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Gender-Variant and Gender-Questioning Youth

The last decade has seen a notable rise in young people who exhibit some level of discomfort with their sex assigned at birth.

 

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The last decade has seen a notable rise in young people who exhibit some level of discomfort with their sex assigned at birth. When this discomfort is persistent and troubles one’s ability to function socially or sexually, it is known as “gender dysphoria.” According to an analysis of health insurance records, at least 42,000 children in the U.S. received a new diagnosis of gender dysphoria in 2021, up 70% from the previous year [28]. In the most extreme cases, gender dysphoria can take the form of wanting sex reassignment through medical interventions. Few issues pertaining to teenagers have generated as much heat and passion or as many misleading claims, whether from opportunistic politicians who want to ban all gender transition for minors or from online trans activists, supported by powerful pharmaceutical companies, who encourage immediate medical transition with little or no psychological evaluation of a minor’s suitability for it. Those who are now questioning the trend toward early medicalization of gender-variant children include not only social conservatives, but also radical feminists concerned about preserving female-only spaces and lesbian and gay activists who worry that young people who could have otherwise grown up as well-adjusted gays or lesbians are instead being led down a path of lifetime medical dependency and sexual dysfunction [124]. 

Well-intentioned parents are understandably confused when they hear on the one hand that their children are likely to commit suicide without “gender-affirming” medical care, and on the other hand that their children’s fertility and future happiness may be ruined if medical intervention comes too early in their process of identity-formation and is later regretted. Anyone who tells you that there is no legitimate debate or that “The Science” is settled in this area is not being honest. Much research remains to be done. We shall try to offer a balanced summary of the scientific evidence both for and against medical intervention, and guidelines for helping your teenage child grapple with the many complex issues surrounding gender stereotypes and gendered self-presentation in today’s rapidly changing social environment.

Any caring parent should of course be “gender-affirming” in the sense of accepting their rainbow child’s unique positionality on the gender spectrum.

One of the things that makes rational discussion of these issues difficult is the appropriation of the phrase “gender-affirming” by activists. Any caring parent should of course be “gender-affirming” in the sense of accepting their rainbow child’s unique positionality on the gender spectrum. However, gender presentation, like sexual orientation, is fluid and subject to continuing revision as a young person grows, discovers, and matures. It is not a fixed essence that needs to be frozen in place whenever a child first begins to think about their gender. Parents have an important role to play in helping children conceptualize and understand how gender functions in our society. Gender affirmation does not necessarily equate with immediate medicalization of a child’s evolving doubts or anxieties about their adequacy within their birth sex. It can also take the form of affording a child time and space to explore different possibilities of self-presentation that can draw on positive aspects of both genders. In some cases, medical transition is the right answer, but not all deviations from gender norms are well-suited to such treatment.

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Every child’s case is unique, and understanding the reasons why your son or daughter may have gender-atypical interests or wish to identify with the other gender can help you determine how to respond. In some cases biological factors make a boy less masculine or a girl less feminine in physical strength, appearance, or deportment. In other cases, a child’s play preferences and gender individuation may be influenced by peculiarities of family structure (e.g. a predominance of older sisters or brothers) or interpersonal dynamics (e.g. a daughter who likes helping her father work, or a mother who wishes she had a daughter rather than another son).

Scientists since the Hippocratic physicians of ancient Greece have recognized that sex exists on a spectrum even within the binary, and does so since birth. However, it is never as simple as the mystical concept of being born with a female brain in a male body or the other way around. Research has not yet identified the presence of distinctively male brain structures in transgender men or female brain structures in transwomen [58]. Much research has focused on prenatal exposure to androgens within the womb, which do appear to have an influence on gendered toy selection, career interests, and spatial abilities; however, these studies show only a weak correlation with later gender identity, cognition, or peer preferences [1,2,3]. Prenatal hormones may have an effect, but only in combination with post-natal family influences, such as parental gender attitudes [4] or the presence of older brothers and sisters [5].

Gender stereotypes perpetuated in popular media often create discomfort and disidentification with one’s birth sex: who can blame a sensitive boy for feeling revulsion when coming into digital contact with masculine stereotypes like gangster thugs, Marine snipers, porn studs, wife beaters, not to mention countless sports stars or performing artists who flaunt morally dubious behavior? With such models, is it surprising that he might wish not to grow up as a man? Or that a girl who dreams of higher education and an ambitious career might prefer to become a man when she hears that women are systematically denigrated in our society, and even professional women routinely face salary discrimination and sexual harassment?

It is natural for children on the brink of puberty to doubt their own adequacy as their bodies change, but they don’t yet see themselves as the equal of adult men or women. Homophobic bullying of boys who are not very athletic or of girls who do not conform to normative standards of female beauty can exacerbate these doubts; in some cases, internalized homophobia leads teens to conclude that changing gender can make their life easier [6,33]. Some gay and lesbian activists are troubled by the homophobic rhetoric on many trans-promoting social media venues aimed at teens, where it is not uncommon to find statements like “Better to be a cute boy than an ugly butch lesbian.” For a compilation of such hateful assertions aimed at discrediting lesbian identity in particular, see https://www.genderhq.org/increase-trans-females-nonbinary-dysphoria

However, not all trans and gender-nonconforming people are motivated by attraction to partners of their birth sex; many are asexual, and many start out as heterosexual males who enjoy intimacy with women so much that they come to identify with them (“autogynephiles”), and some start out as heterosexual females who enjoy being around men and prefer to see themselves as male (“autoandrophiles”), in some cases even coming to identify as gay males post-transition. Autogynephilia is more often characteristic of males who first sense gender dysphoria after puberty [58,88].

Those who wrestle with Autism Spectrum Disorder, problems with body image, borderline personality disorder, or other mental health issues are particularly vulnerable at this time of life, and multiple studies establish a significant overlap between these groups and youth with gender dysphoria, as high as 79% of the latter [7-13,125]. One study of adolescent patients referred to a Canadian gender identity clinic revealed that 20% had experienced physical abuse and 10% sexual abuse [125]. Media attention to trans issues and the popularity of trans social media influencers provide an easy framework within which some young people can understand their feelings of social discomfort and difference from the norm. In certain cases, gender incongruity and its resulting “minority stress” may be the root cause of a child’s depression or anxiety as they approach adolescence [14,15]. However, a recent study of trans and gender non-conforming persons in three different generational cohorts established that mental health problems were most frequent among the youngest generation, even though growing up at a time when gender non-conformity is less stigmatized than it was in the past, such that “minority stress” should be lower [16]. In many other cases the child’s self-diagnosis that they are the wrong sex, like many naïve self-diagnoses, obscures the actual causes of their distress over body image, which may relate to more complex systems of family dysfunction, emotional or sexual abuse, and ambient social discourses around gender [59]. Only careful and open-minded exploration with an experienced therapist can clarify the underlying factors behind the mental health issues faced by your teen.

Having a circle of friends that includes trans, non-binary, or gender non-conforming young people can also influence troubled teens to wonder whether this might be an option to improve their life. Even if they don’t connect with such friends locally, online genderqueer communities are very open and welcoming to other young people who feel that they don’t fit in at school. That clusters of trans youth occur in some schools has led critics to speak of “social contagion” [17,18], whereas trans youth advocates counter that having trans or gender non-conforming friends gives questioning young people more courage and social acceptance in claiming a new gender identity, but is not causative in the absence of other predisposing factors. 

Most adult transgender individuals began to feel gender dysphoria well in advance of adolescence: one study showed an average age of 6, and another calculated the average age of onset as 7.9 [89,90]. However, the vast majority (around 80%) of pre-adolescent children who were seen by gender identity clinics in past decades did not go on to become transgender, but eventually came to terms with their male or female identity after going through puberty [19-21,54]. A large proportion of those who do reconcile with their birth sex turn out to be gay or lesbian. There is no certain way of predicting whether a pre-adolescent child with gender-discordant feelings will be part of the 80% or the 20%, but therapists experienced in dealing with such children point to persistence, insistence, and intensity of disgust with one’s body as key measures to consider [20].

Even before taking your child to a therapist, there is much that you can do as parents to help your child clarify and understand gender-related issues. Insuring that you and your spouse display healthy and respectful gender attitudes is of prime importance. Parents who share household duties and refrain from belittling each other provide better models their children will want to emulate. Gender-questioning children are often reacting to something they don’t like in the gendered behavior of their parents or older siblings [4].

Young children often conceive of gender in starkly dichotomous terms and need help in understanding the many shades of gray that complicate the picture: show your son examples of accomplished men who are sensitive poets and artists, and point your daughter to examples of strong professional women who succeed competitively in business, politics, and sports. Do not let them fall into the trap of thinking that all men must be X and all women Y. Since most gender-questioning kids who ultimately decide to stay within their birth gender turn out to be gay or lesbian, it is important to show them positive examples of gay and lesbian role models. Your goal should be to help your child recognize the broad diversity of confident cisgender men and women who adopt different styles of self-presentation. Help them understand that gender is a creative and dynamic spectrum, not a set of mutually exclusive binaries, and that they do not have to change their sex to be unique and gender-creative.

One of the biggest mistakes that some parents make is to push gender-questioning children in the opposite direction by attempting to toughen them up (in the case of boys) or feminize them (in the case of girls). This is usually counter-productive and will shut down conversation. If a girl is uninterested in wearing dresses or learning to use make-up, do not force her to do so; plenty of girls are attractive wearing blue jeans and short hair. If a boy is not very athletic, don’t push him to go out for team sports, but consider other ways to encourage physical exercise such as teaching him tennis or golf.

It is also a mistake to tell a gender-questioning child that they must be transgender or that it is easy for boys to become girls and girls to become boys. One study showed that nearly 40% of 9-10 year olds did not even understand the meaning of the word “transgender” [25], much less how complicated the process of medical transition can be. If, despite your efforts to broaden their understanding of acceptable male and female styles, your pre-adolescent child still insists that they want to be the opposite of their birth sex, it may be time to find an experienced child therapist to help. It is not advisable to let them transition socially or adopt a new name at school until they have been seeing a therapist for some time and the therapist concludes that they are ready for that step. There is no harm in letting them experiment at home with dressing up as the other sex or engaging in cross-sex play with close friends, but more public self-presentation should only be allowed after extended conversations with your child, their therapist, and the rest of the family, as this is a step that is not easily reversible [32], and studies suggest that early social transition does not produce better psychosocial outcomes [22,23,24]. 

Even explicit advocates of allowing children to live as their “authentic selves” rely mostly on anecdotal accounts of happy children, admitting that pre-pubertal children who socially transition show higher levels of anxiety than their peers and are more subject to bullying, and that there is a lack of long-term follow-up studies of those who have socially transitioned prior to puberty [123]. In the words of the Dutch gender clinicians whose pioneering work is regarded as the model even by advocates of early medicalization, “…parents and caregivers should fully realize the unpredictability of their child’s psychosexual outcome. They may help the child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse” [20]. It is probably best to wait at least until they enter high school before considering full social transition.

Finding the right therapist is very important. Do not expect that your child will receive the proper psychological screening and counseling from a gender-identity clinic, especially in the US; most gender-identity clinics in the US are for-profit medical practices that have a quantifiable financial interest in pushing early transition even in cases where a child may not fully understand the side effects and future consequences of life-long medical dependency on hormones. Seek an independent child therapist who has been in practice for at least ten years, has previously dealt with gender-questioning children, and is not biased either in favor of or against medical transition. Be wary of any therapist who advertises they are “gender-affirming,” as this is generally a euphemism for bias in favor of early medical intervention for any child who says they want it; you should also avoid any therapist who says they follow WPATH (World Professional Association for Transgender Health) guidelines, as WPATH is an activist organization that represents the interests of the for-profit transgender medical industry, and its one-sided propaganda has been strongly contested by many experts [26,27]. Some parents have complained that it is impossible to find a local therapist who does not automatically support the “gender-affirming” approach, because therapists fear accusations that they practice “conversion therapy” if they fail to support immediate affirmation [162]; if this is your experience, you may need to broaden your search to include therapists who offer video-counseling, which has become increasingly common since the COVID outbreak. Contact the Gender Exploratory Therapy Association (https://genderexploratory.com/) for referrals; their associated therapists take a middle-road course that avoids bias either for or against transition, but examines the full range of psychological issues that may be causing your child distress.

Make an appointment to talk with the therapist yourself before bringing your child in: ask how many gender-questioning pre-adolescents they have treated and what percentage of them have gone on to medical transition with puberty blockers or hormones. Given that only about 20% of pre-adolescents are likely to persist after puberty and are thus truly in need of medical intervention, you should be suspicious if the therapist says that they have referred a majority of their pre-adolescent patients to a gender-identity clinic. You should also be suspicious if they say that they have never done so. The right therapist is someone who should be able to distinguish which child is in so much distress that they are a pressing candidate for medicalization and which one would benefit from a couple of years of “watchful waiting” to determine whether they still feel the same way after puberty. Online websites that promote youth transition coach children on how to deceive doctors and therapists with the goal of obtaining medical treatment as quickly as possible; an experienced therapist should know how to detect such deception.

If, after reaching the age of 14 or 15, your teen continues to insist that they want to be the other sex and their therapist concludes that this desire is unlikely to change, they may be a good candidate for success in social and medical transition. If puberty blockers are used, they should probably be limited to a brief period of no more than a year, as the side effects of long-term use have been questioned and are in need of further study. As an intermediate stage, you can encourage your teen to experiment with a period of non-binary or genderqueer identity or gender fluidity before embracing irreversible medical changes. Nevertheless, some teens who persist in their cross-gender identification since childhood will be dissatisfied with anything less than full transition.

The “gender affirming” model advanced by WPATH and trans medical providers recommends putting children with gender dysphoria on one of several “puberty blocker” medications, known technically as GnRH agonists, as early as 12. These medications were approved by the FDA in 1993 to treat a relatively uncommon condition known as “precocious puberty,” when children as young as 8 may begin experiencing puberty and face multiple developmental complications as a result. The known side effects of these medications have been judged by the FDA to be less dangerous than leaving precocious puberty untreated. However, these medications have within the last decade frequently been used off-label by trans medical providers to prevent gender-questioning pre-adolescents from experiencing puberty in their birth sex. This is based on the assumption that experiencing puberty in a sex that a child is unsure they want to be is psychologically traumatic. Their proponents claim that the effects of these medications are reversible when and if the child changes their mind and decides to embrace their birth sex.

These medications work by inhibiting the release of primary sex hormones like estrogen and testosterone, such that menstruation and breast development are prevented in girls, genital growth and development of facial or body hair in boys. They are accordingly useful in producing superior cosmetic results for those patients who do persist in going through with full gender transition. Several are on the market, including leuprolide acetate (Lupron/Fensolvi), histrelin (Supprelin), nafarelin (Synarel), and triptorelin (Triptodur/Gonapeptyl/Decapeptyl). Triptorelin is typically injected into the buttocks every 24 weeks, Lupron more frequently (injection site varies). Histrelin is a one-inch implant placed on the inside of the upper arm and lasts up to two years. Nafarelin is a nasal spray that must be used several times a day. Some of these drugs have also been used to treat prostate cancer in men or for chemical castration of sex offenders. These drugs are all shockingly expensive: $12,725 for a three-month injection of Lupron, $19,164 for a single injection of Triptodur, $47,583 for one Supprelin implant. Private insurance will pay for them only if they are deemed “medically necessary.” Some states are beginning to cover them through Medicaid.

The use of these medications for gender transition was pioneered by the gender clinic in Amsterdam as part of a triad known as “the Dutch protocol” (puberty blockers at 12, cross-sex hormones at 16, surgery at 18). The Dutch physicians found that almost all the young people of either sex who started puberty blockers persisted in their gender dysphoria and eventually wanted to continue with hormone treatment; they regard this as a sign that treatment works if preceded by careful psychological screening of patients for suitability [29,30,31]. Similar results were recorded by the UK’s Gender Identity Development Service [142]. However, the Amsterdam clinic was rigorous in requiring months of psychological pre-screening to select which children were optimal candidates for this treatment, whereas most American gender clinics engage in little or no comparable “gatekeeping,” citing a shortage of qualified personnel available to perform the kind of assessment utilized in The Netherlands [28]. Clinicians feel pressured by long waiting lists, and over 70% of the parents of U.S. children seeking treatment have complained about a process that they find “rushed,” with medication often being dispensed in the first appointment [18,28]. Similar problems have plagued the National Health Service’s gender identity clinic in the UK, leading to a new draft guidance that medications should be dispensed only after careful and lengthy mental health evaluation [26]. The original Dutch researchers have observed that the current population of trans youth receiving treatment in the U.S. is very different from the cohort they treated, and that more research is needed to assess how this less carefully filtered population is affected by the use of puberty blockers; in the words of lead Dutch researcher Thomas Steensma, “stop blindly adopting our research” [44].

Critics of puberty blockers are not surprised that most young people who take them go on to hormones. The 80% of gender dysphoric pre-adolescents who desist from their gender dysphoria and reconcile with their birth sex do so only after experiencing puberty in their birth sex; if they are never allowed to experience full puberty in their birth sex, this process of psychological adjustment never has the opportunity to occur. So although puberty blockers are in theory reversible, in practice once the decision has been made to use them few children go back. Parents should not embrace their use if they are just wanting more time for diagnostic decision-making, as the choice to employ them effectively predetermines the decision to continue with gender transition. In the words of Prof. Michael Biggs of Oxford, “Using GnRHa drugs to block puberty does not mean pressing a pause button, . . . it is more like pressing fast-forward into cross-sex hormones and ultimately surgery” [34].

Both critics and proponents of puberty blockers agree that the medications do have known side effects, but disagree over the severity of the problems. One of the most commonly used drugs, Lupron, has a long history of specialist warnings and litigation against the manufacturer. More than 10,000 adverse event reports have been filed with the FDA, including early osteopenia (bone-thinning), cracked spine, cracked teeth, degenerative disc disease and chronic pain, augmented depression, anxiety, suicidal urges, and seizures [35]. Very recently, the FDA has added a warning to the labels of these drugs about the risk of pseudotumor cerebri (idiopathic intracranial hypertension), but this is based on a very small number of cases [46].

The most widely studied concern over these medications has been with regard to impairment of the bone mass development that usually takes place in puberty, resulting in a higher risk for premature osteoporosis and osteopenia in individuals whose age at puberty is later than usual [36]. In the 1990s, Lupron was sometimes used to treat short stature, but the loss of bone density after 2.6-4.4 years of use (comparable to the frequent length of its use for gender dysphoria) was of sufficient magnitude that a 2003 article in the New England Journal of Medicine recommended against its use for that purpose [37]. Numerous more recent studies that focus specifically on patients taking the drugs for “gender-affirming” purposes have also confirmed varying degrees of bone density loss during relatively short follow-up periods, but what is sorely needed are longer-term studies to determine how often this loss in bone density due to delayed puberty results in earlier onset of severe osteoporosis (normally a disease of old age) and bone breakage. Given that these drugs have only begun to be used on large numbers of early adolescents during the last decade, it may be some time before long-term data will be available.

Another area of great uncertainty surrounds the effects of these medications on cognitive development. Some small-scale studies suggest cause for concern: researchers found an average seven point drop in IQ among 25 children who took the drugs for at least two years [38], and an eight point reduction among 15 girls who took them, compared to a control group [39]. Both of these studies pertained to children taking the drugs to deal with precocious puberty; neuroscientists have also documented a case of one male who took the drugs specifically to treat gender dysphoria and saw a nine point drop in operational memory and global IQ [40]. Researchers working with sheep around the time of puberty found that their ability to negotiate a maze was 1.5 times slower after treatment with these drugs, even if the drugs were discontinued [41,42]. Experiments on mice have shown increased stress responses, including excessive random motion in males, refusal to eat and “despair-like behavior” in female mice [43]. More study of cognitive and behavioral issues with larger populations is clearly needed, but the toxic politics surrounding trans identity today makes many researchers reluctant to do work that might contradict the “gender-affirming” narrative.

Other reservations revolve around future sexual functioning. If male puberty is blocked, a boy’s penis will never grow to the necessary size to permit satisfactory vaginoplasty as an adult, since that operation involves inverting the skin of the penis to create a vaginal cavity; this deficiency can in some cases be corrected with further surgery, but with the additional surgery comes added risk of painful complications, as happened to trans reality TV star Jazz Jennings [93]. Some critics also raise the ethical question whether a child can give informed consent to a medication that will deprive them of the ability to have an orgasm when they have not yet ever experienced an orgasm and thus have no basis for judging whether it is an acceptable or unacceptable loss of function [45]. Understanding Consent

Negative side effects such as weaker bones, lower IQ, and loss of sexual function might be deemed acceptable if a drug has proven benefits that improve the patient’s quality of life in other respects. However, the evidence here is also less impressive than we might wish. A few studies have shown some parameters of modest improvement in mental health of adolescents taking puberty blockers followed by hormones [47,48,49], but these studies and others like them have been sharply criticized for small sample sizes, lack of statistical significance, absence of an otherwise equal control group, confusing positive results due to psychotherapy with those from medical treatment, using patient self-report rather than clinical evaluation of mental health, changing questionnaires to produce more positive results, and even suppressing data that suggested no improvement or negative results [34, 50-53,163]. A longitudinal three-year study of 12-15 year-olds by the UK’s Gender Identity Development Service showed no change at all in behavioral indices [142].

Critics have pointed to the fact that drug manufacturers have been asked to obtain FDA approval for the use of these drugs to treat gender dysphoria, but have refused to do so, citing the cost of the necessary studies. Critics construe this as a sign that the drug companies themselves know that their psychiatric effectiveness is unprovable using the randomized trials normally required for approving a drug in the U.S.

Given the lack of long-term follow-up studies of young people who have received GnRH agonists, especially without the careful gatekeeping practiced by the Dutch clinic, the off-label use of these drugs must be regarded as experimental. Medical authorities in both Sweden and Finland, tolerant Scandinavian countries that have long maintained state-funded gender identity clinics, have halted their use, and they have also essentially been halted in the UK until further study has been done and better systems of psychological evaluation of patients can be put into place. These countries have not seen the kind of political partisanship in scientific matters that has distorted debate in the U.S.

Proponents of early medicalization cite the backing of nearly every relevant medical organization in the U.S., including the American Medical Association, the American Academy of Pediatrics, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and the Endocrine Society, as well as the World Professional Association for Transgender Health (WPATH), which is a group formed specifically to represent the interests of practitioners of transgender medicine. With the authority of so many august professional bodies behind it, parents understandably feel reluctant to question the safety, effectiveness, or medical necessity of what they are told about “gender-affirming” care for children.

Critics of the “gender-affirming” model claim that most of these organizations issued statements based on ideological capture of the relevant committees by a small group of activists who were motivated either by ideological commitment to what they perceived as a progressive LGBT cause or by financial self-interest on the part of specialists who already practiced gender-transition medical care. In almost no case did the relevant committees conduct original research or systematic reviews of the available literature, and in many cases the cherry-picked publications their reports did cite were either irrelevant or inadequate to support their recommendations.

One of the earliest groups to make a statement in support of the “gender-affirming” model was the American Academy of Pediatrics (AAP). In 2016, it established a special committee on “LGBT Health and Wellness.” Four of the six members appointed to the committee were already employed at gender identity clinics that had a financial interest in promoting medical treatment of gender-questioning children [55]. The final statement approved by the committee was written by a single member, Dr. Jason Rafferty, who was one of the four practitioners already engaged in transgender medicine; the report was therefore in no way a neutral document or untainted by serious conflicts of interest. The report was the subject of a devastating review by Dr. James Cantor, a prominent clinical psychologist, Director of the Toronto Centre for Sexuality, and former editor of the journal Sexual Abuse. Cantor, who is himself openly gay and certainly no transphobe, examined in detail every one of the report’s citations and concluded, “Remarkably, not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them” [54]. Neither Rafferty nor anyone else at AAP has responded to Cantor’s critique of their work, and Rafferty has also refused to respond to a journalist who wanted to interview him about it [55].

The medical associations piggyback on each others’ statements. The American Medical Association (AMA) co-authored its issue brief with an otherwise little-known activist group called GLMA: Health Professionals Advancing LGBTQ Equality. As support for its contention that medication and surgery produce better mental health outcomes for youth, the AMA cited exactly the same three studies as the earlier AAP report, in the same order [52]. As Cantor and others have noted, these three studies give no useful outcome data at all. The American Psychiatric Association’s “Position Statement on Treatment of Transgender (Trans) and Gender Diverse Youth” gives no citation whatever to support its claim of “notable gains in psychosocial and emotional development” due to puberty suppression and other “trans-affirming treatments” [52]. The statement from the American Academy of Child & Adolescent Psychiatry was primarily to oppose state efforts to ban “evidence-based care for transgender and gender-diverse youth,” but it also gives no actual evidence that medical treatment with puberty blockers, hormones, and surgery produce better mental health outcomes, instead citing studies about family support [52].

As for the Endocrine Society (the professional association representing hormone specialists), no one should be surprised that it would support more opportunities for prescribing hormonal medications. The recent upsurge of both children and adults wanting gender transition has been a major boost to business for endocrinologists. It should be noted that pediatric endocrinology has traditionally been one of the lowest paid medical specializations, indeed the third lowest of all according to a survey by Doximity [56]. Generally, a medical specialization is lower paid if it is in less demand, requires a narrower base of knowledge and fewer special skills, and poses less risk for insurers. Patients who transition are cash cows who will have to keep coming back to an endocrinologist for the rest of their life. Can anyone imagine that the professional association that represents the interests of this otherwise small and poorly paid specialization would discourage such a lucrative opportunity to expand its market?

The role of the pharmaceutical industry in promoting “gender-affirming” medicine must also be noted. Puberty blocking drugs are very expensive, with a list price of $12,725 for a three-month injection of Lupron, $19,164 for a single injection of Triptodur, $47,583 for one Supprelin implant. These prices are far in excess of what most families can afford, particularly if one starts puberty suppression around the age of 12 and maintains it until 16, as recommended by the “Dutch protocol.” Private insurance will pay for these treatments only if the insurance company can be convinced that they are “medically necessary.” This is why endorsement of puberty suppression by a series of major medical associations is so important to both gender-identity clinics and drug manufacturers. There is a tremendous amount of money to be made from these expensive drugs, and to the extent that private insurance and Medicaid will cover them, we all pay for it. The manufacturer of Lupron was so desperate to create a market for this high-priced drug that it engaged in unethical and fraudulent practices, leading to a record $875 million settlement with the U.S. Department of Justice [57].

In countries like Sweden, Finland, and the UK, where health care costs are socialized and most physicians paid by the state, a more cautious approach toward medicalizing gender-variant youth has now taken hold. The medical system in the U.S., however, is mostly for-profit and pharmaceutical companies do not face the same degree of price regulation. Cynics say that we should follow the money and evaluate who gains from the invention of new medical problems and medical procedures for dealing with them. 

The possibility of suicide for teens with gender dysphoria is cited by many as the reason to begin medical transition at as early an age as possible. Advocates persistently refer to gender-affirming medicine as “life-preserving” care and the only sure way to fend off an early death through suicide [61,63,64]. A common refrain of trans activists asks, “would you rather have a dead daughter or a living son?” [66]. The actual facts are far more complex and suggest that suicide may be almost as common after medical treatment as before. 

The percentage of gender non-conforming people who ideate, attempt, and commit suicide appears to be high in several studies. In a frequently cited 2018 study of US students, the rates of attempted suicide among trans and gender non-conforming adolescents ages 11-19 are 50.8% for female to male trans youth, followed by non-binary identified youth (41.8%), male to female trans youth (29.9%), and questioning youth (27.9%). This is substantially higher than the 17.6% rate for female adolescents and 9.8% for male adolescents overall [62]. However, this survey fails to distinguish between young people who are receiving medical treatment for their gender dysphoria and those who are not, so it really provides no information on the utility of gender-affirming care; many of the suicide attempts come after receiving gender-affirming treatment, once the young person realizes that it does not solve their problems. Meanwhile, some opponents of gender transition use the data on suicidality to assume the inherent psychopathology of gender diverse people and the redundancy of any and all gender-affirmative care [60].

However, there are significant reasons to doubt that actual suicide among gender variant teens is so common [65]. Suicide attempts were recorded with only one question in the 2018 survey: “Have you ever tried to kill yourself?” This is a problem, because incidents of non-suicidal self-injury (NSSI), i.e. self-injury inflicted without true lethal intent, are often self-reported as suicide attempts. Some teens who demand immediate medical transition and face parental resistance or delay will undertake a NSSI in an effort to manipulate their parents into acquiescence; trans-promoting social media even advises them how to do so without actually risking death. Suicide attempts and NSSI overlap, but are two distinct behaviors [24,25]. Studies show that asking about suicide multiple times and in slightly different ways lowers odds of over-estimation and confusing NSSI with sincere attempts [69,71].

The “mischievous responder” is also a common problem when relying on written in-school surveys of teenagers like this one, especially on topics pertaining to unpopular minorities. Straight and cisgender teens sometimes pretend to be other sexual and gender identities on surveys to perpetuate stereotypes or out of a sick sense of humor. In-person follow-up studies on teenagers often reveal much inaccurate reporting [67,68]. 

A different survey conducted by the Williams Institute at UCLA has a number of advantages compared to the 2018 survey: it did not rely on a convenience sample, but used trained interviewers who spoke with each teen over the telephone and measured for suicidality through multiple questions phrased in slightly different ways. It also differentiated by degrees of gender nonconformity [70]. In this study, only 3% of adolescents ages 12-17 whose peers perceived them as highly gender non-conforming reported having ever attempted suicide. It is likely that most of the teens who self-identified as trans were included in this category [70].

Of course, suicide attempts and NSSI are much more common than deaths by suicide. Without dismissing the severe pain and distress that accompany attempts at suicide, it is estimated that there is one death by suicide in adolescents for every 100-200 attempts or NSSI incidents, while 70% of attempts are not followed by any further attempts (23% reattempt non-fatally) [26,27]. In short, the rhetoric that children and teens with untreated gender dysphoria are at intense risk to their own lives is exaggerated.

Suicide research is tricky, as is research into transgender and gender non-conforming populations, which needs to account for the degree to which a person identifies with the other gender, the amount of dysphoria they experience, and what stage they are in their transition (if they are transitioning). Also relevant are the other mental health and socio-economic concerns that often accompany gender nonconformity. For example, approximately 35% of young people referred to the UK’s Gender Identity Development Service presented with moderate to severe autistic traits [72], and this is supported by findings which show a significant link between autism and gender diversity [13]. A recent Danish study shows that people with autism spectrum disorder (ASD) were three times more likely to attempt suicide than those without ASD [73], so the overlap between autism and gender non-conformity may be the source for much of the higher rate of attempted suicide.

Other comorbidities associated with gender diversity and gender dysphoria include anxiety, depression, drug and alcohol dependence, PTSD, and eating disorders [74,75,76], all of which increase the risk of suicide. It is difficult to tell how many of and to what extent these comorbidities may actually be caused by gender incongruity or may predispose troubled young people to falsely attribute their problems to being the wrong sex. 

Several studies have been cited by advocates of early medical treatment of gender dysphoria, but each of these has limitations. For example, one study did not use a control group and failed to distinguish suicidal outcomes before and after treatment, meaning there is no way to know whether gender-affirming medicine produced any improvement [48]. Other studies used a control group, and compared the mental health of gender dysphoric youths who received puberty suppressors against gender dysphoric youths who did not [30,47,78]. However, these studies are flawed, in that gender dysphoric youths whom clinicians believed had psychiatric comorbidities were refused puberty suppressors. Thus, those on puberty suppressors were already in better mental health than those who went without, blurring any causal link between gender-affirming medicine and positive outcomes [79].

Other issues with these sources include ungeneralizable samples, losing more than half of participants before the research was concluded, not controlling for counseling or prescribed psychotropics, and not even discussing gender-affirmative medicine at all [29,80,85,86]. Some studies do show that some cross-sex hormones have an effect on suicidal ideation and attempts, though this is likely to have less to do with alleviation of gender dysphoria and more to do with documented effects of the hormones themselves [49,80]. For example, female to male trans people who took testosterone exhibited less distress and fewer suicidal outcomes. Male to female trans people who took estrogen, however, experience somewhat less distress, but they were more likely to plan, attempt, and become hospitalized from suicide attempts [87]. A three-year longitudinal study of 44 children aged 12-15 who were prescribed the puberty blocker triptorelin by the UK’s Gender Identity Development Service showed absolutely no change in the rate of self-harm or other behavioral indices [142].

While there are numerous cases where gender affirmative care, even in adolescents, can play a role in alleviating distress and fostering a sense of personal authenticity, there is little to suggest that transitioning alone has any effect on the rate of gender-variant teenage suicide, nor does early treatment lead to superior outcomes. According to a long-term follow-up survey of Swedish trans people who have undergone sex reassignment surgery (SRS), those patients were at an even higher risk of suicide and suicide attempts [77]. A Dutch study showed that suicide rates among transgender people in treatment stayed mostly the same, with a slight decrease among transwomen. However, it was still notably higher than the general population, and suicide could occur at any stage of the transition process [29].

The vast majority of transgender adults say they first began to recognize their discomfort with the sex into which they were born before the age of 14: 93% in one study, 95-96% in another [89,90]. However, other studies have suggested that nearly half of male-to-female transsexuals saw “later onset,” but that concept is not always clearly defined in terms of a specific age  [91,92]. An online survey by the National Center for Transgender Equality, with over 27,000 responses, found that 13% first felt their gender was different from that assigned at birth between the ages of 16 and 20, but is of limited usefulness because it lumped adolescent 14-15 year olds together with pre-adolescent 11-13 year olds and failed to distinguish between natal males and females [104]. If your child has never shown cross-gender behavior or interests before puberty, but subsequent to puberty comes forward and tells you they feel they are the other sex, it could be because they did a good job of hiding or repressing their earlier feelings, but it could also be that they are expressing discomfort with the emergence of puberty itself. The influence of friends and social media may play a role as well. Having your child work with an experienced gender therapist can help clarify the origins, depth, and likely persistence of a newly announced gender preference. See our advice on choosing the right therapist here.

Most of the adult trans women who say they first recognized a desire to be female after going through puberty as males are of the “autogynephilic” variety [58,88]: in other words, they were never gay as adolescents, but were attracted to girls and wanted to be like the girls to whom they were attracted. Traditionally, most trans men have recognized their gender incongruence much earlier in childhood [89-92]. Accordingly, the exponential increase in adolescent female patients who are presenting themselves at gender identity clinics over the last decade [94-97], often with no history of cross-gender identification prior to adolescence, strikes many observers as inconsistent with historical trends. Prior to 2010, natal males seeking transition outnumbered natal females, and they still do among pre-adolescents and adults. However, the UK’s Gender Identity Development Service, which maintains the largest database, reports that 68% of the adolescents (ages 12-18) who presented themselves for transition from 2009-2016 were natal females (up to 72% in 2016); clinics in Amsterdam and Toronto have reported similar figures.

Scholars have been puzzled by this recent development. One article suggested tentatively that more adolescent girls than boys may be transitioning now because gender behavior is more rigorously policed among adolescent boys than girls [94], but such behavioral expectations have not grown more rigid since 2010 (if anything, the opposite is the case) and the number of adolescent boys seeking transition has also increased substantially in absolute terms, just not as much as for girls. If intolerance of feminine behavior in adolescent boys were a major factor, it should have been just as much or more of a factor in previous generations, when adolescent boys were more numerous than girls in seeking gender transition. 

Many have pointed out that adolescent girls are more susceptible to social influences, and that this trend has accelerated since the widespread use of social media by adolescents beginning about 15 years ago. Youtube “vloggers” celebrating their euphoria in the aftermath of transition provide appealing models for unhappy adolescents who seek an easy answer to explain their own unhappiness [135]. It has long been recognized that females are far more affected by negative perceptions of their body image [98], eating disorders [99], non-suicidal self-injury [100], and mass psychogenic illness [101,102], all of which are harmful behaviors or ideations that they now find modelled and spread through social media. Long before the internet and social media, the prominent psychoanalyst François Sirois documented 45 outbreaks of bizarre behaviors or beliefs that suddenly appeared among groups of adolescent schoolgirls in both Western and non-Western societies, and classified these as forms of “collective hysteria” [101]. Conforming with narratives and obsessions that circulate among other girls of their age provides a sense of belonging and solidarity that some teenage girls otherwise lack.

Given the emergence of trans identity in minors as a popular topos celebrated in mass media since about 2010 and its appropriation as the new focus of LGBTQ institutional organizing after the acceptance of gay marriage, some scholars and clinicians suspect that it has become for the last decade what anorexia and bulimia were for the 1980s, false “recovered memories” of sexual abuse for the 1990s, or “hysteria” for the late 19th century: an unhealthy, obsessive, and even unconscious form of female adolescent abreaction to a patriarchal society’s expectations, suggested in each case by media visibility of a previously unknown or rare psychological diagnosis [103].

In an influential article published in 2018, Prof. Lisa Littman of Brown University coined the term Rapid Onset Gender Dysphoria (ROGD) to describe the increasingly common phenomenon of teenage girls who had no previous history or signs of discomfort with their birth sex suddenly announcing that they were boys [18]. This article reported on a survey of 256 parents who reported that their children (82.8% natal female, average age of 15 at onset) had suddenly reported an interest in gender transition; 83.5% reported zero objective indicators of gender dysphoria during earlier childhood, and none reported a sufficient number of indicators to justify a clinical diagnosis of childhood gender dysphoria. Parents suspected that recent social contagion was a causative factor: 63.5% of these parents reported that their teen’s announcement of wanting to transition was preceded by an increase in social media use. The teen’s friend group included an average of 3.5 other peers who were trans, although it may not be surprising that young people who think they might be trans would seek out other trans friends. The parents who participated in this survey were mostly well-educated and supportive of LGBTQ rights, but sceptical of rushed medical transition for their teen.  A similar study of Scandinavian parents and clinicians largely replicated Littman’s findings [108].

Littman’s article was sharply attacked by transgender activists, who deny the existence of ROGD; they point out that the parents were all recruited through explicitly anti-transition websites and complain that the study did not include the perspectives of the adolescents themselves [105,106]. Sample bias is a reasonable objection, but the critics of Littman’s research have so far failed to produce any counter-studies showing that most girls who first manifest gender dysphoria as teens had actually suffered from it as pre-adolescents or had come to recognize it gradually. As such, “rapid onset” would seem to be an apt descriptive term for this group. Although Littman’s 2018 study did not aim to survey adolescents themselves, her subsequent 2021 article examined the testimony of detransitioners: 55% of the natal females who later detransitioned reported their onset of gender dysphoria as post-puberty, consistent with the ROGD paradigm [107]. 

This newly emerging population of natal females who first recognize gender incongruence in adolescence is different from those whose gender dysphoria emerges pre-adolescence and is also different from autogynephilic males whose gender dysphoria has long been known to emerge in adolescence or adulthood. Data about the benefits or harm of medical transition garnered from those groups may not apply to this newer population of gender-questioning girls. That gender dysphoria emerges late or with apparent suddenness does not necessarily invalidate its reality or authenticity. In the absence of more complete data, every case needs to be evaluated individually and carefully by an open-minded child therapist who is not predisposed to bias either for or against medical transition. The more you study both sides of the debate, talk with your teen about their motivations, and discuss with them what you have learned about the science, the better you can help them clarify their feelings before making life-altering decisions. It is best to be emotionally supportive and not foreclose future options, but also not to feel pressured to seek a medical solution until you are sure it is in your child’s best interest.

“Detransitioning” occurs when a person who has socially, legally, and/or medically transitioned reverts back to identifying and presenting as their natal sex [109]. Just as there are different ways to transition, there are different ways to detransition. Many people cease taking hormones, some apply to have their original sex restored on their legal documents, others seek surgery to undo any sex-changing procedures they might have had. People who detransition are referred to as “detransitioners,” not to be confused with “desisters” (children with gender dysphoria that fades after puberty).

Detransitioning is an understudied and contentious phenomenon, but we can say that it is very heterogeneous. People may detransition for various reasons which can, according to Expósito-Campos (2021), be divided into two categories: core/primary reasons (internally motivated), and non-core/secondary reasons (externally motivated) [110]. Core reasons include finding other ways to manage gender dysphoria, gender dysphoria going into remission over time, realizing that transition did not improve one’s happiness or that other mental health issues in one’s life were obscured by the diagnosis of gender dysphoria, etc. Secondary reasons include experiencing discrimination against one’s trans identity, difficulty finding a job, pressure from family members/religious advisors, desire to become a parent, dissatisfaction with the results of treatment, etc. Those who detransition often report hostility from the LGBTQ+ community, in large part for supposedly playing into the hands of anti-trans parties who dismiss transgenderism as a brief phase of confusion [111].

The percentage of trans-identified individuals who detransition is disputed because studies look at different populations and use different criteria for what constitutes detransition. Trans activists claim that detransition is exceptionally rare and media coverage of the issue is politically motivated and transphobic [112]. They often cite a study of Swedish transgender people which found that only 2.2% chose to revert back to their original gender identity [113]. However, this 2.2% is only based on people who applied for full surgical and legal sex reassignment, and then made a formal appeal to have their legal gender restored back to their natal sex. This figure does not encompass those who detransitioned before total surgical and legal sex reassignment, nor does it include those who did undergo total surgical and legal sex reassignment and chose to detransition without making a formal appeal to have their legal sex designation changed back to its original form, making 2.2% a considerable underestimate [65].

Additionally, the average age of transition during this time period was well into adulthood (27 for FtMs, 32 for MtFs), and Swedish law required that for a person to be eligible for legal and surgical sex reassignment, they needed to have felt that they were a member of the other sex since youth, lived for a significant amount of time in that gender role, and anticipated living in that gender role throughout their future lives. These strict criteria were in effect for the entire length of the period examined [113]. This study is thus incomparable to the situation today, when so many adolescents are requesting gender affirming medicine in a medical system which calls for much less screening and gatekeeping.  A very recent study specifically of adolescents who requested gender-affirming medical treatment over the last decade found that 29% changed their mind, in some cases more than once [167].

A U.S. survey of the transgender population reports that out of 17,000 people who pursued gender-affirming treatment , 13.1% reported detransitioning, mostly due to external pressure (what Exposito-Campos calls a “secondary” cause); only 15.9% of those said it was due to internal doubts (a “core” reason) [121]. However, this study was conducted exclusively on people who continued to identify as trans in some way, whereas most of those who detransition due to disillusionment no longer identify as trans at all and have disconnected completely from the trans community. Detransitioners typically discontinue seeing their clinicians and are thus unavailable for follow-up, so many of those who detransition are counted by clinicians as people who have successfully transitioned [114].

A study of 237 individuals who actually consider themselves detransitioners showed opposite results, with only 10% saying that discrimination was a factor in their decision, but 70% saying they eventually realized that their feelings of gender dysphoria were really caused by other issues [111].  A different survey of 100 people who have detransitioned found that 23% did so as a result of anti-trans discrimination, while 60% reported their reason as becoming more comfortable with their natal sex. In addition, 55% believed that they did not have proper evaluation before transitioning [107]. However, this latter survey has its own sampling bias, as the respondents were largely recruited from ideologically-rooted online Reddit forums such as r/GenderCritical and r/DysphoricWomen, as well as through snowball sampling, whereby participants send the survey to their acquaintances, usually those of a similar frame of mind [115].

The most recent study, rather than trying to track down individuals, examines pharmacy records in the U.S. Military Healthcare System, covering spouses and children as well as active-duty and retired members of the military. It found that only 70.2% of those who began hormone medications were still seeking refills within four years, suggesting a much higher rate of detransition; the rate for trans men was even lower, at 64.4% [164]. However, this may overestimate the rate of detransition, as some of these families may have left the military or switched to different healthcare systems to obtain their medication. Nevertheless, this study is based on an unbiased sample and probably comes closer to the true rate than any of the earlier ones.

Systematic, large-scale studies of the current population of detransitioners are still lacking, though studies on transgender patients throughout the late 20th century have found a few characteristics common among those most likely to regret transitioning. For MtF trans women, regret was associated with a late onset of intermittent gender dysphoria and heterosexual experiences [116], though sample sizes were small and results were inconsistent.

According to another older study, regret over sexual reassignment surgery was least common amongst same-sex oriented natal males and natal females [117]. Over the last several years, those seeking to detransition have been disproportionately female. 69% of detransitioners in the above referenced survey of 100 detransitioners were natal females, as were 92% out of 237 participants in a later study; about half had transitioned as adolescents [107,111]. In an interview with Sky News, founder of the The Detransition Advocacy Network Charlie Evans (pseudonym) claimed that most of the detransitioning women she encounters are same-sex attracted females in their mid-20s [118], and many of the most popular online support and resource centers, such as Detrans Voices, the Pique Resilience Project, and Detrans United, are primarily led by detransitioned women. Post Trans is a site exclusively dedicated to sharing the testimonies of females who no longer identify as trans. See also Detransition Advocacy Network if your teen or adult child needs support in detransitioning.

A general sketch of the characteristics of these young women, what inspired them to transition, and what inspired them to detransition can be drawn by looking through the numerous testimonies they are sharing. According to two anonymous detransitioners, a common experience they hear when communicating with others like them begins with gender non-conforming behavior in girlhood and same-sex attraction. Often, they grow up in very conservative and heteronormative communities with rigid gender roles [119].

Many factors influenced their dislike of their female bodies. Primary among these are sexism against women and expectations that they submit to male authority. Many trans-identified girls have a high level of intelligence and are prone to questioning orders. Many are also on the autism spectrum and less aware of social codes. Sexual assault and abuse are common factors as well, and many say that feelings of vulnerability after traumatic abuse played a role in their urge to disassociate from their female identities [119].

The authors of these detransition accounts write that each stage of transitioning is accompanied by brief periods of euphoria that do not last, leading to a desire to further speed up the transitioning process. Finally, many realize that transitioning is not helping them feel more comfortable with their lives or their bodies, after which they feel trapped and lost. Barriers to detransitioning include the fear of antagonism from their transgender peers, as well as “seeming like a confused failure to the majority population” [119].

It is unclear whether all of these experiences can or should be analyzed through the lens of Rapid Onset Gender Dysphoria, though the framework may provide a rough outline that can help us make sense of some of the common themes. As we have noted, many if not most of these detransitioning women are same-sex attracted and have a “tomboy” personality.  Multiple testimonies claim that their dysphoria typically began during puberty with the adoption of a trans identification in their mid-teens, and the desire to transition intensifies after heavy exposure to transgender internet personalities and forums which celebrate the tremendous healing power transition can provide.

Lastly, according to numerous personal statements found in a 2019 book, many report that after mentioning feelings of dysphoria to a physician or a therapist, they felt rushed into the process of beginning gender-affirming medicine and were not encouraged to explore any of their other problems. Gender dysphoria was identified as their primary source of pain and transitioning as its ultimate solution [119].

In short, many trans activists claim that regret after transitioning is very rare, and the few people who choose to detransition mainly do so as a result of pressure from family and stigma from society [120,121]. One study concludes, based merely on interviews with 11 clinicians, two administrators, and nine trans patients, that detransitioning is an “unpredictable and unavoidable clinical phenomenon,” and suggests no need for more refined assessment techniques to single out only those likely to be helped by gender-affirming medicine [122].

The loss of disillusioned patients to medical follow-up by clinics makes it impossible to achieve a reliable count of how many people detransition and how many regret that they transitioned in the first place. What we can surmise, based on the sharp increase in historically atypical adolescent female patients who obtain transgender medical treatment with little or no gatekeeping, is that many will eventually conclude transition was not the panacea they thought it might be. It should not be an affront to those with a transgender and gender non-conforming identity if we open our ears to detransitioners and hear how they thought transitioning was going to help them and what they experienced when they realized that it didn’t. We should all agree that we want to see as few cases of detransition as possible; understanding those who have detransitioned forms an important part of the future development of more selective and careful diagnostic practices

How does the mental and physical health of fully transitioned adults fare in the long-term, compared to the cisgender population and compared to trans people who have not received gender affirming care?

Evidence suggests that there are many gender dysphoric people for whom transition is the right choice in their lives. According to one study of 62 transgender Dutch-speaking Belgians who underwent sex reassignment surgery between 1986 and 2001, participants generally saw a positive change in their family and social lives: 86.9% felt happy to very happy after surgery [143]. Rates of suicide attempts decreased from 29.3% before surgery to 5.1% after surgery, though this is still 34 times the suicide attempt rate in the general population (0.15%). Some of the factors associated with positive outcomes that the authors cite are a homosexual orientation, younger age at first consultation, and credibility in their new gender. Those diagnosed with psychiatric problems prior to surgery retained symptoms and felt less satisfaction with their surgeries. 

However, in this study, over 40% of participants were lost to follow-up, and the more time that had passed since the surgery, the lower the response rate. Most of those who could not be reached were MtFs who had moved away. If those who were lost to follow-up were analyzed in this study, it is possible that poorer outcomes would have been found, as according to another study of  transitioned suicide victims, over a third were no longer coming in for treatment [144].

It is also important to mention that even though the authors point out that a younger age at first consultation was associated with better outcomes, nearly all of the respondents were well into adulthood when they initiated gender therapy: 35.6 (SD 9.2) for MtFs and 23.5 (SD 5.6) for FtMs. Furthermore, on average the time between first consultation and sex reassignment surgery was 2.1 years for MtFs and 3.9 years for FtMs [143]. This makes this study less applicable to the current situation with the steep increase in adolescents receiving gender affirming care. For instance, U.S. patients ages 6-17 with a gender dysphoria diagnosis increased from 15,172 in 2017 to 42,167 in 2021, while those receiving hormone therapy for gender dysphoria increased from 1,905 to 4,231 [145]. For this reason, it is difficult to predict how many people undergoing gender transition today will benefit based on studies of transitioned populations in the past.

In one meta-analysis of 28 studies of transgender individuals who have undergone hormone therapy and sex reassignment surgery, significant improvement was reported in gender dysphoria (80%), psychological symptoms (78%), quality of life (80%), and sexual functioning (72%). Again, early onset of gender dysphoria and a homosexual orientation were linked with better outcomes, and participants with pre-existing mental illnesses tended to fare worse. The authors note that this evidence is of low quality due to the studies’ lack of bias protection measures, reliance on self-reports, and non-standardized methodologies, though still it suggests that gender-affirming care has the potential to help many people in various aspects of well-being [146]. But it needs to be used with extra caution in cases where other psychiatric issues are present.

A study of Danish transgender people who have undergone sex reassignment surgery had more mixed results. It was found that there was no significant difference in psychological morbidity diagnosis before sex reassignment surgery (27.9%)  and after (22.1%). However, only 6.7% of participants were diagnosed with psychological morbidity both before and after surgery. The authors conclude that sex reassignment surgery may improve the mental health of some people while aggravating it in others [147].

It is important to remember that with or without gender-affirming medicine, transgender people are a vulnerable demographic. In a Swedish total population study, it was found that people with a gender incongruence diagnosis were about six times more likely to have a mood/anxiety-related health care visit compared to the general population, as well as over three times as likely to have a prescription for psychotropic medicine for treating depression and anxiety, and more than six times as likely to be hospitalized after a suicide attempt [148].

The authors note that the amount of treatment a population receives is not perfectly indicative of their actual mental health, as people in consultation for gender dysphoria are already in a clinical setting where other mental health treatments may be more visible. Hospitalizations after suicide attempts, on the other hand, are likely not subject to this bias. The study did find, however, that while the amount of mental health treatment did not decrease with time since initiating hormone therapy, it did decrease with time since the last gender affirming surgery, suggesting that some types of gender-affirming care may work better than others [148]. It could also mean that those trans people who go so far as to have sex reassignment surgery were more entrenched in their gender dysphoria and more likely to benefit from transitioning.

Physical health, meanwhile, should not be ignored when making personal decisions, even if they are decisions made for the betterment of one’s mental health. The most common form of gender-affirming medicine is transgender hormone therapy, also known as hormone replacement therapy. Hormone therapy for trans women involves estrogens and antiandrogens, while for trans men it involves androgens and antiestrogens. As androgens and estrogens are entirely different substances, their effects on physical health must be looked at separately.

According to multiple studies, trans women on hormone therapy were at a higher risk of strokes and venous thromboembolism (VTE) than both cisgender men and women [149-151,159]. Patients who took more natural estrogens instead of ethinyl estradiol (a chemical linked to cardiovascular problems) were not at a higher risk of VTE than the general population, but risk of stroke remained disproportionately high [149].  

A recent literature review similarly showed that trans women were at a higher risk of ischemic heart disease including myocardial infarction, ischemic stroke, and pulmonary embolism [150]. Trans women are also at a much higher risk of breast cancer than cisgender men, but not as much as cisgender women [160]. Another study listed osteoporosis as a risk, and also found that 6% of trans women in their sample experienced a thromboembolic event and 6% experienced cardiovascular problems after an average of 11.3 years on hormones, even after controlling for patients who took ethinyl estradiol [151].

Compared to trans women, this particular study did not find any hormone-related cancers, cardiovascular events, or osteoporosis in trans men. However, this increased morbidity in trans women compared to trans men may partially be explained by trans women’s lifestyles, including higher rates of smoking. Also, trans women in this study were on average 6 years older than trans men at the time they began treatment, meaning that they were on average 6 years older at the time of this study, which could account for their higher morbidity [151].

Nevertheless, trans men do seem on average to be at a lower risk of adverse effects from transgender hormone therapy, though it is not free from danger. Hormone therapy in trans men has been linked to an increase in TGL, LDL-C (bad cholesterol) and a decrease in HDL-C (good cholesterol), especially after the two year mark, and some studies also connect it to increased blood pressure [150]. According to The World Professional Association for Transgender Health (WPATH) in its “Standards of Care—Eighth Edition” (SOC-8), trans men on testosterone treatment may be at increased risk of cardiovascular events, increased high blood pressure and excess weight. It also increases red blood cell count, which can potentially lead to blood clots [152]. A study based on CDC data showed that trans men were at twice the risk for heart attacks as cisgender men, and four times the risk as cisgender women [161].

One of the side-effects of hormone therapy that affects both trans men and trans women is decreased fertility [152,153]. Fertility and reproduction are deep concerns to transgender individuals, as, like cisgender people, many of them long to have children [154]. Hormone therapy does not always lead to complete and irreversible infertility, though it can make it harder to conceive, and for trans men, because of testosterone’s potentially negative effects on the fetus, the SOC-8 recommends temporarily discontinuing hormone therapy before and during pregnancy [152].

Reproductive options for trans men on hormones include embryo cryopreservation, oocyte cryopreservation, and ovarian tissue cryopreservation, while for trans women there is sperm cryopreservation, surgical sperm extraction and testicular tissue cryopreservation [155]. These procedures are all expensive and may not be covered by insurance. Genital reconstructive surgeries, on the other hand, lead to permanent infertility and should be very carefully considered beforehand.

Gender affirming surgeries in general are much less reversible than transgender hormone therapies, though they are not more likely to increase morbidity and poor overall physical health, as, unlike ongoing cross-sex hormone therapy, gender-affirming surgeries take place within a single day. Adverse physical effects of gender affirming surgeries are usually the result of complications. For vaginoplasties, these include stenosis with an incidence rate of 12%, followed by vaginal necrosis (range, 2.7%–4.2%), clitoral necrosis (range, 1%–3%), genital pain (range, 3%–9%), rectal injury (range, 2%–4.2%), rectovaginal fistula (range, 0.8%– 17.0%), neovaginal prolapse (range, 1%–2%), urethral meatal stenosis (range, 1%–6%), change in voiding function (32%), urinary incontinence (19%), wound dehiscence (range, 12%–33%), local abscesses (5%), and hematoma (3%) [156].

               Incident rates of complications after phalloplasty differ depending on the type of procedure but they include urethral fistula which can occur in <10% to 55% of surgeries, depending on the study, as well as urethral strictures (range, 2.56%-64%), and stiffener related complications (30%) [157]. According to one study, mastectomies can result in persistent (though usually mild pain) in just over a quarter of all operations, as well as sensory disturbances (47.5%), and neuropathic pain (4.8%). Other complications include hematomas (7.8%), and areola necrosis (4.4%) [158]. Complications from gender affirming surgeries are usually not life-threatening and most are fixable, though they can have a negative impact on overall quality of life by causing problems such as discomfort, decreased sexual sensation, and a personally unsatisfying aesthetic appearance.

Ultimately, the outcomes (both physical and mental) for transitioned people in adulthood are wildly different, based on everything from pre-existing psychiatric comorbidities to peer and family support to the final results of the gender-affirming surgeries. As such, there is no way to say for sure how medical transition will or will not benefit an individual with gender dysphoria. Mental health outcomes are even more uncertain, since rigorous psychological screening and counseling are less common for the growing number of young people seeking to transition today than they were at the time of these long-term outcome studies. 

Reasonable people support balanced discussion of the complex issues surrounding gender transition in high school and even in intermediate schools, when young people are often troubled or confused by what is happening to their bodies during puberty. It is not inappropriate to include in high school libraries books like Maia Kobabe’s graphic novel Gender Queer: A Memoir (2019). However, discussion of these issues in early childhood is more controversial even among sex-positive educators. Within the last several years, a spate of picture books centering around trans child characters have been published, aimed at primary school students in the early grades: these include titles such as Jacob’s New Dress (2014), Gracefully Grayson (2014, published by Disney-Hyperion), George (2015, published by Scholastic), Jamie (2015, based on the Cinderella story), Introducing Teddy: A Gentle Story about Gender and Friendship (2016), Are You a Boy or Are You a Girl? (2017), Being Me in Penguin Land (2017, offered in separate Trans Boy, Trans Girl, and Non-Binary versions, all intended to be read to 3 to 6 year olds), Julián Is a Mermaid (2018), They, She, He Easy as ABC: Understanding Names, Pronouns, and Gender Expression (2019, for Kindergartners and pre-K), Calvin: Time for Me (2021, for grades K-2), Born Ready: The True Story of a Boy Named Penelope (2021), and Sam Is My Sister (2021).

Trans activist organizations have put great effort into developing materials designed for elementary educators to use in creating a more inclusive classroom. For examples, see the websites of these organizations:

Human Rights Campaign: https://welcomingschools.org/resources/lesson-plans-gender-identity-transgender-non-binary and https://assets2.hrc.org/files/assets/resources/Schools-In-Transition.pdf?_ga=2.267617610.51438947.1531573378-1996494569.1530396495

Gender Identity Research & Education Society: https://www.gires.org.uk/classroom-lesson-plans/

Stonewall: https://www.stonewall.org.uk/lgbtq-inclusive-books-children-and-young-people and https://www.stonewall.org.uk/resources/introduction-supporting-lgbtq-children-and-young-people

Gendered Intelligence: https://genderedintelligence.co.uk/professionals/education.html

Gender Spectrum: https://genderspectrum.org/articles/educator-resources

Educate and Celebrate: https://www.educateandcelebrate.org/

Allsorts Youth Project:

https://www.allsortsyouth.org.uk/content/uploads/2020/11/Trans-Inclusion-Toolkit-for-Schools-2019.pdf” https://safeschoolsallianceuk.net/wp-content/uploads/2020/11/Trans-Inclusion-Toolkit-for-Schools-2019.pdf

The extent to which these materials have been adopted in elementary school libraries and classroom instruction has never been systematically surveyed, but the fact that they exist in such abundance does indicate a deliberate program by influential organizations to encourage the presentation of these topics from the earliest grades, which has led to political backlash in Florida and some other US states that ban such instruction earlier than the fourth grade. Progressive educators defend the use of these materials to make schools a more welcoming environment for gender-variant children and to promote greater tolerance of trans children by their cisgender peers. Opponents, such as children’s literature and gender studies scholar Susan Matthews, criticize these materials for reinforcing binary gender stereotypes (“you’re either a boy or a girl”), erasing gay identities (by eliding the possibility of feminine gay boys remaining boys or butch lesbians remaining girls), and promoting simple-minded, unscientific essentialism (the notion of an innate male or female brain/soul independent of the body’s biological sex) as if it were established fact rather than an evidence-free theory [126].

In addition, these picture books and lesson plans may give impressionable youngsters the illusion that changing one’s gender is as simple as putting on new clothes. Many kids at this age aren’t even fully aware of the differences in male and female anatomy, let alone the physiology of sexual pleasure. These materials fail to explain complicated issues like gender and sexual fluidity, the difficulty of reversing binary social transition, and the eventual necessity of medical treatment with all of its risks, complications, and uncertainties; those details wouldn’t make for such a nice, warm story. Instead, these books appeal to young children’s capacity for “magical thinking” to suggest that changing sex is an easy and pain-free option.

               There is evidence that some young children find discussions of gender change confusing and even disturbing.  A teacher read the book I Am Jazz and one other transgender themed book to a Kindergarten class at Rocklin Academy Gateway, a prestigious charter school in a suburb of Sacramento, to explain why a male Kindergartner was now converting to female dress, after which parents reported that their children were confused and afraid that they might also undergo spontaneous metamorphosis into the opposite gender [133,134]. Despite outcry from these parents, the school board subsequently voted not to allow parents to have their children opt out of such gender identity instruction on the grounds that doing so would create a “discriminatory environment” for the tiny number of children who do transition, and a child who referred to the transitioned Kindergartner with the wrong pronoun was disciplined by the school. In the aftermath, parents pulled 23 children out of the school. The Kindergarten teacher was subsequently honored as “Teacher of the Year” by a state educational association.

It is unclear whether the growing dissemination of these instructional plans and materials in elementary schools is a causal factor in the rapid increase of gender dysphoric and trans-identifying children or simply an independent development in response to media attention surrounding trans issues. If your pre-adolescent child announces that they are the other gender from their birth sex, it is certainly worth asking them what they have heard in school. As a parent who has read the material on this website, you should fill in whatever gaps in their knowledge may have been left by imperfect or over-simplistic presentations from well-intentioned, but not fully informed educators. 

               Another area of concern to some parents are school policies that allow children to transition socially, adopt new names and pronouns, use opposite sex restrooms, and take physical education classes with the other sex, all without the parents being informed that it is happening. This more often becomes an issue with teenage children who manifest a rapid onset of gender dysphoria, but have been led by trans activist social media and online resources to assume that their parents will be hostile. School boards and officials across the country justify these policies on the grounds of maintaining student privacy and safety [127,128,170]. The California Department of Education has interpreted the 2013 School Success and Opportunity Act as requiring non-disclosure to parents on the grounds that to do so would “compromise the student’s safety” [168]. The assumption that most parents today are transphobic and will reject or abuse a gender-variant child is unsupported by objective evidence, although some parents may elect to adopt a more cautious approach to medical treatment than their child would prefer [129]. The notion that schools can keep social transition or a name change secret from parents very long is flawed; as one experienced gender therapist observes, parents usually find out quickly when they see their child’s assignments submitted under a new name or hear friends using that name to address their child [129].

In contrast, other school districts with a large number of transgender students, such as Clark County, Nevada (including Las Vegas), have adopted a policy of providing gender support plans that outline multiple options and explicitly call for involving a student’s parents in collaboration with school personnel to determine which is best [130]. It is preferable that parents should be involved, as having a supportive family environment is strongly associated with positive mental health outcomes for gender-variant minors. A decision whether a child is ready for social transition is not something that should suddenly be announced by the child to automatically compliant school administrators, but is most likely to be successful if it comes only after careful family deliberation with the aid of an experienced therapist.

               If you discover that your child’s school has socially transitioned them without your knowledge, you should first discuss the matter with your child and ask why they were afraid to tell you. If this is the first indication you have ever had that your child wanted to change gender identity, you should reassure them that you accept them for whoever they want to be and give them the chance to explain why they want to become the other gender. Listen patiently. Based on what you have learned from this website and your other reading, you can explain to them that there are many complications to medical transition and the results in terms of long-term happiness are not always as positive as your child may have been led to believe by social media or lessons in school. Rather than putting your foot down and saying “No, never,” propose that you together find an unbiased gender therapist to explore your child’s gender dysphoria and any other mental health or social issues that may be in play. This will buy you some time. Usually, the school’s first step in socially transitioning your child is just changing their first name; once adopted, it may be difficult to forbid the use of this name, but you can treat it as a nickname if you prefer. Nicknames, like fashion styles, come and go.

               If, after talking with your child, you conclude that their commitment to gender transition is motivated by external factors such as social media influence, bullying, or sexual harassment rather than a deep and abiding alienation from their own body, you should make an appointment to discuss the situation with the school counselor or head. Even if you are angry, be calm and avoid threats that could later be used against you. Explain that you know your child’s mental health history better than school officials do and show that you are well-educated on the subject of gender transition. Cite the studies you have learned about from this website that show early social transition of minors does not result in better long-term psychosocial outcomes. The odds are that the school personnel are not even aware of these studies, but are merely relying uncritically on online resources and training manuals provided by the trans activist groups we have cited above. Reassure the school that you are seeking the assistance of an experienced child therapist to explore your child’s feelings and motivations, but ask that any further steps toward social transition should be put on hold until the therapist has had enough time to make recommendations. If the school is hostile or uncooperative, or tries to accuse you of being a bad parent for not immediately “affirming” your child’s new identity, you can remind them that school districts in California, Maryland, Iowa, and Massachusetts have recently been sued by parents for transitioning children without parental consent [131,132,169,170]; such litigation is typically funded by non-profits, such as the Center for American Liberty, that are alarmed over what is going on in the schools. As a last resort, you can always move your child to a different school; in many of these cases, children desist from feeling they are the wrong gender once they are no longer in a school that encourages them to think they are. Catholic schools do not transition students against parents’ wishes, and offer a quality education for low tuition; they typically do not require religious instruction for non-Catholic students. Although it would entail some time commitment on your part, home schooling is also an option.

Many schools are allowing social transition of students without parental knowledge or consent on the premise that assertion of gender identity is a fundamental human right that should not be determined by parents. Some trans advocates go so far as to argue that children should also be allowed to access medical treatment for gender dysphoria against parental wishes, on the analogy of court-granted abortion access for minors [136,137]. One trans-promoting website even gives teens advice on how to obtain hormones illegally if parents refuse to cooperate [138]. On the other side, some trans critics point to the complex issues surrounding the safety of these drugs, the uncertain psychosocial outcomes of transition, the irreversibility of certain medical treatments, and the difficulties of living as a transgender person who will be dependent on medical care for the rest of one’s life, and argue that these are beyond the capacity of most teens, who have short-term goals and horizons, to understand well enough to give informed consent even if parents are willing to go along with it [139,140]. Given the high proportion of gender dysphoric youth who suffer unrelated mental health problems, critics also argue that this population tends to have a diminished capacity for prudent decision-making even relative to other minors of the same age.

“Informed consent” as a bioethical concept implies that the patient has been fully informed of the known risks involved with a medication or procedure and makes a deliberate decision to proceed after understanding those risks. In the context of puberty blocking drugs, this should include a discussion of the effects on bone development, the risk of premature osteoporosis, and the suggestive, but as yet not fully understood effects on cognitive functioning. Even more importantly, it should include knowledge that 80% or more of the pre-adolescent children who come to gender identity clinics would see their gender dysphoria desist if allowed to go through puberty in their born sex, but never see it desist if puberty blockers are prescribed. They should also be told that puberty blockers do not give them more time to make up their mind, but in practice almost inevitably lead to continuation of the gender modification process. Children and young teens need to be disabused of any notion that surgery can truly make their bodies equivalent to those of the other sex: phalloplasty cannot create a functional penis that swells or ejaculates, or that really even looks like a normal penis, and if vaginoplasty is done on a young person who took puberty blockers, there is a high likelihood that the resulting vagina will be too shallow to experience intercourse that is not painful. Many gender clinics operating in the US fail to inform young people fully of these risks and considerations, and it is unclear how well a pre-adolescent or early adolescent child would be able to assimilate the evidence even if they were told. How can a child who has never experienced sexual intercourse or has any understanding of what it feels like give informed consent to interventions that may lead to permanent impairment of sexual function?

In the context of prescribing hormones, teen patients need to be informed that prolonged use may make them permanently incapable of conceiving children. Natal males need to know that estrogen often results in substantial loss of sexual appetite and could thus affect their ability to sustain long-term intimate relationships with  cisgender partners. Natal females need to know that testosterone may lead to atrophy of the female reproductive organs and the necessity of hysterectomy, even if they do not elect surgery to create an artificial penis. They also need to be informed about the higher risk of cardiovascular events and (in the case of trans women) breast cancer. They should understand that although hormonal and surgical interventions do improve the psychological well-being of many transgender patients, at least in the short term, they do not succeed in doing so for a substantial percentage of others. They need to take account of the challenges of living in a society that are not universally accepting, and in which police harassment and general violence against transgender persons is still too common. In contrast to pre-adolescent patients, older teens should be capable of understanding these issues if informed of them, but gender identity clinics cannot be relied upon to discuss them. It is your role as a parent to make sure that your teen is aware of these factors before proceeding.

In a well-publicized UK case brought by Keira Bell, a detransitioned woman who began hormones at the age of 16 and had a double mastectomy at 20, the High Court in London ruled it “highly unlikely” that a 13 year-old “would be competent to give consent to the administration of puberty blockers” and “doubtful” that a 14-15 year-old “could understand and weigh the long-term risks and consequences” [141]. This verdict was later overturned by the Court of Appeals on technical legal grounds, but the litigation and initial trial court opinion suggest that the question of whether and when informed consent is possible in this branch of medicine is open to serious debate. 

A similar lawsuit was filed in December 2022 by California teenager Chloe Cole, who detransitioned at 17 after starting puberty blockers at 13, then hormones, and undergoing a double mastectomy at 15; her attorney says that she was never informed by the medical provider that most cases of gender dysphoria resolve by adolescence or that it could be treated with psychological counseling, and that her family was manipulated with dubious claims that she would be at high risk of suicide unless they agreed to immediate medical treatment [165,166]. Here the legal issue revolves not just around the age of the plaintiff, but the medical provider’s negligence in failing to provide the requisite information for “informed consent” to take place; this same negligence is unfortunately typical of most U.S. providers of transgender medicine to minors. 

Every teen is different in terms of their maturity, intelligence, and judgment, so there is no universal age at which we can say that all teens are or are not old enough to give informed consent. No one knows your teen’s capacity better than you do. A useful way of thinking about the age at which your child is capable of giving informed consent to medical treatment of gender dysphoria is to consider the age at which you believe they are capable of giving informed consent to sexual relations. Arguably the life-altering consequences of changing one’s sex medically are even more profound and permanent than the consequences of deciding when to first have sexual intercourse, and the considerations involved are certainly more complicated. 

The decision to be sexually intimate with a partner involves the risks of conceiving a child (only in cases of heterosexual intercourse), being infected with a sexually transmitted disease, and later regret over having chosen the wrong partner. The risks of pregnancy and STIs can be greatly reduced by the use of condoms and other forms of prophylaxis; poor partner choice can be corrected by dumping a bad partner. Even in the unlikely worst-case scenarios of a teen becoming pregnant or contracting HIV, both conditions are now treatable in ways that minimize their impact (abortion, adoption, and effective new medications that can reduce one’s HIV load to zero). However, the decision to alter one’s body with drugs and surgery results in a high probability of never being able to conceive a child, becoming dependent on hormone treatments for life, and having a much smaller pool of potential romantic or sexual partners. If you think your child is too immature to choose a sexual partner and have sex safely, then they are certainly too immature to make a decision about gender transition, where the consequences are so much more permanent and the science so contested. This is not to deny that some teens are mature enough to make these decisions and could benefit, but this must be assessed on a case-by-case basis after extensive discussion of the risks with your teen.

We list here some websites both of organizations that support the “gender-affirming” model and of those that advocate a more cautious approach. These are by no means the only organizations of each type but their websites will feature the most detailed and in-depth discussions of the range of issues we have treated, and may point you to the most recent and emerging studies. Do your own research. Be wary of sources that call the other side names such as “transphobes” or “groomers” or make blanket assertions that their approach is “life-saving” and the other approach “life-threatening.” Similarly beware if they assert, without real argument, that the other side’s cited scholarship is “outdated” or “disproven” or respond to opposing studies by questioning the credentials of the authors: one does not need to be an endocrinologist or surgeon who actually treats transgender patients (and thus has a financial conflict of interest) to be able to examine the epidemiology and social science used to justify these treatments. Such tactics are rhetoric, not scientific inquiry.

Among the supporters, see:

World Professional Association for Transgender Health (WPATH): https://www.wpath.org

Gender Identity Research and Education Society (GIRES): https://www.gires.org.uk

Mermaids: https://mermaidsuk.org.uk

Gender Spectrum: https://genderspectrum.org

National Center for Transgender Equality: https://transequality.org

Among the sceptics, see:

4th Wave Now: https://4thwavenow.com/

Transgender Trend: https://www.transgendertrend.com/

GD Working Group: http://gdworkinggroup.org

Gender Health Query: https://www.genderhq.org/

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