Notes from the CATA Conference: keynote address by Stella O’Malley

Guest post by Harriet. Following on from the post Should therapists and counsellors speak about the medicalisation of gender non-conforming children? this post looks at the key note speaker address at CATA‘s Children, Adolescents and Gender – Impacts of transgender ideology Conference. Links supplied by author and editor.

Stella O’Malley is an impressive speaker. Her credentials in talking about gender dysphoria are impeccable. She recounts a childhood growing up with gender dysphoria and dressing and presenting herself as a boy. She is grateful, she tells us, that her family allowed her to be this way without trying to intervene. Her gender dysphoria resolved on its own once she progressed through puberty. Professionally Stella is well qualified to talk on clinical approaches to working with young people with gender dysphoria. This post is a summary of her clinical perspectives given in her key note address at the CATA conference.

There has been an exponential growth of young people presenting with gender dysphoria – a 5337% increase in girls presenting at the UK’s Tavistock Gender Identity Development Service. Genital surgeries on girls in the US increased significantly. Teen boys are following suit.

Previously people seen in gender clinics were either young children (mostly boys onset age three to six years) or middle aged men. 

This new cohort of teenage girls has never been seen before.

Identifying as trans is a self declaration. (Some organisations, such as World Professional Association for Transgender Health (PDF) or Stonewall UK,  state a child as young as two can declare a gender identity). Gender dysphoria is a clinical diagnosis (DSM 5) and it is important to make that distinction. There is a rush to affirm gender identity when young people self diagnose as trans. Previously in clinical practice a watchful waiting approach was used for young people with gender issues.

There any many theories related to what causes gender dysphoria. One theory that has driven and dominated treatment approaches is gender identity theory (the belief that a gender identity lives within us all, like a gendered soul). This theory underpins the affirmation model of treatment.

The affirmation model sees the therapist as facilitator unquestioningly supporting social and medical transition. It requires a lot from those around the young person to enable this social transition (new name, pronouns, toilets, sport teams).

The Cass review, when closing Tavistock GIDS, said the affirmation model was not a safe or viable treatment. 
New gender clinics will open in the UK and will use a more holistic approach.

A developmental model to understanding gender issues is the approach favoured by Stella O’Malley. Gender dysphoria is not uncommon in very young children, many of whom desist without intervention, much like she did. Stella cautions against social transition for children because developmentally they still engage in magical thinking, and social transition may bed down the new identity (particularly a risk for neuro diverse children).

Social transition in young children can also solidify and concretise everyone else’s perspective.

Identity formation is a lifelong process, particularly heightened in teenage years. The tasks of adolescence as we transition into adulthood, include an acceptance of our limitations. We are restricted by our time and place of birth, and we didn’t choose our parents, nor did we chose our bodies. Social transition around 16 years can be part of the adolescent phase of “trying on different hats.”

But social transition, while Stella is o.k. with it, is not a neutral act and strongly correlates with persistence.

Nowadays adolescent identity development is being significantly influenced by what teens are seeing online and this is contributing to increases in presentations of young people with gender issues.

A description of this phenomena was Lisa Littman’s 2018 paper on Rapid Onset Gender Dysphoria (ROGD). ROGD (which is not a diagnosis), identified that some teenage girls were spending excess time in chat rooms, the focus of which was trans related. Exponential increase in case presentations to clinics started around 2012 which was around the time of the introduction of the smart phone.

This was similar to previous waves of clinical presentations, such as young women with anorexia in the 70s (rarely seen before this). Bulimia in the 80s, followed by self harm. All involve young people hating themselves and their bodies.

Cass stated in her review, the new cohort with gender issues (adolescent presentations), are more complex than seen before. This cohort has significant co-morbidities that predate coming out as trans, such as OCD, eating disorders, neuro diversity.

Similar traits are found in this group; they tend to be quirky, intelligent, gullible, socially awkward, often obedient sweet natured kids. They are full of certainly when they self declare.

 Prior to onset of gender dysphoria and/or a trans identity, this group have heightened rates of a traumatic event and of knowing someone who is trans (social contagion is a factor) They come out as trans on the internet, but maintain secrecy about this at home. Not infrequently when they come out (often dramatically) it is a complete surprise to parents/family.

Stella discussed the allure of being someone different especially for awkward, quirky kids. There is a realization, “I can be part of the cool group”. Teenagers who want to transition think it is going to be easy and a solution for all their problems.

Therapy is not necessarily first port of call for these kids.  Parents need to be “heavy” on love, “heavy” on boundaries (particularly around electronic devices). Kids need to be encouraged with activities outside of home and the internet.

A holistic therapeutic intervention is Gender Exploratory therapy. This involves exploring concepts of gender and bodies to build self-awareness. This approach has no planned outcome.  It includes a full discussion about the medical burden of transitioning on the body.  Mostly this approach is enough for the young person to resolve their issues. Stella recognises that when adulthood is reached, some people may still want to transition, which is their choice, but it is a very difficult life, with a heavy medical burden and it is important that people are as well informed about this as possible

Will therapists in Aotearoa be able to practice this new holistic model?  Or does the Conversion Practices Bill mean that any therapeutic approach that isn’t Affirmation is seen as a conversion practice…….More to come.