Growing Pains
Problems with puberty suppression in treating gender dysphoria
One day in the summer of 2023, when Irene’s sixteen-year-old daughter had come home so drunk she was slurring her words, she told her mother that she was questioning her gender, that “I might want to be a boy.” Irene had been through adolescence with an older child and met this confession with equanimity. “It’s very common to explore identities, we love you whatever you are,” she told the teen.
Their relationship in the preceding months had become “extremely bad,” says Irene, who asked to use her first name only to protect the identity of her family. The girl had attempted suicide with pills; there had been weeks in a psych ward, a new therapist, medications for ADHD and depression. The summer was erupting with slammed doors and heavy drinking and pot vaping.
As autumn set in, Irene was growing more concerned about the drug use, skipped classes, falling grades, homework undone, aggression in the home. By this time the teen was demanding to be called by male pronouns. Irene, whose upbringing in the Eastern bloc occasionally reveals itself in her phrasing, was hesitant. Gender had never been an issue for her child. And she suspected there was a social component: “I had noticed that all the friends she had at this time were questioning their gender. Like about eight of them — they all used different names.” Irene felt this was beyond the current therapist’s skills and begged a program near their home in New York City to take her kid.
Irene was still referring to her child as her “daughter,” but at the first appointment the counselor told her she “needed to be educated” on transgender issues. A few sessions in, the counselor recommended socially transitioning: accepting the teen’s new chosen name and male pronouns, and facilitating whatever else was needed — typically wardrobe revisions, a new haircut, and chest binders. “This is the way you’ll build the relationship,” the counselor told Irene.
Irene was amenable to anything that would help get her struggling kid on better footing. But it didn’t seem to. “She lost almost thirty pounds, she started refusing to go to school, was always getting sick,” Irene recalls. Then, in the spring of 2024, the teen went on a full strike. “She refused to go to any therapist, refused to take any pills, said I’m not going to do any of that unless you bring me to a gender clinic for testosterone.” This went on until it became, “‘If you’re not taking me to the clinic, I’m going to kill myself.’”
The debate over providing medical transition treatments for young people who identify as trans, or who have a diagnosis of gender dysphoria, has focused on puberty blockers, cross-sex hormones, and surgeries. As of this writing, 27 U.S. states have restricted some or all of these procedures for minors. In June, the Supreme Court upheld states’ rights to do so.
Among the camp that has been pushing the medical community to, at a minimum, take a more cautious approach, psychotherapy is taking an increasingly prominent position as the most appropriate, least risky first-line treatment for youth. This change follows the lead of the national health agencies of Finland and Sweden. In 2020 and 2022, respectively, they recommended psychotherapy as the first-line treatment, after evidence reviews found that the risks of medicalization outweigh the presumed benefits. England’s four-year Cass Review, published last year, made the same call, urging “extreme caution” on cross-sex hormones for minors. Following its publication, the National Health Service restricted puberty blockers nationwide for people under eighteen, making exceptions only for patients already receiving them and for participants in a clinical trial (which has yet to secure approval).
Advocates often frame criticism of what is called “gender-affirming care” as an incendiary front in the culture war: transphobic reactionaries versus the trans-rights-supporting Left. I’ve been reporting on this topic for three years and have interviewed scores of clinicians, researchers, ethicists, parents, and activists. Some skeptics are politically conservative, but many are coming straight out of a liberal, feminist, “in this home we believe in science” worldview. They believe in protecting kids from what they see as medical overreach, but don’t necessarily support legislative remedies. Nor are they celebrating President Trump’s inflammatory executive orders calling treatments “chemical and surgical mutilation” and expelling trans service members from the military.
For the broad coalition agitating against irreversible medical transition in minors, “therapy first” has turned into a shorthand as well as a rallying cry, the answer to the question If not affirmative care, then what?
“Based on the current state of knowledge and evidence in the field of pediatric gender medicine, we’ve basically got no idea what type of effect hormonal interventions are going to have on these kids’ mental health and psychosocial functioning,” says Dr. Kathleen McDeavitt, assistant professor of psychiatry at Baylor College of Medicine, who recently presented on the topic at the annual conference of the American Psychiatric Association. The long-awaited results of a multi-million dollar NIH study are now in preprint: among 94 kids given puberty blockers and followed for two years, mental health outcomes were unchanged. In the U.K., a 2021 study of 44 young people treated at the now-shuttered Gender Identity Development Service clinic found that after two years, overall mood for one third of the kids improved, and for one third got worse.
“We’ve basically got no idea what type of effect hormonal interventions are going to have on these kids’ mental health and psychosocial functioning.”
While the evidence is inconclusive, says McDeavitt, “we do understand as physicians that these interventions pose significant risks — to fertility, bone density, sexual function. On the other hand, we have evidence-based psychotherapeutic tools that we can use to help kids manage distress.” Though there may not be a strong evidence base for using those tools specifically to treat gender-related distress, because they have not been studied, techniques like dialectical behavioral therapy have far fewer risks than medication or a mastectomy, she argues. “Why wouldn’t that be our standard recommended approach?” Furthermore, she points out, history has not looked kindly on medical practices that disproportionately affected vulnerable populations’ sexual functioning and fertility.
England’s National Health Service is in the process of re-training therapists to meet this moment. But in the United States, every professional organization in the mental health field — the American Psychiatric Association, the American Psychological Association, the corresponding groups for psychoanalysts, therapists, counselors, and social workers — all continue to stand behind the affirmative model: accept a patient’s gender identity as innate and off-limits for exploratory discussion, regardless of the patient’s age or general mental health.
This, says Paul Garcia-Ryan, executive director of a small but growing organization for mental health professionals called Therapy First, has put his colleagues in an unprecedented — and unfortunate — position, asking them to treat trans patients in an exceptional way that precludes the precepts of therapy itself: asking questions and exploring emotions so that their clients may better know themselves. In the context of young people, he says, the model disregards the fluid nature of adolescent identity formation. “I was trained in a gender-affirming way and practiced in a gender-affirming way, and you don’t really get much discussion around developmental considerations,” he says. “We have younger therapists coming in and expressing real concerns about how this is taught to them.”
Psychology was the field from which childhood medical transition originated in the 1990s. Practitioners in the Netherlands thought that puberty suppression could alleviate psychological distress in children and, if they later underwent surgery, help them to pass more convincingly as their felt gender.
As what came to be known as the Dutch Protocol developed, mental health professionals had a central role in conducting an extensive assessment to determine whether the young person in front of them was a good candidate for blocking puberty. That process took a minimum of six months.
Laura Edwards-Leeper, an American psychologist, was sent to the Netherlands in the mid-2000s to learn this methodology and bring it back to Boston Children’s Hospital, which launched the nation’s first pediatric gender clinic. The protocol contracted upon import, shrinking from months to weeks to mere hours. Last year a lawsuit revealed that by 2018 (long after Edwards-Leeper had moved on) patients were getting a green light for treatment after only two hours of assessment.
When I first spoke with her three years ago, Edwards-Leeper lamented how gender clinicians had come to downplay the importance of mental health professionals, “largely because they believe if the young person says they’re trans, they’re trans,” she said. Meanwhile, she said, the term “conversion therapy” — which describes the widely condemned practice of trying to enforce heterosexuality, often through coercion and violence — was being “hijacked” to denigrate therapy itself. Since then, charges of “conversion therapy” have become commonplace among advocates of gender affirmation.
“I was trained in a gender-affirming way and practiced in a gender-affirming way, and you don’t really get much discussion around developmental considerations.”
One leading thinker behind applying this label is Florence Ashley, a University of Alberta law professor and bioethicist. Ashley wrote in a 2022 paper that “proponents of gender-exploratory therapy situate their approach as neutral, agenda-free, and more in line with foundational principles of psychotherapy,” yet they also view “trans identities and gender dysphoria from a position of suspicion.” The piece concludes, “When you begin from the premise that trans identities are suspect and often rooted in pathology, your therapeutic approach soon becomes indistinguishable from conversion practices.”
Most advocates of the cautious approach have since replaced the term “gender-exploratory therapy” with, simply, “therapy.” “The idea of exploring gender, exploring where the dysphoria came from, exploring what your hopes and expectations are for an intervention — all of that was really critical” in the Dutch model, Edwards-Leeper told me. There can be external reasons for distress, like body image concerns, a history of trauma or abuse, or just feeling different and wanting to fit in, she said. “If it turns out that the young person is just very distressed about puberty and anxious, or maybe they’re gender-nonconforming, it doesn’t necessarily mean that they need to transition,” she told me recently. “In fact, the best thing for them to do would be to face their anxiety and have support in going through puberty.”
Edwards-Leeper, a former chair of the committee on adolescents within WPATH, the World Professional Association for Transgender Health, was among the first from within the gender medicine establishment to suggest that transition is not always the best treatment. And it set her and others apart from the thrust of advocates for affirmation, like physician Johanna Olson-Kennedy, head of the now-shuttered gender clinic at the Los Angeles Children’s Hospital and lead investigator of the large NIH study, who told The Atlantic in 2018: “I don’t send someone to a therapist when I’m going to start them on insulin.” Even the American Academy of Pediatrics, in its 2018 policy statement, asserted that kids “know their gender” and can be offered “many medical interventions.”
Edwards-Leeper and others argued that given the research showing that a majority of gender-dysphoric kids resolve their incongruence during puberty, and given also the presence of de-transitioners who have been harmed by treatment, sometimes irreparably, it is incumbent upon pediatric clinics to go slowly and assess carefully. “We don’t have a brain scan or a blood test to determine who will with 99.9 percent certainty benefit. All we have is a psychological assessment that is done by people trained in the mental health field,” she told me. And perhaps one reason the assessment has mostly fallen away is that “generally speaking, medical providers don’t really have an interest in taking their marching orders from a mental health clinician. Which is basically, in this field, what really should happen.”
But Paul Garcia-Ryan and others are staking out a different position: that asking mental health specialists to determine whether a child is likely to persist in their trans identity and benefit from irreversible treatment puts them in a role that’s far outside their scope of practice. “The diagnosis of gender dysphoria, which can only be made through a mental health professional, is what’s used to justify the initiation of medical treatments. And so at least in the United States, it’s really placed therapists in this position of assessing whether those treatments are medically necessary, which is unprecedented. You don’t see that anywhere else.”
Therapy, in fact, played a large role in the treatment he received as a gender-nonconforming teen: “When I was 15, a therapist affirmed my conviction that I was born in the wrong body. After more than a decade of hormonal and surgical interventions, I detransitioned at age 30,” he wrote in a 2024 Washington Post op-ed. “I had come to realize that my transition was motivated by my difficulty reconciling with being gay.”
The gender-affirming model as applied to mental health, he told me, “is leading to therapy that’s not really therapy. I would definitely say that I did not get adequate therapy.”
Last year, Irene’s teen was referred by a therapist to a gender clinic, and the system worked as the Dutch Protocol intended: given the unresolved mental health issues, the clinic would not prescribe testosterone. Meanwhile, Irene entered a group therapy program through Columbia University for parents dealing with all kinds of issues. She was the only one whose child was questioning their gender. When it was her turn to share, her peers were supportive, not dogmatic: perhaps this is a developmental stage, said one parent. Another shared that she had gone through something similar as a child herself and had come out the other side.
Irene opened up about the concerns nagging at her: Were the treatments reversible? How would testosterone affect her child’s body? At this point, the group leader interjected that these topics were veering beyond the scope of the group and urged Irene to discuss them with the treating physician.
“I was neutral at the time,” she tells me, still open to socially confirming her child’s male identity, pronouns and all. But at the next session, the leader referred to the child she still thought of as her daughter as her “son.”
“That hurt me so much,” Irene tells me, her voice cracking. “I couldn’t handle hearing ‘son’ and not ‘daughter’ from this person who’s never seen my kid. That was my turning point of thinking that I have to explore this topic deeper, I have to know much more about this, before I’m doing something stupid.”
The next day, she devoted herself to the computer. She found the podcast Gender: A Wider Lens by therapists Stella O’Malley and Sasha Ayad. She found their book When Kids Say They’re Trans: A Guide for Thoughtful Parents, coauthored with Lisa Marchiano, a psychoanalyst who was among the first to raise the possibility of peer influence, especially in girls. Irene joined Ayad’s parents group.
Soon, her neutrality gave way to the acute nightmare of parental regret. “Oh my God, what have I done?” she recalls thinking, choking on a sob. “How can I go back and tell my daughter that I disagree with what was previously said by me?”
First, she kept reading. She read about WPATH, which suppressed critical evidence as it put together its 2022 guidelines for gender-affirming care, and whose leadership admitted in internal messaging forums to the gaps in data. She read about the Cass Review, and read the review itself, which concludes that the affirming model is based on “remarkably weak” evidence, and that there is no strong evidence that hormonal intervention improves mental health or reduces suicidality. “I kind of started to understand what’s actually going on here in this country,” she tells me. “I grew up under communism. I saw how propaganda works.”
By way of example, Irene texts me a snapshot of the poster hanging up just inside the entrance of the high school her teen was attending. It reads:
I DECIDE
WHAT MY GENDER IS
MY NAME & MY PRONOUNS
WHAT MY BODY MEANS
HOW TO CHANGE — OR
NOT CHANGE — MY BODY
TRANS RIGHTS ARE HUMAN RIGHTS
Zander Keig is a licensed clinical social worker who has been vocal that “young people with gender distress probably shouldn’t be going through a medical transition,” as he told me in a phone call.
Keig rejects the notion that trans is a state of being, and directs me to identify him as transsexual, not transgender. “My gender (masculine) has not changed since childhood,” he clarified in a follow-up email. But at age 39 he went through a process that changed his secondary sex characteristics, official identification, and social presentation from lesbian woman to man. “I’m still female, but look, sound, and navigate society as a man.”
Keig, who has two podcasts in which he expresses opinions at times unpopular with some trans activists, is concerned about the assumptions behind the concept of the “trans kid.” “There’s no way to determine which of these kids is just a gender-nonconforming kid who’s going to grow up to be gay or straight or something else, versus the kids that are going to grow up to do what I did,” he says. Some gays and lesbians charge that gender clinicians are “transing the gays away,” he says, “and I don’t dispute that.”
In the case of a child who is in some sort of discomfort or distress about their bodies, he says, “I don’t even think psychotherapy is the first line of intervention.” Rather, it should be psychosocial support, that is, “getting everybody on the same page to find out, like, why is this kid so distressed? What kind of messages are they getting from the family? What kind of messages are they getting from the school? What kind of messages are they getting that the kind of girl or the kind of boy they are is wrong or bad? Is it the religion? Is it the culture?” In other words, are they simply pushing up against gender expectations or homophobia? In which case, they don’t need psychotherapy as much as to be allowed to play and dress how they please. “These are just children, for God’s sake!” says Keig. Distress doesn’t necessarily mean “that they have a desire to be the other sex or to live as the other sex. I think that comes from the interpretation of the adults.”
Sasha Ayad, the therapist whose parents group Irene joined, told me “I think the place we might miss the mark is that we fail to appreciate the metaphor of gender.” Sometimes a kid who expresses distress about their body is just communicating that “sometimes I feel like I don’t fit in.”
Ayad has been working with gender-distressed young people for a decade. In 2021, she cofounded the Gender Exploratory Therapy Association — exploration as a response to the affirmation model — and it was promptly embroiled in accusations of promoting “conversion therapy,” a charge that has stuck on its Wikipedia page, in spite of its rebranding as Therapy First. “The best way to describe it is we’re just doing therapy,” says Kristin Farrell-Turner, a psychologist and one of its board members.
The field has gotten caught up in a metaphysical debate over whether a person is born with an incongruent soul and body, Ayad says. Whether or not that’s what it means to be trans, it doesn’t need to lead to medicalization, at least not in minors, she argues. “I think the problem that these therapeutic governing agencies and groups have gotten themselves into is that they’ve tied affirming someone’s sense of identity with accessing hormones and surgery. That’s a major split we can make now.”
As Keig sees it, the trans adult who in retrospect says, “I knew when I was a little kid, and it would have been so much better if I wouldn’t have had to have gone through all of that pain and suffering” presents a “compelling argument.” But to superimpose that on all prepubescent children who are rejecting gender stereotypes has sent the wrong message to people in positions of authority over kids. It’s led teachers and school counselors — who, Keig wants to point out, are not trained in psychology or in therapy — to use a kid’s preferred pronouns and name and believe that keeping this from the parents puts them on the right side of history and social justice. “That is a very dangerous thing, to create a rift, a gap between a child and their parent,” he says. “If they’re truly abusive parents, then you should call child welfare.”
In her review of gender-transition treatments, Dr. Hilary Cass called on clinicians and parents to view social transition as an “active intervention” that may have “significant effects” on the child’s psychological well-being and future outcomes. The review found that kids whose cross-sex identity was facilitated at an early age were more likely to proceed to medical intervention.
“Children will believe what adults tell them,” says Sasha Ayad. “We have to keep in mind how concrete their thinking is.” In other words, if a parent agrees to a new name or pronouns for a young kid, they “don’t understand you’re being polite. You’re setting them up to be at war with reality.” Meanwhile, in an adolescent, she sees an opportunity for families to ask, “What does it mean that my child needs medication to be authentic?”
“Maintaining flexibility and keeping options open by helping the child to understand their body as well as their feelings is likely to be advantageous,” wrote Cass in her review. For both young children and adolescents, “the clinician should help families to recognise normal developmental variation in gender role behaviour and expression.”
“What does it mean that my child needs medication to be authentic?”
“Social transition is a major psychological intervention,” says psychiatry professor Kathleen McDeavitt, “but it’s not seen as such.” Families are being encouraged to affirm their small children, “and these are the ones that I worry about the most because the endocrinologist watches these kids like hawks” for the first sign of puberty to begin blockers.
Three years ago, a video of gender surgeon and WPATH president Dr. Marci Bowers went viral. In it, she shared her observation that the male patients she treated whose puberty had been blocked at an early stage never developed the ability for orgasm. “Are they going to be able to achieve sexual satisfaction? It’s important in relationships,” she said. For McDeavitt, this was a stunning admission of how high the stakes are in putting a young person on a medical pathway.
Some physical side effects of early medical transition are not a new concern: one participant in the original Dutch studies died from a bacterial infection after vaginoplasty that was complicated as a direct result of stunted growth: lacking adequate penile tissue, surgeons had to use part of the colon. Yet there is a dearth of published research on the cognitive and sexual side effects, and an apparent squeamishness in communicating to the public what’s known and what isn’t: In the New York Times podcast The Protocol, concerned parties raise the issue of harms several times, but the prospect of a life without sexual intimacy is never articulated, nor are the ethics of adults consenting to such for a minor who has no point of reference — particularly in a population that historically is skewed toward being same-sex attracted.
The word “orgasm” appears nowhere in the 388 pages of the Cass Review, although Hilary Cass brought it up when I interviewed her in person. “There is no question that sexual function may be quite compromised by the treatments. It may not be possible to orgasm subsequently, depending on what medical and surgical treatments you have,” she told me. “And so some people have said, yes, there was a trading off a cosmetic success against sexual satisfaction and sexual success. And that’s before we talk about things like not being able to have children in some instances, and other things that people need really careful counseling about, like, you know, the impact that treatment is going to have … in terms of vaginal atrophy. So this is not something to be entered into lightly.”
Providing the information necessary for a patient to give informed consent is typically the responsibility of the treating physician. However, in the case of gender-affirming care, this is often left to the mental health specialist to cover during the assessment, if there is one.
Laura Edwards-Leeper told me she carefully walks young patients and families through what’s known and unknown and asks them to think through the implications, but that ultimately it’s for the family to decide. In a July interview with Leor Sapir of the Manhattan Institute, she was more blunt: “I tell them that they are guinea pigs and they have to decide if they are okay with that.” She persists out of pragmatism and because, for some, she believes transition to be lifesaving.
For Paul Garcia-Ryan, that’s a level of patient risk he’s not willing to bear. The purpose of comprehensive assessments should be for therapists “to better understand the unique individual they’re responsible for treating,” he told me, not rubber-stamping puberty blockers. “I don’t think any clinician or assessment can determine whose gender dysphoria will persist or desist, or who will be helped or harmed by medical transition. I don’t think it’s the therapist’s job to assess for that, and I don’t think it’s appropriate for therapists to be in the role of approving medical interventions.”
Not long ago, Irene decided to stop using the male name or pronouns for her kid. “I said to her, ‘I did my research, I’m very regretful about using pronouns, I’m not going to do this anymore.’” To keep the peace, she finds linguistic workarounds. “I say ‘my child,’ ‘my sweetie,’ whatever comes to my mind.” She also helped get birth control pills to stop her teen’s periods — one of the main triggers of dysphoria — which has seemed to help with coping. “I also told her whatever happens I see her as my daughter, nothing is going to change the biological body and situation.” She added that if someday, when her child is a grown adult, “you tell me ‘I’m trans and want to be a man,’ then I will deal with that, but until that time, you are my daughter, and I’m going to talk with other people about you as my daughter, and I have the right to do that. I’m your mom, I gave you birth, I’m here to protect you.”
“Therapists now don’t even consider questioning this theory of gender affirmation, because they’ve been taught it’s the only compassionate way to be.”
Irene skipped the final two sessions of the parents group after it became clear that the group leader would continue to use male pronouns for her child. A psychologist from the program reached out to offer an individual session and suggested a new group specifically for parents dealing with sexuality and gender issues, and that experts in gender-affirming care would be invited to speak at several sessions.
But halfway through the sessions there were no experts, and Irene felt she was the only one raising questions. For instance, she shared her concern about the uncertainties around outcomes of hormonal treatments, and that other countries were shifting to a more cautious approach with adolescents as a result. One of the parents said looking at the science was outside their purview as parents. “We love our kids, and we trust the doctors.”
Days before we spoke, the psychologist had contacted Irene to say that some of the parents were complaining about her contributions, and that maybe this wasn’t the right group for her. “What I’m trying to understand is why the affirmative approach is the only one provided and there is no alternative,” she told the group leader, who didn’t have an answer, but reiterated that if Irene wanted to stay in the group, she’d need to keep such musings to herself. And she encouraged Irene to apologize for using terms like “castration” and “brainwashing.” Irene agreed that “I said maybe too much.” But two sessions later, Irene was asked directly to leave. The clinician’s notes, which Irene obtained and shared with me, state that the client was given information about alternative groups. Irene told me none were ever offered.
The reason she stayed in the group as long as she did was because, looking back at her learning curve, she wishes it had been easier to access critical information. Wherever she turned, the world was reinforcing gender transition — at school, online, on every clinic health form with boxes for multiple gender identities. Each week when she met with the teen’s school therapist, Irene referred to her “daughter” in conversation, while the therapist referred to her “son.”
“I asked, why are you doing that, you’re one-on-one with me. He told me ‘I have to, this is the school’s policy.’”
“Gender affirmation is taught as an absolute non-questionable standard of practice,” says Sasha Ayad, pointing to 2015 American Psychological Association guidelines that encourage practitioners “to facilitate access to and provide trans-affirmative care,” including “through assisting clients to access hormone therapy or surgery.” “That’s very different from how I was trained, which is that as a therapist you are supposed to remain clinically neutral. Therapists now don’t even consider questioning this theory of gender affirmation, because they’ve been taught it’s the only compassionate way to be.”
In his op-ed for the Washington Post, Paul Garcia-Ryan gave several examples of mental health professionals who had suffered professional and public sanction for sharing “transphobic” information, such as the link to a Therapy First webinar. They were reported to their licensing boards or had private information revealed on activist websites.
There are about 300 therapists on Therapy First’s membership list. A qualitative study of 89 members found that about half had experienced professional hostility for their questions or views, and a third had experienced or witnessed formal complaints. One respondent, a student at the time, was threatened with a “remediation plan” for sharing articles about European countries shifting policy in response to evidence reviews.
“I think there are a lot of therapists who could do great work with these young people if they felt they had permission to genuinely explore what this identity distress means rather than feeling like their hands are tied.”
I, too, spoke with several therapists and psychologists who are quietly resisting but are not ready to speak out. “I still see basic chilling of dissent and many folks (myself included) afraid to say anything for fear of a licensing complaint if not toeing the line of APA and other large organizations,” one wrote. “Within those large organizations there is (growing?) dissent, but many psych organizations are adept at swiftly silencing it.”
“The professional medical organizations are like Mount Olympus” in U.S. medical culture, says Kathleen McDeavitt, the Baylor psychiatry professor. “They are so super important to us. If just one of these respected organizations came out and made a policy that said the standard of care approach to pediatric patients with gender-related distress should be psychotherapeutic techniques and we support research into which are going to benefit these kids the most, I think that would rapidly and significantly change the practice in this country. I don’t think anything else is going to do it.”
In the meantime, clinicians like Sasha Ayad want to affirm their colleagues’ capabilities: “I think there are a lot of therapists who could do great work with these young people if they felt they had permission to genuinely explore what this identity distress means rather than feeling like their hands are tied,” she says. “I think maybe we can do a better job of communicating this message to other clinicians that, hey, you absolutely have the skills to work with this population, you just can’t be afraid to ask questions and probe and of course do it with compassion, but you have to be willing to go there.”