‘They’re experimenting on young people with their lives ahead of them. It makes me angry.’
So says a young person opening a Swedish documentary (Uppdrag granskning, The Trans Train, which aired in 2019) on the complex topic of gender dysphoria in teenage biological females: a group who are presenting to their GPs and requesting medical interventions and transition to a masculine or non-binary gender role in unprecedented numbers.
At the heart of the film are two stories of young women who later regretted their gender transition, and have returned to identify as their original, natal sex: a phenomenon known as detransition. ‘Mika’ was unaware that regret was even a possibility when she embarked on hormone therapy to affirm her masculine gender identity. Initially, ‘Sametti’s’ medical interventions brought her relief from her gender dysphoria. Years later, her singing voice has been permanently altered by testosterone. While showing photos of her younger self to the filmmakers, Sametti wonders why she ever felt that unhappy with her body.
Are medical interventions for gender dysphoria now simply a case of unquestioningly ‘affirming’ a patient’s identity, rather than the conventional idea of following a diagnosis? If so, what is the role of the clinician? In the experience of one Swedish clinic, Lennart Fällberg, head of department of Lundströmmottagningen, a facility specialising in the treatment of gender dysphoria, explains that patients who detransition can suffer with complex emotional crises, and states: ‘There’s an awful lot we don’t know. That’s what creates this — what we call an ethical stress. That we don’t have satisfactory evidence for what we’re doing.’
The film presents data from Sweden and Norway that suggest that over half of the teenage girls who identify as boys and present to gender clinics also have complex mental health needs such as severe depression, anorexia, post-traumatic stress disorder, or may be on the autistic spectrum.1
Clinicians are concerned that these young natal females might represent an entirely new group of patients, for whom very little long-term evidence of the efficacy of medical transition is available. Dr Per-Anders Rydelius, psychiatrist at Karolinska’s paediatric gender clinic based in Stockholm, Sweden, explains that, since the establishment of their service 19 years ago, referrals have increased from 5–10 cases to 200 per year. When asked who bears clinical responsibility for commencing these treatments, he responds:
‘Well, since these decisions are based on consensus between the child, the parents, and the professionals, then it’s a shared responsibility.’
Would UK GPs, or regulatory bodies such as the GMC, agree that this is appropriate shared decision making? This documentary raises important questions that are applicable to UK practitioners. Are young patients and their carers provided with enough information about the ‘known unknowns’ in the treatment of gender dysphoria? What course of action should be encouraged by responsible healthcare professionals who wish to support a young person’s identity while safeguarding them from potential harm?
The film highlighted the feelings of shame, anger, and ostracisation experienced by two women who detransitioned. Such cases may well be very rare, but, in a consensus model of decision making, who carries the burden of the hypothetical risk of a mistake or regret? What are the ethical duties of the doctor in this emerging, complex field of medical practice?
An investigation into the situation in the UK was ordered last year by the government.2
Acknowledgments
Thanks to Professor Susan Bewley for reading and commenting on a draft of this review.
- © British Journal of General Practice 2019