On what basis do professionals who recognize gender dysphoria support risky and permanent medical intervention for those seeking gender re-assignment?

Question

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.

Answer 1

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.

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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):

• D’Augelli, Grossman, & Starks, Childhood Gender Atypicality, Victimization, and PTSD Among Lesbian, Gay, and Bisexual Youth, Journal of Interpersonal Violence, 2006.
• Garofalo, Deleon, Osmer, Doll, & Harper, Overlooked, misunderstood and at-risk: Exploring the lives and HIV risk of ethnic minority male-to-female transgender youth, Journal of Adolescent Health, 2006.
• Hill, Menvielle, Sica, & Johnson, An Affirmative Intervention for Families With Gender Variant Children: Parental Ratings of Child Mental Health and Gender, Journal of Sex & Marital Therapy, 2010.
• Roberts, Rosario, Corliss, Koenen, & Bryn Austin, Childhood Gender Nonconformity: A Risk Indicator for Childhood Abuse and Posttraumatic Stress in Youth, Pediatrics, 2012.
• Skidmore, Linsenmeier, & Bailey, Gender nonconformity and psychological distress in lesbians and gay men, Archives of Sexual Behavior, 2006.
• Toomey, Ryan, Díaz, Card, & Russell, Gender-nonconforming lesbian, gay, bisexual, and transgender youth: school victimization and young adult psychosocial adjustment, 2010.

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

• McClelland et al., Seeking safer sexual spaces: queer and trans young people labeled with intellectual disabilities and the paradoxical risks of restriction, Journal of Homosexuality, 2012.

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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:

   Gender

   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.

Answer 2

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.