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15 Jun 2021 - 16 Jun 2021

Science-Based Medicine
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Book Review: Irreversible Damage: The Transgender Craze Seducing Our Daughters, by Abigail Shrier

According to Harriet Hall, Abigail Shrier’s book describes a disturbing trend: an increasing number of adolescent girls who suddenly self-identify as transgender and demand puberty blockers and gender surgeries. We have no data on how many of them will suffer irreversible damage and regret their decision, and it appears that at least some of them have been unduly influenced by peer pressure, the internet, and by therapists who follow the affirmative care model.

Harriet Hall on June 15, 2021

In 2018 I wrote about a research study by Lisa Littman. She coined the term rapid onset gender dysphoria (ROGD) to describe reports she had been reading about gender dysphoria appearing rapidly around the time of puberty in adolescents and young adults who would not have met the criteria for gender dysphoria in childhood. Her study raised the possibility that rather than always being an innate, immutable sense of incongruence between anatomical sex and personal sense of gender, some cases of gender dysphoria might be due to social contagion from peer pressure and online influences.

I thought that was worthy of investigation. I got a lot of criticism for writing about it. I was even called transphobic, which I absolutely am not. I only want the best for each individual. If that means transitioning, I fully support that. If it means some individuals transition for the wrong reasons and later change their minds, that’s regrettable and we need to find a better way to identify those individuals and treat their dysphoria without subjecting them to irreversible interventions. I hesitated to tackle this controversial subject again, but in 2020 Abigail Shrier wrote a book that shares my and Littman’s concerns. It combines well-researched facts with horrifying stories about botched surgeries, people who later regret their choices, and therapists who are not providing therapy but just validating their patient’s self-diagnosis. The title is Irreversible Damage: The Transgender Craze Seducing Our Daughters.

Littman’s research methods were flawed but she was unfairly vilified

Littman’s research was widely criticized for its flaws, which I described in my article. It was not good science and didn’t set out to establish that ROGD was real; it was meant to be exploratory and hypothesis-generating. Transgender activists accused Littman of having hurt people with her research; they called it “dangerous.” Her paper drew praise from some world experts on gender dysphoria and from many parents, but she was also tarred as a bully and a bigot. She was denounced by activists to her employer, the Rhode Island Department of Health, and they fired her, even though her job had nothing to do with transgender youth or even young children. She was unfairly attacked, her reputation was tarnished, and she lost a job she loved.

The numbers are alarming

Historically, the conviction that one’s gender doesn’t match one’s anatomical sex typically began around age 2-4. It affected only .01 percent of children, almost exclusively boys. And in 70% of cases, they eventually outgrew it. Prior to 2012, there was no scientific literature on girls age 11-21 ever having developed gender dysphoria at all.

The picture has changed dramatically. Natal girls now constitute the majority. Clusters of adolescents are discovering transgender identities together and are clamoring for hormones and surgery. In 2018 the UK reported a 4,400% rise over the previous decade in teenage girls seeking gender treatments; similar spikes have been observed in many other countries. In the US, the prevalence of adolescent gender dysphoria has increased by over 1,000% in the last decade. In 2016, natal females accounted for 46% of all sex reassignment surgeries; a year later it was 70%.

We are starting to see desisters (those who stop identifying as transgender) and detransitioners (those who had undergone medical procedures, regretted it, and tried to reverse course). No statistics are available on how often this happens.

Those who transition rarely adopt the stereotypical habits of men (like buying a weight set), only 3% have had a phalloplasty (to create an artificial penis), and only 13% say they want one. A common response is “I don’t know exactly that I want to be a guy. I just know I don’t want to be a girl”. Girls who previously would have been classified as tomboys or lesbians are now classified as transgender; sometimes the idea of transgender is first suggested by a therapist. In one school where 15 students had come out as transgender, there wasn’t a single lesbian. Shrier looked for instances where a counsellor suggested to a patient that they might be lesbian rather than transgender; she couldn’t find a single example. In the last decade, lesbians have seen the disappearance of lesbian bars and publications. Lesbians have been denigrated as transgender males who won’t admit they are supposed to be boys.

The mantras of trans influencers

There are many social media sites and online forums that facilitate the discovery of a trans identity. Trans influencer gurus commonly offer advice like this:

If you think you might be trans, you are.
You can start trying out trans by using a binder to flatten your breasts.
Testosterone is amazing and it may just solve all your problems. You don’t have to be certain you are transgender to go on hormones.
If your parents loved you, they would support your trans identity. If your parents are not supportive, it’s OK to cut off contact.
If you’re not supported in your trans identity, you’ll probably kill yourself.
Deceiving parents and doctors is justified if it helps transition. Scripts are provided that will convince doctors to give you hormones. It’s OK to lie and say you have always known you were trans even if it’s not true.
You don’t have to identify as the opposite sex to be “trans.” You can be “genderfluid” and reserve the right to change your mind. One said she wanted to be identified as a woman only some of the time.
If you’ve ever felt different, anxious, or afraid, or felt like you don’t fit in, there is a transgender community ready to accept you and become your new family.

The schools are not helping

In California, students can opt out from sexual health education instruction but cannot opt out of gender identity and sexual identification instruction. Gender stereotypes are taught in kindergarten. Children are taught that they might have a girl brain in a boy body or vice versa; never mind that that is biologically nonsensical. Teens are asked to imagine what it would be like to be the other gender. When a child comes out as trans, schools frequently adopt their preferred new name and pronouns without informing the parents (ostensibly to protect the child’s privacy). The achievements of gender-nonconforming women are downplayed because they don’t count as true women.

One of the tasks of adolescence is establishing an identity. Adolescents are still trying to figure out who they are and which gender they are attracted to. Many of the adolescent girls who adopt a transgender identity have never had a single sexual or romantic experience and have never been kissed.

Shrier gives a personal example of how teens can’t always predict what they will want later in life. She wanted breast reduction surgery. Her father objected that it might interfere with breast feeding, but she was absolutely sure there was no chance she would ever want to nurse a baby. More than a decade later she breast-fed three babies and found it one of the most rewarding experiences of her life. She says, “We are very good at knowing what it is we want right now; far less good at predicting whether the object of our desire will produce the satisfaction we take for granted”.

The customer is always right

A new “affirmative care” standard of mental health care has been adopted by nearly every medical accrediting organization. The American Psychological Association guidelines go much further than respecting and supporting trans identities; they mandate that therapists adopt gender ideology themselves. Therapists must accept and affirm the patient’s self-diagnosis. Shrier likens this to telling an anorexic teen “If you think you are fat, then you are. Let’s talk about liposuction and weight-loss programs”. She asks whether a standard guided less by biology than by political correctness is in the best interests of the patient.

We don’t provide affirmative care for anorexia. We don’t say “Yes, you are fat” and offer to help them reduce their weight even more. Part of a therapist’s role is to question a patient’s self-assessment.

Parents are asked to believe that they never had a daughter but have always had a son. They are told if they don’t affirm, the child may commit suicide: “Would you rather a dead daughter or a live son?” We are asked to disregard DNA and accept the ineffable feelings of an eight-year-old. This amounts to emotional blackmail, and it is not based on good evidence. Suicide is not uncommon, but there is evidence that factors other than gender dysphoria may be causing the suicidal ideation, and there is evidence that affirmation does not ameliorate mental health problems. In one study of adult transsexuals, there was a rise in suicidality after sex reassignment surgery.

The dissenters

Some therapists think the affirmative model is a mistake, but they dare not speak out. Nineteen states prohibit conversion therapy for homosexuality, and they equate questioning a patient’s self-diagnosis of gender dysphoria to a kind of conversion therapy, banning it as well. Dissenting therapists have lost their jobs and risk losing their license. Dr. Kenneth Zucker is a case in point. A highly respected expert on gender dysphoria, he refused to reduce the source of distress to one problem; he insisted on looking at the whole kid. In a series of 100 boys he treated who had not been socially transitioned by parents, a whopping 88% outgrew their dysphoria. He was accused of practicing conversion therapy, was fired, and his reputation was ruined.

Dr. Ray Blanchard questions whether adolescent girls who suddenly identify as trans even have gender dysphoria. He believes they are a mixture of those who will be transgender no matter what, those who will outgrow their dysphoria and live as gay adults, and those who have borderline personality disorders and have identified a kind of faux gender dysphoria as the locus of their unhappiness. Rigorous empirical study is needed to guide diagnosis, understanding, and treatment; but in the current political environment good science has become almost impossible.

Since doctors have no way of predicting whose dysphoria will respond to gender surgery, Shrier says (and I agree) it should be clearly labeled experimental and should be restricted to patients participating in controlled studies overseen by an institutional review board (IRB). Testosterone can seem like a miracle; it can lift depression and anxiety and make young women feel bold and unafraid. Planned Parenthood, Kaiser, and Mayo all dispense it, often on an “informed consent” basis on the first visit, with no referral or therapist’s note required. It is given to patients as young as 15 (the age of consent in Oregon). There are plenty of risks, which Shrier describes. She also describes the risks for puberty blockers like Lupron. Delaying puberty is supposedly harmless, but it isn’t. Imagine a prepubertal child trying to relate to age-mates who have all experienced puberty. Studies have shown that when a kid is put on puberty blockers, almost 100% will go on to take cross-sex hormones. This essentially guarantees infertility. “Top surgery,” or bilateral mastectomy, is advocated by surgeons who believe adolescents can make logical decisions, and is done on girls as young as 13 (legal in California). The surgeons don’t require input from a therapist; they accede to the patient’s wishes and rarely turn anyone away.

Conclusion: An important book

This book will undoubtedly be criticized just as Lisa Littman’s study was. Yes, it’s full of anecdotes and horror stories, and we know the plural of anecdote is not data, but Shrier looked diligently for good scientific studies and didn’t find much. And that’s the problem. We desperately need good science, and it’s not likely to happen in the current political climate. Anyone who addresses this subject can expect to be attacked by activists. Is ROGD a legitimate category? We don’t know, since the necessary controlled studies have not been done. I fully expect Shrier to be called a transphobe and to be vilified for harming transgender people, and I’m sure I will be labeled a transphobe just for reviewing her book.

She brings up some alarming facts that desperately need to be looked into. The incidence of teen gender dysphoria is rising and appears to be linked to internet influences and social peer groups. The number of people identifying as lesbians is dropping. Therapists are accepting patients’ self-diagnoses unquestioningly, and irreversible treatments are being offered without therapist involvement. We know at least some of these patients will desist and detransition, and we have no way to predict which ones. Children are being instructed in how to lie to parents and doctors to coerce them into providing the treatments they want. Families are being destroyed.

For what it’s worth, I will stress again that I am not a transphobe. I support hormones and gender surgeries for adults who will benefit from them. I care about the welfare of these adolescent girls and it bothers me that some of them may be unduly influenced and take irreversible steps they will later regret.

What to do? I think limiting surgeries to a research setting is a good idea. I think the affirmative care model is a mistake and a dereliction of duty and should stop. Shrier advocates not letting girls have cell phones. I disagree. I think refusing to get your daughter a cell phone is a sure way to make her hate you and may make her suffering worse, not better.

Harriet Hall
Harriet Hall, MD also known as The SkepDoc, is a retired family physician who writes about pseudoscience and questionable medical practices. She received her BA and MD from the University of Washington, did her internship in the Air Force (the second female ever to do so),  and was the first female graduate of the Air Force family practice residency at Eglin Air Force Base. During a long career as an Air Force physician, she held various positions from flight surgeon to DBMS (Director of Base Medical Services) and did everything from delivering babies to taking the controls of a B-52. She retired with the rank of Colonel.  In 2008 she published her memoirs, Women Aren't Supposed to Fly.

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Posted in: Book & movie reviews, Medical Ethics, Obstetrics & gynecology, Surgical Procedures Tagged in: Abigail Shrier, affirmative care model, desisters, detransitioners, gender dysphoria, gender surgeries, internet influence, Irreversible Damage, puberty blockers, rapid onset gender dysphoria
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