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Presentation to the forum hosted by Australian Free Speech Association on changes to law proposed by the Tasmanian Law Reform Institute (TLRI) on “conversion” therapy

PARLIAMENT HOUSE, TASMANIA

23 November 2022

Dianna T Kenny PhD

 DEFINING APPROPRIATE TREATMENTS FOR CHILDREN WITH GENDER DYSPHORIA (GD)

My presentation today has two aims. Firstly, to enumerate and summarize the complex interplay of factors whose endpoint is a declaration from the child or young person that they are transgender or non-binary. Secondly, I will describe some of the young people with whom I have worked using exploratory, expressive, and supportive psychotherapy, family therapy, and where indicated, marital and milieu therapy. I hope to demonstrate the legislation criminalizing so-called “conversion therapy” is utterly misguided and in need of urgent re-consideration as it will have the effect of undermining the application of evidence-based treatments for GD young people.

I have proposed an assessment protocol for young GD people, as follows:

  • Developmental disorders – The majority of young people with GD have co-morbid presentations that must be assessed and that require priority in treatment plans. These include ADD/ADHD, autism spectrum disorders (ASD), intellectual disability (ID), specific learning disability (SLD), and academic problems.
  • Psychological disorders – History of body dysmorphia and/or eating disorders, self-harm, suicidality, suicide attempts, internalizing disorders (e.g., depression, generalized anxiety, social anxiety, separation anxiety, and OCD) and externalizing disorders [oppositional defiant disorder (ODD) and Conduct Disorder (CD)], which generally indicate problematic parenting, and incipient (borderline personality disorder (BPD). Substance use/abuse and/or psychosis also needs to be assessed in older young people.
    1. Psychological dynamics, such as the presence of a fragile ego that is prone to fragmentation and magical and/or concrete thinking. Some young people, who are vulnerable as a result of developmental and psychological disorders and other factors described below, when faced with the challenge of their developing sexed bodies at puberty, and impending adulthood, retreat from these challenges and attempt to halt development.
    2. Factors related to cognitive style: Cognitive immaturity, magical and concrete thinking, cognitive rigidity, and cognitive distortions, lack of understanding or misunderstanding of gender ideology and capacity to critically review it, given the illogical and scientifically unsound basis of the ideology. These cognitive errors often extend to confusions between the concept of male/female (which is based on biological sex) and masculinity/femininity which is based on gender roles and gender expression. Here are a couple of examples from my caseload.

A young boy has a special needs younger sister who gets all the attention. Watching his mother tend to his sister one day, he said “Mummy, will you only love me if I am a girl?”

A pre-adolescent 12y boy with an older brother (16y) suddenly started wearing makeup and nail polish and demanded his mother buy him female clothing. He declared himself trans. His father was closely attached to his older brother who shared the same interests (racing cars, football, fishing etc) and spent most of his free time with his elder son. He described his younger son as a “mummy’s boy who will probably turn out to be a poofter if he isn’t already.”

A post-pubertal 15y female from a Mediterranean family suddenly declared herself transgender. During the assessment, she told me that fathers stopped talking to their daughters after they started their periods. Her father had told me during a parental assessment that he did not have much in common with his quirky, bookish daughter and found his relationship with his son much easier.

The first child made an error in attending to the wrong dimension as the source of the attention provided to his sister – her gender rather than her disability. The second boy tried to resolve his anguish at his father’s disdain by defiantly amplifying the dimension of his development so reviled by his father. This girl in the third example wanted her father’s attention and believed she needed to change sex in order to get it.

  • Family constellation, family conflict/dysfunction, marital and sibling dynamics

“Parents are critical mediators of the experiences of their gender variant children…”(Gray, Sweeney, Randazzo, & Levitt, 2016, p. 123), as indeed are siblings, peers, and the wider ecological context in which children grow and learn.

Studies from the developmental psychology literature about factors that influence gender development in traditional families (McHale, Updegraff, Helms-Erikson, & Crouter, 2001; Pierrehumbert et al., 2009; Sumontha, Farr, & Patterson, 2017; Tenenbaum & Leaper, 2002) and families with a gender variant child (Riley, Sitharthan, Clemson, & Diamond, 2011; Zucker, Wood, Singh, & Bradley, 2012) can illuminate parental gender attitudes and behaviours (Dawson, Pike, & Bird, 2016) and explore the impact of sibling relationships (Rust, Golombok, Hines, Johnston, & Golding, 2000) on gender development, a neglected area in the management of GD children.

For example, a study of sibling effects on gender development and identification found that boys and girls with same-sexed older siblings were more sex-typed than same-aged, same-sexed singleton children, who, in turn, were more sex-typed than children with opposite-sex siblings. Having an older brother was associated with more masculine behaviours in both younger male and female siblings (Rust et al., 2000). In a three-year longitudinal study of first-born sibling influences on second-born children, McHale et al (2001) reported that elder siblings influenced the gender role attitudes and behaviours in their younger siblings, but parents exerted more influence over gender role in first-born compared with second-born siblings. These findings raise interesting questions, for example, whether an abusive elder brother may figure disproportionately in the family constellations of later-born sisters who eventually transition from FtM.

A family of two boys aged six and 12 years lost their mother after a long illness. Father was a war veteran with PTSD and alcoholism and unable to manage his children’s grief. The older boy began to mercilessly bully his younger brother, who started to cross-dress, hiding in his mother’s wardrobe, and wrapping himself in his her clothes. At age 12, he came out as transgender, which represented his attempt to bring his loved, lost mother back to tend to the gaping emotional wound inside.

Childhood maltreatment is frequently found in the medical histories of gender dysphoric individuals, with one study reporting that 25 percent of a sample of 109 adult MtF transgender persons disclosed child maltreatment (Bandini et al., 2011), with more serious maltreatment being associated with higher body dissatisfaction. How does an abusing parent affect the gender development of a child, and what other factors pertain to the development of cross gender identification, for example, abuse from a same-sex parent which we could hypothesize could direct the child to identify with the non-abusing, opposite-sex parent?

  • Interpersonal factors, in particular, anxious or broken attachments with primary caregivers, overprotective or over-controlling caregivers who create a drive for premature autonomy and independence in their children, child maltreatment (Bandini et al., 2011); marital dysfunction, marital breakdown, and parental wish for an opposite sexed child all figure in the life histories of transgender declaring children.

One study of traditional families found that preadolescent children who are anxiously attached or who had a preoccupied form of insecure attachment to their mothers experienced lower gender contentedness and fewer gender-typical feelings compared with securely attached children (Cooper et al., 2013). What effect would a parent who preferred a child of the opposite sex have on a child’s gender identity? Such a question could usefully be explored in families with a transgender child.

GD might be better understood as a relational process rather than an inherent property of the individual (Celenza, 2014). It is essential in any ethical treatment to illuminate the interactional dynamics (Ehrenberg, 2010) in which young children assert that they are transgender rather than unthinkingly affirming their cross-gender assertions and going down a “gender-affirming” i.e., medical and surgical path to treatment instead of casting a wider lens over all the possible factors at play. This can only be achieved by painstaking history taking and a systematic analysis of family and social dynamics that are affecting the child’s development.

A 19y female suddenly announced to her very traditional Indian family that she was transgender. During her psychotherapy, she revealed that her mother had made her feel uncomfortable about her body by constantly referring to her developing female form and stating that it would make a man very happy one day. She had grown up in a highly controlling, overprotective family and panicked at the thought of having to marry and have sex with a man.

  • School life experiences g., attitude towards school, peer rejection, bullying, school refusal or truanting, academic performance, and post school aspirations all need to be evaluated. Interactional dynamics extend to peer relationships that are particularly important during childhood and adolescence. Young GD people are very likely to report a history of peer bullying, including victimization, marginalization, exclusion, and vilification. Some have also been disappointed in their first tentative attempts at romantic relationships.
  • Sexual experience history – need to explore the child’s sexual knowledge, sexual anxiety, and romantic/sexual relationships, and possible sexual abuse experiences. Is there an emerging awareness of ego dystonic sexual orientation that could result in internalized homophobia, which often occurs in the presence of external homophobia from parents and/or friends? The majority of young GD adolescents I have worked with
  1. have had no sexual experience (crushes from a distance, hand holding and kissing)
  2. disdain genital sex as “gross”
  3. are indifferent to loss of sexual function and fertility
  4. are confused about the nature of “trans” relationships e.g., A self-declared non-binary male (natal sex = male) in a relationship with a transgender declaring natal female (i.e., a trans man) told their parents they were in a gay male relationship. Similarly, two natal females, both transmen but who had not undergone medical or surgical intervention, rejected the suggestion that they were a lesbian couple and stated that they were a gay male couple.
  • Capacity for informed consent. This is a grave matter, and one must ascertain whether young people understand what gender transition entails, the gravity and irreversibility of medical/surgical transition; and the consequences of treatment (e.g., infertility, sexual dysfunction, complications of cross-sex hormones and surgery, and lifelong patient hood). Even very intelligent and well-informed minors are not mature enough in their cognitive, emotional, and social development to fully comprehend the meaning and consequences of gender transition and are therefore not competent to consent.
  • Explore the systemic function of rapid onset gender dysphoria (ROGD) g., defiance of parents, a struggle for autonomy, finding an “in group,” being “seen”, feeling heroic, denying the development of their sexed bodies, fear of adulthood, and fear of sexual relationships. Although biological and intrapsychic factors are important, we need to investigate the context in which gender dysphoria arises and the reasons for the exponential increase in cases observed over the past decade, an increase tantamount to a psychic epidemic. Social contagion research has shown that females in early adolescence are the most suggestible group and therefore highly prone to peer and social influences arising from social media. This is the group most frequently presenting to gender clinics with gender concerns, which is a reversal of previous patterns of presentation that favoured young boys. Sexual development poses a threat to young people as it signifies approaching adulthood, the demands of which they feel ill equipped to manage. ROGD as an expression of “trauma” or a response to the reality of puberty that one now has a sexed body.
  • Explore the meaning of non-binary identities

It is extraordinary that the concept of the “non-binary identity” has been accepted so uncritically, defined as a gender identity that could be both male and female on a sliding scale, neither male nor female, or something else entirely, which has never been defined. Self-identifying non-binary persons reported that they began to identify as non-binary following what they described as the “discovery” or “realisation” of the non-binary gender category through involvement in the LGBTQ community, which had increased their knowledge of gender variant identities and re-positioned these as valid expressions of gender (Losty & O’Connor, 2018). This is a clear example of social contagion.

These forces play out in the context of

  • sociocultural factors, such as social contagion (Aydt & Corsaro, 2003; Basu, Zuo, Lou, Acharya, & Lundgren, 2017; Saketopoulou, 2011) which has been well documented for other adolescent psychopathologies such as eating disorders, substance use, non-suicidal self-injury, and suicide.
  • Social contagion influences the social milieu e.g., schools, gender clinics, internet content, including social media and online transgender communities, and collusion from government, and the medical, legal, and educational institutions charged with the safeguarding of our children.

Conclusion

The care for children with GD should not be aimed at avoiding adult same sex attraction or transsexualism/transgenderism in the manner of SOCE in the past. I am advocating that no social or medical interventions be provided during childhood or adolescence; that counselling/therapy should be focused on reducing the child’s distress related to GD, other psychological difficulties within the child and his wider ecology, including the family and school, and on optimizing psychological adjustment and wellbeing. The wish to TRANSITION could be

  1. related to a grievance against the parents and a struggle for autonomy/individuation
  2. related to an idea that one can create an ideal self
  3. protective against feelings of inadequacy, anxiety, jealousy, and disappointment
  4. a triumph over feelings of vulnerability
  5. a repudiation of the sexed body and adulthood

It is therefore imperative

  1. to keep the developmental pathway open into adulthood (need frontal lobe maturation that occurs in early 20s to fully comprehend the choices GD adolescents are making).
  2. Psychological trauma from the past forms part of psychic structure in the present. The expression of these traumas are socio-culturally embedded (i.e., social contagion permits particular forms of “acting out” of these traumas).
  3. GD adolescents need assistance to explore their defences and internal psychic conflicts and manage their psychic pain before irreparably altering their bodies.
  4. CLINICIANS, POLITICIANS, TEACHERS, PARENTS, and SOCIETY SHOULD NOT COLLUDE WITH THE PHANTASY THAT THE “EMBODIED” SELF CAN BE ALTERED OR REMOVED.

The proposed legislation will do a great disservice to GD children and their families. The approach that I have described in this paper is far from conversion therapy. It is good clinical practice. I hope that the members of the Tasmanian parliament can now discern the difference. I will conclude with a final case study to demonstrate the folly of automatic gender affirmation in young people. I worked with this young person and his parents weekly over a period of 11 months.

A 14-year-old natal boy first came out via letter to his parents as GAY. He soon changed that declaration to BISEXUAL when he experienced a powerful crush on a female classmate. After she rejected him, he came out as TRANS and demanded puberty blockade and cross sex hormones. In therapy, his demands for transition were strident and incessant. He constantly asked me when I was going to tell his parents that he could go ahead with his transition. He shaved his legs, arms, and body hair, grew his hair long, and started to wear eye makeup and nail polish. He ordered female clothing from the internet and wore it secretly in his room. When his parents confiscated these clothing items, his female friends lent him their clothes to wear. Teachers at his school started calling him by his preferred name and pronouns without parental knowledge or permission. Several months after therapy commenced, while still vehemently protesting his trans-female identity, he wrote a letter to his parents apologising for misleading them. He said he now realised that he was not a trans-female but a DEMIGIRL (denoting partial non-binary, partial female gender identity). He changed this orientation shortly thereafter to DEMIBOY, before again writing to his parents, telling them that he was only joking about the whole thing and that they were the only people who had taken it seriously. (This was very far from objective reality). I advised his parents to give their son the opportunity to exit the gender maze without losing face. The next day he asked his parents to take him for a haircut and declared himself STRAIGHT.

References

Aydt, H., & Corsaro, W. A. (2003). Differences in children’s construction of gender across culture: An interpretive approach. American Behavioral Scientist, 46(10), 1306-1325.

Bandini, E., Fisher, A. D., Ricca, V., Ristori, J., Meriggiola, M. C., Jannini, E. A., . . . Maggi, M. (2011). Childhood maltreatment in subjects with male-to-female gender identity disorder. Int J Impot Res, 23(6), 276-285. doi: 10.1038/ijir.2011.39

Basu, S., Zuo, X., Lou, C., Acharya, R., & Lundgren, R. (2017). Learning to be gendered: Gender socialization in early adolescence among urban poor in Delhi, India, and Shanghai, China. Journal of Adolescent Health, 61(4, Supplement), S24-S29. doi: https://doi.org/10.1016/j.jadohealth.2017.03.012

Celenza, A. (2014). Erotic revelations: Clinical applications and perverse scenarios. New York: Routledge.

Cooper, P. J., Pauletti, R. E., Tobin, D. D., Menon, M., Menon, M., Spatta, B. C., . . . Perry, D. G. (2013). Mother-child attachment and gender identity in preadolescence. Sex Roles, 69(11-12), 618-631.

Ehrenberg, D. B. (2010). Working at the “intimate edge”. Contemporary Psychoanalysis, 46(1), 120-141.

Gray, S. A. O., Sweeney, K. K., Randazzo, R., & Levitt, H. M. (2016). “Am I Doing the Right Thing?”: Pathways to Parenting a Gender Variant Child. Fam Process, 55(1), 123-138. doi: 10.1111/famp.12128

McHale, S. M., Updegraff, K. A., Helms-Erikson, H., & Crouter, A. C. (2001). Sibling influences on gender development in middle childhood and early adolescence: A longitudinal study. Developmental Psychology, 37(1), 115-125.

Losty, M., & O’Connor, J. (2018). Falling outside of the ‘nice little binary box’: a psychoanalytic exploration of the non-binary gender identity. Psychoanalytic Psychotherapy, 32(1), 40-60. doi:10.1080/02668734.2017.1384933

Rust, J., Golombok, S., Hines, M., Johnston, K., & Golding, J. (2000). The role of brothers and sisters in the gender development of preschool children. Journal of Experimental Child Psychology, 77(4), 292-303.

Saketopoulou, A. (2011). Minding the gap: Intersections between gender, race, and class in work with gender variant children. Psychoanalytic Dialogues, 21(2), 192-209. 

Annexure

https://content.govdelivery.com/accounts/FLDOH/bulletins/3143d4c

Treatment of Gender Dysphoria for Children and Adolescents

Florida Department of Health sent this bulletin at 04/20/2022 09:10 AM EDT

Treatment of Gender Dysphoria for Children and Adolescents

April 20, 2022

The Florida Department of Health wants to clarify evidence recently cited on a fact sheet released by the US Department of Health and Human Services and provide guidance on treating gender dysphoria for children and adolescents.

Systematic reviews on hormonal treatment for young people show a trend of low-quality evidence, small sample sizes, and medium to high risk of bias. A paper published in the International Review of Psychiatry states that 80% of those seeking clinical care will lose their desire to identify with the non-birth sex. One review concludes that “hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact is generally lacking.”

According to the Merck Manual, “gender dysphoria is characterized by a strong, persistent cross-gender identification associated with anxiety, depression, irritability, and often a wish to live as a gender different from the one associated with the sex assigned at birth.”

Due to the lack of conclusive evidence, and the potential for long-term, irreversible effects, the Department’s guidelines are as follows:

·       Social gender transition should not be a treatment option for children or adolescents.

·       Anyone under 18 should not be prescribed puberty blockers or hormone therapy.

·       Gender reassignment surgery should not be a treatment option for children or adolescents.

·       Based on the currently available evidence, “encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm.”

·       Children and adolescents should be provided social support by peers and family and seek counselling from a licensed provider.

These guidelines do not apply to procedures or treatments for children or adolescents born with a genetically or biochemically verifiable disorder of sex development (DSD). These disorders include, but are not limited to, 46, XX DSD; 46, XY DSD; sex chromosome DSDs; XX or XY sex reversal; and ovotesticular disorder.

The Department’s guidelines are consistent with the federal Centers for Medicare and Medicaid Services age requirement for surgical and non-surgical treatment. These guidelines are also in line with the guidance, reviews, and recommendations from Sweden, Finland, the United Kingdom, and France.
TLRI report:

Conversion practices involve a course of conduct that aims to change, suppress or eradicate the sexual orientation or gender identity (which, under Tasmanian law, includes ‘gender expression’) of another person.

SOGI conversion practices take various forms. All are motivated by common, intersecting beliefs [see 2.6.6–2.6.10]:

  1. There are fixed ‘correct’ SOGI attributes (normally heterosexual/cisgender); and
  2. That people with ‘incorrect’ SOGI attributes (normally LGBTQA+ attributes) have a fault or dysfunction; and
  3. That these attributes can and should be changed, suppressed or eradicated.

Conversion practice beliefs were once part of mainstream medicine. Those beliefs supported abusive physical, psychiatric and psychological practices that caused profound and lasting harm to LGBTQA+ people. They also contributed to social stigma and discrimination towards and abuse against sexual and gender minorities.

Conversion practices, and the beliefs that drive them, are now firmly rejected by mainstream science and medicine [see Chapter 4]. The mainstream medical consensus now is that:

  1. LGBTQA+ attributes are not faults or dysfunctions;
  2. Conversion practices lack efficacy (they are not successful in doing what they claim to do in a safe or reliable way); and
  3. Conversion practices involve serious risks of causing serious and lasting harm to those subject to them.

The Institute’s recommendations do not affect:

  • Legitimate health care conducted by appropriately qualified health professionals in line with declared standards;
  • Statements, expressions of faith, philosophical or personal views about sexual orientation or gender identity;
  • Public acts done in good faith for academic, artistic, scientific or research purposes or any purpose in the public interest; or
  • Supportive care, guidance, or mentoring of a child by a parent or guardian.

These rights and duties are protected by both existing laws and new exceptions and defences recommended by the Institute.

Tasmanian law should be reformed to ensure people in Tasmania are aware of their rights and duties and that public offices are able to meaningfully respond to:

1. Direct practices, amounting to medical malpractice by health professionals or unsanctioned purported (conduct that emulates or mimics) health practices that occur outside of the clinical space or by non-health professionals [see 6.3].

2. Indirect practices, involving disinformation designed to convince others that certain sexual orientations or gender identities are faulty or dysfunctional and can and should be changed, suppressed, or eradicated.

…………………………….

3.2. No data about the nature and prevalence of SOGI conversion practices in Tasmanian exists. No scientific study has been published on the prevalence of SOGI conversion practices in Tasmania or Australia.