The National Health Service in England began restricting gender-bending treatments for children this month, making it the fifth European country to restrict the drugs due to a lack of evidence on their benefits and concerns about long-term harm.
England’s change came from a four-year review released on Tuesday night by Dr Hilary Cass, an independent paediatrician. “For most young people, a medical pathway will not be the best way to manage their gender-related anxiety,” the report concludes. In a related article published in a medical journal, Dr Kass said the evidence that youth gender treatments were beneficial was “built on shaky foundations”.
The NHS will no longer offer drugs that prevent puberty, except for patients enrolled in a clinical trial. And the report recommended that hormones such as testosterone and oestrogen, which cause permanent physical changes, should be prescribed to minors with “extreme caution”. (The guidelines do not apply to physicians in private practice, who serve a small fraction of the population.)
England’s move is part of a wider shift in northern Europe, where health officials are concerned about the growing demand for sex therapy for teenagers in recent years. Many patients also have mental health conditions that make it difficult to identify the root cause of their distress, known as distress.
In 2020, Finland’s health service narrowed care by recommending psychotherapy as the main treatment for adolescents with gender dysphoria. Two years later, Sweden restricted hormone treatments to “exceptional cases”.
In December, regional health authorities in Norway labeled youth gender medicine a “trial treatment”, meaning the hormones will only be prescribed to teenagers in clinical trials. And in Denmark, new guidelines to be finalized this year will limit hormone treatments to transgender teenagers who have experienced discomfort since early childhood.
Several transgender advocacy groups in Europe have condemned the changes, saying they infringe on civil rights and exacerbate the problems of overstretched health systems. In England, around 5,800 children were on the waiting list for sex services at the end of 2023, according to the NHS
“The waiting list is known to be hell,” said N., a 17-year-old transgender boy in southern England who asked to withhold his full name for privacy. He has been on the waiting list for five years, during which time he was diagnosed with autism and depression. “Beyond the trans panic being pushed by our own government, we feel forgotten and left out,” she said.
In the United States, Republican politicians have invoked the retreat in Europe to justify laws against youth sex medicine. But the European policies differ significantly from the outright bans on teenagers passed in 22 US states, some of which threaten doctors with jail or investigate parents for child abuse. European countries will continue to allow gender-bending treatments for some teenagers and require new clinical trials to study and better understand their effects.
“We have not banned treatment,” said Dr. Mette Ewers Haahr, psychiatrist who leads the Danish Sol youth gender clinic in Copenhagen. Effective treatments must take into account human rights and patient safety, he said. “You have to weigh both.”
In February, the European Academy of Paediatrics acknowledged concerns about youth gender medicine. “The fundamental question of whether biomedical treatments (including hormone therapy) for gender dysphoria are effective remains controversial,” the team wrote. Instead, the American Academy of Pediatrics last summer reaffirmed its support for the care, stating that hormone treatments are necessary and should be covered by health insurers, while also commissioning a systematic review of the evidence.
Europeans pioneered the use of sex therapy for youth. In the 1990s, a clinic in Amsterdam began administering anti-puberty drugs to teenagers who felt they were the opposite sex from early childhood.
Dutch doctors argued that puberty blockers could give young patients with gender dysphoria time to explore their identity and decide whether to go ahead with hormones in the final transition. For patients experiencing male puberty, the drugs would prevent physical changes — such as a deeper voice and facial hair — that could make it harder for them to live as women in adulthood. The Dutch team’s research, which was first published in 2011 and followed a carefully selected group of 70 teenagers, found that puberty blockers, combined with therapy, improved psychological functioning.
This study was hugely influential, inspiring clinics around the world to follow the Dutch protocol. Referrals to these clinics began to increase around 2014, although the numbers remain small. At the Swedish clinic, for example, referrals increased to 350 teenagers in 2022 from around 50 in 2014. In England, these numbers increased to 3,600 referrals in 2022 from 470 in 2014.
Clinics around the world have reported that the increase is largely due to patients growing up as girls. And unlike participants in the original Dutch study, many of the young patients did not develop gender dysphoria until adolescence and had other mental health conditions, including depression and autism.
Given these changes, some clinicians question the relevance of the original Dutch findings to today’s patients.
“The whole world is providing the treatment, to thousands, tens of thousands of young people, based on one study,” said Dr. Riittakerttu Kaltiala, a psychiatrist who has led Finland’s youth gender program since 2011 and has become an outspoken critic. of care.
Dr. Kaltiala’s own research found that about 80 percent of patients at the Finnish clinic were born female and began experiencing gender dysphoria later in adolescence. Many patients also had psychological problems and were not helped by hormone treatments, he found. in 2020, Finland severely restricted drug use.
Around the same time, the Swedish government commissioned a rigorous investigation that found “inadequate” evidence for hormone treatments for youth. In 2022, Sweden recommended hormones only for “exceptional cases,” citing in part uncertainty about how many young people may choose to stop or reverse their medical transitions, known as detransitioning.
Even the original Dutch clinic is facing pressure to limit the patients receiving care. In December, a public documentary series in the Netherlands questioned the basis of the treatments. And in February, months after a far-right political party swept elections in a country long known as socially liberal, the Dutch parliament approved a resolution to conduct an inquiry comparing the current Dutch approach with that of other European countries.
“I wish the Netherlands were an island,” said Dr. Annelou de Vries, a psychiatrist who led the original Dutch research and still runs the Amsterdam clinic. “But, of course, we’re not – we’re also part of the global world. So, in a way, if everyone starts to worry, of course, those worries come to our country as well.”
In England, concerns about the rise in new patients came to a boil in 2018 when 10 clinicians at the NHS’s only youth gender clinic, known as the Tavistock Gender Identity Development Service, complained formally that they felt pressured to approve quickly children, including those with serious mental health problems, for puberty blockers.
In 2021, Tavistock clinicians published a study of 44 children who received puberty blockers that showed a different result than the Dutch: Patients who received the drugs, on average, saw no effect on psychological functioning.
Although the drugs did not reduce thoughts of self-harm or the severity of distress, the teenagers were “thrilled to be on the block,” Dr. Polly Carmichael, head of the clinic, told a conference in 2016. And 43 of the 44 study participants chose later to start testosterone or estrogen, raising questions about whether the drug was serving its intended purpose of giving teens time to consider whether a medical transition was right for them.
In 2020, the NHS commissioned Dr Cash to carry out an independent review of the treatments. It commissioned scientific reviews and reviewed international care guidelines. He also met with young people and their families, transgender adults, people who had retired, advocacy groups and clinicians.
The review concluded that the NHS standard of care was inadequate, with long waiting lists to access drug treatment and few pathways to address mental health concerns that may contribute to gender dysphoria. The NHS closed the Tavistock center last month and opened two new youth gender clinics, which should take a “holistic” approach, with more support for people with autism, depression and eating disorders, as well as psychotherapy to help teenagers explore their identity.
“Children and young people have not been very well served,” Dr Cash said in an interview with the editor of The British Medical Journal, published on Tuesday. He added: “I can’t think of another area of pediatric care where we give young people potentially irreversible treatments and have no idea what happens to them in adulthood.”
The changes introduced by the NHS this month are “an acknowledgment that our concerns were, in fact, valid”, said Anna Hutchinson, a clinical psychologist in London who was one of the Tavistock staff who raised concerns. in 2018. “It is reassuring that we will return to a more robust, evidence-based pathway for decisions related to these children.”
Some critics said that Europe, like the United States, had also been affected by a growing anti-transgender backlash.
In Britain, for example, a long-running fight over a proposed law that would make it easier for transgender people to change the gender on their identity documents has fueled a political movement that seeks to exclude trans women from women’s sports, prisons and domestic shelters. violence.
“The intention with the Cass review is to be neutral, but I think neutral can move,” said Laurence Webb, a spokeswoman for Mermaids, a UK-based transgender youth advocacy group. “Extremist views have become much more normalized.”
Other countries have seen more overt attacks on transgender rights and health care. In 2020, Hungary’s parliament passed a law banning gender identity changes in legal documents. Last year, Russia banned legal gender reassignments as well as gender-related medical treatment, with one lawmaker describing gender reassignment surgery as “the road to the nation’s degeneration”.
In France this year, a group of conservative lawmakers introduced a bill banning doctors from prescribing puberty blockers and hormones, punishable by two years in prison and a fine of 30,000 euros, or about $32,600. And on Monday, the Vatican condemned gender transitions as threats to human dignity.
