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#calling this family therapy /j

most-datable-datable-bracket · 2 months

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ROUND 5 MATCH 3

Elliott propaganda:

“Just look at him. Pure hunk energy.”

“I will punch anyone who dislikes him. He’s like a fire emblem character in the modern day. He’s so flamboyant and handsome, he can play the piano and he’s best friends with the old fishing man!”

“dramatic writer man with sexy hair”

"Since I like elliott. I will state some reasons why I like him

Imagine if Mr. Darcy didn’t insult your family first time you met him, that’s Elliott. The man who’s basically the hallmark romance love interest. He’s a writer who moves to the small town in the country side to find inspiration for his writing. Then he finds the farmer.

He has a crab living in his pocket

He can play the piano (hopefully it isn’t the river flows in you however)

His fans sometimes hc him as a merman and that’s just a major plus IMO

He genre of the book he writes is dependent on what genre you say you like.

He also sends letters to you if you marry him

Okay and also some things I dislike

His liked gifts, the easiest one is pomegranates, which cost like 6000g to grow a tree if you don’t pick the fruit cave. I AM NOT GETTING SQUID INK IN YEAR ONE FOR YOU.

he might be British /j

The fact he has no kitchen but still likes food like lobster, like he is just a mystery. Lives in a cabin, with no kitchen, no washroom (okay no character has a washroom), but still likes the most fancy food out there and has luscious hair worthy of a L’Oréal ad.

Gifting him on rainy days when you don’t have two hearts"

Dimitri propaganda:

“He's chivalrous, he's blood thirsty, all rolled up into one package and calling you "his beloved". Get you a man who can do both.”

“My husband <3 He's schizophrenic just like me and I love him for that.”

"First, look at him. No disrespect to the monster lovers, but even if blonde, blue-eyed hunks aren't your thing, you can't deny that Dimitri is very pretty.

Second, one of the things I love most about Dimitri is how self aware he is of his privilege as a prince (or king) and how seriously he treats the gravity of his position. He has a strong sense of duty and wants to be a good leader who listens to and provides for the needs of all of his people. This includes the citizens of Duscur, who were nearly wiped out by his own countrymen in (mistaken) retaliation for his father's murder. His commitment to righting this wrong is one of his primary goals in life.

Third, while he is more than capable of crushing a man's skull with his bare hands, under normal circumstances he absolutely wouldn't. A large part of the reason why his fall is so shocking and devastating to witness is because by the time he snaps, we know that Dimitri is actually a kind and gentle soul who hates violence and understands that even his enemies are human. Even at his worst point he still recognizes this, which feeds into his extreme self loathing. He extends compassion and forgiveness to others but struggles mightily to allow himself any forbearance for his own mistakes. He's kind quite literally to a fault, as his empathy is both his greatest strength AND his biggest flaw and I find that as heartwarming as it is heartbreaking."

"Okay first for all the "he needs therapy haha funny" (and its annoying corollary "I can fix him") comments, 1) don't we all? And 2) you can't romance him til end game when he is in a much healthier place due to his own choice to change his priorities and the support of you and his friends. He battles daily with severe mental illness in a repressed society that doesn't talk about it. And on multiple occasions tells people that it is okay to feel your feelings and offers support despite his own struggles (I include that bc that is a date able trait to me). If he's not your fave that's cool, but leave the ableist language out of it pretty please 💙💙 Okay reasons he should be your boyfriend now!!

He calls you his beloved and wants to hold your hand 🥺

His happiest moments in game are when you smile

And in conclusion, he is shaped like a dorito and has a huge cloak to snuggle you up in"

#sdv elliott #elliott stardew valley #stardew valley #dimitri alexandre blaiddyd #Fire Emblem #Fire Emblem: Three Houses #FE:3H #Round 5 #MDDC 2

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manicplank · 3 months

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hi what do you headcanon PT cast's parents being like + names

Parental headcanons!

I'm bad with names pls bare with me.

(slight tw I guess, nothing bad, but some of them don't have great parents)

For Peppino: Mama Spaghetti was a sweet, loving lady. She's very patient and kind. Her name is Isabella. She raised him and Maurice but had trouble as Maurice was always such a bully to him. His dad was named Lorenzo. He was okay, but he was emotionally unavailable. He was very stoic. Maurice takes a lot after their father, and Peppino takes after their mother.

For Gustavo: His mom was a wonderful woman. She was sweet and caring. Her name was Gianna. Gustavo's dad was named Stanley. He was patient and had a good temper. They both loved him to death. They made sure he was happy but not spoiled.

Mr. Stick: His mom's name was Bianca. She spoiled the ever loving shit out of him and bought him everything he wanted. His dad was named Stanley. Unfortunately, his dad worked a lot, so he wasn't very present. His family was good to him, though. Despite not spending much time together, he and his dad had a decent relationship.

Pepperman: His mom was named Cayenne. She was very supportive of him and loved him very well. His dad was named Poblano and was pretty mild but assertive when needed. They both supported his art his whole life and sent him to art classes. "Pepperman" is his nickname for himself. His actual name is Phil Bell Pepper.

The Vigilante: His mother's name was Brie. She was an old-fashioned but very loving and nurturing mother. She loved her Vigert very much. His dad's name was Stilton. He was a hard-working farmer who loved his family. They were all very close. Vigi was raised to be a hard-working gentleman. Even his grandpa, John E. Cheese, had a very important role in his childhood.

The Noise: Since his father was absent, he only had his mother. Her name was Perla Noise, but he just calls her mamas. Being a single mother of an autistic child, she was very stressed out and could be very snippy at times. Despite this, she loved her "Teedo" very much and spoiled him. She had a very hard time with him as a toddler and teenager as they fought a lot. (Teedo is her nickname for him. He couldn't pronounce his name as a baby and would say Teedo. Only his mom can call him that.)

Noisette: She had very good parents who seeked behavioral therapy for her autism. Her mom's name was Anais. Her mom was very loving. She was a mellow and patient parent. She was sort of like a trad wife. Her dad's name was Pierre. He was a happy, kind man. He worked a lot but still made time for his family. Noisette's real name is Hazel. She gained the nickname "Noisette" after the paparazzi and media found out she was dating The Noise as well as using the name for her cafe.

Fake Peppino: Technically doesn't have parents. If they were to be anybody, they'd be Peppino (they share DNA) and Pizzahead (who created him).

Pizzahead: Now, this is just my theory. Based off of the pictures in the lobby and the first floor of the tower, as well as granny pizza, Pizzaface was actually Pizzahead's father. Pizzaface and his wife "PizzaMama" adopted Pizzahead as pizza people can't really produce naturally. Pizzahead was less likely to be adopted due to his head being a slice as opposed to a whole pizza, so they chose him. He was only like 6 or 7 when they adopted him. They loved him unconditionally. After PizzaMama passed away, Pizzaface fell into a depression and grew apart from Pizzahead. Granny stepped up as a parental figure. PH blamed himself for PizzaMama's passing, despite having nothing to do with it. Years later, Pizzaface passed as well, leaving Granny to raise Pizzahead once again. Many many MANY years later, Pizzahead discovered a way to recreate his father as a robot with the similar sentience. However, Pizzaface doesn't remember his previous life.

Pillar John: John and Gerome shared a mother named Esmeralda, or Esme for short. She was a wonderful woman. She met John's father, Flint, and the two fell in love instantly. Voila! Out popped John. Esme loved her "John Boy" and Gerome very much. She was patient and kind.

Gerome: John and Gerome shared a mother. However, Gerome's father... wasn't a great guy. His name was Bruce. They called him Bruce the Brute. He was pretty mean to Esme. They got divorced shortly after Gerome was born. Gerome felt very sad about it. When John's dad, Flint, came into his life, it changed. Gerome didn't like Flint until he saw how kind he was to Esme and John. Eventually, he let Flint into his life and they became quite close.

#pizza tower #noise #the noise #headcanon #noisette #pizzahead #peppino #peppino spaghetti #fake peppino #pepperman #the vigilante #mr. stick #pillar john #pizza tower gerome #pizza tower gustavo

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am-i-the-asshole-official · 8 months

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AITA for calling my mother and MIL selfish, insecure, pieces of shit over a friend's necklace?

Some background: I, 25F, just married the love of my life, who we'll call J.

I was introduced to J in our junior year of high school by our mutual friend, who we'll call G. G has always been a super important person to us. She is one of our best friends, and the three of us are very close. She was actually the first person we told when we started dating. We are both pretty protective over G, as she is autistic and has crippling anxiety and struggles a lot day to day. She was actually living with us when this story occurred because she had been spiraling on her own, and her parents lived too far for her to commute to her work from their house. She's been in therapy for years and has been doing a lot better than when we first met her, but we still tend to be pretty protective over her, as she has very few friends besides us. We often joke that she's our practice kid because she goes everywhere with us and has a complete lack of common sense despite being one of the smartest people I know.

In the last week of our junior year, J gave me, G, and another friend of his, necklaces that he made. They were nothing fancy, just pieces of rocks that he carved (?) and tied a string around, but G loved it. It acted as a reminder that she had people who cared about her when her anxiety spiked, and she's worn it almost every day for the last 9 years, to the point where J replaced the string with a thin chain because it broke from use. It's a comfort item, and wearing it is part of her routine.

Another important thing to note is that J and I both have pretty bad relationships with all of our parents. Both of our parents are messily divorced, and the only ones we visit regularly are my dad and stepmom. We still decided to invite all of them to the wedding and involve our mom's in the wedding party to avoid drama, and because some small part of me still wanted my mom to be involved in my wedding like a real parent.

Shortly before our wedding, I was talking to my mom and J's mom in our kitchen about some details for the wedding party and the bridesmaid and groomsmen accessories. I made a joke that no matter what we picked, G would be wearing her necklace. They wanted to know what I meant, and while I was explaining, G came into the kitchen to grab a snack. (Side note: neither of them like G, and my mom in particular has made several abelist comments in the past about her stimming or lack of social awareness) When I was done, my mom turned to G and asked if she was going to wear it at our wedding. Confused, G said yes, and my mom lost it. She called her disrespectful and accused her of trying to break up me and J because J gave her that necklace, and it was bad manners to wear a present from the groom or something. J's mom backed her up and said a lot of awful things I won't repeat, but were really abelist, arophobic (G is open about being aromantic), and included several slurs.

I was completely blindsided. I knew they had those awful opinions, but I had never heard them do anything even remotely close, and I sat there stunned at first until G started to cry and hyperventilate (she has trauma around situations similar to this, and she was already on edge because of a recent death in her family). When that happened, it was like a switch flipped. I got between G and my mom, who at this point had gotten out of her seat and was getting close to G. I told them both to get out, and when they refused I told them they were selfish, insecure, pieces of shit, that they had no right to say any of that to G, and that just because they couldn't keep their husband's didn't mean they had any right to interfere and try to create problems where there weren't any.

At this point, J came home and saw G panicking and immediately reacted. He told our moms to leave, and this time, they left. After they left, it took us almost 2 hours to calm G down from her panic attack, and the whole time, I was boiling with rage over the interaction. After she fell asleep, I told J what had happened. He was completely on my side, and we even discussed banning them from the wedding unless they apologized. G has been far more supportive of us than they have been, and if I had to choose, I would rather have her by my side on my wedding day. Ultimately, we let G decide since she was the one they went after, and she said she would be okay, so they came to the wedding and thankfully didn't mention the necklace at all. However, they told our respective families what happened, and I've been getting texts from family members telling me I went too far in bringing up their divorces, and that I should apologize, especially since the fight was over something as small as a necklace.

I don't think I was wrong to defend G, but I know I tend to overreact in situations where she is involved, and J is as bad as I am. So, AITA?

What are these acronyms?

#aita #am i the asshole

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gorgeouslypink · 1 year

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So I entered the void. Basically I heard such good things abt your alpha state meditation so I did it and I got into alpha state. Anyways I heard u manifest pretty quick in the alpha state so everyday I would do the meditation and affirm that I will wake up in the void and I did this for 6 days and yesterday I woke up in the void. I'm not even going to lie, I didn't have the best mindset like yeah I tried to persist but I would be searching for void subliminals and success stories and stuff and honestly the only consistent manifesting thing I did was the alpha meditation and I mean I got into it so it all worked out lol. I honestly just manifested my desired face as that's honestly my biggest insecurity. I am a dark skinned Asian and all my Asian gals know what that means. I've been called ugly all my life by my family and in seventh grade, I was walking from my class to the restroom and these 2 boys pointed and laughed at me. They were far away but j think they were laughing cuz I was ugly and since then my self confidence has been at an all time low. I would skip school and not want to go out bc I felt so ugly. I would always wear a mask even if it was so hot to cover my face. It's a lot so yeah this manifestation was really important to me and now I look so pretty. Tbh im still very hurt by my past and I'm contemplating revising it or going to therapy. Not sure. I have time but yeah atleast now I have a pretty face and I can walk with my head held up high so thank you so much. I really appreciate what you do. Also anyone who's struggling to enter the void, the alpha meditation is so.short. just do it everyday and you'll enter I promise.

Im so proud of you love! Also I've been in a similar situation, contemplating revision versus therapy and ultimately, the choice is yours but I thought my past experiences were defining so I didn't want to revise them. Again, I emphasize it's your choice. But I'm very happy for you and you deserve the best 💗

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underdark-dreams · 9 months

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Hello! I would first like to thank you for getting me into the Rolan boat, this arrogant emotionally-constipated (affectionate) wizard has taken over my mind and he is all I think about now.

That being said, I was wondering if you would be able to do a rolan x tav like a few years or even a decade into their relationship? Does settling into Sorcerous Sundries and becoming a better mage make Rolan softer? How is he connecting with the rest of the magic community (I am personallya Rolan and Gale rare books reading club supporter) What would be some of the major long term disagreements in their relationship and how do you think they would work through it? What would this man's ideal 'happily ever after' look like?

Thank you so much!

This was great food for thought! 🖤 Thank you so much!

I kind of want to work on future Rolan x Tav as its own little standalone fic, because that idea is so sweet—but here are some headcanons on that & all these other what-ifs. Apologies that they're a bit jumbled, I can't concentrate when Rolan

Rolan loves his tower! He definitely feels the weight and responsibility of being the new steward for all this collected research and knowledge. But he also loves that he can go through his books and satisfy his curiosity whenever he wants, after so long yearning for someone to teach him and nurture his magic. He learns to do that for himself

I think the big thing that will soften and kind of humble him over the years will be once he accepts that personal growth will never stop. There is not a mystical point X where he could stand and say, did it, I have reached the pinnacle of archwizardry. He learns how to stop rushing forward and enjoy other things in life, most of all his relationship with Tav.

Once all the Absolute business is finally settled, Rolan will definitely want to lock that down. It doesn't need to be a legal marriage per se, but he is extremely committed to the relationship & wants the same from them. If he had his way Tav would have moved in yesterday. He's ready to wake up next to them for the rest of his life. Buys a house in the city right beside his old place where Lia and Cal still live & can't wait to merge his found family with his new family. His happily ever after is being surrounded by the people he loves and watching them thrive, especially when it's because of him. Having the capacity to care for Tav and Cal and Lia makes him incredibly fulfilled.

Some big potential sources of conflict in his and Tav's relationship:

Jealousy and insecurity. Rolan has some deep abandonment issues from his past, so if he ever felt like Tav was straying emotionally or making him jealous on purpose, that would really hurt his trust. Deep down he needs to know they love him, and hear it once a day preferably

Control issues/willfulness. Older brother mode activated. Rolan likes to do things his way and is very stubborn and proud about conceding to others. He does see Tav more as his equal, unlike his little siblings, but it's hard for him to translate that into actions. There will be a lot of fights over any big decisions where he & Tav disagree. Part of working through it would probably mean Rolan confronting why he needs to control things so badly (growing up without much control over anything in his life maybe? Hmm). He would genuinely benefit from therapy & from learning how to translate all his feelings into constructive words. Being with someone who would stand up to him would really benefit Rolan in the long run, though.

In the magical community: He's got a reputation as a rebel amongst the wizarding community, because 1) he's very much self-taught which is pretty unusual, and 2) not everyone approves of how freely he hands out information about the Weave, casting, etc to the curious younglings who visit his tower. Of course he'd never let anyone get into anything too powerful unsupervised, but after his experience with Lorroakan and realizing that this famed so-called archmage was actually just an idiot who stole everything from more powerful mages, he's like. The strict apprentice system can kinda get fucked honestly. He just doesn't agree that the basics of magic should be kept behind lock and key. Becomes a sort of magical literacy advocate. Let the children read

You might be surprised at how patient this man can be with children by the way! Lots of little magical prodigies hanging around Master Rolan's tower whenever he lets them. He'll kind of scowl to intimidate them into behaving themselves, but inside he loves to see curious minds reading and learning. As a primarily self-taught wizard, he also has an excellent grasp of pedagogy and how to describe concepts in a way a beginner would understand. He puts together his own beginner's magical textbook over the years. Holding the first printed copy in his hands is probably one of the proudest moments of career

To Rolan, Gale's reputation definitely precedes him at first—even before the events at the Grove he knew the name Gale of Waterdeep. Rolan is younger and admires Gale's skill a lot, so in the beginning of their professional relationship he's a bit intimidated. But you know Gale, he is friendly and endearing from the get go. Rolan often thinks if he'd had a teacher like Gale in his youth, he could have nurtured his magical skills much earlier.

Definitely, definitely also subscribe to the Rolan/Gale book club! They become kindred spirits in that regard over the years. Gale makes a visit to Rolan's tower to inform him of this fascinating manuscript that has just surfaced in Evereska, and Rolan is like "Really? I thought the Fae destroyed that centuries ago…" and the two of them just sort of wander off in conversation. Not to reappear for hours. Probably plotting like naughty children over a bottle of wine about how they are going to get their hands on the Ancient Forbidden Book without Tav finding out

#rolan x tav #rolan bg3 #bg3 rolan #gale dekarios #gale of waterdeep #bg3 headcanons #bg3 spoilers

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bunnieswithknives · 1 year

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For the Hostage Rowan au, how do the resets affect humans? Cause there’s a lot more stuff that can make you forget things then just Soul Rot, and magic probably makes that list longer. Cause I’m imagining the longer he stays, the more his mind tries to adjust by also trying to reset(unhealthy coping mechanism or maybe in this scenario it would be the most healthy option). Like have you ever not been able to fully trust your own memory? That’s what I’m thinking happens except a little more extreme, and he doesn’t notice that until he realizes that he almost forgot his own name and had begun calling himself the name that the others had called him(I’d like to say Red but he’s no longer wearing anything prominently red, maybe David forgot his name was Rowan like that one HC just kept calling him that or they call him that because of his hair and “We can’t just call you Colorful Guy, that’s that crayon guy”(Creative Brendon)).

Knowing something is happening and knowing how to stop it are two different things. He can’t write anything down permanently and even if he could, what if he already forgot something, his sisters, his age, his parents, how could he trust himself to remember that when he almost forgot his own name. I imagine it like that one Spider David scene where he’s like “oh ok” and the next “wait a second!/Stop that!” except instead of just yelling at David he’s also yelling at himself for forgetting, and it just keeps happening, no matter what he does. Cause he can keep reminding himself of facts but he can never get rid of the doubt that he’s forgetting something (example: “My name is Rowan; I have two sisters, Samantha and Sophie- wait do I have two sisters? What if it’s three?! Do I have another sibling!? Do I have a brother!? Did I forget someone! What if that’s not their names! What if that’s not my name-wait no it is, my name is Rowan! Or is it? Dammit David!”), your mind can be your best ally or your worst enemy, and unfortunately for Rowan, it doesn’t seem to want to work with him. And when Red and the puppets do escape like in the au post-canon, he might be very disoriented and never really fully trust himself with that without someone(probably Sammy) constantly reminding and affirming him of things and therapy, lots and lots of therapy.

(Sorry I saw the question + AU and couldn’t stop thinking about it, sorry for the rambling) -J

One of the main differences between director Red and hostage Red is how they're integrated into the house. Director Red is kept an outside observer for the most part, while hostage Red is directly living with the puppets. At first, it would be a lot of crying and breakdowns, but after a while, I think he straight up forgets he didn't always live there. He still wants to see his family again, but it becomes a lot less urgent, and he talking about them like he's just forgotten to reach out in a while, though he will occasionally make omnious mentions wishing he could see them.

When they do eventually get him home, he's still convinced the whole thing is a lesson, which he plays along with for a while, until he finally just breaks down and begs for them to stop pretending to be his family. He's so convinced that it's fake and going to be ripped away from him at any second that he just wants to get it over with.

#trauma dump #ask to tag #two of us!rowan #hostage rowan #two of us au #and yeah the reseting magic of the house also causes memory loss #more like dejavu tho #soulrot means those memories are just gone forever #sorry if this is incoherent

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jaybirdswriting · 9 months

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maybe prompts where the A feels insecure & B re-assures them (them already being a couple) <3

A: Character B is aggressively reassuring to Character A. They're the type to go "YOU'RE THE BEST. INCREDIBLE. THE LOVE OF MY LIFE." and Character A is going "OKAY! OKAY!"

B: Character A tells Character B they feel bad about themselves. Character B responds by giving them the saddest look they've ever seen, and hugging them so incredibly tight as they whisper reassurances over and over again.

C: Character B kisses all of the places Character A is insecure about.

D: Character B gives Character A a nickname thar directly contradicts their insecurities. (EX: Calling them "Gorgeous" when their biggest insecurity is there face.)

E: Character A wakes up one night with Character B gently trailing a finger down their jaw. When they ask what they're doing, they reply, "Sorry. You're just so beautiful."

F: When Character B learns the depths of Character A's insecurities, they make a huge list of all the things they love about their partner to give to them.

More Undercut

G: Character A hides their insecurities under lock and key. That's why it shocks them when Character B directly compliments something they're insecure about.

H: Character B fondly calls Character A their "perfect (something)" (Examples: My perfect rose. My perfect gem. My perfect darling.)

I: Character A has always thought poorly of themselves. That's why it shocked them so much when they overheard Character A talking so highly about them to friends/family.

J: Character B proudly introduces Character A as their partner.

K: Character B not only reassures them, but is heavily encouraging of them to seek therapy.

L: When someone insults Character A's insecurities, Character B is the first person to jump to their defense.

M: Character B has a running joke that if Character A were a celebrity they'd be their biggest fan. Because everything about them is so wonderful.

N: Character B takes nonstop pictures of Character A because they find them so gorgeous. Character A is so shocked and flustered when they find out.

O: Character B has a chance to change Character A through magical means. They choose not to because they think Character A is perfect the way they are.

P: Character B shocks Character A by saying "I wish I was (trait they don't think they have.) like you." with a very genuine grin.

Q: Character A asks Character B how they would describe them. Without hesitation Character B responds with "Talented!"

R: Character B has a hard time fully grasping A's insecurities because they think so highly of them. In a weird way it's very reassuring on it's own.

S: Character B draws Character A and Character A realizes how beautiful they see them.

T: Character B is always there to listen and reassure if Character A needs to talk about their insecurities.

U: Character A is good at telling when people are lying. When Character B compliments them, they can tell that they're being nothing but truthful.

V: Character A can see how Character B's jaw drops whenever they entire the room. Their repeated reaction is a deep reassurance.

W: Character B always loudly acknowledges when Character A does a good job. They want them to understand how proud of them they are.

X: A very drunk/tired/under a truth serum Character B tells Character A that they think they're perfect.

Y: Character B is very full of themself. When Character A admits that they're insecure, Character B responds with "What?! But I am the most wonderful person alive and I assure you we're in the same league."

Z: Character B doesn't need to speak to reassure Character A. All they need to do is look at them with that loving look swirling in their eyes.

#thank you for the ask!#writing #writeblr #prompts #writing prompts #romance prompts #oc prompts #otp prompts

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royalsunshinehotel · 8 months

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may i request nsfw alphabet with napoleon usher?

Napoleon 'Leo' Usher (NSFW Alphabet, 18+)

A/N: I’m writing this after watching Episode Four with @hecuba-of-troy. It’s such a slay, and I love Rahul Kohli so much. This being said, Leo is the worst and I hate him, and I want him. Please enjoy this NSFW alphabet for the worst character ever.

A = Aftercare (what they’re like after sex) It’s minimal, if not nonexistent. Leo, after coming in to the Usher family at age 18, was certified at the ‘fuck-and-run’

B = Body part (their favorite body part of theirs and also their partner’s)

I don't think he likes to look close enough at his partners to have a favorite body part. For him, he likes his hands and his hair

C = Cum (anything to do with cum, basically) He hasn’t got a preference beyond: as much as possible, and everywhere. Cleaning up after is usually a multi-step process.

D = Dirty secret (pretty self explanatory, a dirty secret of theirs) There was definitely a time in his life when he had a spreadsheet of everyone he’d done sexual activities with. Yes, it is now deleted because he’s become more confident in himself in his thirties. Is it always warranted? Who’s to say. Is the spreadsheet now deleted? Yeah, and he’ll deny it ever existed.

E = Experience (how experienced are they? do they know what they’re doing?) Oh he’s a certified slut. He knows what he needs to do to ‘maintain his reputation’, and he’s probably going to do it.

F = Favorite position (this goes without saying) He’s a big fan of his partners either being on top, or being on all fours. He’s pretty tall, so whatever’s best for his upper back that day is usually what makes the choice.

G = Goofy (are they more serious in the moment? are they humorous? etc.) I think he tries to keep it minimal, because goofiness can lead to Intimacy and he can't have that. If he cracks a joke, you’ll laugh and then what !!! chaos (See I)

H = Hair (how well groomed are they? does the carpet match the drapes? etc.) I seriously think it matches his fuck ass haircut. Like short on the sides long on the middle. I don’t know hair growth patterns down there, but you get the idea.

I = Intimacy (how are they during the moment? the romantic aspect) I feel like he’s capable of it, but he’ll have to dump you immediately after. It’s something he actively has to tamp down in the name of getting off.

J = Jack off (masturbation headcanon) A whole lot. 3x daily I fear.

K = Kink (one or more of their kinks) There's no way he’s having a fucking ass stupid ass haircut like that if you’re not the one pulling on it. Fucking fuck ass shaved sides fuckboy. Like I don’t know what that style is called, but it’s right there next to ‘fuck ass bob’.

Next after that, I think he’s really into lite bondage. Just being tied up and used by you, which you’re happy to do.

L = Location (favorite places to do the do) Typically at home, but if it’s been a to of family drama, he’ll fuck you in his car on the way to/from the family event. Next after that, the two of you get nasty in the shower, and then the bedroom.

M = Motivation (what turns them on, gets them going) A gust of air? Typically I feel like Leo gets a little bit stuck in his own head, typically in a negative train of thought. That usually does it, but he’ll never let it on. He’ll literally use you to feel Anything, but not That much. Sorry!! He needs therapy!!

N = No (something they wouldn’t do, turn offs) I feel like choking/ anything to do with pain really, it’s off the table. If there’s one thing about Leo, he would never hurt you on purpose.

O = Oral (preference in giving or receiving, skill, etc.) Receiving. I’m not gonna say any more than that.

P = Pace (are they fast and rough? slow and sensual? etc.) It depends on the mood honestly, fast and rough if he’s had a hard time with his family, but it’s slow and sensual and lazy most other times.

Q = Quickie (their opinions on quickies, how often, etc.) IDK why I feel this way, but I don’t think Leo is very into quickies, just because he doesn’t strike me as a man who is good at multitasking. Like if a partner were to initiate sex, it would suddenly be sex-time for sex havers. Whatever he was doing before, would have to be put on hold.

R = Risk (are they game to experiment? do they take risks? etc.) Oh he’s all about it, anything to feel something. I see a lot of fucking on his balcony, perhaps in the bathroom at a cool restaurant.

S = Stamina (how many rounds can they go for? how long do they last?) I think he’s been blessed with a whole lot of stamina, almost alarmingly so. Just picture his partner, exhausted, and Leo just cheesing like :D need a break?

T = Toys (do they own toys? do they use them? on a partner or themselves?) I think he’s got a substantial collection, because he’s a lazy lover and if he can’t pawn the work off on his partner, he’ll pawn it off on a toy.

U = Unfair (how much they like to tease) I think it’s up to his partners to tease. Leo is a bit of a glutton, so I can’t see him knowing how to tease, or tease well.

V = Volume (how loud they are, what sounds they make, etc.) I know this man’s loud as hell. In canon, he’s a slut who hooks up with his instagram followers. I truly believe he doesn’t care who hears ever, and he’s probably smug and selfish, regardless of his minimal effort.

W = Wild card (a random headcanon for the character) I feel like Leo has his hair like that by mistake. It looks kind of like a mistake, like he went on a bender, and woke up with his hair like that. This being the case, he’s big into wearing hats in the winter, because the sides of his head like that.

X = X-ray (let’s see what’s going on under those clothes) He’s a stallion, in his fucking prime. Thank you, god bless.

Y = Yearning (how high is their sex drive?) As we see on the show, it’s pretty darn high. The two of you are definitely NOT monogamous because I’m betting this man drowns his low self-esteem with a high sex drive. He picks up anything that moves and has sex with it. He’s very much the type to say “i don’t know” when you ask about people in his apartment.

Z = Zzz (how quickly they fall asleep afterwards)

I think regardless of him being on his “best behavior” he knocks out almost immediately after. He’s very much the type to just roll over and fall asleep, for better or worse.

#napoleon usher #leo usher #rahul kohli #rahul kohli smut #the fall of the house of usher #tfothou #fuck ass stupid ass fucker #we see there's room in his heart for love #but he doesn't get a chance to explore it and learn about it

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salon-maiden-anabel · 4 months

Note

the more i think about your mom lucy hc, the more i really adore it. if you don't mind me asking questions about it, what's her general dynamic with kieran & carmine? is she a single mom? how does dahlia fit into the picture?

SORRY THIS TOOK SO LONG TO REPLY TO MY BRAINS BEEN. TRYING . the thoughts are disconnected but by god there are thoughts everything below the readmore

But! Hi hello welcome to Oh lord this family needs therapy and counselling . ! Honestly I have been going into everything with the idea of her being a single mom w/ them! It;s very much a situation of like.... Parent that works away from home constantly, so the relationship is just unfortunately naturally more strained kinda thing .

With all this i go with like.... The idea that they were very much born in Hoenn and lived there with Lucy until Carmine was approximately 9 or so, and Kieran was 7 [I do like to imagine they're 16 and 14 respectively as of the dlcs]. Work being so remote and stuff plus worrying about their education and all just led to living with their grandparents in Kitakami being the best decision for their development as yknow, People. I like to imagine Lucy visits periodically throughout the year and such to check in :> just takes a bit of coordinating. Also shes absolutely the reason they're able to go to blueberry for highschool via both making sure they Can go there financially and putting a word in to a battle focused school of them being kids of a facility head :p even if realistically Lucy isnt the strongest head by any means lol . it's kinda like if an E4 member put a good word in situation. And we can see with Lacey and Drayton both going there... gestures. I wouldnt be surprised if more children of different league figures go to it or schools LIKE it. But thats besides the point Lucy absolutely like, struggles with her emotions and such. Even from the small bits of dialogue we have from her? Maybe its just my autistic ass reading too much into it LMAO but . gestures .

i feel like if this werent a kids game she'd just tell you to fuck off to your face here

sorry just more quick looking too much into dialogue but. cmon. CMON. ...She's . definitely influenced how carmine and kieran act at least somewhat .

Carmine might be the easiest to point a finger to as being like her mom but i genuinely think that it;s actually Kieran who ended up the most Like her, yknow it;s incredibly obvious to point a finger at Kieran during indigo disk and how he talks as being her fault a little bit :p anyways thats just me vaguely mumbling abt that. AS FOR. DYNAMICS. Kieran isnt as close to his mom as Carmine is just due to everything with living with their grandparents. Theres also absolutely like.... Very much a gap because he stopped seeing her as much when he was younger, while Carmine was only a year off of being like. Legally start being a pokemon trainer age. And its just Awkward, relation wise, just because of how little she actually sees them through the years, especially when the discussion would slowly shift to more "How are your studies?" "How are you doing in school?" "How is your pokemon training going?" once they start going to blueberry. Which i don't think was ment to come off as uncaring for them and only focusing on training as it did from Lucy's end, but I dont really think she knew what else to ask and all, because she stopped being able to really pick up on their interests as much as they got older. Plus thats just kinda How she talks... With the importance on strength and luck n all that. Then with all this I imagine she like. Probably only called once maybe twice between the dlc plots n all? And once again with just mainly the training questions it was just a sour spot. I wouldn't doubt Kieran would also struggle with not wanting to be in a shadow/the nepo baby accusations /j that I fully think if Drayton knows about he'd tease him and Carmine about. So like. All that with the instilled importance of ones strength :sob: Lucy you were not helping the Kieran situation. Hell I don't really think she would of even known about anything going down between Kitakami to Blueberry with Kieran just because neither of them wanted to tell her at all? Because again just that Awkward connection between them, just the permanent fog on all communication that feels like someone said something wrong at all times and it got too awkward to finish. IDK I think im waffling on I don't know how to formulate my thoughts the best LMFAO BUT I THINK... DYNAMICS WOULD CHANGE POST-MOCHI MAYHEM ESP. Bc i KNOW she'd find out after carmine and kieran nearly fucking DIE in the underdepths and everything hits her in the back of her head at once that she needs to repair what she can w/ them because she almost lost them. Probably means taking an extended leave from working at the Pike so she doesn't have to worry about scheduling to see them in person for only a short period of time. Especially if the times line up for them having any extended break from school . It's never going to be perfect, far from it, with their dynamics and all but. gestures. Briar needs to sleep with one eye open for a bit at least. in short

AS FOR. DAHLIA im in turbo hell because I can not see? the siblings ending up like they did if she was also around? Shes such a force of positivity as a person im just. blinks a bit. Im in hell bc i adore the ship as my big rarepair ill die on a hill for but nobody expected the kitakami siblings especially not me so . i think if they ever do get together it'd be somewhere nearer to scarvio era which just. yeah. see image below

#talk tag #asks #juniverse tag #sorry this is like all over the place i can Not keep my thoughts in one solid piece

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lost-onpurpose · 4 months

Text

The last month has felt like a badly scripted soap opera.

1/22: Sister passed out at the store. ER found no cause.

1/23: Sister called from school bathroom floor because too dizzy to stand. She went to different ER and they determined migraine/dehydration. IV fluids helped.

1/24-1/26: Residual migraine. Missed school.

2/4: Mom got diagnosed with pneumonia. Started meds.

2/7: J called and said Mammaw's oxygen had dropped into the 70s/80s and they were starting her on supplemental oxygen. She wasn't very coherent but she was alert. The only coherent thing she said was making me and sister promise to take care of Mom. My Aunt S came down to sit with her that night. Alerted her son and the close relatives who live out of state.

2/8: Mammaw fell asleep. Could not wake up. Still breathing. Still had pulse and blood pressure. Called local family and updated our of state family. Stayed with her until 6 pm. Aunt S called at 6:30 pm and told us that Mammaw's breathing had gotten raspy. We went back. She had the death rattle. Called family again. Held Mammaw's hands and talked to her. Told her we'd be okay and it was okay.

2/9: 12:22 am. Hospice nurse called time of death. Called Mammaw's son Uncle J, cousin J, brother, dad, and other Uncle J (didn't realize we had so many J names in the family). 4:00 pm met with the funeral director to start planning. Called Y at the florist and got the casket spray and standing sprays ordered.

2/10-2/13: Helped family find hotels and plane tickets to attend funeral on 2/16.

2/14: Sister did Mammaw's makeup for the services.

2/15: We had private family viewing before services on 2/16. Had dinner with family that we hadn't seen in a while.

2/16: Visitation. Funeral (I spoke some). Graveside service. After service meal.

2/17: Had therapy at 9 am. Cried on my therapist's couch. Went to Barnes and Noble, Five Below, Bath & Body Works, and the mall as an attempt at distraction. Didn't help. Saw family before they left.

2/18: Last of family left to go home. Cried again.

2/20: Mom goes to ER with chest pain (started during funeral planning week but thought it was anxiety). Admitted to hospital with fluid on right lung (lower lobe collapsed, middle lobe collapsing).

2/22: Going to drain lung but she had too much eliquis in her system

2/23: Drained lung. Lidocaine didn't help. She felt it all. 1.4 liters of fluid pulled off. Chest X-ray showed it was almost all of the fluid and lung was reinflating.

2/24: Mom discharged from hospital.

#lost onpurpose #medical stuff #death #family death #funeral planning #hospital #hospice

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booiiee · 4 months

Text

Brooklyn Baby

Pairing: Lee Jaehyun (Hyunjae) × Female Reader

Tags: Fluff, Hyunjae is WHIPPED, They bicker- a LOT, they love each other so much, it's pathetic actually, eventual smut (duh), separate tags and warnings for smut in the smut chapter. MINORS DNI!!

For @un-love 🩷🩷

-------

Chapter 1

It's summer of 2024 you've just shifted your whole life to Brooklyn New York, a decision that you and your friends and family had to all collectively take, Brooklyn is expensive and people are rude sometimes but for the first time you're building your life

You love your job, not a lot of therapist can say that specially with how taxing the job can be, but you really love your job, you're one of the most loved therapist at Brooklyn's biggest hospital NewYork-Presbyterian Brooklyn Methodist Hospital (yes i googled that) and let's just say you earn enough to have an entire studio apartment to yourself, something that you've come to realize, you love.

Your job is many things but it is not a job where you have a lot of free time, it might even be busier than working at a fashion magazine like your friend Daisy does,some days she is the only reminder of your life back in your home country, and your love for kpop and a certain kpop idol- Lee Jaehyun from The Boyz.

“Miss Rose, the director wants to see you.” your thoughts were interrupted by your assistant Liz- or Elizabeth, informing you of your rather sudden meeting with the director. Now the old Jasmine would absolutely lose it over being called by the director but moving to a place like Brooklyn from India has made you indifferent to these small anxiety triggering things.

To say that you were surprised would be the understatement of the century. The director had assigned you a patient of your busy (lazy) colleague, some VIP, whose case was “of utmost importance” to the hospital, which in itself was making you angry as if one life was worth more than the other. Nonetheless, you were gonna treat this patient like any other patient.

“Hi, Mr. Eric? I am Dr. Rose. I am taking over your case as of today, as informed. Please follow me this way” you introduce yourself to a tall man with freshly dyed brunette hair with a mask. He must be some high profile person given the way he was avoiding the stares from people.

R- You can keep the mask on until you feel comfortable to talk without them, our session can happen without you having to show your face.

E- Oh that is a relief thank you doctor.

R- So tell me Eric, what do you love doing when you are the most stressed and when you have a lot of leisure time?

E- Oh I thought you’d start with asking me my sickness

R- You say sickness like it is a bad thing

E- Is it not?

R- Well being sick is not great but it is not something derogatory.

*No one is born a patient and no one stays a patient till the end*.

*(From Daily dose of Sunshine)

As far as the questions go, if you’d rather me start with discussing your diagnosis, i am happy to do so

E- No its…its okay we can do your method.

I am skipping the actual therapy part because I am neither a licensed therapist nor a psych student to be writing that.

The 3 weeks you were assigned Eric’s case you found that against your better judgment, you guys were becoming almost friends, which is to say was weird in more ways than one. You were his therapist and you did not know what he looked like. You never asked him to take off his mask. He never mentioned why he prefers to wear one. So you decided you’d start and stay away from him in the hospital corridors when you often bump into each other after his session with your colleague.

E- I know we are not supposed to be friends and all that protocol, but you have really helped me in ways i could never explain and i am not the best person when it comes to gifts but i asked my friend j and he suggested this since you like to read- i've seen all those books in your office

Your gasp was audible to not only Eric but a few staff around as he pulled out a blue box. Eric quickly pulled you aside and for the first time, took off his mask.

R- You’re THE Eric?????

E- I mean I dont really say that about myself but i think you know me? Which is even better, so you know that i can afford this and im not robbing a bank for this gift, which also is not the case cause J bought this really-

R- Wait, I WILL not accept that, and give me a minute Wow! okay.

Eric, hi, I love your music and you'd understand when i say how weird this is to know my patient is a member of the group i love

E- aww doc you’re a fan. That makes me wanna be your friend even moore

R- Yeah, we’re gonna…we’ll talk about that later.

Wait, you're Eric from TBZ, so your friend J who often drops you to your session, the one who bought this SUPER EXPENSIVE gift, is J, Jaehyun? As in, Lee Jaehyun?

E- Yup you got that right! The one and only! In Fact he is on his way up, now that you’ve seen me, we can all talk comfortably

R- Oh No… no no, NO.

E- But why? Do you not like Hyunjae? *Gasp* Are you a hyunjae antiii??

R- WHAT???? NO! I could never hate my Hyunjae! not in this lifetime for suree!!!

“Well that’s good to know, Miss Rose”

You could identify that voice in a room full of noisy people, let alone the silence of the corridor, so you had no choice but to tun around and see a curly haired masked man smiling at you. Oh this is not good for your job.

-----

Chapter 2 will be posted super soon!!

#hyunjae fluff #hyunjae #lee jaehyun #tbz #tbz hyunjae #tbz × reader #the boyz fic #the boyz smut #the boyz fluff #kpop boygroups

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coexistentialism · 26 days

Note

To put my two cents in (while being admittedly a bit vent-y)

The whole trauma Olympics thing causes SO MUCH HARM- especially to emotional neglect surviors

Like, I'm medically recognized and I almost dropped out of therapy due to the belief that only repeated physical or sexual abuse can cause a CDD

It does cause a lot of harm. And I feel that people would do better if they stopped viewing trauma and stuff as this measurement and instead just Validated people. That's what I want to spread, just validation.

It's hard to grow up feeling suicidal, being depressed, struggling with eating disorder. It's hard to have parents that don't take it seriously, don't see it, don't hear you and help you. Who might even invalidate you, minimize your feelings and experiences. It's hard to grow up lonely with minimal or no friends. It's hard being bullied - whether it's online or not. It's hard being screamed at by family members, to be shunned by peers in school, to struggle in school, to drop out of school for whatever reason. It's hard to be homeschooled, to move houses a lot growing up. These things are severely traumatizing to anyone, especially for children, and I have not even listed half of the things that could affect people. These things are not to be taken lightly and it makes me sad that people don't fully.. Realize how bad these things are. How severe of an effect these things have on people's mental health. These things are severely traumatizing, and I won't stand anyone who says otherwise.

Even if your parents were amazing, genuinely amazing and treated you perfectly, and you experienced trauma from other things, these things have severe consequences on a person's mental health that aren't to be taken lightly, minimized, downplayed, and not taken seriously.

Losing a parent, and/or parents is hard; losing a different family member is hard. Or a friend, etc. Losing a pet, or dealing with medical health problems growing up.

Or having no parents, and/or having one parent; growing up with one loving parent and one abusive parent; growing up with genuinely loving and great parents, but experiencing other things that were hard, painful. Maybe you were bitten by a dog or something, I was bitten by a dog at age 8 and another dog at around ages 9-11, not sure exact age, but I think it traumatized me! Maybe you had an injury as a child and that was traumatizing. Maybe the injury wasn't even "severe", but it hurt you and it was scary and that's real pain and real hurt and deserves to be validated.

Whatever it is, no matter what it is, I just want to validate people. I just want to tell people their hurt is real, valid, and deserves to be validated.

If no-one else will validate you, if you feel as if you experienced anything you and/or others feel is "mild", I want to validate you. Honestly anyone reading this, feel free to send me an ask of anything you've experienced that is ""mild"" in the eyes of society and I will validate you. And I don't mean neglect necessarily, though that's included. I just don't mean things like neglect, I mean truly things that people don't imagine would traumatize someone, like "mild" injuries, like I don't think most people would think a paper cut would traumatize someone, but I want to say "you don't get a say in that. You don't get to tell anyone they should or shouldn't be traumatized by something, or that something didn't traumatize them. That isn't YOUR call to make." I just wanna validate people.

So here's my call, feel free to send me your ""mild"" traumatic experiences and I'm gonna validate you. I don't mean neglect (because everyone immediately thinks of neglect, but neglect isn't mild, even if people try to treat it like it is!) what society truly deems """mild""", like my paper cut example. But I will validate anything. For real, I will, just try me NANXIJE

MY ONLY RULE is to put a TW as best you can AND DO NOT CENSOR THE TRIGGER WARNING please. I hate this, it's a pet peeve, this isn't TikTok! And just try not to be too graphic, but I can handle most other things, and if not, I will read and/or respond to an inbox message whenever I can/am able to.

#My posts #Inbox #Trauma Survivor #ActuallyTraumatized

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religion-is-a-mental-illness · 4 months

Text

By: Jana J. Pruet

Published: Feb 9, 2024

American College of Pediatricians issues its position after reviewing more than 60 studies on mental health in adolescents with gender dysphoria.

A review of more than 60 studies has concluded that “there is no long-term evidence that mental health concerns are decreased or alleviated after ‘gender-affirming therapy,’” according to a national group of physicians.

The American College of Pediatricians (ACPeds) on Wednesday issued its position statement opposing the use of so-called “gender-affirming” medications, such as puberty blockers and cross-sex hormones, social transition, and surgery for youth who have a gender identity not congruent with their sex.

“We urge medical professionals and parents to affirm the truth about childhood gender dysphoria in the presence of harmful thoughts and address the underlying mental illness, adverse events, and family dysfunction,” said Dr. Jane Anderson, lead author and vice president of ACPeds, in a statement.

The group found there is substantial evidence that transgender youth suffer from high rates of mental health problems.

“From this review of the literature, there is strong evidence that children and adolescents who identify as transgender have experienced significant psychological trauma leading to their gender dysphoria,” ACPeds concluded.

ACPeds position outlines the studies that have led a number of European countries, including Finland, Norway, and Sweden, to reverse their positions and reject gender-reassignment treatments in young people.

The group, which has long opposed gender-reassignment treatments, said it is “very concerned that parents, along with health care and educational professionals, who support the transgender ’transition‘ of children and adolescents are, in fact, contributing to increased depression by appearing to validate the children that ’something is wrong with their body and biological sex.’”

“The mental well-being of all adolescents is critical, both for them as individuals, and for the health of the family and community,” the authors wrote.

“Therefore, the American College of Pediatricians (ACPeds) urges parents and all health care professionals to promote and encourage prevention and treatment modalities that will assure optimal outcomes for those affected by sex/gender-identity incongruence, along with all mental illnesses.”

Medical Fact

ACPeds also affirmed “the medical fact that the sex of an individual is based upon biology and not upon thoughts or feelings.”

The so-called “transition” is not a change of sex or even a change of sexual/gender identity, but rather only a change in sexual appearance or presentation,“ they added. ”Thus, ’transgender‘ and ’transition’ are misleading and inaccurate terms, but are used in this document because of their unfortunate standard of use in the medical literature.”

Supporters of gender-reassignment treatments have argued that it saves lives by reducing suicide in youth suffering from gender dysphoria.

The physicians’ report found the rate of suicide attempts or completions was high among those who have received gender-reassignment interventions.

“A study which purported to show a ‘lifetime suicidal ideation’ reduction in those who received puberty blockers actually found twice as many serious suicidal attempts in participants who received the blockers than those who just wished they had received them,” according to ACPeds’ “Position Summary Fact Sheet: Mental Health of Gender Incongruent Youth.”

The decision to transition during adolescence comes with “life-long consequences, including possible sterility and loss of sexual function,” and there should be more support for those seeking to detransition, the report said.

Intensive Psychotherapy Recommended

Reassuring gender dysphoric children to embrace their biological sex, as well as addressing mental illness and other adverse childhood events, is recommended to avoid harmful long-term consequences of gender-affirming treatments, the authors explained.

“Therefore, the ACPeds cannot condone the social affirmation, medical intervention, or surgical mutilation of children and adolescents identifying as transgender or gender nonconforming,” they wrote.

“Rather, intensive psychotherapy for the individual and family to determine and hopefully treat the underlying etiology of their gender incongruence should be pursued.”

[ Via: https://archive.md/SHoVi ]

https://acpeds.org/position-statements/mental-health-in-adolescents-with-incongruence-of-gender-identity-and-biological-sex

Mental Health in Adolescents with Incongruence of Gender Identity and Biological Sex

February 2024

ABSTRACT

Adolescents who have a gender identity not congruent with their biological sex have an increased incidence of mental health issues, including depression and suicidal ideation. Both before and after “gender affirming therapy” (GAT), adolescents who have gender-identity incongruence are at higher risk for psychopathology than their peers who identify with their biological sex. Previous adverse childhood experiences may play a major role in that psychopathology and needs to be explored in helping these patients. There are no long-term studies demonstrating benefits nor studies evaluating risks associated with the medical and surgical interventions provided to these adolescents. There is no long-term evidence that mental health concerns are decreased or alleviated after “gender affirming therapy.” Many individuals who have been treated with “GAT” later regret those interventions and seek to align their gender identity with their sex. Because of the risks of social, medical, and surgical interventions, many European countries are now cautioning against these interventions while encouraging mental health therapy.

Introduction

Adolescents who have a gender identity not congruent with their biological sex have an increased incidence of mental health issues, including depression and suicidal ideation. This is particularly serious given the exponential increase in the number of adolescents identifying as “transgender” in the past decade. For example, the CDC reports every two years on data obtained from the Youth Risk Behavior Surveillance Survey, and in their 2015 report, just 11% of adolescents described themselves as bisexual, gay or otherwise questioning. However, by 2021, just six years later, the number had more than doubled to nearly 25%.[i]

Terminology

It is difficult to discuss this topic without acknowledging the conflict over terminology. The American Psychological Association defines “gender identity” as “ a “person’s deeply-felt, inherent sense of being a boy, a man, or male; a girl, a woman, or female; or an alternative gender which may or may not correspond to a person’s sex assigned [sic] at birth or to a person’s primary or secondary sex characteristics.” “Transgender” is defined as an “umbrella term that incorporates differences in gender identity wherein one’s assigned [sic] biological sex doesn’t match their felt identity.”[ii] The often severe psychological discomfort that comes with gender identity not matching one’s sex is called gender dysphoria.

To further complicate matters, there are a number of other terms being used to describe an individual’s emotions in regards to sexuality including “gender nonconformity,” “gender contentedness,” and “gender expression.” [iii] Therefore, in this paper, these terms may be used when needed to assure accuracy in reporting.

Both gender identity and transgender refer to thoughts and feelings dependent upon one’s emotions as opposed to the biological determination of sex which is based upon the genetic chromosomal composition of the individual. Biological sex is almost always easily identifiable at birth (if not before) based upon phenotypic expression of chromosomal complement. Very rarely, in disorders of sexual development, additional testing may be required to accurately determine sex. To describe sex as “assigned at birth” is inaccurate and misleading.

The American College of Pediatricians (ACPeds) affirms the medical fact that the sex of an individual is based upon biology and not upon thoughts or feelings. The individual’s sex is encrypted in every diploid cell of the body. Since an individual’s biological sex is immutable from the moment of fertilization, it cannot be changed, regardless of hormonal or surgical interventions. Nothing in this paper should be construed to mean the College agrees with or accepts that individuals can change their given biological sex. The so-called “transition” is not a change of sex or even a change of sexual/gender identity, but rather only a change in sexual appearance or presentation. Thus, “transgender” and “transition” are misleading and inaccurate terms, but are used in this document because of their unfortunate standard use in the medical literature.

In addition, ACPeds is very concerned that parents, along with health care and educational professionals, who support the transgender “transition” of children and adolescents are, in fact, contributing to increased depression by appearing to validate to the children that “something is wrong with their body and biological sex.”

Incidence of Mental Health Problems

As the proportion of adolescents who identify as heterosexual decreases, the incidence of mental health issues increases. Using data from an earlier Youth Risk Behavioral Surveillance Survey, researchers found the “proportion of adolescents reporting minority sexual orientation identity nearly doubled, from 7.3% in 2009 to 14.3% in 2017.” Those students who identified as sexual minorities were three times more likely to attempt suicide compared with heterosexual adolescents. In that 8-year time period, as the percentage of sexual minority adolescents almost doubled, the proportion of suicide attempts in that population increased from 24.6 % to 35.6%, indicating that these youth are at greater risk for mental health concerns.[iv]

Of the “sexual minorities”, those with gender dysphoria or transgender identities have higher rates of mental health concerns than other LGBTQ+ identifying adolescents, no matter which measurement tool is utilized. Even young children who identify as transgender are at increased risk. The Adolescent Brain Cognitive Development Study recruited more than 11,000 children across the United States between 9 and 10 years of age with the intention of following them longitudinally to evaluate brain development. In 2022, researchers compared parental reports on the Child Behavior Checklist between children who self-identified as transgender (58) and those who identified as cisgender (7111), with 4692 children excluded who did not understand the question. Children who identified as transgender at this young age were more likely to experience depression (2.53 OR), anxiety (2.70 OR), conduct problems (3.13 OR), and suicidality (5.79 OR). Without considering the possibility that mental health concerns may precede gender dysphoria, the authors state, “Whether this is due to stigma, minority stress, discrimination, or gender dysphoria is unclear.” More interesting is the fact that only 0.48% (58 of 11878) children between 9 and 10 years of age identified as transgender.[v]

In a follow up study, one year later, twice as many children (1.0%) identified as transgender, while 33.2% of 10- and 11- year- olds responded to at least one of four questions in a manner interpreted by the authors as not totally aligning with their biological sex. Several categories of gender diversity were evaluated, and the researchers found, “Significant relationships were observed between mental health symptoms and gender diversity for all dimensions assessed.”[vi]

A contrary conclusion was put forth from an often-cited University of Washington in Seattle study of 73 “transgender children” aged 3 - 12 years whose parents were supportive of their “transition”. When compared with two control groups, the authors stated, “Socially transitioned transgender children who are supported in their gender identity have developmentally normative levels of depression and only minimal elevations in anxiety.” This study has been repeatedly cited as a reason for parents to affirm “transgender children’s” ideation.[vii]However, other researchers re-examined the initial data and found “slightly higher levels of depression but significantly and substantively meaningful differences in anxiety and self-worth, and with results favoring cisgender children, even when the transgender children had high levels of parental support for their gender transitioning.”[viii]

Utilizing data from the 2015-2017 Healthy Minds Study, researchers analyzed the mobile surveys of 65,213 students, including 1237 gender minority students, at 71 college campuses in the United States. Mental health concerns of depression, anxiety, eating disorders, self-injury and suicidality were screened via clinically validated instruments. Seventy-eight percent (78%) of “gender minorities” (GM) compared with 45% of students not identifying as “gender minorities” were found to have those mental health concerns. Twice as many GM students (58%) screened positive for depression compared with 28% of “cisgender” students. The authors found that “GM status was associated with 4.3 times higher odds of having at least one mental health problem.”[ix]

An extensive psychological evaluation of 49 adolescents presenting for gender-affirming medical treatment in Vienna, Austria, was performed prior to the initiation of any treatment. This included 4 - 5 clinic appointments with evaluations by a child and adolescent psychiatrist, a clinical psychologist and a psychotherapist as well as the completion of structured interviews, questionnaires and family assessments. Over half (57%) of the 49 adolescents were diagnosed with at least one psychiatric diagnosis. Previous studies had found co-occuring mental disorders in transgender-identifying children and/or adolescents to range from 32.4% to 85%. The authors acknowledged that “gender dysphoric adolescents are significantly more likely to show psychopathological abnormalities than their cisgender peers, whose gender identity aligns with the sex they were assigned at birth.” [x]

Several factors may contribute to this increased risk of mental health disorders in transgendered youth. It may be that gender dysphoria is more commonly seen in those with other primary mental health diagnoses such as autism spectrum disorder or in those who have suffered a severe trauma, such as sexual abuse. It may be gender dysphoria itself is distressing to the patient, even when the environment is affirming and supportive. Finally, some clinicians theorize that the increase in mental health concerns is secondary to the family rejection or social ostracism the transgender individual experiences.

Researchers have also noted the increased incidence of autism spectrum disorder (ASD) among individuals with sex/gender-identity incongruence. Using five independent cross-sectional datasets consisting of 641,860 individuals, researchers found “transgender and gender-diverse individuals have, on average, higher rates of autism, other neurodevelopmental and psychiatric diagnoses.”[xi]

Another study utilizing the PEDSnet learning health system network evaluated 919,868 youth between 9 and 18 years and found 464 (0.05%) had co-occuring ASD and gender dysphoria. Gender dysphoria was found in 8.6% of those with ASD compared with only 0.6% of those without ASD. In addition, there were greater odds of mental health concerns among those with co-occuring ASD and GD with aOR reaching 20.66 for anxiety, 20.27 for depression and 13.13 for suicidality.[xii]

Risk of Suicidal Behaviors

Along with the increase in mental health concerns, the possibility that adolescents with gender dysphoria are at heightened risk for suicide has been raised. More seriously, many parents are specifically told that if they do not accept their children’s gender identity via social transition, medical treatment, and surgical operations, they risk losing their children to suicide. [xiii]

Early research contributed to the concern regarding increased suicidal behaviors in transgendered adolescents. Utilizing data from the 2013-2015 California Healthy Kids Survey as well as the Biennial Statewide California Student Survey, researchers evaluated the results of 621,189 participating adolescents and found “prevalence of past 12-month self-reported suicidal ideation was nearly twice as high for transgender compared to non-transgender youth (33.73% versus 18.86%).” When the models were adjusted, the transgender youth were almost three times as likely to report past-year suicidal ideation. Between 1.10% and 1.33% of adolescents at that time identified themselves as transgender, and those who did so were more likely to report depressive symptoms and school-based victimization within the past year.[xiv]

Data from the Profiles of Student Life: Attitudes and Behaviors Survey of 120,617 adolescents between 11 and 19 years of age obtained between June 2012 and May 2015 showed nearly 14% of teens reported having made a suicide attempt. The highest rate of suicide attempts (50.8%) was seen in female to male transgender-identifying adolescents, followed by 41.8% of those who identified as “nonbinary”. Heterosexual females (17.6%) and heterosexual males (9.8%) had the lowest rates of suicidal attempts. This study utilized a convenience sample - a methodology that does not allow for broad generalizations as the subjects are not chosen at random, but rather from a group that is conveniently easy to sample.[xv]A smaller study utilizing an online survey of 2020 adolescents between 14 and 18 years of age also found that transgender-identifying adolescents (both male and female) had almost twice the rates of suicidal ideation and attempts compared with “cisgendered” adolescents.[xvi]

From the 2016 and 2019 Kids’ Inpatient Database(KID), researchers identified pediatric patients who had International Classification of Diseases (ICD) - 10 codes related to gender dysphoria and suicidal behaviors. There were over 2 million patient hospitalizations evaluated with 6627 patients with gender dysphoria. “Prevalence of suicidality was greater in individuals with gender dysphoria-related codes than in individuals without gender dysphoria-related codes in KID 2016.” (36% versus 5%) In 2019 the numbers were even higher for those with gender dysphoria with 55% of gender dysphoric patients experiencing suicidal ideation or attempts versus 4% of those without gender dysphoria.[xvii]

This increased risk of suicide has been promoted as a reason for parents to permit gender dysphoric adolescents to “transition” – socially, medically, and surgically. Parents are told their adolescent will commit suicide unless they acquiesce to and accept the adolescent as the gender opposite his or her sex. A British ITV drama Butterfly interviewed parents of transgender adolescents who stated a common refrain - “I’d rather have a live daughter than a dead son.” The program was influenced and promoted by Mermaids, a British organization encouraging children to identify and be affirmed as transgender.

To evaluate this concern, Michael Biggs, Associate Professor of Sociology at the University of Oxford, analyzed the suicide data from England and Wales. Biggs obtained data from the Gender Identity Development Service (GIDS) of the National Health Service (NHS) from 2016 to 2018. They reported three patients had committed suicide and four had attempted suicide in the two-year interval. Biggs utilized other statistics to demonstrate that the suicide rate for transgender adolescents is higher than that for teens overall, but not as high as for adolescents with anorexia nervosa or depression.[xviii]

Four years later, Biggs evaluated data from the Tavistock and Portman NHS Foundation Trust in London for 2007 to 2020, and found four patients from the clinic died of suspected suicide, two of whom were on the waiting list for treatment and two who had been seen in the clinic. The patients seen in the clinic were calculated to be 5.5 times more likely to commit suicide than the general population of adolescents between 14 and 17 years of age, with an annual suicide rate of 13 per 100,000. However, as the author notes, this is not corrected for the increased risk of suicide found in patients with autism who made up 14 - 15% of the patients. Although tragic, this does not translate to the higher suicide rate presented to parents of children seeking care for gender dysphoria.[xix]

Additional research utilizing better methodology has demonstrated that the very high rates of suicide attempts by those identifying as transgender cannot be substantiated. The William’s Institute was contracted by the state of California to use appropriate survey methods and found 22 % of transgender identifying adults had attempted suicide.[xx]Although this rate of suicide attempts is obviously concerning, it is not different from that experienced by individuals who have experienced bullying or who identify as LGB.[xxi]

Mental Health Issues and Transgender Identity

Which comes first? Adverse childhood experiences, mental health disorders, or transgender identity? Adverse childhood experiences (ACEs) were first recognized by Felitti as factors that negatively affect the physical and mental health of adults. [xxii] Felitti developed a 10-item scoring system that identified three major areas of childhood stress and trauma that seriously impacted adult health. ACEs included exposure to domestic violence, mental illness, alcohol or drug use in the home, physical or emotional abuse or neglect, sexual abuse, and parental divorce. In Felitti’s initial study, 67% of adults reported at least one ACE, with physical abuse and alcohol and drug use in the child’s home being the most common. Additional research has demonstrated that ACEs can have an additive negative effect, with four or more ACEs being associated with greater risk of poor physical and mental wellbeing.

The physiologic basis by which ACEs negatively impact health appears to be related to the stress response, leading to elevated levels of cortisol, pro-inflammatory cytokines, and C-reactive protein. Structural and functional changes in the brain occur due to the chronicity of the stress.[xxiii]

One of the first studies to consider the impact of ACEs in LGB adults evaluated data from three states that collected information from over 22,000 adults (2.1% identifying as LGB) using the Behavioral Risk Factor Surveillance System. Twice as many LGB adults (29.7%) had experienced sexual abuse as a child compared with heterosexual individuals (14.8%), and they also had more than twice the odds of reporting physical abuse. Transgendered individuals were not identified in this survey.[xxiv]

Subsequently, researchers evaluated similar data on over 30,000 adults. There were 711 lesbian, gay, and bisexual adults included. Researchers found the LGB adults had a higher prevalence of all ACEs compared to heterosexual adults, with the most significant difference being a threefold increased history of childhood sexual abuse in the LGB respondents. In addition, only 26.8% of LGB individuals stated they had no ACEs, while 40.4% of heterosexuals reported none. Almost twice as many LGB individuals reported between 3 and 8 ACEs (42.4%) compared with 23.9% of heterosexuals. As adults, the LGB community reported twice the rate of poor mental health in the past 30 days (26.8% compared with 10.9%). Again, transgendered individuals were not identified.[xxv]

Transgender-identifying adolescents were included in an online survey of 3508 LGBTQ+ adolescents between 14 to 18 years of age. Researchers found that “Participants reported multiple ACEs (M=3.14, SD =2.44) with emotional neglect (58%), emotional abuse (56%) and living with a family member with mental illness (51%) as the most prevalent.” Nearly half (43%) of the adolescents had experienced at least 4 ACEs, which is much higher than national samples.[xxvi]

A study from the University of Texas in 2019 evaluated the differences in ACE experiences between “transgender” and “cisgender” sexual minorities. “Transgender participants reported emotional abuse, physical neglect, and emotional neglect more frequently compared to cisgender LGB people.”

In addition, the transgender-identifying participants were more than twice as likely to state they were in poor mental health (OR=2.47)[xxvii]

Suarez, et al, assessed the prevalence of ACEs specifically in 131 ‘transmasculine’ adults – those born female – and found 45% reported more than four ACEs. Having experienced four or more ACEs was associated with more than a fivefold increased incidence of depression (AOR=5.3) and suicidality (AOR=5.2).[xxviii]

Giovanardi, et al, evaluated the relationship between complex trauma and gender dysphoria. The researchers defined complex trauma as “a set of experiences of cumulative, chronic and prolonged traumatic events, most often of an interpersonal nature, involving primary caregivers and frequently arising in early childhood or adolescence.” These experiences could include physical and sexual abuse, physical and emotional neglect, and exposure to domestic violence, similar to the items on the ACEs screening tool. Utilizing two tools, a Complex Trauma Questionnaire, along with the Adult Attachment Interview, researchers found significant differences between adults with and without gender dysphoria. 61% of adults without gender dysphoria described their attachment to their childhood caretakers as “secure”, while only 27% of gender dysphoric adults did so. The difference in history of complex trauma was also significant as 90% of gender dysphoric adults had experienced any form of trauma and 56% had experienced four or more types. In the control group, only 7% had experienced four or more types of trauma.[xxix]The authors noted that both “trans men” (biological females) and “trans women” (biological males) “suffered from severe neglect, rejection, and psychological abuse”, and stated, “we believe that attachment and trauma investigation could play a crucial role in bringing to light conflicts and defenses that may interfere with a free exploration of gender identity.”

Electronic medical records were reviewed in a large study of 26,300 children and adolescents who identified with their biological sex who were age and sex matched to 1333 transgender individuals. (Ten females and ten males were matched with each individual identifying as transgender.) Common diagnoses noted prior to the diagnosis of gender dysphoria were compiled. There were high rates of psychiatric disorders and suicidal ideation before gender non-congruence in teens, with psychiatric hospitalizations seen 22 – 44 times higher than in the controls and self-harm 70 – 144 times higher. In adolescent patients between 10 and 17 years of age, the researchers found depressive disorders in 49% of trans females and 62% of trans males.[xxx]

In a prospective study of 79 Australian children with gender dysphoria (33 biological males; 46 biological females), researchers found high levels of distress, including 41.8% with history of suicidal ideation, 16.3% with self-harm, and 10.1% with suicidal attempts on their first presentation. The majority of the children had comorbid mental health disorders, including 63.3% with anxiety, 62% with depression, 35.4% with behavioral disorders and 13.9% with autism. Significantly the majority also had suffered adverse childhood experiences with 39.2% having had maltreatment, 63.3% had parental mental illness and 59.5% had lost an important family member. 10% of the children had been in out-of-home placement, and only two of the children reported no adverse childhood experiences.[xxxi]

In 2018, Littman reported an online survey of 256 parents of a child who had experienced rapid onset gender dysphoria in their adolescence (83% female sex) during or after puberty. The adolescents were a mean age of 15.2 years when they identified as transgender, and 62.5% of the adolescents had “been diagnosed with at least one mental health disorder or neurodevelopmental disability prior to the onset of their gender dysphoria.”[xxxii]

Although retracted due to political pressure, subsequent research confirms Littman’s data regarding preceding mental illness. Surveys completed by 1665 parents visiting a website (Parents of ROGDkids.org) revealed 57% of the transgender-identifying adolescents had a preceding history of mental health concerns that began on average 3.8 years prior to gender dysphoria, and 42.5% had received a ‘formal psychological diagnosis.”[xxxiii] Given this research, it seems likely that preceding trauma and childhood adverse experiences contribute to gender dysphoria and certainly to the mental health concerns and depression experienced by many transgender-identifying individuals.

“Affirmation Treatment” and Mental Health Effects

This is a crucial question since health care professionals should provide appropriate treatment that will allow individuals to attain optimal mental well-being. But what is appropriate treatment for “transgender” adolescents? Will social transition, medications, and surgical intervention prevent or treat depression and suicidal behaviors?

Most of the research attempting to answer these questions is severely flawed. Small sample sizes, biased recruitment, patients lost to follow up, and extremely short durations of follow-up are some of the most common problems seen in the literature. In addition, studies on long-term follow up are, of necessity, reporting on individuals who “transitioned” years ago when, in order to undergo medical and surgical “transition,” the patients had to be adults who had received intense psychological evaluation. The recent surge in the adolescent population identifying as transgender is unprecedented, and no long-term follow up studies are obviously available. Even so, the long-term follow up research on transgender adults is concerning for its inability to show improvement in mental health.

Gender Transition Efforts

There are three interventions used by transgender therapists that must be examined: social affirmation (also known as social “transition”), hormonal intervention with use of puberty blockers followed by cross-sex hormones, and surgical procedures.

Social “Transition”

Social “transition” involves a change in name, pronoun use, hair style, and clothing to more closely match the child’s perceived sexual identity which is incongruent with their biological sex. There is conflicting research regarding possible mental health benefits to social “transitioning” of children with gender dysphoria. One of the earliest studies matched 73 “transgender” children between 3 - 12 years with 73 gender-matched community controls, that included 49 siblings of the “transgender” children. The researchers found parental reports of depression were similar in each group, but there were slight increases in anxiety in the “transgender” children.[xxxiv] However, this study did not provide evidence that social “transitioning” improved psychological well-being.

Psychological functioning assessed via parental reports on 54 children between 5 and 11 years of age who were evaluated at the Hamburg Gender Identity Service in Germany found that peer problems and worse family functioning “were significantly associated with impaired psychological function, whilst the degree of social transition did not significantly predict the outcome. Therefore, claims that gender affirmation through transitioning socially is beneficial for children with GD could not be supported from the present results.”[xxxv] The study by Wong, et al. of 226 “gender variant” children who had socially transitioned compared to those who had not transitioned concurred, with the authors stating, “There was little evidence that psychosocial well-being varied in relation to gender transition status.”[xxxvi]

In addition, social transitioning leads to persistence of gender dysphoria. A study of 127 adolescents who were diagnosed before age 12 years with gender dysphoria in Amsterdam, the Netherlands, found that those who experienced “affirmation” of their cross-gender identification were more likely to persist in that incongruent identification. All four children who socially “transitioned” persisted in their cross-sex identification, while only 35% of the 123 children who did not completely socially “transition” persisted.[xxxvii]

Thus, Zucker states, “A gender social transition in prepubertal children is a form of psychosocial treatment that aims to reduce gender dysphoria, but with the likely consequence of subsequent (lifelong) biomedical treatments as well.”[xxxviii] Cass agreed in her review of gender services for the National Health Services (NHS), and stated social “transition” is “an active intervention because it may have significant effects on the child or young person in terms of their psychological functioning.”[xxxix]

Further, when one considers brain development of the young child, with its neuroplasticity, each thought, behavior and experience affect the brain’s microstructure and function. Social transition can then confirm to a child a new identity. Importantly, the child will have difficulty later questioning the new identity since parents and teachers have confirmed it.

Pubertal Suppression

In an attempt to examine the benefit of pubertal suppression during adolescence with mental health outcomes as adults, Turban, et al, utilized a cross-sectional survey of 20,619 transgender adults between the ages of 18 to 36 years. In their sample, 16.9% of participants reported they had desired pubertal suppression as an adolescent, with 2.5% receiving such treatment. The authors found “those who received treatment with pubertal suppression…had lower odds of lifetime suicidal ideation (adjusted odds ratio = 0.3).”[xl]

However, in a published comment linked to that article, Field and Trumbull pointed out the “exceedingly high rates in both groups of suicide ideation (75% and 90%) and suicide attempts (42% and 51%).” The relatively brief follow-up period and the doubled (45.5% vs. 22.8%) rate of serious suicide attempts requiring inpatient care in the pubertal suppression treatment group during the year preceding data collection contribute to the serious concerns surrounding the use of pubertal suppressing drugs.[xli]

Another letter to the editor noted the Turban survey assumed puberty blockers were available in the United States earlier than they actually were. “Most seriously, Turban et al (2020) barely acknowledged the fact that adolescents with severe psychological problems would have been less eligible for drug treatment, which confounds the association between treatment and suicidal ideation.” This undermines the article’s recommendation to make treatment available for all transgender adolescents who request it.[xlii]

The Florida Agency for Health Care Administration requested McMaster University Department of Health Research Methods to provide an analysis of gender affirming therapies. The two researchers initially found 61 systematic reviews, but utilized 14 for their intense analysis. They found no study comparing outcomes between those using and not using puberty blockers, so they stated “it is unknown whether people with gender dysphoria who use puberty blockers experience more improvement in gender dysphoria, depression, anxiety, and quality of life than those with gender dysphoria who do not use them. There is very low certainty about the effects of puberty blockers on suicidal ideation.” The researchers made similar statements regarding cross-sex hormone therapy and surgical interventions.[xliii] This conclusion was further emphasized by a systematic review of studies on the use of puberty blockers in children with gender dysphoria by the National Health Services (NHS) in the United Kingdom noted the low certainty of the outcomes of the studies and could find no evidence that the use of puberty blockers improved the mental health of patients suffering from gender dysphoria.[xliv]

The Council for Choices in Healthcare in Finland / COHERE Finland reviewed research on gender dysphoria treatment and issued their report in 2020. For hormonal suppression, the report stated, “In cases of children and adolescents, ethical issues are concerned with the natural process of adolescent identity development, and the possibility that medical interventions may interfere with this process. It has been suggested that hormone therapy (e.g., pubertal suppression) alters the course of gender identity development; i.e., it may consolidate a gender identity that would have otherwise changed in some of the treated adolescents. The reliability of the existing studies with no control groups is highly uncertain, and because of this uncertainty, no decisions should be made that can permanently alter a still-maturing minor’s mental and physical development….It is not known how the hormonal suppression of puberty affects young people’s judgement and decision-making.”[xlv]

“Gender-affirming” Hormones - Cross sex hormones

Likewise, a systematic review by the NHS of the use of cross-sex hormones in gender dysphoria evaluating impact on mental health and quality of life also found the “quality of evidence for all these outcomes was assessed as very low certainty.” The report concluded, “Any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria.”[xlvi]

The pro-transgender-affirmation organization, World Professional Association for Transgender Health (WPATH), commissioned a team at Johns Hopkins University to conduct systematic reviews of treatment protocols for transgendered individuals. One of those studies, a systematic review of 20 research papers, evaluated “quality of life (QOL), depression, anxiety, and death by suicide in the context of gender-affirming hormone therapy among transgender people of any age.” Although the authors stated they found “hormone therapy was associated with increased QOL, decreased depression, and decreased anxiety,” they stated that “certainty in this conclusion is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions.” Further, they could not make any determinations about the impact on death by suicide, and so recommended additional studies among larger and more diverse groups of patients.[xlvii]

A 2021 comprehensive data review of all 3,754 trans-identified adolescents in US military families over 8.5 years showed that cross-sex hormone treatment leads to increased use of metal health services and psychiatric medications, and increased suicidal ideation/attempted suicide. When transgender-identifying adolescents who were using gender-affirming pharmaceuticals (963) were evaluated separately, their use of mental health care services did not change but their use of psychotropic medications did increase.[xlviii]

A longitudinal study from Denmark that included all individuals (3812) who had accessed the three national centers for gender care and compared them with 38,120 controls found “that the odds ratio for mental health disorders was more than five times higher in transgendered persons compared to controls at baseline. The risk for mental and behavioral disorders in transgender persons increased rapidly during the first year after the index date followed by a decreasing trend, but the odds ratio remained elevated throughout follow-up, especially in transgender persons assigned male at birth.”[xlix]Upon presentation to the centers, at least 24% of transgender-identifying individuals had been prescribed psychopharmacological treatment, compared with 4-6% of controls. Although the proportion of transgender-identifying individuals with a psychiatric diagnosis decreased slightly after the first year of treatment, the rates of psychopharmacological treatment increased and remained elevated throughout the treatment period, so that 30.5% - 39.5% of individuals were receiving treatment after 8 years, compared with 8 - 14% of controls. Gender-affirming (cross-sex) hormonal therapy was prescribed to 2089 individuals and there was no significant decrease in mental health concerns after treatment. The study had limited ability to evaluate the effects of gender-affirming surgical interventions.

A recent Finish register follow-up study found that individuals who presented for gender identity services “received many times more specialist-level psychiatric treatment both before and after contacting gender identity services than had their matched controls.”[l] The authors reported the relative risk of psychiatric needs in gender dysphoric patients versus controls was significantly higher in 2016-2019 compared to in 1996-2000. Furthermore, this study demonstrated that transgender individuals who underwent medical transition had increased needs for specialist-level psychiatric care compared to those transgender individuals who presented for care but did not receive medical interventions. The authors state their findings, along with other research, “do not suggest that medical GR [gender reassignment] interventions resolve psychiatric morbidity among people experiencing gender distress.”

“Sex-reassignment” (Opposite sex impersonating) Surgery

A population-based cohort study between 1973 and 2003 from Sweden matched each of 324 patients who underwent “sex reassignment” surgery (191 male-to-female; 133 female-to-male) with 10 controls. “The overall mortality for sex-reassigned person was higher during follow-up (aHR 2.8) than for controls of the same birth sex, particularly death from suicide (aHR 19.1). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9) and psychiatric inpatient care (aHR 2.8).” It is extremely important to note that on the Kaplan-Meier survival curve, the mortality of “transsexual persons” started to significantly diverge from the controls after ten years of follow up, increasing substantially by 15 years after surgical reassignment. At 30 years of follow up, the suicide rate was 19 times that of age-matched controls.[li] The authors of this study stated, “Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group.”[lii]

Overall “Gender-affirming Treatment”

“Gender-affirming treatment” (GAT) is a confusing term since the use of the word “treatment” implies there is a medical condition that requires correction. Dysphoria associated with gender/sex-identification incongruence is a psychological problem in need of a psychological treatment, not affirmation of a false sexual identity by altering physical appearance. Affirmation should more appropriately be used to confirm the individual’s biological sex which can never be changed regardless of any “transition” attempted. Despite these concerns, this paper uses the term “gender-affirming treatment” (GAT) since it is now in common usage in the medical community.

Most studies confirm there are no large or long-term studies demonstrating any benefit to GAT. The Centers for Medicare and Medicaid Services provided analysis of 33 studies on gender reassignment surgeries on adults and determined they would not issue a National Coverage Determination for “gender reassignment surgery for Medicare beneficiaries with gender dysphoria because the clinical evidence is inconclusive for the Medicare population.” [liii] States were allowed to determine coverage on a case-by-case basis.

A 2023 study from Germany evaluated loneliness and social isolation in “transgender and gender diverse individuals.” Approximately one-third (38 of 88) of the participants had undergone “gender reassignment surgery,” but the researchers found no significant difference in the extremely high incidence of loneliness between those who had (84.2%) and had not (83.3%) undergone surgical procedures. Similarly, 79.2% of those who had not undergone surgery perceived social isolation, compared with 81.6% of those who had surgery. The authors concluded, “Our data indicate that transgender and gender diverse people, who have undergone gender reassignment surgery feel lonelier. To our knowledge, this is the first study analyzing the levels of loneliness and social isolation in operated transgender and gender diverse people.”[liv]

Researchers utilized the national database of 6,657,456 Danish-born individuals spanning over four decades and found those individuals identifying as transgender had significantly higher rates of suicide attempts, suicide mortality, suicide-unrelated mortality, and all-cause mortality. Of the 3759 individuals identifying as transgender during that time, “Standardized suicide attempt rates per 100,000 person-years were 498 for transgender versus 71 for non-transgender individuals (aIRR 7.7)” The individuals identifying as transgender were 3.5 times more likely to die from suicide, and even the non-suicide death rate was 1.9 times as high. These numbers were barely lower even in 2021 (aIRR of 6.6, 2.8 and 1.7, respectively). [lv]This despite Denmark being recognized by the European chapter of the International Lesbian, Gay, Bisexual, Trans & Intersex Association (ILGA-Europe) as the third best country in Europe for its protection of sexual and gender minority rights.[lvi]

The Swedish National Board of Health and Welfare also examined evidence-based research on the care of children and adolescents with gender dysphoria. After a comprehensive review, the Board concluded, “the risk of hormonal interventions for gender dysphoric youth outweigh the potential benefits.”[lvii]In this report, the Swedish National Board of Health and Welfare noted the insufficiency of evidence for safety and efficacy of treatments (thus any definitive conclusions cannot be drawn), the poorly understood marked change in demographics and the lack of clarity regarding the cause of gender dysphoria as the number of patients continues to increase (especially in adolescent females), the increasing prevalence of young adults who chose to detransition, and the markedly different population involved in previous cases studied with evidence for pediatric transition.

Another systematic review commissioned by the Swedish Agency for Health Technology Assessment and Assessment of Social Services initially reviewed 9934 studies to determine effects of hormone treatment in children on psychosocial and mental health, cognition, body composition and metabolic markers. Out of 9934 studies, only 24 were felt to be relevant with low risk of bias. Most of those studies were small and observations were not reported after age 18 years. The authors concluded, “long-term effects of hormone therapy on psychosocial and somatic health are unknown, except that GnRHa [gonadotropin-releasing hormone analogues] treatment seems to delay bone maturation and gain in bone mineral density.” One of the authors’ key points was, “GnRHa treatment in children with gender dysphoria should be considered experimental treatment of individual cases rather than standard procedure.”[lviii]

Finland also changed its stance and issued new guidelines recommending psychotherapy as the first line of treatment for “gender dysphoric” children and surgical intervention is not allowed for adolescents less than 18 years of age.[lix]The Norwegian Healthcare Investigation Board likewise in May, 2023, stated “research-based knowledge for gender-affirming treatment (hormonal and surgical), is insufficient and the long-term effects are little known.” They recommended revising the guidelines for care of “gender dysphoric” youth.[lx]The French Academy of Medicine has also recommended caution in the use of puberty blockers and surgery in the care of transgendered adolescents.[lxi]

A systematic review of all international clinical practice guidelines (CPGs) concerning “gender minority / trans health” was reported in the BMJ Open in 2021.[lxii] None of the CPGs addressed primary care, mental health or long-term medical concerns. The authors concluded, “A paucity of high-quality guidance for gender minority / trans people exists, largely limited to HIV and transition, but not wider aspects of healthcare, mortality or QoL (quality of life).”

These evaluations of evidence-based medicine should cause health care professionals to pause the social, medical, and surgical transition of adolescents. In fact, pending its reopening under a profoundly different model, Great Britain has closed the Tavistock and Portman clinic, specializing in the care of transgender children and has stopped the prescription of all puberty blockers for children, except those enrolled in clinical trials due to the “lack of clinical consensus and polarized opinion on what the best model of care for children and young people experiencing gender incongruence and dysphoria should be.”[lxiii]

Regrets Concerning “Transitioning” Procedures

Researchers from the University of Toronto provided follow-up data on 139 boys referred to their clinic for gender dysphoria. The boys were initially assessed at a mean age of 7.49 years and followed for a mean of 20.58 years. “Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters.” This fact is crucial when interventions are proposed for adolescents, as it confirms the majority of children with gender dysphoria will feel comfortable with their biological sex if allowed to progress through normal puberty with the influx of natural sexual hormones.[lxiv]

Thus, in the past, with a medical treatment course of “watchful waiting”, 80- 90% of adolescents with gender dysphoria adopted their birth sex as they went through the natural course of puberty with the accompanying hormonal surges. The adults who then “transitioned” were a small subset of patients, and studies at that time demonstrated a low rate of regret, although the duration of follow-up was short.[lxv]

Now, however, with the social transition and “gender-affirming therapy” (GAT) provided to young adolescents whose brains are not yet mature, there is less long-term data regarding how many later regret their transition decision. One author stated, “Recent data, capturing the upsurge in the predominant adolescent-onset variant of gender dysphoria, suggest that detransition and/or regret could be more frequent than previously reported”, and cites five articles.[lxvi]

When evaluating the literature on this topic, it is important to note that several flaws occur. First, studies on regret and quality of life have high rates of patients lost to follow up. Secondly, as noted above, adult patients who transitioned in the past are quite different from adolescents transitioning today. Even more importantly, the term “regret” is defined differently in studies and in some studies is narrowly defined as those who return to the same gender clinic to begin medical detransition. However, as Littman found, only 24% of individuals in her study informed their original medical providers of their decision to detransition.[lxvii]

The methodologically flawed United States Transgender Survey is a cross-sectional survey of 27, 715 transgender and gender diverse adults. From that survey, 17,151 adults stated they had pursued gender affirmation, and of those, 2242 (13.1%) said they had stopped the transition process or detransitioned. Over 80% of these individuals stated pressure from family and social stigma contributed to their decision to detransition, but 15.9% also stated that they had experienced uncertainty about their gender identity. Individuals also stated that fertility and desire for a spouse or partner contributed to their desire to detransition.[lxviii]

Researchers conducted in-depth interviews with 28 Canadian adults who opted to detransition, and learned there were numerous reasons for their decisions, including physical and mental health concerns, surgical complications or postoperative pain, unsupportive family, employment discrimination or inability to access health care. The patients experienced the detransition process as “physically and psychologically challenging”, especially when medical providers lacked appropriate information to help them.[lxix]

Littman studied 100 patients who chose to detransition, 69 of whom were biological females. Of those who chose to detransition, 60% did so because they felt more comfortable with their biological sex, and 38% stated their gender dysphoria was due to trauma, abuse or a mental health condition.[lxx]

A study of 1089 patients referred to pediatric endocrine clinics in England reported 5.3% stopped treatment with puberty blockers or cross-sex hormones before their 18th birthday and identified with their biological sex. Significantly, in this study, the younger adolescents less than 16 years of age at the start of hormonal intervention were twice as likely to align their gender identity with their biological sex than those who were older. (9.2% versus 4.4%)[lxxi] Utilizing the records of the United States Military Healthcare System, researchers evaluated 952 transgender adolescents and adults and found 29% discontinued hormonal therapies within four years.[lxxii]

A retrospective chart review of 68 youth receiving gender care at Children’s National Hospital found 47% of the patients were autistic, and 29% reported a change in their request for treatment. The authors stated in their conclusion, “Shifts in gender-affirming medical requests by gender-diverse youth may not be uncommon during the adolescent’s gender discernment process.”[lxxiii] There are websites for those desiring to detransition, and one website on Reddit has over 47,000 members.[lxxiv]

The short-term follow up of currently advocated “gender affirming” care, along with the high incidence of loneliness and depression among transgender individuals, and the unknown numbers of those who desire to detransition should all cause health care professionals to reconsider treatment offered to those with gender dysphoria.

ADDITIONAL CONCERNS

Politics versus Science.

Levine and Abbruzzese clearly articulate the current state of medical care of individuals with gender dysphoria/incongruence in the United States and the way politics has overtaken and overshadowed the evidence-based science. They list ten key, but false, assumptions that underlie care in the United States, including trans-identity will be lifelong, is biologically determined, is inherently healthy, and that the only appropriate treatment is the affirmation model with medical and surgical interventions without use of psychological evaluation or treatment.[lxxv]

Adolescent Brain Development

The immaturity of the adolescent brain has been well described for the past 20 years, and newer research demonstrates how the immaturity affects decision-making. Studies confirm that adolescents, when faced with real life decisions, are much more likely to depend upon their emotions and peer pressure, with less use of their cognitive reasoning skills and with less concern for future consequences.[lxxvi] The rise of rapid-onset gender dysphoria in adolescent girls who are high users of social media is evidence of this.

In addition, the immaturity of the adolescent brain contributes to participation in high risk behaviors as the teens seek to experience higher levels of dopamine. Dopamine is involved in the pleasure-reward system of the brain, and the immaturity of their brains causes adolescents to seek more exciting stimulation. Since their prefrontal cortex (the brain’s inhibition center) is not yet fully mature, their ability to stop or avoid risky behaviors is limited.[lxxvii] This desire for excitement via novel behavior may entice adolescents to experiment with alternative gender roles.

Finally the adolescent brain is also significantly molded as the neurons experience the sex-appropriate hormonal surges experienced with puberty. Brain cells include receptors for estrogen and testosterone, and the brain is structurally and functionally changed during puberty.[lxxviii] What happens to the development of the adolescent brain when puberty is blocked or when opposite sex hormones predominate? Unfortunately, we have no answers to these questions that are critical to the evaluation of care for individuals with sex/gender identity incongruency.

For more information regarding hormonal impact on brain development during adolescence, see “The Teenage Brain: Under Construction” at https://acpeds.org/position-statements/the-teenage-brain-under-construction

Medical and Surgical Complications of Treatments

It is not the purpose of this paper to document the numerous complications of pubertal suppression, cross sex hormones and surgical interventions, but it should be noted they may include, among other complications, sterility and lifelong hormonal treatment.

CONCLUSION

The mental well-being of all adolescents is critical, both for them as individuals, and for the health of the family and community. Therefore, the American College of Pediatricians (ACPeds) urges parents and all health care professionals to promote and encourage prevention and treatment modalities that will assure optimal outcomes for those affected by sex/gender-identity incongruence, along with all mental illnesses.

However, from this review of the literature, there is strong evidence that children and adolescents who identify as transgender have experienced significant psychological trauma leading to their gender dysphoria. Also, there is no long-term evidence that current “gender affirming” medication and surgical protocols benefit their mental well-being. High rates of suicide attempts and/or completions in those who have received “gender affirming” interventions indicate that at minimum, long term controlled trials should be conducted if these interventions are to be continued. More attention and support should be afforded to individuals seeking help in detransitioning after having made a decision during their formative adolescent years with life-long consequences, including possible sterility and loss of sexual function. Therefore, the ACPeds cannot condone the social affirmation, medical intervention, or surgical mutilation of children and adolescents identifying as transgender or gender nonconforming. Rather, intensive psychotherapy for the individual and family to determine and hopefully treat the underlying etiology of their gender incongruence should be pursued.

https://acpeds.org/assets/positionpapers/mental-health-of-gender-incongruent-youth-fact-sheet-final.pdf

American College of Pediatricians

POSITION SUMMARY FACTSHEET: MENTAL HEALTH OF GENDER INCONGRUENT YOUTH

February 2024

Over 60 studies were reviewed in this analysis of the mental health of gender-incongruent youth.

Youth whose perceived gender identity does not align with their biological sex have high rates of mental health problems regardless of any affirmation of their gender identities.

Adverse childhood experiences, including child abuse of various types, are experienced by over half of LGBTQ+ sexual minorities, with transgender youth reporting more abuse and neglect than other sexual minorities.

Psychiatric disorders commonly precede gender incongruence.

Research casts doubt on claims that social affirmation (like using desired pronouns) of transgenderidentified youth helps their long term psychosocial wellbeing.

Blocking puberty also has not produced significant benefits for gender incongruent youth according to indepth systematic reviews. o A study which purported to show a "lifetime suicidal ideation" reduction in those who received puberty blockers actually found twice as many serious suicidal attempts in participants who received the blockers than in those who just wished they had received them.

Studies from multiple countries indicate cross-sex hormonal interventions result in little mental health benefit. Furthermore, these chemical interventions were associated with greater use of psychiatric services than patients who were not treated with hormones.

On reviewing extensive data, multiple countries have rejected so-called “gender-affirming” therapies in favor of psychological treatment of children with gender incongruence.

There is no evidence-based proof that so-called “gender affirming” therapy is affirming to the health of gender incongruent youth.

Many adolescents who have undergone “gender affirming” therapy (hormonal and/or surgical) later embraced their biological sex as their gender. These youth need support as they often deal with significant harm from their previous medically sanctioned interventions that led to disfigurement and possible sterilization.

Gender-dysphoric youth need to have mental illness, adverse childhood events, and family dysfunction dealt with, and need the reassurance to embrace their biological sex as their gender identity and to avoid the harmful consequences of “transgender-affirming” interventions.

So why the hell are we doing this?

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