Gender-Affirming Care is Not Experimental, Part II

Currently, several states in the U.S. are moving to ban transgender youth from accessing gender-affirming (GA) care. Three days after the Supreme Court overturned Roe v. Wade, Alabama cited the decision as support for a law that makes GA care for youth, including puberty blockers and hormones, a felony. Alabama, Arkansas, and Arizona have current laws banning or restricting gender-affirming care for youth. As MSNBC Opinion Columnist Katelyn Burns has observed, trans youth appear be at ground zero in the conservative culture war. In a Pew Research Center survey of 10,188 U.S. adults, 46% supported making gender-affirming health care illegal for those under 18. A new NPR/Ipsos poll found that 14% of Democrats and 55% of Republicans support state laws that prevent trans youth from accessing gender-affirming care.

GA medicine is the standard of care as acknowledged by all major medical associations. Part I of this series established that GA care is not experimental. In Part II, author and transgender advocate Brynn Tannehill presents, along with Dr. A.J. Eckert and SBM managing editor Dr. David Gorski, what is currently known about science-based GA care. This post will take the form of, in essence, bullet points answering false and misleading claims commonly used to attack GA care for trans adolescents. The answers are not comprehensive, as this list is intended as a useful reference. We might in the future publish more detailed posts addressing specific questions summarized below.

Affirming treatment for transgender youth follows the internationally recognized standards of care

Puberty suppression for trans youth is the standard of care set forth by the Endocrine Society and the World Professional Association of Transgender Health (WPATH), which represents the global consensus on transgender healthcare.

Social transition for pre-pubertal youth improves mental health outcomes

A 2016 study of socially transitioned trans youth between the ages of 6-14 had mental health similar to their peers. This study included a cisgender control group, along with siblings of the trans youth. Transgender children reported depression and self-worth that did not differ from their matched-control or sibling peers, and they reported only marginally higher anxiety (p = .076). These findings are in striking contrast to previous work with gender-nonconforming children who had not socially transitioned, which found very high rates of depression and anxiety. A 2018 meta-study concluded that “Newer research suggests that socially transitioned prepubertal children are often well adjusted, a finding consistent with clinical practice observations”.

Stigma, discrimination, and lack of familial acceptance are predictors of adverse mental health outcomes for transgender youth. Conversely, acceptance is predictive of positive outcomes

Numerous studies have found that stigma, discrimination, and lack of familial acceptance are predictors of poor mental health outcomes for trans youth. A 2017 study of stigma and discrimination found that both were predictors of self-injury, suicide, depression, and anxiety among a sample of 923 Canadian transgender 14- to 25-year-old adolescents. Other studies have found that discrimination, stigma, and bullying are the driving factor behind negative outcomes for youth who are otherwise supported at home. Another found that minority stress was associated with major depressive disorders and anxiety disorders. Another 2020 study found that interpersonal and environmental microaggressions, internalized self-stigma, and adverse childhood experiences (ACEs), and protective factors: school belonging, family support, and peer support affected lifetime recalled suicide attempts and suicidality over the past six months.

Acceptance at home and at schools is predictive of positive outcomes. A 2019 study found that using chosen names associated with large reductions in negative health outcomes and improvements in positive mental health outcomes. A quantitative 2016 study found that parental closeness was related to significantly lower odds of all four mental health outcomes measured, and intrinsic resiliency positively reduced risk for psychological stress, PTSD, and stress related to suicidal thoughts. Trans youth are far more likely to be abused or rejected by their families than their cisgender peers, which results in worse mental health outcomes.

GnRH analogs (puberty blockers) have been FDA-approved for use for minors in the US since 1993

Doctors prescribe drugs which block the onset of puberty in order to give the child’s brain time to mature, to allow for exploration of gender identity, and to avoid an incongruent puberty. Contrary to frequent claims by “gender critical” activists, these drugs are not prescribed for prepubertal children; indeed, these drugs are not prescribed until Tanner Stage II of puberty, which is the onset of secondary sex changes. The most commonly used puberty-suppressing drugs in youth are Gonadotrophin-releasing hormone agonists (GnRHa) such as leuprolide. They have been FDA-approved to prevent precocious (early onset) puberty since 1993.

Treating adolescents with gender dysphoria with puberty suppressing medications is not experimental

GnRHa was first used in the treatment of gender dysphoria in 1988, and its use for this purpose has been common since the mid-1990s. The Royal College of Psychiatrists, in 1998, recommended delaying puberty as the standard treatment in adolescents who experienced strong and persistent ‘cross-sex identification’ and distress around the physical body that intensifies with the onset of puberty. Similarly, the WPATH standards of care since the 1990s (WPATH Standards Of Care For Gender Identity Disorders—Fifth Version) have recommended blockers as the standard of care for dysphoric adolescents entering Tanner Stage II of puberty. When the US District Court for the Middle District of Alabama looked at the question of whether blockers and gender-affirming hormones for trans youth are experimental, it concluded:

Defendants produce no credible evidence to show that transitioning medications are “experimental.” While Defendants offer some evidence that transitioning medications pose certain risks, the uncontradicted record evidence is that at least twenty-two major medical associations in the United States endorse transitioning medications as well-established, evidence-based treatments for gender dysphoria in minors.

Similarly, as discussed in Part I, off-label use does not mean “experimental”.

Gonadotrophin-releasing hormone agonists (GnRHa) and hormone replacement are regarded as generally safe for adolescents by the Endocrine Society

Several studies have examined concerns about puberty suppression. A 2020 study found that suppression does not have an effect on cognitive functioning. Others have looked at those treated with GnRHa for precocious puberty and found that “[bone mineral density was] recovered within 1 year after GnRHa treatment discontinuation, and there were no abnormalities in reproductive function”. It also found that “bone mineral density decreases during GnRHa treatment, but recovers to normal afterwards, and peak bone mass formation through bone mineral accretion during puberty is not affected”. Long term follow up with the patient from 1988 found normal bone mineral density. Though there is a decrease in bone density while on them, the risk of fracture is still very low.

Henriette Delemarre-van de Waal, MD, PhD of the Endocrine Society concluded her 2013 study on the safety and efficacy of puberty suppression by stating:

Hormonal interventions to block the pubertal development of children with gender dysphoria are effective and sufficiently safe to alleviate the stress of gender dysphoria.

Other studies found minimal risks for 16-17 year old youth who began hormone replacement therapy. A 2022 meta-study of bone density in transgender people, including blockers and gender-affirming hormones concluded that, “Gonadotropin-releasing hormone (GnRH) analogues in transgender youth may cause bone loss; however, the addition of GAHT restores in both transboys and transgirls.” It also found that, “GAHT (including blockers) does not have a negative effect on BMD (Bone Mineral Density) in adult transwomen and transmen.”

It is worth noting that the side effects of any drug must be weighed against the harms of non-treatment, which in the case of transgender youth are likely to be significant and permanent.

Puberty suppression is considered fully reversible

The Endocrine Society’s Clinical Practice Guidelines (i.e. standards of care) states:

Pubertal suppression is fully reversible, enabling full pubertal development in the natal gender, after cessation of treatment, if appropriate.

The vast majority of trans adolescents are competent to make medical decisions

Clinicians have standardized psychological tools to assess the competence of patients, whether they are cisgender or transgender. This is the standard by which it is determined whether individuals can give informed consent. In a 2021 study, clinicians applied the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) to 74 trans adolescents between the ages of 10-18. The MacCAT-T tests found that 89.2% were competent. This test agreed with physician assessments 87.8% of the time. It is worth noting that mental health professionals and physicians are always expected to evaluate patients’ ability to give informed consent.

In addition, although laws and conditions vary, a number of US states allow minors between the ages of 13 and 17 to give informed consent for certain medical procedures and treatments under the mature minor doctrine. Eight states have conditional age limits higher than 14 for people to legally consent to certain medical procedures and treatments, with the conditions usually involving whether the minor is emancipated and the nature of the condition for which medical treatment being sought (e.g., infectious disease, mental health, reproductive health). In the remaining states (plus D.C.) it is possible for unemancipated minors under specific conditions to consent to routine medical procedures,

Every major medical and mental health professional organization in the US supports access to transition-related care

Twenty-nine major professional health organizations have recognized the medical necessity of treatments for gender dysphoria and endorse such treatments. Most of these groups have also explicitly rejected insurance exclusions for transgender-related care, and few of these could be considered in any way “liberal” organizations (in the case of, for example, the AMA, quite the opposite, in fact). These include:

Medical organizations supporting restrictions on access to health care are nearly universally small, religiously-based outfits, whose positions on LGBT issues are founded on religious beliefs rather than evidence-based medicine.

A large body of evidence demonstrates the benefits of treatment for transgender youth

Decades of research and dozens of studies have shown that access to treatment to delay puberty, followed by hormone therapy, has a beneficial effect for transgender youth: see de Vries (2014), Costa (2015), and Lara (2020). A 2020 study of transgender adults who had received treatment as youth found that “pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes.” Head author of the study, Dr. Jack Turban, concluded that the findings add to a “growing evidence base suggesting that gender-affirming medical care for transgender youth is associated with superior mental health outcomes in adulthood”. A 2021 meta-analysis of 9 qualifying studies (one which was considered “excellent” quality, five considered “good”) on the effects of GnRHa found that the common benefits among them were decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life. A study released in December 2021 compared two groups of transgender youth: those who wanted Gender Affirming Hormone Therapy (GAHT) but did not receive it, and those who wanted and received it. The study found that those who received GAHT had lower odds of recent depression and of a past-year suicide attempt.

A comprehensive literature review of 16 studies examining the benefits of puberty blockers and gender-affirming hormones in trans youth revealed that 13 of the 16 showed blockers and hormones resulted in statistically significant improvements in mental health, and none of them showed a decline. Two of these three studies found an improvement, but it did not reach the level of statistical significance due to small sample sizes. A 2022 study found that access to transition-related care, including blockers and hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up. A 2020 longitudinal study of access to blockers and gender-affirming hormones found that youth depression scores and suicidal ideation decreased over time while mean quality of life scores improved over time when given access to these treatments.

Some studies even indicate mental health outcomes for transgender youth who have undergone treatment is equal to their cisgender peers

A 2020 study compared the psychological health of 272 adolescents who had been referred for assessment for gender dysphoria at Amsterdam’s VU University Medical Center and had not yet received puberty blockers or hormones, and 178 adolescents who had been diagnosed with gender dysphoria and were taking puberty blockers but had not started hormone therapy. Those who hadn’t received any treatment had higher (worse) scores on measures of internalizing problems, suicidality, and problems with peer relations than the group receiving puberty blockers and a group of cisgender (non-transgender) controls. However, the group taking puberty blockers showed no differences in self-harm or suicidality compared to the cis control group, and even scored lower (better) than cis controls for internalizing problems.

Other studies have found the same. In 2015 a study found that the combination of psychological support and puberty-delaying medication enabled subjects to reach levels of psychosocial functioning comparable to peers. A 2014 study in the Netherlands found that psychological functioning steadily improved over the course of the study and by adulthood these now-young adults had global functioning scores similar to or better than age-matched peers in the general population. More recently a study of trans youth in Spain found the transgender adolescents at baseline had worse measures of mental health than the cisgender control adolescents but that this difference equalized by the end of the study.

It must be noted that achieving results equal to the matched control group is the best possible outcome in mental health care.

There is no evidence that access to transition-related medical care causes harm

Opponents of gender-affirming medical care for transgender people often point to a study by Celia Dhejne as evidence that transgender people do worse if given access to care. However, the study does not say this: in fact it only shows that suicide rates for transgender individuals in Sweden who had surgery prior to 1989 were higher than the general public. It does not show that rates are higher for transgender people who have surgery than those who do not. Dr. Dhejne, lead author for the paper, has gone on record stating that her research cannot (and should not) be used to reach a conclusion that medical care for transgender people is harmful.

Cornell University conducted a systematic literature review of all peer-reviewed articles published in English between 1991 and June 2017 that assess the effect of gender transition on transgender well-being. They identified 55 studies that consist of primary research on this topic, of which 51 (93%) found that gender transition improves the overall well-being of transgender people, while 4 (7%) report mixed or null findings. None found that transition was harmful.

While access to medical care has not been shown to harm transgender people, risk factors for suicidality among transgender people include lack of access to non-surgical medical affirmation. Other key factors are family rejection and lack of government recognition of their identity.

Double blind and randomized control trials (RCT) on healthcare for trans youth are not ethical or feasible

Many opponents of GA health care for trans youth, and even for adults, point out that the studies generally cited to support such care do not meet the “gold standard” of being double blind and RCT. This is an impossible burden of proof for this clinical question for multiple reasons. First, double-blind studies involving blockers or gender-affirming hormones are at least not feasible and, actually, impossible given that both the doctor and the patient will notice whether puberty has not continued (if on blockers alone), or if gender-affirming hormones are causing the patient to develop secondary sex characteristics, such as facial hair, deepening voice, or increased breast tissue.

As for RCT, there is consensus in the field that such a trial would be unethical given the body of literature we have so far indicating that those in the control group would be likely to suffer adverse mental health outcomes compared to those randomized to the treatment groups. For this reason no Institutional Review Board would approve a randomized controlled trial at this time, because there would not be clinical equipoise, the requirement that there be genuine uncertainty based on science and previous clinical studies as to which group in an RCT will do better. Clinical equipoise is a minimum prerequisite for an RCT to be considered ethical.

Trans youth who have had medical treatment have significantly better mental health outcomes than those who do not

While RCTs are not feasible, comparisons of youth receiving treatment and those who haven’t have been done using convenience samples. A 2018 study of young transgender men who underwent chest reconstruction found their mental health was significantly better than the control cohort who were denied the surgery. A 2019 study of 47 trans youth before and after receiving hormone therapy found that the hormone therapy improved their mental wellbeing. It also found that those who had received puberty blockers for some time prior to hormone therapy ultimately reported even lower suicidality than those who had not previously received puberty blockers. In the largest study of this to date, researchers compared 272 transgender adolescents referred to the gender clinic who had not yet received pubertal suppression with 178 transgender adolescents who had received pubertal suppression. They found those who received pubertal suppression had better mental health outcomes than those who did not receive pubertal suppression. A study released in December 2021 compared two groups of transgender youth: those who wanted Gender Affirming Hormone Therapy (GAHT) but did not receive it, and those who wanted and received it. The study found that those who received GAHT had lower odds of recent depression and of a past-year suicide attempt.

Long term follow-up found a similarly positive outcome for transgender adults who had followed the protocol as youth

Dutch researchers who studied young adults over the age of 18 who had followed the protocol of blockers followed by gender-affirming hormones found:

Gender Dysphoria (GD) was alleviated and psychological functioning had steadily improved. Wellbeing was similar to, or better than, same-age young adults from the general population.

Desistance and detransitioning are rare after the onset of puberty

The Royal Children’s Hospital Gender Service in Victoria began treating transgender youth in 2003 and has taken in 701 patients for assessment. The court found that 96% of all youth who received a diagnosis of Gender Dysphoria from 2003 to 2017 continued to identify as transgender or gender diverse into late adolescence. No patient who had commenced gender-affirming hormones had sought to transition back to their birth assigned sex. Similarly, de Vries’ long term study of trans youth did not find any pattern of detransition or regret. Nor did a study of 75 German trans youth have any who expressed regret. A 2020 study of 143 Dutch transgender youth who started blockers found only 5 (3.5%) ended up discontinuing gender-affirming treatment. A 2022 retrospective review of Spanish trans minors found that out of a sample of 124 diagnosed with gender dysphoria, 97.6% persisted over a period of 2.6 years (on average). Prior to the first meeting, 48.5% were living in their affirmed role and, by the end of the study, this percentage rose to 87.1%. A long term (5 year) study of 317 trans youth (average 8.1 years) who socially transitioned found that most youth identified as binary transgender youth (94%), including 1.3% who retransitioned to another identity before returning to their binary transgender identity. 3.5% identified as nonbinary, and only 2.5% identified as cisgender.

Further, UK GIC clinicians conducted a records review of 3,398 transgender patients at the Charing Cross, Tavistock, and Portman clinics. They found only two (.06%) who had detransitioned due to regret or deciding that they were not actually transgender. Similarly, a Dutch study of 6,793 patients who medically transitioned found only 7 (.1%) who regretted transition because they decided they were not transgender. Among those few adolescents who detransition, including those who have undergone hormonal interventions, research indicates that most do not regret having been given the opportunity to explore their gender. A 2021 study of youth who ceased puberty suppression found that many were glad to have had puberty suppression available because it safely offered them time and space to explore their gender identity.

Regret among those trans teens undergoing chest reconstruction is also rare. The most recent study found that less than 1% of trans men who had chest reconstruction before the age of 18 had regrets. Conversely, approximately 5% of cisgender women who undergo breast reduction experience regret, and this is considered by plastic surgeons to be extremely low.

The “watchful waiting” model does not suggest withholding medical care for transgender youth

Most clinicians caring for transgender youth in the UK use the “watchful waiting” approach. This approach has been described by the Center for Expertise on Gender Dysphoria in Amsterdam, the first clinic to offer gender-affirming medical interventions for transgender adolescents. The approach involves waiting until transgender youth reach puberty before recommending that they socially transition (i.e. start living with a name, pronouns, clothing, etc. that match their gender identity). This approach is only about prepubertal children, who do not receive medical interventions under any clinical guidelines. The watchful waiting approach is irrelevant to the discussion of medical interventions for transgender youth. Under existing guidelines, these interventions are never offered before the onset of puberty.

Available evidence does not show puberty suppression causes transgender identity to persist

A 2015 qualitative study of clinicians and pediatric endocrinologists who administer puberty suppression to both transgender and cisgender youth asked the question: does puberty suppression disrupt the formation of gender identity? They noted that none of them had observed puberty suppression to cause dysphoria in youth with precocious puberty. Most of the endocrinologists in the study emphasized that they deliberately start treatment with puberty suppression only when the transgender youth have ‘…reached Tanner stage two or three to give them at least a kind of “feeling” with puberty before starting with puberty suppression,’ to avoid the possibility of steering.

The standards of care recognize the overwhelming consensus that if a youth still has a strong transgender identification after the onset of puberty, it is unlikely to change, and beginning the puberty suppression protocol is likely the best course of action to gain time for further assessment and prevent potential irreparable harms. Dr. Kenneth Zucker, the researcher most associated with the early studies that 80% of youth desist, has himself acknowledged in an interview:

… in adolescence the most likely outcome is the persistence of gender dysphoria… The treatment would be social transition and biomedical treatment.

The more plausible, and generally accepted explanation among those who treat transgender youth is that standards and clinicians have become better over time at identifying youth who are genuinely transgender. In 2013 the DSM-5 changed the diagnostic criteria for transgender youth to require, “clinically significant distress or impairment related to a strong desire to be of another strong cross gender identification,” for a gender dysphoria diagnosis, rather than just gender nonconforming expression, interests, or activities. Similarly, researchers have known for almost a decade what factors are most predictive of continued trans identity into adulthood.

Delaying transition until adulthood is likely to do lasting and irreparable psychosocial harm

A 2006 study by the pioneers of the Dutch Protocol for treating minors noted:

Physical treatment outcome following interventions in adulthood is far less satisfactory than when treatment is started at an age at which secondary sex characteristics have not yet been (fully) developed… [They] Often have difficulties in connecting socially and romantically with peers while still in the undesired gender role, or the physical developments create an anxiety that limits their capacities to concentrate on other issues.

Another follow-up study concludes:

Nonintervention is not a neutral option, but has clear negative lifelong consequences for the quality of life of those individuals who had to wait for treatment until after puberty.

A clinical study published in 2020 compared the outcomes of youth who started medical transition at various points, and found:

Older age and late pubertal stage are associated with worse mental health among Gender Incongruent (GI) youth presenting to Gender Affirming Medical-Care (GAMC).

More recent studies have shown that trans youth receiving treatment have better mental health, and specifically recommends against delaying treatment in order to prevent unnecessary mental anguish and potential permanent harm. The largest sample size study on this subject shows that trans people who began treatment prior to the age of 18 have a significantly lower lifetime risk of suicide attempts. Another study found that youth who had appearances less congruous with their gender identity (caused by treatment delays) were much more likely to suffer from major depressive disorders. A 2021 analysis comparing the results of similarly structured studies in Canada, Switzerland, England, and Australia found that prompt access to gender-affirming care was crucial to ensuring and improving the well-being of the young people who sought it. It was generally found that those who were prevented from prompt access to care self-reported mental health difficulties more often than those who had ready access to care.

Treatment decisions for minors are made based on input from parents, psychologists, psychiatrists, and the adolescent

The decision of whether to administer puberty blockers are not made solely by the child. In practice, a team of specialists evaluates each case extensively before making any decisions about treatment. The youth Gender Clinic in the Netherlands, which the Tavistock’s protocols are based on, describes an assessment process involving the adolescent, their parents, psychologists, and psychiatrists. The GeMS clinic for trans youth at Boston Children’s Hospital also includes parents, psychologists, psychiatrists, social workers, and endocrinologists as part of a comprehensive diagnostic process. WPATH, The Endocrine Society, and bioethicists who have studied the issue, consider 12-13 year-olds capable of giving informed consent to a fully-reversible treatment. Other bioethicists who have looked at the issue have concluded:

…the available scientific evidence does not corroborate the view that adolescent medical transition is dangerous. Consequently, adolescent medical transition should be recognized as ethical and remain available. (from Ashley, F. (June 2022) Adolescent Medical Transition is Ethical: An Analogy with Reproductive Health, Forthcoming in Kennedy Institute of Ethics Journal)

Rapid Onset Gender Dysphoria (ROGD) is not an actual diagnosis

In 2018 Dr. Lisa Littman published an article alleging that transgender identities in youth are a form of social contagion. The article suffered numerous methodological flaws. Dr. Joshua Safer, Spokesman for the Endocrine Society stated that:

Littman has actually written a paper about the anxiety of parents who question an open approach to transgender care and who frequent [web]sites that cast doubt on the current management approaches. No children were involved.

As a result, it was partially retracted with corrections, and the publisher issued an apology. WPATH has put forward the following statement on the subject:

The term “Rapid Onset Gender Dysphoria (ROGD)” is not a medical entity recognized by any major professional association, nor is it listed as a subtype or classification in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Therefore, it constitutes nothing more than an acronym created to describe a proposed clinical phenomenon that may or may not warrant further peer-reviewed scientific investigation.

Higher quality follow up clinical studies have disproven the ROGD hypothesis

Following Littman’s proposed RODG diagnosis, several follow-up studies in clinical settings examined her hypotheses. In both studies involving controlled environments with higher quality data involving both trans youth and their parents, they found the opposite of what Littman suggested. First, a study on whether gender dysphoria onset was rapid found that transgender youth typically wrestled with gender dysphoria for years before coming out to their parents. It also found that parents understanding of their children was often flawed, and generally lagged behind the adolescent’s understanding of themselves. The paper proposed a better model, substantiated by data provided by parents and youth, for how the coming out process works.

A second clinical study attempted to verify Littman’s proposed causes for the emergence of gender dysphoria. The study noted:

…a distinct pathway of rapid onset gender dysphoria was recently hypothesized based on parental data. Using adolescent clinical data, we tested a series of associations that would be consistent with this pathway, however, our results did not support the rapid onset gender dysphoria hypothesis.

The study’s conclusions supported the earlier conclusion that parents’ perceptions of dysphoria onset were incorrect, and that dysphoria drives anxiety and depression, not the other way around:

We did not find support within a clinical population for a new etiologic phenomenon of rapid onset gender dysphoria during adolescence. Among adolescents under age 16 years seen in specialized gender clinics, associations between more recent gender knowledge and factors hypothesized to be involved in rapid onset gender dysphoria were either not statistically significant, or were in the opposite direction to what would be hypothesized. This putative phenomenon was posited based on survey data from a convenience sample of parents recruited from websites and may represent the perceptions or experiences of those parents, rather than of adolescents.

A second study reached a similar conclusion that trans youth generally wait months or years before coming out to their parents, resulting in the revelation seeming sudden to parents, but a long-held secret to the child.

Children are not being rushed into transitioning

Two years ago, the wait time for a youth appointment at the UK’s Tavistock Gender Identity Clinic was over a year. Today, that wait time has risen to over two and a half years. For adults in the UK’s national health system, the wait is now 33-36 months. For a youth to be seen, there must have been a year or more of gender incongruence. There are cases of youth waiting so long that they age out and must start all over again on the adult waiting lists. Other previously cited studies show that teens generally take many months or years before coming out to their parents and seeking treatment.

The number of youths assigned female at birth being diagnosed with gender dysphoria is not disproportionate to the expected transgender population

A 2017 UCLA report, based on CDC survey data, states that 0.7% of youth aged 13-17 in the United States identify as transgender. This figure suggests that 700 in 100,000 youth born female may be transgender. As of 2019, Tavistock reports 1,740 patient referrals who are assigned female at birth. Assuming that there are roughly 6 million females in the UK between the age of 3 and 18 (the age range for Tavistock youth clinic services), only 29 in 100,000 of girls between 3 and 18 are referred for evaluation. This is indicative that there are potentially many youth who identify as transgender, and would benefit from treatment, still not being seen. It does not support the narrative that a large number of youth who are not transgender are availing themselves of Tavistock’s services.

Tavistock reports the number of new cases of trans youth has levelled off

Despite concerns that the increasing number of cases is due to some form of social contagion, the number of youth being referred is still relatively small compared to the expected number, and has levelling off based on Tavistock’s own numbers.

Bell v. Tavistock was overturned on appeal

Opponents of access to transition related care for minors frequently cite the case of Bell v. Tavistock in the UK. They neglect to mention that the initial decision was overturned by a higher court, which found that, “it is for the clinicians to exercise their judgement knowing how important it is that consent is properly obtained according to the particular individual circumstances”.

The connection between autism and transgender identity remains speculative and does not affect the standards of care

Some studies suggest a link between autism and gender dysphoria. Others have looked at the same data and found no link when accounting for other factors. It is also worth noting that just because someone is autistic does not mean that they cannot be transgender, and there is no extant evidence that trans youth with ASD do not benefit from affirming care the same way neurotypical youth do.

Attempts to change a person’s gender identity are both harmful and ineffective

A 2019 study looked at the long-term harms of conversion therapy on transgender youth. It found that adult transgender people who had been subjected to conversion therapy as minors were more than twice as likely to have attempted suicide over their lifetime. This relationship held true whether the therapy was religious or secular. The WPATH Standards of Care state that “Treatment aimed at trying to change a person’s gender identity and expression to become more congruent with sex assigned at birth has been attempted in the past without success, particularly in the long term. Such treatment is no longer considered ethical.” A 2022 study in Korea found that transgender individuals who had undergone conversion therapy were at much higher risk of depression, panic disorders, and suicide attempts.

Transition is not a form of conversion therapy

Conversion therapy is an attempt to change or suppress a person’s sexual orientation or gender identity. Sexual orientation is an enduring pattern of romantic or sexual attraction to persons of the opposite sex or gender, the same sex or gender, or to both sexes or more than one gender. In other words, sexual orientation is who you are attracted to.

Transitioning does not attempt to change who a person is attracted to, and thus is not a form of conversion therapy. The fact that the label for their attractions may change when a person transitions does not make transition a form of conversion therapy.

There is no evidence to suggest that trauma causes people to be transgender

A recent academic post online that has gained attention suggests (without citation) that trauma causes youth to have transgender identities, and that therapy to resolve these issues will cause them to desist in a transgender identity. This model, and the treatment proposed, is not significantly different from the that proposed by foremost proponents of sexual orientation “conversion” or “reparative” therapy in the United States. Entering therapy, with the a priori goal of having them desist in their identity based on the belief that some unnamed trauma is causing them to be transgender or homosexual, is conversion therapy.

There is no evidence to support the efficacy of this approach. There is a substantial body of evidence supporting a more affirming one. Numerous recent peer-reviewed studies show that transgender youth who are supported in their gender identity by parents, schools, and their peers have significantly better mental health outcomes than those whose identities are rejected or stigmatized. Rejection includes efforts to change their gender identity, coercing them into suppressing it, or rejecting it altogether.

The vast majority of trans men who transition do not consider themselves heterosexual afterwards

One of the false narratives about adolescent trans youth is that they are predominantly young lesbians who are transitioning to male to appear straight, or because of misogyny inherent in our society. However, data from large-scale studies dispute that view. The largest survey of transgender men to date showed that only 23% of trans men identified as strictly heterosexual (i.e. attracted only to women). This line of argument also makes the dubious assumption that people think being transgender somehow makes one’s life easier. In the UK, a similar survey found that only 16% of trans men see themselves as heterosexual.

Diagnostic criteria for childhood gender dysphoria specifically forbids diagnosing someone based on “mere tomboyishness in girls or girlish behavior in boys”

The ICD-10, the medical and mental health classification list of the World Health Organization, has this to say about diagnosing childhood gender dysphoria:

This is the current diagnostic criteria used by the most places outside the US. “Mere tomboyishness in girls” is not sufficient for a diagnosis of childhood gender identity disorder. Nor is mere ambivalence towards one’s gender sufficient: it requires a “profound disturbance”.

In the US, the DSM-5 is the standard for diagnosing gender dysphoria in youth. It too requires an insistent, consistent, and persistent cross-gender identity. Atypically gendered interests (e.g. playing with the “wrong” toys) and expression (e.g. what clothes a child prefers to wear) are insufficient for a gender dysphoria diagnosis. Thus, fears that somewhat gender non-conforming youth will be railroaded into transitioning are not supported by the diagnostic criteria put forward by the ICD or the DSM-5 today.

Transmasculine people can still have children after receiving testosterone

The use of exogenous testosterone in transmasculine people (trans men and nonbinary people) generally has the effect of suppressing menses. However, recent studies show that even transmasculine people that have been taking exogenous testosterone for years retain their fertility if they stop taking it. Indeed, their fertility rebounded to levels statistically indistinguishable from that of cisgender women of a similar age cohort. Permanent infertility is not one of common the side-effects of testosterone-driven gender affirmation. Nor does the research suggest that puberty blockers cause permanent sterility if the medication is discontinued.

Transgender people who have medical treatment are less likely to suffer from anorgasmia or sexual aversion

The narrative that transgender people cannot have fulfilling sexual lives, or that transition prevents sexual enjoyment, is false. Transgender people who receive treatment for their gender dysphoria are less likely to suffer from sexual dysfunction than their untreated peers. Trans people who have undergone gender affirming surgery are more likely to enjoy sexual activity. The majority of transfeminine people who eventually undergo gender affirmation surgery report heightened orgasms. Transmasculine people typically report heightened sexual desire while on testosterone. While transgender individuals are more likely to suffer from sexual dysfunction than the general population, this seems to be due in great part to sexual aversion caused by unresolved gender dysphoria. The evidence at hand suggests that reducing gender dysphoria leads to a concurrent reduction in sexual aversion and increased in enjoyment of sex.

Thus, the narrative that medical treatment for gender dysphoria sentences people to a life of sexual dysfunction is categorically false. Conversely, lack of access to treatment increases the long-term risk of dysfunction and dissatisfaction due to sexual aversion.

There is no basis to the assertion that parents believe having a transgender child is better than having a gay one

It is suggested that some parents see having an ostensibly “straight” child as better than having a gay one, and that they are then somehow pressuring their child into transitioning. This is implausible for so many reasons. First and foremost, people with hostile attitudes towards lesbians and gays usually also are hostile to transgender people, and often more so. Another study concluded, “homophobia is likely to always be the ‘best’ predictor of transphobia, and these two constructs probably share a common foundation.”

Indeed, more families feel that being transgender is a worse outcome than being gay. A survey on LGBTQ youth found that the families of 64% of transgender youth, including non-binary youth, made them feel bad about their identities compared to 34% of cisgender LGBQ youth.

One would also have to assume that these theoretically homophobic (but not transphobic) parents would also somehow be able to coerce their child into being (or pretending to be) transgender. They would then have to get a referral, and then wait two years to get an appointment. The youth would then have to talk their way past therapists who see thousands of genuine trans youths every year, and yet produce very few false positives. All of this, taken together, seems highly implausible.

There has been an increase in the number of out transgender people globally for decades as societal acceptance, and access to care, improves

There has been significant growth in the number of people seeking treatment in Western nations for decades. This includes detailed data from the Netherlands, Sweden, and New Zealand. A meta-analysis of 17 studies from 1954 to 2014 found a statistically significant increase over time in the number of trans women and trans men presenting for evaluation and treatment.

The increase should not be unexpected; the UK’s Gender Identity Research and Education Society (GIRES) published a report with grant funding from the Home Office in 2009, predicting growth in the UK’s treatment-seeking transgender population.

Studies over several decades have often seen higher ratios of transgender men to transgender women, or ratios that change over time

Godlewski (1988) found a sex ratio of 5.5 trans men to 1 trans woman in Poland over six years. Cohen-Kettenis & Gooren (1999) later reported a ratio of 5 to 1 trans men to trans women in Poland and Czechoslovakia. Okabe et al. (2008) found a ratio of 1.5 trans men to 1 trans women in Japan. Garrels et al. (2001) found that while the ratio in Germany was 2 trans women to 1 trans man from 1970 to 1994, this later decreased to 1.2 trans women to 1 trans man after 1994. The 2015 US Trans Survey reported nearly equal numbers of people having a trans masculine of trans feminine identity. Sex ratios of trans people seeking transition treatment have varied across regions and across time, with trans men constituting a majority in several places, far longer than ten years ago; and this was not considered cause for alarm at the time.

There are cultural explanations as well. Kirrin Medcalf, the head of trans inclusion at Stonewall, noted of the difference between trans boys and trans girls in the system:

I think because parents and society are more tolerant of children who are assigned female at birth behaving masculine. Those assigned male at birth and presenting feminine behaviour is still much more taboo, and parents are less likely to act on that. Children also pick up on that and come out later.

There is no evidence that youth find it easier to come out as trans rather than LGB

The American Center for Disease Control (CDC) data show that 11.8% of adolescent girls identify as lesbian or bisexual. Only 1.9% of all adolescents identified as transgender. Even if all those are trans boys, it still does not support the assertion that youth find it far easier to come out as transgender. The roughly 10-1 (or greater) ratio between cisgender LGB people, and trans individuals in data sets has held true for close to a decade. In 2011, the Williams Institute at the University of California Los Angeles found that 3.5% US adults identified as LGB, and that 0.3% identified as transgender. Occam’s razor suggests that as society has become more accepting, more people are willing to explore their gender and sexual orientation and come out as a result.

Conclusions

As evidenced above, there are many misconceptions surrounding the medical care of trans youth. The scientific misinformation spread through mainstream media is far from benign as trans youth throughout the U.S. are losing access to potentially life-saving care. Laws targeting access to care are not grounded in reputable science and should not guide the care of this marginalized population.