Diane Ehrensaft

From Gender Identity Disorder to Gender Identity Creativity: True Gender Self Child Therapy

True gender self child therapy is based on the premise of gender as a web that weaves together nature, nurture, and culture and allows for a myriad of healthy gender outcomes. This article presents concepts of true gender self, false gender self, and gender creativity as they operationalize in clinical work with children who need therapeutic supports to establish an authentic gender self while developing strategies for negotiating an environment resistant to that self. Categories of gender nonconforming children are outlined and excerpts of a treatment of a young transgender child are presented to illustrate true gender self child therapy.

The gender affirmative model: What we know and what we aim to learn

in which he stated: ‘‘Cur-rently experts can’t tell apart kids who outgrow gender dysphoria (desisters) from those who do not (persisters), and how to treat them is controversial’’ [Drescher, 2013, p. 1]. As members of a four-site child gender clinic group, we concur with Dr. Drescher regarding the controversy, but take issue with his assessment of experts and their inability to differentially assess ‘‘persisters’’ and ‘‘desisters’’ in childhood. We would like to take this opportunity to outline the gender affirmative model from which we practice, dispel myths about this model, and briefly outline the state of knowledge in our field regarding facilitators of healthy psychosocial development in gender-nonconforming children. The major premises informing our modes of prac-tice include: (a) gender variations are not disorders; (b) gender presentations are di-verse and varied across cultures, therefore requiring our cultural sensitivity; (c) to the best of our knowledge at present, gender involves an interweaving of biology, devel-opment and socialization, and culture and context, with all three bearing on any in-dividual’s gender self; (d) gender may be fluid, and is not binary, both at a particular time and if and when it changes within an individual across time; (e) if there is pathol-ogy, it more often stems from cultural reactions (e.g., transphobia, homophobia, sex-ism) rather than from within the child.Our goals within this model are to listen to the child and decipher with the help of parents or caregivers what the child is communicating about both gender identity and gender expressions. We define gender identity as the gender the child articulates

Psychological and Medical Care of Gender Nonconforming Youth

Gender nonconforming (GN) children and adolescents, collectively referred to as GN youth, may seek care to understand their internal gender identities, socially transition to their affirmed genders, and/or physically transition to their affirmed genders. Because general pediatricians are often the first point of contact with the health care system for GN youth, familiarity with the psychological and medical approaches to providing care for this population is crucial. The objective of this review is to provide an overview of existing clinical practice guidelines for GN youth. Such guidelines emphasize a multidisciplinary approach with collaboration of medical, mental health, and social services/advocacy providers. Appropriate training needs to be provided to promote comprehensive, culturally competent care to GN youth, a population that has traditionally been underserved and at risk for negative psychosocial outcomes.

Alternatives to the Stork Fatherhood Fantasies in Donor Insemination Families

Reproductive technology has presented a challenge to families and clinicians alike in making sense of the psychological experience when a child is born with the use of donated sperm or ova. This article addresses one specific aspect of this challenge: father imagos and fantasies for parents, donors, and children in donor insemination families. Pour psychodynamic issues are explored: denial of reality and denial of the Unconscious, the power of die unconscious and the “unthought known,” reversion and resistance to part-object thinking, and paradoxical psychic construction and destruction of the father. In extension of Winnicotts theory dial there is no infant without a mother, the author concludes dial there is no infant without all the parties who make die child and all the parties who raise die child.

Initial Clinical Guidelines for Co-Occurring Autism Spectrum Disorder and Gender Dysphoria or Incongruence in Adolescents

Evidence indicates an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD). The clinical assessment and treatment of adolescents with this co-occurrence is often complex, related to the developmental aspects of ASD. There are no guidelines for clinical care when ASD and GD co-occur; however, there are clinicians and researchers experienced in this co-occurrence. This study develops initial clinical consensus guidelines for the assessment and care of adolescents with co-occurring ASD and GD, from the best clinical practices of current experts in the field. Expert participants were identified through a comprehensive international search process and invited to participate in a two-stage Delphi procedure to form clinical consensus statements. The Delphi Method is a well-studied research methodology for obtaining consensus among experts to define appropriate clinical care. Of 30 potential experts identified, 22 met criteria as expert in co-occurring ASD and GD youth and participated. Textual data divided into the following data nodes: guidelines for assessment; guidelines for treatment; six primary clinical/psychosocial challenges: social functioning, medical treatments and medical safety, risk of victimization/safety, school, and transition to adulthood issues (i.e., employment and romantic relationships). With a cutoff of 75% consensus for inclusion, identified experts produced a set of initial guidelines for clinical care. Primary themes include the importance of assessment for GD in ASD, and vice versa, as well as an extended diagnostic period, often with overlap/blurring of treatment and assessment.

Just Molly and me, and donor makes three: lesbian motherhood in the age of assisted reproductive technology.

SUMMARY The psychological experiences of lesbian mothers, both coupled and single, are compared and contrasted with heterosexual and gay parents who use assisted reproductive technology, focusing on issues of parental desire, fertility, babies conceived from science rather than sex, presence of an outside party in conception, genetic asymmetry, social anxieties, legal protections, disclosure, and gender. The psychological meaning of the donor or surrogate as an “extra” and “missing” piece of the family, along with the interactive effects of homophobia and “reproductive technophobia” are considered. Lesbian families are recognized to be constructing a new narrative of a bio-social family as they define and live their experience.

The Stork Didn't Bring Me, I Came from a Dish: Psychological Experiences of Children Conceived through Assisted Reproductive Technology

DAVID IS A CHILD FROM A DIVORCED LESBIAN FAMILY. HE WAS conceived with the sperm of an anonymous donor found informally through the mothers’ social networks. Later, by accident, due to the seemingly zero degrees of separation in the local gay and lesbian community, this man was identified to the mothers as David’s donor, but he has no relationship with the family. David has an older brother, Joshua, to whom he has no genetic ties. Joshua was conceived with the help of a known donor, Fred, a gay friend of Sylvia’s, one of the mothers. Fred has stepped in to be more than a donor but rather a father to both Joshua, his biological son, and David, to whom he has no biological relationship. By fluke, Fred is actually an acquaintance of David’s donor. Sylvia is the biological mother of Joshua. Natalie is the biological mother of David. Natalie has adopted Joshua, but Sylvia has not adopted David, as Sylvia and Natalie’s relationship began to deteriorate during Natalie’s pregnancy and terminated when David was only five months old. It is daunting to explain all this, let alone expect a reader to hold it in mind. Yet David and his family live seamlessly within this complex, innovative family formation in a fertile new world. I began seeing David when he was five. It is now eight years later and I have been invited to attend his Bar Mitzvah ceremony, which I do. On the bema to celebrate with him are his two mothers, his nonbiological maternal grandmother (Sylvia’s mother), his nonbiological father, and his

Listening and Learning from Gender-Nonconforming Children

The twenty-first century brings to our clinical doorsteps increasing numbers of children exploring and questioning their gender identities and expressions. This paper begins with a reassessment of the psychoanalytic thinking about gender and then outlines a clinical and developmental model of gender adapted from D. W. Winnicotts concepts of true self, false self, and individual creativity. The underlying premise is that gender nonconformity, when the core psychological issue, is not a sign of pathology but rather a reflection of healthy variations on gender possibilities. Working from that premise, composite clinical material from the authors practice as a psychoanalytic gender specialist is presented of a gender-nonconforming child transitioning from female to male, to demonstrate the psychoanalytic tools applied, including listening, mirroring, play, and interpretation, with the goal of facilitating a childs authentic gender self. Emphasis is placed on learning from the patient, working collaboratively with the family and social environments, and remaining suspended in a state of ambiguity and not-knowing as the child explores and solidifies a True Gender Self.

Prepubertal social gender transitions: What we know; what we can learn—A view from a gender affirmative lens

ABSTRACT  Background: This article provides a review and commentary on social transition of gender-expansive prepubertal youth, analyzing risks, and benefits based on a synthesis of research and clinical observation, highlighting controversies, and setting forth recommendations, including the importance of continued clinical research. Methods: This article involved: (1) a review and critique of the WPATH Standards of Care 7th edition guidelines on social transition; (2) a review and synthesis of empirical research on social transition in prepubertal children; (3) a discussion of clinical practice observations; (4) a discussion of continuing controversies and complexities involving early social transition; (5) a discussion of risks and benefits of social transition; and (6) conclusions and recommendations based upon the above. Results: Results suggest that at this point research is limited and that some of the earliest research on young gender-expansive youth is methodologically questionable and has not been replicated. Newer research suggests that socially transitioned prepubertal children are often well adjusted, a finding consistent with clinical practice observations. Analysis of both emerging research and clinical reports reveal evidence of a stable transgender identity surfacing in early childhood. Discussion: The authors make recommendations to support social transitions in prepubertal gender-expansive children, when appropriate, as a facilitator of gender health, defined as a childs opportunity to live in the gender that feels most authentic, acknowledging that there are limitations to our knowledge, and ongoing research is essential.

Gender nonconforming youth: current perspectives

Beginning with a case vignette, a discussion follows of the reformulation of theories of gender development taking into consideration the recent upsurge of gender nonconforming and transgender youth presenting for gender services and also in the culture at large. The three predominant models of pediatric gender care are reviewed and critiqued, along with a presentation of the recently developed interdisciplinary model of gender care optimal in the treatment of gender nonconforming youth seeking either puberty blockers or cross-sex hormones.