What’s at Stake?

This month’s Psychotherapy Networker focuses on trans youth. I was disappointed to see how uncritically the trans narrative was embraced. In this piece in particular, trans kids are applauded and celebrated as if there isn’t another side to this issue, as if something very, very serious isn’t at stake. The article is also full of bad science. I don’t know that I will have the energy today to cover all of this, but let’s get started.

“As social acceptance continues to grow, will we see an increase in the number of people claiming a trans or otherwise gender-nonconforming identity? Will we see a corresponding increase in those requesting body modification? The answer to the first question is unquestionably yes: as understanding and support expand, more people will come out. But the answer to the second question remains to be seen. As trans people change the definition of identity, some are making idiosyncratic choices with surgery and hormones. Some will modify their gender presentation, but not their bodies. Others will modify their bodies to create nonbinary bodies that match nonbinary identities. Tanner, the 20-year-old son of a friend, takes a low dose of testosterone and presents as male, but doesn’t plan to have either top or bottom surgery.”

Social acceptance of gender-nonconforming people is something we as professionals can generally support and feel good about.

But what about body modification?

In an upbeat, breezy tone, the author treats “body modification,” “surgery,” and “hormones” casually. Like, it’s no big deal to take a “low dose of testosterone” for decade upon decade. In fact, cross-sex hormones given to gender dysphoric young people are being used off label. Very little is known about the long-term effects of these drugs, and we are unlikely to know more for quite awhile.  Meanwhile, some of the potential effects of taking testosterone as a natal female, for example, are permanent or serious including: an increased risk for breast and uterine cancer; deepened voice; possible baldness; liver problems; and growth of facial hair. Surgery in this case refers to removal or modification of healthy tissue. There can be serious complications with such surgeries, and of course they are difficult or impossible to reverse, often resulting in sterility, depending on the procedure.

How is it ethical that we as professionals support and encourage young people in undergoing such treatments as a treatment for gender dysphoria? I would personally favor legislation making it very difficult for young people to access these treatments until they are in their late 20’s. I understand this would mean asking some people to live in a way that felt inauthentic or painful, but it would spare the pain that many might feel in the future when they wake up to realize they have permanently mutilated themselves.

We must be more critical of the assumption that medical intervention is the best option, that is it no big deal, that it is a choice to be celebrated for its “bravery.”

I know the next argument coming — what about suicide?

This question gets to one of the bad science moments in the article.”According to a 2011 survey in the United States, 41 percent of trans people had attempted suicide, as compared to 4.6 percent in the general population.”  This 41% statistic is frequently cited as a reason for ushering young people towards transition. In fact, the number comes from one study with fairly weak methodology. That figure is confounded by issues of co-existing mental illness and other issues. Perhaps most significantly, the study did not ask whether the attempts were made pre or post transition.

The following is a a quote from this blog post:

People who said they “did not want” these services had a lower self-harm rate. Does medical transition, or seeking transition services, decrease or increase suicide attempt rates? We don’t know, because the survey didn’t ask respondents if the self harm occurred before or after such services were soughtas the authors note:

The survey did not provide information about the timing of reported suicide attempts in relation to receiving transition-related health care, which precluded investigation of transition-related explanations for these patterns.

Upshot: The 41% is a questionable number to begin with. In any case, it isn’t clear whether transition helps or even worsens suicidality.

Let’s think first about doing no harm. Transition will remain an option in adulthood, after the prefrontal cortex has had time to develop. As clinicians and professionals, we do young people a disservice when we uncritically sing the praises of the “courageous” path of medical intervention.

2 thoughts on “What’s at Stake?

  1. Great blog. I’m so glad to have found it.

    “In any case, it isn’t clear whether transition helps or even worsens suicidality.”

    In fact, a study found that suicide was higher after SRS (http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885) and even the National Center for Transgender Equality seems to agree (http://www.transcentralpa.org/_content/downloads/Preventing_Transgender_Suicide.pdf).

    I can’t understand why the possibility that surgery is making suicide worse, for which there is at least some evidence, is always brushed aside in favor of the opposite assumption.

    Liked by 3 people

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