By any account, the field of pediatric gender medicine is a mess. Even experts in the field cannot agree about what is going on, where the field is going, or where it ought to go. In politics, the controversies are even worse. At least 20 states have banned gender-affirming treatment. Many other states have passed laws guaranteeing the right to such care.
Since the first pediatric patient seeking hormone treatment for gender dysphoria was evaluated in The Netherlands, in 1987, the number of children who seek evaluation and treatment has skyrocketed, the age at which they seek treatment has plummeted, and the ratio of girls to boys has reversed. The U.K., for example, saw a 3,264 percent rise in referrals over ten years, from 77 around 2009 to nearly 2,590 by 2019. In the United States, there are now nearly 100 clinics for transgender teens and hundreds of thousands of teens who identify as trans.
The rise in numbers of patients and changes in the demographics and clinical presentation baffles the experts and puts an overwhelming strain on clinics that are not staffed to serve this volume of patients. One expert group recognized that the changes create an acute need “to conduct further research to clarify certain issues and to standardize clinical practice and improve counselling in transgender adolescent decision making and avoid regrets in the future.”
Many European countries are backing away from the US model of gender-affirming treatment. Instead, they are mandating that treatment be provided only in the context of careful collection of data about risks and benefits. For example, in Finland, treatment centers will be encouraged to “collect extensive information on the diagnostic process and the effects of different treatment methods on the mental wellbeing, social capacity and quality of life of children and on the disadvantages of procedures and on people who regret them.” A Swedish report notes that “gender-confirming treatment may lead to a deteriorating of health and quality of life.” The Swedish health service is now offering puberty blockers and cross-sex hormones only to youth with the “classic” symptoms of gender dysphoria, that is, ones in which the dysphoria has persisted since childhood and causes clear suffering in adolescence. Others will be offered gender-exploratory psychotherapy. The Swedes are conducting a national study to better understand the outcomes of adolescent gender dysphoria. In the UK, a nationwide study led to the conclusion that the National Health Service needed a continuous research program to “inform understanding of the epidemiology, assessment and treatment of this group.”
In the US, the current model has many passionate critics. Child psychiatrist Miriam Grossman believes that most teens with gender dysphoria need psychotherapy, not hormones, and that most outgrow their gender dysphoria. Psychiatrist Paul McHugh shut down the pioneering gender medicine program at Johns Hopkins University, claiming that “frequently heard claims about gender identity sometimes masquerade as science but are really ideological pronouncements not supported by scientific evidence.” Culture critic Camille Paglia is of the opinion that gender-affirming treatments for teens is a form of child abuse. Psychologist Jordan Peterson agrees and considers such treatments to be “the surgical mutilation of minors.”
Against these critics, many professional organizations endorse gender affirming treatment. For example, the American Academy of Pediatrics, the American Medical Association, and the American Psychological Association all endorse gender-affirming treatment. But these organizations have been the targets of protests. At least a dozen states have banned gender-affirming hormonal treatments.
The message from these controversies is clear. Our understanding of gender identity is changing and with those changes, it is becoming clearer just how much we don’t know. We don’t know whether gender dysphoria is truly becoming more common or whether, as with many other medical and psychological conditions, including autism, depression, and ADHD, awareness leads to more diagnosis.
There is much that we don’t know. Better research is urgently needed. The plethora of questions and dearth of answers is frustrating for doctors, patients, and policy makers alike. Child psychologist Scott Liebowitz is a strong proponent of such research, both as a way of getting answers and as a way of showing respect for teens and families. “It’s irresponsible to reinforce very scary statistics to families in an attempt to gain consent for treatment,” Leibowitz says. “This strategy doesn’t build the type of love and acceptance that a child needs, which is truly at the heart of preventing suicidal behavior.”
The research will require new methodological approaches. It will be impossible to do traditional randomized trials. The medications and surgical procedures are being used “off-label” but they are readily available. The studies will require a level of research integrity that has been sadly absent from the field in the past. There are no studies that report outcomes for all patients evaluated at gender medicine clinics, that clearly specify the criteria used to determine which patients are offered hormonal treatment or surgery, and that then report outcomes for patients who were treated as well as those who were not. Instead, most studies offer results based on idiosyncratically selected subsets of patients. We can do better.