The Complicated Science & Ethics Behind Treatment of Transgender Youth

The issue surrounding transgender youth, and whether they should receive medical care to transition has led to Nationwide controversy.

On one side of the argument, there is the belief that children know as early as 3 years old whether they are transgender, and this remains unchanged well into adulthood.

The opposite argument is the belief that so much as allowing a child to change their clothes, their name, and their pronouns is child abuse, and that parents should be investigated.

The LGBTQ community cites troubling data concerning the suicide rate of transgender youth. According to Forbes, an alarmingly 42% of transgender youth have considered suicide in the past year in 2020. However, the Trevor Project noted that in a 9,000 person study, gender affirming hormones were linked to reduced suicidal ideation. Therefore, they view any limits on this therapy as an attack of transgender youth, almost as though you are wishing them death.

However, there is troubling data on a sudden surge in LGBTQ youth. In Newsweek, they published a study that shows that 40% of Generation Z identify as LGBTQ, which is a 30% increase from the Millennial generation. This disturbing data has been used to argue that perhaps this is, in fact, a social contagion.

This has led me to ask some serious questions, including:

  • What is Gender Dysphoria?
  • How is Gender Dysphoria Diagnosed?
  • Are there objective standards to that diagnosis (Such as brain scans) that can be used to confirm diagnosis?
  • What does the treatment entail and what are the side effects of the treatment?
  • Does ‘transitioning’ actually help patients?
  • How common is ‘de-transition’?

But the most important question of all, has been the one in the forefront of my mind: Can a child, who ethically cannot consent to sex, tattoos, piercings or other life-altering and permanent decisions, be able to consent to fundamentally altering one’s body?

Or, as proponents of treatment argue, is being transgender no different than having a clubbed foot: we treat this disorder just like any other, and there should be no stigma surrounding it.

Gender Dysphoria

Let’s start with some clear cut clinical definitions: Gender Dysphoria is cited in Diagnostic and Statistical Manual of Mental Disorders, or DSM. The DSM has a set of diagnostic criteria for diagnosing Gender Dysphoria and the diagnostic criteria for children are separate from the Diagnostic criteria for adults and adolescents. This disorder must be diagnosed through a psychologist or mental health counselor.

In children, the symptoms must last at least 6 months, and must include six of the following:

  • A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
  • In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
  • A strong preference for cross-gender roles in make-believe play or fantasy play
  • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
  • In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
  • A strong dislike of one’s sexual anatomy
  • A strong desire for the physical sex characteristics that match one’s experienced gender

There appears to be no other objective standards: no blood tests, no MRI, no other diagnostic tools available to diagnose this, other than the patient’s word.

Looking at the diagnostic criteria, I noticed something peculiar about my own childhood: I had six of the characteristics that are used to diagnose children. I hated feminine clothing (and still do) and makeup has always horrified me and left me with a feeling that I was putting on a “show” and that I was “trying too hard.” It leaves me feeling as though I’m wearing a mask.

I had mostly male friends growing up, and although I had a barbie set, I would rather play with the boys. I even went so far as to tell my mom “I think I’m a boy.” to which she replied “No you’re not, you’re just a different kind of woman.”

Looking back on it, I realize that what I was experiencing was gender dysphoria. So what currently is the treatment for Gender Dysphoria?

Treatment for Gender Dysphoria

So treatment for gender dysphoria includes puberty blockers, hormone replacement therapy, surgery and talk therapy. All of these treatments are designed to try and emulate the patients’ vision of what their body should look like.

But these treatments, like everything else in life, have side effects.

Puberty Blockers:

Puberty blockers, or “gonadotropin-releasing hormone (GnRH) analogues”, can be begin as early as 10-11 years old, right when puberty begins according to Mayo Clinic, and can be used to “pause” puberty in order to determine if the child is truly gender dysphoric.

However, Cleveland clinic’s Dr. Cartaya states that puberty blockers start at the onset of puberty, typically between the ages of 8-14. 

They will prevent the development of things like in males, the development of a deeper voice, an Adam’s apple, growth of facial hair, penis growth and scrotal tissue growth in boys. In girls, they prevent the development of breasts and the beginning of menstruation.

The side effects of long-term use can include a limit of how tall a child grows, bone density issues, as well as future fertility problems.

Additionally, parents should be aware that although these drugs are marketed as a “Pause button” for transgender youth for exploring their gender identity, research has shown that the majority of youth on puberty blockers (99%) continue their transition using cross-sex hormones.

Many experts in the field of transgender studies are extremely concerned about the use of puberty blockers with hormone replacement therapy. This combination can lead to complications, including an inability to orgasm and permanent infertility. Also, they are no longer listed as completely “reversible” by the National Health System of Europe.

Here in the United States, as recently as 2019, these drugs were still being prescribed as ‘off label’, meaning that they have not been approved by the FDA for the treatment of transgender youth. Their original use was to suppress puberty in children whose puberty came about too soon, and they were never originally intended to be combined with other drugs.

I have to admit, when my hips and breasts began to come in, I was extremely upset. I thought I was fat, that my body was “awful” and I absolutely hated the way I looked. The idea that I could have gone on the internet, discovered puberty blockers and completely stopped this process (had I grown up in 2020), would have been extremely tempting to thirteen-year-old me.

My mom reassured me though by saying, “You’re not fat! This is what women look like!” and as I finished developing by age sixteen, I began to really like my body.

The next steps in this process, if my mom had listened to medical professionals, would have been Hormone Replacement Therapy and Gender Reassignment Surgery.

Hormone Replacement Therapy for Trans women/men:

Hormone replacement therapy, or “HRT” is known to be the top of the line treatment for someone who wishes to transition.

The female form of HRT was originally used to treat menopausal women. The drug (Prempo) which is a progesterone estrogen mix, increases women’s risks of heart disease, stroke, blood clots and breast cancer.

For trans women, feminizing hormone therapy is not recommended for those who have had a cancer that is sensitive to hormones (such as prostate cancer) or have had blood clots in the past.

The biggest risk factor, however, includes infertility. Ideally, the hormone therapy will begin at age 16, which is before secondary sex characteristics can occur.

Hormone replacement therapy for trans men actually has the same risks of cancer, blood clots and infertility as hormone replacement therapy for trans women. It is also typically begun at age sixteen.

Gender Reassignment Surgery

The gender reassignment surgery for trans women takes on many forms, including vaginoplasty, facial feminization surgery and vocal feminization surgery. For trans men, these surgeries include mastectomy, hysterectomy, vaginectomy, metoidioplasty or phalloplasty. Additionally, mastectomy and hysterectomy are routinely performed on women to treat a variety of cancers.

Gender reassignment surgery has been performed much longer than puberty blockers or hormone replacement therapy, so these surgeries are generally safe. But they are irreversible.

Does the treatment work?

Many transgender activists claim that the only way to prevent suicide rates amongst gender dysphoric youth is through medical transition. However, the science on whether transition actually helps relieve people from the anxiety, depression, and suicide attempts related to gender dysphoria remains unclear.

According to the Trevor Project survey, which interviewed over 9,000 youths, with 50% of them wanting to use hormone replacement therapy, 36% not interested in hormone replacement therapy, and 14% already using hormone replacement therapy. The average age of this group was 17.5 years old.

What they found was that people who are using hormone replacement therapy were 40% less likely to attempt suicide and have depression.

However, longer term studies do not support this assertion. A Swedish study examined the lives of 2,679 people who were suffering from gender dysphoria over a period of ten years. They found that “Specifically, the odds of receiving mental health treatment in 2015 were reduced by 8% for every year since receiving gender-affirming surgery over the 10-year follow-up period.” Additionally, they did not find a positive correlation between hormone replacement therapy (or puberty blockers) and suicide rates over time.

However, the levels of suicide and anxiety treatment were still significantly higher than the rest of the general population, which suggested to them that there is a “need to address factors in addition to gender-affirming treatment availability that may strengthen transgender individuals’ mental health.”

In other words, the idea that hormone replacement therapy, puberty blockers, as well as gender reassignment surgery are “cure-alls” to the risk of suicide amongst transgender individuals is an idea that is simply not true.

Reduction of suicide rates is important, but nonetheless, these youths will continue to have higher than normal suicide rates even after all the gender affirmation therapy that is available to them, well into adulthood.

Which means that parents should be on guard to continue taking their children to therapy as well as helping them join support groups.

For me personally, the way I reduced my own ‘distress’ was simple: I changed my mindset of what it means to be ‘woman’. By sixteen years old, I was perfectly comfortable with my body and with being a woman.

I know for a fact that I’m never going to be that typical “Female Archetype” from the 1950s because that’s just not who I am. My mother, an avid feminist, taught me that the relationship that I have with my gender is not defined by pretending to be something I’m not, but by being the type of woman that I actually am.

De-Transition: The Dark Side of Transitioning

This is perhaps every parent’s worst nightmare. You allow your child to go under hormone therapy, puberty blockers, and eventually gender reassignment surgery under the idea that you are helping them, only for the child to realize that it was all a mistake!

So the next question one has to ask themselves is: how common is it for children to “change their minds” and realize that they were born the correct gender all along?

The current numbers of de-transition are only between 1-3%. However, these low-numbers are based on adults transitioning, with the average age of millennials transitioning being age 22.

Now, thanks to puberty blockers being widespread, a child as young as eight years old can begin to medically transition. This has caused those in generation Z to be an average age of 17 when these children begin to live as their ‘affirmed’ gender. There have been no studies to indicate whether this will have any effect on the percentage of those who choose to de-transition. There have been no studies.

Rather, the idea is that children know from an early age. A 2020 study found that “73% of transgender women and 78% of transgender men reported that they first experienced gender dysphoria by age seven.”

Whether or not a child can essentially “grow out of” gender dysphoria remains unclear. Most activists fight against this idea, however, Cleveland Clinic’s Dr. Cartaya states that 66% of kids will grow out of gender dysphoria, stating:

“A third of kids will have an exacerbation of their gender dysphoria during puberty. These kids often feel like their bodies are betraying them in many ways,” explains Dr. Cartaya. “That can also be an indication that gender dysphoria is going to last throughout their lifetime. This is the reason why we wait until puberty to start children with gender dysphoria on puberty blockers.”

However, by beginning children as young as eight-years-old on puberty blockers, one might ask how this even gives them a chance to experience their gender and their body fully.

As I said before, the distress I felt with my hips and breasts as a thirteen-year-old child would have made puberty blockers extremely tempting. But I have no doubt that in the end, I would be one of the de-transitioners.

This is because gender nonconformity is separate and distinct from your gender identity. Your gender identity is even separated from your sexual orientation!

For example, I have watched women in my family, who enjoy a shorter haircut, men’s jeans, and a great career, become extremely upset when people ask them if they are lesbians, as all of my female relatives are heterosexual and happily married! (you could say it runs in the family!)

Ethical Concerns

Even if you believe that a child as young as eight years old can know that they are transgender, and that this idea will never change, the ethical questions I have are as follows: 

Does a child, at the age of eight years old, have the ability to understand the complete risks of puberty blockers? The risks of hormone treatments? Can a child that young fully comprehend the ramifications, such as infertility & the inability to orgasm?

What age is it appropriate to allow a child to undergo such procedures? Is there any age that this is appropriate?

These are all ethical questions as well as risks that I think any parent should consider before jumping down this rabbit-hole. These risks as well as questions would be what I would consider if I ever have a child suffering from gender dysphoria.

My other concerns are the way that parents are being essentially bullied with rhetoric that their child will commit suicide if they do not give the child what they want, and this is not informed consent. Informed consent, according to the American Medical Association, states the following:

Physicians should:

(a)  Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.

(b)  Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about:

                    (i)        The diagnosis (when known)

                   (ii)        The nature and purpose of recommended interventions

                  (iii)        The burdens, risks, and expected benefits of all options, including forgoing treatment

When a doctor asserts that a child will commit suicide if not given puberty blockers and hormone replacement therapy, the consent that a parent gives is now consent given under duress.

Additionally, this assertion has, of course, only been “proven” by a study hosted by the Trevor Project, a trans rights advocacy group. These results have not been able to be replicated over the long-term and have not been independently verified.

Finally, it gives parents a false idea that their child is now ‘safe’ thanks to the puberty blockers and hormone replacement therapy, despite the fact that the suicide rate for this group remains incredibly high, even ten years after gender reassignment surgery. Parents, whatever treatment options they choose, should be forever mindful that the risk of suicide for transgender people remains incredibly high, even with transition.

The maintaining of the suicide rates amongst transgender people brings to mind, at least to me, ethical questions of whether these treatments actually “work” and about why the medical profession would treat a disorder of the mind with surgery and hormone replacement therapy.

If you notice, the medical community does not prescribe “liposuction” for someone suffering from Anorexia Nervosa, for example, or prescribe plastic surgery to someone suffering from Body Dysmorphia.

I have no doubts that this disorder exists, because it most certainly does, and has existed for centuries. My question is why did the medical community choose to go down the road of body modification to treat a disorder of the mind?

But the biggest, most important question I have for parents is this…

What if your child grows out of their gender dysphoria, naturally?

I certainly grew out of it, and I have to tell you, I am grateful that I am not growing up in 2020! I have since grown up, joined the Catholic church (as an adult), gotten married to my wonderful husband, and I am actively trying to have children at the moment that I write this.

None of which would be possible had I been prescribed puberty blockers and hormone replacement therapy.

This is why I oppose puberty blockers (and hormone replacement therapy) for all children, and why I oppose putting children on the “Fast Track” of gender transition.

Although proponents of puberty blockers state that puberty is “traumatic” for children with gender dysphoria, I think, quite frankly, puberty is a troubling (and traumatic time) for everyone.

As many adults can attest to, waking up with “rose buds” on your chest, or hair in places you never had it before, or random erections, can make anyone feel as though their body is betraying them.

And Although Gender Dysphoria is a real psychiatric illness that deserves our compassion, the medicalization of puberty and gender stereotypes in children is enough to give me “pause” as one should not have to support the sterilization of children in order to be an “ally of the trans community.”

Malcolm X once said, “Being friendly, and being a friend, I think, are two different things.” I don’t believe I’m being a good ‘friend’ to a child if I agree with a child’s assessment that everything is wrong with their body.

I don’t believe I’m being a good ‘friend’ to a child if I allow them to make drastic, radical, and permanent changes to their bodies anymore than if I would allow a child to get a tattoo, have sex, or use drugs.

If an adult wants to transition, that is one thing. But please leave children out of it.

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