Calm discussions of transgender medicine are rare. “There are few other areas of health care where professionals are so afraid to openly discuss their views,” argues Hilary Cass, a British doctor. On April 9th she published a 388-page report, commissioned by England’s National Health Service, assessing the evidence for and against treatments for children who identify as transgender. Its conclusions will reverberate on both sides of the Atlantic, where standards of care differ wildly.
The treatments at issue include puberty blockers, cross-sex hormones and (rarely) surgery. Puberty blockers are drugs that delay the onset of puberty. Cross-sex hormones stimulate the development of opposite-sex characteristics: oestrogen causes males to grow larger breasts, testosterone gives females bigger muscles and deeper voices, among other things.“There is not a reliable evidence base” to show that the benefits of offering such treatments to children outweigh the harms, says the Cass Review. Many studies have been published, but they are often of “poor quality”. Some draw conclusions from tiny samples. Some lack control groups, so that outcomes for patients receiving treatment are not compared with outcomes for those who do not. Far too little effort has been made to observe long-term effects. Some clinics even resisted attempts to gather such data. “It is unusual for us to give a potentially life-changing treatment to young people and not know what happens to them in adulthood,” Dr Cass told the BBC.
In the rich world, approaches to transgender care for children now fall into three broad categories: laissez-faire, draconian and cautious. The laissez-faire approach, common in blue states in America, argues that if children identify as the opposite gender and desperately want to adjust their bodies to align with that feeling, they should be allowed to do so. If denied such “gender-affirming care”, their lives will be blighted and they may consider ending them, proponents say. Some activists add, in forceful language, that only transphobes could possibly object. The American Academy of Pediatrics, a national body, supports the provision of puberty blockers and cross-sex hormones to minors, while evaluating new evidence.
The draconian approach is that such treatments should simply be banned. This is common in red American states, where some politicians stir up antipathy towards transgender people to win votes. Some states combine bans on treatment with harsh penalties for doctors who offer it. Florida threatens them with five years in prison; Idaho, ten.Texas has tried to investigate whether parents who seek such care for their children are fit to be parents; though this is now tied up in court. In all, 22 American states have outlawed or restricted transgender care for adolescents, most of them recently.
The cautious approach, which informs policy in Denmark, Finland, Norway, Sweden and now England, stresses that more evidence is needed. No one is sure why the number of children who identify as transgender has exploded in the past decade. Before giving them drugs which can make them permanently sterile and unable to experience an org*sm, medics should explore other interventions. Many trans-identifying children are on the autism spectrum. Many suffer from depression, and should be offered counselling. Many eventually desist, sometimes realising that they are gay, not trans. Health providers should not rush into invasive treatments even if the child demands them. Thus, the NHS in England now offers puberty blockers only as part of a clinical trial. Cross-sex hormones should be provided only to children over 16, and with “extreme caution”, says the Cass Review.
As The Economist has argued before, the cautious approach is the wisest. Transgender people should always be treated with respect and kindness, and adults should be free to make their own decisions about their bodies. But as Dr Cass concludes, it is essential to guard against “the creep of unproven approaches into clinical practice”. This may be hard in an area that has become so politically contentious. It may also be harder in health systems where private doctors are paid for each intervention, and thus have an incentive to give patients what they ask for. Nonetheless, it is the responsibility of medical authorities to offer treatments based on solid evidence.■
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This article appeared in the Leaders section of the print edition under the headline "The cautious approach to transgender care"
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From the April 13th 2024 edition
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Starting April 1, NHS England will not prescribe puberty blockers — drugs that suppress sex hormones during puberty — as a “routine treatment” to children and other young people seeking gender transitions. In practice, the decision also applies to Wales, which does not have any NHS gender clinics for children.
On March 12, 2024, NHS England issued its puberty blockers (PB) clinical policy (Puberty Suppressing Hormones Policy), disallowing the use of puberty blockers as a treatment for youth gender dysphoria through the NHS.
Trans children who are allowed to socially transition before puberty have normal rates of depression and anxiety, “in striking contrast” with trans children who could not socially transition.
Women are over three times more likely to work part-time than men12. These differences add up over the life course: because women earn less, they save less. Women aged 55 to 64 are almost 20% less likely to have a private pension, and those who do have almost 40% less wealth held in them14.
The U.K. has a persistent gender pay gap, the most significant factors associated with which are part-time work, education, the size of the firm from which the sample is taken, and occupational segregation (women are under-represented in managerial and high-paying professional occupations.)
Puberty blockers (gonadotrophin-releasing hormone analogues) are not available to children and young people for gender incongruence or gender dysphoria because there is not enough evidence of safety and clinical effectiveness.
The changes include banning certain gender-affirming treatments, including puberty blockers, for people who are 15 and under. Smith said the changes are to “preserve choice” for kids and parents. Medical experts are concerned by these new rules, and said they may cause harm to trans patients.
Some children's self-identified gender remains stable, while others may alternate between presenting themselves as a “boy” or a “girl” at different times (sometimes even in the same day). This exploration is normal and healthy. Children become more aware of gender expectations or stereotypes as they grow older.
I recommend that you start with a talk where you respectfully and lovingly let your daughter know how you feel about her gender identity and what your concerns are for her. You can also let her know what you are comfortable doing in support of her and what you are not.
What does it mean for a child to have a nonbinary gender identity? Very simply, it means that neither binary option of being strictly male or strictly female describes their gender.
In a review of 27 studies involving almost 8,000 teens and adults who had transgender surgeries, mostly in Europe, the U.S and Canada, 1% on average expressed regret. For some, regret was temporary, but a small number went on to have detransitioning or reversal surgeries, the 2021 review said.
But in an article we recently published in JAMA Surgery, we challenge the notion that transgender people often regret gender-affirming surgeries. Evidence suggests that less than 1% of transgender people who undergo gender-affirming surgery report regret.
No one knows exactly what causes gender dysphoria. Some experts believe that hormones in the womb, genes, and cultural and environmental factors may be involved.
What the Equality Act says about gender reassignment discrimination. The Equality Act 2010 says that you must not be discriminated against because of gender reassignment. In the Equality Act, gender reassignment means proposing to undergo, undergoing or having undergone a process to reassign your sex.
Under the Gender Recognition Act of 2004, trans people can: apply for and obtain a Gender Recognition Certificate to acknowledge their gender identity. get a new birth certificate, driving licence and passport.
The Equality Act (2010) replaced the many previous equalities legislation and Acts, and outlines nine protected characteristics which are the grounds upon which discrimination is against the law in the UK: Age, Disability, Gender Reassignment, Marriage and Civil Partnership, Pregnancy and Maternity, Race, Religion or ...
Hilary Cass, a consultant pediatrician and former President of the Royal College of Paediatrics and Child Health, led the independent review and said that there was insufficient long-term evidence of what happens to youth who are prescribed puberty blockers.
Introduction: My name is Allyn Kozey, I am a outstanding, colorful, adventurous, encouraging, zealous, tender, helpful person who loves writing and wants to share my knowledge and understanding with you.
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