Gender Dysphoria Resource for Providers

Gender Dysphoria Resource for Providers: 3rd Edition*

From the desk of: 

William J. Malone, MD 

Board Certified Endocrinologist

*This 3rd edition has contributions from Julia Diana Robertson, an award-winning author, and contributor to the Huffington Post, After Ellen and the Velvet Chronicle.  From her unique perspective as an Arab-American, she has been courageously raising public awareness about challenges facing the lesbian community, and the harm being done by medicalizing gender non-conforming youth. I am grateful for her contributions. 

Description: As a practicing endocrinologist, I synthesize information from the medical literature, and then integrate that information with my own personal experiences to generate recommendations for patients that have the highest likelihood of easing their suffering.  I became concerned in 2017 when the Endocrine Society published guidelines for the treatment of gender dysphoric children and adolescents that, if followed, could result in the infertility of those patients.  I was unwilling to accept the “gender affirming model” of treatment at face-value without reading first-hand the literature supporting a model with such an irreversible and consequential side effect.  As I went to the primary sources, I became more concerned.  Contrary to how the model has been presented by our medical societies, the affirmative approach is controversial and has limited to no data supporting its application, especially in children and adolescents.  There are deep ethical and informed consent concerns with the model.  There is a lack of data showing long-term psychological benefit from hormonal and surgical interventions.  In addition, there has been a disturbing suppression of debate about these concerns both within the medical community, and within our broader society in general.  In an effort to advance this debate, I have generated this document summarizing the medical literature that is critical of the “gender affirming model”. Medical professionals, patients and others deserve to know about the existence of this literature so that the best possible care can be provided to those suffering from gender dysphoria.  The same rigorous process of scientific debate applied to other areas of medicine should be applied to this area as well.  

For those who wish to learn more about gender dysphoria and concerns surrounding the “gender-affirming model” of treatment, I’ve summarized key points on the topic, and have embedded links to relevant literature. This document is not meant to be exhaustive, but to give a starting point for further reading. None of the statements below 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: Sex is defined as the state of being male or female. Absent a disease process, males naturally develop the capacity to generate sperm, and females naturally develop the capacity to generate eggs.  A man is an adult human male.  A woman is an adult human female.   Gender is defined as the stereotypes and behavioral traits typically associated with one’s sex.  Currently, gender is being used incorrectly as a synonym for sex. For this overview, the term gender will be used to indicate the behavioral stereotypes and roles expected based on one’s sex.  

Historically, the term transsexual referred to an individual who had taken significant steps to present themselves to society as the opposite sex, in an effort to relieve severe and persistent gender dysphoria.  More recently, the term transsexual has been replaced with the term transgender, leading to confusion.  Culturally, and now medically, transgender is defined as a state of a “mismatch” between one’s gender, and one’s biological sex.  I put mismatch in quotations because the mismatch is a perceived one, not an actual one.  It is not possible to be born into the “wrong” body (“boy brain in a girl body” for example), and no serious scientist has ever made such a claim.   

Every Cell Has A Sex: https://www.ncbi.nlm.nih.gov/books/NBK222291/

Gender dysphoria (GD), is distress 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” girl with more stereotypical male mannerisms and preferences, for example, may become confused into thinking that she is actually male and become distressed at 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.  More on etiology and treatment in later sections, but briefly, such a girl as described above does not need testosterone to make her look like a boy.  She needs psychological support to help her understand the etiology of her rejection of her natal sex. 

  • Natural history of gender dysphoria: 0.5% of children experience gender dysphoria. Approximately 85% of childhood-onset gender dysphoria desists by adulthood. The majority of children who have gender dysphoria will be same-sex attracted or bisexual.  It is impossible to determine whose GD will desist and whose will persist without allowing for pubertal development. Some practitioners claim that they can determine clinically in early puberty who will persist in their gender dysphoria, but there are no validated clinical tools that are predictive of persistence. 

In part due to the lack of evidence that cross-sex hormones and sex-reassignment surgery improve the long-term psychological functioning of gender dysphoric people (see below), puberty blockers were introduced into the treatment protocols for gender dysphoric children and adolescents, with the thought that by preventing the development of secondary sexual characteristics (of men in particular), treated individuals would more resemble their desired sex, thus reducing dysphoria, and improving long-term psychological functioning.  

The first problem with this approach is that hormones and surgery do not help a distressed individual understand the root of their dysphoria.  It reinforces the falsehood that something is wrong with their body, or gender expression.  The second problem with this approach is that it’s an unproven and experimental hypothesis.  The third problem is that no clinician can tell who will persist in their gender dysphoria. Since approximately 85% of gender dysphoria desists through puberty, medically intervening before completion of puberty interferes with the resolution of the majority of cases of gender dysphoria.  In addition, it harms those with persistent GD who may not want cross-sex hormones or surgery. Additionally, there are recent studies showing medical and surgical interventions are associated with increases in cardiovascular disease, cancer, and suicide long-term. A 2016 Center for Medicare and Medicaid Services (CMS) review of the literature concluded that sex-reassignment surgery did not improve long-term psychological functioning.  In any other area of medicine, these findings would result in a vigorous re-examination of the treatment paradigm, and likely a halting of such treatments until convincing data showing benefit was presented. 

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 Desistance and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry,52(6), 582-590.

“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.

Excerpt: Factors predictive for the persistence of GD have been identified on a group level, with higher intensity of GD in childhood identified as the strongest predictor for a future gender dysphoric outcome (Steensma et al., 2013). The predictive value of the identified factors for persistence are, however, on an individual level less clear cut, and the clinical utility of currently identified factors is low.”

Steensma, Thomas D., et al. “Gender Identity Development in Adolescence.” Hormones and Behavior, vol. 64, no. 2, 2013, pp. 288–297.

  • Etiology: The currently understood causes of gender dysphoria include: 1) autogynephilia (a heterosexual male who is sexually aroused at the thought of himself as a woman), 2) internalized homophobia, or a rejection of one’s homosexuality (for example a preference to live life as a “trans woman” attracted to men, vs living as a gay man), 3) concrete thinking processes that characterize autism spectrum conditions (“I don’t like “girl” things therefore I must be a boy”), 4) sexual trauma (a protective mechanism to avoid repeat sexual trauma), 5) conflation of sex and gender (due to the stress of simply not fitting into societal expectations of gender roles). 

No one is born in the wrong body or with the wrong gender expression. An important but overlooked fact is that there is a broad distribution of personality type and behavior within each sex, with significant overlap between sexes.  “Masculine” girls or “feminine” boys have gender expressions that are equally valid to “feminine” girls and “masculine” boys. It is understandable how such an individual could develop gender dysphoria, because they don’t fit the typical mold, so to speak.  However, that these gender non-conforming people are being pathologized by medical professionals is difficult to understand. Pathologizing gender non-conforming behavior can cause psychological harm (persistence of gender dysphoria, for example).  The dysphoria of a gender “non-conforming”person is a signal that resilience and/or self-acceptance needs to be built.  The dysphoria of a gender “conforming”person likely indicates an underlying trauma or psychologically based motivation needs to be addressed and resolved. 

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 woman 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.”

  • Gender Affirming Model: While both the Endocrine Society and American Academy of Pediatrics guidelines promote the gender affirming model as the only psychological support model for gender dysphoric youth, there are actually three counseling models (therapeutic, accommodative, and affirmation) for the treatment of GD. Affirmation is the most controversial, and, as such, it is not used by the Dutch national transgender clinic (considered the international flagship of gender dysphoria treatment), because it likely prevents desistance 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 the social and psychological gender affirming model: “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.”

  • Concerns about Puberty Blockers: There is significant concern that puberty blockers (GnRH analogues) prevent GD resolution. Almost all adolescents who are treated with pubertal blockade go on to cross-sex hormones.  This means their use may prevent resolution of the majority of childhood-onset gender dysphoria (as 85% of GD would normally resolve). Their impact on the resolution of adolescent or late-onset GD is unknown.  These drugs halt the physical, social, sexual, emotional, and possibly intellectual development of an adolescent.  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. In my opinion, and in the opinions of others, 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 our understanding of young-adult brain maturation. 

             Sharma, Sushil, et al. “Maturation of the Adolescent Brain.” Neuropsychiatric Disease and Treatment, 2013, p. 449.

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.

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

EPATH Conference 2019, section on puberty blockers, pg 165: 

Hruz, Paul. “Growing Pains.” The New Atlantis, 2017, www.thenewatlantis.com/publications/growing-pains.

Excerpt: In light of the many uncertainties and unknowns, it would be appropriate to describe the use of puberty-blocking treatments for gender dysphoria as experimental. And yet it is not being treated as such by the medical community. Over the course of decades, experimental medicine has developed many norms, standards, and protocols, including human subjects’ protections, the use of institutional review boards, and carefully controlled clinical trials, as well as long-term follow-up studies. These longstanding practices are meant to make experimental medicine more rigorous and to serve the interests of patients, physicians, and the community. But when it comes to the use of puberty-blocking treatments for gender dysphoria, these standards and protocols seem to be almost entirely absent — a fact that ill serves patients, physicians, the community, and the search for truth. Physicians should be cautious about embracing experimental therapies in general, but especially those intended for children, and should particularly avoid any experimental therapy that has virtually no scientific evidence of effectiveness or safety. Regardless of the good intentions of the physicians and parents, to expose young people to such treatments is to endanger them.

Hruz, P. W. (2019). Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria. The Linacre Quarterlyhttps://doi.org/10.1177/0024363919873762

Excerpt: In summary, the information presented in this report highlights many of the deficiencies in the existing knowledge base regarding the etiology and prevalence of gender dysphoria and current treatment approaches. Although far from exhaustive, these data provide a rationale for exercising caution in accepting the currently proposed gender affirmation treatment paradigms that have been advocated by the WPATH (Coleman et al. 2012) and other professional organizations (Hembree et al. 2017). 

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

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. Additionally, because they present the gender affirmative model as the standard of care for GD, they should be viewed as an opinion piece, not a definitive document for guiding decision making. The document relies on a single, uncontrolled study to justify treating GD youth with PB and CSH. You’ll notice that in the sections detailing puberty blockade and cross-sex hormones, “suggestions”, not recommendations, are made, based on “low quality” evidence.  Therapeutic counseling, plus uninterrupted puberty, results in the resolution of the majority of gender dysphoria. The Endocrine Society has failed in their guidelines to provide evidence that the gender affirming model improves on this high rate of resolution that does not require life-long medicalization. 

             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.

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.

My further analysis of this study: An argument can be made that this study, which the Endocrine Society gender dysphoria guidelines rely on to justify cross-sex hormones and sex-reassignment surgery, actually shows that these interventions don’t improve the psychological functioning of gender dysphoric people at all. 

The major problem with the study is the absence of a control group.  As a consequence, useful conclusions from the study are limited.  

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 function, comparing the 14 y/o patients started on pubertal blockade, to those same patients at 16 y/o when starting cross sex hormones, and then one-year post sex-reassignment surgery (average age 20).

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

With this in mind, there are other possible conclusions from the data:

  1. Intensive counseling, or just the aging process itself, or both, resulted in slow but steady improvements in some markers of psychological health over the course of 6 years, independent of medical and surgical interventions. 
  • Cross-sex hormones and sex-reassignment surgery improved gender dysphoria (at least temporarily), but that had no noticeable impact on psychological well-being. This finding would be consistent with the findings of other long-term studies.  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 also had no positive impact on the rate of psychological improvement. If CSH and/or SRS was an impactful therapeutic intervention, the biggest improvements in psychological functioning would have occurred after these interventions. They did not. 

The point is, this is low quality evidence (Endocrine Society guideline’s words), and definitive conclusions about the impact of hormones and surgery on psychological outcomes cannot be drawn from such a study. This type of study does not justify the use of puberty blockers and cross-sex hormones in adolescent patients, especially when approximately 85% of gender dysphoria resolves after puberty, and the consequences of treatment are irreversible (infertility, permanent physical changes). 

To emphasize, the Endocrine Society is suggesting a protocol of puberty blockade, followed by cross sex hormones, that can result in infertility, lifelong sexual dysfunction, and likely increases in heart disease, based on this single, uncontrolled study, of insufficient duration.

  • 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 M. “Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1–7., doi:10.1080/0092623x.2019.1698481.

Excerpts: The American Academy of Pediatrics (AAP) recently published a policy statement: Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Although almost all clinics and professional associations in the world use what’s called the watchful waiting approach to helping gender diverse (GD) children, the AAP statement instead rejected that consensus, endorsing gender affirmation as the only acceptable approach. Remarkably, not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them.

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.” 

  • 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, and have been shown to result in the resolution of GD in approximately 85% of cases. 

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 transsexual. 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. 33

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.

  • Adolescent, or Late Onset, or Rapid Onset Gender Dysphoria: With the advent of puberty blockade, there has been the development of a new social phenomenon described first by Lisa Littman as “Rapid Onset Gender Dysphoria” (ROGD). There has been an approximate 10-fold increase of predominantly pubertal or post pubertal girls presenting to gender clinics who have no prior history of gender dysphoria. Concerns about higher rates of autism spectrum conditions in this population have been raised.  There appears to be a social contagion aspect to this late presentation, and many of these individuals declare they are transgender after consuming on-line content about the transition process.  

             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.

               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.”

             Hutchinson, Anna: In Support of Research into Rapid-Onset Gender Dysphoria, link.springer.com/epdf/

Excerpt: “While some of us have informally tended toward describing the phenomenon we witness as adolescent onset gender dysphoria, that is, without any notable symptom history, prior to or during the early stage of puberty (certainly nothing of clinical significance), Littman’s description resonates with our clinical experiences from within the consulting room.”

             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.

             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 and Adolescents.” SpringerLink, Springer US, 22 Jan. 2010.

             EurekAlert. “Study Finds Transgender, Non-Binary Autism Link.” EurekAlert!

  1. Lack of Evidence of Cross Sex Hormones and Sex-Sex-Reassignment Surgery Improving Long Term Outcomes: CSH and SRS may temporarily relieve gender dysphoria but long-term (>10 year) studies do not show improvements in psychological functioning.  While the internal feeling of incongruence may be temporarily relieved to some extent, the root issue causing the individual to reject their natal sex is left unresolved, and some describe worsening of dysphoria after beginning transition. This could explain why a landmark long-term study of gender dysphoric individuals who have undergone treatment with cross-sex hormones and sex-reassignment surgery showed high rates of suicide. This study (below) showed the risk of death from suicide was elevated 19 times vs the general population, and the risk of heart disease increased 2-3 times. 

             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.

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

The Center for Medicare and Medicaid Services reviewed the long-term outcome studies of sex-reassignment surgery in 2016. Of the 33 studies that were reviewed, most had methodological problems preventing reliable conclusions.  The useful studies did not show improvements in psychological functioning after gender reassignment surgery. 

             Decision Memo for Gender Dysphoria and Gender Reassignment Surgery (CAG-00446N), www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=282.

Conclusions: “After careful assessment, we identified six studies that could provide useful information.  Of these, the four best designed and conducted studies that assessed quality of life before and after surgery using validated (albeit non-specific) psychometric studies did not demonstrate clinically significant changes or differences in psychometric test results after gender reassignment surgery.”

“Based on an extensive assessment of the clinical evidence as described above, there is not enough high-quality evidence to determine whether gender reassignment surgery improved health outcomes for Medicare beneficiaries with gender dysphoria and whether patients most likely to benefit from these types of surgical intervention can be identified prospectively.”

Regarding the above Dhejne study: “Further, we cannot exclude therapeutic interventions [hormones andgender reassignment surgery] as a cause of the observed excess morbidity and mortality.”

(In other words, not only do the long-term studies not show improvements in psychological functioning, the CMS team felt compelled to remark that the interventions may actually make things worse). 

  1. Side Effects of Cross Sex Hormones: The studies below show that men who take estrogen develop DVTs and strokes at 2-3 times the rate of normal. Women who identify as men have 4 times the odds of developing myocardial infarctions long-term, which testosterone is thought to play a role in. 

             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.

             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.

  1. International Debate and Ethical Concerns: Debate about this issue is more robust than our medical societies have led us to believe. There is significant concern in the broader medical community regarding the treatment of gender dysphoric youth. Multiple editorials have been published on this topic and much discussion has occurred in the international literature about the ethics of treating adolescents with PB and CSH. In July of 2019, the influential Royal College of General Practitioners (RCGP), with 50,000 members, issued a position statement warning about the risks and lack of evidence supporting the affirmation model: 

Bewley, Susan & Clifford, Damian & McCartney, Margaret & Byng, Richard. (2019). Gender incongruence in children, adolescents, and adults. British Journal of General Practice. 69. 170-171. 10.3399/bjgp19X701909.

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.

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.”

Richards, Christopher, et al. “Use of Puberty Blockers for Gender Dysphoria: a Momentous Step in the Dark.” Archives of Disease in Childhood, BMJ Publishing Group Ltd, 1 June 2019.

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 grown 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.

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.”

         Kenny, Diana. “KEY ISSUES IN DECISION-MAKING FOR GENDER TRANSITION TREATMENT: Questions and Answers.” Gdworkinggroup.org, 9 Aug. 2019, gdworkinggroup.org.

         Excerpt: “Does the current scientific evidence support a conclusion that the administration of Gender Transition Treatment (social transition, puberty blocking agents, and cross-sex hormones) can be safe for children and adolescents?   Answer: No.

             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 Concerns: There is no mention of suicide reduction from CSH or SRS in the Endocrine Society guidelines, because it has never been shown.  The suicide studies done on this population suffer from a variety of methodological flaws. 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.  These elevated rates are a concern for everyone, but should not drive hurried or unproven interventions. 

             Zucker, Kenneth J. “Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues.” Archives of Sexual Behavior, 2019, doi:10.1007/s10508-019-01518-8.

             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”.

             Biggs, Michael. “Suicide by Trans-Identified Children in England and Wales.” Transgender Trend, 9 Oct. 2018, www.transgendertrend.com/suicide-by-trans-identified-children-in-england-and-wales/.

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

Butler, Catherine, and Anna Hutchinson. “Debate: The Pressing Need for Research and Services for Gender Desisters/Detransitioners.” Child and Adolescent Mental Health, vol. 25, no. 1, 2020, pp. 45–47., doi:10.1111/camh.12361.

Herzog, K., Baume, M., Polk, L., Keimig, J., Polk, L., & Segal, D. (n.d.). The Detransitioners: They Were Transgender, Until They Weren’t. Retrieved from https://www.thestranger.com/features/2017/06/28/25252342/the-detransitioners-they-were-transgender-un

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 carry significant risks. Neither CSH or SRS have been convincingly shown to improve the long-term psychological functioning of gender dysphoric people. This raises ethical questions about what role physicians should play in providing treatments without convincing evidence that they work.
  2. Conclusions: To conclude, gender dysphoria always has a root cause. No one is born in the wrong body.  There are validated counseling models to treat this condition. Approximately 85% of childhood-onset gender dysphoria desists 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. Puberty blockade, cross-sex hormones, and sex-reassignment surgery do not address the underlying issues that cause dysphoria, are associated with increased cardiovascular mortality, and have not been shown to improve long-term psychological functioning. In any other area of medicine, such findings would result in a re-examination of the validity of such treatments, and a halting of those treatments until data showing benefit became available.  

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 Medi- cine.” 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. 

Roberto D'Angelo

Roberto D'Angelo is a psychiatrist and psychoanalyst in private practice in Sydney, Australia.

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