Page Summary
- Many professional organizations which endorse GAC for minors have not independently verified the guidelines of the World Professional Association for Transgender Health, which lack developmental rigor.
- Systematic reviews have consistently shown that the evidence for GAC’s effectivness is of low quality.
- Many of the European nations that paved the way in this area have since revised their policies, endorsing conventional psychotherapy instead of medical pathways as the main line of treatment.
Does someone’s internal sense of their gender determine their existence as male, female, or other?
Medical objections to the previous article, part 1
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Isn’t it true that medical authorities like the American Medical Association approve of gender-affirming care for minors?
Dozens of medical organizations in the United States have released position statements supporting sex-trait modification procedures (“gender-affirming care” or GAC) for minors. GAC involves the use of puberty blockers, cross-sex hormones, and surgeries to address gender discordance in young teenagers. This seeming consensus suggests that GAC has been well-studied, and that the clinical benefits have been proven to outweigh the risks. Those who cite this consensus without knowing its origins take for granted that doctors and their professional associations would never betray their fundamental ethical duty to “first, do no harm.”
“Expert consensus” is no substitute for clinical recommendations informed by systematic reviews of the evidence. Tellingly, the World Health Organization (WHO) announced that it would not draft GAC guidelines for youth, citing “limited and variable” evidence “regarding the longer-term outcomes.” This statement is consistent with the findings of health authorities and medical researchers in the UK, Finland, Sweden, Denmark, Norway, and Germany.
In Evidence-Based Medicine (EBM), systematic reviews (SRs) are considered the foundation of trustworthy recommendations. These reviews have consistently found “low” or “very low” quality evidence to support pediatric GAC due to the poor quality of research. Absent randomized controlled trials, claims about GAC being safe, effective, and superior to less invasive alternatives such as psychotherapy are unsubstantiated. SRs evaluate the strengths and weaknesses of all available research and follow a reproducible methodology that reduces the risk that authors will “cherry-pick” evidence and ignore methodological flaws. American medical associations have relied on exactly such cherry-picking.2
There have been five SRs on medical interventions for gender dysphoric youth—two in the UK,3 Sweden,4 Finland,5 and Germany6—as well as one “umbrella review“7 done by McMaster University in Canada. The American Academy of Pediatrics also commissioned a systematic review, which is still in progress as of 2024. Significantly, all five completed SRs returned the same conclusion: the evidence base in support of gender affirmation is of very low quality.
Since the mid-to-late-2000s, medical referrals for gender dysphoria have increased dramatically across the West.8 Along with an increase in referrals, the demographics of the gender-distressed have also changed from predominantly boys with childhood-onset dysphoria to predominantly pubertal girls with preexisting psychiatric issues and no early history of dysphoria. Of note, however, even the “Dutch studies” which involved the childhood-onset cohort, and which are widely regarded as the gold standard in this area of research, have been found to have severe methodological shortcomings.9
Even gender clinicians now admit that children and adolescents are fundamentally incapable of issuing informed consent for irreversible medical procedures, considering brain maturation isn’t complete until age 25.10 Moreover, decades of research have shown that 70% or more of children with gender dysphoria will come to terms with their sex by adulthood. Even the Endocrine Society has conceded that there are no clinical tools to predict whether a particular child’s dysphoria will persist.11 For these reasons, irreversible procedures are not appropriate interventions.
There is no “settled science” that GAC is effective in treating gender dysphoria for minors, and treatments come with considerable medical risks that currently outweigh the known clinical benefits.
2) Cantor, J. (2019). Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy. Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2019.1698481
3) de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276–2283. https://doi.org/10.1111/j.1743-6109.2010.01943.x
de Vries, A. L. C., McGuire, J. K., Steensma, T.D.,Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696–704. doi: 10.1542/peds.2013-2958
4) Ludvigsson, J.F., Adolfsson, J., Höistad, M., Rydelius, P.A., Kriström, B., & Landén, M. A. (2023). Systematic review of hormone treatment for children with gender dysphoria and recommendations for research. Acta Paediatr. 2023. doi: 10.1111/apa.16791.
5) COHERE (Council for the Choices in Health Care). (2020). Palveluvalikoimaneuvoston Suositus: Alaikäisten Sukupuoli-identiteetin Variaatioihin Liittyvän Dysforian Lääketieteelliset Hoitomenetelmät [Recommendation of the Council for Choices in Health Care in Finland: Medical treatment methods for dysphoria related to gender variance in minors]. https://segm.org/sites/default/files/Finnish_Guidelines_2020_Minors_Unofficial%20Translation.pdf
6) Zepf, F.D., Konig, L., Kaiser, A., Ligges, C., Ligges, M., Roesnner, V., Banaschewski, T., & Holtmann, M. (2024). Updated systematic review on the current evidence for using puberty blockers and cross-sex hormones in minors with gender dysphoria. Hogrefe eContent. https://doi.org/10.1024/1422-4917/a000972
7) Brignardello-Peterson, R., & Wiercioch, W. (2022). Effects of gender affirming therapies in people with gender dysphoria: Evaluation of the best available evidence. https://ahca.myflorida.com/content/download/4864/file/AHCA_GAPMS_June_2022_Attachment_C.pdf
8) Zucker, K. (2019). Adolescents with Gender Dysphoria: Reflections on Some Contemporary Clinical and Research Issues. Archives of Sexual Behavior, 48, 1983–1992.
9) Abbruzzese, E., Levine B.S. & Mason, J.W. (2023). The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch studies—and research that has followed. Journal of Sex & Marital Therapy, 49 (6), 673-699. https://doi.org/10.1080/0092623X.2022.2150346
10) Casey, B. J., Jones, R. M., & Hare, T. A. (2008). The adolescent brain. Annals of the New York Academy of Sciences, 1124, 111–126. https://doi.org/10.1196/annals.1440.010
11) Hembree, W.C., Cohen-Kettenis, P.T., Gooren, L., et al. (2017). Endocrine Treatment of Gender Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline, The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869-3903.