transport, and offices, and replace glamorous packaging with graphic images of cancerous growths caused by smoking. In addition, smoking prevention supports for existing smokers were developed, including free access to ‘quit smoking’ support programs online.


I have previously discussed the strong evidence for the social contagion of suicide and the public health response of ceasing the practice of reporting suicides in the media as one prong in a multi-pronged effort to reduce suicide fatalities.


I am now advocating for a public health response with the support of government to reduce the number of young people who have fallen prey to this latest psychic pandemic. I propose that it commence with a dictum from government that all medicalized treatment of young people under the age of 18 years cease immediately.
This would include the withdrawal of access, by any means, to puberty blockade and cross sex hormones. Schools will be forbidden to socially transition children without their parents’ knowledge and permission and will adjust the curriculum to reflect biological reality, with an immediate cessation of the propagation of the precepts of gender ideology. This will entail a return to gendered language, removal from all public documents language that does not reflect established science, and a return to the acknowledgement that sex is dimorphic and is not assigned at birth but determined by chromosomes at conception, that there is no such category as non-binary, that children cannot change their sex at will, and that puberty is a natural biological process through which all children must pass.
There should be a withdrawal of the proposed “Self ID” bills and legislation that provides penalties for medical practitioners who continue to prescribe puberty blockade and cross sex hormones to young people under the age of 18.


These measures should lead to an immediate decrease in the numbers of children declaring themselves transgender and presenting to gender clinics. Children and adolescents will no longer be the primary targets of intervention.


The vexed question of capacity of young people to give informed consent to life altering interventions will no longer need to preoccupy ethicists and the courts. A sane society governed by sane politicians, and assisted by expert public health officials will have made that decision a priori, that is, there will be no medicalized gender treatment for minors. This will end the transgender pandemic.


A population approach and a whole of government mandate is the only way to achieve this goal. The current approach, that is, medical intervention without theory or evidence has proved a dangerous, if not disastrous road. Attributions of stable internal experiences of gender in young people as the basis of inflicting lifelong harm on young bodies has had calamitous consequences for young people and their families.


If we attribute gender dysphoria to primarily external, controllable, and unstable factors, that is, to situational determinants such as social contagion, defined in its broadest terms to include the treaters as well as those seeking treatment, and treat instead the societal dysfunction, we have a greater chance of ending the madness.
Notwithstanding, there will be a residual number who do not respond to the public health campaign and who remain gender dysphoric and in need of individual therapy. Hence, we need both a population and an individual, that is, therapeutic approach to the problem. For this to occur, governments will need to repeal conversion therapy ban legislation, thereby restoring autonomy to clinicians to undertake appropriate assessment and therapy and to make informed recommendations within a multidisciplinary team about which children are genuinely in need of medical treatment.


For this group of young people, therapies already exist that are robust, and evidence based. These include individual, marital, and family therapies. We do not need to invent a new form of therapy for gender dysphoria. Rather, we sensitively apply existing therapies to the presenting problem, in this case, a transgender declaring young person.
Just as structural and strategic family therapy view the presenting problem and the identified patient as the stimulus that brings the family into treatment, gender dysphoria often serves the same purpose.


The identified patient will have unique vulnerabilities that need to be addressed, often in individual therapy, depending on the age of the young person. Sometimes, it is necessary to work primarily with the parents when the child is very young, helping them to develop confidence in presenting a united front to their child and to establish clear boundaries around the limits of their autonomy.


In a world gone crazy with “child-led,” “child’s best interest,” “child centred” and fantasies that “children just know” who they are, and parental fear of reprisals if they do not automatically affirm their child, parents have been disempowered and disenfranchised. Parental authority needs to be restored. This is one of many essential changes that needs to help end the transgender pandemic.


Now, to elucidate my therapeutic approach with GD young people and their families – we begin with an intake assessment.
I then develop an individualized psychodynamic formulation relevant to the young person’s intrapsychic world, symptom complex, and family structure. Here is an example in the case of young people with SH/SI.  

I then develop an individualized psychodynamic formulation relevant to the young person’s intrapsychic world, symptom complex, and family structure. Here is an example in the case of young people with SH/SI.