Dianna Kenny

Tuesday, 15 October 2019 14:19

In 2009, South African athlete Caster Semenya won, by a margin of 20 metres from her nearest rival, the women’s 800m event at the athletics world championships. Her victory was short-lived.

Allegations arose that Semenya was “really a man.” The 18-year-old from an impoverished village on the Limpopo River in South Africa became the unwitting subject of an international media outcry that included the release of her private medical details without her consent.

In the past decade, sporting authorities have subjected Semenya to repeated physical and psychological assessments, suspended her from competing, allowed her to return to competition, introduced new rules that tried to regulate her inconvenient physiology and battled to uphold those rules in court.

Semenya continued to excel in the 800m event, when she was permitted to compete, and won another world championships in 2017 as well as gold at the 2012 and 2016 Olympic Games. The existence of athletes like Semenya, whose biological make-up is ambiguous creates complex medical and ethical dilemmas for sporting authorities. In addition, and of relevance to this paper, are the contradictory stances taken by regulatory bodies regarding the ingestion of testosterone and other sex hormones, a practice now widely applied to gender dysphoric children and adolescents.

In April 2018 the IAAF (International Association of Athletics Federation) introduced new eligibility regulations for female classificationofathletes with Differences (Disorders) of Sexual Development (DSD), including hyperandrogenism,defined as those with levels of circulating testosterone of five (5) nmol/L or above and who are androgen-sensitive, for events including the 400m to one-mile races and combined events over the same distances (‘Restricted Events’). 

The regulations require such athletes to meet three criteria to be eligible to compete in Restricted Events in an International Competition. They must:

(a) be recognised at law either as female or as intersex (or equivalent);

(b) reduce their blood testosterone level to below five (5) nmol/L for a continuous period of at least six months (e.g., by use of hormonal contraceptives); and

(c) maintain their blood testosterone level below five (5) nmol/L continuously (i.e., whether they are in or out of competition) for as long as they wish to remain eligible to compete.

IAAF President Sebastian Coesaid the regulations were necessary to 

…ensure a level playing field…testosterone, either naturally produced or artificially inserted into the body, provides significant performance advantages in female athletes. The revised rules are not about cheating, no athlete with a DSD has cheated, they are about levelling the playing field to ensure fair and meaningful competition in the sport of athletics where success is determined by talent, dedication and hard work rather than other contributing factors.”

Most females, including elite female athletes, have low levels of testosterone circulating naturally in their bodies (0.12 to 1.79 nmol/L in blood); after puberty the normal male range is 7.7 – 29.4 nmol/L. No female would have serum levels of natural testosterone at 5 nmol/L or above unless they have DSD or a tumour. Individuals with DSDs can have very high levels of natural testosterone, extending into and even beyond the normal male range.

High levels of endogenous testosterone circulating in athletes with certain DSDs can significantly enhance their sporting performance. These Regulations accordingly permit such athletes to compete in the female classification in the events that currently appear to be most clearly affected only if they meet the Eligibility Conditions defined by these regulations.

About seven per 1000 elite female athleteshave elevated testosterone levels, the majority of whom compete in restricted events. This rate is 140 times higher than rates in the general female population. Treatment is equivalent to taking the contraceptive pill. 

Female athletes who do not wish to lower their testosterone levels will still be eligible to compete in:

(a) the female classification:

(i) at competitions that are not international competitions: in all track events, field events, and combined events, including the restricted events; and

(ii) at international competitions: in all track events, field events, and combined events, other than the restricted events; or

(b) in the male classification, at all competitions (whether international competitions or otherwise), in all track events, field events, and combined events, including the restricted events; or

(c) in any applicable intersex or similar classification that may be offered, at all competitions (whether international competitions or otherwise), in all track events, field events, and combined events, including the restricted events.

The regulations, it is claimed, exist to ensure fair and meaningful competition within the female classification, for the benefit of all female athletes.  As an afterthought, the IAAF stated that they do not question the sex or gender identity of any athlete.

Doping, historically considered the greatest challenge to the integrity of sporting competitions, was defined in 1999 by the Lausanne Declaration on Doping in Sport as “the use of an artifice, whether substance or method, potentially dangerous to athletes’ health and/or capable of enhancing their performances, or the presence in the athlete’s body of a substance, or the ascertainment of the use of a [prohibited] method.” 

Since the introduction of females into elite sport competitions in 1900, two other threats to the integrity of sport have arisen: sex fraud and transsexualism in sport. Ironically, the discovery that some male athletes “masqueraded” as women during the 1936 Olympics resulted in the IAAF taking the extreme measure of requiring all female participants in the 1966 European championships to parade naked in front of a panel of doctors to prove their “femininity”. In 1968, the IOC (International Olympics Committee) required proof of gender before female athletes could participate in the Mexican Olympics. 

Gender testing ceased at the Sydney Olympics in 2000. A number of reasons were cited, including the fallibility of screening tests, uncertainty about how to manage intersex athletes and those born with rare genetic abnormalities such adrenal hyperplasia, 5-alpha-steroid–reductase deficiency, partial or complete androgen insensitivity, chromosomal mosaicism, the stigmatization and trauma of those who find out they have a DSD through testing, and the inability to prove that such athletes do in fact have a competitive advantage. 

Now let us return to Caster Semenya. Between 2011 and 2015, Caster took hormone suppressants to reduce her testosterone levels. During this period, her times for the 800 metres slowed by between one and two seconds but she still managed to win gold in the 2012 Olympic games. Nonetheless, her legal team argued, based on expert opinion, that were Semenya to permanently reduce her testosterone levels, she would run the 800 metres seven seconds slower than her current event-winning times which would place outside contention for a medal or world record.

In February 2019, Caster took the IAAF to the Court of Arbitration in Sport (CAS) on the grounds of discrimination, requesting that the DSD Regulations, which apply only to female athletes who are legally female, have 46XY, DSD, and testes, who are androgen-sensitive and have circulating testosterone above 5nmol/litre be declared invalid and void. (Note: The regulations do not apply to female athletes with 46XX chromosomes, even if they have elevated testosterone levels). The CAS ruled that the DSD Regulations

…were discriminatory but…such discrimination …was a necessary, reasonable and proportionate means of achieving the IAAF’s aim of preserving the integrity of female athletics in the Restricted Events.

The CAS further upheld the requirement of the IAAF that female athletes with excess testosterone must lower their levels in order to compete. Semenya’s legal team countered that the IAAF’s requirement for athletes with DSDs to take hormone suppressants to reduce testosterone is ethically wrong and potentially poses a health risk. Why, then, is it not ethically wrong and potentially dangerous to reduce testosterone in gender dysphoric male adolescents? 

Julian Savulescu, Professor in Biomedical Ethics, outlined 10 ethical flaws in the decision regarding Caster Semenya arguing that although Caster is intersex, she is a female by virtue of her gender identification.Since medical, social and legal opinion now supports the replacement of sex determination with gender self-identification for the community at large, with such opinions being progressively enshrined in legislation, why does this standard not apply to intersex athletes or athletes who do not otherwise meet biological determinants of femaleness? 

The United Nations Human Rights Council arguedthat the IAAF ruling contravenes human rights. The World Medical Association (WMA) also condemned the IAAF rules arguing that it is unethical for physicians to prescribe treatment for excessive endogenous testosterone if the condition is not pathological. The WMA also questioned the scientific validity of the approach, saying it was based on weak evidence from a single study.

The WMA calls on physicians to oppose and refuse to perform any test or administer any treatment or medicine …which might be harmful to the athlete using it, especially to artificially modifying blood constituents, biochemistry or endogenous testosterone.

This is an interesting position given that the WMA does not condemn the prescription of testosterone to girls asserting that they are boys or to reducing testosterone in boys asserting that they are girls. Nor do they baulk at the removal of healthy breasts or reproductive organs of otherwise healthy young women or the amputation of penises in healthy young men. The WMAreleased a set of nine recommendations in 2015 that explicitly condone all available treatments for sex reassignmentincluding cross-sex hormones and sex reassignment surgery for people requesting them, with the sole proviso that they give informed consent, without defining how informed consent is ascertained, particularly in young people. TheFamily Court of Australia has opted out of its gatekeeper role regarding mutilating surgery when there is agreement between parents and treating doctors. In addition, there is currently a drive to reduce the age of consent and to restrict the role of parental consent for such procedures. 

There are more safety barriers in place for children and young people undergoing a tonsillectomy compared with a double mastectomy of healthy breasts. In general, Australian lawregards the parents of children under 18 years of age responsible for consent to medical procedures. In cases where children are approaching 18 years, they are permitted to give their own consent if the doctor believes that they 

“…fully understand the medical advice being given, the nature, consequences and implications of the proposed treatment, the potential risks to health, the emotional impact of either accepting or rejecting the advised treatment, and the moral and family questions involved.” 

Clinical work with gender dysphoric adolescents suggests that this threshold for capacity is rarely reached. I have found that such young people are cavalier about the long-term consequences of gender reassignment treatment, including infertility, sexual dysfunction, and heightened health risks. I have had 14-year-olds telling me that they never wanted to have children so they do not care about loss of fertility and rarely take up the option of fertility preservation. Since almost none of those in my caseload have ever experienced genital sex, they are similarly cavalier about their indifference to loss of sexual function. Further, transitioning adolescents reported that the lack of data on the long-term effects of puberty suppression  lack of data on the long-term effects of puberty suppression does not deter them from proceeding along the transition pathway. These factors lead to serious concerns about the capacity for informed consent in this group of young people.

Sport participation has become one of the few remaining arenas in which the reality of biological sex forms the basis for logical argument, policy and practice. Even respected scientific journals like Scientific American are claiming that “[b]iologists now think there is a larger spectrum than just binary female and male.” Similarly, the Journal Naturerecently criticised a proposal to return to the practice of classifying people on the basis of anatomy or genetics. These claims are based on rare disorders of sexual development in which both male and female chromosomes and/or male and female sex organs are present in one person. These conditions have been fallaciously used to argue the case for a “gender spectrum” while simultaneously relying on binary concepts of male and female to do so. The Intersex Society of North America explicitly reject such arguments, stating that 

“…the vast majority of people with intersex conditions identify as male or female… Thus, where all people who identify as transgender or transsexual experience problems with their gender identity, only a small portion of intersex people experience these problems.”

Nonetheless, the American Academy of Pediatrics advise physicians to treat children according to their preferred gender, regardless of (sexual) appearance or genetics. In counter-argument, the Project Nettie declares that 

Attempts to recast biological sex as a social construct, which then becomes a matter of chosen individual identity, are wholly ideological, scientifically inaccurate and socially irresponsible.

There are grave and fatally flawed ontological and epistemological flaws in the foundational arguments for a gender spectrum and the fluidity of gender that have not been seriously addressed by the transgender lobby. Transgender ontology has created transgender medicine, which has been recalcitrant in failing to grapple with the attempted elimination of biological sex from transgender ideology. We are left with the view that the appropriate determinant of sex is gender identity, thus rendering chromosomes, DNA, sex hormones, secondary sexual characteristics and dimorphous sexual organs without a place in the ontology and epistemology of human sexuality.  

Monday, 16 September 2019 12:29

Is Gender Dysphoria Socially Contagous?

Dianna Kenny, PhD

Introduction

The earliest written record from the town of Hamelin in Lower Saxony is from 1384. It states simply, “It is 100 years since our children left.” Historical accounts indicate that sometime in the 13th century, a large number of the town’s children disappeared or perished, though the details of the event remain a mystery. “The Pied Piper of Hamelin” is…the only Grimm’s fairy tale that is based substantially on a historical event. Both the actual event and the Grimm’s tale suggest an archetypal situation in which adults have allowed children to be seduced away into peril. This tale is a disconcertingly apt metaphor for various social contagions that have overtaken collective life throughout the centuries (Marciano, 2019, p. 345).

Although it is tempting to blame the phenomenon of social contagion on the digital age, in which people, young and old, remain symbiotically tied to their social media devices, eagerly scanning their screens for the latest news, fashion, holiday location, rave party, or dating site to assuage their “fomo” (i.e., fear of missing out), social contagion predated the advent of the cyberage, thereby placing its origins squarely in the minds of humankind, assigning social media to its role as an efficient conduit of contagion. 

In 1774, Johann von Goethe (1990)published a novel, The sorrows of young Werther, in which an idealistic young man finds his actual life too difficult to reconcile with his poetic fantasies, including his unrequited love for his friend’s fiancée. He eventually becomes so depressed and hopeless by the perceived emptiness of his life, he commits suicide. Goethe was able to capture the nameless dread and endless longing of the human condition so well that his novel spawned a number of suicides, committed in the same way that Werther had killed himself, by shooting (Phillips, 1974). Such was the alarm created by this phenomenon, the book was banned in several European cities. 

Two hundred years later, in 1984, the suicide of a young Austrian businessman, who threw himself in front of a train, initiated a spate of similar suicides that averaged five per week for nearly a year. Sociologists argued that this alarming occurrence was amplified by media coverage that glamorised suicide by providing graphic images of the suicidal act and details of the young man’s life. When media exposure of the event was curtailed and then stopped completely, the suicide rate dropped by 80 percent almost immediately. Although the influence of suggestion and imitation on suicide rates was dismissed by Durkheim (2005, 1897), Phillips’s (1974) work indicated that these factors do indeed play a significant role in the increase in suicides following a publicised suicide. 

In 1841, a Scottish journalist, Charles Mackay (2012)wrote a book entitled Extraordinary popular delusions and the madness of crowds. In the preface to the first edition of the book, the aim of writing it is stated thus: 

…to collect the most remarkable instances of those moral epidemics … to show how easily the masses have been led astray, and how imitative and gregarious men are, even in their infatuations and crime (p. 1)…Popular delusions began so early, spread so widely, and have lasted so long, that instead of two or three volumes, fifty would scarcely suffice to detail their history... The present may be considered…a miscellany of delusions, a chapter only in the great and awful book of human folly (p. 3).

The preface to the second edition in 1852 continued this theme:

Nations,… like individuals, …have their whims and their peculiarities; their seasons of excitement and recklessness… whole communities suddenly fix their minds upon one object and go mad in its pursuit; …millions of people become simultaneously impressed with one delusion, and run after it, till their attention is caught by some new folly more captivating than the first. At an early age in the annals of Europe its population lost their wits about the sepulchre of Jesus and crowded in frenzied multitudes to the Holy Land; another age went mad for fear of the devil and offered up hundreds of thousands of victims to the delusion of witchcraft... the belief in omens and divination of the future… defy the progress of knowledge to eradicate them entirely from the popular mind… Men… think in herds; …they go mad in herds, while they only recover their senses slowly, and one by one [Author’s italics] (p. 7). 

Mackay’s book is about popular delusions and the madness of crowds. Today, we use the term social contagion to describe the “spread of phenomena (e.g., behaviours, beliefs and attitudes) across network ties” (Christakis & Fowler, 2013, p. 556). Using very large datasets (e.g., Framingham Heart Study) that have collected longitudinal data on original participants (Original cohort), as well as their children (Offspring cohort) and their children’s children (Third generation cohort) and including their spouses, siblings, friends and neighbours, Christakis and Fowler have shown that social network effects, known as clustering, remain strong and can extend to those up to three degrees of separation from the original cohort. Such effects have been demonstrated across a large range of factors by different researchers using differing datasets. Examples include overweight/obesity, sleep patterns, smoking, alcohol abuse, alcohol abstention, marijuana use, loneliness, happiness, depression, cooperation, and divorce among others. 

Social network analysis, the method applied to study contagions of all kinds, was first developed and used in public health as a way of determining the spread of diseases (e.g., influenza, HIV/AIDS) that resulted in pandemics. It was subsequently applied to the challenges of introducing changes and innovations in the health system (Blanchet, 2013). Its applications have since expanded with the advent of computers, the internet, mobile and smart phones, and social media.  Members of a network play different roles in the dissemination of innovations. A small number will adopt early (i.e., early adopters). Some of these will become opinion leaders who are central to the network who contaminate their “peers” (homophily) who in turn will influence those others at different levels of the network. 

There are three types of social networks; (i) egocentric (networks assessing a single individual); (ii) sociocentric (social networks in a well-defined social space, such as a hospital or a school); and (iii) open system networks (e.g., globalised markets, social media). Each network consists of nodes (members), ties (between nodes), and measures of centrality, density and periphery or distance between the nodes. Networks with high centrality are the most effective in disseminating information or innovation. A key example with respect to this discussion is the transactivist lobby that has achieved spectacular success in a short time in changing health care, educational practices and legislation related to transgender individuals. Other characteristics of networks include cohesion (number of connections within a network) and shape (distribution of ties within the network) (Otte & Rousseau, 2002). 

In this article, I explore the influence of social contagion on the disquieting upsurge in the number of children and young people whose parents are presenting to gender clinics around the world for advice regarding social transition, puberty blocking agents, cross sex hormones, and ultimately surgery in an attempt to change their gender. First, I examine the concept of social contagion and the mechanisms by which it influences behaviour and attitudes. Then I review three key adolescent behaviours that have been shown to be subject to social contagion. Finally, I demonstrate that the same principles of social contagion apply to the increase of young people who believe that they are transgender and are consequently seeking irreversible medical remedies to assuage their gender dysphoria. Finally, I explore the social contagion (i.e., clustering) of medical practice with respect to treatment of gender dysphoria, the precipitous legislation appearing in its support, and changes to policy and practice in education and sport, despite our collective failure to date to fully understand the phenomenon of gender dysphoria and its rapid, epidemic-like spread in the Western world.  

Peer contagion

Peer contagion is a form of social contagion, defined as a process of reciprocal influence to engage in behaviours occurring in a peer dyad that may be life-enhancing (e.g., taking up a sport, studying for exams, health screening, resisting engaging in negative behaviours, altruism) or life-compromising (e.g., illegal substance use, truanting from school, aggression, bullying, obesity).  Peer contagion has a powerful socializing effect on children beginning in the pre-school years. By early childhood, the time spent interacting with same-age playmates frequently exceeds time spent with parents (Ellis, Rogoff, & Cromer, 1981). Further, characteristics of peer interactions in schools (e.g., aggression, coercive behaviours, mocking peers) are carried over into the home environment (Patterson, Littman, & Bricker, 1967). By middle childhood, gender is the most important factor in the formation of peer associations, highlighting the significance of gender as the organizing principle of the norms and values associated with gender identity (Fagot & Rodgers, 1998).

 (i) Deviancy training as a mechanism of social contagion

Different mechanisms of transmission of peer influence have been identified. Deviancy training, in which deviant attitudes and behaviours are rewarded by the peer group have a significant effect on the development of antisocial attitudes and behaviours such as bullying, physical violence, weapon carrying, delinquency, juvenile offending, and substance abuse (Dishion, Nelson, Winter, & Bullock, 2004). Aggression in adolescence becomes more covert and deliberate and takes the form of exclusion, spreading rumours, and suborning relational damage among an adolescent’s friendship network (Sijtsema, Veenstra, Lindenberg, & Salmivalli, 2009). Interestingly, adolescents associated with peers who engage in instrumental aggression became more instrumentally aggressive, while those associated with peers who engaged in relational aggression became more relationally aggressive, demonstrating the specificity of the effects of peer contagion via the deviancy training. 

 (ii) Co-rumination as a form of social contagion

Another form of peer contagion in adolescence is co-rumination, a process of repetitive discussion, rehearsal and speculation about a problematic issue within the peer dyad or peer group that underlies peer influence on internalizing problems such as depression, anxiety, self-harm, suicidal ideation and suicide (Schwartz-Mette & Rose, 2012). Co-rumination is more common among adolescent girls (Hankin, Stone, & Wright, 2010)although a similar phenomenon among boys has been observed. Being in a friendship that engages in perseverative discussions on deviant topics has been associated with increased problem behaviour over the course of adolescence. The longer these discussions, the greater the association with deviant behaviour in later adolescence (Dishion & Tipsord, 2011).

Peer contagion may undermine the effects of positive socializing forces such as schools, rehabilitation programs for young offenders, and treatment facilities for eating disorders among others. Collecting same-minded adolescents into group programs may be counter-productive because the peer influence impacts of a homogeneous peer group to maintain disordered behaviours may be greater than the program effects of the treatment facility  (Dishion & Tipsord, 2011).

Young people are particularly vulnerable to peer contagion if they have experienced peer rejection, hostility and/or social isolation from the peer group (Light & Dishion, 2007). On the contrary, protective factors against peer contagion effects include secure attachment to parents, adequate adult supervision and oversight of the young person’s activities, school attendance, and the capacity for self-regulation (T. W. Gardner, Dishion, & Connell, 2008). 

 (iii) Does social contagion have a causal effect on behaviour uptake?

Establishing a causal role for the effect of peer behaviour on adolescents is difficult because adolescents choose their peer networks; that is, they choose to associate with like-minded adolescents and those exhibiting similar attributes (homophily). This raises the question: Do adolescents choose their peers because they sanction and engage in similar behaviours or can peer social networks explain the uptake of (new) behaviours in individuals in the network? Sophisticated statistical models have been used to tease out the relative contributions of peer selection and peer influence. Correctly attributing the effects of these two factors has important policy implications since most interventions for reducing risky behaviour among adolescents are implemented at a school level (Ali & Dwyer, 2010). 

Three possible causes of peer effects have been enumerated by Ali, Amialchuk, & Dwyer (2011):

i. Endogenous effect. This effect would occur in a situation in which “…an individual is more likely to use marijuana if there is a high rate of marijuana usage among the reference group because friends’ engagement in such activities could develop a social norm which might compel an individual to use drugs in order to fit in with one's peer” (p. 2), a process described as induction (Christakis & Fowler, 2013), colloquially described as “birds of a feather flock together.”

ii. Exogenous or shared contextual effect.This effect occurs when other social factors influence adolescent behaviour; for example, high substance abuse in a community population of adults, in which the adolescent’s parents are also substance abusers. In such a scenario, adolescents whose parents abuse substances will be more likely to abuse, and contagion may occur in adolescents as a result of peer influence even in those whose parents do not abuse substances.

iii. Correlated effect:These effects, known as environmental confounders, occur when adolescents in the same group behave in a similar way due to a third, perhaps unobserved factor, such as socioeconomic or demographic variables that cause their attributes to covary.

iv. The special case of social contagion via social media

In the world of social media, social contagion takes on a new, less complex and narrower meaning:

“Unlike the broadcasts of traditional media, which are passively consumed, social media depends on users to deliberately propagate the information they receive to their social contacts. This process, called social contagion, can amplify the spread of information in a social network” (Nathan & Kristina, 2014, p. 1).

Evidence for social contagion among adolescents

In this section, I review the evidence for social contagion among adolescents for three key psychopathologies that arise in adolescence (eating disorders, marijuana use and suicide) and compare the mechanisms of social contagion in these well documented areas with evidence for social contagion effects in gender dysphoria. 

i. Anorexia nervosa

A number of researchers have identified the central role of social contagion in the development and propagation of anorexia nervosa in adolescent girls (Allison, Warin, & Bastiampillai, 2014). Adolescence is a time in which the focus on oneself becomes intense, and for some, critical and unrelenting. The developing female body constitutes one of the main objects of scrutiny. When this scrutiny is compounded by the collective inspection of all of one’s body’s flaws, the peer group becomes a powerful crucible for both the development and maintenance of disordered eating. 

Intensification of peer influence in closed communities of like individuals, such as schools, inpatient wards, residential units (Huefner & Ringle, 2012), or therapy groups often results in the advocacy of the practices (e.g., self-starvation, compulsive exercise, deceitful practices around eating) associated with anorexia nervosa (Dishion & Tipsord, 2011).

If we add social media and online networks as further sources of influence, affected adolescents can effectively surround themselves exclusively with like minds, thereby normalising cognitive distortions around eating and body image and making recovery very difficult. These effects are further compounded by the high status of thinness in western culture, and an ubiquitous focus on nutrition and exercise. Originally thought to be caused by genetics and pathological family dynamics, this view was revised with the finding, using longitudinal study designs and social network analyses, that same-gender, mutual friends were most influential in the development of obesity in adulthood, with siblings and opposite-sex friends having no effect (Christakis & Fowler, 2007).

ii. Marijuana use among adolescents 

Substance use amongst adolescents is a major public health issue (Fletcher, Bonell, & Hargreaves, 2008), with a population study conducted by the Center for Disease Control and Prevention showing that 10 percent of youths reported using illegal substances before the age of 13, with marijuana the most frequently used substance (Chen, Storr, & Anthony, 2009). Peer influence has long been suspected as a stimulus that amplifies risky behaviours in the social network (Clark & Loheac, 2007; Lundborg, 2006). 

Using the National Longitudinal Study of Adolescent Health (Add Health) (n=20,745) representing a sample of adolescents from grades 7-12 in 132 middle and high schools in 80 communities across the USA examined the influence of peer networks in the uptake and continued use of marijuana. The peer group was identified by the nomination of close friends and classmates within a grade were used to identify the broader social network from which friends were chosen (Ali et al., 2011). 

Results showed that for every increase in marijuana use of 10 percent in adolescents in a close friend network increased the likelihood of marijuana use by two percent. An increase of 10% in usage in grade peers was associated with a 4.4 percent increase in individual use. Reporting a good relationship with one’s parents, living in a two-parent household and being religious were protective against marijuana uptake. When peer selection and environmental confounders were held constant, increases in close friend and classmate usage by 10 percent both resulted in a five percent increase in uptake in individuals within those networks.

iii. Suicide

Although social ties are generally protective against loneliness, depression and suicide, social ties can be toxic and can amplify the risk of psychopathology in members of a social network (Christakis & Fowler, 2008). Exposure to the suicidal ideation or suicide attempts of significant others increases the risk of suicidality in other network members (Abrutyn & Mueller, 2014). Experiencing self-harm or suicide at close quarters may erode the emotionally regulating effects of normative moral precepts against such behaviour (Mueller, Abrutyn, & Stockton, 2015). When vulnerable individuals share “ecologically bounded spaces” (p. 205) like schools or the family home, this may increase suicide contagion if social relationships within those spaces are psychopathological. Our emotional connections to members of our social networks is the mechanism through which social learning and the development of normative behaviours and attitudes are built. However, negative emotions are more “contagious” and thus exert a greater impact on members (Turner, 2007). 

Celebrity suicides also trigger spikes in suicide rates, with the greater visibility of the celebrity and prolonged coverage of the suicide triggering higher spikes and longer duration of elevation of rates of suicide amongst fans (Fu & Chan, 2013; Stack, 2005). Similarly, Durkheim (1951)highlighted the phenomenon of suicide outbreaks or “point clusters” defined as  “temporally and geographically bounded clusters” such as gaols, regiments, monasteries, psychiatric wards, and First Nations reservations (Mueller et al., 2015, p. 206). Individuals in such networks share a collective identity that appears to heighten subsequent suicides following the suicide of the first decedent (Niedzwiedz, Haw, Hawton, & Platt, 2014).  

A well-documented example of a suicide “echo” cluster (an identical suicide cluster occurring within 10 years of a first cluster) occurred in two high schools in Palo Alto that, between them, had suicide rates four to five times higher than the national average.  In 2009, three students committed suicide in a nine-month period by stepping in front of a commuter train. A fourth student committed suicide by hanging. In 2013 a mental health survey showed that 12 percent of students from these schools had seriously considered suicide in the previous 12 months. Thereafter, there was another spate of suicides, with three students taking their lives within three weeks of each other. A fourth committed suicide four months later by jumping off a tall building and a fifth followed shortly afterwards by walking in front of a train. Extreme perfectionism and pressure to excel at school, get into Stanford, make a lot of money, and be ostentatiously successful materially and intellectually were assessed to be far too great a burden for the more vulnerable students to withstand. 

Using the same data set as the study examining marijuana use but following up four waves of these participants into adulthood, Wave IV assessed suicidality in young adults aged 24-32. This study showed that holding all other psychological risks constant, those young people having a role model who attempted suicide were more than twice as likely to report suicidal ideation in the following 12 months. Participants who had a friend or family member commit suicide were 3.5 times more likely to attempt suicide themselves compared with those who had no close associate attempt or commit suicide in the same 12-month timeframe. These effects were enduring. Young adults who reported an attempted suicide of a role model were more than twice as likely to report a suicide attempt six years after the role model’s attempt compared with their otherwise similar peers. Attempting suicide in adolescence increased suicidal ideation and suicide attempts in young adulthood. Significant risk factors for this association included experiencing emotional abuse in childhood, a diagnosis of depression, and a significant other attempting suicide. Thus, suicide contagion appears to be a significant risk factor for suicide in young adulthood but contagion in this study did not require bounded social contexts.

iv. Gender dysphoria

Commentators on the burgeoning incidence of young people claiming that they are transgender assert that peer contagion may underlie this ominous trend. However, it has rarely been systematically studied either theoretically or empirically. Given the strong evidence of peer contagion in suicide, substance abuse and eating disorders, especially among adolescents, the role of peer contagion in gender dysphoria demands urgent attention. 

If we examine the gender dysphoria epidemic in social network terms, we see several features operating. It is an open-system network with nodes and ties expanding across the oceans to the US, UK, Asia, Europe, Scandinavia, and Australia. Most countries are reporting sharp increases in the number of people seeking services and treatment for gender dysphoria. Many are ramping up services and setting up new gender clinics to cope with demand. This network is highly centralised with only one voice – the transactivist lobby - being heard above the desperate whispers of terrified parents and horrified academics, doctors, psychologists and psychotherapists. Opinion leaders operating at the centre of these networks are very influential. The level of density in a network has two effects – firstly, it enhances the circulation of information between members and secondly, it blocks the introduction of dissenting ideas and evidence (Iyengar, Van den Bulte, & Valente, 2011). 

The field is too young to have attracted researchers to undertake social network analyses to assess peer contagion effects in gender dysphoria. Hence, formal empirical studies have not yet been conducted. However, there is evidence from several sources that peer contagion may be a relevant factor in the sharp increases in young people presenting with gender dysphoria.

(i) Low gender typicality, peer victimization, ingroups and the trans-lobby

Low gender typicality (i.e., perceived lack of fit within one’s binary gender) has a significant impact on social acceptance within one’s peer group (Sentse, Scholte, Salmivalli, & Voeten, 2007). It is strongly associated with adjustment difficulties, behavioural problems, lower self-esteem, and increased internalizing disorders (e.g., anxiety, depression) (Smith & Juvonen, 2017). As children progress to adolescence, peer as opposed to parental acceptance becomes paramount. Peers therefore take over the role of gender socializing agents from parents (Blakemore & Mills, 2014). Adolescent peers tend to be critical of behaviours, dress, mannerisms and attitudes that are not gender typical as a way of policing and reinforcing gender norms and respond with criticism, ridicule, exclusion and even intimidation of non-conformers (Zosuls, Andrews, Martin, England, & Field, 2016). The problems accruing to low gender typicality are mediated by peer victimization. Reducing peer victimization may ameliorate these difficulties (Smith & Juvonen, 2017). Conversely, peer acceptance mediated the self-worth of gender non-conforming 12- to 17- year-olds (Roberts, Rosario, Slopen, Calzo, & Austin, 2013). 

Gender non-conformity and gender atypicality have also been associated with higher physical and emotional abuse by caregivers (Roberts, Rosario, Corliss, Koenen, & Austin, 2012). Mental health is difficult to sustain in the face of caregiver abuse and peer bullying and victimization (Aspenlieder, Buchanan, McDougall, & Sippola, 2009). Indeed, gender non-conforming and gender atypical youth are at higher risk of depression, anxiety and suicidality in adulthood (Alanko et al., 2009). 

It is tempting to speculate that these groups of young people, searching for homophily (i.e. like peers) started to exaggerate their points of difference from their gender-conforming peers rather than to hide and minimize them to avoid being bullied and excluded. In so doing, they left the “outgroup” of nonconformers and formed an ingroup of extreme gender-nonconformers, transcending the gender barrier altogether and declaring themselves transgender. Suddenly, the discomfort and fear of not being gender typical becomes a virtue and rather than fearing the disapprobation of their peers, their open revolt in declaring themselves transgender is valorised by a politically powerful transactivist lobby. One would expect that gender atypical children who feel both internal and external pressure to be gender conforming would experience greater discomfort (Carver, Yunger, & Perry, 2003)and therefore be more susceptible to the message of transactivism. 

Ingroups behave in stereotypical ways with respect to outgroups – they favour ingroup characteristics, assigning more positive attributes to its members and derogating outgroups in order to enhance the status of their ingroup (Leyens et al., 2000). It is not surprising, then, that members of the transgender ingroup exaggerate the characteristics of the “trans” gender they take on – becoming more “feminine” or “masculine” than heteronormative groups of cismen and ciswomen. Transactivist groups have proliferated and consolidated in a short time by exploiting the characteristics of ingroups and outgroups. For example, social projection (i.e., the belief that other members of the group are similar to oneself) has been a powerful integrating process that simultaneously creates protection for its own members and distance from outgroup members, using the formula, “if you are not with us, you are against us” – those disagreeing with the ideology of the trans-lobby are labelled “transphobic” and publicly denounced. 

(Ii) Rapid onset gender dysphoria (ROGD) and the role of social media 

The upsurge in rapid onset gender dysphoria (ROGD) tends to occur mostly in girls at around the age of 14 years, which is an age identified by developmental psychologists to be particularly susceptible to peer influence (Steinberg & Monahan, 2007). For example, a study of peer contagion for risky behaviours found that exposure to risk-taking peers doubled the amount of risky behaviour in middle adolescents, increased it by 50% in older adolescents and young adults, and had no impact on adults (M. Gardner & Steinberg, 2005). This group of young people were likely to belong to peer groups in which one or more of their friends had become gender dysphoric or transgender-identified. Their coming-out announcement to parents also tended to be preceded by recent increases in their daughters’ social media and internet usage.  Clinical practice also identifies peer bullying and a romantic disappointment as possible triggers to ROGD. It is only a small step to understanding the social contagion of ROGD in this age group.

Littman (2019)canvassed the perceptions of parents who had children who displayed ROGD during or just after puberty. There were 256 respondents, of whom 83% had daughters, with a mean age of 15.2 years when they declared themselves transgender, 41% of whom had previously expressed a non-heterosexual sexual orientation, and 62.5% of whom had received a diagnosis for a mental health disorder (e.g., anxiety, depression) or a neurodevelopmental disability (e.g., autism spectrum disorder).  Thirty-seven percent (37%) of these young people belonged to peer groups with other members identifying as transgender. Parents also reported a decline in their child’s mental health (47%) and relationship with parents (57%) after declaring themselves transgender. Thereafter, they preferred transgender friends, websites, and information coming from the transgender lobby. 

An indicative case study was written up in an article for The Atlanticby Jesse Singal (2018), in which Claire, a 14-year-old girl decided she must be trans because she was uncomfortable with her body even after she restricted her food intake, was finding puberty uncomfortable, had difficulty making friends, was feeling depressed and was lacking in self-confidence. Against this backdrop of woes, she came across MilesChronicles, thewebsite of an omnipotent and histrionic transboy, now a young transman. Watching this video resulted in Claire pouring all her sadness and unease about herself into the “realisation” that she was really a “guy.” Miles made transitioning appear easy and simple, was effusive in his praise of his new self and supportive of others to follow suit. This is a very common scenario reported by parents of teenage girls with ROGD. 

Such websites, all easily accessible to vulnerable adolescents, can have a very persuasive effect on viewers. Recent studies show that contagion is enhanced when the influencer is perceived to have high credibility and reduced when the influencer is perceived to have low credibility. A similar effect is observed if the influencer belongs to an out-group or an in-group (Andrews & Rapp, 2014). Miles is the quintessential trans pinup icon with a “You can be just like me if you transition!” message. 

Following YouTube posts and social media with respect to the transgender debate over the past couple of years, I have noticed that posts that depict young people struggling with their gender identity or questioning their decision to take puberty blocking agents and cross-sex hormones, or to undergo what is euphemistically called sexual reassignment surgery are rapidly taken down so that only a homogenous message which matches the strident messaging of the transactivist lobby is on display in the ether.

(iii) Empirical evidence

There has been a sharp increase in the population estimates of those identifying as transgender. One study, a meta-regression of population-based probability samples provides compelling evidence of this trend, where estimates have more than doubled in the space of eight years from 2007 to 2015. 

 

 Transgender population size metaregression

Source: Meerwijk, E. L., & Sevelius, J. M. (2017). Transgender population size in the United States: a meta-regression of population-based probability samples. American Journal of Public Health, 107(2), e1-e8.  https://ajph.aphapublications.org/doi/pdfplus/10.2105/AJPH.2016.303578

Figure 1

Data from Australia also show an upward trajectory in the number of children enrolled in gender clinics in the four states of Australia that offer a gender service. The noteworthy feature of this graph (Figure 2) is that three of the four states (WA, Queensland and Victoria) show similar increases over the five-year study period (2014-2018). Although figures in NSW increased, the magnitude of absolute numbers was significantly lower than for the other three states. Victoria had the largest numbers and the largest increases. It is also a state where the trans lobby has been particularly vocal and where the concept of the "safe schools"policy was conceived and implemented. 

Children Enrolled in GD Clinics 2014 18

Figure 2

Source: Kenny, D.T. (2019). Child and adolescent gender dysphoria in Australia – adopting the Zeitgeist but where are we going? Invited paper to the NSW parliamentary forum, Parliament House, Sydney, Australia, 2 July. 

V. Social contagion in treating practitioners, legislators, and educators.

  i. Treating medical practitioners

Iyengar, Van den Bulte, and Valente (2011)found contagion in the prescribing patterns of doctors after controlling for marketing outreach and systemic changes, such as the advent of new drugs and changes in the prevalence of diseases. Shared geographical proximity, shared group membership and self-identified ties between doctors were all factors in behavioural contagion, with self-identified ties the most compelling factor. A critical factor in marketing attempts to manipulate uptake of a new drug or medical treatment is the identification of those in the network who are influential and those who are influenceable - without individual uptake, the marketing campaign will falter (Christakis & Fowler, 2011). Central figures in the network have a stronger tendency to adopt early. Of course, network contagion effects may be modified by product characteristics, for example, the perceived effectiveness and perceived safety of the new drug.

A few salient examples regarding government policy and legislation and changes in educational practice include the following:

  ii. Law and Legislation

Transgender activists in several countries have succeeded in persuading gender clinics to commence social transition in children as young as two and three years of age (e.g., Royal Children’s Hospital, Melbourne, Australia), followed by the administration of puberty blockers at nine or 10 years of age.  They have also been successful in lowering the age limit at which young people can access sex re-assignment surgery without parental consent. For example, in  Oregon, USA the lower age limit for surgery has been removed with parental consent and lowered to 15 without parental consent (Medical Daily on parental consent). It is almost commonplace to read adolescent girls as young as 14 years undergoing double mastectomies (Rowe, 2016). Recently, a judge in Canada found a father potentially guilty of domestic violence if he continued to use his 14-year-old child’s birth name and female pronouns. This child is petitioning the court to commence cross-sex hormones in the face of his father’s strong objection (The Guardian on Canadian case). The lower court ruled that a minor is capable of giving consent to medical procedures. Accordingly, the child has commenced testosterone while the battle continues in the Court of Appeal. 

Other legislative support e.g., Victorian Births, Deaths and Marriages Registration Amendment Bill 2019 for the transgender epidemic includes a bill allowing transgender people to change their birth certificates without undergoing sex-reassignment surgery (The Guardian on birth certificates). Under the legislation a person can self-nominate their sex and list as male, female or any other gender diverse or non-binary descriptor of their choice. Children can alter the sex on their birth certificate with parental support and a statement from a doctor or registered psychologist saying the decision is in the best interests of the child. 

An article published by the Family Court of Australia (Family Court of Australia report) provides legal reasoning and argument regarding the disposition of gender dysphoria treatment for minors that outlines the limits of legal intervention in these cases. The reasoning in this report is underpinned by current, often erroneous information about gender dysphoria. In re Kelvin, the Royal Children’s Hospital, Melbourne gave evidence that there was growing consensus regarding medical treatment of gender dysphoria. The RCH over-stated its positive outcomes but did not refer to the uncertainty and disagreement about treatment and outcomes expressed by a growing number of researchers and clinicians. 

Two Amicus Briefs, each supporting contrary arguments, were presented to the Supreme Court of the United States. They can be found at Amicus Brief 1  and Amicus Brief 2. The interested reader is invited to study both briefs and decide which of the two is more convincing. 

  iii.  Sport 

The Australian Human Rights’ Commission has provided guidelines about sports participation that clearly disadvantage natal females and which may well have a profound effect on female participation in sport (AHRC sport guidelines). It was written with the participation of peak sports’ bodies including Coalition of Major Professional and Participation Sports (COMPS) and Sport Australia. The document purports a victory for “diversity and inclusion.” The reality is that these guidelines neutralise the protections provided to females in the Commonwealth Sex Discrimination Act,1984. A critique of the bill can be found at Critique of sport guidelines.

  iv. Education

The NSW Department of Education has issued a Bulletin (Bulletin 55- Transgender Students in Schools) Bulletin 55, NSW Department of Education that deprives parents of any rights in the management of their gender dysphoric child at school. Bulletin 20 even deprives parents of parental authority regarding the registered name of their child (Bulletin 20). It states, 

If either or both parents object to the change to the way the first name is recorded by the school, the principal needs to make a decision about what is in the child’s best interests. This decision should have regard to the age, capability and maturity of the student and can be informed by advice from a health care professional about the potential impact on the student’s wellbeing of declining to use and record the student’s preferred first name.

These guidelines undermine parental authority in the child’s eyes, setting a dangerous precedent allowing children to make decisions about their wellbeing for which they are not prepared. 

Conclusion

 “All the world is queer save thee and me, and even thou art a little queer.” When the Welsh reformer and philanthropist Robert Owen penned these words in 1771, the word “queer” meant “strange” or “different.” The word “queer”is nowan over-arching term used to describe sexual and gender minorities. I wish to revert to the original meaning of this word in the context of this paper as it highlights yet another worrying psychic epidemic that has spread its tendrils into all corners of society – medical, social, legal, psychological, political, ideological and philosophical. Parents are not exempt from these influences; there are numerous websites offering support to parents of transgender children (e.g.TranscendHuman Rights CampaignGender CentreGender Help for Parents).

 By the time the proponents of gender dysphoria in children and adolescents realise the far-reaching damage they have caused by their unthinking political correctness in supporting gender affirmation, the courts will be clogged with lawsuits brought by transgender adults whose bodies and minds have been irreparably damaged by the zealous compliance to the strident voices of the trans lobby.

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Wednesday, 04 September 2019 15:12

Paper presented at the Forum on transgender children and adolescents at the Parliament of NSW, 2 July, 2019

Professor Dianna Kenny

Introduction

Precise data regarding the frequency of people with gender dysphoria or who identify as transgender have been difficult to source. In attempting to count the transgender population, decisions need to be made about whom to include. For example, some people identifying as transgender live with their gender incongruence and do not seek treatment. Others make a social but not a medical transition, while others make social and medical transitions but not a surgical transition. Some attempt to transition medically outside of the public health system by sourcing cross-sex hormones on the internet and other non-medical suppliers, while others visit their GPs or endocrinologists to obtain medications rather than presenting to specialised gender clinics, often because of the onerous waiting times for an appointment and/or perceived or actual barriers to accessing treatment.

In the USA, the rate of self-identification as transgender doubled in 10 years from 12.5 (0.013%) (2002) to 23 (0.023%) per 100,000 (2011). The Massachusetts Behavioral Risk Factor Surveillance Surveyfound that 0.5% of the adult population aged 18 to 64 years identified as TGNC (transgender and gender nonconforming) between 2009 and 2011. By 2016, the estimated rate of the USA population identifying as transgender was 0.6% (i.e., 1.4 million people)[1]compared with 0.3% in 2011.[2] By 2017, self-reported transgender identity in children, adolescents and adults ranged from 0.5 to 1.3%, rates that are significantly higher than prevalence rates based on clinic-referred samples of adults[3]. 

Attempts to estimate the true transgender population in the USA using meta-regression of 12 population-based probability samples (national surveys) conducted over the years 2007-2015 concluded by extrapolation that there were 390 per 100,000 (0.39%) transgender individuals in the US population. Given that more than 50% of the respondents were in younger age groups, (e.g., 18-31), the authors stated that it may be a more reliable estimate for younger transadults than for the population.[4]

Similar, more pressing difficulties have been encountered in identifying the “true” number of children and young people identifying as gender dysphoric under the age of 18 years in Australia. In the New Zealand Adolescent Health Survey(Youth 2012)[5], a national, cross sectional, population-based survey of 8,166 secondary school students, 1.2% (98) students reported being transgender, 2.5% (204 students) reported not being sure about their gender and 1.7% did not understand the question. Young people (n=719) in Finland aged 16-18 completed a survey using the GIDYQ-A (Gender Identity Disorder Youth Questionnaire) in 2012-2013 and the survey was replicated in 2017 on 1,007 young people. In the 2012 survey, 2.2% of males and 0.5% of females reported possibly clinically significant GD. In 2017, 3.6% males and 2.3% females reported possibly clinically significant GD[6]. 

The Royal Children’s Hospital’s Gender Service, Melbourne reported a 250-fold increase in new referrals to their service between 2003 and 2017[7](from one to 250). A similar increase has been noted in the referral rates to the Tavistock Clinic in the UK[8]. The figure below shows the increases at Tavistock Clinic over the years 2007-2016.

Number of young people under 18 years of age referred to the Gender Identity Development Service

 Number of you people
Source: The Tavistock and Portman NHS Foundation Trust (BBC, 2016)[9]

Figures from the Gender Identity Development Service (GIDS), which is the NHS’s only facility for children with gender dysphoria in the UK, showed that 84 children between three and seven years were referred in 2017, compared with 20 in 2012/2013. Referrals of children younger than 10 years of age showed a fourfold increase from 36 in 2012 to 165 in 20168. In 2016, there were 2,016 referrals for children aged between three and 18 years, a six-fold increase from 314 five years previously. More than twice as many girls as boys are referred to such service. There has been a linear relationship between increasing media coverage, increasing stridence from the transactivist lobby and the numbers of children and young people presenting to gender clinics around the world[10](BBC news, 2016).  The Tavistock and Portman NHS Trust, the only gender treatment facility in the UK reported that the number of under-18s who visited the clinic between 2015 and 2016 had risen by 25% to 2,519. 

Promotional material on the website of the Royal Children’s Hospital (RCH) Melbourne claims that 1.2 percent of Australian school children (i.e., 45,000 children) “are thought to identify as transgender”.[11]It is unknown whether this is an extrapolation from the New Zealand study. The Australian Bureau of Statistics (ABS) Census of Population and Housing, 2016,identified 1,260 adult individuals who stated that their sex/gender was other than male or female, a rate of 5.4 per 100,000 (0.0054%)[12]. Of these 1,260 adults, 340 (27%) identified as either transmale (n=70), transfemale (n=100), or transgender (n=170), i.e., 1.5 per 100,000, a rate vastly smaller than the declared rates for children and young people by RCH, Melbourne. For example, a study by Quinn and colleagues[13], reported that children and youth aged between three and 17 years constituted more than 20 percent of the transgender population.

To gain more clarity regarding the frequency of children seeking services for gender dysphoria in the Australian population of children and young people, more precise figures were sought from the key child and adolescent gender services around Australia.

METHOD

The data forming the basis for this study were obtained through Freedom of Information applications made in the four jurisdictions providing gender services to children in Australia by Greg Donnelly MLC, Parliament of New South Wales. As there were virtually no treatment facilities for children with gender dysphoria in Australia prior to 2014, the study period was identified as the five years between 2014 and 2018. Currently, there are four medical institutions offering services and these are listed below, together with their eligibility criteria.

  1. The Lady Cilento Children’s Hospital Gender Clinic and State-wide Service, Queensland

Eligibility: Children aged under 18 years, living in Queensland, seeking support with their gender identity, referred by local doctor/general practitioner.

  1. The Children’s Hospital Westmead Gender Clinic, Sydney

Eligibility:Children >9 years and/or displaying signs of puberty can be referred to Westmead Children’s Hospital for gender dysphoria review; referred by GP, paediatrician, psychologist, or psychiatrist to the Adolescent Mental Health unit at Westmead Children’s Hospital.

  1. The Royal Children’s Hospital Gender Service, Melbourne

Eligibility: Children and adolescents aged between three and 17 years of age with concerns about gender identity. Referral from GP required. Young people over the age of 17 years may access adult services (i.e., Monash Medial Centre Gender Clinic).

  1. Perth Children’s Hospital Gender Diversity Service, Western Australia

Eligibility: Any child or young person up to the age of 18, who resides in Western Australia, with concerns regarding their gender, gender non-conforming behaviour or gender dysphoria, can be referred to the Gender Diversity Service for consultation.

Three outcome measures were assessed, as follows: 

  • Number of children and young people seeking treatment from gender clinics
  • Number of children and young people receiving stage 1 treatment i.e., puberty blocking agents (PBA)[14][gonadotropin‐releasing hormone analogues(GnRHa)]
  • Number of children and young people receiving stage 2 treatment (cross-sex hormones) in each of the four gender clinics by year.

For each measure total numbers, percent total per state, and increase in incidence by year and state were calculated. Percentages of children seeking treatment for gender dysphoria and the proportion of children from the general population aged 5-19 years in WA, Qld, Vic and 10-19 in NSW were compared to ascertain possible over- and under-representation of children in each state seeking treatment or receiving stage 1 or stage 2 treatment were calculated using the chi-square test of proportions[15].

RESULTS

  • Number of children and young people seeking treatment

Over the five-year period 2014-2018, 2,415 children and young people were enrolled in one of these four gender clinics in Australia. Except for 2014, these numbers may not represent unique cases, because some children remain enrolled over consecutive years. Therefore, these figures are indicative only of the increase in numbers over the study period. These data are presented graphically by year and state (Figure 1). 

Children in GD clinics

Figure 1 

Figure 1 one shows that numbers of children and young people enrolled/seeking treatment for gender dysphoria over the five-year period 2014-2018 in each of the four states of Australia with gender clinics increased for each state but not uniformly. The absolute numbers for NSW were significantly lower compared with the other three states. Table 1 summarises the numbers by state and year, the total numbers for each year, the percent of young people attending in each state and the rate increase for each state. 

Table 1 Number of children seeking services from gender clinics in four states of Australia and rate of increase since 2014.

children seeking services

The incidence of treatment seeking across the four clinics increased more than 11 times over the study period.

Table 2 shows the distribution of treatment seeking by state compared with the numbers of young people in the same age group taken from 2016 Australian Census[16].

Table 2 Percentage of children seeking treatment for gender dysphoria and proportion of children from the general population aged 5-19 years in WA, Qld, Vic and 10-19 in NSW

children seeking treatment

 

Although the population figures only provide an approximation of the population from which children presenting to GD clinics are drawn, the chi square comparison of proportions test identified disparities between expected and actual proportions. For NSW, the difference of -14.9% was significant (Chi-sq=273.5, df=1, p<0.0001; for Queensland, the difference of -2.4% was significant (Chi-sq=6.9, df=1, p<0.008) indicating under representation; for WA, the difference of +8.7% was significant (Chi-sq=151.5, df=1, p<0.0001; for Victoria the difference of +8.6% was significant (Chi-sq=81.9, df=1, p<0.0001) indicating over representation.

  • Number of children and young people receiving stage 1 treatment i.e., puberty blocking agents (PBA)

Figure 2 shows numbers of children and young people receiving puberty-blocking agents in these four gender clinics over the five-year period 2014-2018 in each of the three states of Australia [Note: Victoria failed to provide these figures]. Figures rose sharply for Queensland but not for the other two states for which figures were available. 

children recieving blocking agents

Figure 2

Note 1: Figures for Victoria 2018 were not provided        

Note 2: Figures for Queensland are based on Queensland Children’s Hospital (QCH) pharmacy reports only. They do not include young people accessing medication outside the QCH pharmacy. Hence, these figures are an under-representation of the true number receiving cross-sex hormones. This may also be the case in other states; they do not include children receiving GD treatments through the private health system.

Over the five-year period 2014-2018, 492 children and young people were receiving puberty blocking agents (stage 1 treatment) from these three gender clinics in Australia (Victoria did not supply figures). Victoria (see Table 3) provided the numbers of young people who commenced on puberty-blocking agents in four of the five years requested, as follows: 

Table 3 Number of young people commenced on puberty blockers in Victoria by year[20]

puberty blockers victoria

 

Table 4 presents the total numbers of young people receiving puberty blockers by state (NSW, WA, Qld) and year.

Table 4 Number of children receiving puberty blocking agents (stage 1 treatment) from gender clinics in three states of Australia 2014-2018.

 children recieving puberty blockers stage 1

Table 5 compares the proportions on PBA by state with population proportions.

Table 5 Percentages of children taking puberty blocking agents for gender dysphoria and proportion of children from the general population aged 5-19 years in WA, Qld, Vic and 10-19 in NSW

children taking blocking agents proportion

 

The chi square comparison of proportions test identified disparities between expected and actual proportions. For NSW, the difference of -3.2% was not significant (Chi-sq=2.6, df=1, p<0.12; for WA, the difference of +0.4% was not significant (Chi-sq=0.07, df=1, p<0.79; for Queensland, the difference of +24.6% was significant (Chi-sq=149.5, df=1, p<0.0001). Queensland is significantly proportionately disparate from the other two states, i.e., it has 2.2 times the number of young people taking PBA than expected from the population. 

  • Number of children and young people receiving cross sex hormones in each of the four gender clinics by year

Over the five-year period 2014-2018, 286 children and young people were commenced on cross-sex hormone (stage 2) treatment at one of these four gender clinics in Australia.

Figure 3 shows the number of children in each of the four gender clinics who were receiving cross-sex hormones (stage 2) over the study period in each state. 

children recieving cross sex hormones

Figure 4 

Note 1: NSW supplied “0” in each data cell for each of the five years. A follow-up inquiry to Sydney Children’s Hospital Network (Ref No: SCHN18/7854, 6/8/19) indicated “Sydney Children's Hospitals Network (SCHN) does not and has not initiated stage 2 Gender Dysphoria treatment at The Children's Hospital at Westmead. [O]ccasionally SCHN sees a patient in a cross­over transition phase who has had stage two treatment initiated by an adult physician, as The Children's Hospital at Westmead pharmacy is still providing the patient's treatment in that cross­over phase. However, their primary care at this stage is under the adult physician who prescribes the stage two therapy. I can confirm that the zero response provided in the GIPA Notice of Decision is correct but that there may be instances in which children are receiving active stage 2 treatment elsewhere while still attending The Children's Hospital at Westmead clinic”.

Note 2: Figures for Queensland are based on Queensland Children’s Hospital (QCH) pharmacy reports only. They do not include young people accessing medication outside the QCH pharmacy. Hence, these figures are an under-presentation of the true number receiving cross-sex hormones from QCH. 

Note 3: Figures for Victoria 2018 extrapolated from Victoria 2017 figures   

Table 6 summarises the numbers by state and year, the proportions from each state and the increase in incidence from 2014 to 2018.

Table 6 Number of children receiving cross-sex hormones (stage 2 treatment) from gender clinics in four states of Australia 2014-2018.

Children recieving sross hormones stage 2
The gender clinic in NSW did not count any young person proceeding to stage 2 treatment, explaining that those who did progress to stage 2 (cross-sex hormones) treatment were referred to adult services or private endocrinologists. These numbers are needed to further our understanding about the paths taken by young people exiting children’s services following stage 1 treatments.  

In the other three states, there were sharp increases in the numbers of young people undergoing stage 2 treatment. For WA and Queensland, this occurred only in 2018; in Victoria this occurred in 2017, with a slight decline in numbers in 2018. 

DISCUSSION

This paper presents available data on the numbers and patterns of referral to the four gender clinics for children and young people in Australia, and the number of children who were receiving stage 1 or stage 2 gender transition treatments during the study period (2014-2018). The dramatic increases in the number of children seeking services (between two and 11-fold increases over the five-year study period) concur with overseas data that also show sharp increases in referrals. 

These data significantly under-represent the actual numbers of children receiving some form of treatment for gender dysphoria, given that only four of seven states have gender clinics and could supply data. Not all the available data were supplied from these, so even these data are incomplete. The numbers of children being treated for gender dysphoria in South Australia, Tasmania, Northern Territory and Australian Capital Territory could not be ascertained and could not therefore be included. 

Despite this under-representation of actual cases of gender dysphoric young people seeking treatment, these estimates are discrepant from the number of adults identifying as transgender in the ABS Census of Population and Housing, 2016, from which population comparisons were accessed for this study. In that census, only 340 adults across Australia identified as transgender. 

The four states from which data were collected showed significant differences in treatment patterns. What could account for the anomalies observed in these data between the four states?

One explanation for the lower enrolled/treatment-seeking numbers in NSW over the five-year study period is that NSW only accepts children older than nine years of age, compared with the other three states that either set no lower age limit for referral (Queensland and Western Australia) or set it at three years of age (Victoria). This is not a robust explanation as it would be unlikely that large numbers of children under the age of nine or 10 would be presented to such clinics. The other possible explanation is that some states are more meticulous in their initial assessment of the child and hesitate to conclude that the child requires gender affirming treatment before a thorough individual and family assessment has been undertaken to exclude those with other conditions that need to be treated. This may account for the lower numbers in NSW, the largest and most populous state in Australia.

What can explain the discrepancy in the number of children treated with puberty-blocking agents between Queensland and the other states offering gender services? It is highly unlikely that there would be actual differences in the incidence of gender dysphoria in children living in Queensland compared with children living in NSW or Western Australia. Possible explanations include differences in ideology, criteria for treatment, strong adherents to gender affirming treatment in the Queensland gender service and/or more socio-political pressure on treating practitioners in Queensland compared with other states. 

Similarly, figures in Victoria showing 70 times increase over the study period of young people receiving cross-sex hormones is of great concern and requires urgent investigation. Given the relatively small numbers commencing on puberty-blockers in each year of the study period, the data suggest that those attending the Victorian service may be older, post-pubertal adolescents who are referred to other treatment facilities for their cross-sex hormones where they are not counted and are lost to follow-up. 

Of equal interest is the large numbers of young people in Queensland who have been placed on puberty-blocking agents and the relatively small number on cross-sex hormones. Do the majority of these children desist from progression to cross-sex hormones or are they referred elsewhere for stage 2 treatments, which is the case for NSW and appears to be the case for Victoria? If the former, these results are in stark contrast to overseas research showing that once children commence puberty-blocking agents, most proceed to cross-sex hormones.[24]If the latter, obtaining accurate numbers of those referred elsewhere for stage 2 treatments need to be recorded and made available to the research community and the public.

Sadly, these data stimulate many more questions than answers about the demographic of this population across the four states as well as the treatment protocols in each state that may affect how treatment is decided and delivered. They represent a first attempt to systematize data gathering in gender dysphoria treatment in young people in Australia. It has been difficult to obtain reliable information from the gender clinics and these data are necessarily incomplete because of a failure to supply the requested information in some cases or receiving inaccurate or ambiguous information in others. These data should therefore be treated as incomplete and preliminary. They are presented to stimulate concern and debate about the efficacy of such life-altering treatments for young people.

There is no doubt that the transactivist lobby has been spectacularly successful in their campaign[25]to assert transgender rights and many in medicine[26], social policy, the media and the law have succumbed to their pressure to conform to a gender-affirming ideology without adequate evidence to support its application[27]. These forces are no doubt at play in the pattern of numbers we see in this paper. 

 

[1]Williams Institute, 2016, https://williamsinstitute.law.ucla.edu/wp-content/uploads/CHIS-Transgender-Teens-FINAL.pdf).

[2]Gates, G. (2011).How many people are lesbian, gay, bisexual, and transgender? Williams Institute https://escholarship.org/content/qt09h684x2/qt09h684x2.pdf

[3]Zucker, K. J. (2017). Epidemiology of gender dysphoria and transgender identity. Sexual Health14(5), 404-411.

[4]Meerwijk, E. L., & Sevelius, J. M. (2017). Transgender population size in the United States: a meta-regression of population-based probability samples. American Journal of Public Health, 107(2), e1-e8. 

[5]Clark, T. C., Lucassen, M. F., Bullen, P., Denny, S. J., Fleming, T. M., Robinson, E. M., & Rossen, F. V. (2014). The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth'12). Journal of Adolescent Health55(1), 93-99.

[6]Kaltiala-Heino, R., Työläjärvi, M., & Lindberg, N. (2019). Gender dysphoria in adolescent population: A 5-year replication study. Clinical child psychology and psychiatry24(2), 379-387.

[7]Telfer, M. (2018). Gender dysphoria in children and adolescents: An update on clinical practice, research and advocacy.https://www.chnact.org.au/sites/default/files/Assoc.%20Prof.%20Michelle%20Telfer%20-%20Gender%20Dysphoria%20in%20Children%20and%20Adolescents.pdf

[8]https://www.telegraph.co.uk/news/2017/07/08/number-children-referred-gender-identity-clinics-has-quadrupled/

[9]BBC (2016) https://www.bbc.com/news/uk-england-nottinghamshire-35532491

 

[11]Kids Health Info, The Royal Children’s Hospital, Melbourne https://www.rch.org.au/kidsinfo/fact_sheets/Gender_dysphoria/

[12]https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0~2016~Main%20Features~Sex%20and%20Gender%20Diversity%20in%20the%202016%20Census~100

[13]Quinn, V. P., Nash, R., Hunkeler, E., Contreras, R., Cromwell, L., Becerra-Culqui, T. A., . . . Goodman, M. (2017). Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people. BMJ Open, 7(12), e018121. doi: 10.1136/bmjopen-2017-018121

[14][gonadotropin‐releasing hormone analogues(GnRHa)]

[15]https://www.medcalc.org/calc/comparison_of_proportions.php

[16]http://www.abs.gov.au/websitedbs/D3310114.nsf/Home/2016%20search%20by%20geography

[17]The total number of children aged five to 19 years in each of these four states of Australia was 3,813,130. In NSW, there were 1,369,618 young people aged between five and 19 years, 36% of the total. In Western Australia, there were 464,956 young people aged between five and 19 years, 12.2% of the total. In Queensland, there were 912,522 young people aged between five and 19 years, 23.9% of the total. In Victoria, there were 1,066,034 young people aged between five and 19 years, 28% of the total.  The denominator is smaller for NSW because children must be >9 years to be referred to a gender service. N=891,434 represents the age groups 10-14 and 15-19 years in the Census. Hence, population proportions were adjusted to account for the reduction in numbers in NSW.

[18]http://www.abs.gov.au/websitedbs/D3310114.nsf/Home/2016%20search%20by%20geography

[19]The Australian Bureau of Statistics presents age data in four-year blocks, 0-4, 5-9, 10-14, and 15-19. Because most gender clinics have an upper age limit of 18 years, these figures represent a small over-estimation of the population from which children presenting with gender dysphoria are drawn.

[20]It may be the case as for NSW, that the RCH, Melbourne, treats only a small number of young people with stage 2 drugs, referring the majority to adults clinics or private specialists where they are not counted and are lost to follow-up.

[21]Denominator smaller for NSW because children must be >9 years to be referred to a gender service in NSW. N=891,434 represents the age groups 10-14 and 15-19 years in the Census. 

[22]http://www.abs.gov.au/websitedbs/D3310114.nsf/Home/2016%20search%20by%20geography

[23]The Australian Bureau of Statistics presents age data in four-year blocks, 0-4, 5-9, 10-14, and 15-19. Because most gender clinics have an upper age limit of 18 years, these figures represent a small over-estimation of the population from which children presenting with gender dysphoria are drawn.

[24]De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283. 

[25]Iyengar, R., Van den Bulte, C., & Valente, T. W. (2011). Opinion leadership and social contagion in new product diffusion. Marketing Science, 30(2), 195-212. 

[26]Bizic, M. R., Jeftovic, M., Pusica, S., Stojanovic, B., Duisin, D., Vujovic, S., … Djordjevic, M. L. (2018). Gender Dysphoria: Bioethical Aspects of Medical Treatment. BioMed research international2018, 9652305. doi:10.1155/2018/9652305https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6020665/

[27]Marchiano, L. (2017). Outbreak: On transgender teens and psychic epidemics, psychological perspectives, 60:3, 345-366, DOI: 10.1080/00332925.2017.1350804 https://www.tandfonline.com/doi/pdf/10.1080/00332925.2017.1350804

Monday, 05 August 2019 09:17

In this article, I address key issues in the transgender debate as they pertain to children and young people. These include: Are “gender transition treatments” safe, “curative” and in the child’s best interest? In considering these questions, I explore the known negative consequences of puberty suppression and cross-sex hormones, including infertility and other medical conditions and the purported increase in suicidality without treatment. Can children and young people give truly informed consent to these interventions? What role should parents play in decision-making? On what basis are decisions made to proceed to gender transition? Are the foundations of such decisions logical and scientific? and What social forces are at play in this decision-making process? 

(a) SafetyDoes the current scientific evidence support a conclusion that the administration of Gender Transition Treatment (social transition, puberty blocking agents and cross-sex hormones) can be safe forchildren and adolescents?

Answer:  No.  

The metabolic implications of cross-sex hormone administration and the health effects of hormone manipulation on the bone, muscle, cardiovascular risk, cognition, and quality of life are not well understood (de Souza et al., 2017). Most of the research on health risks of cross-sex hormones have been undertaken on MTF (male‐to‐female) as compared to FTM (female-to-male) transsexuals. This has resulted in insufficient research on the effects of testosterone on FTMs (Newfield, Hart, Dibble, & Kohler, 2006). However, the effects of cross-sex hormones are not neutral for either group, as the literature surveyed below indicates.

Surgical castration of male animals, leading to a loss of testosterone, results in marked decreases in synaptic density in the hippocampus and reductions in the capacity for learning and memory. FTM cross-sex hormone treatment results in loss of bone mineral density (van Kesteren, Lips, Gooren, Asscheman, & Megens, 2001). Venous thrombo‐embolism (Asscheman, et al. 2014) and osteoporosis (Wierckx, 2012) have been identified as complications of cross‐sex hormone treatment of MTF transsexual patients. In a study of transwomen stratified by levels of circulating testosterone, those with the highest levels had the highest incidence of hepatic steatosis (fatty liver) and insulin resistance (Nelson et al.2016). 

Cross-sex hormone treatment may also be associated with hormone-related cancer, a risk that increases with duration of exposure and the aging of the transgender population (Mueller & Gooren, 2008; Quinn et al., 2015). Although the rate of ovarian cancers in FTM transsexuals is not known, several case studies have been reported in the literature, leading to the caution that testosterone treatment may be associated with increased riskof both ovarian and endometrial cancer (Izon, Tejada-Berges, Koelliker, Steinhoff, Granai, 2006). FTM transsexuals who do not proceed to total hysterectomy and bilateral salpingo-oophorectomy are at risk for endometrial, ovarian and cervical cancer (Menvielle & Gomez-Lobo, 2011). Other cancers e.g., (colorectal, lung, lymphatic and haematopoietic, and melanoma) do not appear to be elevated in the TF population compared with the RF group (Quinn et al. 2017).

A significantly higher prevalence of venous thrombosis, myocardial infarction, CVD (cardiovascular disease), and type 2 diabetes was found in trans females (TF) than in a control population (Wierckx et al., 2013). In the Quinn et al. (2017) study, myocardial infarction occurred at twice the rate in TF (1.8%) compared with reference females (RF) (0.9%). Peripheral artery disease (3.1% vs 1.9%) and unstable angina (1.8% vs 1.0%) were also elevated in TF compared with RF (Burcombe, Makris, Pittman, & Finer, 2003). In MTF transsexuals, high estrogen levels need to be avoided to prevent thrombosis, liver dysfunction and the development of hypertension. Up to 20% of MTF treated with estrogens show elevations in prolactin and pituitary enlargement (Menvielle, & Gomez-Lobo, 2011). These issues need constant, lifelong monitoring.

Bilateral mastectomy in FTM transgender patients carries substantial risks of surgical and medical complications. In one study of 57 FTM patients (40.4% of whom had comorbid psychiatric diagnoses), 33% experienced complications including hematoma, infection, seroma, fistula, or partial necrosis of the nipple-areola complex and 9% needed further corrective surgery, mostly for hematoma. A large population survey of TMs reporteda higher risk for breast cancer, cervical cancer and smoking- and viral infection–related cancers (Silverberg et al., 2015).

Pubertal sex hormones affect brain development. For example, testosterone is associated with changes in cortical thickness, and estradiol is associated with grey matter development in girls.

With respect to psychological effects of cross-sex hormones, FTMs experienced more aggressive and sexual feelings and lower affect intensity after hormone administration (Slabbekoorn, 2001).Other personality characteristics such as empathy (higher in females) and aggression (higher in males) are associated with pre-natal testosterone exposure (Hines, 2008). 

References

Asscheman, H., T'Sjoen, G., Lemaire, A., Mas, M., Meriggiola, M. C., Mueller, A., & Gooren, L. J. (2014). Venous thrombo‐embolism as a complication of cross‐sex hormone treatment of male‐to‐female transsexual subjects: A review. Andrologia, 46(7), 791-795. doi: 10.1111/and.12150.

Burcombe, R.J., Makris, A., Pittam, M., Finer, N. (2003). Breast cancer after bilateral subcutaneous mastectomy in a female-to-male trans-sexual. The Breast,2, 4, 290-293.ISSN 0960-9776, https://doi.org/10.1016/S0960-9776(03)00033-X.

de Souza Santos, R., Frank, A. P., Nelson, M. D., Garcia, M. M., Palmer, B. F., & Clegg, D. J. (2017). Sex, Gender, and Transgender: Metabolic Impact of Cross Hormone Therapy. In F. Mauvais-Jarvis (Ed.), Sex and Gender Factors Affecting Metabolic Homeostasis, Diabetes and Obesity(pp. 611-627). Cham: Springer International Publishing.

Hines, M. (2008). Early androgen influences on human neural and behavioural development. Early Human Development, 84(12), 805-807. doi: https://doi.org/10.1016/j.earlhumdev.2008.09.006

Izon D. S, Tejada-Berges T, Koelliker S, Steinhoff M, Granai C, O. (2006). Ovarian cancer associated with testosterone supplementation in a female-to-male transsexual patient. Gynecol Obstet Invest; 62:226-228. doi: 10.1159/000094097

Kääriäinen, M., Salonen, K., Helminen, M., & Karhunen-Enckell, U. (2017). Chest-wall contouring surgery in female-to-male transgender patients: A one-center retrospective analysis of applied surgical techniques and results. Scandinavian Journal of Surgery,106(1), 74-79.

Menvielle, E., & Gomez-Lobo, V. (2011). Management of children and adolescents with gender dysphoria. Journal of Pediatric and Adolescent Gynecology, 24(4), 183-188. doi: https://doi.org/10.1016/j.jpag.2010.12.006

Mueller, A., & Gooren, L. (2008). Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 159, 197-202.

Nelson, M. D., Szczepaniak, L. S., Wei, J., Szczepaniak, E., Sánchez, F. J., Vilain, E., Stern, J. H., Bergman, R. N., Bairey Merz, C. N., & Clegg, D. J. (2016). Transwomen and the metabolic syndrome: Is orchiectomy protective? Transgender Health, 1, 165–171.

Newfield, E., Hart, S., Dibble, S. and Kohler, L. 2006. Female-to-male transgender quality of life. Quality of Life Research, 15: 1447–1457. 

Quinn, V. P., Nash, R., Hunkeler, E., Contreras, R., Cromwell, L., Becerra-Culqui, T. A., . . . Goodman, M. (2017). Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people. BMJ Open, 7(12), e018121. doi: 10.1136/bmjopen-2017-018121

Quinn GP, Sanchez JA, Sutton SK, Vadaparampil ST, Nguyen GT, Green BL, Kanetsky PA, Schabath MB CA (2015). Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations.Cancer J Clin. 2015 Sep-Oct; 65(5):384-400.

Silverberg, M. J., Nash, R., Becerra-Culqui, T. A., Cromwell, L., Getahun, D., Hunkeler, E., ... & Roblin, D. (2017). Cohort study of cancer risk among insured transgender people. Annals of epidemiology27(8), 499.

Slabbekoorn, D., van Goozen, S., Megens, J., Gooren, L. and Cohen-Kettenis, P. 2001. Effects of cross-sex hormone treatment on emotionality in transsexuals. The International Journal of Transgenderism, 5(3) Retrieved from

http://www.wpath.org/journal/www.iiav.nl/ezines/web/IJT/97-03/numbers/symposion/ijtvo05no03_02.htm

van Kesteren, P., Lips, P., Gooren, L., Asscheman, H., & Megens, J. (2001). Long‐term follow‐up of bone mineral density and bone metabolism in transsexuals treated with cross‐sex hormones. Clinical Endocrinology, 48(3), 347-354. 

Wierckx, K., Elaut, E., Declercq, E., Heylens, G., De Cuypere, G., Taes, Y., . . . T'Sjoen, G. (2013). Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: A case-control study.European Journal of Endocrinology, 169(4), 471-478. doi:10.1530/EJE-13-0493

(b) FertilityWhat are the implications for the fertility of children and adolescents following Gender Transition Treatment?

Answer:  Puberty blocking agents (PBA) lower testosterone and estrogen to below normal levels, thus arresting normal puberty. There are no high-quality studies on the short and long-term effects of puberty-blocking agents. Continued suppression of puberty maintains male and female gonads (i.e., sex organs) in a state of immaturity. The addition of cross-sex hormones does not reverse this situation. This combination of drugs renders children infertile.

Prolonged exposure of the testes to estrogen risks irreversible testicular damage, therefore preventing future fertility (Hembree et al., 2009). Thus, cross-sex hormone therapy may result in partial to total impairment of spermatogenesis. GnRH analogs or depot-medroxyprogesterone used to stop menses prior to testosterone treatment. It is important to discuss with the family that there may be temporary or permanent decreased fertility.

Nonetheless, between 40%-50% of transgender adults surveyed reported a desire to have children and half of these wanted their own biological children (Jones, Reiter, & Greenblatt, 2016). Infertility is a very major risk associated with the application of puberty blocking agents and cross-sex hormones to children and young people. So high is this risk that gender clinics are attempting to develop fertility preserving methods for prepubertal children before commencing treatment. These methods are by no means fail safe but the interesting finding is that very few young people take up the option to preserve their fertility (Nahata, Tishelman, Caltabellotta, & Quinn, 2017). This suggests that they are not at the appropriate developmental level to be thinking so far into the future about prospective parenthood. Most children and adolescents attending gender clinics are in an egocentric phase of development and are not ready or able to make long term decisions.

The American College of Pediatrics has concluded:

[A]ffirmation of children’s thoughts which are contrary to physical reality; the chemical castration of these children prior to puberty with GnRH agonists (puberty blockers which cause infertility, stunted growth, low bone density, and an unknown impact upon their brain development), and, finally, the permanent sterilization of these children prior to age 18 via cross-sex hormones... constitutes child abuse https://crtxnews.com/american-college-pediatrics-says-gender-ideology-hurts-children/.

References 

Abel, B. S. (2014). Hormone treatment of children and adolescents with gender dysphoria: an ethical analysis. Hastings Center Report44(s4), S23-S27.

Cretella, M. A., Quentin Van Meter, M. D., & McHugh, P. American College of Pediatricians, What’s Best for Children.

Hembree, W. C., Cohen-Kettenis, P., Delemarre-Van De Waal, H. A., Gooren, L. J., Meyer III, W. J., Spack, N. P., ... & Montori, V. M. (2009). Endocrine treatment of transsexual persons: An Endocrine Society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism94(9), 3132-3154.

Jones, C. A., Reiter, L., & Greenblatt, E. (2016). Fertility preservation in transgender patients, International Journal of Transgenderism, 17:2, 76-82, DOI: 10.1080/15532739.2016.1153992

Michael Laidlaw, Michelle Cretella & Kevin Donovan (2019). The right to best care for children does not include the right to medical transition. The American Journal of Bioethics, 19:2, 75-77, DOI: 10.1080/15265161.2018.1557288

Nahata, L., Tishelman, A. C., Caltabellotta, N. M., & Quinn, G. P. (2017). Low fertility preservation utilization among transgender youth. Journal of Adolescent Health61(1), 40-44.

(c) Suicidality: In the case of a gender dysphoric young person experiencing suicidality, is the administration of Gender Transition Treatment, including pubertal suppression drugs and cross-sex hormones a reasonable or correct treatment for ameliorating suicidality?

Answer:  Gender transition treatment does not lower the risk of suicide. 

Although the suicide risk in this population is high, as the table below attests, there is scant research evidence that gender transition treatment results in lower risk for suicide. There is also a problem in studies on gender dysphoria and suicidality related to how suicidality is measured. Different rates will be obtained in different studies because of the use of different forms of measurement. For example, being asked if you have suicidal ideation will produce higher rates than counting the number of potentially lethal suicide attempts (Aitken, VanderLaan, Wasserman, Stojanovski, & Zucker, K. (2016).

Studies

Source: García-Vega, E. Camero, A., Fernández, M., & Villaverde, M. (2018). Suicidal ideation and suicide attempts in persons with gender dysphoria. Psicothema, 30, 3, 283-288 doi: 10.7334/ psicothema2017.438 

Although further robust longitudinal studies are needed, current evidence (Dhejne, Lichtenstein, Boman, Johansson, Långstrom, et al., 2011) indicates that those having undergone sex reassignment have significantly higher risk for mortality (3 times more likely), suicidality (5 times more likely), death by suicide (19 times more likely), and psychiatric morbidity (3 times more likely) than matched controls in the general population. Figure 1 shows the trends over a 30-year follow-up period. Negative outcomes were greater for MTF compared with FTM individuals. Transgender treatment does not prevent suicide, and may have other adverse effects on mental health post transition.

Figure1

Figure 1: Death from any cause as a function of time after sex reassignment among 324 transsexual persons in Sweden (male-to-female: N = 191, female-to-male: N = 133), and population controls matched on birth year [Source: Dhejne, Lichtenstein, Boman, Johansson, Långstrom, et al. (2011)].

The vexed question is one of causality. Does gender dysphoria cause suicidality or is it the discriminatory treatment and social exclusion suffered by the transgender community that is causative, or are suicidality and gender dysphoria caused by a third factor, such as mental illness, family dysfunction, parental or social factors? In my work with transgender adolescents, I have noted with great concern the serious underlying emotional disturbance in these young people who need intensive psychotherapy and parental and family therapy to resolve these disturbances. I wonder about those who go straight to gender clinics and gender affirming professionals who skate over these cracks in their personalities and social adjustment and proceed to gender transition in the naïve belief that this will resolve all of their presenting difficulties? 

Reference

Aitken, M., VanderLaan, D. P., Wasserman, L., Stojanovski, S., & Zucker, K. J. (2016). Self-harm and suicidality in children referred for gender dysphoria. Journal of the American Academy of Child & Adolescent Psychiatry, 55(6), 513-520. doi: https://doi.org/10.1016/j.jaac.2016.04.001

(d) Child’s Best InterestsAre there circumstances under which the administration of Gender Transition Treatment could be in the best interests of children and adolescents?

Answer If there are, they would be extremely infrequent.

According to the American College of Paediatricians (2018a):

Human sex is a binary, biologically determined, and immutable trait from conception forward. … “XY” and “XX” are genetic markers of male and female, respectively, and are found in every cell of the human body including the brain. Sex is established at conception, declares itself in utero, and is acknowledged at birth. 

There are no objective (laboratory, imaging etc) or psychological tests that can reliably diagnose a “true transgender child.” By late adolescence, children with gender dysphoria who are allowed to experience natural puberty will come to accept their sex. Between 61%-98% of children desist from a transgender identity. One study of gender dysphoric boys (n=246) followed into adulthood showed that 84% spontaneously desisted. Most became either same-sex-attracted or bisexual (Singh, 2012). There is no way of predicting who will remain gender dysphoric. Therefore, 80-90% of children will be irreversibly harmed by gender transition therapy. Puberty blocking agents (PBA) derail the path of natural desistance – once children are placed on PBA, most, as adolescents, desire to progress to cross-sex hormones because of the physiological and/or psychological effects of PBA (Steensma et al., 2013). 

According to the American College of Paediatricians (2018b):

Gender dysphoria (GD) of childhood describes a psychological condition in which children experience a marked incongruence between their experienced gender and the gender associated with their biological sex. When this occurs in the pre-pubertal child, GD resolves in the vast majority of patients by late adolescence. Currently there is a vigorous, albeit suppressed, debate among physicians, therapists, and academics regarding what is fast becoming the new treatment standard for GD in children. This new paradigm is rooted in the assumption that GD is innate, and involves pubertal suppression with gonadotropin releasing hormone (GnRH) agonists followed by… cross-sex hormones—a combination that results in the sterility of minors. …This protocol is founded upon an unscientific gender ideology, lacks an evidence base, and violates the long-standing ethical principle of “First do no harm.

Data on the persistence of the adolescent transgender lifestyle into adulthood is unreliable, primarily because so many are lost to follow up (Dhejne, Lichtenstein, Boman, Johansson, Långström, & Landén, 2011).Recent observations suggest that the rates of those wishing to de-transition are increasing (https://thenewstalkers.com/community/discussion/34788/the-new-taboo-more-people-regret-sex-change-and-want-to-detransition-surgeon-says) but any research or discussion on de-transitioning is being blocked by the transgender lobby and by professionals such as those in ethics committees in universities who fail to show any moral courage in supporting such research https://www.bbc.com/news/uk-41384473

References 

American College of Paediatricians (2018a): https://www.acpeds.org/wordpress/wp-content/uploads/12.4.18-Final_Revised_-12.4.18-Joint-letter-to-HHS-DOJ-DOE-Uphold-Definition-of-Sex.pdf

American College of Paediatricians (2018b): https://www.acpeds.org/the-college-speaks/position-statements/gender-dysphoria-in-children

Bath Spa University 'blocks transgender research' (2017). https://www.bbc.com/news/uk-41384473

Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one, 6(2), e16885. doi:10.1371/journal.pone.0016885

Singh, Devita (2012). A follow up study of boys with gender dysphoria. 
images.nymag.com/images/2/daily/2016/01/SINGH-DISSERTATION.pdf.

Steensma, Thomas D., et al. (2013). gender identity development in adolescence.Hormones and Behavior, 64, 2, pp. 288–297. doi:10.1016/j.yhbeh.2013.02.020. 

The new taboo: More people regret sex change and want to ‘detransition’, surgeon says https://thenewstalkers.com/community/discussion/34788/the-new-taboo-more-people-regret-sex-change-and-want-to-detransition-surgeon-says

(e) Informed ConsentCan children and adolescents understand the risks, benefits, and consequences of Gender Transition Treatment and give informed consent to it?

Answer:  It is very difficult for anyone, particularly minors, to give consent to treatment for a fictitious condition. Further, a significant proportion of children and adolescents seeking such treatment have comorbid psychological, psychiatric, intellectual and cognitive disorders that preclude the capacity for informed consent.

Cases before the Family Court of Australia seeking court authorization for cross-sex hormone treatment or sex reassignment surgery have increased dramatically since 2004, which heard one case, to 18 cases in 2015, and 22 cases in 2016. In total, the court has ruled on 56 cases in this time period, including authorizing five young women for bilateral mastectomy. In these 56 children, 25 of 39 cases in which family constellation could be discerned lived in single parent families or foster care, with only 14 from two parent families. In this same group of 56 children, 50% had a diagnosed psychological disorder, including Autism Spectrum Disorder (ASD), major depression, anxiety, oppositional defiance disorder (ODD), ADHD, and intellectual disability. A recent study has shown a higher prevalence of gender dysphoria in those with ASD (van der Miesen, Hurley, Bal, & de Vries, 2018). 

In a sample of 105 gender dysphoric adolescents and using the Diagnostic Interview Schedule for Children (DISC), anxiety disorders were found in 21%, mood disorders in 12.4%, and disruptive disorders in 11.4% of the adolescents. Males had greater psychopathology compared with females, including comorbid diagnoses (de Vries et al. 2011). 

For some [children identifying as “transgender”], the major issue is cross-gender behaviours or identifications; for others, the gender issues seem to be epiphenomena of psychopathology, exposure to trauma, or attempts to resolve problems such as higher social status or other benefits they perceive to be associated with the other gender (Drescher & Byne, 2012, p. 503).

In the adult transgender population, mental health has also been found to be more impaired in the transgender population compared with male and female reference groups (Quinn et al., 2017). For example, anxiety was diagnosed in 38% of trans females (TF) compared with 22% of reference females (RF). Depression was diagnosed in 49% (TF) vs 25% (RF); suicidal ideation in 5% (TF) compared with 0.6% (RF); and substance abuse disorder in 15% TF compared with 5% RF. In trans males (TM) mental health was significantly worse compared with reference males (RM). For example, 46% TM were diagnosed with anxiety compared with 13% RM. Similarly, for depression (55% vs13%), self-inflicted injury (4.2% vs 0.4%), suicidal ideation (6.7% vs 0.6%), and substance abuse disorder (14% vs 8.4%), TM were significantly more disadvantaged than RM. 

Informed consent can also be impeded by extraneous factors in the environment that “seduce” young people to adopt a particular stance without the full and conscious knowledge of how their thinking and feeling on the subject has been influenced. Given the strong evidence of peer contagion in suicide, substance abuse and eating disorders, especially among adolescents, the role of peer contagion in gender dysphoria demands urgent attention. 

If we examine the gender dysphoria epidemic in social network terms, we see several features operating. It is an open-system network with nodes and ties expanding across the globe. Most countries are reporting sharp increases in the number of people seeking services and treatment for gender dysphoria. Many are ramping up services and setting up new gender clinics to cope with demand. This network is highly centralised with only one voice – the transactivist lobby advocating immediate gender transition treatment - being heard above the desperate whispers of terrified parents and horrified academics, researchers, doctors, psychologists and psychotherapists. Opinion leaders operating at the centre of these networks are very influential. The level of density in a network has two effects – firstly, it enhances the circulation of information between members and secondly, it blocks the introduction of dissenting ideas and evidence (Iyengar, Van den Bulte, & Valente, 2011). Most young people will deny that they are susceptible to such influences and that they have made up their own mind. However, when questioned, they repeat the slogans propagated by the trans-lobby as their reasons for wanting undergo gender transition treatment.

References

De Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disorders, 40(8), 930-936. 

Drescher, J., & Byne, W. (2012). Gender dysphoric/gender variant (gd/gv) children and adolescents: Summarizing what we know and what we have yet to learn. Journal of Homosexuality, 59(3), 501-510. doi: 10.1080/00918369.2012.653317

Iyengar, R., Van den Bulte, C., & Valente, T. W. (2011). Opinion leadership and social contagion in new product diffusion. Marketing Science, 30(2), 195-212. 

Quinn, V. P., Nash, R., Hunkeler, E., Contreras, R., Cromwell, L., Becerra-Culqui, T. A., . . . Goodman, M. (2017). Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people. BMJ Open, 7(12), e018121. doi: 10.1136/bmjopen-2017-018121

van der Miesen, A. I. R., Hurley, H., Bal, A. M., & de Vries, A. L. C. (2018). Prevalence of the wish to be of the opposite gender in adolescents and adults with autism spectrum disorder. Archives of Sexual Behavior. doi: 10.1007/s10508-018-1218-3

(f) Parental RoleShould a role be reserved for a mother or father in assisting their children to understand whether Gender Transition Treatment is right for them?

Answer Definitely. In addition, there is a role for assessment of the parental dynamics, the parent-child relationship and the family constellation of gender dysphoric children before any decisions are made to proceed to treatment.

We need to investigate the context in which gender dysphoria arises and the reasons for the exponential increase in cases observed over the past decade, an increase tantamount to a psychic epidemic. These include family constellation, parental gendered behaviours and attitudes, child maltreatment, and peer contagion and cultural factors. 

Gender dysphoria might be better understood as a relational process rather than as an inherent property of the individual. Illuminating the interactional dynamics in which young children assert that they are transgender rather than unthinkingly affirming their cross-gender assertions is confronting for all concerned, including parents, doctors, therapists, and transactivists. 

Studies in the developmental psychology literature about factors that influence gender development in traditional families (McHale, Updegraff, Helms-Erikson, & Crouter, 2001; Pierrehumbert et al., 2009; Sumontha, Farr, & Patterson, 2017; Tenenbaum & Leaper, 2002)can inform and guide research into families with a transgender child. There is an emergent literature on gender dysphoria that is exploring family dynamics, the interpersonal quality of parent-child (Zucker, Wood, Singh, & Bradley, 2012)and sibling (Rust, Golombok, Hines, Johnston, & Golding, 2000)relationships and parental gender attitudes and behaviours (Dawson, Pike, & Bird, 2016)in families with a transgender child (Riley, Sitharthan, Clemson, & Diamond, 2011)although the literature is still sparse in this respect. 

One study of traditional families found that preadolescent children who are anxiously attached to their mothers or who had a preoccupied form of insecure attachment to their mothers experienced lower gender contentedness and fewer gender-typical feelings compared with securely attached children (Cooper et al., 2013). What effect would a parent who preferred a child of the opposite sex have on a child’s gender identity? Such a question could usefully be explored in families with a transgender child. 

“Parents are critical mediators of the experiences of their gender variant children…”(Gray, Sweeney, Randazzo, & Levitt, 2016, p. 123), as indeed are siblings, peers, and the wider ecological context in which children grow and learn, including gender clinics, social media, and purported experts. The influence of all these factors on the gender dysphoric child are not well understood. Accordingly, great care needs to be exercised and thorough assessments conducted before making irreversible changes to their developing bodies. 

In addition, parents are subject to the same influences as their declared transgender children. They are constantly trawling the internet, joining parent support groups, giving media interviews espousing clichés in which they have been schooled by gender clinics of the kind, “I would rather have a live trans daughter than a dead son.” Parents may have their own psychopathologies that are playing out in the transgender drama of their children. For separated parents, it often becomes a battleground in which one supports their child’s declared gender identity while the other struggles to prevent the administration of harmful drugs and mutilating surgery. Such families need to be assessed for parental alienation.

(g) Faulty logic: What are the assumptions underpinning the understanding of the gender dysphoria in transactivist lobbies?

Answer:  Transgender advocates state that in transgenderism - the belief/assumption that one has been born in the wrong body - the body must be aligned to one’s gender belief, not one’s belief to one’s biological body. They assume that the mind is “correct” in its perceptions and beliefs and the body is diseased and must be treated. Transgenderism is a disorder of assumption and like other disorders of assumption, is solipsistic. Solipsism is the belief that ideas that arise in the mind are true and cannot be questioned. For example, those with anorexia nervosa believe that they are a fat when in fact they are emaciated. People with body image dysmorphia engage in endless plastic surgery to correct their perceived ugliness, when their appearance falls well within the ‘norms’ for their culture. Those with body integrity identity disorder (BIID) perceive one or more of their normal limbs or organs as alien to the rest of their body and wish to have it (them) removed, amputated or paralysed. If refused surgery, they may self-mutilate. Can we, as a society, condone the amputation or paralysis of healthy limbs in people with BIID? In the same vein, is the amputation of a healthy penis and healthy breasts ethically justifiable? Disorders of assumption are disorders of perception. Disorders of perception belong in the domains of psychology, psychiatry, and psychotherapy, not endocrinology or mutilating surgery. 

In the Middles Ages, the belief that some women were “witches” resulted in the murder of thousands of innocents during the Inquisition. More recently, families were torn apart by the “recovered memories” epidemic. Innocent teachers spent many years in jail after false accusations of “ritual sexual abuse” at preschools (Kenny, 2015). If transgender hysteria is not stemmed, it will result in the devastation of the lives of young people who get swept up in the cause of gender transition. Many may change their minds, but sex reassignment surgery and sterility as a result of cross-sex hormone treatment are generally irreversible. 

McHugh (2008; 2014) argued, “Sex change is biologically impossible. People who undergo sex-reassignment surgery do not change from men to women or women to men. Rather, they become feminized men or masculinized women” https://www.lifesitenews.com/news/former-johns-hopkins-head-psychiatrist-transgender-surgery-isnt-the-solution

(h) Social Factors:What are the social forces propelling the gender dysphoria pandemic? 

AnswerSocial contagion and groupthink

Contagion is a biological concept originating in the field of epidemiology. It describes the pattern of dissemination across networks of a disease, allowing patterns and causes of contagion to be identified and tracked. The concept has been borrowed by the social sciences to understand fads, politics, financial behaviour, and the popularity of new theories. 

A related concept is groupthink. Groupthink, a term coined by social psychologist Irving Janis (1972), is an extreme form of conformity in which people are prepared to keep the peace at all costs. It tends to occur more in homogenous groups, when a powerful and charismatic group leader is insistent on the preferred course of action, when the group is under severe stress, where significant moral dilemmas are part of the decision matrix and where objective outside experts are not called upon. The consequences of group think include the illusion of invulnerability, collective rationalization, stereotyping of out-groups, self-censorship, belief in the inherent morality of the group, poor information search, incomplete survey of alternatives, failure to appraise the risks of the preferred solution, selective information processing, and conflation of ethics and expedience (Kenny, 2015; Turner & Pratkanis, 1998).

Transgenderism is primarily a sociocultural and political phenomenon, not a psychological or medical reality that has been fuelled by both social contagion and groupthink social processes. One can observe all the features described above in the conduct of transgender advocacy groups. 

References

Janis, I.L. (1972). Victims of groupthink: A psychological study of foreign-policy decisions and fiascos. Boston: Houghton Mifflin.
Turner, M.E. & Pratkanis, A.R. (1998). Twenty-five years of groupthink theory and research: Lessons from the evaluation of a theory. Organizational Behavior and Human Decision Processes, 73, 105–115. 

 

[1]Please note: I use the term “gender transition treatment” not “gender affirmation treatment” deliberately. “Affirmation” is a loaded term that assumes that a person can be born into the wrong body, a logical fallacy that should not be enshrined in terminology.

 

 

 

Tuesday, 12 March 2019 12:36

Summary of paper

The right to best care for children does not include the right to medical transition

Citation: 

Michael Laidlaw, Michelle Cretella & Kevin Donovan (2019) The right to best care for children does not include the right to medical transition, The American Journal of Bioethics, 19:2, 75-77, DOI: 10.1080/15265161.2018.1557288

Here are the key points of this recently published paper on gender dysphoria in children

  1. Watchful waiting with support (and therapy, if indicated) for gender-dysphoric children and adolescents up to the age of 16 years is the current standard of care worldwide, not gender affirmative therapy (GAT).
  2. Puberty blocking agents (PBA) lower testosterone and estrogen to below normal levels, thus stopping normal puberty. There are no high-quality studies on the short and long-term effects of puberty-blocking agents.
  3. Continued suppression of puberty maintains male and female gonads (i.e., sex organs) in a state of immaturity. The addition of cross sex hormones does not reverse this situation. 

THE PROBLEM OF ACCURATE DIAGNOSIS AND DESISTANCE

  • There are no objective (laboratory, imaging etc) or psychological tests that can reliably diagnose a “true transgender child.”
  • By adulthood, between 61-98% children desist from a transgender identity. There is no way of predicting who will remain gender dysphoric. Therefore, many children will be irreversibly harmed by gender affirmation therapy.
  • Social contagion has been identified as a mechanism of transmission of gender dysphoria.
  • PBA derail the path of natural desistance – once children are placed on PBA, most, as adolescents, desire to progress to cross-sex hormones because of the physiologic and/or psychological effects of PBA.

Comorbid psychiatric conditions

  • Psychological conditions co-occurring in up to 75% of young people with gender dysphoria affect their judgement about proceeding with PBA, particularly when these conditions are not properly considered or treated.

CONSEQUENCES OF “GENDER AFFIRMING THERAPY” IN PREPUBERTAL CHILDREN

Infertility

  • Involuntary infertility in adults creates psychological distress and depression and reduces quality of life. Infertility is the outcome of puberty suppression. Children do not have the maturity to understand the implications of lifelong infertility. 
  • Fertility preservation rates are low – fewer than 5% adolescents attempt cryopreservation.
  • Children receiving puberty-blockers cannot preserve eggs or sperm. The only options are experimental procedures such as ovarian and testicular tissue cryopreservation. 

Impaired sexual function

  • Early blockade of puberty stops genital development which results in limited to absent sexual function in adulthood.
    • In men, erection, orgasm, and ejaculation are impaired or absent
    • In women, puberty blockers induce menopause and reduce sexual desire
    • Reduced sexual desire in both men and women is associated with decreases in general health and mental wellbeing

Disruption of normal bone development

  • Puberty blocking agents cause a decline in bone mineral density that may result in early onset osteopenia or osteoporosis.

INFORMED CONSENT

  • Children cannot give informed consent to GAT as they cannot fully appreciate the consequences of infertility and loss of sexual function and pleasure, nor the myriad complications of the treatment, including surgical complications if they proceed to breast removal or genital reconstruction.
  • Denial of parental involvement is dangerous

 

 

Friday, 14 September 2018 04:01

The role of biological factors in gender identity development

Professor Dianna Kenny, The University of Sydney

Biological factors also make a significant contribution to gender identity development. Recent research in both humans and primates shows that sexually dimorphic toy preferences reflect basic neurobiological differences between boys and girls that precede social or cognitive influences (Williams & Pleil, 2008). Children’s gendered selections of playmates, toys, and activities can be traced to the influence of biological factors, in particular, prenatal exposure to testosterone that occurs via testicular development, which in turn is determined by the presence of the Y chromosome (Hines, 2010).

These sex differences in children’s play commence very early, before gender development and sexual orientation (Berenbaum, Martin, Hanish, Briggs, & Fabes, 2008). Studies with nonhuman primates, who have not been affected by gendered socialization processes or gender identification, confirm sex differences in novel toy selection (e.g., males prefer wheeled toys, females prefer plush toys, dolls) observed in young children (Hassett, Siebert, & Wallen, 2008). In both monkeys and children, males are more rigid in their toy selections than girls. However, girls who have been exposed to abnormally high levels of testosterone, such as those with congenital adrenal hyperplasia (CAH) (Pasterski et al., 2011), and those whose mothers took androgenic progestins during pregnancy show increased male-typical play and toy selection (Hines, 2003). Further, levels of testosterone in the blood or amniotic fluid of pregnant women are associated with the degree of male-typical behaviour demonstrated by their children (van de Beek, van Goozen, Buitelaar, & Cohen-Kettenis, 2009). As well as sex-nontypical behaviour in childhood, women with CAH evince lower heterosexual orientation, diminished identification with female gender, and higher preference to live as a man in adulthood, despite having been raised as girls. CAH women are 600 times more likely than women in the general population to experience severe gender dysphoria (Hines, 2010).

Some personality characteristics such as empathy (higher in females) and aggression (higher in males) are also associated with pre-natal testosterone exposure (Hines, 2008). Hormonal surges in sex hormones (testosterone for boys, and oestrogen for girls) soon after birth may also affect gender development. Those children who have absent or reduced hormonal surges such as boys with hypogonadism and girls with Turner’s syndrome show differential deficits in developments normally associated with their assigned sex (Alexander, Wilcox, & Farmer, 2009).

Biological factors other than testosterone can also affect gender development. For example, newborns can generally be assessed along nine dimensions of infant temperament - activity level, distractibility, intensity, regularity, sensory threshold, approach/withdrawal, adaptability, persistence and mood (Gartstein & Rothbart, 2003).  Zucker and colleagues (Zucker, Wood, Singh, & Bradley, 2012) offer a highly cogent example of how infant temperament can interact with gender development processes to cause confusion about gender identity in young people. Activity level, a sex-dimorphic trait that tends to be higher in boys, is associated with higher physical energy expenditure, one form of which is rough-and-tumble play. Activity level is lower in boys and higher in girls with gender identity disorder (GID) – an inversion of levels that occur in children without GID. Boys low in activity level might find the behaviour of girls more compatible with their temperament, leading them to affiliate with girls, which may direct their toy and play interests towards those typical of girls. This process, if continued, may lead to the development of female gender identity and later to gender confusion and/or dysphoria. This process may be interrupted if boys with low activity level meet and befriend other boys with similar activity levels (e.g., boys who prefer reading and playing chess rather than playing body contact sports). Meeting like, same-gendered minds may make it possible for such boys to expand their previously-held, somewhat rigid views about the nature of boys, thus allowing them to view themselves as a subset of all males, rather than as female “trapped in the wrong body.”

References

Alexander, G. M., Wilcox, T., & Farmer, M. E. (2009). Hormone–behavior associations in early infancy. Hormones and Behavior, 56(5), 498-502. doi: https://doi.org/10.1016/j.yhbeh.2009.08.003

Berenbaum, S. A., Martin, C. L., Hanish, L. D., Briggs, P. T., & Fabes, R. A. (2008). Sex differences in children’s play. Sex differences in the brain: From genes to behavior, 275-290.

Gartstein, M. A., & Rothbart, M. K. (2003). Studying infant temperament via the revised infant behavior questionnaire. Infant Behavior and Development, 26(1), 64-86.

Hassett, J. M., Siebert, E. R., & Wallen, K. (2008). Sex differences in rhesus monkey toy preferences parallel those of children. Hormones and Behavior, 54(3), 359-364.

doi: 10.1016/j.yhbeh.2008.03.008

Hines, M. (2003). Sex steroids and human behavior: Prenatal androgen exposure and sex‐typical play behavior in children. Annals of the New York Academy of Sciences, 1007(1), 272-282.

Hines, M. (2008). Early androgen influences on human neural and behavioural development. Early Human Development, 84(12), 805-807.

                  doi: https://doi.org/10.1016/j.earlhumdev.2008.09.006

Hines, M. (2010). Sex-related variation in human behavior and the brain. Trends in Cognitive Sciences, 14(10), 448-456. doi: https://doi.org/10.1016/j.tics.2010.07.005

Pasterski, V. L., Geffner, M. E., Brain, C., Hindmarsh, P., Brook, C., & Hines, M. (2011). Prenatal hormones and childhood sex segregation: Playmate and play style preferences in girls with congenital adrenal hyperplasia. Hormones and Behavior, 59(4), 549-555. doi: https://doi.org/10.1016/j.yhbeh.2011.02.007

van de Beek, C., van Goozen, S. H., Buitelaar, J. K., & Cohen-Kettenis, P. T. (2009). Prenatal sex hormones (maternal and amniotic fluid) and gender-related play behavior in 13-month-old infants. Archives of Sexual Behavior, 38(1), 6-15.

Williams, C. L., & Pleil, K. E. (2008). Toy story: Why do monkey and human males prefer trucks? Comment on “Sex differences in rhesus monkey toy preferences parallel those of children” by Hassett, Siebert and Wallen. Hormones and Behavior, 54(3), 355-358. doi: https://doi.org/10.1016/j.yhbeh.2008.05.003

Zucker, K. J., Wood, H., Singh, D., & Bradley, S. J. (2012). A developmental, biopsychosocial model for the treatment of children with gender identity disorder. Journal of Homosexuality, 59(3), 369-397.

Monday, 14 May 2018 22:47

Transgender hysteria

Professor Dianna Kenny, The University of Sydney.

Transgender population estimates

The Australian Bureau of Statistics (ABS) included a question on gender diversity for the first time in the 2016 Census. It reported that 1,260 people in Australia identified as “sex and/or gender diverse.” Of this tiny proportion of the Australian population, 35% of sex/gender diverse people indicated they were non-binary (17%) or a gender other than male or female (18%). A further 26% reported they were trans male, trans female (13%), or transgender (13%). 3.2% indicated that they were intersex or of indeterminate sex (i.e., 0.17 per 100,000) of the Australian population. The table below provides a summary. These numbers suggest that the tsunami of transgender hysteria has not yet crashed on Australian shores. Let’s erect the barriers of scientific evidence, sound reasoning, and medical ethics against the rising tide.

DESCRIPTORS FOR PERSONS REPORTING DIVERSE SEX/GENDER IDENTITY(a), 2016

http://www.abs.gov.au/icons/ecblank.gif" > Persons(b) %

Intersex/Indeterminate 40 3.2
Trans male 70 5.5
Trans female 100 7.5
Transgender not elsewhere classified 170 13.2
Non-binary 220 17.3
Another gender 230 18.1
Othernot further defined(c) 440 34.9
Persons 1 260 100.0

Source: ABS Census of Population and Housing, 2016

In the USA, the rate of self-identification as transgender doubled in 10 years from 12.5 (0.013%)(2002) to 23 (0.023%) per 100,000 (2011). The Massachusetts Behavioral Risk Factor Surveillance Survey found that 0.5% of the adult population aged 18 to 64 years identified as TGNC (transgender and gender nonconforming) between 2009 and 2011 (Conron, Scott, Stowell, & Landers, 2012). By 2016, the estimated rate was 0.6% of the USA population (i.e., 1.4 million people) identifying as transgender (Williams Institute, 2016, https://williamsinstitute.law.ucla.edu/wp-content/uploads/CHIS-Transgender-Teens-FINAL.pdf).

Referrals for gender dysphoria and treatment

Health services in the UK dealing with gender issues in young people under the age of 18 years have experienced dramatic increases in referrals over the past few years. Figures from Gender Identity Development Service (GIDS) which is the NHS’s only facility for children with gender dysphoria, showed that 84 children between three and seven years were referred in 2017, compared with 20 in 2012/2013. Referrals of children less than 10 years of age showed a fourfold increase from 36 in 2012 to 165 in 2016. In 2016, here were 2,016 referrals for children aged between three and 18 years, a six time increase from 314 five years previously. More than twice as many girls as boys are referred to such services. https://www.telegraph.co.uk/news/2017/07/08/number-children-referred-gender-identity-clinics-has-quadrupled/

Longitudinal data from the US covering the years from 2005 to 2015 show marked increases in prevalence of referrals for people seeking transgender treatment. As the figure shows, there was more than a three-fold increase in referrals over this timeframe.

Transgender hysteria Prevalence of Gender Status
Source: Quinn, Nash, Hunkeler… et al. (2017).

Although gender reassignment surgeries in the US increased by 20 percent in one year (from 2015 to 2016) with 3,000 surgeries performed in 2016 alone http://www.newsweek.com/transgender-women-transgender-men-sex-change-sex-reassignment-surgery-676777, the proportion of those self-identifying as transgender who were seeking treatment were very low compared with the total population of transgender-identified individuals in the Quinn et al study. Of those registered at the three health sites in Figure 3 (n=6,456), 55% commenced cross-sex hormone therapy, 6% had breast removal surgery, 0.8% had orchiectomy (with or without breast surgery), 4.6% had genital reconstruction surgery, and 11% had surgery to alter secondary sexual characteristics.  In all, about 23% of the transgender group underwent some form of “gender affirmation” surgery). 

Cases before the Family Court of Australia seeking court authorization for cross sex hormone treatment or sex reassignment surgery have increased dramatically from 2004, which heard one case, to 18 cases in 2015, and 22 cases in 2016. In total, the court has ruled on 56 cases in this time period, including authorizing five young women for bilateral mastectomy.

What can possibly account for these alarming increases in transgenderism and other categories of gender? Here are some possible explanations:

Social contagion and groupthink

Contagion is a biological concept originating in the field of epidemiology. It describes the pattern of dissemination across networks of a disease, allowing patterns and causes of contagion to be identified and tracked. The concept has been borrowed by the social sciences to understand fads, politics, financial behaviour, and the popularity of new theories. A related concept is groupthink. Groupthink, a term coined by social psychologist Irving Janis (1972), is an extreme form of conformity in which people are prepared to keep the peace at all costs. It tends to occur more in homogenous groups, when a powerful and charismatic group leader is insistent on the preferred course of action, when the group is under severe stress, where significant moral dilemmas are part of the decision matrix and where objective outside experts are not called upon. The consequences of group think include the illusion of invulnerability, collective rationalization, stereotyping of out-groups, self-censorship, belief in the inherent morality of the group, poor information search, incomplete survey of alternatives, failure to appraise the risks of the preferred solution, selective information processing, and conflation of ethics and expedience (Kenny, 2015; Turner & Pratkanis, 1998).

Transgenderism is primarily a sociocultural and political phenomenon, not a psychological or medical phenomenon, that has been fuelled by both social contagion and groupthink social processes. You will observe all the features described above in the conduct of transgender advocacy individuals and groups.

Normalization and demedicalization of transgenderism

The notion that people are born transgender and that it is a normal variant of sexual development has taken hold within the transgender community and its advocates but is not supported by scientific evidence. The idea that gender identity is an innate characteristic independent of biological sex — that is, that an individual can be “a man trapped in a woman’s body” or “a woman trapped in a man’s body” — is also not supported by scientific evidence.

The American College of Paediatricians issued a statement in March 2016 stating that the transgender agenda harms children. They stated: “Educators and legislators should reject all policies that condition children to accept as normal a life of chemical and surgical impersonation of the opposite sex. Facts — not ideology — determine reality.” The College further states that “Conditioning children into believing a lifetime of chemical and surgical impersonation of the opposite sex is normal and healthful is child abuse” http://www.acpeds.org/the-college-speaks/position-statements/gender-ideology-harms-children.

Transgender advocacy

Activism of the kind being witnessed in transgender advocacy groups hinders accurate diagnosis and optimal care for children presenting to treatment centres with gender dysphoria or beliefs that they are “in the wrong body.” This faulty notion forecloses on exploration of environmental, family, and psychological factors that are associated with the development of such orientations, the most important of which are the experience of child sexual abuse, growing up in a dysfunctional family (e.g., domestic violence, substance abuse in parents etc), and the experience of interpersonal violence before age 18 http://dx.doi.org/10.2105/AJPH.2009.168971. Youth aged 3 to 17 years now constitute more than 20 percent of the transgender population (Quinn et al., 2017).

Ignoring science in favour of ideology

The infamous and thoroughly discredited John Money Introduced the term ‘gender’ as a psychological construct in the 1950s and argued, without evidence, that gender could be socially manipulated. He was responsible for the suicides of twin boys, one of whom suffered a catastrophic amputation of his penis during circumcision. Based on the erroneous belief that gender is socially determined, Money advised his parents to raise the boy as a girl and to socialize him into a female gender. The child rebelled at age 14, insisting that he was male, and his parents finally disclosed his medical history and allowed him to return to his natal sex. However, he had suffered so much trauma in the intervening years that suicide felt like his only option to stop his agony of mind.

Five areas of debate that have been either ignored or minimized by the transgender lobby are discussed below:

(i) The role of personal and familial psychopathologies in the development of gender dysphoria

In the 56 children before the Family Court in Australia, discussed above, 25 of 39 cases in which family constellation could be discerned lived in single parent families or foster care, with only 14 from two parent families. In this same group of 56 children, 50% had a diagnosed psychological disorder, including six with Autism Spectrum Disorder (ASD), major depression, anxiety, oppositional defiance disorder, ADHD, and intellectual disability. A recent study has shown a higher prevalence of gender dysphoria in those with ASD (van der Miesen, Hurley, Bal, & de Vries, 2018).

In a sample of 105 gender dysphoric adolescents and using the Diagnostic Interview Schedule for Children (DISC), anxiety disorders were found in 21%, mood disorders in 12.4%, and disruptive disorders in 11.4% of the adolescents. Males had greater psychopathology compared with females, including comorbid diagnoses (de Vries et al. 2011).

(ii) Desistance

 

Up to 90% of children presenting with gender dysphoria may desist by adolescence https://quadrant.org.au/magazine/2017/05/childhood-gender-dysphoria-responsibility-courts/; de Vries & Cohen (2012). According to DSM 5 (APA, 2013), 98% of gender confused boys and 88% of gender confused girls eventually accept their biological sex after naturally passing through puberty.

(iii) Adverse effects of long term cross-sex hormones on health

Surgical castration of male animals, leading to a loss of testosterone, results in marked decreases in synaptic density in the hippocampus and reductions in the capacity for learning and memory. Female to male cross hormone results in loss of bone mineral density (van Kesteren, Lips, Gooren, Asscheman, & Megens, 2001). Venous thrombo‐embolism (Asscheman, et al. 2014) and osteoporosis (Wierckx, 2012) have been identified as complications of cross‐sex hormone treatment of male‐to‐female transsexual patients. A significantly higher prevalence of venous thrombosis, myocardial infarction, CVD, and type 2 diabetes was found in trans females (TF) than in a control population (Wierckx et al., 2013).  Cross sex hormone treatment may also be associated with hormone-related cancer, a risk that increases with duration of exposure and the aging of the transgender population (Mueller & Gooren, 2008).

In the Quinn et al. (2017) study, myocardial infarction occurred at twice the rate in TF (1.8%) compared with reference females (RF) (0.9%). Peripheral artery disease (3.1% vs 1.9%) and unstable angina (1.8% vs 1.0%) were also elevated in TF compared with RF. Of the cancers surveyed (colorectal, lung, lymphatic and haematopoietic, and melanoma), none had higher numbers of cases in the TF population compared with the RF group. However, HIV was significantly more prevalent in the TF (5.4%) compared with RF (0%).

(iv) Long term adverse health effects associated with sex reassignment surgery

Although further robust longitudinal studies are needed, current evidence http://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0016885&type=printable

indicates that those having undergone sex reassignment have significantly higher risk for mortality (3 times more likely), suicidality (5 times more likely), death by suicide (19 times more likely), and psychiatric morbidity (3 times more likely) than matched controls in the general population. Figure 1 shows the trends over a 30-year follow-up period. Negative outcomes were greater for MTF compared with FTM individuals.

Transgender Hysteria Any Cause of Death

Figure 1: Death from any cause as a function of time after sex reassignment among 324 transsexual persons in Sweden (male-to-female: N = 191, female-to-male: N = 133), and population controls matched on birth year [Source: Dhejne, Lichtenstein, Boman, Johansson, Långstrom, et al. (2011)].

Mental health was considerably more impaired in the transgender population compared with male and female reference groups (Quinn et al., 2017). For example, anxiety was diagnosed in 38% of trans females (TF) compared with 22% of reference females (RF). Depression was diagnosed in 49% (TF) vs 25% (RF); suicidal ideation in 5% (TF) compared with 0.6% (RF); and substance abuse disorder in 15% TF compared with 5% RF. In trans males (TM) mental health was significantly worse compared with reference males (RM). For example, 46% TM were diagnosed with anxiety compared with 13% RM. Similarly, for depression (55% vs13%), self-inflicted injury (4.2% vs 0.4%), suicidal ideation (6.7% vs 0.6%), and substance abuse disorder (14% vs 8.4%), TM were significantly more disadvantaged than RM.

(v) Gender re-assignment regret and “reversal” surgeries

Although there are no reliable statistics on regret, a number of gender reassignment surgeons are reporting increases in requests for reversal surgeries [e.g., http://www.newsweek.com/transgender-women-transgender-men-sex-change-sex-reassignment-surgery-676777]. A poignant BBC documentary One life: Make me a man again, was televised in 2004.

Solipsism

Transgender advocates state that in transgenderism - the belief/assumption that one has been born in the wrong body - the body must be aligned to one’s gender belief, not one’s belief to one’s biological body. They assume that the mind is “correct” in its perceptions and beliefs and the body is diseased and must be treated. Transgenderism is a disorder of assumption and like other disorders of assumption, is solipsistic. Solipsism is the belief that ideas that arise in the mind are true and cannot be questioned. For example, those with anorexia nervosa believe that they are a fat when in fact they are emaciated. People with body image dysphoria engage in endless plastic surgery to correct their perceived ugliness, when their appearance falls well within the ‘norms’ for their culture. Those with body integrity identity disorder (BIID) perceive one or more of their limbs or organs as alien to the rest of their body and wish to have it amputated or paralysed. If refused surgery, they may self-mutilate. Can we, as a society, condone the amputation or paralysis of healthy limbs in people with BIID? In the same vein, is the amputation of a healthy penis and healthy breasts ethically justifiable? Disorders of assumption are disorders of perception. Disorders of perception belong in the domains of psychology, psychiatry, and psychotherapy, not endocrinology or mutilating surgery.

In the Middles Ages, the belief that some women were “witches” resulted in the murder of thousands during the Inquisition. More recently, families were torn apart from the “recovered memories” epidemic. Innocent teachers spent many years in jail after false accusations of “ritual sexual abuse” at preschools (Kenny, 2015). If transgender hysteria is not stemmed, it will result in the devastation of the lives of young people who get swept up in the cause of gender affirmation. Many may change their minds, but sex reassignment surgery and sterility as a result of cross-sex hormone treatment are irreversible. McHugh (2008; 2014) argued, “Sex change is biologically impossible. People who undergo sex-reassignment surgery do not change from men to women or women to men. Rather, they become feminized men or masculinized women” https://www.lifesitenews.com/news/former-johns-hopkins-head-psychiatrist-transgender-surgery-isnt-the-solutio

 

 

References

Asscheman, H., T'Sjoen, G., Lemaire, A., Mas, M., Meriggiola, M. C., Mueller, A., & Gooren, L. J. (2014). Venous thrombo‐embolism as a complication of cross‐sex hormone treatment of male‐to‐female transsexual subjects: A review. Andrologia, 46(7), 791-795. doi: 10.1111/and.12150.

Andrea L. Roberts et al., “Pervasive Trauma Exposure Among US Sexual Orientation Minority Adults and Risk of Posttraumatic Stress Disorder,” American Journal of Public Health 100, no. 12 (2010): 2433–2441, http://dx.doi.org/10.2105/AJPH.2009.168971.

American Psychiatric Association (APA): Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Arlington, VA, American Psychiatric Association, 2013 (451-459). See page 455 re: rates of persistence of gender dysphoria.

Conron, K. J., Scott, G., Stowell, G. S., & Landers, S. J. (2012). Transgender health in Massachusetts: results from a household probability sample of adults. American Journal of Public Health, 102(1), 118-122.

de Vries, A.L.C, Doreleijers, T. A. H., Steensma, T. D., & Cohen-Kettenis, P. T. (2011). Psychiatric comorbidity in gender dysphoric adolescents. Journal of Child Psychology and Psychiatry, 52(11), 1195-1202. doi:10.1111/j.1469-7610.2011.02426.x

de Vries, A. L., & Cohen-Kettenis, P. T. (2012). Clinical management of gender dysphoria in children and adolescents: the Dutch approach. Journal of Homosexuality, 59(3), 301-320.

Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L., Långström, N., & Landén, M. (2011). Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PloS one, 6(2), e16885

Janis, I.L. (1972). Victims of groupthink: A psychological study of foreign-policy decisions and fiascos. Boston: Houghton Mifflin.

Kenny, D.T. (2015). God, Freud, and religion: The origins of faith, fear, and fundamentalism. Oxford: Routledge.

Mueller, A., & Gooren, L. (2008). Hormone-related tumors in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology, 159, 197-202.

Quinn, V. P., Nash, R., Hunkeler, E., Contreras, R., Cromwell, L., Becerra-Culqui, T. A., . . . Goodman, M. (2017). Cohort profile: Study of Transition, Outcomes and Gender (STRONG) to assess health status of transgender people. BMJ Open, 7(12), e018121. doi: 10.1136/bmjopen-2017-018121

Turner, M.E. & Pratkanis, A.R. (1998). Twenty-five years of groupthink theory and research: Lessons from the evaluation of a theory. Organizational Behavior and Human Decision Processes, 73, 105–115.

van der Miesen, A. I. R., Hurley, H., Bal, A. M., & de Vries, A. L. C. (2018). Prevalence of the wish to be of the opposite gender in adolescents and adults with autism spectrum disorder. Archives of Sexual Behavior. doi: 10.1007/s10508-018-1218-3

van Kesteren, P., Lips, P., Gooren, L., Asscheman, H., & Megens, J. (2001). Long‐term follow‐up of bone mineral density and bone metabolism in transsexuals treated with cross‐sex hormones. Clinical Endocrinology, 48(3), 347-354.

Wierckx, K., Elaut, E., Declercq, E., Heylens, G., De Cuypere, G., Taes, Y., . . . T'Sjoen, G. (2013). Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: A case-control study. European Journal of Endocrinology, 169(4), 471-478. doi:10.1530/EJE-13-0493

Wierckx, K., Mueller, S., Weyers, S., Van Caenegem, E., Roef, G., Heylens, G., & T'Sjoen, G. (2012). Long‐Term evaluation of cross‐Sex hormone treatment in transsexual persons. The Journal of Sexual Medicine, 9(10), 2641-2651. doi:10.1111/j.1743-6109.2012.02876.x.

Monday, 19 February 2018 14:41

Gender development and gender affirmation

 

Gender is currently a hot topic in psychiatry, psychology, sociology, and surgery. Many self-appointed experts have materialized who travel the world on the conference circuit espousing often scientifically unsupported doctrine that has led to calls for earlier gender reassignment, preferably before puberty. An example is Diane Ehrensaft, a “paediatric gender therapist”. Her role in life is to liberate gender nonconforming children and youth.

 

In a video clip that I found quite disturbing vimeo.com/185149379 Ehrensaft declares that a female toddler who pulled hair clips out of her hair was communicating a gender message to her parents – i.e., I am a boy (ergo, hairclips are anathema). She then says that another child, born female, who was barely verbal, at around 18 months of age, insisted to her parents “I, boy!” Another child, at one year of age, unsnapped his stud clips on his jumpsuit to, in her words, “make a dress” which she interpreted as a “preverbal gender communication.”These comments demonstrate a deplorable misunderstanding of the cognitive capacities and concept formation of preverbal children. Primarily, they assume that these babies have a clear understanding of the concept of gender, that they associate hair clips and dresses with female gender, and that they can recognize and assert their own gender.  Despite Ehrensaft’s assertions that there are many shades of gender youtube.com/watch?v=HpE3d69SiDU there are underlying assumptions of a gender binary (which she purportedly eschews) in her statements about babies and their early gender awareness.

 

Further, there are inherent assumptions that gender is innate, which discount powerful socialization effects on gender identity, if indeed, as Ehrensaft states, babies “know [their true gender] as early as the beginning of the second year of life; they probably know before, but they are preverbal,” in which case you need to be vigilant for preverbal gender communicationsof the type described above. These assertions stand in stark contrast to research, for an example see onlinelibrary.wiley.com/doi/10.1111/j.1467-8624.2007.01056.x/full demonstrating that children below the age of three are unlikely to have gender constancy.

 

As children develop their concept of gender, they initially focus on the perceptual properties of a person and act as if these properties (e.g., the person’s name, long or short hair, pink or blue clothes etc) arethe defining characteristics of that personThey cannot conserve or retain the person’s basic identity when outward characteristics change. In other words, they are “perceptually bound” they define the concepts of male and female in terms of outward appearance such as hair, clothing, toys etc rather than in terms of the person’s genitalia or biological sex. Some children older than three continue to have difficulty conserving sex across perceptual transformationsand these difficulties may continue up to the age of seven. Even when preschool children do show gender constancy, it is unlikely that they understand its biological basis, a phenomenon called pseudoconstancy.

 

Once gender constancy (i.e., consistency and stability of the concept) is achieved, children display lower levels of rigidity or gender stereotypy in gender-based behaviour and become more flexible in their reactions to gender norm “violations”. This generally occurs around five years of age. Thus, gender constancy becomes an organizing principle for children’s gender beliefs. Part of the gender development process is the attainment of a sense of the importance of and contentedness with one’s gender.Gender typing is a function of increasing age and emerging constancy.

 

Adults should interfere with these processes as little as possible. The best they can do is to allow these developmental processes to unfold naturally by the provision of a safe, stimulating environment in which all gender expressions are valued and affirmed.

Wednesday, 31 January 2018 11:08

Each month I will post a blog that discusses a current hot topic in psychology. Because my expertise is in the field of developmental psychology, the content will often focus on children. However, developmental psychology takes a lifespan perspective, so issues occurring in developmental stages across the lifespan will also be addressed. It is important to consider developmental stages during psychotherapy as many people enter therapy at a critical juncture in their lives – births, deaths, marriages, separation, divorce, relationship crises, onset of illness or disability, or in response to emergent emotional distress that frequently has its origins in childhood.

In my first blog, I want to consider the unseemly haste with which some professionals wish to progress to gender reassignment of very young children.