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Monday, May 9, 2016

Michigan's Proposal For Students With Gender Dysphoria: Is It The Best Solution?

Michigan is currently proposing a new set of guidelines to accommodate LGBTQ students ("The State Board of Education Statement and Guidance on Safe and Supportive Learning Environments for Lesbian, Gay, Bisexual, Transgender, and Questioning (LGBTQ) Students").

Much of the proposal talks about training, sensitivity, and attempts to create a climate free of bullying or discrimination. I think those are goals we can all agree are worthwhile. Toward the end, the proposal gets more specific as it relates to students with gender dysphoria. This is where the policy presents a number of difficulties.

Let me be clear: what I’m about to say is not a commentary on the need to treat those who identify as transgendered with dignity. This is about public policy guidelines that seek to weigh everyone’s rights and promote the common good of all parties involved. I don’t believe this proposed policy does either. I will be highlighting several quotes that stood out to me and offering my concerns about the rationality and impact of this policy.

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“The responsibility for determining a student’s gender identity rests with the student. Outside confirmation from medical or mental health professionals, or documentation of legal changes, is not needed. When requested, schools should engage in reasonable and good faith efforts to change current unofficial student records (e.g., class and team rosters, yearbooks, school newspapers, and newsletters) with the chosen name and appropriate gender markers to promote consistency among teachers, substitute teachers, school administrators, and other staff...

 Transgender and GNC students have the right to decide when, with whom, and to what extent to share private information. When contacting the parent/guardian of a transgender or GNC student, school staff should use the student’s legal name and the pronoun corresponding to the student’s assigned sex at birth, unless the student or parent/guardian has specified otherwise."
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THE VITAL IMPORTANCE OF MEDICAL AND MENTAL HEALTH PROFESSIONALS  - AND THE CHILD'S FAMILY

 Glenn Stanton offers a list of potential causes for gender dysphoria:

  • the “girl trapped in a boy’s body” conviction.
  • family and parental dynamics (“family noise”) 
  • psychosexual disorders 
  • not being directed or encouraged in typical gender behavior
  • a mix of many of factors.

His conclusion? "The truth is that no one really knows what’s behind it, even the most cutting-edge researchers and clinicians. A 2014 book for clinicians, Treating Transgender Children and Adolescents, explains, in academic terms, 'No unequivocal etiological [causal root] factor determining atypical gender development has been found to date.' Translation: We’re just not sure what causes it."

Walt Heyer, a former transgender, writes:
Has any biological basis been found that indicates who will develop into a transgender? Is there a genetic marker in transgenders? The answer is no. Researchers have looked for evidence to prove that transgenders are different biologically but they haven’t found any. One study published in 2014 looked at certain suspected areas of the brain for an association with male-to-female (MtF) transsexualism and found none. Another study, published in 2009, looked for “evidence that genetic variants of sex hormone-related genes confer individual susceptibility to MtF or FtM transsexualism” and didn’t find any. Yet another study, published in 2013, found that “gender disorder does not seem to be associated with any molecular mutations of some of the main genes involved in sexual differentiation." Not a smidgeon of abnormality can be found in the genetic makeup of transgenders so, no, transgenders are not born that way. They are normal males and females.

In response to a flyer that read, "“Gender dysphoria is increasingly understood…as having biological origins,” Kenneth Zucker, one of the top researchers in the world, responded, "In terms of empirical data, this is not true. It’s just dogma, and l’ve never liked dogma. Biology is not destiny.”

The current science has found no compelling evidence that gender dysphoria is a case of being “born that way.”  Genetic or epigenetic arguments offer only speculation based on circumstantial reasons, and an imbalance of hormones seems unlikely. Male to female transgender brains are not feminized. The y-antigen connection has been disproven. One may feel like he or she was 'born that way' because he or she has had the feelings for as long as they can remember, but that is very different from saying there is a verifiable physical cause.

What is abundantly clear, however, is the role that nurture plays. Nurture is a broad term that includes a lot of complexities about how peers and communities affect one’s view of self and gender. Many boys report feeling ostracized because of ineptness at sports. In clinical settings, abuse rates as high as 80% have been recorded. Some feel like they don't fit in with their peers' expectations of gender-related appearances or activities; some are same-sex attracted and don't want to be perceived as gay, and they see switching genders as the solution. The rising number of young girls who are being diagnosed claim they want to be male because of the objectification and pornification they feel even at an early age. However, there is one element that consistently stands out in the category of nurture: family of origin.

  • HealthResearchFunding.org notes that 85% of mothers and 45% of fathers of children with gender dysphoria have had psychiatric problems and/or treatment. You can read a similar conclusion here as well as in Barry Schneider's book, Child Psychopathology. 
  • The Institute of Marital Healing notes: “The evaluation of parents of children with GID is essential in the treatment plan. Drs. Zucker, Bradley and colleagues in a 2003 study found that the rate of maternal psychopathology was high by any standard and included depression and bipolar disorder. The fathers particularly demonstrated depression and substance abuse disorder. They recommended that parental conflicts and psychopathology among the parents of children with GID deserved thoughtful consideration... “ 
  • Multiple studies have noted the overwhelming percentage of fathers who are emotionally distant or physically absent. A New Zealand researcher named Dr. Whitehead has written, “For the most gender dysphoric, in all cases the father was absent. Overall in 54% of cases the father was absent, and in 37% of cases there was no adult male role model. If a father or role model was available, in 60% of cases he was psychologically distant."  
  • For a sobering look at a typical analysis of families in which children with gender dysphoria are raised, read this excerpt from Gender Dysphoria: Development, Research, Management (it begins on the bottom of page 179).

Obviously, having an emotionally/physically absent father or mentally/emotionally troubled mother does not necessarily mean the children will be gender confused, but if children express gender dysphoria, the most consistent part of the narrative is the nurture they have experienced. And the consistently dominant components in that nurture is a physically or emotionally absent father and a psychologically troubled mother.  

I don’t point this out to insult the parents. No parent is anywhere close to perfect, and there are certainly many other way in which parents pass on both functional and dysfunctional legacies to their children. There is, however, this obvious commonality in children and adolescents with gender dysphoria. What has developed in the children does not come from a place of emotional and relational health.

The solution is not to for schools to cut the parents and mental health professionals out of the loop; the solution is to connect the child with them. This team can perhaps identify what has contributed to the child's dysphoria, then help him or her on a path to healing and wholeness.

THE TRANSIENCE OF TRANSGENDER

A child’s desire to be transgender is usually transient. For three-quarters of them (and perhaps as high as 88%), the desire will fade if there is early intervention of the type I described in the previous section. Study after study confirms this.

  • “Multiple longitudinal studies provide evidence that gender-atypical behavior in childhood often leads to a homosexual orientation in adulthood, but only in 2.5% to 20% of cases to a persistent gender identity disorder (3, 6, 22). Even among children who manifest a major degree of discomfort with their own sex, including an aversion to their own genitalia (GID in the strict sense), only a minority go on to an irreversible development of transsexualism…All of the 21 patients who received a new diagnosis of GID in our clinic up to mid-2008 (aged 5 to 17; 12 boys, 9 girls) had psychopathological abnormalities that, in many cases, led to the diagnosis of additional psychiatric disorders. As a rule, there were also major psychopathological abnormalities in their parents.”   
  • “This study provided information on the natural histories of 25 girls with gender identity disorder (GID). Standardized assessment data in childhood (mean age, 8.88 years; range, 3-12 years) and at follow-up (mean age, 23.24 years; range, 15-36 years) were used to evaluate gender identity and sexual orientation. At the assessment in childhood, 60% of the girls met the Diagnostic and Statistical Manual of Mental Disorders criteria for GID, and 40% were subthreshold for the diagnosis. At follow-up, 3 participants (12%) were judged to have GID or gender dysphoria.” 

Dr. Kenneth Zucker, a psychologist and head of the gender-identity service at the Center for Addiction and Mental Health in Toronto, has noted:

“The fantasy solution [a full transgender transformation] provides relief but at a cost. They are unhappy children who are using their cross gender behaviors to deal with their distress. Treatment goal is to develop same sex skills and friendships. In general, we concur with those who believe that the earlier treatment begins, the better... It has been our experience that a sizable number of children and their families can achieve a great deal of change. In these cases, the gender identity disorder resolves fully, and nothing in the children's behavior or fantasy suggest that gender identity issues remain problematic."

PROBLEMATIC CONFIRMATION

I am astounded that no outside confirmation is needed for what is clearly a momentous claim. In a typical school, students need a medical professional to confirm that they are healthy enough to run hard before the school will let them play on a team; they need parental permission to take meds; they can't ride from school grounds with another student without a note.

What reasoning had led to the conclusion that they don’t need a medical or mental health professional to confirm gender dysphoria is present? I was able to find no one in the medical field who simply accepts a momentary claim as proof. Dr. Norman Spack, who treats transgender youth at Boston's Children's Hospital, requires outside counseling for six months to a year before doing his own series of tests and evaluations. Only then will he consider medical intervention. “Those who are sent to us, with parental support, who have had the counseling and go through the psychological testing, are virtually always the real deal." Even then, dysphoria sometimes fades.

It is foolish to unhook children, adolescents and teens, who are still far from mature emotionally, mentally and physically, from the familial and medical authority structures that are in place in their lives. 

DIAGNOSIS CONFUSION

There are a number of things that mimic gender dysphoria, such as autogynephillia, Body Dysmorphic Disorder, Dissociative Disorders, transvestitism, and internalized sexism. How will the school determine what is actually happening if a student simply has to give their opinion? This strikes me as enablement at best and negligence at worst. The children are in a tough situation, and they need help to find their way toward healing and hope. To quote Walt Heyer once again:

What researchers have found is that a majority of transgenders have at least one psychiatric co-existing (co-morbid) disorder, the most prevalent being major depressive disorder, specific phobia and adjustment disorder…What researchers have found is that 30 percent of gender dysphoria patients have a lifetime diagnosis of dissociative disorder (formerly called multiple personality disorder). Dissociative disorder and gender dysphoria appear very similar, and clinicians often cannot distinguish between the two in the transgender patient.

I think psychologists quickly default to the diagnosis of gender dysphoria and don’t consider the possibility of other disorders. I know: this is what happened with me. The most highly regarded gender specialist in the nation diagnosed me with gender dysphoria. He told me that I was a transgender and recommended that I undergo surgery to transition from male to female. All my discomfort would go away after surgery, he said. He was wrong.”

There have even been cases where other co-existing conditions like OCD were treated and the gender dysphoria went away. If psychologists have trouble providing an accurate diagnosis, why should schools simply take the word of a child or adolescent? It is in the child's best interest to get a professional diagnosis.

LACK OF PARENTAL INVOLVEMENT

This policy appears to protect students from parental knowledge if they choose to identify as a different gender at school. Schools could become complicit in hiding a significant, life-altering event from the parents, who would find out …when? When the yearbook comes out? When they get a school newsletter that identifies their child as having claimed a different gender? When the local media outlet runs a story in the school that happens to feature their child? When they show up for a track meet and find out their son is not running on the boy’s team? When children are minors, parents have both responsibilities and rights as it relates to those children. Findlaw.com summarizes it this way:  

“There are many facets of parenting. Two of these are the rights that parents hold regarding the ability to see and raise their children and the responsibilities they have for supporting their children and their children’s actions.”

This basic right cannot happen if the school refuses to tell the parents that their child is reporting gender dysphoria. Look at the protocol in England: the amount of familial (and medical) involvement is astonishing. What reasoning led to the idea that parental involvement or notification is unnecessary?

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“Students should be allowed to participate in interscholastic sports in accordance with their gender identity. Eligibility of transgender students in Michigan High School Athletic Association (MHSAA)-sponsored post-season tournaments is governed by the MHSAA, subject to state and federal civil rights laws.”
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Though Title IX is cited to support policies such as these, this proposal would actually undermine it. Considering how important Title IX is for establishing parity between men and women, I would think that the proposed policy's impact on Title IX would be discussed far more than it is. Zach Pruitt explains why at NewBostonPost.com: 

“Title IX of the 1972 Education Amendments was passed with the intention of ensuring equal opportunities in education for biological females. It has been applied in numerous contexts, from increased allocation of funds to women’s athletics to allowing women to have housing and dormitories that are comparable in quality to those provided to male students. Title IX addressed an important need; the unequal treatment of biological female students in relation to the treatment of biological male students.

However, the entire purpose and effect of Title IX may have just been nullified by a recent federal court decision which held that the definition of “sex” is “susceptible to more than one plausible reading.” The court declared that the relevant statute which says that schools “may provide separate toilet, locker room, and shower facilities on the basis of sex” is “ambiguous” and could be read to encompass biological males that identify as females.

Following the logic of the Fourth Circuit Court, Title IX can now be considered to ensure equal opportunities in education for girls and/or boys who identify as girls. The problem is that in statutory construction, words have singular meaning throughout, so if the word “sex” is changed in the section related to bathrooms, it is changed for the entire statute.

The dissent picked up on this glaring problem and wrote that such a reinterpretation of the term “sex,” as applied to the whole of the statute, would “render Title IX and its regulations nonsensical.” The majority even partly conceded that point, saying, “We agree that ‘sex’ should be construed uniformly throughout Title IX and its implementing regulations.” This is an implicit acknowledgment that they have altered the entire statutory scheme of Title IX. Thus, if “sex” now means gender identity and not biological sex, then there is no real, functional purpose left for Title IX. An anti-discrimination law that affords special protection for women but also allows men to garner the same protection under the same law is absurd and illogical.”

I don't think this "absurd and illogical" redefinition should stand, but let's assume it does. This proposed policy is badly in need of some guidelines to ensure even a modicum of fairness. Could a boy running track or playing tennis show up one day and demand to be on the girl’s team, creating chaos not only on the teams but in the paperwork? Could this student be in different locker rooms on two back-to-back days? Could a 6’4 boy play for the boys' basketball or soccer team one year, then for the girls' the next? The way the current policy is written, the answer certainly appears to be 'yes.' It certainly works this way in California, where a boy who played baseball was cleared to play girl's softball without even having had hormone treatment.

Until last year, the International Olympic Committee (IOC) required transgender athletes to have sex reassignment surgery, undergo hormone therapy for two years (and test into an appropriate range for their new identity), and have their new gender officially recognized. I assume this was to assure that there is no unfair advantage granted by one's birth biology. As of 2014, no transgender athlete had competed. A recent proposal has modified the standards but not the goal of ensuring parity. For a MtF transgender athlete (the emphasis added are mine):

  • The athlete has declared that her gender identity is female. The declaration cannot be changed, for sporting purposes, for a minimum of four years. 
  • The athlete must demonstrate that her total testosterone level in serum has been below 10 nmol/L for at least 12 months prior to her first competition (with the requirement for any longer period to be based on a confidential case-by-case evaluation, considering whether or not 12 months is a sufficient length of time to minimize any advantage in women’s competition). 
  • The athlete's total testosterone level in serum must remain below 10 nmol/L throughout the period of desired eligibility to compete in the female category. 
  • Compliance with these conditions may be monitored by testing. In the event of non-compliance, the athlete’s eligibility for female competition will be suspended for 12 months.

Here's the NCAA's policy (the emphases added are mine):

  • A trans male (FTM) student-athlete who has received a medical exception for treatment with testosterone for diagnosed Gender Identity Disorder or gender dysphoria and/or Transsexualism, for purposes of NCAA competition may compete on a men’s team, but is no longer eligible to compete on a women’s team without changing that team status to a mixed team.
  • A trans female (MTF) student-athlete being treated with testosterone suppression medication for Gender Identity Disorder or gender dysphoria and/or Transsexualism, for the purposes of NCAA competition may continue to compete on a men’s team but may not compete on a women’s team without changing it to a mixed team status until completing one calendar year of testosterone suppression treatment.
  •  Any transgender student-athlete who is not taking hormone treatment related to gender transition may participate in sex-separated sports activities in accordance with his or her assigned birth gender. A trans male (FTM) student-athlete who is not taking testosterone related to gender transition may participate on a men’s or women’s team. A trans female (MTF) transgender student-athlete who is not taking hormone treatments related to gender transition may not compete on a women’s team.

If the Title IX redefinition stands, and if gender dysphoric school students are going to compete on a team that does not align with their birth biology, it only seems reasonable that there be clear, precise guidelines that reflect the concerns addressed by the NCAA and the Olympics.

At minimum, schools should a) implement the timeline of therapy described by Dr. Norman Spack, then b) adjust and monitor hormone levels to ensure they match the normal range of the chosen gender identity. It's worth noting that the United States Endocrine Society, as well as the agencies in many other nations, do not recommend hormone therapy until the age of 16. If students wait a year until they can play per NCAA guidelines, this basically leaves a student's senior year for eligibility.

Having been a high school coach for years, I am far from convinced that even these guidelines would ensure physical parity between boys and girls. However, if this accommodation is going to happen, there should at least be an attempt to level the playing field as much as possible if this policy is implemented. 

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“When requested, schools should engage in reasonable and good faith efforts to change current unofficial student records (e.g., class and team rosters, yearbooks, school newspapers, and newsletters) with the chosen name and appropriate gender markers to promote consistency among teachers, substitute teachers, school administrators, and other staff.ix The Michigan School Code requires proof of identity and age for school entry (e.g., birth certificate, passport) but does not address changing names and gender markers in student records. Per communications with the U.S. Department of Education, the gender marker in the pupil’s official record should reflect the gender identity of the student regardless of what appears on the birth certificate… School districts should comply if transgender students ask the district to amend their secondary educational records, including diplomas and transcripts after graduation, to ensure that those requesting records (e.g., college admissions offices or potential employers) will only see the name and gender marker corresponding to the student’s gender identity.”

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CLERICAL CONFUSION

If students claims to be gender fluid, how often can they demand a change to their records? This policy does not make that clear. Once again, all that is required in this policy is self-identification. In summarizing NPR's special "Young People Push Back Against Gender Categories," Townhall noted the following: 

Adler [the host]  mentioned that, “At one college that Joy Ladin visited, things were so fluid you could make up a different pronoun for a different event.” Yes, Ladin explained, “So you can be she/her at one event and then you go to lunch and you say, OK, now I am he/him. And then one charming young woman told me, oh, yes, today, I'm just using made up pronouns.”
According to Lynn Walker, a director at Housing Works, an organization that provides housing for those with HIV, we must embrace this constantly changing landscape, since “part of the intake [with her transgender clients] is to say, well, what pronoun do you like today? It might be just today.” As Adler explains, this is “because Walker has clients who might be Jimmy one day, and Deloris the next.” 
And what do you do if human descriptions are not enough? 
Walker explains, “We encountered high school students who said, I want you to call me Tractor and use pronouns like zee, zim and zer. And, in fact, I reject the gender binary as an oppressive move by the dominant culture.” 

 One of my friends works at a school where a student’s claimed identity fluctuates daily, and she must be ready to scramble to meet the school’s guidelines for accommodation on the spur of the moment every day. Considering what the school is supposed to do in this proposal, this is not an insignificant issue. Just look at the proposed pronouns that would be a part of the clerical adjustment. Without a much clearer, stricter guideline, this policy will lead to a host of complexities. 

In addition, what happens if the students re-identify later in life? Must schools be ready to constantly adjust their permanent records? These are potentially confusing situations, and this policy as written says nothing about how they should be handled.

THE LIMITS OF SELF-IDENTITY

Based on the language of this proposed policy, what reason do we have to believe that the accommodations for self-identification will stop with gender? Why not include age or race? People like Stefoknee are identifying as a different age than they actually are (Age Dysphoria, or Age Identity Dysphoria). Others are creating a lot of tension by identifying as having an ethnic background different than their actual one.

I wonder what the limits will be? (If the following were not actual examples of self-identity, this paragraph would sound like an argument ad absurdum). Some people have Body Identity Disorder; they are amputating perfectly healthy limbs because they identify as transabled. Some think they are animals (species dysphoria). Others claim to be otherkin or furries, and they are ready to be taken seriously. A Norwegian woman thinks she is a cat; another is convinced she’s a dragon (you can watch a documentary on this phenomenon here).  Vinny Ohh is changing his body to match his self-perception of being a genderless alien. Some think they are vampires, and not everyone is convinced they should be told differently.  A few even think they are dead (Cotard's Syndrome).

I don’t highlight their cases to mock them. I am simply noting that they have a very serious self-identification very much at odds with reality, and they are increasingly asking others to accommodate them. If a student claimed anything on the list I just gave, does the “responsibility of determining X” still simply rest with the student? Will Michigan schools use “reasonable and good faith efforts” to change their records and ask teachers to treat the students as they perceive themselves? Based on what principled argument will the school stop with gender identification? If I am reading the text of the proposed policy correctly, there is none.



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While I applaud the anti-bullying sentiments articulated at the beginning of this proposed policy, I don't believe the specific solution for accommodating gender dysphoric students is rational or workable. I'm also not convinced, considering the reasons why gender dysphoria develops and the rate at which it resolves over time, that it has the best interest of the student in mind - and I haven't even addressed the problems already arising from shared locker rooms. [Update: As of July 2016, Virginia's largest school district, one of the first to pass a non-discrimination policy such as the one Michigan is considering, has cancelled its implementation for the moment because of  legal concerns, as well as the "privacy and dignity of non-transgender students."]

I am in favor of clear, informed, solution that works with students, their families and medical professionals while seriously considering the implications that any proposed solution will have on other students and school organizational structures. I just don't think it's this one.

(NOTE: This post was updated on 6/3/16)

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For more information, read this letter from Kevin DeYoung to the SBE. 
For a pediatrician's perspective about how this effects the psyche of children, read Dr. Meg Meeker's thoughts. 


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