England overhauls medical care for transgender youth

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

The closure followed an external review of the Tavistock Clinic in London, which has served thousands of transgender patients since the 1990s. The review, which is ongoing, 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 transgender young people in England is part of a remarkable shift in medical practice in some European countries with nationalized health systems. Some doctors there are concerned about the increase in numbers, as well as the paucity of data on the 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, as well as more research into treatments, is desperately needed, they worry that the changes will fuel a growing political movement in some states to ban such care altogether.

“How do we draw the line so that we keep care individualized while maintaining standards of safety for all? That’s what we’re trying to address,” said Dr. Marcy Bowers, a gynecologist and reconstructive surgeon and incoming president of the World Transgender Health Professional Association, 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 at children’s hospitals in London and Manchester. The new clinics will expand gender equality services in the country while ensuring children are adequately treated for autism, trauma and mental health issues. Specialists will also carry out clinical research on gender drugs.

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

Puberty blockers, which are largely reversible, are intended to buy younger patients time to make important decisions about permanent medical changes. But Dr Kass doubts whether most adolescents prescribed these drugs have been given the support to reverse course if they choose to do so.

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 opened, it primarily served children who were assigned male at birth. Last year, two-thirds of patients were female at birth.

It is not clear why the number of patients has increased so dramatically or why transgender boys are responsible for 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 are optimistic, cautiously optimistic about the news,” said Susie Green, chief executive of Mermaids, an advocacy group for transgender and gender diverse youth. “There is a two and a half year waiting list to be seen for your first appointment. We have seen the suffering caused to young people because of this.

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

“We would not want any further barriers to be 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 claims she was put on puberty blockers at 16 “after a series of perfunctory conversations with social workers” and had her breasts removed at 20, decisions she later regretted.

The Supreme Court initially ruled that children under 16 were unlikely to be mature enough to consent to such medical interventions. But that decision was overturned in September last year, with judges ruling that “clinicians rather than courts should decide” whether a young patient can give informed consent.

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

Sweden’s National Health Service ruled this year that gender-specific medical care for young people should only be provided in exceptional cases where children experience clear distress about their gender, known as dysphoria. All adolescents receiving the treatment will need to be enrolled in clinical trials to gather more data on side effects and long-term outcomes. Finland took a similar position last year.

“Our position is that we cannot look at this simply as a rights issue,” Dr. Thomas Linden, director of the country’s National Board of Health and Welfare, said in an interview in February. “We need to see patient safety and precision in judgement. We have to be really somewhat sure that we are giving the right treatment to the right person.

Although these European countries have placed some restrictions on transgender care, their approaches are much more permissive than those in some conservative American states. A recent law in Alabama made it a crime for doctors to prescribe puberty blockers and hormones to minors. In Texas, parents who allow their children to receive gender-specific treatment have been investigated for child abuse. Both states are locked in legal battles with civil rights groups.

Some American doctors worry that changing standards in Europe will reinforce the notion that gender-based medicine is dangerous for young people.

“I’m concerned that this will be interpreted as another bias against providing gender-affirming care to children,” said Dr. Angela Goepferd, medical director of the Gender Health Program at Children’s Minnesota Hospital. More services are needed, they said, not less. “That’s our challenge here.”

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