Short Answer




Every gene in your body tells you that you are male or female.

Walt Heyer interview

Sex change remorse

Long Answer


Let’s Just Say It: Transgenderism Is a Mental Illness

It’s time to stop tolerating the gaslighting and tell the truth.


February 15, 2023, 11:35 PM

It isn’t a civil rights cause, it isn’t a new form of free expression, it isn’t a natural societal evolution.

It’s insanity. And facilitating it, as in the case of the supposed “medical professionals” increasingly pushing it on children, is evil.

We’re seeing this in more and more vivid detail as the transgender craze — and it is a craze, make no mistake about that — broadens and touches more and more lives. It’s becoming harder and harder to sustain the myth that chemical castrations and hormone baths and disfiguring surgeries lead to normal lives.

More and more, we know that they don’t. Not that we didn’t know already.

What we know is that post-op transexuals have staggeringly high suicide rates. Over-the-top suicide rates. A 2020 study indicated that some 82 percent of transgender individuals thought about suicide and 40 percent actually attempted it. And that’s for people who’ve “done the work.”

Why doesn’t “gender-affirming medical care” help? Because lopping off body parts doesn’t address the problem, which is in the mind.

And the soul.

Dr. Paul McHugh, the university distinguished service professor of psychiatry at the Johns Hopkins University School of Medicine, described why. McHugh said, “Transgendered men do not become women, nor do transgendered women become men. All (including Bruce Jenner) become feminized men or masculinized women, counterfeits or impersonators of the sex with which they ‘identify.’ In that lies their problematic future.”

You can’t go from a man to a woman just by getting a boob job and chopping off your testicles. You might be able to present as one, but your chromosomes won’t change, and because of that, you’re going to be a medical patient your entire life as you fight your own biology.

And ultimately, you will lose. If your body is exhumed and examined many years after your death, archaeologists will see your biological sex in your remains — not the “gender” by which you identify.

Encouraging people to live a lie is not kind. It’s not the road to health and happiness. Transgenderism used to be called something known as “gender identity dysphoria,” a mental condition. The condition didn’t change; the politics did. The Left was looking for something new it could use as a cultural aggression and transgender mental illness fit the bill — it was suitably shocking and grotesque, its protagonists were suitably transgressive, and it promised suitable expense and profiteering, for a good long run.

The problem is this goes too far. This hurts too many people. Lives are at stake.

Over the weekend, I had a column about Matt Walsh’s testimony in front of a Tennessee General Assembly committee hearing on a bill that would ban “gender-affirming medical care” for children. In that piece, I had a link and an excerpt from a harrowing first-person story by Jamie Reed, a case worker at Washington University in St. Louis’ gender clinic. She’s as culturally and politically left as it’s possible to be, but after seeing the abject quackery passing itself off as health care in that clinic, she had no choice but to blow the whistle on the entire industry.

And it’s an industry.

Our corrupted medical profession has recognized that turning children into transexual Dr. Mengele experiments holds the potential for vast profits over the course of a lifetime. The never-ending battle against one’s own biology necessitates endless consultations, prescriptions, and procedures. Video Walsh uncovered from Vanderbilt University’s launch of its own gender-affirmation division outlined as much.

And what’s just beginning to happen here is well underway across the pond. In the U.K., they’re shutting down the Tavistock Centre, which was the country’s designated transgender house of horrors for kids, after countless tales of pushing confused children into a life of nonstop medical and mental problems:

A new book reveals how Dr Matt Bristow, who worked at the Tavistock Clinic’s Gender Identity Development Service (Gids) for five years, raised concerns that boys and girls who said they wanted to change sex might simply be gay.

He warned gay children were ‘pushed down another path’, towards transitioning, and that there was a ‘reluctance’ from the Gids leadership to engage properly with sexuality.

And the doctor claimed that many heterosexual members of staff ‘just didn’t realise’ that many gender non-conforming behaviours applied just as much to children who grew up to be gay, lesbian or bisexual as to children who would grow up to be trans.

Examples include things like cross-dressing, feeling different, not necessarily fitting in with other children of their own sex, or having friends predominantly of the opposite sex, he said.

Staff at the centre even joked there would be ‘no gay people left at the rate Gids was going’, it was claimed.

Dr Bristow, who was openly gay when he joined the service, said when he raised concerns it was suggested to him that homosexual staff ‘weren’t professionally distant enough’. Gids deny this claim.

It’s about time gay people began distancing themselves from the transgender movement. Transgenderism destroys the gay argument, you know — gay people say they were “born this way,” and while that’s been difficult to prove biologically, it at least makes some sense. But transgender people were certainly not “born this way.” Except for a very tiny portion of the population suffering from, essentially, genetic mutations, people are born either male or female, and transgenderism is a conscious choice to repudiate nature.

It isn’t even driven by sexual desire. It’s driven by self-hatred. It’s driven by mental illness. That’s why none of the therapeutic corruption of the medical establishment has thus far been able to reduce the suicide rate.

But in this horrific age, when speaking the truth is so often “controversial” and forbidden, simply reporting the facts is a revolutionary act.

Things have gone so sideways that the New York Times, which has a near 100-year-old record of printing convenient lies, going all the way back to the cover-up of the Holodomor by its “Pulitzer Prize-winning” Moscow correspondent Walter Duranty, is now under fire from its own employees for publishing material questioning the propriety of the transgender industry. An open letter from more than 200 of the paper’s contributors to Philip B. Corbett, associate managing editor for standards, expresses outrage at the “bias” against transgenderism in its reporting on the issue. From the letter:

For example, Emily Bazelon’s article “The Battle Over Gender Therapy” uncritically used the term “patient zero” to refer to a trans child seeking gender⁠-⁠affirming care, a phrase that vilifies transness as a disease to be feared. Bazelon quoted multiple expert sources who have since expressed regret over their work’s misrepresentation. Another source, Grace Lidinksy⁠-⁠Smith, was identified as an individual person speaking about a personal choice to detransition, rather than the President of GCCAN, an activist organization that pushes junk science and partners with explicitly anti⁠-⁠trans hate groups.

In a similar case, Katie Baker’s recent feature “When Students Change Gender Identity and Parents Don’t Know” misframed the battle over children’s right to safely transition. The piece fails to make clear that court cases brought by parents who want schools to out their trans children are part of a legal strategy pursued by anti-trans hate groups. These groups have identified trans people as an “existential threat to society” and seek to replace the American public education system with Christian homeschooling, key context Baker did not provide to Times readers.

The natural destination of poor editorial judgment is the court of law. Last year, Arkansas’ attorney general filed an amicus brief in defense of Alabama’s Vulnerable Child Compassion and Protection Act, which would make it a felony, punishable by up to 10 years’ imprisonment, for any medical provider to administer certain gender⁠-⁠affirming medical care to a minor (including puberty blockers) that diverges from their sex assigned at birth. The brief cited three different New York Times articles to justify its support of the law: Bazelon’s “The Battle Over Gender Therapy,” Azeen Ghorayshi’s “Doctors Debate Whether Trans Teens Need Therapy Before Hormones,” and Ross Douthat’s “How to Make Sense of the New L.G.B.T.Q. Culture War.” As recently as February 8th, 2023, attorney David Begley’s invited testimony to the Nebraska state legislature in support of a similar bill approvingly cited the Times’ reporting and relied on its reputation as the “paper of record” to justify criminalizing gender⁠-⁠affirming care.

Douthat’s piece was published in the Opinion section, which lost one of the paper’s most consistently published trans writers, Jennifer Finney Boylan, following the Times’ recent decision not to renew her contract.

As thinkers, we are disappointed to see the New York Times follow the lead of far-right hate groups in presenting gender diversity as a new controversy warranting new, punitive legislation. Puberty blockers, hormone replacement therapy, and gender⁠-⁠affirming surgeries have been standard forms of care for cis and trans people alike for decades. Legal challenges to gender⁠-⁠nonconformity date back even further, with 34 cities in 21 states passing laws against cross⁠-⁠dressing between 1848 and 1900, usually enforced alongside so-called prohibitions against public indecency that disproportionately targeted immigrants, people of color, sex workers, and other marginalized groups. Such punishments are documented as far back as 1394, when police in England detained Eleanor Rykener on suspicion of the crime of sodomy, exposing her after an interrogation as “John.” This is not a cultural emergency.

These same 200 will no doubt declare that “climate change” is an emergency. But 40 percent of those people whose lives are directly affected by climate change are not attempting suicide.

Or at least one assumes they aren’t. As it is quite difficult to find anyone whose life is definitively impacted by anthropogenic global warming, it might be difficult to generate a representative sample so as to measure suicidal ideation and action.

The screeching at the Times, which is as friendly a legacy media outlet to transgenderism and other such causes as anyone could possibly hope for, over its relatively benign coverage, is part and parcel of trans advocacy’s operative spirit.

It’s all accusations, threats, and demands.

Straight men are bigots for refusing to date “trans women.” No one stops to notice that the demand is for a straight man to engage in a homosexual relationship with another man; that point isn’t even allowed to be made. Instead the fundamental dissonance is dismissed as bigotry.

You’re similarly a bigot if you find it unacceptable that biological men should declare themselves women and then compete in organized sports. The Lia Thomas debacle showed how utterly dysfunctional the moment is; here was a man swimming against women in women’s events and displaying male genitalia in locker rooms as he leered at women in similar states of undress — and to oppose such lunacy is to be filled with “hate.”

The gaslighting, the screeching, the threats of violence even against famous cultural figures like Dave Chappelle and J.K. Rowling…

It’s all insanity.

These people are insane. They don’t need empowerment. They don’t need facilitation. They don’t need bespoke pronouns. They certainly don’t need to be afforded status as a civil rights cause.

What they need is therapeutic mental health treatment. Because transgenderism is a mental illness. And the sane are making ourselves crazy attempting to go along.


Matt Walsh vs. Tennessee’s Democrats Is an Eye-Opener

Even so-called moderates in a conservative state aren’t about to object to the mutilation of so-called trans children.


February 11, 2023, 10:35 PM

If you didn’t catch this when it popped onto the internet, it’s well worth a catching-up on.

On Wednesday, a bill hit the Tennessee General Assembly’s Health Committee which would ban life-altering transgender medical treatments for minors. It passed onto the floor of the General Assembly on a party-line vote; that isn’t the real news to come out of the hearing.

The important bit about this was what happened when conservative commentator and filmmaker Matt Walsh, whose documentary movie What Is a Woman generated a major stir last summer for challenging the frightening pseudo-medical quackery which is the transgender debate, testified in front of the committee.

If you’ve seen Walsh in action, you know that he doesn’t have a whole lot of time for nicety or subtlety. He tends to give it to you straight, something your typical politician or bureaucrat lacks the stomach for. That makes it easy for the ruling-class crowd to dismiss him as a rube or a demagogue, or at least it’s how they instinctively react to him. But that can be problematic, because while Walsh isn’t better educated than the “subtle” set — he didn’t go to college; he went straight into the working world out of high school — he does tend to be better read and he’s certainly more intelligent than most of them.

And that’s something you could certainly tell from seeing his testimony. Here’s the whole event, for those of you who have 13 minutes to watch it.

A little play-by-play from the testimony is worth our time.

First up among the questioners is Jeremy Faison, a Republican small businessman from Cosby, east of Knoxville, and his question is a bit of  layup. Faison asks Walsh to opine about claims by the opponents of the bill who say opposing it is a “pro-life” position because denying trans kids the freedom to mutilate themselves is sentencing them to suicide. Walsh’s answer, which is that there is no evidence to support such a position and in fact the data shows that well after “gender-affirming” surgery, when the magnitude of what’s been done to them starts to hit home, is when there’s a real danger of suicide.

It’s worth pointing out, though, that this position by the trans crowd — that they’ll kill themselves if you don’t let them chop body parts off — seems like one of the most flagrantly extortionist public policy positions imaginable and really has no place in a political debate. Especially when what’s being discussed here isn’t the suicidal tendencies of the adult trans crowd; the state of the debate here has it that adults are free to pursue whatever bad ideas they like as they relate to cosmetic surgery. We’re talking about kids. The extortion here is actually aimed at the beleaguered parents of “trans” kids who get pushed into demanding “gender-affirming care” by a corrupt medical establishment. It’s to draft the parents into trans advocacy out of terror that their children will off themselves.

But as Walsh notes, it’s a dead man’s game all around, because the suicide rate among the post-op trans crowd is every bit as high as otherwise.

And this point comes up in a major way with the second questioner, an obnoxious Nashville freshman Democrat named Caleb Hemmer who works as the vice president of Longevity Health Plan. Hemmer trots out a Media Matters hit piece on Walsh which mischaracterized a rant he went on when he was a shock-jock radio personality in his early 20’s and talked about how 16-year-olds used to be considered adults and were expected to be starting families by then. That hit piece used Walsh’s rant to extrapolate that he’s a hypocrite for taking the position now that 16-year-olds aren’t capable of consent to “gender-affirming” surgery, and Hemmer throws that in Walsh’s face.

Which is a mistake, because Walsh’s answer leaves Hemmer in ruins.

“I was talking about the fact that people tended to marry young historically, and that’s all that that was about,” Walsh explained about his prior radio statement. “How does that relate to this subject?”

“Just curious of your definition, if you feel like people are adults at 16 —” Hemmer asked.

“People are adults at 18, but, actually, your brain is not fully developed until you’re 25,” Walsh said. “So, we should be having a conversation about whether we should even be doing the surgeries when people are 18. But, certainly, before 18, it’s absurd. I mean, do you think a 16-year-old can meaningfully consent to having their body parts removed?”

Hemmer was silent.

“Do you?” Walsh asked him again. “No?”

It was a very uncomfortable pause before committee chairman Brian Terry, who seemed a bit embarrassed to see one of his committee members getting so badly pummeled, muttered something about how the rules state it’s the committee who asks the questions and not the witnesses.

That led to Walsh’s next questioner, another Nashville Democrat named John Ray Clemmons. Clemmons is a trial lawyer and a veteran legislator, so he wasn’t blindly walking into a jackpot like the rookie Hemmer was. But Clemmons wasn’t prepared for a real debate either; his first question to Walsh essentially came down to “you’re a peasant who doesn’t belong here.” He demanded to know what Walsh’s educational and medical background was that he would be testifying on a bill about medical procedures.

Walsh’s answer was obvious, though it was the one Clemmons wanted.

“Well, my background that qualifies me to speak to this is that I’m a human being with a brain and common sense, and I have a soul, and, so, therefore, I think it’s a really bad idea to chemically castrate children — that is my experience,” Walsh said, clearly a bit irritated. “Also … now it’s true, I didn’t go to college, but I did go to school long enough to learn how to read, so I could read the data for myself, and that’s exactly what I’ve done.”

Remember, Walsh not eight months ago released a 95-minute documentary film on the very issue in question which contained interviews with a large number of academics, medical professionals and others and was heavily researched. Regardless of whether he spent his college years at keg parties or in a radio station there is little question that Walsh is informed on the topic.

Clemmons really should have left it at that, but it got worse.

And for what purpose do you conduct your research and use this brain of yours?” asked the Democrat.

I use it for the purpose of trying to protect children from being castrated and mutilated, that’s one of the things I try to do,” came the response, as quiet chuckling could be heard from the gallery.

You don’t use it to get clicks on your publication?” Clemmons persisted.

And then Walsh unloaded on Clemmons. “Are you using it right now to get clicks with this interaction?” he shot back. “I really like the idea of … drawing attention to the fact that this is happening to children. I know you seem to find it very amusing — I don’t.”

Clemmons then accused Walsh of making a lot of “mischaracterizations” and “misrepresentations” then declared that because he had, it was fair to question his background. Walsh attempted to ask for specifics, but Terry gaveled down the question, and then Clemmons said that because Walsh noted the human brain doesn’t fully develop until 25 he’s questionable for advocating for firearms ownership at 18.

Terry ruled that out of order because it had nothing to do with the bill, but Walsh asked if he could respond anyway. Sensing that he was likely going to lose control of the hearing if he allowed that, Terry moved on to the third Nashville Democrat on the committee, a self-employed “employee benefits” professional named Bo Mitchell.

Things got no less contentious from there.

Mitchell meandered around the topic for a bit, accused Walsh of ginning up the controversy in the first place, and then uncorked an almost comic lie — which was that no transgender surgeries are actually happening in Tennessee, as though if it was true it would negate the desirability of such a law. “I need your evidence of where these surgeries are occurring in Tennessee,” he said. “Could you give me places, times, maybe some names?”

It was a bizarre question, because late last year Walsh had uncovered evidence that the Vanderbilt University Medical Center had opened up an entire division devoted to transgender surgeries, placing a goodly amount of information on its website covering such procedures and there was video of the people working there touting “gender-affirming care” as a big moneymaker for the hospital. That it would be somehow in dispute that trans surgeries are an active phenomenon in Tennessee is notable, and Walsh said as much.

Walsh noted that after he had drawn attention to Vanderbilt’s program which included the double-mastectomy “top surgery” procedure, the hospital announced it was “pausing” such operations. It would seem that if no such procedures were being performed there would be no need for a pause.

Mitchell didn’t like that, so he brought up a poison-pill amendment to the bill he had brought which would have banned breast enlargement surgeries for minors, which Terry said wasn’t germane to the discussion. Walsh then said he’d be all for such an amendment. Then Mitchell attacked Walsh for having touted Singapore’s willingness to execute drug dealers and cane petty criminals as an effective means of fighting crime, which he said disqualified Walsh on “public policy” advocacy.

And finally, Mitchell said Walsh was lying about whether there were any studies showing that “gender-affirming” surgeries reduce suicide among transgender individuals, producing a University of Pittsburgh study he said refuted Walsh’s arguments.

But that was a lie. A writeup about the study in question can be found here; in pertinent part, it says…

The survey study comprised of over 2,000 adolescent participants across the United States ages 14 to 18, including 1,148 who identified as transgender. The researchers’ findings confirmed Marshal’s hypothesis: Transgender adolescents have higher odds of suicidality than cisgender adolescents. More specifically, about 85% of transgender adolescents reported “seriously considering suicide,” while over half of transgender adolescents attempted suicide, according to the study.

“One of the key problems they face is this notion that everyone else in the world can essentially invalidate their identity by just telling them it’s not OK to identify as transgender,” Marshal said. “Their identities are hidden, and when they’re hidden, it’s easy for other people to discriminate against them. This causes a lot of pain and suffering.”

The large sample size gave researchers the opportunity to split the transgender study participants into subgroups, something that couldn’t be done well before.

Going deeper, transgender boys were at the highest risk of a suicide attempt requiring medical attention, followed by non-binary teens assigned male at birth. Transgender girls meanwhile were six times more likely than cisgender boys to have suicidal thoughts.

Nothing in the study indicates anything other than what we’ve already known; suicidal ideation and action among the trans crowd is off the charts compared to straight kids. It doesn’t prove that surgery helps at all.

So Walsh appears and offers facts about the transgender surgery phenomenon in Tennessee, and he’s attacked as an uneducated rube with an ancient history of shock-jock takes as outlined by the leftist attack shop Media Matters by people who won’t even admit the demonstrated fact that a hospital in Tennessee had publicly proclaimed it was in the transgender surgery business.

This is what you get from three Democrats who ran for the legislature as “centrists” and “moderates” and are nonetheless actively supporting chemical castration and the chopping off of body parts among sexually confused and emotionally disturbed children.

And just in case there is any doubt about the quackery and wildly irresponsible advocacy at play here, this harrowing account by Jamie Reed, a former case manager at the Washington University Transgender Center at St. Louis Children’s Hospital, which was published Thursday, one day after Walsh’s testimony. Reed, a lesbian married to a “trans man” who describes her politics as aligned with Bernie Sanders, blasted the transgender medical-industrial complex for unspeakable corruption and profiteering off the misery of children by pushing them into expensive life-altering drugs and medical procedures often creating ghastly effects on the patients.

There is really no argument to be had here. The transgender-kid exploitation industry Walsh and others are working to expose is indefensibly abusive of some of the most vulnerable in society. And yet Democrats like Hemmer, Clemmons and Mitchell are wholly on board with defending it.

That spells corruption. Kudos to Walsh for not backing down amid withering abuse from the Left.

February 25, 2022

Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care

JAMA Netw Open. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978


Key Points

Question  Is gender-affirming care for transgender and nonbinary (TNB) youths associated with changes in depression, anxiety, and suicidality?

Findings  In this prospective cohort of 104 TNB youths aged 13 to 20 years, receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up.

Meaning  This study found that access to gender-affirming care was associated with mitigation of mental health disparities among TNB youths over 1 year; given this population's high rates of adverse mental health outcomes, these data suggest that access to pharmacological interventions may be associated with improved mental health among TNB youths over a short period.


Importance  Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes owing to decreased social support and increased stigma and discrimination. Although gender-affirming care is associated with decreased long-term adverse mental health outcomes among these youths, less is known about its association with mental health immediately after initiation of care.

Objective  To investigate changes in mental health over the first year of receiving gender-affirming care and whether initiation of puberty blockers (PBs) and gender-affirming hormones (GAHs) was associated with changes in depression, anxiety, and suicidality.

Design, Setting, and Participants  This prospective observational cohort study was conducted at an urban multidisciplinary gender clinic among TNB adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 through November 2021.

Exposures  Time since enrollment and receipt of PBs or GAHs.

Main Outcomes and Measures  Mental health outcomes of interest were assessed via the Patient Health Questionnaire 9-item (PHQ-9) and Generalized Anxiety Disorder 7-item (GAD-7) scales, which were dichotomized into measures of moderate or severe depression and anxiety (ie, scores ≥10), respectively. Any self-report of self-harm or suicidal thoughts over the previous 2 weeks was assessed using PHQ-9 question 9. Generalized estimating equations were used to assess change from baseline in each outcome at 3, 6, and 12 months of follow-up. Bivariate and multivariable logistic models were estimated to examine temporal trends and investigate associations between receipt of PBs or GAHs and each outcome.

Results  Among 104 youths aged 13 to 20 years (mean [SD] age, 15.8 [1.6] years) who participated in the study, there were 63 transmasculine individuals (60.6%), 27 transfeminine individuals (26.0%), 10 nonbinary or gender fluid individuals (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question (3.8%). At baseline, 59 individuals (56.7%) had moderate to severe depression, 52 individuals (50.0%) had moderate to severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. By the end of the study, 69 youths (66.3%) had received PBs, GAHs, or both interventions, while 35 youths had not received either intervention (33.7%). After adjustment for temporal trends and potential confounders, we observed 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17-0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11-0.65) among youths who had initiated PBs or GAHs compared with youths who had not. There was no association between PBs or GAHs and anxiety (aOR, 1.01; 95% CI, 0.41, 2.51).

Conclusions and Relevance  This study found that gender-affirming medical interventions were associated with lower odds of depression and suicidality over 12 months. These data add to existing evidence suggesting that gender-affirming care may be associated with improved well-being among TNB youths over a short period, which is important given mental health disparities experienced by this population, particularly the high levels of self-harm and suicide.


Transgender and nonbinary (TNB) youths are disproportionately burdened by poor mental health outcomes, including depression, anxiety, and suicidal ideation and attempts.1-5 These disparities are likely owing to high levels of social rejection, such as a lack of support from parents6,7 and bullying,6,8,9 and increased stigma and discrimination experienced by TNB youths. Multidisciplinary care centers have emerged across the country to address the health care needs of TNB youths, which include access to medical gender-affirming interventions, such as puberty blockers (PBs) and gender-affirming hormones (GAHs).10 These centers coordinate care and help youths and their families address barriers to care, such as lack of insurance coverage11 and travel times.12 Gender-affirming care is associated with decreased rates of long-term adverse outcomes among TNB youths. Specifically, PBs, GAHs, and gender-affirming surgeries have all been found to be independently associated with decreased rates of depression, anxiety, and other adverse mental health outcomes.13-16 Access to these interventions is also associated with a decreased lifetime incidence of suicidal ideation among adults who had access to PBs during adolescence.17 Conversely, TNB youths who present to care later in adolescence or young adulthood experience more adverse mental health outcomes.18 Despite this robust evidence base, legislation criminalizing and thus limiting access to gender-affirming medical care for minors is increasing.19,20

Less is known about the association of gender-affirming care with mental health outcomes immediately after initiation of care. Several studies published from 2015 to 2020 found that receipt of PBs or GAHs was associated with improved psychological functioning21 and body satisfaction,22 as well as decreased depression23 and suicidality24 within a 1-year period. Initiation of gender-affirming care may be associated with improved short-term mental health owing to validation of gender identity and clinical staff support. Conversely, prerequisite mental health evaluations, often perceived as pathologizing by TNB youths, and initiation of GAHs may present new stressors that may be associated with exacerbation of mental health symptoms early in care, such as experiences of discrimination associated with more frequent points of engagement in a largely cisnormative health care system (eg, interactions with nonaffirming pharmacists to obtain laboratory tests, syringes, and medications).25 Given the high risk of suicidality among TNB adolescents, there is a pressing need to better characterize mental health trends for TNB youths early in gender-affirming care. This study aimed to investigate changes in mental health among TNB youths enrolled in an urban multidisciplinary gender clinic over the first 12 months of receiving care. We also sought to investigate whether initiation of PBs or GAHs was associated with depression, anxiety, and suicidality.


This cohort study received approval from the Seattle Children’s Hospital Institutional Review Board. For youths younger than age 18 years, caregiver consent and youth assent was obtained. For youths ages 18 years and older, youth consent alone was obtained. The 12-month assessment was funded via a different mechanism than other survey time points; thus, participants were reconsented for the 12-month survey. The study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Study Procedures

We conducted a prospective observational cohort study of TNB youths seeking care at Seattle Children’s Gender Clinic, an urban multidisciplinary gender clinic. After a referral is placed or a patient self-refers, new patients, their caregivers, or patients with their caregivers are scheduled for a 1-hour phone intake with a care navigator who is a licensed clinical social worker. Patients are then scheduled for an appointment at the clinic with a medical provider.

All patients who completed the phone intake and in-person appointment between August 2017 and June 2018 were recruited for this study. Participants completed baseline surveys within 24 hours of their first appointment and were invited to complete follow-up surveys at 3, 6, and 12 months. Youth surveys were used to assess most variables in this study; caregiver surveys were used to assess caregiver income. Participation and completion of study surveys had no bearing on prescribing of PBs or GAHs.

Mental Health Variables

We assessed 3 internalizing mental health outcomes: depression, generalized anxiety, and suicidality. Depression was assessed using the Patient Health Questionnaire 9-item scale (PHQ-9), and anxiety was assessed using the Generalized Anxiety Disorder 7-item scale (GAD-7). We dichotomized PHQ-9 and GAD-7 scores into measures of moderate or severe depression and anxiety (ie, scores ≥10).26,27 Self-harm and suicidal thoughts were assessed using PHQ-9 question 9 (eTable 1 in the Supplement).

Pharmacological Interventions

Participants self-reported if they had ever received GAHs, including estrogen or testosterone, or PBs (eg, gonadotropin-releasing hormone analogues) on each survey. We conducted a medical record review to capture prescription of androgen blockers (eg, spironolactone) and medications for menstrual suppression or contraception (ie, medroxyprogesterone acetate or levonorgestrel-releasing intrauterine device) during the study period.


We a priori considered potential confounders hypothesized to be associated with our exposures and outcomes of interest based on theory and prior research. Self-reported gender was ascertained on each survey using a 2-step question that asked participants about their current gender and their sex assigned at birth. If a participant’s self-reported gender changed across surveys, we used the gender reported most frequently by a participant (3 individuals identified as transmasculine at baseline and as nonbinary on all follow-up surveys). We collected data on self-reported race and ethnicity (available response options were Arab or Middle Eastern; Asian; Black or African American; Latinx; Native American, American Indian, or Alaskan Native or Native Hawaiian; Pacific Islander; and White), age, caregiver income, and insurance type. Race and ethnicity were assessed as potential covariates owing to known barriers to accessing gender-affirming care among transgender youth who are members of minority racial and ethnic groups. For descriptive statistics, Asian and Pacific Islander groups were combined owing to small population numbers. We included a baseline variable reflecting receipt of ongoing mental health therapy other than for the purpose of a mental health assessment to receive a gender dysphoria diagnosis. We included a self-report variable reflecting whether youths felt their gender identity or expression was a source of tension with their parents or guardians. Substance use included any alcohol, marijuana, or other drug use in the past year. Resilience was measured by the Connor-Davidson Resilience Scale (CD-RISC) 10-item score developed to measure change in an individual’s state resilience over time.28 Resilience scores were dichotomized into high (ie, ≥median) and low (ie, <median). Prior studies of young adults in the US reported mean CD-RISC scores ranging from 27.2 to 30.1.29,30

Statistical Analysis

We used generalized estimating equations to assess change in outcomes from baseline at each follow-up point (eFigure 1 in the Supplement). We used a logit link function to estimate adjusted odds ratio (aOR) for the association between variables and each mental health outcome. We initially estimated bivariate associations between potential confounders and mental health outcomes. Multivariable models included variables that were statistically significant in bivariate models. For all outcomes and models, statistical significance was defined as 95% CIs that did not contain 1.00. Reported P values are based on 2-sided Wald test statistics.

Model 1 examined temporal trends in mental health outcomes, with time (ie, baseline, 3, 6, and 12 months) modeled as a categorical variable. Model 2 estimated the association between receipt of PBs or GAHs and mental health outcomes adjusted for temporal trends and potential confounders. Receipt of PBs or GAHs was modeled as a composite binary time-varying exposure that compared mean outcomes between participants who had initiated PBs or GAHs and those who had not across all time points (eTable 2 in the Supplement). All models used an independent working correlation structure and robust standard errors to account for the time-varying exposure variable.

We performed several sensitivity analyses. Because our data were from an observational cohort, we first considered the degree to which they were sensitive to unmeasured confounding. To do this, we calculated the E-value for the association between PBs or GAHs and mental health outcomes in model 2. The E-value is defined as the minimum strength of association that a confounder would need to have with both exposure and outcome to completely explain away their association (eTable 4 in the Supplement).31 Second, we performed sensitivity analyses on several subsets of youths. We separately examined the association of PBs and GAHs with outcomes of interest, although we a priori did not anticipate being powered to detect statistically significant outcomes owing to our small sample size and the relatively low proportion of youths who accessed PBs. We also conducted sensitivity analyses using the Patient Health Questionnaire 8-item scale (PHQ-8), in which the PHQ-9 question 9 regarding self-harm or suicidal thoughts was removed, given that we analyzed this item as a separate outcome. Lastly, we restricted our analysis to minor youths ages 13 to 17 years because they were subject to different laws and policies related to consent and prerequisite mental health assessments. We used R statistical software version 3.6.2 (R Project for Statistical Computing) to conduct all analyses. Data were analyzed from August 2020 through November 2021.


A total of 169 youths were screened for eligibility during the study period, among whom 161 eligible youths were approached. Nine youths or caregivers declined participation, and 39 youths did not complete consent or assent or did not complete the baseline survey, leaving a sample of 113 youths (70.2% of approached youths). We excluded 9 youths aged younger than 13 years from the analysis because they received different depression and anxiety screeners. Our final sample included 104 youths ages 13 to 20 years (mean [SD] age, 15.8 [1.6] years). Of these individuals, 84 youths (80.8%), 84 youths, and 65 youths (62.5%) completed surveys at 3, 6, and 12 months, respectively.

Our cohort included 63 transmasculine youths (60.6%), 27 transfeminine youths (26.0%), 10 nonbinary or gender fluid youths (9.6%), and 4 youths who responded “I don’t know” or did not respond to the gender identity question on all completed questionnaires (3.8%) (Table 1). There were 4 Asian or Pacific Islander youths (3.8%), 3 Black or African American youths (2.9%); 9 Latinx youths (8.7%); 6 Native American, American Indian, or Alaskan Native or Native Hawaiian youths (5.8%); 67 White youths (64.4%); and 9 youths who reported more than 1 race or ethnicity (8.7%). Race and ethnicity data were missing for 6 youth (5.8%).

At baseline, 7 youths had ever received PBs or GAHs (including 1 youth who received PBs, 4 youths who received GAHs, and 2 youths who received both PBs and GAHs). By the end of the study, 69 youths (66.3%) had received PBs or GAHs (including 50 youths who received GAHs only [48.1%], 5 youths who received PBs only [4.8%], and 14 youths who received PBs and GAHs [13.5%]), while 35 youths had not received either PBs or GAHs (33.7%) (eTable 3 in the Supplement). Among 33 participants assigned male sex at birth, 17 individuals (51.5%) had received androgen blockers, and among 71 participants assigned female sex at birth, 25 individuals (35.2%) had received menstrual suppression or contraceptives by the end of the study.

A large proportion of youths reported depressive and anxious symptoms at baseline. Specifically, 59 individuals (56.7%) had baseline PHQ-9 scores of 10 or more, suggesting moderate to severe depression; there were 22 participants (21.2%) scoring in the moderate range, 11 participants (10.6%) in the moderately severe range, and 26 participants (25.0%) in the severe range. Similarly, half of participants had a GAD-7 score suggestive of moderate to severe anxiety at baseline (52 individuals [50.0%]), including 20 participants (19.2%) scored in the moderate range, and 32 participants (30.8%) scored in the severe range. There were 45 youths (43.3%) who reported self-harm or suicidal thoughts in the prior 2 weeks. At baseline, 65 youths (62.5%) were receiving ongoing mental health therapy, 36 youths (34.6%) reported tension with their caregivers about their gender identity or expression, and 34 youths (32.7%) reported any substance use in the prior year. Lastly, we observed a wide range of resilience scores (median [range], 22.5 [1-38], with higher scores equaling more resiliency). There were no statistically significant differences in baseline characteristics by gender.

In bivariate models, substance use was associated with all mental health outcomes (Table 2). Youths who reported any substance use were 4-fold as likely to have PHQ-9 scores of moderate to severe depression (aOR, 4.38; 95% CI, 2.10-9.16) and 2-fold as likely to have GAD-7 scores of moderate to severe anxiety (aOR, 2.07; 95% CI, 1.04-4.11) or report thoughts of self-harm or suicide in the prior 2 weeks (aOR, 2.06; 95% CI, 1.08-3.93). High resilience scores (ie, ≥median), compared with low resilience scores (ie, <median), were associated with lower odds of moderate or severe anxiety (aOR, 0.51; 95% CI, 0.26-0.999).

There were no statistically significant temporal trends in the bivariate model or model 1 (Table 2 and Table 3). However, among all participants, odds of moderate to severe depression increased at 3 months of follow-up relative to baseline (aOR, 2.12; 95% CI, 0.98-4.60), which was not a significant increase, and returned to baseline levels at months 6 and 12 (Figure) prior to adjusting for receipt of PBs or GAHs.

We also examined the association between receipt of PBs or GAHs and mental health outcomes in bivariate and multivariable models (eFigure 2 in the Supplement). After adjusting for temporal trends and potential confounders (Table 4), we observed that youths who had initiated PBs or GAHs had 60% lower odds of moderate to severe depression (aOR, 0.40; 95% CI, 0.17-0.95) and 73% lower odds of self-harm or suicidal thoughts (aOR, 0.27; 95% CI, 0.11-0.65) compared with youths who had not yet initiated PBs or GAHs. There was no association between receipt of PBs or GAHs and moderate to severe anxiety (aOR, 1.01; 95% CI, 0.41-2.51). After adjusting for time-varying exposure of PBs or GAHs in model 2 (Table 4), we observed statistically significant increases in moderate to severe depression among youths who had not received PBs or GAHs by 3 months of follow-up (aOR, 3.22; 95% CI, 1.37-7.56). A similar trend was observed for self-harm or suicidal thoughts among youths who had not received PBs or GAHs by 6 months of follow-up (aOR, 2.76; 95% CI, 1.22-6.26). Lastly, we estimated E-values of 2.56 and 3.25 for the association between receiving PGs or GAHs and moderate to severe depression and suicidality, respectively (eTable 4 in the Supplement). Sensitivity analyses obtained comparable results and are presented in eTables 5 through 8 in the Supplement.


In this prospective clinical cohort study of TNB youths, we observed high rates of moderate to severe depression and anxiety, as well as suicidal thoughts. Receipt of gender-affirming interventions, specifically PBs or GAHs, was associated with 60% lower odds of moderate to severe depressive symptoms and 73% lower odds of self-harm or suicidal thoughts during the first year of multidisciplinary gender care. Among youths who did not initiate PBs or GAHs, we observed that depressive symptoms and suicidality were 2-fold to 3-fold higher than baseline levels at 3 and 6 months of follow-up, respectively. Our study results suggest that risks of depression and suicidality may be mitigated with receipt of gender-affirming medications in the context of a multidisciplinary care clinic over the relatively short time frame of 1 year.

Our findings are consistent with those of prior studies finding that TNB adolescents are at increased risk of depression, anxiety, and suicidality1,11,32 and studies finding long-term and short-term improvements in mental health outcomes among TNB individuals who receive gender-affirming medical interventions.14,21-24,33,34 Surprisingly, we observed no association with anxiety scores. A recent cohort study of TNB youths in Dallas, Texas, found that total anxiety symptoms improved over a longer follow-up of 11 to 18 months; however, similar to our study, the authors did not observe statistically significant improvements in generalized anxiety.22 This suggests that anxiety symptoms may take longer to improve after the initiation of gender-affirming care. In addition, Olson et al35 found that prepubertal TNB children who socially transitioned did not have increased rates of depression symptoms but did have increased rates of anxiety symptoms compared with children who were cisgender. Although social transition and access to gender-affirming medical care do not always go hand in hand, it is noteworthy that access to gender-affirming medical care and supported social transition appear to be associated with decreased depression and suicidality more than anxiety symptoms.

Time trends were not significant in our study; however, it is important to note that we observed a transient and nonsignificant worsening in mental health outcomes in the first several months of care among all participants and that these outcomes subsequently returned to baseline by 12 months. This is consistent with findings from a 2020 study36 in an academic medical center in the northwestern US that observed no change in TNB adolescents’ GAD-7 or PHQ-9 scores from intake to first follow-up appointment, which occurred a mean of 4.7 months apart. Given that receipt of PBs or GAHs was associated with protection against depression and suicidality in our study, it could be that delays in receipt of medications is associated with initially exacerbated mental health symptoms that subsequently improve. It is also possible that mental health improvements associated with receiving these interventions may have a delayed onset, given the delay in physical changes after starting GAHs.

Few of our hypothesized confounders were associated with mental health outcomes in this sample, most notably receipt of ongoing mental health therapy and caregiver support; however, this is not surprising given that these variables were colinear with baseline mental health, which we adjusted for in all models. Substance use was the only variable associated with all mental health outcomes. In addition, youths with high baseline resilience scores were half as likely to experience moderate to severe anxiety as those with low scores. This finding suggests that substance use and resilience may be additional modifiable factors that could be addressed through multidisciplinary gender-affirming care. We recommend more granular assessment of substance use and resilience to better understand support needs (for substance use) and effective support strategies (for resilience) for TNB youths in future research.

This study has a number of strengths. This is one of the first studies to quantify a short-term transient increase in depressive symptoms experienced by TNB youths after initiating gender-affirming care, a phenomenon observed clinically by some of the authors and described in qualitative research.37 Although we are unable to make causal statements owing to the observational design of the study, the strength of associations between gender-affirming medications and depression and suicidality, with large aOR values, and sensitivity analyses that suggest that these findings are robust to moderate levels of unmeasured confounding. Specifically, E-values calculated for this study suggest that the observed associations could be explained away only by an unmeasured confounder that was associated with both PBs and GAHs and the outcomes of interest by a risk ratio of 2-fold to 3-fold each, above and beyond the measured confounders, but that weaker confounding could not do so.31


Our findings should be interpreted in light of the following limitations. This was a clinical sample of TNB youths, and there was likely selection bias toward youths with supportive caregivers who had resources to access a gender-affirming care clinic. Family support and access to care are associated with protection against poor mental health outcomes, and thus actual rates of depression, anxiety, and suicidality in nonclinical samples of TNB youths may differ. Youths who are unable to access gender-affirming care owing to a lack of family support or resources require particular emphasis in future research and advocacy. Our sample also primarily included White and transmasculine youths, limiting the generalizability of our findings. In addition, the need to reapproach participants for consent and assent for the 12-month survey likely contributed to attrition at this time point. There may also be residual confounding because we were unable to include a variable reflecting receipt of psychotropic medications that could be associated with depression, anxiety, and self-harm and suicidal thought outcomes. Additionally, we used symptom-based measures of depression, anxiety, and suicidality; further studies should include diagnostic evaluations by mental health practitioners to track depression, anxiety, gender dysphoria, suicidal ideation, and suicide attempts during gender care.2


Our study provides quantitative evidence that access to PBs or GAHs in a multidisciplinary gender-affirming setting was associated with mental health improvements among TNB youths over a relatively short time frame of 1 year. The associations with the highest aORs were with decreased suicidality, which is important given the mental health disparities experienced by this population, particularly the high levels of self-harm and suicide. Our findings have important policy implications, suggesting that the recent wave of legislation restricting access to gender-affirming care19 may have significant negative outcomes in the well-being of TNB youths.20 Beyond the need to address antitransgender legislation, there is an additional need for medical systems and insurance providers to decrease barriers and expand access to gender-affirming care.

Article Information

Accepted for Publication: January 10, 2022.

Published: February 25, 2022. doi:10.1001/jamanetworkopen.2022.0978

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Tordoff DM et al. JAMA Network Open.

Corresponding Author: Diana M. Tordoff, MPH, Department of Epidemiology, University of Washington, UW Box 351619, Seattle, WA 98195 (

Author Contributions: Diana Tordoff had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Diana Tordoff and Dr Wanta are joint first authors. Drs Inwards-Breland and Ahrens are joint senior authors.

Concept and design: Collin, Stepney, Inwards-Breland, Ahrens.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Tordoff, Wanta, Collin, Stepney, Inwards-Breland.

Critical revision of the manuscript for important intellectual content: Wanta, Collin, Stepney, Inwards-Breland, Ahrens.

Statistical analysis: Tordoff.

Obtained funding: Inwards-Breland, Ahrens.

Administrative, technical, or material support: Ahrens.

Supervision: Wanta, Inwards-Breland, Ahrens.

Conflict of Interest Disclosures: Diana Tordoff reported receiving grants from the National Institutes of Health National Institute of Allergy and Infectious Diseases unrelated to the present work and outside the submitted work. No other disclosures were reported.

Funding/Support: This study was supported Seattle Children’s Center for Diversity and Health Equity and the Pacific Hospital Preservation Development Authority.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.


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New Data Show “Gender-Affirming” Surgery Doesn’t Really Improve Mental Health. So Why Are the Study’s Authors Saying It Does?

November 13, 2019 By Mark Regnerus

Data from a new study show that the beneficial effect of surgery for transgender people is so small that a clinic may have to perform as many as 49 gender-affirming surgeries before they could expect to prevent one additional person from seeking subsequent mental health treatment. Yet that’s not what the authors say. That the authors corrupted otherwise-excellent data and analyses with a skewed interpretation signals an abandonment of scientific rigor and reason in favor of complicity with activist groups seeking to normalize infertility-inducing and permanently disfiguring surgeries.




Suicide or transition: The only options for gender dysphoric kids?


Sex change regret

Surgical Sex

Correction: Transgender Surgery Provides No Mental Health Benefit

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