A scan of the comments on Pamela Paul’s bombshell piece on detransitioners in the New York Times revealed that many readers were shocked at the reports of minors undergoing irreversible medical procedures for gender dysphoria without first receiving adequate psychological evaluations. They were especially horrified by the story of Kasey Emerick, whose gender distress, depression, anxiety, and suicidal ideation were ultimately rooted in her being sexually abused by a caregiver when she was a small child, along with internalized homophobia. While Kasey gained valuable insight into the nature of her identity struggles through the transition process, it came at the permanent cost of her breasts and the masculinizing effects of testosterone therapy.

Some readers interpreted Paul’s stories as tragic, one-off failures of oversight. But those who have studied so-called gender-affirming care know that these cases of apparent incompetence reflect built-in features of the treatment model. Gender medicine’s failures result not from a “few bad apples” but from its ideological foundations.

Proponents of the gender-affirmative model assume that cross-gender identities are innate, natural, and healthy. Though evidence is growing of multiple developmental pathways to gender dysphoria and trans identification, the gender-affirmative treatment model generally denies the possibility that preexisting psychological issues could contribute to dysphoria or the adoption of a trans identity. Despite the existence of a cohort of detransitioners who realize in retrospect that their trans identity was fueled by complex and untreated psychological issues, the gender-affirmative model assumes that the only reason trans-identifying people experience higher rates of mental illness is because they are a persecuted minority. Troublingly, the model also assumes that these comorbidities can be treated with medical interventions.

These claims, which constitute the crux of the “minority stress theory,” have become orthodoxy among leading gender-medical organizations and practitioners. While the World Professional Organization for Transgender Health (WPATH) recommends that clinicians conduct biopsychosocial assessments to screen for comorbidities, the organization’s own guidance assumes that psychiatric comorbidities in trans-identifying patients are often secondary to dysphoria, and attributes patients’ psychiatric issues to societal prejudice (i.e., minority stress). The chapter on adolescents in WPATH’s latest Standards of Care (SOC8), for example, suggests that elevated rates of depression, self-harm, suicidal ideation, eating disorders, and ADHD in trans-identifying populations are “often related to family/caregiver rejection, and non-affirming community environments.” Similarly, Tamara Pietztke, a whistleblower from the Mary Bridge Pediatric Gender Clinic, recalled her former supervisor’s claim that “there is not valid, evidence-based, peer-reviewed research that would indicate that gender dysphoria arises from anything other than gender (including trauma, autism, other mental health conditions, etc.).”

While the minority stress theory is widely touted by transgender activists, it has several compelling critics. Northwestern’s Michael Bailey, for example, offers a comprehensive challenge to the theory, arguing that reverse causation could be at work in the surveys that claim to document minority stress phenomena. Bailey claims that, instead of stigma and prejudice triggering psychiatric issues, people suffering from them may be more likely to report experiencing stigma and prejudice.

To explain this dynamic, Bailey draws attention to the psychological concept of “rejection sensitivity” (RS). He characterizes RS as a personality trait that emerges early in childhood and makes a person likelier to perceive others’ actions and words as “rejecting”—and to react with more distress—regardless of others’ intentions. Other researchers have found RS to be a potential risk factor for psychological issues beyond gender dysphoria.

While supporters of the minority stress theory also acknowledge the role RS might play, they often claim that it develops in early childhood after experiences of neglect or rejection from caregivers. In the case of trans-identified people, this presupposes that they were rejected as children because of their minority gender identity, which may not have emerged yet. Still, even supporters of the minority stress theory concede that having higher RS leads people to interpret certain social cues negatively.

This alternative hypothesis—that people with psychiatric issues, presumably high in rejection sensitivity, are more likely to interpret innocuous comments or remarks as being rooted in hostility and prejudice, and to report those experiences as discrimination when asked—is highly relevant, because the minority stress literature is primarily built on self-reported data. The studies in this area link mental-health issues to experiences of discrimination and prejudice by asking people whether they’ve experienced discrimination or prejudice because of their minority identity. This type of study design can’t prove that psychiatric issues are caused by stigma and prejudice and can only note associations between documented mental-health issues and self-reports of discrimination.

Another strike against the minority stress concept is implied by activists’ frequent claim that the rise in the number of trans-identifying people is the result of increased societal awareness and acceptance rather than social contagion. If we accept the claim that society is more accepting of “gender diversity,” how can we explain mental-health comorbidities that are attributed to societal prejudice? (In addition, a robust, countervailing research literature exists on psychological resilience in minority populations.)

Third, and most significantly, minority stress theory fails to explain why many studies indicate that today’s cohort of trans-identified youth often have psychiatric issues that presented before the development of a cross-gender identity. Many studies suggest that these youth have complex mental-health profiles that predate their gender dysphoria or gender-diverse identification. In Lisa Littman’s original rapid onset gender dysphoria sample, 62.5 percent of surveyed trans-identifying youth had at least one formal psychiatric diagnosis prior to the onset of their dysphoria. In Suzannah Diaz and J. Michael Bailey’s paper, 57 percent of youth had a “history of mental health issues” prior to their trans identification, while 42.5 percent had been given formal psychiatric diagnoses. A study by Tracy Becerra-Culqui and colleagues found psychiatric comorbidities present beforehand in nearly 75 percent of their sample of “transgender and gender-nonconforming” girls aged 10-17.

These studies dovetail with Littman and colleagues’ recent paper, which lends support to the notion that some portion of trans-identified youth misinterpret the symptoms of unrelated psychiatric issues as gender dysphoria. The researchers surveyed 78 detransitioners (the sample was 91 percent female) between the ages of 18 and 33 who had stopped identifying as transgender for at least the last six months. When asked to rate the importance of various psychosocial influences that could have potentially influenced their identity, participants’ highest-rated item was “interpreting feelings of trauma or a mental health condition as gender dysphoria.”

For children with gender dysphoria, surgical and hormonal treatment often don’t resolve their underlying mental-health issues. Studies suggest that patients with frequent psychiatric-care utilization pre-transition continue to have complex mental-health needs after transitioning. Finland’s Council for Choices in Health Care (COHERE) even declares that “since the reduction of psychiatric symptoms cannot be achieved with hormonal and surgical interventions, it is not a valid justification for gender reassignment.” This reality is made more troubling by new data suggesting that psychiatric issues themselves are most responsible for suicide mortality in trans populations. The authors of a new study conclude that “It is of utmost importance to identify and appropriately treat mental disorders in adolescents experiencing gender dysphoria to prevent suicide.”

Despite this plea, many youth seeking referrals to gender clinics are not properly assessed for psychiatric issues because of the ideological blinders of the affirmative model. And despite the lack of evidence that medical interventions can resolve psychiatric issues, many youth have internalized the idea that transitioning is a cure-all that can resolve their difficulties. Youth in researcher Riittakerttu Kaltiala’s clinic sample, for instance, reported high expectations that medical interventions would fix their other issues in social, academic, occupational, and mental health domains. The same was true for Littman’s ROGD sample.

Such results illustrate why the affirmative-care model is problematic. Its key assumptions—that gender identities are innate, that dysphoria has one cause and treatment pathway, and that comorbid psychiatric issues can be resolved by medical interventions—run contrary to the medical literature. Humanities departments can get away with such hyper-ideological frameworks, but they simply are not appropriate tools for the medical sciences. As Kasey Emerick knows too well, those ideologies come with a human cost that self-reported surveys cannot measure.

Photo: Nadzeya Haroshka/iStock/Getty Images Plus


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