Is Gender Affirming Care for Adolescents with Gender Dysphoria Life-saving?

Author: Tim Platnich

Original Publish Date: February 5, 2024; Updated April 5 and 12, 2024

On January 31, 2024, the Alberta government announced policies for the care of adolescents experiencing gender dysphoria. These policies are expected to become law when supporting legislation is introduced in the fall. By announcing the policies now, whether intentionally or not, time has been left for review and possible modification prior to any legislation being passed.

The purpose of this post is not to answer the question posed in the title but rather to illuminate the state of the science surrounding the question.

This post will focus on three enunciated policies: top and bottom surgeries will be banned for those under the age of 18; puberty blockers and hormone therapy will be banned for those under the age of 16 (except for those who are already undergoing treatment); and for those who are 16 and 17, hormone treatments will be permitted provided approval is obtained from the patient's parents, doctors and a psychologist.

The stated reason for these policies is the protection of children under the age of majority - 18 years.

These three policies (among others that were announced) have provoked a vociferous response from various groups across the country. Responses include assertions that these policies: are illegal; are immoral; and will be harmful to children leading, perhaps, to death by suicide. Does the current state of the science support these assertions?

Gender dysphoria is a distressing condition where a person senses there is a mismatch between their biological sex and their gender identity. The causes of this condition are a matter of scientific debate. So too, are the variety of pathways to resolution of the condition.

One pathway to resolution of the condition is the 'gender-affirming model'. Under this model, the patient's sensed gender identity is immediately affirmed with rapid social transition, then medical intervention. Medical intervention, for pre-pubescent and emerging pubescent youth, includes puberty blockers. For older children and adults, medical intervention includes hormone treatment, top surgery (removal of breasts) and bottom surgery. Bottom surgery for those under 18 is unavailable in Canada so the Alberta policy is nothing new in this respect.

Until recently, the gender-affirming model was the accepted model, almost without question. [Paul W. Hruz, "Deficiencies in Scientific Evidence for Medical Management of Gender Dysphoria", 2020]. Recently, however, this model has come under scrutiny.

In support of the gender-affirming model, assertions, including the following are made [see Rosenthal, "Challenges in the care of transgender and gender-diverse youth: an endocrinologist's view", 2021]:

• true gender identity underlies gender dysphoria meaning that the gender identity is biological and permanent;

• following from the above, medical intervention is the only resolution of gender dysphoria;

• medical interventions have been demonstrated to be effective and safe; and

• failure to follow this model endangers the child: 'would you rather have a dead daughter or a living son'?
  

Other pathways to resolution include the 'wait-and-see' approach; and the 'psychotherapy first' approach.

Studies have shown that childhood onset gender dysphoria often resolves itself simply with time. This data undermines the first two assertions above. It also causes concern about medical interventions being unnecessary and potentially harmful treatment. The 'wait and see' approach allows time for desistance.

Other studies have shown that psychotherapy is a better approach to gender dysphoria particularly where comorbidities such as mental distress, autism, spectral disorders, etc. exist. A high fraction of youth suffering from gender dysphoria have comorbidities. ["Some Limitations of 'Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist’s View'" J. Cohn December 2022]

Regarding the safety and effectiveness of medical interventions, the national government medical bodies of Sweden and England, after conducting evidence reviews, recently concluded that there is insufficient medical evidence to assess the safety or efficiency of medical intervention for the treatment of youth gender dysphoria. [Cohn, supra]. Four other European governments (Norway, Finland, France and the Netherlands) have tapped the brakes on using the gender-affirming model by tightening regulations on medical intervention for minors [Frieda Klotz, 'The Atlantic', April 28, 2023; Elliot Davis Jr., 'US News' July 2, 2023]

The claim that medical intervention improves mental health and quality of life for youth suffering from gender dysphoria is based on low-quality studies which provide very low certainty of evidence. This is of particular concern given the potential risks associated with medical intervention. [Clayton, "Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice" 2023]

"For puberty blockers, there is a dearth of studies regarding their adverse effects when used to treat gender dysphoria... ." [Cohen, supra] However, an evidence review for treatment of adolescents by the Swedish National Board of Health and Welfare (Citation2022) found “The NBHW deems that the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases”. It should be noted that the use of puberty blockers in the treatment of gender dysphoria in adolescents is an 'off-label' use in the US. What this means is that "the FDA has not established that benefits outweigh the risks when any of these medications are used to treat gender dysphoria". [Cohen, supra]

Some media reports suggest that detransitioning is rare and benign. The data begs to differ. "The increasing numbers of detransitioners and their reported distress are spurring many of the calls for more research and increased caution regarding medical interventions in youth (Butler & Hutchinson, 2020; Evans, 2021; Griffin, Clyde, Byng, & Bewley, 2021; Levine et al., 2022; Malone, 2021)." [Cohen, supra]

There are studies that suggest suicide ideation and depression is decreased, at least in the short term, by medical intervention in cases of adolescent gender dysphoria. However, other studies indicate that suicide "remains significantly elevated above the background population after medical intervention to alter sexual appearance. Specifically, a thirty-year follow-up study in Sweden on patients who had undergone medical transition showed a rate of completed suicide that was nineteen fold above the background population Dhejne et al. 2011" [Hruz, supra]. This study does not suggest that medical transition was the cause of suicide. Rather the study shows that medical transition is no panacea for resolving mental health issues associated with dysphoria. Other studies have found that suicide ideation either remains unaffected by medical intervention or, in fact, increases. [Hruz].

Research results are mixed concerning whether the benefits of medical intervention for gender dysphoria outweigh the potential harm. [Hruz]. Deficiencies in the existing knowledge base regarding the causes of gender dysphoria and treatment approaches provide a rationale for exercising caution respecting the gender affirmation treatment paradigms proposed by professional organizations. [Hruz].

Given the current state of research results, assertions that the proposed Alberta policies concerning medical intervention are illegal, immoral and harmful to children may be overstated. One may be tempted to conclude that medical intervention should be left as a matter between the adolescent and the adolescent's doctor. The main problem with this solution is the principle of 'informed consent'. Can a child under the age of 16 really be properly informed of all the considerations that must go into a decision whether or not to undergo potentially harmful medical intervention? This concern becomes particularly elevated where the child suffers from other mental disorders. Another concern is that a child under the age of 16 may illogically believe that medical intervention will be a sure-cure for all of the stresses, anxieties and causes of depression that are affecting the child.

Many advocates of medical intervention advocate that parents should play no role in the decision making process of either social or medical intervention. Indeed, some advocates go as far as to suggest parents shouldn't even be told of the child's desire to transition. If the child is incapable of giving informed consent, and the parents are excluded from the process, who can give the consent? Without informed consent, medical intervention may very well constitute a battery by the medical service provider. This issue is beginning to play out in litigation is the US.

The Alberta policies allow medical intervention for 16 and 17 year old adolescents, with parental consent (in addition to medical approval). Arguably, the policy should be amended to allow medical intervention for younger children under the same conditions of consent and medical approval. In all situations, the consent must be informed. Informed consent may require medical advisors to fully disclose the state of the science on the gender-affirming model.

UPDATE: See the following study dated February 27, 2024 that shows that most of those who identify as 'gender non-content' at age 11 (11%) no longer so identify by age 26 (4%).

UPDATE: See also the Cass Review, Final Report to the NHS England.