Medically Speaking: Providing Gender Affirming Care

“Medically Speaking” is a new column by Dr. Daniel Shumer and members of the Child and Adolescent Gender Clinic team at the University of Michigan.

On April 6, 2021, the Arkansas State Legislature passed a bill making it illegal for medical professionals to provide gender-affirming hormonal treatment for patients with gender dysphoria who are under age 18. Several other states have active legislation pending similar to the new Arkansas law. As physicians who provide this care, we are deeply concerned that these political actions threaten the health and well-being of transgender youth, a population which we would characterize as courageous and resilient, yet profoundly vulnerable.

Gender identity, the deeply felt internal sense of one’s self as a boy or girl, man or woman, or perhaps somewhere else on a gender spectrum, may or may not align with the sex assigned at birth. When it does not align, the term ‘transgender’ is often used as an umbrella term to denote this incongruence. While not all transgender youth feel distress related to their gender identity, when distress is present and persistent, the young person may be diagnosed with gender dysphoria. While being transgender is not a health problem, gender dysphoria is currently listed in the American Psychiatric Association’s Diagnostic and Statistical Manual, Version 5. Similar to other disorders (think anxiety, depression) gender dysphoria can be treated with both non-medical and medical interventions. Non-medical interventions may include therapy, coming-out to loved ones, or making a social transition. Medical interventions may include hormonal or surgical treatments. The appropriate treatment for an individual patient is one made by the patient, their parents, and their health team, and guided by evidence-based standards and guidelines.

Pediatric gender clinics have their origin in the 1990s in Amsterdam. Dutch physicians recognized that transgender youth tend to struggle through adolescence, as secondary sex characteristics develop, and that early intervention could be life-saving. They also appreciated that there is value in delaying decisions which may have a permanent impact on a child. To resolve these conflict, they created a protocol whereby puberty would be paused at Tanner Stage 2 if gender dysphoria persisted, forestalling the development of permanent and unwanted secondary sex characteristics with a reversible intervention. In later adolescence, gender affirming hormones could be initiated if gender identity remained incongruent with the sex assigned at birth. The resulting improvements in well-being demonstrated in long term follow-up were instrumental in the development of guidelines formalizing this practice (including from The Endocrine Society, the World Professional Association for Transgender Health, and the American Academy of Pediatrics), and the increase in access to gender affirming care for youth around the world.

There has been an increase in the prevalence of transgender identity since the Dutch model was first published. A recent survey of high school students in 10 states conducted by the U.S. Center for Disease Control found that 1.8% of students identify as transgender. The incredible vulnerability of these youth is starkly realized by the statistic that more than one in three of the transgender-identified youth surveyed had attempted suicide in the last 12 months2. As providers caring for this population, this statistic alarms us, but also calls us to action. We know that mental health disparities seen are not inevitable, and that with love and support from family and community and access to evidence based mental health and medical interventions, transgender youth survive and thrive.

The Arkansas bill banning physicians from providing gender-affirming therapy for transgender people under age 18 is called the Save Adolescents from Experimentation (SAFE) Act. The name of the bill implies that physicians practicing evidence-based guidelines, and working with patients and families to assess gender dysphoria and then present the risks and benefits of all treatment options, is experimentation. From our perspective, the bill is providing a new an much darker experiment: what will happen to youth with no access to gender-affirming care, living in a state where politicians have formalized discrimination against them, likely increasing a culture of transphobia.

The content of this bill, and other similar bills, is based not in data or medical fact, or even correct knowledge about the process of treating transgender adolescents. By penalizing physicians for practicing evidence-based medicine, this legislation nullifies their expertise and the therapeutic physician-patient-family relationship. It strips power away from patients and families who, at baseline, are extremely vulnerable. It would be speculative to guess the true motivation behind passing this legislation, but it is evident that the result is likely to be tragic for youth trapped in a political experiment.

Daniel Shumer, MD MPH
Pediatric Endocrinologist
Child and Adolescent Gender Clinic, University of Michigan