There’s broad agreement that psychotherapy must come first for gender-distressed youth, but diverging views over whether medical transition should be among the possible destinations
The study by Ristori & Steensma (2016) is probably the most referenced rate of desistence (meaning the child/adolescent no longer wishes to change their gender) as they pass through adolescence is 61% to 98%, meaning that the vast majority of children presenting with gender dysphoria will happily accept their ‘Gender assigned at Birth’ as they pass through adolescence.
The alternative box-ticking at RCH would be to commence the prepubertal child on puberty blockers with over 98% of that cohort proceeding to cross sex hormones and the whole gender transition package with the miserable long-term outcomes so well described.
…Currently approximately1.0% of the U.S. population aged 13 and over (over 2.8 million people) identifies as transgender (UCLA) . In 2011 the earliest estimate of the U.S. adult transgender (TG) population was 0.3% (approximately 700,000 individuals)
…TG women in the US are roughly 50 times more likely to be living with HIV than other adults of reproductive age (WHO)
…the Swedish study tracked 324 individuals who had sex reassignment surgery between 1973 and 2003 found that the overall suicide rate was roughly 19 times that of the general population (ref)
…US TG men accounted for 0.16% of all adults and 11% of all TG adults receiving HIV medical care in the US from 2009 to 2014. (NIH)
….In 2014 Denmark in 4 children requested gender reassignment. By 2022, the number of referrals grew by 8700% to 352.
….TG individuals face disproportionately high incarceration rates in the U.S. with lifetime incarceration estimates ranging from 16% to over 37% compared to the 2.5% general population rate (NIH)
….Approx one million persons (.3%) in the US identify as TG and constitute close to 2% of new HIV diagnoses (CDC)
….US TG individuals face higher all-cause mortality rates than non-TG counterparts. A study utilizing private insurance data from 2011 to 2019 found that TG people were nearly twice as likely to die compared to a 10% randomly selected non-TG (cisgender) cohort (NIH)
….TG individuals experience a significantly higher prevalence of alcohol use, binge drinking, and substance use diagnoses compared to cisgender peers (JAMA)
….TG individuals face higher all-cause mortality rates than non-TG counterparts (NIH)
And finally, be reassured, none of the above is a reason for concern:
….AusPATH strongly endorses the Affirmative Model of Gender Care claiming it is medically necessary, lifesaving and highly effective.
….RCH positions the gender-affirming model as essential, evidence-based healthcare, that significantly improves the mental health, emotional wellbeing, and social outcomes
… The AMA & RACP support gender-affirming care, stating it links to positive health outcomes like lower rates of substance abuse and reduced self-harm.
Thank you, Bernard, for this article, which has allowed me to understand what Therapy First is and how it differs from Genspect.
As you document, Therapy First has moved from "avoiding medicalization" to stating that "medical interventions should be approached with due caution." That difference is not minor: while Genspect maintains that children and adolescents should never be subjected to puberty blockers, cross-sex hormones, or surgery—that is, to procedures to alter phenotypic sexual characteristics—Therapy First keeps that procedure as valid. It does not oppose bans for minors, it has no position on rapid-onset gender dysphoria, and its president believes that mental health professionals should not issue judgments about eligibility for these procedures.
Stella O'Malley's quote is precise: "The difference lies in where that care can lead: Therapy First keeps medicalization as a possible treatment pathway; Genspect does not." And Garfield-Jaeger's observation is equally accurate: Therapy First's policy seems to be "some transition is fine, and if you don't accept it, then you're not compassionate."
On "for the kids'" comment: it raises an interesting question, but in my view, it starts from a premise that should be examined. It asks what would happen if it were demonstrated that "trans kids" do not exist or that they do exist, and whether that would resolve the debate. But the problem is not only whether they exist or not, but whether the procedures offered to them are the appropriate response. And on that, the evidence is already overwhelming: procedures to alter phenotypic sexual characteristics are iatrogenic. There are no "trans kids" who benefit from cross-sex hormones and mutilations, just as there are no anorexics who benefit from weight-loss drugs.
The anorexia argument is pertinent. "People with anorexia can also continue to be functionally normal, as can successful and well-adjusted people who self-harm. This does not make weight-loss drugs an adequate or acceptable treatment for anorexia, nor does it mean that doctors should facilitate self-harm as part of medical care, simply because the person requests it."
Similarly, "the fact that many people who have undergone medical transition continue to function well does not change this position." "Procedures that remove healthy organs, alter bodily functions, or create lifelong medical dependence should not be offered in hospitals or clinical services—nor funded by public health systems—as treatments for psychological suffering."
"Adults may request these medical interventions, but health professionals should not be free to provide them and call it medical care. This type of care resembles more a consumer model based on the principle of 'buyer beware' than medicine's duty to diagnose accurately, treat diseases, restore function, and avoid unnecessary harm."
Finally, I would like to propose a hypothesis about those who defend the "third position" in between, as is the case with García-Ryan (or also with Kinnon MacKinnon, of "The One Percent"). I believe these people may be under the influence of their own life experiences. In their cases, the interventions perhaps did not include surgeries, or, in the case of those who perhaps did receive them, there is no "going back." Combining these two possible situations with the fact that they consider themselves reasonable people and not patients with a psychiatric problem, they cannot, or find it very difficult to, admit how harmful these procedures are. Admission may be very costly to their psychology and emotional stability. They find themselves at an intermediate point, and therefore their position as scientists also remains at an intermediate point. They are unable to abstract themselves from the logical equations in order to understand the whole phenomenon that includes the "trans" issue.
I can imagine there might be some kids who stand a better chance of not ending up medicalised because they find the language & the vibe of Therapy First less confronting to begin with.
I agree. The question should be whether anyone benefits from these interventions. As someone can hate their sex but it doesn't mean these interventions will help them! It's true people sometimes just say of course you do this if nothing else seems to help....but one has to ask...why?
If the current default options are—for young children—social transition followed by blockers, hormones, and surgery, and—for older youth—hormones and surgery, then the issue isn't that nothing works; rather, the approach has been backward from the very start.
Green’s study from over 50 years ago, detailed in his book *The Sissy Boy Syndrome and the Development of Homosexuality*, demonstrated that simply going through puberty caused boys who wished to be girls to abandon that desire.
The problem today is a social one, in which a far-fetched idea is presented as normal and desirable, promoted everywhere from preschools to the practices of therapists and physicians.
What children need, fundamentally, is to be allowed to be themselves without having the idea imposed on them that they might have been born in the wrong body—or having name or pronoun changes suggested to them, or having such requests validated if they initiate them. In such cases, supportive therapy might well be sufficient.
As for older youth, what is needed is talk therapy, exploration, education, and acceptance.
That, along with the passage of time, would help heal many of the wounds.
Assuming that not everyone at the conference is speaking for Therapy First?
It could be a very productive conference if people who disagree strongly (and I am guessing that will be the case) explain to each other what they are basing their arguments on.
Ms. Garfield-Jaeger understands why she believes what she believes regarding what is best for these young people, and I'm sure the ones who believe there are a few children for whom it is appropriate also understand why they believe what they believe. Most people I know believe one or the other quite strongly!
Can the group entertain the following hypothetical cases? The hypothesis is that someone could "show" this conclusively...
What if someone could show conclusively there are not trans kids (kids who would benefit from medical intervention, young), would everyone in the room agree what to do in that case? Why or why not?
What if someone could show conclusively that there are trans kids (kids who would benefit from medical intervention, young), would everyone there agree on what to do next? Why or why not?
What about if there was "true trans" but only 1 in 100,000 kids in this category. There are about 4 million kids at every age in the US. That would be 40 at each age. In the entire country. How would they find them? How would they go about learning how to find them? Presumably the people providing these interventions think they have found some of them. How have they checked how these people are doing and why do they think they are doing better than they would have otherwise? How do they propose showing they are right, to those who believe these patients would have likely been better off otherwise?
I don't know how someone could decisively disprove the existence of a "true trans child". Having said that, I suspect people would disagree what is meant by that term.
I agree that even for those who are in one camp or the other there is a lot to discuss...or those who do not have an opinion. So maybe there is a question of taking time from other things....
"In any event, he believes that mental health practitioners should not be making judgment calls on eligibility for puberty blockers, cross-sex hormones or surgery."
If one thinks these interventions should be provided in some cases, and the above, then who should be making this judgement? It is a treatment for mental distress, isn't it? Is a surgeon qualified? An endocrinologist?
The patient and family has autonomy to refuse/accept treatment but who makes this decision?
Good question. Maybe the idea is that the medicos should take more responsibility rather than shifting it to mental health practitioners. It’s a problem created by our mind-body dualism.
The study by Ristori & Steensma (2016) is probably the most referenced rate of desistence (meaning the child/adolescent no longer wishes to change their gender) as they pass through adolescence is 61% to 98%, meaning that the vast majority of children presenting with gender dysphoria will happily accept their ‘Gender assigned at Birth’ as they pass through adolescence.
The alternative box-ticking at RCH would be to commence the prepubertal child on puberty blockers with over 98% of that cohort proceeding to cross sex hormones and the whole gender transition package with the miserable long-term outcomes so well described.
SOME SOBERING RANDOM TRANSGENDER REALITIES
…Currently approximately1.0% of the U.S. population aged 13 and over (over 2.8 million people) identifies as transgender (UCLA) . In 2011 the earliest estimate of the U.S. adult transgender (TG) population was 0.3% (approximately 700,000 individuals)
…TG women in the US are roughly 50 times more likely to be living with HIV than other adults of reproductive age (WHO)
…the Swedish study tracked 324 individuals who had sex reassignment surgery between 1973 and 2003 found that the overall suicide rate was roughly 19 times that of the general population (ref)
…US TG men accounted for 0.16% of all adults and 11% of all TG adults receiving HIV medical care in the US from 2009 to 2014. (NIH)
….In 2014 Denmark in 4 children requested gender reassignment. By 2022, the number of referrals grew by 8700% to 352.
….TG individuals face disproportionately high incarceration rates in the U.S. with lifetime incarceration estimates ranging from 16% to over 37% compared to the 2.5% general population rate (NIH)
….Approx one million persons (.3%) in the US identify as TG and constitute close to 2% of new HIV diagnoses (CDC)
….US TG individuals face higher all-cause mortality rates than non-TG counterparts. A study utilizing private insurance data from 2011 to 2019 found that TG people were nearly twice as likely to die compared to a 10% randomly selected non-TG (cisgender) cohort (NIH)
….TG individuals experience a significantly higher prevalence of alcohol use, binge drinking, and substance use diagnoses compared to cisgender peers (JAMA)
….TG individuals face higher all-cause mortality rates than non-TG counterparts (NIH)
And finally, be reassured, none of the above is a reason for concern:
….AusPATH strongly endorses the Affirmative Model of Gender Care claiming it is medically necessary, lifesaving and highly effective.
….RCH positions the gender-affirming model as essential, evidence-based healthcare, that significantly improves the mental health, emotional wellbeing, and social outcomes
… The AMA & RACP support gender-affirming care, stating it links to positive health outcomes like lower rates of substance abuse and reduced self-harm.
Thank you, Bernard, for this article, which has allowed me to understand what Therapy First is and how it differs from Genspect.
As you document, Therapy First has moved from "avoiding medicalization" to stating that "medical interventions should be approached with due caution." That difference is not minor: while Genspect maintains that children and adolescents should never be subjected to puberty blockers, cross-sex hormones, or surgery—that is, to procedures to alter phenotypic sexual characteristics—Therapy First keeps that procedure as valid. It does not oppose bans for minors, it has no position on rapid-onset gender dysphoria, and its president believes that mental health professionals should not issue judgments about eligibility for these procedures.
Stella O'Malley's quote is precise: "The difference lies in where that care can lead: Therapy First keeps medicalization as a possible treatment pathway; Genspect does not." And Garfield-Jaeger's observation is equally accurate: Therapy First's policy seems to be "some transition is fine, and if you don't accept it, then you're not compassionate."
On "for the kids'" comment: it raises an interesting question, but in my view, it starts from a premise that should be examined. It asks what would happen if it were demonstrated that "trans kids" do not exist or that they do exist, and whether that would resolve the debate. But the problem is not only whether they exist or not, but whether the procedures offered to them are the appropriate response. And on that, the evidence is already overwhelming: procedures to alter phenotypic sexual characteristics are iatrogenic. There are no "trans kids" who benefit from cross-sex hormones and mutilations, just as there are no anorexics who benefit from weight-loss drugs.
The anorexia argument is pertinent. "People with anorexia can also continue to be functionally normal, as can successful and well-adjusted people who self-harm. This does not make weight-loss drugs an adequate or acceptable treatment for anorexia, nor does it mean that doctors should facilitate self-harm as part of medical care, simply because the person requests it."
Similarly, "the fact that many people who have undergone medical transition continue to function well does not change this position." "Procedures that remove healthy organs, alter bodily functions, or create lifelong medical dependence should not be offered in hospitals or clinical services—nor funded by public health systems—as treatments for psychological suffering."
"Adults may request these medical interventions, but health professionals should not be free to provide them and call it medical care. This type of care resembles more a consumer model based on the principle of 'buyer beware' than medicine's duty to diagnose accurately, treat diseases, restore function, and avoid unnecessary harm."
Finally, I would like to propose a hypothesis about those who defend the "third position" in between, as is the case with García-Ryan (or also with Kinnon MacKinnon, of "The One Percent"). I believe these people may be under the influence of their own life experiences. In their cases, the interventions perhaps did not include surgeries, or, in the case of those who perhaps did receive them, there is no "going back." Combining these two possible situations with the fact that they consider themselves reasonable people and not patients with a psychiatric problem, they cannot, or find it very difficult to, admit how harmful these procedures are. Admission may be very costly to their psychology and emotional stability. They find themselves at an intermediate point, and therefore their position as scientists also remains at an intermediate point. They are unable to abstract themselves from the logical equations in order to understand the whole phenomenon that includes the "trans" issue.
I can imagine there might be some kids who stand a better chance of not ending up medicalised because they find the language & the vibe of Therapy First less confronting to begin with.
I think this sums it up:
"There are no "trans kids" who benefit from cross-sex hormones and mutilations, just as there are no anorexics who benefit from weight-loss drugs".
I agree. The question should be whether anyone benefits from these interventions. As someone can hate their sex but it doesn't mean these interventions will help them! It's true people sometimes just say of course you do this if nothing else seems to help....but one has to ask...why?
Maybe the distress of each generation is met with a fashionable cure.
If the current default options are—for young children—social transition followed by blockers, hormones, and surgery, and—for older youth—hormones and surgery, then the issue isn't that nothing works; rather, the approach has been backward from the very start.
Green’s study from over 50 years ago, detailed in his book *The Sissy Boy Syndrome and the Development of Homosexuality*, demonstrated that simply going through puberty caused boys who wished to be girls to abandon that desire.
The problem today is a social one, in which a far-fetched idea is presented as normal and desirable, promoted everywhere from preschools to the practices of therapists and physicians.
What children need, fundamentally, is to be allowed to be themselves without having the idea imposed on them that they might have been born in the wrong body—or having name or pronoun changes suggested to them, or having such requests validated if they initiate them. In such cases, supportive therapy might well be sufficient.
As for older youth, what is needed is talk therapy, exploration, education, and acceptance.
That, along with the passage of time, would help heal many of the wounds.
Yes, the incentives especially in Western societies point in the direction of identity politics and its medical arm, gender-affirming care.
Assuming that not everyone at the conference is speaking for Therapy First?
It could be a very productive conference if people who disagree strongly (and I am guessing that will be the case) explain to each other what they are basing their arguments on.
Ms. Garfield-Jaeger understands why she believes what she believes regarding what is best for these young people, and I'm sure the ones who believe there are a few children for whom it is appropriate also understand why they believe what they believe. Most people I know believe one or the other quite strongly!
Can the group entertain the following hypothetical cases? The hypothesis is that someone could "show" this conclusively...
What if someone could show conclusively there are not trans kids (kids who would benefit from medical intervention, young), would everyone in the room agree what to do in that case? Why or why not?
What if someone could show conclusively that there are trans kids (kids who would benefit from medical intervention, young), would everyone there agree on what to do next? Why or why not?
What about if there was "true trans" but only 1 in 100,000 kids in this category. There are about 4 million kids at every age in the US. That would be 40 at each age. In the entire country. How would they find them? How would they go about learning how to find them? Presumably the people providing these interventions think they have found some of them. How have they checked how these people are doing and why do they think they are doing better than they would have otherwise? How do they propose showing they are right, to those who believe these patients would have likely been better off otherwise?
The patients need these answers....
I hope the discussions are good.
I don't know how someone could decisively disprove the existence of a "true trans child". Having said that, I suspect people would disagree what is meant by that term.
I agree that even for those who are in one camp or the other there is a lot to discuss...or those who do not have an opinion. So maybe there is a question of taking time from other things....
Just one more question...
"In any event, he believes that mental health practitioners should not be making judgment calls on eligibility for puberty blockers, cross-sex hormones or surgery."
If one thinks these interventions should be provided in some cases, and the above, then who should be making this judgement? It is a treatment for mental distress, isn't it? Is a surgeon qualified? An endocrinologist?
The patient and family has autonomy to refuse/accept treatment but who makes this decision?
Good question. Maybe the idea is that the medicos should take more responsibility rather than shifting it to mental health practitioners. It’s a problem created by our mind-body dualism.