Advice for gender dysphoric teens

Hi Carey,

I am a transgender identifying teen who feels caught between the ultra-affirming trans culture and transphobia. I’m terrified by stories of detransition, and want to make sure I don’t make the wrong choice to transition, however the need to transition is very compelling. I guess I’m looking for any advice you would give to a young trans person on avoiding having to detransition.

I’m so relieved to hear you’re terrified of detransition. Recently the backlash to detransitioners’ heightened visibility in the media have been opinion pieces which argue “De-transition is rare and not as bad as people think.” It’s easy to make such a sweeping minimization when the research into detransition consists of case studies of individuals, and survey research is shut down for being likely to cause controversy. Minimizing the negative psychological, health, social, career, and financial consequences of inappropriate transition and subsequent detransition is unfortunately what we should expect from the doctors who earn money and professional acclaim through pediatric transition. As Upton Sinclair said, “It is difficult to get a man to understand something, when his salary depends upon his not understanding it.”

Detransition is that special kind of hyper-shitty experience where people who will never transition or detransition nonetheless feel they are entitled to be the expert on whether it’s shitty. I refuse to spend this essay establishing its shittiness- there are detransitioners writing all over the internet about why and how it’s shitty. At the end of this essay is a list of detransitioner blogs I find especially useful when I need a reality check that this is a profoundly hard and messed up situation a bunch of us are in.

(While the right wing often fixates on the “regret” detransitioners are imagined to feel about our changed (and endlessly objectified) bodies, here’s a link to a more realistic take on the kinds of regrets the detransitioners I know are processing: https://permutational.tumblr.com/post/180871869901/hypotheticals.)

I am a therapist, but I am not your therapist and never will be. Working with patients who experience gender dysphoria would make me vulnerable to accusations of conversion therapy, and I’m not a masochist anymore. One upside about not being your therapist is that there isn’t a paycheck that forces me to mediate the realness of my advice.

(I can’t tell from your letter if you are male or female. I have more insight into being a female managing gender dysphoria so that’s what I’m going to speak to. Sorry guys, good vibes to you.)

There aren’t any demographic markers you can check yourself against to see if you are likely to detransition. I’ve met women who detransitioned after 20 years, 10 years, 5, or luckily found a way to reconcile with being female before beginning HRT. There are detransitioned women whose lives as trans men were pretty complete- wives or husbands, jobs they enjoyed, and kids. There are straight detransitioned women, lesbian detransitioned women, bi detransitioned women. There are detransitioned women who now identify as butches, detransitioned women who now identify as femmes, detransitioned women who have a chip on our shoulders against identification.

I can’t give you a mechanism for checking how future you will feel about the choices you make today. What you can check is 1) the specifics of the experiences you’re having now 2) the realistic potential consequences to the choices available to you and 3) the values you can live by such that if everything goes to shit you can be at peace with what you did with your money and time.

Investigating the specifics of your gender dysphoria:

Track how your gender dysphoria fluctuates for at least a year. 12 months of tracking a symptom is not long, especially compared to how many years you’ll be navigating the outcomes of your medical decisions. What I observed in the community is that many people experienced a big spike in the intensity of their gender dysphoria when they socially transitioned and began hormones, which surgery then gave them relief from. But then 3–5 years later the gender dysphoria crept back, except now fixated on different aspects of their body than what they initially addressed with surgery. It was common for the trans guys I knew to develop a fixation on their hairline, body hair, or hips and thighs. It was also surprisingly common in my circle for trans men, after the initial high of completing surgery had passed, to express the wish that women they met in passing understood they were female. You shouldn’t assume that your desires about who strangers understand you to be will stay the same as they are today.

Supposedly there are some people whose gender dysphoria does not increase or decrease in intensity based on their social context and health factors. I’ve never met one of these people, transitioned or detransitioned. Friend groups, menstrual cycles, stress, jobs, weight loss or gain, and health problems all end up continuing to affect the intensity of GD after surgery or hormones. Whether your transition works out or you detransition, it is likely GD is going to be an experience you have on an ongoing basis throughout your life.

Here’s a tracking sheet for you use to get some data about what contextual factors affect the intensity of your GD. (I put a copyright claim on this, so copy it all you want, but don’t put it in anything you’re going to sell. I’M LOOKING AT YOU, YOU HERITAGE FOUNDATION F*CKS.) It’s helpful to have real data about how environments, relationships and the choices about your physical wellbeing you are making in your daily life impact your GD. If it turns out your GD increases on days you have to navigate high school, that’s important, because high school is a temporary environment where outrageous sexist abuse and harassment is usually completely normalized. You don’t want to make permanent changes that affect your long term health if a temporary shitty context is escalating your GD. If it turns out there are family relationships that increase your GD, well, you will soon be able to make choices about what family members you allow in your life, so that’s also a temporary context creating distress you don’t want to solve with permanent body modifications.

The reason the tracking sheet makes you rate your GD from 1 to 10 and notice its intensity at different times in the day is that we experience very different physiological processes at different times in the day. It may be physiological factors set off your GD. My GD can be pretty intense first thing in the morning, when my cortisol is high. It’s important to notice that because if your GD is connected to cortisol your plan of action should be directed at decreasing spikes of cortisol, and medical transition tends to set up many high cortisol situations.

It’s helpful to note what substances you’re using, both ones you got from doctors and ones you got from lay people. If you notice your body feels incorrect or unreal on days you take a certain medication, your doctor needs to know that. If you notice that the more pot you smoke the more often your body feels incorrect or unreal, that does not surprise me. Dissociative experiences are what pot was cultivated to create for us, so you can’t smoke it regularly and then be surprised that your body feels like a bad dream. Do yourself the favor of being weed-free for the year you are tracking your GD. If you don’t know how you would manage without weed for a year, that challenge needs to be figured out before discerning your medical transition path.

It’s important to track your screen time for a similar reason. If you’re looking at screens 5 hours a day I’m not surprised that you would feel your body wasn’t real or was in some way incorrect. Your interoception, which is your sense of what’s going on with your physical body, is withering away while you stare at those screens. If you have intense gender dysphoria and you are also constantly on the computer (especially if you’re spending your nights online instead of sleeping), it is time to experiment with not having a computer.

What are the realistic consequences to your choices?

This is where you have to do research. What kinds of health issues do trans guys experience after 5 years on T and how do they address them? What about 10 years? What about 20? What’s aging like for someone who takes testosterone for decades? What are the sources of information for these questions and how trustworthy are they? Who is getting sued for malpractice and what exactly did they do to their patients? Are any sources of information compromised by financial incentives? Are any questions of the safety of medical interventions portrayed as settled when the research is not there to back that portrayal up? You’re going to have to decide for yourself what an acceptable amount of unknowns is when it comes to your health. Because you have the good sense to be terrified of detransition, I believe in your capacity to do this research.

One aspect to medical transition that gets glossed over is that there is a fair amount of maintenance required over the life span, whether that’s ongoing HRT, maintaining a certain weight, or problem solving the complications from HRT and surgeries as your body ages. You will always, for your entire life span, be confronted with how big of a priority your desired appearance will be versus other health concerns. The best case scenario is that the occasions requiring choices and effort from you regarding your medical transition become more infrequent as your life continues. As part of your research you should find and speak to older trans guys about the choices they faced down the road because of taking testosterone. Buck Angel and Aydian Dowling have both been generous enough to talk in detail about the complications that led to their hysterectomies. Talk to as many older trans men as you can. I’ve generally found older trans guys to be very upfront and open about the tough parts of transition, even if they are completely at peace with their decisions to medically transition.

What values are you guided by?

Often, the things we think will make us happy don’t. Degrees, marriages, moves, kids- we work really hard to obtain milestones that usually come with their own complex problems and which at best we feel ambivalent about.

Medical transition is an experiment, for everyone. You will not know whether a mastectomy will make you happier until you get a mastectomy. You will not know whether a new pronoun will make you happier until you ask people to use a new pronoun. You will not know how you will feel 10 years out from transition until you’re 10 years out from transition.

The lead up to transition often involves a lot of obsessive though about what “identity” fits you best. Identities change a lot. Values tend to be more consistent. If you care about beauty, family, and nature at 15, there’s a good chance you’ll care about beauty, family, and nature at 25. If you can identify what you value at 15, then you can spend the years between 15 and 25 building a life full of what you care about.

Identifying your values enables you to choose suffering that will be meaningful to you. We all, no matter what choices we make, end up suffering. Suffering that has a point is easier to bear. If you know what you value in life, you will feel more at peace with the suffering you have to endure to create what you value.

I would suggest that while you’re spending the year (weed free!) tracking your GD, you also devote a substantial amount of time identifying your values. It’s very tempting in the trans community to buy into “poor me” stories in which you don’t have any responsibility for your circumstances or self-efficacy at your disposal. Identifying your values and challenging yourself about whether your actions and patterns reflect those values reminds you that you’re responsible for how your life turns out. If your top values are wealth, friends, beauty, and family, cool, you should go about your transition in a way that prioritizes those, and creates a life full of what you value. If you double check that all your choices prioritize what you value, then even if you detransition you’ll have a life full of (or at least moving towards being full of) what you value.

My top values are health, respect, independence, relaxation and honesty. If I had taken the time before starting HRT to seriously reflect on and identify my values, I wouldn’t have gone about my transition the way I did. I wouldn’t have socially transitioned in a public way, because that choice made me vulnerable to lots of opportunism and disrespect from people being performative in their allyship. I wouldn’t have taken risks with how I earn my money, because that ended up making me dependent on those awful allies. I would have been more aware of and skeptical of people and workplaces within the community that were toxic. I would have done so much more research on what trans guys can expect as they age. (I had to work at an informed consent clinic before I could grok how uninterested researchers are regarding what happens to trans people’s bodies as they get older.) I would not have cultivated dependence on the Bay Area radical queer community, which is so over the top in its authoritarianism. I would have been more cognizant of how stressful all this supposed liberation was, and a lot more aware of what being stressed does to my GD.

(A note about therapists: There are some skilled, careful, ethical therapists out there. There are also lots of avenues by which therapists can get drawn into professional structures, like supervisory relationships and certificate programs, which if led by ideologues can force a shut-down of their critical thinking. If you ever feel that your therapist would feel disappointed or betrayed by your changing ideas about your identity or about the trans community, that is a big red flag that your therapist’s ideological loyalty is being prioritized over your autonomy and well-being. The most cult-like behavior I’ve seen in the trans community has been among the doctors and therapists. People in that crowd act like it’s normal to have “in-group” discussions that they don’t want the general public to catch wind of. That’s not a normal dynamic to encounter in medicine or mental health. I’ve received many personal messages from mental health providers and physicians saying they’re concerned about the potential outcomes of pediatric transition and informed consent care, but they can’t say it publicly. The trans health care scene is currently a wild situation, and I’m grateful I don’t have to be in it.)

Don’t think of transition as one big decision you can get right and then be done with it. Think of each decision (whether that’s what pronoun you ask for, or T, or surgery, or which surgeon you choose) as starting down a path leading to many other branching decisions. Once you make one big decision in life, the big decisions will just keep on rolling right towards you. I think this is a hell of a first big decision to make, especially since the part of your brain that is particularly good at making decisions won’t be done developing till halfway through your twenties. Regardless, try to regard your process of making this first big decision as exploring what your process for making decisions that serve you as an adult will look like. How do you remain realistic when making decisions? How do you rank priorities when making decisions? How do you manage risk and the unknowns when you make decisions?

One day, if you’re very lucky, you’ll get to experience being 55. Lots of people, before they’re 55, don’t ever imagine what their lives might be like at 55. You should imagine being 55 in a lot of detail. Because whatever choices you make about your body now, 55 year old you will be living out the consequences of. Before you give your organs unexpected substances to process, or remove body parts, try to get as clear as you can on how your choices will impact 55 year old you. If you challenge yourself to acknowledge the aspects of reality you really would rather do without, and you get very clear on what’s important to you, you can absolutely use your common sense to create a future you’d like to live out. It’s difficult but simple; like Lao-tzu said, “If you do not change direction, you may end up where you are headed.”

Detransitioner Blogs to Check Out

Crash

23

Redress

Detransition Info

Cari

Detransition Sister

Max

Retransition

Permutational

Butch Coming Home

Tejuina

New Thought Crime