Guidelines and guardrails

America's psychologists have a chance to catch up with a worrying trend in gender clinics

America’s peak body for psychologists should seize the opportunity to take a careful look at the atypical patient profile now dominating youth gender clinics, according to licensed professional counsellor Sasha Ayad.

Ms Ayad, a Texas-based therapist who specialises in helping young people with gender issues, says the American Psychological Association’s task force reviewing its 2015 transgender guidelines should replace the document’s “political jargon” with clear, science-driven advice for clinicians.

“They should also take note of the growing population of detransitioners who feel harmed by the [‘gender affirming’] model,” she told GCN.

Ms Ayad, a founding member of the Gender Exploratory Therapy Association, says today’s typical clients – mostly natal females with teenage-onset gender dysphoria and often serious mental health problems – are “vastly different” from the patients seen by the pioneering Dutch clinic more than a decade ago.

That Amsterdam clinic, which inspired international adoption of puberty blocker drugs as the first step on the “Dutch protocol” path of medicalised gender change, worked with mostly natal males who were free of major psychiatric problems and had suffered the bodily distress of gender dysphoria since early childhood.

In February 2021, a leading expert from that clinic, psychologist Thomas Steensma, gave an interview in the Dutch press chastising gender clinics around the world for “blindly adopting” the Dutch protocol without doing their own research.  

“Can our research from so long ago still be applied to the group of young people who are now reporting [to clinics]?,” Dr Steensma said. “And why are so many girls suddenly dissatisfied with their sex? That really needs to be investigated.”

The APA homepage happens to touch on factors potentially relevant to the international spike in gender dysphoria, although the possible connection is a taboo topic not only for trans activists but also for many health and medical institutions.

Gender clinician Dr Erica Anderson, who is a member of the APA task force reviewing the 2015 Guidelines for Psychological Practice With Transgender and Gender Nonconforming People, says there will be an update on the guideline project at the association’s annual convention in Chicago in May.

Dr Anderson – a clinical psychologist and former president of the US Professional Association for Transgender Health – has gone public with concerns about the surge in gender clinic caseloads and a high-risk trend of medical intervention without comprehensive assessment.

“You can be assured that all my concerns – many publicly expressed – will be addressed in my work on the APA task force on guidelines,” she told GCN.

At the Chicago convention, a small group from the task force will probably present “something less than a draft” of the new guideline – “perhaps the structure of the new revised guidelines, interim reports about issues taken up,” she said.

In October last year, Dr Anderson told journalist Abigail Shrier she was “not sure” that puberty blockers were reversible. For years, “gender affirming” clinicians and activists have promoted these drugs as merely pausing puberty.

Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care

The APA’s 2015 trans guidelines describe blockers (GnRH analogue) as “a reversible medical intervention used to delay puberty”.

The document sends a mixed message of identity politics rhetoric and the professional caution warranted by a weak evidence base.

Psychologists should “strive to recognize the influence of institutional barriers on the
lives of [trans] people and to assist in developing [trans]-affirmative environments”.

They are also warned that the poor state of the evidence prevents any consensus on how to approach trans and gender non-conforming children yet to go through puberty.

The APA guideline admits its recommendations are based mostly on low-quality convenience samples and small-scale studies, meaning the outcomes may not have any general application. (Elsewhere, the guidelines claim there is “strong evidence” for affirmative care.)

The document cites the gender affirming approach as one of two possible approaches with children. It characterises the alternative as encouraging children “to embrace their given bodies and to align with their assigned gender roles”, but notes the opinion that this approach may be unethical “conversion therapy”.

The guidelines acknowledge the body of research reporting that many patients diagnosed with gender dysphoria in early childhood grow out of it, and do not persist in their trans identification. However, the APA document suggests that the frequency of this “desistance” may be overstated.

“Gender-questioning children who do not persist may be more likely to later identify
as gay or lesbian than non-gender-questioning children,” the guidelines say.

The APA document recommends “comprehensive assessment” before medical interventions with adolescents, and advises “moving more slowly and cautiously” in cases of late-onset gender dysphoria.

It acknowledges that cross-sex hormones “may limit fertility” and that young people “often feel that family planning or loss of fertility is not a significant concern in their current daily lives, and therefore disregard the long-term reproductive implications of hormone therapy or surgery”.

In tension with the need for thorough assessment, the document disapproves of past clinicians who acted as “gatekeepers” between trans adults and medical treatment, and recommends an approach to patient autonomy that is “more affirming”.

Parents say it is difficult to find therapists who will explore all possible issues troubling a young person, rather than uncritically affirming a trans identity and fixating on gender.

The APA review task force began its work in August 2021 and is expected to finish in mid-2024, according to Kim Mills, the association’s senior director of external communications and public affairs. She says the draft will be open to public comment.

Ms Mills says practice guidelines expire after 10 years, and have to be updated. She says the transgender document is a practice guideline, not a treatment guideline.

“They do not provide guidance on treating gender dysphoria,” she said. “They are also aspirational in nature.”

Ms Ayad, who is a clinical adviser to the Society for Evidence Based Gender Medicine, said the APA has an opportunity to catch up with the international trend of a more cautious response to young people who present with gender issues.

“Other nations like Sweden, Finland, and the UK, who have more experience treating gender dysphoria in youth, have been adjusting their intervention methods to reflect a more data-driven and scientific basis for first-line treatments,” she said.

“The APA guidelines, on the other hand, have been using unscientific political jargon in their guidance for clinicians.”

American Psychological Association @APA

A simple message is emerging from a growing body of research: When transgender children get support affirming their gender identities, their mental health difficulties go down; when they don't get support, they go up.

apa.orgEmbracing a gender-affirmative model for transgender youthWhen transgender children get support affirming their gender identities, their mental health difficulties are reduced.

The APA document is offered as an adjunct to treatment guidelines from the World Professional Association for Transgender Health and the Endocrine Society; both these guidelines have come under recent scrutiny.

Clinical psychologist Dr Ken Zucker, a world authority on youth gender dysphoria and editor of the Archives of Sexual Behavior, says the APA’s guidelines would rank below others when it came to influence in the field.

“It's definitely WPATH [the World Professional Association for Transgender Health] as the alpha organisation; the American Psychiatric Association is probably second in line,” he told GCN.

What warrants more attention, Dr Zucker says, is the status of gender dysphoria in psychiatry’s Diagnostic and Statistical Manual of Mental Disorders.

“In terms of policy, a key focus in my view should be the likely push to remove gender dysphoria as a mental disorder from the DSM-5,” he said.

“If parents and families want to push back on anything, that should be their focus.”

Dr Zucker chaired the DSM-5 work group that settled on the term gender dysphoria as a less pathologising replacement for the “gender identity disorder” of DSM-4.

The World Health Organisation’s International Classification of Diseases (ICD-11, 2019) removed the condition from the chapter on mental and behavioural disorders, rebadged it as “gender incongruence” and put it in the chapter for “conditions related to sexual health”.

Gender: A Wider Lens Podcast @widerlenspod

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In a recent podcast, Dr Zucker predicted a move by psychiatry to consign gender dysphoria to the DSM appendix, where it would be further depathologised but also ineligible for health insurance cover.

He says some gender clinics already use “creative” work-arounds to come within insurance coverage. “People can make up diagnoses, so they get paid,” he said.

“I know that there are some clinics in the US, when they see children or adolescents with gender dysphoria they don’t use the DSM or the old ICD coding for [the condition], they use ‘unspecified endocrine disorder’, which is essentially, in my view, diagnostic fraud.

“What is an unspecified endocrine disorder? There’s no definition of what that means, but I thought it's kind of creative.” 

Dr Zucker says the gender identity field has “always been political – and it's probably more political now than ever.”

Like many other institutions, the APA’s preoccupation with identity politics and social justice signalling has increased in recent years.

The APA has felt the need to hold forth on climate change, global poverty and a “racism pandemic”.  

In 2019, the organisation trumpeted its “first chief diversity officer, charged with leading a transformational agenda to infuse equity, diversity and inclusion throughout the association’s work”.

American Psychological Association @APA

In the midst of America’s racial reckoning, psychologists are looking inward to dismantle racism within the field and create a more equitable and inclusive discipline.

apa.orgThe fight against racism must continuePsychologists are looking inward to dismantle racism within the field, such as inequities in publishing and unfair practices in hiring, training, and retention of faculty and practitioners of color.

Recent APA resolutions on gender identity and conversion therapy have come sprinkled with ever more jargon, such as people who have “same- and multiple gender attractions” and the catch-all category of “additional gender minority identities”.

This process of mushrooming identities with puzzling variations in nomenclature was already evident in the 2015 guideline.

If psychologists aspire to “foundational knowledge”, they are told they must understand that “gender is a non-binary construct”.

Ms Ayad says this formula may belong in a philosophical text, but is “of little use to therapists and professionals who are attempting to understand gender dysphoria.”

She says the task force has an opportunity to help clinicians untangle the factors leading to gender dysphoria.

“Factors such as sexual trauma, childhood abuse, neurodevelopmental conditions, or other psychiatric comorbidities should be given priority and treated prior to affirming and medicalising adolescent gender identities,” she said.

She points to a recent study showing that many detransitioners who reconciled with their biological sex found it helpful to entertain more expansive ideas of what it is to be a man or a women.

“Clinicians should be aiming to reduce dependence on novelty identity labels,” she says. 

“The APA guidelines seem to be further restricting and limiting ways young people can live in their natal sex identities.”