COMMENTARY

Ban Hormones for Transgender Kids? Point-Counterpoint

Elyse D. Pine, MD; Julia W. Mason, MD, MS

Disclosures

April 28, 2021

Point: Bans on Pediatric Transgender/Gender-Nonconforming Care Are Anti-science, Anti-family, Anti-American

Elyse D. Pine, MD

Seven years ago, in my pediatric endocrine practice, I met a smart, kind, but anxious child who was assigned female at birth. "Charlie" had been insisting that he was a boy since he was a toddler. At age 8, he was in despair as puberty emerged. His mother told me Charlie had said he wished he were dead, and that the world had no place for him. The entire family was in pain and obviously needed help.

Thanks to legislation recently passed in Arkansas and proposed in 14 additional states, I would be forbidden to medically help this family. If I followed national and international medical guidelines and evidence-based standards of care, I would face loss of my license (in Arkansas) or up to 10 years in prison (in Alabama). Do we want government officials and police bursting into the exam room? These medical bans are anti-science, anti-physician, anti-family, and anti-American.

Treatments Are Based on Science

The "dangerous" and "experimental" treatments I would be imprisoned for prescribing have been in use for 40 years to delay puberty in children with central precocious puberty. Had Charlie been a few months younger, no one might have batted an eye at the prescription. Fifteen years of published data on the use of puberty blockers in adolescents with gender dysphoria show that they are safe and effective in reducing depression, anxiety, and suicidality. If legislators are so worried about the terrible side effects of these treatments in youth, why aren't they banning them for treatment of endometriosis or central precocious puberty?

Older adolescents may use hormone therapy to have a puberty congruent with their gender identity. But these laws ban that too, despite ample evidence that when treated with hormone therapy, individuals with gender dysphoria report less anxiety, dissociation, perceived stress, and social distress, and higher mental health–related quality of life and self-esteem.

Timely hormonal intervention is crucial. Patients who are denied treatment can develop serious psychological consequences. Generally, the transgender population is at higher risk for self-harm and suicide. An individualized approach — a case-by-case system — will ensure that the right decision is made in accordance with the patient's maturity, age, and judgment. Over and over, research demonstrates that sensitive, comprehensive, individualized treatment for individuals with gender dysphoria is safe, effective, and beneficial, with low rates of regret.

Legislation Based on Misinformation

The language of these laws and the rhetoric from legislators promoting them are full of misinformation. For example, Alabama State Senator Shay Shelnutt claimed, "Science shows that children that are going through this gender dysphoria, most of them mature or grow out of this stage if they are given the chance." Statements like this are based on outdated, methodologically flawed studies. Many of them conflate any gender variance with being transgender, and claim "desistance" of a whole host of children who were never transgender to begin with.

Data collected by Australia's national gender clinic showed that from 2003 to 2017, 96% of patients who were diagnosed with gender dysphoria continued to identify as transgender or gender diverse into late adolescence. No patient who continued to stage 2 treatment (ie, gender-affirming hormone therapy) sought to transition back to their sex at birth. This law seeks to doom all such children to severe mental health consequences and the irreversible changes of a puberty they do not want. For the 4% who wish to continue in their natal puberty, that option remains fully available to them under medical treatment within the recommended guidelines.

With this legislation, politicians are trying to provide treatment, and it's clear that they do not understand the medical terms and procedures. "This is about protecting minors," said Arkansas Rep. Robin Lundstrum. "Why would we ever even consider allowing a sex change for a minor?"

This is a gross misunderstanding of transgender medical care; none of the current medical guidelines include genital surgeries on minors.

These Laws Don't Protect or Save

To be clear, these bans are not about science or protecting children. They are part of a continued attempt to push transgender people out of participation in public life: no bathroom access, no participation in sports, and now, no medical care.

Those promoting these laws say they are meant to protect children, but every major professional organization — including the American Academy of Pediatrics, the Endocrine Society, the Pediatric Endocrine Society, and AAFP, APA, ACOG, ACP, AOA (representing over 600,000 physicians) — has stated that the laws will harm children by driving up rates of isolation, depression, rejection, suicide, and illicit hormone use, and cause those who can afford to do so to move to other states. This legislative ban on care violates our oath to "first, do no harm."

State governments who introduce these laws are telling Charlie that he's right, that there is no place for him in this world. We need legal protection for every child, family, and physician to make the best individual choice so that people like Charlie will know that the world always has a place for them.

Counterpoint: Legislators Rush In Where Doctors Fear to Tread

Julia W. Mason, MD, MS

As a pediatrician of 25-plus years, a lifelong Democrat, and a classic liberal, I am firmly opposed to legislation that intrudes into the doctor-patient relationship. Thus, I don't support efforts to make puberty blockers and pediatric gender transition illegal. At the same time, I'm obligated to resist the efforts of activists to push an unproven course of treatment on doctors, psychologists, schools, and, most important, children.

The controversy over pediatric medical transition is not a left-vs-right issue, though I see overreach on both sides. For every ham-handed Arkansas ban, there is equally poor legislation outlawing "trans conversion therapy" in a liberal state, making it impossible to compassionately explore comorbidities and take a neutral psychotherapeutic approach to gender dysphoria.

We are doctors, not politicians, and we need to take a hard look at what is currently passing for evidence-based care in the United States. Trans healthcare is vital, but equating trans healthcare with medicalization is overly simplistic. It can help some people, but it can also hurt people — and already has.

Recently, the UK High Court determined that youth under the age of 16 are unlikely to be able to provide truly informed consent for the panoply of side effects and consequences of GnRH agonist treatment (ie, puberty-blocking medications). This decision was in response to a complaint from Keira Bell, a young woman who eventually realized that her desire to become a man had more to do with stress and trauma in her childhood than with an immutable internal gender identity.

At first, she liked how testosterone made her feel, and she had her breasts removed at age 20. A couple of years later, she regretted her earlier decisions and now says the doctors who encouraged her medicalization did not provide good care.

Transition can help, but we don't know who will be hurt instead. There is no validated test, scan, or strategy to predict which children's distress will resolve and which will persist long-term. This field operates on clinical intuition and eminence of society endorsements; neither constitutes evidence-based care.

Various medical societies, driven by young ideologues, have taken the stance that transition is good for every child who requests it. The politicians are responding to the contrary. What we need is nuance, but this is rare.

Lack of Quality Evidence

There have been no controlled studies of puberty blockers for gender dysphoria, and we are giving children powerful medications in an off-label manner. The National Institute of Health and Care Excellence (NICE) recently reviewed the use of puberty blockers and cross-sex hormones in children and found the quality of evidence to be of very low certainty for mental health outcomes.

A 2014 study, which is the basis for what is called the "Dutch Protocol," had a small number of participants who were intensively screened on the basis of being persistent, insistent, and consistent from a young age in their gender incongruence. Social transition was strongly discouraged for these kids, as it was known that without social transition, a majority will desist as puberty ensues.

Of the 70 adolescents whose gender dysphoria persisted and who began to medically transition, one died from surgical complications and several more developed medical complications. Those who were available for follow-up were doing well psychologically at 21, but we don't have any long-term data on how this group is doing now.

The Gender Identity Development Service clinic at the Tavistock attempted to replicate the Dutch study but failed to find any improvements in mental health. In fact, in the report released to the Tavistock's board of directors, the data indicate that the girls given puberty blockers had increased suicidal ideation. These call attention to the still unknown risks of these interventions.

What About the Risk for Suicide?

Whether a teen's sense of gender identity can be influenced by social contagion is still a matter of debate. What is not up for debate is the impact of social factors on suicide. Caution is required in public discussions about suicide, yet a lot of reckless statements are being made in this space. To imply that a gender-dysphoric youth must transition or they will die is the height of irresponsibility.

There is no denying that young gender-dysphoric people do have elevated rates of suicidal ideation and suicide attempts, which are similar to the rates found in young people with other psychiatric diagnoses like anxiety or depression. But as any psychiatrist or psychologist worth their salt will tell you, a patient who threatens suicide if their demands are not met (eg, hospitalization, specific medications) requires careful evaluation of the underlying psychopathology. Treatment decisions cannot be driven by the threat of suicide, and neither should rational and compassionate health policies.

First, Do No Harm

The overall consensus in the medical literature is that further research is needed to address knowledge gaps and improve understanding of the physical and psychological effects of the various treatments for youth with gender dysphoria. As doctors, we have sworn an oath to first, do no harm. The side effects of GnRH agonists are too many to list here and have been fodder for multiple lawsuits already in regard to other off-label uses. The long-term effects of subsequent cross-sex hormone treatments — testosterone in females and estrogen in males — are negative and get worse with time.

When individual doctors and medical societies responsible for educating their physician members fail to acknowledge these significant risks and uncertainties, and instead stay silent — or worse, feel pressured to support the politically expedient positions — it's not surprising that concerned parents are turning to the legislature to safeguard their children. We can't allow the medical care of children to be politicized in this manner.

Elyse D. Pine, MD, is a pediatric endocrinologist specializing in transgender care. She is the trans youth lead physician of the Gender JOY (Journeys of Youth) Program at Chase Brexton.

Julia W. Mason, MD, MS, is a pediatrician who has encountered increasing numbers of gender dysphoric adolescents in the past several years. She is a clinical advisor for the Society for Evidence-Based Gender Medicine.

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