As working with people with gender dysphoria requires a different model of understanding, it remains legitimate to listen, assess, explore, wait, watch development, offer skilled support, deal with co-morbidities and prior traumas, and consider use of a variety of models of care. While respecting individuals’ right to a different viewpoint, it is neither mandatory to affirm their beliefs nor automatic that transition is the goal, particularly when dealing with children, adolescents and young adults. These risk closing the ‘open future’, as well as life-long physical problems including lack of sexual function, infertility and medical dependency. With 85% desistance amongst referred transgender children (8) and increasing awareness of detransitioning (9, 10), unquestioning ‘affirmation’ as a pathway that leads gender dysphoric patients to irreversible interventions cannot be considered sole or best practice.
More good-quality research trials are required to provide reliable evidence of clinical and cost-effectiveness of a range of approaches, including patient selection. These will surely include exploration of underlying unhappiness with the goal of achieving body/mind reintegration. In contrast to previous medical scandals that pathologised homosexuality, something different may be happening here. In effect, transitioning children who would otherwise have grown up lesbian, gay or bisexual may introduce another form of conversion (6). A well intentioned but permanent medical pathway for all is unlikely to achieve the best long-term outcomes. Confirming disgust in natal sex or external sexual organs, especially for those with prior childhood trauma, risks medical collusion with, or reenacting of, abuse.