Waheed 00:39
Assalamu alaikom warahmatullahi ta’ala wabarakatuh, and welcome back to “A Way Beyond the Rainbow”, this podcast series dedicated to Muslims experiencing same-sex attractions who want to live a life true to Allah subhanahu wa ta’ala and Islam. I'm your host, Waheed Jensen, and thank you for joining me in today's episode. In today's episode, we continue our series on gender nonconformity, gender dysphoria, as well as transgenderism. And as you guys remember, in the last two episodes, Br. Mobeen Vaid and I spoke about gender nonconformity, gender atypical individuals and intersex, and in today’s episode, we will, inshaAllah, explore gender dysphoria and transgenderism from scientific and medical perspectives. Are there biological factors that cause transgenderism? What’s the history of gender transitioning? Is gender dysphoria one entity or are there different kinds of GD? What’s the genesis of gender dysphoria? How is it treated nowadays? And is the “affirmative model” healthy and appropriate? We will cover these questions and more today, inshaAllah.

Again, the focus of this episode is purely scientific and medical, so we will not talk about the trans movement from a sociopolitical perspective or discuss the religious and Shar’i perspectives related to gender transitioning, as all this will be covered in the upcoming episodes inshaAllah. The content of this episode is a product of more than two years of research that Br. Mobeen and I put together in the paper that we co-authored together, ““And the Male is Not Like the Female”: Sunni Islam and Gender Nonconformity (Part II)”, the link to which you will find in the episode description, along with other relevant resources and support groups as well for gender dysphoria.

02:27
Much like in the case of homosexuality, recent efforts have been made to implicate biological factors as the cause of transgenderism. Unlike homosexuality, however, the claim of a biological predisposition towards transgenderism has not been primarily anchored in appeals to genetic evidence or the pursuit of a “trans gene.” Though studies have been conducted examining possible genetic origins for transgenderism, the number of studies has been limited, at least relative to studies exploring genetic factors that possibly influence sexual orientation. Additionally, these studies have largely focused on MtF (male-to-female) subjects given the frequency of MtF transgenderism relative to their FtM (female-to-male) counterparts. Moreover, the results have largely been unexceptional or inconclusive due to a variety of factors, including small sample sizes, complications introduced by subjects receiving hormone treatment, and qualitative differences between transsexuals who identify as homosexual relative to their biological sex and those whose attractions are heterosexual relative to their biological sex.

Though studies examining genetic factors for transgenderism have been either inconclusive or supportive of the conclusion that discordant gender identities have no genetic basis, neurological research has delivered more reliable conclusions for those who argue for a biological origin of gender dysphoria. Accordingly, the notion of a “trans brain,” or brain gender incongruities, has been advanced as the primary source of gender dysphoria in contemporary transgender discussions.

In our paper, Br. Mobeen and I go into the details of major brain studies on transsexualism, so if you would like to learn more about them, I refer you back to the paper. But to summarize the major points, the relevant findings to date find morphological divergence in the brain to be most pronounced among homosexual transsexuals (meaning homosexual males who transition to females, or homosexual females who transition to males) though even this research concludes that the main morphological parameters of the brain for homosexual transsexuals who did not receive hormonal treatments are congruent with their biological sex. Greater divergence has been reported among transsexuals who have undergone prolonged hormone therapy, which is consistent with findings in other studies of subjects who have received pharmacological doses of hormones that reach the brain (and this is expected since cross-sex hormones alter brain structures). The data to date does not support significant morphological divergences for untreated heterosexual transsexuals, and many studies on transsexualism remain inconclusive owing to limited sample sizes and other control factors. It should be noted that studies examining MtF behavior and brain structure outnumber FtM studies on account of frequency, with instances of MtF transgenderism exceeding those of FtM transgenderism.

Some researchers have proposed a theory of male-to-female homosexual transsexualism as an extreme expression of homosexuality, and non-homosexual male-to-female transsexualism as correlative with a pronounced cross-gender fetish (namely, autogynephilia, which we will talk about later in this episode), while others have drawn parallels between non-homosexual MtF transsexualism and male desire to carry out limb amputation.

The origins of transgenderism remain contested, while the significance of brain change is itself subject to considerable debate given the state of neurological research and the malleability of brain structures overall. Accordingly, the simplistic notion of transsexualism as involving a “biological male with a female brain” or vice versa does not cohere with actual research findings, and the various studies used to depict transgenderism as a congenital condition can equally be used to problematize the phenomena of gender dysphoria, hormone therapy, and the desire for surgical alteration.

More fundamental questions between the relationship of brain morphology and cognition remain subject to significant scholarly dispute, with critics highlighting that psychological phenomena can not be reduced to localized neural patterns identified in brain imaging. The application of such critique to brain studies on transgenderism introduces important questions: Can “male” and “female” brains be distinguished so conclusively that aberrant brain features may be regarded as either effeminate or mannish? How decisive is this brain difference, and is it different enough to suggest definitively that the brain of this woman is “male”? To what degree should we adopt biological determinism to explain transgenderism as a phenomenon when its substantive claims are all psychological at their core?

We can not have a conversation on brain structure and function without recognizing and fully acknowledging the nature of neurological malleability as represented in the concept of neuroplasticity. We have discussed this concept back in season 4 as you may remember, referring to how the brain and nervous system can change through environmental influences. In other words, people’s brain structures adapt over time to the type of knowledge and experiences they repeatedly carry out in the course of their daily lives. Studies have also shown an impact of self-conception and psychological factors on the brain, such as meditation, stress, and intentionality.

Given the breadth of neurological malleability, it stands to reason that persons who conceive of themselves as gender dysphoric over prolonged periods of time would come to acquire some neurological idiosyncrasies reflecting this self-conception. This is even more the case for those who have convinced themselves for years, if not decades, that they possess a disoriented phenotype and who have received hormone therapy and/or undergone accompanying surgical procedures as a “corrective” measure. An emerging theory of the brain’s interaction with cultural conditions may serve to offer an added explanation of the modifications to brain structure observed in studies of transsexuals. The theory was inaugurated with a paper published in 2015 synthesizing over one hundred studies and formulating what is known as the Culture-Behavior-Brain (CBB) model. The CBB model is an integrated framework which posits that culture, behavior, and the human brain dynamically interact with and influence each other in ways that are more explicit than previously understood.

The process of CBB modifications begins with an idea assimilated into a social setting. The more deeply entrenched the idea, the more it permeates a cultural understanding of the phenomena associated with it. Consider the emergence of “sexual orientation” in the nineteenth century or the coining of the term “religion” as a discrete concept that came into being in the sixteenth century. Prior to the introduction of these concepts, the manner in which the underlying phenomena associated with them functioned, as well as how people conceived of them, differed dramatically. Thus, the introduction of the term “religion” did not merely describe what already existed; it created a sphere of activity that could be detached from other institutional forces and that has come to shape how we now construe world affairs (i.e., the place of religion in the world) as well as the organization of society (i.e., religion vs. the state). The permeation of the concept of “sexual orientation” has had a similar effect by providing a discrete identity and cultural script such that someone who merely experiences same-sex sexual attraction comes to conceive of that attraction as definitional to his/her sense of being and corresponding self-worth.

The idea of transgenderism, though a much more recent phenomenon, has had much the same effect in establishing a new taxonomy for gender nonconformity and providing a cultural script through which particular feelings are understood and subsequently acted upon. What CBB tells us is that once these cultural scripts establish themselves as uncontested understandings of specific happenings in the world, the brains of those experiencing phenomena derivative of that understanding actually alter in structure due to the brain’s inherent plasticity. Once this happens, the modified brain guides individual behavior to fit specific cultural contexts. Hence, culture, behavior, and the human brain interact dynamically through mutual connections, each influencing the other and changing continuously in the process. Human genes are integral to this process too, as they lay the groundwork for the structure and function of the brain as well as for behavior.

Given the myriad brain studies on transsexual and transgendered individuals and their conflicting results, and in light of the CBB model that I’ve just described, the following question must be raised: Are the supposed brain changes in transgender individuals part of the etiological factors leading to transgenderism, or are they a result of the interaction between the brain and a culture that accepts, nurtures, and pushes for transgenderism (be that on a micro or a macro level)? And if they are in fact a byproduct of acculturation, does CBB offer a robust paradigm through which this change can be explained?

This very question is taken up by another paper published in 2018 examining a multitude of brain studies along with their (often conflicting) results, and the authors urge us to look at these studies differently. As mentioned so far, studies on genetic influences for transgenderism have not produced reliable results, and this absence of genetic substantiation has been buttressed by the lack of organic differences in the brains of adolescents with and without gender dysphoria. The congruence of adolescent brain phenotype with biological sex has been accounted for by the lack of sociocultural awareness. In other words, it is argued, children lack a substantial appreciation of their own behaviors, likes, and dislikes—let alone an appreciation of transgenderism and what it entails—at a stage of their lives where their integration into existing gender roles is still an ongoing process. It is only after puberty that a full internalizing of dominating cultural conventions tends to occur and, as a consequence, the distinctions between brain phenotypes become more evident. According to this model, brain changes emerge depending on the strength and length of habituation after initial exposure to the psychosocial phenomenon of transgenderism.

This may also explain why many of the brain studies are contradictory, given that such changes rely on a myriad of external variables. In other words, when a biological male experiencing gender dysphoria elects to regulate his lifestyle based on a female gender identity, it is expected that the brain will adapt to this belief and corresponding lifestyle with time. Consequently, changes first in the function and then in the structure of the brain will occur.

Now, it is crucial to understand that brain plasticity works both ways: just as the brain can learn new ideas and beliefs and change accordingly, it can also, in principle, unlearn said ideas and beliefs and change back to its original state (or something close to it). Therefore, an individual experiencing gender dysphoria who is socialized within a setting that teaches transgenderism as an explanation of gender nonconforming thoughts can nevertheless unlearn the cultural script he/she has been taught, thereby attenuating prior brain changes and returning the brain to a state more congruent with his/her biological sex (which would, in turn, help further diminish nonconforming thoughts). Though further study is needed, CBB may provide an initial framework for therapeutic efforts and support the idea that an effective cognitive reorientation—such as through proper psychotherapeutic interventions, for instance—may be of help to those struggling with gender dysphoria. Such efforts, however, would have to be brought into conversation with Islam’s ontology of human existence, which recognizes that our physical being is inextricably tied to our psychic and spiritual realities.

15:56
The history of modern Western transgenderism is subject to significant debate. Gender theorists maintain that transgenderism predates the modern era and cuts across human civilization. This view treats gender nonconformity as a biologically determined phenomenon that manifests in countless taxonomies and communities across human history. Accordingly, any “third gender,” past or present, is regarded as reinforcing a larger narrative of transgenderism as being an essential part of the human condition for a minority of people whose gender identity differs from their anatomical sex. This characterization, however, is rightly contested by many as an anachronistic transposition of modern Western categories onto past peoples and societies that held no notion of a gender identity distinct from biological sex, at least not in the manner in which it exists today. This history includes recasting eunuchs, transvestites, the belief in gender ambiguous deities, and related phenomena as all supporting an allegedly long and storied history of the transgender experience.

Critics of this reading argue that transgenderism is socially constructed. Scholars like Sheila Jeffreys chronicle this history and date it to a relatively recent past, with the term transgenderism having been coined only in 2005 by cross-dresser Virginia Prince in order to “create a more acceptable face for a practice previously understood as a ‘paraphilia’—a form of sexual fetishism.” Prior to Prince, “transsexualism” was the more common term used to describe persons who desired sex modifications, a phenomenon that itself dates only to the mid-twentieth century. As we will see in this episode when we talk about psychological developments, the reengineering of terms and concepts for the purpose of destigmatization figures heavily in transgender advocacy.

The first recorded case of surgical intervention for gender dysphoria is that of Lili Elbe (born Einar Magnus Andreas Wegener), a Danish painter who, after marriage, moved to Paris in 1912 and openly identified as a female. In the year 1930, Elbe went to Germany for sex reassignment surgery, which was highly experimental at the time, and underwent four separate surgeries over the course of two years, dying shortly thereafter, in September 1931, due to an infection resulting from a labiaplasty. Roughly twenty years later, Christine Jorgensen (born George Jorgensen), a military servicemember during the Second World War, traveled to Copenhagen for a sex reassignment surgery. Unlike Elbe, Jorgensen additionally received hormone therapy, returning to the United States in 1952 to headline stories reading “Ex-GI Becomes Blonde Beauty.” Jorgensen lived a life of celebrity until his passing in 1989.

Sex reassignment surgery was not available in the United States until the year 1965, when the Johns Hopkins Hospital became the first institution in the country to offer it. The founder and chief publicist for the program was psychologist John Money, a figure who fell into disrepute following his handling of the infamous David Reimer case (also known as the “Joan/John” case). Money was an early advocate of gender constructionism, arguing that gender was something learned rather than inherent. He was featured on television and in several print media during the early years of the Johns Hopkins sex reassignment program. It was on account of this publicity that Janet and Ron Reimer approached him seeking advice concerning their infant son, Bruce, who had just experienced a surgical accident that rendered his penis damaged beyond surgical repair, and his parents were concerned about Bruce’s future happiness and sexual function given his genital abnormality. Money and the Hopkins team persuaded Bruce’s parents that sex reassignment was in the child’s best interests, arguing that while a vaginal pathway could be constructed surgically, a penis could not. Moreover, given Bruce’s young age, he would have experienced limited, if any, socialization that would contribute to any conception of a male gender identity (again, Money believed that gender was constructed and learned and not innate). The fact that Bruce had an identical twin brother (Brian) would also offer a unique opportunity to put Money’s constructivist theory to the test as a control factor against which Bruce’s successful socialization as a female could be reasonably assessed.

The Reimers consented to Money’s counsel, and at the age of twenty-two months, Bruce underwent genital reconstructive surgery and was subsequently named Brenda, after which he grew up with periodic hormone treatment and psychotherapy from Money and his extended team to reinforce his new female gender identity. Bruce would go on to experience severe psychological distress and damage throughout his life, threatening suicide at the age of thirteen if he had to return to see Money once more. Approximately two years after that incident, Bruce’s parents revealed to their son that he had undergone sex reassignment as an infant, after which he chose to retransition to a male identity and adopt the name David. David subsequently revealed the details of his life and treatment with Money in a memoir entitled As Nature Made Him: The Boy Who Was Raised as a Girl. Money’s “therapeutic” techniques and procedures bordered on the unspeakable and regularly involved David participating with his twin brother, Brian, in a variety of sexual acts. David went on to commit suicide at the age of thirty-eight, while his brother Brian developed schizophrenia and died of an overdose of antidepressants in his thirties as well.

The significance of the David Reimer case, at least for our purposes, lies in the activities of John Money and his role as a leading exponent of gender constructionism. Money developed a number of concepts that lie at the center of transgender discourse today, including gender identity, the “love map” (a mental map that guides one’s erotic desires), and paraphilia (a term coined by Money to replace “perversions”). It should also be noted that Money himself introduced the now common term “sexual orientation” in place of “sexual preference” to signify an immutability in relation to homosexual desires. Over the course of his work with Reimer, Money routinely misrepresented David’s female development as “Brenda,” describing it as an ongoing success with only rare (and relatively minor) setbacks. This deliberate falsification demonstrated Money’s intractable commitment to gender constructionism and is characteristic of the dogmatism of many present-day gender constructionists.

Johns Hopkins discontinued sex reassignment procedures in 1979, only fifteen years after initiating them. Jon Meyer, who ran Johns Hopkins’ Sexual Behaviors Consultation Unit, published an important review of the Hopkins sex reassignment program in a 1982 study entitled “The Theory of Gender Identity Disorders.” In this study, Meyer reflects upon his decade of work with 526 patients “having the most severe disturbances of gender, disturbances reflected in their application for surgical sex reassignment.” Meyer reported a complex set of clinical symptoms in these patients. For those who underwent sex reassignment procedures, long-term follow-up (ten or more years) “suggested that feelings of isolation and emptiness continued,” while there remained “a profound sense that, whereas externals had been changed, the patient was not truly male or female, merely a reasonable facsimile.” Meyer concluded that transsexual disjunction between self-representation and anatomy was “a defensive, symptomatic condensation of remarkable proportions,” further stating that “the destruction of the meaning ordinarily associated with genital anatomy is a violent psychic act, one means by which the superficially absent rage is expressed.” In a similar vein, an earlier 1979 piece by Meyer concluded that “sex reassignment surgery confers no objective advantage in terms of social rehabilitation.”

Another critical figure worth mentioning here briefly is the former chief of psychiatry at Johns Hopkins Hospital, Paul McHugh, who served as a leading voice in the closure of the Hopkins gender identity clinic in 1979. McHugh has written a number of articles as of late defending that decision, arguing that sex reassignment does little more than “cooperate with a mental illness” and that psychiatrists would do better to try to “fix the minds” of those suffering from gender dysphoria and “not their genitalia.” In October 2016, Johns Hopkins released a letter entitled “Johns Hopkins Medicine’s Commitment to the LGBT Community” where they cleared up people’s concerns about the institution’s connection with McHugh, listed their contributions to LGBT health and well-being, and since then, so-called gender affirmation surgical services have commenced and are now publicly listed among John Hopkins’ surgical services.

Though transgenderism and its underlying clinical diagnosis of Gender Identity Disorder were once regarded as a distinct mental illness, the past decade and a half has witnessed a substantial shift in public opinion. Consequently, determining public and private transgender policy, suitable pronouns, the relationship of gender to personal identity, and the appropriateness of surgical intervention for gender dysphoric adolescents and adults have become politically charged topics that are now being litigated through a mix of policy makers, medical professionals of various fields, activists, and other culturally influential voices.

Simultaneous with this debate has been a marked shift in attitudes towards gender, transgenderism, and adolescent gender self-conception. In a recent study published in the journal Pediatrics, approximately 3% of Minnesota teens reported that they did not identify with traditional gender labels (i.e., “boy” or “girl”). In another study conducted by UCLA, a full 27% of those studied between the ages of twelve and seventeen in California were determined to be “highly gender nonconforming.” Compare this to reported rates of 6.8/100,000 MtF and 2.6/100,000 FtM transgenderism among adults and the disproportion comes into clearer view.

27:54
Transgenderism is not a single, unified phenomenon. Rather, it covers a variety of phenomena that can diverge considerably from one case to the next. Clinically, the condition that is said to cause transgenderism was formerly known as Gender Identity Disorder (GID), a diagnostic label that held until 2013, when the Diagnostic and Statistical Manual of Mental Disorders (DSM) reclassified the condition as Gender Dysphoria (GD). Using the term gender dysphoria served the purpose of destigmatizing transgenderism and shifting the relevant psychological concern to one of distress, anxiety, and related anguish, in contrast to GID, which implies that gender identity divergence is an objective mental illness in and of itself.

Individuals with GD typically experience a strong desire to be treated as the opposite gender, to get rid of their biological sex characteristics, and/or to have feelings and experiences typical of the opposite gender. In examining gender dysphoria, psychologists have attempted to classify the phenomenon into at least three different subtypes. It should be noted that there are other, less common types that have been discussed and written about, though we will not attend to them here for the sake of simplicity. The classification of GD into subtypes is critical for a number of reasons. Classification assists in better understanding the variability in GD cases and gender transitions. This is a marked departure from the current public discourse, in which transgenderism is treated as a single phenomenon with all cases reducible to a simple matter of individual choice. Cases involving transgenderism can differ dramatically from person to person. Consider, for example, the case of Jazz Jennings, a biological male who was very feminine from a young age and earned the diagnosis of GID at the age of four, and his/her life was heavily documented by the media, and now Jazz is a famous media personality. By comparison, Chaz Bono (the child of the famous singers Sonny Bono and Cher), a biological female, publicly identified as lesbian in their mid-20s and only transitioned nearly two decades later. Many of us are also familiar with Caitlyn Jenner (formerly known as Bruce Jenner), a biological male who had been heterosexually married (i.e., to women) on three separate occasions and has six children from those marriages. Each of these individuals presents substantive differences concerning his/her gender identity and ultimate transition.

The trifurcation of transgenderism that we will examine in this episode intersects four factors, namely, (1) age (child vs. adolescent vs. adult), (2) speed of onset (sudden vs. gradual), (3) sexual attraction (homosexual vs. heterosexual as measured against one’s biological sex), and (4) sexual ratio (frequency of occurrence in biological males versus biological females). The three types of transgenderism are: childhood-onset gender dysphoria, autogynephilic gender dysphoria, and rapid-onset gender dysphoria.

Let’s start with childhood-onset gender dysphoria. This is also referred to as early-onset gender dysphoria, and this type of dysphoria refers to children, as young as age three up through adolescence, who behave like the opposite sex in many ways, including dress, mannerisms, type of play, playmates and general interests that they have. The latest edition of the DSM (DSM-5), provides a definition for childhood gender dysphoria as follows: A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration, as manifested by at least six of the following criteria:

1. A strong desire to belong to the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender) - and this first criterion is a must.
2. In boys (biological males), a strong preference for cross-dressing or simulating female attire, or in girls (biological females), a strong preference for wearing only typically masculine clothing and a strong resistance to wearing typical feminine clothing
3. A strong preference for cross-gender roles in make-believe or fantasy play
4. A strong preference for the toys, games, or activities stereotypically used or engaged with by the other gender
5. A strong preference for playmates of the other gender
6. In boys (biological males), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play, or in girls (biological females), a strong rejection of typically feminine toys, games, and activities
7. A strong dislike of one’s sexual anatomy
8. A strong desire for the primary and/or secondary sex characteristics that match one’s experienced gender

And the condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning.

Critics have called the above criteria into question, arguing that they rely heavily on sex stereotypes and include characteristics that are commonly observed among otherwise normal and healthy children. A New York Times op-ed by a mother named Lisa Davis, published in April 2017, makes this precise point. She called her piece “My Daughter Is Not Transgender, She’s a Tomboy,” - and Br. Mobeen previously mentioned this piece in episode 73 when we spoke about gender and gender nonconformity. The mother expresses frustration with others’ calling into question her daughter’s gender identity simply on account of her interests (she enjoys sports), friends (she is friends primarily with boys), and hairstyle (she likes her hair short). She writes: “I want trans kids to feel free and safe enough to be who they are. I also want adults to have a fluid enough idea of gender roles that a 7-year-old girl can dress like ‘a boy’ and not be asked—by people who know her, not strangers—whether she is one.” Fair enough.

Although statistics are not precise concerning the prevalence of childhood gender dysphoria, recent studies have reported relative stability of childhood GD cases over the past decade, though adolescent cases have experienced a marked increase. Possible reasons noted for the increase in adolescent cases include the influence of social media, a preference for being trans over being gay or lesbian, and the social status given in some youth subcultures to transgender individuals. In one study, an adolescent girl is reported to have remarked, “If I walk down the street with my girlfriend and I am perceived to be a girl, then people call us all kinds of names, like lezzies or faggots, but if I am perceived to be a guy, then they leave us alone”—thus resorting to transgenderism as a recourse against hazing or other forms of anti-gay animus.

Causes of childhood GD remain elusive, though according to Psychology Today, “genes, hormonal influences in the womb, and environmental factors are all suspected to be involved.” When GD appears in adolescence, it often falls into the two categories we’ll discuss in a bit (autogynephilic and rapid-onset GD). The American Psychiatric Association (APA) permits a diagnosis of gender dysphoria in adolescents or adults if two or more of the following criteria are experienced for at least six months' duration, and these include: a strong desire to be of a gender other than one's assigned gender, a strong desire to be treated as a gender other than one's assigned gender, a significant incongruence between one's experienced or expressed gender and one's sexual characteristics, a strong desire for the sexual characteristics of a gender other than one's assigned gender, a strong desire to be rid of one's sexual characteristics due to incongruence with one's experienced or expressed gender, and a strong conviction that one has the typical reactions and feelings of a gender other than one's assigned gender. In addition, the condition must be associated with clinically significant distress or impairment.

With adolescent GD, it is reported that parent–infant interpersonal issues and related trauma—including, but not limited to, sexual trauma—can play a contributing role, as well as depression and anxiety, borderline personality disorder, and social contagion. A feature of adolescent GD is the reported correspondence it bears with Autism Spectrum Disorder (ASD). Samples of adolescents who are referred to gender identity services reveal that 6-20% of such cases also have ASD, thus representing a significantly higher correlation as compared with studies conducted on adults (though ASD and GD co-occurrence is nonetheless common among adults as well).

The late Dr. Joseph Nicolosi argued that gender dysphoria is undergirded by a problem of attachment. On this understanding, gender dysphoria emerges in young children who experience trauma and attachment deficiencies at a young age that later materialize at the point of puberty or manifest fully in adulthood. Nicolosi writes: “Experts in the area of childhood gender identity disorder (GID) have found certain patterns in the backgrounds of GID children. A common scenario is an over-involved mother with an intense, yet insecure attachment between mother and child. Mothers of GID children usually report high levels of stress during the child’s earliest years. We often see severe maternal clinical depression during the critical attachment period (birth to age 3) when the child is individuating as a separate person, and when his gender identity is being formed. The mother’s behavior was often highly volatile during this time, which could have been due to a life crisis (such as a marital disruption), or from a deeper psychological problem in the mother herself, i.e., borderline personality disorder, narcissism, or a hysterical personality type. When the mother is alternately deeply involved in the boy’s life, and then unexpectedly disengaged, the infant child experiences an attachment loss—what we call “abandonment-annihilation trauma.” Some children’s response is an “imitative identification”—the unconscious idea that “if I become Mommy (i.e., become female), then I take Mommy into me and I will never lose her.”” We have spoken about trauma and attachment deficiencies in detail back in season 1, episodes 7 and 8. In the case of female SSA and GD, which are more complex than male SSA and GD, we spoke about their genesis in more detail back in episode 10.

From my research into SSA and GD so far, I have come to the understanding that we can think of a spectrum of gender-identity confusion. There are the gender-nonconforming boys and girls (who prefer opposite-sex company and activities, and have same-sex peer problems), and then there are more profound cases of gender-nonconformity with boys and girls who have gender identity confusion/GID (cross-gender mannerisms: like the effeminate boy or the very tomboyish girl), and then there are the extreme cases of complete identification with the opposite gender and rejection of one’s body and biological sex. All these categories are in conflict about claiming their appropriate gender (and have a feeling of gender deficit), and all these conditions lay the groundwork for a “homosexual outcome”, but the most extreme cases have a high likelihood of transsexualism later on. Remember that gender nonconformity is the single most common predictor of the development of SSA and homosexual tendencies in adolescence and adulthood; if I am on the extreme side of this spectrum where I reject my own physiology and prefer that of the opposite sex, then that lays the foundation for transgenderism.

It should be noted here that of all GD types, childhood cases have become a particularly heavy battleground in the public square. Much of the hysteria surrounds the question of what is known as desistance, which refers to the possibility—and, in most cases, the likelihood—of children eventually going on to accept their biological bodies rather than permanently identifying as transgender. What we know is this: Most cases of early childhood-onset GD self-resolve. Eleven out of 11 studies that followed the trajectory of gender-variant youth show that the most common outcome is natural resolution of gender dysphoria around or after puberty. Among those diagnosed as having gender identity disorder, 67% no longer met the diagnostic criteria as adults; among those subthreshold for diagnosis (i.e. didn’t meet the criteria in full), 93% were not gender dysphoric as adults. Gender dysphoria in childhood is more likely correlated with a future homosexual outcome than a future trans identity, and this is keeping in line with our earlier discussions back in season 1 about how gender non-conformity is the single most common observable factor associated with the development of SSA.

So, once again, there are high rates of desistance among child and adolescent GD, with some studies revealing a desistance rate as high as 84%. In other words, the overwhelming majority of children who experience GD will simply grow out of it when they become adolescents or young adults. The self-resolution of childhood GD is quite common, as has been commonly seen in normal childhood development, highlighting the volatility of childhood self-perception.

Considerably more contentious with respect to childhood GD is the issue of medical intervention, including the use of puberty blockers and the initiation of hormone therapy as part of treatment programs. We will talk more about these treatments later in this episode, but it should be noted that, we do not have data on the safety of puberty blockers and hormonal treatments for children and adolescents, yet this is commonplace nowadays, and in fact, the harms and side effects from such treatments are remarkable. Contrary to popular belief, children treated with puberty blockers report higher rates of self-harm and suicidality compared to those who are not treated. Dr. Michael Biggs of Oxford University has spoken out against studies endorsing the use of puberty suppressants published by England’s National Health Service (NHS) and has stated that “puberty blockers exacerbated gender dysphoria. Yet the study has been used to justify rolling out this drug regime to several hundred children aged under 16.” In addition to the complications and side effects of puberty blockers, the popular claim that the effects of hormone therapy are entirely reversible has itself proved tendentious. We will examine this in more detail later in this episode.

More radical transgender advocates today lobby for adolescent independence and affirmative transgender therapy—including medical intervention—for teenagers and youth struggling with GD without even requiring parental consent. Some have even argued for treating individuals who display indicators of GD and transgenderism at very young ages. For young children who display signs of GD, many professionals support “social transitioning” rather than medicalization—with social transitioning considered a precursor to eventual medical intervention. Social transitioning, which can be applied to children of any age (including infants), represents a form of transitioning in which parents and others socialize the child into an alternative gender identity (adjusted name, dress, treatment, etc.). However, it must be noted that social transition does not improve mental health outcomes. Recent studies show that, while socially transitioned children can thrive in the short term, they do not have better outcomes than their peers with GD who did not socially transition. It appears that peer relations and social support through family and friends actually predict mental health in children with GD. We do not have data to predict the long-term trajectories of socially transitioned minors, but studies have shown that minors who socially transition are more likely to persist with gender-related distress rather than to actually outgrow it, which then leads to decades of invasive and risky medical interventions.

Despite the data we have, all of the chaos propagated by the media and trans activists has made it exceedingly difficult for parents of GD children to distinguish truth from falsehood or fact from ideology, and the growth of transgender affirmative guidelines directed towards educators, counselors, medical professionals, parents, and youth has compounded the difficulties that families experience when facing a GD diagnosis in their child. Children with GD can exhibit significant dysfunction in major areas of functioning, like social relationships, school, or home life, while adolescents with GD report significantly higher rates of suicidality, psychopathology, self-harm, eating disorders, poor peer relationships, and higher rates of bullying and social isolation, as well as a greater likelihood of partaking in risky sexual behaviors. What we see nowadays is more of an ideological program dedicated to lowering the possibility of desistance and promoting gender transition, picking and choosing evidence that can be used to encourage gender transition, while at the same time silencing any debate on the matter. The likelihood that these children can function in a wholesome, healthy way with who they are biologically is increasingly marginalized and cast as harmful to children.

So that’s as far as child and adolescent GD is concerned. The second type of GD is known as autogynephilic gender dysphoria. The term autogynephilia was coined thirty years ago by Ray Blanchard and denotes a male (adolescent or adult) who demonstrates a “propensity to be sexually aroused by the thought of himself as a female,” a common symptom in cases of gender identity disorder (GID) and transvestic fetishism. Normally, the development of sexual interest during adolescence typically materializes in sexual fantasies or desires directed towards the opposite sex and can involve sexual arousal, desire, and sexual function. The concept of autogynephilia extends this sexual development for non-homosexual males: an autogynephilic male would, in addition to the normal sexual developments, fantasize about embodying women and, in many cases, act out the fetish. That is, he would feel arousal at the thought of dressing like a woman and, at times, possessing female body parts.

We don’t really have an idea why this tends to happen, as our scope of understanding is limited given the rarity of gender dysphoria and sex reassignment—though in recent years the numbers have increased substantially. Whatever the case may be, it is fair to conclude that autogynephilia is perhaps the most common underlying condition among males who pursue sex reassignment, and reports show that in recent years, 75% of male-to-female transsexualism cases in Western countries have involved autogynephilic patients. Not all of those diagnosed with autogynephilia pursue sex reassignment or express gender dysphoria. In fact, the majority do not, and some with autogynephilia end up marrying and having children. Autogynephilia, like all conditions, exists along a spectrum. Some can suppress the occasional desire to cross-dress, whereas others may engage in infrequent cross-dressing as a sort of release. Other cases include individuals with a higher intensity of fetish.

Autogynephilia can present in men with same-sex or opposite-sex desires (though it is more common among non-homosexuals), while other autogynephilic men are bisexual. For men with heterosexual desires, autogynephilic arousal comes from embodying the sexual other. For men with homosexual desires, arousal often involves the idea of being penetrated as a female. All in all, the idea is that a biological male loves the idea of having a body that resembles a woman’s body, he is sexually aroused by the idea and seeks comfort through it. Of course, the possibility of autogynephilia in female subjects has been argued as well, that is, women being sexually aroused by their own bodies. As a paraphilia, this is certainly not outside the realm of possibility, and both men and women have, at times, reported sexual arousal by seeing themselves naked.

Finally, let’s talk about rapid-onset gender dysphoria, which is the third kind. It’s also known as late- or adolescent-onset GD. Unlike autogynephilia, rapid-onset gender dysphoria (ROGD) is a relatively recent category constructed in response to a growing phenomenon of sudden expressions of gender discordance. Typically, this sudden onset of dysphoria has been observed among (predominantly) female adolescents and young adults. The most thorough and comprehensive treatment of this phenomenon comes to us in the form of a recent study by Dr. Lisa Littman, president of The Institute for Comprehensive Gender Dysphoria Research (ICGDR). She studied parents of children who had expressed sudden gender dysphoria with no preceding history of gender nonconforming expression. In examining their children’s unexpected experience of gender dysphoria, parents described “a process of immersion in social media,” including, among other things, “binge-watching YouTube transition videos and excessive use of Tumblr” prior to the child’s expressing feelings of gender dysphoria. Critically, Littman’s study describes in detail the power of social influences in stimulating dysphoric attitudes and promoting the idea of gender dysphoria among otherwise non-dysphoric adolescents, teens, and young adults.

I’ll share some stories of rapid-onset GD cases from Littman’s piece. One story is that of a twelve-year-old biological female who was bullied specifically for going through early puberty and the responding parent wrote, “As a result she said she felt fat and hated her breasts.” She learned online that hating your breasts is a sign of being transgender. She edited her diary (by crossing out existing text and writing in new text) to make it appear that she had always felt that she is transgender. Another case is that of a fourteen-year-old biological female and three of her biologically female friends who were taking group lessons together with a very popular coach. The coach came out as transgender, and within one year, all four students announced they were also transgender. And a third story is that of a biological female who was traumatized by rape when she was sixteen years old. Before the rape, she was described as a happy girl; after the rape, she became withdrawn and fearful. Several months after the rape, she announced that she was transgender and told her parents that she needed to transition.

These stories describe traumatic encounters or social events that contributed in some direct fashion to an eventual desire to embrace an alternative gender identity. Littman concludes with a few key hypotheses. One is, as we have noted, that social influences—both in person and online—provoke gender dysphoria. Another important hypothesis is that in certain instances, gender dysphoria serves as a maladaptive coping mechanism, much the same way that eating disorders serve as coping mechanisms following acute anxieties, bouts of depression, and traumatic events. In describing this phenomenon, Bailey and Blanchard write: “The subculture that fosters ROGD appears to share aspects with cults. These aspects include expectation of absolute ideological agreement, use of very specific jargon, thinking of the world as “us” versus “them” (even more than typical adolescents do), and encouragement to cut off ties with family and friends who are not “with the program.” It also has uncanny similarities to a very harmful epidemic that occurred a generation ago: the epidemic of false “recovered memories” of childhood sexual abuse and the associated epidemic of multiple personality disorder.”

Over 80% of rapid-onset GD cases involve females, though it is possible, albeit less common, for men to present with sudden GD as well. Many of those presenting with rapid-onset GD had previously been diagnosed with at least one mental health disorder, with several cases of self-harm, sex or gender related disturbances, and family stressors (i.e., death of a parent, parental divorce, etc.). Littman’s conclusions have not been without controversy. Some have characterized Littman’s research and study as “transphobic,” while others disputed rapid-onset GD as a category altogether. The research paper was retracted from Brown University’s website after publication in August 2018 because of public pressure and outrage from activist corners, despite the fact that the study utilized similar methods used in other areas of health research. Littman’s paper underwent a second peer review to address concerns raised during the editorial reassessment and emerged with largely unchanged conclusions; it was republished in March 2019. Since the study's publication, many mental health clinicians working directly with youth experiencing GD have confirmed a rapid onset of transgender identification among teens who did not exhibit any signs of GD before.

Recently, journalist Abigail Shrier built on Littman’s research, authoring a work dedicated to the growing phenomenon of female transitioning entitled Irreversible Damage: The Transgender Craze Seducing Our Daughters. In it, she documents the rising rates of female transitioning, rates that have flipped what was once a predominantly male phenomenon into one that is now majority female-to-male in composition in a number of countries. Gender clinics in Stockholm, Toronto, and Amsterdam all report that their ratios of gender dysphoria have shifted to majority biologically female patients in recent years, while US incidences of gender dysphoria went from being 46% biologically female in 2016 to 70% just one year later. Shrier details features of female transitioners, the vast majority of whom display no dysphoria in childhood, often come from middle- to upper-middle-class backgrounds, and are heavily influenced by their surroundings, especially social media and trans influencers. Prominent trans influencers today command large followings while encouraging social transitioning, putting on “binders” (used to suppress breast protrusion), depicting testosterone therapy as cathartic, and advocating deceit in the path of the “greater good” of arriving at one’s true, transitioned self. Along the way, young girls are taught that parental resistance is an indication of hatred and lack of affection or love and that the threat of suicide is an important tool to employ and weaponize when dealing with counselors, teachers, parents, and others who offer anything other than full-throated support.

Many young women today suffer anxieties related to their body image and a pathologizing of feminine norms and features. In such a context, self-harm, depression, and low self-esteem abound, and a desire to abandon the burdens of being a woman can be profoundly persuasive. Shrier quotes therapist Sasha Ayad, whose practice focuses on gender questioning teens, as saying, “A common response that I get from female clients is something along the lines: ‘I don’t know exactly that I want to be a guy. I just know I don’t want to be a girl.’”

A more recent 2021 study suggests that the rate of transgender identification among America's youth may be as high as 9%. All of the major gender centers in the world have reported a several 1,000% increase in youth presenting with GD. Of course, proponents of gender transitioning argue that this is more of a reflection of social acceptance of transgender identities around the world, allowing more young people to "come out." But such a claim has many inconsistencies. Firstly, for every 10 cases presenting with GD, 6-8 are those of adolescent and young adult females (previously, prepubertal males were more common), so one would expect a commensurate rise in the rate of transgender identification in older females if indeed this rise is due to social acceptance. This has not occurred. In addition, more than 75% of presenting cases have significant mental health problems or suffer from neurocognitive comorbidities such as autism spectrum disorder or attention-deficit/hyperactivity disorder, which is a much higher burden of mental health comorbidities than previously noted. We cannot deny that such comorbid mental health conditions, as well as the influence of social groups and online immersion into transgender topics are playing a vital role in the rapidly growing rates of transgender identification and transitioning among vulnerable youth in particular.

The future trajectory of people whose transgender identity emerged during or after puberty is entirely unknown. Growing numbers of young detransitioners and desisters are precisely from this demographic, suggesting that a transgender identity that emerges in adolescence may not be durable.

1:00:38
The medical pathway of "affirmative care" rests on a single Dutch study, also known as the Dutch protocol. Before the mid-1990s, medical transitioning was mainly reserved for mature adults. However, after noting the "never-disappearing masculine appearance" of many adult male-to-female transitioners, a team of Dutch researchers hypothesized that it might be appropriate to provide early intervention to a carefully selected group of adolescents before the irreversible physical changes of puberty take place. To differentiate the majority of children with GD who would outgrow their dysphoria by adulthood from the few who would have persisting GD and would wish to transition later in life, the Dutch gender clinic designed a rigorous screening protocol, with multidisciplinary teams closely following prospective candidates for several years.

To qualify for early intervention, the adolescents had to have had persistent and severe cross-sex identification from early childhood (so cases of adolescent-onset trans identity were disqualified), the distress had to worsen during puberty, and the adolescents had to be free from any other significant mental health conditions. For qualifying adolescents, puberty blockers were initiated no earlier than 12 years of age, cross-sex hormones at 16, and surgeries upon turning 18. Ongoing psychotherapy was provided through the entire assessment and intervention period.

The Dutch team published the final results of their research in 2014, and the authors reported that at the average age of 21 (approximately 1.5 years post-surgery), the young people were free from gender dysphoria and functioning well. Despite a postsurgical death from infection, several new diagnoses of metabolic illness, and multiple dropouts, the Western world enthusiastically embraced the early-intervention model. However, the only attempt to replicate the Dutch protocol outside of the Netherlands failed to show any psychological improvements, and to this date, no long-term outcome data are available for the cohort of the 55 treated Dutch adolescents.

These irreversible interventions form the basis of the "Dutch Protocol." Currently, this protocol is being scaled in ways it was never designed for. For example, it strongly discouraged childhood social transition and did not transition adolescents with postpubertal onset of transgender identity or those with significant mental health comorbidities. Yet, treating such cases with the interventions outlined in the Dutch protocol is now common, and the age of eligibility for hormonal and surgical interventions has progressively lowered, with children as young as 8 now eligible to begin puberty blockers.

For children, taking puberty suppressants is a step that is often preceded by “social transitioning” as we mentioned before. Puberty blockers (Gonadotropin Releasing Hormone [GnRH] agonists) are typically administered at the pre- or early pubertal stage to suppress puberty as a first step to transitioning to the desired sex. This is followed by cross-sex steroid hormones at fourteen to sixteen years of age. The use of puberty suppressants is recommended by many gender-affirming physicians and therapists as a temporary step to allow adolescent children more time fully to come to terms with their gender identity, to know in which direction to proceed, so to speak.

At times, children exhibiting even mild gender dysphoria or expressing nominal gender confusion are encouraged to take puberty blockers as a stopgap measure to prevent normal pubertal development. Medical monitoring and psychotherapy come in to explore possibilities of living as the other gender and to verify if transitioning is something the child really wants. The reason puberty blockers are used as well is because transitioning to the opposite sex through hormones (with or without eventual surgery) is less invasive on a body with stunted puberty caused by puberty blockers as compared to a body that has started to develop, or has fully developed, sex characteristics of the original sex. In this manner, gender affirmative therapy and treatment can serve to promote transgenderism as an eventual outcome, even when it is not in the patient’s best interest. Unsurprisingly, a rising number of adults who were pressured into adolescent transitioning are now going public with their stories of trauma, anxiety, and malpractice by medical practitioners and therapists, and we will talk more about this later in this episode.

Although hormone therapy as a step following puberty suppression is often presented as only a “possibility,” in most cases it turns out to be an eventuality. Dr. Norman Spack of Boston Children’s Hospital reports having never seen an adolescent decline hormone therapy after GD diagnosis and the use of puberty suppression. Hormone therapy involves the administration of testosterone to biological females and estrogen to biological males. With puberty now blocked and the associated gender-specific physical traits prevented from manifestation, hormone therapy goes on to stimulate opposite-sex gender development. For women, this means an increase in facial and body hair, more severe acne, growth in muscle mass, and no more menses. For men, hormone treatment results in reduced facial hair and slowed body hair growth, the development of breasts, and reduction in testicular size and function. During their years on puberty blockers, adolescents’ genitals and reproductive tracts remain in a pre- or early pubertal state, and the pubertal growth spurt is suppressed. If followed by cross-sex hormones, the possibility of reproduction is eliminated and the person become sterile.

The final possible step is surgical intervention. Sex reassignment surgery—sometimes referred to as “sex confirmation surgery”—begins, for men, with an orchiectomy, a procedure that involves the removal of the testicles. This effectively eliminates testosterone production for men and sets the groundwork for a second surgery, which is either a vulvoplasty or a vaginoplasty. A vulvoplasty is a procedure in which a surgeon uses the skin and tissue of the penis and scrotum to begin fashioning a synthetic vulva, the outside part of the vagina, which includes the labia, clitoris and an opening of the urethra. An alternative to a vulvoplasty is a vaginoplasty, which involves the fashioning of a full vagina from penile skin and tissue. Patients may experience an orgasm through clitoral stimulation following a vulvoplasty, but they will not be able to participate in vaginal intercourse. A vaginoplasty, on the other hand, allows for sexual intercourse and is thus regarded as a more complete and satisfying form of transition for male-to-female GD patients.

In cases of female-to-male transition, medical intervention involves the reduction and reshaping of the breasts and the removal of the uterus and ovaries. The surgical options for female-to-male transsexuals are generally bifurcated into what are referred to as “top surgeries” (involving the chest) and “bottom surgeries.” Top surgeries involve reducing breast size and contouring the chest to make it appear more masculine. Of the two sets of procedures, top surgeries are far more common owing to the lower cost and relatively higher rate of success. Bottom surgeries are considerably costlier and more complicated and take place over the course of multiple procedures that can span months, if not years. Bottom surgeries for a female-to-male patient include the removal of the uterus and ovaries, and the complete or partial removal of the vagina, and the principal bottom surgery for female-to-male patients is a phalloplasty, in which an artificial penis is molded using forearm tissue (or other parts of the body) and then surgically attached in a manner that provides for standing urination. And this involves multiple delicate and complicated surgeries over the course of extended periods of time. Some female-to-male patients, following a phalloplasty, elect to undergo yet another surgery to install a penile implant that allows for the appearance of an erection through the use either of manual inflation or of non-inflatable rigid models that are manually moved to mimic the appearance of an erection.

Bottom surgeries are highly complex, volatile, as one can imagine, and they are perhaps the riskiest of the surgical options just mentioned. There are lots of uncertainties surrounding flap survival and common functional failures. Even relatively successful cases cannot guarantee the rigidity required for successful sexual intercourse.

The complications and side effects of all of these treatments, whether medical or surgical, are non-trivial and are rarely disclosed in full to parents, adolescents, and adults considering medical intervention. Publicly available literature on trans-affirming sites glosses over the possibility of unfavorable consequences or of medical outcomes that introduce pathological changes or previously non-existent ailments. But let us talk about the medical complications of transition treatments, from puberty blockers and cross-sex hormones to sex reassignment surgeries.

To start with puberty blockers, in general, these are medically indicated in pediatrics for the treatment of a condition known as precocious puberty, in which an early secretion of pubertal hormones brings about all the manifestations of puberty at an earlier age than usual. Such puberty blockers aid in delaying puberty until an appropriate age. However, there is no way to infer that such blockers are safe in physiologically normal children who suffer from gender dysphoria.

In the United States, the use of puberty blockers for the treatment of gender dysphoria has not yet been approved by the FDA (although their use for the treatment of precocious puberty, prostate cancer, and other conditions has been). The use of puberty blockers for GD is considered “off-label,” meaning that physicians are legally permitted to use such treatments on children with GD but are barred from marketing them for the treatment of GD due to the lack of FDA approval. The use of puberty blockers for the purpose of treating GD has not yet been proved in clinical trials to be safe and effective. Also, there are many claims that the effects of puberty blockers are reversible and they help kids explore their gender identity without having to deal with the advent of secondary sexual characteristics, hence improving the precision of the diagnosis, but there’s no data to back this up.

Let us ask a couple of questions here: Wouldn’t we expect that the development of natural sex characteristics would help the kid consolidate his/her gender identity, as opposed to interfering with their exploration of it? Also, if we interfere with the physiological process of normal pubertal development, wouldn’t this affect the gender identity of the child by further hindering his/her gender identity development in line with his/her biological sex, as opposed to allowing for a more accurate diagnosis of gender identity? With normal puberty, there is a complex relationship between physiological, psychological, and social factors that shape one’s gender identity, particularly when the physical body matures and sexually differentiates. With puberty blockers, the natural sequence of development is already disrupted. Would such development resume in a normal fashion after puberty blockers are discontinued? And, what are the psychological consequences that arise in children with gender dysphoria whose puberty has been suppressed for some time and who later come to identify with their natal biological sex?

The two main studies that have evaluated the effects of puberty blockers on mental health found no improvements or improvements of marginal clinical significance. Both studies are also at critical risk of bias due to the absence of control groups. Four additional studies looking at the mental health effects of puberty blockers were plagued by design limitations and also failed to show any convincing positive effects on psychological health. There are virtually no published studies of adolescents who have discontinued the use of puberty blockers and then resumed the normal pubertal development process typical for their sex. Most adolescents studied generally go from suppressed puberty to cross-sex hormones later on, bypassing the most essential step of sexual maturation, which is the maturation of one’s reproductive organs (which, in some cases, may eventually even be removed altogether). Infertility is therefore one of the major side effects of puberty suppression. We also have no data concerning the development of primary and secondary sex characteristics in adolescents whose puberty has been artificially suppressed before or at the point of puberty. Hence, there is no rigorous scientific data to support the claim that medical intervention of any sort, including puberty suppression, is reversible.

The absence of a robust public debate and discussion over sterilizing children in the context of “affirmative therapy” programs is striking and honestly very disappointing. For any other group of children, any medical intervention bearing the same degree of medical consequence would be discussed extensively and would include ethics review boards and committees alongside substantial policy debates that would dissect all possible implications on these children. We know that children are not legally capable of consent, and especially prepubescent children who are not capable of understanding the myriad of health consequences of such treatments, including infertility. When confronted with the full length of possible risks, would parents make an informed decision based solely on a child’s subjective experience at a point in time?

One question that arises from all this is, Do such treatments contribute to the persistence of gender dysphoria in adolescents who might otherwise have resolved their feelings of belonging to the opposite sex? As mentioned earlier, most children who are diagnosed with gender dysphoria eventually grow out of it. One effect of puberty blockers has been consistently replicated across studies: At least four studies show that virtually all of the children who start puberty blockers proceed to cross-sex hormones. This suggests that rather than being a pause button, puberty blockers may serve as the "gas pedal" for gender transition.

In this vein, Michael Cretella of the American College of Pediatrics writes: “There is an obvious self-fulfilling nature to encouraging a young child with GD to socially impersonate the opposite sex and then instituting pubertal suppression. Purely from a social learning point of view, the repeated behavior of impersonating and being treated as the opposite sex will make identity alignment with the child’s biologic sex less likely. This, together with the suppression of puberty that prevents further endogenous masculinization or feminization of the entire body and brain, causes the child to remain either a gender nonconforming pre-pubertal boy disguised as a pre-pubertal girl, or the reverse. Since their peers develop normally into young men or young women, these children are left psychosocially isolated. They will be less able to identify as being the biological male or female they actually are. A protocol of impersonation and pubertal suppression that sets into motion a single inevitable outcome (transgender identification) that requires lifelong use of toxic synthetic hormones, resulting in infertility, is neither fully reversible nor harmless.”

That’s as far as puberty blockers. What about cross-sex hormones? A 2018 study carried out by Kaiser Permanente Medical Centers in Georgia and California found a link between cross-sex hormone use in transsexual women (that is, biological males who identify as females and are put on estrogens) and an increase in vascular side effects such as stroke and venous thromboembolism (VTE), that is, the formation of venous blood clots. Results of the study show that rates of VTE in transsexual women were nearly twice as high as those among cisgender men and women, and the rates of stroke and heart attack among transsexual women were 80-90% higher than those observed in cisgender women but similar to the rates found in cisgender men. The increase in the rates of VTE and stroke was more noticeable several years after the initiation of estrogen therapy. In addition, trans men receiving testosterone are at a higher risk for heart attacks. Another study showed that, after an average of ten years of cross-sex hormone treatment, a substantial number of trans women suffered from osteoporosis at the lumbar spine and distal arm, and 12% of trans women experienced thromboembolic and/or other cardiovascular events during hormone treatment, possibly related to older age, estrogen treatment, and lifestyle factors.

As for hormone-related cancers in transgender individuals, case reports of trans women diagnosed after the initiation of medical or surgical “gender affirmation” include cancers of the breast and prostate, prolactinomas (a type of pituitary gland tumor), and meningiomas (a type of brain tumor). In trans men, published case reports describe cancers of the breast, ovaries, cervix, vagina, and uterus. These reports remain sparse, and large studies on the proper incidence of such malignancies in these patient populations remain to be carried out.

As for children, those who transition require cross-sex hormones for significantly longer periods of time as compared to adults and hence are more likely to experience those “physiologically theoretical though rarely observed morbidities in adults.” Hence, boys placed on estrogen treatment may be at a higher risk of developing VTE, cardiovascular disease, weight gain, high blood fat levels and blood pressure, decreased glucose tolerance, gallbladder disease, and breast cancer. Similarly, girls receiving testosterone may experience a higher risk for elevated blood cholesterol levels, liver damage, increased blood viscosity and red cell count, and an increased risk of sleep apnea, insulin resistance, and diabetes, as well as unknown effects on breast, uterine, and ovarian tissues.

That’s as far as chemical treatment, what about surgical reassignment? One of the most robust studies on sex reassignment comes from Sweden, where a nationwide population-based, long-term follow-up study of sex-reassigned transsexual persons was published in 2011. The study followed 324 sex-reassigned persons (191 male-to-females and 133 female-to-males) in Sweden between the years 1973 and 2003. This study found that for sex-reassigned transsexual individuals compared to a healthy control population, there are substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalizations. Authors of the paper argue that even though surgery and hormonal therapy may alleviate gender dysphoria, they are apparently not sufficient to remedy the high rates of morbidity and mortality found among transsexual persons.

Mortality from suicide was strikingly high among sex-reassigned persons (19.1 times increased risk), even after adjustment for prior psychiatric morbidity. In line with this reality, sex-reassigned persons were found to be at an increased risk for suicide attempts (4.9 times more likely). In-patient care for psychiatric disorders was significantly more common among sex-reassigned persons than among matched controls, both before and after sex reassignment, and the authors recommend that there is a need to identify and treat co-occurring psychiatric morbidity in transsexual persons not only before but also after sex reassignment. A 2001 study of 392 MtF and 123 FtM transgender individuals found that 62% of MtF and 55% of FtM subjects suffered from depression, while 32% of each population had attempted suicide. Similarly, in 2009, a study found considerably lower general health and general life satisfaction among fifty-two MtF and three FtM transsexuals a full fifteen years after sex reassignment surgery as compared to controls.

A 2019 longitudinal study from Sweden by Bränström and Pachankis published in the American Journal of Psychiatry followed up 2,679 individuals who received a diagnosis of gender incongruence (that is, transsexualism or gender identity disorder) between 2005 and 2015. Compared to the general population, individuals with a gender incongruence diagnosis were around six times more likely to have had a healthcare visit for mood and anxiety disorders, more than three times as likely to have received prescriptions for antidepressants and anti-anxiety medications, and more than six times as likely to have been hospitalized after a suicide attempt. Increased time since last gender reassignment surgery was significantly associated with reduced mental health treatment. This led the authors to conclude that such data lends support to providing gender reassignment surgeries to transgender individuals who seek them.

Subsequent to the study’s publication, however, multiple clinicians wrote letters to the editor of the journal criticizing the authors’ flawed methodology and cherry-picking of data in order to arrive at the desired conclusions. One such letter was authored by Van Mol, Laidlaw, Grossman, and Paul McHugh (whom we have discussed earlier in the episode). This led the journal to seek statistical consultations, the results of which were presented to the study’s authors, who concurred with many of the points raised. Upon request, a reanalysis was conducted to compare outcomes between individuals diagnosed with gender incongruence who had received gender reassignment surgeries and those diagnosed with gender incongruence who had not. The results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder–related health care visits, prescriptions, or hospitalizations following suicide attempts for that cohort. Given that the study used neither a prospective cohort design nor a randomized controlled trial design, the authors themselves deemed their original conclusion—namely, that “the longitudinal association between gender-affirming surgery and lower use of mental health treatment lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them”—to be too strong. All this led the American Journal of Psychiatry to issue a major correction and the authors of the study to retract their conclusions. In short, the Bränström study reanalysis demonstrated that neither gender-affirming hormone treatment nor gender-affirming surgery reduced the need of transgender-identifying individuals for mental health services.

Cited in the letter by Van Mol and colleagues was the Swedish study by Dhejne and colleagues, which employed population controls matched by birth year, birth sex, and reassigned sex. A follow-up time beyond ten years revealed that the sex-reassigned group had nineteen times the rate of completed suicides and nearly three times the rate of all-cause mortality and inpatient psychiatric care compared to the general population, as outlined previously.

The foregoing considerations reveal that sex reassignment alone does not provide individuals with a level of mental health similar to that of the general population. And for those arguing that it’s social prejudice and discrimination that is responsible for all this, remember that those studies are actually coming from Sweden, one of the most pro-LGBT countries in the world with lowest possibly anti-LGBT discrimination.

Remember the Dutch protocol that we mentioned earlier. Most of the youth presenting for care today would have been explicitly disqualified by the original Dutch protocol, as most have significant mental health comorbidities and post-puberty onset of trans identities. This fact has been recognized by the principal investigators of the Dutch protocol itself, who have recently begun to sound the alarm about the potential misapplication of their protocol and who suggest that psychotherapy, rather than gender reassignment, is more appropriate for many of the currently presenting cases.

All in all, there is now growing evidence that the "gender-affirming" model, based on the unproven assumption that gender reassignment is the best way to help gender-distressed youth, is not living up to its promise. Despite more than 50 years of experience with mature adult gender transitions, there is a lack of convincing evidence that transitions improve the psychological functioning of those with gender dysphoria, and studies on regret have been plagued by high dropout rates that prevent meaningful conclusions for practitioners and patients alike.

1:28:11
There is no historical precedent for drastic surgical changes akin to what we are witnessing today and certainly no historical record for hormone therapy being administered except in the most limited cases of medical necessity. What we are seeing today is literally a global and live experiment on humans. The data related to post-operative and post-medicalized outcomes has only recently been subjected to formal study and examination, though even this is limited and there is much left to be done.

One such area has been that of post-transition regret. A number of articles have appeared online detailing the internal anguish of transitioning, the social factors that apply pressure on individuals struggling with gender dysphoria (including online “affirmative” forums), and post-transition remorse, depression, and general feelings of unhappiness. Just take a look at the stories on the subreddit r/detrans, which counts over 20,000 members (not all of whom are detransitioners, as the forum is open to those fully detransitioned, partially detransitioned, desisted, and questioning their transition), you will find tons of first-hand accounts that should be mandatory reading for any parent, counselor and clinician involved in gender-affirmative care.

A recent site dedicated to trans remorse is entitled “Sex Change Regret”, which is run by Walt Heyer (a detransitioned biological male), the site aims to expose readers to the reality of post-transition regret and to provide resources for those who find themselves in the same boat but do not understand how to revert to the person they once were. A review by the University of Birmingham’s Aggressive Research Intelligence Facility (ARIF) of more than “100 international medical studies of post-operative transsexuals” found “no robust scientific evidence that gender reassignment surgery is clinically effective.” In addition to the inefficacy of surgical intervention, ARIF also highlighted how postoperative reporting is skewed to suggest beneficial outcomes. One particular domain where this imprecision comes into focus is the dropout rate of those tracked following sex reassignment. For example, in one five-year study, nearly five hundred people dropped out of a study of 727 post-operative transsexuals. The growing specter of regret, complications, underlying psychiatric disorders (that are not and cannot be treated by heavy surgical intervention), and more is increasingly becoming a part of the public transgender conversation.

Ryan Anderson’s recent work When Harry Became Sally: Responding to the Transgender Moment includes an entire chapter dedicated to telling the story of “detransitioners.” Anderson mentions a number of stories in the chapter, including that of Ria Cooper, who underwent a sex change operation at the age of seventeen. At the time, the surgery was a matter of some controversy given Cooper’s age; however, it was reported that he had undergone a “thorough psychological evaluation” as well as counseling, thus reassuring those who were concerned about the appropriateness of such a heavy-handed procedure for someone so young. Within a year of living as a woman, Cooper attempted to commit suicide twice and ultimately detransitioned back to his natal sex. Anderson documents a number of other stories, with common themes related to social pressures, the role of online material and interactive forums telling individuals that transitioning is necessary for those who experience gender atypical feelings, and the contribution of mental health practitioners, diverse medical personnel (pediatricians, general practice physicians, etc.), and school administrators (such as counselors and the like) in encouraging otherwise unsure individuals that they should consider and pursue gender transition.

However, this is not the whole story, and not all express regret following a transition. Many advocates of transgenderism claim that the process is lifesaving, with many prominent activists including Chaz Bono, Jazz Jennings, and, more recently, Caitlyn Jenner. Though these figures largely make up the face of the trans movement in America, other transitioned individuals write about the importance of transitioning—and, in some cases, the necessity of sex reassignment—to their mental health. One such figure is Claire Renee Kohner, a prominent MtF who has been featured on HuffPost Live and has written about transgenderism and her story for the New York Times, the Advocate, Bustle, and other publications. Kohner’s story is an important one in that it does not whitewash the difficulties of transitioning, which can often involve serious complications. In a response to the question “What are the most serious negative side effects of gender reassignment surgeries?” Kohner narrates, “I nearly died”, and then goes on to detail the risks and complications endured through a long list of surgeries.

Another transgender individual who has written about his experience is Todd Whitworth, a female-to-male transitioner who describes his transition and life in the following terms: “I take self-administered testosterone injections intramuscularly every two weeks. I’ve had a full hysterectomy and oophorectomy including removal of the cervix. Additionally, I’ve had a double mastectomy with chest contouring so that my chest has a more masculine appearance. I’ve been happy with the results, and I feel fortunate in that regard. I do, however, still know that I am not a biological man. I am happy with the fact that I walk through the world being perceived as male. However, biology reminds me every day that I’m not. I still experience dysphoria with my genitalia. However, I’ve chosen not to have any genital modification because I do not find the options available for a female-to-male transsexual aesthetically o[r] functionally desirable.”

These cases and others support the idea that some form of gender transition can sometimes serve, at a minimum, palliative purposes for those who experience extreme forms of anxiety, depression, and suicidality as a result of gender dysphoria—notwithstanding the heavy risks and ongoing medical and other complications often attendant upon such procedures.

Interestingly, some of America's leading experts on transgender medicine say their concerns about the quality of the evaluations of adolescents and young adults with gender dysphoria are being stifled by activists who are worried that open discussions will further stigmatize trans youth and add fuel to the conflagration of anti-trans legislation sweeping across the nation.

The clinicians who have raised warning flags say the health of young people is their primary concern. Others agree that it is time to take a closer look at the widely backed "gender-affirmative care" model and the quality of care being delivered, but they believe it should be done in the halls of academia, not through the lay press or on social media.

The latest uproar was set off by comments made by Dr. Marci Bowers, a world-renowned vaginoplasty specialist who operated on reality-television star Jazz Jennings, and Dr. Erica Anderson, a clinical psychologist at the University of California San Francisco’s Child and Adolescent Gender Clinic. In the course of their careers, both Marci Bowers and Erica Anderson have seen thousands of patients. Both are board members of the World Professional Association for Transgender Health (WPATH), the organization that sets the standards worldwide for transgender medical care. And both are transgender women. The comments come from an interview with Abigail Shrier whom we mentioned earlier, the author of the book Irreversible Damage, and in the interview, both Bowers and Anderson expressed concern at the current state of medical care for transgender youth, including how the use of puberty blockers on pre-pubescent children inhibits genital tissue growth, which can make surgeries more difficult for children who do eventually transition and choose to opt for gender-reassignment surgery, and how puberty blockers, combined with cross-sex hormones afterwards may impact children's "sexual health later and ability to find intimacy." Bowers told Shrier, "There are definitely people who are trying to keep out anyone who doesn't absolutely buy the party line that everything should be affirming and that there's no room for dissent."

So what’s happening nowadays given all this aftermath? Several European countries that were pioneers in medical transitioning for children and adolescents are now reversing course towards far more caution after their own evidence evaluations failed to show improvements in mental health outcomes after gender transitioning. In Sweden, following Karolinska Hospital's announcement that it will no longer transition people under 18 outside of strictly regulated clinical trials, a number of other pediatric gender clinics followed suit and made the same decision. And even more recently, the Royal Australian and New Zealand College of Psychiatrists also said that mental health evaluations by competent providers are essential before any medical treatments are offered to young people. Finland has arguably undertaken the biggest change of all. The Finnish national Gender Identity Development services issued new treatment guidelines in 2020 stating that psychotherapy, rather than gender reassignment, should be the first line of treatment for gender dysphoric youth.

In the UK, Keira Bell, a young woman who was treated with "affirmative" hormonal and surgical interventions but then detransitioned, brought a challenge against the national gender clinic. Her landmark case and the UK High Court's original judgment against the clinic have highlighted the urgency to reassess treatment approaches for the diverse presentations of gender dysphoria in young people. The UK's national gender clinic won its appeal against Keira Bell (meaning that doctors there can decide whether their patients under 16 can properly consent to puberty blockers), but Bell wants to appeal the decision to the Supreme Court. She said the medical service had become "politicized," and that, even though she lost the case for now, it “has shone a light into the dark corners of a medical scandal that is harming children and harmed me. There is more to be done." The UK National Health Service (NHS) has already commissioned an independent systematic review of data, which concluded that the evidence of benefit of hormonal interventions in gender dysphoric youth is of very low certainty and must be carefully weighed against the risks. An independent taskforce has also been convened to reassess the country's approach to treating gender dysphoric youth.

Parents and professionals alike are expressing concerns about the whole “affirmative care” model and are becoming more vocal against it through groups and organizations. One of those groups is Genspect, an international organization that advocates for "neutral space" for children to explore their gender identity and opposes medical transition for children. In an interview published in the wake of the Abigail Shrier article including Bowers and Anderson, psychotherapist Stella O'Malley who is one of Genspect’s founders told The Australian: "The big names associated with this vast experiment seem to be re-positioning themselves from being fervent advocates to now seeking caution —sadly for thousands of families this is too little, too late."

01:40:36
I realize that this may be a heavy episode, both in terms of the load of content presented as well as coming to terms with what’s taking place on a global scale in terms of trans “affirmative care”. I remember when Br. Mobeen and I were doing the research on the part II article, particularly the parts relevant to science and medicine, I was taken aback by the data and what it’s telling us in comparison with the current status of trans affirmative healthcare. As a physician myself, I can’t help but think of how the current paradigm operates in stark contradiction to the hippocratic oath that I and countless other physicians around the globe have taken to do no harm, to follow treatment which we consider to the best of our abilities and judgments for the best of our patients, to abstain from whatever is deleterious or mischievous, and to not allow the fear of personal harm to turn us from our duties.

Medicine has a pattern of enthusiastically embracing unproven medical interventions, only to find out years or decades later that the harms from those interventions outweigh the benefits. We owe it to our patients to be transparent about the limits of our knowledge and the fact that the "affirmative care" pathway is largely irreversible, fraught with inconsistencies, uncertainties and frankly, many harms - physical, psychological and emotional, to name a few. We can not sit back and remain silent. What is happening on a global scale is nothing short of a crime against humanity.

One of the questions that I kept asking myself as I was researching this topic: Why the rush to transitioning children and adolescents if we know that the majority of them will outgrow their dysphoric feelings and proceed to identify with their natal sex? One of the common answers to that is that fact that children and adolescents with GD are going to continue to suffer mentally and are at a high risk of committing suicide. But studies with quality data reveal a markedly different reality. Yes, youth with GD do have elevated rates of suicidality, but it's not uniquely high. In fact, it's roughly similar to the rate of suicidality found in populations of youth referred for other mental health conditions. Quality long-term studies that explored whether transition leads to reduced suicidality have not been able to demonstrate a reduction. In fact, suicidality either stayed the same post-transitioning or increased. And the same goes for mental health issues. So this argument does not hold.

Another common argument is that acting quickly by starting puberty blockers would make it easier to transition, should the individual choose to transition eventually, as it prevents the body from going into sexual maturation, which would make the transition process more difficult. That argument doesn’t hold either, a. Because, as we’ve seen, puberty blockers are not a “pause button” in a sense that it gives you time to think and choose, but rather more of a gas pedal on a one-way street to transitioning, b. And as indicated by trans-affirming physicians themselves, use of puberty blockers on prepubescent children inhibits genital tissue growth, which can make potential gender-reassignment surgeries even more difficult, and c. Puberty blockers, combined with cross-sex hormones afterwards have an impact on children's sexual health later on and their ability to find intimacy.

As we have seen, social transitioning, puberty blockers, cross-sex hormones and gender-reassignment do not improve mental health outcomes. If anything, they act as temporary palliative measures that soothe the underlying mental health issues, but do they solve the original problem? The answer is pretty clear. So again, why the rush with transitioning and the global media frenzy surrounding that? I’d say, welcome to the queer new world. Enough said, right?

As Dr. William Malone, assistant professor of endocrinology and advisor to the Society for Evidence-Based Gender Medicine, writes “When the benefits of an intervention have not been shown to outweigh the risks, medical ethics dictate that such interventions should not occur outside of clinical trials. We must not conflate medical care for gender-dysphoric youth with experimental and risky interventions that are based on low-quality evidence. It's time to hit pause on gender transitions for youth.”

Please do not get me wrong. None of this is me “hating” on individuals struggling with GD or who are considering transitioning or who have partially or completely transitioned. I know many men and women with GD at different levels of transitioning, and they are some of the most loving and caring individuals I have met, they have hearts of gold, and they are true gems. But their pain is legitimate, which forces me, as a human being first and foremost, and as a physician, in addition to being a Muslim and servant of God, to go against the current and say, we need to wake up and attend to the real problem here. Changing the exterior is not solving the problem, that is only the tip of the iceberg.

From what we have seen in this episode, there is undeniably an element of social contagion and peer influences that undoubtedly contribute to the rise in the cases of GD worldwide. This is something that we have to deal with through awareness, having our resources and support groups, and protecting our youth against these currents through individual and communal efforts. And this is no easy feat. However, social contagion and peer influences explain some cases of GD but not all of them, especially not the ones arising in childhood. In those particular cases, we can not deny the presence of other mental health comorbidities like autism spectrum disorders, ADHD, dissociative disorders (in their many forms), as well as complex trauma and C-PTSD, to name a few. Those should be our focus, in my humble opinion, as gender dysphoria is secondary to that, not a primary event, and that is in the overwhelming majority of cases.

It is time we revise this entire paradigm and do the work. There’s a long way ahead of us, but it is about time we do the work. Please raise awareness on this topic and share this episode and resources within your circles so we can all work together to help children, adolescents and adults who struggle with GD receive the proper care and attention they deserve. We need multi-disciplinary care involving physicians, counselors, mental health professionals, parents and siblings, Imams and community leaders, teachers and educators, as well as the community at large, the kind of care that takes care of children, adolescents and adults with GD - their bodies, as well as their minds, souls and beautiful hearts.

01:47:51
And with this, we have come to the end of today's episode which has focused on the scientific and medical perspectives on gender dysphoria and transgenderism. In the next episode, inshaAllah, Br. Mobeen Vaid joins me one last time to talk about sex-reassignment surgeries and the modern trans movement. Until then, stay safe and healthy, this has been Waheed Jensen in “A Way Beyond the Rainbow”, assalamu alaikom warahmatullahi ta’ala wabarakatuh.

A Way Beyond the Rainbow

#75 - On Gender Dysphoria and Transgenderism: Medical Perspectives

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