Sasha Ayad är en amerikansk psykolog som är specialiserad på hjälp till barn och unga med könsdysfori. Hon publicerar regelbundet filmer och artiklar, och svarar på föräldrars frågor, på sin kanal på plattformen Subscribestar. Prenumerationen kostar 10 USD per månad.

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In this day and age, exploration of sexuality and gender is a normal part of a teenager’s development and maturation. In therapeutic work with teens, I’ve observed some of the interesting ways in which this exploration can unfold. In 2014, I was a school counselor working with low-income and at-risk youth. There, I founded and lead our first GSA, or Gay-Straight Alliance. It attracted students from multiple grade levels and the group was full of bright, creative, and engaged kids – truly inspired teens. I always tried to be watchful and nuanced when framing our discussions because of how sensitive and impressionable teenagers are. I quickly noticed that the kids were expressing a lot of confusion. Specifically, they got into animated conversations about the growing list of divergent (and sometimes bewildering) gender identities and sexualities being introduced by mainstream LGBT advocates. I remember one meeting in particular: a girl told the group about a set of bracelets she had seen online. Each one is a different color, worn to supposedly indicate what gender you are “identifying as” that day – so others know what pronouns to use when addressing you. She seemed puzzled and asked us, “I mean, how exactly can you feel like a boy, or a demi-girl, or non-binary? Are they talking about emotions, like if I’m feeling kinda angry and aggressive, does that mean I’m identifying as a guy that day? Or like, what kind of clothes I am wearing?” Other students chimed in, agreeing, and we had a thoughtful and interesting conversation about what it could mean to have a gender identity. We couldn’t reach a satisfying conclusion, perhaps because gender identity is complex and multi-factorial. 

Interestingly enough, a few years later, the same girl who couldn’t even fathom the notion of gender identity, now suddenly has a new one herself – she identifies as a transboy. She has recently started “coming out” to loved ones and teachers. Apparently, she made this self-discovery after spending a lot of time online trying to learn more about gender identity, precisely because she didn’t understand it and wanted to be a good ally. The iatrogenic nature of this cycle seems clear and deserves more research, but mainstream medical and mental health organizations have been largely silent about the potential causality in this relationship. Informally, this phenomenon – declaring oneself transgender for the first time around puberty after showing no signs of gender dysphoria as a child – has been descriptively termed Rapid Onset Gender Dysphoria.

I’ve spent the last six years trying to understand the historical changes in the notion of gender identity, childhood transition, and the relatively new phenomenon of teens questioning their gender. This emergent population also displays an over-representation of developmental conditions like autism and Aspbergers. Adjustment to pubery, social isolation, anxiety, depression, and body image issues also seem to be correlated with gender questioning.  In my practice I prioritize careful, thorough assessment, long-view mental health considerations, and individualized treatment for the whole person. I follow the standard of therapeutic care which requires clinicians to listen intently, consider nuance and complexity, and read between the lines of what the child may be claiming. This method of practice is endorsed by experts with decades of experience as pioneers in the field of transgender care.

There also seems to be a surge in the number of young people detransitioning, or stopping medical intervention and re-identifying with their birth sex. This population deserves much more attention from the mental health community. Based on my clinical observation with these clients, identity reversals have usually occurred spontaneously, once underlying issues are resolved, same-sex attraction is embraced, or once a more nuanced reflection of identity is undertaken. Many of these young people are sharing their experience of transition and detransition: here, here, and many more here.  The existence of this population supports the need for comprehensive, individualized, person-centered assessment and treatment for gender dysphoria. 

I work with teens in individual therapy, but also consult with families in a collaborative effort to best support gender-questioning teens. I’ve aimed for diligence and patience by carefully listening to trans-identified youth.  In this way, session content can move beyond cliches and kids can speak for (and think for) themselves more authentically. Our therapeutic work revolves around individualized identity exploration and seeks to alleviate distress by building capacity and self-awareness. 

Introspection, self-compassion, and movement towards wholeness are aspirational goals in any therapeutic relationship, and these are the focus of my practice. My work aims to help clients look beneath the literal interpretation of their incongruent feelings, giving them room to explore with nuance and intuition. Each client is different, with a unique story to tell. For some, transition may be the best option. But for many others, resolving underlying issues can bring about an organic resolution to gender conflicts.

A client once told me something like this, “I think being trans was really about not liking myself and wanting to be someone else. I am so glad that you didn’t just rush me off to get hormones, because I’m really happy now and I would have regretted transition. I have a lot of respect for you for taking things slow.” I was touched by this client’s willingness to be so introspective and recognize how other struggles had manifested for her, as a gender issue. However, is this really so surprising? After all, teenage-hood has always been characterized by deeply important and sometimes erratic attempts to navigate the conflicts and responsibilities of growing up. When teenagers can come to appreciate this, it’s a sign of true growth.