Jack Drescher, M.D., Offers Thoughtful Insights on Treating Transgender Youth

Over the past couple of years, perhaps no clinically related topic has sparked as much debate and polarization as the treatment of transgender youth. “This has become a key front in the culture war, where people have very strong opinions,” said Jack Drescher, M.D.

Drescher is a clinical professor of psychiatry and a faculty member of the Division of Gender, Sexuality, and Health at Columbia University. He served on the working groups that revised DSM-5 and ICD-11. Most recently, he was section editor of the DSM-5-TR chapter on gender dysphoria.

At heart, the clinical issue is when and how aggressively to pursue gender-affirming care for youth questioning their gender identity. Drescher noted there are critics who believe the only answer is to provide talk therapy until the youth are talked out of transitioning, advocates who believe any gatekeeping on youth seeking to transition is harmful, and a wealth of thoughts in-between.

But while people are aware of their opinion of transgender care, not many are familiar with the details of the care process and how we got to today’s standards, Drescher said.

Drescher familiarized attendees with some of the key terminology involved when discussing gender, such as distinguishing gender identity and gender expression or the differences between social and medical transitioning. He also described the diagnostic journeys that led physicians from classifying patients as transsexuals to the current definitions of gender dysphoria (DSM-5-TR) or gender incongruence (ICD-11).

Of more timely interest, however, Drescher discussed some of the recent social and political controversies that have been prominently featured in the media, such as “bathroom bills,” sports participation, or the phenomenon of rapid-onset gender dysphoria in teens. He also explored APA’s own foray into controversy, notably the dueling opinions on whether gender dysphoria should have been removed (to reduce stigma) or retained (to maintain insurance coverage) as a mental disorder in DSM-5.

Psychiatrists and other clinicians need to be aware of all these swirling controversies as they affect patient care, Drescher continued. He noted that 20 states and the District of Columbia have banned conversion therapies for LGBTQ minors; other states have introduced bills seeking to ban medical treatment for transgender minors. Texas is the latest. Even in Europe, which is viewed as more progressive for transgender rights, several countries have hit the brakes when it comes to recommending medical treatments for youth experiencing gender dysphoria.

“As with any major life decision, a decision to transition should be thoughtfully and fully explored,” said Drescher. “There are some children who will benefit from gender-affirming treatment, and some who won’t.” But he believes the recent legislation is skewed too much at protecting the youth who eventually return to a cisgender state at the health expense of transgender children.

“We need to find the right balance, and that requires an appreciation of the complexity and nuance of gender dysphoria in youth,” Drescher said.

For those interested in learning more, see Drescher’s special report in the June issue of Psychiatric News that covers controversies in transgender care in more detail. ■