By Greg Ganske

June 8, 2022

Comedian and liberal talk show host Bill Maher recently lamented that kids are coming out as transsexual because it’s “trendy” and because being gay “is not hip enough.” He then displayed a graph of the rapid increase of kids who want to switch gender, joking, “We will all be gay in 2054!”

This is an exaggeration, of course, but one that recognizes the tremendous increase in children and adolescents claiming to be transsexual.  Many think this increase is at least partly due to inappropriate sex education in schools of very young children called “grooming.”  There are many posts on social medial of transsexual teachers bragging about how they encourage their young students to examine their sexual orientation.

In the course of my plastic surgery training and practice I cared for transsexual patients in non-sex change ways.  Transsexuals should be treated with respect and not discriminated against, mocked, or bullied.  They have a hard road to travel.  In 1976, during my surgical internship I cared for a patient who had undergone female to male genital surgery. Unfortunately, he lacked the follow-up support of a team approach to his surgery. This type of surgery was rare then and only a few outlier surgeons in the country were performing it. This patient’s surgeon was operating in a small town in southeastern Colorado.

At that time, Johns Hopkins had shut down its own transgender plastic surgery program and Stanford was the only academic transgender plastic surgery program.  A friend training there told me that one Saturday, Grand Rounds was presented by the chief psychiatrist from the transgender clinic.  He described in great detail the evaluation, screening, and requirement for living as the other gender with cross dressing for at least a year before surgery was considered.  At that time, only about one in a hundred male applicants fit their strict criteria for “gender dysphoria” surgery.  The others were considered to be mainly effeminate homosexuals. As the psychiatrist explained, “You’re not doing an effeminate homosexual any favors if you cut off his penis as he may still derive sexual pleasure from it.”

 In recent years my medical office received many calls from people wanting trans surgery, “top” surgery (mastectomies) and/or “bottom” surgery (vaginal construction or penile construction).  Even though I had done many subcutaneous mastectomies for cancer and some vaginal reconstructions with gynecologists, I turned them down because I strongly feel that sex altering surgery should only be done in the context of a multi-disciplinary program with the strict selection criteria and psychiatric evaluation mentioned above. With surgery should come a lifelong commitment and obligation to these patients to treat future surgical and psychiatric needs.  Surgery is not a cure all. Some who undergo sex change surgery will remain conflicted, angry, unhappy, and lonely especially after the initial year when the newness effect wears off.  Some regret their decisions and have gone public with this.  We need better data on long term satisfaction from non-biased sources, not just the clinics that derive their income from the treatments.

Adults who are fully informed of possible complications have the right to make the decision to change their bodies to conform to their perceived gender. However, the surgeon also has the right to turn down a patient who may have unrealistic expectations.  These are difficult decisions.

I have significant concerns with the large number of adolescents and teenagers who aren’t yet of legal age, yet who are steered to puberty blockers and even surgery.  Many, if not most, doctors and the public think sex change surgery should not be done on minors even with parental approval.  I personally believe such surgery is unethical.

Using pubertal blocking drugs on minors is more controversial. Treating gender dysphoric (GD) children with puberty blocking drugs has been sold to the public as allowing the GD kids to delay puberty and then if they change their minds, they can just go off the drugs.  They say the drug’s effects are reversible and no harm done.

Mounting evidence shows that this description of puberty blockers is cavalier. A recent paper in the Journal of Sex and Marital Therapy exposes the poor empirical basis of those few studies defending puberty blockers.

A lay article in The New Atlantis, “Growing Pains: Problems with Puberty Suppression in Treating Gender Dysphoria” summarizes the concerns over whether vulnerable children are being pushed by politics and other cultural pressures into irrevocable decisions.

 In the last few years, these concerns have caused national gender clinics in France, the United Kingdom, Sweden and Finland to curtail their use. For example, from the article linked above:

“The Gender Identity Development Service in the United Kingdom, which treats only children under the age of 18, reports that it received 94 referrals of children in 2009/2010 and 1,986 referrals of children in 2016/2017 — a relative increase of 2,000%.^[11] The service also reports that it received six referrals for children under the age of 6 in 2009/2010, compared to thirty-two referrals for children under the age of 6 in 2016/2017 — a relative increase of 430%.^[1”

Is this science or a political fad driven by political actors and institutions?

One of the puberty blockers administered to girls who identify as males is called Lupron, which belongs to a class of drugs called gonadotropin hormone-releasing (GnRH) agonists which suppress estrogen production and delay secondary sex development of the breasts and genital area.  This is an off-label use of the drug which was originally approved by the FDA for treatment of prostate cancer.

GnRH agonists are powerful drugs, taking them is not like taking a couple of aspirin.

They are also used for precocious puberty (when children go into puberty much too early). The GnRH agonists are also used for women suffering pain from endometriosis. The drugs can cause significant side effects such as severe joint pain, osteoporosis, compromised immune systems, severe depression and even suicidal thoughts. The Atlanta Journal Constitution reported on a younger patient who was injected at age 10 and ended up in a wheelchair in fifth grade.

While I disagree with some other positions of the American College of Pediatricians (ACPeds), it is right when it cautions out that puberty blockers affect a child’s body in many ways:  “. . .in addition to preventing the development of secondary sex characteristics, GnRH agonists arrest bone growth, decrease bone concentration, prevent the sex-steroid dependent organization and maturation of the adolescent brain, and inhibit fertility by preventing the development of gonadal tissue and mature gametes for the development of the treatment.”

Mounting evidence shows that this is not totally reversible. Particularly worrisome is a study that shows that Lupron can have long term effects on the pituitary in which 62% of women taking Lupron for endometriosis don’t regain baseline estrogen by one year after they stop Lupron.  Endocrinologist Michael Laidlaw warns bone density never recovers.

Traditional treatment for GD is watchful waiting with psychotherapy. 80-95% of adolescent patients outgrow their dysphoria.  However, once the child starts taking puberty blockers a major study found that 100 per cent went on to request cross-sex hormones. The ACPeds cautions, “There is an obvious self-fulling nature to encouraging a young child with GD to socially impersonate the opposite sex and then institute pubertal suppression. . .The suppression of puberty that prevents further endogenous masculinization or feminization of the entire body and brain causes the child to remain either a gender non-conforming pre-pubertal boy disguised as a pre-pubertal girl or the reverse. Since their peers develop normally into young men or young women, these children are left psychosocially isolated. . .”

The Porto Biomedical Journal, Sept-Oct, 2017 in an article, “Buying Time or Arresting Development? The Dilemma of Administering Hormone Blockers in Trans Children and Adolescents” summarizes the main counterarguments to pubertal blockers: 1) the individual is not sufficiently mature to make such a decision, 2) it is not possible to make a certain diagnosis of GD in adolescence, 3) suppression may inhibit the spontaneous formation of a consistent gender identity, 4) considering the high number of children who grow out of GD, early somatic treatment is premature, 5) there is insufficient research of pubertal blockers on the long term development of bone mass, growth and brain development, 6) current research on social, emotional and school functioning with pubertal blockers is skimpy, 7) blockers may interfere with adolescents having appropriate socio-sexual experiences, 8) early interventions may actually limit the exploration of sexual orientation (Lupron in prostate cancer patients decreases sexual desire), and 9) the blockage of phallic growth can result in less genital tissue available for optimal vaginoplasty.

Even some transsexual activists are raising alarms.  Buck Angel is a 59 year old with gender dysphoria who was born a female and is now a transsexual man. “I see a vast, huge desire to fast-track, for lack of a better term, these children into a space of ‘trans kids’ and put them on something that we’re calling puberty blockers.  This could be a very dangerous space and is a dangerous space we are pushing because we are giving drugs to children to stop puberty! I personally believe blocking puberty could be disastrous.”

Finally, we should beware of conflicts of interest.  There is a lot of money involved in GD treatment.  Those who advocate puberty blocking drugs in adolescents are setting those kids on a course to further treatment and surgery and maybe a life of regret.  Be skeptical of proponents’ assurances of the safety and reversibility of GnRH agonist puberty blockers.  Demand better data by impartial researchers .

Doctors should remember what all physicians are taught:

 “First, do no harm.”

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Greg Ganske, MD, is a retired plastic surgeon and served in the U.S. Congress representing Iowa from 1995-2002.