Gender Dysphoria: The Medical Context

7 Apr

The subject of transgenderism, especially with respect to children, has frequently been in the news over the past few months. It is a subject which invokes a variety of emotional responses and needs to be addressed wisely and with compassion. I will attempt to give a brief overview of the subject and suggest some further reading.

Gender dysphoria is defined as the sense of unease a person feels due to a mismatch between their biological sex and their gender identity.

In the UK, children and young people suffering from gender dysphoria are referred to The Tavistock Centre where they should undergo a thorough psychosocial assessment (looking thoroughly at any underlying psychological, mental health or developmental conditions, such as autism or family issues, that may be contributing to their difficulties) before a formal diagnosis is made. Children experiencing distress around puberty are then potentially referred on to be considered for medication to block puberty (known as puberty blockers). These medications are given to children as they start puberty, which can be as young as 10. At the age of 16, these children can progress to cross-sex hormones (testosterone or oestrogen) and following that some will progress to surgery (see here).

There has been increasing concern about this medical and surgical treatment and the lack of psychological and therapeutic support for these children and young people. In addition, there has been an explosion in referrals to this clinic, as well as a significant change in the demographics of referrals. When the clinic opened in 2009 there were 97 referrals, and just over 50% were biological males, whereas last year there were 2728 referrals of which around 76% were biological females. The precise reason for this increase (and in particular the huge rise in teenage biological females) is not understood and has not been formally investigated.

As a result of this rise in referrals, increasing numbers were referred on for medical treatment and concerns started to be raised that adequate assessment and appropriate therapy was not being given to these children and that the long term outcomes were largely unknown.

Another change is that it increasingly common for children to have already undergone social transition (i.e. they already identify and live as if they were the opposite sex) before arriving at the Tavistock clinic (in many cases social transition occurs even before referral or assessment by any medical professional). This may be partly due to increased waiting times, but schools are also increasingly encouraged to allow any child who expresses a gender identity to be allowed to show it, whether it be in the way they dress, their names and pronouns, or the toilets they use.

It is important at this point to look at what the outcomes were for these children prior to the use of puberty blockers. Studies show that between 70 and 90% of children suffering from gender dysphoria would, after going through puberty, become comfortable with their biological sex. Only a small percentage would persist with feelings of gender dysphoria into adulthood.

These statistics are the reason that the ‘watchful waiting’ approach is advocated, especially with children and young people.

It has been common for children with gender dysphoria to be given puberty blockers which suppress normal puberty and the physical and emotional changes that come with it. It was initially intended that giving puberty blockers would reduce distress in the child/young person and enable them to explore their identity without the distress of the physical changes. It quickly became clear that almost all of the children who started taking puberty blockers progressed to taking cross-sex hormones. This is not altogether surprising, bearing in mind that previous studies showed that it was the process of going through puberty, including the brain maturation, that helped a child to become comfortable with their biological sex. (The NHS website was recently updated to reflect the understanding that puberty blockers in this scenario are not easily reversible).

We need to keep clear in our minds the fact that a person cannot change their biological sex. Every cell in the body has XX or XY chromosomes (apart from the extremely rare incidences of genetic disorders). A person who goes down the route of a medical and surgical gender reassignment will be on hormone therapy for the rest of their lives and (depending on what treatment they have had) will likely be rendered infertile and in many cases without sexual function.

It is concerning that the current ideology around gender identity is illogical and operates on the belief that biological sex is irrelevant to being a boy or girl, that being a boy or a girl is based on feelings rather than biological reality.

School are often the place where gender identity issues may first be expressed, and it is therefore important that teachers are well informed on the subject and consider how best to approach individual situations. There is lots of practical advice in this resource.

The issues around gender identity and gender dysphoria are complex and need to be approached with compassion and understanding while ensuring that the truth of biological reality remains clear. Children and young people deserve the best and most effective interventions based on evidence and facts, not on ideology and feelings.

Julie Maxwell is a part-time Community Paediatrician and works for Lovewise (a charity which provides relationships and sex education from a Christian perspective) one day a week. She is involved in leading youth work at her local church, and became increasingly interested in and concerned with the increase in children and young people presenting gender identity issues, as well as the way these issues were being managed. Julie is married with 3 teenage children.