“You’ll notice that the advocates of the accommodation model act as if theirs is the “progressive,” even gender-radical approach. So the TransKids Purple Rainbow Foundation says that they “will strive to encourage families to allow their children the ability to grow up free of gender roles.” Sounds good in theory, at least to most parents who think of themselves as “progressive.” But in fact, the accommodation approach moves your child from being a girly boy or a boyish girl to being a girly girl or a boyish boy. Using the accommodation approach means going from having a William-in-a-dress to having a Julie-in-a-dress. And that may seem pretty attractive to you—no matter what your identity—since it might allow your family to look “normal,” taking away the unrelenting stress of having a “different” child, reducing the cruelty you and your child encounter from those who cannot bear a William-in-a-dress. The accommodation approach might also mean you are more likely to end up with a straight daughter than a gay son, and again, that might take some of the stress off you. (This, by the way, is the approach taken in some very conservative societies, like Iran, where being homosexual is utterly unacceptable, to the point that homosexual people are pressured to transition sex to keep everyone appearing straight.)
By contrast, the therapeutic approach might in the long run leave you with a child who more obviously challenges social norms of gender. And, in the short run, the therapeutic model implies that your family is the problem, that you all have work to do. That, again, might make you more inclined to settle for the accommodation approach, which says your child and your family are not the problem.
There is reason to believe, as accommodation proponents claim, that the stress children and their families feel when the children have GID is caused by social intolerance. Some of that evidence comes from Samoan culture. If a young Samoan boy acts very girlish and identifies with girls, he is incorporated into the category of fa’afafine, or what Westerners would call a “third gender” category. Fa’afafine literally means “in themanner of a woman.”
A biological male living as a fa’afafine adopts a more feminine gender role, and this includes choosing male sexual partners (who are themselves considered straight by all concerned). The vast majority of fa’afafine have no interest in a biological sex change; they are happy living without biological interventions. Researchers Paul Vasey and Nancy Bartlett have shown that most fa’afafine children do not suffer distress over gender atypicality; the culture has a system that accommodates their “difference.”8 (A similar system exists in some Mexican subcultures with the category of “muxe,” although whether muxe children experience distress has not been well studied.)
So why shouldn’t you just go with the accommodation model?
Well, mostly I am hesitant to endorse that approach because we do not know what will happen with that approach. We don’t live in Samoa, and we have no stress-free fa’afafine category; we live in a place where most feminine boys end up as gay men. So what if it turns out, as it seems to with many American men who were gender dysphoric as children, that your child’s dysphoria dissipates within a few years and he stops insisting he’s a girl? Well, if you’ve followed the accommodation approach for those years, you now appear to have a daughter named Julie, in a dress, with a penis, insisting she’s a gay boy. One clinician told me that she has seen adolescents in this situation—adolescents who, as children, were “accommodated” with a public gender change, who then had their gender dysphoria dissipate as they grew. She is concerned that they cannot seem to bring themselves to tell their parents they don’t want to change sex after all, after all the family has already gone through. And what if the therapeutic approach—or even just avoiding the accommodation approach— could eventually make William feel comfortable with his natural-born body? Wouldn’t that be a good thing? It would mean that he keeps his penis and his testes—and, therefore, his full sexual sensation and his fertility; that he does not have to go on lifelong hormonal replacement therapy; and that you all can skip the challenges of changing his sex medically, legally, and socially. All other things being equal, that seems pretty good. That might seem worth the work and social cost of avoiding accommodation.
As Ken Zucker, an advocate of the therapeutic approach has pointed out, if yours were a black family and William were insisting he is white, the right approach would not be to ask doctors to help make
William white.9 Zucker and his colleagues would advocate helping Williams learn, instead, that they can be comfortable with their bodies.On the other hand, Zucker (like most therapeutic clinicians
who treat GID) accepts the overwhelming evidence that adults who are transsexual are better off after medical sex reassignment, and he recognizes that a number of children with GID will “persist” in their transgenderism. Thus, proponents of both models—therapeutic and accommodation—would agree that, if it turns out that William is going to end up as Julie, knowing and accepting that early will make your child’s life easier.
For one thing, you will make the emotional adjustment earlier, presumably causing your child to feel less conflict and rejection. But there’s an even more important reason for early acceptance of eventual transition: If clinicians believe early enough that your child is going to transition sex eventually,
then they might use Lupron, a drug that reduces production of estrogen in females and testosterone in males, to delay onset of natural puberty.10 That would mean William/Julie will not enter full-blown puberty and thus will not become more masculine from a natural male hormonal surge. Later, in
adolescence, Julie could start using feminizing hormones to go through something more like a feminine puberty. That would mean prevention of masculine secondary sex characteristics—like a deep male voice, an Adam’s apple, and masculine facial and body hair—which would mean Julie would not have to
work to try and undo those traits later. As you would suspect, evidence suggests that transsexual adults who “pass” better do better socially, and your child will pass better if she or he can begin planning for the physical transition early. The challenge, of course, is identifying the children in which gender dysphoria will persist.
There are two important points you need to take into account here: First, although gender dysphoria sometimes dissipates after early childhood, if it persists into adolescence, it appears to be here to stay. Second, the use of Lupron for puberty-delay in children with GID is an off-label use. It has not been approved by the Food and Drug Administration for that purpose, and we have no good data about possible long-term negative physical or cognitive effects of using the drug this way. And some children have trouble tolerating Lupron physically.It is not a magic pill.
Notably, we are beginning to see clinics emerge that take a sort of revised therapeutic approach, probably best represented in the work of psychologist Peggy Cohen-Kettenis in Amsterdam. This approach seeks to be less concerned with gender atypicality than both the traditional therapeutic and accommodation approaches are, and most concerned with the child’s and family’s functioning. The idea here is to diagnose and treat functional problems (such as separation anxiety, disorganized
parenting, and depression) if they exist, so that regardless of which gender the child ultimately exhibits, the family is well. Cohen-Kettenis and her colleagues report that the gender dysphoria of the children in her clinic population sometimes dissipates. (Whether this happens because of the clinical interventions remains unclear.) But when a patient’s gender dysphoria persists, Cohen-Kettenis and her colleagues
assist the child and family with psychological and medical preparation for sex reassignment. This is basically a pragmatic approach that tries to leave children and their families as well off as they can be; it privileges individuals’ well-being over particular identity outcomes (gay, straight, transsexual or not).
The final batch of advice I would give parents of children with GID is the advice I give all parents facing optional interventions: Try to identify the real “problem.” Is it that your child is not a typical boy, or is it that he is anxious, sad, or constantly wanting more attention than you give him? Figure out exactly what you are worried about and what your goals are. How do you want your child to end up? When answering that question, try to come up with an answer that is in your child’s best interests while keeping in mind that you will also be subtly inclined to do what makes your own life easier, better, or happier. (That’s the nature of human parenting.)Then find out the goals of the person recommending a particular intervention, see if they match yours, and ask what evidence there is that the intervention will result in particular benefits or harms. (Anecdotes are not reliable forms of evidence.)Consider the possible conflicted interests of the recommender; that doesn’t mean you give up on that person, it just means you be aware of biases.
Don’t believe anyone who tries to sell you a sure bet. Parenting is fundamentally about uncertainty, and no one can change that. Lastly, try, if at all possible, to put what is best for your child above what would make you proudest. I think if you consider the matter long enough, you may agree that children do not ask to come into our lives to make us proud; they do not ask to come into our lives at all. Instead, what they want is for us to make them proud by loving them through difficulty. The shape love should take is often unclear, but love is what we as parents must shape out of our fears, anxieties, desires, and hopes.”