The American Psychiatric Association is the world’s largest and most influential psychiatric organization. Most notably, it produces the Diagnostic and Statistical Manual, considered the bible of psychiatry, now in its 5th edition. The manual codifies psychiatric diagnoses, which are essential for insurance coverage, personal injury lawsuits, and Food and Drug Administration approval of psychiatric drugs.
Last fall, the APA’s publishing arm issued a textbook called Gender-Affirming Psychiatric Care. Described in accompanying promotional material as an “indispensable” resource, the book is written for mental health and primary care clinicians. The publisher, American Psychiatric Association Publishing, APPI, hails it as “the first textbook in the field to provide an affirming, intersectional, and evidence-informed approach to caring for transgender, non-binary, and/or gender-expansive (TNG) people.”
The “affirming, intersectional” textbook is not official APA guidance. Still, APA Publishing describes it as “rigorous” and “an expert view from fields that include psychiatry, psychology, social work, nursing, pharmacy, public health, law, business, community activism, and more. And because each of the 26 chapters features at least one TNG author, wisdom gleaned from lived experience bolsters the professional perspective provided throughout the book.” One would hope that “lived experience” might enhance the scholarship, but that is not the case here.
Affirming care for children with gender dysphoria, a condition that, according to the APA, refers to individuals who suffer from “a marked incongruence between one’s experienced/expressed gender and assigned gender [at birth],” is a major subject of the book. Unfortunately, though billed as a compendium of “best practices,” Gender-Affirming Psychiatric Care, instead of providing even-handed analyses of the controversies within a still-evolving topic of great clinical and social importance regarding the science of treating gender dysphoric youth, the volume approaches it as a settled matter when it is not.
The textbook’s treatment philosophy is that if a child or teen desires transitional steps, then the physicians should proceed, taking the patient’s request on its face. According to the authors, “Clinicians should … always allow patients autonomy in their care.” The authors further advocate for puberty blockers (chemicals that suppress the natural hormonal development and the appearance of secondary sexual traits) and then cross-sex hormones (estrogen or testosterone) to produce the physical characteristics aligned with the patient’s gender identity.
When it comes to gender-affirming surgery (which, for natal girls, can entail the removal of breasts, uterus, and ovaries, as well as penile construction; and for natal boys, involves the genital removal and the creation of a vaginal canal), patients first require a psychiatric evaluation before surgical consultation. In this evaluation, the authors say that “the [mental health] clinician should never place barriers to surgery, only identify those that exist and assist with overcoming them.” (Emphasis added.) While the final decision to operate ultimately lies with the surgeon, who is tasked with obtaining informed consent from the patient and guardian, a psychiatric greenlight is also necessary. Surely, there are times when a yellow or red light is appropriate. It’s telling that a book of 420 pages only mentions guardians once and in the context of saying that guardians and parents (who get five mentions) should not be part of decisions concerning their transitioning kids’ medical data. Parents are referenced only in the context of being unsupportive to their children’s desire to transition.
As a practicing psychiatrist, I would expect this volume to probe how to conduct productive interviews with all patients, especially children and young teens, who consider themselves candidates for a gender-affirming approach. After all, this is a book from the American Psychiatric Association’s publishing arm. As such, it should advise clinicians to examine, over many sessions, patients’ experiences and developmental struggles (such as emerging sexuality and identity formation), to learn about their home lives and social worlds, as well as to treat them for the frequent co-occurring issues, such as depression, anxiety, and posttraumatic stress disorder, which sometimes manifest as gender dysphoria in youth.
This would seem to be at the heart of any responsible psychiatric assessment of whether chemical intervention (which can be irreversible) and procedures as life-altering as “confirmation surgery” should be recommended. However, oddly, such foundational steps are ignored.
More unsettling and, perhaps, revealing is that Gender-Affirming Psychiatric Care omits well-established evidence showing that a majority of minors will “desist”—that is, experience the waning of gender dysphoria before medical gender transition. Many studies of young children with gender dysphoria reveal that a significant number no longer express gender dysphoria when tracked into adolescence or adulthood.
Nor does the textbook mention the robust debate surrounding “rapid-onset gender dysphoria,” or ROGD. This term, which is not part of the DSM, refers to the sudden insistence, during or after puberty, that one is trans. Some doctors recognize ROGD as real—bitter debate surrounds its existence—and regard it as the product of social contagion fostered by peers and social media.
What’s more, de-transitioning gets short shrift in this volume. It’s the desire to stop or reverse the transition process. The book notes the phenomenon only once, merely in a passing reference to older transgender adults who feel pressure to de-transition “out of fear of being misgendered, verbally ridiculed, or abused.” Unmentioned entirely are those who de-transition after no longer identifying with the gender to which they transitioned or who come to regret their decision but do not undergo de-transition.
Finally, a reader gets no sense that gender-affirming care is the subject of vigorous international scientific debate. Remarkably, the textbook does not mention that in 2020, the United Kingdom’s National Health Service commissioned a comprehensive review of puberty blockers and cross-sex hormones and concluded that “the available evidence was not deemed strong enough to form the basis of a policy position” on their use. Similarly, in 2022, Sweden’s National Board of Health and Welfare suspended hormone therapy for minors except in very rare cases and limited mastectomies to research settings. Likewise, the Norwegian Healthcare Investigation Board now defines all medical and surgical interventions for youth as “experimental treatment,” and the French National Academy of Medicine advises caution in pediatric gender transition.
Regardless of the authors’ personal views, a textbook that is advertised as “rigorous—and timely” as well as “informative” should, at the very least, acknowledge, and ideally explore, the tension between the European and American approaches and elucidate the concerns raised by European medical authorities.
When APPI, a division of the APA, receives a textbook proposal, editors send it out for peer review before acceptance. Upon completion of the volume, editors again solicit peer review, which must be completed before the APA Board of Trustees takes final action to authorize publication. APPI states that it offers “information” that is “authoritative [and] up-to-date.”
However, the volume suffers from inadequate oversight from APPI. Was this failing due to naivete or politics? Perhaps the peer reviewers simply did not appreciate the gravity of the debates and the roiling uncertainty surrounding the assessment and care of gender dysphoric teens. Possibly, they were sympathetic to the book’s forceful message about gender affirmation; maybe the press’s editors or Board of Trustees were as well. In any event, the book’s omissions render it neither authoritative nor up-to-date. This is ultimately a disservice to all patients whether or not they proceed with gender-affirming care. All people involved in this process—patients, parents, and practitioners—deserve a comprehensive and fair-minded approach to this complex issue.
Alas, this volume is another instance of activism intruding into psychology and medicine writ large. Perhaps the most well-known example of this social justice trend was using racial categories to determine the distribution of lifesaving COVID-19 treatments. On the psychotherapy front, many counselor education programs are teaching trainees to see patients less as individuals with unique needs and personalities but as avatars of their gender, race, and ethnicity. White patients, for instance, are told that their distress stems from their subjugation of others, while black and minority patients are told that their problems flow from being oppressed. It is especially troubling to see social justice ideology intrude in an area as high-stakes as the treatment of young people with gender dysphoria.
Contrary to the textbook’s full-speed-ahead approach, my stance as a psychiatrist is informed modesty about our understanding of these issues and restraint toward both chemical and surgical interventions. I believe existing evidence isn’t strong enough to support an unhesitating, gender-affirming approach to youth. But neither do I think that state-imposed bans and limits on gender-affirming care should be endorsed when they apply to the care of adults or interrupt the treatment of youth already in progress. At the same time, blanket denial of the reality of gender dysphoria is unacceptable. Legislation is too rigid to guide specific care — it is not credible to say that there are never instances of youth who might benefit from gender-affirming care –and it turns health issues into partisan battlefields. Conversely, it is hard to look to the usual advisers on clinical protocols, namely professional organizations and state medical boards, as they are mainly in sync with the orientation of this textbook.
One hopeful sign is that a message of caution is embedded in guidelines from the World Health Organization that are currently under development. Acknowledging that “the evidence base for children and adolescents is limited and variable regarding the longer-term outcomes of gender-affirming care for children and adolescents,” the new guidance will not include youth gender-affirming care at all. Such humility is to be applauded in an emerging field. The APA’s publishing arm has issued a textbook with no such self-restraint.
Gender dysphoric youth deserve a comprehensive and clinically judicious textbook from the country’s premiere psychiatric association, not a volume that omits essential facts and perspectives in the service of a political agenda.
