A Mostly Compressive Defense Of Gender-Affirming Care
3 Nov 2022
Gender transition is the process a transgender person takes to align their body and expression with their gender identity. Transition is often driven by gender dysphoria which is a sometimes severe discomfort felt by transgender people over their body or gender roles. Transition generally improves the well-being of transgender people and is a goal for many of them.
Transgender people will sometimes undergo medical transition where they use gender-affirming care. Gender affirming can care consists of:
Hormone therapy which helps align someone's secondary sex characteristics with their identity.
Surgery which helps align someone's physical features with their identity.
Puberty blockers which are mostly reversible and temporally halt puberty for transgender youth to stop gender dysphoria and give them more time to decide on a path forward.
Gender affirming has been shown to improve the well-being and mental health of transgender people along with being shown to decrease depression, gender dysphoria, and suicide rates. Gender-affirming care is supported by medical evidence and medical organizations, it's sometimes considered medically necessary. There are also guidelines developed by experts to ensure gender-affirming care is safe and effective. These guidelines are particularly important for treating transgender youth.
Notwithstanding the evidence, gender-affirming care has recently been under attack by the right and anti-transgender activists. These attacks often consist of trying to ban the care for transgender youth or removing coverage of the care. These attacks are not supported by the majority evidence or medical groups and pose a threat to the health of transgender people.
This article will include the arguments and evidence in favor of gender-affirming care along with rebuttals to common objections to it, all sources are below the article.
It's supported by major medical groups
Many major medical groups that represent hundreds of thousands of doctors support access to gender-affirming care and the evidence that it works. Some of these groups include the American Medical Association, the American Academy of Pediatrics, the American Psychiatric Association, the Endocrine Society, and the World Professional Association of Transgender Health.
For example, The American Medical Association said, "Research has demonstrated that improved body satisfaction and self-esteem following the receipt of gender-affirming care is protective against poorer mental health and supports healthy relationships with parents and peers. Studies also demonstrate dramatic reductions in suicide attempts, as well as decreased rates of depression and anxiety." They also said in response to bills attacking care for transgender youth, "The AMA views these bills as a dangerous legislative intrusion into the practice of medicine ..."
These views are shared by other groups like The American Academy of Pediatrics which said, "The American Academy of Pediatrics recommends that youth who identify as transgender have access to comprehensive, gender-affirming, and developmentally appropriate health care that is provided in a safe and inclusive clinical space."
Also, during a lawsuit against a law that Alabama had passed criminalizing gender-affirming care for transgender youth more than 20 medical groups wrote signed a brief opposing the law. They cited reasons like the fact guidelines and assessments exist to make care safe and provided evidence to back up their claims. The Alabama law is currently blocked from going into effect.
One might object to these points by arguing that medical groups in some countries oppose gender-affirming care. While it is true that other places have different and sometimes more restrictive guidelines, no western country has banned the practice, and medical groups in western countries are generally supportive of it. For example, national medical groups in countries like Sweden, England and Finland that are sometimes cited by opposition to gender-affirming care don't oppose the practice.
In conclusion, the medical community currently views gender-affirming care as an effective way to improve the lives of transgender people and opposes actions taken to limit it that aren't in line with guidelines.
There is evidence that it works
There is a decent evidence base showing gender-affirming care works (though more research would certainly be helpful). It shows that gender-affirming care of all types has a positive effect on mental health, decreasing things like gender dysphoria, depression and suicidal thoughts or suicide attempts.
In a literature review on gender-affirming care that looked at 55 studies, 51 of the studies showed gender-affirming care worked while only 4 showed it has mixed results. None of the studies showed care was harmful. The authors stated, "The scholarly literature makes clear that gender transition is effective in treating gender dysphoria and can significantly improve the well-being of transgender individuals," though they also called for more research to further characterize and confirm these findings.
Some other studies include:
A study from Canada that analyzed the suicidal ideation and attempt rates of transgender people, found that someone transitioning was linked to drops in both.
A study in the UK found the same thing as the previous study, that transition was linked to lower suicidal ideation and suicide attempt rates for transgender people.
A study, which did a review on research about gender-affirming surgery found that it often "[leads] to multiple, significant psychological benefits among individuals with gender dysphoria."
A study looking at puberty blockers found they led to fewer emotional problems and depressive symptoms along with significantly improved general functioning, it did not find changes in gender dysphoria or anxiety.
A long-term study found that transition led to improvements.
A large-scale study looking at transgender youth and gender-affirming hormone therapy found it as associated with lower odds of suicidal thoughts, suicide attempts, and depression.
A review of 27 studies on gender-affirming surgery that found less than 1% of patients regretted it.
In conclusion, while more research to further support findings would be great, gender-affirming care currently looks like the best way to support transgender people. It looks like it increases well-being and decreases mental health issues. None of these studies are what you'd expect to find if the opposite was true. Also, in many cases not providing gender-affirming care is often not a neutral option. For example, not providing puberty blockers could lead to the development of permanent unwanted characteristics that could harm a person's well-being through gender dysphoria, though this does not mean puberty blockers should be automatically prescribed.
Guidelines and screening exist to keep it safe
Guidelines are put in place to ensure gender-affirming care is done safely and effectively. While there is no single set of guidelines, they all share many similar things. This article is based on the most widely recognized guidelines issued by The World Professional Association of Transgender Health.
Before being able to access treatment patients are often evaluated and have to meet certain criteria, this is the opposite of what many critics of gender-affirming care claim.
When treating transgender youth these guidelines are particularly important. For an adolescent to receive care some of the guidelines that have to be met are having been diagnosed with gender dysphoria which would mean going through phycological screening, having gender clear incongruence that is sustained over time and being fully informed of possible risks along with being in the right mental state to make informed decisions. While transgender youth are being treated or considering treatment they also generally get therapy or counseling. All of this is generally done with the involvement of the adolescent's parents or guardians.
Another guideline that makes puberty blockers safer for youth is only being able to start the blockers after experiencing early physical changes of puberty. This allows experts to see if gender dysphoria gets worse when going into puberty which is a common sign that the gender dysphoria will be sustained, this prevents people who would have regretted the care or would have been better without it from getting blockers.
Many of these guidelines also exist for transgender adults so they can receive safe and quality treatment (though an informed consent system is probably better in this case).
Also, during treatment transgender people are closely watched for possible side effects so interventions can be made.
Detransition and regret
One of if not the most common arguments against gender-affirming care, especially gender-affirming care for youth is that people will regret it. Detransitioners, people who transition back to their assigned gender are often brought up. However there is a fatal flaw with this argument, detransition and regret are quite rare.
Most studies that looked at detransition and regret found it to happen to only a few percent of people. For example, a study of transgender kids who socially transitioned found only 2.5% no longer were transgender after 5 years. Another study, which did a literature review of 27 studies of people who got gender-affirming surgery found the rate of regret to be less than 1%.
Another important thing to mention is that in many cases detransition is not caused by someone not being transgender. Detransition can happen due to other factors like social pressures and transphobia or economic reasons. One survey found that only 9% of people said their reason for detranstion was because, "Gender Transition Was Not Right For Them," and only 4% said it was because "Transition Didn’t Reflect the Complexity of their Gender Identity." All the other factors were external. However, the number of people who transition because their dysphoria subsides is likely higher because the survey was targeted at transgender people, but remember this does not change the face detransition is overall quite rare.
To recap, regret and detransition are quite rare and even when detransition happens it sometimes happens because of external factors.
One argument against gender-affirming care for transgender youth specifically is that youth would be better off without care. This is because youth without care would have their gender dysphoria resolve naturally, this is called desistance. However, this argument has 2 big flaws.
First, desistance rates seem to be exaggerated. Serval studies that claimed to find high desistance rates (around 80%) had major problems. For example, some of the studies included youth who would not even be eligible for gender-affirming care or meet the modern definition of gender dysphoria and others took youth who could not be contacted at the end of the study and put them in the desistance group.
Another possible problem with high desistance rates is that some transgender youth may de-desist meaning they would go back to being transgender or having dysphoria. While these cases don't appear super common and a lot more research is needed to verify and characterize de-desistance, this does seem to be a small point against the notion of very high desistance rates.
However, despite desistance probably being exaggerated it certainly exists. Despite this, doctors recognize this concern and have ways of dealing with this issue and that brings us to the second problem with the desistance argument.
This problem is that we have ways for differentiating desisters and persisters so that most youth who get care would have persisted.
One way of doing this is by looking at the severity of gender dysphoria, more severe gender dysphoria is associated with persistence, and treatment is generally only given to youth with more severe gender dysphoria. Another way of combating issues with desistance is only starting treatments after the changes of puberty have begun. Research has shown that the start of puberty is a key time in determining if a kid will desist or persist. Some types of phycological screening could also help to see if a kid will desist or persist.
Another thing worth noting is that people have argued that being transgender is not a negative outcome, especially if the mental health concerns often associated with being transgender can be dealt with.
To conclude, it seems likely that desistance is exaggerated and guidelines exist to stop desistance from being a problem in treatment.
Many drugs can have side effects and drugs involved in gender-affirming care are no different, but just because a drug can have side effects does not mean it can't be beneficial if used properly. Patients are fully aware of possible side effects before treatment starts and discuss the risks and befit of treatment with medical experts. Patients are also closely monitored during treatment so that any side effects that do appear can be dealt with. So while side effects do exist they are not exclusive to gender-affirming care, patients are fully informed of them and side effects are dealt with if they do appear.
The theory that being transgender is caused by a social contagion is not backed up by data and is not a good argument against gender-affirming care. If gender-affirming care is the best way of supporting transgender people then the reason why someone is transgender should not matter. The issues with the social contagion theory have been covered elsewhere.
Transition is rushed
One concern with gender-affirming care sometimes levied against transgender youth is that people are rushed into transition. This is not true, the often opposite is. Before getting treatment people, especially adolescents have to go through a long process of screening (to be clear, while screening is helpful in many cases, we are not endorsing needlessly long systems that cause harm like the NHS).
In some gender clinics, there can also be waiting lists. These lists have drawn criticism from transgender people because they can be so long, some people can spend years in them.
For transgender youth in particular, puberty blockers can be provided. These blockers provide youth more time to consider transition and allow them to go back if necessary, if the goal of gender-affirming care was to rush people though then this would not be the treatment model.
One common claim people make against gender-affirming care is that it's child mutilation. This framing is flawed for multiple reasons. First of all, gender-affirming surgery does not happen with children and generally only happens with older teens.
On top of that, many things have to happen for a transgender adolescent to access surgery. On top of in-depth phycological screening and needing sustained gender dysphoria, transgender youth generally have to go through a year or more of hormone therapy to get access to surgery. This waiting period also gives transgender youth and their parents or guardians to assess whether surgery is the right path forward. Discussions are also held with patients on the side effects and risks that come with surgery. All of this is reflected in the fact that surgery for transgender youth is very rare.
Gender affirming surgeries are also seen to be benifical if given in the right cases.
These points don't directly address the effectiveness of gender-affirming care but still prove some sort of point.
No medicine is perfect, including gender-affirming care, just because an issue exists does not mean the entire program has to be scraped. Politicians need to let doctors and experts do their job and continue to improve gender-affirming care while fixing any problems instead of jumping to ban the whole system to gain votes.
Essentially all bills introduced to ban gender-affirming care for youth, at least in the United States have exceptions for nonconsensual surgery on intersex kids. Intersex people are people born with variations in sex development. These procedures which are not medically necessary or address medical issues aim to "fix" intersex babies' genitals by making them conform more to gender stereotypes. These surgeries, which are controversial and can harm intersex people are being increasingly opposed by experts and human rights groups.
So why are exceptions for these surgeries built into bans on gender-affirming care if they are all about protecting kids?
Treatments aren't exclusive to transgender people
Many treatments given to transgender people and youth are also given to cisgender people with less controversy and political backlash. For example, puberty blockers are used in youth to treat early puberty and hormone therapy is used to treat symptoms of menopause and fight cancer among other things.
Gender-affirming care is a useful tool for transgender people that's effective and safe if administered within guidelines along with being supported by evidence and medical organizations.
(Medical Disclaimer: for legal reasons this article is for educational purposes only and is not professional medical advice)
CORRECTION (23 Nov 2022): Two changes were made to the detransition part. A duplicate study was removed, and a limitation of that study was added to make sure the section was accurate.
Major medical groups
Evidence that it works
Guidelines and screening
Detransition and regret
Transition is rushed
Treatments aren't exclusive to transgender people