Court case highlights misconceptions surrounding pediatric transgender care
A Texas court case involving a custody dispute over a young child who may identify as transgender has ignited a national debate about the appropriate course of pediatric treatment, with the state’s governor calling for an investigation into the case and one legislator proposing a bill that would prohibit the use of pubertal blockers for minors.
The case, according to a report in The New York Times, centers on the gender identity of a 7-year-old child who was born male but identifies as female, according to the child’s mother. In custody hearings, the child’s mother, who has expressed support for the child’s gender identity, has sought to compel the father to do the same. The father has stated the child is a boy and sought to raise money to support his cause, stating he is fighting “forced and irreversible medical procedures” for his child, according to the report.
In a ruling Oct. 24, Judge Kim Cooks in the 255th District Court in Dallas said that the parents should have joint custody and that the state could not require the father to treat the child as a girl, according to published reports. In the wake of the decision, Texas State Representative Matt Krause stated he would introduce a bill to prohibit the use of puberty blockers by minors.
The talk of proposed legislation — along with misinformation about gender-affirming care quickly spreading on blogs and social media — has sparked an outcry from the pediatric endocrinology community, with many experts expressing dismay about talk of pediatric treatments that go against all standards of care and practice guidelines.
“I remain completely baffled by attempts to take something which is purely medical and treat it as if there is any political element to it at all,” Joshua D. Safer, MD, medical director of the Center for Transgender Surgery and Medicine at the Mount Sinai Health System, told Endocrine Today. “The key approach to gender-expansive children who might be transgender is to follow their lead in terms of how they want to present and dress. There are no medical treatments for children before puberty of any sort, and there are no surgeries.”
In a clinical practice guideline published in 2017 by the Endocrine Society, researchers recommend avoiding hormone therapy for transgender children prior to puberty. The guideline states that any decisions regarding the social transition of prepubertal youths with gender incongruence should be made with the assistance of a mental health provider or another experienced professional. The guideline is co-sponsored by the American Association of Clinical Endocrinologists, American Society of Andrology, European Society for Pediatric Endocrinology, European Society of Endocrinology, the Pediatric Endocrine Society and the World Professional Association for Transgender Health.
“No one would ever even remotely consider treating a 7-year-old child who may be transgender with any kind of medical intervention,” Stephen M. Rosenthal, MD, founder and medical director of the Child and Adolescent Gender Center at UCSF Benioff Children's Hospital, a member of the board of directors for the Endocrine Society and a former president of the Pediatric Endocrine Society, told Endocrine Today. “It is not part of any standards of care or clinical practice guidelines. That is a distortion of current practice and guidelines.”
In a statement released Monday, the Endocrine Society noted that many of the claims being made about gender-affirming care for transgender and gender incongruent individuals are inaccurate. “Policies concerning the diagnosis and treatment of transgender individuals should be based on science, not politics,” the organization stated.
On Tuesday, the Pediatric Endocrine Society also weighed in with a statement expressing concern for the health risks and safety of transgender and gender-diverse youths and their families when public discourse “delegitimizes” the right to receive gender-affirming care.
“This is not only harmful to the mental and physical health of these youth, but opposes current standard of care recommendations,” the organization stated in a press release. “As pediatricians and pediatric endocrinologists, we strongly oppose public discourse that misrepresents and contradicts evidence-based standard of care recommendations and risks the well-being of transgender youth and their families.”
Mental health risks
In an analysis of the 2015 U.S Transgender Survey published in September, researchers found that transgender individuals who are denied care from a health care provider are more likely to report having suicidal thoughts and suicide attempts. Among individuals who were refused gender-affirming care in the previous year, 62% reported experiencing thoughts of suicide and 14.4% attempted suicide.
“The data with regard to transgender children includes higher rates of suicide consideration and attempts,” Safer said. “When we look more closely at those data, we see that children who are supported by parents have much lower rates of suicidal ideation relative to children who are not supported by parents. The connection seems to be more with support from parents vs. being transgender.”
Supporting social transition
In its statement, the Pediatric Endocrine Society noted that prepubertal children who are gender-questioning should be supported to explore their gender identity freely and, in some circumstances, allow for a social transition, which could include a change of name, pronouns or attire.
“Gender identity can be different from the gender that is presumed based on the sex assigned at birth, and interventions intended to change one’s gender identity are not only ineffective, but also harmful,” the association wrote.
Only after puberty begins, Rosenthal said, would puberty suppression via a pubertal blocker be considered or initiated. The reversible treatment can decrease the distress of experiencing the “wrong” puberty.
“Pubertal blockers are only indicated for someone who has reached the beginning of puberty and has gender dysphoria,” Rosenthal said. “Pubertal blockers are also the gold standard treatment for any child with precocious puberty, a completely unrelated condition. There are decades of worldwide experience using that class of medication that demonstrate it is reversible, and these people go on to resume puberty when they reach an age when it is appropriate with no adverse effects. In adolescents with gender dysphoria, there are important, published scientific data that show, from a mental health standpoint, that pubertal blockers markedly improve mental health and wellbeing.”
When considering a social transition, Rosenthal said, meeting with a multidisciplinary team can offer the family of a gender-questioning child an opportunity to get information, services and support.
“We see many kids like this coming to our clinic, and they are not looking for a medical treatment,” Rosenthal said. “Primarily, they are seeking support and to meet the team, including the medical providers, so that the family has a connection and feels that if they get to a point where the child persists and is suffering, they have options available. It gives the family peace of mind to initiate contact with the medical team members, even though no one is suggesting a blocker at that time.”
In its statement, the Endocrine Society wrote it is “critical” that transgender individuals have access to the appropriate treatment and care to ensure their health and well-being. – by Regina Schaffer
Hembree WC, et al. J Clin Endocrinol Metab. 2017; doi: 10.1210/jc.2017-01658.
Herman JL, et al. Suicide Thoughts and Attempts Among Transgender Adults in the U.S. Available at: williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP-Williams-Suicide-Report-Final.pdf
Disclosures: Rosenthal and Safer report no relevant financial disclosures.