‘Transition or Die’ Is Flawed Premise Pushing Transgender Hormones, Surgeries for Youths, New Guide Says

Longterm counseling, 'informed-consent' processes advocated instead of rapid 'affirming' care

In this photo illustration, a teenager in distress poses for a picture in Arlington, Va., on June 11, 2021. Olivier Douliery/AFP via Getty Images

Some parents have been told that if they fail to support a gender-questioning child’s desire to “transition” to the opposite gender, their child may commit suicide.

But this “transition-or-die” scenario, often used to justify transgender medical treatments for minors, is factually inaccurate and “ethically questionable,” according to a new treatment guide released by the Gender Exploratory Therapy Association (GETA), an organization of professionals from the United States and several other countries.

The UK, home of the world’s largest pediatric gender clinic, recorded a suicide rate of transgender teens at 0.03 percent over a 10-year period. That number is higher than the overall adolescent population but “far from the epidemic of trans suicides described in headlines and public discourse,” GETA stated in its Clinical Guide for Therapists Working with Gender Questioning Youth.

Fears about suicide have helped drive the trend toward gender-transition procedures. Under that model, the therapist readily accepts the patient’s self-diagnosis and then assists with transitioning. This process may put a patient on the fast track to a revamped social identity, puberty blockers, cross-sex hormones, and body-altering surgeries.

Each of those changes can affect a young person’s life for many years.

Yet, “there is little to no evidence that transition reduces the risk of completed suicide,” according to GETA.

Exploratory Versus Affirmative

Thus, instead of affirmation, GETA promotes “exploratory therapy,” which doesn’t steer a patient to a particular outcome. That approach is outlined in GETA’s new guide, which is based on clinicians’ experiences and 17 pages of cited works.

Several groups have welcomed the guide as a much-needed resource for professionals at a time when the “gender-affirming care” model has come under increasing attack and scrutiny. Heart-wrenching stories of regret are emerging as more “detransitioners” publicly reveal stories of being misled into gender-transition procedures.

However, many prominent U.S. medical organizations have continued to go down the “gender-affirming” path, even though countries such as the UK, Sweden, and Finland are moving toward the exploratory approach that GETA is promoting.

Released on Dec. 3, the 120-page GETA guide represents “the world’s first substantial analysis into appropriate clinical care” for minors who are distressed over gender identity, according to Genspect, another international group that favors “evidence-based” alternatives to gender-transition treatments.

“Confirming the young person’s self-diagnosis of gender dysphoria or gender incongruence is easy,” the guide reads. “Clarifying the developmental forces that have influenced it and determining an appropriate intervention are not.”

By following the guide, a therapist can help uncover “the complex psychological, family, and social factors that may have shaped the young person’s current gender identity or their desire to transition,” according to the guide.

Then the patient may accept his or her body as is, may “find non-medical ways to live a better life,” or may decide to pursue medical and surgical interventions, GETA’s guide notes, calling all of those outcomes “equally valid and equally legitimate.”

Affirming a young child’s purported gender identity too readily, without seeking possible alternative explanations, poses an ethical dilemma, according to the guide.

“Children as young as 9–12 may be waiving their future right to sexual function and reproduction long before they are mature enough to comprehend the importance of these functions,” the guide reads.

Many youths who later turn out to be gay are often in distress in adolescence—a sexual orientation or preference issue that may be mistaken for gender dysphoria. Such youths “may not discover their sexual orientation until they are more mature,” the guide points out.

A children's book on gender in Irvine, Calif., on Sept. 7, 2022. John Fredricks/The Epoch Times

‘Winging It’ for a Decade

Stella O'Malley, an Ireland-based psychotherapist who founded nonprofit Genspect and also helped write the GETA guide, criticized the “gender-affirming” model for its lack of a long-term evidence base.

“Gender-affirmative clinicians have been winging it for the last decade, and now the outcomes are emerging and they are not positive,” O'Malley said in a post on the Genspect website. “At GETA, we use time-honored conventional talk therapy to explore the conscious and the unconscious in an ethical and compassionate manner.”

Guide co-author Lisa Marchiano, a licensed clinical social worker in Pennsylvania, told The Epoch Times in an email that the guide is intended to better inform therapists so they'll “feel more confident about their ability to provide psychotherapy to those suffering from gender dysphoria” or distress over one’s gender.

Although some people have referred to GETA’s guide as an “alternative” to the Standards of Care issued by the World Professional Association for Transgender Health, Marchiano gave a disclaimer.

Medical guidelines “have a very specific meaning and require a thorough review of the evidence,” she said, while GETA’s guide offers “a distillation of our therapeutic wisdom” from working with gender-questioning youths.

Author Testifies In Court

Another author of the GETA guide is Dr. Stephen Levine, who has been an Ohio clinical psychiatrist for five decades. He worries about the long-term and unknown effects that young people may suffer as a result of the “gender-affirming” approach.

Levine testified as an expert witness last month in an Arkansas federal court, where a judge is weighing whether to strike down that state’s ban on transgender medical procedures for minors.

The American Civil Liberties Union (ACLU) filed a lawsuit alleging that the law is unconstitutional. The suit claims that the law discriminates on the basis of sex and transgender status. The Save Adolescents From Experimentation Act seeks to forbid medical treatments for gender-transition purposes yet allows those measures for other reasons.

The ACLU of Arkansas lists 22 medical organizations, including the American Medical Association, the American Academy of Pediatrics, and the American Psychiatric Association, among supporters of the lawsuit. The ACLU stated that all of those groups agree: “Access to gender-affirming care is life-saving for transgender youth.”

Dr. Stephen Levine, a clinical psychiatrist who founded an Ohio gender clinic in 1974, is concerned about hormones being used to treat distressed transgender children. Courtesy: Dr. Stephen Levine

But when Levine testified, he emphasized that patients and their parents often seem to be inadequately informed about the possible risks and benefits of transitioning. That point is reiterated in the GETA guide, which was produced with the support of the Society for Evidence-Based Gender Medicine. That organization includes some of the same supporters as GETA and Genspect.

The ACLU and its supporters have characterized such groups as “outliers” bucking the professional consensus. But some testimony during the Arkansas case suggested that the purported “consensus” isn’t as universal as has been portrayed and that it has been forced for political and ideological reasons.

‘Informed Consent’ Lacking

Exploratory therapy promotes true informed consent, which is “not possible without adequate self-awareness, including an appreciation of unconscious motivations, hopes, and fears," the guide states.

Even “social transitioning”—use of a new name, pronouns, clothing, hairstyles, and the like—should require informed consent, the guide states, noting that “there is evidence that social transition may foster persistence of gender dysphoria,” according to two studies.

The guide calls for exploring “the entire landscape” of a person’s life. Thus, a person can figure out whether a conflict with a relative, a history of sexual abuse, or some other factor may be causing feelings of dysphoria rather than a true desire to change one’s gender.

Some patients also have a mistaken understanding of how “transitioning” works.

“Some young and vulnerable people believe that they can fully change sex and that medical and surgical treatment will transform them entirely into the desired sex,” the GETA guide reads.

Adolescence and early adulthood is a time to try to figure out the answer to one of life’s great questions: “Who am I?” But social influences can strongly affect a young person’s self-perception, the GETA guide states.

“Today, young people live in an environment that supports and reinforces trans-identification,” it reads.

Therapists may therefore encounter patients who get defensive during any attempt to explore gender issues, the guide notes.

Exploratory therapy tries to help reveal a person’s “true self,” asking probing questions such as, “Is it about having a voice, or is it a new way of hiding?” and “What is possible in one gender that is impossible in the other?”

The goal is to “understand how this person came to develop negative feelings about their sexed body, or that the gender they were assigned is wrong,” according to the GETA guide.