Lawrence Rubin: Thanks so much for joining me today, Michelle. You are a psychotherapist in private practice in Berkeley, where, among other things, you specialize in gender-affirming mental healthcare for children, teens, and their families. Did I get that right?
Michelle Jurkiewicz: Yes, you did.
LR: we have the gender affirmative model, and then we have gender-affirming care
What exactly is your gender-affirming model as applied to clinical work with kids and teenagers? What does that mean?
MJ: We have the gender affirmative model, and then we have gender-affirming care. The gender affirmative model is a way of thinking about and understanding gender diversity, which applies to everyone. It’s based on the premise that gender diversity is a normal and healthy human variation, that people have the right to live in the gender that feels most true to them, without criticism and discrimination. And it’s also based on the idea that there’s not a preferred outcome in terms of a young person’s gender, whether that’s transgender or cisgender. There’s not one that’s preferred.
Gender-affirming Mental Health Care with Children and Teens
LR: And you said that’s different than gender-affirming care.
MJ: Gender-affirming care is informed by the gender affirmative model. When we talk about gender-affirming care, especially when you hear about it in the media, it’s often referring to medical care. But gender-affirming care often takes place amongst an interdisciplinary team.
So, if you’re talking about puberty blockers and gender-affirming hormone treatment, then that is something that even as a psychotherapist, you would be working in conjunction with an endocrinologist or pediatrician, likely a social worker. There are various members of the team.
The main way the gender affirmative model works with
children and
teens is the way that the therapists themselves are holding the space for a child to be able to explore who they are and be who they are, as well as increase what we call gender literacy. In the most basic sense, gender literacy is increasing an understanding of the sociocultural norms of gender roles and stereotypes, and what potential consequences there are if you step outside of those boxes.
We want children to be able to be themselves and explore who they are while also—in age-appropriate ways—making sure that they understand the world that they live in and that not everyone necessarily understands gender diversity.
LR: the main way the gender affirmative model works with children and teens is the way that the therapists themselves are holding the space for a child to be able to explore who they are
What is your particular role in that network of professionals that converge in working with a kid or a family around gender and gender transition?
MJ: There’s not as much need to be in contact with young children before puberty unless there’s something else going on. Then, of course, like any child, we would be in touch with pediatricians and other relevant professionals.
But when a child enters puberty, and there is the question or desire for puberty blockers or later for gender-affirming hormone treatment, the gender centers require an assessment from a mental health provider, which they take into consideration. It’s one piece of the whole picture of whether this is the right thing for the child. The psychotherapist’s job in those instances is to share your thoughts about whether, in your professional opinion, that is the best next step for this child and family.
LR: So, they will take your input, based on your observation and your work with the child and family, into consideration before the team decides, although I imagine it’s ultimately—hierarchically—it is the physician who makes the decision.
MJ: Well, the parents ultimately, but yes.
LR: Is this evaluative process with pre-pubertal clients what you refer to as your holistic evaluation?
MJ: We typically think of the holistic evaluation even prior to that. But in terms of specifically with pubertal kids who are seeking gender-affirming medical care, we’re referring to taking everything that we possibly can into consideration. And that means that we work very closely with parents as well.
So, we’re looking at all aspects of their history. We’re looking at how parents feel about it because it’s important that if this goes forward, we have the parents’ full support.
LR: While we’ll chat about the family a bit later, I would imagine at this juncture that dealing with parental ambivalence would be an important part of that holistic evaluation.
MJ: I think oftentimes, parental ambivalence is addressed and worked with even prior to this evaluation.
LR: the gender affirmative model does not advocate for specific psychological testing
I would hope so. For those psychometrically driven clinicians out there, are there specific inventories or questionnaires, psychological tests, so to speak, that would be part of an evaluation?
MJ: The gender affirmative model does not advocate for specific psychological testing. Prior to the gender affirmative model, the child had to undergo a whole battery of psychological tests. We don’t do that anymore.
There are various screeners and batteries, and things like that that some clinicians use to help them get a child’s gender into focus. I personally am not using those so much because I feel like I’m well-trained and I have a lot of experience, and that, through my conversations with children and their families, I get a very good picture and don't need those batteries.
I will say, though, that I am an advocate for more research in that area. I think there are some people that are working on a more standardized evaluation process, of course. But I have not found that useful in my own work.
LR: I guess when you’re talking about gender-affirming care, you are already outside of standardized notions. You’re already considering not just the psychological makeup of the child, but the whole ecosystem. To then try to empower some instruments to carry the burden of decision making almost seems antithetical.
MJ: I agree. I think the tension is around insurance companies.
LR: And then there’s the issue of liability. If the clinician is going to be called into court, psychometrics may be desired, or even demanded. In the course of your typical evaluation, what are you looking for historically, developmentally, in a teenager? In other words, what are some of the markers you are looking for that give you a sense that this child has always been on this path?
MJ: That’s a good question because I think what we’re seeing is shifting, and it used to be that the kids that we were working with came out when they were very tiny, and they maintained that identity until puberty, and then they accessed gender-affirming medical care.
I think now we’re seeing more and more kids come out later, in which case, when we’re looking at their history, we’re not necessarily looking for stereotypes, such as they played with stereotypical toys of the other gender, or they wore clothes of the other gender—although we do gather that information, but it’s not a required piece of their history.
If we’re going to introduce gender-affirming medical care, we’re looking for some sort of sense that this has been a consistent and persistent identity, especially once we’re talking about gender-affirming hormones. Because puberty blockers have not been shown to have long term adverse effects once they’re stopped, that could happen potentially more quickly if a child is in a lot of distress and puberty is right then and there. But that doesn’t mean then that that child would necessarily go on to gender-affirming hormones.
We are looking for some sort of consistency in their identities. We’re developing this pathway in conjunction with medical providers, which requires that the child is, at the same time, learning about the risks and benefits in a developmentally appropriate way. In some ways this is asking them to take on something we don’t typically ask of cisgender kids in terms of their medical care, but it does mean that a lot of times these kids know a lot.
LR: if we’re going to introduce gender-affirming medical care, we’re looking for some sort of sense that this has been a consistent and persistent identity, especially once we’re talking about gender-affirming hormones
They’re informed.
MJ: They’re very informed, and that’s a necessary piece of the process.
LR: Why does
WPATH (World Professional Association for Transgender Health) recommend that while evaluating these kids, you look for, if not rule out, autism spectrum disorder? What's the link that they think must be examined there?
MJ: If a child is on the spectrum, it does not disqualify them from gender-affirming care. However, what WPATH is addressing, and what I’ve seen in my own practice, is that there is a huge correlation between gender diversity and being on the
autism spectrum. The most recent statistic I’ve heard is that about 10 to 12% of gender diverse children are also on the spectrum. That’s huge compared to the regular population of kids.
LR: As a clinician, and perhaps intuitively, what do you think the connection is?
MJ: I don’t know, but my best guess, and the way I think about it as of this moment, is that a necessary piece of being diagnosed on the spectrum has to do with social differences, the way that one reads cues, the way that one responds to others and interacts with others. And so, I wonder if children who are on the spectrum feel less inhibited by social norms around gender, so they have naturally more freed up space to take it up.
LR: Do you have to sort of screen for, if not rule it out before proceeding with transitioning?
MJ: We don’t inhibit a child from proceeding because they’re on the spectrum. But what we do need to be screening for is the hyper-focusing and rigidity that often accompanies spectrum-related behavior. We need to make sure that that’s not what’s going on with gender.
LR: here is a huge correlation between gender diversity and being on the autism spectrum
Are there any myths you’ve come across about these gender diverse kids who are searching—and is ‘searching” a good enough word?
MJ: Gender exploring! I think that there are many myths, and one of the ones that comes to my mind immediately is the idea that kids can’t know their gender if they’re gender diverse. They’re likely to change their minds later, so we should not really be listening too much to what they’re saying. We have to wait a while. I think that’s a big myth.
I think another myth, which is part of our bigger culture, and we all hold it and have to work on it, is that being transgender or gender diverse in some way is less ideal than being cisgender. And that’s a big shift in thinking. That’s something that I am monitoring within myself. Oh, and then there’s the myths of the gender affirmative model, that it’s just a fad or a kid might say they’re transgender because they're trying to fit in with peers, or that being a gender-affirming therapist means that if a kid says they’re transgender, the therapist is going to immediately write a letter and say yes, puberty blockers. Yes, hormones. In reality, these are decisions that are very carefully sorted through and that take time.
LR: another myth, which is part of our bigger culture, and we all hold it and have to work on it, is that being transgender or gender diverse in some way is less ideal than being cisgender
Is that second myth related to what you refer to as quieting the gender noise in the clinician’s head?
MJ: We all have a gender. We all grew up with expectations. We all hold biases about gender. And that’s what we think of as gender noise. Gender noise, the myth that I was talking about, was the myth that somehow being cisgender was preferred or more ideal, and that’s just been stated as fact, basically, for as long as we’ve known in Western culture. That’s a more difficult one for some people to really shift around. And even when we shift around it, I think if we’re really not paying attention, it can be easy to slip out of that. This is especially so if I’m not monitoring my countertransference, monitoring my own biases about gender.
LR: Makes me think that gender noise is on one end of the spectrum of therapists’ presence with these kids, and severe unchecked countertransference is all the way at the other end, and there are so many points in between where that noise can impact the therapeutic relationship.
MJ: I want to make one more point about gender noise based on something I’ve noticed in my practice with cisgender people. I’ve had several cisgender male clients who have expressed a lot of stress and even angst around masculinity with questions like, “Am I measuring up?” or “Am I too masculine?” Does that mean they’re aggressive? Just trying to sort out for themselves what it means to be a man and what is okay and not okay. And I would say even that is gender noise.
LR: What is that male bashing concept typically attributed to the dangerousness of hypermasculinity?
MJ: Oh, toxic masculinity?
LR: Is that what you refer to when you say a cisgender male might come in worrying that they’re just a little too beefed up emotionally?
MJ: Some of them worry if they’re even doing masculinity correctly. Like, are they masculine enough? There’s such mixed messages out there right now and I don’t know that historically, I have had so many male clients talking about these issues as I have in the last couple of years.
LR: we all have a gender. We all grew up with expectations. We all hold biases about gender. And that’s what we think of as gender noise
I wonder if the males who come in worrying about their masculinity is more of a function of their education level, their intelligence, their sensitivity, and if they are sensitive to ‘am I being too masculine,’ then that sort of answers its own question.
MJ: Exactly, exactly. And I think the Me Too Movement, along with toxic masculinity, has brought these topics to the forefront.
LR: Not to mention the politicization, but we’ll save that for another conversation. How does gender stress differ from gender dysphoria?
MJ: It’s a good question. When I think about gender dysphoria, in the most basic sense, it’s the distress that someone feels when their gender identity does not match the gender designated to them at birth. And gender dysphoria, often, but not always, can show up around their body, like, not wanting certain body parts they have, or wishing they had body parts they don’t have. Feeling like their face, or their bone structure, or body shape, or genitals are wrong. The distress is very internal.
You don’t have to be gender dysphoric to experience gender stress. You could feel very comfortable with your gender identity and your body and all of that, but on a regular basis, encounter situations based on your gender that cause stress. For example, if you’re a trans girl, and have to choose between men’s or women’s bathroom, the very process of going to the bathroom can become stressful. That would be gender stress even if you’re okay with who you are, and your body, and everything.
LR: when I think about gender dysphoria, in the most basic sense, it’s the distress that someone feels when their gender identity does not match the gender designated to them at birth
How have the gender issues that have been presented in your practice changed over the last 20 years?
MJ: They’ve changed quite a bit! Early on, most of the children that were brought to me around gender were assigned, or designated male at birth and were wanting long hair and to wear dresses and play with dolls, and they were saying that they were girls. Their parents wouldn’t really know what to do at that time. They would have questions like, “Is it bad to let my little boy wear a dress or play with dolls?” or “Do we affirm that and say it’s fine,” or “Do we change pronouns or a name?”
These were little kids that usually ranged in age from 3 to 6. But sometimes they were older, but almost always they were quite young. Early on in this work, I didn’t really ever have a parent bring a child who was designated female at birth when they were little. The way I understood this was that the girl box, so to speak, is a lot bigger than the boy box. It was, and maybe still is okay for little girls to cut their hair short and play with the boys and be good at sports. But it was not seen as okay for a little boy to wear a dress.
Over time, this has shifted. And as I touched on a little bit earlier, while we still see those young kids, they’re not coming to our offices as frequently. I think because parents have more awareness out there and perhaps parents aren’t as worried when the kids are little and they’re going to kind of see what happens and support their kid in the meantime. Parents might only bring their kids into therapy when that kid is nearing puberty and they’re starting to sense stress in the child about a changing body.
The other difference that we’re seeing is that kids come out later. I have many families that bring a teenager to me who has come out as transgender, post puberty. We never used to see that, and now we’re seeing it more and more. I see that pretty equally among “designated male” at birth or “designated female” at birth. But when we start to talk about who is showing up for medical treatment, there is a greater number of designated female teens showing up for hormones than there are designated male teens.
LR: parents might only bring their kids into therapy when that kid is nearing puberty and they’re starting to sense stress in the child about a changing body
Before we shift gears, is there anything else I should ask about the kids?
MJ: Not so much specific questions, but I guess what I would say about the kids themselves is that some of these kids absolutely know who they are. Regardless of how certain or sure they are of their identity, what we know these kids need is family acceptance, and family acceptance does not necessarily mean, “oh, my kid’s trans, so let’s go get hormones.” They need to know that families have their back, and ideally that communities, teachers, churches, have their back and love them no matter who they are.
LR: In your book, you said that if
depression and anxiety develop, it’s likely due to negative social responses, so treatment should be aimed at helping and healing the surrounding environment. Are you saying that effective intervention for the child or teen means that the clinician must work with the family?
MJ: We do help the child, too, but I feel like the root of it is not necessarily about their child’s gender as much as it is about the parents’ response to their child’s gender expression. If we think about just
anxiety and take away the gender piece when we’re working with an anxious child, we often find that we have to work with the parents as well. You know, there’s something going on at home, or there’s ways the parents can do things differently to help work with us, to help treat the anxiety. We were not just treating that in isolation.
So, in that way, it’s not that big of a leap to think about it as you’re starting with the family. And somebody doesn’t have to be out there being super politically active if that’s not what they want to do. But the way that they are holding gender in mind and interacting in the community, in their own communities, for example, and raising awareness, I think is huge.
LR: Do you go to the school in the course of working with a particular child and family? Do you go to churches? Do you go to community centers? What is the extent is your work outside of the therapy office?
MJ: I think gender-affirming care is a team effort. We’re lucky here because we have people at UCSF’s Child and Adolescent Gender Center, where there’s an educational specialist. And if the family wants, that person will go with the family to the school and advocate on the child’s behalf.
If the family doesn't want to bring in an educational specialist, I know about creating a gender and educational gender plan. I can offer information to the family if they feel like they can address the school themselves.
That’s basically about having a discussion with administrators about whether there is a safe person for this child to go to if something were to happen. What bathroom is this child going to use? Do they have access to one that feels safe and comfortable to them? Whether teachers are informed or not, whether the kid is out to peers or not, those sorts of things are talked about amongst the adults to create a plan to support the child at school, for example.
LR: I think gender-affirming care is a team effort
So basically, extending the office to include all possible support members to extend the safety of the office into the world that they actually have to live in.
MJ: Exactly.
LR: What about the kids who express gender stress, even gender dysphoria, but don’t want to, or aren’t committed to chemical intervention?
MJ: We’re seeing this a lot. I think this is one of those myths out there that transgender and gender diverse children and teens necessarily are seeking out medical intervention. Because that’s not true. It’s a subset that wants medical intervention, and even within that subset it has to be determined to be the right next thing for them.
There are many, many young people who identify as gender queer, non-binary, or even as a trans girl or a trans boy who have no desire for medical intervention. They love their bodies the way that they are. And so, there’s that piece, and then in terms of the journey piece like we talked about in the book, is that gender journeys are something we’re all on throughout our life, right!?
Even as a cisgender woman—and being a woman has been an important identity of mine—but how I experienced being a woman, and thought about being a woman, and expressed my femininity or lack thereof at 20 years old is very different than how I do it now in my 40s. So, there can be shifts in how we express gender, experience it, and then there can also be shifts in identities.
That happens over time, and so we don’t think of there ever necessarily being an end point in terms of a gender journey, although there may of course be an end point in therapy when kids are doing well, and they’re not needing that level of support.
Gender-affirming Work with Families and Beyond
LR: What are some of the clinical challenges that the parents have brought to you, or the families? Because it’s not just parents, it’s also siblings, maybe even the extended family.
MJ: There are so many if we got into specifics! But I’ll start general first. When a child comes out as transgender or gender diverse in some way, it impacts the entire family, especially the family unit living together. And siblings have a range of experiences. Sometimes it’s not an issue, and everything’s fine, but other times, the sibling may go to the same school. This sibling may either feel they are a target, or they may actually experience being a target, like being teased for who their sibling is, or they may fear that that is going to happen, even if perhaps it doesn’t. Siblings might not understand and might need support in even understanding what this means.
However, I think parents struggle more than siblings do, partly because we’re finding that young people just tend to have more flexible minds around gender than us adults. One particularly difficult thing is that every parent has dreams for their children and ideas about who their child is, who their child is going to become. When they realize that there’s an aspect of their child where their gender is something different than they’ve imagined, there has to be a reworking of those dreams and expectations. Oftentimes, there has to be a lot of grieving and mourning for what they thought that they would experience with their child, or what their child would experience in life.
There’s often anxiety for parents about how the world is going to accept their child. They may ask, “Is my child going to be hurt in this world because of who they are?” Then there’s the stress of extended family. I’ve worked with families where things are going really well within the nuclear family, but the thought of telling grandparents feels really dicey out of fear that the grandparents aren’t going to understand.
Or I’ve worked with families who are religious, and their particular church or synagogue is not supportive of gender diversity. This is a community that the family loves and relies on, and they’re having to face the harsh reality that they may need to move out of or disconnect from this community in order to support their children. Or they wonder if there is a way for them to bring education to those communities and to help them to grow and expand to accept their children for who they are. So, it's a lot of pieces that parents are holding.
LR: here are many, many young people who identify as gender queer, non-binary, or even as a trans girl or a trans boy who have no desire for medical intervention
What family factors have you experienced that might undermine successful intervention with the child, or do those families simply not come to therapy?
MJ: Rejection is the biggest thing. If parents are absolutely like, “this is not true, it’s not real, I’m not even going to discuss this with you,” that is the worst-case scenario, and we see those children do very poorly. That’s where we’re seeing the highest rates of suicide. The highest rates of runaways. And once these children run away, they’re at greater risk of victimization than their cisgender homeless peers. So, we know that the biggest protective factor is family acceptance.
LR: Are the transgender kids accepted in the broader LGBTQ community, or do you find it depends on the community?
MJ: It’s actually kind of complicated. In my experience, some older adults or adults in general‚ not young adults, but middle age and older in the LGBT community can be quite non-accepting and surprisingly dismissive that these identities are real, coupled with the belief that it’s sexual orientation and not gender identity.
I would say that we see less of this within the younger members of the LGBT community, like adolescents and young adults. I think there’s still some cases, but for the most part, it’s more of a unified community among young people.
LR: if the psychotherapist is unable to have real empathy for parent struggles around this, or if the therapist has an agenda to really push the parents very quickly into this place of acceptance and moving forward, that is not going to work very well at all
One thing I guess I could have asked earlier is similar to the question I just asked. What factors within the therapist might work against effective intervention with a kid and their family?
MJ: Where I see this show up the most is in working with parents. If the psychotherapist is unable to have real empathy for parent struggles around this, or if the therapist has an agenda to really push the parents very quickly into this place of acceptance and moving forward, that is not going to work very well at all.
You have to be able to really understand and support parents in this process, and, of course, that doesn’t mean that you slow the whole process down so slow that there’s no progress forward. But you do have to slow it down enough so that parents have an opportunity to get caught up with the kid, because the kid may have already been thinking about this and reading about it forever, but this is brand new to the parents.
Pragmatics and Considerations in Gender-affirming Care
LR: Any advice or suggestions for clinicians working with young clients who express gender-related concerns, but are really interested in medical transition or exploring what it means to be the other gender? And what about kids first experiencing gender curiosity, but not necessarily gender distress or dysphoria?
MJ: One piece of advice is to be aware that we’re going to be hearing more about gender diversity because of what children are seeing at school and on social media. It doesn’t necessarily mean anything about their own identities, other than that they’re trying to understand the world that they live in, like any other aspect of identity, as they’re growing up.
Also, because a little boy, for example, plays with dolls and wears dresses, doesn’t even mean that child thinks of themselves as anything other than a boy. These behaviors don’t necessarily mean something about gender identity. I think it requires us to think about why we have this idea that this is the only way to be a boy, or the only way to be a girl.
And then, if there is gender curiosity or confusion, it really is going to work itself out over time. And when they haven’t even entered puberty yet, they really have lots of time.
LR: because a little boy, for example, plays with dolls and wears dresses, doesn’t even mean that child thinks of themselves as anything other than a boy
I would imagine then that some therapists might feel pressured—with additional pressure from the parents—to make it something that it’s not, because of their own “gender noise.”
MJ: Yes. One of the hard things about being a therapist is holding that space of not knowing.
LR: Especially for those who believe that they have to do something, they have to fix something, they have to be useful in some way. Any minimum training or educational experiences that would help a clinician be better in this domain? Like if you were on a graduate program curriculum development committee?
MJ: I would like to see a class or classes in gender diversity as it informs clinical work, just like we do for other cultural differences, which is required. Clinicians are seeing more and more of it in their clinical work with children and teens. If a clinician does encounter this and hasn’t had any training in it, my suggestion would be to either refer out or to reach out for consultation or sign up for a training and just get some support around it, like we would do any issue we’re confronted with that we’re not well-trained in.
LR: Absolutely. What would be some of the resources clinicians might consult to gain understanding and support in this clinical domain?
MJ: Well, there's certainly online trainings, which sometimes you can find out about them through WPATH or
USPATH. Those are good places to look for trainings. WPATH also has a list of people who have undergone training to supervise or consult. And I think it’s possible to get names, so you could seek out individuals that you might want to talk with. Those are the two main things I would suggest.
LR: a lot of the pushback from the psychodynamic community is around this idea that the gender affirmative model does not allow for exploration
I wonder when there will be a lawsuit brought by a graduate student who feels that such mandatory graduate training violates their right to practice religion freely or is morally offended. Have you received any pushback from the clinical community about the work you’re doing?
MJ: Almost all of my training has been
psychodynamic or psychoanalytically informed, and I have received a lot of pushback in those communities from what I see as a real fundamental misunderstanding of what gender-affirming care is. A lot of the pushback from the psychodynamic community is around this idea that the gender affirmative model does not allow for exploration. Like I said, I’m informed psychodynamically which I think is a way to open up space and to explore everything that clients bring into the room, and that doesn’t change when the topic is gender. I think that’s the main pushback that I’ve gotten clinically.
LR: Any pushback from the trauma community, and those clinicians who focus on the link between trauma and gender distress?
MJ: I personally haven’t experienced it, but I’ve certainly read about it and heard about it. There’s the trauma-informed people, and I’ve also heard this in the psychoanalytic community, that somehow some sort of trauma like sexual abuse has caused a child to identify with a different gender. And that if you just resolve that trauma, they’ll go back to identifying as the gender designated to them at birth. I think trauma does need to be looked at and dealt with, but this idea that somehow, necessarily, gender identity comes out of an attempt to resolve trauma, I think is mis-informed.
LR: I think trauma does need to be looked at and dealt with, but this idea that somehow, necessarily, gender identity comes out of an attempt to resolve trauma, I think is mis-informed
How would you work with a child or a teen who’s under what you refer to as a “gender gag rule” and what does that mean?
MJ: A gender gag rule is when, for example, a child who is saying, “I’m transgender or I’m non-binary and that’s my identity,” but their family has decided, for whatever reason, that it is vital that this child not tell anybody, and that this is a secret that stays within the family, and perhaps with providers, and that’s it.
In some cases, this may be necessary depending on communities, and at times, it's a parents attempt to keep their child safe. But for some children, this can cause an enormous amount of distress because they’re having to hide who they are, and it prevents them from being able to feel close to others because they’re constantly monitoring that. It can mean not swimming or not having sleepovers. There’s all these things that then can isolate the child.
When we work with children under a gag order or gender gag order, we’re assessing how much distress this is or is not causing this child. Some children don’t want to tell people either, but that’s different. And then it’s working with parents around what is getting in the way. What are they worried about? And is there a way we can address those worries and allow this child to be more out about who they are? Or are there ways we can at least help the child feel like they have more space to be out, even if that doesn’t necessarily mean telling everybody?
LR: when we work with children under a gag order or gender gag order, we’re assessing how much distress this is or is not causing this child
Are there any instances where you might have to push past confidentiality with the client and talk to the parents who may not yet be aware because their child is in such distress around gender?
MJ: You mean like where I would need to talk to the parents, but not necessarily to the level of suicide? Like I might have to break confidentiality?
LR: Either or both!
MJ: How I’ve always worked with it, and I’ve been lucky because this has always worked, is to have a very frank conversation with the child about how we have to enlist the support of their parents. And I go through what they’re afraid of. I talk about being an intermediary. We can make a plan together of how we’re going to do this. I really try to get the child to sign on.
That’s always worked. I’ve never had to override a child in this regard. I would be very cautious if I was presented with that situation because it would make me wonder if there are real safety issues about outing them, and I would want to be sensitive to that. And, I just want to say that those are the exceptions, not the rule, that most parents are going to find a way to come around and support their kids. I think the parents that are completely rejecting are in the minority.
LR: with regard to therapists needing an attorney on speed dial, I know of no one, not a single person, who has been in any kind of legal trouble because of this work
Should therapists who work with gender-affirming care have an attorney on speed dial?
MJ: I think that are moments when therapists working with gender and kids have worried about that. I have not found this to be an issue. I have a huge network of over 200 clinicians that I’m in regular contact with through a group that we’ve created for gender-affirming mental health providers. With regard to therapists needing an attorney on speed dial, I know of no one, not a single person, who has been in any kind of legal trouble because of this work.
I think that the real risk is perhaps when these children are adults, and if something were to happen. But we hear in the media about regret and the fact of the matter is that the regret level is so low and that who’s being paraded out in the media is the same few people over and over again. And there are some young people whose gender identity shifts and changes, and they may choose to stop hormones, or they may have changed their pronouns. But in those cases, we’re not seeing where they have regret about what they did or that they’re upset with providers at all, but it’s just the next step in their journey.
LR: You mentioned that you’re a part of a network of 200 providers. Is that network something you can provide for our readers, or is it sort of a closed group?
MJ: Our group is called
Mind the Gap. We are in community partnership with UCSF’s Child and Adolescent Gender Center. The bulk of our members are here in California, particularly the San Francisco Bay Area. But we do have members who join us from around the country. So certainly, if anyone wanted to get in touch, or even if you’re wanting to consult with somebody, you can look on there, you can see names and reach out to people.
LR: Thanks so much for sharing your wisdom and experience with our readers, Michelle.
MJ: It was a delight talking with you.
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