Who Put the Kids in Charge?
American physicians and psychologists increasingly must rubber stamp the self-diagnosis of "gender dysphoria" from children and teens
This is another in my occasional series on the trans industry.
The United States has one of the world’s most progressive standards of gender affirming care for minors. It requires that professionals, including physicians, therapists, and teachers, must confirm the self-diagnosis of children and young teenagers who believe they are a different gender than their birth sex. The judgment of children cannot be challenged. How did we get here?
It starts with a couple of words that are tossed about without most people knowing what they mean: Gender Dysphoria.
The term is only ten years old.
It was introduced as a treatable psychological condition in 2013 in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Healthcare professionals worldwide rely on the DSM as the authoritative guide to diagnose mental disorders. A dozen leading psychiatrists and mental health professionals worked for a year on developing the gender dysphoria diagnosis.
How was gender dealt with before 2013?
The first DSM published in 1952 did not mention the word gender. It did not appear until the 1968 second edition. That listed mental distress associated with gender identity as a “sexual deviation” in adults. The condition did not apply to children or adolescents.
Twelve years later (1980), the DSM third edition introduced transsexualism as a psychological disorder. That was defined as “a desire to live and be accepted as a member of the opposite sex…and a wish to have surgery and hormonal treatment to make one's body as congruent as possible with the opposite sex.” Patients had to exhibit the desire to be the opposite sex for two years before psychiatrists could make a conclusive diagnosis.
A revised DSM in 1987 (DSM-III-R), changed the disorder’s name from transsexualism to gender identity disorder (GID). It expanded the disorder to include people who did not want hormones or surgery.
The fourth major DSM published in 1994 kept gender identity disorder but again expanded the eligibility criteria to patients who exhibited “discomfort” with their birth sex and demonstrated “clinically significant distress or impairment in social, occupational, or other areas of functioning.”
When the fifth edition replaced gender identity disorder with gender dysphoria in 2013, it liberalized the criteria to include patients who exhibited a “marked incongruence between one's experienced/expressed gender and one's assigned gender.” The previous requirement for at least two years of symptoms before a diagnosis could be confirmed was slashed to six months.
And most importantly, in 2013, the disorder was applied for the first time to minors.
To make a diagnosis that an adolescent (ages 10 to 19) had gender dysphoria, in addition to the feelings of “marked incongruence” over gender, there had to be at least two from a list of ten symptoms:
A strong desire to be treated as the opposite gender or a desire to get rid of one's own sex characteristics
A strong preference for wearing clothes typical of the opposite gender
A strong preference for cross-gender roles in make-believe play or fantasies
A strong preference for the toys, games, or activities stereotypically associated with the opposite gender
A strong preference for playmates of the opposite gender
A strong rejection of toys, games, and activities typical of one's assigned gender
A strong dislike of one's own sexual anatomy
A strong desire for the primary and/or secondary sex characteristics of the opposite gender
A strong belief that one will grow up to have the primary and/or secondary sex characteristics of the opposite gender.
A strong desire to participate in the stereotypical games and pastimes of the opposite gender
As for children younger than 10, the DSM said they had to exhibit six of those symptoms.
While gender dysphoria was a frequently changing diagnosis in the psychiatric world, most professionals agreed that even in the instances in which it might be a correct diagnosis, it was a very rare occurrence. As little as .001 percent of the population had gender dysphoria that was accompanied with a desire for hormonal and surgical treatments.
The missing standard of care for adolescents and children
The 2013 DSM’s introduction of gender dysphoria — and its extension to adolescents and children — created a new world in medicine and psychiatry.
What should the standard of care be for the small number of cases in which doctors, therapists, or other professionals confirmed a diagnosis of gender dysphoria in children or young teens?
There were no guidelines for minors in 2013
A German-born endocrinologist who practiced in New York City, Dr. Harry Benjamin, had developed a protocol for cross-sex hormone therapy and for surgery for transgender adults who felt trapped in the wrong biological body. Benjamin is often called the father of modern transgender medicine [in a future article, I will write about the four endocrinologists and psychiatrists I call the Gods of Gender; Benjamin, John Money, Robert Stoller and Richard Green].
Benjamin was a strong advocate not just for international medical standards but also for gender affirming care for adults (also called “gender confirmation care”). He thought that in most instances, medical professionals should confirm the diagnosis as quickly as they could responsibly do so and then proceed to hormones and surgery.
Benjamin founded a medical association in 1979 to promote the treatment of gender dysphoria (it was called the Harry Benjamin International Gender Dysphoria Association (HBIGDA), renamed later the World Professional Association for Transgender Health (WPATH))
However, Benjamin had not addressed the issue of affirming care for minors in his professional writings. He did not treat minors in his clinical practice. Benjamin died in 1986, 27 years before the DSM introduced gender dysphoria and applied it to children and teens.
Still, many gender advocates contended that the same standards — gender affirming care for adults — should be applied to minors.
The organization Benjamin founded is today at the progressive forefront of interpreting gender affirming care and is essentially an advocacy group operating under the veneer of a medical guidelines association. Dozens of medical groups rely on the WPATH gender-affirming care guidelines, which have been updated eight times over twenty years. WPATH wields outsized influence on trans policies for adults and minors on the WHO, the American Pediatric Association, and the American Association of Clinical Endocrinology. LGBT advocacy groups rely on WPATH’s pronouncements on trans policies to lobby policy makers and the public that the science is settled.
That is false.
The science is anything but settled.
There has never been a double-blind clinical trial, medicine’s gold standard, for determining the short-term safety and long-term consequences of puberty blockers or cross-sex hormones for minors. There are no large-scale studies tracking patients who were given puberty blockers, or cross-sex hormones, or surgical interventions as children to determine if they were satisfied or unhappy with their gender decision.
The Dutch Model and the Introduction of Puberty Blockers
Although gender dysphoria was not a recognized condition that might apply to minors until 2013, the Netherlands had pioneered the concept of hormone blockers to what it called “juvenile transsexuals” in 1998 (many doctors still call it the Dutch Model.) It was developed by three Dutch clinicians based on observations of a handful of patients (only 7 children under the age of 16 had been put on puberty blockers by 2000). The researchers subjectively concluded hormone blockers reduced gender dysphoria agitation (they omitted that one teen died after puberty suppression and a vaginoplasty). Without any clinical research to support their conclusions, the trio claimed that puberty blockers were “completely reversible….in other words, no lasting undesired effects are to be expected.”
A later British study designed to confirm the Dutch results was withheld for years from publication because it did not show psychological improvement and enhanced mental health for the minors. American studies that have attempted to reinforce the Dutch Model have been of poor quality and produced mixed and poor results.
The Drug Industry Money behind the Dutch Model
Two of the original Dutch researchers in 2006 published a paper in the European Journal of Endocrinology. They concluded that puberty blocker “treatment appears to be an important contribution to the clinical management of gender identity disorder in transsexual adolescents.”
Largely ignored in a footnote in their acknowledgments was: “The authors are very grateful to Ferring Pharmaceuticals for the financial support of studies on the treatment of adolescents with gender identity disorders.” The study’s authors had presented their paper in Paris at the 2006 Ferring Pharmaceuticals International Pediatric Endocrinology Symposium.
Why did Ferring pay for the study? It had a patent on Triptorelin, one of the most expensive puberty blockers, used under the brand names Gonapeptyl and Diphereline. The study recommended puberty blockers for gender dysphoric children identified “by the first growth of pubic hair and for girls by budding breasts and for boys by growing testicles—as long as they had reached the age of 12…” The study recommended that cross-sex hormones not be dispensed before the age of 16.
Two of the Dutch researchers were leading advocates for expanded transgender treatment and served as directors of the Harry Benjamin International Gender Dysphoria Association (HBIGDA). When HBIGDA adopted puberty suppression as a recommended standard of care for minors in 2006, it copied it from the Dutch protocol, with the exception that it did not specify a minimum age.
Puberty blockers were prescribed to 111 minors between 2000 and 2008 (70 of them were the subjects of a much-challenged study published by the Dutch researchers, again confirming their own hypothesis.
Not very many clinicians adhered to the liberal Dutch rules. Some children were given endocrinological exams as young as ten. Cross-sex hormones were dispensed to children as young as thirteen.
America’s Permissive Gender Guidelines for Children
The Gender Management Service at Boston Children’s Hospital, founded in 2007, was the first dedicated clinic for transgender minors in America. Its co-founder, Norman Spack, was an endocrinologist who once said he was “salivating” at the possibility of treating his minor patients with puberty blockers. The Boston clinic followed the Dutch protocol, although it did not set a minimum age under which it would not prescribe the drugs. One of the Boston psychologists was dispatched to Amsterdam to be trained by the Dutch lead author.
When the Endocrine Society leadership decided it was necessary to address the first clinical guidelines for “transsexual persons,” it tapped the two primary Dutch authors and Boston’s Spack to lead the committee. It is not surprising that their recommendation was an endorsement of puberty blockers for gender dysphoric children. This formal endorsement by a leading medical society moved the medicalization of children forward.
Within a year of the DSM listing gender dysphoria as a treatable diagnosis for adolescents, the number of clinics specializing in “gender-nonconforming children and adolescents” had skyrocketed from the single Boston clinic to 32 (as of 2023, there are 60 clinics dedicated solely to gender affirming care for minors, and about 350 more that are clinics or medical offices that offer hormonal interventions for children and adolescents).
The U.S. clinics have adopted the most permissive interpretations of the Dutch protocol, everything from the starting ages to the duration of treatment. An international advocacy organization, the Gender Identity Research and Education Society, told parents who lived in Europe that if they wanted their gender dysphoric children to receive puberty blockers, that they should “consider taking their children to the USA.”
American gender clinics have expanded the boundaries of gender affirming care for minors. Children as young as 3 have been treated at Yale’s Pediatric Gender Program. U.S. clinics sharply downplay the role of psychotherapy that had been suggested by the Dutch as a parallel standard of treatment. The Dutch clinicians had also tried reducing the number of false positives, those children whose desire to change their birth sex was a “transient phase” that would pass before they reached 18. To avoid putting those children for whom gender dysphoria was a fleeting stage of adolescence, the Dutch discouraged early social transitioning of minors (such as using the child’s new pronouns and names). However, American clinics, and many U.S. school districts have instead made social transitioning the accepted standard.
The American approach is to put children on hormone blockers at ever younger ages, preferably before they start puberty. That is the only guarantee, contend advocates, for a less complicated series of surgeries for those who ultimately decide to cosmetically transition. It turns out that putting children on puberty blockers assures they will at least move on to cross-sex hormones. Ninety-five percent of minors on puberty blockers go on to further cross-sex hormones or surgeries. However, a study shows that upwards of 90% not taking puberty blockers change their minds and remain with their birth sex. A Canadian study by a psychologist running a gender dysphoria clinic, meanwhile, showed that without pharmacological or surgical treatment, approximately 80% of trans patients went on to identify as having a same-sex attraction.
The liberal U.S. approach has had a stunning effect on the number of minors put on hormones. A review of data at 43 major children’s hospitals shows that puberty blockers were never dispensed to minors from 2004 to 2009; from 2010 to 2016, 92 children were put on them. A larger study of all insurance claims filed for patients aged 6 to 17 in the U.S from 2017 and through 2021, reveals that almost 5,000 were put on puberty blockers, and another 15,000 skipped puberty blockers and went directly to cross-sex hormones.
Even one of the original Dutch clinicians who helped develop the protocol for giving puberty blockers to children, Dr. Thomas Steensma, expressed his concern in 2021 that the “rest of the world is blindly adopting our research….We just don’t know. Little research has yet been done on the treatment with puberty inhibitors and hormones in young people. That is why it also seen as experimental.”
What is Gender Affirming Care for Minors?
Gender affirmation is the standard of care adopted in 2018 by the American Academy of Pediatrics, the world’s largest association of doctors who treat children and adolescents. The American Psychological Association has similarly embraced “culturally competent, affirmative care for transgender and gender nonconforming people, including adolescents.” The Human Rights Campaign, one of America’s most influential LGBTQ+ lobbying groups, with 3,000,000 members, declares that gender affirming care is a medical necessity when it comes to gender dysphoria.
Gender affirming care covers a broad range of treatment options but always involves a confirmation of gender dysphoria by doctors, psychiatrists, and other medical and mental health professionals.
A pediatrician who prefers to stay anonymous shared with me guidelines he received from the large urban hospital with which he is affiliated: “Gender identity is a deeply personal and subjective experience, and individuals should be respected and believed whenever they reveal their gender identity. Therefore, it is generally considered best practice for healthcare professionals to validate and affirm the gender identity of their patients who are seeking gender affirming care. Your role is not to invalidate or question a patient's gender identity but instead to provide compassionate and respectful care that addresses the patient's individual goals. While a formal diagnosis of gender dysphoria is helpful for the patient’s access to full medical services, it should not be a prerequisite for patients who wish to obtain gender affirming care. The decision to seek gender affirming care should therefore be made by the individual based on their own life experience and needs.”
A particular problem with gender affirming care is that it is at odds with therapeutic exploration. It requires that therapists only confirm a minor’s self-diagnosis of transgender and facilitate their access to hormones and surgeries. The professionals cannot question whether the gender dysphoria is a “transient phase” or possibly the result of an underlying mental disorder. To do so would be to question the self-diagnosis, and that is forbidden. In lay talk, that means that professional discretion is eliminated.
This is one issue when it concerns adults, but quite another when children and teens are involved.
When minors self-diagnose with gender dysphoria, however, there is a unique preliminary medical intervention: the dispensing of hormones that block puberty. The idea is that if the birth sex hormones of a prepubescent child are blocked before a child later begins cross-sex hormones, any full transition to the opposite sex will supposedly be easier (no long-term studies have been done, it is a theory that has been put into standard practice).
Administering puberty blocking hormones is problematic because the process has evolved in America so that in many cases, children are making decisions about starting a process with lifelong consequences.
Who Put the Kids in Charge?
All this might be written off as another contagion from social media that affects teens at their most vulnerable time of lack of self-confidence and in a state of brain development where they have little control over impulsive behavior or are not fully appreciating the magnitude of decisions that have life-long consequences.
In interviews with several psychologists who have studied the field, I learned that adolescents cannot fathom risk. They cannot digest long-term consequences; they can only appreciate the gratification from something immediate. Children, especially adolescents, are susceptible to the pressure and influence of their peers, and the outside world has a huge, overdetermined impact on their development.
Social media and internet chatrooms that target children and teens who think they might have gender dysphoria have created a confusion matrix. With more than 100 genders available from which to choose, adolescents and children seem particularly susceptible to the contagion of believing they might be trapped in the wrong body. Experts who visit schools and study trends among minors have observed startling increases, especially among teen girls. Ten years ago, one percent might have talked about gender, now, in some schools upwards of 20 percent of teen girls identify as being the opposite gender.
The social media influence creates a false sense that the child has made a reasoned decision.
“If you're Johnny and you want to be Julie,” a Miami Beach-based psychologist told me, “and parents say, ‘Oh, okay,’ the child gets a charge from that response. Forget the content for a moment. The charge of that response is what kids will react to; hang on to it, it becomes an artificial structure. It's no different than being fed all the increasingly lurid and damaging YouTube or TikTok videos. Children are hypersensitive to external stimuli, and it pulls kids out of themselves, and then they're doing it just to again get the attention that their parents gave them when they said, ‘I want to be Julie.’ Many parents and professionals go along because it is, like a cult phenomenon. They are being bombarded with a particular type of narrative over and over and over again.”
These are the reasons society does not allow teens to get tattoos or buy guns. That is why car rental agencies make twenty-five the minimum age for renting a car; Sweden has twenty-five as the minimum age to decide on sterilization. The brain doesn’t stop its pruning and settle into something that has a degree of reliability before then.
Gender dysphoria is the only area of mental health in which patients are allowed to diagnose themselves, and physicians and psychologists are barred from making any independent medical judgment.
Those who present themselves to doctors or psychiatrists and announce they have depression, anxiety, or schizophrenia are never accepted at their word. But that is precisely what happens under gender affirming care for children and teens.
Failing to fully “affirm” in some countries will land a doctor in professional disciplinary proceedings. In some instances, doctors who refuse to go along with a process they believe is not in the best interests of the children because it is contradicted by science have been dismissed from their jobs and professionally ostracized as transphobic.
Doctors, psychiatrists, and psychologists are not the only ones who can get into trouble if they do not affirm the gender dysphoria presented by a minor. Parents who say no to their children are at risk in some places, such as Sweden, of losing their children to state control. Sweden’s Board of Health and Welfare can place a child into state custody if any third party reports the parents for refusing to approve puberty blocker treatment. Until recently, Karolinska Hospital, Sweden’s medical clinic for treating those aged 17 and younger who self-diagnose with gender dysphoria, had an online, pre-printed template for a report to be filed against resistant parents. A hospital official told reporters that “We refuse to see any children without their guardian’s approval.” That guardian can be the government.
The state of Washington has not let Sweden get too far ahead of the progressive gender trend. Parents who do not affirm and provide treatment for their child's gender choice will be legally at risk of losing custody due to “neglect.”
Oregon bypasses parents. A 2015 law permits 15-year-olds to get puberty blockers or start gender reassignment surgery without parental consent. Fifteen is the same age in Oregon where teens do not need parental consent to get birth control, have a pregnancy test, and get an abortion. Oregon does, however, ban teens until they are 18 from buying cigarettes and marijuana, voting, getting a tattoo, or using a tanning bed.
“It is the greatest medical scandal since lobotomies”
The United States has moved far beyond the Dutch standard of care, in which no surgeries were offered to patients younger than age 18. In contrast, an NIH-funded study reveals that minors as young as 13 can get mastectomies in the U.S. There are instances in which children as young as 12 have started crowdfunding to raise money for surgery. A recent US-based study shows that the average age for mastectomy in minors — dubbed “masculinizing chest surgery” — is 16, with a range of 14-18. A recent Vanderbilt University study found that the number of radical mastectomies performed on teen girls had surged fivefold in recent years.
At Vanderbilt itself, double mastectomies were performed on girls from 16 to 17 years of age. The clinic also provided cross-sex hormones, which can lead in some instances to lifelong sterilization, to kids as young as 13.
California’s Kaiser Permanente Oakland recorded 70 “top surgeries” in 2019 on teenagers between the ages of 13 and 18. Before that, it had only performed five in total since 2013, according to a study.
Until a recent Florida law banned it, Dr. Sidhbh Gallagher, a Miami-based plastic surgeon, performed 40 “top surgeries” per month, including on minors, according to The New York Times. Most patients, she told the Times, were 15 or older, but she admitted she had done the procedure on children aged 13 and 14. Since the Florida law came into effect, she has moved on to so-called bottom surgeries, such as vaginoplasties and phalloplasties.
“It is the greatest medical scandal since lobotomies,” a British physician told me.
It is worth noting that in the last couple of years, the U.K., Finland, and Sweden have all stopped or radically cut back on medical transition of minors. Their retrenchment is the result of a spate of recent studies that have concluded that while the medical interventions have little demonstrable benefit, the potential for lasting harm is not fully known.
When will United States medical associations responsible for treating children follow the lead of progressive European nations and stop embracing the cult of transgender ideology? How many more thousands of children will suffer from getting hooked on the trans contagion will depend on that answer.