- Most transgender individuals do not have “intersex” conditions.
- Many females with gender dysphoria do have polycystic ovary syndrome (PCOS) or high testosterone.
- PCOS and high testosterone have been linked to autism and psychiatric disorders.
- Female-to-male treatments may worsen mental health problems in females who already have high testosterone, PCOS, autism or psychiatric disorders.
Medical studies show that the vast majority of transgender individuals are not “intersex” and do not have “disorders of sex development (DSDs).” Gender transition treatments may be unnecessary and harmful for females who have autism or psychiatric disorders rather than intersex disorders or DSDs.
Many females with gender dysphoria have non-intersex conditions such as polycystic ovary syndrome (PCOS), a condition involving chronic high testosterone. PCOS or chronic high testosterone may cause mental health problems. Studies have linked PCOS or high testosterone to autism and psychiatric disorders in females.
Normally, doctors treat PCOS with drugs to reduce testosterone in females. However, gender clinic doctors do the opposite: They use drugs to raise testosterone to very high levels and suppress estrogen. This may worsen patients’ mental health problems.
Transition treatments may be extremely harmful, especially for females who already have autism or psychiatric problems together with PCOS or high testosterone.
Transition treatments are not FDA-approved and have not been adequately tested.
What Research Shows
“Intersex” disorders are called “disorders of sex development (DSDs)” in medical studies. Even gender transition proponents say that most transgender people do not have DSDs. For example, Johanna Olson-Kennedy, MD and her colleagues say that “the majority of transgender individuals do not have a disorder of sex development (DSD).” Dr. Olson-Kennedy is the medical director of the largest transgender youth clinic in the United States and has served as a consultant to a drug company that sells transition drugs.
DSDs are not that same as hormonal problems that emerge during or after puberty in females, such as endometriosis (a condition that causes extremely painful menstrual cramps) and polycystic ovary syndrome (PCOS). DSDs are conditions one is born with that entail unusual chromosomes (such as XXY), abnormally formed reproductive organs or hormone-related disorders such as classic congenital adrenal hyperplasia (CAH). Many DSDs are rare and many do not tend to cause gender dysphoria.
Chromosomal DSDs are rare in transgender or gender dysphoric individuals. A 2018 study found “no sex chromosome abnormalities directly suggestive of a DSD” in a group of pediatric gender service patients. A 2011 study reported “normal findings” in 97.55% of transsexuals. A 2013 study reported chromosomal abnormalities in just 1.5% of transsexuals overall.
Classic congenital adrenal hyperplasia (CAH) is a hormonal DSD that exposes females (and males) to excess testosterone before birth. It does not cause gender dysphoria in the vast majority of females. It occurs in approximately 1 in every 15,000 live births worldwide. There is also a non-classic form of CAH called non-classic 21-OHD CAH. Only 1%-3% of all females with hyperandrogenism (high testosterone or other high “androgen” hormones) have this. Ashkenazi Jews have the highest rate of non-classic 21-OHD CAH.
Boston Children’s Hospital—which offers a pediatric gender transition clinic—states that “a child with CAH is born with a reproductive tract that is not normally developed, and the child is neither ‘fully’ male nor female.” This is an odd and potentially misleading statement, because the vast majority of CAH females don’t experience gender dysphoria and many also give birth, which obviously requires fairly normal reproductive organs.
A 2004 study found that CAH did not affect 5-12 year old girls’ gender identity. A 2005 study reported that 94.8% of CAH females raised as females “later developed a gender identity as girls and women and did not feel gender dysphoric.” A 2016 study found that CAH girls “reported positive attitudes about being a girl.” A 2018 study found “no differences in emotional or behavioral problems” between CAH girls and their unaffected sisters. These studies suggest that female gender dysphoria may not result from prenatal excess testosterone exposure, and they show that CAH does not usually cause gender dysphoria.
A few CAH females (perhaps 5%) have a masculinized gender identity and may have a masculinized genital appearance due to prenatal testosterone exposure. Transition treatments might be appropriate for some of them, but only if they and their parents are given adequate information about the potential brain and other effects of transition treatments.
Health problems are common in female-to-male transsexuals, but they do not involve chromosomal or hormonal DSDs such as classic CAH in most cases. Instead, there are high rates of polycystic ovary syndrome (PCOS), idiopathic high testosterone, and sometimes non-classic CAH, according to studies in 1986, 1993, 1997, 2007, 2008, 2013, and 2014.
Polycystic ovary syndrome (PCOS) is a very common chronic excess testosterone condition with varying causes. It affects approximately 1 in 10 women of childbearing age. It can emerge during or after puberty but can go undiagnosed for many years or even decades. An estimated 50 to 70 percent of women with PCOS are undiagnosed.
PCOS is not an “intersex” condition. All normal females produce testosterone. Testosterone is an “androgen” hormone. “Androgen excess is the most common endocrine disorder in women of reproductive age.”
High testosterone does not convert XX (female) chromosomes into XY (male) chromosomes. PCOS and high testosterone may trigger mental health problems (because sex hormones affect the entire brain) but females do not turn into males simply because they have high testosterone or PCOS.
PCOS has been associated with female autism and psychiatric disorders including schizophrenia, bipolar disorder, borderline personality disorder, anxiety, and depression. It can develop in pre-teens, teens or older women. Many PCOS females are obese, but thin females can also develop PCOS. It can cause acne, male pattern baldness, excess facial hair, infertility, weight gain, insulin resistance, and many other problems. It may be “silent,” with no or few obvious indicators. One expert said:
“Polycystic ovary syndrome is an extraordinarily prevalent lifelong disorder that many women don’t know they have and many physicians and practitioners don’t know how to manage.
….It’s a condition that affects health across the board. This is not just one disorder, and not all patients are the same” (Azziz, quoted in Olivero 2015).
Doctors say that problems such as PCOS and high testosterone should be investigated in females with gender dysphoria, but patients with gender dysphoria have reported that gender clinic doctors deliberately ignored signs of PCOS—and failed to tell patients that PCOS could be harmful—in order to expedite female-to-male (FtM) treatments. This may be malpractice.
PCOS is normally treated with oral contraceptives, anti-androgens or other drugs to reduce testosterone. Studies indicate that proper treatment may reduce patients’ physical and mental health problems (see Rasgon 2002; Soleman 2016). Female-to-male treatments that raise testosterone may make mental health problems worse.
Doctors have known for a long time that PCOS or high testosterone might cause mental health problems in females. One expert said: “PCOS is one of the most common conditions affecting young women today, and the effect on mental health is still under appreciated” (PCOS 2018).
In medical studies, PCOS and/or high testosterone have been associated with female
- autism (Bejerot 2012; Cesta 2016; Ingudomnukul 2007; Pohl 2014; Schwarz 2011).
- schizophrenia (Cesta 2016; Matevosyan 2011; Worsely 2014).
- bipolar disorder (Berni 2018; Cesta 2016; Rassi 2010; Tan 2017; Wooderson 2015).
- personality disorders, including borderline personality disorder (Cesta 2016; Dettenborn 2016).
- obsessive-compulsive disorder (OCD) (Hussain 2015).
- anxiety (Berni 2018; Cesta 2016; Cooney 2017; Deeks 2010; Himelein 2006; Hussain 2015; Månsson 2008; Sahingöz 2013).
- depression (Berni 2018; Cesta 2016; Cooney 2017; Dokras 2012; Himelein 2006; Hussain 2015; Månsson 2008; Rassi 2010).
- suicidality (Hussain 2015; Månsson 2008).
- cognitive problems (Soleman 2016; Worsely 2014).
- criminality, aggression, and impaired judgment (Dabbs 1997; Ohlsson Gotby 2015; Probst 2018; Stanton 2011).
- eating disorders such as bulimia (Cesta 2016).
Low estrogen may be a problem, too. Researchers have linked low estrogen in females to cognitive problems and psychiatric disorders including
- posttraumatic stress disorder (PTSD) (Sandoiu 2017).
- attention deficit disorder (ADHD) (Roberts 2016).
- memory problems (“Estrogen” 2016).
- postpartum psychosis in bipolar disorder (Meinhard 2013).
- possibly schizophrenia (Newton-Mann 2017).
Conditions that have been associated with high testosterone, PCOS or low estrogen in females are common in people with gender dysphoria. This is true for autism, ADHD, bipolar disorder, borderline personality disorder, obsessive-compulsive disorder (OCD), posttraumatic stress disorder (PTSD), anxiety, and depression (see Becerra-Culqui 2015; Chen 2016; Jones 2011; Kaltiala-Heino 2015; Nahata 2017; Marchiano 2016; Oswalt 2017; “Survey” 2016; Vrangalova 2017). Dysphoric females with autism or psychiatric disorders may have mental health problems because they have high testosterone, PCOS or low estrogen. (Social victimization by peers or other individuals may also play a role. See Devor 2008; Kaltiala-Heino 2015; Marchiano 2016).
Female-to-male (FtM) treatments raise patients’ testosterone to levels that may be 10 times higher than normal and suppress estrogen and estrogen receptors. Those treatments may make patients’ mental health problems worse.
Experimental studies show that when healthy females are given even a single dose of testosterone drugs, their brains and behaviors change in ways that may resemble autism or psychiatric disorders. For example, their ability to identify facial expressions declines (Olsson 2016; van Honk 2011) and “disadvantageous” decision-making occurs (van Honk 2004). Brain circuits responsible for aggression become more activated and brain circuits that support social functioning, moral judgment, and other things are altered (Bos 2016; Chen 2016; Hermans 2008; Radke 2015; van Wingen 2010). Trust in social partners may be inhibited (Buskens 2016).
Female-to-male (FtM) treatment studies are consistent with those experimental studies. They show that FtM treatments suppress activity in social brain areas, and increase aggression proneness and synchronized activity in aggression-related brain areas (van Goozen 1995; Ye 2011). The treatments also cause “functional and structural changes in self-referential and own body perception” areas of the brain (Burke 2018). That might be harmful for patients with conditions in which self-related thinking can be abnormal, such as autism and psychiatric disorders.
Studies also indicate that females who already have high testosterone at the start of FtM treatments might experience especially strong brain effects from those treatments (e.g., Rametti 2012). Some studies suggest that testosterone drugs have stronger brain effects in females exposed to excess testosterone prenatally (Buskens 2016; van Honk 2011).
High testosterone and low estrogen might help to cause mental health problems in many different ways. For example, animal studies indicate that testosterone suppresses the oxytocin system, whereas estrogen receptors do the opposite: They increase oxytocin and its receptor. Oxytocin-related problems are suspected to play a role in autism and psychiatric disorders. Oxytocin treatments affect brain functioning, especially in women with stronger autistic traits (Bethlehem 2017), who may be especially likely to have high testosterone and low estrogen receptor expression (Altun 2017; Crider 2014). A study showed that oxytocin treatments increased synchronized brain activity (“functional connectivity”) in such women:
“Oxytocin increased connectivity between corticostriatal circuitry typically involved in reward, emotion, social communication, language and pain processing. This effect was 1.39 standard deviations above the null effect of no difference between oxytocin and placebo. This oxytocin-related effect on corticostriatal connectivity covaried with autistic traits, such that oxytocin-related increase in connectivity was stronger in individuals with higher autistic traits. In sum, oxytocin strengthened corticostriatal connectivity in women, particularly with cortical networks that are involved in social-communicative, motivational and affective processes” (Bethlehem 2017).
Medical studies suggest that oxytocin problems might impair social functioning and also cause people to experience more severe anxiety and depression in response to social rejection or other difficulties. If females with gender dysphoria might be experiencing oxytocin problems in connection with autism, PCOS or other conditions, then it might be very unhelpful to give high-testosterone/low estrogen treatments that could make oxytocin problems worse.
Patients should be told that PCOS and high testosterone may cause mental health problems—because that is what research shows—and that FtM treatments may make these problems worse. They should also be told that testosterone-lowering treatments are available and may help females with PCOS or high testosterone.
If patients are not told about any of this, then they may not be able to give legally-sufficient informed consent for FtM treatments (see also Murray 2012). Doctors who fail to provide appropriate information may be guilty of ethical violations that can be reported to a medical licensing board. This is true even if doctors fail to provide information because they want to “support” transgender people. Experts say:
“The practice of withholding pertinent medical information from patients in the belief that disclosure is medically contraindicated is known as ‘therapeutic privilege.’ It creates a conflict between the physician’s obligations to promote patients’ welfare and respect for their autonomy by communicating truthfully….
Withholding medical information from patients without their knowledge or consent is ethically unacceptable” (“AMA Code” 2012).
Transition treatments are not FDA-approved and have not been adequately tested. There is “a paucity of high-quality data” regarding these treatments
“due to a shortage of randomised controlled trials (partly because of ethical issues), few prospective and long-term studies, the use of suboptimum control groups, loss to follow-up, and difficulties in recruitment of representative samples of transgender populations” (Irwig 2017).
Doctors should provide this information when treating patients.