Introduction
In our paper, “Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults” (Levine, Abbruzzese, & Mason, 2022), we asserted that the consent process for youth gender transition is so problematic in much of the Western world that it can no longer be considered “informed.”
We reflected on how far the entire field of gender medicine has drifted from the principles of evidence-based medicine and the scientific method. Attempts to study the sharp rise of gender dysphoria in previously gender-normative teens (Bradley, 2022; Littman, 2018) are met with consternation by the gender-medicine establishment (World Professional Association for Transgender Health [WPATH], 2018). The significant rate of problematic adaptations, psychiatric symptoms, and self-harm in this youth cohort (Becerra-Culqui et al., 2018; de Graaf, Giovanardi, Zitz, & Carmichael, 2018; de Graaf et al., 2021; Kaltiala-Heino, Sumia, Työläjärvi, & Lindberg, 2015; Kozlowska, Chudleigh, McClure, Maguire, & Ambler, 2021; Strang et al., 2018; Thrower, Bretherton, Pang, Zajac, & Cheung, 2020) is explained away as merely manifestations of minority stress, with unsubstantiated claims that these mental health problems will resolve with gender transition—and only with gender transition. Efforts to help the distressed teens psychotherapeutically, which is the standard approach for all other types of psychiatric symptoms, are stigmatized as conversion therapy. The growing evidence of detransition, apparent in recent data (Boyd, Hackett, & Bewley, 2021; Hall, Mitchell, & Sachdeva, 2021; Roberts, Klein, Adirim, Schvey, & Hisle-Gorman, 2022), is either dismissed or recast as a benign gender journey (Turban, Loo, Almazan, & Keuroghlian, 2021), and the reports of regret by many of the detransitioners themselves are ignored (Littman, 2021; Vandenbussche, 2022). Perhaps most problematic, the information shared by gender clinicians with patients and families about “gender-affirming” interventions is markedly skewed: it overstates the demonstrated benefits of hormones and surgeries and trivializes their risks and the uncertainties of future outcomes.
Our critical ethical evaluation also included proposed solutions. We suggested that clinicians familiarize themselves with the difference between the classical early-onset of cross-sex identification, which typically spontaneously resolves before adulthood (Ristori & Steensma, 2016; Singh, Bradley, & Zucker, 2021), and the novel presentation of youth with postpubertal onset of gender dysphoria and a much wider range of gender identities, for whom the outcomes are unknown. We suggested that rather than merely deferring to their medical societies’ wholesale adoption of “gender-affirmative” guidelines from the gender medicine establishment, clinicians would benefit from scrutinizing the unconvincing results from key studies. We implored clinicians to slow down and engage patients and families in thorough and thoughtful discussions not only of the possible benefits but also the significant risks and uncertainties inherent in a medically dependent lifetime.
The editor invited four respected academicians to write commentaries (Balon, 2022; Clayton, 2022; Drescher, 2022; de Vries, 2022). Two agreed that current trends are problematic and must be addressed to safeguard youth from harm (Balon, 2022; Clayton, 2022). Two disagreed, but in very different ways (Drescher, 2022; de Vries, 2022). Drescher took a decidedly civil rights-based perspective, arguing that while the evidence is low quality, ultimately, the principles of body autonomy should trump all other concerns. de Vries conceded that the evidence base for pediatric gender transition suffers from deficiencies but asserted that it is of sufficient quality to widely scale hormonal and surgical “gender-affirming” interventions.
Below, we provide our thoughts about the first three commentaries we received (Drescher, 2022; Clayton, 2022; Balon, 2022), starting with our response to Drescher. We have responded to de Vries (2022) in a separate forthcoming publication.
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