Critical Analysis

During the past twenty years, the prevailing clinical approach to child and adolescent gender dysphoria changed dramatically. Before then, most clinicians considered youth gender dysphoria a mental health problem best addressed through psychological management. Typically, childhood gender dysphoria resolved prior to adulthood. Recently, however, the gender-affirming approach has prioritized facilitating social and medical gender transition of dysphoric youth. The ascendancy of gender-affirming care did not arise because of empirical advances. Rather, gender-affirming care triumphed because of the unquestioned ideological beliefs that treating gender dysphoria as a psychological problem is unenlightened, unethical, and akin to conversion therapy for sexual orientation. Clinical referrals for youth gender dysphoria skyrocketed. Adolescent-onset dysphoria among natal females, previously unknown, became the most common subtype, and there are indications it is socially transmitted. Concerns about these developments led to systematic research on the claims that gender affirmation is necessary for improvement and to prevent suicide. Comprehensive reviews failed to support these claims, and gender transition has serious social and medical complications. Thus, gender-affirming care is increasingly seen as a dubious approach. Psychotherapy, including cognitive-behavioral therapy, holds promise as a tool to manage gender dysphoria, ideally until it desists. Gender transition should be considered only after alternatives have been explored. Three distinct pathways are discussed: childhood-onset, autogynephilic, and rapid-onset gender dysphoria. Their optimal treatment may differ.

For twenty years a single therapeutic approach has predominated in the treatment of gender dysphoric children and adolescents: gender-affirming care [1,2]. This approach is based on several propositions, listed in Table 1, and the most important are as follows: Children and adolescents who feel they may be transgender should not be questioned or doubted. The goal of mental health professionals, doctors, and parents should be to facilitate social and medical gender transition as soon as possible. Delaying, or worse, opposing gender transition is courting suicide. Recently, systematic research has examined these propositions and found them either lacking evidence or false (see Table 1).