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FFYFP Blog: Medicine for the Gender Spectrum

  • First Five, News and Events

Written by: Dr. Charissa Ho

For most of us, there was very little (if any) exposure to transgender medicine or people who identify as gender diverse during our training. I was fortunate to have the opportunity to locum for Dr. James Makokis in Edmonton, who guided me through my introduction to caring for people who are gender diverse. In my current practice, I continue to be supported by an amazing group of gender medicine providers of all backgrounds. With the training, resources and supports that I have, I hope this guide can provide you with confidence in providing care for folks on the gender spectrum.

TERMINOLOGY

  • Gender diverse – gender is not a binary, people can identify anywhere on the masculine to feminine spectrum. Gender diverse or gender diversity refers to people who do not identify as the binary.
  • Cis male/female – someone who identifies as the same gender they were assigned at birth
  • Trans male/female – someone who identifies as a different gender they were assigned at birth
  • Assigned male at birth (AMAB) – someone who was born with a penis and testicles that would produce testosterone
  • Assigned female at birth (AFAB) – someone who was born with a vagina, uterus, and ovaries that would produce estrogen
  • Gender non-binary – someone who identifies as neither male nor female. People who are non-binary may be more comfortable being more feminine or more masculine. They may choose to pursue hormone replacement therapy, or surgery, or both, or none

USE PREFERRED NAMES AND PRONOUNS

In medical school, we were taught to ask how someone would like to be addressed. This is the same, except the name the person goes by may not be written on their health care card. When a person is called the name they no longer go by, they are “dead-named”. It can be dysphoria-inducing, for some, it can be traumatizing. It is okay if you use the wrong pronoun or the wrong name, acknowledge it, apologize, and remember to use their preferred name and pronoun next time. This also goes for EMR records and the name and pronouns used by clinic staff.

PEOPLE WHO ARE GENDER DIVERSE HAVE “TYPICAL” HEALTH NEEDS TOO

People who have a cervix still need cervical cancer screening if they have been sexually active. People who have a prostate and are on estrogen can still get prostate cancer. People who have breast tissue still need to be screened for breast cancer at appropriate ages. Everyone can still get sinusitis, eczema, GERD, hypertension, depression, etc. Most conditions have no relevance to their gender identity or their hormones. We have the knowledge and training to evaluate and treat conditions within primary care’s realm, the same principles go for people who are gender diverse.

DIAGNOSIS OF GENDER DYSPHORIA

The DSM-V criteria for Gender Dysphoria can be summarized as follows:
A marked incongruence between one’s gender experience (being more drawn to opposite gender-typical activities, feeling uncomfortable in their own body, desire to have the other gender’s secondary sexual characteristics) and their gender assigned at birth. This experience should be present for at least six months in duration and be associated with significant distress.
Below is the full DSM-V criteria for Gender Dysphoria:

A. A marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months duration, as manifested by at least two of the following:

  • A marked incongruence between one’s experienced/expressed gender and primary and/or secondary sex characteristics (or in young adolescents, the anticipated secondary sex characteristics).
  • A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics).
  • A strong desire for the primary and/or secondary sex characteristics of the other gender
  • A strong desire to be of the other gender (or some alternative gender different from one’s assigned gender)
  • A strong desire to be treated as the other gender (or some alternative gender different from one’s assigned gender)
  • A strong conviction that one has the typical feelings and reactions of the other gender (or some alternative gender different from one’s assigned gender)

B. The condition is associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

HORMONE NEEDS

If you are comfortable with starting and/or providing hormones for gender folks, this is a rough how-to guide. A patient does not need to be formally diagnosed with gender dysphoria in order to start hormone therapy as long as the person is clear on why they are pursuing hormone therapy, the effects it can and cannot have, and possible side effects. Of note, the Endocrine Society suggests that feminizing and masculinizing hormone therapy are “safe without a large risk of adverse events when followed carefully for a few well-documented medical concerns”. Hormones should be viewed as therapy provided with informed consent rather than therapy that providers gate-keep.

For male transitioning to female or trans-feminine, there are two primary components: anti-androgen and estrogen. Most common anti-androgen is a medication we are all familiar with – spironolactone. Another agent is cyproterone, which can have more potent effects and be a bit more expensive. Estrogen formulations are the same that we use for menopause hormone replacement therapy: estradiol oral tablets, estrogen patches, and estrogen gel. The formulation chosen depends on patient preference and drug coverage.

For female transitioning to male or trans-masculine, there is one component: testosterone. Testosterone is available in injectable, gel, and oral. Most commonly, injectable is used. Another consideration for folks assigned female at birth is menstrual cessation. Menstrual cessation for transgender folks is the same for cis folks – progesterone IUD, progesterone implant, oral progesterone, combined OCP, and removal of the uterus.

If you want to learn more and provide hormone replacement therapy for gender diverse folks, there are lots of resources. Rainbow Health Ontario and Trans Care BC are the two resources I use the most.

SURGICAL NEEDS

Not everyone who identifies as gender diverse want to pursue surgery. In 2022 in Alberta, top surgery is covered once the person has been diagnosed with gender dysphoria by a gender provider (someone who practices transgender medicine regularly). For bottom surgery, a psychiatrist diagnosis of gender dysphoria is required, and this is accessed through the Edmonton or Calgary Gender Clinics (pediatrics and adult programs are available in both cities).

Top surgeries available include mastectomy or breast augmentation. Bottom surgeries available include phalloplasty, metoidioplasty, vulvoplasty, and vaginoplasty. Other gender affirming surgeries that do not require a diagnosis of gender dysphoria and are covered by Alberta Health include: orchiectomy and hysterectomy with or without salpingo-oophorectomy. There are many other gender affirming surgeries that are not covered by Alberta Health. These include: facial femin/masculinization, tracheal shave, vocal cord surgery, surgery enhanced fat redistribution, and hair removal.
Learn more on gender affirming surgery coverage.

COUNSELLING AND SOCIAL NEEDS

This is the part where I heavily rely on the primary care network and non-profit organizations that support gender diverse folks. Many people who are gender diverse have experienced significant trauma or mental health struggles in their lives. Many gender diverse folks are also on the autism spectrum and have ADHD. Getting them connected with other supports is crucial! Resources that can help with finances, housing, counselling, peer support, family support, gender affirming gear, etc. can make a world of difference. It helps people feel less alone in their journeys while feeling secured in finances and housing.

Below is a list of resources in Alberta:

Alberta-wide community resource:

Calgary community resources:

Edmonton community resources:

Red Deer community resources:

Other Northern Alberta community resources:

Other Resources:

REFERRALS

For the purposes of this post, I want to provide a general overview on how referrals can be made.

Southern Alberta:

  • The Adult Gender Clinic at the Foothills Medical Centre
    • Referrals for adults. From there, referrals are triaged and may be distributed to community gender providers like myself.
  • The Metta Clinic at the Alberta Children’s Hospital
    • Referrals for children and adolescents
  • The Alex Youth Centre
    • Referrals for people ages 16-24
  • Skipping Stone Foundation
    • Community organization that can connect gender diverse folks with gender providers (as listed above and several community gender providers like myself) and community resources

Northern Alberta:

  • The Gender Program at University of Alberta Hospital
    • Referrals for adults, adolescents, and children. From there, referrals are triaged and distributed to the pediatric program, and may be distributed to community gender providers like myself.
  • Skipping Stone Foundation (see above)

CONTINUING MEDICAL EDUCATION

Getting into gender medicine or supporting your gender diverse patients can seem daunting. It doesn’t have to be. There are numerous resources you can turn to. Many of the resources also provide free CME!

FINAL THOUGHTS

I hope this guide can give you confidence in providing care for gender diverse individuals. You ARE the expert in primary care and gender diverse folks are not that different.

Many gender diverse folks are intimidated when it comes to seeking health care. When finding a family physician, going to a walk-in clinic, going to a specialist, or to the emergency room, they are never sure if they would face discrimination or transphobia.

If you are able to take on gender diverse folks for primary care, please reach out to Skipping Stone Foundation and identify yourself as a safe provider.

17 Responses

  2. We must be extremely cautious with this narrative.

    “A patient does not need to be formally diagnosed with gender dysphoria in order to start hormone therapy as long as the person is clear on why they are pursuing hormone therapy, the effects it can and cannot have, and possible side effects. Of note, the Endocrine Society suggests that feminizing and masculinizing hormone therapy are “safe without a large risk of adverse events when followed carefully for a few well-documented medical concerns”. Hormones should be viewed as therapy provided with informed consent rather than therapy that providers gate-keep.“

    These statements are dangerous and anti-Hippocratic. We do not merely explain risks and benefits and then provide desired drugs and step aside. Further, the irresponsible claim quoted by the Endocrine society is specious at best. Drug companies want us to believe there are no adverse events. To claim that there is no large risk of adverse events is misleading, and any physician who is familiar with these drugs knows this.

    Hormone use for gender dysphoria is off label. No studies have been conducted looking at potential harms of these medications for such an indication. Harms are real and can include permanent sterilization. We must use caution as a profession. Are we following trends at the peril of patients? Is our role for any drug that a patient wants to simply educate about the risks and benefits and then prescribe if they want it? What if the risks are not clear? What about off label use? I will not jeopardize the well being of my patients by being cavalier about prescribing any medications.
    We must first do no harm. We must know what harms we could cause in order to properly help patients with such decisions- primum non nocere.

    Reply

    1. Transgender medicine is identified as a growing need in medicine. People who are gender diverse experience minority stress and it can be hard for them to seek health care, gender related or not. By creating a safe space for people to seek care is not only affirming, it is also life saving. As family physicians we have the unique privilege and opportunity to build trusted relationships with our patients—a foundation for creating safe spaces.

      The World Professional Association For Transgender Health recently published their Standards of Care version 8. Please visit this link for more information on the guideline for caring for gender diverse people. They also published the process that went into producing this evidence based guide. https://www.wpath.org/soc8

      There are many free resources to learn more about caring for gender diverse individuals. PHSA Trans Care is a great place to start. http://www.phsa.ca/transcarebc/health-professionals/education

      Reply

    2. I would respectfully disagree with your comment, Dr Keyes as there are several inaccuracies.
      1) medications, including hormone therapy for gender diverse patients are not provided and then we “step aside”. Besides the informed consent process and assessment for safe use, patients are followed up regularly, with both clinical assessment and lab surveillance.
      No medications have zero side effects, and as with any medication, these are discussed with the patient as safety is of the upmost importance. Would we tell a hypertensive patient that the risk for hypotension is too great as compared to their risk for a stroke?
      2) These medications are not “off label” for gender dysphoria. If you looked at any reputable, evidence based medical resource, you could find that it is “on label”. Aside from that, we use medications as off label regularly, appropriately and safely. Ozempic was used as a weight management drug before it was approved as such.
      3) There are many studies that have been conducted on the safety and the benefits of hormone therapy in gender affirming care.
      4) “permanent sterilization” is not an accurate effect of hormone therapy. Fertility can be affected, but this is discussed in detail with patients and there are options available for patients who desire a family, including having biological children. I would hope that we all agree that families are created in many ways.
      5) There are also many studies on the dangers of denying care to gender diverse patients, ranging from depression to suicide, and self mutilation. Thus, I would agree that we should “first do no harm”. I can assure you that there are no physicians out there being “cavalier” about gender affirming care, just healthcare providers committed to inclusive, evidence based, patient centred care.
      Marginalized members of our society are often denied access to care because of a multitude of reasons, I would hope that we do better.

      Reply

      1. I will respectfully disagree with some of your points.
        1. Harm must be considered first. It does not mean we do not act to ease or prevent suffering even when harm is possible. We must have a clear picture of what harms exist. I do not believe the exploration and documentation of risks of these medications for these indications has been nearly rigorous enough. We must know more about the harms. How else can we respect the Primum Non Nocere? How else can we properly weigh the benefits and harms? I know we will never have a perfect knowledge of all the harms, but currently the narrative does not match the evidence for these medications. Prescription without considering the serious harms is irresponsible. Even if patients understand the risks and still want the treatment. Like it or not, we are gatekeepers. Otherwise we are drug vending machines with lists of side effects and disclaimers. Medicine is rapidly losing its humanity on these slopes.
        2. The use of cross gender hormones and puberty blockers is off label. Please look into this. This is not stopping any doctor from prescribing. I am not being conspiratorial, but this is one of the reasons the drug companies will not do any safety trials specifically for these indications. Why would they do that when physicians and the public are under the impression that these medications are “safe, without a large risk of adverse events.”? They have nothing to gain and everything to lose as long as physicians are the ones Pres off label. They are making millions off these drugs, and if any serious harms happen the companies can just say “That’s off-label use. Don’t look at us. You’re the one prescribing”
        5. Not providing care never does harm. It could violate the principle of beneficence, but this is distinct (and secondary) to non-malfeasance. An argument could be made on the basis of the principle of duty to provide beneficence, but this is not the same as non-malfeasance. You are conflating the two.

        Reply

        1. Dr. Keyes, your approach to medical ethics ignores patient autonomy and human self determination. You demonstrate disdain for the data, the standards of care, and experience of gender diverse patients and those who work with them. “Respectfully” at the beginning of your comments is disingenuous when you use emotionally charged language, unsubstantiated claims, and misdirection- to accomplish what, exactly? We all work with patients who identify and express themselves in ways that do not align with their assigned gender. Dr Ho’s blog summarizes and organizes ways that dedicated, thoughtful, evidence based providers can better align our care of these patients with current standards. If you do not wish to prescribe hormones, then don’t. Your “digging into the research”, I would extrapolate from your comments, is nothing more or less than cherry picking of the existing body of evidence to confirm your implicit bias about trans and gender diverse people. Thankfully, increasing numbers of physicians are able to decide whether to explore your views, or rather follow the standards developed by medical organizations that actually aim to provide- and improve- gender affirming care.

          Reply

        2. Thank you for your comments as it demonstrated that I should be clearer with my own.
          1. How is harm not considered for gender diverse patients when providing gender affirming care? As with any treatment, which includes not treating, we have to weigh the science and provide patient centred care. While we may be gatekeepers as you say, decision making is shared with our patients.Why does patient autonomy and informed care not apply here? We are acting to ease and prevent suffering with inclusive care; this does not always mean medication or surgery but often it does; there are so many other aspects of inclusive care that you are missing from this entire blog post (violence, prejudice, trauma etc). As the other physicians who have commented have stated, there is quite a large body of evidence for this indication for hormone therapy, spanning decades, and I too hope we will continue to assess and gather more information to ensure our practice is in keeping with EBM and safe for patients.
          2. Yes, gender affirming hormone therapy is off label. I should have stated my meaning in more explicit language, in that it is used safely as an indication for gender dysphoria as off label. I have many patients on metoprolol for a fib, it’s off label for this indication. Chemotherapy is off label for some cancers as it was approved for another. Manufacturers are responsible for applying for this authorization, and I agree with you and Dr Donaldson in that pharmaceutical companies are able to take advantage in a way that is more than distasteful. However, are we going to stop prescribing medications because the manufacturer has not applied for it to be on label or because we know that pharmaceutical companies make astronomical amounts of money? I will assume the answer is no. No one is forcing you to prescribe any medications for any reasons. You have stated that you have not seen enough/rigorous evidence, but it seems from your comments that you have not read any of the evidence.
          5. Not providing care, especially when a patient is asking for care and their life depends on it, is doing harm. I have been more fortunate than Dr Donaldson in that all my gender diverse patients are still alive, many whom have been on hormone therapy for years. I have no doubt that gender affirming care, which has included hormone therapy, is a large reason for that.

          Reply

  3. Excellent summary and list of resources. This is an area where need exceeds available resources. The medications in question are well known and regularly prescribed for various other indications. Thank you, Dr Ho for demystifying and destigmatizing there use in patients with gender dysphoria. I hope this inspires many of us to improve our care of gender diverse patients.

    Reply

  5. Individuals with gender dysphoria deserve the same standard of care as anyone. I do not prescribe life changing medications off-label with serious side effects, and no long term safety data to anyone. We physicians love to be the ones with all the answers, but we need to stop over medicalizing everything and exercise some humility.
    My hesitancy to prescribe is only motivated by sincere care for the overall, long-term health of my patients. I doubt the pharmaceutical companies, who are licking their chops at this new frontier, share the same top priority.
    Do you know what the consequences of puberty blockers and cross sex hormones are in 30 years? Do you know the outcomes? Digging in to the research, I find it lacking.
    We are not talking about treating a little ear infection here.
    Forgive me for wanting better answers to harder questions before prescribing. I urge you to do the same.

    Reply

    1. Appreciate everyone’s comments here.

      Dr. Keyes, I share your desire to practice evidence-based medicine. Here is the evidence as I understand it, and I would be happy to share abstracts/links if it would be helpful. If you have evidence to counter the following, I would be interested in seeing it.
      – Transgender individuals are at extremely high risk of mental illness, suicidality, high-risk sexual behaviour, struggling in work and school, substance abuse, homelessness, etc.
      – All of those risks decrease dramatically, approaching that of the general population, when they are in supportive environments, including when they are able to access gender-affirming medical and surgical treatment.
      – Among those who seek gender-affirming medical care, the rates of long-term “regret” in transitioning is around 1-2%… and when those individuals are surveyed many of them regret their changes mainly because they are caught in unsupportive social environments and now have become more of a target of transphobic violence.

      Weighing the evidence above, for me it’s abundantly obvious that the right thing to do when an individual is seeking gender-affirming medical or surgical care, and has been adequately informed of the risks / benefits / alternatives, is to support them in their transition. As one lecturer once said quite bluntly to a concerned family member, “would you rather have a son/brother/father who is alive or a daughter/sister/mother who is dead?”

      It’s a bit strange to me that you do not believe there is enough evidence to support the long term effects of testosterone and estradiol. I trust you are aware that these hormones, when used medically, are bio-identical? And I trust you can tell me what the long term effects of testosterone and estradiol have on bodies? Sure, we can always use more research… and it turns out we do have about 30-40 years of data in the long-term effects of medical therapy for transgender and gender nonbinary individuals, mostly out of the Netherlands. Most of the data we have aligns quite nicely with what we already know about these two hormones.

      Dr. Keyes, I also share your reservations about pharmaceutical companies and their motives, but I (and hopefully you) still prescribe medications when they are indicated, even if we know that drug companies are making criminal amounts of money on those medications. I occasionally care for patients with HIV/AIDS, for example, and it galls me to no end how much those medications cost. I still prescribe them when they are indicated, though, hopefully for obvious reasons.

      You mentioned a concern about the fact that T and E are prescribed off-label, and I think you’re right about that. Do you know if any drug company (or other entity) has ever applied for them to be “on label”? Are you suggesting that doctors never prescribe something off label even when (as in this case) *all* of the medical guidelines recommend it?

      Finally, you wrote above, “Not providing care never does harm,” and I can only assume you misspoke. If someone has a life-threatening medical or surgical condition, say appendicitis, refusing care is most certainly harmful. “Would you rather have a son/brother/father who is alive, or a daughter/sister/mother who is dead?” Again, the evidence shows that it really can be that serious.

      I’ve cared for transgender and gender nonbinary individuals for almost 10 years now. I worry about every one of them, and am immensely relieved that (to my knowledge) I’ve only lost two of them: One to suicide and another to transphobic homicide. But still: That’s two too many.

      Reply

  6. Charissa
    Thanks for a well written article which is a succinct and organized summary of trans and gender diverse health care in Alberta 2022.
    I appreciate all of the comments of my colleagues in the “reply section”.

    I believe those of us practicing trans affirming health care follow the best EBM possible, always with the maxim of “do no harm”. We welcome more research and will continue to evolve our practices when better clinical data/evidence becomes available. Having said this, we can absolutely DO HARM by not acting,

    There is little place for arguments of “off label”prescribing or the influence of pharmaceutical companies in trans health. There is relative and absolute risks in every medical decision we make and we must weigh this out each and every time we prescribe any therapy.

    20+ years of working with gender diverse folks has taught me that the absolute benefits of our therapies far outweigh the relative risks in the vast majority of patients. I stand in solidarity with my hard-working and dedicated colleagues.

    Reply

  7. Thank you for the thoughtful responses.
    Non malfeasance is being confused with beneficence in multiple posts. Of course, a duty to provide care can be standard in cases where very large benefit outweighs even significant harm (eg opiate harm reduction). But do not confuse the two principles, or the order in which they should be considered. I respect any physician that first weighs the harm their actions can cause, even if they come to different conclusions than I do.
    My concerns are primarily around children and youth. My problem with the “affirm or die” assumption is that it is not evidence based, and it is manipulative. Suicide rates after surgical and medical transition do not decrease to any significant degree when examined long term. Suicide rates when normalized for other mental health issues are comparable. Most violence experienced by transgender individuals is by affirming partners in cases of domestic violence and not by “non affirming” others. The rates of detransition and regret among adolescents is much higher than the above quoted 1-2%. (I am sure you have met patients, as I once did, who tearfully regret having gone through medical transition. This young lady sincerely feels she ruined her life with testosterone and wants badly to have her own biological children. She still had no menses after being off T for over a year. She is full of regret and depression). The statement “would you rather have a dead son or a living daughter?” is so unbelievably manipulative and is not based in reality. It only frightens parents into medicalizing real adolescent distress, that often resolves with careful love, listening and support, along with psychological services when needed.

    WPATH has demonstrated they are an organization that cannot be trusted.
    The most recent WPATH standards specifically promote the affirmative care model, continuing to endorse widespread medical treatments (drugs and surgery) for trans-identified youth despite rising scientific skepticism that has led Sweden, Finland, France, and the United Kingdom to retreat from that approach.
    WPATH endorses early medicalization as fundamental while these other countries now promote psychosocial support as the first line of treatment, delaying drugs and surgery until the age of majority is reached in all but the most exceptional cases.
    In a correction issued soon after its release, nearly all lower age limits for suggested medical and surgical interventions were removed – an abdication of responsibility for basic child-safeguarding norms.
    A chapter on ethics that had appeared in earlier drafts was eliminated in the final release – a further abdication of ethical responsibility.
    “Eunuch” was included as a new gender identity (not necessarily a physical condition) without convincing evidence for its existence; a hyperlink within the Standards links to an external site that incorporates graphic and sexual fantasy stories portraying the castration of adolescent males.
    A definition of “detransition” fundamentally mischaracterizes it, invalidates the traumatic experience of many who feel harmed by gender-related medical interventions and subsequently revert to living as their biological sex, and offers no guidance for supporting individuals who are coping with the grief and pain of detransition.
    While presented as evidence-based, the Standards of Care fail to acknowledge that independent systematic reviews have deemed the evidence for gender-affirming treatments in youth to be of very low quality and subject to confounding and bias, rendering any conclusions uncertain.

    Why are physicians in North America not thinking critically about these guidelines?

    Reply

  8. Dr Keyes, please provide your sources. I am familiar with the WPATH standards of care. I am aware of the McMaster study and that the level of evidence is not randomized control trials. However, I have not seen any other guidelines or recommendations from transgender health care research that would lead me to discount WPATH the way you claim to.

    Reply

  10. Thank you for your interest.
    I am not cherry picking. Most of my sources are the very same ones used by WPATH to form their guidelines, and other studies used by gender affirming advocates and activists (Rafferty, Turban etc). Read the studies and focus on the methodology. You will find the strength of the studies to be lacking and full of bias, yet bold conclusions are drawn from them. In some cases they do not at all say what is claimed, and in some cases say the opposite.
    If you don’t have time to read all the studies for yourself, there are many individual critical thinkers who have dug deep on this topic. Also, a growing number of medical societies have examined existing data and now publicly reject the automatic “gender affirming” approach including societies in Sweden, France, Finland, England, and most recently Spain and the US state of Florida. I have posted some links below for those interested.
    This should be an active area of research and rigorous debate and not an exercise in ideological dogma that silences those with questions. I feel many physicians are afraid to ask difficult but important questions for fear of consequences for not going along with the crowd. If the medical community is self censoring, we have a big problem – and it is patients that will pay the price. The science on this topic is hardly settled and many other countries are beginning to question and reject the automatic gender affirming care model. We need more critical thinking here and less prescription pads. I have also posted a link to an article by a Canadian physician on this topic as it relates to asking questions about the assumptions in transgender care.

    https://nationalpost.com/opinion/shawn-whatley-doctors-have-gone-silent-on-gender-dysphoria-thats-not-good-for-patients

    Excellent Resource guide (You will have to scroll to the top for some reason)

    https://www.manhattan-institute.org/how-to-respond-to-medical-authorities-claiming-gender-affirming-care-is-safe?utm_source=twitter&utm_medium=social#notes

    Same thing in pdf form
    https://media4.manhattan-institute.org/sites/default/files/how-to-respond-to-medical-authorities_claiming_gender_affirming_care_safe.pdf

    https://pubmed.ncbi.nlm.nih.gov/31838960/

    New NHS guidelines
    https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/user_uploads/b1937-ii-specialist-service-for-children-and-young-people-with-gender-dysphoria-1.pdf

    https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/user_uploads/b1937-ii-interim-service-specification-for-specialist-gender-dysphoria-services-for-children-and-young-people-22.pdf

    https://acpeds.org/assets/for-GID-page-1-The-Myth-About-Suicide-and-Gender-Dysphoric-Children-handout.pdf

    https://www.thepublicdiscourse.com/2020/09/71296/

    https://www.segm.org/NICE_gender_medicine_systematic_review_finds_poor_quality_evidence

    This last one is not about gender medicine specifically, but it’s about over medicalization and I find gender dysphoria another perfect example.

    https://www.bmj.com/content/bmj/375/bmj.n2807.full.pdf

    Other interesting resources
    https://beyondwpath.org/
    https://genspect.org/
    https://genderexploratory.com/
    https://vimeo.com/ondemand/detransitiondiaries
    https://www.transgendertrend.com/detransition/

    I am not anti-trans, I am pro science. I reject the assumption that the science is settled on the causes of and treatments for gender dysphoria, especially in children and adolescents. All patients are human beings that deserve love, respect, and safety. They also deserve rigorous exploration on the causes of, and treatments for, their suffering. They deserve caution when answers are not clear.

    Reply

  11. Dr Keyes – for clarification in this continuing dialogue (which you are clearly very invested in)

    Do you support medical transition in an adult who has been appropriately diagnosed / “investigated” / explored / supported and consents to this treatment?

    Is your concern specifically focused on the potential medical intervention (hormones / surgery) in trans and gender diverse individuals under the legal age of consent, ie under18 years old?

    “All patients are human beings that deserve love, respect, and safety. They also deserve rigorous exploration on the causes of, and treatments for, their suffering. They deserve caution when answers are not clear”.
    I fully agree, I would add….
    and appropriate and timely intervention when the answers are clear (and in many cases they are). And we act in a clinically wise, systematic and scientific manner.The science is not ideal on either side of the arguments “for and against” (a binary statement in the oft non-binary realm of gender diverse health care).

    Let us also be clear regarding discussions of transgender / gender diverse health and potential medical intervention in adults versus adolescents.versus children. They are not the same.

    Reply

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