(2022-07-30) The Beginning Of The End Of Gender-affirming Care

The Beginning of the End of ‘Gender-Affirming Care’? Over the past three decades, the Gender and Identity Development Service at the Tavistock Clinic in London has seen thousands of British children for gender dysphoria, with a British minister noting a more than 4,000 percent increase of referrals for girls alone in the last decade. But on Thursday, Britain’s National Health Service announced that it was closing down Tavistock for good—and, in effect, rebuking the common American medical approach known as “gender-affirming care” for treating children with gender dysphoria.

The widely respected pediatrician Dr. Hilary Cass, in an independent study of Britain’s care for transgender children, found that Tavistock’s approach was unsustainable and children were receiving inadequate care. There was, Dr. Cass wrote in her report, “a lack of consensus and open discussion about the nature of gender dysphoria and therefore about the appropriate clinical response,” among many other issues.

for now, the move among American medical associations, health officials and dozens of gender clinics is to double down on the affirmative approach, with the Biden administration recently asserting gender affirmation is “trauma-informed care.”

Uber-progressive countries like Sweden and Finland have pushed back—firmly and unapologetically—against the affirmative approach of encouraging youth transition advocated by some transgender activists and gender clinicians.

Sweden’s National Board of Health and Welfare released new guidelines for treating young people with gender dysphoria earlier this year. The new guidelines state that the risks of these “gender-affirming” medical interventions “currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases.”

Finland’s Council for Choices in Health Care (COHERE) came to a similar conclusion a year earlier, noting: “The first-line intervention for gender variance during childhood and adolescent years is psychosocial support and, as necessary, gender-explorative therapy and treatment for comorbid psychiatric disorders.” And: “In light of available evidence, gender reassignment of minors is an experimental practice.” Gender reassignment medical interventions “must be done with a great deal of caution, and no irreversible treatment should be initiated

Both guidelines starkly contrast with those proffered by the Illinois-based World Professional Association of Transgender Health, an advocacy group made up of activists, academics, lawyers, and healthcare providers, which has set the standard when it comes to transgender care in the United States. WPATH will soon issue new standards that lower recommended ages for blockers, hormones and surgeries

In mid-July, I spoke with Thomas Linden, director of Knowledge-Based Policy of Health Care at Sweden’s National Board of Health and Welfare

“At that time, the focus was very much about the rights issues and making visible the need for care in this group and to secure access to care which was not given evenly across all over the country,” he said.

They allowed for puberty blockers and hormones, but urged clinicians to do long-term follow-up of patients who transitioned. What they learned would lead them to shift their approach

The 2015 guidelines were created with a certain cohort in mind. At the turn of the 21st century, the Dutch had designed a medical protocol for what was then called gender-identity disorder, based on a small group, mostly male, that had long-lasting, childhood-onset gender dysphoria and didn’t have other serious mental-health issues. By contrast, the young people who sought care at Swedish clinics after 2015 were increasingly teenage girls with multiple psychiatric diagnoses—and there were a lot of them. “It rose from four to 77 per 100,000 inhabitants,”

The same trend was found in Finland, where clinicians first started providing medical treatments for gender dysphoric youth in 2011.

In 2015, Riittakerttu Kaltiala-Heino and her colleagues started to see the same dramatic increase in female adolescents with gender dysphoria. “The number of referrals skyrocketed,”

they seemed to not have an organic kind of gender dysphoria; rather, they “appeared to be very much influenced by other adolescents.” (social contagion)

According to Vogue, 2015 was the “year of trans visibility,” when Caitlin Jenner appeared on the cover of Vanity Fair, just a year after Time declared there’d been a “transgender tipping point.”

the young people showing up were nothing like the ones in the Dutch research. “We were very astonished to find out that most of the adolescents who were referred to gender-identity assessment—they had severe psychiatric problems,” Kaltiala-Heino said. Clinicians couldn’t be sure whether these problems were the cause or the effect of gender dysphoria. This is the cohort described in Dr. Lisa Littman’s 2018 research paper.

As Kaltiala-Heino wrote in a 2018 paper, “virtually nothing is known” about adolescent-onset gender dysphoria

Data was one thing. The other major shift that occurred was the increasing visibility of detransitioners.

Because the Dutch study had indicated that relatively few patients regretted having transitioned, many clinicians assumed that detransitioning—reverting back to living as one’s birth sex—was rare. But in Finland, clinicians started to see more young people regretting medical transition, Kaltiala-Heino said. “Regrets are not coming immediately,” she said. “It’s after four, five years, maybe.” One study showed that 76% of detransitioners didn’t inform their clinics of any feelings of dissatisfaction or regret, so it was difficult to calculate the actual rate of detransition.

A recent study in the U.K. showed a 10% detransition rate.

“We have a great blind spot there in that we don’t know how many actually there are,” Linden, from Sweden’s NBHW, said about destransitioners

In the U.S., on the other hand, aside from a segment on 60 Minutes, the mainstream media almost completely ignored detransitioners

Meanwhile, there was growing concern in Sweden and Finland about gender-affirming treatments. Doctors were worried about intervening “in the completely healthy and functioning body,” Kaltiala-Heino said, when research on impacts on bone health or metabolic influence or sexual function haven’t been fully researched

COHERE began with a systematic review, conducted by a panel of neutral experts, of the literature on the safety and efficacy of treatments. The panel found that even studies of adult patients were of such low quality that it was impossible to claim medical and surgical reassignment improved psychiatric problems.

And studies of children didn’t clearly assert a correlation between medical interventions and improved mental function

Sweden’s findings were similar. Both guidelines suggest therapy as the first-line treatment for gender dysphoria.

the United States, there has been only one nonpartisan evidence review, commissioned by the Florida Agency for Health Care Administration, earlier this summer. It, too, found “insufficient evidence that sex reassignment through medical intervention is a safe and effective treatment for gender dysphoria.” This report got almost no media coverage

The closest thing we have is a governmental organization called the Agency for Healthcare Research and Quality, which found: “There is a lack of current evidence-based guidance for care of children and adolescents who identify as transgender regarding the benefits and harms of pubertal suppression, medical affirmation with hormone therapy, and surgical affirmation.”

What we have is a culture war. Specifically, we have lots of battles playing out in legislatures and courts, which could go on for years. All the while, we are not conducting long-term research or following up with young patients.

“Our standpoint is that this is a medical treatment, you cannot go into a clinic and order it,” Linden said. “You have to be assessed for your needs and have to be informed of the risks.”