Gender dysphoria in young people is rising—and so is professional disagreement
BMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p382 (Published 23 February 2023) Cite this as: BMJ 2023;380:p382Linked Feature
Gender identity services in the UK are on pause as evidence comes under scrutiny
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Dear Editor
Gender affirming care is frequently referred to as uncontroversial, evidence-based, even lifesaving. As Kristensen, Menkes, and Huntington point out, these claims represent the consensus of several medical societies. However there is also dissent that cannot be dismissed as ideological or political. Finland[1] and Sweden[2] have reviewed the evidence base and are restricting hormonal and surgical treatments in minors. Norway recently released a report recommending a review of national guidelines.[3] England is also in the process of a review and in an interim report emphasised the lack of high quality evidence. . The question driving this piece of reported journalism was if the gender-affirming approach is “settled science”, why is the United States moving in the opposite direction?
“Best practice,” Kristensen and Menkes write, is to treat psychosocial intervention separate from medical intervention. The widely used umbrella term “gender affirming care” encompasses both. In my reporting, I strived to be specific about each intervention and discuss them separately.
With respect to New Zealand, my article made reference to a position statement by the Royal Australian and New Zealand College of Psychiatrists, which bemoans the “paucity of evidence” and states that “professional opinion is divided as to whether an affirmative approach should be taken in relation to treatment of transgender children or whether other approaches are more appropriate."[4] Practice trends and sentiments on the ground may indeed differ from a professional society’s statement. Such divergence is part of the story.
Ashman and colleagues raise questions about the interpretation of the increase in referrals and treatment of minors and correctly point out that the factors driving these numbers are still not fully understood. Regarding the true rate of detransitioning, my article was clear that there is no agreed upon definition for measuring the phenomenon, and pointed to multiple studies as well as WPATH’s position that detransition is rare. Regarding the new study reporting on a cohort in which 1.4% stopped GnRHa,[5] it should be noted that this study is of the Dutch protocol, which differs from contemporary American practice patterns and may therefore not be generalizable. Ashman and colleagues suggest that I erred in not reporting on two studies[6][7] that show “that gender affirmation in trans people is associated with a reduction anxiety and depression.” The first study would have been available to systematic reviewers, who have repeatedly found insufficient evidence to draw strong conclusions. Of course, newer evidence, such as the second study[7], which lacked a comparison group, should be evaluated and reported on, which I intend to do.
Respondents have also taken issue with my not quoting a member of the transgender community. While some of my sources happen to be transgender, my focus was the evidence underpinning professional consensus on the gender-affirming approach, not people’s individual experiences of that approach, be they positive or negative. Thus, my sources, appropriately, were research methodologists, experts in evidence-based medicine with no history commenting on this field, who examined the documents upon which consensus is based, as well as experts with a history in the field, namely the authors of those documents and dissenters.
Others criticise my mention of co-occurring neurodivergent conditions in young people with gender dysphoria. This is not meant to imply “that there is less capacity for making good choices,” as Khan (pseudonym), Sellen, and Jones write. Rather, professionals express concern that patients be treated holistically, rather than for gender dysphoria only on the assumption that such treatment will resolve everything else.
Finally, Kristensen and Menkes point out the “prioritisation of clinical care over research” and defend studies lacking a control group, and that, as Huntington puts it, it is “unethical...to offer no treatment to a sample group.” This is one perspective. The premise of evidence-based medicine is that medical interventions demonstrate a favourable risk-benefit ratio before they become routine practice, and several clinicians I spoke with indicated the need for well-controlled (not necessarily randomised) studies.
References
[1] Palveluvalikoima (Council for Choices in Health Care in Finland). Medical treatment methods for gender dysphoria in non-binary adults—recommendation. Jun 2020. https://palveluvalikoima.fi/documents/1237350/22895623/Summary_non-binar...
[2] Socialstyrelsen: National Board of Health and Welfare. Care of children and adolescents with gender dysphoria. Report 2022-3-7799. 2022. https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelk...
[3] https://www.aftenposten.no/norge/i/jlwl19/vil-ha-tryggere-behandling-for...
[4] Royal Australian and New Zealand College of Psychiatrists (RANZCP). Recognising and addressing the mental health needs of people experiencing Gender Dysphoria / Gender Incongruence. August 2021. https://www.ranzcp.org/news-policy/policy-and-advocacy/position-statemen...
[5] van der Loos MATC, Klink DT, Hannema SE, Bruinsma S, Steensma TD, Kreukels BPC, Cohen-Kettenis PT, de Vries ALC, den Heijer M, Wiepjes CM. Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol. J Sex Med. 2023 Feb 27;20(3):398-409. https://doi.org/10.1093/jsxmed/qdac029
[6] Hughto JMW, Gunn HA, Rood BA, Pantalone DW. Social and Medical Gender Affirmation Experiences Are Inversely Associated with Mental Health Problems in a U.S. Non-Probability Sample of Transgender Adults. Arch Sex Behav. 2020 Oct;49(7):2635-2647. https://doi.org/10.1007/s10508-020-01655-5
[7] Chen D, Berona J, Chan YM, Ehrensaft D, Garofalo R, Hidalgo MA, Rosenthal SM, Tishelman AC, Olson-Kennedy J. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med. 2023 Jan 19;388(3):240-250. https://doi.org/10.1056/NEJMoa2206297
Competing interests: No competing interests
Dear Editor,
We noted the observation transgender youth are more likely “to have concurrent mental health and neurodiverse conditions including depression, anxiety, attention deficit disorders, and autism.” [1]. Pedantically, “neurodiverse” should be neurodivergent. Neurodiversity is the concept that divergent neurotypes exist as a valued part of natural human diversity with both strengths and challenges. Writing “disorders” adjacent to “neurodiverse” shows misunderstanding of the intended inherent demedicalisation.
The authors of this letter are neurodivergent, some of which identify as transgender. Without pretence, the mention of neurodivergence when speaking about transgender people is to imply that there is less capacity for making good choices about our bodies, evaluating risks and benefits. We can assure you as intelligent neurodivergent practising doctors, responsible for the care of others, that this is not the case. A divergent neurotype does not invalidate one’s gender identity. Moreover, the evidence is mounting that both divergences should be affirmed for better health outcomes [2, 3, 4].
Other letters have addressed some of the flaws within J Block’s article [5, 6]. It has been noted the article conflates affirming psychosocial gender identity with medical intervention [6]. The article also further conflates “puberty blockers'' and gender affirming hormonal intervention. The former is a reversible pause of puberty and the latter is where puberty is commenced aligned with identified gender. These are initiated separately, slowly and cautiously; regardless the existing evidence shows good outcomes in transgender youth [7]. It bears repeating that when reaching adulthood 0.3-0.6% regret gender affirming procedures [8, 9], with evidence that even this small figure is largely due to external environmental pressures [10].
For erudite commentary on transgender healthcare, we would alternatively suggest Abigail Thorn; she leverages lived experience as a transgender woman and her background in philosophy [11].
Samira Khan (pseudonym)
Specialty Trainee Doctor
London, UK
Matthew Sellen
Consultant Psychiatrist specialising in neurodivergence and gender divergence
Brisbane, Australia
Bethan Carey Jones
General Practice Registrar
Wales, UK
Sources
1. Becerra-Culqui TA et al. Mental health of transgender and gender nonconforming youth compared with their peers. Pediatrics. 2018. 141.
2. Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender dysphoric/gender-incongruent persons: An endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism. 2017. 102.
3. Turban JL, King D, Kobe J, et al. Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. 2022. PLoS One 17: e0261039.
4. Botha M, Gillespie-Lynch K: Come as You Are: Examining Autistic Identity Development and the Neurodiversity Movement through an Intersectional Lens. Human Development. 2022. 66.
5. Huntington GR. Rapid response to: Gender dysphoria in young people is rising. https://www.bmj.com/content/380/bmj.p382/rr
6. Kristensen Z, Menkes DB. Rapid Response: Professional responses to gender dysphoria: reality checks needed. https://www.bmj.com/content/380/bmj.p382/rr-3
7. Chen D, Berona J, Chan YM, Ehrensaft D, Garofalo R, Hidalgo MA, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med. 2023 Jan 19;388(3):240–50.
8. Jedrzejewski BY et al. Regret after Gender Affirming Surgery – A Multidisciplinary Approach to a Multifaceted Patient Experience. Plastic and Reconstructive Surgery. 2023. 23 (1).
9. Wiepjes CM et al. The Amsterdam cohort of gender dysphoria study (1972–2015): Trends in prevalence, treatment, and regrets. The Journal of Sexual Medicine. 2018. 15.
10. Turban JL et al. Factors Leading to "Detransition" Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health. 2021. 8(4).
11. Thorn A. “I Emailed My Doctor 133 Times: The Crisis in the British Healthcare System”. YouTube. 2022. Available at: https://youtu.be/v1eWIshUzr8 [Accessed 02/03/23. Bibliography available in the recording’s description.]
Competing interests: No competing interests
Dear Editor,
The article on gender dysphoria in young people by Jennifer Block (1) would appear at first inspection to offer an evidence-based review. However, the assertions made are in some cases unsupported by reference, and in others are based on only some of the available evidence.
Early on the article reports that the numbers of people openly identifying as transgender, and being referred for gender affirming care, have ‘surged’ in recent years. However, a similar ‘surge’ was seen in the 20th Century with the rates of individuals openly identifying as left-handed after it became more acceptable to be left-handed. We would suggest that, rather than representing a true increase, the increase in referrals relates to transgender individuals having better access to information, feeling more able to disclose their identities, and being more empowered to access gender affirming care.
The article makes reference to the surgical treatment of children with gender dysphoria, and conflates this with ‘gender affirming care’ as a whole. However, the author does not make reference to NHS England documents that clarify that gender affirming surgical treatment is only offered to suitable candidates over the age of 18 (2).
Of the studies quoted when discussing detransition, one actually refers to hormone continuation rates, not detransition, and finds that individuals who start hormones prior to age 18 are more likely than adults to continue taking them beyond four years (3). The other paper includes just five cases of detransition or regret and was not specifically looking at children and young people (4). There are larger studies looking at young people with gender dysphoria. A case series in the Netherlands of 1,766 children found that those who started hormone blockers were happy to continue their transition in 98.6% of cases (5).
The author discusses the existence of a regret rate following gender affirming care. The piece does not mention that the average regret rate reported by studies looking at various medical procedures unrelated to gender affirming care is 1 in 7 (6). For instance, the regret rate for primary total knee replacement is reported as 17% (7). When we consider that hormone blockers are reversible, but joint replacements are not, we might ask whether gender affirming care should be such a focus of attention.
When talking about the 'surge in treatment of minors', the author references a cross-sectional study which shows the co-existence of gender dysphoria with mental health conditions such as anxiety, depression, autism and ADHD, but does not demonstrate the direction of causation (8). The author does not include the evidence that gender affirmation in trans people is associated with a reduction anxiety and depression (9,10). Meanwhile, the co-existence of gender dysphoria with autism and ADHD is worthy of future study, but does not represent a reason to deny these children effective treatment for gender dysphoria.
We might continue and look at other aspects of the article, but this has been covered to an extent in other rapid responses (11,12), and space here does not permit a more detailed treatment. Suffice it to say that this ‘investigation’ does not report evenly on the available evidence.
(1) Block J. Gender dysphoria in young people is rising—and so is professional disagreement. BMJ 2023;380:p382
(2) NHS STANDARD CONTRACT FOR GENDER IDENTITY DEVELOPMENT SERVICE FOR CHILDREN AND ADOLESCENTS. NHS England, 2013 [accessed 13/03/2023]
(3) Roberts CM, Klein D, Adirim TA, Schvey NA et al. J Clin Endocrinol & Metab, 2022 Sep;107(9):e3937–43
(4) Boyd I, Hackett T, Bewley S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare (Basel). 2022 Jan; 10(1):121
(5) van der Loos MATC, Klink DT, Bruinsma S, Steensma TD et al. Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic- and treatment trajectories during the first 20 years of the Dutch Protocol. J Sex Med. 2023 Mar;20(3):398–409
(6) Wilson A, Ronnekleiv-Kelly SM, Pawlik TM. Regret in Surgical Decision Making: A Systematic Review of Patient and Physician Perspectives. World J Surg. 2017 Jun;41(6):1454-65
(7) Cassidy RS, Bennett DB, Beverland DE, O’Brien S. Decision regret after primary hip and knee replacement surgery. J Orthop Sci. 2023 Jan;28(1):167-72
(8) Mental Health of Transgender and Gender Nonconforming Youth Compared With Their Peers. Pediatrics. 2018 May; 141(5): e20173845.
(9) Hughto JMW, Gunn HA, Rood BA, Pantalone DW. Social and Medical Gender Affirmation Experiences Are Inversely Associated with Mental Health Problems in a U.S. Non-Probability Sample of Transgender Adults. Arch Sex Behav. 2020 Oct; 49(7): 2635–47
(10) Chen D, Berona J, Chan Y-M, Ehrensaft D, Garofalo R, et al. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med. 2023 Jan 19;388(3):240-50
(11) Kristensen Z, Menkes DB. Rapid response to BMJ 2023;380:p382 [accessed 13/03/2023]
(12) Huntington GR. Rapid response to BMJ 2023;380:p382 [accessed 13/03/2023]
Competing interests: The authors represent the RCS England Pride in Surgery Forum, a group of LGBTQ+ individuals and allies working towards cultural change in surgery.
Dear Editor,
Thank you to the BMJ for this excellent and thorough report on the state of evidence behind medical interventions for gender dysphoria, and the relation between evidence-based medicine approaches and the Endocrine Society[1], AAP[2] and WPATH[3] recommendations.
The Endocrine Society and WPATH recommendations both refer to and appear to rely upon positive psychological outcomes from the “Dutch Protocol,” a carefully vetted cohort of 70 young people on puberty blockers[4], 55 of whom were also later assessed at least a year past surgery [5] . However, [4], de Vries et al. (2011), recently failed replication[6]. In addition, [5], de Vries et al. (2014), not only dropped the patient who died as a result of surgical complications (one of the 70 who was not reported in the final 55), but changed the test for gender dysphoria before and after surgery, confounding their main reported benefit of improvement in gender dysphoria [7,8]. Longer term outcomes are now becoming available for some of those treated with the Dutch protocol[8], with 60% of those in their early to mid-thirties still single, around 70% of the MTF reporting apparent sexual problems, and over half of the MTF having had shame for their “operated vagina.” Significant medical difficulties related to medical and surgical interventions are also becoming increasingly known[9,10,11,12].
More generally, interpreting outcomes for these treatments also tends to be difficult due to confounding by mental health interventions and the possible placebo effect[13].
Block’s [14] findings are complemented by [15]'s systematic review and quality appraisal of the Endocrine Society recommendations, and the accompanying rapid response [16] discussing the 2022 WPATH recommendations. For the AAP 2018 recommendations also discussed by Block[14], a notable evidence related concern is that the authors “misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them”[17].
In addition to the lack of information about likely long term outcomes for medical interventions and their considerable physical risks, it is unclear how to determine when mental health interventions alone, such as exploratory therapy[18,19], will resolve gender dysphoria. Ideally this article will increase awareness of the low quality of the evidence base, and motivate better (sufficiently long and more complete) follow up, with outcomes reported in studies which use appropriate measurement instruments and inclusion criteria. The points of expert disagreement and significant lack of reliable evidence regarding risks, benefits and alternatives, as outlined in this article, should be reported to those considering such interventions in order for them to be able to provide true informed consent[7].
[1]Hembree WC, Cohen-Kettenis PT, Gooren L, et al. Endocrine treatment of gender-dysphoric/gender-incongruent persons: an endocrine society clinical practice guideline. J Clin Endocrinol Metab2017;102:3869-903. doi:10.1210/jc.2017-01658 pmid:28945902. Erratum in: J Clin Endocrinol Metab. 2018 Feb 1;103(2):699. Erratum in: J Clin Endocrinol Metab. 2018 Jul 1;103(7):2758-2759. PMID: 28945902
[2] Rafferty J, Committee on Psychosocial Aspects of Child and Family Health, Committee on Adolescence, Section on Lesbian, Gay, Bisexual, and Transgender Health and Wellness. Ensuring comprehensive care and support for transgender and gender-diverse children and adolescents. Pediatrics2018;142:e20182162. doi:10.1542/peds.2018-2162 pmid:30224363
[3]Coleman E, Radix AE, Bouman WP, et al. Standards of care for the health of transgender and gender diverse people, version 8. Int J Transgend Health2022;23(Suppl 1):S1-259. doi:10.1080/26895269.2022.2100644 pmid:36238954
[4] De Vries AL, Steensma TD, Doreleijers TA, et al. Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The journal of sexual medicine. 2011 Aug;8(8):2276-83.
[5] De Vries AL, McGuire JK, Steensma TD, et al. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014 Oct;134(4):696-704.
[6] Carmichael P, Butler G, Masic U, et al. Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PloS one. 2021 Feb 2;16(2):e0243894.
[7] Levine SB, Abbruzzese E, Mason JW. Reconsidering informed consent for trans-identified children, adolescents, and young adults. Journal of Sex & Marital Therapy. 2022 Oct 3;48(7):706-27.
[8] Abbruzzese E, Levine SB, Mason JW. The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed. Journal of Sex & Marital Therapy. 2022 Dec 8:1-27.
[9] Nota NM, Wiepjes CM, de Blok CJ, et al. Occurrence of acute cardiovascular events in transgender individuals receiving hormone therapy: results from a large cohort study. Circulation. 2019 Mar 12;139(11):1461-2.
[10] Cheng PJ, Pastuszak AW, Myers JB, et al. Fertility concerns of the transgender patient. Translational Andrology and Urology. 2019 Jun;8(3):209.
[11] de Blok CJ, Wiepjes CM, van Velzen DM, et al. Mortality trends over five decades in adult transgender people receiving hormone treatment: a report from the Amsterdam cohort of gender dysphoria. The Lancet Diabetes & Endocrinology. 2021 Oct 1;9(10):663-70.
[12] Biggs M. Revisiting the effect of GnRH analogue treatment on bone mineral density in young adolescents with gender dysphoria. Journal of Pediatric Endocrinology and Metabolism. 2021 Jul 1;34(7):937-9.
[13] Clayton A. Gender-affirming treatment of gender dysphoria in youth: A perfect storm environment for the placebo effect—the Implications for research and clinical practice. Archives of Sexual Behavior. 2023 Feb;52(2):483-94.
[14] Block J. Gender dysphoria in young people is rising—and so is professional disagreement. bmj. 2023 Feb 23;380.
[15] Dahlen S, Connolly D, Arif I, et al. International clinical practice guidelines for gender minority/trans people: Systematic review and quality assessment. BMJ open. 2021 Apr 1;11(4):e048943.
[16] Dahlen S, Meads C, Bewley S. WPATH Standards of Care: A new edition using outdated methods weakens the trustworthiness of content. BMJ Rapid response. 2022 October 21
Retrieved Mar 7, 2023 from https://bmjopen.bmj.com/content/11/4/e048943.responses#wpath-standards-o....
[17] Cantor JM. Transgender and gender diverse children and adolescents: fact-checking of AAP policy. Journal of sex & marital therapy. 2020 May 18;46(4):307-13.
[18] Gender Exploratory Therapy Association, https://www.genderexploratory.com/
[19] Evans S, Evans M. Gender Dysphoria: A Therapeutic Model for Working with
Children, Adolescents and Young Adults. Bicester, England: Phoenix Publishing House 2021.
.
Competing interests: No competing interests
Dear Editor
Jennifer Block addresses the clinical approach to individuals with gender dysphoria (1). As has already been pointed out, her article contains several misleading statements and, crucially, fails to include the perspective of individuals from the trans and gender diverse (TGD) community (2).
Additional problems with Block’s essay include, firstly, her tendency to conflate psychosocial affirmation of gender identity with initiation of gender affirming medical intervention. The two are distinct; keeping them conceptually and practically separate is acknowledged as best practice (3), and facilitates engagement and individualised care for patients presenting in various settings.
Second, her claim that models of care outside of the United States have moved away from early medicalisation are misleading. As New Zealand-based practitioners, we were bemused to read that our region is ostensibly part of this trend, contrary to both international and regional guidance (4). This misunderstanding appears to arise from Block’s reliance on a single source which has been effectively challenged by both clinical experts and those with lived experience (5).
Third, Block mistakenly equates the limited evidence underpinning gender affirming care with its propensity for harm. Available studies indicate the benefit of early gender affirming treatment, but have limited statistical power owing to sample size and other aspects of study design (4). These shortcomings reflect the realities of studying a hard-to-reach community, ethical protection of minors, and the prioritisation of clinical care over research in the context of resource constraints and significant unmet need.
Finally, Block neglects the importance of clinical skill development in what is, for many doctors, a novel and challenging area of practice; such skills play an essential role in optimising engagement and care for individuals. In particular, safe and effective practice depends on addressing unconscious bias (6) and demonstrating an appropriate degree of humility in clinical encounters (4).
Zoe Kristensen
David B Menkes
Zoe Kristensen has lived experience of gender diversity
1. Block J. Gender dysphoria in young people is rising—and so is professional disagreement. BMJ. 2023;380:p382.
2. Huntington GR. Rapid response to: Gender dysphoria in young people is rising. https://www.bmj.com/content/380/bmj.p382/rr
3. Ashley F. Thinking an ethics of gender exploration: Against delaying transition for transgender and gender creative youth. Clinical child psychology and psychiatry. 2019;24:223-36.
4. Coleman E, Radix AE, Bouman WP, Brown GR, de Vries ALC, Deutsch MB, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. International Journal of Transgender Health. 2022;23(sup1):S1-S259.
5. Zwickl S, Chaplin B, Bisshop F, Cook T, Soo CTM, Birtles B, et al. Re: The RANZCP position statement on gender dysphoria. Australian and New Zealand Journal of Psychiatry. 2022;56:1217-8.
6. Ortega RP. Do no unconscious harm. Science. 2023;379:870-3.
Competing interests: No competing interests
Dear Editor;
I applaud the author of this article for shedding light on what has been a very controversial topic, the attempt to justify evidence for transgender reassignment in minors. While the medical community stands steadfast for transgender care and reassignment in adults, the idea that holds true for the same justifications in minors has been tenuous put forth by many with what has been felt to be politicizing of the topic with staunch voices on both sides.
As the article so aptly identifies, there is a lack of true medical evidence to justify the use of such treatments in youth compared to the data for adults. True evidence based medicine demands a more rigorous stance to justify treatment protocols that are ultimately held to be none harmful before being instituted. As the article describes, the lack of strong evidence is overwhelming with many societies and organizations around the world stepping back on pediatric recommendations for the use of irreversible or potentially long term harmful treatment options, as they should. However, in true American fashion, it seems major American medical societies not only allow but push ideologies that may have long term harmful consequences in a blind eye to what our neighbors around the world are beginning to realize.
Second, with the lack of satisfactory evidence, these same organizations that have as strong a political arm as they do clinical muddy the waters for the purposes of what should be true strongly evidenced medically necessary care. The political processes of these bodies and statements thereof strongly calls into question their motives when they peddle poor evidentiary protocols for the sake of jumping on a bandwagon.
Science and medicine as a whole deserve better. History is full of examples where modern medicine made mistakes pushing agendas too rapidly without full evidence only to be proven inaccurate and even harmful later on. The first rule in medicine is to do no harm, and we are failing our youth when politics on either side pushes an agenda that lacks strong medical evidence for such justifications. Kudos to the author for shedding greater light on these discrepancies.
Competing interests: No competing interests
Dear Editor
The BMJ is to be applauded for its thorough and balanced exploration of the evidence underpinning the current management of transgender youth in the US and contrasting this with approaches in Europe.
The article gives a historical perspective on the advocacy group WPATH (World Professional Organisation for Transgender Health) which has taken upon itself to provide ‘the standards of care’ required for treating this patient group. It explores the origins of the ‘Dutch Protocol’ for puberty blockers, describing how it was based initially on a very small number of children and makes explicit that the researchers were funded by the makers of the drug that was subsequently used on many of these children.
The article emphasises that the current guidelines advocated by WPATH and others are not guidelines in the modern accepted sense of the word i.e. underpinned by rigorous systematic reviews and recommendations linked to the strength of evidence. WPATH’s recommendations lack a grading system to indicate the quality of the evidence and still rely substantially on consensus opinion - they should not be used uncritically by clinicians.
CAN-SG, a group of clinicians who have become increasingly concerned at the rapid rise in medicalisation of children and young adults with gender dysphoria in the U.K., welcomes this article and calls for greater awareness of the potential harms of a solely affirmative approach. These concerns need to be openly discussed without fear of being labelled ‘transphobic’ in professional bodies, universities and the NHS.
The risks of medicalising an increasing proportion of the U.K. population (up to 2% identified as ‘trans’ in last census) and the costs of this approach must be carefully considered by medical leaders and health policy makers and weighed against the potential benefits of alternative approaches which provide non-invasive care for this population.
Dr Louise Irvine General Practitioner (retired), Professor David Pilgrim Chartered Clinical Psychologist, Dr Lisa Davies Consultant Child and Adolescent Psychiatrist, Dr Tessa Katz General Practitioner, Dr Robin Ion Registered Mental Nurse, Dr Angela Dixon General Practitioner, Dr Shahana Hussain Consultant Child Psychiatrist, Stella O’Malley Psychotherapist, Dr Catherine Bright Consultant Psychiatrist Learning Disability, Dr Juliet Singer Consultant Child and Adolescent Psychiatrist Dr David Bell Retired Consultant Psychiatrist and Psychoanalyst, Dr Maria Atkins Consultant Psychiatrist, Dr Aileen O'Brien Consultant Psychiatrist, Dr Az Hakeem Consultant Psychiatrist, Dr Lenny Cornwall Consultant Psychiatrist
Competing interests: All authors are members of CAN-SG.
Dear Editor,
As a BMJ investigation piece which calls for a better evidence base for offering what is termed gender affirming care for transgender young people, I am disappointed in lack of rigour in this piece. Rather than the medical community being “polarised” as is suggested, the sources and guidelines cited (and not cited) by the author suggest that there is in fact a consensus. Those quotations and single cases produced here as exceptions which prove the rule are from self-citations or Cornish QIPs and not primary sources, which I find curious for an author criticising a medical consensus for lack of strong evidence.
We are left to infer the author’s conclusions from her headings, that the evidence for offering GnRHa treatment, aka ‘puberty blockers’ could be stronger. I am not sure what the polarising issue is here as most large organisations and professional bodies agree with this also. Why then criticise a large trial in development which might examine this area for not including a placebo no treatment arm, given how unethical it is typically considered to offer no treatment to a sample group?
Finally and most importantly, in an era of patient centred care, where are the patient voices used to create this article? Do we hear from transgender individuals themselves? Where 0.3% regret their transition [1] the voices of the other 99.7% are not featured in this piece. The reason we do not hear from them is that this is not a piece of scientific journalism. This article leans on the authority of a medical journal to push an agenda, one of muddying the waters.
Sources
1. Jedrzejewski BY et al. Regret after Gender Affirming Surgery – A Multidisciplinary Approach to a Multifaceted Patient Experience. Plastic and Reconstructive Surgery. 2023. 23 (1).
Competing interests: No competing interests
Re: Gender dysphoria in young people is rising—and so is professional disagreement
Dear Editor
It is clear to us that this article and the responses highlight the need for high quality funded research for this underserved patient population. Such research needs co-production where patients can voice their opinions and share their experiences to try to develop the key questions in this complex area. We would encourage organisations such as the James Lind Alliance to make this a research priority setting where all stakeholders can contribute. It is only with collaborative research that we can implement evidence-based high quality care with accompanying improved education for clinicians and the wider population.
Competing interests: No competing interests