‘We need to reassess’: The evolution of one gender care doctor

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In the pre-social media era, kids who might have struggled with low level dysphoria or transient feelings might have found other ways to deal with it or allowed it to pass, Targownik said.  

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“But now they’re connecting with people who are telling them, ‘Hey, I did this and it’s working for me. This may be why you’re feeling disconnected from society. Maybe the reason you’re having trouble fitting in with other girls is not because you’re autistic, or because you’re marching to your own beat. It’s because you are actually a boy inside.’” 

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Youth can instantly connect with dozens of others who feel the way they do and start down a medical transitioning path. But Khatchadourian worries “we’re changing trajectories for these youth” based on unconvincing and limited data, and with too few mental health assessments by psychologists or psychiatrists trained in the child and adolescent medicine space. 

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“The expertise has not kept pace with the demand, and that worries me,” said Khatchadourian. She’s advocating for a national review in Canada — one involving those working in the field, trans-identified individuals, parents and families and, as well, de-transitioners — to ensure practices are aligned with the best available evidence. 

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Targownik also supports getting better data because, whether a populist or pragmatist, government leaders “are going to start asking for receipts,” she said. 

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“Someone is going to come and say, ‘I know you believe this care works. If you believe so strongly in this, show me that it actually works. Show me your outcomes. Show me that the kids you’re transitioning are doing well a year later, two years, five years later. Give me your best estimate of what the detransition rate in the modern cohort actually is, and the risk factors.” 

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There’s been a reluctance to ask those questions in the past when the practice was completely unhindered and support for gender care at its peak, she said. 

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Now, more countries are questioning that blanket, blind “just affirm” approach.

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Khatchadourian favours aligning with Sweden and Finland’s approach, where puberty blockers and cross-sex hormones are reserved for children and teens with a history of gender dysphoria that started in early childhood and has persisted for many years. 

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For others, she recommends a more holistic approach, supporting youth as they’re going through identity development. She rejects accusations that she’s against gender affirming care. “Gender care means I’m addressing the distress. Of course that is a concern. ‘You have needs. I’m here to support your needs.’ But we haven’t asked the right question: What is the best way to address your needs?’ 

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“We need to take a high level of risk approach, given the uncertainty of the evidence” and medication risks, she said. For her, the biggest stake is irreversible infertility.  

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“The most challenging conversations are always around fertility,” she said. “Most of the time you’re going to hear youth say they don’t want children, they don’t want biological children, or if they do at some point, they will consider adoption. You have to ask yourself, is that a mature response? Have they really given it considerable thought? Have they truly demonstrated capacity to consent?”  

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Early in her training, Khatchadourian spent a month in the Netherlands, the origins of pediatric gender medicine and birthplace of the so-called “Dutch Protocol” that saw doctors begin offering medical transitions for gender dysphoric teens in the early 1990s.  

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Back then, most of the gender distressed Dutch kids were biological males with a history of childhood-onset gender dysphoria that persisted into late adolescence.

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Since then, the sex ratio has shifted dramatically, with 70 per cent of children presenting at clinics now natal females, many with co-occurring  conditions such as autism, depression and anxiety that make it crucial to separate gender-related distress from other sources of distress or trauma that might mimic or add to the gender incongruence, Khatchadourian said.