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One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria

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Archives of Sexual Behavior
One Size Does Not Fit All: In Support ofPsychotherapy forGender
RobertoD’Angelo1,2 · EmaSyrulnik2· SashaAyad2· LisaMarchiano2· DiannaTheadoraKenny2· PatrickClarke2
Received: 4 November 2019 / Revised: 17 September 2020 / Accepted: 19 September 2020
© The Author(s) 2020
Turban, Beckwith, Reisner, and Keuroghlian (2020) pub-
lished a study in which they set out to examine the effects of
gender identity conversion on the mental health of transgen-
der-identifying individuals. Using the data from the 2015
U.S. Transgender Survey (USTS) (James etal., 2016), they
found that survey participants who responded affirmatively
to the survey question, “Did any professional (such as a
psychologist, counselor, religious advisor) try to make you
identify only with your sex assigned at birth (in other words,
try to stop you being trans)?” reported poorer mental health
than those who responded negatively to the question. From
this, Turban etal. concluded that gender identity conversion
efforts (GICE) are detrimental to mental health and should
be avoided in children, adolescents, and adults. The study’s
conclusions were widely publicized by mass media outlets
to advocate for legislative bans on GICE, with the study
authors endorsing these calls (Bever, 2019; Fitzsimons,
2019; Turban & Keuroghlian, 2019).
We agree with Turban etal.’s (2020) position that thera-
pies using coercive tactics to force a change in gender identity
have no place in health care. We do, however, take issue with
their problematic analysis and their flawed conclusions, which
they use to justify the misguided notion that anything other
than “affirmative” psychotherapy for gender dysphoria (GD)
is harmful and should be banned. Their analysis is compro-
mised by serious methodological flaws, including the use of
a biased data sample, reliance on survey questions with poor
validity, and the omission of a key control variable, namely
subjects’ baseline mental health status. Further, their con-
clusions are not supported by their own analysis. While they
claim to have found evidence that GICE is associated with
psychological distress, what they actually found was that those
recalling GICE were more likely to be suffering from serious
mental illness. Further, Turban etal.’s choice to interpret the
said association as evidence of harms of GICE disregards the
fact that neither the presence nor the direction of causation can
be discerned from this study due to its cross-sectional design.
In fact, an alternative explanation for the found association—
that individuals with poor underlying mental health were less
likely to be affirmed by their therapist as transgender—is just
as likely, based on the data presented.
Arguably, even more problematic than the flawed analy-
sis itself is the simplistic “affirmation” versus “conversion”
binary, which permeates Turban etal.’s (2020) narrative and
establishes the foundation for their analysis and conclusions.
The notion that all therapy interventions for GD can be cat-
egorically classified into this simplistic binary betrays a mis-
understanding of the complexity of psychotherapy. At best,
this blunt classification overlooks a wide range of ethical and
essential forms of agenda-free psychotherapy that do not fit
into such a binary; at worst, it effectively mis-categorizes eth-
ical psychotherapies that do not fit the “affirmation” descrip-
tor as conversion therapies. Stigmatizing non-“affirmative”
psychotherapy for GD as “conversion” will reduce access to
treatment alternatives for patients seeking non-biomedical
solutions to their distress.
We originally raised our concerns about the quality of
Turban etal.’s (2020) study and the validity of their conclu-
sions in a Letter to the Editor of JAMA Psychiatry, where the
study had been published. However, our letter was rejected,
apparently due to space limitations. In the ensuing months,
as we observed Turban etal.’s unsupported claims of the
harms of psychotherapy for GD taking root globally (United
Nations, 2020), we felt compelled to write a more detailed
critique of the study, which we present here. Our aim is to
put the spotlight on the more problematic areas of Turban
etal.’s analysis and to illustrate how heeding their recom-
mendations will limit access to ethical psychotherapy for
* Roberto D’Angelo
1 Institute ofContemporary Psychoanalysis, LosAngeles,
CA90064, USA
2 Society forEvidence-Based Gender Medicine, TwinFalls, ID,
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individuals suffering from GD, further disadvantaging this
already highly vulnerable population.
Biased Sample
Turban etal.’s (2020) analysis used data from the 2015 USTS
survey of transgender-identifying individuals (James etal.,
2016). This survey used convenience sampling, a methodol-
ogy which generates low-quality data (Bornstein, Jager, &
Putnick, 2013). Specifically, the participants were recruited
through transgender advocacy organizations and subjects
were asked to “pledge” to promote the survey among friends
and family. This recruiting method yielded a large but highly
skewed sample. While Turban etal. acknowledged that the
USTS may not be representative of the U.S. transgender
population, they treat it as a valid source of data for major
policy recommendations, disregarding the significant bias in
the underlying data.
To demonstrate this apparent bias, we have constructed
Table1, which compares the demographic characteristics of
the USTS participants to those of transgender participants
from a high-quality probability sample collected by the Cent-
ers for Disease Control Behavioral Risk Factors Surveillance
System (BRFSS) (Baker, 2019; CDC, 2014–2017). As Table1
illustrates, even after applying weighting to correct for known
survey biases, the USTS participants were far more likely to be
young (42% vs. 22% were 18–24years old) and educated (47%
vs. 14% had completed post-secondary education) than BRFSS
participants. They were far less likely to own a home (16% vs.
55%) or to be married or coupled (18% vs. 46%). They were
also much more likely to have a non-binary identity (38% vs.
22%) and a markedly different self-reported sexual orientation:
Only 15% of the USTS participants reported a heterosexual
orientation, compared to 69% of the BRFSS participants. (It
is not clear if sexuality in either case was reported relative to
one’s sex or gender identity.)
A number of additional data irregularities in the USTS
raise further questions about the quality of data captured by
the survey. A very high number of the survey participants
(nearly 40%) had not transitioned medically or socially at
the time of the survey, and a significant number reported no
intention to transition in the future. The information about
treatments received does not appear to be accurate, as a num-
ber of respondents reported the initiation of puberty blockers
after the age of 18years, which is highly improbable (Biggs,
2020). Further, the survey had to develop special weighting
due to the unexpectedly high proportion of respondents who
reported that they were exactly 18years old. These irregu-
larities raise serious questions about the reliability of the
USTS data.
In addition to these demonstrable data problems, there are
a number of other biases in the USTS data that likely skewed
the responses. By targeting transgender advocacy groups,
the survey underrepresented the experiences of transgender
individuals who are not politically engaged. The emphasis
on the survey’s goals to highlight the injustices suffered by
transgender people during the recruitment stage and in the
introduction of the survey instrument itself made it vulner-
able to overreporting of adverse experiences due to “demand
bias” (also known as the “good subject effect”). This form of
bias occurs when the researchers reveal their hypothesis and
aims, which encourages participants to support the inves-
tigator’s aims with their answers (Nichols & Maner, 2008;
Orne, 1962; Weber & Cook, 1972). Finally, the experiences
of detransitioners and desisters were not included, as they
were disqualified from completing the survey. Failure to
include detransitioned and desisted individuals in research
regarding psychological interventions for GD is a serious
oversight. These individuals, whose transgender identifi-
cation was transient, may have been hurt by therapies that
affirmed them as transgender, and may have benefitted from
therapies that helped them successfully ameliorate their GD
(D’Angelo, 2020b).
These serious limitations of the USTS survey greatly
undermine the validity of the findings it produced. It is
imperative that any analysis based on this low-quality biased
sample is validated using a high-quality probability sample
before any recommendations stemming from the analysis of
these data can be used to shape clinical or policy decisions.
Invalid Measure ofGender Conversion
Turban etal.’s (2020) conclusions rest on the assumption
that they have a valid way of determining whether or not a
respondent was exposed to the unethical practice of conver-
sion therapy. Yet, the USTS question they relied on (Ques-
tion 13.2) is too non-specific to serve as a valid measure
of gender conversion therapy. Firstly, the question conflates
mental health encounters with interactions with other types
of professionals. Secondly, there is no information about
whether the recalled encounter was self-initiated or coerced.
Thirdly, it does not differentiate between diagnostic evalua-
tions or a specific therapeutic intervention. There is also no
information about whether the focus of the encounter was
gender dysphoria or another condition. And finally, it does
not determine whether shaming, threats, or other unethical
tactics were utilized during the encounter. This lack of con-
text and detail renders the question incapable of differentiat-
ing between ethical non-affirmative (neutral) encounters and
unethical conversion therapy.
Consider a common situation where the patient is seek-
ing approval for medical treatment for GD, where the role
of the therapist is to assess the individual’s mental health to
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ensure that GD is not secondary to another condition. Such
encounters can be experienced by patients as an attempt to
withhold the treatment they so desperately want (Chiland,
1997). Further, patients with psychiatric diagnoses, highly
prevalent in transgender-identifying populations (Gijs, van
der Putten-Bierman, & De Cuypere, 2013; Goodman &
Nash, 2018; Wanta, Niforatos, Durbak, Viguera, & Altinay,
2019), can potentially experience or misinterpret neutral
Table 1 Comparison of
demographic characteristics
of transgender-identifying
individuals in the 2015 US
Transgender Survey (USTS)
and the Behavioral Risk Factor
Surveillance System Survey
(BRFSS) 2014–2017
a US Transgender Survey, 2015 (James etal., 2016). Weighted data
b CDC BRFSS Survey, 2014–2017 (Baker, 2019). Weighted data
c Sexual orientation reported based on the respondent self-identification
d Combines all the response options other than “homosexual,” “lesbian/gay,” or “bisexual.”
e Calculated using 2014–2017 BRFSS data (CDC, 2014–2017). Weighted data
USTS, 2015a
Transgender (n = 27,715)
(n = 3075)
Gender identity
Transgender women (male to female) 33% 48%e
Transgender men (female to male) 29% 30%e
Non-binary/gender-non-conforming 38% 22%e
Sexual orientationc
Heterosexual 15% 69%
Lesbian or gay 16% 10%
Bisexual 14% 15%
Otherd55% 7%
18–24 42% 22%
25–44 42% 30%
45–64 14% 32%
65 + 2% 17%
White, non-Hispanic 62% 55%
Black, non-Hispanic 13% 16%
Asian, Native Hawaiian, or Pacific Islander 5% 5%
Other, non-Hispanic 3% 5%
Hispanic 17% 19%
Education level
Did not graduate high school 2% 21%
Graduated high school 11% 33%
Some college or technical school 40% 32%
Graduated college or technical school 47% 14%
Annual household income
< 25,000 38% 39%
25,000–49,999 24% 24%
50,000 + 38% 37%
Home ownership
Own 16% 55%
Rent 44% 35%
Other arrangement 40% 10%
Marital status
Married or coupled 18% 46%
Divorced, separated, or widowed 10% 21%
Never married 72% 33%
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interpersonal interactions as invalidating or rejecting (Bar-
now etal., 2009; Beck & Bredemeier, 2016; Gotlib, 1983).
Not only does the survey question provide no detail to help
discriminate between these essential therapy encounters and
unethical conversion therapy, but it arguably biases the recall
of neutral encounters toward recall of conversion by using
emotionally charged language (e.g., “stop you being trans”)
and by conflating recall of religiously motivated encounters
with clinical ones.
Turban etal. (2020) ignored these issues and instead cre-
ated a veneer of certainty by referring to USTS question
13.2 as GICE and used it throughout the paper as though it
were a valid equivalent of conversion therapy. Not only it the
term itself novel (the lead author referred to the same USTS
question by yet another term, “PACGI,” in a publication
just weeks earlier [Turban, King, Reisner, & Keuroghlian,
2019]), but its equivalency to conversion therapy is highly
debatable, in part due to the fact that the term itself has not
been defined, other than through a circular reference to USTS
question 13.2 itself.1 Accounting for the many gray areas in
the question wording, we propose that GICE is “any profes-
sional encounter which the subject recalls as non-affirmative
of their transgender identity.” As we have demonstrated, it
is not uncommon for agenda-free, neutral therapy interven-
tions to be experienced by the subjects as non-affirmative.
However, non-affirmative is not the same as “conversion,”
as the latter implies a therapist agenda and an aim for a fixed
outcome (American Psychological Association, 2015). In
fact, it is the utter inability of USTS question 13.2, and con-
sequently, GICE, to differentiate between agenda-free ethical
psychotherapy and coercive, agenda-driven therapy, that is
the Achilles heel of Turban etal.’s entire argument.
Misinterpretation ofaKey Scale
A key finding of Turban etal.’s (2020) analysis is that the
USTS participants who recalled exposure to GICE were more
likely to report severe psychological distress, as evidenced
by their score of
13 on the K-6 scale. From this, Turban
etal. concluded that GICE has adverse effects on mental
health. We will address the unsupported claim of causa-
tion in a subsequent section. Here, we would like to further
explore the use of the K-6 scale to make these claims, and
its implications.
The K-6 scale, and its cutoff score of
13, was specifically
developed by Kessler etal. (2003) in order to discriminate
between cases of non-specific psychological distress and
cases of serious mental illness (SMI). Scoring
13 is pre-
dictive of having a DSM diagnosis of schizophrenia, bipolar
disorder, and a range of other major mental health conditions
that cause serious functional impairment (Substance Abuse
and Mental Health Services Administration, 2020). Thus,
Turban etal.’s (2020) finding of an association between the
recall of GICE and scoring
13 actually suggests that the
USTS participants recalling GICE were more likely to have
a severe mental illnesses diagnosis than those not recalling
GICE. Further, any claim of causation, which Turban etal.
continue to suggest throughout the paper (however unsup-
ported by the study design), would imply that exposure to
GICE caused serious mental illness, in previously mentally
well populations. This is a highly speculative and implausible
hypothesis, which further challenges their claims.
Omission ofaKey Control Variable
Turban etal.’s (2020) hypothesis, namely, that GICE expo-
sure (during lifetime, as well as in childhood) causes poor
mental health and contributes to suicide attempts, is further
weakened by a significant flaw in their data analysis: failure
to control for the individuals’ pre-GICE-exposure mental
health status. Not only does this critical omission confound
the association between exposure to GICE and present men-
tal health, but it may mask reverse causation, namely, that it
was the individual’s underlying poor mental health that led
to their experience of GICE in the first place.
Let us revisit the example of a common clinical encounter
in which a person with GD and one or more comorbid psy-
chiatric conditions presents for assessment with the goal of
obtaining approval for cross-sex hormones. An assessment of
such a complex presentation generally requires multiple ses-
sions and involves ascertaining whether the GD is secondary
to another condition. It is also likely that the clinician might
focus on treating the comorbid condition(s) first, before pur-
suing “gender-affirming” interventions. While such a contact
would be recalled by the respondent as non-affirmative and
thus likely classified as GICE, it is the patient’s poor men-
tal health status that led to the non-affirming content of the
encounter, rather than vice versa. If the said individual had
attempted suicide in the past or continued to struggle with
mental illness more recently, Turban etal.’s (2020) analysis
would erroneously conclude that GICE was likely respon-
sible for those difficulties, when, in fact, no such causation
In fact, failure to control for the subjects’ baseline mental
health makes it impossible to determine whether the men-
tal health or the suicidality of subjects worsened, stayed the
same, or potentially even improved after the non-affirming
encounter. Given the high rate of co-occurring mental illness
in transgender-identifying patients (Gijs etal., 2013; Good-
man & Nash, 2018; Wanta etal., 2019), failure to control for
prior mental health status is a serious methodological flaw.
1 Psychological Attempts to Change Gender Identity.
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Internal Inconsistencies inMental Health
Turban etal.’s (2020) finding that mental health outcomes
of persons exposed to GICE are worse than those whose
encounters were “gender-affirming” is weakened by inter-
nal inconsistencies in the mental health outcome meas-
ures. We have already discussed the fact that the threshold
chosen by Turban etal. on the K-6 scale detects serious
mental illness, rather than distress. Another measure of
psychological distress chosen by Turban etal.—substance
misuse—was not significantly different between GICE and
the non-GICE group. More importantly, there is a lack of
consistency in the suicide measures. While lifetime sui-
cide attempts were elevated among the GICE group, total
suicide attempts in the prior 12months, as well as suicide
attempts requiring hospitalization, which generally indicate
more serious attempts rather than non-suicidal self-injury,
were not significantly different between the two groups.
Turban etal. did not address this inconsistency. Nor did
they explore the relationship between suicidality and the
higher levels of serious mental illness among the GICE
group, despite the well-documented link between serious
mental illness and suicide (Bertolote, Fleischmann, De
Leo, & Wasserman, 2004). Turban etal. did not heed their
own warning not to attribute the increased lifetime suici-
dality entirely to GICE since “other factors are also likely
to be associated with suicidality among gender-diverse
people.” Instead, they treat the inconsistent and unclear
association between GICE and suicidality as causative and
infuse it with an air of certainty by elevating it into title
of their paper.
Claim ofCausation When Only
anAssociation Has Been Found
Although a causative relationship between recalled GICE
and adverse mental health status is possible (even if direc-
tion of the causality is unclear), the cross-sectional design
of the USTS is not capable of determining causation. While
Turban etal. (2020) acknowledged this limitation and cor-
rectly referred to the relationship they found as an asso-
ciation, they strongly implied causation throughout their
discussion, as well as in their “Conclusions and Relevance”
section, which states, “These results support policy state-
ments from several professional organizations that have
discouraged this [GICE] practice.” Presenting a highly
confounded association as causation is a serious error,
given its potential to dangerously misinform and mislead
clinicians, policymakers, and the public at large about this
important issue.
The fact that coercive techniques to force unwanted changes
in individuals are unethical and have no place is modern
psychotherapy is self-evident and needs no additional jus-
tification. However, as we have demonstrated, Turban etal.
(2020) failed to prove that GICE, as defined by affirmative
answers to the USTS question, caused poor mental health or
suicide attempts in study subjects. Further, since Turban etal.
failed to establish equivalence between GICE, which likely
subsumes a range of ethical non-affirmative interventions,
and “gender conversion therapy,” which implies unethical
and coercive attempts to force a change in one’s identity,
their use of the study findings in support of a ban on “gender
conversion therapy” is without any foundation.
Rather than appropriately acknowledging the significant
study limitations and calling for more research, Turban etal.
(2020) used their flawed findings to engage in a media cam-
paign promoting legislative bans of GICE. Two of the study
authors penned an op-ed in which they state, “It’s time for
conversion efforts to be illegal in every state, before more
people die” (Turban & Keuroghlian, 2019). Turban, the lead
author, repeated these sweeping, emotive claims on several
highly visible national media platforms (Bever, 2019; Fitzsi-
mons, 2019). In contrast, the debate regarding this study in
the scientific arena was not allowed to occur. To the best
of our knowledge, all of the letters written to the Editor of
JAMA Psychiatry, many by respected academics and clini-
cians who outlined the serious problems in the study, have
been rejected (some of them were later submitted as non-
indexed comments in the online publication). The omission
of these important arguments from the scientific discourse
stifles scientific debate and perpetuates the current politiciza-
tion of transgender health care, where treatment decisions are
increasingly legislated by politicians.
While the poor study methodology is unfortunate, argu-
ably, the most problematic aspect of Turban etal.’s (2020)
work is the choice to view psychotherapy through a binary
of “affirmation” versus “conversion,” resulting in a confla-
tion of ethical non-affirmative psychotherapy with conver-
sion therapy. The self-evident crudeness of the GICE versus
“affirmation” binary, promoted by Turban etal., and the
potential harms of such a simplistic view of psychotherapy
are illustrated by the following examples.
Consider a female victim of sexual assault, who sub-
sequently develops an intense discomfort with her female
anatomy and expresses a desire to undergo biomedical inter-
ventions to change her body. It would be unethical for the
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clinician to overlook the contribution of sexual victimization
to this nascent GD. A therapist enthusiastically supporting
this patient’s new male identity would be failing to provide
appropriate treatment for what amounts to a post-traumatic
condition, instead providing an inappropriate treatment
with the potential to harm. Similarly, a boy who has been
traumatized by relentless bullying due to his gender “non-
conformity” (e.g., interest in classical music or fashion and
avoidance of sports) may conclude that if he were a girl then
he would “fit in” and the humiliation would stop. In this case
too, gender-affirming interventions miss the mark when what
this traumatized young person requires is psychotherapy.
Another obvious difficulty arises when same-sex attracted
adolescents report cross-sex identifications. Research shows
that a high number of homosexual adults have experienced
periods of “cross-sex” behaviors and cross-gender identifi-
cation in childhood and adolescence, often to a degree that
is severe enough to warrant the diagnosis of GD, or gen-
der identity disorder, as it was previously known (Bailey
& Zucker, 1995; Bell, Weinberg, & Hammersmith, 1981;
Hiestand & Levitt, 2005; Li, Kung, & Hines, 2017). When
a dysphoric same-sex attracted young person in the midst of
this developmental process presents for mental health care,
a clinician overtly affirming the patient’s cross-sex gender
identity would be failing this patient by not addressing the
patient’s struggle with same-sex attraction and/or internal-
ized homophobia. In fact, some homophobic societies and
indeed families that reject homosexuality among their chil-
dren have embraced the “affirmative” biomedical pathway
(Bannerman, 2020; Hamedani, 2014), which poses a question
as to whether “affirmative” care in some instances serves the
role of gay conversion therapy.
Further, GD can present as a transient symptom that
resolves spontaneously or in the context of developmentally
informed psychotherapeutic treatment. Some common exam-
ples of transient gender-dysphoric states include adolescents
girls, often on the autism spectrum, experiencing distress
around the physical and social changes of puberty or gen-
der-non-conforming young women struggling with shame
about being seen as “butch.” These individuals, searching for
ways to understand and remedy their distress, can incorrectly
attribute their discomfort to being transgender. Several case
reports (Churcher Clarke & Spiliadis, 2019; Lemma, 2018;
Spiliadis, 2019) indicate that the distress of young people
with GD can lessen or resolve with appropriate psychothera-
peutic interventions that address the central issues.
If anything other than “affirmation” is viewed as GICE,
it follows that the provision of psychotherapy in these clini-
cal scenarios would be seen as harmful conversion efforts.
Yet these therapeutic interventions do not aim to convert or
consolidate an identity, but instead aim to help individuals
gain a deeper understanding of their discomfort with them-
selves, the factors that have contributed to their distress, and
their motivations for seeking transition (Bonfatto & Cras-
now, 2018; D’Angelo 2020a). These exploratory questions
are consistent with the principle of therapeutic neutrality—a
cornerstone of ethical psychotherapy (Simon, 1992). In fact,
both “conversion” and “affirmation” therapy efforts carry the
risk of undue influence, potentially compromising patient
autonomy. In contrast, the provision of a neutral, unbiased
psychotherapeutic process that allows these patients to clarify
their feelings and assess the various treatment options, which
range from non-invasive to highly invasive, irreversible pro-
cedures, is arguably the only way that meaningful informed
consent for the latter can be obtained (Levine, 2018).
Turban etal.’s (2020) unproven assertion that non-affirming
therapies are dangerous stands in contrast to the documented
risks and uncertainties associated with hormonal and surgi-
cal interventions that are a core part of the “affirmation” treat-
ment path. Until recently, puberty blockers were considered
safe and fully reversible, but there is now emerging evidence
of their adverse effects on the bone and brain health (Klink,
Caris, Heijboer, van Trotsenburg, & Rotteveel, 2015; Joseph,
Ting, & Butler, 2019; Schneider etal., 2017). Additionally,
since almost all of the children treated with puberty blockers
proceed to cross-sex hormones (de Vries etal., 2014), concerns
have been raised that puberty blockers may consolidate gender
dysphoria in young people, putting them on a lifelong path of
biomedical interventions.
Cross-sex hormones are associated with cardiovascular
complications, including a fourfold increased risk of heart
attacks in biological females, and a threefold increase in the
incidence of venous thromboembolism in biological males
(Alzahrani etal., 2019; Nota etal., 2019). “Gender-affirming”
surgeries can cause urethral stricture, neo-vaginal stenosis
and prolapse, and long-term post-mastectomy pain (Larsson,
Ahm Sørensen, & Bille, 2017; Manrique etal., 2018; Rashid
and Tamimy, 2013; Santucci, 2018). The effects of “gender-
affirmative” care on fertility have not been adequately stud-
ied, but infertility is a likely outcome, depending on the spe-
cific treatments pursued. It remains unclear whether fertility
concerns will be important to this group of patients as they
mature, but increasingly, gender centers are recommending
fertility preservation procedures prior to undergoing hormo-
nal interventions.
Given the absence of robust long-term evidence that the
benefits of biomedical interventions outweigh the potential
for harm, especially among young people (Heneghan & Jef-
ferson, 2019), it is self-evident that the least-invasive treat-
ment options should be pursued before progressing to more
risky and irreversible interventions. To the extent that psy-
chological treatments can help an individual obtain relief
from GD without undergoing body-altering interventions,
ensuring access to these interventions is not only ethical and
prudent but also essential.
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The importance of continued access to non-affirmation –non-
conversion, agenda-free evaluation, and treatment is further
underscored by the increasing numbers of detransitioning
patients speaking out in social media forums following gen-
der transitions they have come to regret (Entwistle, 2020).
The rate of regret, detransition, and desistance from transgen-
der identification is largely unknown (Butler & Hutchinson,
2020). The majority of patients with classical, childhood-
onset gender dysphoria (61%-98%) desist from transgender
identification some time in adolescence or young adulthood
(Korte etal., 2008; Steensma, McGuire, Kreukels, Beek-
man, & Cohen-Kettenis, 2013; Zucker, 2018). The minority
who persist with their transgender identification into adult-
hood and undergo “gender-affirmative” surgeries have been
reported to have low rates of regret (van de Grift, Elaut, Cer-
wenka, Cohen-Kettenis, & Kreukels, 2018) and detransition
(Dhejne, Öberg, Arver, & Landén, 2014). However, these
studies may understate true regret rates due to overly strin-
gent definitions of regret (i.e., requiring an official applica-
tion for reversal of the legal gender status), very high rates of
participant loss to follow-up (22%-63%) (D’Angelo, 2018),
and an unexplored relationship between regret and high rates
of post-transition suicide (Dhejne etal., 2011).
The novel cohort of young GD patients increasingly pre-
senting for help is poorly understood. It is overrepresented by
adolescent females with recent-onset GD and with comorbid
mental health and neurocognitive issues (Bewley, Clifford,
McCartney, & Byng, 2019; de Graaf, Giovanardi, Zitz, &
Carmichael, 2018; Kaltiala-Heino, Bergman, Työläjärvi, &
Frisen, 2018; Littman, 2018; Zucker, 2019). The trajectory of
GD among these young patients, including the rates of desist-
ance and detransition, remains unknown. However, many of
us, along with our colleagues, are seeing increasing numbers
of detransitioners with adolescent-onset GD who regret not
having received exploratory psychotherapy to help them
understand their distress and the desire to transition before
they underwent irreversible medical and surgical treatments.
Equally concerning, a number report that when doubts about
their own transgender status arose, their therapists contin-
ued to affirm them as transgender, attributing their doubts to
internalized transphobia, and encouraging them to continue
medical interventions, which, in turn, unnecessarily exacer-
bated the psychological and physical harms.
Advocates of “affirmative care” tend to downplay the risks
of iatrogenic harms resulting from inappropriate transitions
and minimize the seriousness of the resulting harms by
describing them as merely “cosmetic” (Turban & Keurogh-
lian, 2018). In stark contrast to these assertions, we are seeing
increasing numbers of patients who feel deeply traumatized
by inappropriate transitions. They suffer from irreversible
physical changes, including alterations to their genitals and
sexual function, sterility, painful vaginal atrophy, chest/breast
alteration and scarring, deepening of the voice, unwanted
permanent changes to facial hair growth, male-pattern bald-
ness, urinary incontinence, and other lasting effects. Apart
from the distress that these changes cause, they also nega-
tively impact many areas of their lives, including their ability
to form a stable gender identity (many feel trapped in a “gen-
der no-man’s land”), to find romantic partners and supportive
social networks, to bear children, or to secure employment.
The process of coming to terms with these consequences of
their transition is psychologically difficult and can be pro-
foundly painful.
Given the risky and irreversible nature of “gender-affirm-
ing” treatments, it is concerning that for many years now,
there has been a lack of systematic research into the role that
developmentally informed psychotherapy can play in the ame-
lioration of GD, especially among young people. The need
for the continued development and evaluation of non-invasive
psychological treatment alternatives for GD has never been
more urgent, given the fact that over 3% of young people report
transgender identification or ideation (Johns etal., 2019).
Given the sheer magnitude of this change, and the potential
for exponential growth in the number of individuals who are
medically harmed, it is time to raise the bar on science and to
heed the first and most fundamental tenet of medicine: “First,
do no harm.”
Turban etal.’s (2020) singular endorsement of “affirmative”
therapies, which their data failed to substantiate, contrib-
utes to the alarming trend to frame any non-“affirming”
approaches as harmful. We are deeply concerned that this
false dichotomy, reinforced by Turban etal.’s unproven
claims of the harms of GICE, will have a chilling effect on
the ethical psychotherapists’ willingness to take on com-
plex GD patients, which will make it much harder for GD
individuals to access quality mental health care. We main-
tain that availability of a broad range of non-coercive, ethi-
cal psychotherapies for individuals with GD is essential to
meaningful informed consent, which requires consideration
of the full range of treatment options, from highly invasive to
non-invasive. Further, given the potential of agenda-free psy-
chotherapy to ameliorate GD non-invasively among young
people with GD, withholding this type of intervention, while
promoting “affirmation” approaches that pave the way to
medical transition, is ethically questionable.
We believe that exploratory psychotherapy that is neither
“affirmation” nor “conversion” should be the first-line treat-
ment for all young people with GD, potentially reducing the
need for invasive and irreversible medical procedures. This
is especially critical now, when we are witnessing an expo-
nential rise in the incidence of young people with GD who
Archives of Sexual Behavior
1 3
have diverse and complex mental health presentations and
require careful assessment and treatment planning.
We are concerned about the deficit in our knowledge base
about psychological interventions for GD, beyond a few suc-
cessful but small case studies, and we fear that the erroneous
conclusions presented by Turban etal. (2020) will make it
less likely that such research will be carried out in the future.
We call on the scientific community to resist the stigma-
tization of psychotherapy for GD and to support rigorous
outcome research investigating the effectiveness of various
psychological treatments aimed at ameliorating or resolving
GD. The outcomes of psychotherapeutic treatments must
be compared to those of biomedical interventions, so that
evidence-based standards of care that allow patients and cli-
nicians to make fully informed decisions about how best to
alleviate GD can be developed and put into practice.
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... Así mismo, no está justificado el énfasis en favor de la medicación afirmativa con base en mejorías a corto plazo que, por otro lado, tampoco se puede descartar que se deban a otras cosas, como posible medicación psiquiátrica y apoyo familiar que los propios autores reconocen (Tordoff et al, 2022). La mejor ayuda a niños y adolescentes no empieza por meterlos directamente en la terapia afirmativa (D'Angelo et al, 2021;Griffin et al, 2021;Levine et al, 2022;Marchiano, 2021;Zucker, 2019). ...
... La identidad sentida y la terapia afirmativa implican el "autodiagnóstico" sin más opciones para el profesional que el acompañamiento y la talla única para todos los casos (D'Angelo et al, 2021). Por otra parte, es conocida la presencia de trastornos psicológicos en adolescentes con disforia de género, entre ellos, depresión, ansiedad, conducta autolesiva, ideación y comportamiento Tabla 2. Calidad y conclusiones de la pretendida evidencia de la Guía clínica de atención a menores transexuales (Moral-Martos et al, 2022). ...
... La cuestión es cómo han llegado a ser reales, sin dar por hecho que son la expresión prístina de una esencia interior o alma inscrita en el cuerpo (Sadjadi, 2019). Lejos de ser irrelevante la investigación de la desistencia (Ashley, 2021), es fundamental para una mejor comprensión del curso natural de la disforia y la mejor ayuda para cada uno, en vez de la talla única para todos (D'Angelo et al, 2021). ...
Full-text available
La disforia de género en la infancia y la adolescencia está hoy en día más bajo el domino de la ideología queer que dentro de los conocimientos científicos y profesionales. Este dominio de la ideología se traduce en importantes consecuencias prácticas como la autodeterminación de la identidad de género con base en el sentimiento y la terapia afirmativa de la identidad sentida como la única opción aceptable. Como resultado, quedan fuera de evaluación los aspectos psicológicos y se emprenden transiciones fármaco-quirúrgicas que no resuelven el problema para todos. En particular, surge el nuevo fenómeno de los arrepentidos de haber cambiado de género y destransicionistas que quisieran volver atrás. Las profesiones sanitarias incluida la psicología, así como la psiquiatría y la pediatría, debieran reclamar ante la disforia de género los mismos estándares científicos y profesionales que aplican en los demás problemas, empezando por la exploración, la evaluación, el análisis funcional, el diagnóstico, la prudencia, la espera atenta, en vez de asumir sin más la terapia afirmativa .
... Also not justified is the emphasis in favor of affirming medication based on short-term improvements, which, on the other hand, also cannot be ruled out as being due to other things, such as possible psychiatric medication and family support that the authors themselves acknowledge (Tordoff et al, 2022). The best help for children and adolescents does not start with getting them directly into affirmative therapy (D'Angelo et al, 2021;Griffin et al, 2021;Levine et al, 2022;Marchiano, 2021;Zucker, 2019). ...
... Felt identity and affirmative therapy imply "self-diagnosis" with no other options for the professional than accompaniment and a "one-size-fits-all" approach (D'Angelo et al, 2021). On the other hand, the presence of psychological disorders is well known in adolescents with gender dysphoria, including depression, anxiety, self-injurious behavior, suicidal ideation and behavior, eating problems, and autism spectrum (Kaltiala-Heino et al, 2018). ...
... The question is how they have become real, without taking for granted that they are the pristine expression of an inner essence or soul inscribed in the body (Sadjadi, 2019). Far from desistance research being irrelevant (Ashley, 2021), it is fundamental for a better understanding of the natural course of dysphoria and the best help for each individual, rather than "one size fits all" (D'Angelo et al, 2021). ...
Full-text available
Gender dysphoria in childhood and adolescence is currently more under the domain of queer ideology than within scientific and professional knowledge. This dominance of ideology translates into important practical consequences such as self-determination of gender identity based on sentiment and affirmative therapy of felt identity as the only acceptable option. As a result, psychological aspects are left out of evaluation, and pharmaco-surgical transitions are undertaken that do not solve the problem for everyone. In particular, there is the new phenomenon of those who regret having changed their gender and detransitioners who would like to reverse the process. The health professions, including psychology, as well as psychiatry and pediatrics, should demand the same scientific and professional standards for gender dysphoria that they apply to other problems, starting with exploration, evaluation, functional analysis, diagnosis, prudence, and attentive waiting, instead of simply adopting affirmative therapy without question.
... This may be because psychotherapies aimed at changing actual gender identity have been the subject of wide criticism and found to be ineffective or even harmful, including forms of 'conversion therapy' which use coercive tactics to force identity changes (Coleman et al., 2012). Nevertheless, one must be cautious not to categorically view all non-MBM treatment approaches for GD as harmful and therefore unethical, as certain components have been shown to be helpful in GD (D'Angelo et al., 2021). However, the purpose(s) of each of these interventions, for example, to ameliorate the possible causes of the bodily dissatisfaction and distress and/or the desire to physically modify one's body, should also be broadened and more systematically investigated. ...
... This urgently requires a move away from a pure dichotomy of intervention goals (e.g. wanting versus not wanting to change one's own body) to a more dimensional view taking into account other individual facets in order to develop, examine, and then offer realistic alternatives to MBM (D'Angelo et al., 2021). ...
In recent decades, there has been a steady increase in the number of people, including adolescents, undergoing medical body modification (MBM) to alter their physically healthy bodies in invasive and nearly irreversible ways through medical treatment (e.g. surgery). While MBM is often recommended for youth with persisting gender dysphoria (GD), in body dysmorphic disorder (BDD) it has been considered contraindicated. Here, we outline the current controversies surrounding MBM practice and recommendations in adolescents with GD versus those with BDD in order to better understand under what circumstances we may or may not support adolescents who want to change their bodies medically and often irreversibly. We compare the two disorders in terms of the overlap and uniqueness of their behavioural and psychological features. In doing so, we discuss limitations of the existing (often low-quality) evidence for and against MBM in young patients. We conclude that the currently available evidence is too preliminary and far from conclusive to make any robust recommendations in terms of benefits and harms of MBM in youth with persisting GD or BDD. However, we strongly recommend further urgent scientific discussions and systematic research efforts into more robust evaluations and the identification of more precise psychological characteristics that may serve as decision criteria for or against MBM - particularly in those adolescents who did not respond to non-MBM, that is, psychiatric/psychological treatment and psychosocial support, if available at all. This will greatly benefit youth healthcare professionals in their challenging clinical practice of making decisions regarding MBM today and in the future.
... La classification de la DSM-5 affirme l'importance du critère « d'une durée minimale de 6 mois » : les études retrouvent en effet jusqu'à 20 % de jeunes qui ont des comportements, ou souhaitent avoir le sexe opposé « parfois », de façon intermittente. (D'Angelo et al., 2021) (Gauld, 2020) . ...
... (Littman, 2018) (Kaltiala-Heino et al., 2018) (D'Angelo et al., 2021. Pour ces jeunes, il semble bien plus pertinent d'explorer avec eux leur détresse concernant leur identité et leur orientation sexuelle que de traiter médicalement ...
... e(Turban et al., 2020).O uso de terapias humanizadas não deve ser banida, pois pode auxiliar o jovem transgênero, é essencial para um consentimento informado acerca de todas as opções de tratamento e tem o potencial de reduzir a necessidade de procedimentos médicos irreversíveis e pode analisar o paciente em seu contexto de maneira individualizada.(D'Angelo et al., 2021) Uma abordagem terapêutica familiar pode ser mais eficaz quando é capaz de tornar compreensível a experiência e o significado da identidade de gênero do jovem no contexto das diversas identidades da família, já que permite uma exploração mais sutil das experiências na família como um todo e resulta em melhora da saúde mental já que permi ...
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Pessoa transgênero é a que não se reconhece com seu gênero do nascimento. Tal incongruência pode ocorrer desde a infância em pequenas ações notadas pelos pais ou pelos educadores. A relação entre saúde mental e crianças e adolescentes transgênero é um assunto pouco comentado, mas é de extrema importância para a compreensão das dificuldades de modo a minimizar consequências. Dessa forma, esta revisão sistemática de literatura propõe responder à seguinte questão: “Qual a importância da psicoterapia para crianças e adolescentes transgênero?”. Assim, aplicou-se a estratégia PICO (Acrômio para Patient, Intervention, Comparation e Outcome) e analisou-se a produção científica dos anos de 2016 a 2022. Constatou-se que os estudos são limitados, mas o estabelecimento de vínculos entre pacientes transgênero e psicoterapeutas permite apoio em um momento de incertezas na vida da família e das crianças em transição e pode ser benéfico. É válido ressaltar, também, que fatores agravantes como preconceito e intolerância estão instalados na sociedade até mesmo por instituições sociais, o que aumenta a pressão social e os conflitos internos nos jovens que já não estão satisfeitos com sua identidade. Apesar da falta de discussão sobre o assunto e da baixa qualificação de muitos profissionais sobre como lidar com o público alvo, é possível promover benefícios familiares em uma melhor compreensão da temática. Certamente, o artigo busca propiciar uma abordagem mais ampla sobre aspectos médicos e psicoterápicos que são passíveis de realização e mitigar o preconceito que a sociedade em geral possui acerca de jovens transgênero.
What is happening in the United States in terms of support for trans people, as in other areas, is regularly observed and a source of inspiration at the international level; the recent political turmoil around affirmative trans care in some States, especially for minors, has a tremendous impact in Europe, being regularly used by the "camps" that argue today on this issue. However, the political context and the organization of the health and health insurance system color this support in a very specific way in the United States, and omitting these aspects or simplifying them is a source of erroneous interpretations and misinformation. Understanding these determinants is essential to define what belongs to the medical field, and to put back at the center of the discussions the interest of the people concerned, the principles of beneficence, non-maleficence and equity. In this article, we will therefore discuss the organization of care and recommendations for good practice, but also, from "non-scientific" articles and references, the political and social climate and its impact on trans health and care, including in Europe.
Este artículo pretende responder de manera clara, rigurosa y contundente las falacias formuladas en la reciente y polémica obra Nadie nace en un cuerpo equivocado. Para ello se resumirán y responderán las ideas expresadas en dicha obra capítulo a capítulo. Con esto también se pretende contestar y deshacer los habituales bulos, mitos, tergiversaciones y malentendidos que sobre la teoría queer, la identidad de género y la intersexualidad se han difundido en un sector del feminismo y de la sociedad que han asumido posiciones explícitamente transexcluyentes, pues son precisamente estos mismos prejuicios los que con mayor retórica refleja el libro aquí criticado.
In the following pages, an analysis is made of the statements concerning affirmative therapy on trans people appearing in the book “Nadie nace en un cuerpo equivocado: Éxito y miseria de la identidad de género” [Nobody is born in the wrong body: the success and misery of gender identity] (Errasti & Pérez, 2022). To this end, studies are provided that refute the information presented in this manual on issues such as ROGD, detransitions, and the alleged laxity of the affirmative approach.
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The number of people presenting at gender clinics is increasing worldwide. Many people undergo a gender transition with subsequent improved psychological well‐being (Paediatrics, 2014, 134, 696). However, some people choose to stop this journey, ‘desisters’, or to reverse their transition, ‘detransitioners’. It has been suggested that some professionals and activists are reluctant to acknowledge the existence of desisters and detransitioners, possibly fearing that they may delegitimize persisters’ experiences (International Journal of Transgenderism, 2018, 19, 231). Certainly, despite their presence in all follow‐up studies of young people who have experienced gender dysphoria (GD), little thought has been given to how we might support this cohort. Levine (Archives of Sexual Behaviour, 2017, 47, 1295) reports that the 8th edition of the WPATH Standards of Care will include a section on detransitioning – confirming that this is an increasingly witnessed phenomenon worldwide. It also highlights that compared to the extensive protocols for working with children, adolescents and adults who wish to transition, nothing exists for those working with desisters or detransitioners. With very little research and no clear guidance on how to work with this population, and with numbers of referrals to gender services increasing, this is a timely juncture to consider factors that should be taken into account within clinical settings and areas for future research.
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We performed a cross-sectional analysis of the prevalence of psychiatric diagnoses among transgender patients in clinical care using an all-payer electronic health record database. Of 10,270 transgender patients identified, 58% (n=5940) had at least one psychiatric diagnosis compared with 13.6% (n=7,311,780) in the control patient population (p<0.0005). Transgender patients had a statistically significant increase in prevalence for all psychiatric diagnoses queried, with major depressive disorder and generalized anxiety disorder being the most common diagnoses (31% and 12%, respectively). Utilizing an all-payer database, although not without limitations, enables assessment of mental health and substance use diagnoses in this otherwise small population.
This paper explores the therapeutic process between analyst and Josh, a trans man whose life had fallen apart after transition. Repetitive enactments involving hiding, deceiving and mystification constituted a prolonged therapeutic impasse. The analyst’s struggle with these binds and with countertransference confusion and anxiety, ultimately illuminated zones that had remained off-limits for a prolonged period of time. Where the couple had been snared in a bind structured by gender, they were now able to access a history of violation and to ask more profound questions about connection, aloneness, authenticity and loss.
Objective To explore a developmental understanding of childhood gender dysphoria and to compare it to the prevailing paradigm, gender-affirming care. Conclusion Viewing gender dysphoria through a contemporary developmental frame generates a different understanding of the nature of the phenomenon and its treatment and raises ethical questions about our current gender-affirming approach.
Butler and Hutchinson's clarion call (Butler and Hutchinson, 2020) for empirical research on desistance and detransition deserves careful consideration. It formally documents the needs of the emerging cohort of detransitioners, many of whom are in their teens and early twenties. In the absence of specialist services, some detransitioners have been sharing their experiences in public forums. The anecdotal reports by detransitioners indicate that systematic long‐term follow‐up of those who have been prescribed medical interventions by NHS and private clinics is essential to understanding the gestalt. Decision‐making on the basis of misinformation on the effectiveness and necessity of medical interventions for gender dysphoria is a problem, and detransitioners indicate that nonmedical interventions for gender dysphoria are sorely needed. Analysis of the political and organisational systems that have brought us to the current situation is required in order to prevent more young people from being prescribed unnecessary medical interventions for gender dysphoria.
Importance Gender identity conversion efforts (GICE) have been widely debated as potentially damaging treatment approaches for transgender persons. The association of GICE with mental health outcomes, however, remains largely unknown. Objective To evaluate associations between recalled exposure to GICE (by a secular or religious professional) and adult mental health outcomes. Design, Setting, and Participants In this cross-sectional study, a survey was distributed through community-based outreach to transgender adults residing in the United States, with representation from all 50 states, the District of Columbia, American Samoa, Guam, Puerto Rico, and US military bases overseas. Data collection occurred during 34 days between August 19 and September 21, 2015. Data analysis was performed from June 8, 2018, to January 2, 2019. Exposure Recalled exposure to GICE. Main Outcomes and Measures Severe psychological distress during the previous month, measured by the Kessler Psychological Distress Scale (defined as a score ≥13). Measures of suicidality during the previous year and lifetime, including ideation, attempts, and attempts requiring inpatient hospitalization. Results Of 27 715 transgender survey respondents (mean [SD] age, 31.2 [13.5] years), 11 857 (42.8%) were assigned male sex at birth. Among the 19 741 (71.3%) who had ever spoken to a professional about their gender identity, 3869 (19.6%; 95% CI, 18.7%-20.5%) reported exposure to GICE in their lifetime. Recalled lifetime exposure was associated with severe psychological distress during the previous month (adjusted odds ratio [aOR], 1.56; 95% CI, 1.09-2.24; P < .001) compared with non-GICE therapy. Associations were found between recalled lifetime exposure and higher odds of lifetime suicide attempts (aOR, 2.27; 95% CI, 1.60-3.24; P < .001) and recalled exposure before the age of 10 years and increased odds of lifetime suicide attempts (aOR, 4.15; 95% CI, 2.44-7.69; P < .001). No significant differences were found when comparing exposure to GICE by secular professionals vs religious advisors. Conclusions and Relevance The findings suggest that lifetime and childhood exposure to GICE are associated with adverse mental health outcomes in adulthood. These results support policy statements from several professional organizations that have discouraged this practice.
Background More young people with gender dysphoria (GD) are undergoing hormonal intervention starting with gonadotropin-releasing hormone analogue (GnRHa) treatment. The impact on bone density is not known, with guidelines mentioning that bone mineral density (BMD) should be monitored without suggesting when. This study aimed to examine a cohort of adolescents from a single centre to investigate whether there were any clinically significant changes in BMD and bone mineral apparent density (BMAD) whilst on GnRHa therapy. Methods A retrospective review of 70 subjects aged 12–14 years, referred to a national centre for the management of GD (2011–2016) who had yearly dual energy X-ray absorptiometry (DXA) scans. BMAD scores were calculated from available data. Two analyses were performed, a complete longitudinal analysis (n=31) where patients had scans over a 2-year treatment period, and a larger cohort over the first treatment year (n=70) to extend the observation of rapid changes in lumbar spine BMD when puberty is blocked. Results At baseline transboys had lower BMD measures than transgirls. Although there was a significant fall in hip and lumbar spine BMD and lumbar spine BMAD Z-scores, there was no significant change in the absolute values of hip or spine BMD or lumbar spine BMAD after 1 year on GnRHa and a lower fall in BMD/BMAD Z-scores in the longitudinal group in the second year. Conclusions We suggest that reference ranges may need to be re-defined for this select patient cohort. Long-term BMD recovery studies on sex hormone treatment are needed.
Objectives. To examine exposure to psychological attempts to change a person’s gender identity from transgender to cisgender (PACGI) among transgender people in the United States, lifetime and between the years 2010 and 2015, by US state. Methods. We obtained data from the 2015 US Transgender Survey, a cross-sectional nonprobability sample of 27 716 transgender people in the United States, to estimate the percentage exposed to PACGI in each US state. Results. Overall, 13.5% of the sample indicated lifetime exposure to PACGI, ranging across all US states from 9.4% (South Carolina) to 25.0% (Wyoming). The percentage of transgender adults in the United States reporting exposure to PACGI between 2010 and 2015 was 5% overall, and across all states ranged from 1.2% (Alaska) to 16.3% (South Dakota). Conclusions. Despite major medical organizations identifying PACGI as ineffective and unethical, 13.5% of transgender people in the United States reported lifetime exposure to this practice. Findings suggest that this practice has continued in every US state as recently as the period 2010 to 2015.