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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

[See “Pediatric Gender Care: Absence of Evidence is Not Absence of Efficacy”]

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  1. Thank you Gorin for this refreshingly level-headed and beautifully balanced article that expresses care and concern for gender dysphoric patients while not denying the necessity of evidence-based treatment. However, in recognizing the political influence on this issue, is a scientific, medical, bioethical, or any other empirically positioned statement adequate to address the fundamentally political issue at heart? Your article here is compassionate and careful, and I imagine hard for anyone to dismiss as unreasonable. But has ‘unreason’ been the driving issue with what can perhaps be called ‘political interference’ in medicine? I am inclined to think the issue may lie more in the lack of separation between health care and politics, and such a break-up is perhaps not even possible or entirely desirable. Why have other countries appeared to take a more cautious approach to gender dysphoric treatment? I don’t know if it stems from simply having more ‘reasonable’ executives at the helm of health care who care more about empirical evidence. I see this as a distinctly political issue, and no matter the scientific evidence that may be collected, we will not be able to ‘cure’ the underlying political influences unless we confront them head-on.

  2. Thank you for this excellent exploration of scientific validity and ethical soundness regarding care with/for adolescents and young adults. The harmful politicization of gender care for these young persons is manifest on ‘both sides’: e.g. when ‘progressive’ partisans demand that school rules allow – or welcome – that parents/guardians be lied to by school authorities regarding their children; e.g. when ‘conservative’ partisans demand that care for all young persons be prohibited under a state’s law.

    I was involved in advocacy, and research, for the health of transgender persons in Virginia from the early 2010s including landmark, early qualitative and quantitative research (including https://www.icpsr.umich.edu/web/RCMD/studies/31721; findings were incorporated in an early report out of NASEM https://nap.nationalacademies.org/catalog/13128/the-health-of-lesbian-gay-bisexual-and-transgender-people-building). We were able to engage not only metropolitan, but also rural, participation in this research. An incredible effort lead by the late expert in research design and advocacy with sexual and gender minorities, Judith Bradford, who is buried in a humble grave in rural Franklin Virginia.

    We learned – and apparently many LGBTQ ‘experts’ and ‘advocates’ have un-learned – that humility is required in scientific investigation/pronouncements, as it is in ethical inquiry/pronouncements. A hallmark of this humility is the necessity of informed consent.

    Valid, reliable, and humble processes of informed consent – that genuinely intend to protect from harms – are essential in research and in ethical inquiry. And, these are very much missing in my questioning of numerous gender care services, including especially the many online-only gender care services that appear to have proliferated through the pandemic. Perhaps this shallowness comes from high authorities (who should know and behave better). WPATH’s retort to the UK courts’ Tavistock ruling – https://www.wpath.org/media/cms/Documents/Public%20Policies/2020/FINAL%20Statement%20Regarding%20Informed%20Consent%20Court%20Case_Dec%2016%202020.docx.pdf?_t=1608225376 – mentions informed consent in a ‘boiler plate’, ‘seal of approval’ way that is disturbing for its shallowness. Furthermore the fact that these young persons have parent(s) or family is mentioned only once, and only then in a parenthesis. If gender is – as claimed – a social construction then why are parents, families and broader moral communities of the young person – who participate in that social construction – so poorly acknowledged? And why are licensed providers ‘doing’ informed consent in apparently haphazard ways: here in Virginia I see in some transgender care blogs solicitation of someone/anyone with the proper license to ‘write a letter’ required to proceed with certain gender care; implying that it could be done remotely – without significant encounter – and quickly – without much time involved. Are standards and processes of informed consent – that genuinely intend to protect from harms – being observed? Have components of gender care systems become mostly means of generating revenue? virtue-signaling political/cultural ideologies? or something else? that is not genuine informed consent that embodies ‘do no harm’ care?

    I hope that along with the expert systematic review you request – that should, as you imply, take into account the reviews of other societies (Sweden, Finland, etc), and the jurisprudence in other societies (UK, etc) – the ethics community will review both what is and is not being done properly and well regarding informed consent.

    Thank you very kindly,
    edward stricker, rural virginia
    retired, school of medicine, university of virginia
    member and past chair, ethic section, american public health association

  3. I’m concerned that this article cites material from SEGM, SEGM is not a reputable source: https://transsafety.network/posts/segm-uncovered/
    As for “some clinics in the US will prescribe them after a single meeting”, I don’t see evidence of that the Reuters article, I don’t know why a single meeting would necessarily be concerning (I’d argue one very long meeting could be more thorough than multiple short consultations), and as bills felonizing gender affirming care and as testimony from trans people shows, access to gender affirming care seems to be a much bigger issue than insufficient checks prior to providing gender affirming care.
    Dr. Gorin seems to deem “trans-doubting” people as non-political and evidence-based, while rejecting great evidence that gender affirming care is very beneficial. E.g. Dr. Gorin elsewhere cites Dr. Lisa Littman as a pathbreaker (https://twitter.com/GorinMoti/status/1593663555097702400) while ignoring how the ROGD theory and Dr. Littman’s paper on it have been roundly debunked (https://www.caaps.co/rogd-statement).

    Regarding the Cass report, I think this passage from the interim report (https://cass.independent-review.uk/publications/interim-report/) published Feb 2022 is worth quoting in full:
    “”3.31. The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway which culminates in progression to feminising/masculinising hormones by impeding the usual process of sexual orientation and gender identity development. Data from both the Netherlands38 and the study conducted by GIDS39 demonstrated that almost all children and young people who are put on puberty blockers go on to sex hormone treatment (96.5% and 98% respectively). The reasons for this need to be better understood.”
    More research is always a good thing, but regarding almost all children who put on puberty blockers going on to receive hormone treatment, isn’t that evidence that most patients are not ‘desisting’ and that doctors are doing a good job identifying candidates for puberty blockers?

    Dr. Gorin’s article (and the previous comments on it) seem to ignore a whole lot of evidence that gender affirming care is beneficial e.g.: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0261039

    Also see the studies cited in this article: https://www.pinknews.co.uk/2022/02/23/sweden-trans-healthcare-puberty-blockers/

    As for European countries being more friendly towards LGBTQ+ people, support for some gender and sexual minorities does not mean support for all gender and sexual minorities. The UK has faced rising transphobia for years now: https://www.them.us/story/transphobia-surge-endangering-trans-people-uk

  4. To reply to some points from Edward Strickler’s comment, not outing children to parents is not lying. Schools are not surveillance apparatuses for parents. Students do not need parental approval to know what books they should check out or to know what name they want to be called and what pronouns they want to be referred by. And schools need to not enable or take actions that could lead to abuse. Transphobic and homophobic parents/guardians foster abusive environments: https://www.theguardian.com/commentisfree/2015/jan/05/homophobic-transphobic-parents-abusive-homes-lgbt-kids

    Regarding “isn’t gender a social construct”, gender likely has some genetic underpinnings, that doesn’t mean it’s deterministic (that is, similarly to sexual orientation, there’s no series of tests a medical provider or government can do to determine gender short of asking someone what their gender is) and that doesn’t mean there’s not social constructs based on gender (e.g. perceptions of gender roles). The words we use to describe gender (which vary by society and culture) are themselves social constructs. Something being a social construct doesn’t mean it isn’t real, and it doesn’t mean it’s not worth respecting. Attractiveness is a social construct, that doesn’t mean we should felonize plastic surgeries (and yes, minors can and do receive plastic surgery: https://www.plasticsurgery.org/news/press-releases/american-society-of-plastic-surgeons-weighs-in-on-growing-popularity-of-teen-plastic-surgery/). We should discuss how to best assess patient suitability for procedures (and, more critically, how to help patients best their own suitability for elective procedures), but we shouldn’t start with the patronizing and condescending premise that patients seeking these procedures are inherently damaged and incapable of performing risk-benefit analyses. Trans youth are vulnerable because of transphobia, not because they are trans.

    As for not doing harm, withholding necessary care, placing unnecessary and undue obstacles to accessing care, focusing exclusively on the harms of potential procedures and not the potential benefits, and distrusting patients without cause are all harmful. “Do no harm” shouldn’t be taken as a bias towards not providing care.

  5. Anshu,

    Thank you for your response to my essay. A few points:

    1. My sources: I link to SEGM in one place, to the English translation of a Finnish document. As far as I can tell, SEGM is the only organization that has provided an English translation. The original document, in Finnish, is here: https://palveluvalikoima.fi/sukupuolidysforia-alaikaiset. The relevant section is titled “Suositus.” One can use Google Translate, which is imperfect, or perhaps find someone who reads Finnish well, to translate it independently. If you find any errors with their translation, I’m sure SEGM would like to know—and I’m sure the same goes generally for any other possible inaccuracies. I believe substantive objections that show mistakes in fact or in reasoning are to be taken more seriously than vague accusations. For what it’s worth, I have used Google Translate on this document myself and have found the SEGM translation to be accurate.

    2. Littman’s work: Littman’s work is irrelevant to the argument I give in the essay. However, perhaps it’s worth noting that in their chapter on adolescent care, WPATH SOC 8 states, “For a select subgroup of young people, susceptibility to social influence impacting gender may be an important differential to consider.” (WPATH SOC 8, p. S45) Thus, even strong advocates of gender-affirming care now recognize that social influence can play a role, consistent with Littman’s hypothesis.

    3. The Cass Report passage: thank you for including this paragraph. It clearly explains the problem, which is that clinicians are unable to determine whether puberty blockers provide time for the patient to explore their gender identity, on the one hand, or essentially guarantee that patients who take them will move on to more serious hormonal interventions, on the other. Because we lack long-term data, this question cannot currently be answered, and therefore it’s not the case that high rates of persistence at this treatment stage show that physicians are able accurately to diagnose these patients.

    4. The strength of the evidence: you claim there is a “whole lot” of evidence showing that gender affirming care is beneficial. One of my central claims, however, is that without systematic reviews of the evidence, we cannot conclude that the evidence is sufficiently strong to justify the relevant interventions, and that in fact countries that have completed such reviews have concluded just the opposite. As I argue, there is a way for the US to determine whether or not the evidence is sufficiently strong: a trusted medical organization such as the NIH or the IOM can commission systematic reviews of the evidence, to be carried out by impartial experts. I hope everyone, irrespective of their views on the merits of gender-affirming treatment, can agree that systematic reviews of the evidence underlying this care would be helpful in ensuring that these vulnerable patients get the care they need.

  6. Thank you Anshu Sharma.

    Re your comment made directly to/about my comments (section identifiers added):

    “To reply to some points from Edward Strickler’s comment,

    1. not outing children to parents is not lying.

    2. Schools are not surveillance apparatuses for parents.

    3. Students do not need parental approval to know what books they should check out or to know what name they want to be called and what pronouns they want to be referred by.

    4.And schools need to not enable or take actions that could lead to abuse.”

    1. I commented in particular from recent experience in Virginia following two rounds of proposed guidance from Virginia Department of Education (VDOE). It was clear to many commenting on Virginia Department of Education’s (VDOE) first round of proposed guidance that school authorities would be allowed to deceive parents/guardians. In Virginia, school jurisdictions – and other local agencies under supervision of the Commonwealth’s law, regulations, and rules (such as local mental health agencies, local public health agencies, etc) – have considerable discretion in interpreting what they must do or may do. Many parents were/are convinced – from experiences they have endured – that ideological pressures in local jurisdictions would not only allow, but invite deception, contrary to reasonable ‘in loco parentis’ expectations; and instead of scientfically and ethically sound counseling care for gender dysphoria. Deception involves intention to keep the whole truth from those who deserve the whole truth (see for example: “While the noun prevarication is mostly just a fancy way to say “lie,” it can also mean skirting around the truth, being vague about the truth, or even delaying giving someone an answer, especially to avoid telling them the whole truth” https://idioms.thefreedictionary.com/The+Whole+Truth ). The whole truth includes that parents/guardians – with legal and moral duties of care – deserve to know the whole truth about the children in their care.

    It is increasingly clear that discussions about care-ful, not harmful gender care of young persons must include care-ful discussions about legal and moral duties of parenting, whether biological or adoptive parents, ‘in loco parentis’ of public authorities, or lawful custodians of young persons (in social care, in criminal justice care, in other legally authorized care).

    2. From one point of view a valid response is ‘Well, OF COURSE, schools should be informing parents, all the time, about what their child is doing, how their child is behaving, what their child is accomplishing or needs support for!’ That is ‘surveillance’ of a sort consistent with ‘in loco parentis’ and in conformity with many school jurisdictions’ formal disclosures of responsibility/responsiveness/accountability to parents. Perhaps you would define what you mean by ‘surveillance’?

    3. Actually, some school jurisdictions do – as a matter of policy and/or practice – require parental consent, or at least some sort of waiver or opt-out of providing explicit consent, for some assignments, some topical content in curriculum, access to some library content, etc. School jurisdictions may have formal documentation of student names to be used in official records, in school activities, etc; these are typically authorized by parents/guardians and not a matter of what a students says.

    4. Reviewing comments in favor of the VDOE proposed guidance – that would allow deception of parents about the student’s presentation of gender dysphoria – I was especially confused – and alarmed – by the assertion that if parents were asked to guide the school’s decision about the student’s pronouns the school might have to make more effort to protect students from possible abuse following the discussion about pronouns. Well! I thought that would be a good things rather than a bad thing, wouldn’t it: shouldn’t communities be supportive of schools making more effort as mandated reporters of possible students harms. Why were commenters arguing that deception – not including parents/guardians in the whole truth – was better BECAUSE it was easier for school officials? Why would making things easier for school officials to avoid their duties of mandated reporters be a powerful argument? Shouldn’t commenters be demanding greater effort of school officials as mandated reporters?

    Re:

    “Trans youth are vulnerable because of transphobia, not because they are trans.”

    Hateful response to sexual and gender minority persons is real and horrible. But that is not the only reason they are vulnerable.

    They are vulnerable because of revenue-seeking motives of providers, including, as I noted, proliferation of online-only, or online-mostly, gender care groups, referral networks, etc. that poorly understand, implement or care about informed consent and other ethical foundations of care.

    AND they are vulnerable because of manifold online, social media, and other social-cultural pressures (including through secret or otherwise hidden AI algorithims, marketing strategies, and other manipulations, that do not enshrine ‘do no harm’ as a guiding principle).

    AND they are vulnerable because youth brains are not adult brains about which we still know too little [ e.g. https://www.apa.org/monitor/2022/07/feature-neuroscience-teen-brain ] ; but what we do know ought to inform what we regard as a scientifically, professionally ethically, and morally sound approach to informed consent.

    Of course I did not – as you imply – assume that youth are ‘damaged’. But data do, in fact, cause us special care with vulnerable youth. Don’t they? And sexual and gender minority youth are vulnerable in many societies, and households, aren’t they? And they are not vulnerable only because of transphobia, correct? I recently received an invitation to a dance party in observance of Transgender Day of Remembrance (sometimes also called Transgender Day of Resistance). The invitation welcomed ‘All Ages’ for the ‘All Night’ Party and was sponsored by an anarchist media shop and collective. Among their beliefs and mottos is ‘Fuck Around: Find Out’. Many would agree that ‘Fuck Around: Find Out’ is not a very useful message for public health care, mental health care, or moral care or anyone, and certainly not vulnerable youth.

    Returning to my primary argument:

    Scientifically, ethically professional, and morally sound Informed consent is not an ‘obstacle’ to excellent gender care; it is a foundation.

    Thank you.

    Edward Strickler

  7. Moti,
    Your article highlights an enormous issue within an incredibly vulnerable population, and I find the main take away is that we have ultimately failed this population. It is disheartening that the care a pediatric patient with gender dysphoria is greatly dependent on where they live, especially in these times where their care has become highly politicized. I wholeheartedly agree that evidence-based care is mandatory for them to receive the best care, and I loved that you highlighted the importance of “all physicians deserve to practice medicine with the help of authoritative clinical practice guidelines,” even highlighting that it would allow them to practice with nonmaleficence.
    My worry is that this is such a vulnerable population since 1. they are a pediatric patient and 2. they have gender dysphoria. You point out that a systematic review would not be possible since there aren’t enough studies done in this population. Would they ultimately have full autonomy being a pediatric patient to enroll in studies or are the number of participants limited as they may not be comfortable feeling “exposed” or talking openly about something that they may consider to be private, or would their parents even limit their involvement? Are providers also worried about caring for these patients or even not agreeing to see patients for gender dysphoria if it goes against their own personal morals? It’s hard to not compare the care this population is receiving to those wanting an abortion where they unjustly are unlikely to be cared for in certain states and have to travel elsewhere to receive proper care, though your article highlights there is no standard of care to follow for those with gender dysphoria. Will insurance companies not cover care specific to gender dysphoria resulting in seeking care in under resourced settings? The recommendation from Sweden is that the first line of treatment is mental health support, which has been known to mostly be a resource available only for those with financial freedom within the US, likely limiting the ability for many to participate in what’s highly recommended. Your article makes it clear that we need to protect a vulnerable population that is rapidly growing, and I’m worried we as a country may not have the ability to do so currently.

  8. 1. Why isn’t there acknowledgement that without puberty blockers many trans and nonbinary youth may be locked into bodies that don’t align with their identities? Youth who are on puberty blockers choosing to pursue hormone treatment is not a bad thing, and I’m not sure why it’s being treated with such suspicion. I also don’t see any suggestions on how puberty blockers would “lock in” a course to hormone treatment, the percentages alone don’t provide evidence of this proposed phenomena and as I noted above can be read as evidence that puberty blockers are being properly administered. The best available evidence from trans youth who received puberty blockers (and trans adults who didn’t and wish they did https://twitter.com/ErinInTheMorn/status/1592175210916372480) is strong enough to support their continued use in gender affirming care.
    In general, we need to do more work to uphold the tenets of evidence-based care: https://theconversation.com/only-one-in-ten-medical-treatments-are-backed-by-high-quality-evidence-145224
    But absence of specific scenarios is not by itself indication that a specific treatment is to risky to be continued: https://twitter.com/RottenInDenmark/status/1584605941152251904
    Also see https://www.thehastingscenter.org/pediatric-gender-care-absence-of-evidence-is-not-absence-of-efficacy/
    2. Like it or not, almost all healthcare in the US currently is based on revenue seeking models, this isn’t unique to gender affirming care.
    3. In my view, if a student doesn’t want a school to share information related to their pronouns, gender identity, sexual orientation, or other sensitive medical or social information (e.g. sexual activity, pregnancy status), that school has an obligation to honor the students’ wishes and not share that information. If the student is concerned that sharing this information (or any information, frankly; e.g. there are parents who would hit their children because of bad grades) would leave to an abusive situation, the school needs to not potentially produce the abusive situation by sharing such evidence, but needs to offer the students pathways to escape the potentially abusive environment.
    4. The way things should be is not necessarily the way they are. I think parents being able to opt their children out of certain extracurricular activities, reading certain texts, or learning certain content (including but not limited to relationship and sex education and evolution education), and in some cases being able to provide no education to their children (https://www.youtube.com/watch?v=ewalmJTZ7wU), is not model policy, but a sign of the degree to which our society promotes anti-intellectualism under the guise of ‘parental rights’.
    5. Regarding “social contagion” fears, there’s the possibility that social media is educating youth and adults who hadn’t heard about what it means to be trans. This could include youth who are trans but haven’t been exposed to the language to describe that. These aren’t bad things. I don’t see the statement in the WPATH report as an endorsement of Littman’s hypothesis that social media primarily is ‘driving’ minors (esp non-trans minors) to identify as trans.
    6. The percentage of youth identifying as trans and the percentage of youth seeking gender affirming care, and changes in the aforementioned percentages, are not evidence that something nefarious, sloppy, or careless is happening in medicine or in society.
    7. I don’t see what a fun-sounding party open to all ages indicates about the quality of gender affirming care. If the concern is about ‘activists’ being involved in medicine, in my opinion that’s unavoidable and not necessarily a bad thing. For more info, see my FB post and my comments on it: https://www.facebook.com/permalink.php?story_fbid=pfbid02AZjQAx1bYyVJkdUrMsD6hwiV6d1oW6D8N2kVAJw8ER6B2u3ZKe1BK6YHmbpt378sl&id=100006098824835
    8. In the above article, SEGM is cited twice; one link is to a PDF document regarding gender affirming care in Finland, the second is to a webpage regarding care in Sweden.

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