Briefing Paper:Evidence To Date on Gender Affirming Care for Children and Young People Who are Experiencing Gender Distress.Introduction
The countries that have completed research (including systematic reviews that are considered the gold standard) have all concluded that puberty blocker use is not well evidenced, that in general the risks outweigh any potential benefits (including mental health benefits), that other methods of care need to be pursued first, and that medical interventions should be confined to research settings and/or be subject to ethical approval for each individual.
Evidence
1. Sweden National Board of Health & Welfare (NBHW), 2022
“The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) concludes that existing scientific evidence is insufficient for assessing the effects of puberty suppress-ing and gender-affirming hormone therapy on gender dysphoria, psychosocial health and quality of life of adolescents with gender dysphoria [2]. Knowledge gaps need to be addressed and the National Board of Health and Welfare recommends that these treatments be provided in the context of research.”
“At group level (i.e. for the group of adolescents with gender dysphoria, as a whole), the National Board of Health and Welfare currently assesses that the risks of puberty blockers and gender-affirming treatment are likely to outweigh the expected benefits of these treatments. The National Board of Health and Welfare therefore gives the following weak, negative recommendations as guidance to the healthcare system:
• Treatment with GnRH analogues, gender-affirming hormones, and mastectomy can be administered in exceptional cases.
Care must be provided on the basis of scientific evidence and proven experience and according to the principle of doing good and not harm. In revising its recommendations, the National Board of Health and Welfare has taken account of the fact that the efficacy and safety, benefits and risks of treatments are not proven.”
“The new recommendations entail that a larger proportion than before, among adolescents with gender incongruence referred for diagnostic assessment of gender dysphoria, will need to be offered other care than hormonal treatments.”
2. The Cass Review Interim Report (Independent expert review commissioned by UK Government)
“In the short-term, puberty blockers may have a range of side effects such as headaches, hot flushes, weight gain, tiredness, low mood and anxiety, all of which may make day-to-day functioning more difficult for a child or young person who is already experiencing distress. Short-term reduction in bone density is a well-recognised side effect, but data is weak and inconclusive regarding the long-term musculoskeletal impact.
“A closely linked concern is the unknown impacts on development, maturation and cognition if a child or young person is not exposed to the physical, psychological, physiological, neurochemical and sexual changes that accompany adolescent hormone surges. It is known that adolescence is a period of significant changes in brain structure, function and connectivity. During this period, the brain strengthens some connections (myelination) and cuts back on others (synaptic pruning). There is maturation and development of frontal lobe functions which control decision making, emotional regulation, judgement and planning ability.”
3. National Health Service (NHS) Implementing advice from the Cass Review June 2023
After an evidence review, NHS determined that “gender incongruence [usually] does not persist into adolescence,” that “psychological support” and “a watchful approach” are generally recommended instead of “social transition” due to its “risks,” and that puberty blockers/cross-sex hormones will only be given to minors in a research study.
4. National Institute for Health and Care Excellence (NICE) Evidence review, 2020a (UK)
The NICE evidence review on GnRH agonists (puberty blockers) major finding is that GnRH agonists lead to little or no change in gender dysphoria, mental health, body image and psychosocial functioning. In the few studies that did report change, the results could be attributable to bias or chance, or were deemed unreliable. The landmark Dutch study by De Vries et al. (2011) was considered “at high risk of bias,” and of “poor quality overall.” The reviewers suggested that findings of no change may in practice be clinically significant, in view of the possibility that study subjects’ distress might otherwise have increased. The reviewers cautioned that all the studies evaluated had results of “very low” certainty, and were subject to bias and confounding factors.
“The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up. The studies on puberty blockers “are of very low certainty [i.e., quality] using the G.R.A.D.E. rating system... As the studies all lack appropriate control [groups], any positive changes could be a regression to [the] mean.” The G.R.A.D.E. rating system is the most widely adopted tool for grading the quality of [research] evidence.”
5. Finland Board for Selection of Choices for Health Care (PALKO / COHERE Finland), 2020 SEGM
“Medical Treatment Methods for Dysphoria Related to Gender Variance in Minors”
“In a larger study consisting of 201 adolescents, 101 patients with the average age of 15.5 (12-18 years) started an 18-month psychological supportive intervention, and, additionally at six months, pubertal development was suppressed by starting GnRH analogue treatment. The other cohort of 100 only received psychological supportive intervention for 18 months. In both groups, statistically significant increases in global psychosocial functioning were found at 12 and 18 months; among those having received psychological intervention alone, the improvement in global functioning was already significant at the 6-month mark. Both studies lack long-term treatment follow-up into adulthood.”
“The first-line treatment for gender dysphoria is psychosocial support and, as necessary, psychotherapy and treatment of possible 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 behavioural health issues, and their mental health must be stable prior to the determination of their gender identity.”
6. Denmark Joins the List of Countries That Have Sharply Restricted Youth Gender Transitions” (SEGM)
Original research published in Danish. https://ugeskriftet.dk/videnskab/sundhedsfaglige-tilbud-til-born-og-unge-med-konsubehag
“Following systematic reviews of evidence conducted in Europe and the subsequent reversal of the “gender-affirmation” paradigm in favor of a cautious, developmentally-informed approach that prioritizes psychosocial support and noninvasive resolution of gender distress in Sweden and Finland, Denmark appears to have made a quiet but resolute shift to treat most youth presenting with gender dysphoria with supportive counselling rather than puberty blockers, hormones, or surgery. In 2022, only 6% of those referred to Denmark’s centralized gender clinic were prescribed endocrine interventions (puberty blockers and/or cross-sex hormones).”
“Most youth referred to the centralized gender clinic no longer get a prescription for puberty blockers, hormones or surgery—instead they receive therapeutic counseling and support.”
7. Sweden’s Karolinska Ends All Use of Puberty Blockers and Cross-Sex Hormones for Minors Outside of Clinical Studies (SEGM)
Full Article: Sweden’s Karolinska Ends All Use of Puberty Blockers and Cross-Sex Hormones for Minors Outside of Clinical Studies | SEGM
The Karolinska Hospital in Sweden recently issued a new policy statement regarding treatment of gender-dysphoric minors. This policy, affecting Karolinska's paediatric gender services at Astrid Lindgren Children's Hospital (ALB), has ended the practice of prescribing puberty blockers and cross-sex hormones to gender-dysphoric patients under the age of 18.
According to Karolinska’s newest policy, which went into effect in May 2021, going forward, hormonal (puberty blocking and cross-sex hormone) interventions for gender-dysphoric minors may only be provided in a research setting approved by Sweden’s ethics review board. The policy states that careful assessment of the patient’s maturity level must be conducted to determine if the patient is capable of providing meaningful informed consent.
There is also a requirement that patients and guardians are provided with adequate disclosures of the risks and uncertainties of this treatment pathway. It is not clear whether minors under the age of 16 would be eligible for such trials.
The Karolinska Hospital’s new policies echo a growing international concern over the proliferation of medical interventions that have a low certainty of benefits, while carrying a significant potential for medical harm. The latest policy issued by the Karolinska cites the UK NICE evidence review, which found the risk / benefit ratio of hormonal interventions for minors highly uncertain; the 2020 UK judicial review, which highlighted the overarching ethical problems with the practice of medical "affirmation" of minors; as well as Sweden's ownHealth and Technology Assessment (SBU) evidence review conducted in 2019, which found a lack of evidence for medical treatments, and a lack of explanation for the sharp increase in the numbers of adolescents presenting with gender dysphoria in recent years.
8. Puberty Blockers for Children: Can They Consent?
Full article: Puberty Blockers for Children: Can They Consent?Highlights weaknesses of researcher claiming positive mental health benefits:
Turban (Citation 2020) in a paper on the risk of suicidal ideation in young people given PBs concluded that suicidal ideation was reduced in those who had PBs. There are however serious weaknesses in their methodology: they derived the information from a voluntary survey of transgender adults in the U.S. Excluded from this sample of 89 respondents were people who had PBs and then de-transitioned. Any who had committed suicide were of course omitted. Most had started taking PBs after the age of 17 (when puberty would have been well advanced). Since PBs are generally given only to those who are aged 12–16, this means the respondents did not represent the group which is the focus of this review, and is therefore of limited relevance to consent in under 16s.
“It is concluded that children are unable to consent to the use of puberty blockers.”
9. Dr Azeem Ibrahim OBE recent article in the Herald Scotland where he called for the banning of puberty blockers for children in Scotland.
10. The WPATH files are disturbing. In one video, doctors acknowledge that patients are sometimes too young to fully understand the consequences of puberty blockers and hormones on their fertility We understand the SPATH guidelines used in Scotland are based on WPATH guidelines.
11. A Mayo Clinic study released April 2024 found that puberty blockers can lead to withering testicles, fertility problems and even cancer among children who take them, in the latest study to raise alarm about transgender medicine.
12. Banning of puberty blockers in NHS England for children with gender dysphoria 01/04/2024 after a review found insufficient evidence of their safety or clinical effectiveness.
NHS England has carefully considered the evidence review conducted by NICE (2020) and has identified and reviewed any further published evidence available to date. We have concluded that there is not enough evidence to support the safety or clinical effectiveness of PSH to make the treatment routinely available at this time.
13. The CASS Review Final Report (2024)
The recommendations set out a different approach to healthcare, more closely aligned with usual NHS clinical practice that considers the young person holistically and not solely in terms of their gender-related distress. The central aim of assessment should be to help young people to thrive and achieve their life goals.
Services must operate to the same standards as other services seeing children and young people with complex presentations and/or additional risk factors.
Expand capacity through a distributed service model, based in paediatric services and with stronger links between secondary and specialist services.
Children/ young people referred to NHS gender services must receive a holistic assessment of their needs to inform an individualised care plan. This should include screening for neurodevelopmental conditions, including autism spectrum disorder, and a mental health assessment.
Standard evidence based psychological and psychopharmacological treatment approaches should be used to support the management of the associated distress from gender incongruence and cooccurring conditions, including support for parents/carers and siblings as appropriate.
Services should establish a separate pathway for pre-pubertal children and their families. ensuring that they are prioritised for early discussion about how parents can best support their child in a balanced and non-judgemental way. When families/carers are making decisions about social transition of pre-pubertal children, services should ensure that they can be seen as early as possible by a clinical professional with relevant experience.
NHS England should ensure that each Regional Centre has a follow-through service for 17–25-year-olds; either by extending the range of the regional children and young people’s service or through linked services, to ensure continuity of care and support at a potentially vulnerable stage in their journey. This will also allow clinical, and research follow up data to be collected.
There needs to be provision for people considering detransition, recognising that they may not wish to re-engage with the services whose care they were previously under.
A full programme of research should be established to look at the characteristics, interventions and outcomes of every young person presenting to the NHS gender services.
The puberty blocker trial previously announced by NHS England should be part of a programme of research which also evaluates outcomes of psychosocial interventions and masculinising/ feminising hormones.
The option to provide masculinising/feminising hormones from age 16 is available, but the Review recommends extreme caution. There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18. Every case considered for medical treatment should be discussed at a national Multi- Disciplinary Team (MDT).
Implications of private healthcare on any future requests to the NHS for treatment, monitoring and/or involvement in research, and the dispensing responsibilities of pharmacists of private prescriptions needs to be clearly communicated
A summary of the findings can be found here
14 This German study (2024) on the persistence of gender dysphoria shows that identifying as Trans is a temporary phase.
72.4% of people diagnosed with F64 in 2022 (n = 24,624) had at least one other psychiatric diagnosis coded (male: 67.3%, female: 75.6%). The most common were depressive disorders (male: 49.3%, female: 57.5%), anxiety disorders (23.5%/34.0%), emotionally unstable personality disorders of the borderline type (12.1%/17.6%), attention deficit/hyperactivity disorder (12.7%/12.6%), and post-traumatic stress disorder (9.9%/13.6%).
In the longitudinal cohort (n = 7 885, 47.1% 20- to 24-year-olds, 37.7% male), only 36.4% had a confirmed F64 diagnosis after five years, and a diagnosis persistence of < 50% was seen in all age groups (27.3% [15- to 19-year-old women] to 49.7% [20- to 24-year-old men]).
Conclusion
We are sure that like us you would expect that health, Social Work and education provision is informed by evidence. Children in Scotland are no less deserving than children in England and should be given the best medical and psychological treatment.
Mary Howden
Retired Social Worker
Former Head of Education & Workforce Development
06/06/2024
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