Nov. 29, 2021 -- Leading experts on transgender medicine are accusing trans activists of muffling their concerns about the quality of evaluations of adolescents and young adults with gender dysphoria.
While clinicians who have raised the warning flags say the health of young people is their primary concern, activists worry that open questioning of the situation will fuel the anti-trans legislation sweeping across the nation, and further stigmatize trans youth.
Others agree that it is time to take a closer look at the widely backed "gender-affirmative care" model and the quality of care being delivered, but they believe it should be done in the halls of academia, not through the lay press or on social media.
The latest skirmish was set off by comments made by Marci Bowers, MD, president-elect of the World Professional Association for Transgender Health and Erica Anderson, PhD, president of the U.S. Professional Association for Transgender Health.
The comments have drawn controversy because of their claim that some adolescents are experiencing what has been dubbed "rapid-onset" gender dysphoria. The term was first coined in 2018 by researcher Lisa Littman, MD, MPH, president of the Institute for Comprehensive Gender Dysphoria Research.
However, many researchers acknowledge the phenomenon that it describes: A huge increase in the Western world of teenagers and young adults suddenly expressing a transgender identity seemingly out of the blue, when previously there had been no indication that they were uncomfortable with their biological sex.
This phenomenon has also been called late- or adolescent-onset gender dysphoria. It is different from earlier descriptions of gender dysphoria, which was primarily observed in younger children.
‘We're Going to Have More Young Adults Who Regret...This Process’
In their comments, Bowers and Anderson (both of whom are transgender themselves) criticize the quality of assessments and care for children and adolescents experiencing gender dysphoria.
Anderson, a clinical psychologist, said that "due to some of the -- I'll call it just 'sloppy' health care work -- that we're going to have more young adults who will regret having gone through this process."
In an interview with, Anderson says she stands by the comments. "I'm concerned that there are some...providers of mental health [care] and medical providers who are not observing (official) standards of care and who may be less fully qualified to deliver care."
One of the "sloppy" things she says she's witnessed is providers "believing that the gender-affirmative approach is simply taking what the children say and running with it."
The "gender affirmative" approach for children with gender dysphoria means different things at different ages. In the case of kids who have not yet entered puberty, this might include prescribing so-called "puberty blockers" to delay natural puberty — these are drugs that block the hormones that will start puberty, which are licensed for use in excessively early (precocious) puberty in children, as well as for prostate cancer in men.
They have not been licensed for use in children with gender dysphoria, so any such use is so-called ‘off-label’. That is, the FDA has not approved these drugs for use in gender dysphoria.
Following puberty blockade, or in cases where adolescents have already undergone natural puberty, the next step is to begin "cross-sex" hormones. So, for a girl (female) who wants to transition to male, that would be lifelong testosterone, and for a male who wants to be female, it involves lifelong estrogen. Again, use of such hormones in transgender individuals is ‘off-label’ and is not approved by the FDA.
Many of these individuals also decide to undergo surgery, although this usually happens when they are legally adults (at age 18 and older). In the case of females-transitioning-to-male, surgery involves a double mastectomy --often called "top surgery" by transgender people-- to remove the breasts and give the chest the appearance of a male. Boys wishing to transition to female may get breast implants, although in many cases, estrogen causes enough breast tissue to grow.
So-called "bottom surgery" is more complex. For males-transitioning-to-female, it involves removal of the testicles and turning the penis inside out, to form a "neo-vagina". And for female-to-male surgery, it may involve a hysterectomy, removal of the ovaries, and a complex and multistage procedure called a phalloplasty, which involves removal of a large amount of skin, usually from the arm, to create a fleshy protuberance that is shaped like a penis.
A proper evaluation for gender dysphoria requires a comprehensive analysis of every young person, their journey, and a medical and psychological profile, Anderson stresses.
"To simply act as if a child is a reliable reporter about this area but not nearly every other area is preposterous," she says.
Anderson says she's not criticizing all providers or all transgender care.
But she's concerned "that in the haste which some, in my opinion, have exercised to provide gender care to youth...some providers are either ignoring what they know about adolescents, or they're setting it aside for the time being in the service of expediting care that's gender-affirming."
"It disturbs me a great deal, which is why I'm speaking out, even though I've incurred the ire of some people who think that just by speaking out I am causing problems," says Anderson.
Bowers, a gynecologic surgeon, has felt similar pressure. She said in her comments, "There are definitely people who are trying to keep out anyone who doesn't absolutely buy the party line that everything should be affirming and that there's no room for dissent."
She also said she was "not a fan" of administering puberty blockers during the middle of puberty.
Puberty blockers prevent genital tissue growth, which can make gender-affirming ‘bottom surgeries’ more difficult, for example for male to female transitions, because if a boy takes puberty blockers, his penis doesn’t grown to the size of an adult male, which makes it more difficult to form a ‘neo-vagina’ from it, Bowers says. This is what happened to Jazz Jennings, whose transition journey has been broadcast on television in the series, I Am Jazz.
Bowers is also worried that puberty blockers, combined with cross-sex hormones afterward, may impact children's "sexual health later and ability to find intimacy."
Bowers did not respond to requests for additional comment.
Discussions Should Be in Academia, Not on Social Media or in Lay Press
Some 8 days after the their comments were published, USPATH and WPATH issued a joint statement that it stood behind "the appropriate care of transgender and gender diverse youth, which includes the use of 'puberty blockers,'" and "the use of gender-affirming hormones such as estrogen or testosterone."
The two organizations also say they "oppose the use of the lay press, either impartial or of any political slant or viewpoint, as a forum for scientific debate of these issues, or the politicization of these issues in any way."
Jason Rafferty, MD, MPH, lead author of the American Academy of Pediatrics 2018 policy statement on caring for transgender and gender-diverse children and adolescents, said he agrees that discussions about the gender-affirmative care model should be held mainly among professionals.
He also acknowledged that "parents are coming to us with a lot of fear and trepidation about what's ahead."
Bowers’ and Anderson’s comments "played on some of those fears — that the future after gender-affirmative care is really scary," says Rafferty, a pediatrician and child psychiatrist at the gender and sexuality clinic at Hasbro Children's Hospital in Providence, RI.
Nevertheless, he says concerns voiced by Bowers and Anderson are "legitimate."
“The Brave Ones”
Anderson says that she and another psychologist, Laura Edwards-Leeper, PhD, are among the few willing to speak out.
"Others have dubbed Dr Edwards-Leeper and I the 'brave ones' because we're willing to talk about these issues," she says.
Anderson was, until October, a clinical psychologist at the Child and Adolescent Gender Clinic at the University of California at San Francisco. She says she resigned "to pursue other opportunities."
Edwards-Leeper is professor emeritus in the School of Graduate Psychology at Pacific University in Hillsboro, OR, and was on the American Psychological Association Task Force that developed practice guidelines for working with transgender individuals.
She is currently chair of the child and adolescent committee for WPATH.
Anderson and Edwards-Leeper have been criticized for speaking about their concerns, whether in a 60 Minutes broadcast in May that focused on detransitioners (individuals who transition to the opposite sex but then change their minds and 'detransition'), or in other forums.
The two psychologists recently submitted an opinion-editorial to The New York Times but it was turned down by the newspaper.
Even that was fodder for critics. "Please don't talk to anti-trans journalists because you're mad the NYT rejected your op-ed," tweeted Jack Turban, MD, a few weeks after the original comments appeared.
Turban is a child psychiatry fellow at Stanford University School of Medicine who specializes in the mental health of transgender youth, and he also writes op-eds for TheNew York Times. He did not appear to tweet directly at anyone, but his target seemed clear.
Is Gender-Affirmative Care Reversible?
Rafferty, from the American Academy of Pediatrics, believes that transitioning is not a "one-time decision," where "once they start, they're on this train that's left the station and they can't turn back, they can't change anything." He tells parents, "That's not the gender-affirmative care model."
The model says that with every visit the care is affirming, he says. "And if something doesn't feel affirming, to slow down, to explore it," Rafferty emphasizes.
Puberty blockers may be the right approach initially, but they can always be stopped if it's no longer the right tactic, he explains.
"At the end of the day, it's not about people being transgender, it's about people being really confident and comfortable in their body and their identity," he says.
The Endocrine Society, global community of thousands of clinicians from more than 100 countries says the American Medical Association, the APA, the Pediatric Endocrine Society, the European Society of Endocrinology, the European Society for Paediatric Endocrinology, and the AAP "are in alignment with us on the importance of gender-affirming care," which includes puberty blockers.
"Being forced to experience puberty consistent with the sex recorded at birth is extremely distressing for many transgender and gender-diverse individuals," the Endocrine Society says in a statement. That, in turn, can "result in higher psychological problem scores and can raise the person's risk of committing suicide or other acts of self-harm.”
It is, however, widely accepted that most children who take puberty blockers will progress to medically transition with cross-sex hormones.
Therefore, far from being reversible, puberty blockers appear to be a "one-way path" to medical transition, say critics.