Early or Late Onset?

I am concerned for trans kids. My greatest concern is for those who need medical care and are being prohibited from receiving it. In Kentucky, physicians can be indicted for not beginning detransition care. That’s right, they can be arrested for not undoing transitions that have already begun! Altogether this year, there have been 495 laws introduced or signed into law taking away the civil rights of transgender people.

This post is not about those laws, and the damage they are doing to transgender people. I’ve written about that before, and will write about it again. But not today. This blog is about something else.

I have a second concern, one that does not curry favor with everyone in the transgender community. The percentage of the transgender population has remained steady for a long time at about .58 percent of all people. Roughly one in every two-hundred people is transgender. Recently, however, that number has tripled, and almost all of the growth has been among adolescents, specifically adolescents who were identified female at birth.

The vast majority of mental health providers believe that exploring gender identity, particularly during one’s adolescent years, is good and appropriate for individuation and differentiation. In both the United States and Europe, the biggest controversy among medical personnel is not such exploration, but about the medical treatment of adolescents who say they are transgender or nonbinary.

A study in the January 19, 2023 New England Journal of Medicine followed 315 transgender adolescents through two years of hormone therapy. A total of 60.3 percent were transmasculine and the remainder transfeminine. The study found that the majority of young people who received treatment had a remarkably better quality of life after those two years than they had before. The truth is that for a certain subset of the trans population, we have known that to be true for a long time. But the study failed to answer an important question. Were these study participants individuals whose gender dysphoria was later onset or earlier onset?

Most clinicians with concerns about treatment, including those who are generally supportive of medical treatment for trans youth, are concerned about the increasing numbers of young people whose dysphoria is later onset, after the age of 12. It is still true that any child five or six years of age who consistently and persistently says he or she is not the gender listed on their birth certificate, will continue to feel that way throughout life. Providing gender affirming care to these young people is still supported by the vast majority of clinicians in the United States and Europe. I am not talking about that segment of the population. My question about medical care is reserved for adolescents who do not present as transgender until 12 or later.

In the United States, providing medical care to any transgender young people, regardless of age of onset, has become a political lightning rod. To gain a more balanced perspective on the circumstances, I want to turn to Europe, where the subject is less political.

There is significant rethinking of medical treatment for transgender adolescents in Europe, including the United Kingdom. Why? One study in the UK of 221 adolescents receiving treatment at the Tavistock Clinic, found no detectible improvement in overall mental health after three years of medical treatment. While that study is an outlier, it does raise yellow flags.

No European nation has legally prohibited medical care for transgender adolescents, but there is growing concern about the demographic shift. One clinic in Ghent, Belgium has seen a 42-fold increase in those presenting for treatment. The increase in Sweden has been 17-fold. Finland has seen a marked increase of those presenting for treatment as having been identified female at birth, 75 percent of whom have a separate and severe mental health diagnosis, as opposed to fewer than 33 percent comorbidity in other studies. There is even concern being expressed in Netherlands, the birthplace of transgender adolescent care with what became known as the Dutch protocol.

Amsterdam’s first transgender care center was opened in 1972, and they have been the most progressive nation in terms of transgender care since that time. The Dutch protocol for children was developed in the 1990s. Over the last ten years the number of children seeking care has grown from 60 to 1600, with the vast majority being adolescents who were assigned female at birth.

What is increasingly clear is that for children who present as transgender at a very early age, providing puberty blockers during adolescence is appropriate. For those whose presentation with gender dysphoria is later onset, more study needs to be done. Are these children truly transgender, or are other maturational issues at work?

I have a lot of observations, but have reached no firm conclusions. It appears that a lot of young people who might have presented as goth in a previous generation are now identifying as transgender or nonbinary. Is what we are seeing typical differentiation or individuation, albeit with a new presentation, chosen for its ability to shock and trouble a new generation of confused parents or right-wing politicians? I believe it is possible.

How many of the adolescents who present as transgender today will identify as transgender ten years from now? The truth is that we do not know. My suspicion is that it will be about .58 percent, the same percentage that has always identified as transgender.

What about those who are nonbinary? The 2017 US Transgender Survey found that 62 percent of those who identified as nonbinary were between 16 and 26 years of age. Is that because older people were not free to identify as nonbinary until now? It is possible. There are several nonbinary individuals in my church, none of whom fall into the age category above. But it is also possible that the majority of adolescents who identify as nonbinary today will not do so in ten years.

Having anti-transgender zealots attacking all medical care for trans adolescents is tragic. And let’s be clear. It is evangelical Christians who are behind these laws. In 2017, 84 percent of evangelicals believed gender is immutably determined at birth. Sixty-one percent believed we give transgender people too many civil rights, and only 25 percent knew someone who was out as a transgender person.

Six years later, the numbers have gotten worse. Eighty-seven percent of evangelicals now believe gender is immutably determined at birth. Sixty-seven percent believe we give transgender people too many civil rights, and 31 percent know someone who is out as a transgender person. The number of evangelicals who know someone who is transgender has increased, but so has the opposition to trans rights. What accounts for the increase in knowing someone who is trans? It is probably an increase in those who know a transgender adolescent, not those who know a trans adult. That makes a difference in the conclusions one draws about gender dysphoria.

It is not difficult to determine the adolescents who need puberty blockers during adolescence. They are the early-onset individuals who have consistently and persistently identified as transgender since early childhood. They need medical care, or their suicide completion rate will increase dramatically. Being deprived of that medical care could have tragic consequences. No wonder people are moving from Texas to Colorado. Texas has some of the most restrictive transgender laws in the nation. Colorado is a wonderful environment for thoughtful treatment of transgender adolescents. We Coloradans are pleased to see so many families finding refuge in our beautiful state.

As for those who have later onset gender dysphoria, I believe watchful waiting is advised, as well as a good therapist well-versed in gender identity issues. Time will tell if these young people continue to identify as transgender or nonbinary, or if they will later identify as cisgender adults. There is nothing wrong with watchful waiting.

I imagine some of you will have thoughts about this post. I look forward to hearing from you.

Back to Eden

When I was in Hawaii a few weeks ago I began reading James Hollis’s book, The Eden Project – In Search of the Magical Other. I don’t run across a lot of people reading Hollis, though last year’s Ted Lasso season featured a camera pan of the cover of The Middle Passage, more than a bit of a nod to the book’s influence on the writers. My favorite Hollis book is Swamplands of the Soul. Most of life is lived in the swamplands, so a map of the terrain seems like a very good idea.

The Eden Project brilliantly explains why we mess up every romantic relationship we ever have. We cannot avoid wanting the Other to take us back to the earliest stage of longing for the omnipotent, omniscient mother. Until we find that within, we will never truly be the romantic partner our lover deserves. John O’Donohue, in his book Eternal Echoes, writes about doing the work of becoming yourself:

There are no manuals for the construction of the individual you would like to become. You are the only one who can decide this and take up the lifetime of work that it demands. This is a wonderful privilege and such an exciting adventure. To grow into the person that your deepest longing desires is a great blessing. If you can find a creative harmony between your soul and your life, you will have found something infinitely precious. You may not be able to do much about the great problems of the world or to change the situation you are in, but if you can awaken the eternal beauty and light of your soul, you will bring light wherever you go. The gift of life is given to us for ourselves and also to bring peace, courage, and compassion to others.

“A great harmony between your soul and your life.” Yes, that is something precious. Hollis says once we have done the work O’Donohue has so beautifully described, we can finally become a worthy partner to our lover.

Joseph Campbell said marriage has nothing to do with being happy. It has to do with being transformed. The original projection onto the Other offers the fantasy of happiness, but reality cannot sustain that promise. Once the beloved is revealed as really Other, not just the carrier of  our projections, the troubles begin. Hollis says transformation is about enlargement and enlargement comes only through suffering.

Discovering the otherness of the Other can lead to the kind of loving energy which comes through caring for the other as Other, valuing and celebrating their otherness. For those fortunate enough to achieve that kind of love, the relationship is transformative. They allow the beloved to be who they are, even as they struggle to live authentically as they are.

Marriage has never been two halves becoming a whole. It is two wholes creating a third entity, the relationship, that must be nurtured as children are nurtured. It is the only entity created by the couple that stays in the house throughout their lives. Children are gone within a couple of decades. The relationship remains.

I am grateful for the marriage Cathy and I had. We still have a good relationship, though it is very different than it once was. It took us a long time to realize that if you are not committed to your own growth, you cannot truly appreciate the unique otherness of your partner. I wish it had not taken us so long to learn that lesson.

The core wound we all experience, that there is something about us that makes us unworthy of deep human connection, affects all of our relationships. Much of the reason is because our ego expends all of its energy trying to avoid the core wound. The ego believes acquiring power and safety are the only way to deal it. The ego blocks the soul from following its own path. The soul knows it is worthy of deep human connection, so it desires a richer journey. The soul is searching for meaning. It is, of necessity a solo search. You cannot appropriate the meaning your spouse has discovered, or postpone your own search in deference to theirs.

A healthy relationship is a base camp, with each person climbing his or her own mountain looking for the resonance, depth, and awe that indicates great meaning is nearby. You come back to the base camp at the end of the day, exhausted, exhilarated or discouraged. Whatever the case, you return ready to engage the Other on their equally fascinating quest.

You figure out all this good stuff when you’re old and have learned to suffer. We humans are not quick studies or willing sojourners. We have to be forced onto the road less traveled by, the easier road having been blocked by circumstances, leaving us no choice but to traverse the road filled with fallen branches and stones.

I finished The Eden Project and immediately started it again. It feels like one of those books you have to ponder. I might be able to eventually gain the wisdom of James Hollis or John O’Donohue. All I have to do is live another hundred years or so, and then I might be able to fully embody that kind of wisdom. Yep, that’s all I have to do.

And so it goes.