Mental Health Advocacy for Gender Dysphoric Youth
February 27, 2020
by Andrè Van Mol, MD
British general practitioner Sally Howard wondered in The BMJ, “…the significant majority of children do resolve their gender ID in favour of their natal sex by adulthood. Where is the advocacy for the mental health needs of that majority?” Where, indeed.
Our sexed bodies are such objectively, immutably from conception, and evidenced in every nucleated cell we possess., Even the DSM-5 clarifies on page 829 that sex is “understood in the context of reproductive capacity” with evidence “such as sex chromosomes, gonads, sex hormones, and nonambiguous internal and external genitalia.” And, as psychiatrist Stephen Levine emphasizes, “Biological sex cannot be changed.” In contrast to biological sex, gender is an engineered term leveraging linguistics contra biology. Nouns have gender, people have a sex. Whereas sex is biological, gender is ideological. Gender identity is subjective, fluid and self-declared. It’s a feeling, a self-perception, and it often takes the form of a sex stereotype. Ideations are neither innate nor “assigned at birth.”
Gender dysphoria (GD) is a diagnosis—“gender incongruence” applies more broadly to those without distress—but transgenderism is an overarching ideology., They are not the same, except they now arrive to us healthcare professionals as self-diagnoses. The DSM-5 specifies prevalence rates of GD that are infinitesimal: 0.002-0.003 percent for natal females and 0.005-0.014 percent for natal males. Yet surveys from 2019 found 2 percent of American youths claiming they may be trans. But take note, GD is vanishing as a diagnosis, while transgenderism, or non-binaryism, is on the way to normalization.
Social and semantic contagion are making a grass fire out of transgenderism. The former is driven in large part by social media, particularly the dark quadrants, but gets a strong assist from the entertainment and general media. It’s become a fad. As Dr. Lisa Littman explained, gender dysphoria has become “a catch-all explanation for any kind of distress, psychological pain, and discomfort that an AYA [adolescent or young adult] is feeling while transition is being promoted as a cure-all solution.” Semantic contagion occurs when words and phrases previously little or unknown become common parlance. So when nomenclature like transsexual, gender reassignment/confirmation surgery and gender affirming therapy (really transition affirming) become every day speech, minors and even adults start interpreting their thoughts and experiences through the lens the concepts provide.
For minors with GD, desistance is the norm, unless the GD is affirmed. Decades of professional literature confirm that, conservatively, 85 percent of children with gender dysphoria become comfortable with their bodies.,,, The gender incongruence goes away. But that transgender ideation has underlying sources.
The overwhelming majority of people with gender dysphoria have additional mental health conditions (depression, anxiety, bipolar disorder, psychoses, personality disorders,, histories of self-harm or suicidality, etc.), neuro-developmental disabilities (autism spectrum), adverse childhood events and family issues that pre-date or coincide with their gender incongruence. A 2015 report from Finland’s gender identity services noted 75 percent of referred adolescents were or had been receiving psychiatric treatment aside from GD, and 26 percent had autism spectrum disorder. Lisa Littman’s 2018 survey of parent of kids with rapid onset gender dysphoria found more than 62 percent had a psychiatric or neuro-developmental disorder prior to GD onset, with 48 percent having a traumatic/stressful prior event. In both the Littman and Finland studies, more than 80 percent of the patients were female. The 2018 Becerra-Culqui Kaiser-Permanente study of 8.8 million electronic medical records found high rates of psychiatric disorders and suicidal ideation and behavior in youths six months before any evidence of gender non-congruence. And the prevalence ratios listed compared to peers were staggering: 25 to 54 times the suicidal ideation, 22 to 44 times the psychiatric hospitalizations and 70 to 144 times the self-harm, among others. Autogynephilia—the erotic arousal of certain males by thinking or visualizing of themselves as a woman—is a common finding in adult GD males.
The impressive probability in a child with gender dysphoria of both the presence of underlying mental health issues and of desistance of GD by adulthood is in large part why the international standard has been “watchful waiting” of such patients with the understood inclusion of extensive psychological evaluation and support of the patient and family both.,, But now psychological evaluation is being jettisoned in favor of affirming the gender confusion and recommending transition at ever younger ages. This redefined “standard of care” and the pejoratively labeled “conversion therapy” bans for minors now in over 19 states is clearly at odds with patient needs.
Consider the ethics of permanently medicalizing a minor for a thought process with an over 85 percent rate of desistance by adulthood and doing so based on a self-diagnosis. We are without tools—labs, imaging studies or any other objective test—to discern who the persisters will be. Why take the enormously consequential risk? Consider the problem of consent. Children have developing brains, the propensity to change their minds often and the inability to understand long-term consequences. Psychiatrist Stephen Levine presents a two-part test for ethical decision making in anyone requesting gender affirming therapy (GAT) [which, again, is really transition affirming, call it TAT]: “Does the patient have a clear idea of the risks of the services that are being requested? Is the consent truly informed?” For a minor, that is a uniform no. As the Swedish Pediatric Society noted in 2019 in joining that nation’s National Council for Medical Ethics in proposing a systematic review of GAT in GD youth, “Giving children the right to independently make vital decisions whereby at that age they cannot be expected to understand the consequences of their decisions is not scientifically founded and contrary to medical practice.”
The 2017 Endocrine Society Guidelines, which were the first from a medical society to advocate for GAT in minors, assessed their medical evidence rating for puberty blockers and cross-sex hormones in selected minors as “low” and adult genital surgery as “very low.”  They further included a disclaimer (p. 3895): “nor do they establish a standard of care.” Yet the Endocrine Society Guidelines are referred to as exactly that, the standard of care which they are not. The various professional guilds endorsing GAT generally have the publications written or very strongly influenced by members of WPATH (the World Professional Association for Transgender Health), which is an activist group and not a scientific organization, and whose SOCs (Standards of Care) appear to be window dressing that is ultimately not followed. To provide one example, Dr. Levine revealed WPATH’s SOC “recommend an informed consent process, which is at odds with its recommendation of providing hormones on demand.”
There is international questioning of GAT for minors occurring on national levels by medical organizations and academics in the United Kingdom, Sweden and Australia, among others.,, The UK’s National Health Service’s (NHS) only Gender Identity Development Service (GIDS) has seen the exodus of 35 psychologist in over three years. Some reported, among other concerns, that they were “unable to properly assess patients over fears they will be branded ‘transphobic…’.” One also confessed, “we fear that we have had front row seats to a medical scandal.”
Parents and physicians both are increasingly bullied into approving GAT for children and teens. A common shaming question many parents have reported being asked by a counselor was, “Do you want a dead son or a live daughter?” or vice versa. The emotional blackmail that GAT [TAT] reduces suicide is unproven. According to psychologists Bailey and Blanchard, “There is no persuasive evidence that gender transition reduces gender dysphoric children’s likelihood of killing themselves.” Oxford’s Professor Michael Biggs’ critique of the NHS’s GIDS’s one published outcomes study stated, “…there was no statistically significant difference in psychosocial functioning between the group given blockers and the group given only psychological support.” He further examined unpublished evidence and found “puberty blockers exacerbated gender dysphoria.” We have the 2011 study by Dhejne and team that followed all 324 sex-reassigned persons in Sweden over a 30-year period (so selection bias of zero) revealing a completed suicide rate 10 years out that was 19 times that of the general population.
We healthcare professionals need to be boldly advocating for the mental health needs and bodily integrity of our patients with gender dysphoria/incongruence, particularly the young. Watchful waiting with full psychological evaluation and counseling support for patient and family is indispensable and its omission is inexcusable. The chemical sterilization/castration and surgical mutilation of children is not healthcare. It deserves our public and private opposition, while we still can, even if activist groups say uncharitable things about us and colleagues give us the side eye.
 Institute of Medicine (US) Committee on Understanding the Biology of Sex and Gender Differences; Wizemann TM, Pardue ML, editors. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington (DC): National Academies Press (US); 2001. 2, Every Cell Has a Sex. Available from: https://www.ncbi.nlm.nih.gov/books/NBK222291/
 Cretella, Michelle A.,Rosik, Christopher H.,Howsepian, A. A. Sex and gender are distinct variables critical to health: Comment on Hyde, Bigler, Joel, Tate, and van Anders (2019). American Psychologist, Vol 74(7), Oct 2019, 842-844.
 American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (Arlington, VA: American Psychiatric Association, 2013), p. 829.
 Stephen B. Levine (2018): Informed Consent for Transgendered Patients, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2018.1518885.
 Tomer Shechner, Gender Identity Disorder: A Literature Review from a Developmental Perspective, 47 Isr. J. of Psychiatry & Related Sci. 132-38 (2010).)
 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. P.451.
 K.J. Zucker, The myth of persistence: response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al , 19(2) INT ’L J. TRANSGENDERISM 231–45 (2018).
 Johns MM, Lowry R, Andrzejewski J, et al. Transgender Identity and Experiences of Violence Victimization, Substance Use, Suicide Risk, and Sexual Risk Behaviors Among High School Students — 19 States and Large Urban School Districts, 2017. MMWR Morb Mortal Wkly Rep 2019;68:67–71.
 Littman, L. “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports,” journals.plos.org, Aug. 16, 2018. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330.
 Dr. Carl Elliot, “A New Way to be Mad,” theatlantic.com, Dec. 2000.
 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. P.455.
 Bockting, W. (2014). Chapter 24: Transgender Identity Development. In Tolman, D., & Diamond, L., Co-Editors-in-Chief (2014) APA Handbook of Sexuality and Psychology (2 volumes). Washington D.C.: American Psychological Association, 1: 744.)
 Cohen-Kettenis PY, et al. “The treatment of adolescent transsexuals: changing insights.” J Sex Med. 2008 Aug;5(8):1892-7. doi: 10.1111/j.1743-6109.2008.00870.x. Epub 2008 Jun 28.
 Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry. 2016;28(1):13-20.
 Zucker, KJ, et al. Gender Dysphoria in Adults. Annu. Rev. Clin. Psychol. 2016. 12:217–47. (P. 227.)
 Meybodi AM, Hajebi A, Jolfaei AG. The frequency of personality disorders in patients with gender identity disorder. Med J Islam Repub Iran. 2014;28:90. Published 2014 Sep 10.
 Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health (2015) 9:9.
 Littman, L. “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports,” journals.plos.org, Aug. 16, 2018. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330
 Becerra-Culqui TA, Liu Y, Nash R, et al. Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. Pediatrics. 2018;141(5):e20173845.
 Blanchard, Ray. (2005). Early History of the Concept of Autogynephilia. Archives of sexual behavior. 34. 439-46. 10.1007/s10508-005-4343-8.
 James M. Cantor (2019): Transgender and Gender Diverse Children
and Adolescents: Fact-Checking of AAP Policy, Journal of Sex & Marital Therapy, DOI:10.1080/0092623X.2019.1698481.
 de Vries, A. L., and P. T. Cohen-Kettenis. 2012. Clinical management of gender dysphoria in children and adolescents: The Dutch approach. Journal of Homosexuality 59(3): 301–320.
 Michael Laidlaw, Michelle Cretella & Kevin Donovan (2019) The Right to Best Care for Children Does Not Include the Right to Medical Transition, The American Journal of Bioethics, 19:2, 75-77, DOI: 10.1080/15265161.2018.1557288
 Michael K Laidlaw; Quentin L Van Meter; Paul W Hruz; Andre Van Mol; William J Malone. Letter to the Editor: “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline” The Journal of Clinical Endocrinology & Metabolism, Volume 104, Issue 3, 1 March 2019, Pages 686–687, https://doi.org/10.1210/jc.2018-01925.
 Andre Van Mol, “Transing California Foster Children & Why Doctors Like Us Opposed It,” PublicDiscourse.com, October 28, 2018.
National Institute of Mental Health (2001). Teenage Brain: A work in progress. http://www2.isu.edu/irh/projects/better_todays/B2T2VirtualPacket/BrainFunction/NIMH-Teenage%20Brain%20-%20A%20Work%20in%20Progress.pdf.
Pustilnik AC, and Henry LM. Adolescent Medical Decision Making and the Law of the Horse. Journal of Health Care Law and Policy 2012; 15:1-14. (U of Maryland Legal Studies Research Paper 2013-14).
 Stephen B. Levine (2018): Informed Consent for Transgendered Patients,
Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2018.1518885.
 Wylie C Hembree, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, Volume 102, Issue 11, 1 November 2017, Pages 3869–3903, https://doi.org/10.1210/jc.2017-01658
 Stephen B. Levine (2018): Informed Consent for Transgendered Patients,
Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2018.1518885.
 “NHS ‘over-diagnosing’ children having transgender treatment, former staff warn,” news.sky.com, 12 Dec. 2019. https://news.sky.com/story/nhs-over-diagnosing-children-having-transgender-treatment-former-staff-warn-11875624
 J. Michael Bailey and Ray Blanchard, “Suicide or transition: The only options for gender dysphoric kids?” 4thwavenow.com, Sept. 8, 2017. https://4thwavenow.com/2017/09/08/suicide-or-transition-the-only-options-for-gender-dysphoric-kids/