The approach to cases of gender dysphoria or incongruence, in which the individual does not identify with his or her biological sex, has promoted various treatment strategies.

Predominantly those that resort to pharmacological therapies – hormonal blocking and transition – and surgical – mutilation and reconstruction -, which are being strongly questioned recently due to the alarming lack of scientific evidence demonstrating their efficacy. And also because of the accumulation of complications and associated side effects that alarmingly worsen the quality of life of those to whom they are applied.

These types of interventions are based mainly on the recommendation of the World Professional Association for Transgender Health (WPATH), which is inspired by the so-called Dutch Protocol, published in 1996.

One of the reasons that have prompted its defenders to promote the strategies proposed by this protocol is the prevention of suicide associated with cases of dysphoria. In these cases, people with dysphoria are guided towards a modification of their physical appearance so that it is assimilated to their own perception, which is incongruent with their biological sex.

Many articles are based on studies that strive to expose the protective factor that these types of gender transition interventions have on suicide and suicidality rates. But these studies have limitations related to the small size of the statistical samples studied, or they make incomplete follow-ups or the period of time they study is not long enough.

Towards a new paradigm

But these conclusions are being questioned by more and more researchers and clinicians, who confirm the poor results of the application of these protocols to resolve the initial gender dysphoria and the associated psychological problems, which not only persist over time but also they get worse in many cases.

The multiplication of detransition requests to reverse the gender transition interventions to which they have been subjected is one of the indicators that something is not being done well.

As we have previously reported, many countries and scientific societies are alarmed about the dire consequences of the application of these protocols and are requesting that they be relegated exclusively to the field of research or prohibited in adolescents.

In addition, they request the implementation of psychological or psychiatric treatments that address the initial causes of dysphoria, a disorder whose diagnosis and treatment is essential for affected patients to overcome these processes.

A recent article published in the journal Cuadernos de Bioética clarifies that gender incongruence occurs in a healthy body, consistent with genetic sex, and shows the brain modifications that in many cases predispose to a contrary perception of one’s own gender.

The authors clarify that medical treatments are administered aimed at affirming the perceived gender, through the administration of crossed hormones and, occasionally, with surgery, whose objective is to adapt the phenotypic appearance (the body) to the brain. This entails negative consequences, of which the patient, or his parents or guardians should be exhaustively informed, when he is not mature enough to understand them.

Instead, given the complexity of the psychological causes that are usually behind gender dysphoria, it is essential to implement a serious psychological diagnosis and treatment instead of undertaking gender reassignment or affirmation treatments.

Gender dysphoria and suicide

Recently, a new paper published in the journal BMJ Mental Health, questions the effectiveness of gender transition interventions as a method to prevent suicidality in people affected by gender dysphoria.

The study, conducted in Finland, included a sample of more than 2,000 people, with a history of gender dysphoria in the period between the years 1996 and 2019.

The follow-up of the individuals lasted an average of six years, which is a great advantage compared to other similar studies, with shorter follow-up periods and discontinuation in many of the recruited individuals, extremes that represent important biases in the conclusions of these studies.

The authors conclude that “clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for.” That is, in cases of dysphoria in which a psychotherapeutic or psychiatric approach was not carried out, the suicide rate does seem to increase.

The most important thing is that, when psychiatric treatment needs, sex, year of birth and differences in follow-up times were taken into account, suicide mortality did not differ statistically significantly from the control group of either patients who underwent gender reassignment therapies and those who did not.

This implies, according to the aforementioned study, that psychiatric treatment can be related to the prevention of suicidal behavior in cases of gender dysphoria. And that, if this therapeutic approach is carried out, implementing hormonal or surgical gender transition therapies does not provide any advantage in reducing suicides. There are numerous drawbacks associated with the side effects and complications associated with these therapies, which we have previously discussed.

Conclusion

In conclusion, recent studies accumulate evidence on how counterproductive pharmacological and surgical gender transition interventions can be in patients with dysphoria.

This reinforces the need to provide psychological or psychiatric treatments to those affected, which contradicts what many of the recent transsexuality laws establish, which propose exactly the opposite of what the most recent studies show.

The psychological or psychiatric approach to cases of gender dysphoria is what appears to be effective, according to this recent study, in the prevention of suicides related to dysphoria. This shows that gender transition, pharmacological or surgical interventions are not effective in reducing suicide rates, if appropriate psychological or psychiatric interventions have been previously applied.

However, the administration of hormonal, blocking or transition treatments, as well as surgical ones, presents numerous side effects and complications, in many cases irreversible, and contributes to worsening the quality of life of these patients. Therefore, insisting on this type of intervention, ignoring psychological diagnosis and assistance, implies proceeding in the opposite direction to that shown by the most recent scientific-clinical evidence.

Julio Tudela

Bioethics Observatory – Institute of Life Sciences

Catholic University of Valencia

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