Before I pose my question, here are some statements from a slideshow on "Understanding Gender Nonconformity in Childhood and Adolescence" by Robert Garofalo, attributed to the Children's Hospital of Chicago, and hosted by the American Academy of Pediatrics (AAP). They officially support affirming gender change in children, however there is a group of pediatricians who actively reject that position.

According to this slideshow, gender is a social construct (page 7), which "[v]aries by place, time period" .

Next I'd like to list the slideshow's listed side effects and irreversible effects of hormone therapy. Pages 39-41 show the side effects of testosterone therapy.

Irreversible Effect of Testosterone Therapy

  • Lower voice pitch
  • Increased hair growth (arms, legs, chest, ab)
  • Mustache/beard growth
  • Male pattern hair loss (temples, crown) and possibly baldness
    Genital Changes
  • Genital changes (clitoral growth and vaginal dryness/fragility)
  • Fertility?

Side Effects/Risks: Testosterone

  • Increased cardiovascular risk
    • Increased weight
    • Decreased HDL, Increased Triglycerides
    • Increased BP
  • Increased insulin resistance
  • Hepatotoxicity
  • Mood changes: irritability, aggression
  • Headaches
  • Acne
  • Polycythemia
  • Theoretical risk: breast/endometrial cancer

Given these side effects, on what medical basis do health professional support this?

If a person doesn't like themselves they get help with their self-value. They learn the valuable things about their unique identity and also identify why they began to devalue themselves and deal with those root issues. People with phobia's are taught to manage and improve their phobia, not embrace it.

My point is not to compare one disorder to another, but to show that regardless of the type of disorder that the standard treatment is not acceptance, but rather to reveal deeper issues and otherwise manage and overcome the disorder.

Gender Dysphoria is treated categorically different, but there has been no new category defined on which to base that decision.

I know this is a sensitive topic and has many personal stories, but I'd like to focus on the professional medical position and reasoning for that position.

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    $\begingroup$ "According to the APA: Gender is based on culture and varies by place and time" That is a quote from the pdf not APA. The APA stance on gender is at apa.org/pi/lgbt/resources/sexuality-definitions.pdf $\endgroup$ Commented May 24, 2018 at 5:19
  • $\begingroup$ Related: psychology.stackexchange.com/q/9737 $\endgroup$ Commented May 24, 2018 at 5:36
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    $\begingroup$ This post received flags because of its offensive content. The mod team has tried their best to remove the redundant offensive text, while maintaining the question core. Please don't roll back these changes, otherwise your question might have to be removed from this site. $\endgroup$
    – AliceD
    Commented Jan 8, 2020 at 9:27
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    $\begingroup$ I tried to maintain the skepticism in the title, which I think is inappropriate, while removing the parts that seem to insert opinion and criticism without basis. $\endgroup$
    – Bryan Krause
    Commented Jan 8, 2020 at 17:23
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    $\begingroup$ @AliceD I know the stack community has gone through changes, but from a technical stand point I don't see offensive stances in most of what you edited out. Please do me the respect of explaining some of it to me, perhaps in a private chat? $\endgroup$
    – Adam Heeg
    Commented Jan 8, 2020 at 23:16

2 Answers 2


TL;DR: Multiple approaches have been tried over many years. Current medical evidence strongly supports an "affirming approach" to alleviate gender dysphoria. "Corrective approaches" are considered unethical, and withholding treatment is not considered neutral. It's explained in the referenced AAP slides, e.g.:

Children rejected and not supported are at increased risk of the following during adolescence:

  • Depressive symptoms, low life satisfaction, self-harm, isolation, posttraumatic stress, incarceration, homelessness, and suicidality

More up to date is:

This is the first study to examine mental health in these children, finding that they have low levels of anxiety and depression.
Olson, Durwood, DeMeules, and McLaughlin, Mental Health of Transgender Children Who Are Supported in Their Identities, Pediatrics, 2016

Also note that medical treatment is not as easy to obtain as commonly believed: Typically, prior to medical treatment is social transitioning. Reversible puberty blockers are used until the patient is legally an adult (with bodily autonomy). Real-life experience is typically required before hormones and surgery.

The answer to the question is on page 27 of the linked AAP slides, including 7 references.

Why do we believe in Affirming approach?

  • Affirming does not mean encouraging or pushing gender transition

  • Children rejected and not supported are at increased risk of the following during adolescence:–

    Depressive symptoms, low life satisfaction, self-harm, isolation, posttraumatic stress, incarceration, homelessness, and suicidality

  • Family acceptance and support during adolescence is tied to the following in young adults:

    Positive self-esteem, high social support, positive mental health, less depressive symptoms, greater self-esteem, greater life satisfaction (compared with youth whose families were non-supportive)

The references included are as follows (I include links to facilitate access):

I'm not 100% sure what "Travers et al., 2012" refers to. But I guess it's this:

Continuing on...

  1. The AAP admits that Gender is man made, not real, but a social construct (see page 7).

    Based on the American Academy of Pediatrics understanding of Gender, it is a completely arbitrary social construct that varies by place and time(page 7 in the PDF linked above).

    Their talk slides (page 7) actually say:


    Attitudes, feelings, and behaviors that a given culture associates with a person’s biological sex (APA, 2011):

    • Gender expression
    • Gender roles/behaviors
    • Gender identity
    • Varies by place, time period

    Social construct

    This absolutely does not say nor imply "man made" nor "not real". Whether or not you call gender, sexuality, etc., a "social construct" is a matter for feminism and gender studies. In any case, the AAP are clearly not saying gender is unimportant.

    A more reliable source than random talk slides from the same institute is:

    Whether talking about children or adults, it is helpful to think of gender in three parts:

    1. Sex, the combinations of physical characteristics (including but not limited to genitals, chromosomes, and sex hormone levels) typical of males or females.
    2. Gender identity, a person’s internal sense of being male, female, or, for some people, a blend of both or neither.
    3. Gender expression, the many ways people show their gender to others, such as the clothing and haircuts they wear or the roles and activities they choose.

    Supporting and Caring for Transgender Children, AAP, 2016.

    I highlight how gender is closely tied to one's internal sense of self (including one's brain and thought processes). Moreover, everything psychological is simultaneously biological, so you can't cleanly separate gender from sex. (See: Ainsworth, Sex redefined, Nature, 2015.)

    For a description of the history of sex vs. gender, see: Muehlenhard and Peterson, Distinguishing Between Sex and Gender, Sex Roles, 2011.

  2. Gender Dysphoria is treated categorically different, but there has been no new category defined on which to base that decision.

    regardless of the type of disorder that the standard treatment is not acceptance

    In 2013, the DSM V renamed "gender identity disorder" to gender dysphoria. This seems to be the result of the discovery of multiple types of evidence for of biological causes of transsexuality (too many references to include here). (Although the terminology is more complex than that; see Davy and Toze What Is Gender Dysphoria? A Critical Systematic Narrative Review, Transgender Health, 2018. The DSM V critera are available here.)

    Gender dysphoria typically either comes from the person themselves (e.g., a dislike of their own body), or from society (see Injustice at Every Turn, 2012). Saying "pro-Gender Dysphoria" and "mutilation" is loaded language and misleading: medical professionals instead try to minimize gender dysphoria. They might provide medical means for transgender people to become more satisfied with their bodies, and help them become a more functional member of society.

  3. Pages 39-41 show the side effects of testosterone therapy.

    According to the WPATH Standards of Care, there's no medical treatment until puberty. (However, social transition is recommended.) After reaching puberty:

    Fully Reversible Interventions ... Adolescents may be eligible for puberty-suppressing hormones as soon as pubertal changes have begun. ... Adolescents may be eligible to begin feminizing/masculinizing hormone therapy, preferably with parental consent.

    As the level of gender-related abuse is strongly associated with the degree of psychiatric distress during adolescence (Nuttbrock et al., 2010), withholding puberty suppression and subsequent feminizing or masculinizing hormone therapy is not a neutral option for adolescents.
    Standards of Care, version 7, WPATH, 2012.

    Medical treatment is not as easy to obtain as commonly believed (it's not like on TV): It varies from patient to patient, but typically first comes social transitioning, and reversible puberty blockers, and the real-life experience. Side-effects (which occur in virtually all medical treatments) are ordinarily discussed in detail among doctors and guardians.

    As one example of why withholding treatment is not neutral: suicide rates for transgender adolescents are alarming (Williams Institute, 2014; Toomey et al. 2018) but are massively reduced when being supported in one's gender identity (Bauer et al. 2015; Olson et al., 2016).

    (To give a mental picture of why the difference is so extreme: imagine a doctor singling out a non-transgender adolescent male, and encouraging/coercing him to live as a woman. Most people would say it's wrong on so many levels. Now replace "non-transgender" with "transgender". From the transgender adolescent male's perspective, there is no change in these two scenarios: he too will feel it's wrong on so many levels. [It gets worse too: his family joins in, etc.])

  4. People with phobia's are taught to manage and improve their phobia, not embrace it.

    This is what the AAP describe as "rejected and not supported", which leads to the aforementioned consequences. Corrective Approaches are considered unethical:

    Treatment aimed at trying to change a person’s gender identity and lived gender expression to become more congruent with sex assigned at birth has been attempted in the past (Gelder & Marks, 1969; Greenson, 1964), yet without success, particularly in the long-term (Cohen-Kettenis & Kuiper, 1984; Pauly, 1965). Such treatment is no longer considered ethical.
    Standards of Care, version 7, WPATH, 2012.

    I didn't find the Cohen-Kettenis & Kuiper (1984) reference, but the following refrence seems more up-to-date and closely related: Cohen-Kettenis, van Goozen, Sex Reassignment of Adolescent Transsexuals: A Follow-up Study, Journal of the American Academy of Child & Adolescent Psychiatry, 1997.

    The UN also considers corrective approaches contrary to bodily autonomy, a human right.

  • $\begingroup$ in the middle of your first point you disagree with my statement (paraphrased) that 'social construct' is 'man made'. I apologize for the term 'not real' I can't think now of why I added that as I agree that doesn't make sense and is not right. However, to me a 'social construct' is a 'man made' thing. Can you explain or link to something that might explain how that connection is wrong? $\endgroup$
    – Adam Heeg
    Commented Jan 8, 2020 at 23:56
  • $\begingroup$ Also, thank you for so much effort in your answer. $\endgroup$
    – Adam Heeg
    Commented Jan 8, 2020 at 23:58
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    $\begingroup$ When people say gender is a social construct they refer to man-made, somewhat arbitrary gender roles (e.g. men go to work to provide for the family) and presentation (e.g. girls wear dresses). Although gender roles are also motivated by biology, e.g., natal women give birth and breastfeed, leading to the "nurturer" role. However, gender also includes gender identity, aspects of one's internal sense of self (e.g. "I am a woman"). A relevant case here is David Reimer, raised female. $\endgroup$ Commented Jan 9, 2020 at 1:18
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    $\begingroup$ @AdamHeeg I think a relevant example of a social construct would be money, or rather the concept of currency. The value of a 10 dollar bill depends highly on the society you use it in. For example, if you use it in the United States, it would have a value of 10 dollars. However, if you take that same bill and give it to a tribe living in the rainforest, it would be worthless to them. The society in which the bill is used in dictates the value of the bill. As an individual, you can't say that the 10 dollar bill is actually worth 1000 dollars. (TBC) $\endgroup$
    – prata
    Commented Jun 20, 2021 at 8:35
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    $\begingroup$ (continued) Same with gender, if it is a social construct, one would not be allowed to simply change their gender as they see fit. However, despite Rebecca's definition of gender (which I view as a more accurate one), the majority of the population, up until somewhat recently, used gender interchangeably with sex. Even governments use it interchangeably on legal documents, even today. $\endgroup$
    – prata
    Commented Jun 20, 2021 at 8:36

I hope I am qualified to answer this question. I am not a psychologist but have worked with transgender persons in volunteering positions a number of times and am fairly well researched on the topic.

The biggest key point as I have studied simply is based on health outcomes as opposed to comparing this to mental illness.

This page talks about the practical health outcomes of the treatments. Individuals who identify as transgender already often suffer from a variety of issues that reduce both their quality of life and in some cases health. These can include developing mental disorders if they do not get treatment and even self harm or suicide. Overall most of the linked studies in that article showed that the benefits largely outweighed the risks in an overall health decision.

Now you imply that other treatments are used for most conditions which have effects on mental health, usually either "talking cures" or medications. The difference being in almost all cases these treatments are ineffective or even make the situation worse in transgender individuals.

I cannot find a study to link to this which is publicly available right now but in short, treating transgender individuals with treatments used for mental illness usually makes the condition worse. In many cases it causes additional depressive disorders to form as well as long term self image problems and self hatred, as well as increasing the risks of self harm or suicide.

So in summary, it is not to say the treatments used for transgender persons are risk free, but merely that they are better than the alternatives both of doing nothing and of trying to use a purely psychiatric method to treat. As both of those tend to make the condition gradually worse and no other treatments are known which produce a consistent improvement.

  • $\begingroup$ It is hard for me to wrap my head around this one topic being different than others in the case of treatment. You've phrased the intellectual conflict succinctly, so thank you. If you find some material to link to I'd like to see it. $\endgroup$
    – Adam Heeg
    Commented Jan 9, 2020 at 1:00

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