ReThink Identity Medicine Ethics

Why Rethink?

POSITION STATEMENT


There Is An Unprecedented Increase In The Numbers Of Minors Presenting With Gender Dysphoria

  • Children and Youth are presenting to gender clinics in unprecedented numbers (e.g., 400% increase in 5 years in the U.K.) with complex case histories.
  • 2% of high school youth now identify as transgender, according to the CDC.
  • There are now more than 40 gender clinics in the U.S.
  • The reasons for this rise and the standards of care being provided are now a public health concern and being officially reviewed in the United Kingdom and Sweden.

In concert with cultural changes around gender variance, children and youth are now presenting to gender clinics with gender dysphoria symptoms in unprecedented numbers and with complex case histories. There are no exact numbers as to the children and youth who are now presenting, but all indications are that it is in 10s of thousands in the U.S. alone. No longer is gender dysphoria a rare condition affecting a minute population. Rather, the standards of care being offered are now a public health concern.

Gender clinics have documented exponential increases in minors seeking to transition.  The recent CDC Survey estimates that 2% of all high school students in the U.S. now identify as Transgender. (CDC Survey 2019.). There are now over forty (40) gender clinics in the U.S. with the number growing. These minors present at different times (prepubescent and adolescent), with differing amounts of gender dysphoria (moderate and acute), and differing neurodiverse profiles (50% of adolescents are on the ASD spectrum – See Graph), and co-morbid conditions. The reasons behind this unprecedented increase is unknown and is currently being studied both in the UK and Sweden.

Medical Treatments Can Result In Irreversible Changes and Side Effects

The therapeutic regimes for prepubescent children with gender dysphoria include social transition, puberty blockers, cross sex hormones and surgeries.  Children as young a three years old are socially transitioning while those eight years old are being put on puberty blockers (GnRH agonists) that suppress natural puberty followed by cross sex hormones — a treatment pathway that results in permanent infertility 100% of the time. These young people are also having surgeries as young as 13.  The consequences of these treatments include compromised bone density, cardiovascular health and possibly brain development. A male placed on puberty blockers (as young as 10 years old) will develop a “micro penis” which is later removed and replaced with neo-vagina (constructed of colon tissue) that requires life-long dilation to prevent closure. It appears that, in cases where puberty has been blocked early, these natal males may not ever have any sexual desire or function, and they will be permanently infertile.

In adolescents, females as young as 13 are undergoing double mastectomies and are being put on cross-sex hormones as young as eight.  Testosterone causes irreversible changes to the voice and hair growth patterns within a matter of months. Clitoral growth and vaginal atrophy can also occur within a short period of time. These developments may be only partially reversible. It is recommended that females taking testosterone get a hysterectomy after 5 years of use to prevent uterine cancer.  Indications are that for both these populations their fertility and sexual function will be compromised.

The Cause Of Gender Dysphoria Is Unknown, Based Solely On Self Reporting And Can Resolve By Itself

  • Diagnosis of gender dysphoria is based solely on the individual’s self report.
  • The causes of the condition are not known and may vary in origin, strength and duration and can resolve on their own. (Past studies show 60- 80% desistance prior to puberty.)
  • Many presenting children and adolescents have complex case histories and co-morbid conditions.
  • In any individual case, it is not known to what extent a co-morbid condition is causitory or contributing to their distress or if in the long term it will be remedied by early transition.
  • There are no long term studies as to the effectiveness of early transition in treating their distress or remedying co-morbid conditions.

There are no objective traits for gender dysphoria.  (See Bewley et al., 2019)  A diagnosis of gender dysphoria is based solely on the self reporting of the individual with regard to their attitudes, preferences and feelings.  It is generally characterized by distress or problems functioning associated with the individual’s preferences related to the opposite gender or their experienced/expressed gender and those assigned to their biological sex. The causes for the condition in an individual are not known and may vary in origin, strength and duration.

There are no evidence-based theories as to what causes an individual’s gender dysphoria or any tests or assessments that determine if the condition will persist.  The difficult and complicated task of the clinician is to determine whether and to what extent any comorbid conditions are causitory or contributing to the individual’s gender discomfort, and to what extent the dysphoria and other conditions can be remedied or complicated by transition interventions.  For this reason, assessments of dysphoria and its causes are subject to interpretation, and there is a risk of misdiagnosis and/or over diagnosis. Since treatments are invasive and can have life-long consequences, every effort should be made to avoid false positives.

Studies show that 60-80% of childrenwith gender dysphoria experience a remission of symptoms without treatment at the onset of puberty.  Many of these individuals will go on to be same-sex attracted adults.  There is growing concern that the psychosocial treatment of  “socially transitioning” a minor will promote the likelihood that the individual with persist. Where children are put on puberty blockers, nearly 100% go onto cross sex hormones .  As a result, once a child is confirmed in their opposite sex “gender identification” through a course of allegedly reversible treatment, he or she is at risk of not being able to resolve their dysphoria without irreversible medical interventions. 

Adolescents Are “Suddenly” Experiencing Acute Gender Dysphoria In Unprecedented Numbers

  • There is an exponential increase in the number of adolescents presenting at gender clinics without prior symptoms of gender variance or dysphoria.
  • There are no studies as to the causes or the long term effects of medical interventions on this group.
  • 70+% of these adolescents are now females. (1/3 are on the ASD spectrum).
  • Increasing numbers of these girls are detranstioning in their 20s, many of whom attest to their homophobia as a contributing factor.
  • In response, the United Kingdom and Sweden have called for a review to determine the cause of the increase and that standards of care being provided.

A New Onset Of Gender Dysphoria In Adolescents

A new adolescent cohort is now presenting with gender dysphoria that has not been studied and little is understood about them or the long term psychological impact and effectiveness of medical interventions and transitioning.  In the applicable literature, this phenomenon is often referred to as “Rapid Onset Gender Dysphoria.”  In the last five years, gender clinics have documented 400% increase in youth ages 12 -17 with no prior symptoms of gender variance or dysphoria. It is not known whether and to what extent this newly presenting population is stable in comparison to those of children who present earlier and persist.

Adolescence is a complex adjustment to physical and emotional changes that take place during puberty. Depression, anxiety, social isolation, eating disorders, and identity confusion are commonplace at this time. This complexity presents a dilemma for proper assessment and treatment as it is difficult to determine whether the dysphoria may be attributed to preexisting co-morbid conditions or if the co-morbid conditions are secondary to dysphoria and will resolve with medical transition.  For these reasons, extended assessments are being implemented in individual cases in order to provide the adolescent with an opportunity to resolve and address the surrounding issues prior to beginning medical transition.

70+% of Adolescents Now Presenting Are Females

Up to 70+% of the adolescent population who are now presenting at gender clinics are girls – a complete inversion of previous statistics wherein boys had outnumbered girls in the same proportions. (See attached GIDS graphs.)  The Human Rights Campaign/UCONN LGBTQ Online Youth Survey in 2018 (with 17,000 respondents) found that LGBTQ adolescent females identify as Transgender/Non-binary 9:1 over adolescent boys. (See attached HRC graph.) These numbers have led to concerns that there is a social contagion taking place among girls – which has been known to happen in other areas such as self harm and eating disorders, where the primary influence is a group of peers who are initiating or strengthening a condition.  In addition, the vastly disproportionate increase in adolescent girls presenting may reflect concomitant increases in social and sexual anxiety, depression and body rejection known to affect individual girls at the onset of somatic and psycho/social changes during puberty.

This increase is being studied in both the UK and Sweden. Some of the contributing factors being looked at are:

    • Easier to disclose gender variance due to decreased stigma
    • Identity uncertainty and dysphoria generated or exacerbated by societal/psychological factors
    • Homophobia
    • Neurodiversity problem – 33% have autism traits
    • Friendship and social media influence and pressure
    • A preference for male roles
    • Rejection of female stereotyping

(See Bewley et al., 2019)

Since we know that many LGBT youth who are female experience a substantial degree of fluidity as regards their sexuality and identity during adolescence, it could be argued that they ought to be encouraged to delay irreversible medical interventions that they may later regret.

Increased Numbers Of Girls Are Detransitioning And Speaking About Their Lack of Good Care

Until recently, detransition and regret after medical transition were considered so rare as to be barely studied or acknowledged. However, in the last three years, increasing numbers of young women who transitioned in their teens have come forward to publicly acknowledge that they have detransitioned. There are now numerous testimonials and online studies of women who identified as transmen, took hormones, and even had mastectomies who now self-identify as women in alignment with their biological sex. Very few clinical services are available to them to assist in their reidentification. Likewise, there are no good follow-up studies of the frequency of detransition or regret. Many such studies of females who have transitioned have no follow-up response for up to 40 – 70% of those medically treated . Some have attested to not believing as a teenager that there was any alternative. The reasons for this uptick are not known but may be attributed in part to inadequate assessments and counseling and easy access to hormones and surgeries under the protocols of affirming self-identification in which case these numbers are likely to grow.

Rethink Identity Medicine Ethics

In light of these factors, this vulnerable population of gender variant children and youth deserve and need the highest evidence-based standards of care to avoid over diagnosis, misdiagnosis and unnecessary irreversible medical interventions.

In the absence of objective evidence as to the cause or causes of gender variance and dysphoria, and in view of the potential long-term irreversible harm to fertility, sexual function and health of children and youth, along with the lack of long term studies demonstrating the effectiveness and the full import of any risks involved, standards of care and treatment protocols should be informed by high quality research and evidence-based best practices for addressing complex developmental and dysphoric issues related to identity and the body on an individualized case by case basis.

g numbers of young women who transitioned in their teens have come forward to publicly acknowledge that they have detransitioned. There are now numerous testimonials and online studies of women who identified as transmen, took hormones, and even had mastectomies who now self-identify as women in alignment with their biological sex. Very few clinical services are available to them to assist in their reidentification. Likewise, there are no good follow-up studies of the frequency of detransition or regret. Many such studies of females who have transitioned have no follow-up response for up to 40 – 70% of those medically treated . Some have attested to not believing as a teenager that there was any alternative. The reasons for this uptick are not known but may be attributed in part to inadequate assessments and counseling and easy access to hormones and surgeries under the protocols of affirming self-identification in which case these numbers are likely to grow.

We need to think and rethink about the ethics and best practices by which identity medicine is provided.

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