The gender identity phantom

The New York Times article "Helping Pediatricians Care for Transgender Children" pitches the American Academy of Pediatrics policy paper on comprehensive care for transgender adolescents [1,2]. This care includes the most radical and risky of hormone manipulations and surgeries. There is a concept defined called "gender identity" which has no physical presence and apparently can only be made known to the person in which it resides.

Comprehensive gender affirmative therapy is a high risk, experimental therapy based on low quality evidence and represents a treatment for a condition which cannot be diagnosed by any doctor.

Consider, if you were told your child had cancer would you expect to see that a tissue sample had been collected and analyzed to prove the diagnosis? If you were told that your child has diabetes would you expect to see blood sugar results that confirm the diagnosis?

In the first example, toxic chemotherapeutics and radiation may be administered and risky surgeries may be performed to treat the cancer. In the second example, a child‘s blood sugar levels must be monitored very frequently and insulin carefully administered to maintain the delicate balance of blood glucose. Too much insulin may cause severe low glucose levels leading to hospitalization and even death. Too little insulin may lead to placement in an intensive care unit to treat ketoacidosis.

The misdiagnosis of either cancer or diabetes will lead to considerable harm to the child because of unnecessary treatments.

Now change the scenario. Your pediatrician tells you that your 11-year-old daughter is "gender diverse" [3]. Your child has a "gender identity" that is a boy. If treatment is not begun right away there is a good chance that "he" will commit suicide and you will never hold "him" in your arms again.

"I see," you reply gravely, "and what does the treatment entail?"

"Well, puberty must be blocked, it is important that 'he' never has a first period. Testosterone must be administered to help with beard growth, changing of the voice and muscle formation. Later, surgery can be done to remove unneeded breast tissue. Eventually, of course, when 'he' sees fit, he can have 'his' ovaries and uterus removed. Through complicated surgeries the flesh of 'his' forearm, including skin and muscle, can be stripped to make a penis".

"Gosh, that all seems rather drastic. This is the first time I’m hearing this about my daughter. This gender diverse or gender identity condition, can you show me the lab work that verifies this? I am very concerned about the side effects of these hormones and complications of surgery."

"Oh no," the pediatrician replies, "there is no blood test for this, it’s a 'brain thing'," he says with a ring of condescension.

"I see. Well, what do we need, a CT or MRI of the brain to find out about the gender identity?"

"Well, no, that’s not possible. Genetics play a role too."

"But it’s a brain thing, so are there blood tests or biopsies that we could do to confirm this? Can I do genetic testing to confirm? I mean what if we start treatment and this was a mistake. This all sounds very radical and dangerous? How can I be sure of this gender identity?"

The AAP has cleverly reframed the problem of treating the child with gender dysphoria to "affirming" the child’s gender identity [4]. Whereas gender dysphoria has certain diagnostic criteria (as did its related predecessor gender identity disorder) this new self-identified condition does not [5,6,7]. There is apparently something called a "gender identity" which is "a person's deep internal sense of being female, male, a combination of both, somewhere in between or neither" [8].

This is a fantasy or superstitious belief.

I say superstitious, because we are dealing with an entity that has no physical basis in reality. One can see the contradiction in Dr Stever's quote in the New York Times: "gender identity is a brain thing... It is independent of your body parts."

Obviously the brain is a body part, so is it a brain thing or is it independent of the body? This of course cannot be answered. There have been desperate attempts to try to show that magnetic resonance imaging or genetics can somehow show the creation of a "boy brain" inside a "girl's body". However, none of the studies show such a thing.

This is akin to the ghost-hunting reality shows where amateur spirit hunters probe "haunted" houses for material evidence of non-material entities. The photographs never really seem to provide the proof they are desperately hoping to find. Just a blurred image of vapors. So too is the reality of the gender identity. It’s a phantom which appears, wiggles, writhes fluidly like wisps of smoke and then vanishes just as soon as one is close to capturing it.

This condition comes down to a mental state of being. In other words, this feeling that a girl with a girl's body is inside a boy is simply that, a feeling. No matter how deeply or strongly this is felt, the material reality is that this person is a girl.

In the past psychologists and psychiatrists such as Ken Zucker and Susan Bradley had been able to work with children and adolescents whose internal feeling of being a boy, for example, did not match their physical sex. There was success in using psychological methods to resolve this conflict [9]. Currently, licensed therapists such as Sasha Ayad carry on similar work successfully [10].

This type of care has been completely excluded as a possibility in the AAP’s narrow treatment design, as has watchful waiting. This in spite of the fact that "almost all clinics and professional organizations in the world use... the watchful waiting approach," Dr James Cantor relates in his excellent dissection of the AAP’s statement [11].

In fact, he goes on to say that "Not only did AAP fail to provide extraordinary evidence, it failed to provide the evidence at all" for requiring the affirmative therapy approach to the exclusion of all others.

So instead of psychological counseling or plain watchful waiting, parents are now geared (and indeed coerced by threats of suicide and legal action) into a single dangerous treatment paradigm consisting of puberty blockers, high dose cross sex hormones, and surgical destruction of the genitalia and breasts [12,13].

There is a false claim made in the Endocrine Society’s clinical guidelines for care of gender dysphoric/gender incongruent persons which are referenced in the AAP paper [14]. The false claim is that "trans puberty" can be initiated and that one can stop the unwanted sex’s puberty, and magically start and continue the puberty of the opposite sex.

There is no such thing as "trans puberty". What happens is that the abnormal, pathologic state of hypogonadotropic hypogonadism is induced by puberty blocking medications. Then dangerous high dose hormones of the opposite sex are given to cause hirsutism (hair growth of the face, chest, back and abdomen) in females and gynecomastia (abnormal breast tissue growth) in males [15]. The medications also atrophy and chemically degrade the sex organs [16].

Puberty blockers are not a "pause button" as Dr Stever says in the New York Times article. Rather they are an "eject" button for rational thinking. Because their own studies have shown that once a child or adolescent is put on puberty blockers, these kids never decide that their mind and body are in alignment. In other words, it has been shown that 100 percent go on to cross sex hormones [17].

I would go so far to say that these medications are psychologically addictive. Which is not to say that these agents are psychoactive substances per se (though brain neuroreceptors for these agents have been found), but rather that the lack of pubertal development combined with adopting stereotypical clothes and mannerisms of the opposite sex reinforce the child’s gender incongruence [36].

This is borne out by the fact that these adolescents do not follow the established pattern of desistance whereby some 80 percent will desist or realize an alignment of their sex organs and feeling about gender [18]. In other words rather than only 20 percent remaining with gender dysphoria, now 100 percent believe that their mind and body do not match after taking puberty blockers and will go on to dangerous cross sex hormones and irreversible surgical procedures.

The New York Times article and AAP paper completely leave out the recent analysis in which it is shown a five times increased risk of thromboembolism or deadly blood clots from transgender males taking estrogen [19]. Or that both sexes have an elevated risk of myocardial infarction and death due to cardiovascular disease from taking cross sex hormones. Puberty blockers cause diminished bone mineralization and potential for future osteoporosis [20]. Children begun on puberty blockers and continuing to cross sex hormones are infertile.

Fertility preservation rates are less than 5 percent in these children even if they are given the opportunity to do so [21,22]. Removal of the ovaries and testicles cause permanent sterility. These are decisions that their young minds are not prepared to make.

Another important human function that will be altered, diminished and impaired when blocking puberty at a young age is sexual function, because the sex organs will never develop and therefore will remain stunted [23]. All of this treatment paradigm is predicated on “low” to “very low” quality evidence as is shown in the Endocrine Society's guideline paper [24].

The dangers of what they are doing to children with affirmative therapy is, of course, completely left out of the New York Times article. They would like to hide the fact that they are iatrogenically inducing a medical condition called hypogonadotropic hypogonadism. They are then causing damaging effects to the body by high-dose cross sex hormones. They are preparing for the future sterilization of children before they have reached the age of consent or can even understand what such a decision will mean. They are in many cases permanently altering and even eliminating the children's natural function of their sex organs.

Additionally, adolescent girls as young as 13 have had healthy breast tissue utterly destroyed by needless mastectomies [25]. The lead researcher of this unethical endeavor, Johanna Olson-Kennedy, flippantly stated: "If you want breasts at a later point in life you can go and get them."[26,27].

No, functioning breasts cannot be gotten later. What legitimate medical society endorses such nonsense?

And so we have this most extreme treatment method called affirmative therapy. This is a prescription based exactly on what diagnosis and supported by which test or tests? What is the confirmation of the condition? What is the condition exactly? The AAP paper states very plainly that "these terms [such as gender identity and transgender] are not diagnoses; rather they are personal and often dynamic ways of describing one's own gender experience" [28]. And so it's no longer gender dysphoria being diagnosed. (Though the condition is acknowledged as happening and blamed more on the parent, home and school environments).

No, it would appear that the most radical of treatments to the human body with exceedingly powerful hormones and permanently disfiguring and risky surgeries are done because of the child/adolescent’s self-identification -- effectively a self-diagnosis.

Shall we start removing gallbladders and doing brain surgeries on children based on self-diagnosis? Shall we start giving high-dose testosterone to teen male athletes self-identifying as having Herculean strength "inside"? Perhaps any and all sorts of medication should be prescribed to children and adolescents on demand -- opioids, amphetamines, hallucinogens -- because they have self-identified as "needing" these things lest they risk suicide?

And who exactly is excluded from this diagnostic paradigm? In other words, who may be presenting with a mismatch between their perceived gender and their bodily sex for some other reasons?

In the AAP’s statement, mental health conditions such as anxiety and depression are chalked up to external conditions related to factors such as societal prejudice and hostile home and school environments. It asserts this in spite of the fact that in a study of the Finnish gender identity service "75% of adolescents [assessed] had been or were currently undergoing child and adolescent psychiatric treatment for reasons other than gender dysphoria" [34]. In fact, "68% had their first contact with psychiatric services due to other reasons than gender identity issues". The same study also showed that 26% percent had an autistic spectrum disorder and that a disproportionate amount of females (87%) were presenting to the gender clinics compared to the past.

This comports with Lisa Littman's recent parental survey which showed that a similarly high percentage (62.5%) of affected adolescents had "a psychiatric disorder or neurodevelopmental disability preceding the onset of gender dysphoria". She also reports a disproportionately high percentage of affected females (83%) compared to males.

Recently the same lead author of the cited Finnish study, R Kaltiala-Heino, admonished: "In such situations [of adolescent gender incongruence] appropriate treatment for psychiatric comorbidity may be warranted before conclusions regarding gender identity can be drawn" [35].

How is it that the AAP policy is remiss in accounting for these other possibilities -- pre-existing psychiatric disorders, autistic spectrum disorders, maladaptive coping mechanisms and potential for peer pressure and group contagion -- underlying the desire to undergo radical hormonal and surgical changes to the body? Why is there no admonition to at least rule out other causes of a gender identity mismatch?

What is being advocated is medicalization of children and adolescents of the worst possible kind. Big pharma, big hospital systems, surgical centers and doctors seek to gain huge profits [29]. Lupron monthly is US$775 alone. That’s a $27,000 “pause button” at 5 years [30]. Creating a pseudo-vagina is $25-30,000. Creating a pseudo-penis from arm skin flaps and forearm muscle and removing the ovaries and uterus can easily cost $30-40,000 and take multiple surgeries to complete. Not to mention complications and the need for repeat surgeries as Jazz Jennings has related [31]. Multiply this together with the huge rise in cases documented or observed in Western nations and a major windfall is to be had [32,33].

Precious few in academia or otherwise seem to be willing to acknowledge all of these problems with notable exceptions.

Where I would agree with those quoted in the New York Times is that variations in gender expression (behaviors that fall outside sex stereotypes) are normal aspects of human diversity. No child should be teased or bullied for failing to conform to sex stereotypes. These children should be supported in the reality of both their biological sex and their non-conforming sex typed behaviors.

There is a classic work from Scottish journalist Charles Mackay entitled "Extraordinary Popular Delusions and the Madness of Crowds" [37]. It is a study of crowd psychology and discusses irrational economic fads such as the Dutch tulip mania and pseudo-scientific belief systems such as alchemy. If someone decides to revise or add to this classic work, then the 21st century treatment of gender identity will certainly be worthy of the chapter. In his study Mackay noted that many of the practitioners of alchemy were themselves deluded. The same can be said for those practicing "gender affirmative therapy", they are deluded -- deluded by their gender identity phantoms.

Michael K. Laidlaw MD is a physician board certified in Endocrinology, Diabetes and Metabolism and Internal Medicine. Research interests have included circadian rhythms, magnesium and bone disorders, thyroid carcinoma, type 2 diabetes education, weight loss and food addiction.  He has been active in private practice for 12 years. Most recently he has been involved in education regarding male and female sex hormones and development including critically examining childhood gender dysphoria diagnosis and treatment from the perspective of an endocrinologist. Find him on Twitter @MLaidlawMD 

This article originally appeared on the website of the Pediatric and Adolescent Gender Dysphoria Working Group. It has been republished with permission.


1. Klass P. "Helping Pediatricians Care for Transgender Children". The New York Times. Oct 15, 2018.

2. Rafferty J. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents” Pediatrics. 2018 Oct; 142(4). (AAP)

3. Littman, L. Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports. PLoS One. 2018 Aug 16;13(8):e0202330.

4. AAP p. 5

5. American Psychiatric Association. Gender dysphoria. In: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, American Psychiatric Association, Arlington, VA 2013. p.451.

6. "What is Gender Dysphoria?" American Psychiatric Association. Accessed 10/20/2018.

7. American Psychiatric Association. Gender identity disorders. In: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 4th ed, American Psychiatric Association, Washington, DC 2000. p.576.

8. AAP p. 2 table 1

9. Zucker KJ, Wood H, Singh D, Bradley SJ. A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder. J Homosex. 2012;59(3):369-397.

10."Toward a more nuanced exploration: An interview with Sasha Ayad". 4thWaveNow. Sep 20, 2018.

11. Cantor J. "American Academy of Pediatrics policy and trans- kids: Fact-checking". Sexology Today! Oct 17, 2018.

12. AAP p. 5, 8

13. Christensen J. "Judge gives grandparents custody of Ohio transgender teen". CNN. Feb 16, 2018.

14. Hembree WC, Cohen-Kettenis PT, Gooren L, Hannema SE, Meyer WJ, Murad MG, Rosenthal SM, Safer JD, Tangpricha V, T’Sjoen GG. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903.  (Endo guidelines)

15. Laidlaw M. Graphic comparing Testosterone levels in Females: normal, PCOS, endocrine tumor, FtM. Twitter. June 10, 2018.

16. Grynberg M, Fanchin R,Dubost G, Colau JC, Brémont-Weil C, Frydman R, Ayoubi JM. Histology of genital tract and breast tissue after long-term testosterone administration in a female-to-male transsexual population. Reproductive Medicine Online. 2010; 20:553-58.

17. De Vries ALC, Steensma TD, Doreleijers TAH, Cohen-Kettenis, PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011;8:2276-2283.

18. Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry. 2016;28(1):13-20.

19. Irwig MS. Cardiovascular Health in Transgender People. Rev Endocr Metab Disord. 2018;Aug 3 epub.

20. Klink D, Caris M, Heijboer A, van Trotsenburg M, Rotteveel J. Bone mass in young adulthood following gonadotropin-releasing hormone analog treatment and cross-sex hormone treatment in adolescents with gender dysphoria. J Clin Endocrinol Metab. 2015 Feb;100(2):E270-5.

21. Nahata L, Tishelman AC, Caltabellotta NM, Quinn GP. Low Fertility Preservation Utilization Among Transgender Youth. J Adolesc Health. 2017;61:40-44.

22. Chen D, Simons L, Johnson EK, Lockart BA, Finlayson C. Fertility Preservation for Transgender Adolescents. J Adolesc Health. 2017 Jul;61(1):120-123.

23. Laidlaw M. "Gender Dysphoria and Children: An Endocrinologist’s Evaluation of 'I am Jazz'". Public Discourse. Apr 5, 2018.

24. Endo guidelines pp 3870-3872.

25. Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatr. 2018 May 1;172(5):431-436.

26. Robbins J. "Tax-Funded Researcher Studying Trans Children Is Married To Trans Woman; Both Profit From Child Mutilation". The Federalist. Sep 27, 2018.

27. Johanna Olson-Kennedy recorded 6th July 2018 at the Gender Spectrum Conference.

28. AAP pp 3.

29. Bilek J. "Who Are the Rich, White Men Institutionalizing Transgender Ideology?" The Federalist. Feb 20, 2018.

30. Laidlaw M. "AB 2119. Estimated Costs of Puberty Blocking Agents". Letter to California State Legislators. Apr 30, 2018.

31. Jensen E. "Jazz Jennings' opens up about the challenges she faced with gender confirmation surgery". USA Today. Oct 16, 2018.

32. Grew T. "Inquiry into surge in gender treatment ordered by Penny Mordaunt". The Sunday Times. Sep 16, 2018.

33. Williams E. "There’s a sudden surge of trans students coming out at my college … and I’m scared to talk about it". 4thWaveNow. Oct 2, 2018.

34. 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.

35. Kaltiala-Heino R, Bergman H, Työläjärvi M, Frisén L. Gender dysphoria in adolescence: current perspectives. Adolescent Health, Medicine and Therapeutics. 2018:9 31-41.

36. Skinner D, Albertson A, Navratil A, Smith A, Mignot M, Talbott H, Scanlan-Blake N. GnRH Effects Outside the Hypothalamo-Pituitary-Reproductive Axis. J Neuroendocrinol. 2009 Mar; 21(4): 282–292.

37. Mackay C. "Memoirs of Extraordinary Delusions and the Madness of Crowds". London, 1852. 


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