Physician FAQs

First and foremost, establish your role as an advocate for the patient and secondarily for the family.  Let the patient know that your intent is to listen to their story.  Review with the patient and family all Adverse Childhood  Experiences (ACE’s).[1] Do a complete physical exam to document the stage of puberty.  Avoid direct referrals to the regional transgender centers. Realize that it is extremely likely that the patient has significant mental health issues and is searching for an answer.  Explain to the patient and family that the international standard is to refer the patient to a competent counselor who will agree to address the depression and/or anxiety as the core issue.[2]  Mental health providers who label themselves as specializing in transgender health should be avoided as they favor medical interventions that fail to address underlying issues. Refer to our list of competent counselors in your geographic region.

You may consider sharing with your patient that you are a professional who will give them information to help them make the healthiest and best decisions for the rest of their lives.  Tell them that it is impossible to change biological sex with hormones or surgeries, but there is evidence transgender hormones and surgeries worsen one’s health (see questions below). 

Ask them to give you written permission to talk with the counselor(s) involved to gain an understanding of the evaluation and any therapy provided.  You can easily determine the depth of the evaluation(s) and the background of the counselor/psychologist/psychiatrist.  Find out if the family has been interviewed.  Let the patient know that you wish to gain insight into what has laid the foundation of the incongruent gender identity. Again, be sure to restate your role as the advocate for the patient.  This allows you to determine if the mental health provider has uncovered ACE’s and/or recognized depression or anxiety which they are attempting to address in which case you can encourage your patient to stay the course with individual and family therapy. Alternatively, if the mental health provider mistakenly believes that gender dysphoria in youth requires social and medical transition, it is an opportunity to tell the patient that you believe they have not been fully evaluated and recommend that they obtain a second opinion. The goal is to help your patient understand that no medical or surgical procedures should be pursued in the presence of unresolved precipitating emotional, social or psychological issues.

Something as simple as allowing the patient to pretend they are the opposite sex by dressing, changing hairstyle, and declaring a new name and pronouns sounds totally reversible and benign, but it opens a pandora’s box that can’t be readily closed.[3],[4]  It abruptly tears the family relationships apart and drives a wedge between the patient and their social circle of friends, many of whom will reject the patient, causing further anxiety and depression.  For some, interpersonal trust is abolished. Explain to the patient that you are following the guidelines accepted worldwide to start the process of evaluating the mental and emotional health of the patient first prior to any affirmation of gender incongruence.

It is important to explain that binding the breasts to flatten their contour is not healthy for the developing breast tissue and it causes restrictions of normal respiratory effort.[5]  Tell the patient it is much healthier to wear loose clothing than to bind the breasts.  If the patient is a male and is tucking his genitalia, explain that such a practice can harm at least the testes[6] and suggest they wear  their shirts untucked or wear pants that don’t show the genital outline readily.  Some gender dysphoric females wear a “package pouch” to pretend they have a generous penis and scrotum as part of their social transition; this should be discouraged since opposite-sex role playing increases the likelihood of going down a medical pathway and fails to address the underlying mental health issues.

First, remind the patient and family that puberty is not a disease, but a necessary process whereby the immature, infertile child becomes a fertile adult capable of reproduction, usually through sexual intercourse with a person of the opposite sex.  The changes in the human body which occur during puberty affect every organ system.  The biological sex of the patient determines the responsiveness of each cell to the hormones produced at puberty is a sex-specific manner.[7],[8]  The pituitary gonadotropins tell the sex-specific gonad to produce testosterone and to mature the sperm-making apparatus in the male and to produce estrogen and mature the ova in the female.  This is a process that is gradual over 2-4 years.  Interrupting this signaling during true puberty in the adolescent years wipes out production of testosterone and stops testicular maturation in the male and halts estrogen production and arrests the maturation of the oocytes in the female.[9]  We do know without question that accrual of calcium into the skeletal bank occurs from the onset of puberty through age 25 years of age.  Using puberty blockers at the onset of puberty is widely known to deplete would-be calcium storage in a way that can’t be retrieved should puberty be allowed to resume naturally.[10] 

The brain is dependent on the natural, expected hormones of puberty to mature.  There is no long term evidence that all returns to normal when puberty is allowed to resume.  The guidelines of the Endocrine Society clearly state that valid clinical studies are needed to assess the far-reaching consequences of interrupting normal puberty before puberty blockers can be safely given.  There are enough case reports of worsening mental health in children given these drugs to have it included as a known side effect of treatment.[11]  More recently, pseudotumor cerebri has been reported to be directly related to puberty blockers in children of all ages.[12] There is no FDA-approved indication for using puberty blockers to halt the biologically-intended pubertal maturation in children suffering from gender identity incongruence, hence there is no insurance coverage.  The average out-of-pocket cost is $60,000 per year. Prior to the widespread use of social and medical transgender interventions, multiple studies found the vast majority of gender-identity incongruent youth resolved their incongruence by young adulthood; i.e. by the time they completed normal puberty.[13],[14] In contrast, the vast majority of gender dysphoric youth started on puberty blockers (98%) go on to claim a transgender identity and take cross-sex hormones.[15]  Social transition coupled with puberty blockers appears to lock in the gender dysphoria. Stated differently, stealing normal puberty from gender dysphoric youth robs them of the critical developmental period during which many would embrace their bodies.

The patient should be told there is no rush to consider puberty blockers and/or cross-sex hormones as an option until such time as the mental health issues are fully resolved. Given the potential for ruining gonadal maturation to the point of inevitable infertility, it would seem wise to withhold this option entirely.  When the patient insists that they are likely to commit suicide if they do not block what they percevie as “the wrong puberty,” inform them that three systematic reviews of the world literature done by three different international organizations found no evidence that blocking puberty improves mental health or reduces suicide among gender dysphoric youth. This is why several European countries have decided to fervently prioritize mental health counseling and to restrict puberty blockers and cross-sex hormones before the age of majority.[16],[17],[18] 

Again the simple answer is that there are no valid studies that follow the patient long enough to show safety.  It can be extrapolated from endless data on naturally-occuring diseases (adrenal hyperplasia, PCOS, hormone-producing tumors) that high levels of oppostie-sex hormones create havoc and cause higher risk of stroke, cancer, and heart disease.[19]  Because of these known, proven risks, medical treatment protocols have been developed to diminish the levels of wrong-sex hormones to a minimum, thereby extending lifespan.  In these naturally occurring diseases, the blood levels are as little as 10% of the levels achieved by giving the suggested doses of cross-sex hormones given to effectively change the outward appearance of the body to mimic that of the opposite sex.[20]  A study in Lancet found that transgender-identified adults (in LGBQT-affirming Netherlands) treated with cross-sex hormones have a 4 to 5-fold increased risk of death compared to the general population.[21]  Again, it makes more sense to work on the undercurrent mental health issues before considering cross-sex hormones, which also happen to halt gonadal maturation and create infertility.

Although physicians doing these interventions deny that such procedures are performed prior to age of majority, mainstream media news stories, social media and court cases prove otherwise. Transgender interventions in children beginning with puberty blockers at Tanner stage 2 and followed by cross-sex hormones result in both permanent sterilization and sexual dysfunction. The financial cost is exorbitant, and many detransitioners attest that the physical and emotional costs are fathomless. These are significant and irreversible harms. It is imperative that we physicians stand by our oath to first do no harm and encourage our gender dysphoric youth to begin or continue counseling. There are 16 case series demonstrating that many adolescents and even adults have healed from their gender dysphoria and embraced their bodies through counseling.

Rational and compassionate medicine is not driven by the threat of suicide. Recognize the threat of suicide as a cry for help and treat this patient exactly as you would treat any other patient who declares suicidal intent. About 22% of gender dysphoric youth attempt suicide. This incidence is the same as for autistic patients and patients suffering from depression and/or anxiety.[22] Among all patients who complete suicide, 96% have a diagnosed mental health disorder.[23] There is no evidence that youth and young adults with gender dysphoria who complete suicide are any different. Thus, prevention of suicide for those with gender dysphoria is the same as for any other suicidal patient – identify and treat the underlying comorbidities. Move immediately to engage the patient in effective counseling with a gender exploratory mental health professional. 

(Physicians should be aware that published studies used by some health professionals to frighten parents into consenting to medical interventions for their children suffer from convenience sampling and other methodological flaws).[24],[25],[26]


[1] Kozlowska K, Chudleigh C, McClure G, Maguire AM, Ambler GR. Attachment Patterns in Children and Adolescents With Gender Dysphoria. Front Psychol. 2021 Jan 12;11:582688. doi: 10.3389/fpsyg.2020.582688. PMID: 33510668; PMCID: PMC7835132

[2] E. Abbruzzese, Stephen B. Levine & Julia W. Mason (2023): The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2022.2150346

[3] Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism 2017; 102(11): 3869-903

[4] Zucker, K. J. (2019), Debate: Different strokes for different folks. Child Adolesc Ment Health. doi:10.1111/camh.12330

[5] S Peitzmeier, I Gardner, J Weinand, A Corbet and K Acevedo,  Health impact of chest binding among transgender adults: a community-engaged, cross-sectional study,Culture, Health & Sexuality, 2017VOl. 19, NO. 1, 64–75

[6] I de Nie, J Asseler, A Meißner, IAC Voorn-de Warem, EH Kostelijk,M den Heijer, J Huirne, NM. van Mello, A cohort study on factors impairing semen quality in transgender women, Am J Obstet Gynecol 2022 206 390.e1.pdf

[7] Institute of Medicine (US) Committee on Understanding the Biology of Sex and Gender Differences; Wizemann TM, Pardue ML, editors. Exploring the Biological Contributions to Human Health: Does Sex Matter? Washington (DC): National Academies Press (US); 2001. 2, Every Cell Has a Sex. Available from:

[8] Researchers Identify 6,500 Genes That Are Expressed Differently in Men and Women,” Weizmann Wonder Wander (Weizmann Institute of Science), May 3, 2017, online at: https://wiswander.

[9] Laidlaw MK, Van Meter QL, Hruz PW, Van Mol A, Malone WJ. Letter to the Editor:“Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline”. The Journal of Clinical Endocrinology & Metabolism 2019; 104(3): 686-7.9.

[10] Mariska C. Vlot, Daniel T. Klink, Martin den Heijer, Marinus A. Blankenstein, Joost Rotteveel, Annemieke C. Heijboer, Effect of pubertal suppression and cross-sex hormone therapy on bone turnover markers and bone mineral apparent density (BMAD) in transgender adolescents, Bone, Volume 95, 2017, Pages 11-19, ISSN 8756-3282,

[11] Schneider, M. A., Spritzer, P. M., Soll, B. M. B., Fontanari, A. M. V., Carneiro, M., Tovar-Moll, F., et al. (2017). Brain maturation, cognition and voice pattern in a gender dysphoria case under pubertalsuppression. Frontiers in Human Neuroscience, 11. https :// .2017.00528

[12] AAP news “Risk of pseudotumor cerebri added to labeling for gonadotropin-releasing hormone agonists” July 1,2022.

[13] Singh D, Bradley SJ and Zucker KJ (2021) A Follow-Up Study of Boys With Gender Identity Disorder. Front. Psychiatry 12:632784. doi: 10.3389/fpsyt.2021.63278

[14] Bockting, W. (2014). Chapter 24: Transgender Identity Development. In Tolman, D., & Diamond, L., Co-Editors-in-Chief (2014) APA Handbook of Sexuality and Psychology (2 volumes). Washington D.C.: American Psychological Association, 1: 744.)

[15] de Vries  AL, Steensma  TD, Doreleijers  TA, Cohen-Kettenis  PT.  Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8(8):2276-2283. doi:10.1111/j.1743-6109.2010.01943.x



[18] The National Institute for Health and Care Excellence ( N.I.C.E.) Evidence review: Gonadotropin releasing hormone analogues for children and adolescents with gender dysphoria (2020).; and N.I.C.E. Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria (2020).

[19] Radix A, Davis AM. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. JAMA.2017;318(15):1491–1492. doi:10.1001/jama.2017.13540

[20] Coleman, E., Radix, A. E., Bouman, W.P., Brown, G.R., de Vries, A. L. C., Deutsch, M. B., Ettner, R., Fraser, L., Goodman, M., Green, J., Hancock, A. B., Johnson, T. W., Karasic, D. H., Knudson, G. A., Leibowitz, S. F., Meyer-Bahlburg, H. F.L., Monstrey, S. J., Motmans, J., Nahata, L., … Arcelus, J. (2022). Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health, 23(S1), S1-S260.

[21] de Blok CJ, Wiepjes CM, van Velzen DM, Staphorsius AS, Nota NM, Gooren LJ, Kreukels BP, den Heijer M. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. Lancet Diabetes Endocrinol. 2021 Oct;9(10):663-670. doi: 10.1016/S2213-8587(21)00185-6. Epub 2021 Sep 2. PMID: 34481559

[22] Herman JL, Wilson BD, Becker T. Demographic and Health Characteristics of Transgender Adults in California: Findings from the 2015-2016 California Health Interview Survey. Policy Brief. UCLA Cent Health Policy Res. 2017 Oct;(8):1-10.

[23] Nock MK, Green JG, Hwang I, McLaughlin KA, Sampson NA, Zaslavsky AM, Kessler RC. Prevalence, correlates, and treatment of lifetime suicidal behavior among adolescents: results from the National Comorbidity Survey Replication Adolescent Supplement. JAMA Psychiatry. 2013 Mar;70(3):300-10.

[24] Haas AP, Rodgers PL, Herman JL, “Suicide Attempts Among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey,” Williams Institute, UCLA School of Law, January 2014,

[25] James SE, Herman JL, Rankin S, Keisling M, Mottet L, Anafi M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality.

[26] Toomey RB, Syvertsen AK, Shramko M (2018). Transgender Adolescent Suicide Behavior. Pediatrics. 2018;142(4): e20174218.