Several months ago, a 16-year-old patient came to see me with a complaint of intense menstrual cramps. Over 30 years of practicing pediatrics, I’ve successfully treated this problem because it’s straightforward. But when I saw this patient, I was dumbfounded regarding what to do.
I opened the door to see a patient with a beard, a deep voice, purple hair, nail polish, and a dress.
“How are you today?” I started, immediately feeling a wave of sadness since I’d known the person as a girl for many years.
“What’s going on?” I asked.
“I’m having periods that are out of control and really painful,” my patient said.
I asked many questions, including what medication was currently prescribed without my knowledge. I learned that my patient was taking oral contraceptives (estrogen and progesterone) as well as testosterone. Never, in 30 years, had I ever seen a patient given this combination of medicine by a physician.
I stared at my patient with disturbing uncertainty regarding a diagnosis. When I haven’t known what to do before in cases like this, I called a colleague for help. In this case, I couldn’t think of anyone to call. In all honesty, I had no idea what to do for this patient. I could send the person to the transgender clinic, which, for all I knew gave the combination of pills, and I didn’t believe that was good for my patient’s health. I could send them to an OB/GYN or an internist, but I didn’t know that they’d know what to do any more than I did. Both my patient and I were stuck.
Transitioning children not only harms them physically and psychologically, but it also causes medical conflicts. Physicians find themselves opposing treatments that other physicians have given. While doctors have often disagreed, the division among them now is unprecedented.
Why do kids transition? For many, treatment is driven by parents. Kids go along with what parents, doctors, and teachers feel must be done. This poses serious issues.
First, children under the age of 21 lack sufficient cognitive or emotional maturity to make a decision with these kinds of long-term consequences. In other words, a 16-year-old literally cannot wrap his mind around how the decision will affect him years ahead. Adults who fail to recognize this aspect of normal cognitive development reveal that they either haven’t been taught about or don’t understand child development. Or don’t care.
Second, it will be interesting to see how many transgender children actually go through with complete surgical transition on their own. I asked if my patient intended on having a hysterectomy (thereby completing the transition to a male). The reply was, “Oh no! I’d never do that.”
It also will be telling to see how many boys will agree to being surgically castrated. When it comes down to it, the idea of transitioning is appealing to many teens, but that sentiment may waver when it comes right down to the surgeries involved in order to transition every part of their bodies.
Looking like a boy when genetically female or like a girl if genetically male is one thing. But to cut off breasts and do hysterectomies, or cut off penises and testes is another thing altogether.
This begs the question: What do teens really need and want?
They want a solution to their pain and confusion regarding their gender.
Depression and anxiety have skyrocketed in the United States, reaching unprecedented levels. Depression stems from feeling lonely, isolated, unaccepted, and full of self-contempt. At the heart of depression is often self-hatred.
In other words, the young girl hates herself and the young boy hates himself. Could it be that depression, anxiety, and gender dysphoria are intertwined? If so, this would make the diagnosis muddier. In fact, the diagnosis of gender dysphoria is made primarily on feelings.
The DSM-5 criteria (simplified) for gender dysphoria diagnosis are the following: a marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics; a strong desire to be rid of one’s primary and/or secondary sex characteristics; a strong desire for the primary and/or secondary sex characteristics of the other gender; a strong desire to be of the other gender; a strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender); and a strong conviction that one has the typical feelings and reactions of the other gender.
As a staunch child advocate, I always accept and support a child’s feelings. But this doesn’t necessitate encouraging the child to act on those feelings in a way that might harm them. A research review by the Institute for Research and Evaluation based on several studies came to the conclusion that it’s best not to offer immediate transition treatment.
This prestigious team concluded the following:
“Many scientific agencies—both U.S. and international—do not recommend medical ‘transition’ for youth because the research claiming to show positive effects from cross-sex hormones or surgery is methodologically flawed and not scientifically reliable.
“The limitations of these studies include lack of control groups, small sample sizes, recruitment bias, nongeneralizable study populations, short follow-up times, and high numbers lost to follow-up.”
But while the studies supporting gender reassignment surgeries and hormone treatments for children were of generally poor quality, the opposite was true of studies raising concerns about these protocols.
“Studies finding negative outcomes from medical transition tend to be of adequate scientific quality. In other words, reliable studies have shown harmful effects. ‘Watchful waiting,’ is the option recommended by many scientific agencies. It means deferring transgender interventions for gender-confused children or youth for an extended time during which counseling can occur and a natural desistance or persistence process can play out.”
One of the arguments frequently made to compel support for gender reassignment for children is that it can reduce suicide. Again, the evidence supporting this claim appears to be lacking, the institute said.
“Research does not show that medical gender transition is necessary to prevent suicide. In fact, there is evidence that medical transition procedures may increase suicide risk in gender-confused teens.
“Widely cited studies claiming that suicidality in gender-confused youth is reduced by cross-sex hormonal and surgical interventions have been found to have significant methodological flaws and therefore should not be relied on. Scientifically sound studies have found either no reduction or an increase in transgender suicidality after youth have received cross-sex medical procedures.”
Given the uncertain quality of evidence supporting gender reassignment for children, it makes the risks harder to justify.
Giving children hormones and surgery is inherently dangerous. There’s also the possibility of misdiagnoses of gender dysphoria and not recognizing comorbidities that may be present, including other mental health issues. With a lack of solid medical data that clearly, reliably, and reproducibly shows that children who are treated for gender dysphoria are happier, healthier, and more content as adults, giving kids life-altering hormones and surgical intervention looks like mismanagement.
Gender dysphoria should be handled first with the child’s primary care physician and include long discussions about possible benefits and known risks that must occur over time.
Parents need to learn how complex the issue of gender dysphoria is. There are psychological, developmental, social, and physical dimensions that must be addressed and this takes time.
Rather than slapping a label on a child in order to implement a solution (which physicians have learned to do), we must slow down. Kids deserve an infusion of wisdom and truth from adults.
We must be strong enough to give children the time they need to mature to a point where they can make life-altering decisions. After all—they’ll live with the consequences of those decisions, not us.