England overhauls medical care for transgender youth

The National Health Service in England announced on Thursday that it was closing the country’s only youth clinic in favor of a more distributed and comprehensive network of medical care for youth seeking hormones and other gender-specific treatments.

The closure followed an external review of London’s Tavistock Clinic, which has treated thousands of transgender patients since the 1990s. The ongoing review has raised several concerns, including long wait times, inadequate mental health support and the rising number of young people undergoing gender-based treatment.

The overhaul of services for transgender youth in England is part of a notable shift in medical practice in some European countries with nationalized health systems. Some doctors there are concerned about the increase in numbers, as well as the lack of data on long-term safety and outcomes of medical switches.

In the United States, doctors specializing in youth gender care have mixed feelings about reforms in Europe. While many agree that more comprehensive health care for transgender youth is badly needed, as well as more study of treatments, they fear the changes will fuel the growing political movement in some states to ban such care outright.

“How do we draw the line so that we can personalize care while maintaining safety standards for everyone? We’re trying to figure that out,” said Dr. Marci Bowers, a plastic surgeon and President-elect of the World Professional Association for Transgender Health who is transgender. “It’s the local people who have to make these decisions, not the people of Washington or the state legislatures.”

The NHS said current patients at the Tavistock Clinic could continue to receive care there before being transferred to two new centers at Children’s Hospitals in London and Manchester. The new clinics will expand the country’s gender services while ensuring that children with autism, trauma and mental health issues receive appropriate care. The specialists will also conduct clinical research on gender drugs.

There are “crucially important unanswered questions” about the use of puberty blockers, wrote Dr. Hilary Cass, head of the external review of the country’s youth gender identity services, in a letter to the head of NHS England last week.

Puberty blockers, which are largely reversible, aim to buy younger patients time to make serious decisions about lasting medical changes. But dr Cass questioned whether most youngsters prescribed these drugs received the support to reverse course should they choose to do so.

Tavistock received more than 5,000 patient referrals in 2021, up from just 250 in 2011. The types of patients seeking referrals have also changed over the past decade. When the clinic opened, it mainly cared for children who were classified as male at birth. Last year, two-thirds of patients were assigned females at birth.

It’s unclear why the number of patients has increased so dramatically, or why transgender boys are driving the increase.

Transgender advocates in the UK welcomed the changes but stressed that many questions remained about how they would affect the care of young people.

“We’re optimistic, cautiously optimistic about the news,” said Susie Green, executive director of Mermaids, an advocacy group for transgender and gender-balanced youth. “There is a two and a half year waiting list for your first appointment. We have seen the hardship this causes young people.”

But Ms Green, who has an adult transgender daughter, said the group was concerned about whether mental health services would be prioritized over medical care. Gender diversity, she said, should not be treated as a mental disorder.

“We don’t want to see any more barriers being erected in terms of access to medical procedures,” Ms Green said.

In 2020, a former Tavistock patient, Keira Bell, joined a high-profile lawsuit against the clinic. She claimed she was put on puberty blockers at 16 “after a series of perfunctory conversations with social workers” and had her breasts removed by the age of 20, decisions she later regretted.

A Supreme Court first ruled that children under the age of 16 were probably not mature enough to consent to such medical procedures. However, that decision was reversed last September when judges ruled that “it was for the clinicians rather than the court to decide” whether a young patient could give informed consent.

In 2020, Tavistock staff raised concerns about medical care at the clinic, prompting the NHS to hire Dr. Cass, a pediatrician in London unaffiliated with the clinic, to do an outside review. Their interim report was published in February this year.

Sweden’s National Health Service ruled earlier this year that gender-specific care for young people should only be given in exceptional cases when children have significant problems with their gender, known as dysphoria. All adolescents receiving treatment must participate in clinical trials to gather more data on side effects and long-term outcomes. Finland took a similar stance last year.

“Our position is that we cannot just look at this as a rights issue,” said Dr. Thomas Linden, director of the country’s National Board of Health and Welfare, in a February interview. “We have to see patient safety and precision in judgement. We really need to have some level of confidence that we are giving the right treatment to the right person.”

While these European countries have placed some limits on transgender grooming, their approaches are far more permissive than those in some conservative US states. A recent Alabama law made it a criminal offense for doctors to prescribe puberty blockers and hormones to minors. In Texas, parents who allow their children to undergo sex treatment have been investigated for child abuse. Both states are locked in legal battles with civil rights groups.

Some American doctors feared that changing standards in Europe would reinforce the notion that gender-based treatments were dangerous for young people.

“My concern is that this will be interpreted as another step against the provision of gender-affirming care to children,” said Dr. Angela Goepferd, medical director of the Gender Health Program at Children’s Minnesota Hospital. More services are needed, they said, not fewer. “That is our challenge here.”

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