Transgender Identity: Let's Look at the Science

Puberty suppression therapy through hormone intervention is increasingly being recommended for children with gender dysphoria and at younger ages. Advocates argue that puberty blockers may improve the mental health of transgender adolescents on the grounds that puberty can be "unbearable" for transgender teens.

A 2011 study that analyzed 70 adolescents who received puberty suppression between 2000 and 2008 found that behavioral and emotional problems and depressive symptoms decreased after the puberty blocking treatment. The study concluded that "puberty suppression may be considered a valuable contribution in the clinical management of gender dysphoria in adolescents."

Although advocates claim that puberty blockers are safe and reversible, others argue that it can do more harm than good.

Cretella told CP that puberty blockers have been associated with possible bone damage in young women, as well as obesity, and testicular cancer in men and cognitive deficits.

"More importantly, when a child is placed on blockers between the ages of 9 and 12, followed seamlessly (or concurrently) with cross-sex hormones (testosterone and estrogen), the child is rendered permanently sterile," she warned.

In a June 2017 report, Mayer, McHugh and Paul Hruz, associate professor of Pediatrics, Endocrinology and Diabetes at Washington University in St. Louis, warned that physicians and parents are endangering children when they expose them to puberty-blocking hormone therapy considering that it has not been adequately researched yet.

"[U]ntil controlled clinical trials of puberty suppression are carried out, this intervention should be considered experimental," the report states.

Hruz contended: "In essence, what is being done with these children is uncontrolled experimentation on them and they are not even being told that they are being experimented on. It is not presented in that way."

The scholars also noted that gender dysphoria in children does not often persist into adulthood.

In biological males, persistence of gender dysphoria has ranged from 2.2 to 30 percent, and in biological females, persistence has ranged from 12 to 50 percent, according to the American Psychiatric Association.

Mayer, who recently retired as professor of statistics and biostatistics at Arizona State University and scholar-in-residence at Johns Hopkins University, warned in an interview with CP that putting children through hormone therapy could almost eliminate the possibility that gender dysphoria will stop persisting into adulthood.

"The benefits are that you will have this person to be more comfortable in their identity," he said. "But what choice do you give a kid who has been without hormones for three years? And now, a lot of these kids may just go along. You are foreclosing on the chance for them to return to a gender identity consistent with their biological sex."

Sex Reassignment Surgery

According to the Encyclopedia of Surgery, the number of gender reassignment procedures conducted in the United States each year is estimated at between 100 and 500.

Transitioning to the opposite sex requires several surgeries.

For males transitioning to females, Cretella explained that one would need facial reconstruction, reduction of the Adam's apple, breast implants, surgical castration, and surgery to remove the penis and construct a "neovagina." The neovagina is "really just a pouch," she noted. Also, the urinary tract must be re-routed.

As for females looking to become men, Cretella explained that the the patient may obtain a double mastectomy (removal of breasts), hysterectomy (removal of all or part of the uterus), and an oophorectomy (removal of ovaries).

"But many only go through with the double mastectomy," Cretella noted.

She told CP that even though genital surgery is not recommended before the age of 18, some surgeons are performing procedures on patients of younger ages.

Although advocates say that hormone therapy and sex reassignment may improve the mental health of transsexuals, an extensive long-term study conducted in Sweden by scholars at the Karolinska Institute and Gothenburg University concluded that "persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population."

The study analyzed 324 sex-reassigned persons (191 male-to-females, 133 female-to-males) for over 30 years after their gender transitions from a period of 1973 to 2003.

"Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group," the study reads.

Cretella told CP that the Sweden study is "the best study we have."

"Initially, most subjects reported feeling relief and experienced improved social functioning. Beginning at 10 years out, however, rates of depression and anxiety began to rise significantly," Cretella said. "By 30 years following surgery the completed suicide rate was nearly 20 times that of the general population. Transgender activists are quick to point out that it is possible that transgender identified individuals denied surgery might experience even higher suicide rates (we do not have that data), but all experts agree that hormones and surgery are clearly not the cure many proclaim them to be."

Mayer and McHugh's 2016 report considered the Sweden study to be "one of the more robust and well-designed studies to examine outcomes for persons who underwent sex-reassignment surgery." However, "the study did not compare outcome variables before and after sex-reassignment surgery; only outcomes after surgery were evaluated."

In analyzing various reports and studies on whether reassignment surgeries have a positive effect on a transgender person's mental health, Mayer and McHugh concluded that a "skeptical view" should be taken "toward the claim that sex-reassignment procedures provide the hoped-for benefits or resolve the underlying issues that contribute to elevated mental health risks among the transgender population."

"While we work to stop maltreatment and misunderstanding, we should also work to study and understand whatever factors may contribute to the high rates of suicide and other psychological and behavioral health problems among the transgender population, and to think more clearly about the treatment options that are available," the report stated.