Prohibition of Gender-Affirming Care as a Form of Child Maltreatment: Reframing the Discussion

The authors acknowledge the diversity and vastness of gender identity and experiences and therefore the complexities of gender affirming care (GAC), though a full exploration of these nuances fell outside of this article’s objectives. However, it is worth highlighting two key concepts. First, everyone has a gender identity. Second, GAC entails providing a holistic, patient-centered approach that supports individuals in living their authentic gender identities, in partnership with the patient, the family, and the medical provider. This should be done at every clinic visit, for every child, as everyone should be supported in who they are. GAC looks different for each child and can include supporting social transition (e.g. coming out to loved ones, using preferred pronouns and names, or dressing in a manner that aligns with one's gender identity) as well as medical interventions (e.g. puberty blockers, hormone therapy, and at times surgical intervention). This process is nuanced, and providers weigh the risk and benefits for each patient, as they do with any medical decision.  GAC is informed by international guidelines, like those created by the World Professional Association for Transgender Health, and is understood to be routine healthcare (See Reference 2 from original article). These guidelines are a great place to go if one is interested in a comprehensive review of the literature that informs decision making of those in the medical community.

There is a wealth of research on the safety and effectiveness of gender-affirming hormone therapy1-3 and surgical interventions4-7 in adult populations. Additionally, the potential negative repercussions for denying pediatric patients access to GAC have been well documented8-11. While the body of literature assessing long-term outcomes in pediatric patients continues to grow, in the literature that exists, there are similar trends supporting the safety and effectiveness of this treatment in improving the mental health and quality of life of TGD youth12-15. Furthermore, the body of literature that does exist is more than adequate to support GAC clinical practices and policies (Again see Reference 2 from original article).

As a perspective piece, rather than a review of the literature, a full evaluation of the existing literature fell outside the scope of this piece. Below is additional literature that exists regarding GAC.  While this is in no way a comprehensive list, it highlights the research that medical providers rely on to guide their GAC shared decision making with families.. The complexity of GAC is precisely why doctors, rather than policy makers, should be interpreting the literature and working with families and patients to determine what care and support children need.

REFERENCES

1) Aldridge Z, Patel S, Guo B, Nixon E, Pierre Bouman W, Witcomb GL, Arcelus J. Long-term effect of gender-affirming hormone treatment on depression and anxiety symptoms in transgender people: A prospective cohort study. Andrology. 2021 Nov;9(6):1808-1816. doi: 10.1111/andr.12884. Epub 2020. PMID: 32777129.

2) Baker KE, Wilson LM, Sharma R, Dukhanin V, McArthur K, Robinson KA. Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. J Endocr Soc. 2021;5(4):bvab011. doi: 10.1210/jendso/bvab011. PMID: 33644622; PMCID: PMC7894249.

3) Wierckx K, Van Caenegem E, Schreiner T, Haraldsen I, Fisher AD, Toye K, Kaufman JM, T'Sjoen G. Cross-sex hormone therapy in trans persons is safe and effective at short-time follow-up: results from the European network for the investigation of gender incongruence. J Sex Med. 2014;11(8):1999-2011. doi: 10.1111/jsm.12571. Epub 2014 May 14. Erratum in: J Sex Med. 2016 Apr;13(4):732. Fisher, Alessandra [corrected to Fisher, Alessandra D]. PMID: 24828032.

4) Bertrand B, Perchenet AS, Colson TR, Drai D., & Casanova D. Female-to-male transgender chest reconstruction: A retrospective study of patient satisfaction. Annales de Chirurgie Plastique Esthétique. 2017;62(4), 303–307. https://doi.org/10.1016/j.anplas.2017.05.005.

5) Buncamper ME, van der Sluis WB, van der Pas, RSD, Özer M, Smit JM, Witte BI, Bouman MB, & Mullender MG. Surgical outcome after penile inversion vaginoplasty: A retrospective study of 475 transgender women. Plastic and Reconstructive Surgery. 2016;138(5):999–1007. https://doi.org/10.1097/ PRS.0000000000002684.

6) Javier C, Crimston CR, & Barlow FK. Surgical satisfaction and quality of life outcomes reported by transgender men and women at least one year post gender-affirming surgery: A systematic literature review. International Journal of Transgender Health. 2022;23(3): 255– 273. https://doi.org/10.1080/26895269.2022.2038334.

7) Eftekhar Ardebili M, Janani L, Khazaei Z, Moradi Y, & Baradaran HR. Quality of life in people with transsexuality after surgery: A systematic review and meta-analysis. Health and Quality of Life Outcomes. 2020;18:264. https://doi.org/10.1186/s12955-020-01510-0.

8) Green AE, Price-Feeney M, Dorison SH, & Pick CJ. Self-reported conversion efforts and suicidality among US LGBTQ youths and young adults, 2018. American Journal of Public Health. 2020;110(8): 1221–1227. https://doi.org/10.2105/ajph.2020.305701.

9) Grossman AH, D’Augelli AR, Howell TJ, & Hubbard S. Parent’ reactions to transgender youth’ gender International Journal of Transgender Health S203 nonconforming expression and identity. Journal of Gay & Lesbian Social Services. 2005; 18(1): 3–16. https://doi. org/10.1300/j041v18n01_02.

10) Klein A, & Golub SA. Family rejection as a predictor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health. 2016;3(3): 193–199. https://doi.org/10.1089/lgbt.2015.0111.

11) Turban JL, King D, Carswell JM, Keuroghlian, AS. Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics. 2020; 145(2), e20191725.

12) Marinkovic M, Newfield RS. Chest reconstructive surgeries in transmasculine youth: Experience from one pediatric center. International Journal of Transgenderism. 2017; 18:4, 376-381, DOI: 10.1080/15532739.2017.1349706..

13) Olson-Kennedy J, Warus J, Okonta V, Belzer M, & Clark LF. Chest reconstruction and chest dysphoria in transmasculine minors and young adults: Comparisons of nonsurgical and postsurgical cohorts. JAMA Pediatrics. 2018;172(5): 431–436. https://doi.org/10.1001/ jamapediatrics.2017.5440.

14) de Vries AL, Steensma TD, Doreleijers TA, Cohen-Kettenis PT. Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study. J Sex Med. 2011 Aug;8(8):2276-83. doi: 10.1111/j.1743-6109.2010.01943.x. Epub 2010 Jul 14. PMID: 20646177.

15) de Vries ALC, McGuire JK, Steensma TD, Wagenaar ECF, Doreleijers TAH, & Cohen-Kettenis PT. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4): 696–704. https://doi.org/10.1542/peds.2013-2958.

 

 

The authors state that GAC “does not cause harm” and “decreases many negative health outcomes, including rates of depression.” No relevant citations are provided for this claim. Although youth GAC has the support of the professional medical community in the United States,[1-3] that does not mean there is no risk of harm. Infertility, lack of development of genital tissue, problems with sexual functioning, psychosocial/cognitive delay, decrease in bone mineral density accrual, and the known side effect profiles of estrogen and testosterone (e.g., thrombotic events, cardiovascular disease, etc.) are all potential risks associated with the hormonal agents used in youth GAC.[4] Furthermore, systematic reviews[5-8] have found the quality of evidence in this field is low, meaning the literature does not actually show, with any reasonable degree of certainty, that youth GAC decreases rates of negative mental health outcomes. This runs contrary to the authors’ claim that use of hormonal interventions in this population is “supported by a wealth of research on their safety and effectiveness.” Later in the paper, the authors reiterate that “GAC…entirely mitigates the increased risk of depression and suicidal ideation.” The citation for this claim is Tordoff et al. 2022,[9] which is the only clinical research study involving youth GAC in the reference list. This was an observational study of hormonal treatment in which there was no significant change in mental health outcomes over time. Some participants did not start hormones and had high rates of depression/suicidal ideation at the end of the study period; however, this was a tiny number (n=7), and any resulting statistical comparison cannot support the assertion that depression and suicidal ideation were “entirely mitigated” in this study.[9]

In fact, there are multiple clinical research studies looking at hormonal treatment in TGD youth in which depression outcome measures did not significantly improve over time.[10-13] In the largest such study, the depression outcome measure actually significantly worsened after initiation of hormonal treatment.[14] It is also worth noting that suicidality research in this field is decidedly mixed. For example, in a recently-published study, n=2 participants taking hormonal treatment completed suicide during the study period.[15]

It is important for the health and well-being of children and adolescents in the United States that loving and supportive parents not be unjustly criminalized. However, this perspectives paper paints a complex and controversial issue as simplistic, and depicts circumspect approaches to care (i.e., any type of management that does not involve using hormonal interventions in TGD adolescents) as “abuse.” If this is the case, should doctors and parents who favor conservative management (as is increasingly the standard of care in European countries, some of which have changed guidelines after the publication of the above-mentioned systematic reviews) be considered “abusers” due to concerns about risks and a tepid evidence base? Ultimately, it is not helpful to patients, parents, or pediatricians for evidence to be misrepresented, for opinion to be stated as fact, or for the complexities of youth GAC to be ignored in favor of portraying the issue as an uncomplicated one.

1.    Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2017;102(11):3869-3903. doi:10.1210/jc.2017-01658
2.    Rafferty J. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018;142(4). doi:10.1542/peds.2018-2162
3.    Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgender Health. 2022;23(Suppl 1):S1-S259. doi:10.1080/26895269.2022.2100644
4.    Clayton A. Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect-The Implications for Research and Clinical Practice [published correction appears in Arch Sex Behav. 2022 Dec 13;:]. Arch Sex Behav. 2023;52(2):483-494. doi:10.1007/s10508-022-02472-8
5.    National Institute for Health and Care Excellence. Evidence Review: Gonadotropin releasing hormone analogues for children and adolescents with gender dysphoria. [NICE Evidence Review]. Published 2020. https://cass.independent-review.uk/nice-evidence-reviews/
6.    National Institute for Health and Care Excellence. Evidence Review: Gender-affirming hormones for children and adolescents with gender dysphoria. [NICE Evidence Review]. Published 2020. https://cass.independent-review.uk/nice-evidence-reviews/
7.    Ludvigsson JF, Adolfsson J, Höistad M, et al. A systematic review of hormone treatment for children with gender dysphoria and recommendations for research. Acta Paediatr. 2023. doi:10.1111/apa.16791
8.    Thompson L, Sarovic D, Wilson P, et al. A PRISMA systematic review of adolescent gender dysphoria literature: 3) treatment. PLOS Global Public Health. 2023;3(8):e0001478. doi:10.1371/journal.pgph.0001478
9.    Tordoff DM, Wanta JW, Collin A, et al. Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Netw Open. 2022;5(2):e220978. doi:10.1001/jamanetworkopen.2022.0978
10.    de Vries ALC, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014;134(4):696-704. doi:10.1542/peds.2013-2958
11.    Cantu AL, Moyer DN, Connelly KJ, Holley AL. Changes in Anxiety and Depression from Intake to First Follow-Up Among Transgender Youth in a Pediatric Endocrinology Clinic. Transgender Health. 2020;5(3):196-200. doi:10.1089/trgh.2019.0077
12.    Carmichael P, Butler G, Masic U, et al. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One. 2021;16(2):e0243894.
13.    Becker-Hebly I, Fahrenkrug S, Campion F, et al. Psychosocial health in adolescents and young adults with gender dysphoria before and after gender-affirming medical interventions: a descriptive study from the Hamburg Gender Identity Service. Eur Child Adolesc Psychiatry. 2021;30(11):1755-1767. doi:10.1007/s00787-020-01640-2
14.    Hisle-Gorman E, Schvey NA, Adirim TA, et al. Mental healthcare utilization of transgender youth before and after affirming treatment. J Sex Med. 2021;18(8):1444-1454. doi:10.1016/j.jsxm.2021.05.014
15.    Chen D, Berona J, Chan Y-M, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med. 2023;388(3):240-250. doi:10.1056/NEJMoa2206297