From Affirmation to Moderation: The U.K.’s new approach to treating gender dysphoric youth
Last week, the UK’s National Health Service (NHS) delivered long-awaited suggestions for the kind of treatment children with gender dysphoria should receive. They’ve moved from a model in which children’s transgender identities are automatically affirmed to a cautious, multidisciplinary, evaluation-heavy approach to assisting kids navigating gender issues—a model similar to those of countries like Sweden and Finland.
The shift comes after pediatrician Hilary Cass released an Interim Report earlier this year on the UK’s only state-funded pediatric gender clinic, the Gender Identity Development Service (GIDS) for children and adolescents at the Tavistock and Portman NHS Foundation Trust in London. It had a waitlist 5,000 kids deep and a pile of whistleblowing complaints against it. The report noted multiple problems, from children’s complicated mental health issues being overlooked in the wake of gender issues—known as diagnostic overshadowing—to clinicians feeling pressured to affirm and send the child down a medical path, rather than investigate the source of gender dysphoria. The report specifically called out the "affirmative model” of gender healthcare “that originated in the USA.”
Like several other countries, including the U.S. and Canada, the U.K. has seen a sharp spike in teen girls with no history of gender issues suddenly seeking medical interventions—a cohort never studied, to whom past research doesn’t apply. They’ve also seen the emergence of detransitioners—individuals who went through medical gender transitions but now regret doing so, and returned to living as their natal sex. Meanwhile, Cass chaired a group that commissioned systematic evidence reviews of puberty blockers and cross-sex hormones, which found the evidence of their safety and efficacy to be of very low quality.
After the Cass report, the National Health Service announced that GIDS would be shut down and replaced with a new model of care: regional centers “with strong links to mental health services.” Proponents of the gender-affirming model in America insisted this was not a condemnation of their approach but an expansion of it, to address the long waitlist, but this week’s revelation put that false assertion to rest.
Now, children will be seen not just by experts in gender dysphoria, but also “experts in pediatric medicine, autism, neurodisability and mental health” because “there is a higher prevalence of other complex presentations in children and young people who have gender dysphoria.” That is, the NHS will be directly addressing the diagnostic overshadowing issue. There will be “a more structured approach for collaboration with local services”—meaning, kids will be properly evaluated before being referred to this new service, which should reduce the waitlist.
Instead of referrals made by schools, colleges, and “voluntary organizations,” the new service “proposes that referrals may be made by GPs and NHS professionals.” In other words, schools, as well as nonprofits like Mermaids, a charity that supports trans kids and has garnered outsized political and educational influence—and is now under investigation for supplying breast binders to girls—can no longer be so directly involved.
Many such schools and nonprofits support social transition, in which a child is facilitated to identify as the opposite sex (or nonbinary) and assume the stereotypes associated with that sex, in names, haircuts, or clothing. But the NHS now acknowledges that “social transition in prepubertal children is a controversial issue, that divergent views are held by health professionals, and that the current evidence base is insufficient to predict the long term outcomes of complete gender-role transition during early childhood.” Rather than being an anodyne or psychologically necessary intervention, as it's often thought of here in the States, social transition “should not be viewed as a neutral act” but rather “an active intervention,” NHS notes. Recent research shows social transition seems to increase the likelihood of medicalization later, but, as the NHS now asserts, “in most cases gender incongruence does not persist into adolescence.” Thus, “social transition should only be considered where the approach is necessary for the alleviation of, or prevention of, clinically significant distress or significant impairment in social functioning and the young person is able to fully comprehend the implications of affirming a social transition.”
As for medical interventions, puberty blockers and cross-sex hormones will only be administered “in the context of a formal research protocol,” and families are discouraged from seeking these drugs “from unregulated sources or from on-line providers that are not regulated by UK regulatory bodies.”
These changes are quite different from the blunt force instrument of bans, or defunding the entire medical practice, as red states have aimed for in the United States. Nor are they as radical as the gender medicine sanctuary state laws of New York and California, which remove roadblocks to medical transition. Both methods of addressing this ballooning population are extreme and punitive, even if employing opposite tacks.
The NHS suggestions, on the other hand, note that clinical leads will be doctors, overseeing “a broader range of medical conditions in addition to gender dysphoria” because “the service may provide medical interventions to some children and young people.” Instead of legislatures imposing their will onto doctors and patients, in the UK, both psychological and medical treatment is carefully controlled by the medical and mental health establishments, with multi-tiered treatment options and multidisciplinary teams to evaluate children, and medical interventions only in the context of studies, which will lead to long-term follow up.
What will it take for the U.S. to follow the U.K.’s lead? Our healthcare system is so different that it’s a difficult question to answer. Countries with socialized medicine have no financial incentive to continue this kind of care, while in the U.S., the gender surgery market is “expected to expand at a compound annual growth rate (CAGR) of 11.23% from 2022 to 2030,” per one market research company. More than twenty-five American medical associations (which are not nonpartisan) have endorsed the affirmative approach the U.K. has now rejected. Both the American Academy of Pediatrics and the World Professional Association for Transgender Health, which creates standards of care for “gender diverse” people, have refused to do the kinds of systematic evidence reviews that the U.K., Sweden, Finland and the state of Florida have all done, which led to policy changes. Each came to the same conclusion: the quality of evidence was so low that these medical interventions couldn’t be deemed medically necessary. Here, we tout the same evidence as showing life-saving benefits, not uncertainty.
The U.K.’s new guidelines aren’t set in stone. They’re open to public comment until December 4th. But it’s clear that they’ve weighed the evidence and listened to the whistleblowers. In America, we’re still waiting for that to happen.
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