Our aim is to promote safe, compassionate, ethical and evidence-informed healthcare for children, adolescents, and young adults with gender dysphoria.

Historically, the small numbers of children presenting with gender dysphoria were primarily prepubescent males. In recent years, there has been a sharp increase in referrals of adolescent females to gender clinics. Many do not have a significant history of childhood gender dysphoria and a number suffer from comorbid mental health issues and neurodevelopmental conditions such as autism (ASD) and Attention-Deficit/Hyperactivity Disorder (ADHD). The reasons for these changes are understudied and remain poorly understood.

Childhood-onset gender dysphoria has been shown to have a high rate of natural resolution, with 61-98% of children reidentifying with their biological sex during puberty. No studies to date have evaluated the natural course and rate of gender dysphoria resolution among the novel cohort presenting with adolescent-onset gender dysphoria.

de Graaf NM, Giovanardi G, Zitz C, Carmichael P. Sex ratio in children and adolescents referred to the gender identity development service in the UK (2009-2016). Arch Sex Behav. 2018;47(5):1301-1304.

Benefits, Harms and Uncertainties of the Gender-Affirmative Treatment

Until recent years, medical interventions to achieve the appearance of the desired sex, known as the "gender-affirmative" model, have been reserved primarily for adults with long histories of dysphoria. However, in Western Europe, North America, and Australia, hormonal and surgical interventions are increasingly becoming the first line of treatment for adolescents and young adults with gender dysphoria, including those with relatively recent onset.

In the past, medical interventions were preceded by a prolonged engagement with the patient, including ongoing psychological assessment. Now there has been a shift to a more automatic "affirmation" of the individual's view of themselves as transgender. As such, the provision of medical intervention now happens with a much-reduced psychological assessment.

The Dutch Protocol: the Basis of the Gender-Affirmative Treatment

In recommending the "gender-affirmative" model of care, the Endocrine Society cites a a single observational study of 55 Dutch young people whose gender dysphoria manifested in childhood and had not resolved by early adolescence. The participants were treated with puberty blockers, cross-sex hormones, and surgeries. Using a "before and after" study design that lacked a control group, the authors concluded that these medical interventions were successful, on the basis of participant scores on measures of psychological functioning one year after surgery.

A number of important limitations noted by the authors themselves challenge the study's applicability to the new cohort of mainly adolescent females: the small, carefully selected participant sample; the measurement of short-term psychological outcomes only; and the lack of evaluation of any physical health outcomes, despite the known risks of hormonal interventions on fertility, cardiovascular and bone health. Although hypothesis-generating, this intervention model was not followed - as would have been expected - by formal testing.

Gender-Affirmative Care: Further scaling of the Dutch Protocol

Despite the significant limitations of the research, the Dutch study is used to justify medical intervention - but to a new population of adolescents with recent-onset gender dysphoria, and with untested adaptations to the research protocol. All participants in the Dutch study received extensive psychological evaluations and support prior to the initiation of medical interventions. In contrast, psychological evaluations are now abbreviated to a few sessions, and are frequently bypassed altogether in the US and Canada. The Dutch protocol explicitly discouraged early social transition, recognizing that the majority of gender dysphoric children do re-identify with their sex, and that the minority of "persisters" benefit from a firm grasp of biological reality as they embark on highly invasive surgeries and lifelong dependence on hormonal treatments. Again, this contrasts with present "gender affirmative" model, which requires that the young person be "affirmed" as already being - rather than wishing to be - another sex.

Arguably, the lack of good research for young adults receiving medical interventions is even more problematic, as there are no rigorous trials of cross-sex hormones, and existing protocols are being used for the more recent largely female population. "Affirmation" - rather than an inquiring, trauma-informed psychological assessment with integrated therapy if needed - has become normal practice in several countries.

The medical pathway of the Gender-
Affirmative model consisting of...

  • Puberty blockers (GnRHas)
  • Lifelong cross-sex-hormones
  • Mastectomy or breast implants
  • Removal of ovaries or testes
  • Hysterectomy
  • Surgical removal and revision of sex organs

...is based on a single Dutch study:

  • 55 subjects (only 40 completers)
  • 100% had childhood-onset gender dysphoria  (no adolescent-onset gender dysphoria cases)
  • Only one year post-surgery follow-up at an  average age of under 21
  • No control group
  • No physical health effects evaluation
  • One adolescent died as a result of post-operative complications. Several others could not pursue treatment due to new health issues arising following hormonal administration
  • Unchanged or worsening gender dysphoria and body image difficulties while on puberty blockers, especially among natal adolescent females

Hormonal & surgical interventions
can lead to:

  • Irreversible physical changes
  • Medical complications/ drug side effects
  • Surgical complications
  • Infertility
  • Arrest of a normal developmental process (puberty)
      

Multiple studies have found associations:

  • Bone/skeletal impairments
  • Cardiovascular complications
  • Premature death
  • High rates of post-surgery suicide

Despite the uncertainties and poor evidence, hormonal and surgical interventions are being scaled up. They go beyond the experimental “Dutch protocol” by:

  • Encouraging early social transition, explicitly discouraged by the Dutch protocol
  • Being applied to young people with adolescent-onset gender dysphoria, a population not included in the Dutch study

Need for Caution and Better Research

The history of medicine has many examples in which the well-meaning pursuit of short-term relief of symptoms has led to devastating long-term results; for example the past use of thalidomide, lobotomies, and the recent opioid epidemic. The "gender affirmative" model commits young people to lifelong medical treatment with minimal attention to the etiology of their conditions, and the psychosocial factors contributing to gender dysphoria. This model dismisses the question of whether psychological therapy might help to relieve or resolve gender dysphoria and provides interventions without an adequate examination.

We are asking clinicians and researchers to halt this uncontrolled experimentation on youth and replace it with a supportive framework of research that generates useful evidence about the etiology of gender dysphoria and the benefits and harms of various interventions. We need to know:

  • Which factors contribute to the development of gender dysphoria?
     
  • Which are the most effective interventions in gender dysphoria?
     
  • What are the long-term outcomes of those interventions?
     

We propose that, in view of the current dearth of evidence, the application of the model to children, adolescents, and young adults is unjustified outside of research settings. Patients, families and clinicians cannot make informed healthcare decisions without knowing the likely benefits and harms of the various interventions.

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