Transgender Belief in Pediatrics: A Call to Heal Minds, Embrace Bodies and Save Lives

By Dr. Michelle Cretella, M.D.

Contrary to the insistence of some Western governments and medical associations, transgender-affirming interventions, including social transition, puberty blockers, cross-sex hormones and surgeries, are not evidence-based international standard of care for youth with gender dysphoria (GD) which is also referred to as transgender belief. Since 2019, there have been several systematic reviews of the world’s scientific literature regarding medical management of childhood gender dysphoria. All have concluded that pediatric gender transition is based on low to very low-quality evidence. This means the alleged benefits put forth in those studies are likely not true due to significant flaws in the studies’ design.[1][2][3][4][5][6] As a result, the UK, Sweden, Finland, Norway and Denmark have greatly restricted the use of transgender interventions among youth with gender dysphoria and recommend psychotherapy as the standard of care.[7] All nations currently promoting pediatric trans-affirming interventions should similarly reverse course and nations that have never embraced them should maintain this position.

Gender dysphoria (GD) of childhood describes a psychological condition in which children experience a marked incongruence between their experienced gender and their sex. The associated emotional distress may result in impaired social function. However, when this occurs in the pre-pubertal child, GD resolves in the vast majority of patients by young adulthood.[8] Prior to the 21st century, the international standard of care for GD in children was watchful waiting with or without psychotherapy to identify underlying causes and then align patients’ thoughts with physical reality. The protocol of socially, chemically and surgically altering children’s bodies to match their incongruent gender beliefs first arose in the Netherlands for only the most resistant cases of pediatric GD. Between 2007 and 2016, however, this “Dutch Protocol” as it was initially called, gradually became widespread across Western nations with social affirmation being recommended for all gender incongruent children regardless of age.[9] The pervasive application of this protocol, beginning with social transition for children as young as 18 months of age, and puberty blockers as young as 8 years of age followed by cross-sex hormones, is rooted in the ideological assumption that a transgender identity is innate. Significant debate over the protocol arose because pubertal suppression with gonadotropin releasing hormone (GnRH) agonists (puberty blockers) followed by the use of cross-sex hormones can result in the permanent sterility of minors as well as other long-term iatrogenic diseases across the lifespan. What follows is a brief review of important definitions, the protocol’s potential harms, and how to best uphold the medical ethics principle of “First do no harm” while effectively treating gender dysphoria in children.

 Normality has been defined as “that which functions according to its design.”[10] One of the chief functions of the brain is to perceive physical reality. Thoughts that are in accordance with physical reality are normal. Thoughts that deviate from physical reality are abnormal—as well as potentially harmful to the individual and others. This is true whether or not the individual who possesses the abnormal thoughts feels distress. A person’s belief that he is something or someone he is not is, at best, a sign of confused thinking; at worst, it may be a delusion. Just because a person thinks or feels something does not make it reality. This would be true even if abnormal thoughts were biologically hardwired which they are not.

The norm for human development is for an individual’s thoughts to align with physical reality; for an individual’s gender identity to align with his or her sex. People who identify as “feeling like the opposite sex” or “somewhere in between” remain biological males or biological females. Gender dysphoria (GD) is a problem that resides in the mind not in the body. Children with GD do not have a disordered body—even though they may believe and feel as if they do. Similarly, a child’s distress over developing secondary sex characteristics does not mean that puberty should be treated as a disease because puberty is not, in fact, a disease. 

Sex is a binary biological trait that is determined at fertilization, declares itself in utero and is acknowledged at birth. To understand what sex is, one must first identify and distinguish between what defines sex and what determines sex. In the life sciences, sex is defined by how that organism is structured to function during the reproductive act. [11] The primary purpose of the reproductive system is to propagate the species. Among organisms that reproduce sexually (whether plant or animal), the structure of the sexual reproductive system consists of two complementary halves. Sexual reproduction requires the union of exactly two distinct sex cells, which arise from exactly two distinct sets of sexual organs, to form a new organism. Organisms whose reproductive organs are structured to donate genetic material during the reproductive act are designated male. Organisms whose reproductive organs are structured to receive that genetic material during the reproductive act are called female. This is why sex is a binary trait. In humans, sex is determined at fertilization by sex-determining genes on the sex chromosomes. [12] Every nucleated cell in a person’s body—every organ—has the same sex chromosomes. Thus, no one is born with an ‘opposite-sexed brain’; no one is ‘born in the wrong body’. The sex-determining genes in individuals with XY chromosomes result in the development of male gonads (testes) which produce male sex cells (sperm). Sex-determining genes in individuals with XX chromosomes result in the development of female gonads (ovaries) which produce female sex cells (ova). Since social affirmation, drugs and surgeries do not change a person’s genetics, they also do not change a person’s sex. This is why sex is a binary, innate and immutable trait from fertilization forward.

Some ideologue physicians and scientists object claiming that intersex conditions prove that sex is a spectrum and that the sex binary is a social construct. This is false. Intersex conditions are not additional sexes on a spectrum; they are rare disorders in the development of the normal binary reproductive system called Disorders of Sexual Development (DSD). DSD are abnormal conditions that fall into one of two categories. One set of DSD includes disorders like congenital adrenal hyperplasia (CAH) which cause infants to be born with ambiguous genitalia. Infants with ambiguous genitalia do not represent a new sex because they do not possess any new reproductive sex cells. Further medical testing will in fact reveal that they are either male or female. A second set of DSD, including but not limited to complete androgen insensitivity syndrome (complete AIS) is associated with unambiguous genitalia, but causes patients’ physical appearance (phenotype) to be inconsistent with what their sex chromosomes (genotype) would predict. For example, due to a genetic abnormality, pheonotypic females with complete AIS are found to have XY chromosomes. [13] Here again, the genetic abnormality fails to produce new functional sex cells; complete AIS is not another sex. Abnormalities, genetic or otherwise, that affect the reproductive system are disorders – not a spectrum of functional human sexes. In other words, DSD or intersex conditions are medically diagnosable disorders of the body that result in deficiencies and/or malformations of the normal male/female reproductive system. Additionally, all categories of DSD have been associated with impaired fertility. Although the majority of males and females with DSD can be successfully diagnosed and treated, affected individuals experience varying degrees of suffering. For all of these reasons, intersex conditions are correctly understood as disorders of sex development not merely differences of sex development. Fortunately, DSD are exceedingly rare, occurring in only 0.02% of the general population.[14] 

For similar reasons, people who possess different combinations of sex chromosomes, such as females with Turner’s Syndrome and an XO karyotype, or males with Klinefelter’s Syndrome who possess an XXY karyotype, also do not violate the sex binary. To represent an additional sex, one must possess a new functional reproductive sex cell (something other than male sperm or female eggs that can result in human offspring). The absence of an X chromosome does not result in these individuals producing new sex cells. Individuals with Turner’s Syndrome are anatomically female as would be expected in the absence of a Y chromosome. Similarly, individuals with Klinefelter’s do not represent an additional sex; they are anatomically male as directed from fertilization by the presence of male sex-determining genes on their Y chromosome.

Gender identity, in contrast to sex, is neither innate nor immutable. There is no medical test to identify people who claim to be ‘transgender’ because a ‘transgender identity’ exists only in the mind not in the body. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), gender is defined as the “lived role” of male or female, resulting from the interaction of cultural and psychological factors with a person’s biological constitution. [15] Gender identity is defined similarly as “a category of social identity” that is determined by the interaction of cultural, psychological and biological factors. [15] Since gender identity is shaped by many factors and not determined by genetics alone, incongruent gender identities have long been documented to align with sex during childhood, adolescence, and adulthood. In other words, gender dysphoria and incongruence has long been documented to desist across the lifespan. [16]

Prior to widespread social and medical transgender interventions, the vast majority of young children with gender incongruence outgrew it by young adulthood when supported through natural puberty. [17]  Most gender-distressed teens are ordinary girls and boys who are anxious, depressed, traumatized, and uncomfortable with their bodies and struggling with their identity. [18] Research suggests gender dysphoria arises from the interaction of many factors from among three categories. These categories include a person’s biological vulnerability (e.g.: certain personality traits, autism/other neurologic difference, mental illness), plus one or more of a person’s environmental factors (e.g: childhood traumas, parent mental illness, social contagion via friend groups), plus individual free will choices (e.g. joining LGBT student groups, choosing to binge on social media, pornography use). [19] 

Two large studies found that the vast majority of  self-identified transgender youth experienced on average five childhood traumas and/or suffered from mental illness, sometimes including suicidal thoughts, before developing signs of gender dysphoria or expressing transgender belief. [20] [21]   Since the traumas, mental illness and suicidal thoughts occurred prior to any sign of gender dysphoria or transgender identification, one cannot conclude that the mental illness and suicidal ideation among transgender identified youth is due to lack of social acceptance or lack of transgender interventions. This is consistent with the many studies that demonstrate children and teens with GD can come to embrace their bodies through counseling alone. [22]

Puberty is not a disease. It is a critical window of normal physical, cognitive, emotional, psychological, social and spiritual development that is permanently disrupted by puberty blockers. When normal puberty is artificially arrested with puberty blockers, valuable time is forever stolen from these children, time that should be spent in normal development. This time, during which highly significant and irreplaceable advances in bone, brain, social, emotional, spiritual and sexual maturation occur, is time in normal and active development – that can never be given back. 

Lupron is one of the most commonly prescribed puberty blockers and lists the following side effects in its package insert: emotional lability, worsening of current psychological illness or new onset psychological illness.[23] In light of this, it is no surprise that one British study revealed that after a year of receiving puberty blockers the mental health of 34% of GD youth deteriorated and another 37% experienced no improvement. [24] Another British report found that gender-distressed girls exhibited more self-harm and emotional problems, and greater body dissatisfaction while taking puberty blockers. [25] All puberty blockers, including Lupron, arrest pubertal development by acting on the brain. Boys are chemically castrated and girls are essentially chemically driven into premature menopause for as long as the puberty blockers are used. This developmental arrest may result in permanent sexual dysfunction, infertility, bone loss, and potentially altered brain development with cognitive impairment. [26][27]

As previously stated, prior to the social and medical affirmation of incongruent gender identities, the majority of gender-distressed children would embrace their bodies when supported through natural puberty. When gender-dysphoric youth are instead socially transitioned and given puberty blockers nearly 100% of them go on to identify as ‘transgender’ and request cross-sex hormones. [28] This suggests that social transition and puberty blockers “lock” kids into their gender confusion. As a result, these children who have their development blocked in early puberty, and are later given cross-sex hormones, will be permanently sterilized rather than healed. [26][29] It seems clear that those who participate in transgender pediatric interventions are sterilizing emotionally troubled youth. Cross-sex hormones also put these youth at an increased risk of heart attacks, stroke, diabetes, blood clots, cancer and other diseases across their lifespan. [26][30] This is a clear violation of “First do no harm”.

Nevertheless, some transgender affirming ideologues insist these harms must be accepted because social affirmation, blockers, hormones and surgeries prevent youth suicide. This too is false. In reality, suicide risk among trans-identifying youth is similar to the elevated suicide rates among other at-risk youth. Based upon data from the United Kingdom’s Tavistok Gender Identity Clinic, Oxford sociologist, Dr. Michael Biggs, has reported that being trans-identified increases suicide risk by a factor of 13. He notes that this elevated risk, while concerning, is less than or within range of the suicide risk associated with other disorders: anorexia increases suicide risk by a factor of 18; depression multiplies one’s risk by a factor of 20, and autism raises suicide risk by a factor of 8. Anorexia, depression and autism also often coincide with gender dysphoria. [31] Although individuals may report a “honeymoon period” of relief and happiness with the cosmetic results from cross-sex drugs and surgeries, these interventions do not improve mental health in the longterm. A thirty year study of a large population of transgender-identified adults who used hormones and surgeries to impersonate the opposite sex (in LGBT-affirming Sweden) found that their mental health was significantly worse than that of the general population ten years after surgery and by the conclusion of the study, their completed suicide rate was 19 times greater than that of the general population. [32] In short, suicide prevention for youth with gender dysphoria should be the same as it is for all other at risk youth; namely, individual and family counseling to identify and resolve underlying issues, and psychiatric medications when indicated.

Ethical medicine restores normal development, health and function, and relieves suffering. The use of social transition, puberty blockers, cross-sex hormones and cross-sex surgeries, in contrast, disrupt normal health, function and development especially in children. In fact, these interventions permanently sterilize, disease and mutilate emotionally distressed youth. Sadly, many minors, young adults and their parents, as well as church and government leaders, are being led astray by a vocal sector of the medical establishment driven by a dangerous ideology and economic opportunism. Christians and all people of good will must unite against this latest eugenic assalt of the Culture of Death.

 

Michelle Cretella, M.D. for the John Paul II Academy for Human Life & Family

Chair, Sexuality Council of the American College of Pediatricians

Medical Division member, Alliance for Therapeutic Choice

Board member, Advocates Protecting Children

REFERENCES

[1]   Ludvigsson, J.F., Adolfsson, J., Höistad, M., Rydelius, P.-A., Kriström, B. and Landén, M. (2023), A systematic review of hormone treatment for children with gender dysphoria and recommendations for research. Acta Paediatr. Accepted Author Manuscript. https://doi.org/10.1111/apa.16791 

[2]  Swedish Agency for Health Technology Assessment and Assessment of Social Services’ 2019 literature review. https://www.sbu.se/en/publications/sbu-bereder/gender-dysphoria-in-children-and-adolescents-an-inventory-of-the-literature/

[3] Finland 2020:“Recommendation of the Council for Choices in Health Care in Finland (PALKO/ COHERE Finland). Medical Treatment Methods for Dysphoria Related to Gender Variance In Minors” https://segm.org/sites/default/files/Finnish_Guidelines_2020_Minors_Unofficial%20Translation.pdf

[4]  2020. UK’s The National Institute for Health and Care Excellence (NICE) reviews:

N.I.C.E. Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria.:  https://ia802301.us.archive.org/4/items/gov.uscourts.ared.128159/gov.uscourts.ared.128159.45.9.pdf  or https://cass.independent-review.uk/nice-evidence-reviews/; see also N.I.C.E. Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria.: https://cass.independent-review.uk/nice-evidence-reviews/

[5] Cass Review, Interim Report (2022) https://cass.independent-review.uk/publications/interim-report/

[6] 2020 Florida AHCA Generally Accepted Professional Medical Standards Determination on the Treatment of Gender Dysphoria, comprehensive literature review (Attachment C), Romina Brignardello-Petersen, DDS, MSc, PhD and Wojtek Wiercioch, MSc, PhD: Effects of Gender Affirming Therapies in People with Gender Dysphoria: Evaluation of the Best Available Evidence. 16 May 2022. https://ahca.myflorida.com/letkidsbekids/docs/AHCA_GAPMS_June_2022_Attachment_C.pdf

[7] Society for Evidence Based Medicine (2023) “Denmark Joins the List of Countries That Have Sharply Restricted Youth Gender Transitions” Available at https://segm.org/Denmark-sharply-restricts-youth-gender-transitions 

[8]  American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (Washington, D.C.: American Psychiatric Publishing, 2013), p. 450-455.

[9] Rafferty J. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics (2018). Available at https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for?autologincheck=redirected 

[10] King CD. The meaning of normal. Yale J Biol Med 1945;18:493-501.

[11] McHugh PR and Meyer LS. Sexuality and Gender: Findings from the Biological, Psychological, and Social Sciences. The New Atlantis; No.50, Fall 2016, p90. Available at http://thenewatlantis.com/wp-content/uploads/legacy-pdfs/20160819_TNA50SexualityandGender.pdf 

[12] Wilhelm D, Palmer S, Koopman P. Sex Determination and Gonadal Development in Mammals. Physiological Reviews. American Physiological Society. 2007;87(1). Available at  https://journals.physiology.org/doi/full/10.1152/physrev.00009.2006.  

[13] Sax L. How Common is Intersex? A response to Anne Fausto-Sterling. J. Sex Res. 2002 Aug;39(3):174-8. doi: 10.1080/00224490209552139. PMID: 12476264. Available at https://www.leonardsax.com/how-common-is-intersex-a-response-to-anne-fausto-sterling/ 

[14] Slowikowska-Hilczer J, Hirschberg AL, Claahsen-van der Grinten H, Reisch N, Bouvattier C, Thyen U, et al. dsd-LIFE Group. Fertility outcome and information on fertility issues in individuals with different forms of disorders of sex development: Findings from the dsd-LIFE study. Fertility and Sterility, 108. 822-831. Available at https://www.fertstert.org/article/S0015-0282(17)31708-9/fulltext 

[15] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders: DSM-5 (Washington, D.C.: American Psychiatric Publishing, 2013), pp. 451 and 822.

[16] Ristori J, Steensma TD. Gender dysphoria in childhood. Int Rev Psychiatry. 2016;28(1):13-20. See also: Clarke A, Spiliadis A. ‘Taking the lid off the box’: The value of extended clinical assessment for adolescents presenting with gender identity difficulties. Clinical Child Psychology and Psychiatry. 2019;24(2):338-352. Available at https://journals.sagepub.com/doi/full/10.1177/1359104518825288  See also:

Zucker KJ, Lawrence AA, Kreukels BP, Gender Dysphoria in Adults, Annual Rev of Clinical Psych. 2016;12: 217-247 (p.237) Available at https://www.researchgate.net/profile/Kenneth_Zucker3/publication/291340368_Gender_Dysphoria_in_Adults/links/56fc815108ae8239f6dc4a74/Gender-Dysphoria-in-Adults.pdf (quote p. 237).

[17]  Jiska Ristori & Thomas D. Steensma, “Gender Dysphoria in Childhood” International Review of Psychiatry 28(1):13-20 (2016) at 15; Thomas D. Steensma, et al., “Desisting and persisting gender dysphoria after childhood:  A qualitative follow-up study” Clinical Child Psychology and Psychiatry 16(4) 499–516 (2010) at 500; Kenneth J. Zucker, “The Myth of Persistence” International Journal of Transgenderism 19(2):231-245 (2018).

[18] Riittakerttu Kaltiala-Heino, et al., “Two years of gender identity service for minors: overrepresentation of natal girls with severe problems in adolescent development” Child & Adolescent Psychiatry & Mental Health 9:9 (2015); Lisa Littman, “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria” PLOS One 14(3):e0214157 (2018); Melanie Bechard, et al., “Psychosocial and Psychological Vulnerability in Adolescents with Gender Dysphoria: A ‘Proof of Principle’ Study” Journal of Sex and Marital Therapy 43(7):678-688 (2017).

[19] Cretella M. Gender Dysphoria. A Position Statement of the American College of Pediatricians published 2016. Available at https://acpeds.org/position-statements/gender-dysphoria-in-children 

[20] Kozlowska K, Chudleigh C, McClure G, Maguire AM, Ambler GR. Attachment Patterns in Children and Adolescents With Gender Dysphoria. Front Psychol. 2021 Jan 12;11:582688. doi: 10.3389/fpsyg.2020.582688. PMID: 33510668; PMCID: PMC7835132.

[21] Becerra-Culqui TA, Liu Y, Nash R. et al. Mental Health of Transgender and Gender Nonconforming Youth Compared with Their Peers. Pediatrics. 2018;141(5).

[22]  Clarke, A. & Spiliadis, A, “’Taking the Lid Off the Box’: The Value of Extended Clinical Assessment for Adolescents Presenting With Gender Identity Difficulties,” https://journals.sagepub.com/doi/10.1177/1359104518825288, Feb. 6, 2019; Kenneth J. Zucker, et al., “A Developmental, Biopsychosocial Model for the Treatment of Children with Gender Identity Disorder,” Journal of Homosexuality 59(2):369-397 (2012); Kelley D. Drummond et al., “A follow-up study of girls with gender identity disorder,” Developmental Psychology 44(1):34-45 (2008); Meyenburg B. Gender identity disorder in adolescence: Outcomes of psychotherapy. Adolescence. 1999;34:305-313; Kronberg J, Tyano S, Apter A, Wijsenbeek H. Treatment of transsexualism in adolescence. Journal of Adolescence. 1981; 4:177-185; Lothstein LM, Levine SB. Expressive Psychotherapy With Gender Dysphoric Patients. Archives of General Psychiatry. 1981; 38:924-929; Lothstein LM. The adolescent gender dysphoric patient: an approach to treatment and management. Journal of pediatric psychology. 1980; 5:93-109; Davenport CW, Harrison SI. Gender identity change in a female adolescent transsexual. Archives of sexual behavior. 1977; 6:327-340; Barlow DH, Reynolds EJ, Agras WS. Gender Identity Change in a Transsexual [male aged 17]. Archives of General Psychiatry. 1973; 28:569-576; Philippopoulos, G.S. A case of transvestism in a 17-year-old girl. Acta Psychother. 1964; 12: 29–37.

[23]  Lupron Package Insert available at:  https://www.lupronped.com/about-lupron-depot-ped?cid=ppc_ppd_msft_Lupron_Branded_lupronped.com_Phrase_USLUPR220485  

[24]  BBC News “Children on puberty blockers saw mental health change – new analysis” Available at https://www.bbc.co.uk/news/health-66842352; study pre-print by McPherson and Freedman available at: https://www.medrxiv.org/content/10.1101/2023.05.30.23290763v3.full.pdf+html 

[25]  Michael Biggs. “Tavistock’s Experimentation with Puberty Blockers: Scrutinizing the Evidence”. Transgender Trend. March 2, 2019. Available at https://www.transgendertrend.com/tavistock-experiment-puberty-blockers/ 

[26] Laidlaw M, Van Meter QL, Hruz PW, Van Mol A and Malone WJ. The Journal of Clinical Endocrinology & Metabolism, 2019;104(3): 686–687, https://doi.org/10.1210/jc.2018-01925

[27] Vigil P, et al., “Endocrine Modulation of the Adolescent Brain: A Review” Journal of Pediatric & Adolescent Gynecology 24(6):330-337 (December 2011). See also Craig MC, Fletcher PC, Daly EM, Rymer J, et al. Gonadotropin hormone releasing hormone agonists alter prefrontal function during verbal encoding in young women. Psychoneuroendocrinology. 2007;32(8-10):1116-27. DOI:10.1016/j.psyneuen.2007.09.009; Christian J. Nelson, et al., “Cognitive Effects of Hormone Therapy in Men With Prostate Cancer” Cancer 113(5):1097-1106 (2008).

[28] Brik T, Vrouenraets LJJJ, de Vries MC, Hannema SE. Trajectories of adolescents treated with gonadotropinreleasing hormone analogues for gender dysphoria [published online ahead of print March 9, 2020]. Arch Sex Behav. doi:10.1007/s10508-020-01660-8; Kuper LE, Stewart S, Preston S, Lau M, Lopez X. Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics. 2020;145(4):e20193006; Annelou L.C. de Vries, et al., “Puberty suppression in adolescents with gender identity disorder: A prospective follow-up study” The Journal of Sexual Medicine 8(8): 2276–2283 (2011). Wiepjes CM, Nota NM, de Blok CJM, et al. The Amsterdam cohort of gender dysphoria study (1972-2015): trends in prevalence, treatment, and regrets. J Sex Med. 2018;15(4):582–590; Carmichael P,  Butler G, et al. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. medRxiv 2020.12.01.20241653.

[29] Leena Nahata, et al., “Understudied and Under-Reported: Fertility Issues in Transgender Youth—A Narrative Review” Journal of Pediatrics 205:265-271 (February 2019)

[30] Dorte Glintborg, Katrine Hass Rubin, Tanja Gram Petersen, Øjvind Lidegaard, Guy T’Sjoen, Malene Hilden, Marianne Skovsager Andersen, Cardiovascular risk in Danish transgender persons: a matched historical cohort study, European Journal of Endocrinology, Volume 187, Issue 3, Sep 2022, Pages 463–477, https://doi.org/10.1530/EJE-22-0306; Talal Alzahrani, et al., “Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population” Circulation 12(4):e005597 (2019); Katrien Wierckx, et al., “Prevalence of cardiovascular disease and cancer during cross-sex hormone therapy in a large cohort of trans persons: a case-control study” European Journal of Endocrinology 169(4):471-478 (2013).

[31] Biggs M. Suicide by trans-identified children in England and Wales (October 2018).

Available at: https://www.transgendertrend.com/suicide-by-trans-identified-children-in-england-and-wales/ 

[32] Cecilia Dhejne, et al., “Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden” PLOS One 6(2):e16885 (2011) available at https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0016885