Consistent with the principle, “First, do no harm,” in Clinical and Ethical Considerations in the Treatment of Gender Dysphoric Children and Adolescents: When Doing Less Is Helping More, psychologist David Schwartz, Ph.D. exhorts clinicians to treat children and adolescents with gender dysphoria (GD) using psychotherapy rather than pharmacological and surgical interventions. He asserts, “in the treatment of children and adolescents, no matter what the diagnosis, encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm.”

Drawing on his extensive experience with GD youth and their parents, Dr. Schwartz elaborates a psychotherapeutic approach for young people with GD that has proven effective. He observes, “Gender dysphoria in pre-adolescent children is a condition that ameliorates by itself in most cases if you are just patient."

Key messages

• Gender identity exists in the mind and “refers to the persistent sense of belonging to a particular gender category...It's a sense of belonging.”
• Hormones and surgery have recently become standard treatment for GD youth.
• When the quality of evidence is low, and the risk of harm is unknown, “…be wary of the possibility of doing harm precisely because often, and especially often when we administer chemical agents, we don’t know the real consequences of what we are doing. Consider the possibility of harm, because chemicals can be powerful and without carefully controlled longitudinal studies, we really don’t know what we are instigating.”
• Although puberty blockers are promoted as “a safe way for an uncertain child to have time to consider whether they want to go ahead with more irreversible procedures,” their use is known to adversely affect bone density and fertility. Worse still, their use promotes the idea that puberty is deleterious and calls for medical intervention. 
• Most adolescents who undergo puberty suppression tend to proceed to transition away from their natal sex. 
• Research reveals that most children who go through puberty no longer complain about GD by late adolescence; many grow up to be gay or lesbian adults.
• It is impossible to predict which children will persist with trans-identification as adults.
• Hormonal interventions have documented adverse health consequences ranging from acne to increased cancer risk.
• Surgical interventions remove healthy tissue, disable functional organs, impede development and operation of inborn neuro-chemical systems and render previously fertile individuals into sterile, post-surgical, chronically medicated ones.

Advice for Clinicians

• Question the rapid increase in cases of GD.
• “There is no common underlying meaning to gender dysphoria. In each case the preoccupation with gender conceals something different, something idiosyncratic."
• A child’s sense of urgency about transition is “a symptom, not a mandate.”
• Help children navigate puberty rather than fear it.
• Since most children outgrow gender distress, view trans-identifying children as potential desisters rather than patients who will need surgery and/or hormones. This view can also promote "more optimism and less panic" in parents.
• Children no longer preoccupied with the idea that their lives depend on obtaining surgery and hormones should be encouraged.
• Psychotherapy, a low-tech treatment option, has much to offer children with GD and it will “do no harm.”

SEGM Perspective

Dr. Schwartz offers a welcome and safe alternative to “affirmative care,” guided by the principle, “First do no harm.” He presents a thoughtful, cogent, well-researched case for making psychotherapy the first-line treatment for children and adolescents with gender dysphoria and helping children navigate the challenges associated with puberty. Drawing on a decade of work with GD children and adolescents, he offers therapists and clinicians practical advice about how to approach and establish effective therapeutic relationships. Parents of children and adolescents with GD will find valuable guidance in his sensible, compassionate approach.