BMJ Article (DRAFT)
An article has been making the rounds recently on the concept of “consensus” in transgender health care, and I wanted to share some thoughts that are too long for a Twitter thread.
First, you can start by reading the article in the British Medical Journal (BMJ) by journalist Jennifer Block here: Gender dysphoria in young people is rising—and so is professional disagreement | The BMJ. You can also read the response by Doctor George R Huntington (London), which critiques the article for several issues he sees.
As a synopsis, the article generally attempts to chronicle what it says is professional disagreement over what course of care is for transgender individuals, particularly minors.
The questions I want to focus on are:
Does the data she presents actually show that there is substantial and relevant disagreement?
What do we do with that disagreement at the moment?
Full disclosure, I am a transgender woman who began my medical transition in November 2022, at the age of 40.
Ethics of transgender people
First, it’s worth noting that there are some, particularly in conservative Christian circles, who believe that gender transition is sinful. They may believe that gender dysphoria is real or they may believe that those claiming it are suffering from a “delusion.”
These people have ethical issues with the entire concept of trans people, both adult and minors. They undoubtedly disagree with gender affirming care for minors, but they start from an ethical conviction, not a medical one.
This article won’t cover those objections, but this blog covers them extensively.
Instead, this article will cover the medical conversation about gender affirming care, with assumptions that:
Trans people are real
Gender Affirming Care is the right and proper course of treatment for at least some trans people.
Therefore, the open question is under what circumstances various components of Gender Affirming Care should be administered.
“Professional Disagreement”
I worked for 17 years at Microsoft. In my career, I am not sure there were many days where I didn’t disagree with someone. Professionals disagree. All the time. That’s not shocking, and in fact it’s a good thing. It means ideas are being surfaced, discussed, and debated. If there’s never any disagreement, it’s likely because people don’t feel comfortable voicing it. See this excellent TED talk on psychological safety by Harvard Professor Amy Edmonson.
So the fact that there would be some debate over exactly what the treatment should be for any given person seems normal to me.
In my early 30’s, I had a diagnosis of Duane’s Syndrome (a rare nerve condition in which my left eye doesn’t turn left as much as it should, resulting in double vision to my left). One optometrist missed it. One ophthalmologist misdiagnosed it and prescribed vision therapy. The vision therapist rediagnosed it as Duane’s syndrome and I got sent to another ophthalmologist who properly diagnosed it and recommended surgery. The surgical ophthalmologist recommended not surgery, but left it up to me. I chose to have the surgery. It was successful, and has led to a significant improvement in my vision and reduced headaches I was having for a very long time.
This article is at least being used by people on the right to say “ban trans care for children.” But if professional disagreement always meant that we proceed with the least intervention possible, then many would not get treatment for much of anything, as there frequently exists at least one professional who argues for something more conservative.
Not to mention, given religious differences and the fact that some medical professionals are religious, it’s reasonable to assume that at least some of those professionals are morally opposed to gender affirming care to begin with.
So the question is not “does disagreement exist”, it’s “is there sufficient disagreement to justify a broad reduction or elimination of Gender Affirming Care as a treatment for minors.”
I will not say that we can’t learn more and do better. But the argument among some is that the disagreement is so significant that we must stop Gender Affirming Care for youth, or maybe everyone. Indeed, laws are being proposed across the country to do just that (well over 400 laws this year alone, at time of writing).
What are the disagreements?
Ok, so let’s look at the disagreements and consider:
Are the two sides both of similar weight?
Is either side more supported by facts?
American Academy of Pediatrics Conference: 2022
The article opens with this scene:
Last October the American Academy of Pediatrics (AAP) gathered inside the Anaheim Convention Center in California for its annual conference. Outside, several dozen people rallied to hear speakers including Abigail Martinez, a mother whose child began hormone treatment at age 16 and died by suicide at age 19. Supporters chanted the teen’s given name, Yaeli; counter protesters chanted, “Protect trans youth!” For viewers on a livestream, the feed was interrupted as the two groups fought for the camera.
The AAP conference is one of many flashpoints in the contentious debate in the United States over if, when, and how children and adolescents with gender dysphoria should be medically or surgically treated.
While Abigail Martinez’ story is heartbreaking, it’s unclear whether even a single protester (or counter-protester) is a medical professional. Later in the article we find this statement:
Scott Hadland, chief of adolescent medicine at Massachusetts General Hospital and Harvard Medical School, dismissed the “handful of cruel protesters” outside the AAP meeting in a tweet that morning. He wrote, “Inside 10 000 pediatricians stand in solidarity for trans & gender diverse kids & their families to receive evidence-based, lifesaving, individualized care.”
The article further cites that a proposal was made by five (5) members of the AAP.
Sarah Palmer, a paediatrician in private practice in Indiana, is one of five coauthors of a 2022 resolution submitted to the AAP’s leadership conference asking that it revisit the policy after “a rigorous systematic review of available evidence regarding the safety, efficacy, and risks of childhood social transition, puberty blockers, cross sex hormones and surgery.”
That resolution failed to get the co-sponsorship needed for comment or consideration, and was thus defeated. You can read more about that here: AAP Stands by Policy on Gender-Affirming Care for Trans Youth | MedPage Today
Among other things, the AAP stated that the 2018 policy was up for revision anyways, because policies like it are reviewed every five years.
Wikipedia notes that one of the resolution’s coauthors is affiliated with Genspect (and indeed you can read Resolution 27 on Genspect’s website), a gender critical (anti-trans) organization. Note that Genspect is not a medical organization - it’s an activist organization founded by a psychotherapist. Activist organizations aren’t bad, but it’s just important to note that they are not a research or professional organization. They have a cause, and they push for it. From Wikipedia’s page on Genspect:
Genspect is an international group founded in June 2021 by psychotherapist Stella O'Malley that describes itself as "gender-critical".[1][2][3][4] Genspect is known for criticizing and opposing gender-affirming care and social and medical transition for transgender people.[5][6] Genspect opposes allowing transgender people under 25 years old to transition,[7][8][9] opposes laws that would ban conversion therapy on the basis of gender identity,[10] and opposes public health coverage for transgender healthcare at any age.[7] Genspect also supports the concept of rapid-onset gender dysphoria (ROGD), which proposes a subclass of gender dysphoria caused by peer influence and social contagion. ROGD has been rejected by major medical organisations due to its lack of evidence and likelihood to cause harm by stigmatizing gender-affirming care.[11][12][13][14][15]
The difference between an organization like AAP and an organization like Genspect is that the latter was literally founded two years ago to oppose gender-affirming care, whereas the former is a broad professional organization that has been devoted to the care of young people for nearly a century.
The final piece of information the article presents is that Chloe Cole was at the protest. Cole has achieved noteriety as a detranstioner. A detransitioner is someone who undergoes at least part of medical transition, and then chooses to go back to the sex assigned at birth (definitions can vary somewhat).
Chloe Cole, now aged 18, had a double mastectomy at age 15 and spoke at the AAP rally. “Many of us were young teenagers when we decided, on the direction of medical experts, to pursue irreversible hormone treatments and surgeries,” she read from her tablet at the rally, which had by this time moved indoors to avoid confrontation. “This is not informed consent but a decision forced under extreme duress.”
In Cole’s case (summarizing here, from Wikipedia), she began a transition from female to male (FTM) at age 13, had a double mastectomy at age 15 (after having been sexually assaulted), and then at age 16/17 detransitioned back to male. She has attended numerous legislative hearings, appeared on Fox News, and been featured at a number of rallies against gender-affirming care. Starting last month, she is suing Kaiser Permanente, the health care provider which administered her care. Interestingly, her claim in the suit is not that the guidelines were not good guidelines (though she does advocate against them). She claims that in her case, the provider did not provide the standard guidelines set forth by the World Professional Association for Transgender Health (WPATH). I fully agree that providers must be held accountable to follow relevant best practices. She further claims that she and her parents were not given sufficient information in order to be able to truly give informed consent. Informed consent only works if the patient (and caregivers, if the patient is a minor) are truly informed. If important details about side-effects, reversibility, the risks (or lack thereof) to waiting are not readily available, the patient may make an ill-informed decision.
Summary of rally
I’d like to observe the “both sides” here.
On one side, we have the AAP, the largest association of pediatricians in the country, with 67,000 members, who endorses gender-affirming care, while periodically updating their guidelines to adapt to latest findings (like any other healthcare guideline).
On the other side, we have:
A few dozen protestors, including two tragic stories:
Abigail Martinez, whose child who began transition at age 16, only to die by suicide at age 19.
Chloe Cole, who transitioned as a teen, only to experience regret.
Five members of the AAP, one of whom is affiliated with an anti-trans activist organization, who introduced a proposal which was not even co-sponsored.
Do these sides seem equivalent? Undoubtedly, the protestors deserve to be able to protest. The mother and Chloe Cole deserve to be able to tell their stories. If either the mother’s child or Cole were victims of shoddy care and malpractice, they should sue and they should win. Standards of care should be updated based on the latest greatest data. But an organization of 67,000 doctors does not seem equivalent to me to five of its members expressing disagreement. And for the article’s title saying that “professional disagreement is growing”, the rally is irrelevant (no medical professionals were in attendance, or at least the article does not say they were), while the growth within the AAP is technically true if there were fewer than five previously. But the number is still small.
Debate is healthy and good, but we need to be able to recognize that the existence of debate does not mean that both sides are equally valid (after all, even Chloe Cole would argue that the two sides are not equally valid, though she would take the minority position).
United States vs. Other Countries
The second “both sides” the article presents is one of the United States vs. “Europe.” The article states:
The AAP conference is one of many flashpoints in the contentious debate in the United States over if, when, and how children and adolescents with gender dysphoria should be medically or surgically treated. US medical professional groups are aligned in support of “gender affirming care” for gender dysphoria, which may include gonadotrophin releasing hormone analogues (GnRHa) to suppress puberty; oestrogen or testosterone to promote secondary sex characteristics; and surgical removal or augmentation of breasts, genitals, or other physical features. At the same time, however, several European countries have issued guidance to limit medical intervention in minors, prioritising psychological care.
Before I get into the “both sides” of it: surgical changes to the genitals in minors are rare when done for the purpose of gender affirmation. In fact, so rare that while the conservative Daily Caller wrote an article about how it was happening, they pointed to a total of zero cases in which it had been done Yes, Doctors Are Performing Sex Change Surgeries On Kids | The Daily Caller. They only cited guidelines under which it could potentially be done, and even then, only at age 17. This article from last week in the Des Moines Register states that one clinic in Iowa was serving 211 trans minors, only five of whom received a double mastectomies, while they appear to have performed no other surgeries of any kind.
Iowa doctors told lawmakers that they do not perform genital surgery on transgender minors, and they remove breast tissue only in rare cases.
The University of Iowa LGBTQ Clinic told the Des Moines Register they have served 211 transgender children in the last 12 months.
The clinic prescribed puberty blockers to 43 kids and cross-sex hormones to 90 children. They performed five mastectomies on minors.
In general, my understanding of gender affirming care is that the goal is to delay irreversible decisions as long as possible. For example, prior to onset of puberty, nothing but social transition and therapy are permitted. Puberty blockers are used to delay natural puberty while the individual matures, so that they can have more time to live in their gender identity, and ensure that it’s right for them. And then hormone therapy is used to achieve the puberty matching that gender identity (this avoids things like a trans girl’s voice dropping due to natural puberty). The most common surgery is a double-mastectomy on trans boys, if their natural breast growth was substantial enough that it is causing them distress (frequently because the breasts can’t be hidden by using a binder). Even these surgeries are uncommon, and the goal is to be able to wait until 18. In general, things happen later if:
They can be masked/covered. For example, a double-mastectomy is more common than breast augmentation because it’s easier for a trans woman to augment via padded bras or inserts than it is for a trans man to appear flat-chested by using a binder once the breasts have grown beyond a given size. In fact, a trans woman can’t even get breast augmentation until hormone therapy has done its work, whereas for a trans man, hormones will never reverse any breast growth that occurred prior to hormone therapy. With the right clothing choices, a person’s genitalia is relatively easily masked except when in a state of undress.
They are less reversible or more major: a double-mastectomy can, to some degree, be reversed by doing a breast reconstruction, though breast feeding will not be an option. A trans man taking hormones will experience a voice drop and facial hair growth, both of which can be reversed the exact same ways that trans women deal with them (voice training, laser hair removal). But bottom surgery like a vaginoplasty for trans women is a huge surgery (though it can be reversed to some degree), requiring long recovery and can require one or more revisions.
The combination of that means that few surgeries are performed on minors, and most of those rare surgeries are double-mastectomies due to the combination of:
Reversibility of appearance (but not the function of breastfeeding)
Inability to mask prior breast growth
Relative safety of the procedure and recovery from it
United States
The article notes that “US medical professional groups are aligned in support of ‘gender affirming care’ for gender dysphoria.” That, as shown above, is entirely true.
The article does mention the Florida Agency for Health Care Administration. This group is under the oversight of the governor of Florida, Ron DeSantis, who is one of the most anti-trans politicians in the United States. This board also approved DeSantis’ COVID policies (anti-mask, anti-vax). This thread by Erin Reed (click the link, then scroll up to the top of the thread) follows the chain that led to the Florida Board of Medicine adopting standards of care that are different than what all of the US medical organizations state:
In 2022 the state of Florida’s Agency for Health Care Administration commissioned an overview of systematic reviews looking at outcomes “important to patients” with gender dysphoria, including mental health, quality of life, and complications. Two health research methodologists at McMaster University carried out the work, analysing 61 systematic reviews and concluding that “there is great uncertainty about the effects of puberty blockers, cross-sex hormones, and surgeries in young people.” The body of evidence, they said, was “not sufficient” to support treatment decisions.
Elsewhere, in Arkansas, we see Jon Stewart interviewing the Attorney General, who outright fails to defend a legal case for blocking gender-affirming care.
Outside the United States
Internationally, however, governing bodies have come to different conclusions regarding the safety and efficacy of medically treating gender dysphoria. Sweden’s National Board of Health and Welfare, which sets guidelines for care, determined last year that the risks of puberty blockers and treatment with hormones “currently outweigh the possible benefits” for minors.24 Finland’s Council for Choices in Health Care, a monitoring agency for the country’s public health services, issued similar guidelines, calling for psychosocial support as the first line treatment.25 (Both countries restrict surgery to adults.)
Medical societies in France, Australia, and New Zealand have also leant away from early medicalisation.26 27 And NHS England, which is in the midst of an independent review of gender identity services, recently said that there was “scarce and inconclusive evidence to support clinical decision making”28 for minors with gender dysphoria29 and that for most who present before puberty it will be a “transient phase,” requiring clinicians to focus on psychological support and to be “mindful” even of the risks of social transition.30
One thing I want to note quickly, is that I have heard conservatives trash the socialized medical systems of countries like England, Sweden, and Finland for as long as I can remember. Now, you can hear conservatives highlighting “Finland and Sweden” almost constantly. Of particular interest is that conservatives typically claim that with socialized medicine the government could deny you care that you need, just to save money. But for some reason they believe that Finland and Sweden’s actions here are prudent medicine, even while all of the medical organizations in the United States support gender-affirming care.
Sweden’s National Board of Health and Welfare
Sweden’s National Board of Health and Welfare, which sets guidelines for care, determined last year that the risks of puberty blockers and treatment with hormones “currently outweigh the possible benefits” for minors.24
I’ll be honest - I’m not Swedish, so this one’s hard for me to figure out. It does look like in the wake of a backlash against trans care starting in 2020, Sweden did pull back on some care. Hormones are still avaiable for “exceptional” cases. This news article seemed helpful to me: Teenage transgender row splits Sweden as dysphoria diagnoses soar by 1,500% | Transgender | The Guardian.
I did find the BMJ’s cited paper to be interesting in that it repeatedly cited detransition as a reason for being more cautious. It also called for randomized controlled trials, which people have repeatedly stated are simply not possible for trans individuals. The effects of hormones are obvious on those taking them (one puberty, vs. the other puberty). It’s simply not possible to do a double-blind trial where the patient does not know whether they are taking cross-sex hormones or a placebo.
They’ve also published no research showing that gender-affirming care is causing harm, and the pullback instead simply appears to be “we don’t know.” Here is the summary from one of the documents announcing the new guidelines (translated using the Microsoft Edge browser’s “Translate” feature, since I don’t speak Swedish):
"While waiting for a research study to be in place, our assessment is that the treatments can be given in exceptional cases. Here we propose a number of criteria that healthcare can be based on in the individual clinical assessments.
At the same time, it is important that young people with gender dysphoria continue to receive care and treatment in health care. It is both about hormonal treatments in cases where they are deemed justified and about, for example, psychosocial interventions, child psychiatric treatment and suicide prevention measures when needed.
- Healthcare needs to continue to ensure that children and young people suffering from gender dysphoria are taken seriously, well treated and offered adequate care measures. In the future, this care will become national highly specialized care, and then the opportunities for research and knowledge development in this area of care will increase, as well as for further strengthened patient safety and quality," says Thomas Lindén.
Finlands’s Council for Choices in Health Care
I’m going to pretty much skip this one, as the cited article has literally nothing to do with adolescents. It’s on the treatment of non-binary adults.
France
Medical societies in France, Australia, and New Zealand have also leant away from early medicalisation..26 27
The citation (26) takes us to the Académie nationale de médecine (French Acadamy of Medicine), specifically a statement made titled Medicine and gender transidentity in children and adolescents, from February, 2022. It does not change the care guidelines in France, nor does it recommend changing them in terms of what treatments are available at what age. In fact, the recommendations it makes effectively argue for the same general idea seen in the US: psychological assessment and care, plus hormones and surgeries if the gender dysphoria is persistent and warrants such treatment. It also argues for ensuring that the “informed consent” is as informed as possible, something I’ve seen no great disagreement about.
I do not see evidence for “leant away from early medicalisation” in this article, only caution in ensuring that professionals are not just rubber stamping approvals with no appropriate evaluations.
Most alarming is this statement citing the much-debunked study by Lisa Littman, which popularized the notion of “Rapid Onset Gender Dysphoria” (Wikipedia article discussing the study). The study had to have a correction issued, and methodological issues abound. Most importantly, the study spoke only to parents of trans youths, and recruited those parents from three online anti-trans communities. The wikipedia article states that three fourths of the parents held anti-trans views. The study’s primary finding, that trans youth were “suddenly trans” relied entirely on the parents perception of this, and did not account for the fact that these trans youth may not be forthcoming with their parents. It’s not uncommon for trans youth to be forbidden from getting care. In other cases, trans youth may be abused or kicked out if they proceed with their transition.
The fact that this statement cites this study, 3 years after it was pretty well debunked, makes me concerned that those writing it may harbor significant anti-trans bias. However, as I said, even with that, the recommendations are hardly a ban on medical care for trans youth.
Australia and New Zealand
Medical societies in France, Australia, and New Zealand have also leant away from early medicalisation..26 27
The citation of Australia and New Zealand is actually to a single organization: the Royal Australian and New Zealand College of Psychiatrists (RANZCP). It’s a position paper published in August 2021. What’s not made obvious by BMJ is that this statement is by an organization of psychiatrists. Being produced by psychiatrists, it understandably focuses on medical health.
The recommendations in it specifically focus on supporting the mental health and psychological needs of the patients.
The statement begins with the following summary:
This position statement developed by the Royal Australian and New Zealand College of Psychiatrists (RANZCP) provides an overview of Gender Dysphoria and highlights the importance of respecting an individual’s gender identity.
The paper explicitly states that it does not produce guidelines for care:
There are a number of guidelines and resources available which relate to Gender Dysphoria. [19-27] The RANZCP does not preference any specific guidelines. The RANZCP encourages psychiatrists to be aware there are multiple perspectives and views.
The paper cites a “paucity of research” for outcomes among transgender youth, but the citation takes us to a 2013 paper (pages 10 & 11 have the summary) which was due to be updated in 2018. The 2013 paper called for additional studies, and there have been many in the years up to 2021, and indeed until now, nearly 10 years after the 2013 paper was cited. The paper makes basically a full endorsement of gender affirming care, but includes this, which just seems wise, particularly back in 2013.
There remains a paucity of research in the field. Research should be encouraged and funding set aside to offer specific grants looking at outcome and satisfaction with interventions and transition
Overall, this position paper seems to simply state that those adolescents with Gender Dysphoria should be fully cared for in line with typical views on gender-affirming care, and specifically stressing the importance of affirming the Gender Identity of the individual, and giving them the right mental health resources as they are treated for it.
England
And NHS England, which is in the midst of an independent review of gender identity services, recently said that there was “scarce and inconclusive evidence to support clinical decision making”28 for minors with gender dysphoria29 and that for most who present before puberty it will be a “transient phase,” requiring clinicians to focus on psychological support and to be “mindful” even of the risks of social transition.30
First, I recommend reading this: NHS Gender Identity Development Service - Wikipedia, specifically the “Cass Review” and “Closure Decision”. The closure of the Tavistock clinic has been widely reported. But what’s less reported is that it’s being closed in favor of more regional clinics, since the increase in adolescents with gender dysphoria was overwhelming the single clinic. In fact, Mermaids, a trans-rights advocacy group, is apparently generally supportive of these current changes, which they would not be if it was a substantial reduction in the availability of care.
The rest appears to be accurate, but the paper comes nowhere close to banning gender affirming care, and instead is informing clinicians of possible factors in determining that course of care, which seems quite responsible to me.
Summary of Non-US Countries
These two paragraphs may leave the individual with the impression that these countries are banning gender-affirming care in minors. None of them have done this. The closest is Sweden, and even they still offer hormones in “exceptional cases” (and psychological help in all cases). In the case of Finland, the citation didn’t talk about minors. In the UK, the coverage model is being overhauled after the single clinic was overwhelmed. In France, Australia, and New Zealand, the provided references showed no significant evidence of any significant reduction of the availability of care, and France in particular leaned on a widely debunked study, leading me to question the value of the citation used by BMJ.
Summary of Analysis
There’s much more to the article, but I’m stopping here for now. I can answer questions others have, but at this point in the article, I simply believe it to be too low quality to be worth much more time. Each of its examples so far (and I’ve just been working through it from top-to-bottom) has been somewhat misleading or outright incorrect. To treat “a few dozen protestors” and the AAP as “both sides” or even “professional disagreement” (when the protestors don’t appear to have any professionals among them) is just bad journalism.
I personally am somewhat skeptical of institutional authority, and I’m always open to hearing from differing opinions or whistleblowers. However, especially when advocating for public policy changes, they need to bring substantive “receipts” for their case. In this case, I see no such thing. One of the things that I appreciate about Erin Reed is that she almost always has screenshots, links, etc to support her claims, while anti-trans people almost never do (see the Daily Caller article above).
Here’s my opinion. Currently, decisions regarding gender-affirming care are made through a combination of:
The patient
A psychologist/psychiatrist
An endocrinologist
A primary care physician
The surgical team if surgery is to be considered
And, if the patient is a minor, a parent or guardian (exceptions exist if the parents are abusive)
The current view on the right, that the state must fully ban gender-affirming care for minors (and they are starting to push for this in adults as well), says essentially this: We believe that the collective view of a majority of the citizens in our state/country should override the collective view of all major medical organizations, the patient, the parents, and the patient’s medical team. And not just that the government should have to give its consent, but that the government should step in and stop treatment in 100% of cases, criminalizing providers and parents who provide this care.
Even the studies cited do not go this far. They push for more evidence, and they are medical organizations discussing what the best treatment is. All of them preserve some options for treatment, and none argue for criminalizing treatment.
Professional disagreement is interesting and vital to continuing to develop better and better standards of care. But to use its (small) existence to have the government step in to stop all gender-affirming care is truly madness, and I can think of no other situation in which the government has done such a thing. Even the anti-vax, anti-mask laws passed in places like Florida simply prevented mask and vax mandates (preserving the freedom of the individual to mask/vax at their own discretion). But in this, and I know I’m banging a drum here, the government, acting on behalf of voters, simply wants to make this care illegal, despite it being the consensus best practice of all major medical organizations.
A pluralistic society demands more freedom than this.