The Torah unequivocally teaches us that our gender is not only a biological reality but part and parcel of the unique, holy mission designated for every Jew. Thus, a transgender lifestyle is highly discordant with the sensibilities of a Torah Jew. What is even more unsettling to our sensibilities is the explosion of interest in and encouragement of transgender lifestyles that has developed in the secular world over the last ten years. This encouragement is accelerating and saturating the public consciousness. 

What is particularly concerning is that the Torah world is not only watching from the sidelines, unimpacted. We too are part of this drama. This sea change is influencing our youth. And the parents of such impacted children are often left to their own devices in trying to understand what is going on with their children and how to help them. 

The present political and social battle surrounding gender identity and gender politics is nothing less than a battle for the soul of a generation. What makes matters worse is that the whole area is awash in misinformation. We desperately need to start sharing clinically reliable information about gender dysphoria and distinguish it from the myth and hyperbole that are disseminated about it from both the right and left.

That being said, I offer the following information, knowing that my discussion will be far from exhaustive, but doing my best to provide a primer for the perplexed. 

Gender dysphoria is a real and extremely emotionally distressing condition that needs to be taken seriously, often, literally, as a matter of pikuach nefesh.

Gender dysphoria is clinically defined as an observable incongruence between one's birth gender and their experienced or expressed gender, often accompanied by marked psychological distress about the situation. In the standard psychiatric diagnostic manual, the condition is defined by different lists of symptoms for children and for adolescents/adults. For children, the majority of listed symptoms are behaviorally observable (e.g., strong preference for cross-gender attire, cross-gender roles in make-believe play, and playmates of the opposite gender; and rejection of toys, games, and activities generally associated with the birth gender), but also include more internal experiences (e.g., strong desire to be the other gender and dislike for one’s gender-related anatomy). For adolescents and adults, symptoms can include a feeling of incongruence between one’s bodily form and experienced or expressed gender, a desire to remove one’s physical sexual characteristics, and a desire to be the opposite gender or to be treated as the opposite gender. Children have to present with a greater range of symptoms to receive the diagnosis, as compared to adolescents or adults. 

Stories of children and adolescents with gender dysphoria can be nothing less than heartbreaking. Children who go on to develop gender dysphoria often express cross-gender behaviors at ages as young as between two and four years. Their dissatisfaction with their physical anatomy can increase over time, and they often eventually exhibit depression, poor adjustment, isolation, and even self-mutilation. 

True gender dysphoria is a very rare condition. For biological males, the prevalence ranges from .005% to .014%, while the prevalence for biological females is .002% to .003%. As demonstrated by these numbers, there has been a longstanding clinical observation that this condition is significantly more common amongst males as compared to females. 

Individuals with gender dysphoria are at heightened risk for depression, anxiety, substance abuse, and suicidality. It is particularly concerning that prior research has reported a 41% lifetime prevalence of suicide attempts amongst transgender people. What makes matters more confusing is that the suicide attempts could be an outcome of their depression, the social effects of the gender nonconformity, or both. Nonetheless, the suffering of those who have gender dysphoria is real and needs to be taken seriously. For some, the only pathway beyond their distress may be to transition to a social presentation that is congruent with their gender identity. I am aware of a number of Orthodox rabbis (e.g., Rabbi Tzvi Hirsh Weinreb) who have expressed recognition that such a course of action may indeed be pikuach nefesh for some of these afflicted individuals. 

Transition can be pursued with or without medical intervention. Medical interventions include puberty blockers, cross-gender hormones and surgery. Where there is no social, psychological or medical encouragement of children with gender dysphoria to present as opposite from their biological sex, roughly 80% of them will grow out of this condition by the time they reach adulthood.  That being the case, there certainly seems to be value in delaying medical interventions until the individual has a clearer and more established self-identity (ideally waiting until adulthood). 

To make matters worse, research on the value of medically assisted transition has often been of poor quality (including lack of representative samples, lack of proper control group, short follow-up periods, insufficient psychological examination of the participants and other weaknesses in research design). At this point, all that can be safely said about such research is that we need more time and patient, disciplined study of the issue before when can conclude that medical transition is generally helpful, neutral or harmful to psychological outcome. Given the many uncertainties about the actual psychological benefits of medical transition, it is important to evaluate any such action with healthy skepticism and caution. 

It is very important to distinguish classic presentations of gender dysphoria from such dysphoria that is of recent onset in adolescence and is socially influenced

Miri is a twelve-year-old girl who has two older brothers. She has always looked up to her athletic, confident brothers, who have the ability to instantly make friends. She tried to keep up with them in backyard football games and wrestling matches in the living room. The in-house wrestling was sometimes a little too much for their mother, who would shout and send them all to their rooms when things got out of hand. According to her parents, Miri was a delightful child: upbeat, obedient, and comfortable with her peers. Then, when she was eleven and the younger of her two brothers turned fourteen, he developed bipolar disorder. This was a tremendous emotional challenge to the whole family. As their parents dealt with hospitalizations, consulting with doctors, and the like, Miri felt like she was increasingly left to her own devices. Her happy family had now become sullen, serious, and stressed.

Miri started using YouTube and social networking on the family computer to seek some pleasant distraction from the drama around her and from her own increasing sense of agitation. Her parents did not really like that she was spending so much time on the computer, but they were loath to take away something that did seem to make her happy at a time when everyone in the family was suffering. Miri started spending four to five hours online on school days, more on Sundays. Her parents had so much on their minds that they could not supervise what she was doing online. 

Three months later, Miri announced to her parents that she was a boy and that she wanted them to call her Yoseph. She claimed to have always been uncomfortable with a girl identity, although her parents had never heard her say anything like this before, nor seen her show discomfort at wearing dresses or other aspects of female appearance. She cut her hair short, put on a kippah, would only wear pants, and threw out her nail polish and pink bedspread. She had previously loved davening, but now has stopped completely. She says that she will not pray to a G-d who forbids people to be what they are. 

A number of factors over the recent years have transformed gender dysphoria from a psychiatric condition into a fascination and trend, in which adolescents frequently influence each other to adopt a gender image that contradicts their biological one. These young people are influenced not only by their peers but by trans activists and spokespeople, most commonly found via the internet (on YouTube and social networking sites). The trans encouragers look at the developmentally normal confusions of preteens (changing bodies, intense emotional reactions, shifting sense of self, sudden development of attractions that they may never have had before) and offer these youths a new narrative for these experiences. That narrative is that the young person is socially anxious or depressed or confused or uncomfortable with the changes in their body because they are really trans and are just now coming to terms with it. “Of course you are struggling,” goes that narrative, “You are a female trapped in a male body (or vice versa) and it is the prejudices and strictures of society that limit your true expression of who you are inside, resulting in your marked distress.” 

There are a number of compelling pieces of evidence that social influence is the origin of the great majority of gender dysphoria seen today. Take, for example, the well-known phenomenon, referenced above, that, with the exception of the most recent years, throughout the period that gender dysphoria has been studied, it has been much more prevalent in biological males than females. Over the last ten years, that ratio has shifted to the point that the condition is much more prevalent in biological females. This change is dramatic and appears to be accelerating. In the last decade, the prevalence of gender dysphoria increased by 1,000%. In 2016 biological females accounted for 46% of all sex reassignment surgeries in the US. A year later, it was 70%. In 2018, the UK reported an increase in cases of gender dysphoria, over the previous decade, of 4,000%, and three-quarters of those referred to gender treatment there are biological females. Clinicians from multiple treatment centers throughout the world are reporting a sudden and dramatic demographic shift in those presenting with gender dysphoria, from predominantly preschool-aged boys to predominantly adolescent girls.

These changes are so new that much work needs to be done to properly research and clarify the nature of the phenomenon and its causes. There is a very compelling piece of research conducted by a physician named Lisa Littman (published in 2018) titled Parent Reports of Adolescent and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria. In that study, parents of children presenting with this rapid-onset condition completed lengthy questionnaires, examining their own and their child’s experience. Some of the key findings in that study were:

--Over 80% of the adolescents were biological females with a mean age of 16.4.

--The vast majority had absolutely no indicators of childhood gender dysphoria.

--Almost one-third of the adolescents did not seem at all gender dysphoric, according to their parents, before announcing their trans identity.

--Nearly 70% of the adolescents belonged to a peer group in which at least one friend also had come out as transgender. In some groups, the majority of friends had done so.

--65% of teens increased their time spent online immediately before coming out.

--For those parents who were privy to information about social status, 60% indicated that the announcement of being trans appeared to increase their child’s popularity. 

--47% reported that their child’s mental health worsened after their identification as transgender.

There is a well-known tendency for certain mental health dysfunctions to spread through adolescent girl peer groups. Examples include anorexia nervosa and self-harm/cutting, both of which are more commonly found amongst girls than boys. Girls tend to have intense social alliances and empathize deeply with the struggles of their friends. Along with this innate empathy goes a tendency to be influenced and drawn into the emotional experiences and dysfunctional behaviors exhibited by their peers. This process provides a good explanation for why anorexia, cutting and, now, rapid-onset gender dysphoria are much more common in female than in male populations. 

It is also interesting to note that many anorexics experience anxiety about growing up and deliberately starve themselves to make themselves look smaller, younger, and less like a woman. It is likely that many girls exhibiting rapid-onset gender dysphoria are experiencing those same misgivings about oncoming adulthood and may turn to a trans identity to slow that maturation process down. It is notable that autistic spectrum disorder often co-occurs with gender dysphoria. Might such young people on the autism spectrum be perplexed about the social and emotional challenges of upcoming puberty, and, fearing its onset, hope for a way to delay it? These desires for delay are facilitated by the medical system, which provides puberty blockers for an extended period of time to give the youth time to “think though” their gender identity. 

Effective parental responses to their children’s gender questioning is becoming increasingly difficult in a political, social, and clinical environment governed by gender ideology.

Over the past fifteen years, gender identity exploration has been decreasingly seen through a clinical lens and increasingly is being treated as a matter of personal choice and exploration and as a basic human right. In many circles, simple congruence with one’s biological gender is seen as dull and also as giving in to the oppressive social and religious forces that dictate “acceptable” versus “unacceptable” forms of gender expression. 

As an acknowledgement to this new conceptualization of gender questioning, the standard of care in the medical community has shifted to something called “affirmative care.” Affirmative care can best be understood in contrast with older medical approaches to gender dysphoria, in which a therapist would patiently explore the gender identity history and present self-perception to determine if a gender transition even makes sense, and, if so, when the patient is ready to proceed. In affirmative care, that gatekeeping function has been removed from the therapist. The therapist is told that a person IS the gender that they say they are (even if that gender may vacillate from week to week) and it is the therapist’s responsibility to affirm that gender and to aid the patient to actualize a gender expression that is congruent with their perceived gender. Of course, what starts with simple affirmation very often progresses to treatment with cross-sex hormones, and finally with surgical gender-changing procedures.

This affirmative care standard is now the official position of the American Psychological Association and the American Academy of Pediatrics. In addition, twenty states (which include New York, New Jersey, and Maryland) now have laws on the books banning “conversion therapy” with minors (which presumably includes therapy that encourages the patient to explore and even question their conviction that their actual gender differs from their biological one). Therapists fear that they could lose their license if they do not conform to this law, and many therapists have consequently withdrawn from providing any treatment to minors with gender dysphoria. 

Other trends threaten to further undermine parents' role as guardians of their perhaps well-meaning but immature charges. This year, Maryland adopted a law allowing minors as young as twelve years of age to consent to mental health treatment, joining California, Georgia, Illinois, and West Virginia, who similarly allow such consent to preteens. These statutes open the door for gender-questioning youth to seek out affirmative gender mental health care on their own, even in the face of parental opposition. 

Advice for parents of children with gender dysphoria

Where does this state of affairs leave parents who question the wisdom of the affirmative care model? It leaves them in a precarious position. So many of these children are deeply troubled, frustrated, and confused. Their parents fear to take their child to therapy and have them further indoctrinated, but equally fear to not take their child to therapy and have them sink deeper into depression, dysfunction, withdrawal, etc.

The first and, perhaps, most vital step that parents need to take is to see the challenge that is now facing their child and their family as a bracha. As our sages have abundantly taught us, Hashem gives us tsuris to burnish the rough diamond that is our soul and to make us grow. It is not up to us to understand why He brings such challenges to families, but it is at the core of Jewish emunah that it is Hashem who has brought all these family members together to jointly face this and other challenges and spiritually grow from them. In that process, all family members are students—there to learn the lessons that their close ones are there to teach. We are not advocating that parents cede legitimate authority, but they must, at the same time, realize that they, too, are students and that their children often are teachers. 

Rabbi Yitzchak Breitowitz of Ohr Somayach, in a recent talk on gender identity issues, made reference to an idea (which is described by Rav Kook and Rav Tzadok Hakohen) that at various times, powerful ideas that have a great holiness enter the world. The powers of evil in the world rise to resist this holy light and pervert it into channels that are destructive. Our challenge is to not reject the holy idea on the basis of how it has been perverted. Rather, it is our mission to extract the kernel of holiness that is hidden and liberate it from the klippa (shell) that traps and darkens it. 

What does all of this have to do with gender identity? As Rabbi Breitowitz went on to explain, our deepest Jewish sources teach us that there are male and female elements in the world and within each man and woman, which reflects the fact that Hashem Himself has masculine and feminine attributes. The holy idea embedded in the whole trans movement is that we must take responsibility for the way that we all may have been too shallow about our gender attributions. Messages like girls are sweet and boys are tough or girls look for consensus while boys compete are simplistic and gross generalizations. These messages will certainly leave children who do not conform to these expectations feeling like they are “less than.” The message we need to learn from the transgender movement is that we have to be open to emotional and sensitive boys and that there is more to a girl than her dress, hairstyle, and makeup. If this is the message that we must humbly learn from our gender-challenging children, then they are indeed teaching us a good and holy message.

Beyond the above considerations, it is my advice that parents be careful, planful, and strategic about how they respond to a gender-questioning child. Parents should seek out therapists who, at the very least, do not view immediate gender transition, hormone modification, and/or surgery as THE solution to gender dysphoria. In addition, such therapists should be open to the idea that depression, an anxiety disorder, or some other condition may be the primary cause for the gender confusion and that attention needs to be given to those other mental health problems, which may in itself, over time, allow the gender confusion to abate. If it is hard to find such people who are still treating minors, then parents should consult with them anyway, without the therapist seeing their child, for the parents to get expert advice on how to interface with their children regarding these issues. 

In addition, parents need to strategically size up areas in which they may still have control (e.g., still having a parental right to veto the child’s receiving medical transition treatment) as opposed to areas that they have much more difficulty controlling (e.g., the child going by a new name amongst her friends, changing her dress style, or referring to herself as the opposite gender). The dictum of Hippocrates is vital here: First, do no harm. Parents should do their best to avoid unnecessary drama. They need to acknowledge the limits of their control and to help maintain sanity through acceptance, connection, and love. There should be no forbidden conversations. Whatever their moral or halachic views, parents still need to be open to the child’s honest experience of themselves and their world. Much as a therapist does, the listening comes first and then gentle guidance can gradually proceed.

It is perfectly okay to ask your child questions about their experience. Just be careful to not make it sound like an interrogation. A well-placed question can demonstrate that you want to understand your child better and that you are willing to listen. Questions should be formed in such a way that they invite longer answers (e.g., Can you tell me more about “really being a boy” and what that means to you?), rather than seek specific information (e.g., when did you start feeling like you were a boy?). Most importantly, be patient and allow silence while a child takes time to think and formulate an answer or offer additional thoughts. Often, the biggest mistake parents make is talking too much or trying to make their child talk more than they are ready to. Generally, parents act this way because they are having difficulty managing their own anxiety. (If that is the case, you may need to see a therapist yourself to develop strategies to cope with your child’s behavior and your reaction to it.) When talking with your child, be sensitive to if they become frustrated or agitated or start to shut down. Maybe at that point, they need some space, and the conversation can be taken up at a later time. 

An additional caution to parents: Gender politics are filled with ideology, which has the intensity of religious zealotry. Do not be drawn into debates with your children about this ideology. Transgender advocates, who now include your child, feel that they are literally advocating for something that saves lives. Carefully clarify your goals: Do you want to prove yourself to be a better debater than your child, or do you want to keep a connection with them, which will leave the door open to a way back?

That being said, it still is important to inform your child of the physical outcomes and side effects related to a medically assisted gender transition. Here are some examples: Delaying puberty will put children in a type of biological time capsule, while their peers will look, speak, and act increasingly differently from them. This mismatch with peers can result in increased feelings of not belonging. It is also quite concerning that little is known about the lasting effects of puberty blockers on brain development. In addition, Lupron, one of the drugs widely used as a puberty blocker is associated with depression, bone thinning and chronic pain (in women who have used it for precocious puberty). Further, puberty blocker treatment followed immediately by cross-gender hormone treatment seriously threatens fertility, and it is unknown if this can be reversed. 

There are also a host of serious negative long-term health impacts that could result from the administration of cross-gender hormones. Feminizing hormones have been associated with increased risk of cardiovascular disease and deep vein thrombosis. Masculinizing hormones have been associated with increased blood pressure and increased risk of heart attack. Research into the effects of cross-sex hormones is complex and often contradictory, and some of the above-mentioned impacts are still being questioned. But at the very least, we can presently say that use of these regimens may pose a serious threat to long-term health. 

I also advise parents to read Irreversible Damage by Abigail Shrier, who provides a clear-eyed and courageous examination of the transgender craze and all the concerns and hazards that surround it.

This is a vexingly complex area. My attempt herein was only to provide a brief introduction and to help parents of gender-questioning children guide them along their tortuous path. Without a doubt, it is a journey that will be transformative, spiritually and emotionally, to both parent and child. 

*(The story of Miri/Yoseph above is based on a conglomeration of different cases, none of which are associated with those names). 

Michael Milgraum is a clinical psychologist and author, who has been in private practice in Maryland for more than twenty years. 

(c) 2022 Michael Milgraum