England revises medical care for transgender youth

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

The closure followed an external review of the Tavistock clinic in London, which has helped thousands of transgender patients since the 1990s. The review, which is underway, has raised several concerns, including about long waiting times, insufficient support for mental health services and the rising number of young people seeking gender treatments.

The overhaul of transgender youth services in England is part of a remarkable shift in medical practice in some European countries with nationalized health care systems. Some doctors there are concerned about the proliferation and lack of data on the long-term safety and outcomes of medical transitions.

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

“How do we draw the line so that we tailor care while maintaining safety standards for everyone? That’s what we’re trying to figure out,” said Dr. Marci Bowers, a plastic surgeon and the new president of the World Professional Association for Transgender Health, who is transgender. “It’s the people on the ground who have to make these decisions, not the people in Washington or the state legislature.”

The NHS said current patients at the Tavistock clinic could continue to receive care there before being transferred to two new hubs at children’s hospitals in London and Manchester. The new clinics will expand the country’s gender services and ensure that children receive adequate treatment for autism, trauma and mental health issues. The specialists will also conduct clinical research on gender medication.

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

Puberty blockers, which are largely reversible, are intended to give younger patients time to make important decisions about permanent medical changes. But dr. Cass wondered if most adolescents prescribed these drugs had the support to reverse course, if they wanted to.

Tavistock received more than 5,000 patient referrals in 2021, up from just 250 in 2011. The type of patients seeking referrals has also changed over the past decade. When the clinic opened, it mainly served children who were assigned a man at birth. Last year, two-thirds of patients were assigned a female at birth.

It is unclear why the number of patients has risen so drastically or why transgender boys are causing 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, chief executive of Mermaids, an advocacy group for transgender and gender-diverse youth. “There is a two-and-a-half-year waiting list for your first appointment. We have seen the suffering inflicted on young people as a result.”

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

“We wouldn’t want to see any more barriers to accessing medical intervention,” said Ms Green.

In 2020, a former patient in Tavistock, Keira Bell, joined a widely publicized lawsuit against the clinic. She claimed she was put on puberty blockers “after a series of superficial conversations with social workers” at age 16 and that her breasts were removed at age 20, decisions she later regretted.

A Supreme Court initially ruled that children under 16 are unlikely to be mature enough to consent to such medical interventions. But that decision was reversed last September, with the judges ruling that “it was up to clinicians rather than the court to decide” whether a young patient could give informed consent.

In 2020, Tavistock staff expressed concerns about medical care at the clinic, prompting the NHS to prompt Dr. Cass, a pediatrician in London who was not affiliated with the clinic, for an external assessment. Her interim report was published in February this year.

The Swedish National Health Service has ruled this year that gender-based care for young people should only be provided in exceptional cases when children are clearly suffering from their gender, known as dysphoria. All adolescents receiving treatment should be enrolled in clinical trials to collect more data on side effects and long-term outcomes. Finland took a similar stance last year.

“Our position is that we can’t just see this as a rights issue,” said Dr. Thomas Linden, director of the country’s National Board of Health and Welfare, in an interview in February. “We need to see patient safety and precision in judgment. We really need to make sure to some degree that we’re giving the right treatments to the right person.”

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

Some US doctors feared that changing standards in Europe would reinforce the idea that gender treatments are dangerous for young people.

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



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