Episode 60: Gender Transitioning – What Do the Studies Tell Us?

We have discussed some of the key philosophical ideas and cultural changes that led to the development of gender theory and subsequently “gender-affirming treatment”.

“Gender-affirming treatment” basically refers to therapy that affirms individuals in their gender dysphoria. This could consist of any single or combination of a number of social, psychological, behavioural, medical or even surgical interventions, in the hope that this would help the individuals feel better about themselves and relieve their psychological distress arising from gender dysphoria.

We noted that some of the most liberal countries which had initially embraced this idea and promoted “gender-affirming treatment” and transition for the young, such as those in Scandinavia and other parts of Europe, have now gone back on their policies and put a hold on this practice.

Here, we will discuss what contributed to this U-turn.

Over the past few years, concerns have arisen from studies that do not seem to support such gender-affirming treatment for the young. As a result, countries such as Finland, Sweden and Denmark have reversed their policies and no longer prescribe puberty blockers, hormones or surgery. Instead, they encourage therapeutic counselling and support as essential aspects of holistic care.

The Cass Review

The rationale that supported this rather radical change in approach was well-documented by a review that was commissioned by NHS England. Its objective? To make recommendations on how to improve gender identity services based on the best available evidence, and ensure that children and young people who are questioning their gender identity or experiencing gender dysphoria receive a high standard of care that meets their needs, is safe, holistic and effective.

This report, 388 pages long, was submitted to NHS England in April 2024. It was named the Cass Review, after Dr Hilary Cass who chaired the Independent Review of gender identity services for children and young people.

In presenting its findings, the Cass Review took note of several important points.

1. Without social, medical or surgical intervention, gender dysphoria naturally resolves in a vast majority of young individuals. According to the American College of Paediatricians, this figure is between 80 to 95 percent.

 

2. Systematic evidence reviews demonstrated the poor quality of published studies that were used to support the use of puberty blockers and cross-sex hormones. On the contrary, results from an NHS early intervention study in the use of puberty blockers showed there was a lack of any positive measurable outcomes. There was no evidence that puberty blockers improve body image or dysphoria, and very limited evidence for positive mental health outcomes (CR, page 179)

 

3. The review recommended that young people referred to gender services must receive a holistic assessment of their needs. This would include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment. Why? Because studies indicate that up to 42 percent of these individuals meet criteria for autism,[i] and up to 62 percent had one or more diagnoses of a psychiatric disorder (such as anxiety, depression, obsessive-compulsive disorder, and eating disorders, among others).[ii] A Finnish study found that more than three-quarters of the referred adolescent population needed specialist child and adolescent psychiatric support due to problems other than gender dysphoria, many of which were severe, predated, that is, before the onset of gender dysphoria, and were not considered to be secondary to the gender dysphoria (CR, page 91, 5.30). It seems quite apparent then, that gender dysphoria is often not the main source of the problem, but a symptom of something else that goes much deeper.

 

4. A further concern is the complications of treatment with puberty blockers and cross-sex hormones, such as weakening of bone structure resulting in osteoporosis, as well as adverse effects on the cardiovascular system, whether in the short or long term. Another worry concerns their neurological development. It is thought that adolescent sex hormone surges may trigger the opening of a critical period for maturation of the part of the brain concerned with planning, decision-making and judgement. If this is the case, brain maturation may be temporarily or permanently disrupted by the use of puberty blockers, which could have a significant impact on the young person’s ability to make complex risk-laden decisions, as well as having possible longer-term neuropsychological consequences. (Cass Review, page 178, 14.38)

 

5. With regards to suicide, it has been claimed that individuals with gender dysphoria would have a higher risk of committing suicide if they were not allowed to transition. But the Cass Review, which extensively reviewed the available data, concluded that the evidence does not support the claim that gender-affirming treatment reduces suicide risk at all. (CR, pages 186 to 187)

 

All these explain why the Cass Review recommended a different approach to healthcare, one that considers the young person holistically and not solely in terms of their gender-related distress, in contrast to the so-called “gender-affirming” model.

 

Allow me to summarise what we have discussed so far:

1. Studies that appear to promote the use and benefits of so-called “gender-affirming care” have been found to be of poor quality.

 

2. A significant proportion of the population with gender dysphoria has associated neuropsychiatric conditions such as autism and mental health issues such as anxiety, depression, obsessive-compulsive disorder, and eating disorders, among others

 

3. There are health concerns related to the medical treatment offered as part of “gender-affirming care”.

 

4. The claim that gender-affirming treatment reduces suicide risk is not supported by the evidence available.

 

5. Gender dysphoria resolves spontaneously in the vast majority of cases if individuals are allowed to follow their natural development through puberty to adulthood.

 

We have talked about what gender theory is, how it came about, and shared some data about transitioning among youth. It is now time to turn our attention to the most important subject of this topic – the person who experiences gender dysphoria.

 

We can see from the data presented that many individuals with gender dysphoria are challenged with various neuropsychiatric disorders such as autism, anxiety, depression, obsessive-compulsive disorder, and eating disorders, among others.

 

Which is why it is so important to differentiate between the concept of gender ideology and the individuals who experience gender dysphoria, individuals who deserve our love, empathy and understanding, no less. How do we do this? How can we journey with them, especially if they are our children, our sibling, our friend? We shall look into that in an interview with a psychologist/counsellor who will share with us some tips on how we can go about doing so.

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[i] Cf. DSM-5, 55; S. Stagg, “Autistic Traits in Individuals Self-Defining as Transgender or Nonbinary, European Psychiatry 61 (September 2019), 17-22.

[ii] Littman, “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria”.