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?