The Repercussions of “Gender Affirming Care”

Gender-affirming care – the approach of affirming a person’s self-defined gender identity and changing the appearance of the body to align with this identity – is essentially the only response to gender dysphoria. So, this treatment, these puberty blockers, cross-sex hormones, and surgical transitions, must have a solid track record of success, right?

Unfortunately, no. There are no studies that compare the health outcomes of children and adolescents who receive gender-affirming care with those whose gender dysphoria resolved after puberty without medical or surgical intervention. We’ll repeat that. There are no studies that compare the health outcomes of children and adolescents who receive gender-affirming care with those whose gender dysphoria resolved after puberty without medical or surgical intervention.

The reason where there are no studies comparing whether watchful waiting or gender-affirming care is the better response to gender dysphoria is primarily because researchers have considered it unethical to randomly selecting some patients for medical transition and some patients for a wait and see approach.¹ Such a random assignment is critically important to determine cause and effect and to generalize results to a broader population. Researchers have devised other ways to design studies to measure the impact of gender-affirming care on patients, but none of them are of high quality or high confidence.²

There are no studies that compare the health outcomes of children and adolescents who receive gender-affirming care with those whose gender dysphoria resolved after puberty without medical or surgical intervention.

In other words, there is no gold-standard evidence that receiving remarkably invasive and irreversible gender-affirming care leads to better outcomes than interventions that actively decrease cross-gender identification or watchfully wait for gender dysphoria to subside.³

In fact, there is lots of evidence that suggests that gender-affirming care is actually harmful.

Let’s start with puberty blockers. Puberty blockers are often compared to hitting the pause button on puberty to allow time for a child to explore their gender identity. But endocrinologist William Malone describes how, after a while, “the [endocrine] system ‘goes to sleep’ and at some point it may not wake up.”⁴ Abigail Shrier notes, “we wouldn’t consider a drug that stunted your growth in height and weight to be a psychologically neutral intervention – because it isn’t one… and yet the change in height brought on by growth hormones is arguably far less profound than that caused by puberty’s years-long flood of hormones, which transform our bodies into sexual adults.”⁵ Another concern is that one of the drugs commonly used to block puberty, Lupron, is the same drug was used to chemically castrate sex offenders. It is approved to treat symptoms of prostate cancer, endometriosis, and precocious puberty but is used “off-label” in a medical transition.

“We wouldn’t consider a drug that stunted your growth in height and weight to be a psychologically neutral intervention – because it isn’t…”

Abigail Shrier

Common side effects of puberty blockers are redness/burning/stinging/pain/bruising at the injection site, hot flashes, increased sweating, night sweats, tiredness, headache, upset stomach, nausea, diarrhea, constipation, stomach pain, breast swelling or tenderness, acne, joint/muscle aches or pain, trouble sleeping (insomnia), reduced sexual interest, vaginal discomfort/dryness/itching/discharge, vaginal bleeding, swelling of the ankles/feet, increased urination at night, dizziness, breakthrough bleeding in a female child during the first 2 months of leuprolide treatment, weakness, chills, clammy skin, skin redness, itching or scaling, testicle pain, impotence, depression, increased growth of facial hair, and memory problems.⁶

And then there is cross-sex hormones. The risks from cross-sex hormones are even more serious, and include venous thromboembolism (blood clots), hyperkalemia (high potassium), hypertriglyceridemia (high level of fats in blood), polycythemia (high red blood cell count), hyperprolactinemia (high prolactin hormone levels), decreased HCL cholesterol and increased LDL cholesterol, hypertension (high blood pressure), cardiovascular disease, cerebrovascular disease, meningioma (brain tumor), polyuria (excessive urine production), dehydration, cholelithiasis (gallstones), type 2 diabetes, low bone mass, osteoporosis, weight gain, acne, sleep apnea, androgenic alopecia (hair loss), erectile dysfunction, and infertility.⁷

And this is just the list of possible effects of hormonal treatment. Surgical interventions can bring a host of new adverse effects, depending on the type of surgery. For example, there are numerous reports of hair painfully growing within the neo-vaginal lining follow a vaginoplasty, urination complications following a phalloplasty, and even fatal sepsis following a mastectomy. Most forms of bottoms surgery are guaranteed to lead to infertility: how can someone father a child if their testicles have been removed or conceive a baby of their uterus is gone?

Those are the risks for what is supposed to be gender-affirming care. But are there any benefits?

While some studies document improved mental health outcomes after hormonal or surgical interventions,⁸ these studies only report on short-term outcomes. Much more valuable studies, known as longitudinal studies, track outcomes over long periods of time. The best longitudinal study, headed by Swedish researcher Cecilia Dhejne, found that health outcomes deteriorate just one year after undergoing a surgical transition. By the fifth year after surgery, patients had poorer outcomes in seven of eight measured categories: mental health, vitality, bodily pain, social function, emotional functioning, physical functioning, and general health.⁹

“Gender-affirming care” is a misnomer.
It’s not caring at all.

These are only some of the harms of medical gender transitioning. And this is why “gender-affirming care” is a misnomer. It’s not caring at all. It ignores our biological identity as a male or a female, and so perhaps it isn’t all that surprising that there are all of these negative effects of medical or surgical transitioning.

So, what counts as success when treating gender dysphoria? All sides in this debate should agree that, at a minimum, the loss of fertility and increased risk of a host of serious medical conditions, are not signs of success. Yet, these are the results of medical transitioning far too often.

Defining success as improved life satisfaction and decreased risk of suicidality and self-harm is a good step in the right direction, but even on this score, the long-term data on these measures of success do not favour medical transitioning.

1. See Michelle A Cretella, “Gender Dysphoria in Children and Suppression of Debate” 21, no. 2 (2016). ↩︎
2. See Society for Evidence-Based Gender Medicine, “International Perspectives on Evidence-Based Treatment for Gender-Dysphoric Youth Conference,” October 10-11, 2023, New York ↩︎
3. See Yarhouse, Understanding Gender Dysphoria, 102–3. for a description of these approaches ↩︎
4. Shrier, Irreversible Damage, 165. ↩︎
5. Shrier, 164. ↩︎
6. Lupron, (October 12, 2021), RxList, https://www.rxlist.com/lupron-drug.htm ↩︎
7. Talal Alzahrani et al., “Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population,” Circulation: Cardiovascular Quality and Outcomes 12, no. 4 (April 2019): e005597, https://doi.org/10.1161/CIRCOUTCOMES.119.005597; Michael S. Irwig, “Cardiovascular Health in Transgender People,” Reviews in Endocrine and Metabolic Disorders 19, no. 3 (September 1, 2018): 243–51, https://doi.org/10.1007/s11154-018-9454-3; Stephen M. Rosenthal, “Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist’s View,” Nature Reviews Endocrinology 17, no. 10 (October 2021): 581–91, https://doi.org/10.1038/s41574-021-00535-9; Silvano Bertelloni et al., “Final Height, Gonadal Function and Bone Mineral Density of Adolescent Males with Central Precocious Puberty after Therapy with Gonadotropin-Releasing Hormone Analogues,” European Journal of Pediatrics 159, no. 5 (April 1, 2000): 369–74, https://doi.org/10.1007/s004310051289; Ana Antun et al., “Longitudinal Changes in Hematologic Parameters Among Transgender People Receiving Hormone Therapy,” Journal of the Endocrine Society 4, no. 11 (November 1, 2020): bvaa119, https://doi.org/10.1210/jendso/bvaa119; Hayley Braun et al., “Moderate-to-Severe Acne and Mental Health Symptoms in Transmasculine Persons Who Have Received Testosterone,” JAMA Dermatology 157, no. 3 (March 1, 2021): 344–46, https://doi.org/10.1001/jamadermatol.2020.5353; Mauro E. Kerckhof et al., “Prevalence of Sexual Dysfunctions in Transgender Persons: Results from the ENIGI Follow-Up Study,” The Journal of Sexual Medicine 16, no. 12 (December 1, 2019): 2018–29, https://doi.org/10.1016/j.jsxm.2019.09.003; Spyridoula Maraka et al., “Sex Steroids and Cardiovascular Outcomes in Transgender Individuals: A Systematic Review and Meta-Analysis,” The Journal of Clinical Endocrinology & Metabolism 102, no. 11 (November 1, 2017): 3914–23, https://doi.org/10.1210/jc.2017-01643; M. Kyinn et al., “Weight Gain and Obesity Rates in Transgender and Gender-Diverse Adults before and during Hormone Therapy,” International Journal of Obesity 45, no. 12 (December 2021): 2562–69, https://doi.org/10.1038/s41366-021-00935-x; Sebastian E E Schagen et al., “Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones,” The Journal of Clinical Endocrinology & Metabolism 105, no. 12 (December 1, 2020): e4252–63, https://doi.org/10.1210/clinem/dgaa604; Daniel Klink et al., “Bone Mass in Young Adulthood Following Gonadotropin-Releasing Hormone Analog Treatment and Cross-Sex Hormone Treatment in Adolescents With Gender Dysphoria,” The Journal of Clinical Endocrinology & Metabolism 100, no. 2 (February 1, 2015): E270–75, https://doi.org/10.1210/jc.2014-2439; Magdalena Dobrolińska et al., “Bone Mineral Density in Transgender Individuals After Gonadectomy and Long-Term Gender-Affirming Hormonal Treatment,” The Journal of Sexual Medicine 16, no. 9 (September 1, 2019): 1469–77, https://doi.org/10.1016/j.jsxm.2019.06.006; Darios Getahun et al., “Cross-Sex Hormones and Acute Cardiovascular Events in Transgender Persons,” Annals of Internal Medicine 169, no. 4 (August 21, 2018): 205–13, https://doi.org/10.7326/M17-2785; Mariska C. Vlot et al., “Effect of Pubertal Suppression and Cross-Sex Hormone Therapy on Bone Turnover Markers and Bone Mineral Apparent Density (BMAD) in Transgender Adolescents,” Bone 95 (February 1, 2017): 11–19, https://doi.org/10.1016/j.bone.2016.11.008; Iris E. Stoffers, Martine C. de Vries, and Sabine E. Hannema, “Physical Changes, Laboratory Parameters, and Bone Mineral Density During Testosterone Treatment in Adolescents with Gender Dysphoria,” The Journal of Sexual Medicine 16, no. 9 (September 1, 2019): 1459–68, https://doi.org/10.1016/j.jsxm.2019.06.014; Michael Biggs, “Revisiting the Effect of GnRH Analogue Treatment on Bone Mineral Density in Young Adolescents with Gender Dysphoria,” Journal of Pediatric Endocrinology and Metabolism 34, no. 7 (July 1, 2021): 937–39, https://doi.org/10.1515/jpem-2021-0180; Rafael Delgado-Ruiz, Patricia Swanson, and Georgios Romanos, “Systematic Review of the Long-Term Effects of Transgender Hormone Therapy on Bone Markers and Bone Mineral Density and Their Potential Effects in Implant Therapy,” Journal of Clinical Medicine 8, no. 6 (June 2019): 784, https://doi.org/10.3390/jcm8060784; Tobin Joseph, Joanna Ting, and Gary Butler, “The Effect of GnRH Analogue Treatment on Bone Mineral Density in Young Adolescents with Gender Dysphoria: Findings from a Large National Cohort,” Journal of Pediatric Endocrinology and Metabolism 32, no. 10 (October 1, 2019): 1077–81, https://doi.org/10.1515/jpem-2019-0046; Kyinn et al., “Weight Gain and Obesity Rates in Transgender and Gender-Diverse Adults before and during Hormone Therapy”; Noreen Islam et al., “Is There a Link Between Hormone Use and Diabetes Incidence in Transgender People? Data From the STRONG Cohort,” The Journal of Clinical Endocrinology & Metabolism 107, no. 4 (April 1, 2022): e1549–57, https://doi.org/10.1210/clinem/dgab832. ↩︎
8. See Coleman et al., “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” for a sample of studies ↩︎
9. Cecilia Dhejne et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden,” PLOS ONE 6, no. 2 (February 22, 2011): e16885, https://doi.org/10.1371/journal.pone.0016885. ↩︎