Etiology, Treatment, & Outcomes

Understanding the current science on gender dysphoria's causes, available treatments and outcomes, and live clinical controversies is essential to supporting families well. This page organizes relevant publications — separated by whether the transgender family member is a child/adolescent or an adult — alongside several current issues clinicians are likely to encounter.

​

A note on inclusion: listing a publication here doesn't imply endorsement by the Regeneration Resource Center. Few resources are written from an explicitly Christian perspective — the main exceptions are the Christian Medical & Dental Associations' transgender resources and Yarhouse (2015) below. Even where you may disagree with an author's underlying view of transgender identity, the information presented can still be useful.

​

Etiology (causes) of gender dysphoria

• Gender Identity Disorder and Psychosexual Problems in Children and Adolescents — see chapters 6–7 on biological and psychosocial etiology. Though published in 1995, its summary of the research gaps largely still holds; Hruz (2020) offers some updates on biological etiology (pp. 35–36).

• From Mental Disorder to Iatrogenic Hypogonadism — a balanced peer-reviewed discussion of the "pathologic condition vs. natural variation" debate (pp. 5–9), concluding that gender identity is likely best understood as a complex interaction of biological, individual, and environmental factors, without strong empirical support yet for any single model.

• Lev, A. (2004). Transgender Emergence. New York: Routledge — see Ch. 4, Etiologies.

 

Treatments for gender dysphoria & outcomes

• WPATH Standards of Care — useful for helping family members understand available treatment options.

• Transgenderism and Intersexuality in Childhood & Adolescence — see chapters 6–7 on clinical management.

• Advancing the Practice of Pediatric Psychology with Transgender Youth — current treatment options, useful for explaining these to families.

• Adolescents with Gender Dysphoria — covers rising referral rates, the growing share of referred biological females, suicide risk, and rapid-onset presentations.

• The Battle Over Gender Therapy (NYT) — summarizes current clinical debates.

• They Paused Puberty, but Is There a Cost? (NYT) — tradeoffs of puberty blockers.

• CMDA Transgender Resources

• Brown, M. & Rounsley, C.A. (2003). True Selves. San Francisco: Jossey-Bass — secular perspective.

• Yarhouse, M. (2015). Understanding Gender Dysphoria. Downers Grove, IL: InterVarsity Press — conservative Christian perspective; Ch. 5 covers treatment.

• Yarhouse, M. & Sadusky, J. (2022). Gender Identity & Faith. Downers Grove, IL: InterVarsity Press — for clinicians helping clients reconcile faith and gender identity.

 

Interventions for families with a transgender child or adolescent

• Brill, S.A. & Pepper, R. (2008). The Transgender Child. San Francisco: Cleis Press — Ch. 2, Family Acceptance: From Crisis to Empowerment.

• Coolhart, D. & Shipman, D.L. (2017). Working Toward Family Attunement. Psychiatr Clin North Am, 40(1), 113–125 — secular family therapy model.

• Ehrensaft, D. (2011). Gender Born, Gender Made. New York: Experiment — Ch. 2, The Family's Path Is Covered with Roses and Thorns.

• Gottlieb, A.R. & Lev, A.I. (2019). Families in Transition. New York: Harrington Park Press — Ch. 5 on extended family, Ch. 11 on parents' identity, Ch. 17 on siblings.

• Raj, R. (2008). Transforming Couples and Families. Journal of GLBT Family Studies, 4(2), 133–163 — the Trans-Formative Therapeutic Model, written by a transgender clinician.

• SAMHSA (2014). A Practitioner's Resource Guide: Helping Families to Support Their LGBT Children. Available here.

• Wahlig, J.L. (2015). Losing the Child They Thought They Had. Journal of GLBT Family Studies, 11(4), 305–326 — ambiguous loss perspective.

• Additional secular resources: Cooper (2009); Golden & Oransky (2019); MacNish & Gold-Peifer (2014); Malpas (2011); Vanderburgh (2009).

 

Interventions for families with a transgender adult

• Lev, A. (2004). Transgender Emergence, Ch. 8, Family Emergence — one of the earliest resources specifically addressing families with a transgender adult.

• Raj (2008), above, also addresses the Trans-Formative Therapeutic Model as applied to families with a transgender adult.

 

Current Issue: How does clinicians' treatment of transgender people affect their families?

Family members may want to discuss their reactions to a transgender relative's ability — or inability — to access care from Christian or non-Christian providers. Research indicates that a shortage of knowledgeable providers is the largest barrier to transgender health care, followed by discrimination and other systemic barriers. Family members may bring mixed feelings about scenarios like:

• their relative wanting care that simply isn't available locally

• local providers being capable but unwilling to provide it

• their relative experiencing rejection or judgment while seeking care

• (in some cases) relief, surprise, or shock that care was obtained at all

 

One helpful reframe for processing these feelings with families: How would you, as a clinician, want another provider to treat one of your own transgender loved ones?

 

This also raises a genuinely contested question: under what circumstances should a clinician refer a transgender patient elsewhere for transition-related care? Some medical professional groups hold that Christian providers shouldn't be required to provide treatment they believe is morally wrong or harmful — for example, prescribing medication or writing letters supporting a minor's transition. But what's the right course when a physician is capable of providing care but believes it may be harmful? Secular ethicists note the physician's obligation to provide non-emergency care isn't clearly defined (McCoy, 2006), and the AMA's Principles of Medical Ethics allow physicians to choose whom they treat outside emergencies — though this sits alongside ACA Section 1557's non-discrimination protections around gender identity in insurance coverage (more in the Clinical History section).

 

Where a physician is simply unfamiliar with transgender care standards rather than morally opposed, referral may be the better option; secular ethicists recommend a harm-reduction approach to such referrals when options are limited (Dietz & Halem, 2016).

 

For mental health clinicians specifically, a related tension can arise when a client professes strong Christian faith and the clinician assumes that faith and transgender identity are incompatible. Two articles explore when referral is ethical versus discriminatory:

• Cox, M.R. (2013). When Religion and Sexual Orientation Collide. Counseling Today.

• Dessel, A.B. et al. (2017). LGBTQ Topics & Christianity in Social Work. Social Work & Christianity, 44(1–2), 11–30 — see "Referring LGBTQ Clients," pp. 17–19.

 

Further reading: Barsky (2019); Gerritse et al. (2018); Hruz (2020); Kaplan (2014); Kimberly et al. (2018); Reamer (2014); Swann & Hebert (2009).

 

Current Issue: The "Desister" Debate

Parents may ask whether their child's gender dysphoria will persist or "desist" (i.e., the youth later changes course) — a question The Atlantic explored that some parents may have already read. Several peer-reviewed studies (Drummond et al., 2008; Steensma et al., 2011, 2013; Wallien & Cohen-Kettenis, 2008) found that while a meaningful proportion of youth persist (12–58%, depending on the study), most — over half in three of four studies — do not. This sparked debate over whether emphasizing desistance rates risks overshadowing the needs of youth whose dysphoria does persist, alongside methodological critiques of the underlying studies (Temple Newhook et al., 2018).

 

A more recent Pediatrics study (Wagner et al., 2021) followed gender-diverse children for an average of 3.5 years and found 29% received a gender dysphoria diagnosis and 25% received hormone therapy — consistent with Wallien & Cohen-Kettenis (2008) and Steensma et al. (2013). A separate follow-up of boys with gender identity disorder found 12.2% remained dysphoric at reassessment ("persisters") versus 87.8% who did not ("desisters"); persisters tended to be older at assessment, from lower social-class backgrounds, and more gender-variant in childhood (Singh, Bradley, & Zucker, 2021). A secondary analysis of the U.S. Transgender Survey found 13.1% reported a history of detransition, 82.5% of whom cited an external factor (family pressure, social stigma); detransition was also associated with male sex assigned at birth, nonbinary identity, bisexual orientation, and family unsupportive of gender identity (Turban, Loo, Almazan, & Keuroghlian, 2021).

 

Researchers have called for more study of what distinguishes desisters from persisters (Butler & Hutchison, 2019).

 

Clinical implications for families:

• Recognize that not everyone with a transgender identity maintains it over time, and help families understand this variability without over- or under-stating it

• Help families manage the uncertainty and anxiety this can create, which may itself precede ambiguous loss (see I'm a Clinician)

• Encourage contact with clergy for support, if the family wants it

• Alongside individual/group psychotherapy, consider that social transition — a reversible step — is increasingly recommended for pre-pubertal youth (Chen, Edwards-Leeper, Stancin, & Tishelman, 2018; Singh et al., 2021)

• Make sure families understand which interventions are reversible and which aren't, and that exploration can take many months and doesn't always resolve toward medical intervention — and even medical intervention isn't always permanent (e.g., a case of starting, then discontinuing, puberty blockers to resume natal puberty; Turban, Carswell, & Keuroghlian, 2018)

 

Current Issue: The Effect on Families of State Bills Banning Medical Treatment for Transgender Youth

Do these bans protect child welfare, or preserve traditional views of biological sex? Families are caught in the middle either way.

​

Starting January 2021, states began proposing bans on puberty blockers, hormone therapy, and gender-related surgery for minors. (Puberty blockers — gonadotropin-releasing hormone agonists — have been used since the 1980s to delay early puberty; synthetic hormones were first used for intersex children in the 1930s, then transgender youth shortly after.) By April 2022, 20 states had proposed such laws, with three enacted (Alabama, Arkansas, Tennessee); restrictions vary by age and treatment type, generally exclude youth with chromosomal or sexual development conditions, and can carry felony or civil liability for providers.

 

The child-protection framing: these bills are cast as protecting children from medical procedures without adequate scientific support, encouraging mental health treatment first given pre-existing psychiatric conditions. Arkansas's bill, for instance, noted the absence of randomized controlled trials on cross-sex hormones for this purpose — though one such trial is now underway. Georgia's proposed "Vulnerable Child Protection Act" and Texas's classification of these treatments as child abuse follow similar logic; in February 2022, Texas's governor directed state investigations into families pursuing this care, though a state judge later ruled the policy improperly adopted and temporarily halted it.

 

The counter-framing: these bills may instead function to preserve a traditional link between gender and biological sex, since child-protection laws normally presume parental neglect or abuse — yet parental consent is already required for these treatments. This raises the question of why the state would override parental medical decisions here specifically, but not elsewhere. Proponents' concerns about insufficient evidence also cut both ways: about half of all medical treatments generally lack strong evidence, and off-label prescribing affects roughly 21% of medications overall — raising the question of why this particular, relatively small population draws such intense scrutiny.

 

How restrictions compare to existing guidelines: in practice, the bans may change little, since current guidelines already don't recommend gender-related surgery under 18 or hormone therapy before puberty begins. Arkansas's surgery ban and Tennessee's prepubertal hormone ban both track existing practice rather than changing it — meaning the main effect may fall on families rather than on clinical practice itself.

 

Effects on families, regardless of one's view of the underlying treatments:[†]

• Parents may fear for their child's emotional and physical safety — including clergy members themselves navigating this with their own children

• Family conflict between the transgender member and others may increase

• Youth who feel alienated may face higher anxiety, depression, suicide risk, or substance use, and may come to mistrust the health care system broadly, affecting unrelated future care

• Non-transgender family members may feel stigma, helplessness, or a sense of being abandoned by the health and government systems

• Some families consider relocating to states without restrictions — which can isolate them from existing support networks

• Restricted access to monitored hormone therapy may push some toward unsupervised, unmonitored alternatives

 

Notably, psychotherapy itself isn't restricted by these laws, meaning demand for psychotherapeutic support (for gender dysphoria as well as related depression, anxiety, and substance use) may rise even as medical options narrow. Social transition, without medical intervention, also remains available to families in restricted states.

​

[†] This section describes documented effects on families regardless of a reader's own view of whether these laws are appropriate — it is not making an argument for or against the legislation itself.

 

Current Issue: Rapid Onset Gender Dysphoria (ROGD) Controversy

The term "rapid onset gender dysphoria" originated in 2016 recruitment materials for a study of parents' perceptions that their child developed dysphoria symptoms with little prior warning (Ashley, 2020). Littman's 2018 study in PLOS ONEsurveyed such parents and found 83.5% observed two or more DSM-5 gender dysphoria indicators, high co-occurring anxiety/depression, and that in a third of cases the child requested immediate transition. Over two-thirds of children were in friend groups where another member had also recently come out as transgender — leading Littman to hypothesize a possible role for social influence and "maladaptive coping."

 

The study drew significant methodological criticism: that it used a pathologizing framework leading to biased results (Restar, 2020), and that recruitment via social media groups already skeptical of rapid referral to medical treatment introduced selection bias. One critique argued the ROGD concept risked being used to dismiss a growing evidence base for transition's benefits (Ashley, 2020). In response, the journal republished a corrected version with expanded methodology, limitations, and author clarification (Littman, 2019), and the editor issued a public apology for shortcomings in the review process while affirming that readers should weigh multiple views on the topic (Heber, 2019).

 

Some clinicians found Littman's described presentation consistent with their own clinical experience and called for further study (Hutchinson, Midgen, & Spiliadis, 2020); others maintained the field still lacks diagnostic and treatment consensus for this presentation (Brandelli Costa, 2019). So far, only one study has directly tested whether ROGD is a distinct clinical phenomenon (Bauer, Lawson, & Metzger, 2021) — it did not support that hypothesis, though differences in study populations and diagnostic rigor between the two studies leave the question genuinely open (Brandelli Costa, 2019; Collin, Reisner, Tangpricha, & Goodman, 2016).

 

Clinical implications for families:

• Different presentations of gender dysphoria may exist; using a validated, psychometrically sound instrument (e.g., the Gender Identity/Gender Dysphoria Questionnaire for Adolescents and Adults, Deogracias et al., 2007) during assessment can help clarify what's actually being observed

• Including parent and primary care physician input in the diagnostic process (similar to ADHD assessment practice) may add useful perspective

• If onset has been recent, expect the family may be in a state of acute crisis or panic — help them manage anxiety and tolerate uncertainty (Brandelli Costa, 2019), and recognize this may anticipate ambiguous loss

• Encourage clergy involvement if the family wants it

• Help the family weigh the advantages and disadvantages of any immediate steps, understanding exploration can take months and doesn't guarantee a particular outcome — including the possibility that a young person may return to their birth gender presentation after a period of exploration (Turban et al., 2018)

 

Continue exploring:

• Implications for Clinicians

• Services & Other Resources