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
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Allen, C. (2022, March 11). Children's Gender Services
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