Safeguarding adolescents from premature, permanent medicalisation
The article Safeguarding LGBT+ adolescents (1) was interesting but the authors did not cover the range of current thinking and used confusing, inaccurate ideological concepts such as "assigned" sex (2,3). Determined at conception, objectively observed and recorded at birth, sex characteristics at birth are almost always aligned with chromosomal sex. It is crucial that doctors are clear about embryology as prenatal sex determination is the basis for sex-selective abortion (4). When intersex features exist, these indicate a medical condition; factual attributes are not assigned. Intersex should not be confused with transgenderism; it is now accepted that medical intervention to ‘correct’ genitals is associated with poor outcomes and should have clear clinical indications (5).
We agree about not conflating sexual orientation and gender identity when making compassionate and therapeutic responses especially for those vulnerable to, or actually experiencing, abuse. Within families and communities upholding strict religious or ‘honour’ tenets, variations may be considered serious affronts. Individuals may experience extreme psychological pressures and physical violence tantamount to torture in an effort to change them. This undoubtedly requires safeguarding. It is long-accepted that conversion therapy for homosexuality is ineffective, damaging and unethical. The Royal College of Psychiatrists has explicitly supported a ban (7). As working with people with gender dysphoria requires a different model of understanding, it remains legitimate to listen, assess, explore, wait, watch development, offer skilled support, deal with co-morbidities and prior traumas, and consider use of a variety of models of care. While respecting individuals’ right to a different viewpoint, it is neither mandatory to affirm their beliefs nor automatic that transition is the goal, particularly when dealing with children, adolescents and young adults. These risk closing the ‘open future’, as well as life-long physical problems including lack of sexual function, infertility and medical dependency. With 85% desistance amongst referred transgender children (8) and increasing awareness of detransitioning (9, 10), unquestioning ‘affirmation’ as a pathway that leads gender dysphoric patients to irreversible interventions cannot be considered sole or best practice.
More good-quality research trials are required to provide reliable evidence of clinical and cost-effectiveness of a range of approaches, including patient selection. These will surely include exploration of underlying unhappiness with the goal of achieving body/mind reintegration. In contrast to previous medical scandals that pathologised homosexuality, something different may be happening here. In effect, transitioning children who would otherwise have grown up lesbian, gay or bisexual may introduce another form of conversion (6). A well intentioned but permanent medical pathway for all is unlikely to achieve the best long-term outcomes. Confirming disgust in natal sex or external sexual organs, especially for those with prior childhood trauma, risks medical collusion with, or reenacting of, abuse.
1. Salkind J, Bevan R, Drage G, Samuels D, Hann G. Safeguarding LGBT+ adolescents. BMJ 2019;364:l245 https://www.bmj.com/content/364/bmj.l245 (last accessed 5 February 2019)
2. Byng R, Bewley S, Clifford D, McCartney M. Trans health needs more and better services: increasing capacity, expertise, and integration https://www.bmj.com/content/362/bmj.k3371/rr-0 (last accessed 5 February 2019)
3. Byng R, Bewley S, Clifford D, McCartney M. Gender questioning children deserve better science. Lancet 2018; 8;392:2435
4. Neogi SB, Zodpey S, Negandhi P, Gupta R. Use of Sex Selection Techniques for Social Reasons: A Menace. Indian Pediatr;54(2):99-101
5. Cools M, Nordenstrom A et al. Caring for individuals with a difference of sex development (DSD): a Consensus Statement. Nature Reviews Endocrinology 14, 415-429 (2018)
6. The Royal College of Psychiatrists Statement on Sexual Orientation PS02/2014 April 2014
7. Ristori J, Steensma TD. Gender Dysphoria in Childhood. Int Rev Psychiatry . (2016) 28 (1): 13-20
8. Butler G, De Graaf N, Wren B, Carmichael P. Assessment and support of children and adolescents with gender dysphoria. Arch Dis Child 2018 https://adc.bmj.com/content/early/2018/04/26/archdischild-2018-314992 (last accessed 5 February 2019)
9. Mills L. A letter to young trans people. https://www.transgendertrend.com/letter-to-young-trans-people/ (last accessed 5 February 2019)
10. Turban JL, Keuroghlian AS.Dynamic Gender Presentations: Understanding Transition and "De-Transition" Among Transgender Youth. J Am Acad Child Adolesc Psychiatry. 2018;57(7):451-453.
Competing interests: No competing interests