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Last month we published an article written by an experienced clinical psychologist on the risks of socially transitioning young children. We are very grateful for this follow-up post on the affirmation and social transition of adolescents. When a teenager says they’re transgender, is affirmation and encouragement to socially transition the most supportive approach?

A Really Powerful Intervention

I’m surrounded with teenagers who have changed their gender. It’s everywhere, both in the young people I see at work and in young people I know socially. It has become entirely unremarkable to be told that Beth is now Seth, and to please try to get their new pronouns right as otherwise they get very upset.   

Like many people, I used to see affirmation and social transition as a low-risk strategy. “It’s fully reversible”, people say, as a reason to push forwards and act quickly. Sometimes within weeks of a young person expressing distress, they’ve been transitioned at home and at school. 

The more young people I meet, the less I think it’s low risk. The ‘fully reversible’ story is missing any psychological angle at all. Trying to be perceived as one sex, whilst developing the body of another, is never going to be a trivial thing to do. We can’t reverse the experiences of adolescence.

Seth’s mother tells me a typical story. Her voice lowers to a whisper. ‘He was so distressed about his body’, she told me, ‘that he went on the internet and ordered testosterone. Just think of how desperate he must have been. I feel so guilty’. 

Seth’s story started years ago. Born Beth, she was bullied at primary school. Things got worse when she moved to secondary school where she was excluded by other girls and started finding academic work hard. She felt unhappy and that no one understood.

As she went through puberty, her anxiety about how others saw her started to intensify. She strongly disliked the male attention which came with her maturing body and then she was sexually assaulted on the bus one day coming back from school.  Ashamed and embarrassed, she told no one. Her emotions started to feel overwhelming, and Beth didn’t know how to manage them. She thought maybe she was losing her mind. She started to spend a lot of time on the internet. There, she found people on TikTok and YouTube talking about gender dysphoria and she recognised herself. 

The influencers offered hope and a way out. ‘The reason you feel so bad is because you’re really trans’, they said, ‘And in order to feel better you need to change gender. Look at how well it worked for me!’

Beth has a moment of intense relief. She has an explanation and there’s light at the end of the tunnel. Maybe she feels so bad because she is living in the wrong body. It feels so good to think this that she’s sure it must be right.

Finding an explanation for your feelings is a great comfort. It’s so much better than thinking that you will feel like this forever, or that you are going mad. It can resolve feelings of uncertainty, silencing frightening thoughts like ‘Maybe I’m losing my mind’. Unfortunately that effect is there whether the explanation is right or not.  

The relief of finding an explanation is wonderful but short lived for Beth. She thinks she knows now why she is so distressed – she is in the wrong body. But that body is changing into that of an adult female. The relief evaporates to be replaced with urgency. She must do something. Now. She wants that feeling of relief back. 

When Beth decides to disclose how she is feeling, she starts with a teacher. She’s seen others go down this route before. Miss F is immediately sympathetic and congratulates her on her bravery at coming out. She totally gets it and understands Beth doesn’t want her parents involved yet. Miss F says she’ll help Beth transition.

Beth becomes Seth at school, changes uniform and does P.E. with the boys. Everyone tells her it’s wonderful she came out and she finally has a group of friends, all of whom are trans or non-binary. She feels good. She lives a double life for a while, changing her skirt and pronouns on the way home in a public toilet. She feels her life has a purpose and a sparkle. She has found her place.

When she tells her parents, it’s as a fait accompli. They are shocked but she tells them that there is no discussion left to have. Seth is trans and has already partly transitioned. She transitions at home as well.

All the people around Beth have now agreed with the explanation that she has found – that the reason that she feels so distressed is because she’s living in the wrong body. No one has suggested that there might be another reason, or asked questions about how Beth came to this conclusion. She gets too upset about it to have a real discussion. Avoidance feels safer.

On a psychological level this consensus is really powerful for Beth. It reinforces her certainty that she has found the right answer. She cuts out from her life anyone who might say otherwise and surrounds herself with supporters. She’s now living in a world where everyone is behaving as if it’s Beth’s body, not her feelings, which is the problem. No other suggestion is allowed in.

If social transition worked, we might have thought that things would settle down now and everyone would be happy. Actually what happens is that Seth and their family find that they are on an emotional roller coaster. Each step – finding the explanation, telling a teacher, transition at school, transition at home, brings short term relief. They all breath out for a while.

But with each change the contrast between Seth’s desire to be male and their female body becomes more obvious. Now Seth literally is in the wrong body, as he tries so hard to be seen as male. The relief fades and he becomes preoccupied with his female body and how much he hates it. The more he thinks about it, the worse he feels. Anxiety and unhappiness come back. He starts to self-harm. No one can talk about whether his transition might be making the distress worse, however, because that would be transphobic. The reason is assumed to be because it’s so hard being trans, and so everyone is even more careful to avoid any reminder of Seth’s female body.

Before transition, Beth was someone who felt deeply unhappy and anxious, and there were many possible reasons for that. Now that it has been decided that Seth is trans, the other reasons aren’t talked about. The body is defined as the problem.  

Everyone pretends that they see Seth as male, that they’re cool with changing pronouns and uniforms. Feeling okay now relies on other people not noticing or mentioning their femaleness. It’s a fragile way to live, where being accidentally referred to as ‘she’ can send Seth down a tunnel of misery and self-hatred. The more Seth tries to be male, the more he wants to avoid any reminder that this is not in fact the case.  But he is carrying these reminders around with him, in his female body. That body doesn’t pretend. It tells the truth, and so to Seth it feels like their body is the liar. They think if only their body was different, they would be happy.

It seems to Seth that the solution is to try to force his developing body down a route which it would not naturally follow. Medical intervention feels more and more urgent. It’s the only way to stop their body constantly reminding them of what they would like to forget. They come to believe that their psychological well-being is dependent on changing their physical reality.

Seth’s research on the internet tells him what to do. He orders testosterone from an unregulated site. He is hopeful and happier again. No longer will his body betray him. He thinks he can go through a male puberty. He feels better.

His mother finds the package with drugs and is horrified. Seth explains that he just has to stop his body changing. He said he feels like he’s falling into a black hole. His mother takes him to the doctor straight away and they are referred to a psychiatrist. The psychiatrist prescribes an anti-depressant and suggests they wait to see how things develop. Seth curls up and howls. ‘When I think of not getting hormones, I feel like dying’ he cries. Then he turns on his mother, ‘You took my testosterone away’ he says. He is furious. His mother feels terrible. She contacts a private gender clinic. 

This has all happened before she talks to me. Up to now there has been no discussion about the meaning of what is happening, beyond the ‘born in the wrong body’ explanation. There has been no exploration of other possible reasons for Seth’s distress. No one has suggested that perhaps many girls feel uncomfortable in their developing female body, particularly when they have been sexually assaulted.

Everyone has agreed with the explanation which Seth found for themselves – that they are trans, and therefore that the way to feel better is to transition. They are all living as if this is true. This is a really significant intervention, which confirms to Seth every day that he is correct in thinking that he is trans. Everyone is pretending that it’s a superficial change and that it’s ‘fully reversible’. They’re scared that to question the idea that Seth is trans would be seen as transphobia, or conversion therapy.    

The reason most parents give for their teenager’s transition is just how extreme their distress was.  They assume that when I hear how upset they were, I will agree that there was no other choice. Seth’s mother tells me how he has a panic attack when he learns there’s a waiting list for the gender clinic.  She tells me she’s worried she’ll lose him all together if she doesn’t move things on fast enough. Other parents tell me their children said they would jump out the window unless they agreed to a transition. Most of them say they want to hurt themselves. All the parents have found information online which tells them that their child is at very high risk of suicide if they aren’t allowed to quickly transition. 

Understandably this makes parents extremely anxious. Highly distressed teenagers are saying that the only way to relieve their distress is to transition. They really believe that’s the case and it’s tempting to believe them. The need to alleviate distress drives decisions.  

The problem is that trying to avoid emotional distress about reality is not a good reason to make a life-changing decision. In fact, it’s an inconvenient truth that even well-intentioned efforts to reduce distress can end up making it worse.

I sometimes work with people who started to feel anxious in crowded places. In order to avoid these feelings they stay at home, and the result of this is that over time they become more, not less, frightened of going out. When I see people after years of staying indoors they will sometimes have panic attacks just walking down their front path. All their strenuous efforts to avoid distress have resulted in a problem which is far more serious than it was at the start. Often their whole family will be involved in organising life so they never have to go out. The person is behaving as if the outside world is the problem, rather than addressing the way they feel about the outside world, and everyone else is supporting them to live as if they are correct. 

 Something similar is happening to Seth. He wants to avoid distress triggered by his female body.  Seth’s school, friends and teachers behave as if Seth’s distress must be avoided by pretending that his body is not female. The more they do this, the more likely it is that Seth will feel distressed about the femaleness of his body. This distress will be interpreted as further evidence that he is trans or gender dysphoric. No one will consider that it might be a side effect of affirmation.

As Seth avoids the reality of his female body, the more distressed he feels. He takes the pill back-to-back so that he no longer has periods. He wears a binder even though it hurts. Both things remind him every day that his body is not male, and that his body refuses to pretend. There is no peace for Seth, because his body is developing into an adult female, whilst he tries so hard to be male. His whole life is based on a contradiction. A contradiction that was made worse by his transition.

There’s an imbalance in Seth’s life. Everywhere he goes, transitioning is celebrated as the brave and liberating choice – whilst learning to accept his body as it is? No one is celebrating that, or even suggesting that it is a possibility. No one is congratulated for their bravery for deciding not to change their pronouns, or for deciding not to have top surgery. No one is championing the affirmation of biological girls as female. No one is even suggesting that this might be an option. They know better; that would be transphobic.

By the time I talk to Seth’s mother, there are no decisions left to make. She wants me to help him feel less depressed and anxious as he waits for the gender clinic. I know that I can’t ask questions about gender, or whether medical transition is really the only choice here. I can’t suggest that it might be useful to dig deeper into the distress about his female body, to experience distress rather than avoid it. I can’t suggest that learning to live in your body might possibly be better than a life of medicalisation.  That could be seen as conversion therapy. It’s like working with both hands tied behind my back. It feels like I am years too late. Affirmation and social transition have completely shut off any other options.

Everyone has affirmed Seth’s explanation, and with each new step, it became harder to consider any other possibilities. Now, just mentioning delaying hormones is enough to provoke a panic attack. Affirmation is a really powerful intervention. 

Agreeing with young people that they were born in the wrong body and organising their life around that belief is not a low risk thing to do. It’s a serious psychological intervention based on denial and avoidance. Believing their happiness is conditional on denying reality puts young people in a fragile state, dependent on the pretence of others for their psychological wellbeing. Affirmation feels like such a relief, but it’s a seductive illusion. Holding options open and sitting with uncertainty has never felt more difficult, or more important.

Our young people need more from us. Supporting them doesn’t have to mean agreeing with them. We owe them honesty, even if it’s painful to hear. We need to tell them that there are many reasons to feel distressed with your developing body, and just because an explanation feels right now, it might not do so for ever. We need to show them that they can tolerate distress and that we’ll help them learn.  We need to tell them that we can’t avoid biological reality, no matter how hard we try, and one day they too will find this out. We need to do this now, or in the future too many of them will turn to us and ask, “Why didn’t you ever tell me I might be wrong?”