Following the 60 Minutes episode earlier this week, which highlighted the controversies surrounding medical interventions for gender dysphoric youth, SEGM has been receiving an increasing number of inquiries about the state of gender care for youth in the United States. One question in particular has been asked most frequently: how difficult or easy is it to obtain hormones and surgeries in the US?
There are over 60 pediatric “gender clinics” in the US, according to the Human Rights Campaign's interactive map. However, the total number of clinics and medical offices that provide hormonal interventions to minors is likely much higher, and is currently estimated at over 300. We cannot speak for all the clinics and their practices. However, we can provide some general observations and insights about the state of pediatric gender care in the US.
Before we outline the practices in the US and the significant issues with the lack of safeguarding, we would like to emphasize that SEGM is an independent, not-for-profit organization with no political or religious affiliation. We recognize that the issue of transgender health has been politicized by those on both sides of the aisle. We believe this politicization will hurt the health of gender dysphoric young people.
The Basis for Current Practices
The current practice of transitioning minors, known as "affirmative care," is largely based on a single study from the Netherlands of 55 adolescents that was published in 2014. The study subjects all had early-childhood onset of gender dysphoria which persisted into mid-adolescence. The teens were carefully screened to reduce the possibility of “false positives”— those who would transition in adolescence but would later come to regret their transition because underlying mental health or developmental issues contributed to their gender distress. For example, teens whose gender distress appeared for the first time after puberty were considered at a high risk for false positives and thus were considered ineligible for hormonal and surgical interventions under the Dutch protocol.
The study evaluating the protocol showed that 1 year post-surgery, at the average age of 21, these 55 young people had a high level of psychological function. The study did not evaluate physical health, nor did it assess the risks associated with hormone administration and surgery, but it did note that 1 adolescent from the original cohort of 70 died from complication of surgery, and several others developed obesity in the course of hormonal treatments, making them ineligible for surgery.
Affirmative Care for Youth
The Dutch protocol (the sequence of puberty blockade, cross-sex-hormones and surgeries) has become the basis for “affirmative care.” However, affirmative care goes significantly beyond the original Dutch protocol. For example, surgeries were not offered to patients younger than age 18 in the Netherlands. However, according to an NIH-funded study, minors as young as 13 can get mastectomies in the US. A recent US-based study shows that the average age for mastectomy in minors is 16, with the range of 14-18.
Another significant deviation from the Dutch protocol in North America is the sharply reduced role of psychotherapy and a lack of concern over false-positives. To reduce false positives, the Dutch clinicians discouraged early social transition of minors, and provided extensive psychological exploration to minimize future risk of regret. In contrast, in the recent years, social transitioning of minors in North America has become the norm, while mental health professionals are increasingly discouraged from providing exploratory therapy, and are instructed to provide “affirmation” instead.
Affirmation, as a psychological practice, is naturally at odds with exploration; it requires that therapists confirm a minor’s self-diagnosis of transgender and facilitate their access to hormones and surgeries. Exploratory therapy affirms a young gender dysphoric person's feelings as real and valid, but rather than confirming their self-diagnosis, questions and probes, looking for developmental factors that may have contributed to gender-related distress.
Further, the “informed consent” practice, which is widespread the US, does not require any psychological evaluation at all. A young person merely signs an informed consent form, stating that they are aware of the risks, and can then receive hormones at the first or second visit. Although some clinics specify that only those 18 and older are eligible for informed consent care, we are aware of instances where hormone interventions were offered under this model to those younger than 18.
We are also aware of instances where the parents and patients, who expressed doubt over the hormonal and surgical treatment path, were incorrectly told by clinicians that hormonal interventions are vital to prevent an otherwise likely death of the young person by suicide. Both suicidal thoughts and attempts at self-harm, which are present at higher rates in trans-identified youth, are a concern that must be taken very seriously. Clinicians working with suicidal children, adolescents and young adults need to provide thorough psychological assessments and adhere to evidence-based suicide prevention protocols, which are well-established. The provision of puberty blockers, cross-sex-hormones, or surgeries has not been demonstrated to reduce suicides. Thankfully, suicides are exceedingly rare in all children, including trans-identified children.
It’s notable that England, Finland, and Sweden’s leading hospital, the Karolinska, have all stopped or sharply curtailed medical transition of minors in the last 12 months. They cited the results of systematic reviews of evidence that showed very low certainty of the benefit, the potential for harm, and an unclear risk/benefit assessment of the interventions.
In contrast, in North America, medical transitioning of minors is gaining momentum, in large part due to the advocacy of WPATH and its significant influence on key professional organizations (including the Endocrine Society and the American Academy of Pediatrics). There is also growing pressure on primary care physicians, such as pediatricians, to start broadly prescribing hormones, and increasing calls to make mastectomies available to all gender dysphoric youth who wish them.
It is currently estimated that between 2-10% of US children, adolescents and young adults identify as transgender or have gender-divergent identities. The growing number of gender clinics focused on the provision of hormonal treatments, the reduced role of psychotherapy, and the proliferation of the informed consent model will likely lead to growing numbers of children, adolescents and young adults who will prove to be "false positives," receiving the wrong treatment for their gender distress.
SEGM firmly believes that medical decisions must remain between patient and clinicians, without political interference. However, we also believe that it is incumbent on US medical societies to urgently examine the evidence base for hormonal and surgical interventions for youth using rigorous systematic research methods. Given the results of the recent systematic evidence review conducted by NICE, which concluded that the evidence of benefits of these intervention is of very low certainty and the risk/benefit profile is unclear, SEGM believes that exploratory psychotherapy should be first-line treatment for gender dysphoric people age 25 and under.