by James C. Sherlock
We have discussed at length the controversial policies of the American Academy of Pediatrics (AAP).
It is time to consider the impact of Great Britain’s ongoing National Health Service Review of its transgender support to children and young people.
It offers new concerns about clinical challenges in the diagnosis and treatment of gender dysphoria in adolescent patients, especially the safety of puberty blockers.
And it causes us to discuss what has been going on for years at the University of Virginia Children’s Hospital Transgender Youth Health Services.
It is a state hospital that has treated hundreds of patients from the earliest stages of puberty with both puberty blockers and cross-gender hormones.
Background. In Britain, a decade had seen a dramatic increase in the numbers of referrals to the Gender Identity Development Service, at Tavistock and Portman (the only commissioned specialist service for this population in England), from around 50 in 2009 to over 2,700 in 2019/20.
Similar surges have been seen in America.
This was accompanied by a change in the case mix from predominantly birth- registered males presenting with gender incongruence from an early age, to predominantly birth-registered females presenting with teenage onset of reported gender-related distress.
In 2019, Dr. Hilary Cass was asked by NHS England to chair a policy working group to review the published evidence on the use of hormone treatments in children and young people with gender dysphoria, and in 2020 to extend that remit to conduct an independent review into the broader clinical approach and service model for this group.
The context for the commissioning of this broader review was the weak evidence base underpinning the current practice of prescribing puberty suppressor hormones to pause puberty in children and young people with gender dysphoria, as well as the uncertainties about the subsequent prescription of cross-sex hormones.
There had also been complaints that Tavistock and Portman had been too forward-leaning in proceeding to hormone treatments.
NHS commissioned Dr. Cass to lead an Independent Review of Gender Identity Services for Children and Young People, now commonly referred to as the Cass review.
Her Interim Report recommended moving from the centralized Gender Identity Services, the largest transgender gender support clinic in the world, to a regional model. That is happening.
That approach will break up the group of physicians who were criticized, fairly or not, for rushing patients into hormone therapies.
A month ago. On 19 July of this year Dr. Hilary Cass wrote a letter to John Stewart, NHS National Director, Specialized Commissioning. Dr. Cass’s letter was titled “Further Advice.”
I recommend you read the “Pathways of Care” section in that letter, where she recommends careful steps prior to medical intervention.
Then see the section on “Embedding research in clinical practice.” Key elements illustrate the gaps between science and practice in medical transition of adolescents.
My interim report highlighted the gaps in the evidence base regarding all aspects of gender care for children and young people, from epidemiology through to assessment, diagnosis, support, counselling and treatment.
As already highlighted in my interim report, the most significant knowledge gaps are in relation to treatment with puberty blockers, and the lack of clarity about whether the rationale for prescription is as an initial part of a transition pathway or as a ‘pause’ to allow more time for decision making.
For those who will go on to have a stable binary trans identity, the ability to pass in later life is paramount, and many will decide that the trade-offs of medical treatment are a price that is fully justified by the ability to live confidently and comfortably in their identified gender. The widely understood challenge is in determining when a point of certainty about gender identity is reached in an adolescent who is in a state of developmental maturation, identity development and flux.
Clinical challenges. The Interim Cass report wrote of the challenges faced by clinicians. They include:
- advising on treatment options when the underpinning evidence base is weak,
- complex issues of risk and safeguarding,
- ethical dilemmas about how to ensure best interests of vulnerable individuals,
- service safety in the face of workforce shortages, and
- polarized societal views on what the NHS can and should do.
Clinicians working with children and young people with gender-related distress face every one of these dilemmas.
Exactly as in America.
The same report expressed clinicians’ concerns about standards of care in diagnosis of gender dysphoria:
Some clinicians also reported feeling unable to undertake the process of assessment and differential diagnosis that would be the norm in their clinical practice because they perceived that there is an expectation of an unquestioning affirmative approach. They felt that this was at odds with a more open and holistic evaluation of the factors underpinning the young person’s presentation, and consideration of the full range of possible support and treatment options.
Much of the existing research base is observational, and there is a lack of longer term follow-up data on outcomes for children and young people receiving hormone treatment.
In addition, the focus on medical treatment has meant that the impact of non-medical interventions such as social transition and therapeutic support are ill understood.
Again, exactly as reported in America.
Diagnosis of gender dysphoria. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), among individuals who are assigned male at birth, approximately 0.005 percent to 0.014 percent are later diagnosed with gender dysphoria. Among individuals who are assigned female at birth, approximately 0.002 percent to 0.003 percent are later diagnosed with gender dysphoria.
But if the child and parent/guardian actively want the diagnosis of gender dysphoria, which has been noted in the U.K. review, they can look up the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) Diagnostic Criteria for Gender Dysphoria.
The authors of that manual itself have been accused of gaming the politics of the diagnosis of trans people.
Patients/parents/guardians anxious to begin treatments can read the criteria for the diagnosis online ahead of the mental health visit, parrot the acceptable answers, and use the diagnosis to set up the treatments. If they don’t get the diagnosis the first time, they can try another provider.
Safety of hormone therapy
The AAP notes some of the risks of puberty blockers.
Delaying puberty beyond one’s peers can also be stressful and can lead to lower self-esteem and increased risk taking. Some experts believe that genital underdevelopment may limit some potential reconstructive options.
Research on long-term risks, particularly in terms of bone metabolism and fertility, is currently limited and provides varied results.
The AAPs risk list for cross-gender hormones:
- Partially reversible (skin texture, muscle mass, and fat deposition);
- irreversible once developed (testosterone: Adam’s apple protrusion, voice changes, and male pattern baldness; estrogen: breast development);
- unknown reversibility (effect on fertility).
Let’s assume that Virginia doctors tell the parents and the adolescents that information. If they do (note to attorneys: I hope it is on a waiver form the patient and his/her parent/guardian sign), let’s agree that they must really think transition is important.
But the U.K. review in that same July 2022 letter, as we have read above, identified significant new concerns over the safety of the use of puberty blockers not referenced by AAP.
The letter notes that natural bodily hormones make significant contributions to psychosexual and gender maturation, and “we cannot be sure about the impact of stopping these natural hormone surges.”
Among the concerns noted:
adolescent sex hormone surges may trigger the opening of a critical period for experience-dependent rewiring of neural circuits underlying executive function (i.e. maturation of the part of the brain concerned with planning, decision making and judgement).
If this is the case, brain maturation may be temporarily or permanently disrupted by puberty blockers, which could have significant impact on the ability to make complex risk-laden decisions, as well as possible longer-term neuropsychological consequences.
To date, there has been very limited research on the short-, medium- or longer-term impact of puberty- blockers on neurocognitive development….
I searched The Journal of Pediatrics of the American Association of Pediatrics (AAP) for articles about concerns expressed in the July U.K. letter above.
The search yielded no results. But I’m not a medical professional. Maybe they know about those risks. (Another note to attorneys).
UVa Children’s Hospital. Hormone treatments for gender transition for children in Virginia is centered at the University of Virginia Children’s Hospital’s Transgender Youth Health Services, which has treated hundreds of children with hormones. You will notice that their promotion of those services leads with:
- Puberty blockers that delay sex-related physical changes
- Cross-sex hormones, like testosterone and estrogen
- Referrals for gender-affirming surgeries and voice therapy
They offer referrals for therapy to help manage anxiety, depression, and ongoing emotional issues, but that is not what they are selling at that clinic.
It is reasonable to ask how often the finding from the U.K. survey noting a patient/parental expectation of an unquestioning affirmative approach is encountered in that clinic.
Bottom line in Virginia
As a government culture, Virginia was for eight years on the leading edge of progressive thought.
The U.K. has disestablished their national center for child and youth gender transitions over concerns it was leaning too far forward in initiating hormone treatments.
In Virginia, our biggest “setting” for adolescent “gender affirmation” hormone treatments is the University of Virginia Children’s Hospital, a state institution. They claim to have treated hundreds of adolescents.
That hospital’s Transgender Youth Health Services offers hormone treatments at Tanner Stage 2 (age 11 is the posted minimum at that hospital), the earliest of the options available worldwide as reported by World Professional Association for Transgender Health. As reported above, they have treated hundreds of adolescent patients.
Virginia has a law prohibiting surgical sterilization of minors, but not chemical sterilization. So no legal fuss about that “unknown risk” of sterilization by cross-gender hormones thing. Bad luck if it happens. It is (or will be tomorrow) on the waiver paper the patient team signs.
As for insurance, as a departing gift from the Northam Administration on its way out the door, Medicaid as of July 1 covers gender dysphoria treatments. Our tax money at work. A senior Youngkin administration official with knowledge of the matter informs me the administration is reviewing that – and that they are not amused by the late Christmas present.
So if Virginia parents and their early adolescent child want to get a diagnosis of gender dysphoria, they can get one.
The hormone treatments for that diagnosis are risky and very harsh on the patient, but they are just one stop away in Charlottesville and I suspect other hospitals in Virginia. UVa will refer for surgery.
There is equity – Medicaid will pay.
It doesn’t get any better than that.