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

The authors of “Prohibition of Gender-Affirming Care as a Form of Child Maltreatment: Reframing the Discussion”¹  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,^2 –4  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 (eg, thrombotic events, cardiovascular disease, etc) are all potential risks associated with the hormonal agents used in youth GAC.⁵  Furthermore, systematic reviews^6 –9  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 2022,¹⁰  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.¹⁰ 

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.^11 –14  In the largest such study, the depression outcome measure actually significantly worsened after initiation of hormonal treatment.¹⁵  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.¹⁶ 

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 (ie, 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.