Scott Gibson: Drop the dogmatism

The treatment of children and adolescents with gender dysphoria — the sense that they belong to the opposite gender of their physical status — has been problematic for decades, but now has emerged as a hot-button political issue.

Several trends have led to the heightened attention to treating young people with gender-affirming care, also known as sex-change or transition therapy.

One is the increased acceptance of such treatment and a concomitant increase in demand. In the U.S., medical therapy for gender dysphoria only became available widely in 2010 and has increased since.

Another is that children are receiving care at earlier ages than in years past.

The increase in teenage depression and transgender issues also intersect. Depression and suicides are going up across the board among adolescents but are particularly high among gender-dysphoric youth.

About forty percent of transgender persons report having attempted suicide at least once. Recent studies indicate that gender-affirming treatment might slow that dangerous trend.

Gender-dysphoric kids face serious challenges, and their parents are reasonably concerned. The issue has become politically charged as numerous state legislatures have stepped in to ban or limit gender affirming care on the grounds that such treatment can result in irreversible physical changes.

Other states focus on the high suicide risk among gender-dysphoric youth denied the chance to transition. So they pass laws protecting the option of medical and surgical therapy in the hope of saving lives.

And thus, the battle is waged. Terms such as “genital mutilation” and “teen sterilization” combat against “life-saving therapy” and “personal and family autonomy.”

In medicine, there’s an old saying that the loudest arguments happen when the least amount of data is available.

For many years, that was the case. But in the last decade, a growing number of studies have made the risk-benefit ratio of transition therapy clearer.

We are dealing with young people who are in the most emotionally chaotic phase of life, and at a time when social media is warping the self-image of young people with deadly effect. In addition, today’s youth are more open to examining their own sexual sense of themselves than those of any other prior generation.

Is it any wonder that people long for an earlier time when these uncertainties didn’t exist, and we could assure ourselves that every person on the planet fit into a tidy binary gender slot? But we have always had people who felt out of place in their designated gender.

The harm done to those who didn’t “fit the mold” has been enormous. Depression, disabling anxiety, and suicide have long been higher in the transgender community, and autism is over-represented among gender-dysphoric youth.

In spite of gender-affirming therapy having been used for decades, important questions remain, especially as regards transition care in adolescents. Progress in research is being made, but the answers are not all in yet.

So, where are we now in the science of transgender care? Let’s look at an important recent study published in the New England Journal of Medicine in January and see what it does and doesn’t answer.

In this two-year study, transition therapy led to a decline in depression, anxiety and suicidal ideation. This study affirms another, shorter-term study that found that depression dropped by 60% and suicidality by a stunning 73%.

These results certainly suggest that transition therapy in adolescents may be life saving for some youth. But concerns remain that some young people may choose transition therapy too early and regret the decision later after irreversible changes have occurred.

So, what do we know about how often people “detransition”?

A review of 27 studies on regret after transition therapy found only 1% of youth and adults who had transitioned felt they made the wrong choice. Careful pre-treatment psychological evaluation and counseling, along with family support, appeared key to a durable satisfaction with transition therapy.

Another study of those who stopped treatment or reversed transition found that external factors such as family or social pressure were cited far more often as the reason to detransition (83%) than an internal factor, like changing their minds about their gender status (16%).

Taken together, these studies show that gender-dysphoric adolescents who transition experience less depression and far less suicidality, while largely retaining their expressed gender identity.

Still, a small percentage of those who transition regret the decision later. We need to refine our ability to identify those individuals early and direct them to another treatment pathway.

Given the existing evidence about transgender care, where is the common ground? I suggest a short menu of approaches.

First, drop the dogmatism. We all need to admit that we don’t know as much as we need to.

Each side has valid concerns, and those need to be addressed respectfully. The goal is the best outcome for the greatest number.

Next, we must all be supportive of our fellow gender-dysphoric and transgender citizens, whether they’re 16 or 60. They are not villains. They’re just people. Many bear emotional wounds from rejection and ill treatment simply for being themselves. They deserve our sympathy and support.

We should use the current — though unfortunate — disparities in laws to continue research.

If transgender treatment restrictions survive court challenges, we should compare outcomes of gender-dysphoric youth in restrictive states to those with permissive laws. We would see if differences developed in life satisfaction, depression, and suicide rates within a few years.

We should continue studies long-term to find if gender dysphoric adolescents change their attitudes later in life. And that leads to my last point.

We must all be willing to follow the evidence and accept what it shows, whatever the outcome. If studies indicate that mental health care alone brings equally good outcomes to transition therapy for suicidality and quality of life, delaying or avoiding transition treatments may be best.

If, however, studies show that kids do better when they transition even while still minors, that approach should remain an option.

We will never have a perfect answer for all gender dysphoric young people. Human biology and psychology are too complex for that.

But we can improve our understanding of which treatments to advise for these kids. The advances will come from carefully designed studies.

The final decisions on medical care belong, after all, not to politicians agitating in marbled legislative halls but to the patients and their families conferring with their doctors.

Guest writer Scott Gibson returned to his childhood home 30 years ago to practice medicine. A board-certified internist, he served on the McMinnville School Board from 2011 to 2017, when he and his wife, Melody, moved to the outskirts of Amity to open the Bella Collina B&B. In addition to medicine and science, he counts history, economics and writing among his interests.