Over 20 years ago, I trained in emergency departments filled with narcotic overdose survivors. My fellow physicians and I didn’t recognize the connection between these people brought back to life outside the hospital and the opioids we were prescribing for patients in the hospital. The medical community believed that slashing patients’ self-described pain from 10 to zero and prescribing opioids as needed constituted safe and compassionate care.
But hundreds of thousands of prescription opioid-related deaths spurred a renewed focus on data. The Centers for Disease Control and Prevention introduced International Classification of Disease diagnosis codes acknowledging opioid disorders that facilitate surveillance and research. Clinicians now use evidence-based opioid prescribing guidelines.
Evidence-based medicine guides wayward practice back to safe and compassionate care.
The medical pathway of “gender-affirming” care instead rests on an assumption, rather than evidence, that children experiencing gender dysphoria were, as advocates say, “born in the wrong body.” The American Psychiatric Association, the American Academy of Pediatrics, and other prominent medical organizations favor affirming the new gender identity over an objective evaluation of gender dysphoria, which can be a symptom of any number of mental health problems.
“Gender-affirming” care uses pharmacological and surgical treatments based on an idea rather than reasoned medical decision-making, without having fully explored the possibility of co-occurring psychiatric or neurodevelopmental conditions.
Recently, the British pediatrician Hilary Cass released an independent review of pediatric gender care commissioned by England’s National Health Service. Echoing conclusions reached by experts in other countries that advise caution when administering medical treatments, the Cass Review found that current research does not support medicalization for most children with gender distress.
The evidence revealed no sure way to know which children will maintain a lasting transgender identity and no high-quality evidence for puberty blockers or cross-sex hormones. Importantly, the Cass Review found no convincing evidence that hormones reduce the risk of death from suicide in patients with gender dysphoria. It recommends a holistic approach that screens struggling children for neurodevelopmental and mental health conditions.
The AAP was unmoved by the Cass Review and deflected to the political drama surrounding medical “gender-affirming” treatments, while overlooking the elephant in the room: the paucity of evidence for these treatments.
Take puberty blockers, which can negatively affect cognition and bone density. Since most children on puberty blockers choose to take the cross-sex hormones estrogen or testosterone, sterility in this group is practically guaranteed.
Considering the cardiovascular and cancer risks of cross-sex hormones and the permanence of sex-reassignment surgeries, reaching the correct diagnosis prior to treatment is essential.
Adolescents are increasingly seeking emergency care for psychological crises, while the number of children diagnosed with gender dysphoria has skyrocketed — many without the necessary comprehensive evaluation.
Evidence shows that when children mature through puberty without intervention, most will cease experiencing gender distress and embrace their biological sex, with many identifying as non-heterosexual. Blocking puberty may inhibit the very cure for gender dysphoria in most children.
Negatively affected by this ideological rather than medical approach are patients who received life-altering “gender-affirming” treatments but have since realized that their psychological distress was not due to gender incongruence. Some of these “detransitioners” are left with permanent physical changes, infertility, and reliance on hormone replacement.
The emerging harm from medical gender care is squelched by chatter disparaging those adversely affected as anti-LGBT. This victim-blaming strategy is in stark contrast to the medical community’s correction to minimize harm from prescription opioids.
We need evidence, not political flamethrowing. The potential for over-diagnosing gender nonconformity is mostly ignored in the U.S. In 26 chapters, the APA-sanctioned textbook Gender-Affirming Psychiatric Care cautions against misdiagnosing transgenderism as something else, but is silent on mistaking other conditions for transgenderism. It only touches on detransition in the elderly.
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ICD diagnosis codes exist for gender transition, but there are none to document and research detransition, relegating the detransition rate to a perpetual unknown. Health equity? Not for detransitioners. While “gender-affirming” surgeries are often covered by health insurance, detransition procedures are usually excluded.
The road to patient harm is sometimes paved with good intentions, but patients, especially children, deserve both good intentions and safe treatments. Evidence-based medicine for children with gender distress is the definition of compassionate care.
Aida Cerundolo, M.D., is an emergency medicine physician and fellow at Do No Harm.