This article was written by Julie, a WoLF member and volunteer

Introduction

In fall 2022, the National Institutes of Health (NIH) requested feedback from stakeholders in regard to research opportunities for the upcoming NIH Scientific Workshop on Gender-Affirming Care for Transgender and Gender-Diverse Populations. According to the NIH, “the overarching purpose of this workshop is to identify and prioritize key infrastructure and research needed to further our understanding of gender affirming care for transgender and gender diverse populations across the life course.”

In response to the NIH’s request, WoLF submitted a 22-page document intended to educate its readers about research opportunities and needs related to “gender-affirming care.” This compendium of comments was written by a group of WoLF members and volunteers who are current professionals in various healthcare fields. Each author is an expert in areas including women’s reproductive health and mental health counseling. WoLF’s suggestions for research focused specifically on the physical and psychological impacts of “gender-affirming care” on female patients. 

Pediatric and Adolescent Care

First, WoLF addressed issues regarding pediatric and adolescent care, an area in which evidence-based research is sorely lacking. WoLF noted that by a conservative estimate, the number of pediatric gender clinics in the US increased by 500%. There is little data to indicate how many children in the US are receiving puberty blockers, which are commonly prescribed, off-label, with the supposition that the children can take a “pause” from pubertal development. However, when researchers in the UK studied such children, they found that 98% of those taking blockers continued down the path to further medical transition. As a result, and in addition to other concerns, the UK National Health Trust shut down its Gender Identity Development Service this year.

WoLF noted that the justification for pediatric and adolescent medicalization relies heavily on the notion that “transgender” or “gender dysphoric” children are at greater risk for suicide. This claim is largely based on a single study from 2015, which has faced significant criticism. A 2020 study asserting that puberty blockers decreased suicidal ideation is also being questioned due to design flaws. WoLF informed the NIH that rather than preventing suicide, some studies have shown that “gender-affirming care” actually harms patients’ mental health, producing “considerably higher risks” of suicidal behavior, psychiatric morbidity, and death.

Many “gender-affirming” care treatments disregard any co-morbidities presented, with the assumption that they will vanish after transition. These commonly include conditions such as anxiety, OCD, ADHD, autism, mood disorders, PTSD, eating disorders, and personality disorders, raising the possibility that many of these children and adolescents may be receiving mis-diagnoses, resulting in treatments which do not lead to improved mental health. Researchers in Sweden and Finland found that in “follow-up study of adult cases, psychiatric morbidity, suicide attempts and suicide mortality persisted” after transition. 

WoLF also recommended that research needs to be done on the concept of “social transition”, especially in light of how social media and peer pressure affects adolescents, particularly girls, during puberty. “Social transition” is presented as a less drastic measure for adolescents, yet WoLF noted that “numerous studies suggest that social “transitioning” is a very potent psychological force that can propel a child toward medical interventions.” Schools rush to laud their newly declared “transgender” students, and social media presents ecstatic transitioners touting their new lives. It’s easy to see how a girl dealing with unwanted attention to her developing body may seek a way to alleviate that discomfort. WoLF explained that it has received numerous anecdotal reports from young women, parents, and mental health professionals about sexual abuse being a motivating factor for girls who want to “transition” into boys.

Adult and Older Adult Care

WoLF emphasized to the NIH that much more research is also needed in the realm of adult and older adult care, especially the affects of “gender-affirming care” on women. For much of history, the female body was considered to be little different, physically, from the male body, except for being smaller and having the capacity to bear and nurse children. We know, now, that there are profound differences between men and women in many bodily systems. These differences can dramatically alter both the presentation of illness and the effects of medication. The recent explosion in the number of women and girls taking testosterone to produce cosmetic changes in their bodies is unprecedented in human history, and no one knows what the long-term effects will be on their health. 

Excess testosterone in a woman’s body has a profound impact on the female reproductive system, leading to possible infertility, loss of sexual function, and may result in increased risks for developing ovarian, cervical, and endometrial cancer. WoLF explained to the NIH that testosterone affects the female circulatory system in several ways, leading researchers in one study to find that “female patients who use testosterone experience an increased overall risk of myocardial infarction (heart attack) above the rates of males.”

In addition to the lack of information regarding long-term hormone usage, there have been few studies of the surgical side of “transitioning,” and its long-term effects on physical and mental health. Complications from surgical procedures in male to female transitions are very high. 

WoLF also explained the importance of conducting research among people who now identify as “detransitioners,” and the motivating factors for them to initially believe they needed “gender-affirming care.” Given the rise in numbers of transitioners in recent years, especially in younger demographics, it should come as no surprise that the number of detransitioners presenting has also dramatically increased. Much research could be done with this population. A few research opportunities include: whether “gender-affirming care” ignored or even exacerbated other comorbidities; if same-sex attraction played a role in patients’ decisions to obtain “gender-affirming care”; to determine whether social pressures led patients towards “transitioning”; and the role that previous traumas might have played in patients’ beliefs that they were “transgender” or “non-binary.”  

Systemic and Institutional Policies

In the third section of its comments, WoLF recommended that research be done into the freedom of discussion around the topic of “gender-affirming care” in professional associations and governmental agencies, especially since both of these types of entities are involved in developing guidelines and recommending treatments for gender affirming care. 

Several countries – Finland, Sweden, and the UK – have recently made drastic revisions in their approach to pediatric gender transition care. Each nation has chosen to favor a therapeutic approach, emphasizing psychotherapy, rather than medicalized treatments. Their concerns included: 

• lack of neurological maturity those under 25

• general instability of identity for everyone in the adolescent developmental stage

• risk of regret after irreversible procedures

• possibility that puberty blockers could impair brain development

• paucity of quality research and lack of evidence

WoLF also encouraged the NIH and researchers to carefully consider how medicalization of “gender non-conformity” could potentially be a form of converstion therapy, and how important it is for researchers to consider how homophobia might be a driving force for “gender-affirming care,” citing how countries like Pakistan and Iran have embraced “gender transitions.” In these countries, WoLF explained, “the “born in the wrong body” narrative has been notably embraced [and] … homosexuality is punished by death, but “sex changes” are government subsidized.” WoLF encouraged the NIH to consider the role that  homophobia might play in leading parents and school teachers who observe children acting outside of sex-based stereotypes to be an indicator of “transgender” status. 

In its feedback, WoLF provided the NIH with a brief overview of various medical and mental health associations, and their guidelines for practitioners. WoLF explained that it is imperative for research to be conducted regarding the impact that these types of professional organizations have on their members. Do professional and student members feel compelled to agree with their organizations' public promotions of “gender affirming'' care, and do they have the academic and professional freedom to openly disagree if they have concerns about these types of treatments? Or, do they feel compelled to stay silent out of fear of losing their jobs or being expelled from graduate programs? 

Professional boards and associations for physicians and mental health professionals are also involved in developing protocols. The “affirmation” model is widely taught as the only appropriate approach to gender dysphoria, while at any other time the therapist can follow the “exploratory model.” In the exploratory model, WoLF explained, “clinicians use curiosity, collaboration, and positive regard. There is no evidence to suggest that it is contraindicated with gender dysphoria, and yet currently, clinicians are discouraged from using anything outside of an “affirmative” model.” Indeed, many professionals are afraid of treating “dysphoric patients” lest they are accused of performing “conversion therapy.” Mental health professionals face social stigma, censure, malpractice claims, and even loss of their licenses if they question gender ideology and “gender-affirming care.” This fear is understandable considering the stance of many professional medical and mental health associations in the US, which openly tout “gender-affirming care” as the only viable treatment method for patients.  

Conclusion

In closing, WoLF critiqued the NIH’s conflation of sexual orientation with “gender identity,” stating that the NIH has not identified reasons for combining these disparate populations of “sexual and gender minorities.” WoLF expressed concern that the NIH appears to be embracing the notion that if a person does not “grow out of” his or her non-conformity with sex stereotypes, that person can be medicalized out of it. 

Despite its critiques of the NIH’s conflation of sexual orientation and “gender identity,” WoLF greatly appreciated the opportunity to submit its feedback to the NIH. We hope that our feedback will result in higher-quality research about the impact of “gender-affirming care” on patients, especially female patients. 

Learn more about why WoLF cares about protecting children from harmful, unnecessary medical interventions, and take action to show your support for a federal bill that will protect children.