Transgender healthcare conversation is uncommon. There aren’t many other fields of medicine where doctors are so adamant about openly disclosing their opinions, claims British doctor Hilary Cass. On April 9th, she published a 388-page report, commissioned by England’s National Health Service, assessing the data for and against solutions for kids who identify as trans. Its opinions may have repercussions on both sides of the Atlantic, where standards of care vary enormously.
The treatments at issue include puberty blockers, cross-sex hormones, and (rarely) surgery. Puberty therapy is a class of drugs that stops the beginning of menstruation. Cross-sex hormones stimulate the development of opposite-sex characteristics: estrogen causes males to develop larger breasts, testosterone gives females bigger muscles and deeper voices, among other things. According to the Cass Review, “There is not a credible database” that the benefits of providing treatments to children outweigh the drawbacks. Several studies have been published, but they are often of “poor value”. Some people arrive at conclusions from minuscule examples. Some don’t have control groups, resulting in outcomes that aren’t compared to those who receive treatment. There has been far too much research to examine long-term effects. Some clinics yet fought off for data-gathering attempts. Dr. Cass told the BBC, “It’s uncommon for us to treat young people who have potential for life-changing things without knowing what happens to them as adults.”
In the wealthy globe, approaches to transgender care for children then fall into three large categories: laissez-faire, harsh, and careful. The laissez-faire technique, which is prevalent in violet states in America, claims that children should be able to change their systems to fit their needs if they want to. Their lives may suffer if they are denied “gender-affirming care,” claim opponents, and they may consider ending them. Some campaigners add, in violent language, that just transphobes may possibly object. The American Academy of Pediatrics, a regional body, supports the delivery of puberty blockers and mix-sex hormones to minors, while evaluating novel evidence.
Such treatments should be merely prohibited, according to the draconian approach. This is prevalent in red American states, where politicians use antipathy toward transgender people to win electoral votes. Some states combine severe penalties for doctors who provide it with strict bans on treatment. Florida threatens them with five years in prison, Idaho, ten. Although this is currently being litigated in court, Texas has tried to determine whether parents who seek such care for their children are suitable parents. In all, 22 American states have outlawed or restricted transgender care for adolescents, most of them recently.
The cautious approach, which informs policy in Denmark, Finland, Norway, Sweden, and now England, stresses that more evidence is needed. Nobody knows why the number of transgender children has increased in the last ten years. Before prescribing them any medications that could render them permanently sterile and prevent them from having orgasms, doctors should look into other options. On the autism spectrum, many transgender children are present. Many suffer from depression and should be offered counseling. Many eventually desist, sometimes realizing that they are gay, not trans. Even if the child demands them, medical professionals shouldn’t rush into invasive treatments. Therefore, the NHS in England only currently offers puberty-blockers as part of a clinical trial. Cross-sex hormones should be provided only to children over 16, and with “extreme caution,” says the Cass Review.
As The Economist has argued before, the cautious approach is the wisest. Adults should be free to choose their own bodies, and transgender people should always be treated with kindness and respect. However, as Dr. Cass points out, it is crucial to stay away from “the creep of unproven approaches into clinical practice.” In a region where politics have become so heated, this may be challenging. In health systems where private doctors are paid for each intervention and have an incentive to give patients what they ask for, it might be harder. Nonetheless, it is the responsibility of medical authorities to offer treatments based on solid evidence.
