Can the child still grow up?
Last summer, I had the opportunity to go to Paris to listen in on and help write up the proceedings of a fascinating conference centered on the question: L’enfant peut-il encore grandir? Can the child still grow up? Speakers explored ideas about identity, limits, transgression, the clash between science and ideology, and confusion about the role of medicine, as well as introducing an alternative framework for making sense of young people’s distress.
You can read the full write-up (excerpted below) in English or French, listen to recordings from the conference, and learn more about L’Observatoire La Petite Sirene here!
L’Observatoire La Petite Sirene has long questioned gender dysphoria as a diagnosis, proposing an alternative framework for making sense of young people’s struggles: pubertal sexuation anxiety. “Anxiety is something we can hear in all these young people,” Masson remarked. “It’s an anxiety when faced with pubertal maturation or sexual development.” Caroline Eliacheff observed that “collectively, we refused to have this concept of ‘gender dysphoria’ imposed on us.”
“We resisted for a long time. The detransitioners we spoke to pushed us to come up with this new classification, telling us that they had received the wrong diagnosis with gender dysphoria. It was the diagnosis of gender dysphoria that led to the treatment of transition. We wanted to describe instead what was going on.”
This process of understanding and describing what young people were experiencing required L’Observatoire La Petite Sirene to bring together experts from diverse disciplines—from psychiatry and anthropology to the history of medicine and the law.
Jean-François Solal tied the experience of pubertal sexuation anxiety to “the very nature of adolescence,” since “anxiety is associated with desire, and this is indeed what is at stake in adolescence”:
“If we say that anxiety is universal, it is not a disease, not a pathology. Rather it is just a marker of puberty. Anxiety means you are getting close to the desire, which is enigmatic, ambivalent, which has to do with love and hate… The bodily changes of puberty, the effects of new sexual impulses, are at first seen as alien, as something that attacks you before it can be tamed and integrated. Pubertal sexuation anxiety forces a child to rework their relationship to others. In some cases, the adolescent cannot integrate these new impulses and, in that case, they are very happy when adults come to them with something that is ready to use—a medical solution! You were born in the wrong body and we, as adults, will remedy that.”
As Didier Sicard observed above, “puberty is a struggle between your mind, your inner self, the outer world, and your body.” Adults should not rush to foreclose this process by ‘affirming’ a child’s transgender identification. Eliacheff emphasized the need for an open-minded approach to youth struggling with gender, since a child presenting with signs of distress is “not necessarily trans.” Instead, “these may be mere symptoms” of underlying issues that will only surface through open-ended and sensitive psychotherapeutic exploration.
David Bell has long warned about the dangers of labeling young patients as “transgender” and reiterated these concerns at the conference:
“We shouldn’t use the term ‘transgender’ when it comes to young people. By doing so you’re behaving as though you know what you’re talking about, as though there is such a diagnosis. But it’s not a diagnosis, it’s a symptom, and if it’s a symptom we need to know what lies behind it.”
A trans identity becomes a defensive script from which young patients read, effectively blocking exploration and discussion of underlying factors. As Bell noted, “it takes a long time to get a person to trust you. They have a script. You have to get beyond the script. And that means you need to get to know the child very well. It takes not weeks or months, but years.”
Lisa Littman discussed her hypothesis that “social influences, maladaptive coping mechanisms, and other psychosocial factors” can contribute to gender distress and transgender identification. Alternative explanations—like increased social acceptance and access to gender transition—do not explain why teenage girls with no history of cross-sex identification, many of whom had other mental health issues, began to come out in droves in the mid-2010s. Meanwhile, parents were reporting clusters of girls coming out together—suggesting that researchers should look at the possibility of social influence. Evidence to support Littman’s rapid-onset gender dysphoria hypothesis is growing, and fits the observations made by parent groups like Ypomoni, Reseau Education Sexe-Identite, and the Association pour une approche Mesurée des Questionnements de Genre.
Roberto D’Angelo observed that—if Littman’s hypothesis holds—clinicians will “have to accept that we have been doing harm.” D’Angelo said he was struck by the “complete erasure” of “risk, harm, and vulnerability related to gender-affirming care.” There is little concern about what drives young people to seek such extreme body modifications. “The psychic pain we see in our consulting rooms, and which appears in study after study, is completely exiled from awareness.” D’Angelo cautioned that guilt over psychiatry’s pathologization of homosexuality may blind today’s clinicians, who—out of a desire to demonstrate acceptance for their trans-identified patients—refuse to see the psychic pain “humming beneath” trans identification:
“The shadow of this part of our history hangs over our profession… unconscious guilt is a powerful driver of [clinicians’] defense of trans identity at all costs, representing an attempt to make amends and demonstrate moral virtue. This overcorrection, involving full acceptance of the claims of the trans community, is a way of distancing the past and convincing themselves they’re doing important liberating work.”
A young man in the audience shared his experience identifying as transgender:
“As a gay boy who does not comply with stereotypes, when I was younger, there was nothing I could refer to, nothing I could identify with in cartoons, movies, TV series, or in everyday life. Everything was very codified based on sex. And I did not have a father figure, so I thought I was born in the wrong sex. I wanted to transition from a very young age because I thought that homosexuals did not exist, that feminine men did not exist. I thought that I was the problem and in order to please everybody and to be accepted I needed to transition… I think our generation sees that it is still difficult to be a homosexual today, so maybe they think it’s better to shift to the other sex and just pretend to be straight.” He concluded by asking whether transitioning is a way of “eradicating the homosexual.”
Bell agreed that gay and lesbian young people are overrepresented in gender clinics and cautioned that gender seems to have “annihilated” clinicians’ ability to think about the role confusion and discomfort over one’s sexual orientation may play in gender distress. “In trans world, there’s been a regression in thinking where you are either a girly-girl or not a girl, or a macho boy or not a boy.” Kathleen Stock warned that “clinicians have biases like everyone else. They have ideas about how children should be.” Thus, even if the prescription of puberty blockers is curtailed, highly gender-nonconforming children will remain at risk of medicalization: “If you’re presented with an extremely effeminate boy—or an extremely boyish girl—some clinicians will be more likely to think of [transition] as justified. It may seem natural, fitting. It may seem more fitting [in these cases] than for a gender-conforming child.”
Nicole Althea situated the rise in trans identification in a context of deteriorating mental health among young people—in particular among girls. “These girls are vulnerable… social contagion is by no means something exceptional in medicine,” Althea said, pointing to the development of tic-like disorders and the way eating disorders like anorexia spread through social networks. Unlike anorexia, however, where the desire to drastically alter the body is seen by medical providers as pathological, “we offer these adolescents the possibility to change their bodies.” Thus, we should not be surprised when the distress—which runs deeper than any physical intervention can touch—persists. As Claude Habib expressed it, transition is a “mirage that disappears as you get closer.”
Thus, no matter what we call it—whether gender dysphoria or pubertal sexuation anxiety—what these young people experience is perhaps best conceptualized as an idiom of distress. Braunstein discussed the philosopher Ian Hacking’s concept of ‘looping effects’—the way categories in human sciences “manufacture people” to fit those categories, and vice versa—and Edward Shorter’s concept of the ‘symptom pool,’ from which distressed people unconsciously select symptoms that will lead doctors and loved ones to take their distress seriously. Or, as David Bell put it, “All psychiatric illness occurs on the boundary between the individual and the culture” and the ways distress manifests shift in response to cultural changes.
Chantal Delsol highlighted the gap between the ways transgender identities and transition are represented in popular culture and the limits of what hormones and surgeries can offer: “Gender transition is presented as an extraordinary adventure, a trip to the limits, the ultimate revolution that turns things around.” But step outside of this highly specific cultural context and it becomes clear that gender is not a “revolutionary adventure, but rather a nightmare of mental and physical suffering.”
I can't help but wonder to what degree the ready availability of graphic pornography is making female adolescence more anxiety ridden and even quite traumatic. To be a twelve year old girl and to inevitably be exposed to pornography that often depicts women servicing multiple men in sexual acts most twelve year olds have little conception of - must certainly at least make it easier to imagine and entertain the idea that one wasn't - "born" for "this" - and there must be some "mistake."
This all makes even more sense when we consider *the rise in MH disorders*. Young people with mental health disorders = even younger people with failed developmental processes, abandonment, or trauma.
Human development is *sequential* so earlier developmental milestones that are NOT achieved can undermine later developmental leaps.
I think the kids are arriving at puberty *terribly ill equipped* for it. They lack emotional self regulation. They lack sense of self. They lack independence and grit. Then all these changes hit and feel overwhelming. Then someone gives them an 'escape hatch.'