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A call on SA medical professionals to heed evidence on child and adolescent gender distress

A call on SA medical professionals to heed evidence on child and adolescent gender distress
The immediate side-effects related to puberty blockers and cross-sex hormones (reproductive sterility and loss of bone density) are well understood. However, there are few long-term studies examining the long-term impact on mood, memory, learning and psychosexual maturation. (Photo: Simon Hausberger / Getty Images)

Internationally, a growing number of public health authorities recognise that less medically invasive approaches, such as exploratory psychotherapy, should be the first-line treatment for young people with gender distress. These include Sweden, Finland, Australia, New Zealand and the UK.

Over the past few years there has been a dramatic increase in children and adolescents being diagnosed with gender dysphoria, gender incongruence or gender distress.

This phenomenon has been noted both internationally as well as in South Africa and is an issue that concerns parents, the medical profession, the Department of Education and other sectors of South African society. The best approach to providing care for these vulnerable children and adolescents has been fiercely contested.

A vocal sector of the medical community, locally and internationally, has presented a “gender affirming” approach as the standard of care. This approach assumes that children and adolescents who self-report that they wish to adopt a gender role different from their sex are “transgender”, and that they should be “affirmed” in this, meaning they are socially supported by parents, extended family, educators and broader society in adopting the gender of their choice.

This starts with “social transition” including change of name and pronouns, adopting certain clothes and hairstyles and use of different toilets. The next step is medical interventions where drugs such as puberty blockers and cross-sex hormones are prescribed if requested. Finally, if they choose, they are provided with surgical procedures such as mastectomies and genital surgery.

This relatively new approach gained international popularity after the publication of two Dutch studies in 2011 and 2014. The approach is foundational to the management guidelines promulgated by the World Professional Association for Transgender Health and has fallaciously been presented as the  global standard of care for “transgender health”.

However, there is now emerging scientific consensus that the two Dutch studies, as well as several other subsequent studies, suffer from serious methodological problems. These include a high risk of bias due to small sample sizes, lack of control groups, confounding factors and poor study design.

Further, attempts to replicate the Dutch studies at the Tavistock Gender Identity Development Services in the UK, the world’s largest paediatric clinic, failed to demonstrate the psychological improvements reported by the Dutch.

The uncritical adoption of gender-affirming management strategies for children with gender dysphoria is not aligned with the best medical evidence.

Four major systematic reviews of the medical evidence supporting gender-affirming care have been conducted in Finland, Sweden and the UK.  All of the reviews concluded that social transition and puberty blockers in children and adolescents could not be recommended as the benefits they sought to achieve were not realised and that clear harm could be demonstrated. A letter published in the Wall Street Journal on 13 July 2023, and signed by 21 clinicians from nine countries, including some authors of this article, summarises these findings as follows:

“Every systematic review of evidence to date… has found the evidence for mental health benefits of hormonal interventions for minors to be of very low certainty. In contrast, the risks are significant and include sterility, lifelong dependence on medication, and the anguish of regret. For this reason, increasing numbers of European countries and international professional organisations now recommend that psychotherapy rather than hormones and surgeries should be the first line of treatment for gender-dysphoric youth.”

These systematic reviews of medical evidence have shown previously published guidelines that encouraged a gender-affirming approach to be unreliable. Further, proponents of the gender-affirming approach commonly claim that the interventions reduce suicide risk.

However, these reviews show that this claim is not supported by the published scientific evidence. As noted in the Wall Street Journal letter, this makes claims of increased suicide risk in children not receiving gender-affirming care both unfounded and irresponsible.

In recent years, it has been difficult for people to challenge the gender-affirming approach, both internationally as well as in South Africa. There has been a lack of respectful dialogue about an issue that affects vulnerable young people in profound ways. Many of those who have questioned the gender-affirming ideology have been labelled “transphobes” – a common and pejorative way to shut down the discussion and intimidate those with different perspectives.

Internationally, a growing number of public health authorities recognise that less medically invasive approaches, such as exploratory psychotherapy, should be the first-line treatment for young people with gender distress. These include the traditionally liberal Scandinavian countries like Sweden and Finland, as well as Australia, New Zealand and the UK. The Finnish National Health service guidelines on the management of gender dysphoria recommend:

“In adolescents, psychiatric disorders and developmental difficulties may predispose a young person to the onset of gender dysphoria. These young people should receive treatment for their mental and behavioural health issues, and their mental health must be stable prior to the determination of their gender identity.”

The immediate side-effects related to puberty blockers and cross-sex hormones (reproductive sterility and loss of bone density) are well understood. However, there are few long-term studies examining the long-term impact on mood, memory, learning and psychosexual maturation. This raises serious questions about the ability of children to understand the implications of these interventions over a long time and so to provide true informed consent for gender-affirming care. 

A holistic management approach, centred on watchful waiting is being proposed. This includes psychotherapy as well as the management of a wide range of common coexisting disorders such as anxiety, depression, ADHD, psychosis, eating disorders, suicidal ideation, self-harm and autistic spectrum disorders.

While much attention has been focused on the impact of puberty blockers and cross-sex hormones, it must be understood that social transition is not a neutral action – a key finding in the NHS Cass review.

In the vast majority of cases, gender dysphoria in children will resolve once they have gone through puberty. However, social transition results in up to 97% of these children having persistent gender dysphoria and many proceeding to puberty blockers and cross-sex hormones.

Where to now?

Over the past few years there has been a significant increase in the number of countries rejecting social transitioning, puberty blockers and cross-sex hormone therapy as the de facto “standard of care” for children with gender distress.

Rather, a holistic management approach, centred on watchful waiting is being proposed. This includes psychotherapy as well as the management of a wide range of common coexisting disorders such as anxiety, depression, ADHD, psychosis, eating disorders, suicidal ideation, self-harm and autistic spectrum disorders.

This contrasts with recent publications in South Africa, which include a guideline by the South African HIV Clinicians Society and the Professional Association for Transgender Health South Africa that advocate a gender-affirming approach in children and adolescents.

The safety and protection of children should be one of the highest priorities in any society. It is crucial that any social, psychological or medical interventions provided to children do not cause harm and should increase their well-being. Due to children’s inherent vulnerability, their rights need to be promoted and protected by all sectors of society. 

The South African Constitution states: “A child’s best interests are of paramount importance in every matter concerning the child.” As noted in the United Nations Convention on the Rights of the Child, childhood is a special, protected time in which children must be allowed to grow, learn, play, develop and flourish with dignity. 

As such, we call on members of the medical profession and others in South Africa to “first do no harm” when faced with vulnerable children and adolescents. The uncritical adoption of gender-affirming management strategies for children with gender dysphoria is not aligned with the best medical evidence and is out of step with international developments and an increasing number of national regulatory authorities.

First Do No Harm SA is a voluntary association of South African professionals who are advocating for evidence-based care of children and adolescents with gender distress. Anyone who would like to know more can email [email protected]. DM

This article is signed by the following professionals, who are members or supporters  of FDNHSA: Dr Janet Giddy: Family Physician, Cape Town; Assoc Professor Reitze Rodseth: Anaesthesiologist & critical care specialist, Pietermaritzburg; Dr Tygie Sidhambaram Nadesan: Family Physician, Durban; Prof WJ Steinberg: Family Physician, Bloemfontein; Dr AK Lutakwa: General Surgeon, Durban; Dr Martin Bac: Family Physician, Gauteng; Dr M Gounder: Urologist, Durban; Dr Erika Drewes: Family Physician, Cape Town; Dr Ami Muller: General Practitioner, George; Dr Jonathon Pons: Eye Surgeon, Eswathini; Dr Jolanda Niemann: General Practitioner, Gauteng; Dr Allan Donkin: General Practitioner, Western Cape; Dr Albu van Eeden: General Practitioner, KZN; Dr Francois Potgieter: Child Psychiatrist, North West; Dr Hein Pohl: Surgeon, Western Cape; Dr Frances Scholtz: General Practitioner, Western Cape; Dr Maria Rossouw: Medical Officer in Endocrinology, Bloemfontein; Dr Caroline Armstrong: Emergency Care doctor, Pietermaritzburg; Dr Jon Larsen: Obstetrician, KZN; Melindie Pretorius: Researcher & medical student, Western Cape; Jaco van Zyl: Clinical Psychologist, South African in Ireland; and Vincent Deboni: Counselling Psychologist. South African in Sweden.


Comments - Please in order to comment.

  • Clare Kerchhoff says:

    Thank you FDNHSA. It is high time that medical professionals in South Africa look at evidence based research for treatment of gender dysphoria in vulnerable young people, and remain true to the principal of “First do no harm.”

    • Emelie Prince says:

      Finally we can start seeing research that unpacks the true narrative of gender dysphoria in children. Social media pushes an extremely biased perspective that does severe harm. It is time that the medical field start protecting children and base their practise on evidence instead of cultural pressures.

  • James Webster says:

    This article has a lot of words but does not say very much, just repeating again and again that “puberty blockers + surgery bad, psychotherapy good”. It’s also worth pointing out that the perspectives aired in this article suffer from the same limitations used to attack the contrary position on gender dysphoria management and those are the lack of significant research supporting the position and the relatively low certainty that its management approach is effective. It appears as if the signatories to this document are a group of old women who are too afraid to do anything concrete and so advise standing on the sidelines. It’s just so much easier to do nothing isn’t it.

  • Kari Schoonbee says:

    The overwhelming majority of doctors signing this letter are ideologically opposed to any gender affirming care, even in adulthood. They are overwhelmingly evangelical Christians and are not following the science without fear or favour. They are also not specialists in the care of gender diverse children and are mostly practising in completely unrelated fields of medicine. The cherry-picked and misrepresented studies are therefore only a smokescreen – even if the data couldn’t be more clear, they would still oppose gender affirming healthcare.

    It is also simply untrue that rigorous evaluation and psychotherapy is not done before blockers and hormones are prescribed to trans children in SA. Gender dysphoria is often the root cause of a number of other mental or even physical health issues, and to propose that all these other symptoms be resolved before any affirming treatment can proceed is harmful. “First do no harm” does not consider the harm done by inaction, which is one of the reasons the Hippocratic oath has fallen by the wayside. By forcing children who are consistent, insistent and persistent in their gender identity, often from very young ages, to undergo their natal puberty, they condemn them to incredible mental anguish and a possible lifetime of ostracisation due to secondary sex characteristics that can not be altered, even by prohibitively expensive surgery. It is noted that not other treatment model over decades of treatment of trans children has produced better outcomes.

    For scientific and referenced responses to the claims made above, I would recommend reading the WPATH’s public statements in response to articles like the above.

    • Clare Kerchhoff says:

      Ask the parents about the ‘rigorous evaluation and psychotherapy’ before medicalising. You will find a number of parents shocked by the lack of it and the very fast tracking onto hormones and surgeries in SA.
      Please consider the growing research from other LGBTQIA friendly countries who are becoming much more cautious in their treatment of gender distressed people and have found WPATH to be ideologically driven rather than patient driven.

      • Kari Schoonbee says:

        That is not true. Providers following WPATH doesn’t stand to gain anything from un-evidenced decision making as high numbers of bad outcomes will prevent those who need the care from accessing it. You can raise the aspect of ideological capture by the so called “LGBTQIA friendly” countries’ review boards too. The unfortunate thing is that any timeline that involves medical care can feel very “fast tracked” for parents who have fears, understandably so, but it does not mean that the decision making was not rigorous. Time also does not stand still during puberty so the luxury of waiting for years on end is not there.
        The authors here are even against social transition, which does not even involve medical treatment and often happens organically.

    • Eugene visser says:

      Systematic Review that Ranks WPATH guidelines as Poor Quality
      This 2021 BMJ first of its kind “systematic review and quality assessment” used “to assess all international clinical practice guidelines” rated WPATH’s (World Professional Association for
      Transgender Health) SOC 7 with a quality score of zero out of six.
      Dahlen S, Connolly D, Arif I, et al International clinical practice guidelines for gender minority/trans people: systematic review and quality assessment. BMJ
      Open 2021;11:e048943. doi: 10.1136/bmjopen-2021-048943

      • Peter van Heusden says:

        The doi that you supply leads to a BMJ “Rapid Response” which is a “moderated but not peer reviewed online response to a published article in a BMJ journal”. That’s commentary, not peer reviewed science.

  • Eugene visser says:

    Top Studies on the Science Against Transgender Interventions
    September 2023
    Studies that Show Transgender Interventions Harm, not Help
    ● This 2011 Swedish study of post-sex reassignment surgery adults showed a completed
    suicide rate 19 times that of the general population 10 year out, along with nearly 3 times
    the rate of psychiatric inpatient care.
    o Dhejne C, Lichtenstein P, Boman M, Johansson ALV, Langstrom N, et al. (2011)
    Long-Term Follow-Up of Transsexual Persons Undergoing Sex
    Reassignment Surgery: Cohort Study in Sweden. PLoS ONE 6(2): e16885.
    ● This 2020 study, claiming to be the first total population study of 9.7 million Swedish
    residents, showed neither “gender-affirming hormone treatment” nor “gender-affirming
    surgery” improved the mental health benchmarks.
    o Bränström R, Pachankis JE: Reduction in mental health treatment utilization
    among transgender individuals after gender-affirming surgeries: a total population
    study. Am J Psychiatry 2020; 177:727–734.

    o Kalin NH: Reassessing mental health treatment utilization reduction in
    transgender individuals after gender-affirming surgeries: a comment by the
    editor on the process (letter). Am J Psychiatry 2020; 177:765

    ● This 2021 comprehensive data review of all 3,754 trans-identified adolescents in US
    military families over 8.5 years showed that gender hormone treatment lead to increased
    use of mental health services and psychiatric medications, and increased suicidal
    ideation/attempted suicide.
    o Elizabeth Hisle-Gorman, MSW, PhD and others, Mental Healthcare Utilization of
    Transgender Youth Before and After Affirming Treatment, The Journal of Sexual
    Medicine, Volume 18, Issue 8, August 2021, Pages

  • Evidence Based says:

    People can, in good faith, assess the evidence and disagree that the ‘affirmative’ model (broadly speaking, blocking puberty & administering cross-sex hormones to minors) is the best way to treat gender distress in young people. FDNHSA is a welcome voice in this debate in South Africa.

    Some advocates of the ‘affirmative’ model would say that being skeptical about the benefits of administering puberty blockers and exogenous hormones to children amounts to denying them treatment or care. In this view, undergoing one’s natal puberty – which not only involves the development of secondary sex characteristics, but vital brain maturation – is a harm that must be avoided. If halting a child’s puberty and putting them on exogenous hormones were the only, proven way to treat gender dysphoria (and if the benefits clearly outweighed the risks and long-term side effects), this claim might be true. But it is not.

    Several countries – such as Sweden, Finland, and the UK – have embarked on systematic reviews to look at the evidence for medicalising minors who have gender dysphoria. They found that the evidence in favour of blocking puberty and giving cross-sex hormones to minors is weak, and that the benefits do not outweigh the significant risks and potential harms of this treatment. Based on these findings, these countries have limited ‘affirmative’ treatment to research settings, with the acknowledgement that this medicalised approach is experimental and has unknown long-term consequences.

    The ‘affirmative’ model is based on a treatment regimen codified in the Netherlands, the so-called Dutch Protocol. The studies which formed the basis of the Dutch Protocol have methodological flaws, as do several of the studies frequently cited to support puberty blockers and hormone regimens as the only valid treatment of gender dysphoria in minors.

    In contrast, the ‘exploratory’ approach prioritises therapeutic interventions as a first-line treatment. It seeks to understand why a young person is expressing distress over their sex-related physical characteristics, and recognises that psychiatric comorbidities, personal and family history, sexual orientation, and social context can all contribute to this form of body dysmorphia in young people.

    Ad hominem responses to disagreement do nothing to help us understand this issue, nor help children in distress.

    Further references:
    J. Block ‘Gender dysphoria in young people is rising—and so is professional disagreement’, BMJ 2023; 380.

    E. Abbruzzese, Stephen B. Levine & Julia W. Mason (2023) ‘The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies — and research that has followed’, Journal of Sex & Marital Therapy, 49:6, 673-699.

    M. Biggs (2023) ‘The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence’, Journal of Sex & Marital Therapy, 49:4, 348-368.

    L. Edwards Leeper & E. Anderson (24 November 2021) ‘The mental health establishment is failing trans kids’, The Washington Post, 24 November 2021

    • Kari Schoonbee says:

      This “exploratory therapy” is conversion therapy by another name. It will never accept that the root cause can just be gender identity and will always postpone and gaslight patients into seeking the “real” cause. Never has an “exploratory therapist” actually referred a patient for affirming care. It seeks to oppose itself to affirmative therapy – which actually does include ruling out of other causes or misunderstandings through the normal process – but is also open to blockers and hormones when appropriate. Notably prior to affirmative care, this type of care was the only available and did not produce good results, which is why doctors reluctantly moved to the affirmative model in the first place.

      There is also no evidence to suggest trans youth’s brain maturation is affected, this allegation is invented from whole cloth. Exogenous hormones does induce puberty and all the normal effects from puberty happens, just for the opposite sex. Puberty is not blocked indefinitely.

    • Kari Schoonbee says:

      If there were a fringe group of doctors arguing against blood transfusions and citing very selective research to back up their position but presenting it as neutral, would pointing out that they are Jehova’s Witnesses be an ad hominem? It’s just relevant context.

      This can also be seen in the arguments that are NOT offered. Opponents of the affirmative care model often cite the flawed stat that 80% of gender diverse children desist by puberty. (This is based on old criteria that included all kids who were not gender stereotypical, not kids with strong gender dysphoria and cross-gender identification) Most of those kids grew up to be gay members of their biological sex. Of course for many members of FDNH this is also a bad outcome so that trope is conveniently left out.

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