The following essay is an adapted excerpt from Miriam Grossman’s new book, Lost in Trans Nation: A Child Psychiatrist’s Guide Out of the Madness, out now from Skyhorse Publishing.

I was contacted by lawyers in Salt Lake City about a 13-year-old boy whose divorced parents were in litigation over his social transition. Zach had recently declared himself a girl, and his mother was 100 percent on board—new name, pronouns, dresses. His father wasn’t going along with it.

I reviewed the records from Zach’s recent psychiatric hospitalization. Staff listed gender dysphoria as one of his diagnoses and consistently used his girl’s name and female pronouns, but the reasoning for those clinical decisions was absent. The hospital records indicated Zach heard voices and saw “ghosts.” I searched for more information about the voices and the ghosts but found none.

Was it possible no one had asked? Psychotic symptoms such as auditory or visual hallucinations always warrant further questions. An obvious one: what did the voices say? Was Zach hearing voices telling him he’s a girl?

These were questions that demanded attention from his clinicians prior to affirming a new identity. Maybe Zach’s gender dysphoria was related to his disordered thinking and hallucinations. Perhaps instead of lip gloss he needed Risperdal (anti-psychotic medication).

I found similar problems in the care of 17-year-old Nicole in Boston. Nicole’s life had been chaotic; her father left when she was two, her mother had five other kids with two other men, she was sexually abused by a neighbor, and her family had been homeless for months on several occasions. She had an IQ of 68 and was on three psychiatric medications to treat hallucinations, ADHD, and depression. When she discovered her mother was pregnant, Nicole came out as a boy.

At the time I was consulted, Nicole was in foster care due to charges of physical abuse by her mother.

Nicole wanted testosterone. I was asked by the court to provide my professional opinion regarding “gender-affirming” care, including testosterone, for her.

Having read this far, I trust you can figure out what I said. No testosterone for Nicole.

A person walks past a Transgender flag during The TransFest 2023 in the Queens borough of New York City on July 29, 2023.
Leonardo Munoz / AFP/Getty Images

Zach lives in Utah and Nicole in Massachusetts—both states that ban “conversion therapy” for minors. That means any approach that fails to immediately affirm a child’s new identity is prohibited.

I put myself at l risk when I argued that Zach and Nicole should not be affirmed but instead have their long-term mental health issues treated.

At least with those two consultations, my role was to provide my professional opinion. But that wasn’t the case with David, a patient in Colorado with whom I worked directly.

One day David told his parents that he is transgender and asked to be called Zoe, “she,” and “her.” He wanted blockers because the hair sprouting over the corners of his lips and his cracking voice reminded him he’s a boy. If only he could take estrogen, he told me, having breasts and wider hips would make him feel confident and secure.

The medical establishment, the DSM-5, and the state of Colorado say the only permissible response is to act as if he was a girl. David must be in the driver’s seat—forget about “do no harm.” If he picks a different gender identity, name, and pronouns next week, I must use those. I am to instruct parents to tell everyone—family members, school staff, his piano teacher and dentist—to do the same. His mom, dad, and I are all supposed to celebrate what doctors at Johns Hopkins call David’s “evolving sense of self.”

Celebrating an evolving sense of self sounds fine and dandy. But I happen to know that when David first appeared at a family event in a dress, his mother—a strong feminist and lifelong liberal who supported gay marriage and survived 9/11 and breast cancer—had to flee to a restroom, where she had the first panic attack of her life. I also know puberty blockers might be followed by estrogen and perhaps even orchiectomy—castration. He could end up disfigured and infertile and still not be satisfied with his body.

When David is ready, I must share those dangers with him. I took an oath to prevent harm, no matter what the gender medical establishment or the state of Colorado might say.

For refusing to validate the opposite-sex identities of David and many others, I risk an investigation, but I’ll live with that. I’m going to do what’s best for my patients.

Miriam Grossman MD is board certified in child, adolescent and adult psychiatry. The author of five books, Dr. Grossman’s work has been translated into eleven languages. She has testified in Congress and lectured at the British House of Lords and the United Nations.

The views expressed in this article are the writer’s own.