As Europe Retreats From Gender Affirmative Care, US Rushes Forward: Psychiatrist

General view of the LGBTQIA+ (lesbian, gay, bisexual, transgender, questioning, intersex, asexual, and agender) flag outside a bookshop during UK Pride Month 2021 in London on June 1, 2021. Edward Smith/Getty Images

Tavistock Center’s Gender Identity Development Service (GIDS), the United Kingdom’s first and largest gender clinic for children, is scheduled to close in 2023.

The closure of Tavistock’s gender identity clinic comes after the publication of an independent review funded by the UK’s National Health Service (NHS).

The report cited a lack of conclusive evidence about the benefits of hormonal treatment in gender-affirmative care, signifying at least a partial retreat from using medical and surgical means as part of the clinic’s gender-affirmative approach to treating minors.

It is unexpected that Europe, the seedbed of gender-affirmative ideas such as the “Dutch Protocol,” has also become the first place to halt its growth.

In February 2022, Sweden’s National Board of Health and Welfare (NBHW) updated its recommendations, citing a lack of scientific evidence on gender-affirmative care, calling for restraint in hormonal interventions in gender dysphoric minors.

In the same month, France’s National Academy of Medicine issued a statement on hormone blockers, stating that “the greatest reserve is required in their use, given the side effects such as impact on growth, bone fragility, risk of sterility, emotional and intellectual consequences and, for girls, symptoms reminiscent of menopause.”

The Academy’s statement also recommended that the “irreversible nature” of surgical treatments must be emphasized. Finally, the Academy noted that “the risk of over-diagnosis is real, as shown by the increasing number of transgender young adults wishing to ‘detransition.’” The statement was adopted by a majority vote of members of the Academy.

Sweden, U.K., and France now advocate for psychotherapy and mental health interventions as the top priority for gender dysphoric minors.

Yet the United States show no sign of retreat.

The assistant secretary of health, Dr. Rachel Levine, a transgender woman, has strongly advocated that “gender-affirming care” be made available to minors.

“We really want to base our treatment [sic] and to affirm and to support and empower these youth, not to limit their participation in activities such as sports, and even limit their ability to gender affirmation treatment in their state,” Rachel Levine said in an MSNBC interview in July 2022. 

The number of minors in the United States identifying as transgender has doubled over the past five years. In 2017, only 0.7 percent (around 150,000) of teenagers aged 13 to 17 identified as transgender (pdf). A report (pdf) showed that this number has increased to 1.4 percent (300,100 teens).

The original case was brought against the Tavistock and Portman NHS Foundation Trust Aaron Chown/PA

Return to Psychotherapy

In 1980, the term “gender identity disorder” was formally adopted into medical practices when it first appeared in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

At that time, people who identified as transgender were diagnosed with gender identity disorder and treated with psychotherapy. The clinician would aspire to find the psychological reasons behind the person’s discomfort with his or her biological sex, and see if the resolution of these psychological reasons would mitigate the person’s dysphoria.

Research has shown that gender dysphoric children usually grow out of their discomfort with their sex. A report reviewing 10 studies that followed children who did not socially transition found that in around 80 percent of the children who met the criteria for gender dysphoria, their sense of dysphoria would subside with puberty.

In 1981, a study titled “Expressive Psychotherapy with Gender Dysphoric Patients” evaluated the effects of providing psychotherapy to 50 gender dysphoric males who expressed a desire for gender change. After partaking in psychotherapy, “70% have adjusted to nonsurgical solutions, 20% are receiving treatment, and 10% have received SRS [sex reassignment surgery] and psychotherapy.”

Among these cases was an eight-year-old boy who dressed as a girl. His father had been killed in a bar brawl, and the boy was, for a time, raised by his uncle, who was later killed in Vietnam.

Two women then raised the boy, and he adopted feminine characteristics. Subsequent therapy sessions uncovered that he wanted to be a girl because he was scared of being killed or partaking in killing. After these fears were confronted, his desire to become a girl subsided.

“After two years of therapy, he now socializes with other boys, engages in competitive Cub Scout activities, has ceased playing with dolls and dressing in girls’ clothing, and has improved his overall school performance. Moreover, he now enjoys being a boy,” the study’s authors wrote.

The study also documented adult males who came to accept their bodies due to finding and resolving intrinsic reasons for wishing to become female.

Other studies have also chronicled successes with psychotherapy in resolving feelings of discomfort and unease in gender dysphoric people. A report published by the American College of Pediatricians evaluated 14 studies that found success or partial success (defined as contentment with their biological sex and body) in treating transgender-identified individuals with psychotherapy.

However, in 1996, a Holland study suggested the possibility of using hormonal therapy to treat gender dysphoric children; this study soon became incorporated into treatment guidelines, forming the above-mentioned Dutch protocol.

The protocol had strict rules: a patient must have been dysphoric from early childhood and be psychologically stable—that is, have no concurrent mental health issues.

The treatment used in the study was rapidly adopted into clinical practice, but there was less acknowledgment of the original exclusion criteria on psychological stability and childhood gender dysphoria. Psychotherapy also gradually took a back seat to medical treatments including administering hormones and surgically altering children.

Studies have shown that gender dysphoric children with mental co-morbidities including anxiety, depression, autism, personality disorders, anorexia, and many other issues were prescribed hormonal treatment (1, 2). Mental health problems besides gender dysphoria were present in more than half of the children identifying as transgender or non-binary.

At the same time, the scope of a transgender diagnosis has also broadened. With political advocacy pushing for accessible transgender medicine, clinicians are less likely to have the opportunity to explore the psychology of individuals with other underlying mental health problems.

Instead of long-term work with therapists, these individuals (many of whom are children) are being referred to gender clinics and shuttled into a gender change.

Increased Leniency of Transgender Medicine with Limited Science

Advocates for transgender medicine have, over the past four decades, expanded the clinical definition of what it means to be transgender.

While such advocacy may have stemmed from good intentions to reduce stigma relating to transgender people, changes without solid scientific grounding may have also led to mistaken referrals to gender clinics, for which many detransitioners have expressed profound regret.

“Many of the doctors can’t distinguish between what science knows and their political views about trans rights,” Dr. Stephen B. Levine (referred to henceforth in this article as “Levine”), clinical professor of psychiatry at Case Western Reserve University School of Medicine and practicing psychiatrist, told The Epoch Times.

Dr. Stephen Levine, a clinical psychiatrist who founded an Ohio gender clinic in 1974, is concerned about hormones being used to treat distressed transgender children. Courtesy: Dr. Stephen Levine

Before 1993, people who sought a surgical gender change as part of their gender identity disorder were diagnosed with transsexualism, considered the most extreme type of gender identity disorder.

However, with the release of DSM-IV in 1993, the term “transsexualism” was replaced with “gender identity disorder,” defined as a condition in which a person identifies with the opposite sex and is distressed with his or her own biological sex.

In 2013, the term “gender identity disorder” was changed to “gender dysphoria.”

The difference between these two labels is noteworthy.

According to pediatrician Dr. Miriam Grossman, gender identity disorder indicates a disease of the mind. In contrast, gender dysphoria is defined as a person’s discomfort with features of his or her body related to gender and indicates that the clinician should be focused on mitigating the unease the person experiences.

In recent years, some gender-affirmative clinics (1, 2) have called for eliminating the necessity of gender dysphoria diagnosis, claiming that a requirement for this diagnosis can keep people from receiving “essential” healthcare.

“Trans people, those who experience gender dysphoria and those who don’t, have a right to access gender-affirming support,” reads the statement from a gender-affirmative clinic. The clinic went on to say that, ”we believe that you are who you say you are.”

These “non-gatekeeping” sentiments have caused harm to children.

In a report published by Society for Evidence-Based Gender Medicine (SEGM), clinicians from the above-mentioned Tavistock clinic claimed that such a “non-gatekeeping” approach led children with autism, depression, anxiety, and many other mental challenges into gender transitioning rather than therapy.

Dr. David Bell, a senior staffer at the Tavistock clinic, mentioned that at some point, the clinic had a lot of anorexic people referred to it.

“So they’re people dealing with similar kinds of problems, but they get refracted through the lens of what’s going on in the culture.”

“A lot of them became self-harmers, had borderline personalities, and then became transgender.”

Gender, a Recent Invention Based on a Failed Experiment

Fundamental to transgender ideology is the concept of gender identities, founded on a single failed experiment.

Dr. Miriam Grossman said on American Thought Leaders that gender ideology is a relatively young concept.

The word “gender” in the “‘male-or-female sex’ sense of the word is attested in English from early 15c.” However, the coining of “gender” to explain social and cultural differences between the two sexes is a recent phenomenon.

It came from a renowned psychiatrist at Johns Hopkins Hospital named Dr. John Money. In 1955, he put forward a  theory on gender roles, arguing that all infants were born as a clean slate. Money claimed that babies learn either feminine or masculine traits from their parents and society.

Money sought to prove this by experimenting on a set of identical male twins, Bruce and Brian Reimer. Due to a failed circumcision during infancy, Bruce’s penis was damaged beyond repair; at the suggestion of Money, Bruce was named Brenda and raised as a girl.

Before he was two years old, his male genitals were removed and replaced with rudimentary female-like organs. He was given female hormones as he progressed from adolescence to maturity.

Money followed the twins and in 1972 published a final study on them, claiming that Bruce had fully adjusted to living as a girl.

However, in his autobiography, Bruce reported that he always felt he was different; he could not fit in with girls, did not want to do things stereotypically associated with girls, and was even reported to be more aggressive than his brother, Brian. When his parents finally told him that he was born a boy, Bruce made the immediate decision to live as a male.

As an adult, he publicly discouraged the medical practices that Mooney had used in his experiments. At age 38, Bruce committed suicide.

By the time Bruce’s story surfaced, gender theory had already taken root throughout the education system.

“The entire gender ideology … is entirely based on a concept that was never proven,” said Grossman. “In fact, the opposite was proven.”

Grossman explained that in Money’s time, the understanding of human biology—sex—was still very limited. What sets females and males apart is that males have a Y chromosome; at that time, the Y chromosome was considered a wasteland.

However, in recent years, researchers have found that on the Y chromosome, there are many genes related to masculinization. There is a section called the sex-determining region, responsible for the development of the male genitals, which produce testosterone.

A study in mice has shown that within a few weeks after conception, the testosterone formed in the testes enters the brain and causes “masculinization” of the brain. Mice with a masculinized brain develop male-typic behaviors, including aggression.

The sex differences between biological males and females are not restricted to sexual organs. Studies on kidney donors (1, 2) have shown that patients who received a kidney donation from someone of the same sex will usually have a higher chance of a successful transplant.

The Unknown Consequences of Medical Transition

A significant driver behind Northern European countries’ walk back on gender-affirmative care is the irreversibility and potentially harmful impacts of hormonal therapy and gender-altering surgeries.

A recent study has shown that more than 90 percent of children who have socially transitioned by changing their pronouns, name, way of dress, and mannerisms would go on to medical transition—starting on hormone blockers.

Depending on their age, adolescent and pubescent children generally go on puberty blockers to prevent the development of secondary sexual characteristics that differentiate biological males and females. General guidelines recommend children start on cross-sex hormones at around age 16 to develop features of the opposite sex, though many cases begin even earlier.

Chloe Cole, an 18-year-old woman who regrets surgically removing her breasts, holds testosterone medication used for transgender patients, in Northern California on Aug. 26, 2022. John Fredricks/The Epoch Times

There are serious risks and possible long-term implications of medical transition that need further study.

Puberty is not only a time of sexual development but also a critical time for cognitive and physical growth. During puberty, bone density increases, and there is significant growth in height and physical changes, such as greater muscle mass in males and greater fat mass in females.

There is extensive development in the brain’s frontal lobe; this area of the brain is responsible for critical thinking, decision-making, and various high-order cognitive functions. Sexual function also matures during puberty; this is when females’ eggs develop, and males produce sperm.

Blocking puberty will block all these complex processes.

While puberty blockers have been advertised as reversible, this is because they are only FDA-approved for the pediatric treatment of precocious puberty (pdf 1, pdf 2), a medical condition where children reach puberty early. Girls with precocious puberty, when given gonadotropin-releasing hormone analogs (GnRHa) to temporarily block puberty until they reached pubescent age, seemed to normally develop when they stopped taking GnRHa. 

However, puberty blockers are not FDA-approved for treating gender dysphoria and the consequences of giving puberty blockers to children who would otherwise develop puberty normally are unknown.

Studies have shown that early pubescent transgender children often have low bone mineral density linked to their use of puberty blockers. Transgender adolescents and teenagers are also associated with lower-than-average height.

For both natal females and natal males, blocking puberty can cause infertility.

Cross-sex hormones, which are hormones of the opposite sex, are generally recommended by clinicians after adolescents have gone on puberty blockers or are taken in conjunction with puberty blockers.

The effects of cross-sex hormones are irreversible and can be immediate.

Menstruation ceases after a few months of therapy, with one study showing that menstruation in six biological females stopped after one dose.

The lack of female hormones and increased exposure to testosterone for natal females can desiccate the vagina, making it more prone to tearing. It is also associated with polycystic ovarian syndrome.

Due to the numerous complications with high testosterone levels, clinicians often recommend the removal of the uterus within the first five years after biological females begin testosterone.

For natal males, studies have shown that estrogen treatment is associated with a greater risk of blood clots and cardiovascular disease (1, 2). Those who went on hormonal therapy also showed lower brain volumes that resembled those of a biological female (study 1, 2).

Some research has also raised the question about increased risks of breast cancer in transgender women due to prolonged exposure to estrogen.

Another concern with gender transition in children is the risk of infertility.

Many children who want to change their gender may be prepared to say they do not want their own children. However, some changed their minds and would go off cross-sex hormones to have children.

Finally, as a side effect of going on puberty blockers and cross-sex hormones early, natal males may have greater difficulty than people who transitioned as adults in getting a vaginoplasty.

Since blocking puberty would lead to a lack of development in their external genitalia, many of these biological males’ genitalia would still be the size of a child’s; there is not enough tissue in the external genitalia to form a vagina. Therefore, clinicians would need to revert to the second option of using the section of a colon to form a vagina, which can cause all sorts of complications with hygiene, sexual pleasure, and inflammation.

Conflicts of Interests With Standard of Care Guidelines

Conflicts of interest are prevalent among committee members who write standard-of-care guidelines for transgender medicine, said Levine.

He gave an example using guidelines published by the World Professional Association for Transgender Health (WPATH). Though there are many guidelines for transgender health, WPATH is international and serves as a reference for other countries’ medical associations, similar to the American Psychological Association (APA) and the American Academy of Pediatrics (AAP) in the US.

When creating clinical guidelines, it is generally advised to convene a multidisciplinary group so that the people on the committee will not promote special interests above the interests of patients.

However, just looking at WPATH’s Standard of Care 8 (SOC8), published on Sep. 5, 2022, it is clear that the majority of the committee members writing the guidelines have professional and financial interests in transgender medicine (pdf).

They are either psychiatrists and psychologists who practice gender-affirmative medicine, surgeons who take part in gender-altering surgery, endocrinologists, doctors who specialize in working with transgender people, or transgender advocates, some of whom do not even practice medicine.

The leading author and committee chair, Prof. Eli Coleman, is not a clinician. According to the Canadian Gender Report, his academic position at the University of Minnesota is funded by Jennifer Pritzer, a trans woman and the head of the Tawani Foundation.

“[The WPATH] lobby and advocate for the transgender community,” said Grossman, “There’s nothing wrong with that, but there is something wrong when that organization passes itself off as if it was purely a medical organization that wanted to help practitioners in providing guidelines to them to make the most medically accurate, up-to-date, research-supported decisions, to protect patients from harm.”

Dr. Miriam Grossman, a child and adolescent psychiatrist, in New York on Sep. 23, 2022. Blake Wu/The Epoch Times

Levine pointed out that the committee removed age limits between the draft version of SOC8, made available in December 2021, and the final guidelines published in September.

The draft showed that the WPATH committee originally made 15 the minimum age limit for mastectomies, but WPATH removed the age limit in the final version.

Even before this change in guidelines, a 2021 study published in JAMA reported on a girl who received a mastectomy at age 13 in a Californian clinic and five girls who were 14 at the time of their operations.

Though mastectomies are recommended to biological females who want to change their gender so that they would appear or feel more male, many detransitioners who later identified with their biological sex express regret for their decision to have their breasts amputated.

Chloe Cole, a detransitioner activist, has been particularly vocal about her regret, having gone through a double mastectomy at the young age of 15 and still suffering from complications of the operation three years later.

Questioning Universal Care

“What’s happening is Europe, which started this [gender affirmation] phenomenon, is now backing away,” Levine said.

A walk back from gender affirmation is perhaps a sign of a more nuanced approach to care for transgender individuals.

In an interview with SEGM, Bell, the senior staffer at Tavistock, compared medical transitioning children to lobotomies in the early 1900s.

“Like lobotomy, there is no evidence. Like lobotomy, it starts with a patient in an impossible state and, initially, seems to work, then it becomes the universal cure.”

Bell said that with mental health medicine, “the existence of a treatment creates the illness. Good centers for pneumonia wouldn’t create more pneumonia cases.”

Yet, Levine mused that the United States seems to be going “full speed ahead” on what he coined as an “ethical, scientific, and clinical misadventure.”

“It’s not an open and shut case, even though the vast majority of doctors have been educated, that the best treatment for transgender youth is biologic treatment, but we’re questioning that very seriously.”

“[Medicalizing treatment] is one option for them, and it may be one answer to their distress,” said Grossman.

“I tell people, ‘I don’t believe it’s the best answer. I believe that there may be other answers for you.’ And I certainly wouldn’t want a young person to be given material ... celebrating this process that ends in medicalization.”