Affirmation OR Assessment
Therapy First's Thomas Sherry writes on difference between "gatekeeping" and clinical assessment
Until recently, “gate keeping” expressed the simple idea that qualified individuals would determine the best course of medical intervention for a particular individual or ailment. It merely describes clinical assessment. Many therapists, providers, and activists claim “assessment” remains an essential element in the process of pursuing medical care for gender dysphoric youth. Others argue “gate keeping” is discriminatory because assessment itself invalidates the assertion “children know who they are.” In this world view, if the child says they are trans—they are. And it would be inappropriate to question that in the same way it feels inappropriate to question a teen’s stated sexuality. But assessment is the process of “questioning that.” In the US, the “affirmation model” is so robust that nearly 100% of children referred to youth gender clinics are placed on a medical pathway regardless of what comorbidities they may have. So, which one is it? Are we assessing or affirming?
Providers, clinicians, and the public want to be kind and supportive to this growing cohort of distressed youth. Affirming them feels like the right thing to do. Many of my friends responded to my concerns with the simple axiom, “I choose love.” But they confuse affirmation with validation. I can validate my son’s anxiety about being the worst player on the team without agreeing with him. As a clinician I validate an individual suffering from anorexia, acknowledging that they feel overweight, without affirming the idea they are overweight. Validating a person’s experience is vastly different from affirming it. Caregivers should validate a child’s experience by providing support and reassurance as they work through these turbulent years. It is appropriate, loving, and kind to encourage children to explore the entirely of their distress and to help them question their internal experiences and understandings. Evidence is overwhelming that most individuals who experience gender dysphoria in childhood end up being well adjusted gay adults.
The crucible of puberty and adolescence enables most individuals to accept their bodies and form stable identities. European countries that pioneered medical interventions for trans identifying youth have moved away from the affirmation and medical model to a “watch and wait” approach. In fact, the Dutch Protocol, upon which youth “gender affirming care” is based, had a very robust assessment system.
There are individuals whose trans identities will persist into adulthood. But right now, there is no way to determine which child is working through a developmental process and which one will persist as trans identifying adult. Children do know themselves, but parents also know their children. It is possible to validate both a child’s individual claims and a parent’s expressed concern. Both childhood and parenthood are an evolving process. Why is the therapy profession so fixated on a child’s fixation and so eager to invalidate or dismiss parental observations?
Those of us at Therapy First and in the “watch and wait” camp want children to explore all kinds of identities and possibilities as they march towards adulthood. Gender expression should be celebrated and encouraged. Distress associated with puberty and body image should normalized. Parents I work with are totally fine with their child’s individual expression and experimentation. Most are only concerned about the possibility of permanent physical modification to what could be a transitory adolescent experience. We live in strange times when we need to remind people that adolescence is a time OF transition not a time TO transition.
Tom Sherry is a child and family therapist who has focused on adolescents and parents for the past 25 years. He lives with his wife and son in Asheville, North Carolina. When inspired, he posts to his Substack Chill the F Out.
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Thank you for writing this post. I can attest to the parent part.
"In the US, the “affirmation model” is so robust that nearly 100% of children referred to youth gender clinics are placed on a medical pathway regardless of what comorbidities they may have."
-None of the many comorbidities my daughter had were addressed, and I begged for them to be treated first, before medicalization, and I failed. The medical field was captured and did not feel a mom (parent) mattered. "Affirmation-only Care" does not consider treatment of underlying comorbidies important or necessary.
"Validating a person’s experience is vastly different from affirming it. Caregivers should validate a child’s experience by providing support and reassurance as they work through these turbulent years. It is appropriate, loving, and kind to encourage children to explore the entirely of their distress and to help them question their internal experiences and understandings. Evidence is overwhelming that most individuals who experience gender dysphoria in childhood end up being well adjusted gay adults."
-My daughter did grow up to be gay and was accepted for that by me and the family and still decided to "trans away the gay" in her 20s.
"Children do know themselves, but parents also know their children. It is possible to validate both a child’s individual claims and a parent’s expressed concern. Both childhood and parenthood are an evolving process. Why is the therapy profession so fixated on a child’s fixation and so eager to invalidate or dismiss parental observations?"
-As a mom, I was demonized, censored, and called derogatory names.
Yes, parents matter. I have written all about it on my Substack for anyone who is open to the parent perspective you elude to. https://thetranstrain.substack.com
Thanks, Tom!!