Bioethics Forum Essay
The Cure for Politicized Pediatric Gender Care
Though medical care can vary to some extent regionally and internationally due to economic, social, and cultural differences, the similarities in treatment protocols far outnumber the dissimilarities. How best to treat a broken arm, or a melanoma, or diabetes is consistent across borders. Yet children and adolescents diagnosed with gender dysphoria receive radically different treatments depending on where they live. With gender clinics in the United States under significant stress due to the intense politicization of this field of medicine, and with the well-being of especially vulnerable children at stake, it is crucial that these inconsistencies be addressed. The best way to do this would be for a major, trusted medical organization such as the National Institutes of Health or the National Academy of Medicine to commission a systematic review of the evidence underlying pediatric gender medicine.
No U.S.-based organization has conducted such a review at the national level, putting American professional medical associations and physicians at odds with their counterparts and colleagues in other countries. All patients deserve evidence-based care, and all physicians deserve to practice medicine with the help of authoritative clinical practice guidelines. Clinical practice guidelines are “statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options.” The inclusion of systematic reviews in the formation of guidelines for the treatment of gender dysphoric youth is necessary to ensure that medical care is evidence-based and patients are not exposed to medically unnecessary risks. When clinicians practice evidence-based care, they abide by a core ethical principle of medicine—nonmaleficence.
The time to conduct a systematic review is now. There has been a sharp increase in the number of minors diagnosed with gender dysphoria in the U.S. An analysis of insurance claims found that in 2017, 15,172 patients aged 6 to 17 were diagnosed with gender dysphoria; in 2021, the number grew to 42, 167, an increase of roughly 300%. Other countries have also seen an increase in minors presenting with gender dysphoria.
U.S. physicians treating an adolescent patient suffering from gender dysphoria are guided by professional organizations, such as the Endocrine Society, the American Academy of Pediatrics, and the World Professional Association for Transgender Health (WPATH), to employ gender-affirming care, which can involve the prescription of puberty blockers, cross-sex hormones, or surgery. These organizations’ guidelines are not based on systematic reviews of the benefits of these treatments. Although some U.S. states have moved to ban or restrict youth access to gender affirming care, physicians in most states follow these organizations’ guidelines. In its most recent guidance document, WPATH reported that it is “not possible” to conduct a systematic review of adolescent care due to the overall low number of studies and the “few outcome studies that follow youth into adulthood.” Nevertheless, the title of WPATH’s document is called “Standards of Care for Transgender and Gender-Diverse People” and its recommendations for the treatment of minors have been described as “evidence-based” by U.S. Assistant Secretary of Health, Rachel Levine.
Meanwhile, physicians treating children and adolescents with gender dysphoria in Sweden, which did conduct a systematic review, are told by their National Board of Health and Welfare that “the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and . . . the treatments should be offered only in exceptional cases.” It recommends mental health support and exploratory psychological care as the first line of treatment for gender dysphoria in youth and states that hormonal interventions “should be restricted to research settings.”
Across the border in Finland, which also conducted a systematic review, physicians are told by the Council for Choices in Healthcare that psychosocial support is the first-line treatment for adolescent gender dysphoria, along with exploratory therapy and treatment for psychiatric comorbidities. Finland considers the medical transition of minors to be an experimental practice and claims that no medical treatment can be considered evidence based.
In England in 2020, the National Health Service commissioned independent, systematic reviews of the evidence for clinical benefit of prescribing puberty blockers and cross-sex hormones to gender dysphoric youth. The reviews found that studies showing positive correlations between these interventions and improvements in mental health, quality of life, and gender dysphoria were “not deemed strong enough to form the basis of a policy position.” Last month, the National Health Service issued a draft guidance that restricts puberty blockers to research settings. Echoing Sweden and Finland, NHS-England now concludes, “The primary intervention for children and young people who are assessed as suitable for The Service is psychosocial (including psychoeducation) and psychological support and intervention.”
Given the vulnerability of youths with gender dysphoria, inconsistencies in clinical guidance for treating these patients are both ethically concerning and medically consequential. A patient in Sweden, Finland, or England will receive blockers or cross-sex hormones only in exceptional circumstances, while some clinics in the U.S. will prescribe them after a single meeting. This discrepancy in clinical approach cannot be explained by national cultural differences in attitudes toward LGBT+ people; research shows that Sweden, Finland, and the Great Britain all rank higher than the U.S. for acceptance of sexual and gender minorities.
At a time of intense political polarization in the U.S. over LGBT+ health care, and with the dramatic rise in gender dysphoria diagnoses among the pediatric population, it is crucial that trusted medical authorities in the U.S. make every effort to establish clinical practice guidelines. Such guidelines require systematic reviews of the available scientific evidence, which other LGBT+-friendly countries have shown are possible. It is crucial that these reviews be conducted by impartial experts to avoid bias. There can be no medical or ethical reason why care provided to vulnerable adolescents should vary so drastically from one place to the next. Evidence-based medicine is the cure for politicized medicine.
Moti Gorin, PhD, MBE, is an associate professor in the department of philosophy at Colorado State University. @GorinMoti