Debate Heats Up on How Best to Treat Gender-Questioning Kids

March 02, 2022

The past week has seen heated debate about the complex issue of how to best treat children with gender dysphoria, with further developments in a number of US states as well as in Sweden and France.

In the United States, more states have moved to prevent the use of any medical treatment, such as puberty blockers or cross-sex hormones, in kids younger than the age of 18, most recently in a state Senate vote in Alabama last week, and in Texas, where Governor Greg Abbott is said to have ordered state agencies to investigate reports of gender-transition procedures on children as "child abuse." 

Indeed, as a result of this, a countersuit has been filed there by the ACLU of Texas and Lambda Legal, a civil rights organization, on behalf of one parent said to be under investigation. And at least one parent has established a crowdfunding page to try to raise money to move away from Texas, fearful of being accused of child abuse if their child with gender dysphoria receives hormone therapy.  

But on the flip side, parents living in states where children under the age of 18 can often get hormones to transition without parental consent are considering moving out of them to prevent this happening. These parents are concerned that their kids do not know enough about the side effects of puberty blockers, or lifetime use of cross-sex hormones and its implications, to be able to make properly informed decisions at such a young age.  

Specific data on how many parents intend to move out of those states are hard to come by, but some are represented by numerous organizations including Genspect, 4th Wave Now, and Parents With Inconvenient Truths About Trans (PITT).

Sweden and France Tighten Restrictions

Meanwhile, Sweden has further tightened its restrictions on medical therapy to treat gender-questioning kids, with a recent announcement from its National Board of Health and Welfare (NBHW) urging restraint in hormone treatment of minors with gender dysphoria following a review by the agency there that assesses health technologies.

Based on the review results, the NBHW's overall conclusion is that the risks of puberty blocking and cross-sex hormone treatment for those younger than 18 currently outweigh the possible benefits for the group as a whole. The agency now says hormone treatment should only be offered in exceptional cases outside the framework of research, and principally, only in adolescents with childhood-onset gender dysphoria, as opposed to those who develop it during puberty, or in their teens, as is the case with most teenagers currently presenting. 

Asked to comment, Erica Anderson, PhD, former president of the US Professional Association for Transgender Health (USPATH), told Medscape Medical News that there is a need "to portend more rigorous consideration of the issues highlighted by Sweden's NBHW, including the disproportionate rise in teenage girls...presenting at gender clinics following the onset of puberty."

"We may be witnessing a new cohort not previously seen in the university gender clinics, a cohort upon which there is limited to no research. As Swedish authorities also acknowledge, it is not reasonable to apply the expectations that this cohort will exhibit the same degree of positive outcomes that the methodically, carefully screened patients [with childhood-onset gender dysphoria] in the Netherlands, Sweden and elsewhere have revealed in the past."

Anderson, who herself is transgender, is one of two prominent psychologists who work in the field. She has previously told Medscape Medical News that they are concerned about a lack of "gatekeeping" — adequate psychological evaluations of youth with gender dysphoria, before any medical treatment is considered.

Further, she continues: "Sweden may be conceding that social isolation and high levels of consumption of worrisome social media during the pandemic are having uncertain impact upon some adolescents. And previous co-occurring/preexisting mental health challenges may not be alleviated by gender-affirming medicines alone as some believe."

France, too, has just urged caution, with its National Academy of Medicine issuing new guidance regarding the medical care of children and adolescents with gender dysphoria.

Translations of the Swedish and French guidance are available on the Society for Evidence Based Medicine website.     

Effects of Gender-Affirming Hormones on Depression/Suicidality: Survey

At the same time, a new US survey published in JAMA Network Health reports that gender-affirming hormone treatment for adolescents who identify as transgender or nonbinary is associated with changes in depression and suicidality.

But experts who spoke to Medscape Medical News were critical of the study, noting it was small, conducted in just 104 youth who were an average age of 15.8 years and of whom only 63% completed the survey at the final timepoint, just 1 year after starting therapy. In addition, there was no control group, among other limitations.

"The most worrying thing is that they haven't described the pros and cons of the treatment that they are researching. We know that there are risks inherent in using gender-affirming medicine, as with all medications," Anna Hutchinson, DClinPsych, of the Integrated Psychology Clinic in London, United Kingdom, told Medscape Medical News.

"For example, when people with gender dysphoria use cross-sex hormones there is a burden of treatment that can last a lifetime, both for those who benefit from the treatment and those who detransition or regret later on," said Hutchinson, who has extensive experience of working with young people with issues related to sexuality or gender.

"This isn't mentioned at all, which makes the paper appear quite biased towards using one approach for managing gender dysphoria and related distress, whilst not acknowledging any risks of doing so or considering alternatives," she noted.

Why Were Some Treated With Hormones While Others Weren't? 

The newly published survey is by PhD student Diana M. Tordoff, MPH, of the Department of Epidemiology, University of Washington, Seattle, and colleagues. Published alongside was an invited commentary by Brett Dolotina, BS, of Massachusetts General Hospital, Boston, and Jack L. Turban, MD, MHS, of Stanford University, California.

The study was conducted at an urban multidisciplinary gender clinic in Seattle among transgender and nonbinary adolescents and young adults seeking gender-affirming care from August 2017 to June 2018. Data were analyzed from August 2020 to November 2021.

Participating in the study were 104 youths aged 13-20 years (mean age, 15.8 years), 63 transmasculine (born female) individuals (60.6%), 27 transfeminine (born male) individuals (26.0%), 10 nonbinary or gender-fluid individuals (9.6%), and four youths who responded, "I don't know," or did not respond to the gender-identity question (3.8%). 

At baseline, 59 individuals (56.7%) had moderate-to-severe depression, 52 individuals (50.0%) had moderate-to-severe anxiety, and 45 individuals (43.3%) reported self-harm or suicidal thoughts. 

By the end of the study, 69 youths (66.3%) had received puberty blockers, cross-sex hormones (testosterone for girls transitioning to male and estrogen for boys transitioning to female), or both interventions, while 35 youths had not received either intervention (33.7%). 

After adjustment for temporal trends and potential confounders, there was a 60% lower odds of depression (adjusted odds ratio [aOR], 0.40; 95% CI, 0.17 - 0.95) and 73% lower odds of suicidality (aOR, 0.27; 95% CI, 0.11 - 0.65) among youths who had initiated puberty blockers or cross-sex hormones. 

There was no association between these treatments and anxiety, however (aOR, 1.01; 95% CI, 0.41 - 2.51).

In their commentary, Dolotina and Turban observe: "The rate of suicidality among the Tordoff et al sample after receiving gender-affirming care was still much higher than national rates of suicidality among youth in the US, denoting that...other mental health determinants must be addressed...including gender minority stress."

Hutchinson questions the use of the terms "nonbinary" and "gender fluid," stating they "are not diagnostic or clinical terms," adding, "there is no information about how the groups were chosen or if any of them met the criteria for gender dysphoria. It seems strange to not have measured gender dysphoria, both before and after interventions in a group of children presenting with gender dysphoria." 

Small Study, No Control Group, Large Loss to Follow-Up

Hutchinson also criticizes the small sample size of just 104 youth and "large loss to follow-up, whereby only 65 of those 104 [youth] completed the final survey in a short time [1 year]." This could indicate "that only the most satisfied kids stayed the course," she suggests. 

And importantly, the findings on depression and suicidality rely on the experience of only five people in the no-treatment group at 12 months, she points out. 

Also, as the authors themselves acknowledge, they didn't control for other psychiatric medicines that the participants might have been taking at baseline.

"It's important to know more about all of this in order to draw accurate conclusions about what works, or does not, for whom," noted Hutchinson.

Most patients, too, she notes, were females-to-males taking testosterone. Therefore, the finding that they experienced a reduction in depression might simply reflect the widely reported antidepressant effects of testosterone. 

Also expressing concern about the small sample size and "lack of a control group" is Michelle Mackness, MC, a Canadian counselor in private practice who has experience working with gender-questioning individuals, detransitioners, and those experiencing complications related to their transition. 

"Tordoff et al's assertion that there is a 'robust evidence base' supporting pediatric transition seems out-of-step with recent global developments in care policies and protocols for gender-questioning youth," she points out.

"Neither the study authors or commentators acknowledge, let alone address, the fact that Finland, the UK, and Sweden have recently determined that the evidence allegedly supporting medical interventions for pediatric transition is 'inconclusive'," she adds. 

Asked to respond, Tordoff did not directly address this question. Rather, she reiterated to Medscape Medical News: "We found that receipt of puberty blockers and gender-affirming hormones was associated with a 60% lower odds of depression and a 73% lower odds of suicidal thoughts by the end of our study follow-up. We conducted extensive sensitivity analyses, which support the robustness of our study findings."

She added: "These results are consistent with other recently published prospective cohort studies," and directed readers to citations within her manuscript.

Meanwhile, Anderson says there is a "growing chorus" regarding the potential for detransition among adolescents who present with gender dysphoria after puberty, which raises "questions about evaluation and double down on mental health evaluation and treatment." 

"The very nature of what constitutes gender-affirming care for youth is in question. It's time to get serious and specific," she concludes.

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