Some Limitations of “Challenges in the Care of Transgender and Gender-Diverse Youth:AnEndocrinolog"
There is significant disagreement about how to support trans-identified or gender-dysphoric young people. Different experts and expert bodies make strikingly different recommendations based upon the same (limited) evidence. The US-originating “gender-affirmative” model emphasizes social transition and medical intervention, while some other countries, in response to evidence reviews of medical intervention outcomes, have adopted psychological interventions as the first line of treatment. A proposed model of gender-affirming care, comprising only medical intervention for “eligible” youth, is described in Rosenthal (2021). Determining eligibility for these medical interventions is challenging and engenders considerable disagreement among experts, neither of which is mentioned. The review also claims without support that medical interventions have been shown to clearly benefit mental health, and leaves out significant risks and less invasive alternatives. The unreliability of outcome studies and the corresponding uncertainties as to how gender dysphoria develops and responds to treatment are also unreported.
There has been a rapid rise in reported cases of gender dysphoria and trans-identified youth in the last few years (de Graaf, Giovanardi, Zitz, & Carmichael, 2018; Cass, 2021; American College Health Association, 2021). Gender dysphoria (GD) is a distressing condition that requires compassionate care (American Psychiatric Association, 2020), but neither gender dysphoria itself nor what constitutes best care are well understood. Gender dysphoria appears to have many different etiological influences, with biological, cultural, social, and psychological factors, and a variety of pathways to resolution (several presentations and pathways are shown in Figure 1, reproduced from the Cass Interim Report [Cass Review, 2022a, page 57]). It has been suggested that many forms of gender dysphoria exist, including childhood onset which typically resolves and is associated with adult homosexual orientation (Ristori & Steensma, 2016; Singh, Bradley, & Zucker, 2021), a condition (paraphilia) observed in older men (Blanchard, 1989; Bailey & Blanchard, 2017), and other less-understood presentations that appear to be associated with comorbid mental illness, autism spectrum disorders, trauma, or other mental health issues (Bockting, Knudson, & Goldberg, 2006; Churcher-Clarke & Spiliadis, 2019; Evans & Evans, 2021; Evans, 2022; Lemma, 2018; Parkinson, 2014; Withers, 2020).
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