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Britain’s National Health Service this month began restricting sex-specific treatments for children, becoming the fifth country in Europe to restrict the drug, citing a lack of evidence about its benefits and concerns about long-term harm.
England’s changes emerge from a four-year review published on Tuesday night by independent pediatrician Dr Hilary Kass. “For most young people, health care is not the best way to address gender-related distress,” the report concludes. In a companion editorial published in a medical journal, Cass said the evidence that gender treatment in young people is beneficial is “built on shaky foundations.”
The NHS will no longer offer puberty-blocking drugs, except to patients enrolled in clinical studies. The report recommends “extreme caution” when prescribing hormones such as testosterone and estrogen to minors that promote permanent physical changes. (This guideline does not apply to practitioners who serve a small portion of the population.)
The UK move is part of broader changes in Northern Europe, where health authorities are concerned about a surge in demand for gender treatment among adolescents in recent years. Many patients also have mental health conditions that make it difficult to identify the root cause of their distress, known as dysphoria.
In 2020, Finnish health authorities recommended psychotherapy as the main treatment for adolescents with gender dysphoria, restricting treatment. Two years later, Sweden limited hormone treatment to “exceptional cases”.
In December, Norway’s regional health authorities designated gender medicine for young people as an “investigational treatment.” This means that hormonal drugs are only prescribed to young people during clinical trials. And in Denmark, new guidelines to be finalized this year will limit hormone treatment to transgender youth who have experienced dysphoria from an early age.
Several transgender advocacy groups in Europe have condemned the changes, saying they violate civil rights and exacerbate problems in an overstretched health care system. Around 5,800 children were on waiting lists for gender services in England at the end of 2023, according to the NHS.
“Waiting lists are known to be hell,” said N, a 17-year-old transgender boy from the south of England who asked that his full name not be used to protect his privacy. He was on the waiting list for five years, during which time he was diagnosed with autism and depression. “On top of the transgender panic that our government is promoting, we feel forgotten and left behind,” he said.
In the United States, Republican politicians have cited the backlash in Europe to justify legislation against gendered health care for young people. But the European policy differs markedly from the outright bans on juveniles passed in 22 U.S. states, some of which threaten doctors with prison terms and investigate parents for child abuse. There is also. European countries still allow gender treatments for certain adolescents and mandate new clinical trials to study and better understand their effectiveness.
“We are not banning this treatment,” said Dr. Mette Ewers Haar, a psychiatrist who heads Denmark’s only youth gender clinic in Copenhagen. Effective treatment requires consideration of human rights and patient safety, she said. “You have to weigh both.”
In February, the European Academy of Pediatrics acknowledged concerns about gender medicine in young people. “The fundamental question of whether biomedical treatments for gender dysphoria (including hormone therapy) are effective remains controversial,” the group wrote. In contrast, the American Academy of Pediatrics last summer said hormone therapy is essential and should be covered by health insurance companies, reaffirming its support for the treatment and commissioning a systematic review of the evidence.
Europeans pioneered the use of gender therapy for young people. In the 1990s, an Amsterdam clinic began administering puberty-suppressing drugs to young people who had identified as a different gender from an early age.
Doctors in the Netherlands reasoned that puberty blockers could give young patients with gender dysphoria time to explore their identity and decide whether to continue taking hormones to eventually transition. . For patients facing male puberty, the drug helps prevent physical changes, such as a deeper voice or thicker facial hair, that can make it more difficult to live as a woman in adulthood. It will prevent it. A study first published in 2011 by a team of Dutch researchers that followed a carefully selected group of 70 young people found that the combination of puberty blockers and therapy improved psychological functioning.
This study was so influential that clinics around the world began to follow the Dutch protocol. Referrals to these clinics started to skyrocket around 2014, he said, but the numbers are still small. For example, in a clinic in Sweden, the number of referrals increased from about 50 in 2014 to 350 in 2022. In the UK, the number of referrals increased from 470 in 2014 to 3,600 in 2022.
Clinics around the world reported that this increase was primarily driven by patients who were raised as girls. And unlike the participants in the original Dutch study, many of the new patients did not experience gender troubles until adolescence and had other mental health conditions such as depression and autism.
Given these changes, some clinicians question whether the initial Dutch study results are relevant for today’s patients.
“Based on one study, thousands and tens of thousands of young people all over the world are being treated with this treatment,” says a psychiatrist who has been leading a youth gender program in Finland since 2011 and is a vocal critic. said Dr. Rithakertu Karutiyala. Of care.
According to Kartiala’s own research, about 80 percent of the patients at the Finnish clinic were born female and began experiencing gender troubles in late adolescence. She found that many patients also had psychological problems and did not respond to hormone therapy. In 2020, Finland severely restricted drug use.
Around the same time, the Swedish government commissioned a rigorous research study that found “insufficient” evidence about hormone therapy for young people. In 2022, Sweden recommended giving hormones only in “exceptional cases,” in part because of concerns about how many young people will choose to stop or reverse their medical transition in the future ( It was pointed out that there was uncertainty about whether to choose “de-transition”.
In the UK, 10 clinicians at the NHS’s only youth gender clinic, known as the Tavistock Gender Identity Development Service, said they had to admit children quickly in 2018, when concerns about a surge in new cases reached a boiling point. He formally complained that he felt under pressure. People with serious mental health issues, including those that inhibit puberty.
In 2021, Tavistock clinicians published a study of 44 children who took puberty blockers, which showed different results from the Dutch. In other words, patients who received the drug had, on average, no effect on their psychological functioning.
Although the drug did not reduce thoughts of self-harm or the severity of the discomfort, the adolescents were “very excited to be able to take a blocker,” said Polly Kerr, director of the clinic. Dr. Michael said this at the 2016 conference. And 43 of 44 study participants later chose to start testosterone or estrogen, raising questions about whether the drugs were serving their intended purpose of giving adolescents time to consider whether a medical transition was right for them. occurred.
In 2020, the NHS commissioned Mr Cass to conduct an independent review of the treatment. She commissioned a scientific review and considered international guidelines for treatment. She also met with young people and their families, transgender adults, detransitioned people, advocacy groups, and clinicians.
The study found that the standard of care on the NHS is inadequate, with long waiting lists for drug treatment and few routes to address mental health concerns that may be contributing to gender distress. I concluded that no. The NHS closed its Tavistock center last month and opened two new youth gender clinics. Mr Cass said there should be more support for people with autism, depression and eating disorders, as well as a “holistic” approach with psychotherapy to help young people explore their identity. Ta. .
“Children and young people are being served really badly,” Kass said in an interview with the editors of the British Medical Journal published on Tuesday. She added: “I can’t think of any other field in pediatric medicine that provides irreversible treatment to young people who don’t know what will happen in adulthood.”
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