The controversy over trans teens

Should young people with gender dysphoria be prescribed puberty blockers and hormones? Here's everything you need to know:

What is gender dysphoria?

Gender dysphoria is the psychological distress people suffer when their biological sex doesn't match their gender identity, or "experienced gender." About 0.6 percent of American adults identify as transgender, the Williams Institute at the UCLA School of Law has estimated. But in recent years, vastly more young people are seeking treatment for gender dysphoria, teen girls in particular. In surveys by the American College Health Association, the number of students brought up as girls identifying as transgender soared from 1 in 2,000 in 2008 to 1 in 20. There are now at least 50 clinics in the U.S. to treat young people with gender dysphoria; in 2007, there was just one. The growing number of children being prescribed puberty blockers and hormone treatments has become a political issue: In March, Arkansas' legislature banned such treatments for people under 18 as "experimental," and similar legislation has been introduced in 19 other Republican-controlled states.

How has treatment changed?

There's been a wide shift from a noninterventionist "watchful waiting" approach to what's called "gender affirmative" care. Previously, many therapists, guided by (now contested) studies showing that the majority of gender dysphoria cases resolve over time, focused on encouraging young people to accept the bodies they were born with. In contrast, "affirmative" care focuses on encouraging the patient to embrace the experienced gender. For young children, that means "social-transitioning" — such as changing one's name, style of clothing, and overall appearance. For kids from age 9 into the teens, it often also calls for prescribing puberty blockers to prevent secondary-sex characteristics such as breasts, widened hips, periods, facial hair, and deeper voices. That is usually followed by hormone treatments that produce physical traits of the experienced gender.

What is the impact of treatment?

Leaders in the trans community say it brings enormous relief to trans teens, who suffer high rates of suicide and depression. Medical intervention "is what is keeping my child alive, literally," said Heather Crawford, the mother of Cass, a nonbinary 14-year-old Texan who attempted suicide before hormone treatments eased the distress. "They were in so much pain that they were willing to die." In a new study, researchers found a 73 percent decrease in suicidal ideation among transgender and nonbinary youth who received puberty blockers or hormone treatments. But some medical specialists in trans patients question the widespread shift toward affirmative care.

Why is that?

Some doctors warn that these treatments can cause lasting problems with fertility, bone mineral density, and the ability to experience sexual pleasure. The critics also insist that some kids and teens who might eventually come to terms with their biological sex — often deciding they are gay or bisexual, not trans — are being too strongly encouraged to make lasting changes in their bodies. Instead of having true gender dysphoria, these critics contend, some young people may be going through a period of sexual confusion or struggling with other mental health issues. There is also some evidence of "social contagion," in which teens are influenced by friends who come out as trans and by online forums of trans teens. The critics say that the decision to change genders is hard to reverse. "You're going to go socially to school as a girl, and you've made this commitment," said Dr. Marci Bowers, a transgender woman and surgeon who's performed thousands of sex reassignments but urges caution. "How do you back out of that?"

Do people ever change their minds?

There are no accepted hard statistics, but as the number of people who transition has risen, so has the number of people who say they regret it. A Reddit detransition support group has drawn about 22,000 members, and some with regrets say they felt rushed into their decision. Keira Bell, a 24-year-old British woman who "detransitioned" after gender reassignment surgery, sued the National Health Service's clinic for transgender youth, which she said after three appointments steered her toward a "devastating experiment" with puberty blockers at 16, and later "top" surgery to remove her breasts. A detransitioned young man told 60 Minutes he was given "my letter to go get on cross-sex hormones" after two appointments, and had his testicles removed three months later. "I didn't get enough pushback," he said.

Where is this field headed?

In Europe, there are signs of a pendulum swing. After Bell's lawsuit, children under 16 in England were required to get court approval before taking puberty blockers. Sweden's Karolinska Hospital this year stopped using puberty blockers and hormone treatments for patients under 18. Finland's national gender program last year altered its guidelines to prioritize therapy over medical treatments. In the U.S., some doctors say they are afraid to speak out on the need for caution because of fierce backlash from LGBTQ activists. Erica Anderson, a clinical psychologist at the University of California-San Francisco's Child and Adolescent Gender Clinic, said that as a result of a new dogma calling for medical interventions, "we're going to have more young adults who will regret having gone through this process."

A forbidden topic

Some doctors and researchers say the conversation about transgender youth is stifled by a climate of fear, with those who question medical interventions risking their careers. When Lisa Littman, a behavioral science professor at Brown University, published a paper suggesting that gender dysphoria among teen girls might be attributable in part to "social contagion" and underlying psychological issues, she said she met with a "strategy of harassment and intimidation" from trans activists. She lost a consulting job, and the university removed a link to her work from its website. When the American Booksellers Association last summer mailed out sample copies of Irreversible Damage, a book by journalist Abigail Shrier that raises similar questions, the blowback from the trans community was so fierce that the association issued an apology for what it called "a serious, violent incident." Doctors fear the same reprisals, said Laura Edwards-Leeper, a clinical psychologist who works with transgender youth. "Everyone is very scared to speak up," she said.

This article was first published in the latest issue of The Week magazine. If you want to read more like it, you can try six risk-free issues of the magazine here.

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