Medical Transition Bans for Adolescents: Anti-trans or Pro-child

But we are very, very reserved about this treatment. Hormonally speaking it's safe. But psychologically speaking, did we do the right thing? Do people of 13 never have second thoughts of what they are doing?

Professor Louis Gooren                    

Endocrinologist                   

There are currently two extreme approaches to dealing with gender identity confusion and gender transition for adolescents and teens. One approach sees gender affirmation therapy as a right for transgender and non-gender-conforming youth. At its extreme, this is the approach taken by British Columbia as established by the BC Infants Act. It is also the approach taken for children in foster care in California with adoption of Assembly Bill 2119. The opposite approach is to ban medical gender transition outright. This is the approach taken by the Arkansas legislature after overriding the governor's veto of Arkansas House Bill 1570. South Dakota passed a bill banning teaching about gender identity and gender dysphoria in public schools.

The BC approach has been called child abuse and the Arkansas approach harmful to trans children. Hyperbole aside, recognizing that either extreme might neglect the specific needs of individual children, it's important to consider the consequences. Is it more damaging for a child to transition who might desist and later detransition or is it more dangerous for a child not transitioning who should? The emotional appeal to protect children seems to curtail honest comparative evaluation of the negative impacts of both approaches.

Gender Affirming Therapy

According to the American Psychiatric Association, "Gender Affirming Therapy is a therapeutic stance that focuses on affirming the patient's gender identity and does not try to 'repair' it." Considering adolescents, this may mean taking a regimen of puberty blockers over years, followed by cross sex hormones, and possibly surgery. Under what circumstances would you consider it medically best practice to give pharmaceuticals with a high chance of permanent adverse effect followed by surgery on a healthy body based on the subjective understanding of the patient? How rare should such an occurrence be for adolescents? Proponents of gender affirmation claim that it is life saving care. The strongest impetus behind gender affirmation is to prevent self ham and suicide by trans teens. The claim is that gender affirming care lowers suicide ideation and suicide attempts for trans people based on the results of self reporting surveys.

The Arkansas bill banning gender affirmation therapy for adolescents through puberty suppressing drugs and surgery is called the Save Adolescents From Experimentation (SAVE) Act. The proponents claim the majority of children experiencing gender dysphoria will desist or eventually identify with their biological sex. They are also concerned about the lack of longitudinal studies on the risks and benefits of using puberty blockers. The fear is that the risk of long term harm is greater from gender affirmation than any potential benefit.

Evaluating The Claims

We should be cautious with attributing any singular reason for suicide or suicidal ideation. Despite the number of journalists and organizations making the claim that gender affirming care prevents suicide, the claim is not supported by the data. In this survey from UCLA's Williams Institute there's no distinction between suicide attempts before and after transition. The survey also doesn't measure the impact of co-occurring psychological issues on suicidal ideation. In reviewing their guidelines for children with gender dysphoria, The Swedish National Board of Health concluded in a preliminary report:  

People with gender dysphoria, especially young people, have a high incidence of co-occurring psychiatric diagnosis, self harm behaviors, and suicide attempts compared to the general population. Co-occurring psychiatric diagnoses among people with gender dysphoria are therefore a factor that needs to be considered more closely during investigation.

The Arkansas ban and similar proposals in other states are accused of blocking trans healthcare and targeting trans youth. A Buzzfeed article suggests that the concerns of legislators are made on a psuedo-scientific basis. The piece links to a study frequently used to declare a connection between puberty suppression drugs and decreased suicidal ideation. I'm not a medical professional but it seems obvious that the paper doesn't support that connection. It concludes, "[a]mong transgender adults in the United States who have wanted  (Emphasis mine.) pubertal suppression, access to this treatment is associated with lower odds of lifetime suicidal ideation." In other words, some trans adults think, without experience, that they would be happier if they had taken puberty suppressing drugs. That's hardly conclusive.

Sociologist Michael Biggs wrote a more thorough review of this paper. He indicates that it relies on a low quality self reporting survey in which participants seem to confuse puberty blocking drugs with cross sex hormones. He notes that the paper offers caution not seen in the reporting, "the study's cross-sectional design...does not allow for determination of causation. Longitudinal clinical trials are needed to better understand the efficacy of pubertal suppression." It stands to reason, then, that we also lack longitudinal studies on the adverse effects of these drugs. This would seem to lend credibility to the Arkansas ban while casting doubt on the assertion that gender affirming therapy is life saving. 

A study published in The British Medical Journal is much less cautious in its conclusions, "[p]uberty blockers used to treat children aged 12 to 15 who have severe and persistent gender dysphoria had no significant effect on their psychological function, thoughts of self harm, or body image." In an official review into gender identity services The National Institute of Health and Care Excellence (NICE) in the UK found that evidence for use of puberty blockers was very low.

Hidden Assumptions

One important assumption behind gender affirmation is that the adolescent's subjective understanding of their gender identity must be true and that current understanding is permanent.  Otherwise, why make permanent changes to the body with pharmaceuticals and surgery to bring it in line with that understanding? Affirmation isn't evaluation. Gender affirming care does not necessarily engage the child around the reasons for their gender confusion. It simply determines if the child meets a certain threshold of mental wellness.

Another important implication is that medical and surgical transition is the best practice in every case of gender dysphoria. That's what it means to suggest that banning puberty suppressors is an attack on trans healthcare: the belief is that the drugs are essential to the well being of young people now identifying as trans. A number of studies have shown that 80-94% of children with gender dysphoria will desist, or "grow out of it" after puberty. The young people with the highest persistence rate of gender dysphoria are those who had begun a partial or complete social transition prior to the onset of puberty. Approximately 98% of adolescents who begin on puberty blockers go on to eventually take cross sex hormones. Despite doing nothing for the mental health of the child, one thing that puberty suppressors do is help ensure that the child will continue to transition.

How do we know if a child currently expressing symptoms of gender dysphoria is part of that majority that will desist or minority that will persist? It's not clear with the gender affirmation model that it's possible to know. Talk therapy, which might explore the origins of the child's gender dysphoria, is increasingly considered an attempt to 'repair' gender id or conversion therapy. The irony of calling an approach that considers options which may result in desistance conversion therapy is that most of the children who will desist will grow to be lesbians and gay men. There are a number of young people who are transitioning in reaction to community and internalized homophobia. There is no evidence that this is a primary reason for adolescents identifying as trans.

The most crucial assumption of gender affirmation is that distressed adolescents can understand the potential consequences of medical transition and are capable of giving informed consent. This assumption was tested in court and found to be false by a three judge panel. Keira Bell brought a legal complaint against Tavistock, which runs the Gender Identity Development Service (GIDS) in the UK. After being disgusted by her body and being referred to GIDS, she was prescribed puberty blockers at 16, and then hormones at 17. At 20 she had a double mastectomy before deciding to detransition a few years later. One judge wrote in the ruling, "There is no age-appropriate way to explain to many of these children what losing their fertility or full sexual function may mean to them in later years." As a result of the ruling, appealed by Tavistock, GIDS will only permit puberty blockers when specifically authorized by court.

This ruling has impacted adolescent treatment for gender dysphoria in the UK and influenced ethics reviews in other European states. Prior to the judgement Sweden and Finland had both begun reviews of their treatment guidelines. In June 2020 Finland became the first nation to issue new guidelines emphasizing psychological treatment. In April 2021 Sweden followed suit explicitly referencing the Bell case and considerations of informed consent. Rejecting the Dutch Protocol they have prohibited hormonal therapy for adolescents under 16 outright. Patients 16-18 should have court approval for hormone therapy and understand all of the risks. Also, in recognition that this treatment is still experimental, "it is decided that treatment may only take place within the framework of a clinical study that has been ethically approved."  It's not yet clear how much policy guidelines in the US will be impacted by the Bell ruling.

The Institutional Capture of A Live Experiment

Gender affirming therapy has tremendous institutional capture within US medical and civil associations. The Endochrine Society, American Academy of Pediatrics, American Psychiatric Association, American Civil Liberties Union and Planned Parenthood and numerous others have offered statements in support of gender affirming therapy and the use of puberty blockers followed by cross sex hormones for adolescents. Michael Biggs traces the origins of puberty suppression for treatment of gender dysphoria in adolescents to research in 1996 which led to the creation of the Dutch Protocol. Under the Dutch Protocol dysphoric adolescents might begin puberty blockers at 12, cross sex hormones at 16, followed by surgery after 18. Clinicians applied strict criteria for puberty blockers. The adolescent had to have exhibited symptoms of dysphoria early in childhood which worsened with puberty. The patient also needed to be psychologically stable with no other mental health problems and have strong familial support. The criteria for gender affirming therapy is much less stringent.

The podcast Gender: A Wider Lens hosted endocrinologist Dr. Will Malone in December 2020. He contrasted the method by which gender affirmation guidelines had been disseminated by the Endocrine Society with guidelines for other treatments. "In stark contrast to my previous experiences they rolled out a set of guidelines for gender dysphoric adolescents, and children that had really no evidence base, and essentially said that, okay, your job as endocrinologist now is to medically affirm children." There was little opportunity to ask questions about or challenge the guidelines. This was especially concerning because they were based on a single low quality study with no control group. As many have noted, this use of puberty blockers constitutes an ongoing live experiment.

Gonadotropin-Releasing Hormone agonist (GnRHa) stops the production of the sex hormones testosterone and estrogen. The commercial name in the US is Lupron. It was first licensed as a treatment for prostate cancer in men. Another primary use of the medication is for endometriosis in women. They are allowed to take the drug for up to 6 months because of the potential consequences. It was later licensed for precocious puberty in girls starting puberty before 7 and for boys starting puberty before 9. It has not been a treatment completely free of serious negative consequence. Gender clinicians used this treatment to justify its use as a puberty blocker for gender dysphoria in adolescents. Influenced by the Dutch Protocol, treatment may begin as early as 12. The youngest patient given puberty blockers was 10 in the UK. 98% of patients on puberty blockers begin taking cross sex hormones around 16. The drug is also used for men with severe sexual deviation. Put simply, it's a chemical castration agent for sex offenders. A 2018 review of the drug recommended that it "should be reserved for patients with...the highest risk of sexual offending because of their extensive side effects." In a very real sense, there is much less caution with adolescents at an important stage of physical and cognitive development than with adult pedophiles. "Considered as a treatment in its own right, the suppression of puberty with GnRHa might be the only treatment provided by the NHS for which the costs clearly exceed the benefits. The sole justification for GnRHa is to prepare a child for lifelong medicalization with cross-sex hormones and surgeries, with irreversible consequences for sexuality and fertility."

Either all of these major medical associations are unable to tell the difference between high and low quality research or they are influenced by something other than the needs of confused adolescents. The previous maker of Lupron paid an $875 million settlement for rewarding doctors for prescribing it in the early 2000s. The FDA approval documents estimate that precocious puberty affects approximately 2000 US children.  Treatment costs $20,000-$40,000 for two years. Gender Affirmation therapy is a growth opportunity. It promises a growing number of adolescents who will be medicalized for life. The first pediatric gender clinic in the US was Boston Children Hospital's Gender Management Service in 2007. Estimates are that there are now 30 juvenile gender clinics in the US. An organization of volunteers methodically tracking gender services state by state produced this map, the purple are juvenile gender clinics:

 The Question Not Asked

As mentioned above, the criteria for engaging the gender affirmation model is much less rigid than for the Dutch Protocol. Dutch researcher Thomas Steensma said, "[w]e conduct structural research in the Netherlands. But the rest of the world is blindly adopting our research. While every doctor or psychologist who engages in transgender health care should feel the obligation to do a proper assessment before and after intervention." What does a proper assessment entail under the gender affirmation model?

Planned Parenthood now provides gender affirmation services. It entails some degree of psychological assessment followed by a consultation with a healthcare worker for hormones. These are the intake and informed consent forms:

I'm not the best judge of whether this constitutes a proper assessment and true informed consent. I'll leave it to someone who went through it. Rather than detail her Twitter thread on the impact on her of this model I recommend reading it in its entirety. TLDR; it was neither a proper assessment or enough information to be informed consent.

In British Columbia an adolescent can initiate the process of sexual transition. Consent looks like this:

This form belongs to a 13 year old who began social transition in 7th grade with a school counselor. The parents were not informed. The school eventually sent her to a psychologist who has reportedly helped 1000 children transition who referred the family to the endocrinology unit of BC Children's Hospital. There, a doctor laid out a plan for sexual transition to which the father, Rob Hoogland refused consent. He pointed out that she had claimed to be a lesbian before believing herself to be a boy. He also indicated that she had obsessive tendencies. She had been so obsessed with 2 male teachers that the school was forced to intervene. When she reached 14 he was informed that the clinic was beginning medical transition. He received a letter that said in part"

In British Columbia a minor may give an effective consent to health care if his provider, first, is satisfied that he understands the nature, consequences, benefits, and risks of the proposed treatment and, second, concludes that the treatment is in his best interests...[a]lthough the child's parent may serve the crucial role of friend and adviser with respect to a healthcare decision, the parent cannot veto that decision.

Hoogland's refusal to accept this treatment plan and desire to inform other BC parents by sharing the consent form led to his arrest for "family violence" for misgendering his daughter. He was convicted to 6 months in prison in April 2021.

Dutch researchers are beginning to express increasing caution even with the Dutch Protocol. Steensma explains, "[w]e don't know whether studies we have done in the past can still be applied to this time. Many more children are registering, and also a different type...[s]suddenly there are many more girls applying who feel like a boy. While the ratio was the same in 2013, now three times as many children who were born as girls register, compared to children who were born as boys." Depending on the accounting, between .002-.014% of the population identifies as trans. Among high school students that number rises to 1.8%. A large number of them are girls. No one knows for sure what's responsible for this exponential increase. Again, how do we know which of these adolescents are part of the majority who will desist after puberty and the minority who will persist in their gender dysphoria? Gender affirming therapy doesn't ask and offers no criteria for assessing.

As part of his explanation of the history of the use of puberty blockers Michael Biggs asked an important question: Are puberty blockers for diagnosing or for creating transsexuals? The original research offered contradictory explanations of their purpose. On the one hand they were considered a diagnostic tool. The language now is that they give the adolescent time to consider transitioning without taking on secondary sexual characteristics. On the other hand, they are the first step in transitioning. Again, 98% of adolescents prescribed puberty blockers go on to take cross sex hormones. Starting a child on puberty blockers almost certainly ensures that they will continue to transition rather than desist. Since gender affirmation offers no assessment, there is no guarantee that the transition is the best option. In the same way that there is no evidence that puberty blockers improve mental health, there is also no evidence that gender affirming surgery improves mental health. It didn't for Keira Bell. Having gender dysphoria does not automatically mean one is trans, despite the insistence of the affirmation model that it does. We have to ask: Does gender affirmation therapy serve trans youth or does it create trans youth?

To Ban or To Affirm?

The state bans on medical transition stop young people from initiating permanent changes to their minds and bodies to bring their bodies aesthetically in line with their current self concept. The idea that this will lead to suicide is not reflected by the evidence. Yet, this seems to be the central premise behind the opposition to medical transition bans for adolescents. Jack Turban-- one of the authors of the study that failed to make a connection between puberty blockers and suicidal ideation-- attributes his continued advocacy for puberty blockers and medical transition to the the guidelines disseminated by the Endocrine Society. In a systematic review of international guidelines only 1 of the 6 judges was willing to recommend the Endocrine Society guidelines in their current form. Overall they found the guidelines focused on transition to have a low evidentiary basis.

Because it is so politicized in the US it's difficult to have a nuanced conversation on this complex topic. Still, the evidence appears to be strongest for a ban. Consider the Keira Bell case, the guideline changes for the UK, Finland, and Sweden, and Dutch researchers acknowledging the experimental nature of this use of puberty blockers. There is a growing number of mostly girls identifying as trans. We are not completely sure why. The majority will desist with their gender dysphoria. Most of them will grow to be lesbians and gay men. The burden of proof is for those still advocating medical transition as the only option for people with gender dysphoria to explain how to know if a child will desist. The idea that stopping adolescents from beginning a treatment likely to lead to sterility and infertility is attacking trans healthcare is a chilling connection to make. It should be acknowledged that the state governments banning medical transition are following a new international standard. Where they fail is in funding additional psychological support services that gender dysphoric youth might need in those states.