Sex, Gender and Gender Identity: A Case for Conceptual Clarity

In a newly published article in Acta Paediatrica, the Swedish psychiatrist Professor Mikael Landén argues that the lack of definitional clarity around the concept of “gender identity”—which serves as the basis for invasive “gender-affirming” endocrine and surgical interventions—creates a serious problem for medicine. The problem is especially pressing now that the patients are predominantly adolescents with pre-existing mental health difficulties. 

Landén argues that the definitional ambiguity of “gender identity” further compounds already serious problems in youth gender medicine. These problems include insufficient evidence for the presumed benefits of endocrine and surgical interventions alongside documented risks; a lack of knowledge about how permanent adolescent trans identities will be if “gender-affirming” interventions are not provided; an inability to predict those who will be helped versus harmed by the interventions; and a lack of information about what happens to gender-associated distress when less invasive interventions are pursued, such as treatment of co-occurring mental health problems. 

The article concludes that until these questions are clarified, gender-affirming interventions should not be offered as part of standard medical care to young people, following one of the oldest guiding principles in medicine: first, do no harm. 

In making the case for a “do no harm” approach to youth, Landén makes the following points:

• Biological sex is binary. Sex is rooted in reproduction: humans, like other animals, are organized to produce either small gametes (sperm) or large gametes (ova). Sex tends to be associated with certain traits—men, for example, are on average taller and more aggressive than women. There is considerable variation within each sex and overlap between the sexes, but this does not make sex itself a spectrum. An unusually tall or aggressive woman is still a woman, not an “intermediate” between the sexes.
• The concept of “gender identity” is ambiguous. The term was coined in the 1960s and is now embedded in healthcare questionnaires, consumer surveys, and even legal definitions of sex. Yet, as the philosopher Alex Byrne—whom Landén cites—has observed, the concept has become circular: “gender identity” is described as one's own internal sense of one's gender, while “gender” itself is never independently defined. 
• The patient population has markedly changed. For most of the twentieth century, patients requesting medical and surgical interventions to change the sexed appearance of their bodies were extremely rare—Landén's own data show roughly 12 legal sex-reassignment applications per year in Sweden between 1972 and 1992—and those individuals clearly wished to live as members of the opposite sex. Today's picture is markedly different. There has been a sharp post-2013 rise in referrals of adolescents, especially females, whose self-understanding is now refracted through the poorly defined lens of “gender identity.” 
• The surge in gender-questioning adolescents likely has multiple causes. Landén does not attribute the increase in gender-questioning or trans-identifying adolescents to any single factor, pointing instead to several plausible contributors: changing social norms, an identity-focused culture, greater access to gender transition, and heightened media and social-media attention. Many of these young people also present with co-occurring psychiatric conditions, histories of trauma, or dysphoria that emerged relatively suddenly—a more complex clinical picture poorly served by the assumption that each person harbors an innate gender identity waiting to be discovered.
• The stakes of tolerating the definitional ambiguity of “gender identity” are too high. Landén argues that while the ambiguity of the concept of “gender identity” had little practical consequence when the concept applied to a small, homogeneous group of mostly mature adult males seeking to transition—the stakes are considerably higher now that the primary patient population is adolescents. Landén notes that since the concept has entered various domains of life, youth with sex-atypical interests or traits may be culturally prompted to question their “gender identity,” rather than question the rigid gender stereotypes. 
• Gender dysphoria creates real distress—but the hoped-for benefits of medical transition have not been demonstrated. Landén is explicit that gender dysphoria can involve profound suffering and that clinicians rightly want to relieve it. Yet the evidence for the puberty-suppression-and-cross-sex-hormone model has been found wanting by multiple research efforts, including the Swedish health-technology review, England's Cass Review, and a Finnish register study. The Finnish study found that nearly half of referred youth had received psychiatric care before their first gender-clinic assessment, and that specialized psychiatric service use rose substantially among those who subsequently underwent hormone treatment—a pattern Landén calls difficult to reconcile with the claim that medical treatment improves mental health. He is careful to add, however, that as an observational study it cannot establish that treatment caused the increase; the underlying reasons remain unknown.
• Until the natural history is understood, caution should prevail. Landén's conclusion is that until research clarifies how dysphoria in youth develops over time, whether treating co-occurring conditions itself relieves distress, and—crucially—which adolescents are helped versus harmed, the precautionary principle should prevail: primum non nocere (first, do no harm). He extends the same caution to policy, questioning the move toward self-declaration of gender and suggesting that biological sex be retained as the primary category, with gender identity serving as a complementary concept for individual experience.

SEGM Take-Away

It has become common for proponents of gender transition for minors to deflect criticism by branding the community of concerned clinicians and researchers as “armchair critics”—discounting well-reasoned objections rooted in the principles of evidence-based medicine, science, and medical ethics on the grounds that the critics lack clinical experience with gender-dysphoric patients. Yet, as the Cass Review—and the broader UK tradition of independent reviews—has shown, distance from the field under scrutiny is exactly what is needed when a medical practice begins to operate in ways that threaten patient safety.

Those working inside a field are often the last to see its problems. The 2001 UK Bristol Inquiry into another pediatric medical scandal (unsafe pediatric cardiac surgery) put it in words that could be transposed onto pediatric gender medicine almost unchanged:

The enduring lesson is that independent oversight—comprehensive, external scrutiny by those outside the field—is indispensable once a specialty's own mechanisms of self-correction break down.

Against that backdrop, Professor Landén bucks the trend. Neither the “outsider” nor the “too close to see it” charge applies to him. Landén can hardly be dismissed as an “armchair critic”: a professor of psychiatry at the University of Gothenburg's Sahlgrenska Academy and at Karolinska Institutet, he has studied transsexualism and gender dysphoria for more than two decades. His doctoral work examined the epidemiology, phenomenology, etiology, and regret rates of transsexualism in Sweden, and he has since published on the incidence and sex ratio of transsexualism, the factors that predict regret after sex reassignment, and the long-term mortality and psychiatric outcomes following sex-reassignment surgery. 

Nor is he an insider shielding his own field: he co-authored the 2023 systematic review of hormone treatment for children with gender dysphoria that helped move Sweden away from pediatric transition as a routine intervention and toward offering it only in exceptional circumstances. His most recent publication in Acta Paediatrica builds on his earlier reflections on gender medicine in general, and pediatric gender medicine in particular. 

Professor Landén does not stand alone in his willingness to critically examine his own field. The Finnish register study he cites was led by Professor Riittakerttu Kaltiala, professor of adolescent psychiatry at Tampere University, who helped establish Finland's adolescent gender service and then, following the evidence, became one of its most candid critics. In the United Kingdom, the clinical psychologist Anna Hutchinson and the psychotherapist Anastassis Spiliadis both worked at the Tavistock's Gender Identity Development Service (GIDS) and were initially involved in gender transitions before becoming vocal critics of the practice. 

In the United States, following the early, brave voices of concern by the therapists Erica Anderson and Laura Edwards-Leeper that called out deep problems in clinical approaches to gender dysphoric adolescents and young adults, the whistleblower Jamie Reed spoke bluntly about the clinical realities in the gender clinic where she worked. And earlier this year, the American Society of Plastic Surgeons, whose members had been performing mastectomies on gender-dysphoric adolescents, issued a position statement rejecting gender-transition surgery for minors. 

The styles of these critical voices vary greatly, but what unites them is a willingness to question prior practice—and the courage to speak the truth in the interest of patient well-being. Had every gender clinician and medical society shown similar wisdom and courage to self-correct, the top-down regulation of this contentious area of medicine currently underway in the United States might not have occurred.