Gender Identity and Children
....a review of the current science.
This column tries hard to present child welfare news objectively. Today we’re going to dive into an issue on which, for the past few years, it’s been almost impossible to find objectivity: how to care for children whose gender identity doesn’t seem to fit with their sex.
Over the past decade, there’s been tremendous growth in the medical subspecialty of gender pediatrics. In 2022, Reuters reported that the number of US gender clinics serving children had grown from 0 to 100 in a 15-year period. The number of children diagnosed with gender dysphoria — distress caused by a mismatch between their sex and their identity — tripled in the US between 2017 and 2021. Similar surges in gender identity issues among children were recorded across the pond.
For the past few years, medical protocols in the US, UK, and in much of Europe called for children with gender dysphoria to socially transition — adopt a name and pronouns associated with their identified gender, present in the stereotypical dress and hairstyles of that gender. Then, as the child approached puberty, doctors would prescribe puberty blockers to prevent puberty associated with the natal sex and, later, hormones associated with the sex aligned with the child’s identity. For many, surgeries to complete the “transition” to the preferred gender identity followed in late adolescence or early adulthood.
Over the past three or four years, this practice has come under fire, and political and legal battles have raged across the US over the issue. In Georgia, legislative efforts to ban cross-sex hormones and surgeries for anyone under 18 brought large protests to the Capitol and charges that banning such medical treatment would result in gender-dysphoric children committing suicide.
Anyone questioning whether a medical protocol involving puberty blockers and hormones is the right approach was vilified. When the New York Times ran a series of stories raising questions about the medical approach, advocates protested and claimed the paper was publishing “dangerous opinions from non-experts as objective facts, neglecting both medical science and the overwhelming consensus support for trans healthcare among major medical associations.”
In the interest of full disclosure, I was involved in those efforts to limit medical treatment for childhood gender dysphoria, motivated not out of disdain for or lack of empathy for children struggling with their gender identity but out of concern that we seemed to be making permanent, life-altering decisions for children who couldn’t understand how such medical treatments would affect their lives as adults. I wrote about it here.
In the past year, and especially in the past few weeks, it appears that the medical and mental health communities in the UK and Europe are also rethinking the issue. Hannah Barnes has documented the child protection concerns raised by staff at the UK’s Tavistock gender clinic for children, where professionals became increasingly concerned about the practice of prescribing puberty blockers and hormones. “[P]atients presented at the clinic with a recent history of gender dysphoria and also histories of parental conflict, time spent in foster care, suicidal ideations, extreme anxiety, obsessive-compulsive disorder, and sexual abuse. Often, parents or children came to the clinic pushing for an immediate referral for puberty blockers. A few parents expressed opinions that they’d rather have a trans child than a gay child.”
The Tavistock issues led Britain’s National Health Service (NHS) to commission a rigorous study of the evidence supporting the treatment of gender dysphoria with puberty blockers, hormones, and surgeries. That study, led by prominent pediatrician Hilary Cass, has led the NHS to bar the routine use of puberty blockers and cross-sex hormones. As Dr. Cass told the New York Times recently, there is little evidence supporting the idea that a medical approach is appropriate for children who may well “grow out of” their gender identity struggles, and there are serious concerns regarding the long-term damage these medical interventions cause. “I can’t think of any other situation where we give life-altering treatments and don’t have enough understanding about what’s happening to those young people in adulthood,” she said.
At the same time, other European medical authorities have rejected these medical treatments for gender dysphoria in children. In the past week or so, the European Society for Child and Adolescent Psychiatry (ESCAP) published a position paper stating that “research on treatment benefits and harms of gonadal suppression and cross-sex hormones for children and adolescents with gender dysphoria has significant conceptual and methodological flaws, that the evidence for the benefits of these treatments is very limited, and that adequate and meaningful long-term studies are lacking.” As a result, ESCAP called for “healthcare providers not to promote experimental and unnecessarily invasive treatments with unproven psychosocial effects.” Germany’s medical society, likewise, adopted a resolution to “permit puberty blockers, sex-change hormone therapies or gender reassignment surgery in under 18-year-olds with gender incongruence (GI) or gender dysphoria (GD) in the context of controlled scientific studies and with the involvement of a multidisciplinary team and a clinical ethics committee and after medical and, in particular, psychiatric diagnosis and treatment of any mental disorders.”
In the United States, medical associations including the American Academy of Pediatrics, the American Medical Association, and the Endocrine Society continue to promote a medical treatment protocol for gender dysphoria in children. The American Psychological Association continues to call such treatment “life-saving,” suggesting that it prevents suicide in gender-dysphoric youth.
Many US groups advocating for these medical treatments continue to claim that medically transitioning children with gender identity issues is not only “best practice” but also “the only effective treatment for trans youth to prevent self-harm and suicidal ideation.” In her NYT interview, Dr. Cass suggested that US medical associations, perhaps due to political pressure from such advocates, are “holding on to a position that is now demonstrated to be out of date by multiple systematic reviews.”
In other news:
The federal government has issued a final rule regarding IV-E payments for legal representation for children and parents.
An investigation by the US Attorney in Rhode Island found the state had violated the civil rights of children in foster care with mental health issues.
The New Yorker explores whether children of incarcerated parents should have a right to “hug” them — or at least visit in person.
Since 1997, the US government has been under a court order regarding it treatment of migrant children in its custody. It’s filed a motion to end that oversight.
The Maine legislature’s government oversight committee has issued a report critical of the child welfare agency. The agency’s commissioner is stepping down at the end of the month.
Oregon’s child welfare class action suit was scheduled to go to trial this week but has been delayed, possibly to work out a settlement.
Have a great week!