Burton: Politics and gender-affirming care for young people

While the veracity of specific allegations made by the case manager await inquiry, serious questions have been raised about the timing of the op-ed amid a push in the state Legislature for anti-transgender legislation, just one example in a rash of such legislation nationwide. Beyond questions of motive, the case manager’s lack of qualifications in clinical diagnosis and treatment do not offer confidence in her evaluation of patients’ clinical circumstances. There are, however, important lessons to take from her words.

First, gender-affirming care is highly complicated and requires true multi-disciplinary care, especially in youth and adolescents. Transgender youths are at risk for a panoply of adverse mental health conditions and outcomes, including depression, eating disorders and suicide. It is not surprising that the case manager observed a high prevalence of psychiatric and social conditions in the patients she worked with.

And though these conditions are often tightly wound with patients’ gender identity — perhaps they are bullied at school or experience conflict with their parents — no medical provider would expect hormonal therapy alone to act as panacea for what may be years of repression, self-hate or internalized guilt elicited from the crime of being different. These marks are often exacerbated by the dramatic changes wrought by puberty.

It is for these reasons that the World Professional Association for Transgender Health recommends that any mental health concerns that interfere with the diagnostic clarity of a patient’s gender incongruity are addressed before undertaking gender-affirming medical care. The case manager’s allegations argue for more resources to address a nationwide dearth of therapists and mental health professionals who are qualified to treat gender diverse young people.

Second, gender-affirming care is evolving. We are still learning which patients respond well to medical therapy and what the complications of long-term hormone use may be. Medicine is in perpetual evolution, and patient care cannot wait for randomized-controlled data or large, longitudinal epidemiological studies that are years away to guide treatments that are needed today. The limited data that does exist is largely positive regarding the effects of early medical treatment for transgender adolescents, including improved psychological functioning and body image. In the meantime, professional guidelines limit medical therapy to adolescents with severe gender incongruence lasting for six months to years, reasonably well-controlled mental health and the cognitive and emotional maturity to fulfill informed consent. These guidelines, formed by professional expertise and best consensus and not politicians, are what should be dictating the type and availability of pediatric gender-affirming care.

Lastly, the medical community needs to treat those who reverse their gender transition, or detransitioners, seriously and with compassion. There is no true figure on the number of people who choose to reverse a gender transition, but prior studies have reported that fewer than 5% of adolescents who begin puberty blockers choose to stop medical therapy. However, the idea that transgender people, especially transgender children, will regret transitioning is a pervasive idea rife not only in anti-trans spheres but the general public as well.

This idea is manifest in the case manager’s writing, where she unceasingly mis-genders the patients she describes, implicitly suggesting their ongoing regret. While the proportion of people receiving gender-affirming care who detransition is likely small, it is important that we learn about what was the experience of these detransitioners to better guide future care. To ignore this population is to provide further fodder to anti-trans advocates who use detransitioners as proof for an indefinite moratorium on the provision of gender-affirming care.

The transgender community deserves our compassion. While the medical profession lacks all the answers on how to best care for transgender people, we still possess many life-altering treatments and strict criteria to guide the proper dispersion of care. Most importantly, the self-correcting progress of medicine will provide further, more complete solutions in the future. It is wrong to deprive transgender youths of care under the pretense of child protection. We can help these kids. Let us.

Jackson Burton is a medical student and researcher on gender-affirming care at Washington University.