Medical Treatment for gender identity evidence archive thread

DE VRIES ET AL ON CONSENT FOR CHILDREN’S MEDICALISATION CANNOT BE FULLY ESTABLISHED, BUT TREATMENT SHOULD STILL BE GIVEN

The Fiction of Prior Knowledge: Rethinking Informed Consent in Adolescent Gender-Affirming Medical Care

published online August 13, 2026

Ezra D. Oosthoek, Karl Gerritse and Annelou L. C. de Vries

Abstract

Current debates on adolescent gender-affirming care often revolve around questions of decision-making capacity and informed consent. Rather than asking whether adolescents are capable of providing informed consent, this article takes a different starting point by examining the assumptions embedded in the medico-legal model of informed consent itself and how these play out in clinical practice. Drawing on qualitative interviews with transgender youth and clinicians in the Netherlands, as well as observations of multidisciplinary team meetings, we analyze the tensions that arise concerning informed consent and the clinical realities of adolescent gender-affirming care. We show that informed consent becomes entangled with diagnostic assessment, treatment indication, and the evaluation of readiness, resulting in a form of normative overburdening that exceeds its conventional medico-legal function. We argue that this overburdening reflects a deeper misalignment between the medico-legal model of informed consent and the processual character of gender becoming. We conceptualize this misalignment along three interrelated dimensions: ontological, epistemic, and temporal. Together, these reveal how informed consent comes to depend on forms of subjectivity, knowledge, and temporal certainty that cannot be fully established in the context of this care practice. Instead of treating this as a problem of adolescents’ decision-making capacity or of gender-affirming care itself, we call for rethinking informed consent under conditions in which subjectivity, knowledge, and futures remain inherently in the making.

Conclusion

Much of the contemporary debate on gender-affirming care for youth has centered on whether young people are capable of providing informed consent for medical treatment. Rather than examining whether adolescents are capable of providing informed consent to gender-affirming treatment, we examined the assumptions embedded in the medico-legal model of informed consent itself and how these translate into everyday clinical practice. Drawing on qualitative interviews and ethnographic observations, we have shown that in the context of gender-affirming care for youth, the practice of informed consent does not just protect patient autonomy but is also entangled with broader clinical practices of diagnostic assessment and treatment eligibility, making it difficult for young people to access this care. As we have argued, informed consent is made to carry demands that extend beyond its conventional medico-legal function. We explain this normative overburdening as the effect of a deeper tension between the medico-legal logic of informed consent and the emergent realitiy of gender becoming.
These findings also have implications for legal and policy debates. Concerns about informed consent in adolescent gender-affirming care are frequently addressed through calls for stronger evidence about long-term treatment outcomes, safety, and regret rates. While such efforts may address certain empirical uncertainties, they will not resolve the more fundamental, constitutive uncertainties that accompany gender transition. In fact, increasing demands for certainty risks intensifying the very dynamics identified in this article, placing further pressure on adolescents to present themselves as more certain and future-oriented than may be possible. These demands reflect a more fundamental assumption embedded in dominant understandings of gender as a stable, individual identity that can be known prior to treatment. As long as this assumption remains intact, informed consent will likely continue to bear expectations of certainty that sit uneasily with the emergent character of gender becoming.

Just to highlight:

In fact, increasing demands for certainty risks intensifying the very dynamics identified in this article, placing further pressure on adolescents to present themselves as more certain and future-oriented than may be possible.

As long as this assumption remains intact, informed consent will likely continue to bear expectations of certainty that sit uneasily with the emergent character of gender becoming.

THE FINNISH STUDY ON MENTAL HEALTH AFTER GENDER DYSPHORIA TREATMENT

https://onlinelibrary.wiley.com/doi/10.1111/apa.70533

Psychiatric Morbidity Among Adolescents and Young Adults Who Contacted Specialised Gender Identity Services in Finland in 1996–2019: A Register Study

Sami-Matti Ruuska, Katinka Tuisku, Timo Holttinen, Riittakerttu Kaltiala

First published: 04 April 2026

ABSTRACT

Aim
To examine the prevalence of severe psychiatric morbidity among gender-referred adolescents, focusing on gender differences and outcomes related to medical gender reassignment.

Methods
Finnish nationwide cohort of all under-23-year-old gender-referred individuals between 1996 and 2019 (n = 2 083) and 16 643 matched controls. Cross-tabulations with X2 statistics and Cox regression were used to analyse the data.

Results
Gender-referred adolescents showed significantly higher psychiatric morbidity than controls both before (45.7% vs. 15.0%) and ≥ 2 years after referral (61.7% vs. 14.6%). Those referred after 2010 had greater psychiatric needs than earlier cohorts, both before (47.9% vs. 15.3%) and ≥ 2 years after (61.3% vs. 14.2%) referral. Among adolescents who underwent medical gender reassignment, psychiatric morbidity increased markedly during follow-up—rising from 9.8% to 60.7% in feminising gender reassignment and from 21.6% to 54.5% in masculinising gender reassignment. After adjusting for prior psychiatric treatment, all gender-referred adolescents had similarly elevated risks of psychiatric morbidity, with hazard ratios approximately three times higher than female controls and five times higher than male controls.

Conclusion
Severe psychiatric morbidity is common among gender-referred adolescents and appears to be more prevalent in those referred after the recent surge in referrals. Psychiatric needs do not subside after medical gender reassignment.

Summary

-Gender-referred adolescents show high psychiatric morbidity, yet gender differences and mental health trajectories after medical gender reassignment remain poorly understood.

-These adolescents had markedly higher psychiatric morbidity than controls before and after referral, with treatment needs often persisting and even intensifying after medical interventions—on some, they might even have a negative impact.

-Findings emphasise the need for thorough psychiatric assessment and ongoing treatment throughout medical gender reassignment.

Just pulling this out.

After adjusting for prior psychiatric treatment, all gender-referred adolescents had similarly elevated risks of psychiatric morbidity, with hazard ratios approximately three times higher than female controls and five times higher than male controls.

Gender Identity Disorders Among Young People in Germany:
Prevalence and Trends, 2013–2022 (2024)

https://api.aerzteblatt.de/pdf/di/121/11/m370.pdf

Results
In the period 2013–2022, the prevalence of as confirmed coded F64 diagnoses among insured persons aged 5 to 24years increased from 22.5/100 000 to 175.7/100 000 (M1Q) and from 15.2/100 000 (M2Q) to 132.6/100 000, respectively. The prevalence of the diagnose F64.0 was fairly constant (range: 70.2% to 78.5%). At the same time, the prevalence of F66 diagnoses declined from 216.7/100 000 to 73.7/100 000 (M1Q) and from 37/100 000 to 19.4/100 000 (M2Q), respectively. Looking at the two diagnoses (F64/F66) in conjunction, a clear increase in prevalence is noted when the M2Q criterion is applied. Applying M2Q, the prevalence increases from 51.9/100 000 to 149.8/100 000, while in M1Q hardly any changes are observed (compare Figure 1).

In almost all years, the highest prevalence of F64 diagnoses (M1Q) was noted among female adolescents in the age group 15 to 19 years (2022: 452.6/100 000, Figure 2). This finding was also observed for F66 (2022:191.5/100 000). In 72.4% of the persons with an F64 diagnosis in 2022 (n = 24 624), at least one additional psychiatric diagnosis was coded (males: 67.3%; females: 75.6%). The most common diagnoses were depressive disorders (males: 49.3%, females: 57.5%), anxiety disorders (23.5%/34.0%), emotionally unstable personality disorder of the borderline type (12.1%/17.6%), attention-deficit/hyperactivity disorders (12.7%/12.6%), and post-traumatic stress disorders (9.9%/13.6%)..

In the longitudinal cohort (n = 7885, 47.1% in the age group 20–24 years; 37.7% male), only 36.4% still had a confirmed F64 diagnosis after five years and diagnosis
persistence was below 50% in all age groups (range 27.3% [15–19-year-old females] to 49.7% [20–24-year-old males]).

Tweet about it here with a graphic.

https://x.com/VincentPsychSE/status/2036449596344254777?s=20

Germany National Data: Gender Dysphoria Dx*
Persistence was below 50%
Lowest persistence: 27.3%
among females aged 15–19 years → 72.7% non-persistence/desistance in the adolescent female group
Highest persistence: 49.7% among males aged 20–24 years.
*Consider the thousands who desisted before Dx

INDEPENDENT REVIEW OF WPATH SOC GUIDELINES

https://link.springer.com/article/10.1007/s10508-025-03399-6

19th February 2026

Yuan Zhang, Dominika Januś, Riittakerttu Kaltiala, Milla Karvonen, Jeffrey J. Ptak & Juan Jose Yepes-Nuñez

Quality of the World Professional Association for Transgender Health Guideline Standards of Care 8: An Appraisal Using the AGREE II Instrument

Conclusion

Our assessment revealed that WPATH’s SOC8 guidelines have limitations in scientific and methodological rigor, applicability, and transparency in managing competing interests. Evidence-based guidelines addressing the needs of transidentified children and adolescents are urgently needed, but the uncritical adoption or endorsement of WPATH’s guidelines may result in a disservice or even harm to this vulnerable population. It is imperative that healthcare providers, researchers, and policymakers recognize and address the limitations of WPATH’s SOC8.

Here is a tweet about the review from Ray Yuan Zhang

x.com/real_yuanzhang/status/2027058245576143312?s=46

WPATH guidelines are not evidence-based.

This week, our study assessing the methodological quality of the WPATH guidelines was published. We invited a group of healthcare professionals, including six physicians and two methodologists, to evaluate the guidelines using AGREE II. (AGREE II is the most widely used tool for assessing guideline quality. It examines 23 items across six domains related to rigor, applicability, editorial independence, and overall development quality.)

We selected reviewers with open minds and diverse expertise who are committed to evidence-based medicine. They are not inherently opposed to transition; if evidence shows that the benefits outweigh the risks, they would support such treatments. We also provided training on evidence-based medicine, guideline development, and the use of AGREE II.

The results indicate serious limitations in the WPATH guidelines, particularly in applicability, rigor of development, and editorial independence. The low score in rigor of development is especially concerning. This domain includes items such as "whether the strengths and limitations of the evidence are clearly described" and "whether there is an explicit link between recommendations and supporting evidence". A low score suggests that the guideline does not clearly demonstrate how the evidence supports its recommendations. The recommendations may be correct or incorrect, but the evidence basis is not transparently presented.

If you are interested in reading our study: link.springer.com/article/10.100…

As we concluded: “Evidence-based guidelines addressing the needs of trans-identified children and adolescents are urgently needed, but the uncritical adoption or endorsement of WPATH’s guidelines may result in a disservice or even harm to this vulnerable population. It is imperative that healthcare providers, researchers, and policymakers recognize and address the limitations of WPATH’s SOC8.”

The goal is not to dismiss care needs, but to provide the best possible help to those in need. If recommendations are developed with poor methodological quality, the guidelines cannot be truly helpful.

MALE PEOPLE WITH TRANSGENDER IDENTITIES HAVE DISTINCT PATTERNS OF BRAIN FUNCTION WHILE BEING MORE ALIGNED WITH THE MALE RANGE

Comparing local brain activity and distant functional connectivity in transgender women compared to cisgender controls

https://www.nature.com/articles/s41598-026-40083-8

16 February 2026

Xiongyu Li, Zhibiao Xiang et al

Abstract
To date, the knowledge about the neurobiological mechanisms associated with transgender populations, especially transgender women (TW), remains limited and lacks consensus. This study aims to fill such gaps using the functional magnetic resonance imaging (fMRI) method. Resting-state fMRI data was obtained from 16 TW, 16 cisgender men (CM), and 16 cisgender women (CW). Measures of local brain activity and distant functional connectivity (FC) were compared among groups. Several corresponding dynamic measures were also explored based on the assumption of fluctuating brain functional organizations over time. For local brain activity, TW showed higher amplitude of low-frequency fluctuation within the cerebellum, precentral gyrus, and thalamus, as well as lower regional homogeneity in the precuneus than cisgender participants. For FC measures, TW showed weaker FCs mainly involving the ventral attention and sensorimotor networks, as well as lower local efficiency than cisgender participants. In most of these measures, CM were intermediate among the three groups (i.e., TW < CM < CW, or TW > CM > CW). Our results suggest that TW have distinct patterns of brain function compared with cisgender people, while they are more aligned with those of CM (their sex assigned at birth) rather than CW.

https://www.nature.com/articles/s41598-026-40083-8_reference.pdf

Noted within the review : ”Another limitation regarding the sample is that we did not control for the impact of hormones.” and I also noted “Finally, given the higher risk of depression andmood disorders in TW, absence of emotional assessment as a control variable limits the robustness of our conclusions”.

GENDER TRANSITION SURGERY IS NOT A FORM OF SUICIDE PREVENTION

https://x.com/benryanwriter/status/2018183879035629603?s=46

”Dr. Loren Schechter, the head of gender-affirming surgery at Rush University Medical Center in Chicago and the president-elect of the World Professional Association for Transgender Health (WPATH), testified that gender-transition surgery is not form of suicide prevention.”

This quote below is from Ryan’s reporting of the testimony in the Fox Varian case.

” Schechter, the plastic surgeon, testified that Einhorn had misconceived the purpose of gender-transition mastectomies. "Surgery in and of itself is not a treatment or a mechanism to prevent suicide," he said.”

AMA REACTION TO ASPS POSITION

“The AMA said in a statement to National Review that because “the evidence for gender-affirming surgical intervention in minors is insufficient for us to make a definitive statement . . . the AMA agrees with ASPS that surgical interventions in minors should be generally deferred to adulthood.””

https://www.nationalreview.com/news/first-major-medical-org-comes-out-against-trans-surgeries-for-minors/amp/

3 Feb 2026

STATEMENT FROM THE AMERICAN SOCIETY OF PLASTIC SURGEONS - Feb 2026

www.plasticsurgery.org/for-medical-professionals/health-policy/position-statements

"Consistent with ASPS’s August 2024 statement that the overall evidence base for gender-related endocrine and surgical interventions is low certainty, and in light of recent publications reporting very low/low certainty of evidence regarding mental health outcomes, along with emerging concerns about potential long-term harms and the irreversible nature of surgical interventions in a developmentally vulnerable population, ASPS concludes there is there is
insufficient evidence demonstrating a favorable risk-benefit ratio for the pathway of gender-related endocrine and surgical interventions in children and adolescents. ASPS recommends that surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old."

and

ASPS’s Understanding of the Evidence Base and Related Ethical Considerations

"In August 2024, ASPS communicated to members that the Society had not endorsed any external organization’s clinical practice guidelines or recommendations for the treatment of children or adolescents with gender dysphoria. At that time, ASPS recognized that the evidence base informing medical and surgical interventions in this population was limited and characterized as low quality/low certainty (i.e., there was limited confidence that the intervention’s reported effects reflected the true effects). This understanding was informed by new systematic reviews published in Europe as well as the 2024 Independent Review of Gender Identity Services for Children and Young People: Final Report commissioned by NHS England and authored by Dr. Hilary Cass.

ASPS’s understanding has continued to evolve in light of additional comprehensive evidence reviews, including the 2024 Plastic and Reconstructive Surgery article Mastectomy for individuals with gender dysphoria younger than 26 years: a systematic review and meta-analysis and the 2025 report from the U.S. Department of Health and Human Services (HHS) titled Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices. These reviews have not resolved earlier uncertainties regarding treatment benefit; in some areas they have contributed to a clearer understanding of potential harms, while also highlighting limitations of the available evidence, including gaps in documenting long-term physical, psychological, and psychosocial outcomes. For an evidence summary, ASPS directs members to Appendix 4 of the HHS report, which details the types of interventions (medical, surgical, psychological), reported outcomes, magnitude and direction of effects, and overall certainty of evidence available in the published literature."

SOME OF THE IMPACTS OF TESTOSTERONE ON FEMALE BODIES

Pelvic Floor Dysfunction in Transgender Men on Gender-affirming Hormone Therapy: A Descriptive Cross-sectional Study

Lyvia Maria Bezerra da Silva et al. Int Urogynecol J. 2024 May.

Abstract

Introduction and hypothesis: The objective of this research is to explore the effects of hormone therapy using testosterone on pelvic floor dysfunction (PFD) in transgender men. We hypothesize that PFD might be prevalent among transgender men undergoing hormone therapy. Therefore, this study was aimed at verifying the frequency of these dysfunctions.

Methods: A cross-sectional study was conducted between September 2022 and March 2023 using an online questionnaire, which included transgender men over 18 years old who underwent gender-affirming hormone therapy. Volunteers with neurological disease, previous urogynecology surgery, active urinary tract infection, and individuals without access to the internet were excluded. The questionnaire employed validated tools to assess urinary symptoms, such as urinary incontinence (UI), as well as sexual dysfunction, anorectal symptoms, and constipation. The data were analyzed descriptively and presented as frequencies and prevalence ratios with their respective confidence intervals (95% CI), mean, and standard deviation.

Results: A total of 68 transgender men were included. Most participants had storage symptoms (69.1%), sexual dysfunction (52.9%), anorectal symptoms (45.6%), and flatal incontinence (39.7%). Participants with UI symptoms reported moderate severity of the condition.

Conclusions: Transgender men on hormone therapy have a high incidence of PFD (94.1%) and experience a greater occurrence of urinary symptoms (86.7%).

An article about the study with some commentary from Elaine Miller (gussiegrips)

Trans men taking testosterone getting ‘postmenopausal’ problems aged 28’

The Telegraph
26 May 2024

www.telegraph.co.uk/news/2024/05/26/trans-problems-urinary-bowel-incontinent-young-detransition/

https://archive.is/wNl3q

“Elaine Miller, a pelvic health physiotherapist and member of the Chartered Society of Physiotherapy, said: “A lot of women are absolutely fine until the menopause and then they start to get leaky. That appears to be exactly the same trajectory for female people who take cross-sex hormones, but there hasn’t been much in the way of research.”

She said she had worked with around 20 detransitioners who sought help for pelvic floor issues - and many more from around the world had been in touch - but that there was a “stigma” around incontinence and that people were “embarrassed” and minimised the issue.

“Wetting yourself is something that just is not socially acceptable, and it stops people from exercising, it stops them from having intimate relationships, it stops them from travelling, it has work impacts,” she said.

“The impact a bit of leaking has on these young people’s lives is huge. It really needs to be properly discussed within gender clinics because I would expect that almost 100 per cent of female people that take cross-sex hormones will end up with these problems,” she added, noting that the study was “robust” and probably underplayed the issue.

“It’s really sad when we hear people say, ‘nobody ever told me this’, and they should have been informed of the risks in gender clinics.”

“The menopause causes a loss of muscle mass and body strength, which affects the pelvic floor and can cause incontinence.

Women who start the menopause early or prematurely, under the age of 45, should be offered Hormone Replacement Therapy (HRT) on the NHS because the oestrogen can help prevent the onset of conditions such as coronary heart disease, osteoporosis and dementia.

Taking testosterone may accelerate the menopausal process because it stops the ovaries from functioning and reduces the amount of oestrogen the body produces.

Testosterone is also known to affect muscle mass and hair loss, and has been linked to blood clots and gallstones, but there has been little research into pelvic floor issues and incontinence.”