April 06, 2023
By Susan Bane
Original article can be viewed on The Wilson Times HERE
Picture this: A patient has a ruptured appendix, and his surgeon says an emergency appendectomy is needed. Another patient has cancer and chemotherapy is recommended by her doctor. A third patient has diabetes, and her doctor wants to prescribe insulin.
The doctor-patient relationship in each of these clinical scenarios requires trust at its foundation — trust that the doctor is practicing Hippocratic medicine and thus is guided by the principle of “First, Do No Harm.”
These four simple words, “First, Do No Harm,” are emphasized over and over in the training of doctors — both during medical school and residency. Whether the intervention involves medication, surgery, therapy or watchful waiting (time), if patients cannot trust that their health care practitioners are making recommendations based on this core principle, then medicine becomes a very scary place. Lost is the trust that our doctors’ knowledge and expertise will be used to try to help and heal us as we journey toward wholeness together.
The controversary in the medical literature related to the ethics of gender-affirming care that I described in my last column is a trust issue — can doctors truthfully answer the following questions as they care for patients, particularly children, who are suffering from gender incongruence/gender dysphoria? Does gender affirmation care help or harm patients? Do social, legal, hormonal and surgical gender-affirming interventions help or harm patients?
There are two lines of thought when it comes to the treatment of gender incongruence/gender dysphoria in children and adolescents: one believes in gender-affirming care that is designed to affirm an individual’s gender identity when it conflicts with the gender assigned at birth (based on external genitalia). The other desires to examine root causes of the incongruence/dysphoria, while helping individuals recover their gender identity consistent with their biological sex.
Let’s focus this week on treating gender incongruence/dysphoria without offering gender affirmation care, often known as “watchful waiting.”
Watchful waiting involves caring for children and adolescents suffering from gender incongruence/gender dysphoria with an approach that recognizes the very real struggle that these children face, while at the same time searching for root causes of the incongruence. Professional pediatric medical organizations differ in their support of this approach.
The American College of Pediatricians, or ACPeds, supports watchful waiting that includes an ethical obligation to see those struggling with gender incongruence/gender dysphoria as patients who deserve loving and authentic care that helps them face their struggles and recover their gender identity consistent with their biological sex. The American Academy of Pediatrics calls this approach outdated and recommends GAC, including social, legal, hormonal and/or surgical interventions.
ACPeds supports watchful waiting for a variety of reasons. Two of these reasons are addressed below, and others will be addressed in the next column.
GENDER INCONGRUNECE DOESN’T PERSIST FOR MOST YOUTHS
Studies have consistently shown that for about 80% to 95% of youths, gender incongruence does not persist through adolescence, meaning the vast majority of youths ultimately identify with their biological sex. This natural course of gender incongruence, however, often does not happen once GAC is introduced, as noted by the literature and observations by clinicians in gender-affirming clinics.
A 2011 study that assessed gender dysphoria and psychological function before and after puberty suppression in 70 young people between ages 12-16 found that all of the youths who began puberty suppression went on to begin cross-sex hormone treatment.
Why would this happen? Why is the natural progression of gender incongruence typically transient, yet when GAC is introduced, this natural progression is halted? Our brains are neuroplastic, meaning the nervous system can change its activity in response to intrinsic or extrinsic stimuli by reorganizing its structure, function and connections. This is particularly true in children and adolescents, but has been found to happen throughout the entirety of our lives. This plasticity helps us learn new things, recover from brain injury and change behaviors.
Since our brains are neuroplastic, they are molded by our life experiences. Thus, parents who support even social interventions such as dressing their children as the opposite sex, calling them “they” until children choose a gender identity or calling them an opposite sex name (and insisting everyone else do the same), are affecting neuroplasticity and future identification of their gender.
If the natural course of gender dysphoria is that in most children it does not persist, then the GAC model of social, legal, hormonal and/or surgical affirmation is not allowing children time to receive compassionate care that seriously addresses their struggles and underlying psychological conditions that often exist.
UNDERLYING PSYCHOLOGICAL CONDITIONS OFTEN COEXIST
Most children and teens with gender identity issues are struggling with other psychological diagnoses that predate their gender incongruence. These psychiatric or neurodevelopmental diagnoses most often include depression with and without suicidal ideations, anxiety, bipolar disorder, ADHD and autism spectrum disorders. On top of this, individuals with gender incongruence often struggle with stigma and bullying in addition to underlying psychological conditions.
Many are seeing therapists and take medications for their mental health issues at the time of presentation at medical practices that offer GAC. The suicide rate for individuals with gender incongruence/gender identity disorder is much higher than the general population, and sadly, this suicide rate remains high after GAC, including surgical interventions. This suggests that simply changing physical characteristics of one’s body without addressing underlying psychological conditions does not always help patients.
Research suggests that gender-incongruent children and adolescents can embrace their biological bodies through counseling when it is directed toward underlying psychological issues.
As ACPeds states in its position statement on gender incongruence, “extensive, decades-long published evidence has shown that returning to the biological integrity of the body occurs in the vast majority of gender dysphoric patients, particularly with appropriate mental health evaluation at the outset and continued therapy which resolves the undercurrent anxiety and depression — and ameliorates other mental health issues and traumas — that so often haunt these children otherwise.”
Susan Bane, M.D., Ph.D, is an associate professor of allied health and sport studies at Barton College and a physician.