The January issue of National Geographic magazine featured profiles of gender-bending young people around the world, from the United States to Samoa. It was surfing a wave of interest in gender dysphoria amongst children. In the United Kingdom, the Gender Identity Development Service, which treats only children under the age of 18, has reported an incredible surge of interest. In 2009/10, 94 children were referred to it, but 1,986 in 2016/17 — an increase of 2,000 percent.
What are parents and doctors supposed to do when children insist that they have been “born in the wrong body”? Or like 9-year-old Oti, another of National Geographic’s case studies: “When she learned to speak, she didn’t say, ‘I feel like a girl,’ but rather ‘I am a girl’.”
Parents are torn.
On one hand, it is ethically questionable whether a child can consent to transitioning to another gender. The teenage brain is still undeveloped; most are not capable of planning beyond next weekend’s party, let alone the rest of their lives. How can 17-year-olds possibly know what it means to be a man or a woman if they have not experienced it? How can a 9-year-old?
But parents want their children to be happy. So often, the solution proposed by doctors and counsellors is “transitioning”. This means affirming the new gender of small children, suppressing puberty as they grow older, and eventually having “gender affirmation surgery” when they reach 17 or 18 or later.
But a stunning new article in the journal The New Atlantis questions the science behind this increasing popular pathway for gender dysphoric kids. The authors are an endocrinologist, Paul W. Hruz, a medical statistician, Lawrence S. Mayer, and a psychiatrist, Paul R. McHugh.
First of all, they contend, despite all the glowing cover stories and TV specials,
There is strikingly little scientific understanding of important questions underlying the debates over gender identity — for instance, there is very little scientific evidence explaining why some people identify as the opposite sex, or why childhood expressions of cross-gender identification persist for some individuals and not for others.
Second, even though children can be very stubborn and persuasive about their conviction that they are in the “wrong body”, most of them do grow out of it. According to the Diagnostic and Statistical Manual of Mental Disorders, the bible of psychiatry, studies show that between 70 and 98 percent of boys do not persist and 50 to 88 percent of girls. So, alarmingly, kids are being treated with hormones and surgery for a condition which they may grow out of naturally.
And third, the central point of their research, the success of puberty suppression is unproven. No clinical trials have been conducted. The cute kids who appeared in National Geographic are basically research subjects in a potentially dangerous experiment. “Regardless of the good intentions of the physicians and parents, to expose young people to such treatments is to endanger them,” say the authors.
As they point out, “Experimental medical treatments for children must be subject to especially intense scrutiny, since children cannot provide legal consent to medical treatment of any kind (parents or guardians must consent for their child to receive treatment), to say nothing of consenting to become research subjects for testing an unproven therapy.”
Supporters of puberty suppression claim that it gives children space to explore their sexuality. Professor Art Caplan, the most quoted bioethicist in the American media, has said that “if it’s decided to stop the treatment, puberty will resume.” Norman Spack, of Boston’s Children Hospital, a renowned expert on gender dysphoria, describes the effect of the drugs as “totally reversible.”
But the authors dismiss the notion of “reversibility” as a myth. We cannot turn back the clock.
If a child does not develop certain characteristics at age 12 because of a medical intervention, then his or her developing those characteristics at age 18 is not a “reversal,” since the sequence of development has already been disrupted. This is especially important since there is a complex relationship between physiological and psychosocial development during adolescence. Gender identity is shaped during puberty and adolescence as young people’s bodies become more sexually differentiated and mature. Given how little we understand about gender identity and how it is formed and consolidated, we should be cautious about interfering with the normal process of sexual maturation.
There is very little evidence for resumption of completely normal development after puberty suppression. “There certainly have been no controlled clinical trials comparing the outcomes of puberty suppression to the outcomes of alternative therapeutic approaches [and] there are reasons to suspect that the treatments could have negative consequences for neurological development.” In boys there is some evidence that puberty suppression may be associated with testicular cancer and obesity.
The claim that puberty-blocking treatments are fully reversible makes them appear less drastic, but this claim is not supported by scientific evidence. It remains unknown whether or not ordinary sex-typical puberty will resume following the suppression of puberty in patients with gender dysphoria. It is also unclear whether children would be able to develop normal reproductive functions if they were to withdraw from puberty suppression. It likewise remains unclear whether bone and muscle development will proceed normally for these children if they resume puberty as their biological sex. Furthermore, we do not fully understand the psychological consequences of using puberty suppression to treat young people with gender dysphoria.
So, the authors contend, the mantra that puberty suppression is “totally reversible” may be close to being totally bunk.
Modern medicine prides itself on rigorous testing of hypotheses, careful analysis of ethical issues, and diligence in follow-up studies. This is what differentiates it from the hexes of witchdoctors and the nostrums of snake oil salesmen. But when it comes to gender dysphoria, they claim, the profession is ignoring the most elementary requirements of good science. As the authors point out:
Physicians should be cautious about embracing experimental therapies in general, but especially those intended for children, and should particularly avoid any experimental therapy that has virtually no scientific evidence of effectiveness or safety. Regardless of the good intentions of the physicians and parents, to expose young people to such treatments is to endanger them.
This study is the most significant push-back to date against the conventional wisdom about children who want to transition to a different gender. The conclusions reached by Hruz, Mayer, and McHugh will be bitterly disputed; they will be smeared on Twitter as transphobic bigots, shills for conservative think tanks and mediocre scientists. That’s the way that debate on this issue is normally conducted at the moment. But it will be interesting to see how transgender experts deal with the ethical issues they have raised.
Michael Cook is editor of MercatorNet.
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