Help from around the world
Parental resources from Agrupacion Kairos
Trans-identification for troubled young people is a worldwide phenomenon, It’s exponential growth is fed by social contagion and cheered on my “glitter families”. But there are resources to push back.
Agrupacion Kairos, a Chilean-based group of families with children and adolescents who identify as trans, has recently reached out to PITT to share some advocacy resources for parents.
As they explain: “We know many parents have assumed an advocacy role, defending our rights to apply caution and time before our children are pushed in to “gender affirming care”. We would like to share with other parents material we have compiled that provides arguments and resources to counter political figures, the press, education heads, doctors, etc. This material may be useful when writing letters and can be easily "customized" by any other parents to fit their situation. We hope it will help all parents to amplify their voices.”
AFFIRMATIVE MODEL IN CHILE: A CRITICAL APPROACH
AGRUPACIÓN KAIRÓS CHILE - WHO ARE WE?
We are parents of Chilean children and adolescents who have declared themselves transgender. We are concerned about the explosive increase in cases like those of our children in recent years, and the response of local health professionals who have abandoned a more cautious approach and quickly affirm the feelings of our children without a proper prior psychological evaluation.
Our children are in different stages of gender transition: some have made the social transition and others have desisted. As parents, we are sceptics that transitioning will solve or completely alleviate their basic problems. But for openly stating these doubts, there are parents who have been accused of violating the rights of their children and are currently in court, with processes underway or have already lost their custody.
Several of our cases were collected in the report1 by journalist Sabine Drysdale "Puberty interrupted: trans children start hormone treatment in the midst of controversies" published by Bio Bío on May 29 of last year, causing a great stir, which adds to the international debate about the use of hormonal treatments (puberty blockers and then cross-hormones) in children.
Our position is that there is an urgent need for debate, reflection and review of the way in which the gender-affirmative approach is implemented in Chile. We consider that our societies have privileged the affirmative model of therapeutic approach over others that are equally valid, such as exploratory therapy or the watchful waiting approach.
CONTROVERSIES ABOUT THE AFFIRMATIVE APPROACH
The indications we have received from professionals and specialists derive from the exclusive application of the gender-affirmative approach. However, neither Chilean Law nor its Regulations establish that the affirmative approach or any other model must be exclusively applied.
Precisely, this years-long debate is related to the rapid implementation worldwide of the Gender Affirmative Care approach that leads the child to a path in which one step paves the way for the next: it begins with the unrestricted and unquestionable affirmation of the gender identity declared by the child or adolescent and continues with the social transition, then with hormonal interventions and finally surgeries.
This formula is applied for all cases. There is no acknowledgment of adjacent mental health problems of our kids, which is due, in part, to a misinterpretation of the principle of non-pathologization, and it is assumed that these mental health issues (present in the vast majority of current cases) are due exclusively to minority stress. All this, without considering that adolescence is precisely the stage in which children and adolescents starts questioning and developing their identity2 and that "each stage of gender-affirming care interrupts the natural course of identity development".3
Current cohort of minors presenting with gender dysphoria or incongruence
Today we are facing a different cohort from the one that occurred most frequently before 2010: mostly males, who early in childhood began to show signs of gender incongruence or dysphoria.
It is based on this classic presentation of early-onset gender dysphoria that the Dutch Protocol4 was developed, which was then the basis for the Watchful Waiting approach. Subsequently, the initial safeguards established by the Dutch Protocol (verifying the absence of mental pathologies and carrying out a psychological evaluation of the patient, among others), were removed and it led to the gender-affirming model as we know it.
However, as of today, the vast majority of cases, both in Chile and in the world5, are female adolescents who did not show signs of discomfort with their sex in childhood and who begin to manifest gender dysphoria at the onset of puberty (or after). This new cohort has high rates of mental health morbidities such as depression, anxiety, autism spectrum disorder, personality disorders or have suffered violence or sexual abuse prior to their trans declaration.
We have, then, on the one hand, the application of a single approach – gender affirmative – to deal with cases of children and adolescents with gender dysphoria (and which the Chilean regulations assimilate to the concept of "trans child or adolescent"); and on the other hand, the application of this approach in a population that differs substantially from the cohort for which the affirmative model was originally created, which leads specialists to ignore the possible mental health disorders present in this new cohort, becoming a "gateway" to hormonal treatments.
OUR MAIN CONCERNS
1. The threat of suicide
Suicide is often used to suggest that this could be the result of non-transition in children, but also as the "expected" result of the trans population, according to their poor mental health indexes, or the result of minority stress.
Suicide is a very complex issue and is usually multi-causal, so it is not cautious nor ethical to associate such a drastic result with a single cause, as it would be in this case not to affirm the gender identity of the child. This is precisely the false and cruel dichotomy that is presented to us parents by many doctors and other mental health professionals, when they ask us “Would you rather have a dead son or a living (trans) daughter?" (or vice versa). We have heard these statements, many times even in front of our children, which in our opinion represents coercion and emotional blackmail for anguished parents and their kids, as well as a lack of medical ethics.
Following the publication of the Cass Review6 Report, the English activist group The Good Law Project indicated that there was an explosive increase in suicides in children and adolescents after the ban on the use of puberty blockers. This was quickly contradicted by a UK government report7 showing that there has been no substantive change in the data reported by the NHS.
This report cites the recent Finnish8 study that "represents one of the strongest measures of suicide in young people with gender dysphoria to date" and which was published earlier this year (Ruuska et al, BMJ Mental Health 2024).
In it, it is reported that "the risk of suicide was reduced after gender reassignment, but that the improvement was explained by treatment of coexisting poor mental health" and concludes that: "Clinical gender dysphoria does not appear to predict all-cause mortality or suicide mortality when psychiatric treatment history is taken into account. Clinical implications: It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide." (Emphasis added).
Finally, we should note that "suicides should not be confused with 'suicidality', a related but distinctly different measure. Suicidality refers to a wide range of behaviors, from thoughts about suicide and non-suicidal self-harm to serious suicide attempts; it is usually assessed by self-report; it usually excludes actual suicides; and it is considered a less robust and reliable outcome. The large sample (more than 2000 cases of gender-referred youth) provides a high degree of confidence in the size of the estimate and strongly points out that suicide is an unusual event for gender-referred adolescents in Finland, regardless of their gender transition status.".9
According to the Cass Report, although it is recognized that adolescents with gender dysphoria are at greater risk of suicide than the general population of the same age, this risk is not greater than groups of adolescents who consult for other mental health problems.
2. Minority Stress
"Many gender-affirmative clinicians subscribe to the minority stress theory: the assumption that frequently coexisting psychiatric symptoms in individuals with gender dysphoria are the result of prejudice and discrimination brought on by gender nonconformity and that gender transition will improve these symptoms. The theory of minority stress as the sole explanatory mechanism of coexisting mental illnesses has also been questioned in light of evidence that psychiatric symptoms frequently precede the onset of gender dysphoria. Other clinicians recognize the limits of gender-affirming care and are aware that youth with underlying psychiatric issues are likely to continue to struggle after transitioning, but are unaware of alternative approaches such as gender-exploratory psychotherapy or watchful waiting, these well-meaning professionals continue to treat youth with gender-affirming interventions despite lingering doubts."10
3. Puberty blockers and scientific evidence
Puberty blockers – gonadotropin-releasing hormone (GnRH) analogues – are used to temporarily delay puberty in cases of precocious puberty or for the treatment of certain cancers, such as prostate cancer in adults. Its off-label use in gender dysphoric children or adolescents has been justified as a way to give them time to explore their gender identity, avoiding the pressure of going under the physical changes of puberty. This is supposed to improve their mental health and reduce the risk of suicide.
However, there is growing scientific concern about the reversibility of its effects. In theory, once puberty blockers are stopped, the natural process of puberty should resume. But recent studies have indicated that prolonged suppression of puberty can have irreversible effects on bone density, brain development and fertility.
During puberty, increased levels of sex hormones play a crucial role in strengthening bones and prolonged disruption of puberty by blockers can lead to significantly reduce its density, which is not always fully recovered after stopping treatment. This would increase the risk of osteoporosis and fractures. In addition, brain development, which is also influenced by sex hormones during puberty, could be affected, and research suggests that some changes in its brain structure and function may not be completely reversible.11
Fertility is another critical aspect that can be compromised by its prolonged use: sex hormones are essential for the development of the gonads and the production of gametes (eggs and sperm) and the suppression of puberty can interfere with this process, leading to infertility. To date, there are no studies that have evaluated the effects of prolonged suppression of puberty in adolescents who have received gender-affirming therapy, but there are testimonies from detransitioners about its various effects, which include infertility. The promoters of the affirmative approach are aware of this effect, because together with prescribing puberty blockers they recommend freezing the gametes of our children.
It is worth considering the studies that indicate that more than 95% of minors who presented to gender clinics in countries such as the United Kingdom continued with cross-hormone treatment, which it should compel us to question the argument that PB actually give time to think and their reversibility. We can conclude that the affirmative model leads inexorably to medical transition. This is extremely alarming as there is no way to have certainty about the persistence of a child´s trans identification.
Regarding the supposed benefits in mental health and suicide risk prevention of hormonal treatments, our position is as follows:
1. If children and adolescents do not have mental health problems, we see no ethical justification for starting medical treatment in a physically and mentally healthy person, which could lead to iatrogenic damage, not respecting the medical principle of non-maleficence or primum non nocere (first do no harm).
2. If children and adolescents have mental health problems, how is it determined that they come only from minority stress? If these patients are not undergoing an in-depth psychiatric evaluation, how would it be possible to rule out that they suffer from underlying mental health pathologies?
3. Depression, anxiety or suicidal ideation should be treated with psychological therapy and/or psychiatric medications supported by evidence. As there are no studies with robust scientific evidence that supports the off-label use of puberty blockers, they should not be prescribed for the treatment of gender dysphoria. Its use should be a last resort, once other treatments for associated mental health problems have been ruled out.
4. Desistance
Another of our concerns is related to the speed with which the trans declaration of children and adolescents is assumed: In the public and private health sector, kids are offered a menu of "interventions" such as social transition, puberty blockers, cross-hormone treatments and even surgeries considered as “sex-affirming”.
However, it is worth looking at studies that reflect the persistence of trans identification or the reality of desistance in order to evaluate the consequences of gender affirming interventions, including social ones (for example, returning to a previous name). Desistance usually implies that a person who once sought medical transition no longer does so.
Evidence from 10 available prospective follow-up studies12 from childhood through adolescence indicate that childhood gender dysphoria will recede with puberty in about 80% of cases, with many later recognizing a homo or bisexual orientation in adulthood.
A Dutch article13 notes that follow-up studies show that the rate of gender identity disorder persistence is about 15.8%, or 39 of the 246 children reported in the literature. In one study14 of 54 children referred to a clinic in infancy due to gender dysphoria and then investigated using a follow-up study, only 21 (39%) still had gender dysphoria.
A different study15 on Canadian children with gender identity disorder showed that 87.8% desisted and only 12.2% (less than 1 in 8) persisted in their transgender identity. In this study with follow-up data from the largest sample to date of children referred to the clinic for gender dysphoria (n = 139) with respect to gender identity and sexual orientation, the persistence rate of 12% was somewhat lower than the overall persistence rate of 17.4% of previous follow-up studies of children combined.16
Therapeutic approach
There are many therapeutic approaches used for the treatment of gender dysphoria. The three main ones are:
Gender-affirming care: This approach supports and validates the gender identity expressed by the child or adolescent. It involves facilitating social transition and, if appropriate, considering medical treatments such as puberty blockers, hormone therapies, and surgeries. The aim is to reduce distress related to gender dysphoria and improve quality of life and psychological well-being.
Watchful waiting model: It suggests a more cautious and less interventionist approach, watching and waiting for how the child's gender identity evolves over time. It is not a passive or repressive waiting. Rather, it implies a model of care that considers taking into account a series of factors that affect the kid, postponing a social or medical transition. In this cautios model, therapists focus on providing individual psychological and psychiatric support—in addition to family therapy—with the expectation that gender identity can be consolidated or changed during adolescence. As we noted previously, this model developed from the classic presentation of early-onset gender dysphoria.
Exploratory therapy: Involves an in-depth exploration of the child or adolescent's feelings and gender identity, ensuring that any subsequent intervention is well-grounded. Thus, exploratory therapy does not imply a commitment to a specific outcome, such as transition or desistance. In this model, therapists help patients understand and express their feelings and their associated conceptions about what it means to be a man or a woman. Underlying and contextual factors that could influence gender dysphoria are also considered. This therapy may involve a longer process before making final medical decisions.
In the light of the latest reviews of the available scientific evidence and questions about the supposed benefits of the affirmative approach and the use of medical therapies (hormones and surgeries) in minors, countries such as Finland, Sweden, UK and others have moved away from this approach and have developed their own guidelines for the treatment of children and adolescents who identify as trans or present gender incongruence. These are the two models of therapeutic approach recognized in the Cass Report as based on robust evidence, and on their own systematic studies that did not find enough evidence to recommend medical treatment, except in cases reserved for clinical studies:
Finland:https://segm.org/sites/default/files/Finnish_Guidelines_2020_Minors_Unofficial%2 0Translation_0.pdf
Sweden:https://segm.org/segm-summary-sweden-prioritizes-therapy-curbs-hormones-for- gender-dysphoric-youth
Identity, Youth and Crisis, E. Erickson, 1968 https://philpapers.org/rec/ERIIYA
5 Levine, S.B., Abbruzzese, E. Current Concerns About Gender-Affirming Therapy in Adolescents. Curr Sex Health Rep 15, 113–123 (2023) https://link.springer.com/article/10.1007/s11930-023-00358-x
6 Biggs, M. (2022). The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence. Journal of Sex & Marital Therapy, 49(4), 348–368. https://doi.org/10.1080/0092623X.2022.2121238
7 Kaltiala-Heino, R., Sumia, M., Työläjärvi, M. et al. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child Adolescent Psychiatry Ment Health 9, 9 (2015) https://capmh.biomedcentral.com/articles/10.1186/s13034-015- 0042-y
10 Ruuska S, Tuisku K, Holttinen T, et al. All-cause and suicide mortalities among adolescents and young adults who contacted specialized gender identity services in Finland in 1996-2019: a register study. BMJ Ment Health 2024;27:e300940. https://mentalhealth.bmj.com/content/27/1/e300940
13 -Baxendale S. The impact of suppressing puberty on neuropsychological function: A review. Acta Paediatrica. 2024 Jun;113(6):1156-1167. doi: 10.1111/apa.17150. Epub 2024 Feb 9. PMID: 38334046
Thank you for sharing.
So sad that this is a GLOBAL phenomenon. :-( I'm thankful to our fellow parents in Chile, however, for sharing this.