There is a lack of adequate assessment before surgery in trans children and young people, says psychologist

Children and young people are undergoing medical interventions for gender transition without proper evaluation, and some end up regretting it. This is the warning of American psychologist Laura Edwards-Leeper, co-founder of the first clinic to care for trans children.

According to Edwards-Leeper, professor emeritus at Pacific University, there is an increase in the number of young people who identify themselves as transgender, which is very positive.

“It’s definitely safer to come out as a transgender person in many places around the world, and that’s wonderful. Many people who would be hiding are able to come out and access the treatments they need more quickly,” he says.

However, many doctors are indicating irreversible surgery in children, or use of hormones that can result in infertility, without conducting a thorough evaluation first.

“I’m afraid that this discussion will fuel a conservative agenda that wants to block access of trans young people to treatments that can benefit many of them; I don’t want clinics closing down. At the same time, I don’t think censoring this discussion is a solution.”

You founded the first clinic for transgender children and adolescents in the US. Based on your experience of many years with the subject, do you think that the current medical approach to these young people is correct? Medical interventions (puberty blockers, hormone treatments, and gender affirmation surgery) are very appropriate for trans young people who have been adequately evaluated.

My concern is for young people who are not receiving the proper assessment before deciding whether medical intervention is the best approach at that time. In many cases, in many places, this assessment is not being done. The demand for these services is greater than the offer of qualified professionals to serve them.

So, many times, clinics need to speed up the entire process, otherwise the waiting list will increase. Many colleagues want to serve these young people in the best way possible, but they end up accelerating everything and there is no careful evaluation. That worries me. There are children and adolescents without a history of childhood gender dysphoria who quickly begin to undergo these medical procedures.

There are no specific numbers, but our impression is that this is happening with a certain frequency. It takes comprehensive evaluation and therapy sessions to ensure that a medical procedure will be the right decision.

Today, 1.8% of young people under 18 in the US identify themselves as transgender, more than double five years ago, according to the Trevor Project. Is the number growing because young people and people are more aware and informed, and prejudice is decreasing, so more people feel safe to identify themselves? Or is there also more social pressure and influence from social media? I think it’s both. It is definitely safer to come out as a transgender person in many places around the world, and this is wonderful, many people who would otherwise be hiding are able to come out and access the treatments they need more quickly.

But I also think that, in part, there is peer pressure, and there is identity exploration, common during adolescence. Teens question their gender, which is great, it’s healthy. But as the result of this, sometimes, can be permanent medical interventions, it is necessary to approach this in a more thoughtful way, with proper evaluation.

How should parents of young people or children who claim not to identify with the designated gender at birth react? What is the best way to approach the issue? The best thing is to support the child or young person and, together with a mental health professional, talk. In these conversations with the son or daughter, talk about the steps of transition. It can start with a haircut or change, dressing in the gender the young person identifies with, changing his name and pronouns he adopts.

It is always good to have an outsider, a health professional, to help the young person and their family to navigate this process. And it is always important for parents to demonstrate that they support their sons and daughters.

Is it still common for parents to feel that their child is just going through a phase, and that they don’t want to support them in their decision to make the gender transition? In the US, there has been a big change. These days, most of the parents I talk to are very open to the fact that their children are transgender. There are others who are surprised that the teenage son or daughter, who has never had a history of gender dysphoria, assumes that they are transgender.

These parents say that if their children really feel that way, they will fully support them if they want to make the transition, medical procedures or not. But they want professional support and guidance, to feel more confident that this is actually happening, because it doesn’t fit with what they knew about the child. It is best for parents to encourage their children to talk more about it, listen to them carefully, ask how they became aware of their dysphoria.

Often, young people have been feeling this for a long time and the parents had no idea. So if parents leave that door open, they make the child comfortable to talk. And therapy can help a lot when a child doesn’t feel secure enough, or comfortable enough, to talk about their gender dysphoria with their parents. Often a therapist can help bridge this gap with parents.

In a recent article, you state that there is a portion of young people who reverse the gender transition, although it is a minority. Why does it happen? There aren’t many studies on this. A recent study by Lisa Littman of 100 people who reversed the gender transition showed that 38% believed that their dysphoria, their feeling of not identifying with the sex they were assigned to at birth, was due to “some specific thing, such as trauma, abuse, or a mental health disorder.”

And 55% said they “did not receive a proper assessment from a physician or mental health professional before beginning the gender transition.” Many people suffer trauma and develop dysphoria as a result of that trauma. Others who reversed the transition say they were too influenced by friends and social media to transition, and that at the time this seemed like the solution to many of the problems they were experiencing.

Some don’t regret it, they say: I needed it then, but now, at another time in my life, I don’t think I need hormones anymore. Others get really bad, regret it, and feel that the medical professionals didn’t help them to assess properly at the time.

Many doctors even use the adult informed consent form with children and young people. They hear the patient say they need a procedure, and then they just do it. They follow the rationale that this isn’t a matter of mental health, it’s a matter of identity, and people know which one is yours.

Doctors say puberty blockers are a more conservative medical approach because they have no permanent effect. How difficult is it to undo gender transition medical procedures? I’m not a doctor, but from my experience with patients and conversations with my fellow doctors, blockers are reversible and very safe unless you’ve been using them for many years, which causes bone damage.

Blockers help children and young people buy time as they decide whether they want to have other medical procedures for gender transition (female or male hormones, mastectomy or breast implants, Adam’s apple reduction, removal of penis, uterus or ovaries, construction of vagina and penis).

When a young person switches from puberty blockers to hormones, they can become permanently infertile. And when you have eight- or nine-year-olds having to decide about their future fertility, you need to think carefully about the decision to take hormones, and think together with families, because often these children are very young.

At the same time, it has become taboo to recommend more therapy sessions before decisions about hormones and gender-transition surgeries for children and young people. And some psychologists are accused of trying to do “conversion therapy” by recommending gender exploration therapy. Have you ever been criticized for this? Yes, I have been accused of being prejudiced, transphobic, of believing I know more about their gender identity than the children themselves. But I get a much larger number of positive reactions for proposing that the issue be addressed more nuanced.

As I said at the beginning, I am not against trans teens undergoing gender transition medical procedures. I’m only concerned that some doctors are not following standards of care, and many use adult informed consent forms with children and teenagers. This is irresponsible and unethical.

I believe that mental health specialists need to be involved in evaluating these young people, and their parents. Many parents tell me that they are totally excluded from the process, and are accused of transphobia when they ask too many questions, want to slow down the process, or seek therapy for their son or daughter.

You mention in your Washington Post article a doctor who criticizes the insistence on psychological evaluation before procedures. He says: “If a person tells me they are trans, I believe them. There is no need for therapy, because being transgender is not a pathology.” How do you react to this criticism? I agree 100% with the fact that transgenderism is not a pathology. But we are talking about gender dysphoria. Many colleagues and I have seen that some young people experience gender dysphoria at some point, but are not transgender.

It could be because of a history of trauma, going through puberty and feeling uncomfortable as a woman or a man, and having a lot of trans friends — there is often social contagion. So many of the young people who begin to experience gender dysphoria may not benefit from medical interventions.

It is necessary to determine, together with the person, whether this is the best path for him or her. If the person, after having all the information, says he wants the procedures, that’s fine, he made a decision with full knowledge.

​In a way, we live with antagonistic problems —you point out that there are people rushing into the gender transition with permanent medical interventions, without proper evaluation, but, on the other hand, most transgender people in the world do not have access to treatments, and conservative lawmakers try to make this access even more difficult , mainly for trans children. It’s a very difficult balance. The last thing me and Erica [Anderson, psicóloga trans que é especialista em atendimento de crianças trans] what we wanted, when writing the article for the Washington Post, was to feed the conservative agenda, or contribute to the lack of treatment for these young people.

But at the same time, I think it doesn’t do us any good not to have these conversations about what’s going on. I’m afraid this discussion will fuel a conservative agenda that wants to block trans young people’s access to treatments that can benefit many of them; I don’t want clinics closing their doors. At the same time, I don’t think censoring this discussion is the solution.