Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria

Gender-affirming care through the lens of abnormal illness behaviour and abnormal treatment behaviour

OBJECTIVE

To describe the increasing number and changing demographics of patients presenting with gender dysphoria and provide an account of patient- and clinician-related factors which may have contributed to these changes. The concept of abnormal illness behaviours introduced by Pilowsky, and its extension to the concept of abnormal treatment behaviours by Singh, provides a framework for understanding healthy and pathological interactions between gender dysphoria patients and their doctors.

CONCLUSIONS

Abnormal illness behaviours driven by the reinforcing contingencies of gender-affirming care may explain, in part, the increasing number and changing demographics of gender dysphoria, as well as the increasing incidence of desistance and detransition. The under-diagnosis and under-treatment of mental health disorders by clinicians treating these patients are examples of abnormal treatment behaviours. Uncritical affirmation of patient reported gender identity appears likely to conceal unconscious motivations of some patients and clinicians, increasing the risks of harm to both.

Association of Pubertal Blockade at Tanner 2/3 With Psychosocial Benefits in Transgender and Gender Diverse Youth at Hormone Readiness Assessment

PURPOSE

Compare psychosocial function at the time of hormone readiness assessment for transgender and gender diverse (TGD) youth who received pubertal blockade to prevent a nonaffirming puberty with those who did not.

METHODS

Retrospective cohort study of psychological assessment data from hormone readiness evaluations conducted at a multispecialty gender clinic. Participants include all TGD youth between the ages of 13 and 17 assessed for hormone readiness between 2017 and 2021.

RESULTS

Our cohort consisted of 438 TGD youth, 40 who were prescribed pubertal blockade at Tanner stage 2 or 3, and 398 who had not. The blocker population was younger, more likely to be assigned male and affirming a female identity, and had a different racial/ethnic identity distribution. Having puberty blocked was associated with significantly lower T-scores on the Youth Self Report for internalizing problems (β = -7.4, p < .001), anxiety problems (β = -4.6, p = .003), depressive problems (β = -6.5, p < .001), stress problems (β = -4.0, p = .01), and total problems (β = -4.9, p = .003). The blocker population was also significantly less likely to report any suicidal thoughts (odds ratio = 0.38, p = .05). With the exception of increased risk of suicidal thoughts, these associations remained significant when adjusted for gender.

DISCUSSION

At the time of hormone readiness evaluation, TGD youth who received pubertal blockade at Tanner 2 or 3 were found to have less anxiety, depression, stress, total problems, internalizing difficulties, and suicidal ideation than TGD peers who had been through more of a nonaffirming puberty.

Toward a Standard of Medical Care: Why Medical Professionals Can Refuse to Prescribe Puberty Blockers

That a standard of medical care must outline services that benefit the patient is relatively uncontroversial. However, one must determine how the practices outlined in a medical standard of care should benefit the patient. I will argue that practices outlined in a standard of medical care must not detract from the patient's well-functioning and that clinicians can refuse to provide services that do. This paper, therefore, will advance the following two claims: (1) a standard of medical care must not cause dysfunction, and (2) if a physician is medically rational to not provide some service which fails to meet the above condition (i.e. fails to be a standard of medical care), then she may refuse to do so. I then apply my thesis to the prescription of puberty blockers to children with gender dysphoria.

Commentary: The Signal and the Noise-questioning the benefits of puberty blockers for youth with gender dysphoria-a commentary on Rew et al. (2021)

This commentary is a critique of a recent systematic review of the evidence for the use of puberty blockers for youth with gender dysphoria (GD) by Rew et al. (2021). In our view, the review suffers from several methodological oversights including the omission of relevant studies and suboptimal analysis of the quality of the included studies. This has resulted in an incomplete and incorrect assessment of the evidence base for the use of puberty blockers. We find that Rew et al.'s conclusions and clinician recommendations are problematic, especially when discussing suicidality. A key message of the review's abstract appears to be that puberty blockers administered in childhood reduce adult suicidality. However, the study used for the basis of this conclusion (Turban et al., 2020) did not make a causal claim between puberty blockers and decreased adult suicidality. Rather, it reported a negative association between using puberty blockers and lifetime suicidal ideation. The study design did not allow for determination of causation. Our commentary concludes by demonstrating how the GD medical literature, as it moves from one publication to the next, can overstate the evidence underpinning clinical practice recommendations for youth with GD.

Two dilemmas for medical ethics in the treatment of gender dysphoria in youth

Both the diagnosis and medical treatment of gender dysphoria (GD)-particularly in children and adolescents-have been the subject of significant controversy in recent years. In this paper, we outline the means by which GD is diagnosed in children and adolescents, the currently available treatment options, and the bioethical issues these currently raise. In particular, we argue that the families and healthcare providers of children presenting with GD currently face two main ethical dilemmas in decision making regarding treatment: the pathway dilemma and the consent dilemma.

Reflections on the Clinician's Role with Individuals Who Self-identify as Transgender

The fact that modern patterns of the treatment of trans individuals are not based on controlled or long-term comprehensive follow-up studies has allowed many ethical tensions to persist. These have been intensifying as the numbers of adolescent girls declare themselves to be trans, have gender dysphoria, or are "boys." This essay aims to assist clinicians in their initial approach to trans patients of any age. Gender identity is only one aspect of an individual's multifaceted identity. The contributions to the passionate positions in the trans culture debate are discussed along with the controversy over the official, not falsifiable, position that all gender identities are inherently normal. The essay posits that it is relevant and ethical to investigate the forces that may have propelled an individual to create and announce a new identity. Some of these biological, social, and psychological forces are enumerated. Using the adolescent patient as an example, a model for a comprehensive evaluation process and its goals are provided. The essay is framed within a developmental perspective.

Gender incongruence and gender dysphoria in childhood and adolescence-current insights in diagnostics, management, and follow-up

Gender incongruence (GI) is defined as a condition in which the gender identity of a person does not align with the gender assigned at birth. Awareness and more social acceptance have paved the way for early medical intervention about two decades ago and are now part of good clinical practice although much robust data is lacking. Medical and mental treatment in adolescents with GI is complex and is recommended to take place within a team of mental health professionals, psychiatrists, endocrinologists, and other healthcare providers. The somatic treatment generally consists of the use of GnRH analogues to prevent the progression of biological puberty and subsequently gender-affirming hormonal treatment to develop sex characteristics of the self-identified gender and surgical procedures. However to optimize treatment regimens, long-term follow-up and additional studies are still needed. What is known • The prevalence of gender dysphoria increased significantly in the past years and can lead to significant complaints and burdens especially during puberty. • Pubertal suppression and gender-affirmed treatment can be effectively used in adolescence with gender dysphoria. What is new • Transgender mental and medical healthcare is a long-lasting process during which not only the child/adolescent with GI but also their parents/family have to be counseled in making choices about their social, medical, and legal transitions. • There are an increasing number of transgender persons defining as nonbinary. Therefore, an individualized approach by an experienced team is necessary.

Transgender medicalization and the attempt to evade psychological distress

In this paper the author argues that trans-identification and its associated medical treatment can constitute an attempt to evade experiences of psychological distress. This occurs on three levels. Firstly, the trans person themselves may seek to evade dysregulated affects associated with such experiences as attachment trauma, childhood abuse, and ego-alien sexual feelings. Secondly, therapists may attempt to evade feelings, such as fear and hatred, evoked by engaging with these dysregulated affects. Thirdly, we, as a society, may wish to evade acknowledging the reality of such trauma, abuse and sexual distress by hypothesizing that trans-identification is a biological issue, best treated medically. The author argues that the quality of evidence supporting the biomedical approach is extremely poor. This puts young trans people at risk of receiving potentially damaging medical treatment they may later seek to reverse or come to regret, while their underlying psychological issues remain unaddressed.