At the prestigious Center of Expertise on Gender Dysphoria, at Vrije Universiteit University Medical Center, in Amsterdam—often referred to simply as “the Dutch clinic”—an older cohort of kids who went through the puberty-blockers-and-cross-sex-hormones protocol was also found to be doing well: “Gender dysphoria had resolved,” according to a study of the group published in 2014 in Pediatrics. “Psychological functioning had steadily improved, and well-being was comparable to same-age peers.”
These early results, while promising, can tell us only so much. Olson’s findings come from a group of trans kids whose parents are relatively wealthy and are active in trans-support communities; they volunteered their children for the study. There are limits to how much we can extrapolate from the Dutch study as well: That group went through a comprehensive diagnostic process prior to transitioning, which included continuous access to mental-health care at a top-tier gender clinic—a process unfortunately not available to every young person who transitions.
Among the issues yet to be addressed by long-term studies are the effects of medications on young people. As Thomas Steensma, a psychologist and researcher at the Dutch clinic and a co-author of that study, explained to me, data about the potential risks of putting young people on puberty blockers are scarce. He would like to see further research into the possible effects of blockers on bone and brain development. (The potential long-term risks of cross-sex hormones aren’t well known, but are likely modest, according to Joshua Safer, one of the authors of the Endocrine Society’s “Clinical Practice Guideline” for treatment of gender dysphoria.)
Meanwhile, fundamental questions about gender dysphoria remain unanswered. Researchers still don’t know what causes it—gender identity is generally viewed as a complicated weave of biological, psychological, and sociocultural factors. In some cases, gender dysphoria may interact with mental-health conditions such as depression and anxiety, but there’s little agreement about how or why. Trauma, particularly sexual trauma, can contribute to or exacerbate dysphoria in some patients, but again, no one yet knows exactly why.
To reiterate: For many of the young people in the early studies, transitioning—socially for children, physically for adolescents and young adults—appears to have greatly alleviated their dysphoria. But it’s not the answer for everyone. Some kids are dysphoric from a very young age, but in time become comfortable with their body. Some develop dysphoria around the same time they enter puberty, but their suffering is temporary. Others end up identifying as nonbinary—that is, neither male nor female.
Ignoring the diversity of these experiences and focusing only on those who were effectively “born in the wrong body” could cause harm. That is the argument of a small but vocal group of men and women who have transitioned, only to return to their assigned sex. Many of these so-called detransitioners argue that their dysphoria was caused not by a deep-seated mismatch between their gender identity and their body but rather by mental-health problems, trauma, societal misogyny, or some combination of these and other factors. They say they were nudged toward the physical interventions of hormones or surgery by peer pressure or by clinicians who overlooked other potential explanations for their distress.
Some of these interventions are irreversible. People respond differently to cross-sex hormones, but changes in vocal pitch, body hair, and other physical characteristics, such as the development of breast tissue, can become permanent. Kids who go on puberty blockers and then on cross-sex hormones may not be able to have biological children. Surgical interventions can sometimes be reversed with further surgeries, but often with disappointing results.
The concerns of the detransitioners are echoed by a number of clinicians who work in this field, most of whom are psychologists and psychiatrists. They very much support so-called affirming care, which entails accepting and exploring a child’s statements about their gender identity in a compassionate manner. But they worry that, in an otherwise laudable effort to get TGNC young people the care they need, some members of their field are ignoring the complexity, and fluidity, of gender-identity development in young people. These colleagues are approving teenagers for hormone therapy, or even top surgery, without fully examining their mental health or the social and family influences that could be shaping their nascent sense of their gender identity.
That’s too narrow a definition of affirming care, in the view of many leading clinicians. “Affirming care does not privilege any one outcome when it comes to gender identity, but instead aims to allow exploration of gender without judgment and with a clear understanding of the risks, benefits, and alternatives to any choice along the way,” Aron Janssen, the clinical director of the Gender and Sexuality Service at Hassenfeld Children’s Hospital, in New York, told me. “Many people misinterpret affirming care as proceeding to social and medical transition in all cases without delay, but the reality is much more complex.”
To make sense of this complex reality—and ensure the best outcome for all gender-exploring kids—parents need accurate, nuanced information about what gender dysphoria is and about the many blank spots in our current knowledge. They don’t always get it.
. it's not like our private insurers/HC is a ton better, I have a two month wait for some odd thoracic back pain I've got..... and two months of back pain is not trivial.......
