Amy Tishelman has been near the center of the field of youth transgender health for more than a decade.
A clinical psychologist, Tishelman was the director of research at Boston Children’s Hospital’s gender clinic for eight years. She was a lead author of the international standards of care for treatment of gender-diverse children.
She has also become a critic of the field she has helped shape. During courtroom testimony in late October, she called Boston Children’s Hospital’s process for assessing minors for medical transition treatments “reckless.”
The clinic, she and other clinicians testified, had shortened its in-person evaluation to determine a patient’s readiness for hormone treatments to two hours. That’s far too little time, Tishelman said, to evaluate a patient’s needs, as well as their mental health, and determine whether it is appropriate to recommend medical interventions.
Some of her former colleagues testified that truncating the in-person assessment was appropriate, and necessary in light of the clinic’s growing waitlist. Parents have also defended the clinic, known as the Gender Multispecialty Service or GeMS, saying the assessments are merely one step in a decision-making process that can, in some cases, last years.
The testimony, stemming from a gender discrimination lawsuit Tishelman filed against Boston Children’s, came at a tumultuous time for the field of youth gender medicine. More than 20 states have banned medical transition treatments for minors, and the Supreme Court is hearing a challenge to one of those bans. The field is also roiled by debates about how best to care for young people who are transgender or experiencing gender-related distress.
A Boston Children’s spokesperson said, “Our clinicians and mental health professionals partner with families to ensure that care options and decisions are made thoughtfully and with the patient’s well-being at the center.” The spokesperson asked to not be named because of previous threats against hospital staff related to GeMS.
Tishelman won her lawsuit against Boston Children’s last month. A jury found the hospital retaliated against her by firing her in 2021 after she sued, although it also found she did not prove her discrimination allegations. When she was fired, more than two dozen leaders in the field urged the hospital to reinstate her. Currently, she is a professor and researcher at Boston College.
She spoke with the Globe recently about her concerns about the field, her first extensive interview since the trial’s conclusion. The conversation has been edited for length and clarity.
Q. Some parents have said a lengthy assessment isn’t benign, it isn’t neutral. It’s an ordeal for their child to be made to prove to a stranger that they are who they know themself to be.
A. Those families may be right. Some people come in after years of figuring this out and going to therapists, being [patients] in GeMS, and the extra scrutiny is just redundant. By the time puberty came around, those families were ready to go with all the information they needed.
But that’s a minority of the kids that come to GeMS.
What’s the majority?
In general, across the country and in GeMS, families are coming in at an older age — more at the onset of puberty, and many come in after that. And, unlike in the past, kids are reporting gender dysphoria or discomfort in their gender that was not apparent when they were younger. For some of these people, they may have felt gender dysphoria when they were younger, but didn’t convey it to anybody until they were teenagers. For others, they’re reporting first feeling gender dysphoric as teenagers. And that’s very different from the way it was in the past.
What was it like in the past?
The first research that was done on gender-diverse youth took place in the Netherlands, and almost all that research was for youth who understood themselves to be gender-diverse prior to puberty. So [today] this is a new demographic of kids who are first understanding themselves to be gender-diverse at or after puberty begins.
Another change in the kinds of kids who are coming forward is it didn’t use to be majority-designated girls at birth. Two-thirds of the kids who are coming in for services now were initially raised under the assumption they were girls. That didn’t used to be the case.
The other change that’s been dramatic is just the overall exponential rise in numbers of kids seeking consultation and possibly intervention. And that puts a lot of pressure on the field.
What does it mean to you that the demographics of the patient population has shifted?
Well, I would say we don’t understand the shift. We don’t understand the exponential rise in patients and we don’t understand why it shifted towards more children raised as girls. There has been lots of speculation as to why. But as somebody with a research and science background, I would say that these are at the level of hypotheses right now.
What are the hypotheses?
One of the hypotheses is that when you build services, they will come out of the woodwork. Maybe there were always so many gender-diverse or trans people, but there was no place for them to go for support. And now that there are gender clinics, people are saying, This is me and I need these services you are offering.
Other people are thinking that the rise in numbers of kids could have to do with other things.
Some people speculate: Well, the fact that more people who are raised as girls are expressing discontent with their gender or saying it’s not their real gender may indicate that it’s hard for girls to be teenagers and that they may be interpreting the stress that they feel as teenage girls as meaning that they’re transgender or gender-diverse.
Other people think that there could be a kind of contagion effect, meaning that kids are being influenced by other kids to think that they’re transgender and that there’s some confusion about it. Others think it may be that kids who have had certain kinds of experiences may view being transgender as a way to cope with those experiences. For instance, somebody who’s been sexually abused.
All of these hypotheses could be true, and they’re not necessarily mutually exclusive. But we don’t really know.
That idea that some patients might be confused about their identity, that their transgender identity might flow from some other hardship or mental health comorbidity, that’s very controversial, contested, and some even call it transphobic. The pushback is that transgender identity is innate and what might look like confusion to one person is actually just the result of the discrimination that transgender people face in the world.
I think it’s a valid concern. I can validate and understand why transgender youth and transgender adults are worried that’s going to happen, given the history of marginalization and negation of transgender identities.
What an assessment shouldn’t be, and I want to make this very clear: Assessment should not be a way to talk trans people out of being trans. And I think there’s a lot of fear of that.
In terms of the idea that it’s controversial — people mistaking their transness for trauma, for example — the fact is that there are some small numbers, but growing numbers of people saying just that. I thought I was trans. I went on gender-affirming hormones. I had breast reduction surgeries. And it harmed me. I realized in the end it was all because I had another issue going on in my life and nobody asked me about these other things.
There are former patients who were seen with minimal evaluation who have now come forward across the country with lawsuits against their former providers. We’re being informed by patients themselves that they should have had more of an assessment.
What’s the assessment for?
Some people call it a readiness assessment. I’ve never been happy with that way of characterizing it. I feel like an assessment should encompass more than just, Should a person get medical intervention or shouldn’t they?
People can get the appropriate hormonal intervention or puberty blockers, but also really need family therapy, or support for depression and anxiety, or trauma treatment. I don’t think we can sort of chop off one part of a person and say, Here, we’ll just assess gender dysphoria and whether you need medical intervention.
I think we need to understand what a person and a family needs as a whole.
What’s wrong with a short assessment? What’s the risk in your view?
A huge part is that there’s often family conflict. So if you have an assessment that’s two hours, it’s one hour with the parents, one hour with the kid. The parents might be screaming at each other the entire time because they don’t agree. And then that’s the last time you see them. That’s not sufficient.
You’ve been a leading researcher in the field for more than a decade. How do you assess the current state of the research?
I feel really concerned about the current state of the research, to be blunt about it. Hindsight is 20/20, but it’s so unfortunate that clinics around the country sprung up without a priority on collecting data and conducting research.
When I was at Children’s, I was trying to get research together so we could follow up the earliest kids who were seen in GeMS who would be in their 30s now, or older. We should know more about what the medical outcomes are, what the satisfaction is with care, how much detransition there has been. People often say there’s very little detransition, and hopefully that’s true, but we don’t really know that if we haven’t followed up the patients.
We don’t know how those early patients are doing?
No, we don’t.
Some parents are sharply critical of your public comments. They said you’re feeding false narratives about clinics rushing young people toward transition. And they said your testimony could fuel efforts to restrict or ban medical transition treatments. What do you make of that criticism?
I don’t want to restrict access to treatment or ban access to treatment. I’m talking about the processes to get to treatment. But I have been worried that the lack of caution that some people in our communities perceive, and the rushed way we may do assessments in this field, might feed these bans, or feed people’s fears.
Mike Damiano can be reached at mike.damiano@globe.com.