Let's talk about gender identity

Updated: Apr 18, 2022

I'll admit it: I am afraid to write about gender. I'm sure to say the wrong things. I'll say "gender dysphoria" when I should say "gender incongruence" or "disorder" when I should say "difference." I want to keep up but I cannot. It is impossible not to offend someone or, sometimes, everyone. But I'm going to try to speak about it, anyway.

We recently analyzed a case in which a non-binary teen wanted to delay puberty. That, in itself, is a pretty standard request. A multidisciplinary evaluation concluded that treatment was appropriate and, as is the standard of care, the doctors started treatment with drugs to delay puberty. Such treatments are used to give the teen more time to sort out their own gender identity. Such treatment can be life-saving by reducing the risk of suicide.

This case had a twist. The teen decided that short-term wasn't enough. They wanted to continue to delay puberty forever. The doctors were troubled. Long-term safety of such medications has not been well-studied.

The arguments on both sides were compelling. The teen's preferences were completely clear. Their parents agreed. After comprehensive counseling, both consented to treatment. The medical risks included were real but unquantifiable.

So...when a patient wants a medication that has medical risks and psychological benefits, the doctor needs to make a clinical judgment.

Such cases arise every day in countless clinics around the country and the world. Doctors, patients and families struggle to engage in a process of shared decision making.

Most children's hospital now have specialized clinics for children and adolescents who struggle with issues related to gender identity. These clinics offer multidisciplinary evaluation and gender-affirming treatment that can include medication or surgery. The health professionals are - whether they like it or not - gatekeepers. They determine whose suffering should be treated with psychotherapy and whose needs medication or surgery. They decide when to block puberty or remove sexual organs. Decisions require nuanced value judgments.

Unless, of course, you think that no gender-affirming treatment is appropriate. That is a big debate that mostly pits the clinician insiders who are dealing with actual patients against the philosopher outsiders, some of whom think that such treatments are outside the proper scope of medicine.

Ideally, we would have more research on this important problem. But that would require public support for the research. The public is going in the opposite direction, vilifying transgender children and the doctors who treat them and invoking God and religion to justify their intolerance.

Ironically, such policies make the prognosis for gender-nonconforming youth worse and the need for gender-affirming treatment more urgent.