BioEdge, 28 July, 2019
Reproduced under Creative Commons Licence
Michael Cook*
More and more young people believe they were born in the wrong body. According to the US Centers for Disease Control, about 1.8% of American high school students (grades 9-12) identified as transgender in a survey.
In 2008 that the Endocrine Society approved puberty blockers as a treatment for transgender adolescents as young as 12 years old. Many parents feel that it is a matter of life and death for their children. As one San Francisco mother told NBC, “At first…it’s hard to swallow. But really it’s this child’s happiness. I would rather have a transgender daughter than a dead son.”
However, there are no long-term studies which support medical interventions for children, which can include “top” and “bottom” surgery for children over 16.
What are the ethics of treating children with untrialled treatment? Surprisingly little has been written about this.
This could be changing, as critics of transgender treatment are beginning to surface in the media.
This week the UK’s Royal College of Paediatrics and Child Health asked its ethics experts to examine the rapid increase in the use of puberty blockers to treat under-16s. According to The Times (London), this is first time the issue has been formally addressed by the College, which is responsible for setting professional standards. This is a bit late in the day, as gender clinics have been using them for more than a decade.
Carl Heneghan, director of the Centre of Evidence-based Medicine at the University of Oxford, told The Times that there was a “paucity of evidence” for the “off-label use of drugs” in gender dysphoria treatment. He said that it was basically “an unregulated live experiment on children”.
In June, the Royal College of General Practitioners (RCGP) complained that “the significant lack of evidence for treatments and interventions which may be offered to people with dysphoria is a major issue facing this area of healthcare”.
The question has become urgent in the wake of indications that the blockers themselves might make children more disposed to suicide. A BBC investigation found that the Gender Identity Development Service (Gids) at the Tavistock and Portman NHS Foundation Trust in London and Leeds has referred thousands of children for hormone treatment but that a small study of 44 of them had negative results.
As far back as 2015, the board of directors of Gids received information from a survey that there was “a significant increase” in the number of youngsters agreeing with the statement “I deliberately try to hurt or kill self”. Admittedly the data was inconclusive. Yet referral continued unabated despite the amber light.
Prof Susan Bewley, the chair of Healthwatch, a charity for science and integrity in healthcare, told the BBC that any change around suicidal thoughts "is very worrying". "Good medical practice would normally be very reflective about an increase in harms".
A psychologist who resigned from Gids recently published an open letter complaining that scepticism about transgender diagnoses was met with abuse and bullying. Kirsty Entwistle said that there was an “unspoken rule that means GIDS clinicians do not tell families, ‘your child is not transgender’.” She felt that transgender treatment was being administered as a quick fix for complex problems:
I was also shocked by the complexity of referrals. I read many referrals of children who have been sexually abused and many children have witnessed and/or been subjected to domestic violence.
I also felt that was an overrepresentation of the young people who were living in poverty. I had a young person whose family were living within such extreme financial constraints that he considered it a treat to buy a can of pop. I also had another young person who was living in a very complex and unstable arrangement who arrived to sessions in a poor state of hygiene and said that there wasn’t money for hygiene products. How is it ethical to undertake a gender identity assessment with the view to a medical pathway when there are children and young people do not have their most basic needs met?
Dominic Wilkinson and Julian Savulescu, of the University of Oxford, acknowledge that the BBC report has identified a difficult problem in clinical ethics. Is it possible to conduct a trial which will show whether puberty blockers are harmful or not? They believe that it is, but with great caution. “If puberty suppression is to be used with uncertain consequences, it is imperative that we study the effects as systematically as possible.”
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