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In 1952, front page headlines trumpeted “Ex-GI Becomes Blonde Beauty.” George Jorgensen was an American army veteran who had sex reassignment surgery in Denmark and returned to the US as a woman, Christine Jorgensen. Doctors removed his penis and testes, administered female hormones, and created an artificial vagina. It was not the first instance of such surgery, but it was the one that led to widespread publicity and public awareness.

With celebrity examples like Chas Bono and Caitlyn Jenner, society has become more aware and more accepting of gender transitions, although the question of bathroom choice still invokes much controversy. More and more children are reporting gender dysphoria. When is it appropriate to offer gender transition interventions to these children?

Some definitions

Transgender is an umbrella term for people whose gender identity and/or gender expression differs from the sex they were assigned at birth. Sexual orientation refers to preference for sexual partners. Transgender people have the same spectrum of sexual orientation as cisgender people: they may be heterosexual, homosexual, bisexual, or asexual.

Transsexual refers to those who seek medical assistance in transitioning from one sex to another. If a person with male XY chromosomes transitions to female and is attracted to men, she is considered heterosexual. Gender dysphoria is a term denoting distress caused by a gender conflict.

The Diagnostic and Statistical Manual of Mental Disorders ( DSM-5 ) replaced the previous designation of gender identification disorder (GID) with the term gender dysphoria and provided specific criteria for making the diagnosis in adults and adolescents. People who don’t fit the criteria but are experiencing clinically significant distress can be diagnosed with Other specified gender dysphoria or Unspecified gender dysphoria.

In addition to the criteria for diagnosing adults and adolescents, DSM-5 provides these separate criteria for diagnosing gender dysphoria in children:

At least six of the following and an associated significant distress or impairment in function, lasting at least six months: A strong desire to be of the other gender or an insistence that one is the other gender A strong preference for wearing clothes typical of the opposite gender 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 A strong preference for playmates of the other gender A strong rejection of toys, games and activities typical of one’s assigned gender A strong dislike of one’s sexual anatomy A strong desire for the physical sex characteristics that match one’s experienced gender

These are largely subjective: just how strong is “a strong preference”? It’s left up to the clinician’s judgment and leaves some wiggle room for different clinicians to disagree.

When do children know?

Signs of gender dysphoria have been reported as early as the age of two. But there is also late-onset dysphoria that manifests in adults. Caitlyn Jenner married three women and fathered six children before her gender change at age 66. Some transgender adults remember having had opposite-gender feelings in childhood that they never expressed. Sometimes early-onset gender dysphoria patients first identify as gay before they express a desire to be the other gender.

The problem with diagnosing early onset gender dysphoria is that some children will feel differently when they grow older. A comment from a reader of a New York Times article:

At about the age of 5, I was convinced I was a boy who had mistakenly been born in the body of a girl. This was in the 1950s, so there was never any discussion of my feelings, and obviously I never heard of “gender dysphoria.” By the time I was an adolescent, these feelings had disappeared. Parents who rush to allow children to “transition” when they are young may be harming their children more than if they just waited to see if the child still felt that way when they got a little older.

How many children will “grow out of it”?

That NYT article reported:

Several studies have tracked the persistence of gender dysphoria in children as they grow. For example, Dr. Richard Green’s study of young boys with gender dysphoria in the 1980s found that only one of the 44 boys was gender dysphoric by adolescence or adulthood. And a 2008 study by Madeleine S. C. Wallein, at the VU University Medical Center in the Netherlands, reported that in a group of 77 young people, ages 5 to 12, who all had gender dysphoria at the start of the study, 70 percent of the boys and 36 percent of the girls were no longer gender dysphoric after an average of 10 years’ follow-up.

It said there is no way to predict which ones will persist, but persistence increases with age at diagnosis: in adolescents, about 75% of gender dysphoria will persist.

A presentation to the 23rd World Professional Association for Transgender Health Biennial Symposium, Feb. 16, 2014, Bangkok questioned the methodology of those studies. It questioned the selection of subjects, some didn’t fit the diagnosis and some had undergone treatment. It said follow-up was not long enough, retrospective evidence was ignored, and unwarranted assumptions were made. It concluded that:

The evidence shows that the majority of gender nonconforming children are not gender dysphoric adolescents or adults.

The evidence does not show that most truly gender dysphoric children will desist in their gender identities before adolescence.

The evidence shows that intense anatomic dysphoria is associated with persistence.

The evidence does not support the speculation that allowing childhood social transition will trap cisgender youth in roles incongruent with their identities.

In a recent article, James Cantor disagreed. He thought the methodologies were OK but thought it didn’t matter. He said, “Even if the criticisms were valid, the studies’ conclusions would remain the same.” There have been 12 studies in all that followed up transgender kids to see how they felt in adulthood, and all 12 came to the same conclusion: “the majority of kids cease to feel transgender when they get older.” The studies and the numbers they reported are listed here.

Some have speculated that being transgender is more acceptable to Christian ideology than being gay or lesbian. One parent said:

My fear is that there are many gender non-conforming kids being medicalised at young ages and set on a path of infertility, surgery, and lifelong hormone injections when, if given the time to grow up, would be health happy gay and lesbian adults. Or even straight adults who just don’t happen to be gender-conforming.

And it’s not just Christian ideology. In Iran, they execute gay people but pay for sex reassignment surgeries.

Treatment

The history of gender reassignment surgeries is marred by the disastrous story of David Reimer. He lost his penis at the age of 8 months in a circumcision accident. Dr. John Money believed that gender was merely a social construct, a matter of nurture rather than nature, so he advised that David be surgically altered to resemble a female and raised as a girl, Brenda. Things did not go well. At 14, he began the process of reassignment to being a male. He married a woman, suffered from depression and drug abuse, and committed suicide at the age of 38.

Dr. Money’s views on gender were challenged by Paul McHugh, a psychiatrist at the same institution. McHugh denied that reassignment surgery was ever either medically necessary or ethically defensible. He felt that surgeons were merely cooperating with delusional thinking. He likened it to providing liposuction for an anorexic who is underweight but believes she is overweight.

Family Courts in Australia have authorized consent to three-stage medical therapy known as the Dutch protocols:

Puberty is blocked with gonadotrophin-releasing hormone (GnRH) Hormones of the opposite sex are given (estrogen and testosterone) Gender reassignment surgeries.

Concerns have been raised about possible irreversible damage from the hormones used to delay puberty. And surgery is obviously irreversible.

Ethics

This issue raises ethical concerns about treating children who are too young to legally consent. Similar concerns have been raised about neonatal circumcision, ear piercing, and refusal of lifesaving treatments for children whose parents have religious objections. There is another dysphoria, body integrity dysphoria, where people experience a mismatch between their body image and their anatomy, often resulting in a strong desire to have a limb amputated. Would it be ethical to amputate a 10-year-old’s leg because he doesn’t want it anymore? Would it be ethical to amputate his penis because he doesn’t want it anymore? Or a girl’s breasts because she doesn’t want them anymore? At what age should we give in to children’s wishes rather than deciding for them that what they want is not in their best interests?

In 2011, 4,830 breast augmentation surgeries were done on adolescents under the age of 18; should they have been delayed until they reached 18? 21? Children don’t all mature at the same rate, and the decision-making part of the brain is not fully developed until around age 25. For that matter, some surgeons refuse to do vasectomies on men of any age who have never had a child, because many of them will change their minds, regret the surgery, and ask for a reversal procedure that may not be successful. This is where the principle of patient autonomy comes into conflict with the principle of non-maleficence (do no harm). These are difficult decisions for ethicists to grapple with, and I don’t presume to have any answers. There are potential harms from delaying gender transition: psychosocial consequences, bullying, suicides, etc. How can the clinician weigh the harms and benefits for the individual case?

Walt Heyer points out that the politically correct stance is to encourage, affirm and assist the child in “coming out” as transgendered. But this may not always be the wisest course. We don’t know what will happen over the next 20 years, yet we are herding parents and children in one direction as if we knew.

Heyer says condoning gender identity change, socially and medically, for children can be characterized as child abuse. He says,

For 12 years now, people have contacted me after visiting my website, SexChangeRegret.com, to tell me about their dissatisfaction with their gender change and their desire to transition back to their birth gender. Lately, the frequency is rising and I feel a great sense of urgency to warn anyone contemplating a gender change to tread carefully.

Conclusion: Tread carefully

Children with gender dysphoria are suffering. Some of them have coexisting mental health disorders, some of them are bullied, and some of them attempt suicide. They should be treated with compassion and not with false assurances that gender transition will reliably solve their problems. We can’t predict whose dysphoria will persist into adulthood. We can offer counselling, use medical treatments cautiously, and delay irreversible surgeries until the child is truly able to give informed consent. Perhaps the best solution would be for society to reject the 2-gender dichotomy, accept that gender is a spectrum, and be more accepting of individual differences in feelings and behaviors that fall anywhere along that spectrum. Until that happens, we should indeed tread carefully.