The year 2020 has been pivotal in the field of gender medicine. Earlier this month, in a landmark decision, the UK High Court ruled that children under 16 are unlikely to be able to consent to the use of puberty blockers, which the Court deemed to be an experimental treatment. Rather than a “pause button,” the court recognized puberty blockers as the first step in a largely irreversible pathway of medical transition. After a thorough evaluation of expert evidence, the judges cautioned clinicians that even 17-year-olds may not be able to fully comprehend the lifelong consequences of these interventions. The implications of the UK High Court judgement are poised to reverberate worldwide, according to the article published by the Economist last week.
The Case of Keira Bell
The case brought before the High Court was that of Keira Bell. As a teenager, Keira identified as transgender. The UK gender clinic, Tavistock, which runs the country’s Gender Identity Development Service (GIDS), affirmed Kiera’s transgender identity, and, as dictated by the “affirmative” protocol, provided her with puberty blockers, testosterone, and subsequently referred for a bilateral mastectomy. At 23, Keira regrets her transition and asserts she was misinformed about the scientific basis for transitioning.
Keira’s story is not unique. Although many people who undergo transition express satisfaction with their treatment, others have begun to voice transition regret on social and mainstream media. Their stories challenge the prevailing notion that hormonal and surgical transition have low rates of regret.
Notable Events of 2020
Several other recent developments were also instrumental in shifting the tone and tenor of the debate, with increasing acknowledgement of the weak evidence basis for the “affirmation” treatment model for young people:
Following a 2019 review by Professor Carl Heneghan, which concluded that there is no quality evidence base to support the use of hormonal and surgical interventions in young people, two systematic reviews (one from Finland and another from Sweden) came to similar conclusions. Consequently, Finland became the first country in 2020 to issue new guidelines for treatment of gender dysphoria for young people; the new guidelines prioritize psychological treatment over treatment with hormones or surgeries.
In Sweden, broad coverage of the controversy, including the documentary The Trans Train produced by Sweden’s national public television broadcaster, appears to have decreased demand for gender reassignment among teens, which began to decline significantly in late 2019.
In the US, the issue of adolescent-onset gender dysphoria was brought to the attention of a general audience by Abigail Shrier’s "Irreversible Damage," chosen by The Economist as one of its Books of the Year.
The UK NHS initiated a review of evidence, with the goal of reassessing treatment approaches for gender dysphoria in persons under age 18. The UK NHS also commissioned a wide-ranging independent review of gender identity healthcare for the under 18s, to include an exploration of why there has been a marked increase in the number of females seeking gender reassignment.
The analyses and conclusions of several widely quoted studies that misrepresented the success of “affirmative care” have been challenged and refuted. A major study that originally proclaimed to be the first to provide evidence of long-term mental health benefits of biomedical treatment for adults was critiqued and subsequently corrected, ultimately concluding that neither hormones nor surgery show any benefit in terms of long-term mental health or suicidality. Two other widely-quoted studies purporting benefits of puberty blockers and suggesting harms of psychological approaches to gender dysphoria were also found to have errors and misrepresentations that invalidated the papers’ conclusions.
One of the principal authors of the "Dutch Protocol,” the basis for the “affirmative” model of treating teens with hormones and surgeries, published a commentary in the journal Pediatrics, alerting clinicians that biomedical transition is currently being applied to young people for whom it was not designed and who might not benefit from it. The author emphasized the need to identify those people who need enhanced mental health support, rather than gender reassignment.
As the evidence for biomedical interventions underwent much-needed scrutiny, a number of small but promising case reviews of psychological approaches to gender dysphoria treatment in young people have been published. Much research is needed into the role of psychotherapy for young people with a novel, adolescent-onset variant of gender dysphoria, especially in light of the significant mental health and neurodevelopmental comorbidities found in this group.
At the same time, 2020 was marked by increased politicization of healthcare for gender-dysphoric young people. In particular, there has been a wave of proposed legislation that misrepresents ethical psychotherapy for gender dysphoria as a form of conversion therapy. A recent Economist editorial concluded that such conflation “could criminalise counselling that raises the distinct possibility that a particular trans-identifying child or adolescent might one day desist. So such laws are a bad idea.”
SEGM maintains that although well-meaning, the legislation that fetters the clinical freedom of ethical clinicians attempting to help young people understand factors that contribute to their gender distress and to resolve it non-invasively, ultimately hurts the individuals it aims to protect.
SEGM in 2020 and Beyond
Since SEGM formed in early 2020, more than 120 clinicians and researchers have joined us in our mission to promote safe, compassionate, ethical and evidence-informed healthcare for children, adolescents, and young adults with gender dysphoria. We have established a thriving online collaboration space, with a number of researchers evaluating the current evidence basis, writing research papers, and engaging with medical societies.
Our work has already begun to impact the quality of scientific discourse regarding treatments for gender-dysphoric young people. For example, the work conducted by SEGM-affiliated clinicians led to the official correction of a key study that mistakenly claimed that “gender-affirmative” surgeries improve mental health outcomes. At SEGM’s request, Medscape withdrew its inaccurate coverage of the study, and is currently in the process of notifying over 6,000 clinicians who took its Continued Medical Education (CME) class that the original conclusions of the study were incorrect.
SEGM-affiliated clinicians also published a key publication, “One Size Does not Fit All: In Defense of Psychotherapy for Gender Dysphoria,” which, according to Almetric, is in the top 1% of all scientific publications, and has been downloaded more than 20,000 times. SEGM-affiliated experts also provided critical evidence in the Keira Bell case, highlighting the risks and uncertainties of the “affirmative” intervention model for gender-dysphoric young people.
As we prepare for 2021, SEGM has set several ambitious goals:
Curate key topics in the area of gender dysphoria debate. We aim to examine the risks, benefits, and uncertainties associated with biomedical transition; critically evaluate published studies; direct particular attention to the reported rates of suicide among trans-identified youth and explicate how transition impacts this risk. We will assess the ethics of the informed consent model of providing cross-sex hormones to any young person who desires them, without a psychological evaluation or exploration. This model of care for gender-dysphoric young people is increasingly used in North America.
Publish an online bibliography of literature we consider reliable and which we believe highlights the need for a more cautious approach to hormonal and surgical transition of young people. The existence of this research literature is often overlooked and can serve to inform researchers, clinicians, journalists, and public policy makers. In addition, we will continue to build an extensive internal library of research studies.
Publish practice guidance to help clinicians care for gender-dysphoric young people, supporting them along their vitally important journey toward maturity in a developmentally informed way that prioritizes their longer-term mental and physical health.
Continue engagement with medical societies, alerting them to the rapidly shifting evidence base in the field of gender medicine and the implications for ethical clinical practice. We will also continue engaging with independent researchers, journalists, legislators and policy makers, enabling open discourse and interaction with the scientific evidence-base.
These efforts require painstaking work and significant resources. If you would like to support our work, your donation would be greatly appreciated.
Last year, generous donors helped SEGM launch and set in motion vitally important work others are unable to do, some of which has already borne fruit. We hope you are encouraged by the growing interest in the use of quality evidence to guide treatments of young people struggling with gender dysphoria, and we hope you will help us make 2021 an even more productive and fruitful year!
Thank you for your ongoing support!
Roberto D’Angelo, SEGM President, on behalf of SEGM Board of Directors:
William Malone, MD
Julia Mason, MD
Stephen Beck, MD