After the Keira Bell verdict
An English ruling on transgender teens could have global repercussions
Worries grow over treatments that can leave children sterile
In 2018 Andrea Davidson’s 12-year-old daughter, Meghan, announced she was “definitely a boy”. Ms Davidson says her child was never a tomboy but the family doctor congratulated her and asked what pronouns she had chosen, before writing a referral to the British Columbia Children’s Hospital (BCCH). “We thought we were going to see a psychologist, but it was a nurse and a social worker,” says Ms Davidson (both her and her daughter’s names have been changed). “Within ten minutes they had offered our child Lupron”—a puberty-blocking drug. “They brought up the drug directly with our child, in front of us, without discussing it with us privately first.” There was no mention of other mental-health issues, which are known to increase the likelihood of gender dysphoria, the feeling that you are in the wrong body. “There was no therapy on offer and we were just brushed aside when we raised it.”
Meghan belongs to a wave of children across the Western world who have identified as transgender in recent years. America had one gender clinic in 2007; now it has more than 50. Piecemeal evidence around the world suggests that three-quarters of children expressing gender dysphoria at such clinics are adolescent girls, whereas until recently it was roughly evenly split. An increasing number are also de-transitioning, choosing to revert to their previous gender. Unfortunately, if children have already begun a medical transition, including hormone treatment, it can leave them infertile and unable to have a full sex life.
Earlier this month the High Court in London looked at the case of one detransitioner, Keira Bell, who had brought a judicial review against the Tavistock clinic, England’s only specialist youth gender-identity centre. She claimed that the clinic should not have allowed her to take puberty blockers and later undergo testosterone treatment and a double mastectomy. The court ruled that it was “highly unlikely” that a 13-year-old and “doubtful” that 14- and 15-year-olds are mature enough to consent to such a procedure, and that doctors treating 16- and 17-year-olds may also need to consult a judge before starting.
Trans activists argue that a long-marginalised group is now finding its voice in popular culture. Their critics retort that vulnerable teenagers are losing themselves in an online world which adulates anyone who comes out as trans. Both could be right. “Being straight is boring,” says Meghan’s younger sibling.
Society is struggling to strike a balance. Some children who feel they are in the wrong body will always feel that way and might benefit from altering their bodies. Others will change their minds—many of these will simply turn out to be gay. No medical test can tell these two groups apart. Children with mental-health problems or conditions such as autism are more likely to experience gender dysphoria. Untangling all this is extremely hard.
However, there are worries that rich countries have the balance wrong. One of the Dutch scholars on whose work the prescribing of hormones and surgery is based has said that her research is being applied to young people for whom it was not designed. And a growing number of people are dissenting. The Economist spoke to more than four dozen people in rich English-speaking countries, including trans people, parents, doctors, social workers, teachers and people who had identified as trans when they were children. Most of those who were critical wanted to be anonymous for fear of losing their jobs or being branded bigots on Twitter.
“The first duty of medicine is ‘Do no harm’,” says a Canadian paediatrician. “In any other branch of medicine, if you were causing permanent sterility with body-altering surgery and cross-sex hormones, you had better have some pretty strong data...But we’re already going down that road with no strong data at all.”
To find the best approach will require debate. Some activists do not welcome debate, however. “We are liberal people,” says Ms Davidson. “But we are always made to feel like we are right-wing crackpots for raising questions.”
Crossing a Rubicon
Nobody has global statistics for the rate of trans cases among children. Referrals to the Tavistock in London have surged 30-fold in a decade, with 2,700 children referred there last year. Nearly half those referred will start on puberty blockers. In 2019-20, the BCCH treated 382 patients in its gender clinic, up from 123 in 2016-17. America does not publish statistics. However, in a survey of American high-school students in 2017 by the Centres for Disease Control 1.8% said they were transgender and a further 1.6% said they were unsure.
The case for puberty blockers is that they can help children with severe gender dysphoria, who feel desperate about developing the “wrong” sex characteristics. That is because the drugs could spare them distress and, potentially, traumatic interventions later: a double mastectomy; a hysterectomy or the shaving of the Adam’s apple.
Many who go through full medical transition say they are happy with the result. Tru Wilson, who lives in Vancouver, is one. Tru was a gentle boy, and Tru’s parents thought their child might be gay. They then watched a programme together on trans kids and Tru said, “That’s me!” Tru, now 17, began on blockers at 12, on oestrogen at 14, and is expecting to go through surgery within the next year. “I have zero regrets on how my journey went,” she says. Her father, Garfield, has been impressed by physicians at the BCCH. “There was no pressure pushing us to do anything that we didn’t feel was right for our daughter.” Many other parents also report positive experiences. bcch says that they take the use of puberty blockers seriously and all their patients “go through rigorous assessments including confirmation that they are capable of considering the benefits and risks”.
But other transitioners come to see such procedures as a mistake. Claire (not her real name), now a 19-year-old student in Florida, started on testosterone aged 14 because of a loathing for her body. (She was also deeply depressed.) “I felt it was the only option, especially with the insistence that having dysphoria meant you are irrevocably trans and thus you will probably kill yourself if you don’t transition.” Obtaining hormones was easy, she says. “They pretty much gold-stamped me through.” Then, aged 17, her dysphoria disappeared. “I felt extremely lost. I had never heard of this happening.” She came off testosterone, embraced her identity as a lesbian, and is furious. “It is the medical industry and the general social attitude towards dysphoric people that failed me.”
Such “desistance” appears to be common. At least half a dozen medical studies show that between 61% and 98% of children presenting with gender-related distress were reconciled to their natal sex before adulthood. However, all these studies looked at children with early-onset dysphoria. One recent study on adolescent dysphoria among girls suggested that in many cases it is brought on by the influence of the internet, by female friends who have transitioned and by the miseries of puberty. “What is needed is quality research into adolescent-onset dysphoria among girls, and the overlap with autism and mental-health diagnoses,” says Will Malone, an endocrinologist and director at the Society for Evidence-Based Gender Medicine, an international group of doctors and researchers.
The decision to desist is hardest for those who have received medical treatment. Lisa Marchiano, a Jungian therapist in Philadelphia, counsels several such people. They all believe they were given access to medical interventions too soon. “It takes enormous strength to admit you have invested so much in a strategy that is a mistake,” she says.
The evidence in favour of medical treatment is being challenged, too. Arguments for providing hormones and surgery to dysphoric teenagers lean heavily on an intervention approach pioneered in the Netherlands, which has come to be known as “the Dutch protocol”. This was tested on 55 young people with early-onset dysphoria. The teenagers were treated with puberty blockers, cross-sex hormones and, after they turned 18, surgery. There was no control group. Instead the results of a study of the approach, published in 2014, concluded that these medical interventions were successful on the basis of psychological functioning at least one year after surgery.
The authors warn that their paper contains a small sample, measures only short-term psychological outcomes and has no evaluation of the implications for physical health. One of its researchers, Annelou de Vries, this year published a commentary in Pediatrics, a medical journal, saying that the approach is being wrongly applied to children (mostly girls) with adolescent-onset dysphoria. She emphasised the need to identify those who need enhanced mental-health support, rather than gender reassignment. Carl Heneghan, a professor at the Centre for Evidence-Based Medicine at Oxford University, wrote last year that use of the Dutch protocol amounts to an “unregulated live experiment on children”. The High Court in England also called such interventions “experimental”. The flood of hormones in puberty help reconcile a child to their sex in a way that doctors do not fully understand. Blockers stop that.
No turning back
The Tavistock clinic argued that puberty blockers are reversible. That is true up to a point. However, they can affect bone density and so doctors often want to move patients on to cross-sex hormones, which have more permanent effects. The court concluded that blockers almost always lead on to hormones, which carry health risks. Testosterone heightens the chance of heart problems. It leads to vaginal and uterine atrophy which can make a hysterectomy necessary in later life.
Despite the uncertainties, many doctors have embraced medical intervention. The standard approach used to be “watchful waiting”, which advocates counselling before moving on to hormones and surgery. However, Joshua Safer of the Mount Sinai Centre for Transgender Medicine and Surgery in New York says puberty blockers are now “the conservative option” because they allow children time to decide what they want to do. Medical bodies including the World Professional Association for Transgender Health (WPATH) now say that affirming a person’s transgender identity is “international best practice”.
In America intervention was boosted by the Affordable Care Act of 2010, which banned health insurers from discriminating on the basis of sexual orientation and gender identity. In effect, they were thus obliged to cover hormones for people who say they are trans just as they provide contraceptive hormones for women.
In 2018 the American Association of Pediatrics (AAP) said that all medical evidence supports the “affirmative” approach. But according to a detailed rebuttal by James Cantor, a Canadian sexual-behaviour scientist, none of the 11 academic studies of the subject reaches that conclusion.
Plenty of doctors fail to observe even WPATH’s guidelines. Laura Edwards-Leeper, a professor of psychology at Pacific University in Oregon who helped found America’s first transgender clinic for children and teens in Boston, says she gets many emails from parents “desperate to find a therapist who will not just blindly affirm that their child is trans”. Ideally, she said, an adolescent with gender dysphoria would have been regularly seeing a therapist, who encouraged them to explore other possible causes for their feelings and had a comprehensive psychological assessment before being put on blockers or hormones. “It is very rare that even one of these things happens,” she says.
Schools, the new front line
Affirmation in the clinic often echoes affirmation at school. Canada and some Australian states forbid discrimination against anyone on the basis of their self-declared gender identity. The main school programme, taught in British Columbia and Alberta and due to be rolled out across Canada, is called SOGI-123. Much of the SOGI programme is uncontroversial, about being kind and opposing bullying. But critics worry it makes questioning a child’s decisions difficult.
Pamela Buffone, who runs a website called Canadian Gender Report, says that such programmes attach the concept of “gender identity” (the idea that a biological male can identify as a woman, or a female as a man) to the more familiar concept of “sexual orientation” (being gay or straight). In March last year Ms Buffone launched a legal complaint against a school board in Ottawa over a lesson, under a different programme, in which she says her six-year-old daughter was taught that there is no such thing as boys and girls.
People who support the new curriculum say that it is important to teach trans issues in school just as it is important to teach about race or religion. Glen Hansman, a Canadian teacher who was instrumental in the implementation of SOGI, says that affirming pronouns and names in schools is “not a gateway drug to other things”. Vince, an 18-year-old trans boy in rural Canada, (also not his real name) says that SOGI is a lifeline for many young trans people. He wishes the programme had existed in his school, where he says he was assaulted for being gender non-conforming.
Many legislators, not wanting to look bigoted, are supportive, too. Having seen how the state failed gay people, they are determined that it should not repeat the mistake with trans people. In America Joe Biden has promised to sign the Equality Act into law. That will do a lot to combat widespread discrimination against trans people, such as in housing and the workplace. But it also redefines sex to include gender identity. That could be read to endorse the idea that children should be affirmed in the identity they choose and receive treatment for it—even if that identity may turn out to be temporary.
In Australia the capital, Canberra, and the state of Queensland have outlawed “conversion therapy” in relation to sexual orientation or gender identity. So too have some American states. Canada is considering a similar law. This conflates two separate issues. Many people would say it is wrong to try to convert gay people into being straight. But the implicit definition of trans conversion therapy risks outlawing any counselling that helps children decide whether their dysphoria is permanent or a phase, and what to do about it.
A backlash is beginning. In Sweden, after a 1,500% rise in gender dysphoria diagnoses among 13- to 17-year-old girls in 2008-18, more media coverage has focused on the problems of children transitioning. Aleksa Lundberg, an activist, said that she would probably not undergo surgery if she had the same choice today. Referrals of children to gender clinics have fallen by 65% in a year. Finland recently released stricter guidelines, recommending different treatment for early-onset and adolescent-onset dysphoria, and encouraging patients to seek counselling.
In America trans activists see questions about treatment as political. Chase Strangio, a trans lawyer at the American Civil Liberties Union, tweeted of the English court’s decision: “Please see this for what it is—an attempt to weaponise our happiness, our hopefulness, and our love of our bodies. This is a dangerous attack on trans survival and it is spreading.”
Some politicians in conservative American states have drawn up bills that would make it illegal for doctors to prescribe puberty blockers or hormones to children. This is largely an attempt to inflame the culture wars, but it also reflects the worries of some parents.
Ms Buffone says she raised concerns with her daughter’s school and the local authority. “It was as though I had left Canada and arrived in some kind of authoritarian state. They said this is what we are doing and it was clear I had no recourse.” Some parents in Quebec, which has its own curriculum, are also objecting. When Catherine, a consultant, asked to see the content of her six-year-old’s sex-education class, the school refused, so she made a freedom-of-information request. It turned out teachers are told that “Children can begin to explore their gender identity between the ages of 3 and 7” and that sex is “assigned” at birth rather than observed.
A legal minefield
The Australian Family Court has in recent years removed itself from decisions about giving blockers and hormones and even surgery for teenagers, unless parents disagree. Instead, it has recently seen the first case of a child being removed from parents who did not support transition. The ruling was hardly reported in the press.
Patrick Parkinson, dean of law at the University of Queensland, says Ms Bell’s judgment in England means that such parents will have a basis to oppose their daughter’s removal. He thinks doctors’ claims that puberty blockers are reversible and do no harm have been debunked. “This is a massive wake-up call for the medical profession in Australia,” he says.
However for many doctors in transgender clinics in America, the idea of restricting the use of puberty blockers in children is anathema. Johanna Olson-Kennedy of the Centre for Transyouth Health and Development at Children’s Hospital Los Angeles says she mourns the loss of “this incredible tool” for English children. “I think there is going to be an avalanche of lawsuits,” says Dianna Kenny, recently retired professor of psychology at the University of Sydney. “But they won’t be in time to save a generation of adolescents who have been wrongly diagnosed as being trans.”
As for Ms Davidson, daughter Meghan still struggles with depression. However she decided, with her parents, not to take the Lupron. In May, by then 14, she announced: “Mum, I’ve decided I’m a girl.” She put on lots of make-up and went to the shopping mall to get her nails painted. But the experience has turned her mother into an activist. She has signed up with CAWSBAR, a women’s group that advocates for rights to be based on biological sex. “I’m mad as hell,” she says.■
This article appeared in the International section of the print edition under the headline "Boys and girls"