The History of Diagnosis for Gender for Children

Jen: 00:01:21 Hello and welcome to the Your Parenting Mojo podcast. Today, we're going to talk about a topic that originated from a question in the Your Parenting Mojo Facebook group. Now, sometimes I have questions on my list for a long time, but other times when someone expresses an interest in a topic, they also point me toward a place to start the research, which really does speed things up and that's actually what happened with this episode. So, listener Elizabeth asked if I'd done an episode on children's gender identity and some other listeners chimed in with potential resources, one of which was Dr. Diane Ehrensaft’s book, The Gender Creative Child. And after I read the book, I knew that Dr. Diane Ehrensaft was the right person to talk to about this topic. So, she's here with us today. Dr. Ehrensaft is a Developmental and Clinical Psychologist in the San Francisco Bay Area and the Director of Mental Health and founding member of the Child and Adolescent Gender Center, a partnership between the University of California, San Francisco and community agencies to provide comprehensive into disciplinary services and advocacy to gender conforming and transgender children and youth and their families. She's an Associate Professor of Pediatrics at the University of California, San Francisco and the chief psychologist at the UCSF Benioff Children's Hospital Child and Adolescent Gender Center Clinic. Her research and writing focuses on the areas of child development, gender, gender nonconforming and transgender children and youth parenting, parent-child relationships and LGBTQI families. She also serves on the board of Gender Spectrum and National Organization offering educational training and advocacy services to promote gender acceptance for youth of all genders. Welcome Dr. Ehrensaft. Dr. Ehrensaft: 00:02:52 Thank you so much for having me. Jen: 00:02:54 So, to help us understand more about the research on this topic as well as what to do with it practically in our real lives as parents, listener Elizabeth is here as well. Her child, John was assigned a male gender at birth. John is now 4 and has been telling his parents pretty insistently for a while now that he is a girl, even though he still likes to use the pronouns he, him and his as well as the name his parents gave him at birth. Welcome Elizabeth. Elizabeth: 00:03:18 Thank you. I am glad to be here as well. Jen: 00:03:20 And so I do want to say briefly before we get started that even if your child seems fairly convinced that the gender they were assigned at birth is the one they want to express, that you might want to listen to this episode anyway because I'd say there's a reasonable chance that somebody in your child's class is probably somehow exploring their gender identity. And so knowing the information we're gonna discuss today will help both you and your child be a better friend and ally. So, let's start off with some terminology please, Dr. Ehrensaft because I didn't know a lot about this topic before I started researching it. And even now I find I have to constantly revisit the definitions to remember what's what. So, can you kind of give us a crash course in some of the terminology we’ll be using today, please? Dr. Ehrensaft: 00:04:00 Absolutely. So, we start out with what we call the sex designated at birth and the sex designated at birth is usually what you will see on a birth certificate and it's typically one or the other F or M and that essentially is based primarily on your chromosomes, whether you have XX or XY chromosomes. And it's usually determined by whoever delivered the baby, looking between the baby's legs and seeing what genitalia up here and then declaring the sex of the baby. It's often declared before birth these days in a sonogram, so that you can know early in your child's gestation what people think the sex of your baby's going to be. So it's just physical. Gender is the next thing. And that's very different than sex. We actually don't assign a gender at birth. We assign a sex at birth and that's the physical part. Dr. Ehrensaft: 00:04:58 Then the world around the baby comes in to match that sex with the gender. And the gender is really how we live out being male, female or other in the world and it's based both on inside and outside. And certainly has a very strong social component, looks really different from one culture to another, but I don't know any culture in the world that does not use some organization around gender, not necessarily into boxes. And when we understand gender, let’s divide that up. There's a gender identity and that is who I know myself to be as male, female or other. It's just an inner sense of being. Your gender expressions have more to do with how you do gender. For a little kid that might be the clothes they wear, the toys they play with, the kids they want to play with, the activities that they want to do, how they move and so forth. Dr. Ehrensaft: 00:06:00 And sometimes we lump the two together and it's really important to keep them separate. And those two things, again, needs to be kept separate from our sexual identities. And we often lump all three together, gender identity, gender expressions and sexual identity or orientation. They are absolutely different. Gender is one path, sexuality is another, then they cross, but really your sexuality is who you desire, who you are attracted to, who you want to be with. And it might be someone who is the same gender as you, someone who's opposite or different gender than you. All these things come in quite different combinations, which is the beauty of it all. Jen: 00:06:44 Okay. Already having a hard time keeping it straight in my head. So to summarize, I guess gender identity and expression is kind of about who you are. Is that a good way of thinking about it? And sexual identity and expression is about who you desire? Dr. Ehrensaft: 00:06:59 Mm-hmm. Jen: 00:07:00 Okay. Okay, super. That helps then. And so then we start talking about things like cisgender, gender-expansive. Can you talk a little bit about those? Dr. Ehrensaft: 00:07:08 Yes. The cisgender people in the world are the people who are experiencing the gender they lived at, usually starting out with who their parents assumed them to be based on their sex. And so their gender is the same and matches the sex designated to them at birth. So, those are our cisgender people. And then our transgender or gender-expansive people, people who are saying, I have a different match. It's not based in our culture, the gender binary boy, girl, man, woman. So it might be, for example, a little person who says, you all have it wrong. You think I'm a boy, but I am a girl, I am a girl with a penis. I'm an XY girl. So, transgender means a cross that your gender does not match the sex designated to you at birth and those are transgender children. Dr. Ehrensaft: 00:08:14 Gender-expansive children are also children who say, look, it's not an exact fit for me, so we're going to have to expand it some because it's not totally working for me. They may have a gender identity that's a good match for the sex designated at birth. So, maybe they were born, somebody said, oh, you have a boy. And they say, yeah, I'm a boy, but I don't like the rules for boy. And I like dresses. I like to play the Mommy in all my role play activities, but I am a boy and that’s the way I like to do. So, those would be different combinations that wouldn't be your fit under the cisgender umbrella. Jen: 00:08:59 Okay, that's really helpful. And so in the reading that I was doing about this, I think I learned that there's really no inherent problem with not feeling like the gender you were assigned at birth or I guess would it be more correct to say the sex you’re assigned at birth? Dr. Ehrensaft: 00:09:14 I like to use the sex assigned at birth. Jen: 00:09:15 Okay. Yeah. Yeah. Okay. That makes sense. So the sex you are assigned at birth, but we also have a diagnosable disorder related to this, right? Can you talk about that nuance, please? Dr. Ehrensaft: 00:09:26 There is a history of diagnosis for gender for children and it actually began when the diagnosis of homosexuality was taken out of the American DSM (Diagnostic Statistical Manual). And what took its place when homosexuality was removed from the books in the 1970s was a new diagnosis for gender. So, we now have gender identity disorder to basically pinpoint those people who did not feel cisgender as I just described it. And that diagnosis remained on the books for a long time. And then it was changed recently to gender dysphoria, which is a step up from gender identity disorder because it really just designates those people now who feel distress about their designated sex at birth, not being a good match for the gender they know themselves to be. So it's a step up, but from my perspective it's not good enough because there's still places that under the category of a mental disorder or a mental problem and it pathologizes what I call gender infinity, all different kinds of gender modalities, the rainbow of gender. Dr. Ehrensaft: 00:10:52 So, it is a controversial issue in the field right now. And I will disclose that I am a proponent of, particularly with children, removing the diagnosis from any mental health manual because the intent right now is to depathologize gender and say it's the beauty of humanity to have such a wide variation of gender and all its possibilities. And there is nothing that is unusual or mentally discordant about that. And I would like to give a new diagnosis and I call that social gender dysphoria. It’s the society that needs to be treated, not the child. Jen: 00:11:41 Yeah. And I imagine health insurance programs wouldn't pay for that, isn't it? But yeah, that was sort of where I was thinking on this was it seems to me that the dysphoria, which is sort of the discomfort, is arising from the lack of support that the child feels may be from their parents, may be from society and not from these sort of feelings of not feeling an alignment between their sex and gender. Dr. Ehrensaft: 00:12:04 I think that's absolutely correct. I will say that with all the support in the world, we still have some kids who feel uncomfortable about the poor body match for themselves. And I do think that this is exacerbated by continuing to say boys have penises, girls have vaginas, rather, there are penis-embodied people and vagina-embodied people and most vagina-embodied people identify as girls, but some are boys, etc., etc. So, I think we always will need to pay attention to people who would like to be able to bring their body in better alignment with the gender they know themselves to be. But we might want to get rid of the word dysphoria for that and just call it discordance. Jen: 00:12:59 Yeah. And so just kind of playing on that for a few minutes, I have a bit of a long sort of statement/question before we start getting into the super practical stuff and pulling Elizabeth in for that. So, we talked about how the diagnostic and statistical manual does list this gender dysphoria as a pathological condition and in the previous 4th edition of the DSM, the diagnosis was gender identity disorder in children abbreviated to GIDC. And so the shift is that in the 4th edition it was the cross-gender identification itself that was the problem. Whereas now it's discomfort without identification is the problem. And so I just want to tip my hat to Dr. Jake Pyne, who is a postdoctoral fellow at the University of Guelph for putting some things into words that were kind of swirling around in my mind and I couldn't quite figure out. Jen: 00:13:44 And so Dr. Pyne notes that Dr. Ken Zucker, who was a big proponent of this GIDC diagnosis defends it based on “expert consensus”. So in other words, if a bunch of experts think that something is an illness, then it's an illness. And the threat of social ostracism is cited as sufficient rationale for treatment. And Dr. Zucker said that children often misclassify their own gender and he believes a child who disagrees with a clinician is inherently wrong. And it isn't society's phobia of gender variant people, but rather the active being gender variant itself that causes distress in children. And this diagnosis is the result of poor parenting. It's up to the clinician to save the child from their inevitable fate as a social outcast and remake the child into a normal person. And so this shows up in places like the DSM, which has this unstated but nevertheless powerful view of what normal is, which is White and heterosexual and male. Jen: 00:14:38 And so it's kind of unfortunate that it's the psychologists who carry a lot of the weight of responsibility for the way that gender variant people have been persecuted since it’s their theories that legitimize the actions taken by people like teachers and social workers who control what a child does as well as parents who are taught to surveil their children and administer this humiliation and a desire for success in normalcy. And while the three of us on the call today are all White, I also want to acknowledge the Black and Brown youths who face an incredibly potent combination of threats. There was one researcher whose work I read said that I quote “I always marvel at the ways in which non-White children survive a White supremacist US culture that prays on them. I'm equally in awe of the ways in which queer children navigate a homophobic public sphere that would rather they did not exist. The psychic survival of children who are both queer and racially identified as non-White is nothing short of staggering.” Jen: 00:15:32 And so Dr. Ehrensaft, I know you were co-interviewed with Dr. Zucker for an NPR show in 2008 where you acknowledged that his approach to treating GIDC was still the most prevalent one, but his clinic has since been closed down after it emerged the children he treated were not experiencing positive outcomes. And your model of embracing gender variance is becoming much more normalized. So, I'm sorry to put you on the spot here, but I wonder if you could speak just briefly to the way in which gender variance has been kind of problematized over the years. And we as a society have tried to make gender-variant people fit into our norms rather than adapting our norms to fit this huge variation in the human experience. Dr. Ehrensaft: 00:16:12 So, I want to start out by having my field be accountable and that is the field of psychology, mental health, gender studies, and we are the best of the worlds and the worst of worlds. And some of the so-called experts who based the shaping of a diagnosis on research should be humbled enough now to say they were wrong. The research was flawed and history is proving them wrong and I would say going back to the interview on NPR in 2008, at that time I remember being put on the spot around the question about whose model is more prevalent and I had to be honest and I think I gave a nervous laugh and said, oh, Ken’s. If you ask me now in 2019 and not just because his particular clinic has been closed, but because what has happened in this last decade, I will tell you without a doubt that our model which is the gender affirmative model is the ascendant model of care throughout the world right now and I'm very happy to be able to say that because I think we are repairing what did great damage to gender-expansive people, particularly children throughout history and continues to damage children every time someone tries to employ reparative or conversion therapy with the child to make them conform to what society wants them to be. Dr. Ehrensaft: 00:17:42 The challenge to that that we are offering is to basically enhance these kids resilience and the adults around them and the Trans Community and also to both educate and increase the gender literacy in the world around them because it's the support of others and their own resilience, persistence and gender creativity that's going to make such a better world for everybody. As you said in the introduction, this is not just about children who are gender-expansive. This is about any child who has a gender and every child in our culture has a gender and the acceptance in the room at the table for everybody as not just being but it is dividing will hopefully challenge the kind of intersectionality of oppression that you mentioned before that can happen no matter what it is that creates you as a category of being other than what someone else said was normative. Jen: 00:18:50 Yeah, and thank you for addressing that. And I'm wondering what happens to a child if we don't permit them to live as the gender that they perceive themselves to be? Dr. Ehrensaft: 00:19:01 The data coming in is simple, elegant and common sense....