by James C. Sherlock
To get this out of the way, I personally support qualified diagnosis and psychological treatment for gender dysphoria in children and adolescents.
I oppose puberty suppression, cross-gender hormonal treatments and transgender surgical procedures in minors.
That said, transgender individuals, like everyone, deserve skilled, safe and standards-based medical care.
Virginia laws and regulations protect people from all sorts of things, but somehow they do not protect transgender persons from bad medical treatment. It seems axiomatic to regulate transgender medical practice to the most up-to-date and widely accepted professional standards.
But that is not the case in Virginia. It is not that the standards are out of date; they apparently do not exist.
I searched the regulations of the Department of Health for the term “transgender” and it came up “no results found.” But VDH protects us from bad shellfish.
The Department of Behavioral Health and Developmental Health has lots of regulations, but a search for the term “dysphoria” comes up empty.
The 2022 Standards of Care (SOC) for the Health of Transsexual, Transgender, and Gender Nonconforming (TTGN) People Ver. 8 published by the World Professional Association of Transgender Health (WPATH) is uniformly excellent.
Those standards are thorough, professional, compassionate and incorporate the latest research.
The internationally recognized WPATH SOC are the obvious basis for state healthcare regulations in Virginia.
It needs to happen.
Lack of standards. Let’s go right to the top of Virginia’s transgender youth treatment food chain.
UVa’s Transgender Youth Health Services, the commonwealth’s mother ship for hormone therapy and referrals for surgery for adolescents, asserts on its website that it follows Endocrine Society guidelines in its hormone delivery to minors.
I have compared the WPATH standards to the Clinical Practice Guidelines of the Endocrine Society. It is clear from the differences that Endocrine Society guidelines (not standards) are indeed from 2017.
The Endocrine Society indicates no intention to update its guidelines anytime soon. Those guidelines do, however incorporate this statement:
Those clinicians who recommend gender-affirming endocrine treatments—appropriately trained diagnosing clinicians (required), a mental health provider for adolescents (required) and mental health professional for adults (recommended)—should be knowledgeable about the diagnostic criteria and criteria for gender-affirming treatment, have sufficient training and experience in assessing psychopathology, and be willing to participate in the ongoing care throughout the endocrine transition.
“Should be knowledgeable” and “should … be willing.” That is a guideline.
“Must be knowledgeable and willing” seems a reasonable standard, but it is not a standard — nor a requirement- – in Virginia.
Or, apparently, an observed guideline at UVa Health’s endocrine clinics for youth and adults.
UVa Health requires only that children and adolescents arrive at the door of its endocrine and surgical practices with a gender dysphoria diagnosis.
Diagnosis From a Mental Health Professional
In order for one of our clinical providers to discuss treatment, we require a diagnosis of gender dysphoria. This term is used when a child’s sense of their gender differs from the sex assigned to them at birth.
Our care team can provide referrals to the appropriate mental health professionals.
That is not even an approximately accurate definition of gender dysphoria. The definition from the American Psychiatric Association:
For a person to be diagnosed with gender dysphoria, there must be a marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her, and it must continue for at least six months. In children, the desire to be of the other gender must be present and verbalized. This condition causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
It is an embarrassment for my alma mater when its transgender youth clinic can’t even muster a reasonable definition of gender dysphoria.
We are left to wonder at what the positive diagnosis rate is among the “appropriate” mental health professionals recommended by UVa’s clinic.
“Transient phase.” The National Health Service in Great Britain recently warned that its studies showed:
that most children who identify as transgender are experiencing a ‘transient phase.’
In light of the report, the NHS will adopt a more cautious approach to treating gender dysphoria in minors, banning the use of puberty blockers in patients under 18 but for strict clinical trials.
Clinical trials to ascertain the long-term health effects of puberty blockers in early adolescence also seem axiomatic. It just hasn’t happened. Advocates have driven the “guidelines” in the U.S., and have been unwilling to wait.
UVa Health is waiting for nothing.
It is most certainly not interested in the banning of puberty blockers in patients under 18 except for clinical trials, as in Britain.
I am sure that opposition is out of a misplaced sense of compassion, but such a pause would also wipe out a high-volume, highly-profitable practice at UVa’s transgender youth endocrine clinic.
False positives in gender dysphoria diagnosis in youth. Within Gen Z, social pressure is 180 degrees out from what Virginia laws expect and claim it necessary to protect against.
Newsweek has reported a poll it describes as scientific that nearly 40% of Gen Z (born in the mid-to-late 1990s through the early 2010s) identify themselves as LGBTQ. The pollster…
attribute(d) the unusually high number he found to social and news media coverage that makes it “safe and cool” for young Americans to identify as LGBTQ—whether or not it represents their actual sexual orientation.
So, below the level of industrial production of transgender youth hormone care represented by UVa Health endocrinologists lie general practitioners, pediatricians, and the known acute shortages of child psychologists and psychiatrists across Virginia that are expected to diagnose gender dysphoria in youth.
Teens have access to online scripts to game the diagnosis and gain the social status that a diagnosis of gender dysphoria brings in some Virginia zip codes. It is necessary then that the diagnosis, to be valid, require significant training and experience in that specific matter to sort out role-playing from actual distress.
UVa Health, and almost surely the medical school since the practitioners in the transgender youth health clinic also teach at the school, expresses no interest in the training and qualifications of the “mental health professional” that diagnosed gender dysphoria.
Or the age at which that diagnosis was made.
Neither does the Commonwealth.
Documentation in Medical Records. One of the problems that has been encountered for years in research on the outcomes of medical treatment of transgender persons is the lack of standardized treatments and record-keeping throughout the patients’ lives so that the gaps in the science can be filled in.
That led most of the early research on long-term effects to be conducted with the records and interviews of the 104 individuals (56 were man-to-woman, 48 woman-to-man) who underwent sex reassignment surgeries at a single clinic in Denmark in the period from 1978 to 2008.
Lack of standardized treatment and documentation remains a major problem to the science of transgender health care.
Actions. The Commonwealth can and must do better.
Virginia should not only adopt by reference the WPATH standards, but also require that the successful completion of each of those standards be documented and signed by the patient or, in the case of minors, a parent or other person serving in loco parentis.
Specific recommended actions include:
- The Virginia Secretary of Health and Human Resources consider recommending to the governor, in exercise of his powers under Article V, Section 8 of the Virginia Constitution, that he request written reports from state agencies and institutions on the standards applied and the process for their enforcement in the teaching or provision of transgender medical services. Institutions and agencies of interest include state-supported medical schools, state-supported health systems, the Department of Health, the Department of Health Professions, the Department of Medical Assistance Services and the Department of Behavioral Health and Developmental Services;
- The Virginia Department of Health publishes online Transgender Health Risk Assessment: A Clinicians Guide. It is completely inadequate. The Department should take it down and instead refer clinicians to the WPATH standards;
- The Board of Health adopt WPATH standards by reference as statewide regulations as soon as possible and require training, practice and clinical record keeping reflecting those standards;
- The Board of Health define and the Virginia Department of Health Professions enforce strict training and experience standards for medical health professionals to obtain a specific license endorsement for the diagnosis of gender dysphoria in minors.
Note that I did not list my personal positions or those of the NHS in Great Britain as recommendations for Virginia. That is in an attempt to gain wide acceptance for the imposition of up-to-date and widely accepted standards for skilled transgender healthcare.
That leaves those who may oppose adoption of WPATH standards in Virginia as by definition careless of the quality of treatment.
We will see who steps up to object.