Transgender, Asexuality and SSRIs
Last week, there was a post Asexual, Transgender and SSRIs about possible links between antidepressant use in pregnancy or early childhood and a later development of asexuality.
In recent weeks RxISK has had several emails asking about possible links between transgender issues or Gender Dysphoria and antidepressants. In one a woman wondered about a brother who went on antidepressants and soon after became convinced that he should transition. The woman talked about an epidemic of gender dysphoria where she lived and wondered if that too had something to do with antidepressants.
In another email a neurologist had been asked by a colleague about the possible effects of antidepressants on his son who was now talking about transitioning. As a neurologist he got to see the profound effects dopamine agonists can have on sexual orientation and he thought it might well be possible that SSRIs could do something similar but thought he should touch base with us.
The question of Gender Dysphoria and Transitioning is febrile. The picture above is of Ben, who believes he is Amy, and is already taking hormones to forestall puberty. A program about his story has featured on Children’s BBC – CBBC – that is seen by 6 year olds. It’s drawing a heated response.
Serotonin and gender
The very first English language paper on imipramine, the first relatively potent serotonin reuptake inhibitor, in 1958, mentioned that some people with a homosexual orientation transitioned or converted on treatment to heterosexuality. This was a cause for celebration. As late as 1993, Peter Kramer in Listening to Prozac was saying the same thing and the implication was still celebratory.
But there is no reason to think all transitions are going to go one way and every reason to think heterosexuals may become homosexual. The recent literature on venlafaxine – Efexor – and on the dopamine agonists make this very clear.
Until very recently most sexologists figured that sexual orientation could not change like this. It was just not possible. What about gender orientation? This too seemed fixed. Not fluid. Something else other than a true change in sense of gender must be going on.
Well the antidepressants and dopamine agonists suggest certain things may be more fluid than anyone once thought.
One of the first academic papers on Gender Dysphoria was written by Pierre Deniker the discoverer of chlorpromazine, coincidentally. Deniker was very aware in the 1950s that new endocrine and surgical treatments were about to open up a world of novel possibilities but he also noted that in this new world the media would play a huge part especially among people who were in a fluid, uncertain or vulnerable state. Gender dysphoria might be the surface manifestation of a deeper dysphoria.
Later work made it clear there are many different Gender Dysphorias. Some link to homosexuality, some to autogynephilia, many have nothing to do with either of these states and some are people who get pulled in because they are unsettled and the chance to remake a self sounds appealing.
Beyond this are the gender fluid or non-binary states that leave some veteran transgender campaigners and their doctors confused and sometimes angrily denying there can be such states – you are either a man or a woman even if you are in the wrong body.
Somewhere in this mix there are people who are on or have been on SSRIs. They may be there purely by coincidence. There is a lot of gender fluidity these days and a lot of people on SSRIs and related drugs. Or there may be something about these drugs in some of us that brings us there. These drugs can induce compulsive behaviors like gambling in some and pre-occupations in others. They can change a balance in our impulses and inhibitions.
Who are we?
The people best placed to work out what might be happening is the gender fluid community itself. We need accounts from people whose orientation and self view has changed dramatically on exposure to or withdrawal from some of these drugs. But behind the change on the outside, we need to know more about any changes on the inside. What did the change feel like? What changed to bring about the change? These things could be linked to primitive effects like effects on our smell or sense of smell.
Right in the middle of all the debates and fuss is the word Choice. We have to respect the choices people make – we are told. The General Medical Council don’t issue guidelines on the treatment of any other condition – but they do for Transgender states. They tell doctors they have to treat people who choose to transition. They also tell doctors that this is an individual choice not a disease. But “treating” a choice is a contradiction in terms.
There is almost nothing we choose in this world in quite the way Choice gets used now in healthcare. We don’t choose our religion, our nationality, hardly any of our tastes, and probably almost nothing of our taste in clothes or food. We operate within groups and close to all of what we do is pre-chosen by the groups we come from. On the rare occasions we choose, it is often about leaving these groups.
We are a “we” first and individuals making individual choices only occasionally.
The US election campaign shows we are badly fucked up about gender. Seen through this lens it is not surprising a whirlpool has begun to circle around gender. But, it still looks like there is a good reason to think one of the currents that could drop some of us into this maelstrom is a serotonin current. Difficult though it is to work out what might have happened from within a maelstrom or circling round its edges, we still need someone on the verge of a gender breakdown to pull off a miracle and help tease some of these currents apart.
Addendum added 18th November 2016
Channel 4’s new documentary series ‘Kids On The Edge’ kicked off this week with the first episode focussing on London’s Tavistock Gender Identity Development Service (GIDS) for children and young people. This clinic is the only NHS funded service of its kind in the whole of the UK and has treated children as young as 3 years old. Despite seeing a 100% rise in referrals to the GID service, there seemed to be little understanding of why and what exactly might be going on.
The programme featured two 8 year children, Matt and Ash, both presenting with gender dysphoria. Matt also has a diagnosis of autism. The documentary narrator, in passing, mentioned that according to the Tavistock Clinic themselves, half of the children referred to them also show Autistic Spectrum Disorder (ASD) type traits. This observation has seemingly not been explored any further.
One of the major decisions facing the two children and their families was whether going down an endocrine treatment route was going to be the answer for them. From the age of 11 children can be offered ‘hormone blockers’ until the age of 16, after which cross-sex hormones become a subsequent option.
To explain the use of hormone blockers the families were reassured at their clinic visit that any effects of such treatments were fully reversible and that they should view the treatment as hitting a pause button on puberty.
Among the blockers used is the Gonadotrophin-releasing hormone analogue (GnRHa) leuprolide (Lupron), a drug used to treat cases of advanced prostate cancer, as well as uterine fibroids and endometriosis. It is also a drug we have looked at on the RxISK Blog previously (see Lupron: a nightmare produced by AbbVie). This post generated 69 comments and much discussion about the short and long term side effects – from hot flashes, raised blood pressure, muscle cramps, bone weakness and depression – in both men and women of all ages and ranging in levels of severity. But what do we really know about the effects these drugs might have in children and adolescents at such a crucial time in their physical and emotional development?
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Last week RxISK picked up a new FDA warning on testosterone supplements. It addressed withdrawal effects from stopping testosterone, from fatigue and depression to irritability and muscle pain. It was directed mainly at adult males – both athletes and bodybuilders “abusing” black-market hormones, and those prescribed testosterone by doctors. (Many of the latter, especially older men, take it for a rather dubious “Low-T” syndrome said to be responsible for lowered energy/libido/mood … )
We passed this along on Twitter – and immediately got inquiries about “why no warning for females”? Seemed like a good question. I initially thought this was about doctors prescribing testosterone to women for low sex drive (another fairly dubious practice that was medically trendy a few years ago). But in fact they were concerned about girls and young women seeking a female-to-male transition.
It’s a hot question in the US as well as the UK – especially for young kids like Ben/Amy, whose ultimate medical decisions will be made by their parents. Some feel this will avoid real suffering for kids who are truly “trapped in the wrong body.” Others feel the kids are being locked in to a risky medical choice they don’t yet understand. Some worry they are under the influence of parents who have been too quick to endorse and advocate for a child’s possibly-transitory identification with the other gender.
Finally, some critics are opposed to any notion of transgender, and think all this is the work of male “perverts” who are trying to legitimize their own kinky choices by portraying them as something kids are born with. Some also spread fear that trans women (or cross-dressing men) will enter women’s restrooms to embarrass or even molest “real” females. It’s mainly to avoid identifying with that group – which seems simply bigoted – that I have steered clear of asking questions.
I think you’re right: the people best placed to work this stuff out are those undergoing the experience. Hopefully we can identify drug effects that may be overpowering some people’s natural tendencies, without de-legitimizing those who might actually be expressing their true natures for the first time.
I would hazard a guess that whatever is going on, howevermuch SSRIs are to account – wholly or partially – for the changes, are changes that happen, somewhere within the brain, without the patient having any control whatsoever over what is going on. Having seen a quiet, pleasant, happy young man change to what I can only describe as a raging bull, hell-bent on destruction of anything in his way, within a few days of taking an SSRI dose I can well believe that they can also change a person’s sexual orientation. Once medicines start meddling with our brain – all hell can be let loose. I wonder if working in an environment where SSRIs are manufactured could have the same effect? Now, there’s a thought – let’s falsify evidence that this is so and watch the workers scurrying away from the pharma companies………in our dreams at least!
M
There probably is a case that all of us are imbibing a little SSRI in our drinking water as is. And there can be some taken simply by physical contact. In the ordinary course of events these are minor amounts but DDT in the ordinary course of events was harmless too – it was only when it traveled down unforeseen routes that it became an issue
D
You are absolutely right about everything Mary
When I went to my Doctor and told him I thought I was Napoleon, he never offered me trans-Napoleon treatment, he just said I was mad. Just sayin….
@PCNG
A sane comment in an insane world! Although I HAVE heard SSRI can have a strange effect on “FEMALE Perverts” looking to get into the MEN’s Bathroom!
A couple of observations: gender confusion/blurring seems to have burst into the public domain fairly recently. Maybe it’s always been there, just easier to talk about now – although as Johanna says there are some vociferous and unpleasant voices out there. Maybe exploring different sexual identities is now part of adolescence? In young children though… there are many accounts by older people who came out as lesbian/gay of having always felt trapped in the wrong body. This seems different somehow. And the notion that parents have control over a child’s gender is quite scary.
A friend told me recently that ‘all the students are on antidepressants, they hand them out like sweets’: this of Oxbridge, where her son is studying. The academic pressure these youngsters are under is enormous so no wonder anxiety is rife – but that means a generation of 18 year olds is on SSRIs. A stark contrast to my uni days in the 1970s when we were far more interested in sex’n (illegal) drugs’n rock and roll than passing exams.
I think that in the UK today, children as young as four are put under pressure in the name of education. To me, ‘education’ means ‘discovery’. A teacher’s place is to create an environment where ‘discovery’ can take place. This takes place through play and experimentation – young children gather information like a sponge soaks up water and, generally, hang on to it for use in later years. If we are testing them at all levels then the pleasure of learning soon disappears. The pleasure is replaced by tension. The best ‘teacher’ any child can have is another child who plays alongside him/her. With ‘testing’ however, you are putting each child in turn on the spot and are refusing to allow the natural urge to help one another.
By the age of eleven, the majority of children feel a sense of failure that has come their way at some point or other. With this comes low self-esteem and a lack of confidence. By the age of eighteen many of the brightest pupils are struggling to cope with the expectations of their schools and/or parents. If lucky, they move on to colleges with the prospect of leaving there with a massive debt.
When we consider all of this, is it any wonder that they are all popping pills right, left and centre?
The resulting catastrophe is yet to be seen, I feel.
We learn on BBC News today that the Court of Appeal has decided that NHS England should be asked to consider covering the cost of prescribing the new AIDS prevention daily pill, PrEP which costs £355 per month for a pack of 30 tablets, I think. This means, we calculate, a cost of £4,260 per person per year. Whilst wondering whether SSRIs do influence change in one’s sexual orientation, here is yet another Pharma ‘solution’ on the health agenda, for people to ‘Choose’. Availability will be provided through sexual health clinics. It is felt that this pill will be more cost effective, as it is preventative of AIDS, than current treating of those who get it.
There was an interesting ‘Horizon’ documentary last night on BBC 4 ‘Is Your Brain Male or Female?’
Generally, it seemed from scans and illustrations that male brains do function differently, in two separate halves, passing messages back and forward in each side, whereas with women the messages cross over, back and forth, between the two halves ( left and right brain).
Testosterone levels before birth seemed to define gender initially. Even small babies seemed programmed naturally to reach for toys like dolls for the girls, trucks for the boys, even when dressed as babies of their opposite sex and offered toys by a researcher who thought the girls were boys and vice versa. Even monkeys in a Safari park did the same. Male monkeys went straight to trucks to spin wheels or sit on them, females showed no interest in trucks but picked up baby dolls. Toys had been scattered in equal numbers across a large grassland area.
At no time were medications discussed, sadly. Sexual orientation seemed mainly defined by hormone levels pre-birth, but environment, nurturing etc were said to influence later too. We do get a lot of hormones in our drinking water, recycled from rivers where we know fish have been affected by gender change due to estrogens (from the Pill), and if so many millions of us take SSRIs, and if these drugs affect sexual function and hormones ( the acne drug RoAccutane/isotretinoin we know changes hormones and DNA) – then could it be that they are indeed causing a lot of the trans gender results we see today. The film showed how incredibly important hormones are.
One other interesting comment on the programme – women do not recover so well from stroke generally as men do. We wondered whether this could be because men’s brains seem to function in separate halves, whereas there is so much cross over in messages between the women’s left and right brains?
More on this subject today, 1.12.16 on BBC’s Victoria Derbyshire Show. A little girl/turning into boy aged 10 told us about his feelings of always having known she was really a boy. It started when he was 4. His puberty which started early, aged 9, has been put on hold. A medical expert explained that if this hadn’t been done now, the physical surgery required later would be more invasive, removing breasts etc. But by the time he is 13, final decision making will have to take place, and the steps taken then will be irreversible.
Also discussed was the complex situation where some people consider themselves to be of neither sex exclusively. Was this always so but no one talked about it, or is this a new phenomenon, caused by some external agent, like SSRIs?
The 10 year old on the VD Show spoke well and convincingly about how he felt, and his mother was doing her best for him, despite outside criticism. It was all very thought-provoking.
We should just let children be.
When I was young, I played with dolls, pushed my brothers small miniature cars around in the dirt, played marbles on the sand field with the boys, played a lot of boys sports and wore so many shorts and t-shirts.
Mmmmm, that was until I attended an all girls school – yuk!
So what if I was considered a tomboy back then! ~ I had fun.
Irrespective of how an individual perceives themselves, everyone needs support to work out where and how they fit in.
Mary speaks with common sense.
Let children be children.
Generally, people have an idea of who they want to be, when they reach a level of maturity. Sometimes, whatever, the outcome, things are out of our control.
People, just want to be loved and through role playing, children learn a lot about themselves.
We can learn so much from watching children play.
Will you be publishing any updates to this conversation? It seems the time is ripe.
L
There was a post last week on Rxisk Snakes in a Love Drug – and am just about to post Snakes in a Love Drug 2 – there are also several posts on Cis and Trans Drug Wrecks..
D
I am a 45 year old transgender women. I was biologically born a boy but knew I was a girl in kindergarten. I tried to tell my parents, teachers, friends that I was NOT A BOY! this was 1980. Only to be punished,bullied,beat up. After my mom made me sit down with a Catholic priest and he told me I was a disgrace to GOD and going to hell for who I was. I tried to kill myself. I ended up shooting myself in my leg. I turned to drugs and alcohol to numb the pain. over 30 years I got brought back to life 3x from over dose. I finally found a HRT doctor to work with me at 43 years old. As soon as I started testosterone blockers and estrogen my mind calmed and I felt right. it was like testosterone was poisoning me. Anyway 2 years into HRT and I feel great. I do not have problems with drugs or alcohol anymore. I never thought I could be this happy. I just wish people would realize it’s not a choice.well I guess if you consider suicide a choice it is. kids like me that just know they are not in the right body have a 43% likely hood to kill themselves unless we adults help them. love and understanding is all that matters.❤️
The Observer
NHS gender identity clinic whistleblower wins damages
Child safeguarding expert awarded £20,000 after bringing claim against Tavistock and Portman trust