Gender Dysphoria in Children: Two Views

[Puppycow]

So, I'm going to present two articles here with differing views on how doctors should handle gender dysphoria in children. Then, I think we could discuss the two views (preferably after reading both articles, or at least enough to get the general idea; the second article is quite long, but worth reading if you want to understand the current "best arguments" for each view).

The first one is a recent opinion piece I came across in the New York Times. I found it to be persuasively written.

Hannah Is a Girl. Doctors Finally Treat Her Like One.

The author of the piece is:

Jack Turban is a research fellow at Yale School of Medicine, where he lectures on the treatment of transgender and gender-nonconforming youth.

Please read the whole thing, but I'll try to quote enough to give you the gist:

NEW HAVEN — Hannah is a 14-year-old girl, clad in leggings and an oversize T-shirt, with long brown hair that she curls around a finger. She was also born a boy.
. . .
Hannah is using a puberty-blocking implant and getting ready to embark on the path of developing a female body by starting estrogen. Ten years ago most doctors would have called this malpractice. New data has now made it the protocol for thousands of American children.
. . .
The implant has been in place for two years, preventing the process that would have deepened her voice and given her an Adam’s apple. She has been happy with the blocker, but is ready to move on.

“I’m tired of being the only girl in my grade who looks like a little kid,” she says.

She has a point. A review of recent studies suggests we could start cross-sex hormones as early as 14, so that transgender kids don’t suffer the stigma of starting puberty years after their classmates.
. . .
Once transgender youth hit puberty, their gender identity is unlikely to change. At that point, doctors often consider medical interventions. The puberty blocker is the first step. In the unlikely event that a child were to change her mind about being transgender, we could remove the implant, and she would then go through male puberty. The implant has some mild side effects, most notably a decrease in bone density, but that quickly improves after the removal of the implant or the initiation of cross-sex hormones like estrogen or testosterone.

The effects of cross-sex hormones like estrogen are not easily reversible. The hormones can impair fertility, but transgender teens are offered fertility preservation options before that stage, like freezing sperm or eggs. Surgery, which often follows in young adulthood, is also, of course, essentially permanent.
. . .
Adult transgender people often tell me what it would have meant for them to have escaped the wrong puberty. They mourn for their bodies that were permanently changed, while celebrating the future for children who can live the way they feel.

There's more of course, but I can't quote all of it.

Basically, kids diagnosed as transgender could be given a so-called "puberty blocker" before the onset of puberty so that their bodies don't take on the sex characteristics of their biological sex. After that, the proposal seems to be to start giving them "cross-gender hormones" at around age 14 so that they go through the puberty of their chosen gender. Apparently, this is already being practiced in many places.

So here is another view that a member of another forum pointed me to, from the American College of Pediatrics. It was published in August 2016, less than a year ago, and as far as I know, their view hasn't changed.

Gender Dysphoria in Children

This one is very long, with footnotes, etc. I'll quote the Abstract but I suggest reading more to understand the reasoning.

ABSTRACT: Gender dysphoria (GD) of childhood describes a psychological condition in which children experience a marked incongruence between their experienced gender and the gender associated with their biological sex. When this occurs in the pre-pubertal child, GD resolves in the vast majority of patients by late adolescence. Currently there is a vigorous, albeit suppressed, debate among physicians, therapists, and academics regarding what is fast becoming the new treatment standard for GD in children. This new paradigm is rooted in the assumption that GD is innate, and involves pubertal suppression with gonadotropin releasing hormone (GnRH) agonists followed by the use of cross-sex hormones—a combination that results in the sterility of minors. A review of the current literature suggests that this protocol is founded upon an unscientific gender ideology, lacks an evidence base, and violates the long-standing ethical principle of “First do no harm.”

So my own reaction after reading the two articles is that, although I was initially persuaded by the first one, the second one gave me plenty of reasons to doubt it. One of the main issues is the fact that this process will render the children infertile (the "fertility preserving options" notwithstanding). Is it ethical to allow such a young person to make that choice? What are your thoughts?

 

[Tsukasa Buddha]

FWIW, the American College of Pediatricians is a small, ideologically conservative advocacy group, different from the American Academy of Pediatrics. They split off from the AAP when they supported gay adoption.

 

[Puppycow]

Oh, that's interesting. Does the American Academy of Pediatrics have a consensus position on this issue?

 

[Puppycow]

Here is their "About Us" page from their own website:

https://www.acpeds.org/about-us

Core Values of the College

The American College of Pediatricians:

Recognizes that there are absolutes and scientific truths that transcend relative social considerations of the day.
Recognizes that good medical science cannot exist in a moral vacuum and pledges to promote such science.
Recognizes the fundamental mother-father family unit, within the context of marriage, to be the optimal setting for the development and nurturing of children and pledges to promote this unit.
Recognizes the unique value of every human life from the time of conception to natural death and pledges to promote research and clinical practice that provides for the healthiest outcome of the child from conception to adulthood.
Recognizes the essential role parents play in encouraging and correcting the child and pledges to protect and promote this role.
Recognizes the physical and emotional benefits of sexual abstinence until marriage and pledges to promote this behavior as the ideal for adolescence.
Recognizes that health professionals caring for children must maintain high ethical and scientific standards and pledges to promote such practice.
Recognizes the vital role the College has in promoting quality education for parents, physicians, and other health professionals.

Objectives of the College

The Objectives of the College are:

To foster and stimulate improvements in all aspects of healthcare of infants, children, and adolescents;
To promote the basic father-mother family unit as the optimal setting for childhood development, while pledging to support all children, regardless of their circumstances;
To affirm that parents have the inalienable right and responsibility to educate and rear their children;
To advocate for children at all stages of development, from conception to young adulthood;
To cultivate and encourage parental responsibility for and involvement in the child’s life;
To engender the honest interpretation of scientific pediatric research, without deference to current political persuasions;
To promote the highest standards of medical practice among its Members and within the field of pediatrics;
To encourage and support sound, ethical scientific research in all aspects of healthcare for infants, children, and adolescents; and
To cooperate with other organizations having similar purposes and standards.

I guess you could say that they are socially conservative, and don't approve of same-sex couples raising kids. Also pro-life if I'm reading that correctly. Also opposed to out-of-wedlock sex.

That's not to say they are wrong, just to point out that their opinion isn't necessarily representative of a general consensus of pediatricians.

 

[Tsukasa Buddha]

Oh, that's interesting. Does the American Academy of Pediatrics have a consensus position on this issue?

They endorse affirmative therapy and transitioning in general, but I don't find they have a position on exact timing of which kind of medical intervention.

There really isn't a lot of quality research on these things. The first article cites a review for the down to 14 year old transitioning, but that paper has extensive caveats:

The ability to provide optimal health care to gender-dysphoric/transgender youth is limited by areas of uncertainty, controversies, and barriers to state-of-the art practice. Only limited safety and efficacy data currently exist, with virtually no published data on the use of pubertal blockers in gender-dysphoric individuals < 12 years of age or cross-sex hormones in transgender youth < 16 years of age. Furthermore, randomized controlled trials for hormonal interventions in gender-dysphoric youth have not been considered feasible or ethical (66). The clinical practice guidelines that currently exist are based on best available evidence, with significant reliance on expert opinion. A 2011 report from the Institute of Medicine of the National Academies in the United States has endorsed the need for prospective, longitudinal safety and efficacy studies of medical interventions in gender-nonconforming/transgender youth (67). Barriers to implementation of current clinical practice guidelines include the fact that pubertal blockers and cross-sex hormone treatments are off-label in gender-dysphoric youth and are expensive, and coverage is often denied by insurance companies. Furthermore, whereas an increasing number of clinical programs have emerged in recent years, there are many geographic regions in which such services do not exist, limiting access to care and often requiring patients and families to travel long distances. In addition, access to optimal care may be limited by a lack of training of providers and by prejudice and misunderstanding on the part of family, community, and medical and mental health professionals.

Linky.

These treatments are expensive, not covered by insurance, and are off-label because of lack of FDA approval.

Even the study the AAP cites for simple social transitioning has a large section about how the results could be due to the self-selecting nature of the sample.

Although it does not establish a causal relationship, this finding is crucially important to professionals who work with these children, as well as their families, in showing us that they are not likely to suffer any additional harm and may benefit from early social transition. While there is obviously more research needed to determine if providers should recommend social transition as a beneficial intervention, for families who have already chosen this avenue for their children, professionals should have no concern over supporting the family’s (or mental health team’s) decision, and reassuring the parents that social transition should have little negative impact on their child’s mental health.

Linky.

 

[Puppycow]

Still, I am interested in any responses to the actual arguments they put forward.

 

[Puppycow]

One more interesting study published by the AAP (2012):

http://pediatrics.aappublications.org/content/129/3/418

In 1979, the World Professional Association for Transgender Health established standards of care for the treatment of GID, which included partially irreversible cross-sex hormone therapy treatments (androgens for genotypic female individuals and estrogens for male individuals) for patients who had completed or nearly completed puberty, and fully irreversible gender reassignment surgery thereafter. Although cross-sex hormones and genital reconstructive surgery promote cross-gender physical features, they often fail to achieve the appearance of the affirmed gender. Cross-sex hormones cannot undo breasts, body contour, and limited height in genotypic females or male-pattern facial/scalp hair distribution, skeletal changes, voice pitch, and “Adam’s apple” in genotypic male individuals. These cause emotional distress and can be altered only with expensive out-of-pocket treatments, often with unrewarding results.

In September 2009, the Endocrine Society published guidelines for the treatment of adolescents with GID that recommended suppression of puberty by using reversible gonadotropin-releasing hormone (GnRH) analogs at Tanner stage 2/3 for adolescents who fulfill strict readiness criteria. The World Professional Association for Transgender Health has just released its latest standards of care (7th edition), which echo the Endocrine Society in its recommendation to offer reversible pubertal suppression in young adolescents. All guidelines require close collaboration with mental health providers.

Pubertal suppression with gonadotropin-releasing analogs has been used since the 1980s for central precocious puberty. In 2000, the Amsterdam Clinic for Children and Adolescents initiated a protocol for the use of a GnRH analog with adolescents with GID who were at least age 12 and had reached Tanner stage 2 or 3, in doses comparable with treatment of central precocious puberty. Some teenagers were older and more developed. This fully reversible treatment allowed patients time until age 16 to decide, in consultation with health professionals and their families, whether to begin hormone treatment that would allow them to transition physically. The first 70 Dutch candidates treated with GnRH analogs between 2000 and 2008 showed improved psychological functioning. None opted to discontinue pubertal suppression and all eventually began cross-sex hormone treatment. More recently, the Amsterdam group found that adolescents with GID who underwent pubertal suppression had improved behavioral, emotional, and depressive symptoms with psychometric testing.

One of the most striking characteristics of our population is the prevalence of psychiatric diagnoses and history of self-harming behaviors, which corroborates previous findings. Comorbid psychiatric conditions may hinder the diagnostic evaluation or treatment of gender dysphoria.
. . .
Our observations reflect the Dutch finding that psychological functioning improves with medical intervention and suggests that the patients’ psychiatric symptoms might be secondary to a medical incongruence between mind and body, not primarily psychiatric.

So there are risks I suppose on both sides, but if you don't block puberty and wait until they are 16 or older to begin treatment, their body will have already undergone a lot of changes that cannot be easily or completely undone. And that's just the physical part. It seems that, although further study is needed, it also helps emotionally and behaviorally. Also, the pubertal suppression had been used since the 1980s for precocious puberty, but not for gender dysphoria.

 

[Trebuchet]

FWIW, the American College of Pediatricians is a small, ideologically conservative advocacy group, different from the American Academy of Pediatrics. They split off from the AAP when they supported gay adoption.

Described as an anti-gay hate group by the SPLC.

Or, for a more "neutral point of view", here's Wikipedia.

Of course, Rational Wiki has something to say as well.

 

[CaptainHowdy]

Described as an anti-gay hate group by the SPLC.

Or, for a more "neutral point of view", here's Wikipedia.

Of course, Rational Wiki has something to say as well.

The SPLC has its own ideological issues. I wouldn't trust their judgement on anything.

 

[stargazer0519]

I've heard that 14 is too young to make life-changing decisions about fertility.

I've heard that 14 is too young to decide to have sex, or to become pregnant, or to give birth, or to have an abortion. Yet 14-year-olds have done all these things.

14 isn't too young to commit suicide.

Depending on how seriously my own 14-year-old felt about the issue, I'd do whatever I could to protect his or her or "they're" mental health.

My inner grammar Nazi doesn't enjoy using plural pronouns when I want to use a singular pronoun, but I also don't want transgender people to feel badly about themselves because of something insensitive that I said.

 

[Ziggurat]

I've heard that 14 is too young to make life-changing decisions about fertility.

I've heard that 14 is too young to decide to have sex, or to become pregnant, or to give birth, or to have an abortion. Yet 14-year-olds have done all these things.

And? Is it a good thing when they do so? What exactly are you arguing here?

The fact that people do a thing doesn't mean that they should.

 

[catsmate]

Here is their "About Us" page from their own website:

https://www.acpeds.org/about-us



I guess you could say that they are socially conservative, and don't approve of same-sex couples raising kids. Also pro-life if I'm reading that correctly. Also opposed to out-of-wedlock sex.

That's not to say they are wrong, just to point out that their opinion isn't necessarily representative of a general consensus of pediatricians.

They're also in favour of beating children, oppose any support for gay teenagers, oppose HPV vaccination, support gay conversion therapies and oppose proper sex education.
The SPLC class them as a hate group due to their virulent anti-gay agenda.

Oh and they have a history of distorting studies to support their agenda.

 

[Brainache]

I have long been of the opinion that the problem is only a problem because of people's insistence on conformity to a particular perceived gender role.

I'm no expert, but if a boy wants to play with dolls, wear dresses, or whatever, I think that is perfectly fine. I don't understand why that type of behaviour has to be associated with the shape of a person's genitals. Of course that also applies to girls who want to play with trucks, wear trousers, or whatever.

The problem IMO is with a society or culture that makes children think that they have to radically alter their bodies just to feel "normal". Why is being an "effeminate male" or "masculine female" such a problem in our society that people want to surgically correct it?

Call me an idealist, but I think the idea of "gender norms" is the problem and that living outside those "norms" really should be as problematic as having green eyes or freckles.

 

[luchog]

The problem IMO is with a society or culture that makes children think that they have to radically alter their bodies just to feel "normal". Why is being an "effeminate male" or "masculine female" such a problem in our society that people want to surgically correct it?

Thus demonstrating a profound lack of understanding of what gender dysphoria actually is. Little hint, it has nothing to do with cultural gender norms.

 

[Brainster]

I've heard that 14 is too young to make life-changing decisions about fertility.

I've heard that 14 is too young to decide to have sex, or to become pregnant, or to give birth, or to have an abortion. Yet 14-year-olds have done all these things.

14 isn't too young to commit suicide.

Depending on how seriously my own 14-year-old felt about the issue, I'd do whatever I could to protect his or her or "they're" mental health.

Say your 14-year-old seriously wanted to get married. Would you agree, to protect their mental health?

 

[stevea]

Is the condition real ?
Is the diagnosis accurate and reliable ?
Is the suggested treatment safe and effective compared to all alternatives ?
What is the medical necessity that dictates treatment ?

--

I don't think anyone would question effectively neutering a 14yo with testicular cancer, but only b/c we understand that cancer is a very real condition, that the tests for cancer are generally reliable & accurate, and that treatment regimens have reasonable statistically understood outcomes, and that without treatment the outcome would likely be death.
--

So what is the medical necessity in these hormone cases ?
Is this condition real, as oppose to a fad [like hysterical reactions] ?
Is the diagnosis accurate and reliable ? Seems unlikely.

Certainly the hormone treatment is quite severe and irreversible - so what is the effectiveness vs alternatives ? How is effectiveness measured ? Survival vs suicide ? Measures of happiness or satisfaction ? Is this even known ?

 

[Brainache]

Thus demonstrating a profound lack of understanding of what gender dysphoria actually is. Little hint, it has nothing to do with cultural gender norms.

OK. I agree that I don't understand what gender dysphoria is.

But are we sure that it has nothing to do with cultural gender norms?

I can only imagine that in a (hypothetical) society which had no such thing as "gender norms", gender dysphoria could not exist. How could anyone feel that they were born into the wrong gender if there were no "norms" associated with it?

 

[Delvo]

How could anyone feel that they were born into the wrong gender if there were no "norms" associated with it?

There are people who think that their bodies are wrong in other ways, such as thinking one's left arm moves on its own instead of under one's own control, or that their feet aren't really theirs (although typically without any explanation of whose they are). Such people often want the offending part that doesn't belong there amputated. I have never seen it suggested that this was not a mental condition... but I think I have seen it seriously suggested that the best or only way to alleviate the problem might be to do what they want anyway.

 

[luchog]

Is the condition real ?
Is the diagnosis accurate and reliable ?
Is the suggested treatment safe and effective compared to all alternatives ?
What is the medical necessity that dictates treatment ?
(...)
Certainly the hormone treatment is quite severe and irreversible - so what is the effectiveness vs alternatives ? How is effectiveness measured ? Survival vs suicide ? Measures of happiness or satisfaction ? Is this even known ?

But are we sure that it has nothing to do with cultural gender norms?

Yes. There is a great deal of literature on the subject, along with a great deal of consensus in the medical community, and it is quite clearly nothing to do with culture.

References to the actual medical literature have been posted already in this thread and the numerous other threads on the site where the issue has been discussed, threads I know at least one of you has participated in, so assertions of ignorance at this point are rather on the disingenuous side.

All measurements of "satisfaction" with sexual reassignment have been consistently extremely high, in the 80-90th percentile range. It's also extremely difficult to get SRS, most jurisdictions have regulations requiring years of counseling followed by hormone treatment prior to surgery.

There are risks with the treatment and surgery, both physical and psychological, but research and case studies have found that these risks are lessened the earlier the process is started; hence the American Academy of Pediatrics support of puberty postponement and earlier start on the transition process.

 

[Brainache]

Thanks.

I will admit my ignorance and accept the science on this subject.