Gender Dysphoria: The Science is Not Settled

Some parents have taken it upon themselves to read the research and understand the science and we are very concerned by what we’ve found! Please take the time to read our research…

Gender dysphoria (GD) is the suffering from a mismatch between one’s body and one’s gender identity.  There has been an enormous surge in cases in the past decade, especially among adolescents and young adults with onset starting strongly at or after puberty, a new and different cohort.  Earlier cases were mainly adult or child onset GD.  The science of how to treat GD, a temporary condition for many, is not settled.

Old treatment practice

Until recently, it was understood that if someone had GD you could/would try 

1. “Watchful waiting” (especially if a young person, still developing, brain matures ~26)

   •  ~80% (61% - 98%) with childhood onset [+here] grow out of it; it’s a developmental phase for them.

   • Socially transitioning young people can make gender dysphoria persist (also here).

2. Explorative supportive psychotherapy

   • This is particularly important because other conditions (OCD, autism, [+here], trauma, anxiety, distress[+here]) can cause GD and were in fact often disqualifying for medicalization.

3. Some people have their gender dysphoria persist even after the first two approaches. These adults could undergo an arduous and aggressive intervention (sterilization, body parts removal, lifetime off-label hormones with many significant health risks, including to the heart, also here, blood clots, bones, brain, also here and here, endocrine, immune systems, altered biomarkers, risks not yet fully understood, especially long term). 

   • This medical procedure was extended to younger people with the Dutch Protocol, studies of 55 stringently vetted kids (with many requirements not imposed today). This was an attempt to streamline the first two approaches by attempting to identify, and then medicalize sooner, the small fraction of eventual persisters.  

     • Their mental health outcomes were only evaluated a few years past surgery, not the ~10 years already known necessary to catch many known problems.  

     • Treatment included puberty blockers which have risks to bones, brain (and here, here), heart, fertility effects not known, long term not known.

• The sizeable adolescent onset group is a new phenomenon and not well studied or understood; many have mental issues as well.

• For some individuals, this aggressive medicalization is inappropriate and they eventually no longer want to identify with a gender different from their biological sex (“detransitioners”).  No one knows how many there are, especially given the long average time to regret (~4-10 years), and the evolving prerequisites for starting medicalization (currently almost absent in the US beyond self diagnosis) .

• The evidence supporting these treatments is lacking (and here, here) or of low quality (here, here, here). Studies have not been able to show these treatments improve mental health over time, or that they are safe. Many studies are too short to catch the known problems appearing after 7-10 years or lose participants to follow-up. Many extant studies are flawed, having evidence GRADE of low or very low quality.

There is a lot of support for protecting the people who have gone through this arduous medical treatment from discrimination, and those with this identification.  Absolutely.  Yes. Of course.

A fallacy appears

However, around 2010 there was a change and a false assumption was introduced. This was the (false) claim that having gender dysphoria is innate and unchangeable: if you experience GD you are immutably trans.  Period.  Does not change.  (Even some physicians inaccurately say it's biological.)

There is no evidence for the claim that a given gender identity will persist for all those with gender dysphoria.

Again, it is simply not true that everyone who is dysphoric will be so forever unless they transition.  This is why there has long been the usual route of first trying watchful waiting and/or psychotherapy for co-occurring mental health issues, which will resolve GD for many. There is no known test to determine who might heal from these first two protocols, which is another reason why they have been tried first.  

With this false premise about being immutably trans, again, which is not supported by evidence, the first two treatment steps became labelled unethical conversion therapy.  Now one is told to “affirm”. In spite of having no basis in evidence, this approach was rapidly adopted, and flawed research is quoted to support it, e.g. incorrectly conflating therapy and unethical conversion therapy (and falsely implying ethical psychotherapy is harmful, a non-specialist version of the rebuttal is here), or using flawed research to argue medicalization lowers suicidality. 

This fallacy puts children, adolescents, and young adults at risk. It promotes a harmful unnecessary medicalization of those who would desist with the first two interventions, including the majority of children.  For these young people, the aggressive medicalization and surgery would be a terrible mistake.  Some of these are coming forward now, see r/detrans for an informal “look”.

Keeping the fallacy alive

The false premise of immutable gender identity has been buttressed with untrue claims: that the above first two interventions to heal gender dysphoria cannot succeed and that true detrans people do not exist.  The following inaccuracies facilitate this erroneous presumption: 

• “The desisters aren’t really suffering GD, they are just tomboys”, etc. (there is evidence to the contrary).  There is even a claim that desister studies should be halted (direct rebuttals here and here).

• “Therapy is conversion therapy” (This is a false equivalence, only true if gender identity is immutable, which it isn't).  

• “True detransitioners do not exist, people only detransition or are dissatisfied because of discrimination or lack of funding for treatment” (false).  One spin is here. And the additional untrue statement, that if someone transitions, they are saved from suicide (+here).  This is also, dangerously, told to young people themselves.

These are all false. These are all quoted to support the fallacy that all who feel GD will never stop feeling the distress, unless they transition.  That one treatment fits all.

Again, this claim is not true.

Several professional societies do support the current affirmative approach.  They do not have reliable evidence that supports rapid affirmation.  You can see the low quality GRADE that the Endocrine Society gave for almost all of its supporting evidence, concluded as well in multiple other recent evidence reviews, mentioned above. The AAP policy is based on conflating being gay and being trans, a fallacy, and misquoting the literature.  A formal review of treatment guidelines was released in spring 2021, finding those from WPATH and the Endocrine Society (which concern treatment of gender dysphoria) inadequate.  Note WPATH guidelines are “practice guidelines [...] suggestions or recommendations to improve care that, depending on their sponsor, may be biased.” 

Summary and plea

Some people do heal from gender dysphoria with ethical supportive psychotherapy.  

It is false to say this therapy is the same as (unethical!) conversion therapy for gays. Trans is not the new gay.  One is about sexual orientation and one is about how you see yourself. For the people who heal with therapy, GD is reportedly more like anorexia, something one hopes everyone would want people to heal from.  Explorative supportive psychotherapy used to be the first thing to try, for a good reason.  

One size does not fit all. The urgency to medicalize, without exploration, especially given how many (also here) of these young people have mental issues which are known to cause temporary GD, is not supported by evidence.  Originally a last resort for treating GD under careful supervision, this aggressive, dangerous and experimental medicalization, with irreversible consequences, has been promoted to an “on-demand” commodity.  It is now being marketed directly to vulnerable young people in distress (most of whom would not have even qualified for the few earlier studies) as the only option forward, the way to be “their authentic self.”

Those who try to point out the contraindications of the current rush to medicalization are often falsely accused of a phobia of those who have gone through this painful difficult process. It is not anti-trans to investigate the facts. People are wielding “anti-trans” to make people shut out facts.  Please take a look at the evidence. Again, the science is not settled: it is unknown who will have long term mental health benefits or who will instead be harmed.  The physical toll is enormous and irreversible. If you care about these kids, please become aware of the serious debate in the research community.  

Check out www.segm.org, look at what is being said by experts (books, essays, also podcasts and videos, there are many, one can start here), look at the UK,  Sweden (see Trans Train I, 2, 3). Parents can't speak up.  You can.

Please investigate.