England overhauls medical care for young transgender people

England’s National Health Service announced on Thursday that it is closing the country’s only youth gender clinic in favor of a more distributed and comprehensive network of medical care for teenagers looking for hormones and drugs. other gender-related treatments.

The closure follows an external review of the Tavistock Clinic in London, which has served thousands of transgender patients since the 1990s. The review, which is ongoing, has raised several concerns, including long waiting times, insufficient mental health support and the growing number of young people seeking gender-related treatment.

The overhaul of services for young transgender people in England is part of a noticeable shift in medical practice in some European countries with nationalized healthcare systems. Some doctors there are concerned about the increase in numbers as well as the lack of data on long-term safety and outcomes of medical transitions.

In the United States, doctors specializing in adolescent gender care have mixed feelings about the reforms in Europe. While many agree that more comprehensive health care for transgender youth is badly needed, as is more study of treatments, they fear the changes will fuel the growing political movement in some states to ban such care altogether.

“How do we draw the line so that we keep individualized care while maintaining safety standards for everyone? That’s what we’re trying to sort out,” said Dr. Marci Bowers, plastic surgeon and incoming president of the World Professional Association for Transgender Health, who is transgender. “It’s the people on the ground who have to make those decisions, not the people in Washington or the state legislatures.”

The NHS said current patients at the Tavistock Clinic could continue to receive care there before being transferred to two new centers in children’s hospitals in London and Manchester. The new clinics will expand the country’s gender services while ensuring children are adequately treated for autism, trauma and mental health issues. Specialists will also carry out clinical research on gender-related drugs.

There are “crucially important unanswered questions” about the use of puberty blockers, wrote Dr. Hilary Cass, lead external reviewer of the country’s youth gender identity services, in a letter to the head of NHS England last week.

Puberty blockers, which are largely reversible, are intended to give younger patients time to make important decisions about permanent medical changes. But Dr Cass wondered if most teenagers who were prescribed these drugs received the support they needed to reverse the trend, if they wanted it.

Tavistock received more than 5,000 patient referrals in 2021, up from just 250 in 2011. The types of patients seeking referrals have also changed over the past decade. When the clinic first opened, it primarily served children who had been assigned a boy at birth. Last year, two-thirds of his patients were assigned to a woman at birth.

It is unclear why the number of patients has increased so drastically or why transgender boys are driving the increase.

Transgender advocates in Britain welcomed the changes, but stressed that many questions remained about how they would affect care for young people.

“We’re optimistic, cautiously optimistic, about the news,” said Susie Green, chief executive of Mermaids, an advocacy group for transgender and gender-diverse youth. “There’s a two-and-a-half-year waiting list to see for your first date. We have seen the distress caused to young people because of this.

But Ms Green, who has a transgender adult daughter, said the group were concerned about whether mental health services would take priority over medical care. Gender diversity, she said, should not be treated as a mental disorder.

“We wouldn’t want to see any other barriers put in place in terms of access to medical intervention,” Ms Green said.

In 2020, a former Tavistock patient, Keira Bell, joined a high-profile lawsuit against the clinic. She claimed she was put on puberty blockers at 16 ‘after a series of superficial conversations with social workers’ and had her breasts removed at 20, decisions she has regretted later.

A high court initially ruled that children under the age of 16 were unlikely to be mature enough to consent to such medical procedures. But that ruling was overturned in September last year as judges ruled “it was for clinicians rather than the court to decide” whether a young patient could give informed consent.

In 2020, Tavistock employees raised concerns about medical care at the clinic, prompting the NHS to commission Dr Cass, a London pediatrician who was not affiliated with the clinic, to an external review. Its interim report was published in February this year.

Sweden’s national health service determined this year that gender-related care for young people should only be provided in exceptional cases when children have overt distress about their gender, known as dysphoria. All adolescents who receive treatment will need to participate in clinical trials to collect more data on side effects and long-term results. Finland took a similar position last year.

“Our position is that we can’t see this as just a rights issue,” said Dr. Thomas Linden, director of the country’s National Board of Health and Welfare, in an interview in February. “We have to see patient safety and accuracy in judging. We really have to be certain to some degree that we’re giving the right treatment to the right person.

Although these European countries have imposed some limits on transgender care, their approaches are much more permissive than those of some conservative US states. A recent law in Alabama has made it a crime for doctors to prescribe puberty blockers and hormones to minors. In Texas, parents who allow their children to receive sexist treatment have been investigated for child abuse. The two states are linked by court battles with civil rights groups.

Some American doctors feared that changing standards in Europe would reinforce the idea that gender treatments are dangerous for young people.

“I fear this will be construed as another notch against providing gender-affirming care to children,” said Dr. Angela Goepferd, medical director of the gender health program at Children’s Hospital of Minnesota. More services are needed, they said, not less. “That’s our challenge here.”

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