Previously in Part 1: Endocrine aspects, cardiovascular risk, and sexual functioning.
No “objective tests”? Affirming treatment and persistent gender dysphoria in youth
There are no laboratory, imaging, or other objective tests to diagnose a “true transgender” child. Children with GD will outgrow this condition in 61% to 98% of cases by adulthood (3). There is currently no way to predict who will desist and who will remain dysphoric. The degree to which GAT has contributed to the rapidly increasing prevalence of GD in children is unknown. The recent phenomenon of teenage girls suddenly developing GD (rapid onset GD) without prior history through social contagion is particularly concerning (4).
Laidlaw et al.’s argument from the lack of “laboratory, imagining, or other objective tests to diagnose” gender dysphoria is far less persuasive than they seem to believe. There may not be one perfectly definitive and binary biomarker for gender dysphoria or transgender identification. There aren’t perfectly definitive biomarkers for a broad array of known and recognized conditions which are not ever invalidated solely on this basis. By the authors’ reasoning, one could likewise note that there is no blood test for major depression, and speculate that perhaps we can’t or shouldn’t diagnose or treat depression at all if we lack the ability to identify a “true depressed” person in this manner.
Conversely, one could note that the repeatedly validated GIDYQ-AA inventory of symptoms of adolescent and adult gender dysphoria has been found to distinguish gender-dysphoric patients from cisgender controls with a sensitivity of 90% and a specificity of 99%. One could also note that transgender patients respond to cross-sex hormone therapy with a measurable decrease in blood levels of the stress hormone cortisol (Colizzi et al., 2013).
More concerning are Laidlaw et al.’s references to “children” who “will outgrow this condition … by adulthood”. This choice of deceptive phrasing is practically guaranteed to produce confusion about distinct phenemena in the gender identity trajectories of trans children, adolescents, and adults, and allows the authors to conflate these phenomena in a highly misleading manner. The observed discontinuity of children with gender dysphoria who enter the early stages of adolescence, where their dysphoria either remits or persists and develops into adolescent and adult gender dysphoria, is the subject of “desistance research”. Figures regarding the prevalence of a desistance outcome in these youth are far less certain than the authors imply: in one group of youth studied, only 45% experienced desistance of their dysphoria around the onset of puberty, suggesting the possibility that gender dysphoria may be more likely to persist into adolescence among these youth than not (Temple Newhook et al., 2018).
Crucially, there is no analogous discontinuity between “adolescent gender dysphoria” and “adult gender dysphoria” during which trans adolescents would supposedly experience their dysphoria remit before adulthood. In fact, these aren’t even different conditions in any meaningful way: both would be grouped under “gender dysphoria in adolescents and adults” (302.85) in the DSM-5, in contrast to “gender dysphoria in children” (302.6). Childhood gender dysphoria and adolescent gender dysphoria are clinically distinct conditions, but adolescent gender dysphoria and adult gender dysphoria are not.
Allowing the earliest stages of natal puberty to take place for gender-dysphoric children, prior to the decision of whether to administer puberty blockers, is considered diagnostically meaningful because some will experience their dysphoria remit during this time and some will not. However, what Laidlaw et al. are implying here is that waiting until adulthood is clinically meaningful for gender-dysphoric children, when there is no indication that this is the case – there is no discontinuity between gender dysphoria in adolescence and in adulthood. By stating that a large proportion of gender-dysphoric children “will outgrow this condition … by adulthood”, the authors entirely erase the clinical value of observed persistence of gender dysphoria at the onset of puberty in allowing for early identification of adolescent/adult gender dysphoria and prompt treatment with puberty blockers.
There is no need to wait longer, until adulthood, to see whether these adolescents will experience remission of their dysphoria. But an unfamiliar reader, upon encountering the authors’ unacceptably deficient summary of these concepts, could believe there may be. The implication that withholding treatment until adulthood is necessary in order to maximize desistance is not supported by any of the literature in this area, and worse, it dismisses the importance of early treatment with puberty blockers in order to prevent worsening of gender dysphoria caused by going through the wrong puberty. Laidlaw et al. may instead want to look at rates of regret for transitioning among adults, which hover at around 2%, or rates of initially gender-dysphoric adolescents on puberty blockers choosing to discontinue treatment and experience their natal puberty, which are around 4%. But either figure would be nowhere near as striking as the brazen claim that up to 98% of these trans adolescents will experience rapid-onset cisness by adulthood.
The authors’ assertion that there “is currently no way to predict who will desist and who will remain dysphoric” is likewise inaccurate – a number of factors predisposing youth to persistence of their dysphoria into adolescence have been identified in literature and have been termed predictive, including in the very publication the authors cite (Ristori & Steensma, 2016):
A central finding from all quantitative studies focusing on the topic is that the persistence of GD is most closely linked to the intensity of the GD in childhood and the amount of reported cross-gendered behaviour; in other words the more intense GD is in childhood, and the more cross-gendered behaviour is reported by parents or through self-report, the higher the chance that the GD persists. . . .
In addition, Steensma et al. (2013) found that a social transition in childhood, especially in natal boys, and verbal identification with the desired/experienced gender was predictive for the persistence of GD. Interestingly, the identification finding was reported in an earlier qualitative study by Steensma, Biemond, de Boer & Cohen-Kettenis (2011) who observed differences in reported experiences of GD between persisters and desisters who were interviewed. For example, the persisters explicitly indicated that they felt they were the ‘other’ sex and the desisters indicated that they only wished they were the ‘other’ sex.
Particularly surprising is this sentence from Laidlaw et al.:
The degree to which GAT has contributed to the rapidly increasing prevalence of GD in children is unknown.
This is not so much unknown as it is undefined, in the manner of a math equation that produces a nonsensical or impossible answer. This sentence is so poorly phrased as to be conceptually incoherent: Laidlaw et al. previously used the term “gender-affirming therapy” to refer to medical treatment of dysphoric adolescents with puberty blockers and cross-sex hormones – for these treatments to cause someone’s gender dysphoria, they would have to predate someone’s gender dysphoria. But no endocrine treatment is given to dysphoric youth before they’ve experienced the initial stages of their natal puberty, and certainly these interventions aren’t being delivered scattershot for no apparent reason to cisgender youth who currently don’t even have gender dysphoria.
Laidlaw et al. have confused the ordering of events: Trans adolescents are given these treatments after they have already been diagnosed with gender dysphoria and their dysphoria has persisted into adolescence. The supposed trajectories of gender dysphoria proposed by the authors in this brief letter are simply not borne out by fact. Leaving an adolescent’s gender dysphoria untreated until adulthood is not known to make it go away, and treating cis people with puberty blockers – which were originally developed to treat endocrine conditions in cis youth – is not known to cause gender dysphoria or transgender identification.
This error-dense paragraph concludes with an invocation of the alleged “rapid onset gender dysphoria” phenomenon, which the authors describe as a “recent phenomenon of teenage girls suddenly developing GD … without prior history through social contagion”. Unfortunately for them, the now-notorious Littman “ROGD” study cited here was corrected and substantially revised in recent weeks, with the phenomenon in question being retitled to “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria” to clarify that this is indeed a study of attitudes and beliefs among parents, and no youth with this alleged condition were evaluated or included in the study at all (Littman, 2019). In the course of actually apologizing to the entire transgender community for having published the original uncorrected paper, the editor-in-chief of PLOS One stated:
In our view, the corrected article now provides a better context of the work, as a report of parental observations, but not a clinically validated phenomenon or a diagnostic guideline.
This reflects the observations of Dr. Joshua Safer of the Endocrine Society, who noted in September 2018 that:
“I don’t know if there is such a thing as ROGD — a phrase that applies to the parent might be legitimate but the term ROGD is a complete overreach and it is unfair to the field. We need to limit this to what the data show us only. . . . Littman has actually written a paper about the anxiety of parents who question an open approach to transgender care and frequent sites that cast doubt on the current management approaches. No children were involved.”
Littman herself now states in her correction that the study “did not collect data from the adolescents and young adults (AYAs) or clinicians and therefore does not validate the phenomenon” of rapid onset gender dysphoria. This reliance on parental observations of youth’s apparent gender identity may in fact compromise the quality of the data collected: previous studies have found that trans people are typically aware of their gender identity for years before this comes to the attention of their parents, meaning that what appears to be a “sudden” development of gender dysphoria seen from a parent’s perspective may not have been sudden at all.
It is not even close to confirmed that a real clinical entity known as “rapid onset gender dysphoria” actually exists at all, rather than being an illusory artifact generated by one study’s subpar choice of methodology. And when the existence of the “condition” itself has yet to be established, Laidlaw et al. are not justified in stating with certainty that this condition is indeed contagious and is specifically known to be transmissible through social contagion. Nothing supports this, and much contradicts it.
We’re just two paragraphs into this, by the way.
Next: Medical ethics, fertility preservation, and ovarian pathology.