Getting gender transition
treatments is like driving down a rough road while blindfolded and not being
able to see where you're going. This makes many people feel lost and unable to
find their way back. The world governments need to take a break and figure out
where we are before going further down this uncertain road – especially given that many people who have gone through
the procedure are now struggling with depression and making the hard decision
to de-transition.
Are the doctors that perform
gender transition treatments truly saving lives or destroying the fabric of our
society? Are gender transitions the new pandemic? As far as I can tell,
COVID-19 still hold the title for pandemic. The truth, however, is that this
current surge in gender dysphoria is not just a coincidence. And, it appears as
if the new pandemic in town is gender transitions.
Simply put, the issue of
gender-affirming and gender transition care for teens is far from simple. On
one side, there are people who say it's a treatment for people with gender
confusion that can save their lives. On the other hand, some people say that
doctors are taking advantage of weak teens by basically "grooming"
them to undergo the treatment. The hype will make your head spin! But don't
worry, dear readers, because I'll look into this difficult subject and try to
figure out the politics that is going on here.
We begin with this
scenario: Betha Clay (the name has been changed to protect her privacy) was 17
when she was given testosterone for the first time in a clinic in California.
She had told her parents that she was a boy, so the doctors gave her
testosterone. The whole drama began after she was sexually assaulted when she
was a teen, and she started having some trouble with anorexia and sadness. Chelsea
Botha (her real name has been changed to protect her privacy) is a 16-year old
who live with her parents in Virginia. She
had both breasts taken off because she felt that she was supposed to be a boy.
Brittany Davidson (whose name was changed to protect privacy) was a year
younger when she had a double mastectomy in California. She had been taking
testosterone and drugs to stop puberty since she was 13. This was also after
she was sexually assaulted.
All three girls had gender
dysphoria, which is a feeling of being very uncomfortable in their own
bodies. Once a rare diagnosis, the number of people who claimed they suffer
from it has grown a lot in the last ten years. Since 2011 to 2022, about
seventeen times as many teens in England and Wales have gone to
the Gender Identity Development Service (GIDS), which is the
main clinic for treating dysphoria, for help (see Table 1). According to
the available published evidence, more than 42,000 American children and
teens were diagnosed in 2021, which is three times as many as in 2017.
Rich countries like Australia and Sweden have also seen their numbers grow
quickly.
Table 1
U.K.: Referrals to the
Tavistock Gender-Identity Clinic
|
Year
|
Number of Teenagers (Approximately)
|
|
2011
|
102
|
|
2013
|
333
|
|
2015
|
750
|
|
2017
|
2,000
|
|
2019
|
2,801
|
|
2021
|
2,400
|
|
2022
|
3,500
|
Source: Culled from The
Economist, 2023
As the number of cases
has grown, so has a treatment method called gender-affirming care that
was first used in the Netherlands. It involves letting patients know how they
feel when they complain that their body and sense of self don't match up.
After a psychological evaluation, some patients are given a mix of drugs that
stop puberty, hormones that make them feel like the opposite sex, and sometimes
surgery to try to make them feel better. As was reported in The Economist,
a news magazine, around 5,000 teenagers in the U.S. were given
puberty-blockers or cross-sex hormones in 2021. This is twice as many as in
2017.
From Gender Reassignment
to Gender Regret
The treatment has drawn a
lot of criticism. It has become yet another front in the culture wars in a lot
of different countries, but especially in the United States of America. In an
effort to support transgender persons, many Democrats characterize
critics of gender-affirming care as uncaring individuals who neglect the great
anguish and even suicides that often occur among adolescents who suffer
from gender dysphoria. Meanwhile, the Republicans and other critics
on the right accuse physicians of being so intent on encouraging gender
transitions, and that they
basically groom vulnerable youngsters (which is a phrase that is
typically used to refer to sexual predators of children) to undergo the
treatment. During a conference of the American Academy of Pediatrics in
October 2022, those in favor of gender-affirming care and those opposed to it
staged heated demonstrations against each other. Several states in the United
States, including Florida and Utah, have enacted legislation that makes it
illegal to provide gender-affirming care to minors. Such regulations have been
regarded as "close to sinful" by America's President Joe Biden.
Many well-respected
medical professionals in the United States stand for gender-affirming care.
While people in Britain, Finland, France, Norway, and Sweden are in favor of talk therapy as
a first step in the treatment process, they have reservations about the
pharmacological and surgical components of the treatment. According to the
findings of a review conducted in Finland and released in the year 2020, gender
reassignment in youngsters should be considered "experimental," and
treatment should only rarely go beyond talk therapy. The Swedish
authorities came to the conclusion that the risks of using physical treatments
currently outweigh the possible benefits and that these procedures should
only be used in extraordinary circumstances. An evaluation that was conducted
in the United Kingdom and was led by a pediatrician named Hilary Cass
discovered that gender-affirming care had developed without some of the
regular quality controls that are typically performed when new or innovative
therapies are introduced. The National Academy of Medicine of France issued a
warning to medical professionals in 2022, instructing them to proceed with
medications and surgery only with great medical caution and the greatest
reserve.
Without a shadow of a
doubt, there are a great number of children and parents that are aching to
receive assistance with gender dysphoria. Some people believe that the physiological
components of gender-affirming therapy were the treatments that ultimately
saved their lives. In spite of that, the harsh reality is that many patients
emerge from the gender-transition treatment wounded and scared. Ms. Betha Clay,
Ms. Chelsea Botha, and Ms. Brittany Davidson are all considered
"detransitioners," which means that they no longer wish to be
perceived as male and are bitterly regretting their
new gender identity. They are furious with their doctors, who,
according to them, hurried them into the therapy, and they regret the
irreparable results of the treatment they received. Brittany Davidson believes
that she was basically "butchered" by the health departments
and institutions that she had trusted, and that she is a victim of
institutionalized violence.
The treatment regimen
that was created in the 1980s and 1990s with the purpose of transitioning
youngsters has its origins in the Netherlands. It is supported by three main
components: puberty-blockers (also known as GnRH antagonists), cross-sex hormones,
and surgical procedures. The mental suffering of the patient was intended to be
alleviated by changing the patient's body in such a way that it more closely
matched their perception of their cross-sex identity. The experiences of some
of the first patients were detailed in a pair of publications authored by
Annelou de Vries, who was a pioneer in the development of the Dutch protocol.
These studies were published in 2011 and 2014. They came to the conclusion that
patients who used puberty-blockers had fewer symptoms of sadness, and that gender
dysphoria "resolved" and psychological functioning steadily
improved after receiving cross-sex drugs and surgery. Yet that conclusion
may be based on a small sample size or a short time of follow-up, and there may
be risks and side effects that come with using puberty-blockers, cross-sex
drugs, and surgery.
One-Way
Ticket or a Round Trip?
Puberty-blockers
are exactly what their names imply that they will do. It is hypothesized that giving
patients time to reflect on their dysphoria and decide whether or not
they want to pursue more extreme treatments may be beneficial if the
puberty-blockers temporarily halt the development of undesirable sexual
characteristics. The central precocious puberty condition, in which
puberty occurs at an extremely young age, is treated with medications from the
same family. In some nations, they are also used as a method of chemical castration
for sexual offenders. The use of puberty-blockers in gender medicine is considered
off-label, which means that they do not have regulatory permission for
that purpose. This is similar to the situation with many other drugs that are
administered to children.
Patients
who have made the decision to continue with their transition are subsequently
given hormones that are specific to their new gender. In males, the development
of breasts and changes in the manner in which fat is stored on the body are
likely to occur. When administered to women, testosterone causes irreversible changes
such as a deepening of the voice, a change in the bone structure of the face,
and the growth of facial hair. In addition, testosterone causes an increase in
muscle growth.
However,
as demonstrated by the cases of Ms. Brittany Davidson and Ms. Chelsea Botha, there
are some locations in which mastectomies are performed on patients who are
younger than the age of 18, contrary to the initial protocol that was
established in the Netherlands. Patients of any gender have the option of receiving
breast implants. On minors, more complex treatments such as those in which
girls have a mimicked penis fashioned from a tube of skin extracted from the
forearm or the thigh, or in which males have an artificial vagina made in a penile
inversion, are carried out only very infrequently. These procedures are
reserved for adults.
The
National Institute for Health and Care Excellence (NICE), a British
organization that evaluates the scientific rationale behind medical treatments,
conducted an investigation into puberty-blocking medications and cross-sex
hormones in the year 2020. The scholarly evidence that it uncovered was a black
hole, where any hope for support for the procedure was sucked in and basically
disappeared with out a treace. According to its findings, puberty-blocking
medication had minimal effect on the individuals. It is possible that cross-sex
hormones will improve mental health, but the likelihood of this happening is
low, and NICE has warned of the unknown dangers of adverse consequences
that people that received the procedure will endure.
NICE
noted that the quality of the papers it reviewed in that area was
very low - for both categories of drugs - and this is the
organization's lowest rating possible. Some of the studies presented their
findings without making any attempt to evaluate them statistically for
significance. Even though cross-sex hormones are a medication that must be
continued for the rest of a gender transitioner's life, the follow-up period
was just one to six years long. The majority of studies merely followed one group
of patients who were given the medications, rather than comparing them to
another group of patients who were not given the drugs. Because these studies
lacked a control group, the researchers were unable to determine whether the
events that occurred to the patients in the studies were due to the medicines,
to other treatments that the patients might have been getting (such as
counseling or antidepressants), or to some other factor that was unrelated to
the first two possibilities.
As
a result, it might be challenging to determine whether any alleged
effects—positive or negative—reported in the studies are, in fact, true.
Reviews in Sweden and Finland reached comparable conclusions. The finding of
the Swedish study that there is little scientific justification for hormone
treatments that prevent puberty is a dagger in the heart of the proponents for
gender variety.
The
science underlying teenage transitions has also been examined by two American
professional organizations, the Endocrine Society (ES) and the World Professional
Association for Transgender Health (WPATH). However, ES's review did not aim to
investigate whether gender-affirming care reduced gender dysphoria or in
any other way enhanced mental health. Instead, it concentrated on the negative
impacts, for which it claimed that there was scant support. But the review is
now "fundamentally flawed" due to this omission. For their part, WPATH did research the psychological impacts of
hormones and blockers. It discovered little and weak evidence. Despite these
findings, both groups maintain that their studies and the subsequent
recommendations are reliable and continue to advocate physical therapy for
gender dysphoria.
One
argument in favor of puberty-delaying medications is that they buy time for
kids to make up their minds about using transgender hormones or not. However,
the statistics collected to date from clinics indicate that the majority of
patients choose to proceed. Published evidence has revealed that as much
as 98% of adolescents who are taken blockers go on to use cross-sex
hormones. Similar high figures have been noted in other places.
The
comforting explanation is that blockers are being carefully administered and
only given to people whose dysphoria is ingrained and unlikely to
improve. The worrying aspect of puberty-blockers is that at least some
youngsters are forced to continue receiving treatment. Hannah Barnes, a British
journalist who wrote the new book "Time to Think" about GIDS, quotes
British healthcare professionals who are worried about the latter scenario.
Patients allegedly obtained blockers following brief and superficial
assessments.
The
Dutch researchers consider both theories and conclude that the majority of
persons who start using puberty-blockers likely have long-lasting gender
dysphoria. They said that it was impossible to rule out the potential that
beginning puberty-blockers increases adolescent likelihood of continuing
medical transition.
The
biggest unknown is perhaps how many patients who have the medications and
surgery and who ultimately changed their minds. These individuals in this group
have chosen to "detransition," having made peace with their biological
sex. Those who do frequently experience new pain as they adjust to lasting and
obvious changes to their bodies.
Again,
good data are hard to come by. One issue is that people who give up on a
transition are likely to stop communicating with their doctors, which causes
them to vanish from the statistics. The few estimates that do exist differ by
at least an order of magnitude or more. Detransition rates as low as 1%
have been recorded in several studies. However, three articles that examined
patients in the British and American military forces and were published in 2021
and 2022 discovered that between 7% and 30% of them discontinued treatment
after a short period of time.
The
initial Dutch investigations, which were published in 2011 and 2014, followed
the same group of patients throughout their treatments because they were
longitudinal studies. Three recent analyses that were published in the Journal
of Sex and Marital Therapy, as was reported in the news magazine The Economist,
find issues with the studies' data.
The
limited size of the original samples is one of the issues with the new
investigations. The 2011 study examined 70
patients. However, only 32 to 55 of them had a known treatment outcome (the
precise number varies depending on the measure). Even though, the final
evaluation of results took place about 18 months following surgery, which is a
fairly brief amount of time for a procedure whose consequences will endure a
lifetime. Longer observation was given to the initial patient, "FG".
Researchers noted his feelings of shame about his genital appearance and
inadequacy in sexual matters in 2011 when he was in his mid-30s. But a
decade later, things were better, and FG had a steady girlfriend.
The
criticisms further contend that the observation that gender dysphoria
improved with treatment may have been a product of the evaluation procedures
used on the subjects. Before beginning therapy, female patients were asked to
affirm or refute statements like, "Every time someone treats me like a
girl, I feel hurt." This confirmed their desire to be perceived as men.
The same people had surgery, hormone therapy, and blocker therapy before
answering questions on a scale designed for men. It had phrases like
"Every time someone treats me like a boy I feel hurt." Patients who
desired to be perceived as men naturally disagreed. In essence, the yardstick
was altered in a way that might be seen as increasing the likelihood of
successful results.
Last
but not least, it appears that the initial studies unintentionally
cherry-picked the individuals who responded best to the medication. Starting
with 111 adolescents, the researchers later dropped those whose
puberty-blocking medication did not work out effectively. Of the remaining 70,
some were left out of the analysis because they failed to complete
questionnaires, refused outright to do so, stopped receiving care, or, in one
instance, passed away as a result of complications following genital surgery.
Therefore, the data may have specifically omitted individuals who experienced
injury from or were unsatisfied with their treatment.
Dr.
de Vries insists that the original studies demonstrated a considerable
improvement in gender dysphoria, the disorder the procedure was intended
to treat, in a rebuttal article that was published in the same journal. Even
while she acknowledges that altering assessment scales is not ideal, she
insists that this does not suggest that the study's findings were
incorrectly measured. Concerns about the relatively brief follow-up were
addressed by her statement that a study reporting longer-term results is scheduled
to be published in the following years.
Since
then, other recent longitudinal studies have been published, although they also
have limitations. Teenagers treated with cross-sex hormones for two years were
the focus of one study, which Diane Chen of Northwestern University and
colleagues published in January's New England Journal of Medicine. On a scale
that ranges from 0 to 100, participants did frequently report improvements in their
mental health, but they were typically modest—mostly single-digit gains. There
was no control group in the study. Out of 315 patients, two died by suicide.
Regardless
of the merits of the Dutch team's initial research, the patients seen in
contemporary clinics today are noticeably different from those who were
evaluated in their articles. Twenty years ago, prepubescent boys made up the
majority of patients; lately, teenage girls have taken over. The results of earlier studies might not be
relevant to patients today.
The
Dutch squad took a purposefully cautious approach. Gender dysphoria had
to have affected the patients ever since they were children. Many patients
today claim that they first experienced dysphoria as teenagers. According
to the Dutch guideline, people who have mental health issues cannot receive
therapy. However, three recent research examining patients in America,
Australia, and Finland found that at least 70% of young people seeking treatment
have mental health issues.
The
guideline advises caution, although in practice, especially in America, it is
frequently the case that transitions should be continued rather than stopped
due to mental health difficulties. Americans are now warned that if they don't
deal with the mental-health issues produced by young people's dysphoria with
transition, they will commit suicide.
The
Confusing Diagnosis Game
The
official standards in the majority of countries, as well as the original
protocol from the Netherlands, place an emphasis on the importance of careful
screening and evaluations. However, there are continuous claims that the
guideline is not being followed in practice, and this is the case regardless of
the guidance. According to Ms. Betha Clay, she had one appointment that
lasted 15 minutes before she was given testosterone. A significant
number of patients in the United States have reported receiving such cursory
evaluations.
Recently, people started talking about the
potential that many young people who present as trans could actually be gay
instead. According
to the findings of a study that was conducted in the Netherlands in 2011,
almost all of the participants were attracted to people of the same or opposite
gender to themselves. In 2019, a group of clinicians who had left from GIDS expressed
their concerns about homophobia in some of their former patients and parents in
an interview with the Times, a news magazine. They were
concerned that the clinic was, in fact, providing a new sort of conversion
therapy for gay youngsters by changing children into simulacra of the
opposite sex. This was the basis of their concern.
It
might be true that the vast majority of practitioners in both the United States
and other countries are merely attempting to alleviate the genuine pain of
adolescents who are troubled by gender dysphoria. This might be the case
regardless of where in the world they practice. However, in the United States
of America in particular, the charged environment has made it exceedingly difficult
to differentiate between scientific research and political debate.
The
medical practices of European countries have not come to the conclusion that it
is always inappropriate for a teenager to transition. They are not making any
attempt to hide patients who are in distress. They have merely arrived at the
conclusion that there is a need for additional research and data before
physical treatments for gender dysphoria may become standard practice.
It is possible that additional study will result in the development of guidelines
that are comparable to those that have already been adopted by medical
organizations in the United States. On the other hand, this is yet another way
of expressing the idea that it is hard to support the existing recommendations
about gender-affirming care on the basis of the data that is now available.
The
bottom line is this: It's as clear as the sky on a bright summer day that we
need to slow down on gender change treatments for the time being. Many people
who have gone through the process are now struggling with depression and making
the hard decision to detransition. This is a red flag that we can't ignore. Now
is the time to put a lid on this pot until we have all the facts and evidence
we need to make a well-informed choice. Let's not keep going down this bumpy
road until we know where it goes.
Notes
Académie Nationale de Médecine. (2022, February 25). Communique:
Medicine and Gender Transidentity in Children and Adolescents. Retrieved
from https://www.academie-medecine.fr/la-medecine-face-a-la-transidentite-de-genre-chez-les-enfants-et-les-adolescents/?lang=en
Allen, C. (2022, March 11). Children's Gender Services
Need Transformation - Review. Retrieved from BBC News: https://www.bbc.com/news/health-60698414
Barnes, H. (2023). Time to Think: The Inside Story of the
Collapse of the Tavistock's Gender Service for Children. London, UK: Swift
Press.
Biggs, M. (2022). The Dutch Protocol for Juvenile
Transsexuals: Origins and Evidence. Retrieved from Journal of Sex &
Marital Therapy: https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238?scroll=top&needAccess=true&role=tab&aria-labelledby=full-article
Cohen , D., & Barnes, H. (2021, April 1). Evidence for
Puberty Blockers Use Very Low, Says NICE. Retrieved from BBC Newsnight:
https://www.bbc.com/news/health-56601386
Cohen-Kettenis, P. T., Sebastiaan E. E. Schagen, S. E.,
Steensma, T. D., de Vries, A. L., & Delemarre-van de Waal , H. A. (2011).
Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up. Archives
of Sexual Behavior, 40, 843–847.
Conlin, M., Respaut, R., & Terhune, C. (2022, November
18). Youth in Transition. Retrieved from Reuters: Special Report:
https://www.reuters.com/investigates/special-report/usa-transyouth-topsurgery/
de Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar,
E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young Adult
Psychological Outcome After Puberty Suppression and Gender Reassignment. American
Academy of Pediatrics, 134(4), 696–704.
Hembree, W. C., Cohen-Kettenis , P. T., Gooren, L., Hannema,
S. E., Meyer, W. J., Murad, M. H., . . . T’Sjoen , G. G. (2017). Endocrine
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Henderson, E. (2023, February 23). Some Professionals
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from News Medical Life Sciences: https://www.news-medical.net/news/20230224/Some-professionals-disagree-on-the-treatment-for-gender-dysphoria-in-young-people.aspx
Kelleher, R. (2023, January 2). The Dutch Model is Falling
Apart. Retrieved from Genspect: https://genspect.org/the-dutch-model-is-falling-apart/
Levine , S. B., & Abbruzzese , E. (2023). Current
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Liptak, K. (2023, March 13). Biden Says Efforts to
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Respaut, R., & Terhune, C. (2022, October 6). Putting
Numbers on the Rise in Children Seeking Gender Care. Retrieved from
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The Economist. (2023, April 5). Briefing Trans
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