Gender Dysphoria in Adolescents

Note from Dr. Harriet “SkepDoc” Hall: I now have the dubious distinction of being the only author on the Science-Based Medicine website to have ever had an article retracted, my book review of Irreversible Damage: The Transgender Craze Seducing Our Daughters by Abigail Shrier. Michael Shermer promptly republished it on Skeptic.com at https://www.skeptic.com/reading_room/trans-science-review-of-abigail-shier-irreversible-damage-transgender-craze-seducing-our-daughters/  SBM’s retraction resulted in a flood of comments and a brouhaha of controversy that I have decided to stay out of. I am observing a strict “no comment” policy. But I have taken some of the criticisms of my review to heart and have revised my book review accordingly. Here it is.  

In 2018 I wrote about a research study by Lisa Littman. She coined the term rapid onset gender dysphoria (ROGD) to describe reports she had been reading about gender dysphoria appearing rapidly around the time of puberty in adolescents and young adults who would not have met the criteria for gender dysphoria in childhood. Her study raised the possibility that rather than always being an innate, immutable sense of incongruence between anatomical sex and personal sense of gender, some cases of gender dysphoria might be due to social contagion from peer pressure and online influences. 

I thought that was worthy of investigation.  I got a lot of criticism for writing about it. I was even called transphobic, which I absolutely am not. I only want the best for each individual. If that means transitioning, I fully support that. If it means some individuals transition for the wrong reasons and later change their minds, that’s regrettable and we need to find a better way to identify those individuals and treat their dysphoria without subjecting them to irreversible interventions. I hesitated to tackle this controversial subject again, but in 2020 Abigail Shrier wrote a book that shares my and Littman’s concerns. It combines well-researched facts with horrifying stories about botched surgeries, people who later regret their choices, and therapists who are not providing therapy but just validating their patient’s self-diagnosis. The title is Irreversible Damage: The Transgender Craze Seducing Our Daughters.

Littman’s research methods were flawed but she was unfairly vilified

Littman’s research was widely criticized for its flaws, which I described in my article. It was not good science and didn’t set out to establish that ROGD was real; it was meant to be exploratory and hypothesis-generating.  Transgender activists accused Littman of having hurt people with her research; they called it “dangerous.”  Her paper drew praise from some world experts on gender dysphoria and from many parents, but she was also tarred as a bully and a bigot. She was denounced by activists to her employer, the Rhode Island Department of Health, and they fired her, even though her job had nothing to do with transgender youth or even young children. She was unfairly attacked, her reputation was tarnished, and she lost a job she loved. 

The numbers are alarming

Shrier says that historically, the conviction that one’s gender doesn’t match one’s anatomical sex typically began around age 2-4. It affected only .01 percent of children, almost exclusively boys. She says that in 70% of cases, they eventually outgrew it (she supports this claim with two published studies). She says that prior to 2012, there was no scientific literature on girls age 11-21 ever having developed gender dysphoria at all.

Shrier reports that the picture has changed dramatically: girls now constitute the majority, clusters of adolescents are discovering transgender identities together and are clamoring for hormones and surgery. She cites a study showing that in 2018 the UK reported a 4,400% rise over the previous decade in teenage girls seeking gender treatments. She reports that similar spikes have been observed in many other countries; that in the US, the prevalence of adolescent gender dysphoria has increased by over 1000% in the last decade; and that in 2016, natal females accounted for 46% of all sex reassignment surgeries, while a year later it was 70%.  Whatever the true numbers, an increase in adolescent gender dysphoria has been noticed by many observers, and this phenomenon deserves our attention and further investigation.

There are reports of desisters (those who stop identifying as transgender) and detransitioners (those who had undergone medical procedures, regretted it, and tried to reverse course). No statistics are available on how often this happens.

She says that those who transition rarely adopt the stereotypical habits of men. The example  she gives of stereotypical habits of men is buying a weight set. (Whaat!?) Only 3% have had a phalloplasty (to create an artificial penis) and only 13% say they want one. (I don’t know what that means: there could be many other explanations for those phenomena.) A response she commonly heard was “I don’t know exactly that I want to be a guy. I just know I don’t want to be a girl.”  She claims that girls who previously would have been classified as tomboys or lesbians are now classified as transgender and sometimes the idea of transgender is first suggested by a therapist. She reports that in one school where 15 students had come out as transgender, no one had come out as a lesbian. Shrier looked for instances where a counsellor suggested to a patient that they might be lesbian rather than transgender; she couldn’t find a single example. I have seen numerous news stories about the disappearance of lesbian bars and publications over the last decade: the reasons are not clear. Shrier says lesbians have been denigrated as transgender males who won’t admit they are supposed to be boys. Maybe; there are no data on how often that happens.

Advice online

There are many social media sites and online forums that facilitate the discovery of a trans identity. Shrier reports that these sites commonly offer advice like this:

• If you think you might be trans, you are.
• You can start trying out trans by using a binder to flatten your breasts.
• Testosterone is amazing and it may just solve all your problems. You don’t have to be certain you are transgender to go on hormones.
• If your parents loved you, they would support your trans identity. If your parents are not supportive, it’s OK to cut off contact. 
• If you’re not supported in your trans identity, you’ll probably kill yourself.
• Deceiving parents and doctors is justified if it helps transition. Scripts are provided that will convince doctors to give you hormones. It’s OK to lie and say you have always known you were trans even if it’s not true.
• You don’t have to identify as the opposite sex to be “trans.” You can be “genderfluid” and reserve the right to change your mind. One said she wanted to be identified as a woman only some of the time.
• If you’ve ever felt different, anxious, or afraid, or felt like you don’t fit in, there is a transgender community ready to accept you and become your new family.

The schools are not helping

In California, students can opt out from sexual health education instruction but cannot opt out of gender identity and sexual identification instruction. Gender stereotypes are taught in kindergarten. Children are taught that they might have a girl brain in a boy body or vice versa; (Shrier says that is “biologically nonsensical.”  When I read the book, I agreed with that statement, but I have since been educated in a long email exchange with Larry Cahill, a neuroscientist with extensive experience in the field who explained that neuroscience in the past 20 years has witnessed a remarkable shift, from simply assuming sex influences outside reproductive functions don’t exist, to recognizing that mammalian brains are deeply influenced by sex at all levels of their function, right down to the cellular level. He sent me links to seventy references supporting this. But he also said that these brain differences have nothing to do with gender dysphoria. He said “nobody knows what happens to create the feeling in a biological female that she is male, or vice versa.” 

Teens are asked to imagine what it would be like to be the other gender. When a child comes out as trans, schools frequently adopt their preferred new name and pronouns without informing the parents (ostensibly to protect the child’s privacy). This is true: I have seen published school policies that confirm it. Shrier says “The achievements of gender-nonconforming women are downplayed because they don’t count as true women.” Maybe, but we have no data on this.

One of the tasks of adolescence is establishing an identity. Adolescents are still trying to figure out who they are and which sex they are attracted to. Many of the adolescent girls who adopt a transgender identity have never had a single sexual or romantic experience and have never been kissed. Shrier is not suggesting that sexual attraction has anything to do with transgender; she just offers it as an example of how adolescents lack life experience and are trying to establish an identity.

Shrier gives a personal anecdote of how teens can’t always predict what they will want later in life. She wanted breast reduction surgery. Her father objected that it might interfere with breast feeding, but she was absolutely sure there was no chance she would ever want to nurse a baby. More than a decade later she breast-fed three babies and found it one of the most rewarding experiences of her life. She says, “We are very good at knowing what it is we want right now; far less good at predicting whether the object of our desire will produce the satisfaction we take for granted.” I certainly agree with that!

The customer is always right

A new “affirmative care” standard of mental health care has been adopted by nearly every medical accrediting organization. Therapists must accept and affirm the patient’s self-diagnosis. 

Shrier thinks this is misguided; the duty of the therapist should be to evaluate the patient’s symptoms, figure out whether the patient’s self-assessment is accurate, and challenge it if it is not.  She considers simply accepting the patient’s self-diagnosis to be a dereliction of duty. She likens this to telling an anorexic teen “If you think you are fat, then you are. Let’s talk about liposuction and weight-loss programs.” She is not saying gender dysphoria is like anorexia; she’s talking about the duty of the therapist. She asks whether a standard guided less by biology than by politicalcorrectness is in the best interests of the patient. Critics of Shrier’s book have pointed to published guidelines for transgender care, which are laudable; but if Shrier is right, the official guidelines are not always being followed. If they are not, we need to know and take appropriate action. But the data are lacking. Shrier says “We are asked to disregard DNA and accept the ineffable feelings of an eight-year-old.” 

Shrier says that parents are threatened that if they don’t affirm, the child may commit suicide: “Would you rather a dead daughter or a live son?” She says this amounts to emotional blackmail, and it is not based on good evidence. Suicide is common, but she cites evidence that factors other than gender dysphoria may be causing the suicidal ideation, and evidence that affirmation does not ameliorate mental health problems. In one study of adult transsexuals, there was a rise in suicidality after sex reassignment surgery. In my opinion, we need better data before we accept that affirmation prevents suicide. 

The dissenters

Shrier reports that some therapists think the affirmative model is a mistake, but they dare not speak out. Nineteen states prohibit conversion therapy for homosexuality, and they equate questioning a patient’s self-diagnosis of gender dysphoria to a kind of conversion therapy, banning it as well. Dissenting therapists have lost their jobs and risk losing their license. Dr. Kenneth Zucker is a case in point. A highly respected expert on gender dysphoria, he refused to reduce the source of distress to one problem; he insisted on looking at the whole kid. In a series of 100 boys he treated who had not been socially transitioned by parents, a whopping 88% outgrew their dysphoria. He was accused of practicing conversion therapy, was fired, and his reputation was ruined.

Dr. Ray Blanchard questions whether adolescent girls who suddenly identify as trans even have gender dysphoria. He believes they are a mixture of those who will be transgender no matter what, those who will outgrow their dysphoria and live as gay adults, and those who have borderline personality disorders and have identified a kind of faux gender dysphoria as the locus of their unhappiness. He says that rigorous empirical study is needed to guide diagnosis, understanding, and treatment; but in the current political environment good science has become almost impossible. 

Shrier says that since doctors have no way of predicting whose dysphoria will respond to gender surgery, it should be clearly labeled experimental and should be restricted to patients participating in controlled studies overseen by an institutional review board (IRB). I agree. Testosterone can seem like a miracle; it can lift depression and anxiety and make young women feel bold and unafraid. She reports that Planned Parenthood, Kaiser, and Mayo all dispense it, often on an “informed consent” basis on the first visit, with no referral or therapist’s note required.  It is given to patients as young as 15 (the age of consent in Oregon). There are plenty of risks, which Shrier describes. She also describes the risks for puberty blockers like Lupron. Delaying puberty is said to be harmless, but she says it isn’t. She asks us to imagine an adolescent who remains prepubescent while her age-mates have all gone through puberty. Studies have shown that when a kid is put on puberty blockers, almost 100% will go on to take cross-sex hormones. She says this essentially guarantees infertility,  “Top surgery,” or bilateral mastectomy, is advocated by surgeons who think adolescents can make logical decisions and is done on girls as young as 13 (legal in California). Shrier says some of these surgeons don’t require input from a therapist; they accede to the patient’s wishes and rarely turn anyone away. If this is true, it is despicable. Does it really happen? How often? We need better data.

Conclusion: An important book that is flawed but raises serious questions

This book will undoubtedly be criticized just as Lisa Littman’s study was. Yes, it’s full of anecdotes and horror stories, and we know the plural of anecdote is not data, but Shrier looked diligently for good scientific studies and didn’t find much. And that’s the problem. We desperately need good science, and it’s not likely to happen in the current political climate. Is ROGD a legitimate category? We don’t know, since the necessary studies have not been done. Shrier was vilified for harming transgender people, and I was called a transphobe just because I reviewed her book. Anyone who addresses this subject can expect to be attacked by activists.

Shrier’s book has 23 pages of references. Many of them were from internet or popular magazine and news sources, but she also included a large number of studies from the peer-reviewed scientific literature. Sure, she probably missed some studies that don’t support her thesis; but that’s not the point.  After all, the book is not a scientific treatise; it is a descriptive and observational book by a journalist. 

She reports things that desperately cry out for further investigation. I think there are plenty of indications that the incidence of teen gender dysphoria is rising and there are reasons to suspect it might be linked to internet influences and social peer groups. At least some therapists are accepting patients’ self-diagnoses unquestioningly, and it appears that irreversible treatments are being offered without therapist involvement in some cases. We know at least some of these patients will desist and detransition, and we have no way to predict which ones. Children are being instructed in how to lie to parents and doctors to coerce them into providing the treatments they want. 

I fully support hormones and gender surgeries for adults who will benefit from them. I care about the welfare of adolescent girls and it bothers me that some of them may be unduly influenced and take irreversible steps they will later regret. 

What to do? I think Shrier’s recommendation to limit surgeries to patients enrolled in a research trial is a good idea. I agree that if therapists are affirming patients’ self-identification without any attempt to rule out other possible causes of their gender dysphoria, that is a dereliction of duty and should stop. Shrier advocates not letting girls have cell phones. I disagree. I think refusing to get your daughter a cell phone is a sure way to make her hate you and may make her suffering worse, not better.