Iatrogenic Gender Dysphoria and Harm Cycle in Gender Affirming Care
- La Petite Sirène
- Apr 25
- 31 min read
Iatrogenic Gender Dysphoria and Harm Cycle in Gender Affirming Care
Zeki Bayraktar - 27 mars 2025
Abstract
In recent years, there has been a significant increase in cases of gender dysphoria among children and adolescents. Iatrogenesis, as a result of early social and medical transitions in the gender-affirming care model, has contributed to this rise, leading to a group of cases that could be described as ‘iatrogenic gender dysphoria.’ Iatrogenesis also causes potential harm in the medical and surgical treatments of these cases. Thus, gender dysphoria cases are effectively encircled by an iatrogenic harm cycle, from development to treatment. Pressures that restrict academic freedom in the field of gender medicine, political influences, issues of ‘spin’ in publications related to the gender-affirming care model, and misleading or exaggerated statements made by some clinicians to the public also contribute to this harm cycle. This article discusses the role of iatrogenesis in the increase of gender dysphoria cases and its effects within the harmful cycle surrounding these cases.
Introduction
In recent years, there has been a dramatic increase in cases of gender dysphoria (GD) among children and adolescents. Although this increase began before the 2000s, the trend continued in subsequent years and saw a sharp acceleration, particularly after 2010 (Cass, Citation2024; Zucker, Citation2019). This article argues that iatrogenesis plays a role in the increase of adolescent GD cases and discusses the iatrogenic harms occurring during medical and surgical transition processes.
One of the first to report this increase was Zucker et al., who published a letter in this journal in 2008 titled "Is gender identity disorder in adolescents coming out of the closet?" The rhetorical question was based on their observation of a sharp rise in the number of adolescent patients assessed in their clinic between 2004-2007 compared to previous four-year intervals dating back to 1976-1979. In the letter, they remarked on this sharp increase in adolescent GD cases, stating, "There’s something happening here. What it is ain’t exactly clear." The rise in the number of adolescent patients evaluated sharply increased in subsequent years (Wood et al., Citation2013), showing that the prior trend was not merely a fluctuation (Zucker, Citation2019). For instance, while Ontario’s Ottawa-based specialized gender identity service received "one or two" referrals before 2010, this number rose to 189 in 2018 (Zucker, Citation2019). In the United Kingdom, referrals to the Gender Identity Development Service for children and adolescents increased from 51 cases in 2009 to 1,766 cases in 2016 (Cass, Citation2024). This surge in adolescent referrals to specialized gender identity clinics has become an international phenomenon observed across North America, Europe, Scandinavia, and other regions (Kaltiala et al., Citation2020; Zucker, Citation2019).
There is an apparent global epidemic of adolescent GD cases. Marchiano (Citation2017) characterizes this rise in adolescent GD referrals as an "epidemic." A study conducted in Germany examining a 10-year cohort from 2013-2022 found an eightfold increase in individuals aged 5-24 diagnosed with "F64. Gender Identity Disorders" or "F64.0 Transsexualism," with rates rising from 22.5/100,000 to 175.7/100,000 and 15.2/100,000 to 132.6/100,000, respectively (Bachmann et al., Citation2024). Similarly, an international registry-based study (TriNetX, 80% U.S. data) covering the 2017-2021 period reported a more than tenfold increase in individuals diagnosed with F64.0 Transsexualism at age 16, with rates rising from 47/100,000 to 479/100,000 (Sun et al., Citation2023). By the Williams Institute’s estimates, TGNB prevalence among adults is highest in the 18–24 years old age group at 700 per 100,000 (0.7%), compared with 600 per 100,000 (0.6%) in those aged 25–64 and 500 per 100,000 (0.5%) in those aged 65 and older (Nolan et al., Citation2019).
There are at least two developmental pathways leading to GD. In early-onset GD, symptoms are evident from an early age (e.g., in preschool or even earlier). In late-onset GD, symptoms do not appear until adolescence. Early-onset GD occurs in both males and females, but since the 1990s, late-onset GD has been increasingly reported among females (Zucker, Citation2019).
Since 2010-2011, there has been a sharp increase—marked by a significant acceleration—in GD cases, predominantly among individuals assigned female at birth (AFAB) (Bachmann et al., Citation2024; Sun et al., Citation2023). While GD was traditionally a rare condition more common in individuals assigned male at birth (AMAB), recent studies show a reversal, with greater increases in AFAB individuals and a shift in the AMAB:AFAB ratio (Sun et al., Citation2023; Thompson, Citation2022; Turban et al., Citation2021). Sun et al. (Citation2023) reported that the AMAB:AFAB ratio, which was 5:6 in 2017, increased to 5:7 in 2021, with a combined ratio of 10:13 over the 2017-2021 period. The majority of this change was driven by an increase in the number of AFAB adolescents and young adults, a finding corroborated by a recent national study in Sweden (Indremo et al., Citation2021).
The average age of GD diagnosis is decreasing, and the true AMAB:AFAB ratio varies by age group and study population. Sun et al. (Citation2023) identified a GD prevalence of 155/100,000, reporting that GD prevalence among AFAB individuals rises sharply at age 11, peaks at ages 17-19, and falls below that of AMAB individuals by age 22. In contrast, GD prevalence in AMAB individuals begins to rise at age 13, peaks at age 23, and gradually decreases thereafter (Sun et al., Citation2023).
Possible reasons for the increase in adolescent gender dysphoria cases
The etiology of GD is still not fully understood. However gender identity differentiation does not occur in a psychosocial vacuum; instead, research in the field suggests that the developmental course is influenced by numerous psychosocial factors, likely in continuous interaction with biological factors (Kaltiala-Heino et al., Citation2018). During pubertal maturation, biological and psychological [internal] factors may interact with psychosocial [external] factors, playing a role in the development of adolescent GD; it is thought that biological, psychological, and social factors all play a role in the development of GD through a complex interaction (Leibowitz & de Vries, Citation2016).
Several explanations have been ofered to explain this increase in GD cases; (1) the visibility given to transgender issues in print media, television, etc.; (2) the Internet, which provides innumerable sites to read about gender dysphoria and transgender care; (3) the gradual depathologization/stigma reduction with regard to gender dysphoria and a transgender identity; and (4) the availability of biomedical treatment, including hormonal delay or suppression of somatic pubertal development (de Vries et al., Citation2016; Zucker, Citation2019). Zucker (Citation2019), argues that these are likely interconnected and that all of these factors taken together (reflected in the “affirmative” care model adopted by many gender identity clinics and teams) may have made it psychologically easier for adolescents and their families to seek mental health care.
Internet interactions should also be included among these factors. Today, adolescents’ social interactions have largely shifted to online environments. For adolescents, gender identity development heavily relies on social processes, including discovery and experimentation through external feedback (Pullen Sansfaçon et al., Citation2023). Indeed, a new clinical form of adolescent GD, thought to have originated online, has been identified: Rapid Onset Gender Dysphoria (ROGD). Littman (Citation2018), who first described this clinical picture, argues that ROGD primarily stems from internet-based interactions: "Social and peer contagion, alongside deep immersion in social media, often within clusters of gender dysphoric peer groups" (Littman, Citation2018, Citation2019).
Another potential contributing factor worth mentioning is iatrogenic influences, such as early social transition and puberty blockers. Iatrogenesis, derived from the Greek words iatros (doctor) and genesis (origin), refers to adverse outcomes, side effects, and risks associated with medical diagnoses and treatments (Peer & Shabir, Citation2018). Iatrogenic harms can result not only from diagnostic and therapeutic interventions by healthcare professionals, particularly doctors, but also from medication side effects or institutional healthcare practices.
There is no simple explanation for the dramatic increase in GD cases; however, there is a general consensus that it arises from a complex interaction of biological, psychological, and social factors, with the balance of these factors varying for each individual (Cass, Citation2024). Iatrogenesis, among other factors, may also play a role in the rise of GD cases (Cass, Citation2024; Zucker, Citation2020).
The role of social transition in iatrogenesis
A systematic review of 10 prospective studies by Ristori and Steensma (Citation2016) that followed childhood-onset GD cases into adolescence found decedence in GD during adolescence in approximately 80% of cases. A recent study by Singh et al. (Citation2021) confirms these findings; in AMAB individuals, with a mean follow-up age of 20.58 years, the persistence rate of GD was only 12%, while decedence was observed in 88% of cases. A recent study from the Netherlands—despite the fact that this study did not include a formal GD diagnosis and assessed gender non-contentedness in adolescents/young adults with a single question—suggests that this trend of desistance might continue beyond the age of 18. This study, which tracked 2,772 adolescents, found that the prevalence of gender non-contentedness was 11% in early adolescence, decreased with age, and dropped to 4% by the final follow-up around the age of 26. Gender Non-Contentedness completely resolved in 78% of cases, decreased in 19%, and increased in only 2%. In one-quarter of the cases, the decedence of gender non-contentedness occurred after the age of 18 (Rawee et al., Citation2024). These data suggest that recedes in GD may continue beyond age 18 in some cases; at the very least, this possibility exists and warrants further investigation. More importantly, there is a clear and significant increase in the number and variety of GD cases today, as well as notable limitations in current treatment practices (Zucker, Citation2019; Zucker et al., Citation2016).
These data show that in children with GD who are followed without undergoing social or medical transition, GD resolves in 80-88% of cases during adolescence. Moreover, there is no published study showing that a cautious "wait-and-see" approach harms children with GD or leads to adverse outcomes. On the contrary, there are differing opinions regarding affirmation and social transition. According to a systematic review conducted by Dr. Cass in the UK, which spanned approximately four years, examined all relevant studies, and included a review of all relevant studies as well as interviews with approximately a thousand cases, children with GD who underwent social transition at an early age and/or before attending a clinic are more likely to proceed toward a medical pathway. The gender in which a child is raised does have some influence on their ultimate gender, and social transition during childhood may alter the trajectory of gender identity development in children with early gender incongruence (Cass, Citation2024).
According to a study by Steensma et al. (Citation2013), the strongest predictor of the persistence of childhood GD is social transition. Zucker (Citation2020) issues a similar warning regarding the risks of pre-pubertal social transition, stating:
A gender social transition in prepubertal children is a form of psychosocial treatment that aims to reduce gender dysphoria, but with the likely consequence of subsequent (lifelong) biomedical treatments as well (gender-affirming hormonal treatment and surgery). Gender social transition of prepubertal children will increase dramatically the rate of gender dysphoria persistence when compared to follow-up studies of children with gender dysphoria who did not receive this type of psychosocial intervention and, oddly enough, might be characterized as iatrogenic. Parents who bring their children for clinical care hold different philosophical views on what is the best way to help reduce the gender dysphoria, which require both respect and understanding.
As Zucker points out, prepubertal social transition may dramatically increase the persistence of GD, warning that this could be characterized as an iatrogenic intervention. Similarly, Kaltiala, who has overseen transition processes for adolescents in Finland since 2011, does not view the social affirmation of children with GD as an act of kindness but rather as a powerful intervention with the potential to cause iatrogenic harm to a young person’s psychosocial development. According to her, affirming a child’s social transition by using their preferred name and pronouns is not a "neutral act." Instead, it is a significant intervention that turns what would otherwise likely be a temporary phase into a fixed mental state or "identity," solidifying it and leading the underage child toward medication/hormones and surgical procedures.Footnote1 As an expert who has managed this process and witnessed its outcomes, Kaltiala states, “Gender-affirming care is dangerous. I know because I helped pioneer it.” (Kaltiala, Citation2023).
A study by Olson et al. (Citation2022) supports the predictions of Kaltiala and Zucker. In follow-ups conducted five years after affirmation and social transition, the rate of desistance was only 6%, with 94% continuing to live as transgender, and nearly two-thirds undergoing medical transition with puberty blockers or sex hormones. In other words, while approximately one in ten children with GD followed without social transition continued to live as transgender, nine out of ten children with GD who were socially transitioned continued to live as transgender. Consistent with Kaltiala and Zucker’s predictions, the rate of persistent GD increased dramatically (by ninefold), with around two-thirds of cases using hormones.
Furthermore, the children in Olson et al.’s study did not even meet the DSM-5 diagnostic criteria for Gender Dysphoria in Children—it was not assessed whether the participants met these criteria. The children’s gender was identified not based on their sex assigned at birth but rather their gender, as reported at their initial visits. In other words, the parents had already labeled their children explicitly as "transgender" and supported their social transition, while the professionals conducting the research affirmed and reinforced this, effectively directing the children toward an inevitable medical pathway. The children were not provided with alternative options or ways to conceptualize their feelings throughout the study.
As observed in the study by Olson et al., cases of GD that might otherwise resolve during active follow-up but persist (iatrogenically) due to social transition could be labeled as “iatrogenic GD.” Is there a new clinical form of GD that we could classify under the term "Iatrogenic Gender Dysphoria"? If so, what are its characteristics? While we cannot yet answer these questions—since specific studies are needed to determine whether such a clinical form can be defined and, if so, what its characteristics might be—we can assert that iatrogenic factors have played a significant role in the dramatic increase in adolescent GD cases observed in recent years. This is because, nowadays, it has become the norm for children with GD to have undergone social transition (Cass, Citation2024). Steensma and Cohen-Kettenis (Citation2011) reported that, before the year 2000, very few prepubertal children desired social transition, but this number gradually increased over the following years and has recently surged dramatically.
Before the year 2000, only 2 (1.7%) prepubertal boys out of 112 referred children to the Amsterdam gender identity clinic were living completely in the female role. Between 2000 and 2004, 3.3% (4 out of 121 children; 3 boys and 1 girl) had completely transitioned (clothing, hairstyle, change of name, and use of pronouns) when they were referred, and 19% (23 out of 121 children; 9 boys and 14 girls) were living in the preferred gender role in clothing style and hairstyle but did not announce that they wanted a name and pronoun change. Between 2005 and 2009, these percentages increased to 8.9% (16 out of 180 children; 10 boys and 6 girls) and 33.3% (60 out of 180, 17 boys and 43 girls), respectively (Steensma & Cohen-Kettenis, Citation2011).
Today, it has become the norm in most Western countries (or internationally) for many children and adolescents to present to gender clinics having already undergone full or partial social transition (Cass, Citation2024). Given that this significantly increases the persistence rate of GD (Olson et al., Citation2022; Steensma et al., Citation2013; Zucker, Citation2020), we could classify these cases as “iatrogenic GD.” Even if we do not adopt this classification, we could at least describe them as “GD influenced by iatrogenic factors” or “GD persisting due to iatrogenic factors.” As noted by authorities like Kaltiala (Citation2018) and Zucker (Citation2020), the determining factor here (social transition and affirmation) can be characterized as iatrogenic.
To the best of my knowledge, the term "iatrogenic gender dysphoria" was first used in the literature by Wise and Lucas (Citation1981) in their case report titled “Pseudotranssexualism: iatrogenic gender dysphoria.” However, they did not use the term in the sense I am employing here. Instead, they used it to describe the emergence of gender dysphoria in a 32-year-old homosexual woman undergoing therapy for depression, discussing the role of eroticized transference in this context. They applied the term in the sense of “pseudotranssexualism” and as a complication of therapy.
The role of puberty blockers
Puberty blockers (PB) may have played a role in the increase in gender dysphoria (GD) cases. As previously mentioned, when GD cases are left to their natural course or provided with partial psychosocial support, approximately 90% of cases resolve, with a persistence rate of around 10%. In today’s diverse GD cases, some resolve without treatment (Singh et al., Citation2021; Steensma et al., Citation2013). In other words, only one in ten GD cases followed naturally or with partial support becomes transgender. In contrast, children and adolescents with GD who are placed on PB almost inevitably start using the opposite sex hormone, with nearly all of them (98-100%) becoming transgender (Brik et al., Citation2020; Carmichael et al., Citation2021; de Vries et al., Citation2011).
This data suggests that, like social transition, medical transition may have iatrogenically increased the persistence of GD. Additionally, PB has other negative physical and mental health consequences. PB does not improve the mental health of individuals with GD (Carmichael et al., Citation2021) and adversely affects bone, brain, and phallus development, fertility, and sexual function. It also disrupts the psychological maturation, relationships, and natural gender identity development of young individuals (Cohen-Kettenis et al., Citation2008; Giovanardi, Citation2017; Lemma, Citation2020). PB leads to a decline in bone mass accumulation, slower growth rates, increased fat mass, and halted maturation of sperm and oocytes (Betsi, Citation2024). It also has sex-specific negative effects on cognitive and behavioral functions (neurodevelopment), with no evidence suggesting these effects are reversible (Baxendale, Citation2024).
The method known as the Dutch Protocol is based on two studies: a 2011 study that reported on 70 cases of puberty suppression using gonadotropin-releasing hormone analogs (GnRHa) in individuals aged 12 to 16 with GD (de Vries et al., Citation2011), and a 2014 study that reported on cases where testicles and ovaries were removed at age 18 (de Vries et al., Citation2014). In the 2011 study, which lacked a control group, de Vries et al. reported significant improvements in behavioral and emotional problems, depressive symptoms, and overall functioning during PB, with no changes in anxiety or anger. No changes were observed in gender dysphoria or body satisfaction. None of the adolescents discontinued puberty suppression, and all proceeded to cross-sex hormone therapy, the first step of gender transition.
These two studies defining the Dutch model have been criticized by some authors for methodological biases and are argued to be insufficient as evidence (Abbruzzese et al., Citation2023). According to these authors, the research suffers from three major methodological biases: (1) participant selection ensured only the most successful cases were included; (2) the "resolution of gender dysphoria" finding was due to a reversal in the scoring of the questionnaire used; (3) concurrent psychotherapy made it impossible to separate the effects of this intervention from hormones and surgery.
These authors also highlight the problem of "spin" in clinics actively performing hormonal and surgical interventions, where weak or negative results are presented as definitive and positive. They stress the need for objective systematic reviews in gender medicine and for young people and their parents to be informed about these issues. Furthermore, there are serious concerns regarding informed consent for gender transition in adolescents. The field tends to exaggerate known benefits while downplaying serious health risks and uncertainties (Levine et al., Citation2022).
Researchers have shown that there are significant issues with the data in these studies, including the exclusion of many who regretted transitioning or changed their minds. One patient died from complications related to genital transition surgery (Kaltiala, Citation2023). Despite this, the method was widely applied in the U.S. and Europe for nearly a decade. However, since 2020, citing “the lack of expected mental health benefits, insufficient evidence, and unknown long-term outcomes,” it has been banned or restricted in over 20 U.S. states and some European countries that pioneered its implementation. Its use is now limited to clinical research with control groups, with psychotherapy recommended as the primary approach (Block, Citation2023; Sinai & Sim, Citation2024).
The first warnings about the Dutch model came from Kaltiala-Heino et al. (Citation2015), as young people treated with this model were not improving; their lives were worsening instead. In an article titled "I knew others were making the same observations at their clinics, and I hoped my paper would spark discussion about their concerns—that’s how medicine corrects itself. But our field, instead of acknowledging the problems we described, became more committed to expanding these treatments" published in The Free Press, Kaltiala (Citation2023) writes:
Even during the first few years of the clinic, gender medicine was becoming rapidly politicized. Few were raising questions about what the activists—who included medical professionals—were saying. And they were saying remarkable things. They asserted that not only would the feelings of gender distress immediately disappear if young people start to medically transition, but also that all their mental health problems would be alleviated by these interventions. Of course, there is no mechanism by which high doses of hormones resolve autism or any other underlying mental health condition.
Soon after our hospital began offering hormonal interventions for these patients, we began to see that the miracle we had been promised was not happening. What we were seeing was just the opposite… The young people we were treating were not thriving. Instead, their lives were deteriorating. We thought, what is this? Because there wasn’t a hint in studies that this could happen. Sometimes the young people insisted their lives had improved and they were happier. But as a medical doctor, I could see that they were doing worse. They were withdrawing from all social activities. They were not making friends. They were not going to school. We continued to network with colleagues in different countries who said they were seeing the same things.
Because what the Dutch had described differed so dramatically from what I was seeing in our clinic, I thought maybe there was something unusual about our patient population. So I started talking about our observations with a network of professionals in Europe. I found out that everybody was dealing with a similar caseload of girls with multiple psychiatric problems. Colleagues from different countries were confused by this, too. Many said it was a relief to hear their experience was not unique.
But no one was saying anything publicly. There was a feeling of pressure to provide what was supposed to be a wonderful new treatment. I felt in myself, and saw in others, a crisis of confidence. People stopped trusting their own observations about what was happening. We were having doubts about our education, clinical experience, and ability to read and produce scientific evidence (Kaltiala, Citation2023).Footnote2
After being widely implemented for about 10 years, the Dutch model began to be abandoned in some European countries such as Finland, the UK, Sweden, Norway, Denmark, and Italy; however, it is still applied in other countries (Sinai & Sim, Citation2024).
One of the pioneering countries that banned the method, citing "insufficient evidence to support its clinical effectiveness and safety as a routine treatment," was the UK. The basis for this decision was the systematic review conducted by Dr. Hilary Cass (at the request of the National Health Service), which lasted four years and included thousands of interviews and seven systematic reviews. The interim report was released in July 2022, and the final report was published in April 2024 (Cass, Citation2024). Similarly, the UK’s Tavistock Clinic, which was a pioneer in gender-affirming care, showed in 2021 that there was no detectable improvement in the mental health of adolescents who were treated with puberty blockers and followed for up to three years (Carmichael et al., Citation2021). The Commission on Human Medicines (CHM) also issued an independent expert opinion stating that prescribing puberty blockers to children currently posed an unacceptable safety risk and recommended indefinite restrictions to ensure safety for children and adolescents. Based on these reports and the Cass review, the NHS stopped routinely prescribing puberty blockers for gender dysphoria in individuals under 18 in March 2024. The UK now bans puberty blockers for new gender dysphoria cases, unless prescribed under a research protocol, and promotes a holistic approach emphasizing psychological assessment and support (Cass, Citation2024).
A systematic review conducted at the Karolinska Institute in Sweden also examined the effects of hormone treatment on psychosocial and mental health, cognition, body composition, and metabolic markers, and concluded that there was insufficient evidence in this regard (Ludvigsson, Citation2023).
Based on these findings, national health authorities in Sweden, Norway, Finland, and Denmark have also banned puberty blockers and adopted treatment guidelines that prioritize psychosocial interventions, such as psychodynamic psychotherapy, as the first-line treatment for GD (Sinai & Sim, Citation2024). Similarly, in November 2024, Italy joined the list of countries banning puberty blockers for GD. The Italian National Bioethics Committee declared that puberty blockers in GD cases should only be used after mental health interventions fail and only within the context of appropriate research trials.Footnote3 Although France has not yet banned puberty blockers for GD, the National Academy of Medicine issued a statement of "the highest level of caution" ("la plus grande réserve") on their use and recommended prioritizing psychotherapy.Footnote4 A similar trend is observed in the United States; in 2023, the number of states banning medical transition for minors was approximately 20 (Block, Citation2023). This number had risen to 25 in 2024, and now in 2025, it has been banned in all states by a presidential decree.Footnote5
In fact, the long-term outcomes of the method have been unknown from the beginning, and there was insufficient evidence; the published studies were numerically inadequate, small-scale, uncontrolled, and short-term, making it impossible to draw reliable conclusions about effectiveness and safety (Betsi, Citation2024). Nevertheless, this method has been widely applied for nearly 10 years. In other words, risky experiments were conducted on children with gender dysphoria, leading to iatrogenic harm. Indeed, Finland’s national medical authority COHERE, in its 2020 report, stated that studies praising the success of the gender-affirming model were biased and unreliable—systematically so in some cases—and said, "In light of the current evidence, gender change in minors is an experimental practice."Footnote6
However, this model is unfortunately still applied in some countries; in other words, experiments on minors continue. Yet, the Dutch model presents significant risks, and it cannot be applied during a time when the number and diversity of cases are increasing (Abbruzzese et al., Citation2023; Levine et al., Citation2022). Today, both the number and diversity of GD cases are growing (Zucker et al., Citation2016), the epidemiology of GD is changing—for example, GD is increasing more rapidly in those who are biologically female (Kaltiala, Citation2023; Kaltiala-Heino et al., Citation2015; Sun et al., Citation2023)—and there are new clinical forms of GD believed to be internet-originating that start during adolescence (Littman, Citation2018). Additionally, the frequency of psychiatric difficulties among young people with GD and the prevalence of psychiatric comorbidities are rising (Abbruzzese et al., Citation2023; Kaltiala et al., 2023; Kaltiala-Heino et al., Citation2015; Zucker, Citation2019).
These data show that pubertal blockade (PB) is not an appropriate method in a significant portion of today’s GD cases. Nevertheless, it has been applied for over 10 years to thousands of children and is still in practice. In a large portion of these children and adolescents—at least in some of them—GD likely persisted due to this method, meaning these children became transgender due to this model. They were/are condemned to a series of invasive surgeries and hormones they will use for life (and their side effects) due to iatrogenesis.
Gender affirming surgery and iatrogenic harm cycle
The primary justification put forward for gender-affirming surgery (GAS) is the improvement of mental health (Coleman et al., Citation2022). However, there is no definitive evidence to support this claim. Not only does GAS fail to improve mental health issues (Bränström & Pachankis, Citation2020; Jensen et al., Citation2016; Lindqvist et al., Citation2017), but in approximately one-fifth of cases, it further worsens mental health (Robinson et al., Citation2021). Additionally, it causes significant harm by leading to permanent loss of organs, tissues, and functions. Individuals who undergo GAS lose reproductive function completely (in gonadectomy) and significant sexual function, while between one-third and three-fourths of cases also experience damage to urinary function (Bayraktar, Citation2025; Horbach et al., Citation2015; Veerman et al., Citation2020; Wang et al., Citation2022).
GAS increases somatic and psychiatric morbidity and mortality, and decreases quality of life and life expectancy (Kuhn et al., Citation2009; Simonsen et al., Citation2016). According to a study examining nearly all trans individuals who underwent GAS in Denmark between 1978 and 2010, the average life expectancy in Denmark is 81.9 years for women and 78 years for men, while the average age of death in the GAS group was 53.5 years (Simonsen et al., Citation2016).
Changing the healthy anatomic and physiologic body to conform to a current form of gender identity flies in the face of a 2500-year-old principle, Above All Do No Harm (primum non nocere). This time-honored guidance remains relevant since there are many indicators that the long-term outcomes bring sterility, sexual dysfunction, reduced stable pair bonding, substance abuse, and shortened life expectancy to many (Hembree et al., Citation2017; Jackson et al., Citation2023; Levine, Citation2024; Newcomb et al., Citation2020).
Detransitioners as evidence of iatrogenic harm
In recent years, there has been a notable increase in the number of detransitioners (Cohn, Citation2023; Dolotina & Daniolos, Citation2023; Exposito-Campos, Citation2021; Gribble et al., Citation2023; Hall et al., Citation2021; Irwig, Citation2022; Jorgensen, Citation2023a,Citation2023b; Kaltiala et al., Citation2024; Littman, Citation2021; Littman et al., Citation2024; MacKinnon, Citation2022; MacKinnon et al., Citation2021, Citation2022; Citation2023a, Citation2023b; Marchiano, Citation2021; Pullen Sansfaçon et al., Citation2023; Sanders et al., Citation2023; Turban et al., Citation2021; Vandenbussche, Citation2022). The 2015 U.S. Transgender Survey reported that 13.1% of the 17,151 respondents had later regretted their transition, listing the following reasons: parental pressure (35.6%), community or societal stigma (32.5%), difficulty finding work (26.9%), and at least one “internal driving factor” such as fluctuations or uncertainty regarding gender identity (16%) (Turban et al., Citation2021). It is particularly striking that in about one-sixth of the cases, an “internal driving factor” was identified in this study.
Irwig (Citation2022) defines detransition as an "increasing and increasingly complex phenomenon." Jorgensen (Citation2023a) states that while the exact rate of detransition is not known, it is increasing and is expected to continue to rise. According to Jorgensen, the probable reasons for the increase in the number of detransitioners (and its expected future rise) include: Studies that report low detransition rates generally come from an older era, when hormonal treatment and surgeries were only performed under strict protocols. Nowadays, however, the protocols are much more flexible, and individuals who have not yet completed puberty (i.e., minors) make the decision to transition. Therefore, dramatic increases in detransition rates can be expected in the coming years. In the past, it was recommended to determine whether gender-related distress was secondary to other mental health problems or sociocultural factors, and comprehensive psychological assessments were advised for this purpose. However, nowadays, due to transgender advocacy, this sensitivity and care are viewed as unnecessary medical "babysitting" and are not carried out (Coleman et al., Citation2022; Jorgensen, Citation2023a).
In a study conducted by Littman (Citation2021), the reasons for detransition were identified as follows: feeling more comfortable identifying with their biological sex (60%); concerns about potential medical complications related to transition (49%); coming to the conclusion that gender dysphoria was caused by trauma, abuse, or mental health issues (38%); difficulty accepting oneself as lesbian, gay, or bisexual (23%); and experiencing discrimination (23%). A key finding in Littman’s study documenting iatrogenic harm during the transition process is that the majority of participants (55%) felt they were not adequately informed by a doctor or mental health professional before starting the transition. Another important finding was that although all participants in the study were detransitioners, only 24% of them had informed their doctor or clinician that they had decided to detransition. This means that more than three-quarters of detransitioners did not inform their doctor about their decision (Littman, Citation2021). This is because detransitioners are excluded from the LGBTQ community and face difficulties finding doctors. A study by Vandenbussche (Citation2022) showed that detransitioners reported a general lack of support, along with numerous negative experiences from the medical and mental health systems and the LGBTQ community. Most detransitioners shared that they lost support from the LGBTQ community and friends after abandoning their transition, experienced negative interactions with medical professionals, struggled to find a therapist who was familiar with detransition, and faced general social isolation after their transition (Vandenbussche, Citation2022).
Studies conducted by MacKinnon et al. also provide evidence supporting these findings (MacKinnon, Citation2022; MacKinnon et al., Citation2021, Citation2022; Citation2023a, Citation2023b). This situation exacerbates or highlights feelings of anger, grief, and regret among detransitioners. Indeed, in a study by Pullen Sansfaçon et al. (Citation2023) with detransitioners who underwent social, medical, or legal transition, it was found that 60% of participants experienced significant negative emotions such as regret and grief. This rate was even higher among those who underwent medical and legal transitions, and a quarter of the sample showed a new form of body dysphoria, with extreme dissatisfaction with the bodily changes caused by transition.
Jorgensen (Citation2023a) considers the existence of detransitioners as evidence that “cracks in the gender-affirming care model can no longer be ignored,” and interestingly, she describes detransitioners as “survivors of iatrogenic harm” who should be acknowledged as such and provided with the personalized medication and support they need. Detransitioners can truly be defined as individuals who both provide concrete evidence of iatrogenic harm during the transition process and have escaped the maximum iatrogenic harm of this process. This is because the maximum iatrogenic harm during the transition process, as observed in some cases, occurs in gender-affirming surgery (GAS) procedures, which also mandate lifelong hormone use. GAS may represent one of the greatest systematic iatrogenic harms in medical history, as these procedures—characterized by their extensive outcomes—are systematically implemented under current guideline recommendations. In cases involving orchiectomy and oophorectomy, reproductive function is irreversibly lost. Furthermore, urogenital deterioration leads to the near-total loss of sexual function, while urinary function is impaired in approximately one-third to half of all cases. Despite these invasive interventions, GAS does not result in significant mental health improvements (Bränström & Pachankis, Citation2020; Jensen et al., Citation2016; Lindqvist et al., Citation2017), and severe urogenital harm remains a common outcome (Bayraktar, Citation2025; Horbach et al., Citation2015; Veerman et al., Citation2020; Wang et al., Citation2022).
There is no justifiable reason (medical indication) based on a risk-benefit analysis for GAS, and the medical evidence on this issue is of low or very low quality. According to the "Grading of Recommendations, Assessment, Development and Evaluations (GRADE)" system defined by Guyatt et al. (Citation2008), medical evidence is categorized into four levels: strong, moderate, low, and very low. According to this classification, nearly all recommendations for gender-affirming treatments are based on "low" or "very low" quality evidence. The only area that reaches "moderate" quality is related to negative medical outcomes (Hruz, Citation2020). This also applies to hormonal treatments such as puberty blockers and cross-sex hormone use. In two systematic reviews conducted by Miroshnychenko et al. (Citation2025a,Citation2025b), which included Guyatt, who defined the GRADE system, the authors noted that the existing research provided "very low certainty" evidence almost entirely in both papers, and concluded that there was "substantial uncertainty" regarding the effects of each intervention. Specifically, regarding hormone therapy, they concluded that "the possibility of benefit or harm cannot be ruled out," and they identified only one research finding that reached a "high certainty" level, which was related to adverse cardiovascular outcomes. The relevant cohorts (Getahun et al., Citation2018; Nota et al., Citation2019) show that transgender women using hormones have higher adjusted incidences of stroke and venous thromboembolic events compared to reference women and men, and both transgender women and men have a higher risk of myocardial infarction compared to reference women.
Exaggerated claims, hypocritical narratives, and the placebo effect
Another factor supporting iatrogenesis is the misleading information provided by some clinicians regarding gender affirmative treatment (GAT); while the benefits and certainty of GAT are exaggerated, its risks are insufficiently presented, and alternative treatment options are disparaged (Clayton et al., Citation2023a, Citation2023). For example, some GAT clinicians acknowledge in peer-reviewed publications in academic journals that there is a lack of empirical evidence and critical gaps in knowledge (Olson-Kennedy, Citation2019), emphasizing the need for more evidence for this relatively new treatment approach (Tollit et al., Citation2019). However, the same clinicians exaggerate the certainty of the benefits of GAT in their public communications directed at young people with gender dysphoria (GD), the public, and policymakers, and offer insufficient discussions on the risks (Clayton et al., Citation2023, Citation2023); for instance, GATs are described in such communications as " absolutely life-saving" (Olson-Kennedy, Citation2015) and “robust scientific research” (Telfer, Citation2019). This hypocritical narrative misleads young people with GD, their families, and policymakers. While there is a more realistic narrative in peer-reviewed journals and the research community that highlights uncertainty and a lack of evidence, public communications offer an unrealistic narrative. This narrative exaggerates the certainty of benefits and the strength of evidence, thus amplifying the placebo effect (Clayton et al., Citation2023). In fact, exaggerated narratives about GAT are also observed in peer-reviewed publications. Indeed, in recent years, several publications that made overly exaggerated claims about GAT have necessitated corrections due to these exaggerated claims (Bränström & Pachankis, Citation2020; Pang et al., Citation2021; Zwickl et al., Citation2021).
Exaggerated narratives about GAT can increase the placebo and nocebo effects. There is a problematic tension between the research and clinical agendas of child and adolescent gender clinics (Clayton et al., Citation2023). GAT is provided by clinicians in a clinical setting that maximizes the placebo effect, and the same clinicians are investigating the effectiveness of GAT in the same clinical setting. This situation is particularly risky for both clinicians and patients, especially when double-blind randomized controlled trials (DBRCT) are not conducted, and this risk exists in studies on GAT; because, to date, no study on GAT has been a DBRCT study (Cass, Citation2024; Clayton et al., Citation2023).
The treatment ritual and the encounter between the patient and the clinic is a powerful psychosocial event. Clinicians, particularly doctors, are designated healers, and their prestige, status, and authority help promote patients’ trust and expectations of relief from pain (Benedetti, Citation2021; Clayton et al., Citation2023). This situation, which enhances the placebo effect, may be suitable for a clinical environment, but it is far from ideal for treatment efficacy research, especially when DBRCTs are not possible and RCTs are not conducted (Clayton et al., Citation2023). A placebo-effect-enhancing clinical setting, in which warm and empathic clinicians provide supportive and attentive health care, creates a "therapeutic bias" in patients, giving them hope and expectation of improvement. This is "legitimate" as long as it is done without deception and in a manner consistent with informed consent, trust, and transparency (Clayton et al., Citation2023; Kaptchuk & Miller, Citation2015). However, the legitimacy of this in GAT clinics can be debated. The question of how the entire ethical environment of GAT clinics and the media/social media atmosphere can affect young patients and their families, and how it may undermine their capacity for true informed consent, is important. A proper informed consent process can both prepare parents and patients for the difficult choices that they must make and can ease professionals’ ethical tensions. Even when properly accomplished, however, some clinical circumstances exist that remain quite uncertain (Levine et al., Citation2022).
Informed consent is a cornerstone of modern medical ethics, requiring clinical honesty and transparency. Clinical professionals who deceptively use placebo treatments do not fulfill this requirement (Barnhill, Citation2012; Kaldjian & Pilkington, Citation2021). If a medical profession fails to distinguish placebo effects from specific treatment effects, it becomes little different from the quackery and pseudo-science of the past (Benedetti, Citation2021; Clayton et al., Citation2023). Ten-year-old children, who lack the capacity for informed consent, are likely starting a treatment process that will render them infertile, impair their urogenital function, and cause significant health issues; this creates complex biological ethical dilemmas (Baron & Dierckxsens, Citation2022; Clayton et al., Citation2023). Therefore, there is a need for strong evidence showing that GAT is truly effective for the claimed significant mental health outcomes and that there are no less harmful alternatives; however, such evidence does not exist for GAT (Cass, Citation2024; Miroshnychenko et al., Citation2025a, Citation2025b).
Another topic with exaggerated narratives is the increased suicidal tendencies in GD. Every adolescent with increased suicidal tendencies or at risk of suicide should, of course, be carefully assessed and managed by professional mental health experts. However, there is an exaggerated narrative about suicide risk in GD cases, and this is dangerous; clinicians and the media’s excessive focus on this exaggerated suicide risk narrative can create a harmful nocebo effect (for example, it could create a “self-fulfilling prophecy” effect) and may worsen suicidal tendencies in these vulnerable young individuals (Biggs, Citation2022; Clayton et al., Citation2023).
The overly negative depiction of alternative treatment options
The previous common practice was to provide only psychosocial care to young people with GD under the age of 18 or 21 (Clayton et al., Citation2023; Smith et al., Citation2001). However, this was largely replaced by GAT, which involves hormonal and surgical interventions (Coleman et al., Citation2022). Recent systematic reviews, however, have shown that the evidence related to GAT has ‘very low certainty,’ the evidence regarding the appropriate management of GD in youth has ‘substantial uncertainty,’ and there are significant gaps in knowledge (Cass, Citation2024; Miroshnychenko et al., Citation2025a,Citation2025b).
Clinicians advocating for GAT tend to frame any non-“gender affirmative” treatment approach as harmful, ineffective, and unethical, and sometimes equate psychotherapeutic approaches with “conversion” practices (Ashley, Citation2023). However, some clinicians argue that there are a number of contemporary therapeutic approaches that are “gender affirmative” and not “conversion” practices (D’Angelo et al., Citation2021; Sinai & Sim, Citation2024; Zucker, Citation2019). These non-“gender affirmative” approaches, which should not be considered as conversion therapy, may include: careful assessment and diagnostic formulation, appropriate treatment of co-existing psychological conditions, supportive and educative individual/family psychological care, group therapy, developmentally informed gender exploratory psychotherapy, trauma-informed psychotherapy, and a non-promotion of early childhood social transition (sometimes labeled under the umbrella term of “watchful-waiting,” which should not be interpreted as “doing nothing”) (Clayton et al., Citation2023; D’Angelo et al., Citation2021; de Vries & Cohen-Kettenis, Citation2012; Hakeem, Citation2012; Kozlowska et al., Citation2021; Lemma, Citation2021; Sinai & Sim, Citation2024). In all cases, an initial comprehensive psychiatric evaluation (CPE) should be conducted. The purpose of the CPE is to prepare the patient, their parents, and their psychotherapist regarding what needs to be done to improve the mental health of young people (Levine, Citation2024). The CPE is sometimes described as a psychodynamically informed detailed case formulation. Despite this essential disagreement, almost all clinicians agree that a CPE is the necessary first step to considering how to respond to parents and their transgender-identified offspring. Twenty-three treatment guidelines published since 1998 from 12 countries share this agreement. Indeed, in both the United States and Europe, new guidelines in both continents emphasize that for patients with gender dysphoria/incongruence, the first line of treatment should be sufficient psychotherapy attempts by mental health professionals before considering medical intervention (Cass, Citation2024; Drobnič Radobuljac et al., Citation2024).
It should be noted that psychotherapeutic approaches for this patient group are also based on limited evidence. However, they seem to at least have this advantage: These ethical psychological approaches do not have the negative risk profiles associated with hormonal and surgical treatments (Baron & Dierckxsens, Citation2022). The unfairly negative depiction of these contemporary psychotherapeutic approaches could create nocebo effects and weaken the possibility of providing this ethical care to young people with GD (Clayton et al., Citation2023; Kozlowska et al., Citation2021).
The role of academic pressure in iatrogenesis
Academic pressures that restrict academic freedom may also play a role in iatrogenesis involved in the development of GD and in the iatrogenic harm cycle surrounding GD cases (Kaltiala, Citation2023). Our medical practices should be based on evidence, not ideological views or cultural beliefs. However, the experiences shared by Kaltiala (Citation2023) show that this principle is violated in gender medicine practices. Researchers are unable to present evidence showing that the gender affirming care model is harmful, as they are labeled as transphobic, face disproportionate reactions, and are suppressed when they do so. Some advocates of this model appear to adopt an ideological approach rather than a scientific one. This limits academic freedom and hinders open discussion. Such a situation is unacceptable, as it occurs only in cult-like structures or dogmatic schools, not in scientific disciplines.
This structure in the field of gender medicine primarily harms individuals with GD because it blocks research aimed at developing better care models in physical and mental health that they need, thus preventing GD individuals from accessing optimal healthcare. In short, this structure contributes to the iatrogenic increase of GD (iatrogenesis) and the iatrogenic harm cycle in GD cases.
Breaking this harm cycle in GD cases and minimizing the resulting complications is primarily the responsibility of the specialists performing these procedures. As relevant specialists and researchers, we must fight against academic pressures contributing to this iatrogenesis and engage in evidence-based discussions on these issues freely. It is encouraging to see the existence of brave authors who have managed to do this despite all the restrictions (Halasz & Amos, Citation2024; Jorgensen, Citation2023a; Kaltiala, Citation2023). We must all contribute courageously to this process, as healthcare professionals, we cannot escape our ethical and clinical responsibilities.
Gender medicine requires the careful and thoughtful application of clinical evaluation, a thorough review of the available data, and also a willingness to change practice in response to new evidence. Researchers in this field must dedicate themselves to conducting solid research, challenging fundamental assumptions, examining patterns of practice, and embracing discussion (Jorgensen, Citation2023a).
Recommendations
These data show that iatrogenesis plays a role in the increase of GD cases. In the gender-affirming care model, early social and medical transitions not only increase the number of GD cases but also cause harm during the medical and surgical treatment processes of these cases. In GD cases, an iatrogenic harm cycle is forming.
It seems that academic pressures, along with political and ideological factors, prevent the explanation of the negative outcomes of medical and surgical transitions, thereby contributing to the harmful cycle surrounding gender dysphoria cases. Breaking this harm cycle is primarily the responsibility of specialists working in the field of gender medicine. This harm can only be minimized through the ethical and scientific approaches of these specialists. This attitude should not be limited to adopting a more cautious approach in medical practices; it should also involve being sensitive to academic and social pressures and encouraging health professionals to freely engage in evidence-based discussions.
There is a need for more objective systematic reviews in the field of gender medicine. As shown by some recent systematic reviews (Cass, Citation2024; Miroshnychenko et al., Citation2025a,Citation2025b), more emphasis should be placed on the lack of evidence in this area and the ‘very low certainty’ of the evidence. Serious health risks and uncertainties should not be underestimated, known benefits should not be exaggerated, and the common ‘spin’ issues in studies related to gender affirming care should be addressed; thus, young people with GD and their parents should be accurately informed about these matters (Levine et al., Citation2022).
In this context, the first task seems to be increasing professional awareness and fostering discussion (Clayton et al., Citation2023). Reviews conducted by independent experts, who are not currently involved in clinical practice and research in this field and thus minimize the risks of emotional distance and intellectual conflict, could provide valuable suggestions for further research and clinical strategies. The UK’s Cass Review is an example of such an approach (Cass, Citation2024). Clinical experts should provide measured and honest explanations to patients, families, policymakers, and the public about the evidence available for the benefits of Gender-Affirming Treatment (GAT) and clarify that there is no conclusive evidence on this matter. Additionally, they should also explain the placebo effects, not only in the limitations section of research papers but also in public statements. Clinical experts should not only share success stories but also the realistic, positive experiences of individuals with GD who have chosen not to transition or have postponed it until they feel more ready. They should also include the narratives of patients who have benefited from ethical psychological approaches, as well as the stories of individuals who have faced negative outcomes from transitioning. Detransition, regret, harm caused by transition, and surgical complications must be recognized as significant risks and openly communicated to the public (Clayton et al., Citation2023).
Conclusions
In conclusion, iatrogenesis plays a role in the increase of GD cases, and an emerging group of cases can be described as ‘iatrogenic gender dysphoria’ due to early social and medical transitions. It also causes harm in the medical and surgical treatment of GD, thereby creating an iatrogenic harm cycle in these cases. Issues such as ‘spin’ in publications related to GAC, pressures that restrict academic freedom, and political influences also contribute to this harm cycle.
Breaking this harm cycle requires fundamental changes in the attitudes of healthcare professionals and the adoption of stronger ethical principles. Successfully managing this process will not only fulfill clinical responsibilities but will also promote evidence-based practices, ensure that GD cases receive better healthcare, and minimize the harm caused by current treatment protocols.
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