The release of a major review of gender identity services for children has sparked debate about the best approach to providing care for young people with gender dysphoria or gender incongruence; a complex, contested and controversial issue globally and in South Africa, writes MedicalBrief.
After the recent release of the “Cass review” in the UK – which was, interestingly, rejected by many “experts” in America – it is clear a change of course is needed in South Africa, suggest doctors Janet Giddy, Allan Donkin, and associate professor Reitze Rodseth in Spotlight.
They write:
The Independent Review of Gender Identity Services for Children and Young People – also called the Cass review – was released by Britain’s National Health Service (NHS) in April.
Led by paediatrician Dr Hilary Cass, former president of the Royal College of Paediatrics and Child Health, the review is the culmination of a four-year investigation into how the NHS provided care to children and young people with gender dysphoria at the largest gender clinic in the world, the controversial Tavistock Gender Identity Development Service (GIDS).
The 388-page report was accompanied by nine studies, eight of which were systematic reviews of evidence, supporting the recommendations.
This landmark report heralds the end of an era of the heavily medicalised gender-affirming care approach to the treatment of young people with gender-related distress.
In this context, medicalised care means prescribing hormone blocking medication to halt the physical changes of puberty, as well as opposite sex (cross-sex) hormones, with the final possible step in the process being “gender-affirming surgery”: major surgical procedures, including mastectomy and removal of genital organs, which can cause severe and permanent side effects like sexual dysfunction and infertility, among others.
At the heart of the new review is a profound concern expressed by Cass for the welfare of children and young people.
In meticulous detail, the report reveals what was going on inside GIDS. Cass concludes that the gender-affirming medical treatments it provided, like puberty blockers and cross-sex hormones, were based on “wholly inadequate evidence”.
Doctors are usually cautious when adopting new treatments, but Cass said “quite the reverse happened in … gender care for children”.
Instead, thousands of children were put on an unproven medical pathway. Worse still, medical professionals seemed largely uninterested in uncovering the side effects and long-term risks of these drugs. Cass said that all but one adult gender clinic refused to share patient data that would allow her team to study how the children who were transitioned fared as adults.
This made it virtually impossible to research the potential longer-term consequences of transitioning. This has largely been driven by a focused and very successful campaign by transactivists to lobby for change at all levels of society.
The major recommendations of the Cass report provide much-needed clarity about the extremely dynamic field of gender medicine.
She recommends re-orientating care for vulnerable young people away from medicalisation and towards less invasive methods, like psychological interventions, and cautions against social transitioning, as it is the first step in the gender-affirming pathway.
Social transitioning is allowing the child to socially present themselves as the opposite sex by changing names, and pronouns, and appearance to match the opposite sex.
The report recognises the need for proper exploration of children’s complex mental health concerns and acknowledges that many of those seeking treatment may simply end up as gay, lesbian or bisexual adults without a transgender identity if allowed to develop naturally.
It emphasises the need for robust safeguards to protect and ensure children’s safety, saying all treatment must be underpinned by a clear evidence base, preferably via systematic reviews (which provide the highest quality of medical evidence).
Importantly, Cass highlights the distinct needs of children (and adults) who have de-transitioned – needs that are often neglected, denied, or ignored.
The report’s main recommendation is that in the UK, care of youth with gender dysphoria who are under 18 should no longer be based on the gender-affirming model of care but instead, should be similar to care for youth with other developmental struggles, and use standard psychological and psychotherapeutic approaches.
Any use of hormones should be regarded as experimental and need to be provided in the context of a carefully monitored clinical trial. Further, the review noted that young adults between 18 and 25 are also vulnerable, and should be subject to many of the same limitations as the under-18s.
Adult gender clinics are now also in the spotlight, partly because of concerns by the Cass review that the 18 to 25 year-olds (who access adult gender clinics) need similar protection from care and interventions that are not evidence-based.
The adoption of the Cass Review recommendations now aligns the UK with Sweden, Denmark, and Finland, which centre standard psychological and psychotherapeutic care for these children and confine puberty blockers and cross-sex hormones to clinical trials.
The WHO has not yet produced international guidelines regarding gender-affirming care for either children or adolescents.
What is happening in South Africa?
Gender services and clinics exist in various metropolitan areas and are part of state funded referral and academic hospitals. These are mostly adult clinics, but there is a gender clinic for children at the Red Cross Hospital in Cape Town.
Some adolescents who were started on puberty blockers at this hospital have been referred to Groote Schuur Hospital to receive cross-sex hormones in their adolescent years. Gender-affirming care is also provided in the private sector.
The National Department of Health has not produced any guidelines or policies recommending gender-affirming care, however, for the past few years, this approach has been actively promoted by individual clinicians, the Professional Association for Transgender Health South Africa, and some medical societies and institutions.
The Southern African HIV Clinicians’ Society has published Gender Affirming Health Care guidelines for South Africa, with some activists and clinicians considering these to be national treatment standards.
Articles have been published recommending gender-affirming care and talks given at conferences, universities and online have done the same.
A common thread has been the recommendation that South African healthcare providers adopt gender-affirming healthcare, that it should be provided at a primary care level (including rural areas), that staff need to be trained to provide it, and that it should be taught at medical schools so that it will become part of mainstream medical care in this country.
A significant area of concern is that it has been difficult to have open debate about these issues in South Africa, as was the case in the UK, until recently.
Where we and others have raised questions at meetings about the medical evidence supporting gender-affirming care of children, discussion is often shut down and at times we’ve been accused of transphobia. Some clinicians have expressed fear that they may suffer personal or academic reprisals if they question gender-affirming care with their colleagues.
As international recognition of the lack of evidence for gender-affirming care grows, the South African medical community stands at a crossroads.
Will the Cass Review’s call to provide compassionate, evidence-based care to vulnerable children be taken seriously? Will clinicians who have advocated and implemented medicalising treatment approaches for children and adolescents with gender dysphoria find the humility and courage to change their practise?
Will the medical societies who have promoted the gender affirming model revise their position statements and support a less medicalised, more holistic management strategy?
There is an urgent need for South African clinicians, academics, medical organisations and societies to bravely step forward and provide sound guidance and leadership regarding the care of vulnerable children and adolescents with gender dysphoria.
We sincerely hope that this issue will be engaged with honesty, courage and integrity so that vulnerable children are protected from being irreversibly harmed.
Meanwhile, back in the USA…
While Britain was quick to restrict puberty blockers and other interventions in light of the report, the American medical establishment has doubled down on supporting gender transitions for young people, reports Unherd.
The Endocrine Society, which supports puberty blockers and cross-sex hormones for minors, said the Cass Report “does not contain any new research” that would contradict those guidelines.
Stephen Hammes, the organisation’s president, also defended its position in the media last year. “More than 2 000 studies published since 1975 form a clear picture: gender-affirming care improves the well-being of transgender and gender-diverse people and reduces the risk of suicide,” he wrote.
The American Academy of Paediatrics, one of the most vocal champions within the US medical establishment of child gender transitions, declined to comment on the Cass Report and instead reiterated its opposition to legal restrictions on the practice.
The AAP’s 2018 statement in support of child gender transitions calls for minors to have access to “comprehensive, gender-affirming, and developmentally appropriate healthcare”, for doctors to advocate for laws expanding access to such treatments, and for children’s medical charts to reflect their gender identity rather than their biological sex.
The American Medical Association, which supports cross-sex treatments for minors and resolved last year to intensify its lobbying efforts in support of youth access to gender transitions, has not yet made a public statement on the review.
The World Professional Association for Transgender Health (WPATH) said Cass’ report was “rooted in the false premise that non-medical alternatives to care will result in less adolescent distress for most adolescents”.
While many Western countries are restricting transgender treatments for children, there’s no end in sight in the US, where the debate has taken on distinctly partisan contours. Red states have attempted to ban the procedures, while the Biden administration has promoted childhood gender transitions throughout the federal government.
Politicians and media outlets have often sought advice on transgender issues from these medical organisations, whose guidelines are formed by a small number of vocal activists with views which do not necessarily reflect those of the majority of members.
The AAP’s guidance on child gender transitions, for example, was written by a single doctor. Cass described the relationship between these groups as an “echo chamber”, saying there was a circularity to their guidance.
The groups have thousands of members, most of whom do not specialise in gender and are not deeply involved in the organisation, meaning the members who themselves work in gender clinics are often the ones writing these guidelines.
*The Spotlight authors are all members of First Do No Harm Southern Africa, a voluntary association of health professionals advocating for evidence-based care of children and adolescents with gender distress. Giddy is a family physician, Donkin is a general practitioner, and Rodseth is an associate professor and anaesthesiologist and critical care specialist.
Unherd article – US medical establishment rejects Cass Report (Open access)
See more from MedicalBrief archives:
NHS gender treatment model slammed in damning report
NHS England bans puberty blockers at clinics
NHS drafts new guidelines for treating transgender youth
1 000 families to sue UK gender identity service