by James C. Sherlock
When there is significant public interest in complex and controversial topics, it is best to let experts debate in public.
Such a topic is why Virginia children’s hospitals and clinics treat gender dysphoric children and adolescents with puberty blockers and cross-gender hormones as a standard practice.
And whether Virginia should permit them to continue to do so.
I offer for debate the recent decision by Sweden that the risks of hormonal interventions for gender-dysphoric youth outweigh the potential benefits. They have restricted those specific interventions for minors to a very limited number of circumstances.
I recommend that the Virginia Secretary of Health and Human Resources sponsor a televised, structured debate among prominent medical experts.
Use the Swedish decision (below) that set strict limits on the use of hormones on minors as the motion, with the proposition/affirmative team arguing that decision is correct.
Ask leaders of the gender transition clinics at UVa and VCU to argue the negative side. Use standard debate format and rules.
Such a public debate, as far as I know, would be the first of its kind on this topic in the United States. It would draw a national audience and provide a national service.
Finding a broadcast venue to televise it should not present a challenge.
I offer below the Summary of Key Recommendations from the Swedish National Board of Health and Welfare dated February of this year:
Background
In February 2022, the Swedish National Board of Health and Welfare (NBHW) issued an update to its health care service guidelines for children and youth <18 with gender dysphoria / gender incongruence.This update contains 14 distinct “recommendations, with justification for each, referencing a recently completed systematic review of evidence. Three of the recommendations provide guidance for social support for gender dysphoric youth and their families; nine focus on the assessment of gender dysphoria/gender incongruence; and two target hormonal interventions: puberty blockers and cross-sex hormones. Additional updates are anticipated later in 2022.
Key Changes in the Updated Guidelines
Following a comprehensive review of evidence, the NBHW concluded that the evidence base for hormonal interventions for gender-dysphoric youth is of low quality, and that hormonal treatments may carry risks. NBHW also concluded that the evidence for pediatric transition comes from studies where the population was markedly different from the cases presenting for care today. In addition, NBHW noted increasing reports of detransition and transition-related regret among youth who transitioned in recent years.NBHW emphasized the need to treat gender dysphoric youth with dignity and respect, while providing high quality, evidence-based medical care that prioritizes long-term health. NBHW also emphasized that identity formation in youth is an evolving process, and that the experience of natural puberty is a vital step in the development of the overall identity, as well as gender identity.
In light of above limitations in the evidence base, the ongoing identity formation in youth, and in view of the fact that gender transition has pervasive and lifelong consequences, the NBHW has concluded that, at present, the risks of hormonal interventions for gender dysphoric youth outweigh the potential benefits.
As a result of this determination, the eligibility for pediatric gender transition with puberty blockers and cross-sex hormones in Sweden will be sharply curtailed.
Only a minority of gender dysphoric youth—those with the “classic” childhood onset of cross-sex identification and distress, which persist and cause clear suffering in adolescence—will be considered as potentially eligible for hormonal interventions, pending additional, extensive multidisciplinary evaluation.
For all others, including the now-prevalent cohort of youth whose transgender identities emerged for the first time during or after puberty, psychiatric care and gender-exploratory psychotherapy will be offered instead.
Exceptions will be made on a case-by-case basis, and the number of clinics providing pediatric gender transition will be reduced to a few highly specialized centralized care centers.
That statement is followed by a Summary of Key Points:
Following a rigorous analysis of evidence base, there has been a marked change in treatment recommendations. The guidance has changed from a previously strong recommendation to treat youth with hormones, to new caution to avoid hormones except for “exceptional cases.” A more cautious approach that prioritizes non-invasive interventions is now recommended, due to recognition of the importance of allowing ongoing maturation and identity formation of youth.
Currently, the NBHW assert that the risks of hormonal treatments outweigh the benefits for most gender-dysphoric youth
- Poor quality/insufficient evidence: The evidence for safety and efficacy of treatments remains insufficient to draw any definitive conclusions;
- Poorly understood marked change in demographics: The sharp rise in the numbers of youth seeking to transition and the change in sex ratio toward a preponderance of females is not well-understood;
- Growing visibility of de-transition/regret: New knowledge about de-transition in young adults challenges prior assumption of low regret, and the fact that most do not tell practitioners about their detransition could indicate that de-transition rates have been underestimated.
Psychological and psychiatric care will become the first line of treatment for all gender dysphoric youth <18.
- A substantial focus is placed on gender exploration that does not privilege any given outcome (desistance or persistence).
- The presence of psychiatric diagnoses will lead to prolonged evaluation to ensure that these conditions are under control and that gender transition does not do more harm than good.”
The diagnosis of ASD (autism spectrum disorder) will necessitate additional evaluation.
- The well-known lack of adherence to gender norms among ASD individuals could lead them to misattribute their experience to being “transgender” and inappropriately transition.
- The guidelines also posit that some youth on the autism spectrum who are suffering from gender dysphoria may not come across as genuinely suffering because they take little care to present in ways consistent with the gender they identify with.
Access to hormonal interventions for youth <18 will be tightly restricted. The goal is to administer these interventions in research settings only, and to restrict eligibility criteria to mirror those in the “Dutch protocol.
- The key prerequisite for hormonal treatment of youth is the prepubertal onset of gender dysphoria that is long-lasting (5 year minimum is mentioned), persists into adolescence and causes clear suffering.
- Some exceptions apply. Puberty blockade can be offered in extreme circumstances to those with post-pubertal onset of gender dysphoria, especially for biologically male patients. However, it does not appear that cross-sex hormones can be offered to the <18 youth with no childhood history of gender dysphoria.
Social transition may be recommended to some youths. Social transition may be recommended at the latter stage of assessments.
Most youth will receive psychotherapeutic care in their home regions. Gender-affirming interventions will be provided at few highly specialized centers and in the context of research.
- Home regions will need to develop competence in managing gender dysphoria with psychological and psychotherapeutic interventions.
- Centers offering “gender-affirming” interventions will be centralized, and their number reduced.
Treatment eligibility will be based on the criterion of “distress,” and not “identity.”
- “The DSM diagnosis of “gender dysphoria” will be a prerequisite for eligibility for “gender-affirming” hormonal interventions.”
- “The presence of a transgender identity that is not causing distress or functional impairments is not sufficient.”
- “At the current time, youth who identify as nonbinary will not be eligible for hormonal interventions even in research settings. Future updates to these guidelines will address appropriate treatments for this patient population.
Clear and concise.
That is basically where France is on this subject, and where Great Britain is quickly headed. Finland has been there since 2020.
In the United States, by contrast, we see the medical establishment continuing to promote an “affirmation-only” model of treating childhood gender dysphoria while suppressing internal dissension and debate in their professional societies.
In the United States, even long-time advocates of gender transition call the medical practices by many physicians “sloppy,” “dangerous,” and “hasty.”
A flood of referrals to mental health providers and gender medical clinics, combined with a political climate that sees the treatment of each individual patient as a litmus test of social tolerance, is spurring many providers into sloppy, dangerous care. Often from a place of genuine concern, they are hastily dispensing medicine or recommending medical doctors prescribe it — without following the strict guidelines that govern this treatment.
Seemingly proving the point, the University of Virginia Children’s Hospital, under external criticism, only very recently assigned psychologists to its transgender youth clinic, where previously parents and children had been greeted by endocrinologists.
For adolescents with gender incongruence, the Swedish national health system deems that the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases.
Perhaps Virginia hospitals offering that risky and poorly understood treatment will explain to Virginians, as represented by Secretary of Health and Human Resources, why they do not adopt the Swedish standard. Or maybe they will accept it.
If not, I recommend he convene a public debate on that very topic.
I also recommend a video by Dr. Elizabeth Grossman, M.D., a New York clinical child and adolescent psychiatrist.
In it she offers a relaxed, highly informative and plain-English discussion of the medical errors, including a discounting of basic human biology and the role of puberty in human development, contained in the treatment of adolescents for gender incongruence with puberty blockers and cross-gender hormones.
Invite Dr. Grossman and pediatrician Dr. Julia Mason, who co-authored the WSJ article on suppression of such debate, to debate the leaders of the UVa and VCU clinics that have routinely provided the treatments to minors.
Televise it.
It would draw a national audience.
And maybe even provide some clarity.
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