Gender Dysphoria Resource for Providers

William J. Malone, MD

William Malone is a board certified endocrinologist. He has a BA from Stanford University and an MD from New York University. He is currently the medical director at an endocrinology and diabetes center in Idaho.

Gender Dysphoria Overview

Description: this document is meant primarily for health care providers who wish to learn more about gender dysphoria and the harm caused by gender affirmation therapy. I’ve summarized key points on the topic, and have embedded links to relevant literature. Some of the links lead to full-length articles, but some do not due to copyright restrictions, and the reader will have to personally acquire the full-length versions. This document is not meant to be exhaustive, but to give a starting point for further reading. None of the statements in this document are intended to be recommendations for treatment of individual patients, and the opinions expressed here are my own, based on my clinical experiences and reading of the medical literature.

  1. Definitions: Medically, the term transgender/transsexual refers to an individual who has taken significant steps to present themselves to society as the opposite sex, in an effort to relieve severe and persistent gender dysphoria.  No one is born transgender or transsexual and no serious scientist has ever made such a claim. It is not possible to be born into the “wrong” body (“boy brain” in a girl body for example).

Institute of Medicine (US) Committee on Understanding the Biology of Sex and Gender Differences. “Every Cell Has a Sex.” Exploring the Biological Contributions to Human Health: Does Sex Matter?, U.S. National Library of Medicine, 1 Jan. 1970, www.ncbi.nlm.nih.gov/books/NBK222291/.

There are individuals who suffer from gender dysphoria (GD), which is an uncomfortableness about being biologically male or being biologically female, in relationship to societal expectations of gender roles. Another way to say this is that GD is a feeling of distress at being gender non-conforming.  A masculine adolescent girl with preferences for more stereotypical male activities, dress, and mannerisms, for example, may become distressed at the disconnect between her gender expression and her female appearing physical body.  GD can be mild to severe, and its onset can occur at any time, but classically before puberty, or peri-puberty.

  • Etiology: Gender dysphoria always has an underlying cause. Those main causes include:  1) autogynephilia (a heterosexual male who is sexually aroused at the thought of himself as a woman), or 2) rejection of one’s homosexuality (for example preference to live life as a “trans woman”, attracted to men, vs a gay man), or 3) is the consequences of concrete thinking processes that characterize autism spectrum conditions (“I don’t like dresses therefore I must be a boy”), or 4) is a protective mechanism to avoid repeat sexual trauma, or 5) is due to the stress of simply not fitting into society’s stereotypical expectations of gender roles. No one is born in the wrong body. That’s biologically impossible. Rather, the dysphoria is a signal that an underlying issue needs addressing, and resilience and/or self-acceptance needs to be built.

             Blanchard, Raymond. “Gender Dysphoria Is Not One Thing.” 4thWaveNow, 7 Dec. 2017, 4thwavenow.com/2017/12/07/gender-dysphoria-is-not-one-thing/.

Excerpts: “One problem with the current mainstream narrative regarding gender dysphoria is that it makes no distinctions among apparently very different kinds of persons.”

“The failure of so many therapists and activists to acknowledge this distinction is disturbing for at least two reasons. First, it suggests they are either ignorant of relevant scientific evidence or are purposefully ignoring it. Second, failure to make scientifically valid and functional distinctions among different types of gender dysphoric persons can only prevent progress toward finding the best approach to helping each.”

Blanchard, Ray. (2005). Early History of the Concept of Autogynephilia. Archives of sexual behavior. 34. 439-46. 10.1007/s10508-005-4343-8.

Excerpts: “Since the beginning of the last century, clinical observers have described the propensity of certain males to be erotically aroused by the thought or image of themselves as women. “

“It is notable that the idea of having women’s breasts appears to rise quite often in autogynephilic fantasy.”

Patient statement: “Real girls come and go, but my one true and permanent girlfriend was myself in female role.”

Bailey, J & Triea, Kiira. (2007). What Many Transgender Activists Don’t Want You to Know: and why you should know it anyway. Perspectives in biology and medicine. 50. 521-34. 10.1353/pbm.2007.0041.

Excerpt: “We believe that advocacy for the standard feminine essence narrative (‘I’ve always felt that I’m a women born into a man’s body’), and against Blanchard’s theory, is primarily conducted by, or at least on behalf of, non-homosexual transsexuals who incorrectly deny their autogynephilia.”

  • Desistance: 0.5% of children experience gender dysphoria. Approximately 80% of childhood-onset gender dysphoria resolves by age 20.  A majority of the children who had gender dysphoria will be same-sex attracted or bisexual.  It is impossible to determine whose GD will resolve and whose will persist without allowing for pubertal development. Some practitioners claim that they can tell clinically in early puberty who will persist in their gender dysphoria, but there are no validated protocols that are predictive of persistence.

Due to the general lack of evidence that cross sex hormones and sex reassignment surgery improve the long term psychological functioning of gender dysphoric people, and due to evidence that suicide rates actually increase long term post surgery (see below), in approximately 2010, puberty blockers were introduced into the treatment protocols for gender dysphoric children and adolescents, with the thinking being that by preventing the development of secondary sexual characteristics, that person would be more likely to look like the opposite sex long term, reducing dysphoria and improving long term psychological functioning.  The first problem with this approach is that it’s completely unproven, and the second is that no one can tell who will persist in their gender dysphoria. This means treating all adolescents with gender dysphoria, in an effort to help the 10% who have persistent gender dysphoria, harms 90% of those treated. In addition, it harms those with persistent GD who may not want cross sex hormones or surgery.  Based on recent studies showing a significant increase in cardiovascular dz, and increase suicide rates long term, a good argument can be made that no person with gender dysphoria should ever be treated with hormones or surgery (more below).

Endocrine Society Guidelines: “… the large majority (about 85%) of prepubertal children with a childhood diagnosis (of GD) did not remain gender dysphoric in adolescence.”

Steensma, T. D., Mcguire, J. K., Kreukels, B. P., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry,52(6), 582-590. doi:10.1016/j.jaac.2013.03.016

“To date, the prospective follow-up studies on children with GD, for whom the majority would meet the DSM-IV diagnostic criteria for Gender Identity Disorder (GID) collectively reported on the outcomes of 246 children. At the time of follow-up in adolescence or adulthood, these studies showed that, for the majority of children (84.2%; n= 207), the GD desisted.”

             Singh, Devita. “A Follow up Study of Boys with Gender Dysphoria.” nymag.com, 2012, images.nymag.com/images/2/daily/2016/01/SINGH-DISSERTATION.pdf.

Excerpts: “We do not understand the process of how desistance occurs and the possible interaction that occurs between biological and psychosocial variables to give rise to the observed trajectories in these children.”

“There have been no quantitative follow-up studies that have systematically examined the developmental process through which GID desists (e.g. how and at what age).”

“This type of question would be best evaluated using a prospective study that included multiple follow-up assessments around critical time points in children’s development.”

“Instead of allowing adolescents more time to “wait and see” and evaluate their gender identity options, puberty blocking treatment may unintentionally push adolescents towards cross sex hormonal treatment and sex reassignment surgery.”

“Allowing children to socially transition in childhood may have the effect of increasing the chances of persistence into adolescence and adulthood.”

             Ristori, Jiska, and Thomas D. Steensma. “Gender Dysphoria in Childhood.” International Review of Psychiatry, vol. 28, no. 1, 2016, pp. 13–20., doi:10.3109/09540261.2015.1115754.

Steensma, Thomas D., et al. “Gender Identity Development in Adolescence.” Hormones and Behavior, vol. 64, no. 2, 2013, pp. 288–297., doi:10.1016/j.yhbeh.2013.02.020.

  • Puberty Blockers: It is feared that puberty blockers (GnRH analogues) prevent GD desistance. They halt the physical, social, sexual, emotional, and possibly intellectual development of an adolescent, and it appears that almost all adolescents treated with pubertal blockade go on to cross-sex hormones. Therefore, treatment of an adolescent with pubertal blockers (PB) and cross-sex hormones (CSH) will create four cases of persistent GD (dysphoria lasting past puberty), when there only would have been one (of five adolescents with gender dysphoria, four would historically desist, and only one would persist— pubertal blockade stops the four from desisting (see below for reference)).  In addition, treating an adolescent at Tanner Stage 2 (currently recommended by the Endocrine Society) with puberty blocking drugs and cross-sex hormones has a high likelihood of causing infertility. It is not possible for a socially, emotionally, and intellectually immature adolescent to consent to life-long infertility or permanent physical changes brought on by hormones and surgery, given current understandings of young adult brain maturation.

             Sharma, Sushil, et al. “Maturation of the Adolescent Brain.” Neuropsychiatric Disease and Treatment, 2013, p. 449., doi:10.2147/ndt.s39776.

Vries, A. L. C. De, et al. “Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment.” Pediatrics, vol. 134, no. 4, 2014, pp. 696–704., doi:10.1542/peds.2013-2958.

Vrouenraets, Lieke Josephina Jeanne Johanna, et al. “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study.” Journal of Adolescent Health, vol. 57, no. 4, 2015, pp. 367–373., doi:10.1016/j.jadohealth.2015.04.004.

Excerpt: “I believe that in adolescence, hypothalamic inhibitors should never be given, because they interfere not only with emotional development, but [also] with the integration process among the various internal and external aspects characterizing the transition to adulthood.” -Psychiatrist

Giovanardi, Guido. (2017). Buying time or arresting development? The dilemma of administering hormone blockers in trans children and adolescents. Porto Biomedical Journal. 10.1016/j.pbj.2017.06.001.

Excerpts:

Summary of concerns raised in the literature:

“At Tanner stage 2 or 3, the individual is not sufficiently mature to authentically free to take such a decision.”

“It is not possible to make a certain diagnosis of GD in adolescence, because in this phase, gender identity is still fluctuating.”

“Considering the high percentage of desisters, early somatic treatment may be premature and inappropriate.” 

“Research about the effects of early interventions on the development of bone mass and growth — typical events of hormonal puberty — and on brain development is still limited, so we cannot know the long term effects on a large number of cases.”

“The impact on sexuality has not yet been studied, but the restriction of sexual appetite brought about by blockers may prevent the adolescent from having age-appropriate socio-sexual experiences.”

“In light of this fact, early interventions may interfere with the patient’s development of a free sexuality and may limit her or his exploration of sexual orientation.”

  • Problems with the Endocrine Society Guidelines: The Endocrine Society guidelines for the treatment of gender dysphoric youth omits significant sections of relevant literature, and as it wrongly promotes affirmation therapy and cross sex hormones as the standard of care for GD, it should be viewed as an opinion piece, and not a definite document for guiding decision making. The document relies on a single, uncontrolled, poorly designed study to justify treating GD youth with PB and CSH. You’ll notice that in the sections detailing pubertal blockade and cross sex hormones, “suggestions”, not recommendations, based on “low quality” evidence, are made.

             Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society* Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 2017, pp. 3869–3903., doi:10.1210/jc.2017-01658.

Vries, A. L. C. De, et al. “Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment.” Pediatrics, vol. 134, no. 4, 2014, pp. 696–704., doi:10.1542/peds.2013-2958.

My further analysis of this study: A good argument can be made that *the* cornerstone study (Vries above) which the Endocrine Society gender dysphoria guidelines use to justify cross-sex hormones (CSH) and sex reassignment surgery (SRS) in adolescents, actually shows that they don’t help improve psychological outcomes of gender dysphoric youth at all. 

There have been approximately 56 studies done on cross-sex hormones and sex-reassignment surgery in adults, and there are approximately 16 studies looking at pubertal blockade, cross-sex hormones and sex reassignment surgery in adolescents.

The quality of evidence in those studies as a whole is so poor, that the Endocrine society guidelines site only this single study as justification for CSH and SRS in adolescents. 

There are many problems with the study, to be polite (no counseled-only controls, have to go to a second referenced paper to understand the type of counseling provided to patients, poor peer review as other conclusions are possible from the data). 

The paper’s authors conclude: “A clinical protocol of a multidisciplinary team with mental health professionals, physicians, and surgeons, including puberty suppression, followed by cross-sex hormones and gender reassignment surgery, provided gender dysphoric youth who seek gender reassignment from early puberty on, the opportunity to develop into well-functioning young adults.”

The charted representation of psychological improvements (table 3), shows some improvements in global functioning and other standardized measures of psychological functions, comparing the 14 y/o patients started on pubertal blockade, to those same patients at 16 y/o when starting cross sex hormones, then 1 year post sex reassignment surgery (average age 20).

Very importantly, each of the patients were afforded intensive counseling, which involves psychological support for both patients and their families, through monthly visits (per descriptions of this model in referenced papers). Also to keep in mind is that the 1st year after surgery is often referred to as the “honeymoon” phase, and may not be an accurate reflection of long term psychological functioning after SRS.

With this in mind, after a review of the charted data in the paper, there are other possible conclusions from the data:

  1. Most importantly, the intensive counseling provided to gender dysphoric youth, or just the aging process itself, or both (?)(no control group) resulted in slow but steady improvements in some markers of psychological health over the course of 6 years. 
  • Cross-sex hormones and sex-reassignment surgery improved gender dysphoria (at least temporarily), but that had no noticeable impact on psychological well-being. Why do I say that? Psychological improvements (global functioning scores for example) did not “speed up” after CSH/SRS, they stayed the same, or even slowed down over the 6 years.  CSH/SRS had no positive impact on the rate of psychological improvement. If CSH &/or SRS was an impactful therapeutic intervention, the biggest improvements in psychological functioning would have occurred after these interventions. They did not. 

Possible explanations?

  1. Gender dysphoria is a symptom of an underlying root issue (autogynephilia, or rejection of one’s same sex attraction, or more recently of trauma, or concrete ASC thought processes (“I like boy things therefore I must be a boy”), or pubertal stress, not a stand-alone primary entity. CSH & SRS treat the symptom (gender dysphoria), not the underlying etiology (conflict of identity). (Tylenol treats a fever, but not the underlying cause, to borrow an analogy).
  • This is in keeping with the medically accepted understanding of the term “transsexual” or “transgender”: traditionally these terms have been used to describe an individual who has taken significant steps to present themselves to society as the opposite sex, in an effort to relieve severe, persistent gender dysphoria. The treatment does not actually change their sex, but is an effort to improve psychological wellbeing. Also, there is also no medical evidence that an individual can be born into the wrong sexed body.
  • Intensive counseling or brain maturation as a result of aging, or both (?)  helps resolve conflicts of identity. 

The point is, this is low quality evidence (Endo society guideline’s words, not mine), and definitive conclusions about the impact of hormones and surgery on psychological outcomes cannot be drawn from such studies. This type of study does not justify the use of pubertal blockade and cross sex hormones in adolescent patients, especially when 80-90% of gender dysphoria resolves after puberty, and the consequences of treatment can be irreversible (sterility, permanent physical changes). 

For clarity, the Endocrine society is suggesting a protocol of puberty blockade, followed by cross sex hormones, that can result in sterility of those treated, based on a single study, of insufficient follow-up, without a control group.

  • Problems with the American Academy of Pediatrics (AAP) guidelines: The AAP guidelines regarding the treatment of GD are devoid of scientific rigor. The following critique by an expert in the field summarizes the deficits of the document:

             Cantor, James. “American Academy of Pediatrics Policy and Trans- Kids:Fact-Checking.” American Academy of Pediatrics Policy and Trans- Kids:Fact-Checking, Oct. 2018, www.sexologytoday.org/2018/10/american-academy-of-pediatrics-policy.html.

Excerpt: AAP’s statement is a systematic exclusion and misrepresentation of entire literatures. Not only did AAP fail to provide extraordinary evidence, if failed to provide the evidence at all.  Indeed, AAP’s recommendations are despite the existing evidence.”

  • Affirmation therapy: While both the Endocrine Society and AAP guidelines promote affirmation therapy (support of a person’s preferred pronouns, dress, medical transition) as the only treatment model for gender dysphoric youth, there are actually 3 counseling models (therapeutic, accommodative, and affirmation) for treatment. Affirmation is the most controversial, and as such it is not used by the Dutch clinic who pioneered transgender medicine, because it likely prevents resolution of GD.

             Singh, Devita. “A Follow up Study of Boys with Gender Dysphoria.” nymag.com, 2012, images.nymag.com/images/2/daily/2016/01/SINGH-DISSERTATION.pdf.

             (A description of the 3 counseling models is on pg 16.)

Excerpt regarding affirmation therapy : “There are some serious concerns about this approach.  The most striking implication of an approach that facilitates early transitioning is that it may steer some children down a transgendered path who might have otherwise not desired to transition as they progress in development.  Proponents of the early transitioning model have not addressed how the approach fits conceptually or clinically with the finding that the majority of children with GID show a desistance in adolescence.” (pg 20)

From the Endocrine Society guidelines themselves: “Social transition is associated with the persistence of GD as a child progresses into adolescence.”

  • Other Validated Psychological Support Models: The use of a therapeutic, or modified therapeutic model of counseling for gender dysphoria has been validated, and described in the literature, and is the mainstay of the “Dutch model” of GD treatment. These models focus on exploring developmental factors that could be contributing to GD.

Zucker, Kenneth & Wood, Hayley & Singh, Devita & Bradley, Susan. (2012). A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder. Journal of homosexuality. 59. 369-97. 10.1080/00918369.2012.653309.

Summary: “This article provides a summary of the therapeutic model and approach used in the Gender Identity Service at the Centre for Addiction and Mental Health in Toronto.  The authors describe their assessment protocol, describe their current multifactorial case formulation model, including a strong emphasis on developmental factors, and provides clinical examples of how the model is used in the treatment.”

Vries, Annelou & Cohen-Kettenis, Peggy. (2012). Clinical Management of Gender Dysphoria in Children and Adolescents: The Dutch Approach. Journal of homosexuality. 59. 301-20. 10.1080/00918369.2012.653300.

Excerpts: “Adults, whose parents had indicated that their children either showed gender variant behavior or expressed the wish to be of the other gender during childhood, more frequently indicated that they were either homosexual or bisexual, but none of them was transexual. This proves that gender variant children, even those who meet the criteria for GID prior to puberty, for the most part are not gender dysphoric at a later age.”

“To date, we do not yet know exactly when and how gender dysphoria disappears or desists.”

“In the diagnosis and treatment of gender dysphoric children and adolescents, one must take the perspective of development into account. Gender variant behavior and even the wish to be of the other gender can be either a phase or a normal developmental variant without any adverse consequences for a child’s current functioning.”

“If they (parents) speak about their natal son as being a girl with a penis, we stress that they have a male child who very much wants to be a girl, but will need an invasive treatment to align his body with his identity if this desire does not remit.”

             Clarke, Anna Churcher, and Anastassis Spiliadis. “‘Taking the Lid off the Box’: The Value of Extended Clinical Assessment for Adolescents Presenting with Gender Identity Difficulties.” Clinical Child Psychology and Psychiatry, vol. 24, no. 2, 2019, pp. 338–352., doi:10.1177/1359104518825288.

Excerpts: “Issue of homophobia, internalized shame, family narratives, relational ruptures, and beliefs and fantasies associated with mid adolescence could be meaningfully thought about and integrated into a story of who one is becoming.”

Common themes: prior to GD onset patients had “experienced teasing/bulling, exclusion, isolation, difficulty in social communication, distress in relation to awareness of a developing sexed body.”

The majority “had an existing diagnosis of an autism spectrum condition (ASC) or would be likely to obtain one.”

“Louise struggled with symbolic thinking”, and “had a particular thinking style which shaped her understanding of gender diversity” (concrete thinking characteristic of ASC’s), and “had anxieties around loss of control in relation to pubertal changes” (menstruation, breast development).

Key point: these kids weren’t treated with conversion therapy. They were given time, and help, to navigate the complexities of adolescent development, including understanding how/why GD was part of that developmental experience for them.

  • Rapid Onset Gender Dysphoria: With the advent of pubertal blockade, there has been the of development of a new phenomenon described as “Rapid Onset Gender Dysphoria” (ROGD). There has been a approximate 10 fold (depending upon country) increase of predominantly adolescent girls presenting to gender clinics who had no prior history of gender dysphoria. Many have autism spectrum conditions, or are lesbians confused about their sexual orientation. The term ‘Rapid Onset Gender Dysphoria’ has been used to describe this phenomenon.  There appears to be a social contagion phenomenon occurring, and many of these individuals declare they are transgender after binge watching Youtube videos about the transition process, and in particular how good testosterone makes one feel (more confidence etc).

             Littman, Lisa. “Parent Reports of Adolescents and Young Adults Perceived to Show Signs of a Rapid Onset of Gender Dysphoria.” Plos One, vol. 13, no. 8, 2018, doi:10.1371/journal.pone.0202330.

               Excerpt: “This descriptive, exploratory study of parent reports provides valuable detailed information that allows for the generation of hypotheses about factors that may contribute to the onset and/or expression of gender dysphoria among adolescents and young adults.  Emerging hypotheses include the possibility of a potential new subcategory of gender dysphoria (referred to as rapid-onset gender dysphoria) that has not yet been clinically validated, and the possibility of social influences and maladaptive coping mechanisms.”

             Vrouenraets, Lieke Josephina Jeanne Johanna, et al. “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study.” Journal of Adolescent Health, vol. 57, no. 4, 2015, pp. 367–373., doi:10.1016/j.jadohealth.2015.04.004.

               Excerpt: “They are living in their rooms, on the internet during night-time, and thinking about this [gender dysphoria]. Then they come to the clinic and they are convinced that this explains all their problems and now they have to be made a boy.” -Psychiatrist

             Marchiano, Lisa. “Outbreak: On Transgender Teens and Psychic Epidemics.” Psychological Perspectives, vol. 60, no. 3, 2017, pp. 345–366., doi:10.1080/00332925.2017.1350804.

“Currently, we appear to be experiencing a significant psychic epidemic that is manifesting as children and young people coming to believe that they are the opposite sex, and in some cases taking drastic measures to change their bodies. Of particular concern to the author is the number of teens and tweens suddenly coming out as transgender without a prior history of discomfort with their sex.”

             Vries, Annelou L. C. de, et al. “Autism Spectrum Disorders in Gender Dysphoric Children andAdolescents.” SpringerLink, Springer US, 22 Jan. 2010, link.springer.com/article/10.1007%2Fs10803-010-0935-9.

             EurekAlert. “Study Finds Transgender, Non-Binary Autism Link.” EurekAlert!, www.eurekalert.org/pub_releases/2019-07/aru-sft071619.php.

  1. Failure of Cross Sex Hormones and Sex-Sex-Reassignment Surgery to Improve Long Term Outcomes: CSH and SRS may temporarily relieve gender dysphoria but do not have any positive impact on the long-term psychological functioning of gender dysphoric people.  While the internal feeling of incongruence may be relieved to some extent, but not always,  the root issue causing the individual to reject their natal sex is left unresolved. As such, the well designed long-term studies of gender dysphoric individuals who have undergone treatment with cross-sex hormones and sex reassignment surgery show increased rates of suicide. The below study shows the risk of death from suicide is increased 19 x’s vs controls.

             Dhejne, Cecilia, et al. “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden.” PLoS ONE, vol. 6, no. 2, 2011, doi:10.1371/journal.pone.0016885.

Excerpt: “Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

  1. Side Effects of CSH:  Testosterone increases the risk of heart disease in women by 4 fold, and estrogen increases the rate of DVT and stroke by approximately 3 fold in men. 

             Alzahrani, Talal, et al. “Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population.” Circulation: Cardiovascular Quality and Outcomes, vol. 12, no. 4, 2019, doi:10.1161/circoutcomes.119.005597.

             Getahun D, Nash R, Flanders WD, Baird TC, Becerra-Culqui TA, Cromwell L, et al. Cross-sex Hormones and Acute Cardiovascular Events in Transgender Persons: A Cohort Study. Ann Intern Med. [Epub ahead of print 10 July 2018]169:205–213.doi: 10.7326/M17-2785

  1. International Debate and Ethical Concerns: Debate about this issue is more robust than we have been led to believe. There is significant concern in the medical community regarding the treatment of gender dysphoric youth. Multiple editorials have been published to this effect and much discussion has occurred in the international literature about ethical concerns regarding the treatment of adolescents with PB and CSH.  The influential Royal College of General Physician (RCGP), with 50,000 members, in July of 2019 issued a position statement warning about the risks of affirmation therapy:

The role of the GP in the care of gender questioning and transgender patients. RCGP position statement. 

Excerpt: “The significant lack of evidence for treatments and interventions which may be offered to people with dysphoria is a major issue facing this area of healthcare. There are also differences in the types and stages of treatment for patients with gender dysphoria depending on their age or stage of life. Gonadorelin (GnRH) analogues are one of the main types of treatment for young people with gender dysphoria. These have long been used to treat young children who start puberty too early, however less is known about their long-term safety in transgender adolescents. Children who have been on GnRH for a certain period of time and are roughly 16 years of age can be offered cross-sex hormones by the NHS, the effects of which can be irreversible.15 There is a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of such treatments for people with gender dysphoria, particularly children and young people, which prevents GPs from helping patients and their families in making an informed decision.”

             “GPs Risk Causing Transgender Storm after Issuing Unprecedented Warning over ‘Lack of Evidence’ on Treatments That Pave Way for Children to Have a Sex Change.” Daily Mail Online, Associated Newspapers, www.dailymail.co.uk/news/article-7220897/amp/GPs-risk-transgender-storm-issuing-unprecedented-warning-lack-evidence-treatments.html?__twitter_impression=true.

Excerpts:

“Professor Richard Byng, a practicing GP and professor of primary care at Plymouth University, said: ‘I hope it will provide GPs with the confidence to talk openly and compassionately with patients about the differences between gender identity and biological sex, the limited evidence for the treatments available, and the fact that transitioning can be an irreversible process with lifelong implications.’”

Physician quote; “Youngsters can pressure us to provide puberty blockers when they have little idea of the long-term implications. But then most of their information appears to come from social media, which perpetuates the notion that these medicines are safe”

“RCGP warns there is ‘a significant lack of robust, comprehensive evidence around the outcomes, side effects and unintended consequences of such treatments for people with gender dysphoria, particularly children and young people’”

             Heneghan, Carl. “Gender-Affirming Hormone in Children and Adolescents.” BMJ EBM Spotlight, 21 May 2019, blogs.bmj.com/bmjebmspotlight/2019/02/25/gender-affirming-hormone-in-children-and-adolescents-evidence-review/.

             Excerpts: “There are significant problems with how the evidence for Gender-affirming cross sex hormone has been collected and analyzed that prevents definitive conclusions to be drawn.”

             “An Archive of Diseases in Childhood letter referred to GnRH treatment as a momentous step in the dark. It set out three main concerns: 1)Young people are left in a state of developmental limbo without secondary sexual characteristics that might consolidate gender identity 2) use is likely to threaten the maturation of the adolescent mind, and 3) puberty blockers are being used in the context of profound scientific ignorance.”

             “The current evidence does not support informed decision making and safe practice in children.”

Michael K Laidlaw, Quentin L Van Meter, Paul W Hruz, Andre Van Mol, William J Malone, Letter to the Editor: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline” , The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 3, March 2019, Pages 686–687.

Excerpt: “How can a child, adolescent, or even parent provide genuine consent to such a treatment? How can the physician ethically administer gender affirming therapy knowing that a significant number of patients will be irreversibly harmed?”

             Salkind, Jessica, et al. “Safeguarding LGBT+ Adolescents.” Bmj, 2019, p. l245., doi:10.1136/bmj.l245.

Excerpts: “With 85% desistance amongst referred transgender children, and increasing awareness of detransitioning, unquestioning ‘affirmation’ as a pathway that leads gender dysphoric patients to irreversible interventions cannot be considered sole or best practice.”

“In effect, transitioning children who would otherwise have gown up lesbian, gay or bisexual may introduce another form of conversion.  A well intentioned but permanent medical pathway for all is unlikely to achieve the best long term-outcomes.  Confirming disgust in natal sex or external sexual organs, especially for those with prior childhood trauma, risks medical collusion with, or reenacting of, abuse.”

             Sadjadi, Sahar. “The Endocrinologist’s Office—Puberty Suppression: Saving Children from a Natural Disaster?” Journal of Medical Humanities, vol. 34, no. 2, 2013, pp. 255–260., doi:10.1007/s10912-013-9228-6.

Excerpts: The piece “aims to call to attention the effects of scare tactics and sensational stereotypes of transgender people used to convince people of the necessity of treatment.”

“To pathologize their (gender non-conforming children’s) refusal of and discomfort with the social expectation of their natal sex and locate the source of the problem within the child ignores the conditions in which the suffering has developed.”

             McHugh, Paul. “Transgender Surgery Isn’t the Solution.” The Wall Street Journal, Dow Jones & Company, 13 May 2016, www.wsj.com/articles/paul-mchugh-transgender-surgery-isnt-the-solution-1402615120.

             Shrier, Abigail. “Opinion | Standing Against Psychiatry’s Crazes.” The Wall Street Journal, Dow Jones & Company, 3 May 2019, www.wsj.com/articles/standing-against-psychiatrys-crazes-11556920766.

  1. Suicide Myths: There is no mention of suicide reduction from CSH and SRS in the gender dysphoria Endocrine Society guidelines, b/c it has never been shown.  The most widely circulated statistic of “48% of transgender kids attempt suicide” was a survey including only 27 transgender identified people and had serious methodological problems.  Dr. Ken Zucker has publicly presented his clinic’s suicide data, showing suicide rates in transgender identifying adolescents are comparable to other adolescents with a psychological condition.

             Blanchard, Raymond and Bailey, Michael. “Suicide or Transition: The Only Options for Gender Dysphoric Kids?” 4thWaveNow, 13 Oct. 2017, 4thwavenow.com/2017/09/08/suicide-or-transition-the-only-options-for-gender-dysphoric-kids/.

Excerpt: “Parents with gender dysphoric children almost always want the best for them, but many of these parents do not immediately conclude that instant gender transition is the best solution. It serves these parents poorly to exaggerate the likelihood of their children’s suicide, or to assert that suicide or suicidality would be the parents’ fault.

             “Suicide Facts and Myths.” Transgender Trend, www.transgendertrend.com/the-suicide-myth/.

Excerpt: The Tavistock and Portman GIDS clinic states that amongst children referred to the clinic “suicide is extremely rare”.

  1. Detransitioners: Many gender dysphoric youth who were inappropriately medicalized are now “detransitioning”, to the extent that this is even possible. There are irreversible physical effects of testosterone in particular on a female body (Adam’s apple development, permanent deepening of voice, clitoromegaly, jaw enlargement) and the surgical changes are partially to completely irreversible.

Stella, Cari. “Why I Detransitioned and What I Want Medical Providers to Know (USPATH 2017).” YouTube, YouTube, 6 Feb. 2017, www.youtube.com/watch?v=Q3-r7ttcw6c.

Grove, Wheston Chancellor. “Testosterone Side Effects after 14 Years – FTM Transgender ‘Hybrid.’” YouTube, YouTube, 27 Mar. 2019, www.youtube.com/watch?v=QRTuu9rcuYw.

Mills L. A letter to young trans people. https://www.transgendertrend.com/letter-to-young-trans-people

https://www.piqueresproject.com/

Female Detransition and Reidentification: Survey Results and Interpretation.” Archive, 3 Sept. 2016, guideonragingstars.tumblr.com/post/149877706175/female-detransition-and-reidentification-survey.

The Heritage Foundation. “He Used To Be Trans-Here’s What He Wants Everyone To Know.” YouTube, YouTube, 4 Apr. 2019, www.youtube.com/watch?v=qlRkLtKqSrY.

The Heritage Foundation. “Former Transgender Activist: Transitioning Is Dangerous-Especially For Youth.” YouTube, YouTube, 4 Apr. 2019, www.youtube.com/watch?v=dJMMqREtQJc&t=8s.

  1. Perspectives: It is without doubt that cross-sex hormones are medically dangerous. Neither CSH or SRS improve the long term psychological functioning of gender dysphoric people. But this does not matter to those pushing these treatments.  They believe that regardless of the risk, GD people have a right to access these treatments.  This approach reduces physicians to hired syringes, who for the right price will provide a harmful therapy to people on demand.  This an unethical and nihilistic approach to medicine and life, and should be rejected.
  1. Conclusions: To conclude, gender dysphoria always has a root cause. No one is born transgender/transsexual.  There are validated counseling models to treat this condition. 80-90% of childhood gender dysphoria resolves through the process of pubertal development.  The recent wave of adolescent onset gender dysphoria is a completely new phenomenon, and application of the childhood onset GD protocol to them is inappropriate. Pubertal blockade, cross-sex hormones, and so called sex-reassignment surgery do not address the underlying issue causing the dysphoria, significantly increase cardiovascular mortality, and do not improve long term psychological functioning. The medicalization of people suffering from gender dysphoria is unsafe, and unproven, and should be halted.

Additional Links:

             Blake, Nathanael. “What We Don’t Know: Does Gender Transition Improve the Lives of People with Gender Dysphoria?” Public Discourse, 2 May 2019, www.thepublicdiscourse.com/2019/04/51524/.

             Deborah, Soh. “The Unspoken Homophobia Propelling the Transgender Movement in Children.” Quillette, 28 Oct. 2018, quillette.com/2018/10/23/the-unspoken-homophobia-propelling-the-transgender-movement-in-children/.

             The Heritage Foundation. “Medical Risks of Hormonal and Surgical Interventions for Gender Dysphoric Children.” YouTube, YouTube, 4 Apr. 2019, www.youtube.com/watch?v=rYtGPLpW-g8&t=656s.

             Vanderlast, Sajber. “Julia Beck Speaking How Lesbians Get Hurt by Gender Ideology.” YouTube, YouTube, 28 Jan. 2019, www.youtube.com/watch?v=FbzPthhj6vI.

             The Heritage Foundation. “Gender Dysphoria in Children: Understanding the Science and Medicine.” YouTube, YouTube, 12 Oct. 2017, www.youtube.com/watch?v=GOniPhuyXeY&t=2072s.

             McHugh, Paul. “Part Three: Gender Identity – Sexuality and Gender.” The New Atlantis, 2016, www.thenewatlantis.com/publications/part-three-gender-identity-sexuality-and-gender.

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  1. Along with autism, ADHD is a common co-morbidity in ROGD.

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