Draft:Transgender youth

An issue that invokes, if possible, even more hysteria than the existence of transgender adults. Among more reasonable people, apparently a debate no one wants to touch, leaving it to the experts. Unfortunately, that small group of experts - child psychologists and psychiatrists who have been working on the issue for many decades - has not always been getting it right. As things thaw on the psychological and medical front, giving some young transgender a chance to access treatment, the issue is dragged into the spotlight as a political hot-button issue.

=Approaches in psychology= The DSM has the label "gender dysphoria in children", improving the label (but not much else) from the previous "gender identity disorder in children". The (newer) ICD-11 has moved all transgender-related diagnoses from the "Mental and behavioural disorders" section to their own category "conditions related to sexual health". Transgender minors would be diagnosed with "Gender incongruence of childhood" or "Gender incongruence of adolescence or adulthood", as applicable, recognizing that the adolescent presentation is more similar to adults than children. Similarly, in the upcoming WPATH-Standards of Care 8, for the first time "children" will likewise be conceptually split from "adolescents" with separate chapter and recommendations.

In past decades, research and scientific literature have been problematic. The literature has been dominated by a small network of senior figures, whose content is significantly more conservative than their colleagues but who have set the tone. The older literature, and unfortunately some current literature, among other things misgenders patients habitually, such as categorizing AFAB people including trans boys as "natal girls" in a data table. The terms "desistance" and "persistance" are ubiquitous, despite being borrowed from the criminology literature, painting transgender identity as an undesirable behavior. With an explosive increase in research attention and widening participation, the debate started to shift around 2010.

The progressive
Cite Ehrensaft and others

The mainstream
The leader in so-called "watch and wait" approaches are Dutch clinics, which can claim good sampling because they are the only ones offering the treatment in the country. They have been extremely slowly and carefully making medical interventions available to "carefully selected candidates" who have to wait through year-long assessments, then monitoring cohorts of these patients over years of follow-up. So far, the outcome has been that we see no detrimental effects or significant regrets in "carefully selected candidates" - but the studies can't tell us one way or another what would happen if young people were allowed to access medical interventions without being made to wait for years. A sufficient amount of time to wait for follow-up studies has to pass before conclusions are drawn and treatment protocols are carefully adjusted. This would be a perfectly reasonable way of making scientific progress if rushed decisions to transition were the only risk. It completely ignores the possibility of any harm to young people who do turn out to be transgender (or even would have benefited from being allowed to experiment) and suffered through years of waiting or complete exclusion from treatment. The fate of those who attended the clinic, but did not qualify for treatment is never mentioned. The sole purpose seems to be to mollify those who fear premature transitions.

The regressive
Assume confusion

Holding on to the 80% study. Back then, diagnoses were made based on criteria such as toy or dress preference with little listening to the children; the pool of initial "children diagnosed with gender dysphoria" is not the same as it would be today, where the diagnosis is based on children's self-declaration. The original set of children is also biased to include those whose parents are sufficiently worried by, for example,  their son playing with a doll to being them to a psychiatrist. Most importantly, those throwing about the "80 % desistance rate" lump teenagers in with younger children, when we now know that older adolescents are far more likely to continue identifying as transgender.

=Talking points= Arrranged from most to least apparently reasonable: at the top of the list we have talking points coming from or shared by concerned psychologists. At the bottom, the reaction fits smoothly into the general trend of the alt-right accusing their political opponents of pedophilia, conspiracy mindsets, and viewing the world in a innocent children, sexual aggressors, and everyman protectors trichotomy.

Experimental treatments, unknown side effects
Despite having been around for a relatively long time now, being carefully and restrictively prescribed, and being the preferred treatment by international consensus, treatment with puberty blockers, gender affirming hormones, or surgery is often called experimental when minors are discussed. By the ignorant and hysterical, all of these treatments, as well as merely letting a young person socially transition, are often conflated to "giving experimental sex change surgery to children".

Relatedly, it could be mentioned that puberty blockers prescribed to transgender minors are an off-label treatment. However, this is true of many commonly prescribed medications: it simply means that the pharmaceutical industry has not run clinical trials for that specific demographic (such as children or the elderly) and/or for that specific indication.

The same puberty blockers have been prescribed to cisgender children to delay precocious puberty for a while. However, because psychologists and doctors are often reluctant to allow transgender young people to progress to gender confirming therapy until an age limit of 16 or 18, some transgender youth stay on puberty blockers for far longer than in previous cases, which could have physical and psychological risks. The situation must be assessed individually, with the trend going towards lowering age limits for gender confirming hormone therapy in such cases.

When puberty blockers turn out to be short-term physically harmless (and psychologically beneficial), concerned people start shifting the goalposts: what about the effect on bone mineral density in 30 years? We don't know, because no one has done a follow-up study that long on a relatively new treatment. The standards of evidence demanded are such that they won't be met in a while, or ever if opponents had their way. Randomized controlled trials are similarly infeasible and unlikely to ever happen.

In practice, as with any medical treatment our best estimate of the risks and benefits, including unknown far-future risks, must be weighed against the estimated harm that would arise from no treatment or from alternative treatments. Even for some people such as doctors, who would know this about medicine in general, somehow this awareness seems to go out the window as soon as the scary transgender concept is involved.