Caring for young people with gender dysphoria

The debate on gender dysphoria perfectly captures all that is unsavoury about the intersection of science, medicine, and social media. Entrenched, even aggressively argued views are nothing new in science and medicine. But when it comes to gender dysphoria, just as with covid-19, there is little room for constructive dialogue. Unfortunately, what suffers is people’s welfare.

The priority for health professionals must be to offer the best possible care to their patients. Difficulties arise when the evidence base is preliminary or inconclusive. In that situation, when faced with a person seeking care, what is the best care to offer?

The dilemma is more acute if the person seeking care is a child or adolescent. This is the complex and difficult challenge that specialists in gender dysphoria must master to provide the best possible care to young people. John Launer describes the hostility and criticism that colleagues experienced at London’s Tavistock Clinic in striving “to make the best decisions they could in a situation where evidence was thin and the politics noisy” (doi:10.1136/bmj.p477).1

The principle of care, however, remains the same: ensure that the strength of your management recommendations is in line with the strength of the evidence. But the weaker or the more disputed the evidence base, the harder it is to offer a clear way forward. Other factors need to be weighed up, such as how invasive is the intervention you are recommending.

For a medical journal the focus is rightly on the quality of evidence behind a treatment recommendation. The BMJ has a longstanding and leading position in acknowledging the limits of evidence and advocating against overdiagnosis and overtreatment—even when the state of the science disagrees with individual preferences.

A review of the Gender Development Identity Service at the Tavistock Clinic by Hilary Cass reported interim findings last year acknowledging the difficulties that clinicians face when providing care to young people with gender related stress (doi:10.1136/bmj.p589 doi:10.1136/bmj.o629).23 The service had seen a rapid rise in referrals, and “there were different views held within the staff group about the appropriate clinical approach,” Cass wrote (https://cass.independent-review.uk/publications/interim-report).4 Cass’s final report will be delivered this year, but her interim report’s effect has been to question the evidence behind interventions, other than psychological support, being offered to young people seeking gender transition. Similar shifts are evident in other countries, such as Sweden.

The US, however, has moved in the opposite direction. An investigation by The BMJ finds that more and more young people are being offered medical and surgical intervention for gender transition, sometimes bypassing any psychological support (doi:10.1136/bmj.p382).5 Much of this clinical practice is supported by guidance from medical societies and associations, but closer inspection of that guidance finds that the strength of clinical recommendations is not in line with the strength of the evidence. The risk of overtreatment of gender dysphoria is real.

If we have the best interests of young people at heart, then surely our duty is to offer evidence informed care? And, if the evidence base is weak, we must provide the necessary support to young people as well as prioritising research to answer questions on issues that are causing a great deal of distress, much of which is amplified by social media. Taking this route is essential: an evidence void not only exposes people to overtreatment but can also be used to deny people the care that they seek, such as through the draconian laws now being introduced in some US states (doi:10.1136/bmj.p533).6 A better appreciation of the evidence, as well as the limits of medicine, is also the basis of a more constructive dialogue.