A mother brings in her 10-year-old daughter because she identifies as male and wishes to promptly begin transitioning. Your advice is not solicited, just your authorization for the consult to get the process moving quickly. The mother seems defensive and informs you she knows her child’s rights, and then she preemptively warns you she doesn’t want to hear one word of your “religious ideas.” What can you tell her at this point that is medically, ethically and spiritually sound?

As for how to proceed with the parent and patient, less is more. A few facts delivered with professionalism, compassion and gentle courage is a good approach. Having them in a handout would be particularly helpful. Here are some main points.

1) 80 to 95 percent of minors with gender dysphoria/transgender identification will desist by adulthood. Professional literature consistently reports that gender dysphoria in children is far more likely to resolve than persist.1 2 3 4 5

2) Underlying issues need addressing first, and there can be many. Various psychological problems, parental and family dynamics, environmental/relational difficulties, and social contagion can contribute, even in the best of homes.6 7 8 9 10 11 12 Addressing these possible contributing issues takes focused effort by the patient and parents both, and it is well advised to neither avoid nor delay this.

• The APA Handbook on Sexuality and Psychology cautions against a rush affirm and transition that “runs the risk of neglecting individual problems the child might be experiencing and may involve an early gender role transition that might be challenging to reverse if cross-gender feelings do not persist” (Bockting, W. Chapter 24: Transgender Identity Development, p. 750).

3) The short- and long-term risks and permanent consequences of a minor undergoing transition are sobering. 

• Hormone blocking of puberty followed by administration of cross-sex hormones can cause permanent sterility, and the removal of internal reproductive organs through reassignment surgery always does. 
• Hormone blocking of puberty can leave too little genital tissue for later reassignment surgery by minimizing genital growth.
• The World Professional Association for Transgender Health Standards of Care lists these among cross-hormone therapy risks:
  • For women: polycythemia, weight gain, balding, sleep apnea, possible cardiovascular disease, diabetes type 2, bone density loss and increased risk of cancers (breast, cervical, ovarian and uterine).
  • For men: gallstones, weight gain, blood clots (venous thromboembolisms) and sexual dysfunction; also possible cardiovascular disease, diabetes type 2 and breast cancer.
• WPATH states genital and non-genital (face, hair, voice, chest, buttocks, etc.) sexual reassignment surgeries involve many short- and long-term risks. 
• Patients, either minor or adult, who undergo gender transitioning will be patients for the rest of their lives. Lifelong need for sex hormones and management of their complications, along with further surgeries and management of surgical consequences, complications and shortcomings, must be taken into consideration.15 16

4) The long-term benefits and safety to a child undergoing hormonal therapy, let alone surgical transitioning, have not been documented.

• The NIH in 2016 began the largest-ever study of transgender youth, and it is the first to track medical effects of delaying puberty and only the second to follow its psychological impacts.17
• WPATH Standards of Care confirms, “To date, no controlled clinical trials of any feminizing/masculinizing hormone regimen have been conducted to evaluate safety or efficacy in producing physical transition.”18
• The UC San Francisco Center of Excellence for Transgender Health states, “the impact of GnRH analogues [puberty blockers] administered to transgender youth in early puberty and <12 years of age has not been published.”19
• A 2011 Swedish study of adults found a post-gender-reassignment suicide rate 19 times that of the general population despite Sweden being overwhelmingly LGBT affirming.20
• A 2001 study also showed a very high rate of depression and suicidality in post-transition people.21

5) Regret is neither rare nor limited to conservatives and/or people of faith.22

• Two left-leaning, pro-LGB(adult)T groups (YouthTransCriticalProfessionals.org and 4thWaveNow.com) are opposed to hormonal therapy and surgery for children and adolescents due to high rates of regret and many de-transitioning later. Their strongest statements are from post-transition members.23
• SexChangeRegret.com is a site committed to the topic.

6) A child or teen has a developing brain, so they aren’t “there” yet for adult decisions.24 25 26 Minors are not allowed to vote, serve in the military, purchase alcohol, sign contracts or provide informed consent for a number of things until adulthood because of this reality. At a minimum, gender reassignment is a very adult decision, and no one should make it before adulthood. No one.

In summary, as healthcare professionals, our conclusion is to inform the parent(s) and child that this decision should and must wait until adulthood, lest profound permanent and avoidable harm be the result.

1 APA Diagnostic and Statistical Manual, 5th edition, “Gender Dysphoria,” p. 455.
2 APA Handbook on Sexuality and Psychology (American Psychological Association, 2014), Bockting, W. Chapter 24: Transgender Identity Development, p. 744. 
3 Cohen-Kettenis PY, et al. “The treatment of adolescent transsexuals: changing insights.” J Sex Med. 2008 Aug;5(8):1892-7.
4 “Do Trans- kids stay trans- when they grow up?” Sexologytoday.org, 11 Jan. 2016.
5 Kaltiala-Heino et al. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health(2015) 9:9.
6 APA Handbook on Sexuality and Psychology (American Psychological Association, 2014), Bockting, W. Chapter 24: Transgender Identity Development, p. 750.
7 Kann L, et. al. “Sexual Identity, Sex of Sexual Contacts, and Health-Risk Behaviors Among Students in Grades 9–12 — Youth Risk Behavior Surveillance, Selected Sites, United States, 2001—2009.” MMWR/June 10, 2011/60; 1-33.
8 Mazaheri Meybodi A, et al. “Psychiatric Axis I Comorbidities among Patients with Gender Dysphoria.” Psychiatry J, 2014, Article ID :971814.
9 Heylens G, et al. “Psychiatric characteristics in transsexual individuals: multicentre study in four European countries,” The British Journal of Psychiatry Feb 2014, 204 (2) 151-156.
10 Zucker KJ, Bradley SJ, Ben-Dat DN, et al. Psychopathology in the parents of boys with gender identity disorder. J Am Acad Child Adolesc Psychiatry 2003;42:2-4.
11 Zucker KJ, Bradley SJ. Gender Identity and Psychosexual Disorders. FOCUS 2005;3(4):598-617.
12 Kaltiala-Heino et al. Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development. Child and Adolescent Psychiatry and Mental Health(2015) 9:9.
13 WPATH Standards of Care, pp. 37-40, 50, 97-104, available at http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351.
14 WPATH Standards of Care, pp. 63-67, available at http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351.
15 Moore E, Wisniewski A, Dobs A. Endocrine treatment of transsexual people: a review of treatment regimens, outcomes, and adverse effects. J Clin Endocrinol Metab 2003;88:3467-3473.
16 Feldman J, Brown GR, Deutsch MB, et al. Priorities for transgender medical and healthcare research. Curr Opin Endocrinol Diabetes Obes 2016;23:180-187.
17 “Largest ever study of transgender teenagers set to kick off,” nature.com, 29 March 2016.
18 WPATH Standards of Care, pp. 47, available at http://www.wpath.org/site_page.cfm?pk_association_webpage_menu=1351.
19  “Health considerations for gender non-conforming children and transgender adolescents,” transhealth.ucsf.edu, site visited April 29, 2017.
20 Dhejne C, et al, “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,” journals.plos.org, Feb. 22, 2011.
21 Kristen Clements-Nolle et al ., “HIV Prevalence, Risk Behaviors, Health Care Use, and Mental Health Status of Transgender Persons: Implications for Public Health Intervention,” American Journal of Public Health 91, no. 6 (2001): 915 – 921.
22 Stella Morabito, “Trouble In Transtopia: Murmurs Of Sex Change Regret,”TheFederalist.com, Nov. 11, 2014. 
23 “Interview with a Detransitioned MtF,” youthtranscriticalprofessionals.org, Dec. 14, 2016.
24 National Institute of Mental Health (2001). Teenage Brain: A work in progress. http://www2.isu.edu/irh/projects/better_todays/B2T2VirtualPacket/BrainFunction/NIMH-Teenage%20Brain%20-%20A%20Work%20in%20Progress.pdf. 
25 Pustilnik AC, and Henry LM. Adolescent Medical Decision Making and the Law of the Horse. Journal of Health Care Law and Policy 2012; 15:1-14. (U of Maryland Legal Studies Research Paper 2013-14).
26 Stringer, H. (Oct. 2017) Justice for teens, APA Monitor on Psychology, pp. 44-49. http://www.apamonitor-digital.org/apamonitor/201710/MobilePagedArticle.action?articleId=1169604&app=false#articleId1169604