Why Have Many Nations Concluded That Psychological Care Is Preferable to Medical Transition for Kids and Adolescents?

And When Will the United States Catch Up?

If you’re skeptical of the benefits of transitioning children and adolescents, you might have already heard that many nations, such as the UK, Finland, Sweden, France, Australia, New Zealand, and Norway, after many years of giving affirmation and transition a try, have examined the evidence, leading them to move away from transition and toward psychological treatments.

But here in the United States, we’re often unaware of what other nations are doing. You might want to learn a bit about what exactly these other countries decided, and on what basis.

UK

In the past in the UK, all pediatric patients with gender dysphoria were referred to a single clinic — it was therefore easy for their National Health Service (NHS) to notice that there had been a 40-fold increase in referrals between 2008 and 2018. They also found it increasingly hard to ignore a number of complaints from their own clinicians that kids were being fast-tracked for transition, leading to dozens of resignations in the late 2010s.

In response, the NHS called for a systematic review of all the available evidence, without cherry-picking. They appointed Dr. Hilary Cass, a pediatrician and the former president of the Royal College of Pediatrics and Child Health from 2012 to 2015, to lead this effort. Her report — currently an interim report, pending further data — is known informally as the Cass Report.

Among other conclusions, Dr. Cass wrote, “[In the UK] the clinical approach has not been subjected to some of the usual control measures that are typically applied when new or innovative treatments are introduced…. [T]here are significant gaps in the research and evidence base.”

In other words, although American doctors, mental-health professionals, and media would have the public believe that “gender-affirming care” is settled science, that is not what Dr. Cass discovered upon reviewing all the evidence.

Although Dr. Cass’s report did not include the evidence base for surgery (because surgeries, unlike in the US, are not allowed before age 18), it did include a lot of information about puberty blockers and hormones, which I encourage people to read for themselves. If you want the TL;DR version, here it is:

Dr. Cass on Feminizing and Masculinizing Hormones

• The available evidence on cross-sex hormones is of poor quality.

• Young people remain fluid in their identity until their 20s.

• The (poor quality) data that are available are based on the old cohort of gender dysphoric kids (historically boys who were very effeminate from a young age), and not the new cohort of girls and boys who developed gender dysphoria in their teens.

If you were to ask, “Then why are we transitioning kids at all, when the evidence is poor, doesn’t relate to the cohort of kids seeking care, and the kids might later change their minds?” — well, those would be good questions.

Dr. Cass on Puberty Blockers

Dr. Cass notes that even more is unknown about puberty blockers. Some of these unknowns, about which she believes we need to gather evidence, are:

• Whether the many and sometimes intense side effects of blockers might make patients feel emotionally worse.

• Whether the failure to build bone density as a result of taking blockers is permanent.

• Whether blockers are a “pause button” or instead lock kids into their gender identity.

• Whether puberty blockers temporarily or maybe even permanently disrupt critical brain development associated with puberty.

In a follow-up letter / addendum to her interim report in July 2022 she writes:

“Brain maturation may be temporarily or permanently disrupted by puberty blockers, which could have significant impact on the ability to make complex risk-laden decisions, as well as possible longer-term neuropsychological consequences.”

The “benefits” of puberty blockers are hardly the settled science that you might believe if you were to read only mainstream media sources of information in the United States.

Although the situation is still developing in the UK, the proposed solutions — gathering more evidence and developing clinical guidelines based on the evidence — clearly indicate a lack of faith in the current “full speed ahead” model of care of affirming every kid who walks in the door.

Finland

In 2020, Finnish researcher Kaltiala and colleagues published research about Finnish kids who had taken hormones for gender dysphoria and concluded they didn't work: “Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria. Appropriate interventions are warranted for psychiatric comorbidities and problems in adolescent development.”

Kaltiala and colleagues noted that the kids’ emotional function pre-transition stayed the same post-transition. That is, the kids who had poor mental health before transition continued to have poor mental health after transition.

That, along with some other research in recent years, led the Finnish government to conclude in 2020:

The first-line intervention for gender variance during childhood and adolescent years is psychosocial support and, as necessary, gender-explorative therapy and treatment for comorbid psychiatric disorders….

In adolescents, psychiatric disorders and developmental difficulties may predispose a young person to the onset of gender dysphoria. These young people should receive treatment for their mental and behavioral health issues, and their mental health must be stable prior to the determination of their gender identity.

Clinical experience reveals that autistic spectrum disorders (ASD) are overrepresented among adolescents suffering from gender dysphoria; even if such adolescents are presenting with gender dysphoria, rehabilitative interventions for ASD must be properly addressed.

In light of available evidence, gender reassignment of minors is an experimental practice.

So basically, the TL;DR here is “Gender dysphoria is a mental health problem, it needs to be treated as such, and gender reassignment of minors is experimental.”

Hardly “settled science.”

Sweden

Sweden, too, similar to the UK, decided to look at all the available evidence to see what was happening with transition of minors and whether it was helpful. In February 2022, the Swedish National Board of Health and Welfare concluded:

Based on the results that emerged, the National Board of Health and Welfare's overall conclusion is that the risks of puberty-inhibiting and gender-affirming hormone treatment for those under 18 currently outweigh the possible benefits for the group as a whole.  

The assessment is that treatment with hormones should continue to be given within the framework of research. Increased knowledge is needed, among other things, about the treatment's impact on gender dysphoria as well as the mental health and quality of life of minors, in both the short and long term….  

Similar to Finland, despite having transitioned minors for many years and being a very progressive nation which is famously supportive of gender-questioning people, Sweden has concluded that there just isn’t enough information to warrant transition.

Not only is the science not settled: The Swedes believe the risks currently outweigh the possible benefits.

That’s a powerful conclusion.

France

In early 2022, the French National Academy of Medicine, too, issued a strongly worded statement about gender transition in kids:

…A great medical caution must be taken in children and adolescents, given the vulnerability, particularly psychological, of this population and the many undesirable effects, and even serious complications, that some of the available therapies can cause. In this respect, it is important to recall the recent decision (May 2021) of the Karolinska University Hospital in Stockholm to ban the use of hormone blockers.

Although, in France, the use of hormone blockers or hormones of the opposite sex is possible with parental authorization at any age, the greatest reserve is required in their use, given the side effects such as impact on growth, bone fragility, risk of sterility, emotional and intellectual consequences and, for girls, symptoms reminiscent of menopause….

Therefore, faced with a request for care for this reason, it is essential to provide, first of all, a medical and psychological support to these children or adolescents, but also to their parents, especially since there is no test to distinguish a “structural” gender dysphoria from transient dysphoria in adolescence. Moreover, the risk of over-diagnosis is real, as shown by the increasing number of transgender young adults wishing to “detransition.” It is therefore advisable to extend as much as possible the psychological support phase.

Again, if we were to ask ourselves if this sounds like “settled science,” the answer would be no. In fact, the more time passes and we see how this new cohort of teens is faring with transition, the more doctors around the world seem to develop concerns that transition is not delivering what it promised. Medical professionals are beginning to suspect we’ve been on the wrong track.

Australia and New Zealand

An article from Medscape Psychiatry in 2021 described the new position statement from the Royal Australian and New Zealand College of Psychiatrists (RANZCP) as emphasizing the importance and primacy of mental health evaluation and treatment before “gender-affirming care” is even considered:

"There is a paucity of quality evidence on the outcomes of those presenting with gender dysphoria. In particular, there is a need for better evidence in relation to outcomes for children and young people," the guidance states.

Because gender dysphoria "is associated with significant distress...each case should be assessed by a mental health professional, which will frequently be a psychiatrist, with the person at the center of care. It is important the psychological state and context in which gender dysphoria has arisen is explored to assess the most appropriate treatment," it adds.

The move by the psychiatry body represents a big shift in the landscape regarding recommendations for the treatment of gender dysphoria in Australia and New Zealand.

Asked to explain the new RANZCP position, Philip Morris, MBBS, FRANZCP, said: "The College acknowledged the complexity of the issues and the legitimacy of different approaches."

Exploration of a patient's reasons for identifying as transgender is essential, he told Medscape Medical News, especially when it comes to young people.

"There may be other reasons for doing it and we need to look for those, identify them and treat them. This needs to be done before initiating hormones and changing the whole physical nature of the child," he said.

"A cautious psychotherapy-first approach makes sense. If we can do that with adolescents then we will take a big step in the right direction," stressed Morris, who is president of the National Association of Practising Psychiatrists in Australia.

It looks as if Australia and New Zealand psychiatrists are beginning to understand that the science around “gender affirming care” is not settled, and they seem to be coming to some of the same conclusions as experts in other nations: psychotherapy for a psychiatric diagnosis.

Norway

In March 2023, Norway became the latest nation to revise its position on gender-affirming care. Their report is published here. It is very long, but the summary about the evidence base is this:

The teenage population, which makes up a large part of the increase in referrals to the specialist health service over the past ten years, is a new population of patients where the knowledge base is deficient both nationally and internationally. The stability of gender dysphoria that occurs or is expressed in the teenage years is not known as there is a lack of follow-up studies. It is unknown to what extent gender incongruence and gender dysphoria persist in this patient group compared to previous patient populations. A large proportion have mental illness, developmental disorders or other conditions that were not described in previous studies. The documentation available from earlier is therefore not necessarily transferable to the group of teenagers with gender incongruence and gender dysphoria who are increasingly seeking puberty delaying and gender affirming treatment.  

[The Norwegian Healthcare Investigation Board] considers that it is necessary for patient safety that the knowledge base on gender incongruence and gender dysphoria be strengthened, and that the health service offer be arranged in line with the knowledge base. In Norway, there has not been a systematic summary of knowledge in the field, updated assessments of recent foreign summaries of knowledge or a complete method assessment of puberty blockers and gender confirmation treatment with hormones and surgery for children and young people. No medical quality register with national status has been established to get an overview and assess the quality of the treatments given to children and young people with gender incongruence and gender dysphoria in Norway. Such measures are crucial for obtaining a better knowledge base for making clinical decisions and for promoting clinical research and development in the field.

The upshot of Norway’s investigation seems to be similar to that of the UK; they recommend gathering a lot more evidence and they suggest restructuring gender care and being more cautious about providing experimental treatments to children and youth. As the Society for Evidence-Based Gender Medicine (SEGM) describes it,

[Norway] notes that the right to medical care does not include the right to experimental treatments. As an experimental intervention, gender transitions will be subject to heightened scrutiny around informed consent, eligibility criteria, and outcomes evaluation.

Norway's proposed model appears to resemble the model of care outlined in the Cass review…. Youth gender transitions will be an exception, not the rule.

Again: “experimental” is quite the opposite of “settled science.”

But When Will the United States Catch Up?

Critical thinkers and skeptics in the United States might well be wondering when our own health care leaders will catch up with other nations in recognizing that when it comes to gender medicine, “There is no ‘there’ there”: The evidence doesn’t support medical transition of children and youth, and as such, transition is an experimental practice with many known and unknown risks.

How many American parents would be on board with the notion of transitioning their child if they were told honestly, “This treatment is experimental, and we don’t have the evidence to support it. In fact, the risks might outweigh the benefits. We simply don’t know.”

And your guess is as good as mine, quite honestly, as to when the United States might decide to evaluate the available evidence and change course.

The cynic in me believes that it’s no accident that most of the pro-transition “research” (using the term very loosely) is based on low-quality questionnaires given shortly after the kids are given what they thought they wanted — and plastered in the media by journalists who don’t know how to read medical journal articles.

Suppose a kid wants to eat only cookies for dinner every night. You agree to give him only cookies for dinner, and then you give him a questionnaire that asks whether he’s pleased. He says yes. That’s the type of research that is done on “trans kids” by pro-transition researchers.

We don’t have any research on whether these same people, 20 years later, are happy to have been given cookies for dinner every night, and what the outcomes on their health might have been. We know only whether they are “happier” immediately after being given what they asked for. Is it any surprise most say yes?

The cynic in me also believes that it’s not a coincidence that the nations backtracking on medical transition provide some form of universal health care for their people. These governments have a stake in keeping people healthy and in using resources wisely.

Our government in the United States doesn’t provide health care for all, and so has no such stake. Meanwhile, those providing “gender-affirming care” are profiting a lot from these procedures: In September 2022, Dr. Shayne Taylor, a doctor affiliated with Vanderbilt’s Clinic for Transgender Health was quoted as saying, “These surgeries make a lot of money.” As the linked article describes it, Dr. Taylor mentioned that

a “chest reconstruction” can bring in $40,000 per patient, and someone “just on routine hormone treatment, who I’m only seeing a few times a year, can bring in several thousand dollars … and actually makes money for the hospital.”

There’s simply a lot of money to be made on transitioning kids in the United States, where the medical system is profit-driven.

The drug companies profit nicely too. Figures published in 2015 (no doubt significantly higher now) estimate that the cost of two years’ worth of the puberty blocker Lupron was $20,000 to $40,000.

As Upton Sinclair once said, “It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

Our profit-driven health care system in the US presents an obstacle to those who might be interested in the truth of the evidence. Those who support medical transition of children and youth are not incentivized to look closely at whether medical transition helps kids.

The unfortunate reality: the role of parents and other concerned critical thinkers in the United States is arguably more important than in other nations. Our government has made no moves toward looking at the evidence and deciding whether “the science is settled.” Our government has no intention of stopping the profitable gender-medicine practices in the US. Our government — unlike the governments in many other places — is not coming to save our children and youth from medical harm.

We all — but those of us in the United States especially — need to keep talking about gender medicine and to share information about the real evidence, or lack thereof, behind it.