Gender-focused textbook for psychiatrists draws criticism

Thousands of medical professionals have objected to a textbook published last November by the American Psychiatric Association, saying it makes controversial and even dangerous recommendations for psychiatrists working with individuals who struggle with gender dysphoria and mental illness.

Earlier this month, the group Foundation Against Intolerance and Racism issued an open letter calling for the book’s withdrawal, accusing it of encouraging practices that are “unacceptable, unethical and unsafe.” The letter has over 5,000 signatures.

Gender-Affirming Psychiatric Care, available through the association’s publishing house, is a 420-page academic reference meant for new psychiatrists, students, and researchers working with patients who identify as transgender. Medical experts who reviewed the textbook say it makes dubious claims about sex and prescribes solutions for mental health problems that aren’t based on the best scientific evidence. The textbook redefines biological sex on page 32, saying sex refers to the “biological components of an individual” rather than the individual him or herself. So a uterus is a female body part, the authors would say, but that doesn’t necessarily mean the human with the uterus is female.

Dr. Miriam Grossman, a board-certified psychiatrist who signed the open letter, said the textbook is inaccurate. She worries that young, misinformed patients will be subjected to potentially dangerous treatments. “It’s not based in medicine,” Grossman said. “It’s not based on science. And parents are simply unaware.”

The textbook tells psychiatrists to prescribe birth control pills, puberty blockers, and cross-sex hormones to alleviate the mental health problems of the gender-confused. An anorexic with gender dysphoria who is troubled by her breast size, for example, would be offered cross-sex hormones and referred for breast reduction surgery, according to the book’s chapter on treating eating disorders in transgender people.

Grossman said the book neglects to tell readers about the serious risks posed by these treatments.

Recent systematic reviews—rigorous evaluations of the best evidence—done in Sweden, Finland, and the United Kingdom concluded there isn’t enough evidence to support the use of puberty blockers and cross-sex hormones in young people. As a result, each of those countries ended up either scrapping or walking back their transgender treatment protocols.

Yet the textbook makes no mention of this, Grossman said.

“The book is filled with unsubstantiated medical claims, for example, calling puberty blockers safe and fully reversible,” Grossman said. “That is simply unconscionable for them to say that at this point with all the evidence that we have to the contrary.”

WORLD reached out to the American Psychiatric Association, as well as the textbook editors, Dr. Teddy Goetz and Dr. Alex Keuroghlian. None responded to our requests for comment.

The psychiatry association is not the only professional medical association taking heat for publishing books with controversial treatments for gender dysphoria. The American Academy of Pediatrics planned to publish its own 320-page reference for pediatricians entitled, Pediatric Collections: Gender-Affirming Care, this month. According to the book’s description, it offers “practical guidance and overview on access to care … for gender-diverse and transgender children.” But last month, the academy pulled the book, citing “an upcoming policy review on this topic.” A December New York Sun article notes that the book’s discontinuation came not long after a group of detransitioners sued the American Academy of Pediatrics for transgender treatments they received as minors.

According to the psychiatry textbook’s introduction, 50 of the 56 psychiatrists, professors, researchers and others in the field who contributed to the book identify as “transgender, non-binary, or gender expansive.” This includes the editors: Goetz prefers “they/them” pronouns and Keuroghlian uses “any pronouns.”

Having personal experience about a disorder can inform one’s research, said Dr. Karl Benzio, a board certified psychiatrist and co-founder of Honey Lake Clinic in Greenville, Fla. Benzio said his experience as a recovering alcoholic, for example, has helped him guide patients through addiction. But he wonders whether the 50 researchers who say they are transgender or non-binary have fully recovered from their own journeys through gender dysphoria.

“Where are they in the disorder or the struggle process?” he asks. “Are they out the other end, fully healed and functional and engaging in life and walking into their God-given potential?”

Benzio said that academics who have fully recovered from their gender identity struggles can study the data and review the literature with objective eyes. Those who are still struggling, on the other hand, would not be qualified, he said.

Benzio, who also signed FAIR’s open letter, said he opposes the textbook’s recommendations to give cross-sex hormones and other transgender treatments to gender-confused individuals struggling with psychiatric problems.

Instead, he recommends psychotherapy. This might involve a patient answering questions about how he came to conclude he should identify as a different gender, telling a psychiatrist his life story, and unpacking any underlying trauma or emotional baggage.

“I say, ‘Hey, tell me a little bit more about your childhood, tell me about growing up. Tell me about what you’re really stressed about, what are you really struggling with in life,’” he said. “Then we’ll start talking about their depression, their anxiety, their relational conflicts, their difficulty having or maintaining friends.”

Once a patient acknowledges and deals appropriately with the stressors in his life, Benzio said, his gender confusion will dissipate as he gradually understands his true identity in a way that makes sense to him.

Both Benzio and Grossman agree with the psychiatry textbook’s emphasis on the importance of showing compassion towards those dealing with mental health struggles. But they disagree with the book’s authors on what’s considered “compassionate.” For Benzio, a Christian who has practiced psychiatry for 35 years, truth is the most compassionate thing to offer.

Patients, he said, should always receive love and grace first. “Then I’m going to try to maneuver into truth in a little bit more of a nuanced way as they allow me into their space,” he said.