Hormone Treatment of Transgender Adolescents in Virginia – New Concerns

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:

  1. advising on treatment options when the underpinning evidence base is weak,
  2. complex issues of risk and safeguarding,
  3. ethical dilemmas about how to ensure best interests of vulnerable individuals,
  4. service safety in the face of workforce shortages, and
  5. 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.


Share this article



ADVERTISEMENT

(comments below)



ADVERTISEMENT

(comments below)


Comments

23 responses to “Hormone Treatment of Transgender Adolescents in Virginia – New Concerns”

  1. Paul Sweet Avatar
    Paul Sweet

    People are not arbitrarily “assigned” male or female at birth. Their sex is identified as male or female based on their chromosomes and plumbing.

    1. James C. Sherlock Avatar
      James C. Sherlock

      I agree. Did you take my article to somehow state differently? Point me to the language and I will evaluate it.

      1. Paul Sweet Avatar
        Paul Sweet

        It’s the so-called “experts” who say they are “assigned” male or female at birth.

        “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.”

        1. James C. Sherlock Avatar
          James C. Sherlock

          I did not take you point that way. That is a direct quote. I did not change it.

  2. LarrytheG Avatar
    LarrytheG

    If Medicaid will pay does that imply that employer-provided insurance will also pay?

    What determines if Medicaid will pay (or not)? What guides them in making such determinations? If they will pay, does that imply that there is a set of doctors and researchers who agree and recommend so?

    1. James C. Sherlock Avatar
      James C. Sherlock

      It’s similar to a regulation, Larry. Handled pretty much the same way under the administrative process act,

      1. LarrytheG Avatar
        LarrytheG

        whether or not Medicaid, Medicare or employer-provided insurance will pay for a treatment or not is determined by what process? Is there a panel of doctors and medical experts who will render a view that a particular treatment or therapy is effective and “legitimate” or that it is quackery or similar and will not be reimbursed?

        I was under the impression that a panel of medical experts and similar make such determinations and if they feel a therapy or treatment is not effective, inappropriate, experimental, etc, they will not reimburse for it.

        You’re a guy that does a lot of reading. You’ve never run into a description of this process?

        What Does ‘Medically Necessary’ Mean?

        https://www.medicare.org/articles/what-does-medically-necessary-mean/#:~:text=Not%20Medically%20Necessary%20Services%20and%20Supplies&text=According%20to%20CMS%2C%20some%20services,Medicare%20length%20of%20stay%20limitations

    2. James C. Sherlock Avatar
      James C. Sherlock

      No. It is a political move in this case.

  3. Kathleen Smith Avatar
    Kathleen Smith

    This was an interesting read. I am somewhat perplexed about Virginia’s code on sterilization but the lack of code around transgender issues. I am most concerned about puberty blockers that may have serious impact down the road. Maybe the Department of Health and Department of Behavioral Health and Development Services need to focus on this issues and make some recommendations. At least, JLARC could be asked to research what other states are doing.

  4. Eric the half a troll Avatar
    Eric the half a troll

    “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.”

    It is really funny (in a sad sort of way) that you think there are patients and families hanging out just waiting to “game the system” and get all those sweet puberty-blocking hormonal drugs…

    1. James C. Sherlock Avatar
      James C. Sherlock

      Not what I think, Eric. That is in the report of the U.K. commission.

      “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. “

      I note the attempt once again at snark, but once again you did not read the article. Getting boring. And annoying.

      1. Eric the half a troll Avatar
        Eric the half a troll

        And again you paint the searching for an affirmative diagnosis (something I am sure is natural given the stress patients and families are under) the same way Conservatives depict all similar issues, like abortion and welfare. Like there is a population just trying to “game the system” to get those sweet, sweet abortions, food stamps, hormone drugs… pick your issue and insert here…

        Sorry to be annoying… of course you thank me for my attention below… please make up your mind…

  5. Eric the half a troll Avatar
    Eric the half a troll

    “They offer referrals for therapy to help manage anxiety, depression, and ongoing emotional issues, but that is not their specialty at that clinic.”

    Fixed it for you.

    1. James C. Sherlock Avatar
      James C. Sherlock

      Read the website. They are advertising. They are reimbursed significantly for the work they do. They are selling it.

  6. Eric the half a troll Avatar
    Eric the half a troll

    “The authors of that manual itself have been accused of gaming the politics of the diagnosis of trans people.”

    I assume this is what you are referring to at your link:

    “…members of the Workgroup suggested that they would also be concerned with the destigmatization of transpeople while preserving a diagnosis that medical insurance companies would accept for issuing payments for transitioning treatments (Drescher, 2013).”

    Hardly “gaming the politics” to seek to destigmatize a diagnosis. Maybe you prefer the stigmatization…

    1. James C. Sherlock Avatar
      James C. Sherlock

      The name of the article linked is “The DSM-5 and the Politics of Diagnosing Transpeople”.

      To quote what you did not:

      “Secondly, the article explores the development of the GD diagnosis, and illustrates how the scientific data this were founded on are contentious.”

      “The article then demonstrates how the trans anti-pathologization movement has challenged the perceived pathologizing effects of the DSM-5 classification of GD.”

      “The article examines a selection of Western transgender community advocates’ websites, forums, and blogs. From these sources, the article then explores the different narratives of transpeople and political groups who offer details of their praxis, and evidences how the trans anti-pathologization advocates use the available science and human rights discourses to contest the role of psychiatry in the treatment of transpeople.”

      Moving on to my assessment, DSM-5 “games the politics” of the diagnosis of trans people, making the terms of the diagnosis more acceptable to “trans people and political groups” in order to reduce their opposition to “the role of psychiatry in the treatment of trans people”

      But thanks as always for your keen interest in my work.

      1. Eric the half a troll Avatar
        Eric the half a troll

        Yet, again, the entire goal of the anti-pathologization group is to destigmatize the diagnosis – as I noted above. Why do you oppose those efforts?

        1. James C. Sherlock Avatar
          James C. Sherlock

          I pointed it out in passing to show again the power of the lobby.

        2. Nancy Naive Avatar
          Nancy Naive

          The Pope sez it’s a “no-no”.

    2. Nancy Naive Avatar
      Nancy Naive

      Compare and contrast to the so-called “pregnancy crisis centers”. Proselytizing in the name of helping, take AA, for example.

  7. Nancy Naive Avatar
    Nancy Naive

    Don’t worry ’bout it, Captain. This is America. We have NIH**. It assures that whatever we do, it will be homegrown and not something that any other countries do, no matter how much better they do it. We don’t do what the smart kids do.

    When Winston Churchill said, “You can always count on the Americans to do the right thing after they have tried everything else,” he was being optimistic. He didn’t count on the possibility that we just stop at the first attempt that no one else has tried.

    ** No, not the National Institutes of Health, it means “Not Invented Here”.

  8. Warmac9999 Avatar
    Warmac9999

    The LPGA is about to have their first transgender tour golfer. Oh you lucky gals.

  9. Nancy Naive Avatar
    Nancy Naive

    ADD and ADHD.

Leave a Reply