Gender Therapy and Gender Assessment

This NYT Magazine article may be behind a paywall.  The "battle" is two-fold. 

There is an external cultural/political battle between advocates for gender transition for youth and those who oppose the availability of this type of therapy for those under age 25, the age at which brain development is completed.

NYT: The Battle Over Gender Therapy 

The author however focuses upon the internal battle among therapists as to whether or not clinicians should accept a child/adolescent's desire for gender transition at face value or have an extensive assessment of contributing factors before engaging in any form of transition. A good presentation of the need for better assessment is contained in this WAPO article by two gender transition therapists who stress the importance of assessment.

The mental health establishment is failing trans kids

Rather than trying to evaluate the state of the field for the reader, the author tells the story by focusing upon the primary author and group that has responsibility for revising the Standards of Care. She was given a lot of access to these people and some of the top people in the field. A lot of them have concerns about the changing nature of the field and how to improve it. Unfortunately, the publication of all these concerns provides folder for the right-wing culture warriors who want to shut down the legality of doing gender transition among children and adolescents. In my summary I am less concerned about the professional disputes and infighting that what we know in terms of evidence. However, I do not have enough interest to read the original research articles.  You can find links to them at the following National Library of Medicine page

Doctors Debate Whether Trans Teens Need Therapy Before Hormones

The Standards of Care issued by the World Professional Association for Transgender Health (WPATH). are meant to set a gold standard for the field of transgender health care. The current update is the first update since 2012. 

It is being done at a time when there is a significant rise in the number of teenagers identifying as transgender and seeking gender care, and a right-wing backlash in the United States against allowing them to medically transition, including state-by-state efforts to ban it.

More teenagers than ever are seeking transitions, but the medical community that treats them is deeply divided about why — and what to do to help them.

During the last decade, transgender care for youth has shifted from a handful of pediatric gender clinics in the United States to more than 60 comprehensive gender clinics in the United States, along with countless therapists and doctors in private practice who are also seeing young patients with gender-identity issues. The number of young people who identify as transgender nationally is about 300,000, according to a new report 

In addition, the current caseload is around two-thirds youths who were female at birth and identify as trans boys.  In the past, by contrast, most patients at gender clinics were trans girls who were “assigned male at birth.”

The increased visibility of trans people in entertainment and the media has played a major role in reducing stigma and helping many kids express themselves in ways they would have previously kept buried. 

In adolescence, peers and culture often affect how kids see themselves and who they want to be. Their sense of self can consolidate, or they can try on a way of being that doesn’t prove right in the long run as the brain further develops the capacity for thinking long-term. 

To make matters more complicated, as a group, the young people coming to gender clinics have high rates of autism, depression, anxiety and eating or attention-deficit disorders.

Could some of the teenagers coming out as trans today be different from the adults who transitioned in previous generations? For them the benefits are well established, and the rate of regret is very low. How many young people, especially those struggling with serious mental-health issues, might be trying to shed aspects of themselves they dislike?

In 2019, right-wing groups, the Heritage Foundation and Family Policy Alliance, which fought for many years against same-sex marriage, held a meeting on “Protecting Children from Sexualization” that covered “controversial medical treatments to treat gender dysphoria,” which is defined as a form of distress and is also a psychiatric diagnosis. Model legislation followed. Organizations like Family Policy Alliance helped state legislators draft a ban on gender-related medical treatment for anyone under age 18. Arkansas passed the first such ban in April 2021, and over the next months, similar bills were introduced in 18 other Republican-led state legislatures.

WPATH is a 3,300-member international organization, mostly made up of health care professionals. It came into existence in 1979, the year it issued its first Standards of Care. These standards influence the positions taken by major medical groups, including the American Academy of Pediatrics and the American Psychological Association, and the coverage offered by health insurers and national health services around the world. Trans and nonbinary practitioners are helping to write and oversee the new guidelines, called the SOC8 because it’s the eighth edition.

First, the draft said preteens and teenagers should provide evidence of “several years” of persistently identifying as, or behaving typically like, another gender, to distinguish kids with a long history from those whose stated identification is recent. And second, they should undergo a comprehensive diagnostic assessment, for the purpose of understanding the psychological and social context of their gender identity and how it might intersect with other mental-health conditions.

This draft not only got strong criticism from right wing groups, it got strong criticism from the transgender community as betraying its cause by continuing to require psychiatric involvement for kids when that is being dispensed with for adults 

The Dutch were the first to revolutionize transgender identity by dispensing with therapy for adults in favor of medical solutions. Their patients were pleased with the results, and there was little regret. In fact, many expressed their belief that the whole transition would have been better if they had started it in adolescence.

In 2011, de Vries and her colleagues published the first of two landmark studies about medical interventions in adolescence. Among the first 70 patients who received puberty suppressants at the Amsterdam clinic after their initial assessment at the mean age of about 13½, the researchers found “a significant decrease in behavioral and emotional problems over time.” A second study published in the journal Pediatrics in 2014, of about 55 of those who went from puberty suppressants to hormone treatments at the mean age of about 16½, showed that five years after starting hormone treatments and at least one year after surgery, they had the same or better levels of well-being as a control group of cisgender adults their age. None of the 55 regretted their treatment. (The 15 of the original 70 who were not included in the follow-up study did not take part mainly because of the timing of their surgery.)

Other forms of treatment evolved including emphasis on the social rather than the medical aspects of transitioning. 

In the United States and Canada, meanwhile, two dueling approaches to therapy for young children, before they reached puberty, were vying for supremacy. At what is now called the Child and Adolescent Gender Center at the University of California, San Francisco, Diane Ehrensaft, a developmental and clinical psychologist, was counseling families to take what she and others called a “gender affirming” approach, which included a social transition: adopting a new name and pronouns for a child who expressed such a preference, along with letting kids dress and play as they pleased.

However, an approach which emphasized giving support for the child's birth identity found that it also seemed to work, except that many of the children became gay.

For years, Ehrensaft’s intellectual foil was Ken Zucker, a psychologist and prominent researcher who directed a gender clinic in Toronto. Between 1975 and 2009, Zucker’s research showed that most young children who came to his clinic stopped identifying as another gender as they got older. Many of them would go on to come out as gay or lesbian or bisexual, suggesting previous discomfort with their sexuality, or lack of acceptance, for them or their families. Based on this research, in some cases Zucker advised parents to box up the dolls or princess dresses, so a child who was being raised as a boy (a majority then) wouldn’t have those things to play with.

At the end of 2015, the Canadian medical center that ran Zucker’s clinic in Toronto shut it down because of complaints from activists about his method. (Zucker sued the center for defamation and later received an apology and a settlement of $450,000.) In February 2017, protesters interrupted and picketed a panel featuring Zucker at the inaugural conference of USPATH (the U.S. affiliate of WPATH) in Los Angeles. After that controversy, other providers were on notice that Zucker’s methods were no longer acceptable. His approach was likened to conversion therapy, which treats being gay or trans as a mental illness to be cured, and which many states and localities have made illegal.

One long-term study, published in 2021, of 148 kids in the United States who socially transitioned with their families’ support between the ages of 8 and 14, found that five years later their psychological well-being was on par with their siblings and a control group of cisgender peers.

One of the clearest and most consistent findings about L.G.B.T. young people is that support from their families is essential for protecting them from a host of poor outcomes, from depression and suicide attempts to homelessness. The Family Acceptance Project, a research and intervention program for families of L.G.B.T. children, tells parents that refusing to use a child’s chosen names and pronouns is a form of rejection. But the project stops short of saying that parents who delay or refuse to consent to medication, despite their children’s wishes, are rejecting them or putting them at risk.

To summarize the above research, it seems like if parents and gender therapists interact with young patients in a positive manner, they can transition the child with medications and social support getting the child past the high rates of suicide for those with gender dysphoria.  However, they may still be long term problems. There are some people who detransition. 

Marci Bowers, a gynecologic and reconstructive surgeon who is slated to be the next president of WPATH, who voiced a separate concern about blocking puberty too early. Though there is no published data on this question, over hundreds of surgeries, Bowers has found that trans girls who don’t go through male puberty may find it difficult to have an orgasm after they have genital surgery as adults. They also could have less penile tissue with which to create a vagina, which can lead to more complications from surgery, according to Bowers. These concerns apply in a small percentage of cases in the United States, as most teenagers come to gender clinics at 14 or older, after puberty. But for the younger kids, Bowers advocated delaying puberty suppressants to a later stage of development.

While the successful Dutch approach did abandon psychotherapy as a means of resolving young people's dysphoria, they still did very good assessments over a long period of time. They admit that they excluded anyone that they had any doubts about.   

About a week after Shrier’s post appeared, USPATH and WPATH issued a statement opposing “the use of the lay press” for scientific debate about gender-related medical treatment. Anderson disagreed with the directive. “Some of our colleagues would have us shut up,” she told me in the fall. “No. It’s not OK to ignore the problems.” In late November, she and the child psychologist Laura Edwards-Leeper published an opinion essay in The Washington Post. They said they were “disgusted” by the proposed state bans on gender-related medical treatment for minors, but they warned that some providers in the United States were “hastily dispensing medicine” and skipping comprehensive assessments.

Other physicians take a quite different approach 

St. Amand thinks the purpose of an assessment is not to determine the basis of a kid’s gender identity. “That just reeks of some old kind of conversion-therapy-type things,” he told me over the phone in April. “I think what we’ve seen historically in trans care is an overfocus on assessing identity.” He continued: “People are who they say they are, and they may develop and change, and all are normal and OK. So I am less concerned with certainty around identity, and more concerned with hearing the person’s embodiment goals. Do you want to have a deep voice? Do you want to have breasts? You know, what do you want for your body?”

Gender-related care is now far more accessible. Since the Obama administration included gender identity in its rule against denying health care benefits on the basis of sex. Now a lot of affluent people in progressive metropolitan areas have access to gender transition through their health insurance. At 18 teenagers can go to Planned Parenthood, one of the largest providers of gender-affirming hormones after a half-hour consultation. 

A few European countries that had liberal practices concerning medication are now imposing new limits, including Sweden, Finland and France. England asked for an independent review of its services. A number of situations have occurred that led authorities to feel the need to set limits on medical professionals. 

De Vries (the leading Dutch authority) said she was disappointed by the developments in Scandinavia and France. But she thought the retreat in those countries signaled a different kind of conservatism, about how to practice medicine in light of scientific uncertainty, from the bans in the red American states, fueled by anti-trans vitriol. The shift from European health authorities also suggested that scientists and physicians who don’t have the clinical experience of seeing young people receive gender treatments felt more constrained by the limitations of the research.

 MY OPINION

As a researcher who spent several decades talking with clinicians about their data, I early on recognized that clinicians often cannot see the forest for the trees. Unfortunately, the trees they concentrate on are particular people with particular problems that fit a pattern. If they fit a client into a pigeon- hole, they often ignore other data.

So, I am very partial to comprehensive assessments that would collect a lot of data, and make that available before, during and after any interventions. Busy clinicians can easily think they have all the pieces to the puzzle that they need.

I also found that clinicians are very biased by their successful clients and tend to ignore those that never come back or drop out of treatment early.

I am also partial to data systems because researchers can use them well in dialog with clinicians. In something as novel as gender transition, data systems and independent researchers should have been involved very early. 

All that being said, it looks like gender transition works for many people. Many are taken off suicide watch and can lead normal lives.  However, some clearly embark on a trajectory that they sooner or later decide is a mistake. We need to become better at predicting those for whom gender transition is inappropriate. 

Clearly both strong gender transition advocates and those strongly opposed to gender transition do not do those that have gender dysphoria any favors. Those with dysphoria and their families need to be surrounded by people who willing to walk with them through some very difficult issues and decisions. 

My hope is that church authorities will not claim they have moral answers to the problem of gender dysphoria.  Their pronouncements on homosexuality as a disorder have made ministry to the gays very difficult if not impossible.