Update: Worried Doc is a dad.

A few days ago, a commenter calling himself “worried doc” wrote to me. He is a physician who is skeptical of the current transition trend. Not only is his own teenage son embarking on this medical journey. The young man is also enrolled in the new multicenter NIH study of pediatric medical transition. Here is the doctor’s story.

“First, Do No Harm”: The Gender Dysphoria Hustle

by Worried Doc

I am surprised and dismayed to find myself having to write this letter. I am a physician, having practiced for forty years as a specialist in primary care medicine. As such, I would occasionally have patients who would complain of “being in the wrong body”, not being comfortable with who they are, or similar concerns. Having no way in my practice to evaluate or deal at all with this constellation of symptoms, I would refer them to what I presumed was appropriate psychiatric care.

I have a very difficult teenage son. He has been treated for mental health issues for a number of years without improvement, and has also attended multiple residential psychiatric facilities where he was tagged with diagnoses including anxiety and depression with intermittent suicidal tendencies. What has emerged more recently and prominently is his expressed desire to become a woman, with the threat of suicide if he is thwarted in doing so. I would bring this up to his therapists, who simply washed their hands of it, stating that they don’t treat this problem and suggesting he move on to someone else who does.

My first experience with a therapist who deals with “gender dysphoria”– the state of one’s self-perceived gender being incongruent with one’s natal biology– was alarming. Her suggestion was to immediately start my son on a lifelong regimen of cross-sex hormones and prepare him for multiple surgeries, including chondrolaryngoplasty (scalpular scraping of the thyroid cartilage to reduce the size of the Adam’s Apple) and a procedure described to me simply as “down below”, in order to feminize him as quickly as possible. I later learned that “down below”, or “bottom surgery”, is a polite, casual euphemism for a bilateral orchiectomy (surgical castration) and penile inversion vaginoplasty: the skinning and removal of the penis, with the empty flap of penile and scrotal skin inverted into a newly-made body cavity to create a “neovagina”. These recommendations were all made during the first visit, with no further insight given as to the nature or cause of the situation at hand. I was, however, referred along to a doctor “who knows that stuff” at a major medical facility. Upon arriving at that office, I was met with a friendly physician’s assistant who performed a physical exam on my son, after which we were promptly instructed on how to proceed. Very little of the discussion was regarding diagnosis or etiology; the risks, benefits, and side effects of the proposed treatment went largely unaddressed. He was to be started on estrogen at this stage, despite there being only the most superficial of clinical work-ups required for the diagnosis of gender dysphoria. The diagnosis was based almost entirely on the self-reported say-so of my troubled 15-year-old son.

My son was not advised, nor was I, regarding the frequency and treatment of complications arising from male-to-female transgender hormone therapy. This off-label administration of hormones to children was foreign to me, though as a doctor I knew the names of the drugs involved, and I also knew their possible side effects: deep vein thrombophlebitis, permanent infertility, polycythemia, pulmonary embolism, and death. The issue of infertility was raised by myself, concerned about the risk of my son becoming sterile and therefore having no chance to have a family of his own one day. All care at the facility prescribing his cross-sex hormone treatment was provided by a PA; I never saw a physician. I have scoured the medical literature and found little legitimate science regarding the medical treatment of pediatric gender dysphoria, the long-term outcomes of such treatment, or the sudden, recent groundswell of young people diagnosed with this previously-uncommon condition: so much speculation, so many unanswered questions, so few studies.

I took an oath with my medical degree. It states, “first, do no harm”. I wrestle with that oath daily: advised of my son’s suicidal ideation– which, I was told, will only increase in severity if his feminization treatments are denied– his gender therapist told me he was “better a live girl than a dead boy”, and what parent could possibly disagree? And yet, as a doctor, I know what these drugs can do. When the time comes for my son’s sex reassignment surgeries, I– and he– will have to contend with another set of potentially life-threatening complications, including the possibility of a rectovaginal fistula, a hole between the neovagina and rectum that can require the use of a colostomy bag, and can also result in infection and death. I can only hope that the day will come when my child, and other children faced with gender dysphoria, will have safe, legal guidelines and regulations for the treatment of their dysphoria, and that those laws will be based on quality, unbiased scientific studies. This brave new world of radical, life-changing gender reassignment for children too young to drive or vote seems all too much like the Wild West.

As I write this letter, there is a study underway regarding the hormonal treatment of pediatric gender dysphoria, yet with tremendous conflicts of interest throughout: at least a few of the doctors running the study are, or have been, employed as consultants by the pharmaceutical companies that manufacture the hormones being used. Is this why my son was seemingly sped through the process of diagnosis and prescription, hustled into hormones? There remain far more questions than answers. Yes, there is now a study, but the terrible irony is that one of the study’s subjects is my own son.

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