Briefing

Treating gender dysphoria in kids

RISHA MOSLEY was 17 when she was first given testosterone in a clinic in North Carolina, after she had declared to her par ents that she was a boy. She had struggled through her teen years with anorexia and depression after a sexual assault. Luka Hein had both breasts removed as a 16 yearold in Nebraska. Chloe Cole, in Cali fornia, was a year younger when she had her double mastectomy. She had been on testosterone and pubertyblocking drugs since 13, also after a sexual assault. All three girls were experiencing “gen der dysphoria” , a feeling of intense dis comfort with their own sexed bodies. Once a rare diagnosis, it has exploded over the past decade.

In England and Wales the number of teenagers seeking treatment at the Gender Identity Development Service (GIDS), the main clinic treating dysphoria, has risen 17fold since 201112 (see chart 1 on next page). An analysis by Reuters, a news agency, based on data from Komodo, a healthtechnology firm, estimated that more than 42,000 American children and teenagers were diagnosed in 2021—three times the count in 2017. Other rich coun tries, from Australia to Sweden, have also experienced rapid increases. As the caseload has grown, so has a method of treatment, pioneered in the Netherlands, now known as “genderaf firming care” .

The treatment is controversial. In many countries, but in America most of all, it has become yet another front in the culture wars. Many on the left caricature critics of genderaﬃrming care as callously disre garding extreme distress and even suicides among adolescents with gender dysphoria in their determination to “erase” trans peo ple. Zealots on the right, meanwhile, ac cuse doctors of being so hellbent on pro moting gender transitions that they “groom” vulnerable teenagers—a term usually applied to paedophiles. In October supporters and critics of genderaﬃrming care held rival, rowdy protests outside a meeting of the American Academy of Pae diatrics.

Several American states, such as Florida and Utah, have passed laws ban ning genderaﬃrming care in children. Joe Biden, America’s president, has described such laws as “close to sinful” . Almost all America’s medical authori ties support genderaﬃrming care. But those in Britain, Finland, France, Norway and Sweden, while supporting talking therapy as a first step, have misgivings about the pharmacological and surgical el ements of the treatment. A Finnish review, published in 2020, concluded that gender reassignment in children is “experimen tal” and that treatment should seldom pro ceed beyond talking therapy. Swedish au thorities found that the risks of physical interventions “currently outweigh the pos sible benefits” and should only be offered in “exceptional cases” .

In Britain a review led by Hilary Cass, a paediatrician, found that genderaﬃrming care had developed without “some of the normal quality con trols that are typically applied when new or innovative treatments are introduced” . In 2022 France’s National Academy of Medi cine advised doctors to proceed with drugs and surgery only with “great medical cau tion” and “the greatest reserve” . The evidence to support gender transitions in adolescents is worryingly weak

Pubertyblockers do what their name sug gests. The idea is that suspending unwant ed sexual development can give patients time to think about their dysphoria, and whether or not they wish to pursue more drastic interventions. The same family of drugs is used to treat “central precocious puberty” , in which puberty begins very ear ly. Some countries also use them to chem ically castrate sex offenders. As with many other medicines used in children, the use of pubertyblockers in gender medicine is “offlabel” , meaning that they do not have regulatory approval for that purpose. Patients who decide to proceed with their transition are then prescribed cross sex hormones.

Males will see the develop ment of breasts and alterations to how fat is stored on the body. Giving testosterone to females boosts muscle growth and caus es irreversible changes such as deepening the voice, altering the bone structure of the face and the growth of facial hair. Under the original Dutch protocol, sur gery was permitted only after a patient turned 18, although as the cases of Ms Cole and Ms Hein show, in some places mastec tomies occur at a younger age. Male pa tients can have artificial breasts implant ed. More elaborate procedures, in which females have a simulated penis built from a tube of skin harvested from the forearm or the thigh, or males have an artificial va gina made in a “penile inversion” , are per formed extremely rarely on minors.

In 2020 the National Institute for Health and Care Excellence (NICE), a Brit ish body which reviews the scientific un derpinnings of medical treatments, looked at the case for pubertyblockers and cross sex hormones. The academic evidence it found was weak, discouraging and in some cases contradictory. The studies suggest pubertyblockers had little impact on pa tients. Crosssex hormones may improve mental health, but the certainty of that finding was low, and NICE warned of the unknown risks of lasting sideeffects. For both classes of drug, NICE assessed the quality of the papers it analysed as “ve ry low” , its poorest rating.

Some studies re ported results but made no effort to ana lyse them for statistical significance. Crosssex hormones are a lifelong treat ment, yet followup was short, ranging from one to six years. Most studies fol lowed only a single set of patients, who were given the drugs, instead of comparing them with another set who were not. With out such a “control group” , researchers cannot tell whether anything that hap pened to the patients in the studies was down to the drugs, to other treatments the patients might be receiving (such as coun selling or antidepressants), or to some other, unrelated third factor.

The upshot is that it is hard to know whether any of the supposed effects re ported in the studies, whether positive or negative, are actually real. Reviews in Fin land and Sweden came to similar conclu sions. As the Swedish one put it, “The sci entific base is not suﬃcient to assess…pu bertyinhibiting or genderopposite hor mone treatment” in children. Two American professional bodies, the

Endocrine Society (es) and the World Pro fessional Association for Transgender Health (wpath) have also reviewed the sci ence underpinning adolescent transitions. But ES’s review did not set out to look at whether genderaﬃrming care helped re solve gender dysphoria or improve mental health by any measure. It focused instead on sideeffects, for which it found only weak evidence. This omission, says Gor don Guyatt of McMaster University, makes the review “fundamentally flawed” . WPATH, for its part, did look at the psycho logical effects of blockers and hormones. It found scant, lowquality evidence. Despite these findings, both groups continue to recommend physical treatments for gen der dysphoria, and insist that their reviews and the resulting guidelines are sound.

One justification for pubertyblockers is that they “buy time” for children to de cide whether to proceed with crosssex hormones or not. But the data available so far from clinics suggest that almost all de cide to go ahead. A Dutch paper published in October concluded that 98% of adoles cents prescribed blockers decide to pro ceed to crosssex hormones. Similarly high numbers have been reported elsewhere. The reassuring interpretation is that blockers are being prescribed very precise ly, given only to those whose dysphoria is deeprooted and unlikely to ease. The trou bling one is that pubertyblockers lock at least some children in to further treat ment.

“Time to Think” , a new book about gids by a British journalist, Hannah Barnes, cites British medical workers con cerned by the latter possibility. They say patients received blockers after cursory and shallow examinations. The Dutch researchers weigh both ex planations. “It is likely that most people starting [pubertyblockers] experience sustained gender dysphoria,” they write. But, “One cannot exclude the possibility that starting [pubertyblockers] in itself makes adolescents more likely to continue medical transition.” Perhaps the biggest question is how many of those given drugs and surgery eventually change their minds and “de

Britain, referrals to the Tavistock gender-identity clinic

[chart annotation] Source: Gender Identity Development Service

*From July 2021, referrals to GIDS were restricted to a narrower group of practitioners 1 4,000 /three.fitted,000 2,000 1,000 0 22 * 19 17 15 13 2011

[chart annotation] Years ending March

012

or explicitly refused to do so, or dropped out of care or, in one case, died of compli cations from genital surgery. The data may therefore exclude precisely those patients who were harmed by or dissatisfied with their treatment. In a rebuttal published in the same journal, Dr de Vries insists that the original papers found a significant improvement in gender dysphoria, the condition the proto col was designed to treat. She concedes that the switching of assessment scales is “not ideal” but says this does not imply the studies’ results were “’falsely’ measured” . In response to worries about the relatively short followup, she noted that a study re porting longerterm outcomes is due “in the upcoming years” . Newer longitudinal studies have been published since, but they have drawbacks, too. One published in January in the New England Journal of Medicine by Diane Chen of Northwestern University and colleagues looked at teenagers after two years of crosssex hormone treatment. Although participants did typically report improve ments in their mental health, they were small—generally singledigit increases on a scale that runs from 0 to 100. The study lacked a control group. Two of the 315 pa tients committed suicide. What is more, whatever the merits of the Dutch team’s original research, the pa tients passing through modern clinics are strikingly different from those assessed in their papers. Twenty years ago the majority of patients were prepubescent boys; in re cent years teenage girls have come to dom inate (see chart 2 on previous page). The findings of older research may not apply to today’s patients. The Dutch team’s approach was deliber ately conservative. Patients had to have suffered from gender dysphoria since be fore puberty. Many of today’s patients say they began to suffer from dysphoria as teenagers. The Dutch protocol excludes those with mentalhealth problems from receiving treatment. But 70% or more of the young people seeking treatment suffer from mentalhealth problems, according to three recent papers looking at patients in America, Australia and Finland. Despite the protocol’s caution, says

Will Malone of the Society for Evidence Based Gender Medicine, an international group of concerned clinicians, the reality is often the reverse, especially in America, with mentalhealth issues becoming a rea son to proceed with transitions, rather than to stop them. “We are now told that if we don’t address young people’s mental health problems caused by dysphoria with transition, they will kill themselves.”

The original Dutch protocol emphasises the need for careful screening and assess ments, as do oﬃcial guidelines in most countries. But whatever the guidance, there are persistent allegations that it is not being followed in practice. “I had one 15minute appointment before I was given testosterone,” says Ms Mosley. Many Amer ican patients contacted by The Economist reported similarly brief examinations. The possibility that many teenagers presenting as trans could instead be gay has long been discussed. The Dutch study of 2011 found that 97% of the participants were attracted either to their own sex or to both sexes.

In 2019 a group of doctors who resigned from GIDS told the Times, a British newspaper, of their worries about homo phobia in some patients and parents. They worried that, by turning children into sim ulacra of the opposite sex, the clinic was, in effect, providing a new type of “conversion therapy” for gay children. Both within America and without, whatever the loudmouths may claim, the vast majority of practitioners are simply trying to ease the genuine suffering of ado lescents aﬄicted by gender dysphoria. But in America in particular the charged atmo sphere has made it very diﬃcult to sepa rate the science from the politics.

European medical systems have not concluded that it is always wrong for an ad olescent to transition. They are not trying to erase distressed patients. They have simply determined that more research and data are needed before physical treatments for gender dysphoria can become routine. Further research could, conceivably, lead to guidelines similar to those already in use by American medical bodies. But that is another way of saying that it is impossi ble to justify the current recommenda tions about genderaﬃrming care based on the existing data. n transition” , having reconciled themselves with their biological sex.

Those who do of ten face fresh anguish as they come to terms with permanent and visible alter ations to their bodies. Once again, good data are scarce. One problem is that those who abandon a tran sition are likely to stop talking to their doc tors, and so disappear from the figures. The estimates that do exist vary by an order of magnitude or more. Some studies have re ported detransition rates as low as 1%. But three papers published in 2021 and 2022, which looked at patients in Britain and in America’s armed forces, found that be tween 7% and 30% of them stopped treat ment within a few years. The original Dutch studies published in 2011 and 2014 were longitudinal—that is, they followed the same group of patients throughout their treatment.

Yet three re cent critiques published in the Journal of Sex & Marital Therapy nonetheless find fault with the studies’ data. One of the new studies’ concerns is the small size of the original samples. The 2011 paper looked at 70 patients. But the out come of treatment was only known for be tween 32 and 55 of them (the exact number depends on the specific measure). And even then, the final assessment of out comes occurred around 18 months after surgery—a very short timeframe for a treat ment whose effects will last a lifetime. (The first patient, “FG” , was followed for longer. In 2011, when in his mid30s, re searchers reported his feelings of “shame about his genital appearance” and of “inad equacy in sexual matters” .

A decade later though, things had improved, and FG had a steady girlfriend.) The critiques also suggest that the find ing that gender dysphoria improved with treatment may have been an artefact of how the participants were assessed. Before treatment, female patients were asked to agree or disagree with such statements as, “Every time someone treats me like a girl I feel hurt.” This established their desire to be seen as male. After blockers, hormones and surgery the same individuals were asked questions on a scale originally devel oped for those born male. It offered state ments such as, “Every time someone treats me like a boy I feel hurt.” Naturally, pa tients who preferred to be seen as male dis agreed.

In effect, the yardstick was changed in a way that might be seen as making positive outcomes more likely. Finally, the original studies seem to have inadvertently cherrypicked patients for whom the treatment was most effec tive. The researchers started with 111 ado lescents, but excluded those whose treat ment with pubertyblockers did not pro gress well. Of the remaining 70, others were omitted from the final findings be cause they did not return questionnaires, 012

Treating gender dysphoria in kids

Treating gender dysphoria in kids

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