Should Transgender Youth Care be Guided by Beliefs or Science?

• Introduction
• Forces Shaping Attitudes About Transgender Care
• Sources of Controversy about Affirmative Care
• Problems Facing Transgendered Persons
• Affirmative Care Assumptions
• Conclusion
• References

Introduction

The current American approach to transgender-identified youth and adults is strongly affirmative. Many professional organizations in the United States have endorsed the safety and efficacy of social transition, puberty-blocking hormones, cross-sex hormones, and breast, genital, and facial surgeries as the ideal treatment of gender dysphoria.
 

These prestigious decade-old endorsements have led to the development of gender specialists in over 70 US clinics where children, adolescents, and younger and older adults are seen. It also has led to affirmative care being taught in medical schools, residency training programs, and various mental health continuing educational programs. For half a century, WPATH has been the key nongovernmental organization that has gathered specialists, provided courses that promulgate clinical principles, and published standards of care. WPATH represents itself as an advocacy, policy, and scientific organization.

Its membership recognizes a great need for social change as discrimination in housing, employment, health care, intrafamilial and peer relationships, and incarceration are significant cultural sources of stress for the transgendered. WPATH considers its recommendations to be scientific, even though its author-committees recognize a need for improved scrutiny of outcomes of social, medical, and surgical interventions. While it recognizes that the quality of supportive evidence is objectively low, nonetheless, it treats affirmative care as a settled scientific matter. DSM-5-TR and ICD-11 diagnostic criteria exist, elective treatment sequences have been defined, and many clinicians and patients consider affirmative care to be life-enhancing and sometimes lifesaving.  

Affirmative care, however, is not a scientifically settled matter. There is much justifiable ferment. Affirmative care is far more fraught and uncertain than WPATH and professional associations have suggested. (^1-3) It is a paradox for WPATH to portray itself as a trustworthy authoritative advocacy, policy, and scientific organization in the face of uncertainties about long-term treatment outcomes, the unexplained dramatic explosive incidence of new gender identities, and the increasing recognition of de-transition.

There is an ongoing culture war within the US about the treatment of transgender youth who are uncomfortable with their bodies. (⁴⁾ The political aspect of this culture war addresses transgender treatments as a conflict between those who support and those who oppose the civil rights of LGBTQI+ individuals. Those who question the wisdom of affirmative care are described as “anti-trans.” A medical perspective begins with a different question: Is the scientific basis for affirmative care sufficiently established? If the answers are either no or uncertain, three other questions follow.  

• Can gender specialists separate their beliefs from what is scientifically known about etiology, incidence, psychopathology, and the long-term benefits and harms of affirmative interventions?  
• Can these specialists provide parents and patients with the legal and ethical requirements for informed consent? (⁵⁾    
• Can high-quality research be designed and funded to answer the current relevant clinical uncertainties?  

Usually when health is the topic the medical profession leads the way, relying first on rigorous science, and second on the values of individual patients and their families. In the arena of trans care, however, values have historically played a more important role than science. This may be summarized as eminence-based or fashion-based medicine dominating over evidence-based medicine. As has been seen with the COVID vaccine, mask mandates, the opioid epidemic, and the FDA approval of a drug for Alzheimer’s disease, trust in the medical profession is far from universal. Consequently, what individual doctors, gender care clinics, professional societies, and mental health professionals may have to say about the ideal care of trans persons may not be the most powerful force governing social policy.    

Forces Shaping Attitudes About Transgender Care

Transgender phenomena elicit intense feelings among laypersons and professionals. Such passion, which is destructive to objective scientific appraisal, derives from many personal sources. While numerous factors influence attitudes toward transgender care, their confluence makes it difficult to judge their relative contributions to how individuals and institutions regard trans healthcare.  

There are five universal potential influences.      

1. Fascination with sex change. The intriguing question, “Can sex be changed?” has long been explored in the arts, where men and women have for centuries been presented as the opposite sex in humor, drama, dance, opera, drag, and popular music. Today, it is better understood that in a basic biological sense, sex cannot be changed, but gender presentation can, with or without medical assistance. 

2. Political sensibilities. The Left may consider transgenderism the courageous pursuit of self-expression, a civil right, a movement to improve diversity in all walks of life, and a praiseworthy social movement to eliminate discrimination. Their political values lead them to view studies and clinical services with trust. The Right, on the other hand, may consider transgenderism morally wrong, threatening to societal health, and dangerous to the health and well-being of individuals and families. These assumptions lead to a skeptical approach to studies and clinical services.

3. Religious sensibilities. These value-laden thought patterns derive from theological assumptions. They may resemble the Right or the Left. In the United States, the most vocal religious institutions on this topic lean to the political Right. 

4. Sexual orientation sensibilities. Membership in the heteronormative or sexual minority communities often generates opposite responses — the former may have initial unease with, and the latter, initial comfort with trans phenomena. One’s sexual orientation, per se, does not guarantee a particular attitude any more than one’s political or religious affiliations do. However, many of the leaders who advocate trans care identify as a sexual minority.

5. Intuitive age-related sensibilities. Intuitive sensibilities are best reflected through age. Younger and older generations have different life experiences with which to be intuitive regarding attitudes toward the transgender experience. The very existence of sexual minority communities and their entitlement to civil rights are far more visible today than was the case when older persons were growing up. These generational differences reach into each group’s system of values. 

There are four influences that are unique to professionals.  

6.Personal clinical experience. The 7th edition of WPATH’s Standards of Care (SOC) downgraded the importance of a comprehensive assessment of psychiatric co-morbidities in determining the next step. ⁶ The process of evaluation was then pejoratively referred to as gatekeeping. Prior to 2012, adults who immediately wanted hormones or surgery were often impatient, demanding, rude or dishonest about their histories. With the 2012 guidance, adults and older adolescents were assumed to know best what should be done. Respect for Patient Autonomy became the primary ethical principle to follow. The frequency of unpleasant clinical experiences dramatically diminished. When professionals experience unpleasant patients, those with conspicuous emotional impairments, or those who deteriorate with hormonal treatment, they are more likely to be avoidant of future encounters. Positive experiences with appreciative patients and families yield more willingness to engage. 

7. Knowledge of clinical reports from clinical innovators. Positive outcome studies of transgender treatments typically consist of retrospective case series without control groups and without predetermined measurement instruments. Such outcome reports are numerous for each intervention. Positive results tend to be more often published than negative or uncertain outcomes. The most influential studies for minors were published in 2011 and 2014, and while they too lacked a control group, they were interpreted as establishing the concept that selected prepubertal cross-gender identified children could benefit from affirmative social, endocrine, and surgical care. (^7),8 

Clinicians cannot be expected to keep up with the burgeoning literature; they trust what they read, heard about, or were taught. Such learning reflects a chain of trust that is basic to all medical education. It has become apparent that the chain of trust is not necessarily trustworthy, as positive studies are published in peer-reviewed journals only to have their conclusions criticized by knowledgeable academics. Once clinicians begin to facilitate patients’ transitions based on the studies they have seen, they believe they are facilitating happy, successful, productive lives even without having the reassuring follow-up information to verify their beliefs.

8. Scientific studies. Groups of studies demonstrate patterns that individual studies do not. Scientific data are widely assumed to dominate institutional policy. This is not necessarily so, however. For example, high desistance rates in trans children have been demonstrated in 11 of 11 studies, (9) but a committee of pediatricians created a policy of supporting the transition of grade school children. (¹⁰⁾ As a result of these often-conflicting processes and sources of data, comprehensive evaluation and psychotherapy rather than affirmative care are increasingly being recommended

9. Source of income. With 70+ clinics in the United States, with many individuals in private practice who practice affirmative therapies, and with special units within prisons to support trans inmates, the attitudes of new-to-this-arena clinicians may be quickly determined by their work environment. In these settings, disapproval of affirmative care, which may grow with experience, as it did for many psychologists at the Tavistock Clinic, means resignation or job loss. 

Sources of Controversy about Affirmative Care

1. Morality — Conservative citizens, religious denominations, politicians at local, state, and federal levels, and some gay, lesbian, and feminist groups view affirmative care as dangerous. They ask, “What are we doing to these young people? What will be the outcome for them and their families? Do doctors really know what is best for my son or daughter? Why is it acceptable to sterilize young people? Why is the suicide rate high after completion of medical and surgical interventions?” Such questions burrow down into moral values.

some religious groups assert that since God made male and female, this provides fundamental guidance to decision-making

Some religious groups assert that since God made male and female, this provides fundamental guidance to decision-making. However, because these groups have historically been similarly against homosexual lives, the power of this theological assumption is politically diminished for many others.

Some gay and lesbian organizations see affirmative care of feminine boys and tomboys as an attempt to eliminate gay and lesbian people. Almost all groups recognize that cross-gender identification is nothing new. What is new is its dramatically increased incidence and Medicine’s response to it.  
 

2. Questions Emanating from Medical Ethical Concerns

• Are children and adolescent patients experienced enough, cognitively mature enough, to make life-altering decisions that will predispose them to known challenges such as sterility, sexual dysfunction, decades-long medical care, discrimination, and loneliness (^{11, 12)}  
• Do their frequent co-existing psychiatric diagnoses further impair their ability to thoughtfully consider the consequences of each of the steps of affirmative care? 
• Are affirmative professionals knowledgeable about the limitations of their recommendations? 
• Do they know the inadequacies of the outcome data supporting the policies of socialization of children and endocrine and surgical interventions with adolescents?
• Do they know the fate of most patients given hormones a few years after they age out of pediatric endocrinology?
• Are they aware of the rates of complications, physiological consequences, long term unhappiness after the surgical procedures that they recommend?
• Are parents sufficiently informed about the limitations of outcome data?
• Are they told of Sweden’s, Finland’s, UK’s, and France’s shifts towards psychotherapeutic-first interventions?
• Are they informed about the social, economic, vocational, physical, and mental health problems of transgendered adults? 
• Are they told about detransition following hormonal and surgical treatments? 
• Are they told about the elevated suicide rates after surgical treatment of adults? 

3. Confirmation bias — When defending a particular position, authors tend to quote studies supporting their position and ignore contrary findings or glibly dismiss them as methodologically unsound. This confirmation bias creates important scientific concerns on both sides of the debate. Science advances by defining controversy and designing a study that may better answer a specific question. Independent reviews have concluded that the evidence is not convincing that puberty blockers and cross-sex hormone administration lastingly improve mental health, decrease suicidal ideation, or eliminate gender dysphoria. (¹³⁾ 

The Endocrine Society acknowledges a low level or very low level of supportive evidence. Advocates, however, portray certainty that science has already demonstrated these lasting benefits without significant harm. When they list supportive studies there is no mention of the published criticisms of them. A scientific review is characterized by balance; it is not performed only by those who deliver the treatment. (^14,15) Trustworthy reviews point out the limitations of studies and ideally suggest a study design to answer the specific question.  

4. Political — Nowhere in Medicine has free speech been as limited as it has been in the trans arena. Skeptics are being institutionally suppressed. Critical letters to the editor in journals that published affirmative data are refused publication, symposia submitted for presentation at national meetings are rejected, scheduled lectures are canceled, and pressure has been exerted to get respected academics fired. A notable exception to this pattern occurred when a paper investigating the long-term mental health outcomes of trans adults (a basic unanswered question) was published in the American Journal of Psychiatry.

It, of course, had undergone a peer review process by experts in gender care. When the authors asserted in their online publication that their data supported increased access to surgeries, the editor received seven critical letters. In response, Dr. Kalin had two independent statisticians review the work. They agreed with the twelve authors of these letters to the editor that the data did not demonstrate improvement in mental health. The editor published the original article, the seven letters, and the authors’ response. The authors retracted their conclusions. (^15,16) When critical letters have been sent to other journals, they have been rejected. As a result, they are published in separate journals.

This makes it more difficult for clinician readers of the original journal to know about the critique. Unless published with open access, the original flawed article’s limitations are difficult to access in another journal. A significant paywall is often encountered to obtain articles in journals to which the professional does not subscribe. Given the well-known attacks on those who question the prevailing wisdom of affirmative care, it is not surprising that many mental health professionals avoid working with these individuals and their families for fear of being labeled as anti-trans, transphobic, or conversion therapists.  
 

5. Familial — The parents, siblings, and extended family members, each of whom have different relationships and responsibilities for the trans-declared person, typically have intense feelings about their relative’s gender change. Family members’ affects, attitudes, and behaviors derive from one or more of the five sources discussed above but take on a new poignancy. While parents are the only ones that professionals deal with, the intrafamilial ramifications affect everyone.

Parents have realistic, reasonable concerns. What will gender change mean for my child’s developmental future physical, social, and mental health? Their assumptions that the outcome will be negative often create an acute depression. This intensifies when their expectation of informing the mental health professional (MHP) about the child’s development, personality, and previous challenges.

Many parents are distressed when the MHP seems far more interested in making the diagnosis and declaring their belief in affirmative care. Parents who have not previously seen behavioral evidence or heard expressions of cross-gender identifications prior to puberty want this new identity to be taken away. Other concerns emerge over time. How will the gender change impact siblings and grandparents? How to discuss it with others? How to ensure we don’t lose our relationship? What to do with one’s anger at the child and one’s guilt of not seeing this earlier? How to find an MHP who will not quickly affirm but is willing to spend time understanding the family situation? 

Parents who are not supportive are often described as transphobic by their child. They often learn this accusation on the Internet. A more accurate and kinder description of these parents might be trans-wary or trans-opposed. When transphobic is used, it induces some adolescent patients to behave hatefully toward their parents. While the medical profession focuses on the patient, parents are immersed in a dramatic conflict within the home. Gender specialists only gradually become aware of this when they follow the family. This is one of the reasons for an extended evaluation process. (^8, 17)   

Problems Facing Transgendered Persons

There is agreement about the challenges that transgender adults as a group are facing. The medical profession has been repeatedly told that the explanations for the poor state of physical and mental health and the diverse health disparities are minority stress, discrimination, and barriers to health care. (¹⁸⁾ There is no mention in such discussions of the possibility that the mental health of a trans person may be intrinsically compromised even though many studies have shown the poor mental health of children before the diagnosis of gender dysphoria is made. (¹⁹⁾ 

gender minorities are more likely to live in poverty, be unemployed, be victimized by domestic partners, be homeless at some time, and be on disability

Rather, discrimination experienced by some in healthcare settings and fear of mistreatment in health facilities by others are emphasized. Higher rates of cardiovascular diseases, obesity, cancer, sexually transmitted diseases including HIV, syphilis, hepatitis C, and papillomavirus, and shorter life spans have been noted. Higher rates of depression, anxiety, substance abuse, suicide attempts, and suicide, (²⁰⁾ as well as seeking psychiatric services have been documented. 2¹ Gender minorities are more likely to live in poverty, be unemployed, be victimized by domestic partners, be homeless at some time, and be on disability. (²⁰⁾   

Nowhere in these well-documented patterns is the suggestion that what is known about adult trans populations should create more caution about affirmative care for minors. Rather, many articles urge better medical education to promote affirmative care for young persons, (^{20, 22)} or for medical institutions to fight against the legislative forces that are attempting to limit affirmative care to minors. (^{23, 24)} These authors ignore the more cautious approaches developing in Europe.  
 

Affirmative Care Assumptions

The following concepts, sometimes articulated as principles of care, (⁶⁾ enable the conviction that more, rather than less, affirmative care is indicated. When these ideas are presented as unproven, those who practice or support affirmative care of youth often react with hostility.  

• Trans identity is immutable  
• Trans identities are primarily caused by prenatal biological forces  
• Sexual orientation is entirely independent of gender identity    
• No form of gender identity is abnormal or a symptomatic reflection of some other problem  
• Gender dysphoria is a serious medical condition that requires medical intervention — if the patient wants it  
• Associated emotional problems are primarily due to living in a discriminatory world    
• No effective alternative approaches to affirmative care exist 
• Attempts to provide psychotherapy are unethical varieties of conversion therapy   
• Affirmative care lastingly improves mental health and social function  
• Affirmative care reduces the rates of suicidal ideation and prevents suicide  
• Young teens know best what will make them happy in the future  
• Meeting diagnostic criteria for Gender Dysphoria predicts a good outcome 
• Regret and de-transition are rare among these patients  

Most of these assumptions originally appeared in the 7th version of WPATH’s Standards of Care and can be found in its 8th edition. These are often presented in courtrooms as well-established facts. Incongruence between one’s gender identity and their biologically sexed body is typically distressing among the patients that clinicians see. Affirmation conceptualizes diminishing the distress through changing the body. Affirmation rejects approaching the distress through the mind.

But advocates then label those who do as “unethical.” Affirmative therapy aims to convert the body of the patient, but they label those who want to first do a therapeutic exploration of the patient’s life as conversion therapists. In doing so, they invoke the original meaning of conversion therapy that referred to psychiatric misadventures of trying to cure homosexual persons of their orientation. (²⁾  

Despite the hopes of patients, families, and professionals, affirmative care does not promise to ameliorate all the patient’s symptoms, items #9 and #10 notwithstanding. When mental health difficulties continue, the clinician can revert to the idea that affirmation is the treatment only for the incongruity of gender and sex.

When gender dysphoria does not improve or increases after endocrine treatment, the patients look to surgery or several surgeries to lessen their incongruence. The hormonal treatments are then viewed as merely a step along the way. When all surgical treatments are completed (a significant minority have new urinary and sexual difficulties and a large minority undergo reoperations) without an improvement in mental health and function (elevated rates of psychiatric care and suicide), clinicians can remind themselves that no treatment helps everyone.  

When an affirmative therapeutic process is begun in youth, it is apparent that most patients are manifesting significant developmental challenges and psychiatric diagnoses. (²⁵⁾ By not seriously addressing the commonly associated problems of autism, social anxiety, depression, isolation, self-harm, eating disorders, suicidal ideation, and substance abuse, the clinician-patient-parent triad colludes in the assumption that these problems are due to the gender incongruence and will be ameliorated by transition.

Given what is known about the impact of transition itself on interpersonal relationships, (26) the impact of hormones and surgery on fertility, sexual function, and life expectancy, (²⁷⁾ promises of a happy, successful, full life should be skeptically viewed as a poignant, compassionate hope until science can verify these expectations.   
 

Conclusion

It is not reasonable to think that elective affirmative care sequences will help every patient. One tragic outcome, therefore, is insufficient to interrupt care for all others. It is reasonable, however, to ask the question, “What is the rate of harm of such care?” To provide an answer, the field needs to define and operationalize terms such as regret, suicide attempt, psychiatric care, self-harm, substance abuse, physical or mental disability, depression, detransition, and all-cause mortality.

The field also needs to agree on when and how these parameters are to be measured. Agreement about definitions, valid measurement tools, and intervals of measurement do not yet exist. Stakeholders should ask, “What rates of harm should limit the employment of affirmative care?” Would 20%, 30%, or 40% of evidence of harm after five years, for instance, be enough?

after 60 years of evolving surgical care for this form of psychological pain, neither the rates nor the parameters of benefits and harm are known

After 60 years of evolving surgical care for this form of psychological pain, neither the rates nor the parameters of benefits and harm are known. When studied at all, they are methodologically limited. The state of the art is that beliefs, not follow-up data, rule the treatment of transgendered persons’ struggles with their bodies and minds.  
 

References

1. Dahlen, S., Connolly, D., Arif, I., Junejo, M. H., Bewley, S., & Meads, C. (2021). International Clinical Practice Guidelines for Gender Minority/trans People: Systematic Review and Quality Assessment. BMJ Open, 11(4), e048943.

2. Clayton A. (2022). The Gender Affirmative Treatment Model for Youth With Gender Dysphoria: a Medical Advance or Dangerous Medicine Archives of Sexual Behavior, 51(2), 691–698.

3. Balon R. (2022). Commentary on Levine Et Al: Festina Lente (Rush Slowly). Journal of Sex & Marital Therapy, 1–4. Advance online publication. 

4. Douthat, R. Opinion | How to Make Sense of the New LGBT Culture War. New York Times April 13,2022. https://www.nytimes.com › transgender-culture-war

5. Levine, S. B., Abbruzzese, E., & Mason, J. W. (2022). Reconsidering Informed Consent for Trans-identified Children, Adolescents, and Young Adults. Journal of Sex & Marital Therapy, 1–22. Advance online publication.

6. Coleman, E., et al, (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232.

7. de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., & Cohen?Kettenis, P. T. (2011). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. The Journal of Sexual Medicine, 8(8), 2276–2283. 

8. de Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics, 134(4), 696–704.

9. Cantor JM. (2020). Transgender and Gender Diverse Children and Adolescents: Fact-checking of AAP Policy. J Sex & Marital Therapy, 46(4):307-313.

10 .Rafferty, J., Committee on Psychological Aspects of Child and Family Health, Committee on Adolescence, and Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness (2018). Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, 142(4), e20182162.

11. Vrouenraets, L., de Vries, A., de Vries, M. C., van der Miesen, A., & Hein, I. M. (2021). Assessing Medical Decision-making Competence in Transgender Youth. Pediatrics, 148, e2020049643. Advance online publication. 

12. Latham A. (2022) Puberty Blockers for Children: Can They Consent? The New Bioethics, 28:3, 268-291.

13. Hembree, W. C., et al. (2017). Endocrine Treatment of Gender-dysphoric/gender-incongruent Persons: an Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology and Metabolism, 102(11), 3869–3903. 

14. Dreger, A. (2015). Galileo's Middle Finger: Heretics, Activists, and the Search for Justice in Science. Penguin Group.

15. Malone, W., D'Angelo, R., Beck, S., Mason, J., & Evans, M. (2021). Puberty Blockers for Gender Dysphoria: the Science is Far From Settled. The Lancet. Child & adolescent health, 5(9), e33–e34. 

16. Kalin N. H. (2020). Reassessing Mental Health Treatment Utilization Reduction in Transgender Individuals After Gender-affirming Surgeries: a Comment by the Editor on the Process. The American Journal of Psychiatry, 177(8), 764. 

17. Levine S. B. (2021). Reflections on the Clinician's Role With Individuals Who Self-identify as Transgender. Archives of Sexual Behavior, 50(8), 3527–3536.

18. Liu, M, Sandhu, S, Keuroghlian AS. Achieving the Triple Aim for Sexual and Gender Minorities. (2022) NEJM 387; 4, July 28, 2022.p294-297.

19. Kaltiala-Heino, R., Sumia, M., Työläjärvi, M., & Lindberg, N. (2015). Two Years of Gender Identity Service for Minors: Overrepresentation of Natal Girls With Severe Problems in Adolescent Development. Child and Adolescent Psychiatry and Mental Health, 9(1), 9. 

20. Liszewski W, Peebles, JK, Yeung, H., Arron, S. Persons of Nonbinary Gender: Awareness, Visibility, and Health Disparities, (2018) N.Engl J Medicine, 379; 25: 2391-3   

21. Bränström, R., & Pachankis, J. E. (2020). Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-affirming Surgeries: a Total Population Study. The American Journal of Psychiatry, 177(8), 727–734. 

22. Ard, KL, Keuroghlian,  AS. (20218) Training in Sexual and Gender Minority Health: Expanding Education to Reach All Clinicians. N. Eng J Medicine, 379; 25: 2388-2392 

23. Turban, J. L., Kraschel, K. L., & Cohen, I. G. (2021). Legislation to Criminalize Gender-affirming Medical Care for Transgender Youth. JAMA, 325(22), 2251–2252. 

24. Warling A, Keuroghlian AS. Gender Dysphoria in Childhoodclinician-level Implications of Bans on Gender-affirming Medical Care for Youth in the Us. JAMA Pediatr. Published online August 08, 2022. 

25. Ristori, J., & Steensma, T. D. (2016). Gender Dysphoria in Childhood. International Review of Psychiatry, 28(1), 13–20.

26. Anzani, A., Lindley, L., Tognasso, G., Galupo, M. P., & Prunas, A. (2021). Being Talked to Like I Was a Sex Toy, Like Being Transgender Was Simply for the Enjoyment of Someone Else: Fetishization and Sexualization of Transgender and Nonbinary Individuals. Archives of Sexual Behavior, 50(3), 897–911. 

27. Levine S. B. (2018). Ethical Concerns About Emerging Treatment Paradigms for Gender Dysphoria. Journal of Sex & Marital Therapy, 44(1), 29–44. 

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