Navigating the Controversy: Understanding and Managing Gender Dysphoria in Young People
Dr Philip Morris AM
Introduction: Gender dysphoria is a complex and controversial area within medical practice, particularly in Western countries. The intersection of biological sex and gender identity presents challenges that demand careful consideration and ethical reflection. Prof Philip Morris AM, a Distinguished Fellow of the Pacific Rim College of Psychiatrists and President of the Australian National Association of Practising Psychiatrists (NAPP), sheds light on the multifaceted nature of gender dysphoria, advocating for a comprehensive and cautious approach in its management.
Defining Gender Dysphoria: The dichotomy between biological sex and gender identity is a central theme in discussions surrounding gender dysphoria. Recognized by the International Classification of Diseases (ICD-11) as gender incongruence and by the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as gender dysphoria, this condition manifests as a misalignment between one’s assigned sex at birth and their deeply-felt gender identity. This incongruence is acknowledged as a spectrum, ranging from what might be considered normal variation to abnormalities that some may label as ‘unnatural.’
Navigating the Spectrum: Prof Morris draws parallels between the spectrum of gender dysphoria and the historical model used for understanding homosexuality. Unlike same sex attraction, gender dysphoria involves medical interventions for transitioning to the desired gender, and doctors are reminded of their ethical obligations, rooted in the Hippocratic Oath—to “first do no harm before doing good.”
Critical Considerations in Gender Dysphoria Treatment: The management of gender dysphoria prompts critical questions about appropriateness, causality, effectiveness, safety, and informed consent. Prof Morris emphasizes the lack of long-term outcome studies and the questions about the reversible and irreversible effects of medical interventions such as puberty blockers, gender-affirming hormones, and sexual reassignment surgery. The emotional and cognitive capacity of young individuals to make lifelong decisions is also a paramount concern.
The NAPP Guide’s Approach: In contrast to a strictly affirmation approach to medical transition, the NAPP Guide advocates for a compassionate, caring, and cautious approach. A comprehensive bio-psycho-social assessment is deemed essential before any medical intervention. Prof Morris stresses the importance of recognizing gender dysphoria as both a symptom and a syndrome, urging a focus on psycho-social interventions—such as psychotherapy, psychoeducation, individual therapy, school-home liaison, and family therapy—as first-line treatments.
The Role of Psychotherapy: The NAPP Guide places a strong emphasis on psychotherapy as a respectful, supportive, and exploratory process for children and adolescents experiencing gender dysphoria. Prof Morris notes that individuals who undergo medical transition sometimes express regret and a desire to de-transition, highlighting the need for careful consideration and long-term support.
Informed Consent and Cautious Guidance: Parents and children are urged to be fully informed about the potential risks associated with gender transition, and their consent is considered pivotal. The cautious approach advocated by NAPP aligns with general clinical guidance from national treatment advisory bodies in various countries (UK, Sweden, Norway, Denmark. Finland, and France)
Conclusion: Gender dysphoria demands a nuanced and empathetic approach. Prof Morris and the NAPP Guide provide valuable insights into the complexities of this condition, emphasizing the importance of comprehensive assessment, psycho-social interventions, and careful consideration of potential long-term consequences. In a landscape where controversy persists, a balanced and thoughtful approach remains paramount in supporting young individuals navigating their gender identity.
Dr Philip Morris AM
From the UK Department of Health and Social Care 11 December 2024
Ban on puberty blockers to be made indefinite on experts’ advice
Existing emergency measures banning the sale and supply of puberty-suppressing hormones will be made indefinite, following official advice from medical experts.
- Sale and supply of puberty blockers via private prescriptions for the treatment of gender incongruence and/or gender dysphoria to be banned indefinitely in UK for under 18s
- It follows a targeted consultation and advice on patient safety from the independent Commission on Human Medicines and Cass Review
- Government and NHS continue to improve children’s gender services to provide all-round holistic support
- Legislation will be updated today to make the order indefinite and will be reviewed in 2027
Existing emergency measures banning the sale and supply of puberty-suppressing hormones will be made indefinite, following official advice from medical experts.
The Commission on Human Medicines (CHM) has provided independent expert advice that there is currently an unacceptable safety risk in the continued prescription of puberty blockers to children. It recommends indefinite restrictions while work is done to ensure the safety of children and young people.
The NHS stopped the routine prescription of puberty blocker treatments to under 18s in March 2024, following the Cass Review into gender identity services.
Puberty blockers for the treatment of gender incongruence and/or gender dysphoria in under 18s were banned temporarily in May 2024 after the Cass Review found there was insufficient evidence to show they were safe. Legislation will be updated today to make the order indefinite and will be reviewed in 2027.
Health and Social Care Secretary Wes Streeting said:
Children’s healthcare must always be evidence-led. The independent expert Commission on Human Medicines found that the current prescribing and care pathway for gender dysphoria and incongruence presents an unacceptable safety risk for children and young people.
Dr Cass’ review also raised safety concerns around the lack of evidence for these medical treatments . We need to act with caution and care when it comes to this vulnerable group of young people, and follow the expert advice.
We are working with NHS England to open new gender identity services, so people can access holistic health and wellbeing support they need. We are setting up a clinical trial into the use of puberty blockers next year, to establish a clear evidence base for the use of this medicine.
Professor Steve Cunningham, Vice-Chair of the Commission on Human Medicines, said:
The Commission on Human Medicines was requested by the Secretary of State for Health and the Northern Ireland Minister for Health to provide advice on the safety of GnRH agonists when used to suppress puberty. CHM made 8 recommendations.
CHM has advised that a statutory indefinite ban is placed on the use of GnRH agonists for puberty suppression until our 3 recommended structures are in place to support safe UK prescribing, with a first review date of 2027.
The indefinite ban is made in the context of a significant waiting list for gender specialist services in the UK. In making this decision, CHM considered the safety, actual and potential, of using GnRH agonists to suppress puberty, and also risks to children and young people associated with accessing GnRH agonists via alternative routes.
Dr Hilary Cass, author of the independent review of gender identity services for children and young people, said:
Puberty blockers are powerful drugs with unproven benefits and significant risks, and that is why I recommended that they should only be prescribed following a multi-disciplinary assessment and within a research protocol.
I support the government’s decision to continue restrictions on the dispensing of puberty blockers for gender dysphoria outside the NHS where these essential safeguards are not being provided.
James Palmer, NHS Medical Director for Specialised Services, said:
Evidence reviews by NICE and NHS England, supported by Dr Cass, clearly showed there is not enough evidence to support the safety or clinical effectiveness of puberty suppressing hormones for the treatment of gender dysphoria or incongruence, which is why the NHS decided that they would no longer be routinely offered to children and young people.
We welcome the government’s decision to further ban access through private prescribers, which closes a loophole that posed a risk to the safety of children and young people, but this will be a difficult time for young people and their families who are affected, so we are extending an offer of targeted support to anyone affected by the banning order from their local mental health services.