In yesterday’s post, I focused on the situation in the United Kingdom, where the school system is deeply enmeshed with a trans activist organization which peddles its message to kids as young as 4 years old. And the majority of posts on this blog document the seemingly unstoppable trend to diagnose and treat children as “transgender.” With this overwhelming level of societal and medical support, the issue must be pretty much settled—right?
Not according to the gender specialists themselves, it isn’t.
Hot off the presses, in the October 2015 issue of the Journal of Adolescent Health, a team of Dutch researcher-clinicians report findings from a survey of gender clinics which serve dysphoric children around the world.
Although you’d never know it, judging by the accelerating trend to socially “transition” kids as young as 3, freeze adolescents’ natural puberty with GnRh agonists, and then move on to chemical sterilization via cross-sex hormones thereafter, there is no consensus amongst gender specialists that this current treatment protocol is the way to go.
The qualitative survey, entitled “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study” was conducted by a group of well-known Dutch researchers/gender specialists who are themselves actively involved in administering puberty blockers and other treatments to “transgender” children. The authors surveyed 17 treatment teams (endocrinologists, psychologists, MDs, psychiatrists, ethicists) regarding their views and experiences.
Many of the parents who contribute to and read this blog agonize about their difficulty finding therapists and doctors critical of the I’m-trans-if-I-say-I-am paradigm. I hope this post gives some measure of hope to those parents. While the skeptical specialists (nearly all of them psychologists or psychiatrists, with most endocrinologists and pediatricians apparently submitting pro-transition comments) are quoted anonymously, at least we know they’re out there. And enough of them exist to tell us that the runaway pediatric transition train may not have completely lost its brake pads—yet.
The Endocrine Society and the World Professional Association for Transgender Health published guidelines for the treatment of adolescents with gender dysphoria (GD). The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions…
Seven themes give rise to different, and even opposing, views on treatment: (1) the (non-)availability of an explanatory model for GD; (2) the nature of GD (normal variation, social construct or [mental] illness); (3) the role of physiological puberty in developing gender identity; (4) the role of comorbidity; (5) possible physical or psychological effects of (refraining from) early medical interventions; (6) child competence and decision making authority; and (7) the role of social context how GD is perceived…
As long as debate remains on these seven themes and only limited long-term data are available, there will be no consensus on treatment. Therefore, more systematic interdisciplinary and (worldwide) multicenter research is required.
Because my aim here is to show that gender specialists are not unanimously aboard the child transition bandwagon, this post will mostly highlight the comments from the more skeptical gender specialists surveyed. Amazingly (to me), the doubters seem to hit nearly all the same points I do in my blog posts. [Note: Use of boldface to emphasize certain passages is my own, not that of the authors.]
So what is gender dysphoria?
Is GD a normal variation of gender expression, a social construct, a medical disease, or a mental illness? In the DSM-5 and the to-be-released ICD-11, the main challenge in classifying GD has been to find a balance between concerns related to the stigmatization of mental disorders and the need for diagnostic categories that facilitate access to health care, payment by insurance companies, and the communication between diverse professions.
I spend a fair amount of time reading articles and social media posts authored by gender specialists. It’s quite evident that there is currently pressure to completely de-stigmatize the transgender diagnosis…yet still find a way to get the “treatment” paid for by private insurance companies (or the taxpayer via public insurance such as Medicare or Medicaid). This thread from the WPATH public Facebook page [commenter names redacted] is illustrative of the dilemma the survey authors point to in the passage above.
So, this thread seems to indicate that providers are moving away from gender dysphoria as a disorder; even as an experience which causes distress. But why then would there be a need for medical treatment? This conundrum is addressed by the 17-clinic survey authors:
The interviews and questionnaires show that most informants find it difficult to articulate their thoughts about this aspect. Most see GD as neither a disease nor a social construct, but as a normal, but less frequent variation of gender expression. However, some note that you would not need medical procedures to make the lives of people with GD more satisfying if it were merely a normal variation.
Another thread from the WPATH public Facebook page seems to justify transition services for someone who just wants a “joyful and loving life.”
But when it comes to young people, at least one psychiatrist in the survey study gives us a less sanguine view of such quality-of-life justifications for medical transition:
“I find it extremely dangerous to let an adolescent undergo a medical treatment without the existence of a pathophysiology and I consider it just a medical experimentation that does not justify the risk to which adolescents are exposed. Gender dysphoria is the only situation in which medical intervention does not cure a sick body, but healthy organs are mutilated in the process of adapting physical and congruent psychological identity.” –Psychiatrist
I feel certain at least a few of the parents who frequent this blog wish they had the office phone number for this reasonable clinician. Amirite?
On the wisdom of puberty blockers
How many of us have asked, “but what if puberty blockers also inhibit the psychological/neurological maturation that comes with puberty–and beyond?” And, because many kids actually outgrow their gender dysphoria, interrupting puberty would deny them the opportunity to become comfortable in their bodies and avoid a life as a permanent medical patient.
It’s a pleasant surprise to see an acknowledgement of some of these concerns here:
In the literature, the concern is raised that interrupting the development of secondary sex characteristics may disrupt the development of a gender identity during puberty that is congruent with the assigned gender. The interviews and questionnaires show that some treatment teams share this view.
One clinician even talks about lesbian women who would have been misdiagnosed as “trans” children in an earlier time.
“I have met gay women who identify as women who would certainly have been diagnosed gender dysphoric as children but who, throughout adolescence, came to accept themselves. This might not have happened on puberty blockers.”–Psychologist
So at least one psychologist who works on a pediatric transition team acknowledges what many, formerly gender dysphoric women, say: that if there had been “gender clinics” for kids in the 1950s, 60s, 70s, or 80s, they would not be happy lesbian adults today, but sterilized “trans men.”
Speaking more broadly, another therapist has this to say:
“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
On co-occurring psychological/psychiatric issues
If you read through the part of this blog where most parents congregate and introduce themselves for the first time, some common themes emerge. One is the observation by many parents that their kids have other mental health issues, nearly always predating the (sometimes sudden) announcement that they are transgender. While most activists insist that transition is the cure for what ails a dysphoric child or teen, the clinicians working in the trenches aren’t so sure.
The risk of co-occurring psychiatric problems in children and adolescents with GD is high. The percentage of children referred for GD who fulfilled DSM criteria of at least one diagnosis other than GD is 52%. The psychiatric comorbidity in adolescents with GD is 32%. Another study shows that 43% of the children and adolescents seen in a gender identity clinic suffer from major psychopathology. To date, the precise mechanisms that link GD and coexisting psychopathology are unknown.
Miscellaneous physical and psychological risks of medical transition
The surveyed clinicians acknowledge many of the concerns discussed regularly on this blog.
The possible consequences of suppressing puberty for cognitive and brain development are unclear and debated at this moment. The normal pubertal increase in bone mineral density may be attenuated by puberty suppression, and it is uncertain if there is complete catch-up after treatment with cross-sex hormones.
While it only merits one sentence (and no direct quotes), the surveyed clinicians appear to view sterilization as an important concern:
In the interviews and questionnaires, the loss of fertility was often mentioned as a major consequence of treatment.
And here’s an additional worry I haven’t seen in writing before: the potential negative impact of puberty blockers on future SRS surgery.
In addition, various informants stressed the importance of the fact that the penis and scrotum should be developed enough to be able to use this tissue to create a vagina later in life. Very early use of puberty suppression impairs penile growth and consequently makes certain surgical techniques impossible.
Will we see this rather thorny issue discussed on an episode of the Jazz Jennings reality show? Will the Tumblr trans activists screaming “now or never” take heed?
On whether kids are mature enough to make these decisions
One informant stated that the decision whether to start with hormones should only be made during adulthood: “We should facilitate his or her process of integration in the society and if he or she would undergo hormone- and surgical treatments he or she could decide [on this] during adulthood.” —Psychiatrist
Influence of the Internet and social media
You know how trans activists scoff at our observations that our kids only started talking about “transition” after binging on YouTube and Reddit?
They speculated that television shows and information on the Internet may have a negative effect and, for example, lead to medicalization of gender-variant behavior.
“They [adolescents] 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 [gender dysphoria] explains all their problems and now they have to be made a boy. I think these kinds of adolescents also take the idea from the media. But of course you cannot prevent this in the current area of free information spreading.” –Psychiatrist
Hello? The Advocate? The Boston Globe? The Washington Post? Anybody?
Furthermore, interviews and questionnaires show that treatment teams feel pressure from parents and adolescents to start with treatment at earlier ages.
Puberty suppression has been adopted as part of the treatment protocol by increasing numbers of originally reluctant treatment teams. More and more treatment teams embrace the Dutch protocol but with a feeling of unease…these professionals also have doubts because of the lack of long-term physical and psychological outcomes.
Hey, journalists. Obscure blogger over here quoting actual gender specialists, so you can’t say it’s just a bunch of nervous Nellie-moms making shit up. Need the link again? Oh, that’s just the abstract, here’s the pre-publication full-text, right here.
For several informants, a reason to use puberty suppression was the fear of increased suicidality in untreated adolescents with GD. Research shows that transgender youth are at higher risk of suicidal ideation and suicidal attempts. Nevertheless, caution is needed when interpreting these data because they do not show causality or directionality.
The meaning of that last sentence is crystal clear, and entirely in accord with what I, and other critics of the harmful “transition or suicide” meme that adult trans activists continually propagate, have tried to point out. While no one disputes that there is a higher self-harm and suicidality rate amongst trans-identified young people, there is no evidence that such self-harming behaviors and thoughts are ultimately alleviated by “transition.” Further, as this sentence implies, the “directionality” could be the reverse of what trans activists promote. Having a trans identity and/or facing the monumental prospect of medical transition could be a cause of self harming (in addition to the preexisting or comorbid mental health issues so many of these young people seem to have).
This is not the moment for another flippant call for journalists to take heed. This is deadly serious business: the terrible toll of self harm and suicide among trans-identified youth. I have not seen a single news treatment of suicide or suicide risk that has even hinted at what these clinicians are stating baldly. Isn’t it time for a more nuanced discussion?
And finally: Leave it to a medical ethicist to point out the huge logical fallacy in the “informed consent” model of treatment now running rampant:
“The fact that somebody wants something badly, does not mean that a health care provider should do it for that reason; a medical doctor is not a candy seller.”— Professor of health care ethics and health law
Imminently sensible. So how is it that “informed consent” and the demonization of “gatekeepers” is more and more the norm? How is it that self identification as trans, even for young children, is fast becoming the only requirement for obtaining treatment? There is something strange going on here. If even some experienced gender specialists are expressing doubts, why does the media behave as if the issue has been settled?
“The positive attitude of many health care providers in giving hypothalamic blockers…is based on the need to conform to international standards, even if they are conscious of a lack of information about medium and long term side effects.” –Psychiatrist
But how can there be “standards” (they are talking about WPATH here) that these providers feel pressure to conform to, if the standards are not based on solid information about risks and benefits? Exactly which cart is pulling this runaway horse?
As still little is known about the etiology of GD and long-term treatment consequences in children and adolescents, there is great need for more systematic interdisciplinary and (worldwide) multicenter research and debate.
Reason for hope?
The article concludes in a way that makes me feel a whisper of hope for the future.
Several professionals mentioned that participation in the study made them think more explicitly about the various themes, and it encouraged them to discuss the issues in their teams. In the Dutch teams, we therefore introduced moral deliberation sessions to talk about these ethical topics. The first reactions of the professionals were positive; the sessions made them rethink essential aspects of the protocol.
Will this “moral deliberation” and “rethinking” result in more caution, or even a desire to put a halt to the pediatric transition train? Time will tell, but it is encouraging that at least the Dutch researchers may be losing some sleep in pondering the incredible power they wield over the lives of children and their families.
At least we know there is controversy. At least we know they are not all marching in lockstep.
And that is something.