When Cari Stella recounts her transgender experience in a series of YouTube videos, she doesn’t shed tears, but she does talk about pain.

As a teenage girl, Stella felt a strong desire to live as a man. A therapist obliged. After three or four visits over a three-month period, and without suggesting other options, the therapist prescribed testosterone. Stella was 17. A few years later, she underwent a double mastectomy.

Stella says her family was supportive, and her workplace included transgender leadership. Her transition seemed like a success. Except it wasn’t.

Soon, Stella says, she felt worse, not better. It took a while, but she says testosterone “made me even more dissociated” than she felt when she started: It was “hard to figure out that the treatment you’re being told is to help you is actually making your mental health worse.”

After three years of hormones, Stella stopped taking testosterone and detransitioned to living as a woman. She’s still grappling with the effects of her ordeal: “I’m a real, live 22-year-old woman with a scarred chest and a broken voice and 5 o’clock shadow because I couldn’t face the idea of growing up to be a woman.”

Eventually she realized, “I could not continue running from myself. …”

Stella’s not a conservative. She affirms the lesbian lifestyle of many women who are formerly transgender. But she told viewers she’s frustrated at how easy it is for conflicted minors to obtain hormones to change their bodies: “How many other medical conditions are there where you can walk into the doctor’s office, tell them you have a certain condition, which has no objective test, which can be caused by trauma or mental health issues or societal factors, and receive life-altering medications on your say-so? Does that sound like gatekeeping?”

Stella’s message isn’t popular—and woe to those who agree with her. Therapists and physicians who encourage restraint face retribution, and former transgender people who regret their choices face scorn.

Christians have an urgent task: be prepared to speak Biblical truth, and be prepared to offer Biblical help. Heath Lambert, executive director of the Association of Certified Biblical Counselors, says this begins with recognizing the agony some people face. “This is real pain,” he says. “It’s a lot of tears on a lot of pillows on a lot of nights.”

First some numbers: Though estimates vary, transgender people reportedly make up between 0.3 and 0.6 percent of the U.S. population. Still, activists have been part of a relentless push to persuade society to accept the practice as healthy.

Until 2012 the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) identified transgender feelings as “gender identity disorder.” A year later, the organization changed the designation to “gender dysphoria”—a condition that produces distress over transgender feelings, but is no longer considered a disorder.

In 2016 the Obama administration demanded most physicians facilitate gender transitions for any child referred by a mental health professional, even if the doctor thought the process harmful to children. A Texas court struck down that mandate in January.

But battles will continue at least on state and local levels, where health policies often affirm transgender students, and school curricula sometimes teach all children that gender is an abstract concept.

National Geographic glorified that message in January, with a special issue celebrating transgender children. On the cover: a 9-year-old boy dressed as a girl. Inside, a full-page image showed a 17-year-old girl with a bare chest and scars from her recent mastectomy. Another photo showed a little boy dressed like a girl, with a caption saying the boy was “gender creative.” The magazine added a statement that would amaze most parents: “At six years old, he is already very sure of who he is.”

Michelle Cretella, president of the American College of Pediatricians (ACP)—a group that includes conservative physicians—compared the magazine’s approving displays to “institutionalized child abuse.”

“You don’t treat medical confusion by putting people, especially children, on toxic hormones and cutting off healthy body parts,” she said. “Just because a person thinks and feels something does not make it true.”

It’s one of the most perplexing dynamics regarding transgender youth: Adults allow children to lead the way.

Though it’s critical to listen to children, Allan Josephson, a psychiatrist and member of the Christian Medical & Dental Associations, says parenting involves guiding kids in what is true: “Children aren’t sure of much of anything, let alone their identity.”

Indeed, studies show as many as 80 percent of children who express signs of gender dysphoria grow out of those feelings by adulthood.

Still, the Endocrine Society approves the use of puberty-blocking drugs to “pause” sexual development and give children a couple of years to figure out one of the most fundamental pieces of their identity.

‘You don’t treat medical confusion by putting people, especially children, on toxic hormones and cutting off healthy body parts.’ —Michelle Cretella, president of the American College of Pediatricians

If children decide to live as the opposite sex, they may begin taking cross-sex hormones at as young as 13. Some of the obvious results: Boys grow breasts, and girls grow facial hair.

Neither process is without peril. Though physicians have prescribed puberty blockers to children entering puberty too early, the practice of giving such drugs to healthy children before natural puberty begins is relatively recent. Some say the drugs could interfere with neurological development and bone growth, since the blocked hormones promote those functions.

In the case of cross-sex hormones, the dangers are more serious: Many will stay on hormones for a lifetime, and doctors warn of increased risk for heart disease, diabetes, and blood clots.

Even more tragic: Cross-sex hormones can induce sterility. That means children as young as 13 or 14 must make momentous decisions about whether they are willing to forgo having biological children later in life. Courtney Finlayson, a pediatric endocrinologist who prescribes such drugs to children, acknowledged the magnitude of children making those decisions during a PBS interview: “I do worry that at that stage in life many of them may not be able to realize how important that would be to them someday.”

Nevertheless, the number of children visiting gender identity clinics is growing. The numbers are hard to track, but the first transgender clinic for children in the United States opened in Boston in 2007. Ten years later, some 40 such clinics exist.

Parents don’t always encourage a child’s gender confusion, but other adults sometimes intervene. In Oregon, the group TransActive Gender Center provides teenage girls with free chest binders—a compression garment for girls who want to compress their breasts to appear male. The group says it’s mailed over 1,500 garments in plain envelopes in the last five years.

At least one “top surgeon”—a doctor dedicated to performing mastectomies on healthy women who want to live as males—has warned of the dangers of chest binding: compressed ribs, collapsed lungs, and back pain.

On the social media site Tumblr, a site full of networking for transgender teens, one woman said she bound her breasts for two years before a mastectomy: “I still can’t take a full, deep breath like I used to.”

If the physical risks seem overwhelming, some parents of young children still are willing to follow the lead of physicians who tell them transition is healthy. An article on the gay website The Advocate told the story of a mother of a “transgender toddler.”

The mother said her 10-year-old child transitioned at age 5, but she knew her daughter was different by 18 months old. Her adamant advice to parents: “Never let anyone question you. If your child is happy and a nice person, you are doing the right thing.”

But are transgender youth happy? Some would say yes, but a recent study showed at least 30 percent of youth identifying as transgender had attempted suicide. Another 40 percent reported self-injury.

Transgender activists say that’s because society doesn’t affirm transgender people and drives them to despair. But others say it’s because transgenderism is a sign of deeper psychological and spiritual problems. A Swedish study in 2011 reported transgender men said sex change surgery alleviated some distress, but their deeper psychological problems remained.

‘How many other medical conditions are there where you can walk into the doctor’s office, tell them you have a certain condition, which has no objective test … and receive life-altering medications?’ —Stella

Some activists and psychologists have questioned that study, but it’s harder to ignore the personal stories of transgender young people who regret their decisions. On a blog called Born Wrong, a young woman named Max talks in a video about transitioning to living as a boy, only to find her distress continued.

She began transitioning at 16, and eventually underwent hormone treatment and a double mastectomy. Max says she felt better, “until I had completed all the steps I had wanted to accomplish and was extremely disappointed to find myself still facing pretty much the same issues I had as a teenager.”

Max stopped short of having a hysterectomy, but says she realizes the damage done by having a surgeon “cut away healthy tissue from my body, being seen as a man when I’m not one, the side effects of testosterone. … I can name the ways they hurt me now.”

On another video blog, a woman who calls herself Crash says she started living as a man when she was 18. She says she took testosterone for four years before she realized her dysphoria was rooted in trauma.

In school, kids had bullied her for coming out as a lesbian, and she says: “I also see a connection between my decision to transition and my mom’s suicide. She killed herself when I was 20, and I started hormones about three months after.”

It seems obvious to explore psychological and spiritual problems with children or teenagers distressed over their biological sex. But therapists and physicians who suggest it’s better to encourage a child to embrace his or her biological sex often face scorn or retribution.

It wasn’t always this way. Paul McHugh, professor of psychiatry at Johns Hopkins Medicine, helped persuade the institution to stop performing sex-change operations in the 1970s after evidence suggested patients weren’t substantially better off after the surgeries.

McHugh continues to warn against the transgender trend, pointing out that birth sex is an objective, biological fact, not a perception or a feeling. In the rare instances when it is hard to identify biological sex at birth, McHugh and other physicians say careful, compassionate care is critical on a case-by-case basis.

But the majority of people, including children, who say they are confused about their sex aren’t suffering from biological problems obvious at birth. The rare and difficult cases don’t justify encouraging biologically healthy children or adults to alter their bodies permanently.

McHugh suggests therapy for those confused about their sex, and he uses the example of people suffering from other problems that produce confused perceptions: “We wouldn’t agree with an anorexic child that he’s fat.”

Those views are anathema to activists promoting transgenderism. Last September, NBC reported the Human Rights Campaign threatened to revoke Johns Hopkins’ elite position on its list touting LGBT equality if the hospital didn’t distance itself from McHugh’s conclusions. A hospital spokesman said Johns Hopkins allows academic freedom but doesn’t endorse the views of all its physicians.

A month later, the hospital released a statement affirming its commitment to transgenderism, and slipped in a major announcement: Soon the hospital would begin offering sex-change surgery again. McHugh knew his views drew angst, but in a phone interview he said he was surprised the hospital would perform the surgeries again: “Johns Hopkins is a place that clamors for evidence, and there is not evidence this is good for people.”

What does McHugh make of medical professionals’ push to encourage children to change their bodies? “I think they’ve just fallen in love with another cause,” he says. “But these children are going to be their victims.”

Indeed, other physicians point out the absence of evidence about what will happen to children who remain on cross-sex hormones for a lifetime. “Frankly, we don’t know what happens when a male is exposed to 50 years of estrogen,” says Robert Hoffman, a pediatric endocrinologist in Ohio and a member of the ACP.

Quentin Van Meter, a pediatric endocrinologist in Atlanta, says in his 40 years of practice he had only seen one case of parents concerned their child was confused about gender. Last year, four such patients came to the clinic. Van Meter suggested psychological help.

“You’re never changing the sex of the patient,” he says. “Never. Every cell in the body is programmed to be male or female.” Despite those objective realities, Van Meter says physicians go along with children’s distorted perceptions: “It’s like the Emperor’s New Clothes.”

For those who do argue, the price can be steep. Kenneth Zucker, a psychologist for decades, led the Child Youth and Family Gender Identity Clinic at the Centre for Addiction and Mental Health in Toronto. Zucker, well respected by his peers, isn’t known as a conservative.

When it comes to children, Zucker takes a cautious approach. Citing his decades of experience, Zucker noted transgender feelings usually don’t persist into adulthood. He encouraged therapists to explore the possibility of helping children become secure with their birth sex.

Activists railed against Zucker until the health center pledged to perform an external review. In December 2015 the center announced it was “winding down” its gender identity clinic. Zucker was out of a job. “We want to apologize for the fact that not all of the practices in our gender identity clinic are in step with the latest thinking,” medical director Kwame McKenzie stated.

‘You’re never changing the sex of the patient. Never. Every cell in the body is programmed to be male or female.’ —Quentin Van Meter, pediatric endocrinologist

More than 500 professionals in the field of sexuality and gender identity signed a petition protesting the center’s treatment of Zucker. (The figure suggests perhaps more mental health professionals are skeptical of the rush to affirm pre-pubescent children who believe they’re transgender.)

Zucker said he’s not commenting on the case at this time, but Ray Blanchard, a psychiatry professor at the University of Toronto, said Zucker’s dismissal could have a chilling effect on other professionals with similar opinions.

“In the present climate, many mental health professionals are afraid to state publicly that they believe the first treatment approach, with young gender-confused children, should be helping them become comfortable with their biological sex,” Blanchard wrote in an email. “Professionals might, with good reason, fear harassment from trans activists, negative coverage in the media, cold shoulder from politically correct colleagues, or even censure from their employers.”

It’s a distressing reality for therapists and physicians who want to protect and help children. John Whitehall, professor of pediatrics at Western Sydney University, wrote about Zucker after he learned about his dismissal.

In his article, “Gender Dysphoria and the Fashion in Child Surgical Abuse,” Whitehall wrote, “In fifty years I have not witnessed such a reluctance to express an opinion among my colleagues.”

In a phone interview, Whitehall said he polled 28 medical professionals about the rush to change children’s bodies: Many said they thought “the whole thing is ridiculous,” but “no one wanted to go on the record.”

McHugh isn’t afraid to go on the record. After decades of practice, he’s convinced the seeds sown now will reap a harvest of sorrow, especially for parents who encouraged their children to do harm to themselves: “They’re going to regret it very soon. … Some parents are going to believe that they’ve been drawn into doing something with their children that is unforgivable.”

In her online video, Cari Stella says activists and therapists won’t be able to ignore transgender regrets forever: “You may not agree with us, but the fact is we exist, we’re going to continue to exist, and our numbers are growing. … You won’t be able to ignore us any longer.”

Do no harm

As psychologists and physicians affirm transgender impulses in children and adults, Christians should prepare for people looking for help when those impulses bring despair.

This begins with a Biblical understanding of how God made people—He created them in His own image, male and female. God’s design is good, but sin marred the reflection like a pane of glass shattering into a million pieces. Among the jagged shards: transgenderism.

Heath Lambert of the Association of Certified Biblical Counselors says, “Transgender people have declared war on their Creator, and the battleground is their bodies.” All of us who are not truthful about that sin or others “suppress the truth in unrighteousness,” and Christians should speak to transgender people as “co-sinners.”

To love transgenders we must work through the complicated layers of sin and pain—a process that requires the relational context churches can provide. “It will be the death knell if we say this is wrong, but then we can’t help,” says Lambert.

For those looking for specific resources, the Christian group Harvest USA offers helpful links and articles on the subject of transgenderism and Biblical sexuality. In one particularly poignant piece, a Christian, homeschooling couple writes about trying to help their son who wanted to be a girl.

The couple said they persisted in teaching their son Biblical truth. They prayed. They cried. They trusted God. Their son moved past transgender impulses in his teenage years, but now battles same-sex attraction.

The couple says in their own suffering they “fight for glimpses of God’s glory in His Word and His world. One day, however, our faith will be sight. We will see Him as He is, and be changed to be like Him.” —J.D.

–Also in this series on transgenderism: “Sounding the alarm” / “Walt’s story”