The Medical Field Is Finally Getting Serious about Helping Adolescents with Gender Dysphoria
And while I expect very little (or nothing) to change in the United States in
the short term, it's never too late to begin the discussion.
I was listening to
KUOW the other day, their
On Point program, and for a moment I thought
(a) I was dreaming and (b) it was Christmas.
The topic of conversation was Gender Dysphoria in Adolescents (and the implications for
their medical care), and I couldn't believe what I was hearing. The guests said
stuff like:
- "[The Cass Review] found that the evidence base for medicalized treatment of
adolescent gender distress was quote: inadequate and poor."
- "Young people are in a state of mental health crisis, and we
can't pretend like that's not a piece of what's going on for a lot of the
gender-distressed kids coming in these days."
- "I worry about how politics has infused this field in a way that I think
can be detrimental to all youth."
- "And it's so critical to do comprehensive assessments [of adolescents
seeking gender affirming care] that are very individualized."
- "I think we need to re empower professionals to not be afraid [of the
social-political implications of their medical decisions related to gender-affirming care]."
- "Many [adolescents seeking gender affirming care] often suffer from
concurrent mental health issues or autism."
- "The Cass Review recommends exercising caution and having full
parental buy in."
I was absolutely incredulous.
Involve the parents in their adolescents medical care?!?
Make the best medical decisions for our adolescents instead of worrying about the social-political implications??!
There are serious mental health issues that are being largely ignored here?!?
Do comprehensive assessments of our adolescents who say they're experiencing gender dysphoria?!?
It was all so rational. I thought perhaps it was too good to be true.
I had to listen to
the entire episode,
and so that's exactly what I did.
My first post was written in October of 2022 and was titled
What's Happening To the Gender Identities of Our Adolescent Girls?.
In re-reading this post, I'm sticking by it. This topic is still wickedly toxic. It has put
parents (and families) into a simply impossible (and cruel) position, and the vast majority
of the cohort known as "ROGD" or more appropriately
"gender distressed, cisgender children"
is still at risk in the ways I pointed out in that article.
My main interest was/is that I believe we're actually doing great harm to this generation of
adolescent, [biologically] female, girls who are presenting as transgender for the 1st
time in their teens. As a result, my interest has been strictly medical, politics be damned.
Only now,
other people
are starting to notice
(Alternate link to that article)
If you'd like a relatively succinct summary of the issues at hand, that's a good one.
Here's another
recent article
by
Leor Sapir
from the Manhattan Institute. I've highlighted
some wonderful excerpts in the footnotes. The article is definitely worth reading in it's entirety.
And change is happening as a result.
Following the publishing of the Cass Review,
Scotland joined
Finland, Sweden, Norway & Denmark (who had conducted their own reviews prior to the Cass report and reached
the same conclusion), has paused hormone treatments for adolescents under 18.
Wales
did the same.
I still think this topic is toxic, and I suspect I'll be accused of being transphobic (similar to nearly
every other person who has tried to discuss this topic in any nuanced way whatsoever), but at least
now I'll have a lot of company.
I'll admit right away that I don't think I can produce a suitable summary of
this podcast:
it's just too good, and it's fairly dense, and so I think if you care
about this subject, I highly recommend listening to the the entire thing.
In the footnotes, there are two important links. Number one is the full
interview with Dr Cass,
and the other is the link to the Cass Review itself.
Both are provided for those who are diligent enough to want to read/hear
from the source, with no interpretation.
Below, I'll try to identify ~ten distinct topics and then cite relevant
excerpts about each topic (anyplace you see emphasis, it's mine).
On proper treatment protocols:
[The study] found that the evidence base for medicalized treatment of
adolescent gender distress was quote: "Inadequate and poor".
For most gender-distressed young people, a medical pathway will not be the best
way to manage their distress.
Many often suffer from concurrent mental health issues or autism.
And disappointingly, the team did not find improvements in mental health. In fact,
some young people got worse, some made no changes.
So we've not taken a position that any form of care is best, but what we have
said is that it is important that all young people get access to evidence-based,
non-medical interventions that address the full range of their difficulties.
So this group of young people, if they are depressed, if they're anxious,
if they need an autism diagnosis, all of those things should be put in place.
That is honestly the reason I have been vocal. Because I do care about the
well-being of trans children. Tremendously, that's what my career is focused on,
but I also care about the well-being of gender distressed, cisgender children.
And to only focus on one group and not both, I think is harmful.
But actually, there are many different ways in which we can manage distress and
anxiety in a 15-year-old that don't involve puberty blockers. And yet we've somehow
stopped short of trying those, just because puberty blockers have become so widely
believed to be effective.
On the risk of suicide in transgender adolescents:
And as the report says, "It is well established that children and young people
with gender dysphoria are at increased risk of suicide." But then the report
adds this, "But suicide risk appears to be comparable to other young people
with a similar range of mental health challenges." So first of all, what's
the evidence for that?
CASS: So how do we know if this is down to the gender-related distress? Or
is it because they also have an eating disorder, or they're depressed or
a whole raft of other issues? And because a majority of these young people
have all of these issues, then what you need to do is compare to what
the population rates are of suicidality in young people who have all
of those other issues, but are not gender questioning.
And that's where you find that the rates are fairly comparable.
So we can't say that it is the gender questioning or the gender incongruence
that's giving you additional suicide risk. And so the second part is,
does the gender-affirming treatment pathway reduce that suicidality?
But such data as we have shows that we can't detect a difference in
the suicide rates before and after treatment.
On doctors and psychologists being afraid of questioning the current medical care model:
I think we need to re empower professionals to not be afraid. And they could
see somebody who would really see them as a whole person, then I think they
would get a much better deal.
The politically infused public discourse is getting this wrong and it's
impacting the way that doctors care for their patients. Physicians must be
able to practice medicine that is informed by their medical education,
training, experience, and available evidence freely and without threat of punishment.
There's so much backlash. (Backlash from where?). With the internet and social media, there
are people who have very passionate feelings and are very scared and traumatized, who may
get angry at some of the things that either Laura or I are saying, and feel that we're not
advocating enough for their communities. And I understand that, but I also think it's really
problematic. Because we need to have good debate and we should be listening to one another,
at least for people who have the best interests of youth in mind.
I would just add that it is terrifying. There's no other
way to put it from my perspective to engage in these conversations publicly.
On the need for adolescent girls to establish mental health treatment 1st:
Young people are in a state of mental health crisis, and we
can't pretend like that's not a piece of what's going on for a lot of the gender-distressed
kids coming in these days.
That has changed drastically in the last 15 years or so, where the
mental health issues occur for young people prior to there ever being any
gender distress. And it's so critical to do comprehensive assessments
that are very individualized. I think to your question, these days, if
that isn't being done, then I do worry that there are young people being
treated medically who shouldn't be.
Yeah, I don't think we can mandate that all children who socially transition
have mental health treatment in our country, because we don't have a national
health service.There's tremendous problems with access to mental health care for all youth.
The Cass Review recommends exercising caution and having full
parental buy in, and mental health services available for young people who seek to socially
transition in any way.
But for others who are distraught and experiencing significant mental health
issues and trying to understand why they feel so different and so miserable, then
in some of these cases, it just doesn't.
Because it doesn't fix the underlying mental health issues.
On involving parents in the treatment of their adolescents:
I will tell you that what I have seen over and over in my clinical practice is
how withholding information from parents is really very rarely in the child's best
interest. Because 99% of the time, these young people have significant mental health
issues and so by not sharing the gender distress with parents, it also often means
not sharing the rest of the mental health picture.
And it ends up tearing families apart. Parents feel that they've been left out of
the loop. Many times, the parents are very supportive of their child's gender questioning,
but simply want to be involved in their care. And so I do agree with Dr. Cass. And what
she speaks about in the report regarding the adolescence, that it really needs to involve the parents.
On the need for assessments (and how these don't even exist):
EDWARDS-LEEPER: In addition to putting more resources into research, from my
perspective, the focus these days really needs to be on the mental health needs
first, as the Cass Report points out. And that means that the majority of
providers within these clinics need to be mental health providers and need to be
offering the kind of thorough assessment. And then, ongoing support for the
young people.
TISHELMAN: One final point I would say is we're talking about assessments, but we
really don't have research on what assessments are effective. Right now, we don't
have a research basis for making those decisions, but at least we could bring
together a diversity of sophisticated clinicians who do believe that transgender
youth exist, to come up with some guidelines about what we mean by assessment.
CHAKRABARTI: That is so remarkable. We don't even know yet what the best assessments
are, let alone we don't have an evidence base to know what the best treatments are.
TISHELMAN: No.
On how politics has caused great harm to everyone involved:
And I worry about how politics has infused this field in a way that I think can
be detrimental to all youth.
And I'm not entirely sure how we got to this place, but so many seem to be in sort
of an echo chamber, where they will not even entertain these conversations or these
considerations, and so somehow that has led the field, at least in the United States,
somehow we've just spiraled into an inability to critically think, and I do think
the political scene is a huge part of that problem.
On the profoundly negative effects on the families involved:
I can't tell you how much empathy I have for these parents that are going
through this. To be caught up in this political and polarized field right now is
ripping families apart and just causing so much distress for the young person, but
for the parents and for the families as a whole. So what I recommend, that they
ask the potential provider if they've read the Cass Review.
In support of the data that there's been a huge increase in girls seeking treatment:
This comes as the number of young people seeking clinical help for gender
distress continues to grow. And unlike a decade or two ago, most of these
people are adolescent natal girls.
And that population has changed in recent years .. to predominantly birth
registered girls presenting in the teenage years.
On what might have changed that explains the exponential rise in the number of the adolescent girls seeking treatment for gender dysphoria:
In fact, you have a chart here that shows that around 2013, 2014, every year, essentially,
the numbers spike up higher and it's more, many more adolescent girls. What do you think,
or what did the review seem to find in terms of what may be driving that rapid rise?
So we looked at what we understand about the biology, but obviously, biology hasn't changed
suddenly in the last 10 years. So then we tried to look at what has changed?
And one is the overall mental health of teenage girls in particular.
These next couple of quotes are from
this op/ed
(which I've already cited in the 1st footnote but is too good to be completely relegated to the footnotes).
The author (Leor Sapir) has clearly been paying attention. The entire article is very much worth reading.
A couple of sections really resonate with me because here in WA State, the legislature
has [rightfully] banned conversion therapy. This is very good. But
where things have gone wrong is that
"trying to understand the reasons for say, body dysmorphia"
has been pulled under the conversion therapy umbrella (and is similarly banned). That part is
very broken (as it forbids the possibility of diagnosis). Here's the relevant quote:
In a political climate such as ours, in which mere exploration of the reasons for rejecting
one’s body can be labeled “conversion therapy,” differential diagnosis becomes impossible.
It's like poetry.
Another section that succinctly sums up what's been happening at a macro level:
What is likely happening is that an ongoing youth mental health crisis whose origins
predate and have little to do with gender is being misdiagnosed and mistreated with harmful
and experimental drugs.
A quick nod to the idea of what was called Rapid Onset Gender Dysphoria (one of the many
rational, discussable ideas that was simply incredulous to many in the trans-rights
community):
Most adolescents referred to pediatric gender clinics are teen girls who have no
history of dysphoria in childhood but who do have other mental health challenges that
predate their distress with their bodies.
And finally, touching on what wasn't mentioned in the Cass Report article (that upwards of 2/3rd of
adolescent girls who show signs of gender distress have a history of mental challenges
like depression, abuse, or neurodiversity, which is a critical part of the story):
Puberty is difficult for all teens, and it is not a disease. Puberty blockers offer
teens in distress — especially girls with history of sexual abuse, autistic kids
and gay kids — false hope by casting puberty as optional.
My hope is that we can begin to set aside the socio-political nonsense surrounding this
issue and get back to basics, which is to provide the right level of support for this
cohort, so kids get an accurate diagnosis, relevant support, and yeah, we should
probably explore an actual diagnosis as step number one.
