“I know what’s wrong,” my patient winced, clutching his chest. “I Googled it, it’s costo…”
“Costochondritis?” I volunteered.
“Yes! I’m sure that’s what I have,” he replied.
I then did what I do with every patient who walks through the emergency room doors: I explained the need to investigate and began gathering a history — the foundation of all thorough patient evaluations. His story would help guide me to the correct diagnosis while I objectively ranked all possibilities. The facts did not fit costochondritis, an inflammation of the rib joints, but suggested something more dangerous. Tests ultimately revealed blood clots in each of his lungs and ominous heart strain. With appropriate
, he did well.
But had I affirmed this patient’s self-diagnosis, he might be dead.
American Psychiatric Association
American Academy of Pediatrics
, and other influential
abandon the objective approach the medical community has long abided by when evaluating patients with
. They promote “
,” defined by the APA as “a therapeutic stance that focuses on affirming a patient’s gender identity and does not try to ‘repair’ it.” The idea is that even adolescents can self-diagnose their dysphoria as stemming from a gender identity that is incongruent with their sex. Strikingly, gender-affirming therapy recommends that the patient’s own diagnosis be accepted. Delving deeper into the dysphoria or questioning it in any way implies an ailment that requires fixing, which is considered inherently discriminatory against transgender patients.
Gender-affirming therapy for adolescents often employs “puberty blockers,” synthetic hormones that inhibit the release of natural hormones that usher in sexual maturation. Approved by the Food and Drug Administration for rare instances of precocious puberty, these medicines are
off-label as a pause button for physically healthy children struggling with gender dysphoria, allowing time to consider
. In one
, all children started on puberty blockers proceeded to testosterone or estrogen — a prescription for life-long medicalization.
Puberty blockers and cross-sex hormones carry risks. Artificially pausing puberty impedes other vital functions, such as
. Cross-sex hormones tempt
, and, ultimately, infertility, as natal sex organs are often surgically removed to reduce the cancer threat.
To make matters worse, attempts to provide comprehensive assessments and discover why a young person feels like a gender different than his or her sex have been written off as harmful. A frequently referenced
warns of the perils of not affirming a patient’s new gender, reporting increased odds of lifetime suicide attempts and suggesting an objective evaluation actually worsens mental health. These conclusions have been
since the methods of data collection from online
invited skewed results and biases went ignored. Significantly, researchers failed to establish participants’ baseline mental health, so the results are difficult to interpret.
A different long-term study showed sex reassignment had
in preventing suicide.
We need additional research on this topic, and doctors must look at gender dysphoria comprehensively, as they do with every mental or physical affliction. Adolescents with gender dysphoria can have
coexisting mental health conditions
, such as attention deficit hyperactivity disorder and clinical depression, that require further investigation and treatment, while 61%-98% of children will
their gender dysphoria if given enough time. One study of
, people who had transitioned to a different gender but then transitioned back, found that 55% felt they had not received an appropriate evaluation before transitioning and that 38% realized their dysphoria was caused by something else.
Early adopters of such treatments in the United Kingdom, Sweden, and Finland have since reined in hormone treatments for children, cautioning that the benefits have not been shown to outweigh the risks. An
of the United Kingdom’s Tavistock gender identity clinic led to its closure in July, finding “gaps in the evidence base” that did not allow for recommendations for the use of hormone treatments for gender dysphoric children and adolescents. In February, Sweden’s National Board of Health and Welfare
the use of hormones in patients under 18 years of age due to insufficient evidence for safety and efficacy, prioritizing psychological care instead. The Finnish Health Authority determined in 2020 that
treatment for children with gender dysphoria should utilize psychotherapy, limiting hormone use.
Physicians must be the compass that points to ethical patient care. Individuals with true gender dysphoria need compassionate and appropriate treatment. But the millennia-old Hippocratic oath requires that we affirm the value of every human soul with thorough, unbiased evaluations that seek to mend ailments of the body and mind — and, most importantly, do no harm.
Dr. Aida Cerundolo is a practicing emergency medicine physician.