acfm position statement on Gender dysphoria

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There are two biological sexes, male and female, genetically determined at conception based on the presence or absence of a Y chromosome. A person’s biologic sex is apparent antenatally by ultrasound or genetic testing and at birth on physical exam. Biologic sex, male or female is not “assigned” at birth; it is an inherent, biologic trait. There are rare causes of abnormal sexual development that may result in ambiguous genitalia at birth, occurring in 1 in 5,000 live births. This is distinct from the psychiatric and cultural phenomena of gender dysphoria.  A person’s biologic gender, male or female, is synonymous with biologic sex. This differs from gender norms, such as types of dress, use of make-up and jewelry, work and role choices. Gender norms are fluid and may vary between individuals and cultures and may change in a single individual over time. 

A person’s biologic gender directly affects the medical care he or she receives. Besides the obvious differences in hormonal status and organ function, males and females have different propensities for diseases, present with different symptom complexes for similar disease states, and react differently to medical therapies.  There are disease states that are gender specific such as prostate cancer in men and abnormal uterine bleeding in women. Good medical practice demands recognizing each patient’s biologic gender.

Gender dysphoria is a well-recognized psychiatric disorder defined by thoughts and feelings that a person’s phenotype does not match their perceived or desired gender.  This mismatch of biologic gender with psychological gender can lead to significant anxiety, depression, and disruption of optimal functioning. The natural course of adolescent gender dysphoria is most commonly resolution by adulthood. Conservative estimates place spontaneous desistance at 85% unless there are interventions to disrupt this natural history. Transgenderism, by contrast, is an ideology which states affirmation of the perceived gender, and medical or surgical “transition,” are the only reasonable treatments for this condition.  

Gender dysphoria is strongly associated with underlying mental health disorders, autism spectrum disorder, adverse childhood experiences, and troubled family dynamics. Not recognizing and attending to these important psychiatric and psychosocial issues and simply affirming a person’s perceived gender by embarking on “gender affirming” medical therapy and surgical interventions is bad medicine and can result in permanent harm to the person. Emerging research is demonstrating that medical and surgical therapies are harmful to patients suffering from gender dysphoria. Healthcare systems in other countries that once routinely performed “gender affirming” therapies now recognize this is harmful and are now emphasizing talking therapy. 

As members of the American College of Family Medicine, we reaffirm the necessity of faithful adherence to the Hippocratic Ethic, and declare the following:

1. A person is an integrated whole—body, mind and soul.  A person cannot be born in the wrong body.

2. Research has not demonstrated “gender affirming therapies” are safe or effective; they do not reduce the rate of suicide in patients suffering from gender dysphoria and they do not treat underlying mental health disorders and past trauma. Adhering to the principle, first do no harm, necessitates avoiding these potentially dangerous therapies. 

3. While we respect patient choice, there is a more honest and comprehensive way to deal with gender confusion than chemical sterilization and/or surgical mutilation of a person’s natural and healthy body.

4. Addressing underlying psychiatric disorders and family dynamic issues through talking therapy is the best way to treat individuals with gender dysphoria. 

Bibliography

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. P.455. 

Becerra-Culqui TA, Liu Y, Nash R, et al. Mental Health of Transgender and Gender Nonconforming Youth Compared with Their Peers. Pediatrics. 2018;141(5):e20173845.  

Bockting, W. (2014). Chapter 24: Transgender Identity Development. In Tolman, D., & Diamond, L., Co-Editors-in-Chief (2014) APA Handbook of Sexuality and Psychology (2 volumes). Washington D.C.: American Psychological Association, 1: 744.)

Cohen-Kettenis PY, et al. “The treatment of adolescent transsexuals: changing insights.” J Sex Med. 2008 Aug;5(8):1892-7. doi: 10.1111/j.1743-6109.2008.00870.x. Epub 2008 Jun 28. 

Hembree, W., Cohen-Kettenis, et al., (2017) Endocrine treatment of gender-dysphoric/gender-incongruent persons: An Endocrine Society clinical practice guildeline. J Clin Endocrinol Metab,102:1–35. 

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; DOI: 10.1192/bjp.bp.112.121954. 

Kaltiala-Heino R, Sumia M, Työläjärvi M, Lindberg N. 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. 

Kozlowska K, McClure G, Chudleigh C, et al. Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service. Human Systems. 2021;1(1):70-95. doi:10.1177/26344041211010777

Littman, L. “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports,” journals.plos.org, Aug. 16, 2018. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202330

Singh D, Bradley SJ and Zucker KJ (2021) A Follow-Up Study of Boys With Gender Identity Disorder. Front. Psychiatry 12:632784. doi: 10.3389/fpsyt.2021.632784 

Thyen U, Lanz K, Holterhus PM, Hiort O. Epidemiology and initial management of ambiguous genitalia at birth in Germany. Horm Res. 2006;66(4):195-203. doi: 10.1159/000094782. Epub 2006 Jul 27. PMID: 16877870.

Zucker, K. J. (2018). The myth of persistence: response to “A critical commentary on follow-up studies and ‘desistance’ theories about transgender and gender nonconforming children” by Temple Newhook et al. International Journal of Transgenderism, 19(2), 231–245. Published online May 29, 2018. http://doi.org/10.1080/15532739.2018.1468293