Endocrine Societies Say Science Should Inform Trans Health Policies

Jeff Craven

December 17, 2020

Science should be the cornerstone for health policy, and decisions on medical care of transgender and gender-diverse (TGD) individuals should be between a patient and their doctor.

That's according to a joint policy statement from the Endocrine Society and Pediatric Endocrine Society published in the Journal of Clinical Endocrinology & Metabolism expressing concern about recent proposed legislation that would limit access to medical care for TGD individuals.

"The main emphasis is that we are simply medical people trying to be conservative and science driven in the care of our patients," Joshua D. Safer, MD, coauthor and executive director of the Center for Transgender Medicine and Surgery at Mount Sinai Health System, and professor of medicine at Icahn School of Medicine at Mount Sinai, New York, said in an interview. "Why the health care for a particular group of people should be considered political is a mystery to me."

TGD individuals have seen a recent uptick in efforts to limit or restrict their access to medical care at the federal and state levels. In June 2020, the Department of Health & Human Services finalized a revision to Section 1557 of the Affordable Care Act, rolling back a 2016 rule that determined the phrase "on the basis of sex" included nondiscrimination based on a person's sex and gender identity. The Endocrine Society opposed this rule revision, arguing that it would allow "providers to deny care to TGD persons as well as discourage patients from seeking routine and gender-affirming care or reporting discrimination."

Over a dozen U.S. states have introduced proposed legislation concerning medical care of TGD individuals that contain erroneous and misleading information. Proposed laws in AlabamaMissouri, and Texas, for example, would prohibit any use of medical treatments for minors for the purpose of gender-affirming medical care, including "gonadotropin-releasing hormone agonist therapy for pubertal suppression and gender-affirming hormonal therapy," the authors of the joint statement wrote. In some cases, medical professionals who provide medical care for TGD patients could face criminal charges.

Outside the United States, three High Court judges in the United Kingdom recently ruled that minors aged under 16 years could not legally consent to pubertal suppression. "The recent U.K. court decision could be very disruptive because it would raise a barrier to transgender children receiving puberty blockers at exactly the ages that puberty blockers would be typically used," Safer said.

Misleading characterizations of gender-affirming medical care for TGD individuals have also been spread to the general public. A recent Republican primary ballot proposition in Texas asked whether the state should ban "chemical castration, puberty blockers, cross-sex hormones, and genital mutilation surgery on all minor children for transition purposes," falsely asserting that "Texas children as young as 3 are being transitioned from their biological sex to the opposite sex," referencing a high-profile custody battle of a transgender child in Texas.

There are several tiers of misinformation that exist within these statements, Safer noted. "Some statements have suggested that gender-affirming treatment for young children can include hormone therapy or even surgery. Of course, there are no medical treatments for transgender and gender-diverse children prior to puberty."

For adolescents aged under 18 years, Endocrine Society guidelines released in 2017 state that pubertal suppression is fully reversible and "offered to adolescents who meet diagnostic and treatment criteria, and are requesting care, for gender dysphoria/gender incongruence after they exhibit physical changes of puberty," Safer and coauthors wrote in the joint policy statement. Other, more permanent – but still partially reversible – treatments such as hormone therapy are available as options for adolescents with confirmed and persistent gender dysphoria/gender incongruence, after meeting with a team of medical and mental health professionals and giving informed consent, according to the guidelines.

Safer expressed surprise at the opposition to puberty blockers in proposed state legislation. "Puberty blockers are the conservative option so that we can avoid permanent changes while thoughtful decisions are being made by our adolescent patients with their families and health care providers," he said.

The perception that puberty blockers will lead to hormone therapy is another misunderstanding and source of misinformation, Safer explained.

"The fear is that these data suggest that puberty blockers are a 'gateway drug' of some sort. But that is false. The reason that most adolescents who take puberty blockers go on to hormone therapy is because most of the adolescents who are identified in our conservative systems are actually transgender and interested in more gender-affirming care as they age," he said.

Effects of Discrimination on TGD Persons

Many of these proposed state bills have not advanced through state legislatures, but a few – such as the proposed laws in Alabama, Missouri, and Texas – are still currently under consideration.

"In the United States, most recent efforts to single out transgender and gender-diverse people for discrimination in health care have failed. However, the demonization of trans people and attempts to disrupt care have been the source of much stress among our patients," Safer said.

Restricting access to health care has "multiple implications" for TGD patients. "In the era when we did not provide care to transgender youth, we had a situation where approximately 40% of transgender people had considered suicide in their lives," Safer said. In contrast, having access to these treatments has been shown to improve mental health outcomes in these patients, according to an Endocrine Society position statement.

The purpose of earlier interventions such as puberty blockers is to allow an adolescent to "explore options and live in the experienced gender before making a decision to proceed with gender-affirming hormone therapy," the authors of the Endocrine Society and Pediatric Endocrine Society joint statement said.

Blocking access to puberty blockers, on the other hand, forces transgender youth to experience a puberty that doesn't match their gender identity, Safer noted. "The puberty will include permanent changes which will then have to be reversed with surgery. Why would we intentionally allow that to happen?"

Safer reported that his spouse is an employee of Parexel. Tangpricha is the current president of the World Association for Transgender Health and a board member of the American Association of Clinical Endocrinology. The other authors reported no relevant conflicts of interest.

SOURCE: Safer JD et al. J Clin Endocrinol Metab. 2020. doi: 10.1210/clinem/dgaa816.

This article originally appeared on MDedge.com, part of the Medscape Professional Network.

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