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First Do No Harm

 

Editor’s note: This article is written by a dear friend who was our North Star when we initially came to understand our child’s needs. I’m so happy that she was able to provide her personal and professional perspective. -Melissa

First do no harm

All persons should have the opportunity to live naturally

Intervene only as much as necessary to reduce the distress to manageable levels

Jesse is a 14 year-old smart, funny, precocious girl who would rather be with friends than do homework (or do anything actually). She won’t eat anything green, is a night owl, spends too much time on her phone, and loves, absolutely adores, Taylor Swift and Lorde. She cries copious tears when she is hurt; cares very deeply about people, animals, and the earth; and is fiercely protective of her self, her friends, her family, and her puppy. She is mostly vegan, and all the way vegetarian. Oh, and she is transgender.

By the time Jesse was two years old, two profoundly meaningful events occurred that would eventually become catalysts for a long journey into a great unknown. One was her first haircut in which she told me that she wanted me to do it like “Cinder-lella.” Shortly afterwards, Jesse got into a large bag full of hand me downs intended for her newborn sister. As one might imagine, the bag was full of things pink, pretty, and sparkly. Jesse beamed in what she thought was her new wardrobe. Our approach was to gently try to help her ‘organize’ and manage her preferences, interests, needs, and identity.

Over the next several years, and despite our very exceptional ‘organizing’ skills, Jesse’s female identity continued to strengthen. Every shooting star and every birthday candle held the same wish, “Please, please…let me wake up a girl.” One night when we came into her room to say goodnight, we caught her praying. Her hands were held in prayer and she was repeating the same old wish, “Please, please, let me wake up a girl.” So, finally, we stopped managing and organizing, and right smack in the middle of second grade, we helped her make a social transition to all things feminine. We came to understand that, for her, in order to not hurt her, we would simply have to let her be who she was. So we did. We said a few prayers of our own and allowed her to be her.

Then the phone calls started. As a Licensed Clinical Professional Counselor, I had been providing therapy for a number of years. Of course, I researched treatment options for transgender children and found that at the time, the ‘best’ advise out there was to remove all things girly from the ‘boys’ life and help him be comfortable with his body. I knew, not thought or suspected, but knew for sure that this was not always going to be possible, and was rarely going to be ideal. I also knew for sure that it was going to be harmful. Especially for our Jesse and likely others like her. So I developed a treatment approach with three main tenets: First, do no harm. Second, all persons should have the opportunity to act naturally. Third, intervene as minimally as possible to get the distress down to manageable levels.

Through word of mouth, anxious parents began calling me after hearing of this unique approach to working with transgender children. Families came to me from all over the Midwest for treatment, for consultation, for advise.

While my treatment strategy was not typical for the times, it really was not ground breaking. I was simply applying sound evidence based therapy to what we thought was a new population of children. There is no approach in psychotherapy that states that it is better to “hurt them a little now to protect a better outcome later” (these words were actually said to me by a psychologist and educator in justifying the corrective approach to counseling transgender children). This statement stimulated several questions for me. First, by “hurt” how much would be OK? How much hurt in early childhood would be commensurate with the better outcome that one might envision? Does this ‘better outcome’ include trauma? Or are we specifically measuring for transgender identity? What exactly is this better outcome? All of these questions led me to develop the first tenet of my approach: First, do no harm. This is the first law of medicine and provides the basic scaffolding surrounding healing and competent care. And this applies to all persons, young and old, regardless of race, sexual orientation, gender identity, or religion. First do no harm. As I said, not ground breaking. This has been the Hippocratic Oath for many decades. I simply applied it to a very vulnerable and marginalized group: gender diverse children.

The second tenet of my treatment approach is that all persons should have the opportunity to act naturally. Lets be clear, I am not talking about people who think they are cats or people who identify as a toaster. I am talking about a typically functioning individual whose gender identity is something other than what we, in binary America, think that it should be. There is much we do not know about the brain, about gender, and identity. Cross cultural research, as well as observational studies done in the animal kingdom, suggests that a binary code, while fine for computers, is overly simplistic for gender, and, in fact, humans. Social, personality, and sexual development are complex processes and 0’s and 1’s do not really explain us very well.

In this state of not knowing, it becomes critical to approach diversity issues with regard. Especially for children. I remember a time early in my process when I had a boy bodied child dressed as a princess and another boy bodied child dressed as batman. It is horrifying to me now to recall how one had to change into more appropriate attire to go to grandmas house and the other one didn’t. I can’t help but consider the impact of traumatic experiencing that this type of situation is likely to facilitate. At the very least, a child learns to develop a false self in the face of an unaccepting, critical, and dangerous world. This is one of the fundamental goals of psychotherapy for a great many number of clients: to help in the development of a true self with the goal of living an authentic and personally meaningful life. Therefore, I felt that all persons should be able to act naturally. All of our clients should be met with positive regard. It is just not up to us to tell them who they are. Who we think they are. Or aren’t. It is not up to us as therapists. For my family, it isn’t up to parents either. It is up to parents to teach values, to get the children to bed at a reasonable, to try to get them to eat something green. It is up to us to help the child develop and learn routines and structure. It is up to us to be a cook, chauffeur, tutor, manager, housekeeper, cheerleader…. It is not going to be our decision whether the child is going to have intrinsic interest in dolls, trucks, or games. Whether they will excel in gymnastics or debate team. Whether they will pursue a career in medicine or education. We can protect and guide. But for the vast majority of children, it is just not up to us to decide about orientation or identity.

Research has shown that a large percentage of gender dysphoric children may desist in their transgender identities. In a nutshell, this research concluded that many will grow out of it. These ‘outcomes’ caused significant anxiety in parents of gender diverse and transgender children. With medical technology exploding, and cross sex interventions becoming a viable option, parent’s questions and concerns regarding best practice were well founded. How do I know if my child will grow out of it? How do I support without encouraging? How do I help but not hurt? How much do I intervene? These are all valid concerns. To really capture parental and clinical panic regarding these outcomes and corresponding questions, research has also shown that suicidality for transgender youth was disproportionately high. In other words, gender diverse and transgender children, as a group, was not doing well.

However, the terms ‘gender diverse’ and ‘transgender’ are not necessarily the same and research had not yet empirically operationalized them. This research, while informative, had its limitations. So far, people weren’t yet talking about distress level as a diagnostic feature at that time. As a therapist, of course, this factor is critical in assessment and diagnosis for any mental health issue. Symptoms that do not cause marked impairment or distress isn’t diagnosed. And so this third tenet was to help parents navigate these very difficult questions and concerns. In a world where we simply don’t know, let your child’s overall wellness be your guide. Is their anxiety manageable? Are they learning to read? Or are they so distracted with gender incongruity that they can’t learn? Are they aggressive with others? How are they developing socially? This enable parents to map unchartered waters in a uniquely idiosyncratic way. Broad brush strokes simply aren’t going to be effective with this community. Nurture does have an impact. Community does have an impact. There are just too many variables. At the end of the day, we want healthy children who are well and whole. And the least harm approach to get there is to assist in the development of a true, natural, psychologically fit, and physically well self.

Back in 2010, when Jesse was right smack in the middle of second grade, we made some crucial decisions. First, we just weren’t going to knowingly hurt her. No way were we going to hurt any of our three children on purpose. Second, we were going to treat her, and of course all of our children, with positive regard, and allow them to be natural. Finally we were going to look at her overall distress/wellness as the primary guide for intervention. When we computed this fairly basic and humanistic algorithm, all of our anxiety decreased.

Today, we have three healthy children who are otherwise preoccupied with the natural emergencies of teenage life. Jesse is a remarkable, insightful, and charming 14 year-old transgirl. Our next problem? How do we get her to turn off her phone and get to bed on time. Maybe even eat something green. All things considered, these are good problems to have.

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