If DBT is the best tool for teens, why make an exception for "trans" identifying teens?

New York Times correspondent Matt Richtel has spent the last two years doing a deep dive into the youth mental health crisis—the crisis that has escalated to the point that, in December 2021, US Surgeon General Dr. Vivek Murphy issued a Surgeon General’s Advisory to highlight the urgent need to address it. In the last days of August 2022, Richtel had two articles published that immediately rose to the top of the New York Times most-read list. Neither article mentions the rapid increase in the number of teens with multiple mental health diagnoses identifying as transgender—but, for parents and professionals concerned about this population of kids, the relevance is easy to see.

“‘The Best Tool We Have’ for Self-Harming and Suicidal Teens” raises even more concerns about doctors, therapists, and even the US Department of Health and Human Services is telling parents that affirmation and gender affirming medical treatments are crucial to the mental health of highly distressed gender confused and dysphoric teens. This becomes especially relevant as many doctors and psychologists involved in youth gender medicine reject the idea that children and adolescents should be required to have psychological assessments and treatment before being socially or medically transitioned. They often describe a youth’s ability to access trans healthcare without any “gatekeeping” as “a matter of life or death” and frequently cite “shocking rates” of attempted suicide among trans adolescents as their justification for immediate “gender affirming” medical intervention.  

Richtel’s article introduces the reader to an adaptation of cognitive behavioral therapy  developed for people who feel their emotions very intensely called Dialectal Behavior Therapy, or DBT. According to the Cleveland Clinic, “DBT focuses on helping people accept the reality of their lives and their behaviors, as well as helping them learn to change their lives, including their unhelpful behaviors.” It is one of the most successful treatments available for adolescents who are suicidal or who self-harm.

So, if DBT is the best tool therapists have for treating suicidal and self-harming adolescents, why isn’t every doctor and therapist, every medical organization, and every activist group lobbying for every highly distressed child to have immediate access to it, including trans-identifying adolescents?

This quote from the article suggests one possibility for what might be unconsciously motivating some therapists and the American Psychological Association at large to choose and promote referrals to gender clinics and the affirmation model of therapy (affirm the child’s trans identify and support whatever the child says she needs and wants as a transgender person) both of which require less time and training from therapists:

…Anthony DuBose, [is] the head of training for Behavioral Tech, an organization that trains D.B.T. therapists. He cited another reason for the relative scarcity of D.B.T. counseling: Some therapists fear that the therapy is too intensive and might overtake their available time. “We need to convince mental health providers they can do this,” he said.

When therapists are faced with highly distressed youth with complex histories and multiple mental health diagnoses, the idea that they can solve them all and make the child immediately happy by giving exactly what is being asked for, while also avoiding the more challenging parts of a child’s history, choosing affirmation over the more labor and time intensive DBT is especially enticing. Affirming a trans identity and referring a child to a gender clinic can be especially appealing to therapists who are looking at packed caseloads, long waitlists, and messages from their professional organizations that accessing puberty blockers or hormones is a matter of “life or death.”

Additionally, because the article does not mention anything about transgender youth, it is able to provide a more unvarnished look at the realities and challenges of treating adolescents who are highly distressed. It can honestly and openly raise questions about their ability to reason and process information without having to navigate the minefield of gender identity and the restrictions organizations try to put on journalists writing on these topics.

The intensive nature of D.B.T. reflects the difficulty of the challenge it confronts: regulating the emotions of teenagers who are so overwhelmed that they struggle to reason. At that age, Dr. Rathus said, the adolescent brain is often not developed enough to process the flood of incoming news and social information.

“The brain just goes into overload, flooded with high emotional arousal,” Dr. Rathus said, “and you can’t learn anything new, can’t process incoming information and so suggestions of what to do or to try just bounce right off you.”

Dr. Rathus’s assessment raises serious questions about the self-awareness and the decision-making capabilities of adolescents, such as highly distressed trans identifying teens with co-morbid mental health diagnoses, and what that means for the ethics of “informed consent” treatment models. Journalists who attempt to raise these questions in the context of trans-identifying youth will face immediate backlash and false accusations of transphobia.

Considering the constant warnings of high rates of self-harming and suicidal ideation in gender dysphoric and transgender teenagers, shouldn’t the American Psychological Association, the American Academy of Pediatrics, and the US Department of Health and Human Services be fighting for this population to have immediate access to the “best tool we have for suicidal and self-harming teens?” Why do their recommendations focus so heavily on affirmation and “gender affirming medicine” with so few references to anything else?

For the highly distressed trans-identifying teens who do end up in treatment programs that provide DBT, affirmation usually comes with the DBT programs. For example, there is the Mount Sinai Adolescent Health Center Approach which specifically calls for “gender affirming DBT’ or this private residential program that includes “exploration of gender identity” for all its patients along with DBT.  Some combination of the two occurs in any program with a “gender affirmation policy” and programs in states with laws that consider anything other than affirmation to be conversion therapy.

However, there are tensions and inherent contradictions in combining unquestioning affirmation with DBT. Are programs that prioritize affirmation providing quality DBT?

As a subtype of cognitive behavioral therapy (CBT) a central tenet of DBT is teaching people to challenge their thoughts and beliefs. How much can the therapist explore, much less challenge, any of the teen’s beliefs about about their gender identity, gender roles in society, their parents’ concerns about medicalization, internalized homophobia, past trauma, or body image, without the teen accusing the therapist of transphobia or conversion therapy? This popular meme shared by Helena Kerschner illustrates those challenges.

A key component of DBT is helping people understand what is underneath the intense emotions they feel unable to manage. How effective will DBT be if there is a list of topics that’s off limits for these discussions?

Another important part of DBT involves patients learning they cannot control others, including what others say or do, or how they think or perceive situations. How is that addressed in an affirming model of DBT when we are told the teen’s mental health, indeed their very lives, depends on the individuals around them and society as a whole seeing them only in the way they want to be seen?

Or what about the components of DBT that require people to connect to their body, become highly aware of physical sensations, and use physical, body-based strategies to manage overwhelming emotions? How is the efficacy of these DBT strategies affected in light of the body image distortions and dissociations of gender dysphoria that are affirmed?

And what happens if some portion of teens go through DBT programs and ultimately desist or detransition because of changes in their thinking patterns and coping skills the teen developed in the program? How does an affirmation-only program respond to a teen who starts to question their trans identity? Many parents admit their child into affirming DBT programs, even when they do not support affirmation, because they rightfully want access to “the best tool we have for self-harming and suicidal teens,” and they should not be criticized for this. Parents are doing the best they can in the very broken systems they have to deal with.

Perhaps these contradictions and tensions ultimately don’t have that much of an effect on the efficacy of treatment with affirmed teens. As has to be said so often on this topic, we simply don’t have the research to answer these questions.

Are doctors and therapists—and the US Department of Health and Human Services—really choosing the best, most effective, most evidence-based path for gender dysphoric teens, or are they choosing the path that doesn’t challenge them with difficult questions? These are serious questions that need to be studied and answered without fear that the results may challenge someone’s— anyone’s—deeply held beliefs in this debate. Suicide is NOT an issue that should EVER be seen as left vs right, liberal vs conservative, or pro-child transition vs no-child transition. Behind all the New York Times articles, Twitter fights, and political posturing are real young people who are suffering, who have real families who are desperately trying to find them good treatment and keep them safe. It is time that suicide stop being used as a weapon and a pawn in these battles. ALL at-risk youth, whether gender dysphoric or not, should have access to “the best tool we have for self-harming and suicidal teens.”