First Do No Harm
I applaud Hilary Cass’s emphasis on complexity and uncertainty in the treatment of young people with gender dysphoria and wholeheartedly agree that the care of this group is ‘everyone’s business’.
As a GP, I have become increasingly concerned about the potential long-term risks of medical intervention faced by gender dysphoric adolescent patients. When a young person's care is managed in a specialist gender clinic, the issue of their gender identity becomes the dominant narrative, subsuming the possible wider origins of their distress. Once prescribed puberty blockers, they are likely to go on to be treated with cross sex hormones and in time offered gender reassignment surgery (1). As a profession, we are putting children on treatment pathways that may lead to adult lives of infertility and impaired or absent sexual function. We do not currently have the evidence to support these highly consequential clinical decisions.
The concept of an innate immutable ‘gender identity’ is a contested one, as Cass acknowledges. Evidence against includes the transient nature of gender dysphoria in the majority of individuals, the apparent element of social contagion in teenage girl peer groups, and the increasing number of ‘detransitioners’ speaking out against the treatment they received as children. The toxic ‘culture wars’ nature of this issue currently prevents measured and reasoned discussion of differing views (2).
There is much to suggest that gender dysphoria is just one of a range of available expressions of distress displayed by young people with histories of childhood trauma. Common comorbidities include depression, anxiety, eating disorders and self-harm (1). As Cass states, many child patients of specialist gender clinics are on the autistic spectrum.
Many commentators question the recent sharp rise in gender dysphoria among teenage girls (3). What is it about our society that means unprecedented numbers of girls do not want to become women? Theories include the overwhelming social media pressures to conform to unattainable ideals of femininity, the high levels of exposure to violent pornography from a young age, and the increasing awareness of ubiquitous male violence, as highlighted for example by the #metoo movement and the Sarah Everard case.
So how can we respond as a profession to this highly complex psychosocial phenomenon in helpful therapeutic ways? I would argue that GPs are well placed to approach the presentations of distressed gender dysphoric teenagers with neutrality and curiosity, setting aside the unhelpful bias of positive affirmation. With the benefits of continuity of care, we are likely to know the child and the family. We can explore, contextualise and contain the child’s distress, with the support of primary care psychology or local CAMHS when needed. By taking care to refer to specialist gender clinics only when really appropriate, we can reduce the chance that gender dysphoria becomes the overarching explanatory framework, locking the young person into treatment pathways with potentially catastrophic lifelong consequences.
2 Stock, K. 2021 Material girls: why reality matters for feminism
3 Joyce, H. 2021. Trans: when ideology meets reality
Competing interests: No competing interests