The American state of Florida has warned health professionals against medicalised gender change for minors, highlighting its weak evidence base, the risk of irreversible harm and an international trend towards caution.
“Children experiencing gender dysphoria [a distressful disconnect between a feeling of ‘gender identity’ and birth sex] should be supported by family and seek counselling, not pushed into an irreversible decision before they reach 18," Florida’s state surgeon-general Dr Joseph Lapado said in an April 20 statement.
“Countries such as Sweden, Finland, France, and the United Kingdom are currently reviewing, reevaluating, stopping, or advising caution on the treatment of gender dysphoria in children and adolescents,” Dr Lapado said.
“The current evidence does not support the use of puberty blockers, hormone treatments, or surgical procedures for children and adolescents.”
Florida’s guidance is intended to be one among various “authoritative sources” for a physician to draw upon in deciding the best treatment for a patient, a spokeswoman for state governor Ron DeSantis told The Miami Herald.
Amid polarised politics, the intervention by Florida’s Republican administration follows multiple initiatives by Joe Biden’s Democratic White House to endorse, promote and potentially enforce the “gender affirming” approach involving puberty blocker drugs, synthetic cross-sex hormones and transgender surgery, such as mastectomy for teenage girls who identify as boys.
“Even though ‘affirmative care’ for gender dysphoric kids has been a thing in the US for years, this is a really new development — to have the [federal] government actually officially advocate for it — and it actually goes further than just advocate”, said Denise, the founder of a pioneering parents’ gender blog 4thWaveNow. (Her last name has been withheld for privacy.)
“The US Justice Department issued a letter essentially warning all the states that if they didn’t facilitate gender transition for any ‘youth’ who ‘seeks it’, they could be running afoul of the Constitution by discriminating against those minors,” she told GCN.
“Nothing was said about a lower age limit, or whether the [federal] government would try to override parents who have concerns about doing this.”
Like other Republican states seeking to restrict medicalised gender change for minors, the guidance from Florida Health cites systematic reviews of the research literature showing low-quality or inconclusive evidence for hormonal and surgical interventions with young people.
Florida’s document also references data on young people growing out of gender dysphoria without medical intervention, and claims the vast majority of “those seeking clinical care will lose their desire to identify with the non-birth sex”.
It cites “the importance of puberty to brain development”, arguing against chemical suppression of natural puberty, and warns of medical transition’s risks, including cardiovascular disease, thrombosis, osteoporosis, infertility, and increased cancer risk.
The agency’s advice discourages not only medical transition with drugs and surgery but also “gender-affirming” social transition, in which clinicians, family and teachers “affirm” the opposite-sex identity declared by a child who takes on a new name, pronouns, hairstyle and clothes.
Early social transition before the onset of puberty is itself a psychological and social intervention that may lock in feelings of alienation from the body and increase the likelihood that the child goes on to medical transition, according to psychologist Dr Ken Zucker, a world authority on youth gender dysphoria.
If a child is given hormone blocker drugs at Tanner stage 2 of puberty (roughly age 9-12) and then put on cross-sex hormones, “sterility is the expected outcome”, according to the Society for Evidence based Gender Medicine, which campaigns for higher standards of care.
“Other risks are less certain but are concerning, especially the effects on bone health, brain development, and cardiovascular complications later in life,” a spokesman for SEGM said.
HHS asserts that early gender-affirming care is “crucial to overall health and well-being”, and “improves the mental health and overall well-being of gender diverse children and adolescents”.
Genspect, a group for parents of gender-questioning youth, said Florida’s guidance was “a ray of hope” which would “protect vulnerable kids from making decisions [about life-altering medical interventions] they are ill-equipped to make”.
“We are delighted that Florida is fighting back against [the Biden] administration that seems, frankly, disoriented on this issue,” a spokesman for Genspect said.
“[The new guidance] brings Florida closer into line with other jurisdictions leading the way on changing this situation, such as the UK, France, Finland and Sweden.”
International flight to caution: the overseas trend influencing Florida
UK: Health Secretary Sajid Javid reportedly plans an urgent inquiry into hormonal treatment of vulnerable children. He is said to be alarmed at accounts of staff at the Tavistock gender clinic feeling pressure “to adopt an unquestioning affirmative approach” with minors seeking puberty blockers and cross-sex hormones.
Javid has described the Tavistock clinic approach as “bordering on ideological”. According to The Times newspaper, he believes “far too many public figures have been avoiding [gender clinic issues] for too long” and says “there is a militant lobby [favouring pediatric transition] that doesn’t want a debate”.
News of Javid’s inquiry came days after Florida’s new policy, which cites the existing review of the Tavistock clinic by paediatrician Dr Hilary Cass. That clinic is known internationally for its legal battle with a former patient, Keira Bell, given puberty blockers at age 16.
Sweden: In February the National Board of Health and Welfare updated its advice on medicalised gender change for minors, urging “restraint” in the use of hormonal drug treatments and warning that the risks appear to outweigh the benefits. Florida’s guidance notes a key influence in this national policy change — the May 2021 decision by Sweden’s largest youth gender clinic (part of the Karolinska Institute) to cease routine use of puberty blockers and cross-sex hormones outside strictly controlled clinical trials.Asked her reaction when she first heard of Dr Lisa Littman's concept of Rapid Onset Gender Dysphoria, Prof. Kaltiala says: "Oh, I thought, this is exactly what we are seeing in our clinic".
Finland: In 2020 the Council for Choices in Health Care shifted the emphasis from hormonal and surgical interventions to psychiatric care and support as first-line treatments. This reflects concern that medicalised gender change may be premature with today’s patients who present with multiple psychiatric issues and whose adolescent identity is still in flux.
France: In March the French National Academy of Medicine issued a statement warning physicians of the epidemic-like rise in minors seeking hormonal drug treatments and the possible role of social media immersion. The academy has moral authority but observers say the lobby for medicalised gender change is still strong in France, where there is as yet no shift in national public policy comparable with Sweden or Finland.
Uncle Sam: you need gender medicine
On March 31, celebrated as “Transgender Day of Visibility, the Biden White House issued a 4400-word “Fact Sheet” with a slew of trans rights measures including statements “confirming the positive impact of gender affirming care on youth mental health”.
(This confidence is somewhat undercut by a reference to more money for the National Institutes of Health to enable research “to further develop the evidence base for improved standards of care.
“Research priorities include a more thorough investigation and characterisation of the short- and long-term outcomes on physical and mental health associated with gender-affirming care.”
The NIH did not reply when asked for detail.)
High on Biden’s March 31 list is a Department of Justice letter to state attorneys-general suggesting that Republican states legislating to prohibit hormonal and surgical interventions for minors are in breach of constitutional guarantees of equality.
In Alabama, for example, physicians who give minors puberty blockers, cross-sex hormones or surgery could face up to 10 years in prison.
Lawfare between the Democratic White House and Republican states is consistent with the idea, promoted by trans activists and centre-left media, that the Christian Right is the mainstay of scepticism about gender medicine.
Yet many parents who oppose medicalisation of gender non-conforming children are leftists and centrists who now identify as “politically homeless” because the Democrats — and corresponding political parties in many countries — insist that the trans medical model is “progressive”.
“It certainly is a dilemma for more liberal and left-wing voters,” says Denise, of the 4thWaveNow website, who has watched the political and media background to gender medicine for seven years now. She herself is a lifelong political liberal.
“I can't speak for everyone, but criminalising paediatric transition, threatening doctors with jail and fines, while understandable, to me seems a bridge too far,” she told GCN.
“The real issue is that all of the professional organisations [such as the American Academy of Pediatrics and the Endocrine Society] have been captured and a lot of doctors and therapists are simply following those [treatment] standards, such as they are.
“It seems many people, parents in particular, have really had it — and I have seen many stating they have changed their voting affiliation and have become single issue voters.
“How this will play out in the November midterms [elections for Congress] is anyone's guess.”
Florida’s disapproval of social transition lines up with its Parental Rights in Education law to prohibit teachers serving up material on sexual orientation or gender identity to very young children from kindergarten through to third grade.
The Twitter account Libs of TikTok has shot to almost one million followers with the simple device of reposting, often without comment, woke video clips that appear instantly absurd or repellent when glimpsed outside their social justice eco-bubble.
Among the most viral content are teachers boasting about how they introduce kids to the galaxy of gender identities without alerting unhip parents.
“The combination of ‘affirmative’ [gender clinic] practitioners [who are poorly regulated] and the indoctrination going on in schools is what is driving these bills in Florida and elsewhere [against paediatric transition],” Denise says.
Florida physician Dr Christie Grazie Christisays the new state guidance on gender dysphoria may give “cover” to doctors and therapists who have been worried they might lose their licence to practise if they did not immediately “affirm” a child presenting with gender issues.
She says health professionals in her circle “believe, as I do, that the proper treatment is conservative talk therapy with medication for anxiety and depression if needed. They know that most young people grow out of [gender dysphoria]”.
Dr Christie is an outspoken Catholic but says “that is not why I object to affirming children with gender dysphoria. I object from a medical, scientific and ethical perspective”.
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The tight grip of groupthink in American media has loosened a little in the last few years. Here’s a sample of breakthrough reportage and commentary:
Lesley Stahl, CBS 60 Minutes, 23 May 2021, Introducing Detransitioners
Jesse Singal, The New York Times, 7 September 2021, Trans: When Ideology Meets Reality
Abigail Shrier, The Truth Fairy Substack, 7 October 2021: Why Marci Matters: Dr. Marci Bowers’ and Dr. Erica Anderson’s Candor Could Help Thousands of Families
Laura Edwards-Leeper and Erica Anderson, The Washington Post, 24 November 2021: The Mental Health Establishment is Failing Trans Kids
Lisa Selin Davis, Skeptic magazine, Vol 27 No. 1, Trans Matters: An Overview of the Debate, Research, and Policies
Azeen Ghorayshi, The New York Times, 13 January 2022, Doctors Debate Whether Trans Teens Need Therapy Before Hormones
Leon Sapir, City Journal, 2 March 2022, Misguided Affirmations: Media Coverage of Transgender Issues Tends to Make Four Conceptual Mistakes
Frieda Klotz, Undark magazine, 6 April 2022, The Fractious Evolution of Pediatric Transgender Medicine
Andrew Sullivan, The Weekly Dish Substack, 9 April 2022, Who Is Looking Out For Gay Kids? The Risks of Imposing Critical Gender Theory on Young Children
Corinna Cohn, The Washington Post, 11 April 2022, What I wish I’d known when I was 19 and had sex reassignment surgery
Jenny Jarvie, Los Angeles Times, 17 April 2022, A Transgender Psychologist Has Helped Hundreds of Teens Transition, but Rising Numbers Have Her Concerned
Ben Appel, Newsweek, 21 April 2022, The New Homophobia
Florida’s new guidance on gender dysphoria relies in part on systematic reviews of the evidence base, as well as papers debunking weak or misleading studies used for media promotion with the claim that the affirmative medicalised approach is “lifesaving”. What follows is a sample of key journal articles cited by Florida Health.
“Low-quality evidence suggests that hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact are generally lacking.
“In all studies [in the systematic review], there was a medium to high risk of bias. In most studies, there were only small sample sizes. There were controls [to allow firm conclusions about the outcome of treatment] in only 2 studies. There was often significant loss to follow-up [meaning no known outcomes for ex-patients], attributed partially to most studies being retrospective with missing data.
“… [Authors] of existing studies have neglected several key outcomes. These include the following: psychological symptoms related to gender dysphoria, which is a critical knowledge gap given the high rates of mental health problems observed in transgender youth and justification of these treatments as treating gender dysphoria; the impact of hormonal treatments on fertility, which is an integral part of the counselling recommended by current guidelines; and potential adverse effects such as arterial hypertension. … [There] are no known studies to date in which researchers have reported the rates and circumstances under which transgender youth cease their hormonal therapy in an unplanned manner or the risk of subsequent regret, which would be of great clinical utility.”
This study by Australian researchers is described as “the first systematic review” of evidence for hormonal treatment in adolescents with gender dysphoria. Its authors include Dr Ken Pang, head of research for Australia’s largest gender clinic at the Royal Children’s Hospital Melbourne, and one of the four RCH authors of a treatment guideline promoted as the first specific to children and adolescents. The hospital did not respond when asked why its updated guideline does not cite this systematic review of the literature.
“Although strong recommendations have been made for invasive and potentially irreversible interventions, high-quality scientific data on the effects of this approach are generally lacking. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on ‘expert’ opinion.”
“Virtually all of those who promote physical interventions for gender dysphoric children point to the use of puberty blockers as a safe way for an uncertain child to have time to consider whether they want to go ahead with more irreversible procedures. They describe puberty blockers as providing a respite from the stress of puberty and a pause. This is mistaken on two counts: First, we do not have certainty about the harmful effects of puberty blockers as we do have for cross-sex hormone administration, because we do not have good longitudinal data on their effects in general. But we do know that puberty blockers adversely affect bone density … and adversely affect fertility. It is false to say that we know them to be physiologically benign. And second, what about the psychological consequences of this manoeuvre? The claim of providing a respite, or pause, suggests that puberty suppression is a benign, non-prejudicial move in the life of a gender dysphoric child. It seems to me that this is extremely misleading. Consider: what is the implicit message we give a child when we offer puberty blockers? We are validating the idea that the advent of puberty is a fearsome thing that calls for a prophylactic medical intervention.
“And what about the social situation of the child who has undergone puberty suppression? Here is a child, side-by-side with other children of his or her own age who are showing secondary sex traits and behaving sexually, while he or she is not. To my knowledge no one has studied the ramifications of this psycho-social situation, but to me it hardly reads as a respite, with its potential to magnify difference and stigma, albeit in a suppressed form. Puberty is challenging for all children, and for the child with conflict about gender it may be especially challenging. But it is not intrinsically traumatic to any child and I want to communicate to the child that, as with all inexorable developmental phenomena, it is manageable: you can do it, I’ll help [as a therapist].”
This paper scrutinises a review of puberty blocker studies by University of Texas researchers Rew et al, who declare these drugs “potentially life-saving”.
Clayton et al say the Rew review illustrates a trend in the gender dysphoria field “to overstate the evidence underpinning clinical practice recommendations … New publications reference prior ones with increasing and unwarranted confidence, and with the risk of misleading clinicians regarding the state of evidence. There is also a marked asymmetry in outcomes reporting: findings of positive outcomes of medical interventions are trumpeted in abstracts, while their profound limitations remain [in the body of the journal article] behind the paywall, thus, below the radar of busy clinicians.
“Clinicians relying on Rew et al’s review are likely to misinform patients and families about the risk/benefit profile of puberty blockers. Can such patients really be considered as giving informed consent? [In fact, reviews of the evidence show] that there is very low certainty of the benefits of puberty blockers, an unknown risk of harm and there is need for more rigorous research”.
Note: GCN sought comment from the US Professional Association for Transgender Health and a prominent US gender-affirming clinician.