It's Been a Tough Year for Transgender Medicine

Over the course of the year, MedPage Today reported on several issues in transgender medicine, including threats made to hospitals serving the transgender youth community and the Florida Medical Board's ban on gender-affirming care for kids. In this report, we follow up on what has happened in both the medical practice and politics of transgender medicine.

Last month, testimony wrapped up in a trial focused on Arkansas' ban on gender-affirming care, and advocates are eagerly awaiting a verdict.

The Arkansas ban was the first in the nation to prohibit physicians from administering hormone therapy or puberty blockers to transgender youths under age 18, and several other states have since enacted similar bans or have taken other measures to restrict access to care for transgender youths.

The year also brought additional controversy for the field of transgender medicine -- including threats against hospitals that provide such care, and even dissent within the community itself about the right path forward for treating kids with gender dysphoria.

State Actions

Arkansas Gov. Asa Hutchinson (R) originally vetoed a ban on youth transgender care in April 2021, calling it a "government overreach," but the state legislature subsequently overrode that veto.

The American Civil Liberties Union (ACLU) then filed suit challenging the constitutionality of the law, which has since been blocked from going into effect. If enacted, Arkansas physicians who provide gender-affirming care could lose their licenses or be subject to litigation.

It's still unknown as to when the judge will issue a ruling, according to the New York Times.

Joshua Safer, MD, executive director of the Mount Sinai Center for Transgender Medicine and Surgery in New York City, said he's hopeful that a favorable decision could prevent other states from moving forward with similar bans.

Safer has two major concerns about attempts to ban care for transgender youth: "Targeting any group to deny them healthcare is always worrisome," he said. "It's even more notably problematic because the medical establishment is quite consistent in the need to keep medical care between doctors and patients (and the patients' families in the case of youth)."

"In addition," Safer said, "we are talking about vulnerable people at a very challenging time in their lives, whether trans or not trans. The repeated attacks by certain non-medical political people is very upsetting in and of itself, even if care ends up being maintained."

Not long after the Arkansas law passed, Tennessee enacted its own ban on gender-affirming care, prohibiting doctors from providing hormone treatment to minors who haven't yet gone through puberty. Lawmakers there are now pushing to restrict access to gender-affirming care even further, allowing kids to sue their parents and stiffening penalties for healthcare providers.

Arizona enacted a ban on gender reassignment surgery for minors in March 2022, and the following month, Alabama became the first U.S. state to make it a felony to provide puberty blockers or hormone therapy to kids under age 19. Doctors could face up to 10 years in prison and be fined up to $15,000 for providing that care.

That law, however, was largely blocked by a federal judge -- though its ban on surgery for minors remains in place.

Then, in November, Florida's medical board approved a rule banning puberty blockers and hormone therapy as well as gender-affirming surgery. Once enacted, the rule will put physicians who disregard it at risk of losing their medical license.

And although it's not legislation, Texas Gov. Greg Abbott (R) ordered the state's Department of Family and Protective Services in early 2022 to investigate families of trans youth for providing gender-affirming care, after the state's attorney general equated it to child abuse.

The Biden administration has attempted to counter the state actions, including by issuing an Executive Order in June aimed at protecting transgender healthcare by expanding access to gender-affirming treatment, not allowing federally funded programs to offer conversion therapy, and a handful of other measures.

The administration also attempted to uphold transgender care protections in the Affordable Care Act that were dumped by the Trump administration. In July, HHS issued a proposed rule to restore those protections, but federal appeals courts have since blocked those efforts.

Threats Against Hospitals

The increased politicization of gender-affirming care has led to an unprecedented level of threats against hospitals and physicians who provide such care.

In October, three medical groups -- the American Academy of Pediatrics, the American Medical Association, and the Children's Hospital Association -- called upon the U.S. Department of Justice to investigate a spate of threats against doctors and hospitals that provide such care.

Last summer, Boston Children's Hospital was hit with "threatening and aggressive" phone calls, emails, and online attacks regarding its transgender care services. A Massachusetts woman and a Canadian man both face separate charges for calling in bomb threats against the hospital.

The hospital was still receiving bomb threats as recently as November, according to reports.

Similar events occurred at Children's National Hospital in Washington, D.C., at Vanderbilt University Medical Center in Nashville, and at Akron Children's Hospital in Ohio earlier this year.

The medical groups' letter said the threats made it difficult for these institutions to provide care and disrupted many other services.

Scientific Debate

Honest scientific debate within the transgender medicine community has also been weaponized by those who are pushing for bans on gender-affirming care for minors.

In the second half of this year, two significant events happened that raised questions about the body of evidence behind youth transgender treatments.

In July, the National Health Service in the U.K. announced that it would move gender care for minors away from the nation's lone clinic for such care, Tavistock and Portman NHS Foundation Trust, and replace it with regional services.

A substantial increase in referrals to the clinic -- to more than 5,000 in 2021, up from 250 in 2011, with a particular increase among pediatric patients, according to the New York Times -- prompted a review of the country's youth transgender care system, which was conducted by Hilary Cass, MD.

The interim report by Cass was released in February 2022, and it found a need to know more about the population being referred, as well as long-term outcomes. The report stated there hasn't been routine and consistent data collection. It also pointed to a lack of consensus and open discussion about the nature of gender dysphoria and the subsequent "appropriate clinical response."

Sweden also determined this year that all youth seeking puberty blockers or hormone therapy would have to enroll in clinical trials in order to collect more data on side effects and long-term outcomes. Finland took a similar position in 2021.

The second major event was the release of the World Professional Association for Transgender Health (WPATH) updated Standards of Care (SOC8) for transgender care in September.

One section of the guidance garnered particular attention for its stance on gender-affirming care among transgender youth. It called for substantive mental health assessments, and stated that transitioning youth must have been questioning their gender for "several years" before starting any drugs or surgeries.

Some advocates argued that gender diversity shouldn't be treated as a mental health disorder. Such statements also risked being weaponized by conservative groups pushing an anti-gender-affirming-care agenda, they said.

Safer said he supports the WPATH guidance. "The short of it is to make gender-affirming care as accessible as we can," he said. "But also, we know that we are dealing with young people where we want to be conservative in making sure that we are understanding them and that they are understanding the impact of certain treatment choices."

The vast majority of medical organizations support gender-affirming care for trans youth, including the American Academy of Pediatrics, the Endocrine Society, the American College of Obstetricians and Gynecologists, and the American Psychiatric Association.

An NIH-funded study involving four U.S. gender clinics that launched in 2015 may provide some answers, as it will investigate both the psychological impact of treatment as well as the safety of puberty blockers and hormone therapy. It's not yet known when those results will be reported.

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