Gonadotrophin-releasing hormone agonists (GnRHa) chemically castrate recipients and suppress puberty in adolescents. Clinicians in New Zealand use GnRHa to treat gender dysphoria in adolescents.
Fully Informed documents the poor quality of research that supports this practice. We encounter several broader issues that come up when looking into the GnRHa research. This article summarises some of these issues:
- The connection with eating disorders and autism.
- The use of GnRHa as a pause button.
- Psychotherapy as an alternative treatment.
- Recent medical policy and research reversals.
Connection with eating disorders and autism
Eating disorders, autism, and abuse are common experiences in the female trans population. Adopting a male identity appears to follow experiences of abuse.
Eating disorders are seven times as common in trans-identified females (Goodman and Nash, 2019 [pdf]). 50% and 33% of trans-identified females surveyed by Counting Ourselves report being the victim of an attempted rape, or rape respectively.
Most people know that eating disorders have a connection to body image and media representation. A less well-known explanation is "objectification theory". The theory links eating disorders to sexual harassment. When a girl experiences sexual harassment, she objectifies her body linking her appearance to the risk of abuse. She feels powerless to stop the harassment and fears it will continue. She may starve herself to prevent pubertal development, and, in her mind, reduce the risk of harassment. The eating disorder is, in effect, DIY puberty suppression. Petersen and Hyde (2013) found that girls who experienced sexual harassment were more likely to develop an eating disorder.
The Counting Ourselves report does not specify when the rapes and attempted rapes occurred. The implications are very different if the abuse occurred before a declaration of a trans identity. Testosterone gives a female the appearance of a male. She will grow facial hair and gain muscle mass. It is implausible that testosterone-treated females are more vulnerable to male rape. The more likely explanations are that:
- abuse occurred before the girl announced her new identity, and
- some girls are using a male identity, GnRHa, and testosterone as a maladaptive strategy to avoid harassment.
A highlighted comment in Counting Ourselves makes this strategy explicit.
"..the hormones have meant I 'pass' and I won't risk being abused/harassed because of my gender." (Trans Man, Adult) p.75.
44-49% of children referred to Australian gender clinics have mild-to-severe autism. Much higher than the 3% autism rate in the general population. Autism expert Professor Atwood highlights one girl's very similar harassment avoidance strategy.
"A girl that I knew wanted to become a boy — where did this come from? She was bullied by girls who didn't bully boys, so her autistic logic was, if I become a boy they will stop bullying me," (Lane, 2020a)
Autistic people are less "tuned in" to social cues. Autistic adults do not internalise gender stereotypes to the same degree a neurotypicals (Kallitsounaki and Williams, 2020). Their lack of a "gender identity" may help explain the over-respresentation of autistic adolescents at gender clinics. School materials now teach that everyone has an innate gender identity. If an autistic girl cannot locate a "girl identity", she may believe her differences are due to her "really being a boy".
The statistics and statements from abused and bullied girls above are very troubling. The connection between abuse, autism, eating disorders and now a trans identification indicate that opposite sex imitation has become the "new anorexia". The difference is that naive doctors will celebrate the harmful strategy as the child becoming their "true self". The obvious feminist position is that efforts to address abuse should be directed at abusers, not by giving the victims of abuse body and mind altering medical treatments.
GnRHa treatment aims to give an adolescent time to explore a trans identity. Supposedly, the GnRha-treated adolescent can consider their options without the pressure of puberty. But, the vast majority of those on GnRHa go on to cross-sex hormones [cite]. It is unclear if the treatment works as intended. In Stein's (2012) view, GnRHa may be pushing the adolescent into a medical pathway. Adolescence is a period to explore social identities. But, opposite sex imitation experts assume that a trans identity is a special case. They do not engage with the broader social identity literature (Sadjadi, 2019).
We hypothesise that acceptance into a GnRHa treatment regime validates a "true trans" self-concept. Validation can improve a vulnerable person's mental well-being. But, stopping treatment will invalidate this self-concept. Most adults, let alone children, would find such a step extremely difficult.
There are now several case studies of gender dysphoria ameliorating without medical intervention ( Clarke and Spilliadis, 2019; D'Angelo, 2020 ; Withers, 2020) This raises several difficult issues for the clinician. Patients and their parents have rights to information on alternative treatment options. But, the Waikato guidelines insist the clinician can begin GnRHa treatment without delay. D'Angelo et al., (2020) discuss how conversion therapy laws could outlaw beneficial psychotherapy. The NZ government intends to ban conversion therapy. It is unclear if the ban will include psychotherapy for gender dysphoria.
Medical Policy reversals
Readers of Fully Informed know it is common for research on GnRHa to be low quality. Not surprisingly, several health bodies are undertaking reviews of medical interventions. In August, the Journal of American Psychiatry published a correction to a study of surgery and hormone treatments. The study was initially hailed as a definitive breakthrough. The Society for Evidence-based Gender Medicine details> the reasons behind the correction and its implications.
The NHS, and the Swedish Government are also undertaking reviews. The President of the National Association of Practising Psychiatrists has urged practitioners to be “extremely careful” before endorsing so-called “gender-affirming” treatment for minors.
The Finnish Government has issued new guidelines. The Finns restrict youth opposite sex imitation to a centralised research institute. A summary of the Finnish guidelines is available in English. Please support efforts to translate the full guidelines and accompanying literature review.
Updated 23-11-2020: An earlier version had the RANZCP had urged caution. This was incorrect. It was Phillip Morris the President of the National Association of Practicing Psychiatrists who made this statement.