Tag Archives: puberty blockers

The trans-kid honeymoon is sweet—while it lasts

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I recently received comments from two readers (here and here) regarding a 2014 Dutch survey study of 55 young transgender adults (average age 20). The study, which reported overall positive psychological outcomes after medical transition, surveyed youth who had been diagnosed with gender dysphoria, after which they had received puberty blockers, then cross-sex hormone treatments, and finally SRS surgery. The average length of time from first pre-treatment assessment to post-surgery was 6 years.

RESULTS:
After gender reassignment, in young adulthood, the GD was
alleviated and psychological functioning had steadily improved. Well-
being was similar to or better than same-age young adults from
the general population. Improvements in psychological functioning

were positively correlated with postsurgical subjective well-being.

These findings would likely reassure parents and others who have ushered children down the medical transition road. And frankly, anyone who has watched even a few YouTube teen transition vlogs would not find these results particularly surprising. For these kids, it must be an exhilarating experience, to feel they can escape their dissatisfaction with sex-role stereotypes and/or physical characteristics, and embark upon the long-awaited transformation into the opposite sex.  The speed with which the metamorphosis happens—with many young people “passing” as the opposite sex after only a few months of hormone treatment–is  downright magical.

No doubt, at least some of these people will go on to live happy, long lives with no regrets. But it’s likely some will begin to question (at what age? 30? 40? 50? 60?) whether giving up their fertility; permanently altering their bodies; and facing a lifelong regimen of injections and medical monitoring were ultimately worth the price.

Here is one young woman who has begun to raise a few questions. In a recent video entitled “Gender Troubles” (uploaded 6 years after she first decided to “transition,” and after 4 years of videos on her channel that mostly celebrated that choice), she acknowledges what she values about her “transition,” while sharing her realization that things are not quite as simple as they originally seemed to her younger self:

 When I decided to go on hormones…it seemed like the most logical choice for me. I was in a very bad place emotionally…I hated myself a lot. I hated my body. I didn’t identify with it….and I felt very separate from my body. And finding YouTube videos of other people who were transitioning and finding out it was an option to do so kind of deeply affected me. It was very difficult to resist those changes….to resist taking hormones, to see those changes in myself, especially because feeling so disconnected from myself it seemed like the best idea….and you don’t often see other narratives out there, on YouTube, about gender…

…. I struggled with the changes, how I felt about them, how it made me feel and why. At first I accepted them. It was exciting. It was euphoric. It was certainly a ride. And I really liked seeing myself with more muscle, I liked my voice deepening, the hair that was growing…

… My parents were really cool with it. They were not cool with me being a lesbian at all…. [now] they didn’t have to say “I have a lesbian daughter. I have a son who’s straight”….My family was supportive of my transition, so we became a lot closer because of that…

…As time went on, I really felt like…I didn’t identify with the changes I was seeing…I didn’t like the fact that these changes weren’t natural. Part of it felt like I was burying a piece of myself…

…The other night, I cried, because I realized I really want to be able to get pregnant. And I really want to be able to breastfeed. … Maybe it’s me getting older, the internal clock…ultimately I don’t regret getting top surgery…but there are elements where I miss having them….only about 15% of the time. But I can’t deny that this happens…

…There’s a lot more that happens besides achieving a male body or a more masculine body….a lot of things change and you don’t realize it. I don’t think I realized it as much until  …  a year or two off hormones. Things started kind of affecting me…

…When I was transitioning I was really caught up in the thrill of it, the excitement of it, the endorphins that went along with it…[but now]  I’ve been thinking about things I wasn’t before.

Transition regret videos aside, even if we restrict our focus to the 55 subjects in the Dutch research study cited above–young people who (so far) are reporting largely positive benefits from their transition–there is more nuance to this study than first meets the eye. 4thWaveNow contributor fightingunreality delves into some of the study’s unexamined implications in the post below.

As you read fightingunreality’s analysis, consider whether survey studies like this one might be subject to the  “interpersonal expectancy ” of researchers and “supportive” parents. The interpersonal expectancy effect is also known as self-fulfilling prophecy, or the Pygmalian effect, extensively studied by preeminent psychological researcher Robert Rosenthal:

 …the tendency for experimenters to obtain results they expect, not simply because they have correctly anticipated nature’s response, but rather because they have helped to shape that response through their expectations. When behavioral researchers expect certain results from their human or animal subjects, they appear unwittingly to treat them in such a way as to increase the probability that they will respond as expected…

In more recent years….research has been extended from experiments, to teachers, employers, and therapists whose expectations for their…patients might also come to serve as interpersonal self-fulfilling prophecies.

Analysis of the 2014 Dutch study (available in full at the link, and introduced above),

by fightingunreality

Any discussion of the “outcomes” for those children chosen for the experimental use of puberty-blocking drugs would be remiss without first addressing the ethics of what has been done.

First, this study is about young people, many of whom initially presented to the clinic as prepubescent children. Children’s understanding of gender is primarily comprised of the simplistic social stereotypes through which they have learned to perceive the meaning of biological sex, and which they lack the certainty of identity to resist. Developmentally unable to fully comprehend abstract concepts, they have little understanding of the social forces which inform and compel both them and the adults to behave in certain manners deemed to be “appropriate” on the basis of sex. The vast majority of these children were socially transitioned by their parents prior to their arrival at the clinic, thereby disrupting the chance that they may have had to experience a typical childhood.

hormone graph 2

Because 85% of the fathers and 95% of the mothers were supportive of their children’s desire to live as the other gender, and since virtually all of the children were living for all intents and purposes as socially transitioned, we can assume, with little doubt, that these parents subscribed to the idea of sex-based gender roles for their children akin to those we have seen in the plethora of news stories of (mostly) moms citing wrong toys and early color preferences as indications that their children were different.

Since none of these child-transition studies (this Dutch study being no exception) report the extent to which parents enforce traditional gender roles, we have no real sense of the degree of their influence on these children or how much they might affect the kids’ willingness to defy them in order to express their non-traditional likes and dislikes– without the expressed belief that they are in fact, a different sex. Is it only a coincidence that 94% of the males in this study were either same-sex attracted or bisexual (87.9% SSA, 6.1% BI) or that 100% of the females (89.2 SSA, 10.8% BI) had same sex attractions? Are we really expected to believe that social and parental attitudes in regards to homosexuality play no part in either the formation of the children’s understandings of what constitutes “feeling like the other sex,” or, more importantly, the acceptability to parents of what, in effect, becomes medicalized gay conversion therapy?

Since the stated protocol by these researchers is to provide a six-months to a year “diagnostic phase,” this means that prior to the first assessment for this particular study, they had already been living as cross-gendered for at least that amount of time, plus the previously acknowledged but unspecified duration of social transition. During the actual diagnostic phase, all of them “officially transitioned” –including name changes. Since the youngest, at the time just prior to the administration of hormone blockers, was 11.1 years old, that means this child had been living cross-gendered since a minimum age of 10.6 years old –in addition to the time prior to arriving at the clinic. What can such a child actually know about what it means to live as his or her own natal sex?

Given the willingness, as noted in the study, of peers and parents to promote and solidify by reinforcement these children’s sense of being wrong-bodied, it is hard to see how such children could establish a basis by which they could reasonably fully comprehend–let alone reevaluate–their child-based understanding of gender and gender roles. As has been noted in previous posts on this blog, identity formation throughout childhood and adolescence is both malleable and fluid. It is impossible to believe that the interventions by both the parents and the clinicians did not directly interfere with these children’s identity development. How does a child who has basically reordered their family’s lives by their insistence that they are actually the other sex back down from such claims? How do they tell their friends? We are not talking about adults, here, after all. By the time these children reached the point of choosing to delay their puberty, they had been living as the other gender for years –in some instances possibly half of their young lives. By the time it came to choose whether or not to imbibe cross-sex hormones, it is no surprise that none of these children chose to revert to living as their own sex: they had been socialized trans.

It’s interesting to note from the information in this paper that during the time between starting hormone blockers and their choice to be put on cross-sex hormones, these kids –especially the girls –actually experienced greater levels of “gender dysphoria.” I think it’s important to ask ourselves why that is. These kids were not facing the risk of further development of secondary sexual characteristics. They were living as their chosen gender. Why wouldn’t they be at least somewhat relieved of their dysphoria? Since levels of such dysphoria consist of self-assessment, this worsening could merely reflect the child’s desire to fully transition along with the knowledge that admitting a decreasing level of dysphoria might threaten the willingness of the clinicians to advance their transitions. That is one possibility. The other more likely possibility is that living as fully socially transitioned children, their awareness of not physically “matching” their chosen gender while assuming that role actually worsens the sense of being wrong-bodied. In other words, telling someone that you are actually a boy or a girl when you clearly are not increases self-awareness of and discomfort with your actual sex.

As was articulated in a BBC documentary by a gay Iranian who was pressured into transition, prior to transitioning he often heard, “He’s so girly. He’s so feminine.” After the surgery, whenever [he] wanted to feel like a woman or behave like a woman, everybody would say “look, she’s like a man. She’s manly.” This phenomenon can readily be applied to children who may have been considered like the other sex prior to living akin to that sex, but become seemingly less like the other sex when attempting to assume that role. The very fact that they are attempting to live as the other gender may very well increase the dysphoria that assuming such a role is meant to lessen. Is it a wonder that 100% of the children that comprised this cohort chose to go on to cross-sex hormones?

The gender specialists promoting these studies want us to believe that the use of hormone blockers provides extra time without the stressful development of secondary sexual characteristics. They’d like us to believe that the children are being given a sort of “time-out” to consider their choices and become more mature before committing to irreversible changes, but is that really the case? The hormones required for adolescent brain reorganization and development are not released when a child has received GnRh agonists. Physical development typical for teenagers is prevented, setting the children even farther apart from their peers, and sexual and romantic involvements –a key factor in desistance –are avoided.

Ultimately, 100% of the children who chose to utilize hormone blockers in this study went on to fully transition. In fact, virtually all children inducted for such therapy demonstrate 100% persistence rates despite that fact that even today, major proponents of this therapy (such as Johanna Olson-Kennedy and Robert Garofalo, in their 2016 paper detailing research priorities on gender identity development and biopsychosocial outcomes) acknowledge that “Clinically useful information for predicting individual psychosexual development pathways is lacking.” They do not have reliable information on who will or will not desist. Are we really expected to believe that these hormone blocker advocates are exceptionally lucky in their selection process when they themselves profess such uncertainty and bemoan the lack of adequate research? Or should such absolute rates of persistence be setting off alarm bells to those of us concerned with the practice of funneling children into a pipeline that flows in only one direction: towards lifelong medicalization with unknown long-term consequences?

Because of the extraordinary persistence rates of children infused with hormone blockers, it’s obvious that hormone blockers do not allow these children extra time. The choice to participate in this protocol becomes the decision to transition, because it prevents the aspects of maturation necessary for desistance from ever occurring. The one thing it does do, however, is to make it seem safer to interfere with the children’s natural course of development. Parents are assured that the effects of blockers are reversible, and the moral burden of placing young children in the position of making adult decisions is put aside.   As a result, even more children are being swept up by this 21st century version of reparative therapy. Altogether, we will never know the number of children who would have desisted had they been allowed to develop without social and medical intervention. This is a travesty.

As far as the “positive outcomes” this study purports, there are numerous problems. First, in order to understand this study, we must consider the selection process detailed in a previous paper by the same authors.  The 70 children chosen for this study were selected from an original cohort of 111 (out of 196 children arriving at the UV hospital seeking treatment for GD) eligible for hormone blockers, after having been “thoroughly screened after a comprehensive psychological evaluation with many sessions over a longer period of time” and found “eligible for puberty suppression and cross-sex hormones.” It was a group chosen on the basis of their likelihood of coping with the transition process. They had “no psychosocial problems interfering with assessment or treatment,” and “adequate” (in the case of this cohort, very high) “family or other support,” and what the researchers described as “good comprehension of the impact of medical interventions.” (We can only guess what that could mean, given the fact that pre-adolescents and adolescents do not have the frontal lobe development to fully project themselves into the future.) Altogether, they seem very unlike the average children and adolescents who are currently being inducted into this process of life-long medicalization either in regard to screening or support and ongoing therapy, which the study notes was provided to them for an average of 6 years “after first presenting at the clinic.”

Fifteen of the cohort of 55 had “some missing data” which we are assured resulted in “no significant differences” on the pre-treatment tests.   I think, too, that when considering the outcomes of these children, it would be remiss to ignore the 15 members of the original cohort of 70 who did not participate in follow up: six had not met the one year gender reassignment surgery anniversary for this study and were, therefore, excluded. Two refused to complete the assessment, and two did not return their questionnaires. (Why?) Three had health problems which prevented them from undergoing gender reassignment surgery, one “dropped out of care” (no clarification) and 1 died from complications from surgery. (How does one weigh such a loss against “positive outcomes?”)

Given the fact that all of these children had what is in essence a “gender obsession” since childhood and had been socially transitioned for years, it comes as no surprise that they experienced relief at finally accomplishing their goals. The kids as a whole did overall demonstrate better functioning than at their initial assessment –possibly from the counselling and special attention they were getting –but “it cannot be ruled out that it relates instead or as well to the benefits that accrue from being validated and accepted for treatment.” They were getting what they wanted, after all. Research has shown that gender non-conforming children and adolescents are at higher risk for PTSD due to abuse and bullying because of being different, and the prospect of “fitting in” provided by merely initiating action towards this goal certainly provides a degree of psychological relief- regardless of the actual physical changes that have yet to take place. This is evidenced by the “significant quadratic effect” that commences immediately upon initiation of cross-sex hormones, well before significant physiological effects of the hormones could possibly have occurred.

Would body image and psychological well-being have improved in these children had they been allowed to experience a natural childhood and identity formation without medical intervention? It is well known in the field of child development that children go through a period of significant peer gender enforcement which corresponds with their concrete thinking and familial socialization which certainly affects the self-image of those who fail to conform. This rigidity begins to relax at around 8 to 10 years –after some of the children in this study have already been socially transitioned due to the discomfort this rigidity has created. Would they have come to a more nuanced understanding of gender roles had they made it past this stage? We –and they –will never know. Logically, children have been shown to be more accepted by members of the sex with which they share interests, rather than those whose similarities are based solely on sex, and gender enforcement prior to adolescence tends to be enacted by members of the same sex. Is it any wonder that children tend to “identify” with those who seemingly accept them and share common interests? Would a more mature understanding of abstract concepts assist them in accepting their own bodies without conforming to artificial gender roles as it did for many of us who matured without the alluring possibility of appearing to actually change sex?

As adolescence progresses, criticism is most likely directed by male peers who are not known for impulse control or empathy. Certainly those of us who have been on the receiving end of such mockery can attest to the resulting social stigma and humiliations we suffered in light of it due to our vulnerability at that age and the fact that we were insecure in our own identities and lacking the self-assurance that maturity brings. It has been demonstrated that peer and social disapproval for gender non-conformity peaks in the adolescent years and gradually decreases throughout young adulthood and adulthood. Not only do we mature, but the peers responsible for the harassment mature, as well. The insults decrease. As gay rights activists in the past often said, in an attempt to help bullied gay and lesbian children, “it really does get better.”

Unfortunately, none of the children in this study will ever know whether this would have been the case for them, because they left behind in childhood the bodies which they very well may have come to accept in the absence of such criticism. In a study in which there is no viable way to create a control group with which to compare these children, there’s no way of knowing how well they would have fared with just the extensive psychotherapy alone, nor of desistance which may have taken place without these prolonged social and medical interventions which prevented the maturation and social and sexual experience that would have occurred otherwise.

As a gender non-conforming adult, I am occasionally harassed by what are typically groups of two or three teen boys out to impress their friends. Because I am an adult with a fully-formed sense of self, my identity is not threatened as are those of the children who have not yet discovered, through experience and physical development, who they really are or can be. Sadly, the ultimate result of medicalized disruption of identity formation –which would have included their whole selves, bodies included –creates an identity which is dependent upon exogenous substances, conscious gendered performance, and the willingness of others to deny their own perception in order to validate it. As such, the identity is not sustainable without significant degrees of external support, and remains more highly vulnerable to what are perceived as being threats to self when it is not validated.   As a result, they may be “at increased risk for the development of narcissistic disorders…as a consequence of the inevitable difficulties they face in having their cross-gender feelings and identities affirmed by others.” (Note: While the linked study is not specifically of children, it seems to me children subjected to early medical transition would also be at some risk of narcissism, given the confluence of factors brought to bear upon them.)

Perhaps the greatest hindrance to accurately critiquing this study is related to the ages and the timing of this so-called “long-term” study: it was completed after only a minimum of one year after gender reassignment surgery. These now young adults had barely any life-experience living as fully transitioned persons. They were still in the honeymoon phase of what had become a fully supported childhood desire. A significant portion of them were still living at home with their supportive parents and attending school. Their lives as fully transitioned adults were just beginning, and the difficulties of navigating sexual relationships and the hardships that entails for those not of their natal sex were in their infancy. They were many years away from the rise in suicidality noted in a Swedish long-term study of adult transgendered persons, which began to rise around 8-10 years after transition.

Because of the failure of the Dutch authors to denote significant variables among these youths (as I’ve outlined in this post), their study inspires more questions than it provides answers.   Have these children been harmed by the parental and medical reification of childhood fantasy and desire? We have primarily their own self-reports to rely on –the reports of young adults who never were given the opportunity to experience childhood or adolescence as one would experience their own actual sex. They have nothing with which they can compare their current experienced “gender.” They will not know what it’s like to have sex in their natural bodies, nor be loved as such. Certainly, as partially formed adults (remember- maturation takes place concurrently with hormonal action and resulting brain development and theirs was delayed), they had not reached fully adult status at the time of their self-assessment. We do not know how the difficulties of living as transgendered people will affect them. We do not know if the long-term effects of injecting artificial cross-sex hormones will damage them physically (or mentally). We will never know whether they might have resolved their gender dysphoria, as others have, and pressed on through life, because they were never given the chance to find out.

Their childhood fantasies were to become a different sex. What they have been given, instead, is the means of promoting that illusion—and the reality of becoming a life-long medical patient.

 

Blocking puberty–and the right to an identity crisis

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I recently wrote about research findings that gay and lesbian youth are typically older than their heterosexual counterparts when they first act upon and realize their sexual orientation. While same-sex attracted girls, in particular, reach this milestone between 19-early 20s, the current trend is to “socially transition,” then puberty block, and finally move on to cross sex hormones at age 16.

It’s easy to see that many of these teens are being set up to short-circuit the natural discovery of their sexual orientation. But is that the only potential problem with social transition and puberty blocking—the preemptive conversion of likely gay and lesbian youth to transgender?

Not by a longshot. There are so many important things that happen at puberty which are critically important to the maturation necessary to make informed decisions about major life changes (you know–things like sterility, loss of breasts, and a permanently deepened voice) that a developmental psychologist or cognitive scientist could write a doctoral dissertation about the subject.

In fact, many have; the research and clinical literature going back to the mid-20th century is chock-a-block with replicated studies, clinical observations, and meta-analyses. More recently, we have MRI and fMRI studies corroborating earlier observations.

What we don’t have, at least not yet, are the PhD theses showing how the experimental “treatments” currently being implemented by pediatric endocrinologists and gender specialists—many of whom have no professional background in child or adolescent psychology—fly in the face of that large body of literature.

I have spent hundreds of hours poring over the literature on gender dysphoria and pediatric transition. But in all the studies and papers I’ve read, I have not seen mention of the vast body of extant knowledge about child and adolescent psychology. It’s as if these gender specialists just started from scratch.

Erik-Erikson-portrait

Erik Erikson

What exactly are they ignoring? Well, for starters, there’s the work of Erik Erikson, a preeminent child and adolescent psychology expert of the 20th century. You can’t read the scholarly or clinical literature on pediatric psychology without finding a reference to Erikson’s work; in fact, much of the current knowledge in the field is built upon his fundamental insights. A blog post is not adequate to even summarize it, but his bedrock finding about the psychological journey of adolescence is this: Developing an identity takes place in stages, culminating in an integrated adult personality; and “identity work”—including an identity crisis—is critical to healthy adult psychological functioning.

erikson capAdolescent psychology expert James Marcia was another foundational thinker who built upon Erikson’s framework:

… two distinct parts form an adolescent’s identity: crisis (i.e., a time when one’s values and choices are being reevaluated) and commitment. He defined a crisis as a time of upheaval where old values or choices are being reexamined. The end outcome of a crisis leads to a commitment made to a certain role or value.

But we don’t need a study, a theory, or someone with a PhD after their name to prove this to us, do we? Any adult who has lived through that time of life called “adolescence” can attest to the fact that questioning, and trying on and discarding different ways of being, go with the territory. And it’s a rough time. How many adults would willingly relive the fraught and tumultuous days of middle and high school? Every psychologist (until the Age of the Trans Child) has agreed: it’s not supposed to be an easy ride. In fact, without the essential but painful work of adolescence, a person will not reach their adult potential: “unable to achieve an integrated adult identity, either because they have failed to resolve the identity crisis or because they have experienced no crisis. ”

Contrast this long-accepted understanding of adolescence with the approach taken by today’s gender specialists. Instead of helping children weather the natural and not necessarily comfortable process of cognitive and emotional development, they concretize and freeze in place the certainties of childhood, in what should be a time for exploration, not stasis.

It would be one thing if these gender clinics were really in the business of helping a child expand or explore different gender identities, without medical interference. But we know that they support and encourage “transition” from one sex to the other, with all the permanent physical changes that entails. In terms of adolescent psychological development, once these kids have taken the irrevocable step of moving from blockers to cross sex hormones, they have been denied the opportunity to go through an identity crisis.  So, a 16-year-old girl who has lost her fertility and her breasts, and who has already committed to a permanent testosterone-deepened voice and increased body hair — how easy will it be for her to experience James Marcia’s “time of upheaval where old values or choices are being reexamined?” That adolescent girl has been cheated of that stage of life. And when did we, as a society, decide that was a good thing?

The media stories and anecdotes from gender clinics are all the same: The kids are uncomfortable, so they and their parents seek relief. Then, according to everyone, the treatment “works” because the kids are happy. For how long? No one knows.

Be that as it may, an identity crisis isn’t supposed to be resolved in preschool, or kindergarten, or even middle or high school: It is the work and the challenge of adolescence, not complete until late adolescence.

 Adolescence has long been characterized as a time when individuals begin to explore and examine psychological characteristics of the self in order to discover who they really are, and how they fit in the social world in which they live. Especially since Erikson’s (1968) theory of the adolescent identity crisis was introduced, scholars have viewed adolescence as a time of self-exploration. In general, research has supported Erikson’s model, with one important exception: the timetable. It now appears that, at least in contemporary society, the bulk of identity “work” occurs late in adolescence, and perhaps not even until young adulthood.

“Late in adolescence”—after the time when most “trans” youth have moved on from puberty blockers to cross-sex hormones, thus bypassing the period when they would have been able to explore possibilities in their original bodies—including, but not limited to, their sexual orientation and other essential aspects of their identities and personalities.

The insights of the earlier child development experts have been corroborated by advanced visualization technologies, such as MRI and fMRI, which have revolutionized our understanding of the human brain and psychological development. In recent years, we have come to understand that full maturation occurs much later than previously thought.

Recent research has shown that human brain circuitry is not mature until the early 20s (some would add, “if ever”). Among the last connections to be fully established are the links between the prefrontal cortex, seat of judgment and problem-solving, and the emotional centers in the limbic system, especially the amygdala. These links are critical for emotional learning and high-level self-regulation.

Beginning at puberty, the brain is reshaped. Neurons (gray matter) and synapses (junctions between neurons) proliferate in the cerebral cortex and are then gradually pruned throughout adolescence. Eventually, more than 40% of all synapses are eliminated, largely in the frontal lobes. Meanwhile, the white insulating coat of myelin on the axons that carry signals between nerve cells continues to accumulate, gradually improving the precision and efficiency of neuronal communication — a process not completed until the early 20s.

In addition to reading research studies, I spend a fair bit of time reading the blogs, tweets, and social media writings of trans-identified teens. While most teens are pretty self-absorbed, with these kids, I am always struck by the depth of self-involvement, the extreme obsession with looks and appearance, and the constant focus on getting what they want, when they want it.

What is conspicuously absent in the narratives of many of these teens is another key aspect of pubertal maturation: self reflection and awareness. Concrete, literalist thinking is a hallmark of childhood. So a preadolescent frozen at Tanner Stage 2 of pubertal development (when blockers normally begin to be administered) may still think literally and concretely: “I am a boy.” Instead of: “Maybe I think I’m a boy because I like trucks and hate girly clothes. Maybe there’s a reason I think I’m a boy, but I’m really not.” The name for such higher level reflection, or “thinking about thinking,” is metacognition.

So when these young people, frozen at an earlier stage of cognitive development, are asked at age 15 or 16, “Are you SURE you’re really a boy?” why would any of them say “no”? And in fact, in the small number of studies that have looked at kids who have been socially transitioned and puberty blocked, none of them have failed to move on to cross sex hormones. Is this because they are “truly trans” and their clinicians have godlike diagnostic skills, with zero—zero!—false positives? Or is it because the very act of endorsing and reifying their self-proclaimed concretized self-images has helped them persist in those self-perceptions?

 No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment.

It’s not just metacognitive and abstract thinking that develops slowly, reaching fruition in late adolescence. As I wrote about in this post, executive function—the ability to make decisions, plan, and think of future consequences (like, “do I want to have children of my own, ever”?) doesn’t begin to consolidate until the mid-20s.

Then there’s social maturity and a more nuanced understanding of how to interact with one’s peers. Who doesn’t remember the awkwardness, the trying-to-fit-in, seasick self-consciousness of adolescence? Social development takes place in concert with one’s peers, along with the slow dawning of self-reflection. A socially transitioned, puberty-blocked 14-year-old who has avoided the rigors of hormone-fueled social issues won’t  understand any of this.  How will that lack of experience inform their decision to continue on to cross sex hormones?

 We previously investigated how the ability to understand social emotional scenarios using mixed emotions varied across puberty in girls aged 9–16 (Burnett et al., 2011). There was a change between early and late puberty in the number of emotional responses that participants gave in social emotion scenarios, with girls in late puberty attributing a wider combination of emotions in social scenarios than their peers in early puberty

… Our findings of puberty-related changes in neural activation, together with those shown in other recent fMRI studies using different ‘social’ tasks as described in the introduction, suggest that aspects of functional brain development in adolescence, like these behavioral changes, may be more closely linked to the physical and hormonal changes of puberty than chronological age.

 As the authors note, social intelligence—a more nuanced understanding of “social emotion” scenarios—develops as a result of the release of hormones, not chronological age. This is so obvious it hardly seems worth studying (or proving on a functional MRI study).  Yet gender specialists talk as if the brain develops separately from the body; as if hormones are only important for secondary sexual characteristics. They are constantly reassuring skeptics that blocking puberty gives these incredibly immature kids the time to figure out if this is really what they want—without the benefit of the cognitive, emotional, and social maturation processes that comes with the secretion of pubertal hormones.

I’ve touched upon only a few facets of adolescent cognitive-emotional development in this post. The literature in this area is vast, still accumulating, and spans decades and millions of pages of writing. Contemporary cognitive scientists like Russell Viner, Sarah-Jayne Blakemore and Jay Giedd are continuing to add to the body of knowledge. But their work on adolescent psychology and brain development is not referenced in the media or in the writings of trans activists or pediatric gender specialists. In point of fact, what little peer-reviewed research there is in the field of “gender identity” is going in the exact opposite direction of the rest of developmental psychology and cognitive science—towards a reification of rigid, unchanging identity and decision-making “agency” for younger and younger children; while the replicated research of developmental psychology and neuroscience is moving toward an understanding of neuroplasticity, the necessity of undergoing an identity crisis, and a later age for brain maturation than was previously thought.

Cognitive scientist Jay Giedd:

One of the most exciting discoveries from recent neuroscience research is how incredibly plastic the human brain is. For a long time, we used to think that the brain, because it’s already 95 percent of adult size by age six, things were largely set in place early in life. … [There was the] saying. “Give me your child, and by the age of five, I can make him a priest or a thief or a scholar.”

[There was] this notion that things were largely set at fairly early ages. And now we realize that isn’t true; that even throughout childhood and even the teen years, there’s enormous capacity for change. We think that this capacity for change is very empowering for teens. …

Instead of respecting this “enormous capacity for change,” gender specialists are tampering with the endocrine system, freezing gender dysphoric children in a state of suspended development—and then expecting these psychologically and emotionally immature children to make permanent decisions about their future as adults. It’s a huge clinical gamble. What it amounts to is hoping for the best.

But is anyone preparing for the worst?

Skeptical ethicist: “A medical doctor is not a candy seller”

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candy seller

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 journal article can be read in its entirety here, and the abstract summarizes the key findings:

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…

CONCLUSIONS:

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.

wpath gender incongruence

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.”

wpath joyful 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.

Self-harm/suicidal ideation

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.