The Complicated Science and Ethics Behind Treatment of Transgender Youth
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The Complicated Science and Ethics Behind Treatment of Transgender Youth
The issue surrounding transgender youth, and whether they should receive medical care to transition has led to nationwide controversy.
On one side of the argument, there is the belief that children know as early as three years old whether they are transgender, and this remains unchanged well into adulthood. The opposite argument is the belief that so much as allowing a child to change their clothes, their name, and their pronouns is child abuse, and that parents should be investigated.
The LGBTQ community cites troubling data concerning the suicide rate of transgender youth. According to Forbes, an alarmingly 42 percent of transgender youth have considered suicide in the past year in 2020. However, the Trevor Project noted that in a 9,000 person study, gender affirming hormones were linked to reduced suicidal ideation. Therefore, they view any limits on this therapy as an attack of transgender youth, almost as though you are wishing them death.
However, there is troubling data on a sudden surge in LGBTQ youth. In Newsweek, they published a study showing that nearly 40 percent of Generation Z identify as LGBTQ, which is a 30 percent increase from the Millennial generation. This disturbing data has been used to argue that perhaps this is, in fact, a social contagion.
This has led me to ask some serious questions, including:
What is gender dysphoria?
How is gender dysphoria diagnosed?
Are there objective standards to that diagnosis (such as brain scans) that can be used to confirm diagnosis?
What does the treatment entail and what are the side effects of the treatment?
Does “transitioning” actually help patients?
How common is “de-transition”?
But there is one centrally important question that remains at the forefront of my mind: Can a child, who ethically cannot consent to sex, tattoos, piercings or other life-altering and permanent decisions, be able to consent to fundamentally altering one’s body?
Or, as proponents of childhood transition argue, is being transgender no different than having a clubbed foot that should be treated without controversy just like any other ailment?
Gender Dysphoria
Let’s start with some clear cut clinical definitions: Gender Dysphoria is cited in the Diagnostic and Statistical Manual of Mental Disorders, or DSM. The DSM has a set of criteria for diagnosing gender dysphoria, and the diagnostic criteria for children are separate from those used for diagnosing adults and adolescents. This disorder must be diagnosed through a psychologist or mental health counselor.
In children, the symptoms must last at least 6 months, and must include six of the following:
A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender).
In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing.
A strong preference for cross-gender roles in make-believe play or fantasy play.
A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender.
In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities.
A strong dislike of one’s sexual anatomy.
A strong desire for the physical sex characteristics that match one’s experienced gender.
There appears to be no other objective standards: no blood tests, no MRI, no other diagnostic tools available to diagnose this, other than the patient’s word.
Looking at the diagnostic criteria, I noticed something peculiar about my own childhood: I had six of the characteristics that are used to diagnose children. I hated feminine clothing (and still do), and makeup has always horrified me and left me with a feeling that I was putting on a show and trying too hard. It leaves me feeling as though I’m wearing a mask.
I had mostly male friends growing up, and although I had a barbie set, I preferred playing with the boys. I even went so far as to tell my mom “I think I’m a boy,” to which she replied “No you’re not, you’re just a different kind of woman.”
Looking back on it, I realize that what I was experiencing was gender dysphoria. So what currently is the treatment for gender dysphoria?
Treatment for Gender Dysphoria
Treatment for gender dysphoria includes puberty blockers, hormone replacement therapy, surgery, and talk therapy. All of these treatments are designed to try and emulate the patients’ vision of what they feel their body should look like.
But these treatments are not a panacea; there are serious side effects.
Puberty Blockers
Puberty blockers, or “gonadotropin-releasing hormone (GnRH) analogues,” can be begin as early as 10-11 years old, right when puberty begins according to the Mayo Clinic, and can purportedly be used to “pause” puberty to give the child more time to sort out and explore their gender identity.
In males, puberty blockers will prevent the development of things like a deeper voice, an Adam’s apple, facial hair, and the further growth of the penis and scrotal tissue. In girls, they prevent the development of breasts and the beginning of menstruation.
The side effects of long-term use can include a limit of how tall a child grows, bone density issues, as well as future fertility problems. Parents should also be aware that although these drugs are marketed as a “pause button” for gender dysphoric youth to explore their gender identities, research has shown that the vast majority of youth on puberty blockers (99 percent) eventually choose to continue their transition by proceeding on to using cross-sex hormones.
Many experts in the field of transgender studies are extremely concerned about the use of puberty blockers with hormone replacement therapy. This combination can lead to complications, including an inability to orgasm and permanent infertility. Also, they are no longer listed as completely “reversible” by the UK’s National Health Service.
Here in the United States, as recently as 2019, these drugs were still being prescribed “off-label,” meaning that they are being administered despite not having FDA approval for treating gender dysphoria. Their original use was to suppress puberty in very young children whose puberty came about so early that it would result developmental issues. Puberty blockers were also never intended, or tested, to be used in combination with other drugs.
I have to admit, when my hips and breasts began to come in, I was extremely upset. I thought I was fat, that my body was awful, and I absolutely hated the way I looked. The idea that I could have completely stopped this process (had I grown up in 2020) would have been extremely tempting to 13-year old me.
My mom reassured me though by saying, “You’re not fat! This is what women look like!” And, as I finished developing by age 16, I began to really like my body.
The next steps in this process, if my mom had listened to medical professionals, would have been Hormone Replacement Therapy and Gender Reassignment Surgery.
Hormone Replacement Therapy for Trans Women/Men
Hormone replacement therapy, or “HRT,” is the main treatment for someone who wishes to transition given its full-body effects. The female form of HRT was originally used to treat menopausal women. The drug Prempo, which contains both progesterone and estrogen, increases women’s risks of heart disease, stroke, blood clots, and breast cancer.
For trans women, feminizing hormone therapy is not recommended for those who have had a cancer that is sensitive to hormones (such as prostate cancer) or have a history of blood clots. Hormone replacement therapy for trans men (females who identify as males) actually has the same risks of cancer, blood clots, and infertility as hormone replacement therapy for trans women. It is also typically begun at age sixteen.
Gender Reassignment Surgery
Gender reassignment surgery for trans women takes on many forms, including vaginoplasty, facial feminization surgery, and vocal feminization surgery. For trans men, these surgeries include a double mastectomy, hysterectomy, vaginectomy, metoidioplasty, or phalloplasty.
Gender reassignment surgery has been performed much longer than puberty blockers or hormone replacement therapy, and so we have a much better understanding of the many risks involved to inform patients. Whether gender surgeons are always accurately communicating these risks to their patients is another story. But these surgeries are irreversible.
Does the treatment work?
Many gender activists claim that the only way to prevent high suicide rates in gender dysphoric youth is through medical transition. But the science on whether transition actually helps ameliorate the anxiety, depression, and suicidal ideation related to gender dysphoria remains unclear.
According to the Trevor Project survey, which interviewed over 9,000 trans-identified youths, those who were using hormone replacement therapy were 40 percent less likely to attempt suicide and exhibit depression.
However, longer term studies do not support this assertion. A Swedish study examined the lives of 2,679 people who were suffering from gender dysphoria over a period of ten years. The researchers found that “the odds of receiving mental health treatment in 2015 were reduced by 8% for every year since receiving gender-affirming surgery over the 10-year follow-up period.” Additionally, they did not find a positive correlation between hormone replacement therapy (or puberty blockers) and suicide rates over time.
The levels of suicide and anxiety treatment were also still significantly higher than the general population, which suggested to them that there is a “need to address factors in addition to gender-affirming treatment availability that may strengthen transgender individuals’ mental health.” In other words, the idea that hormone replacement therapy, puberty blockers, as well as gender reassignment surgery are “cure-alls” to the risk of suicide for those with gender dysphoria is simply not true.
Reduction of suicide rates is important, but these youths will continue to have higher than normal suicide rates even after all the gender affirmation therapy that is available to them, well into adulthood. This means that parents should be prepared to have their children continue with therapy and help them join support groups.
For me personally, the way I reduced my own distress was simple: I changed my view of what it means to be woman. By sixteen years old, I was perfectly comfortable with my body and with being a woman.
I know for a fact that I’m never going to be that typical Female Archetype from the 1950s because that’s just not who I am. My mother, an avid feminist, taught me that my relationship with my sex is not defined by pretending to be something I’m not, but by being the type of woman that I actually am.
De-Transition: The Dark Side of Transitioning
This is perhaps every parent’s worst nightmare. You allow your child to be put on puberty blockers, cross-sex hormones, and eventually sex reassignment surgery under the idea that you are saving them, only for your child to realize that it was all a mistake, and that you have instead irreparably harmed them.
But how common is it for children to change their minds?
The current numbers of de-transition are only between one to three percent. However, these low-numbers are based on adults transitioning, with the average age of millennials transitioning being 22.
Now, thanks to puberty blockers being widespread, a child as young as eight years old can begin to medically transition. For Generation Z, the average age of beginning transition is 17. There have been no studies to indicate whether this will have any effect on de-transition rates. There have been no studies.
Rather, the idea is that children simply know from an early age. A 2020 study found that “73% of transgender women and 78% of transgender men reported that they first experienced gender dysphoria by age seven.” Whether or not a child can essentially “grow out of” gender dysphoria remains unclear. While most activists fight against this idea, Cleveland Clinic’s Dr. Cartaya reports that 66 percent of children will grow out of gender dysphoria, stating:
A third of kids will have an exacerbation of their gender dysphoria during puberty. These kids often feel like their bodies are betraying them in many ways. That can also be an indication that gender dysphoria is going to last throughout their lifetime. This is the reason why we wait until puberty to start children with gender dysphoria on puberty blockers.
But given that nearly 100 percent of children who begin puberty blockers choose to continue with their transition, this raises the serious concerns that puberty blockers are actually solidifying cross-sex identities and placing children on a one-way path to being lifetime medical patients.
As I said before, the distress I felt with my hips and breasts as a thirteen-year-old child would have made puberty blockers extremely tempting. But I have no doubt that I would have been one of the de-transitioners. This is because gender nonconformity is separate and distinct from gender identity, and both are distinct from sexual orientation.
I have personally watched women in my family with great careers who prefer shorter haircuts and men’s jeans become extremely upset when asked if they are lesbians, as all are heterosexual and happily married!
Ethical Concerns
Even if you believe that a child as young as eight years old can know that they are transgender, and that this idea will never change, there are still many ethical concerns.
Does a child, at the age of eight years old, have the ability to understand the complete risks of puberty blockers and hormone treatments? Can a child that young fully comprehend the ramifications, such as infertility and the inability to orgasm? What age is it appropriate to allow a child to undergo such procedures? Is there any age that this is appropriate?
These are all ethical questions every parent should consider before jumping down this rabbit-hole.
My other concerns are about the ways parents are being rhetorically bullied with false suicide statistics if they do not immediately give their child what they want. This is not informed consent. Informed consent, according to the American Medical Association, states the following:
Physicians should:
(a) Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.
(b) Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about:
(i) The diagnosis (when known).
(ii) The nature and purpose of recommended interventions.
(iii) The burdens, risks, and expected benefits of all options, including forgoing treatment.
When a doctor asserts that a child will commit suicide if not given puberty blockers and hormone replacement therapy, the consent that a parent gives is consent given under duress.
Additionally, this assertion has, of course, only been “proven” by a study hosted by the Trevor Project, a trans rights advocacy group. These results have failed to be replicated in long-term studies, and they have not been independently verified. It also gives parents a false idea that puberty blockers and hormone replacement therapy make their child safe, when in reality the suicide rate for this group remains very high, even ten years after surgical transition.
The persistence of high suicide rates after transition also raises ethical concerns about whether these treatments truly “work,” and why medical professionals would choose to treat a disorder of the mind with surgery and hormone replacement therapy. For instance, the medical community wouldn’t dream of prescribing liposuction for someone suffering from anorexia nervosa, or prescribe plastic surgery to someone suffering from body dysmorphia.
I have no doubts that this disorder (gender dysphoria) exists. Rather, I question why the medical community would choose to go down the road of body modification to treat a disorder of the mind.
But the biggest and most important question I have for parents is this:
What if your child grows out of their gender dysphoria, naturally?
I grew out of it, and have since grown up, joined the Catholic church (as an adult), gotten married to my wonderful husband, and I am actively trying to have children at the moment that I write this. But this would not have been possible had I been prescribed puberty blockers and hormone replacement therapy.
Although proponents of puberty blockers claim that puberty is “traumatic” for children with gender dysphoria, I think, quite frankly, that puberty is a troubling (and often traumatic) time for everyone. As many adults can attest to, waking up with “rose buds” on your chest, or having hair in places you never had it before, or experiencing random erections, all of this can make you feel as though your body is betraying you.
And although gender dysphoria is a real psychiatric illness that deserves our compassion, the medicalization of puberty and gender stereotypes in children is a great cause for concern, as one should not have to support the sterilization of children in order to be an “ally of the trans community.”
Malcolm X once said, “Being friendly, and being a friend, I think, are two different things.” I don’t believe I’m being a good friend to a child if I agree with a child’s assessment that they were born in the wrong body.
I don’t believe I’m being a good friend to a child if I allow them to make drastic, radical, and permanent changes to their bodies anymore than if I would allow a child to get a tattoo, have sex, or use drugs.
If an adult wants to transition, that is one thing. But please leave children out of it.
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The Complicated Science and Ethics Behind Treatment of Transgender Youth
I had all 6 as well. Puberty was terrifying. Now I am a mom with a husband I adore (pretty boy collegic soccer player who is always put together 😂), and our 2 kids who are my world. As the universe has a sense of humor, I also have natural 32DD’s. And muscles because I look like a blonde hair blue eyed typical soccer mom, but I’m still a tomboy that hates pink, loves to play hard, and I still don’t get plastic dolls.
What is happening to children with gender theory is cruel. Telling fabulous boys they are really girls is cruel. Telling strong girls who like trucks and mud they are really boys is cruel.
It is a sad life, shortened by loneliness and big pharma subscriptions, for those who persist in gender dysphoria past the age of 25. I am all for allowing adults to do whatever they want, so long as those with a functioning penis don’t think they have a right to demand my daughter as a college roommate or prance around naked in pool changing rooms with young girls. We have separate spaces because of biology, not self proclaimed identity.
In 2-3 decades we will return to acknowledging both immutable biological reality, and the cruelty of trying to force little children who don’t fit stereotypes to mutilate their bodies long before anyone can know who they will be or what they will want as adults. This is not the first time society has allowed others to turn little boys into eunichs or mutilated the genitals of little girls. It’s cruel, always has been, always will be.
Thank You for this wonderful article. My son is a trans man and I did not allow him to transition until he was an adult (he started T therapy at age 21).
He struggled throughout his adolescence and actively fought against being transgender.
I think this was a healthy process, because being transgender is extremely difficult and turns a person into a lifelong medical patient. That is nothing to be taken lightly.
My son was also treated for anxiety and depression prior to transitioning to make sure that his dysphoria was not a result of these conditions.
I tried to convince my son to just be a butch lesbian, but he finally told me with great exasperation "Mom, I'm not as masculine as a butch lesbian. I don't even know if I'm attracted to women. I just feel like a man."
And it's true - my son is not as masculine as what we'd typically think of as a butch lesbian. As a trans man he is still a science nerd, but like many genetic men, he is not particularly masculine. He's no Ru Paul, but he's not macho either.
I truly believe there is something neurological going on with my son. He is on the autism spectrum and there has been research by Simon Baron-Cohen to indicate that autism is a type of hyper-male brain (I don't know - I haven't read the research).
My son has always been wired a little differently in multiple ways, so it makes sense that his dysphoria would be related to his neurology.
But I don't know.
I pray every day that transitioning was the right decision for him, because he does seem happier and more peaceful.
I wonder if, at a more primitive stage of our evolution, we were wired to have a specific sex identity. We don't need a wired sex identity anymore, because we can just look at our bodies and see what sex we are - but this was not always the case.
I have wondered if having sex dysphoria was similar to have a broken tail bone - we don't really need tail bones anymore and we don't notice them unless they're broken.
Anyway, thank you for advocating for women and children.
I definitely believe that confusing sex with gender has been a disaster for kids who far too easily diagnose themselves with dysphoria.
And I do not for one minute believe that all or most of the kids claiming to be trans actually are trans.
How anyone could rush children into a situation that paints them into a social corner, makes them infertile, and requires lifelong hormone treatments and medical monitoring is a mystery to me.
I'm not a conspiracy theorist but this does seem like quite a boon to the medical/pharmaceutical industries.
Thank You again for your thoughtful and compassionate position on this issue.