Gender Dysphoria, Trauma, and Online Misinformation

There are, of course, plenty of fair critiques one could make of my Atlantic cover story on gender dysphoria from this summer. A story of that length and complexity on such a controversial subject — one that many people view, understandably, as life-and-death — is going to generate strong opinions. Some people think that the happily transitioned trans kids in the piece should have been higher up, or that I should have started with a different character, or that various other questions of emphasis should have been answered differently. These are eminently fair, good-faith critiques that I happen to disagree with: All I can say is that the decisions in question were a matter of careful and often-anguished collaboration with my editors as the piece was written, and that moving any one part up would have necessitated bumping some other part down. There are tradeoffs inherent to structuring a piece this large and complicated, and there’s no way to do it that won’t generate valid critiques from some party or another. I stand by the piece and the decisions we made in building it completely.

But at the risk of sounding self-serving, I did think some of the responses to it published in left-of-center outlets simply got basic facts wrong. In certain cases, outlets inserted into my article or my brain stuff that isn’t there, and then responded to that fictional material rather than to the actual text. In other cases, they got the science wrong in potentially damaging ways.

I’ll start with the former, where Jezebel is the most notable example. Following the publication of my article, Harron Walker, a contributor there, published some tweets ridiculing me in a rather puerile manner — in one of them, the ‘joke’ appears to be her imagining that I have multiple speech impediments — and sent me a bunch of harassing emails that clearly weren’t good-faith requests for comment. She proudly posted much of this in her article, “What’s Jesse Singal’s Fucking Deal?,” for some reason:

When I didn’t respond, Walker took that as license to simply manufacture, based on who knows what, my ostensible opinion about the informed consent model of trans healthcare, or the idea that trans adults, once informed of the benefits and potential risks of treatments like hormone replacement theory, should get to decide whether to avail themselves of those treatments, without doctors and other potential gatekeepers unduly stymieing them from making that decision:

Since he won’t tell me himself — my tweets and emails have gone unanswered — here’s what I think Jesse Singal’s deal is: He’s a reactionary with a deep mistrust of the informed consent model of trans health care that has allowed a lot of trans people, myself included, to get on hormones in a matter of weeks. (In decades past, I would’ve had to undergo a two-year “real-life test” before a doctor prescribed me hormones. Thankfully, I live in a place like New York where I have Callen-Lorde, Apicha, and Planned Parenthood at my disposal. Many trans people are still forced to grapple with such gatekeeping practices in other parts of the country.)

I don’t have a “deep mistrust” of the informed consent model; I’m in favor of it. I obviously — obviously — don’t think a two-year “real-life test” is a reasonable prerequisite for adults who want hormones. Walker could have found that out by sending me a legitimate interview request, or, simpler still, by fully reading the article she was critiquing, which I don’t think she did. That seems like a fair assumption, at least, given that there’s a section of my piece, not too far down, in which I make the exact same points about lack of access to care and the importance of informed consent that Walker herself made in her response:

Today, the situation in the U.S. has improved, but the lack of access to transition services continues to be a problem. Whether trans people in this country can access treatments such as hormones and surgery depends on a variety of factors, ranging from where they live to what their health insurance will cover (if they have any) to their ability to navigate piles of paperwork. Erica Anderson, a trans woman and clinical psychologist who works at the Child and Adolescent Gender Center, at UC San Francisco’s Benioff Children’s Hospital, had no luck when she tried to get hormones from an endocrinologist in Philadelphia just a decade ago. “Even I, with my education and resources, was denied care and access,” she told me. “The endocrinologist simply said, ‘I don’t do that.’ I offered to provide her the guidelines from her own Endocrine Society,” Anderson said. “She refused and wouldn’t even look me in the eye. No referral or offer to help. She sent me away with nothing, feeling like I was an undesirable.”

Many trans people have stories like Anderson’s. For this reason, among others, trans communities can be skeptical of those who focus on negative transition outcomes. They have long dealt with “professionals who seem uncomfortable giving trans people the go-ahead to transition at all,” Zinnia Jones, a trans woman who runs the website GenderAnalysis, told me in an email. They have also faced “unnecessarily protracted timelines for accessing care, a lack of understanding or excess skepticism of our identities from clinicians, and so on.”

Groups like Wpath, the primary organization for psychologists, psychiatrists, endocrinologists, surgeons, and others who work with [transgender and gender nonconforming] clients, have attempted to reverse this neglect in recent years. A growing number of adult gender clinics follow “informed consent” protocols, built on the philosophy that trans adults, once informed of the potential benefits and risks of medical procedures, have a right to make their own decisions about their body and shouldn’t have their need for services questioned by mental-health and medical professionals.

This shift is seen by many trans people and advocates as an important course correction after decades of gatekeeping — aloof professionals telling trans people they couldn’t get hormones or surgery, because they weren’t really trans, or hadn’t been living as a trans person long enough, or were too mentally ill.

Now, I do go on to talk about how the situation for minors is different, but that’s just a statement of fact: Under U.S. law, with a few exceptions, there isn’t such a thing as “informed consent” for medical treatments for minors, because minors can’t consent to most medical treatments without the green light of a guardian. When we talk “informed consent,” we’re talking about adults. The point is, no one could read that as me being opposed to the informed consent model, let alone having a “deep mistrust” of it. And yet that was Walker’s — and Jezebel’s — take: to simply attribute to me an opinion I don’t hold, and which is directly contradicted by what I actually wrote in the article supposedly being critiqued.

Other outlets did the same thing. In ThinkProgress, for example, Zack Ford wrote: “Singal defends the ‘desistance myth,’ the claim that some 80 percent of transgender children will ‘desist’ in their gender identity.” Not only do I not do that, I do the opposite — in my section on desistance, I nod to the 80 percent figure (without referencing it directly) to point out that it’s likely an overestimate:

The desistance rate for accurately diagnosed dysphoric kids is probably lower than some of the contested studies suggest; a small number of merely gender-nonconforming kids may indeed have been wrongly swept into even some of the most recent studies, which didn’t use the most up-to-date criteria, from the DSM-5. And there remains a paucity of big, rigorous studies that might deliver a more reliable figure.

As a writer, this is frustrating — you want people to respond to what you actually wrote, not to a caricature of it. If I use my platform in The Atlantic to explain to people that the most commonly referenced desistance estimate is probably wrong, and ThinkProgress responds by saying that I am defending that estimate, how do we get anywhere? How do we talk about anything?

But I’m more concerned about outlets that got the science wrong, and there is one particular example of this — a subtle-seeming one — that’s worth unpacking to better understand the ways in which, in my view, liberal outlets are not doing a good job of covering the debates surrounding gender identity and dysphoria. (Conservative outlets aren’t doing a good job either — later on I’ll explain why I’m focusing on left-of-center media in this post.)

In my piece, I write:

Meanwhile, fundamental questions about gender dysphoria remain unanswered. Researchers still don’t know what causes it — gender identity is generally viewed as a complicated weave of biological, psychological, and sociocultural factors. In some cases, gender dysphoria may interact with mental-health conditions such as depression and anxiety, but there’s little agreement about how or why. Trauma, particularly sexual trauma, can contribute to or exacerbate dysphoria in some patients, but again, no one yet knows exactly why.

That last sentence caused some furrowed brows. Here’s Evan Urquhart in Slate:

Singal writes: “Trauma, particularly sexual trauma, can contribute to or exacerbate dysphoria in some patients, but again, no one yet knows exactly why.” Although one or two individuals have linked their histories of abuse to their detransition journeys, Singal provides no scientific support for the idea that sexual trauma leads to gender dysphoria, and to my knowledge no evidence of such a connection exists.

And here’s Ford, again, in ThinkProgress:

Singal also highlights the supposed “causes” of transgender identities frequently referenced by [allegedly transphobic] parental groups. “Trauma, particularly sexual trauma, can contribute to or exacerbate dysphoria in some patients, but again, no one yet knows exactly why,” he claims with no citation.

There are zero studies supporting that claim, but it’s a common justification among proponents of [rapid onset gender dysphoria] for rejecting trans kids. If the trauma can somehow be healed, parents believe the kid will end up not being trans. Singal simply asserts it as truth.

For the sake of a general audience, I should have been clearer about where that claim came from, even if that explanation just took the form of a quick parenthetical. But it’s genuinely alarming that the journalists writing about gender dysphoria for major publications haven’t come across the idea of the trauma-dysphoria link. I mean that. It’s hard to come up with a precise equivalent, but it would be like someone who is treated as an authority on astronomy being unaware that there has been a debate over Pluto’s planethood. It isn’t the first thing you learn when you start covering this subject, but it comes up pretty quickly.

In my case, I’ve encountered this link over and over and over in my dozens of hours of conversations with gender clinicians, the more experienced of whom have all seen it firsthand. (It’s also come up in my conversations with individuals who have or had gender dysphoria, and with their parents.) I first heard about it when I was reporting on Ken Zucker’s firing, speaking with clinicians in and around his then-recently-shuttered Gender Identity Clinic (the hospital that closed his clinic has since settled a lawsuit with Zucker, acknowledging libelous errors in the “external review” that precipitated the GIC’s closing). Then it came up some more in multiple conversations I had with clinicians, none with any connections to Zucker’s clinic, while I was working on the Atlantic piece. It keeps coming up because it’s something clinicians see over and over and over. Does that mean many or even most kids with gender dysphoria felt the dysphoria emerge in the immediate wake of a trauma? No. I bet most of the clinicians I spoke with would describe it as “rare” or “pretty rare.” But it still happens, and it’s still one piece of the puzzle that clinicians keep in mind when working with individual patients — and therefore an important thing for anyone with an interest in this subject to know about.

The gender dysphoria-trauma link hasn’t been studied a great deal, to be sure, but its fingerprints are all over the literature if you do a simple Google Scholar search. To take just one example, a 2012 paper by Jack Drescher and William Byne notes that “For some of these minors, the major issue is cross-gender behaviors or identifications; for others, the gender issues seem to be epiphenomena of psychopathology, exposure to trauma, or attempts to resolve problems such as higher social status or other benefits they perceive to be associated with the other gender.”

Then there’s Diane Ehrensaft, the highly regarded affirming clinician and author who has written not one but two books about gender identity in children. She’s no one’s idea of a transphobe. Yet here she is talking about trauma twice in 2011’s Gender Born, Gender Made: Raising Healthy Gender-nonconforming Children:

Studies have shown that children have been known to insist on a change in gender or become gender-confused after a trauma or major disruption in their attachments. For example, a three-year-old boy survived a serious car accident that his mother did not. Afterward, he started insisting he was a girl. Before that, he never indicated any gender-nonconforming behavior. Now, to reclaim his dead mother, he became her. There is no doubt that children like this little boy did not just roll into the world as gender non-conforming, like those in parents’ reports of their children who “just show up” that way, but were responding to intense emotional issues in or outside the family through their expression of gender. Another obvious example of what I will call “reactive gender dysphoria” is how a young girl who has been molested may go on to create an emotional equation that if she becomes a boy, no one will bother her anymore. Children with reactive gender dysphoria do present themselves, and it is our responsibility to first get to the root of the emotional problems causing them to express their gender in the ways they do, and then to untangle those underlying psychological knots so the children can evolve into their authentic gender, based not on trauma but desire. Yet I would argue that these children represent only a tiny minority of gender-nonconforming children. And often the strongest indicator of their “minority” status is that they did not gradually become that way but changed their gender expression, at times suddenly and radically, subsequent to a trauma or emotionally distressing experience. (30)

…

There are also children who suddenly show up with a gender issue after a trauma and with no previous history of gender bending. Here, too, we may be seeing children who are expressing other troubles through gender. For example, the three-year-old who suddenly announces that he is a girl after losing his mother to sudden death may be in a desperate emotional search to reclaim his lost mother by becoming her, rather than in a journey toward discovering his true gender self. (222–223)

And here she is in her second book on trans and gender non-conforming kids, 2016’s The Gender Creative Child: Pathways for Nurturing and Supporting Children, making similar points:

Let’s think a little more about the relationship between trauma and the gender self. If gender is a mix of nature, nurture, and culture, and we have a child who has been repeatedly abused, sexually, to the point that the child would prefer to repudiate the gender that caused all that harm and enter life in another gender, is that any less authentic than the child who is persistent, consistent, and insistent since toddlerhood about their cross-gender identity? To test this out, we can help this child heal from the trauma of the abuse and pay attention to whether gender as a solution to those ills goes by the wayside as the child works through the horrors of what happened. This process is best guided by a trusted adult (or hopefully, more than one — parent, caregiver, therapist, teacher, support group leader) and should be accompanied by a revisit to the gender issue if it’s still there. But supposing that child will then feel that along the way, no one ever took the gender identity issue seriously. So here’s a question for all of us: If a child composes a unique gender web in a way that also serves as a salve for past injuries, why would we want to take that away from the child? (88)

Ehrensaft’s argument here reminds me a bit of what one experienced clinician told me during an an interesting exchange on this subject:

CLINICIAN: I take that trauma history at every clinical intake. I take a full, complete review of systems, and I always take a trauma history. And the vast majority of my patients have trauma histories. And some are linked to their gender development, some aren’t, and some have really worked on their trauma and healed from it, and still are identifying as the gender they’re identifying and still having gender dysphoria. I think, you know, you can work on trauma-related distress, but identity is what it is at the end of the day. And while one piece of identity may be the trauma history, it doesn’t necessarily always mean it’s the only component, and/or that gender identity just hasn’t landed and stuck and it is where it is, and it should just be honored — regardless of if it came from [the audio’s indistinct: either “the ashes” or “reaction”], so to speak. And if a person’s really struggling with exploring their gender identity and there’s trauma related to it then you need to slow it down and explore it with them. Just like I wish someone had explored that trauma history with that one patient [who this clinician had mentioned earlier in our conversation] who had started testosterone and then began to resemble their father, their perpetrator — you know, someone should have explored that with them and talked about it a little bit more. I just — I don’t see the treatment of trauma typically resulting in someone altering their gender identity or their desire to change.

SINGAL: Gotcha. Okay, but it sounds like you don’t disagree that a competent clinician will take that into account. The problem is it’s such, like, a noisy signal because basically anyone in the transgender or gender nonconforming category is likely to have some degree of trauma.

CLINICIAN: Right. You’re gonna get too many false positives if you say, “This distress is only related to trauma, not gender dysphoria, and any patient with trauma doesn’t have gender dysphoria — they just have trauma.” You’re going to really hurt a lot of people — you’re going to ignore their gender dysphoria and you’re going to attribute [it to] something that’s not relevant.

Yet another experienced clinician (who, like the one quoted above, has no connection to the Zucker clinic, for what that’s worth) echoed this point in our interview: “There are kids who become traumatized and identify as trans directly after the trauma, and that is a true, stable identity. And there are others who, when you work through the trauma, they figure out a stable sense of self that is in line with their birth sex. It’s just the latter happens much less frequently than one would expect, in my experience.”

(As a side note, it’s worth pointing out that in some cases the causality could be flipped: A kid is gender dysphoric or nonconforming, leading to parental abuse or rejection that in turn leads to trauma. But the above examples all clearly refer to the idea of trauma causing or contributing to dysphoria, not the reverse.)

This is a really key point, because there’s a risk of people misinterpreting the trauma-dysphoria link in the same way some people misinterpret the desistance literature. If your reaction to learning that a significant number of kids desist — that is, their gender dysphoria goes away in time — is to point to an individual kid with gender dysphoria and say, “He shouldn’t transition! Statistically, he’ll desist!,” that is a terrible and completely uninformed way of interpreting that finding. Some kids desist and some kids don’t; no one has a foolproof way of knowing (though some early hints do percolate in the limited literature on this subject). Similarly, if your reaction to learning that there’s a link between trauma and dysphoria is to point to an individual kid and say, “She isn’t really trans — it’s just the trauma talking,” that is a terrible and completely uninformed way of interpreting that link. Sometimes when the trauma is addressed, the gender dysphoria dissipates; but sometimes it doesn’t.

What good clinicians who work with transgender and gender nonconforming kids and youth do — and one of the upsides of having spent so much time talking to them is that I often get their voices in my ear when I think or write about this stuff — is try to understand kids on an individual level. It would of course be irresponsible for gender clinicians to ignore the possibility that a gender dysphoric kid will desist, or that addressing their trauma will ameliorate their dysphoria; that would just be making the same mistake in the other direction. What good clinicians do instead is keep all these possibilities in mind as they try to better understand, in a holistic way, who their young patients are. Good clinicians are less concerned than you might think with whether a given kid is “really” trans or cis or something else, or with applying labels in general (though if a given label helps a kid understand him- or herself, a good clinician will of course respect that label). What they care about is their patient’s source of discomfort at a given moment and what can be done to alleviate it, and to help that patient grow up to be a confident, happy person who feels authentic in their own skin and in how they present themselves to the world — whether or not that involves physical interventions.

I’m not trolling when I say I’m genuinely worried about the sorts of slipups that appeared in Slate and ThinkProgress. They are just the tip of the iceberg. Liberal outlets get basic stuff about gender dysphoria and the best therapeutic practices for treating it wrong all the time — and I’m not just referring to the response to my piece, which is a tiny, tiny fraction of the work that has been published on this subject lately. In this case, there could be parents with gender dysphoric kids out there who read one or both of those articles, and who now think, wrongly, that anyone who posits a link between trauma and gender dysphoria has some sort of ulterior motive. People, as a general rule, don’t read academic papers. They don’t do searches on Google Scholar. They seek out the outlets they trust and, to a certain approximation, take what is written there as the truth. These parents might, in turn, come to believe it isn’t important to seek out clinicians who are trauma-informed, and who will address their children’s trauma in addition to or in concert with “just” examining gender-stuff. That could be really bad.

On the other side of the ledger, parents who are the exception to the rule and do have a foot in the scientific literature might read these outlets, say, “This person has no idea what they’re talking about,” and eschew these mainstream liberal media outlets for guidance on these issues — and instead turn toward outlets that are genuinely antagonistic toward trans people, overly skeptical of physical interventions for adolescents, or both. And while this would be regrettable, could you blame them for ignoring outlets where it’s clear the reporters writing on these issues don’t have even a basic grounding in the literature and in clinicians’ experiences?

This was just a really, really silly error for Slate and ThinkProgress to have made. All Ford or Urquhart had to do was pick up a phone and call any of the gender clinicians I cited in my piece, or do a Google Scholar search. But at the end of the day, this is indicative of a bigger problem: Liberal journalism is not doing a good job covering this subject. There aren’t enough journalists, at the moment, who treat this like a genuine beat, who take the time to have the conversations and read the literature that’s required to understand the conversations and debates going on in the field itself. Instead, many liberal journalists and pundits rely too much on this heuristic:

1. Bad people could use Claim X to harm trans and gender nonconforming people.
2. Therefore, we need to reject X, or view evidence for it in the most intensely critical light possible, and question anyone who would offer support for it.

You can see Ford employing this thinking rather transparently in his article — Parents I view as transphobic believe this thing, so it is a bad belief and there must not be evidence for it. And that’s a terrible approach to scientific controversy, because it can obviously be true that a given fact is true and that people use it for bad ends. If we accept the idea that any idea that can be twisted to hurt people needs to be rejected, we won’t be left with very many ideas. Often it’s the twisting that hurts people, anyway, and not the idea itself. Here, the problem isn’t parents claiming there’s sometimes a link between trauma and gender dysphoria — which there is — but rather those parents then jumping to the conclusion that a kid definitely isn’t trans or definitely won’t need puberty blockers or hormones.

A final note: I don’t want to ignore the fact that there’s an immense amount of right-wing misinformation on these subjects as well. Of course there is. Some outlets make offensive and unscientific claims that because trans people are “delusional,” it doesn’t help them to allow them to transition. But the evidence we have suggests that transitioning often helps greatly ameliorate gender dysphoria, if not dispel it entirely — that is, transitioning can literally cure the underlying condition. So to say that it doesn’t help trans people to allow them to transition is 180-degrees wrong. I also often see credulous, overinflated estimates of the desistance rate — 90%, in some cases — that completely ignore both the valid, if sometimes overstated, controversy over the DSM IV versus 5 criteria, and the fact that some of the earlier studies on desistance really should be discounted rather heavily relative to bigger, more recent ones. But at the end of the day, I don’t think much that I can say or do on the subject will change how The Federalist or Breitbart or other outlets that are behind the times on this subject, or which have ideological agendas inimical to trans people being treated with dignity and flourishing, will cover it. I’d like to think I can nudge things, at least a bit, in a better direction when it comes to left-of-center coverage.

But I could certainly be wrong about that! I can’t say I’m hopeful. I do wish that Slate and ThinkProgress would update those two stories to address the fact that they are spreading misinformation about the trauma-dysphoria link, though. That would at least be a start.