When Kids Say They’re Trans: A Guide for Parents, by Sasha Ayad, Lisa Marchiano, and Stella O’Malley (Pitchstone Publications, 304 pp., $19.95)

In the small world of gender-critical discourse, and for families torn apart by gender ideology, Lisa Marchiano, Stella O’Malley, and Sasha Ayad are already akin to cult heroines and household names. The three psychotherapists have sounded alarm bells about what they’ve seen in their clinical practices. Now they’ve written a book chronicling their experience.

Marchiano, O’Malley, and Ayad have worked for years with today’s emergent cohort of gender-distressed youth and their families. Each is a member of the Gender Exploratory Therapy Association (GETA), a leading gender-medicine group. O’Malley founded Genspect, an influential professional and educational organization that promotes evidence-based approaches to conceptualizing and treating gender dysphoria. Ayad, together with O’Malley, hosts a podcast entitled Gender: A Wider Lens, which explores the concept of gender with nuance lacking in most coverage of this topic. Marchiano cohosts a podcast on the depth psychology of Carl Jung, aptly titled This Jungian Life.

In When Kids Say They’re Trans: A Parent’s Guide, the authors consolidate their clinical knowledge into a pragmatic handbook—it may be a lifeline for some—designed to educate parents about the state of knowledge on gender dysphoria and present the range of treatment options at parents’ disposal. Each chapter is short and digestible, covering topics like medical and social transition, family dynamics, sexuality, detransition, desistance, managing conflict with your child, and parental self-care. Despite its concision, the book impressively interweaves useful anecdotes from case studies with a masterful command of the psychological and medical literature on gender-affirming care.

What’s most striking about When Kids Say They’re Trans is its spirit— refreshingly psychologically grounded, humble, and responsive to both the developmental needs of children and the well-founded concerns of parents.

A perceptive reader might wonder why it is refreshing to find a book written by three psychotherapists that’s psychologically grounded. Too often, today’s mental-health professionals stray from the principles of their field. Clinicians who accept the tenets of the “affirmative-care paradigm”—that gender identity is innate, that social and medical transition are the primary means of treating gender dysphoria, and that comorbidities are the product of minority stress—have a cookie-cutter script to follow, and often stray from sound psychological theory.

In the affirmative-care paradigm, once a child declares a transgender identity or admits gender dysphoria, clinicians accept his or her declaration at face value, setting in motion a predictable series of steps: social transition, followed by “medical treatment,” potentially including hormones or surgery. In essence, these clinicians, while likely motivated by good intentions, have outsourced their psychological analysis to an unfalsifiable belief system.

Clinical psychologists, social workers, and psychotherapists build “case formulations” to understand their patients better. A case formulation is a working hypothesis about the nature of a client’s “presenting problem” and the treatment implications of that problem, informed by psychological theory. For a gender-affirmative clinician, though, the presenting problem and case formulation are one and the same. Their interpretive work is over before it really begins.

By contrast, in the opening chapter of When Kids Say They’re Trans, the authors take as their starting point a developmental model of gender dysphoria that rejects the premises of gender-identity theory and the existence of the “trans child.” Unshackled from the affirmative-care paradigm and its assumptions, the authors can explore new horizons of meaning. Rejecting the easy certainties of the affirmative paradigm, the authors instead assess messy clinical realities in the context of broader social developments—including the rise of social media, Internet-based rather than play-based childhoods, identity politics, social-justice activism, and changes in parenting styles—that influence those clinical cases.

Whereas gender-affirming clinicians already have all the answers, clinicians like Marchiano, O’Malley, and Ayad start with a question: “What does this particular case of gender dysphoria mean?” Their answer, to adapt Anna Karenina’s opening line, often is “non-dysphoric children are all alike, every dysphoric child is dysphoric in its own way.” When Kids Say They’re Trans shines brightest when its authors use their experience and psychological insights to assess the possible causes of gender-dysphoria cases.

While no two cases are the same, the authors explore some of the commonalities they’ve observed in the field. They’ve found, for example, that some teenagers embrace gender ideology to differentiate themselves from parents and establish their own identities; other isolated and lonely young people use gender ideology to find a community; still others use it as a psychological defense against self-hatred, or to opt out of gender roles that make them uncomfortable. In some cases, the authors found, teens embrace gender ideology as a trauma response to sexual violence, or as an obsessive hyper-fixation linked to autism, ADHD, or OCD. (The authors do not deny that certain presentations of gender dysphoria have a biological basis. Their larger point, though, is that specific cases, especially among today’s emergent cohort of youth with comorbidities, may be influenced more by an amalgam of social and psychological causes that are overlooked in a more essentialist framework.)

The authors recognize how cultural practices influence presentations of psychological distress. They emphasize how expressions of psychic pain are shaped by “idioms of distress” or “culturally approved symptom pools” that dictate both how people understand their psychological experiences and how those experiences themselves are structured. In this case, gender ideology’s ascent to cultural prominence has real implications for how young people make sense of their inner lives.

It’s worth noting, too, that despite being antagonistic toward gender ideology for propagating sex stereotypes, the authors champion and celebrate gender-nonconformity. In their recommendations for parents, the authors fully support children engaging in whatever kind of gender self-expression suits them, while maintaining, crucially, that one’s gender expression has no bearing on one’s biological sex. In short, they more than tolerate gender-nonconformity, but reject society’s current view of what gender-nonconformity means. This is a crucial but overlooked distinction.

Marchiano, O’Malley, and Ayad are sensitive to the pains of young people but also attuned to the unique position of trans-identifying children’s parents. While gender-distressed youth are often isolated and lonely, the same can be said of parents who reject gender ideology—especially when all good liberals, along with every major medical organization and institution, support it. Parents’ experience must often be akin to waking up alone in a bizarro, upside-down twilight zone. When Kids Say They’re Trans addresses the needs of both parents and children.

Much of the authors’ advice to parents involves ignoring gender ideology and not giving it room to breathe. They use the phrase “lean in with love” as shorthand for being responsive to children’s needs, taking their opinions seriously, and promoting emotional and cognitive growth, while still setting firm boundaries. Through open-but-firm parenting, young people often flourish and outgrow their preoccupation with gender. The authors recognize that successful parenting does not involve controlling children or telling them what to think but requires doing something far more remarkable: helping them grow into young adults who can navigate life’s challenges by thinking for themselves.

Photo by Halfpoint/iStock


City Journal is a publication of the Manhattan Institute for Policy Research (MI), a leading free-market think tank. Are you interested in supporting the magazine? As a 501(c)(3) nonprofit, donations in support of MI and City Journal are fully tax-deductible as provided by law (EIN #13-2912529).

Further Reading

Up Next