This post will be an introduction to gender therapy, mainly focusing on its origin and treatments. To clarify language I will use the terms “male” and “female” to refer to whether someone has XY or XX sex chromosomes, respectively. I will use “man” and “woman” to refer to gender. For transgender people I will use the gender that they identify as, for instance: “trans woman” conveys the information that I am referring to a male that identifies as a woman. Sometimes language is used that says male-to-female for this instance, but that is confusing because is blends the concepts of sex and gender, so I will avoid this and my language will be consistent. For youth ages I will use “trans-boy” or “trans-girl”.
The first thing to establish is how common it is for someone to feel that their gender doesn’t match their sex. I will not use the term “sex assigned at birth” because once again it conflates sex and gender. That term is only useful in the context of intersex individuals, which is an exception that proves the rule. There are many different studies that look at the rate of transgenderism, which has been increasing in children in the last decade, but I think it’s safe to say it remains well under 1%. A recent 2022 study estimates that 0.5% of adults in the US identify as transgender. Youth ages 13-17 were far more likely (1.4%) to identify as transgender than adults (0.5%), and the study found large differences by state. Youth ages 13-17 identifying as transgender ranged from 0.6% in Wyoming to 3.0% in New York.
The controversial question is what to do with a child with a gender identity that is discordant with their sex. We have to start with the Netherlands, where modern gender therapy was developed.
The Dutch Approach: The Dutch pioneered gender therapy in the 1990’s, and we will start by looking at what they have found in their clinics. Among children that experience gender dysphoria, the vast majority ~80-90% will desist by adulthood, usually occurring by the onset of puberty. Many of these children will grow up to be gay or lesbian. Given these numbers, they recommend avoiding social transition (defined later) in pre-pubescent children with gender dysphoria.
A quick aside: gender dysphoria can be loosely defined as the experience of significant psychological distress associated with discordance between one’s sex and perceived gender. This distress is why therapies were developed for these individuals.
In contrast to younger children, adolescents who experienced gender dysphoria since childhood and continue to do so after the onset of puberty were shown to rarely desist in their identity. Puberty suppression can be achieved with the use of GnRH agonists, which block the HPG axis, shutting down the release of sex hormones. This can be used as a method to prevent an individual from continuing to develop secondary sexual characteristics that don’t align with their gender identity. The Dutch approach endorses the use of puberty blockers (GnRHa) after the onset of puberty, use of cross-sex hormones as early as 16, and surgical intervention in adulthood.
Importantly, every step of this process was accompanied by comprehensive psychological evaluation and therapy. I recommend reading the paper on their approach, as it represents the basis for modern gender therapy.
Current Questions: What are the long term effects of these therapies? Does the recent increase in adolescents identifying as transgender represent a social phenomenon? Can a child consent to elective treatment that ends in sterility? What is the best way to address gender dysphoria? What should be done if one or more parents disagree with their child’s wishes regarding medical treatment? To what degree do these therapies improve/worsen mental health? How often do individuals desist after these interventions? What is the safety profile of puberty blockers, cross-sex hormones, and surgical intervention?
This doesn’t represent anything near an exhaustive list, but they are largely unanswered questions. We truth is we remain in the dark regarding these therapies. To limit the scope of this post, I will not address these questions now. It’s clear that we simply don’t know very much about the benefits/harm of medical intervention at this point. It should also be noted that many European clinics that began these therapies early on have recently restricted or eliminated their use in minors as safety concerns have mounted. I will address this in detail in a future post. For now, let’s summarize major topics in terms of management and/or treatment of the transgender youth.
Social Transition: This refers to the practice of using different clothes, a different name, and pronouns, to accord with one’s gender identity. In other words, if “Matthew” is an eight year old male, who begins identifying as a girl, social transitioning might consist of using the pronouns she/her, using a chosen name like “Maggie”, and dressing in stereotypical girls clothing. The obvious problem here is that if the vast majority of children desist in their transgender identity, this process makes it socially and psychologically difficult to reverse course, and could create a psychological barrier for the majority of children that might otherwise revert to concordant gender identity. I agree with the Dutch recommendation that social transition should be avoided before the onset of puberty.
Puberty Blockers: As mentioned above, these serve to postpone sexual development to avoid worsening gender dysphoria experienced by transgender youth. A well known negative effect of these drugs is impaired bone development. This may resolve following cross-sex hormone administration, but serious injuries are well documented. The safety profile of these drugs for this population is largely unknown. Referring to these treatments as completely reversible is misleading at best. More on this in a future post.
Cross-Sex Hormones: Pretty self-explanatory. A trans-boy would take testosterone in order to develop secondary sexual characteristics that match his gender identity. Similar concerns arise regarding safety, and this is where infertility comes into play. This raises profound questions for physicians regarding appropriateness of care. It is not clear to me that a child(<18) is capable of giving consent to a treatment that may render them sterile. Referring to these treatments as partially reversible is also misleading.
Surgery: The same issues arise regarding consent and sterility if used in children. I may address these surgeries in a dedicated post in the future, but the complexity is too much for now.
Final Thoughts: Gender therapy is obviously a fraught topic. My hope in this post was to present some basic information regarding where it stands today. I think it’s unfortunate that voicing concerns about the safety and appropriateness of therapy is often conflated with some kind of antipathy towards transgender persons. I also think this topic has been caught up in our raging cultural debates and is considered by some to be a simple moral issue of tolerance.
These therapies are given to children. Physicians must exercise caution to avoid harm. We should look to our European neighbors and ask why many of them have heavily restricted the use of these therapies in minors, that we might understand the best path forward.
primum non nocere
What are their recommendations for rapid onset gender dysphoria for a teen midway through puberty who has previously been explicitly happy and proud of their sex? It seems there are more teens experiencing this and there’s very little info for parents who want to both support and protect their teens.