by James C. Sherlock
Attorney Hans Bader and I in parallel articles have pointed out the serious questions posed by national and international experts about current medical practices in gender transitions for minors.
Those questions include both the ethics of the diagnosis and treatment processes in use and the safety of the puberty blockers and cross-gender hormones used in those treatments. Hormone treatments are administered to hundreds of minors annually in Virginia in the face of both new FDA warnings and other major open questions about their safety and long-term outcomes.
Virginia taxpayers pay for a lot of these treatments in state hospitals and clinics with state-funded private insurance plans and now Medicaid.
I will recommend the Virginia Secretary of Health and Human Resources organize and oversee practice and research networks in Virginia that mirror the recommendations of the Cass Review in the U.K. to make it safe.
Virginia has the assets necessary to carry out those recommendations and the state has the authority. It must demonstrate the will.
No new law appears necessary.
New issues with the treatments. Mr. Bader has reported and demonstrated through Freedom of Information Act (FOIA) requests and a follow-up lawsuit that the:
HHS guidance document, titled “Gender Affirming Care in Young People,” was issued not by HHS agencies that have expertise in transgender issues (such as the Food and Drug Administration, which regulates drugs such as puberty blockers), but rather by the Office of Population Affairs, which deals with family planning, teenage pregnancy, and adoption.
The FDA recently added a warning to the puberty blockers used by transgender children undergoing gender transitions. The warning was added after the FDA identified “a serious potential side effect” that can “cause cause a dangerous surge of spinal fluid pressure in the brain,” as well as “headaches, nausea, double vision, and even permanent vision loss.”
This aligns with my reporting and that of The Wall Street Journal that the leadership of the American Academy of Pediatrics has refused internal requests to review its position on hormone treatments for gender dysphoria in minors.
Inappropriate sales pitches. We also see happy talk interviews given by UVa Teen and Health Center staff that portray hormone treatments for 11-year olds, the youngest patients accepted, as providing “a sense of relief,” without mentioning the under-studied but acknowledged sterilization and known dangers that come with those same hormones.
Dr. Nancy McLaren: We really are, you know, let’s get a therapist involved, we’ll get that going for you. And I think families appreciate that because it is a thoughtful process. [Author’s note: If a child shows up at the clinic with a gender dysphoria diagnosis in hand, proceed to the next paragraph.]
Once a child is diagnosed with gender dysphoria, an endocrinologist can prescribe what are called “puberty blockers” to delay, for instance, breast development in a transgender boy or facial hair growth in a transgender girl.
Dr. Christine Burt Solorzano, MD (Professor at the Medical School) says that every patient’s transition is different, but the most frequent response she sees once her patients start gender-affirming hormones?
Dr. Solorzano : “It’s just a sense of relief that they’re finally on the path that affirms who they are.”
That is a sales pitch, pure and simple. Issues with that happy talk include:
- The American Association of Pediatrics calls the sterilization effects of hormone treatments unknown;
- The Mayo Clinic, in contrast, cautions that the use of puberty blockers might have long-term effects on future fertility depending on when pubertal blockers are started;
- The new FDA warning described by Mr. Bader.
Suicide prevention. Then there is the sticky issue of suicide. Suicide is seldom discussed in the context of “gender affirming” hormone treatments of a population notably prone to it except for those occasions when hormone treatments are said to lower suicide rates.
Mayo Clinic, in contrast, is up front about the additional psychological risks:
Delaying puberty beyond one’s peers can be stressful. Your child might experience lower self-esteem.
Cass Review recommendations. In the U.K., the Cass Review has urged a reset on the National Health Service (NHS) services to minors questioning their genders.
In a letter to John Stewart, National Director, Special Commissioning of the NHS, Dr. Cass recommended a reset on the NHS pathways of care.
I would recommend that consideration is given to intake procedures that ensure that children and young people referred to these services are able to access the most appropriate package of support at the earliest feasible point in their journey. One model might be that each regional centre would host a regular intake meeting involving multi-professional staff from the tertiary centre, the designated local specialist services and other relevant local children’s services. [Emphasis in original.]
Discussions with Gender Identity Development Service clinicians have highlighted the importance of differentiating different subgroups within the referred population who may be at risk and/or need more urgent support, assessment or intervention; there may also be subgroups where early advice to parents or school staff may be a more appropriate first step. Given that it is not always possible to make these judgements based on written referral information, consideration should be given to ring-fencing senior clinical time to make early contact with referrers or families in order to ensure that children and young people are allocated to an appropriate pathway.
There should be a whole system approach to care across the network so that children and young people can access a broad range of services relevant to their individual needs, including supportive exploration and counselling. This is important both for those who go on to medical transition and those who resolve their gender distress in other ways. There should be the ability to move flexibly between different elements of the service in a step-up or step-down model, allowing children and young people and their families/carers to make decisions at their own pace without requiring re-referral into the system. [Emphasis added.]
Stakeholders have raised the need for individuals who are distinct from the professionals that they view as ‘gatekeeping’ access to the medical treatment to provide support and a safe space for questioning. There is considerable scope for local innovation and partnerships with voluntary sector organisations in developing these services in a range of settings. [Emphasis added.]
The appropriate age for transition to adult services will need further discussion, balancing the workload and capacity of services for children and young people with the need to provide ongoing holistic family-centred care during a critical point in the young person’s gender care, particularly for those with neurodiversity/special educational needs or other vulnerabilities. [Emphasis added.]
To achieve this end, Dr. Cass recommended a national provider collaborative/research network:
…that a formal national provider collaborative with an integral research network is established, bringing together clinical and academic representatives from the regional centres. The national provider collaborative should undertake a range of functions including:
• a forum for discussion of complex cases and/or decisions about medical care, and ultimately subsuming the role of the Multi-Professional Review Group
• an ethics forum for cases where there is uncertainty or disagreement about best interests or appropriate care
• providing opportunities for peer review between regional centres
• development of a programme of ongoing Continuing Professional Development for staff at all levels, as well as educational standards for
practitioners within the various tiers of service provision
• collation of the national dataset and conduct of national audit
• development of a quality improvement programme to ensure evolving best practice
• ongoing research in areas of weak evidence” [Emphasis added.]
Virginia. Virginians deserve to know that the same professional pathways to care and a collaborative/research network recommended in Britain are available to them and their children.
Everything Dr. Cass recommended for the U.K. is appropriate and necessary in Virginia, yet we do not have anything resembling a statewide system for transgender services in Virginia.
To quote an article published by the UVa Medical Center:
Hormone therapy, for instance, is available at the Health Brigade and the Planned Parenthood in Richmond, at the Carilion Clinic in Roanoke, and at Augusta Health in Fishersville. But, in the last few years, the University of Virginia has emerged as a kind of oasis for transgender patients.
We already know that on the way out the door the Northam administration authorized Medicaid funding for transgender services.
Further in the UVa article, we learn:
In 2016, UVA’s student & employee health insurance plans both began covering virtually the full range of trans-specific healthcare needs.
Counseling services, hormone therapies, top and bottom surgeries. We will cover it. And so, I mean, the institution is extremely supportive of transgender students and we try to let you know that.
Aetna provides taxpayer-funded coverages at UVa for staff and students. And I suspect other state institutions. For Aetna coverages, see here.
So taxpayers are invested.
Virginia research capabilities. I note that there is already an integrated Translational Health Research Institute of Virginia, or iTHRIV, a National Institutes of Health (NIH)-funded Clinical and Translational Science Award (CTSA) Program Hub.
In practice, iTHRIV is a cross-Commonwealth collaboration between University of Virginia , Virginia Tech, Carilion Clinic, and the Inova Health System. iTHRIV unites the research infrastructure of these flagship institutions with the latest advances in data science to accelerate innovation in health-related research and foster the next generation of collaborative health research professionals.
Perhaps it would be useful to determine more specific answers to the sterilization question and other issues around hormone treatment before proceeding further with such treatments in children. Or at least warn them and their parents and get liability waivers.
Proposal. I propose the Virginia Secretary of Health and Human Resources take for action the recommendations of Dr. Cass on pathways of care and provider collaborative/research network and establish them in Virginia with state oversight.
The Departments of Health, Behavioral Health and Developmental Services, Health Professions, Medical Assistance Services, Social Services and Office of Children’s Services can have integrated oversight roles under his leadership.
The University of Virginia and Virginia Tech are state universities.
Carilion Clinic, Augusta Health and Inova are not-for-profits and as such, in return for their tax exemptions, are required under IRS rules to use profits to provide for improvements in the health of their communities.
All get taxpayer funding.
In other words, each has a reason to cooperate in such an initiative under state oversight without the necessity of a new statute.
Or a lobbying campaign against these well-examined reforms.
