In the United States, a total of 23 states have implemented laws to prohibit medical treatment for minors with gender dysphoria. This condition refers to the distress experienced when a person’s gender identity does not align with the sex they were assigned at birth. Conversely, 12 state legislatures have introduced legislation to safeguard access to transgender healthcare for young individuals. This type of care encompasses various treatments such as puberty blockers, which suppress the body’s production of sex hormones, as well as cross-sex hormones like testosterone or estrogen that modify secondary sex characteristics. In rare cases, it may also involve sexual reassignment surgery.
U.S. policies on both ends of the spectrum are not based on scientific evidence but rather stem from opposing ideologies. In contrast to Europe, there seems to be no space for an unbiased approach to determining the most effective care, one that considers the latest clinical evidence and adapts policies accordingly.
Religious groups are playing a significant role in driving state efforts to limit transgender medicine, according to Axios. These groups are driven by their deeply held beliefs about the unchangeable nature of gender and family, and they seek to shape policy accordingly. A key aspect of their objection to transgender care is rooted in the belief that God created humans as either male or female. They also emphasize the importance of parental rights and express concerns about the maturity of adolescents in making decisions about permanent alterations to their bodies. Additionally, lawmakers highlight cases where young individuals have experienced regret after undergoing irreversible body-altering treatments.
The prohibition on medical treatment can stem from strong religious beliefs. As an illustration, last year, The Associated Press highlighted a case where Oklahoma state Sen. David Bullard proposed the “Millstone Act,” a bill that would criminalize the provision of gender transition procedures to individuals under the age of 26. Bullard justified his proposal by invoking a Bible passage that implies severe consequences for those who lead children astray and suggested they should be drowned. Eventually, the age limit was reduced to 18.
Advocates, on the other hand, view gender-affirming care as a means to provide medical treatment that allows individuals to live in alignment with their gender identity. They often emphasize the potential benefits of such care, particularly for children who may face negative mental health outcomes without access to these services. Research suggests that gender-affirming care can lead to short-term improvements, including reduced rates of depression and suicidality among youth. However, it is important to note that some studies lack rigorous methodology, failing to adequately control for other psychological conditions, substance use, and factors that influence suicide risk. This raises concerns about the potential misinterpretation of data and the attribution of significant differences between groups when, in reality, no differences exist.
U.S. policies on both ends of the spectrum are not science-driven but rather emanate from polar-opposite ideologies.
In a critique published in The Economist, the presumed consensus among U.S. health care providers, including the American Academy of Pediatrics (AAP), regarding the unquestionable benefits of gender-affirming care and its accessibility was questioned. The critique highlighted the lack of empirical evidence supporting the ease of access to such care. In 2020, the British National Institute for Health and Clinical Excellence conducted two systematic reviews on puberty blockers and cross-sex hormones. These reviews revealed no clear clinical benefit of these treatments in alleviating symptoms of gender dysphoria. The analysis found that the studies on the impact of puberty blockers were either of questionable clinical value or lacked reliability. As for cross-sex hormones, the institute acknowledged short-term benefits but emphasized the need to consider the unknown long-term safety profile of these treatments.
In March, the National Health Service in England announced a significant policy change regarding the availability of puberty blockers to children and young people. Led by Hilary Cass, a four-year review concluded that these medications will only be accessible to individuals enrolled in clinical research trials. This decision was further supported by the release of the final report in April.
The U.S. should consider adopting a more rational approach by looking to the Dutch as pioneers in gender care. The Dutch model of care for individuals with gender dysphoria emphasizes caution and has been developed over a period of two decades. Gender specialists in the Netherlands have meticulously created a comprehensive set of guidelines, known as the Dutch protocol, for providing trans care to minors. This protocol includes specific requirements such as the documented onset of gender dysphoria in early childhood, an increase in the experience of gender incongruence after puberty, the absence of other significant psychiatric conditions, and a demonstrated understanding of the consequences of medical transition.
When a young person seeks help at a clinic, they go through a diagnostic phase that typically lasts for a minimum of six months. During this time, there is a thorough evaluation that includes in-depth questionnaires and discussions between the individual and a mental health support team. If a young person decides to pursue a medical transition, they may be prescribed puberty blockers, and it could take a couple more years before they are eligible for cross-sex hormones.
Treatment with puberty blockers typically starts at around the age of 12. Irreversible and partially irreversible interventions, such as cross-sex hormones and surgery, cannot be administered until the individual reaches the ages of 16 and 18, respectively. Patients who undergo the transitioning process receive ongoing psychotherapy support.
To take a more rational approach, the U.S. ought to adopt the European perspective and look to the forerunners in gender care.
Psychologist James M. Cantor, in his analysis of the AAP’s policy, disagrees with the watchful waiting approach to helping gender-diverse children. According to Cantor, U.S. clinicians criticize the Dutch process for being too slow and creating unnecessary obstacles for gender transition. These clinicians advocate for faster access to puberty blockers, cross-sex hormones, and even surgeries for young individuals. While sex reassignment surgeries are relatively uncommon in the U.S., recent research based on data from 2016 to 2020 reveals that 3,678 (7.7 percent) of these surgeries were performed on individuals aged 12 to 18. In Europe, such surgeries are largely inaccessible to young people.
European countries are reevaluating their approach to pharmaceutical care for gender-incongruent minors, highlighting the necessity for additional caution beyond the Dutch Protocol. Medical professionals are drawing attention to the lack of robust, high-quality evidence supporting the use of drugs. Their evaluations are based on comprehensive evidence reviews conducted by public health authorities in Finland, Sweden, and England, aimed at assessing the risks and benefits of puberty blockers and cross-sex hormones. The findings from these reviews indicate an uncertain, unfavorable, or insufficient risk-benefit ratio based on scientific grounds.
A groundbreaking study published this year investigated the mortality rates among Finnish adolescents and young adults who sought treatment at specialized gender identity clinics. The study, which spanned from 1996 to 2019, revealed that there was no evidence to suggest that pharmaceutical intervention or surgery reduced the risk of suicide, especially when considering the participants’ psychiatric treatment history.
Findings from studies have played a significant role in shaping policies regarding the treatment of gender incongruence in minors. While England has implemented bans on such treatments, most health authorities in other countries have not followed suit. However, in European countries like Sweden, Denmark, France, and Finland, which have traditionally been at the forefront of youth gender medicine, individuals under 18 are typically only given puberty blockers and cross-sex hormones if they meet strict eligibility criteria. Health authorities acknowledge that several important questions still need to be answered, including the long-term impacts of these treatments on bones, the brain, sexual function, and fertility. In the meantime, clinicians are focusing on approaches that address potential psychological conditions associated with gender dysphoria and explore the psychological and other factors that may influence a person’s transgender identity.
Despite these findings and the changing viewpoints in Europe, the AAP and other U.S. medical professional societies remain adamant about not changing their stance. While the AAP has finally called for a review of the medical research after years of resistance, it still advocates for its position. In a politically charged statement, an editorial in the AAP journal Pediatrics claimed that denying gender-affirming care is detrimental to children and is equivalent to state-sanctioned medical neglect and emotional abuse.
Europe takes a different approach to medicalized transgender care for minors compared to the U.S. Rather than banning it outright, Europe opts for restrictions based on emerging clinical evidence, rather than gender-identity politics or theological ideology.
Joshua Cohen, a healthcare analyst and freelance writer based in Boston, brings a wealth of independent expertise to the field.
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