Last May, more than 20 conservative states filed an amicus brief against the inclusion of gender-affirming care for transgender people under the North Carolina State Health Plan in the court case Kadel v. Folwell. The case is still open, so I'm more concerned about the brief's arguments than its outcomes.
I didn’t mean to read a legal document — my idea of court cases is that they can be long, painful and expensive, which makes me want to avoid all things judicial — but an article I was reading linked to it. I was curious, and before I knew it I had read the whole thing and also gathered 38 pages’ worth of notes on articles, medical studies and legal documents on transgender care.
I read the brief because I can think of many arguments in favor of providing gender-affirming care, all of which are based on the belief that people who experience gender dysphoria — defined as severe or persistent distress associated with incongruence between one’s gender identity and biological sex — should be able to access effective treatment if this harms no one else and doesn’t cost exorbitant amounts of money. Yet I was at a loss about why and how people would argue against gender-affirming care, except possibly due to religious beliefs or unfamiliarity with transgender issues.
Is gender-affirming care medically necessary for transgender people? And secondly, is gender-affirming care medically necessary for transgender youth? The brief made three arguments in the negative, presented verbatim here:
1. “Chemical and surgical interventions cannot be assessed separately from the conditions to be treated.”
That is, the authors of the brief argue that procedures that are effective for one diagnosis (such as puberty blockers to treat precocious puberty) are inappropriate for a diagnosis of gender dysphoria (such as puberty blockers for children with gender dysphoria who’ve started puberty).
The authors also uphold physiological normality as a good thing: For example, they draw a distinction between mastectomies used in breast cancer treatment and top surgery meant to decrease the psychological distress a transmasculine person feels about their chest.
I agree that normal is absolutely the goal in some situations — for example, it’s a good thing to have the normal five-ish liters of blood in your body, not twice that or none that — but “normal” is not synonymous with “optimal” in all situations. For example, if everyone were forced to wear normal-sized clothing, only people who were normal-sized to begin with would be happy — some people would have clothes that simply don’t fit and are uncomfortable or pose health hazards. In the same way, transgender people, if forced to conform to their assigned sex at birth, can experience gender dysphoria.
2. “Health authorities across the globe consider the gender transition interventions at issue here to be “experimental” and unproven.”
I was confused by this statement. If it’s true that gender-affirming care is medically unsound, then why do major medical associations in the U.S. — such as the American Medical Association, the American Psychiatric Association and the American Academy of Pediatrics — all support care for transgender and gender-expansive youth? And why can I easily find studies showing that being able to access gender-affirming care if you have gender dysphoria earlier rather than later is beneficial? Transgender and nonbinary youth who can access puberty blockers and hormone therapy are significantly less likely to be depressed or suicidal: In transgender and nonbinary youth under the age of 18, the use of hormone therapy was associated with 39% lower odds of recent depression and 38% lower odds of attempting suicide in the past year compared to youth who wanted hormones but didn’t get them. In addition, the vast majority of people who transition are happy they did: Less than 1 to 2% of people 13 and older who underwent any gender-affirming surgery regretted it.
The brief cites statements from the United Kingdom and several other European countries that have rolled back gender-affirming treatment for minors, which include puberty blockers and gender-affirming hormones, as evidence that such treatments are medically unsound.
I won’t argue that, like many other medications, puberty blockers and hormones can have physiological side effects even as they increase psychological well-being. But the UK’s decision to only offer puberty blockers in clinical research settings, not routine care, has been criticized by its own patients, family and friends of patients, medical providers, and the general public. 72% of those consulted responded that not all of the relevant evidence has been taken into account in making this decision, with 3,492 of those consulted believing that puberty blockers are beneficial and should be made routinely available, compared to 180 who believed that blockers were harmful, unnecessary or unproven and should not be made routinely available to gender dysphoria youth.
Similarly, the focus of the Swedish recommendations that the brief cites seems to be more on ensuring that youth who transition are indeed transgender. Children with gender dysphoria onset before puberty are eligible for hormonal interventions after extensive evaluation, and children with gender dysphoria onset in puberty will be able to explore other options before gender transition care — which doesn’t mean that gender-affirming care won’t be offered.
This is where I think the authors’ wording is slightly misleading. Specifically, it seems to me that gender-affirming care isn’t experimental in the sense that we don’t know if it works for transgender people or not; gender-affirming care is experimental because we could better differentiate transgender kids (who are suffering from gender dysphoria) from cisgender kids (who are suffering, but not from gender dysphoria). That is to say, therapy and gender exploration before medical transition are important. And the authors of this paper would partly agree with me.
3. “Unlike puberty blockers, cross-sex hormones, and surgeries, counseling care enjoys widespread support and has no physical side effects.”
Although being able to transition medically improves the lives of transgender youth, it’s important that other conditions aren’t mistaken for gender dysphoria. People can indeed be mistaken about the source of their distress or their gender identity. For example, cisgender people may mistake trauma from sexual assault or bullying for gender dysphoria.
Indeed, the World Professional Association for Transgender Health’s (WPATH) standards of care do acknowledge that psychological counseling is important: comprehensive assessment is recommended for all dysphoric youth before any medical interventions. When properly implemented, psychological counseling may last from a few months in cases where gender dysphoria is relatively clear-cut and enduring to several years if other mental health factors are present.
I found it interesting that the authors misrepresent WPATH’s standards of care for transgender health to imply that the only gender-affirming care that should be offered is counseling care: “[A] method of treatment with no physical side effects has been recognized — even by prominent proponents of chemical and surgical intervention — as an effective clinical response to gender dysphoria.” If it were true that psychological counseling alone could resolve gender dysphoria in transgender people, that would be amazing. Unfortunately, while psychological counseling can be very helpful in understanding one’s gender identity and learning how to cope with dysphoria, it doesn’t seem to consistently and successfully resolve gender dysphoria on its own. At least, I could find nothing suggesting so with a Google search.
In reality, WPATH’s standards of care state that counseling should be offered because not every transgender person needs hormone therapy or surgery to alleviate dysphoria. Sometimes social transition is enough, but the experience of being transgender varies so much that it truly depends on the individual.
It’s not that gender-affirming care is expensive, either. California and Massachusetts found that the benefits of gender-affirming medical treatment outweigh the costs. Including transgender-specific care in insurance is actually cost-effective in comparison to not treating gender dysphoria.
Instead of trying to help by making it harder for people with gender dysphoria to access gender-affirming care, I’d like to propose a somewhat controversial idea (by which I mean that I hope it isn’t controversial at all): What if we focused on decreasing discrimination against transgender people instead?
I was taken aback when I learned that compared to cisgender adults, transgender adults have four times as many suicidal thoughts and six times more suicide attempts over a lifetime compared to the U.S. population. Part of the difference in statistics is probably explained by the gender dysphoria that some transgender people experience, but discrimination against transgender people certainly accounts for a good part of this difference. In a survey of U.S. transgender adults in 2015, 13% of respondents who were denied medical treatment because they were transgender attempted suicide in the past year, compared to 6% of respondents who weren’t denied; 11% of those rejected by family attempted suicide in the past year, compared to 5% who were accepted; and 9% who wanted gender-affirming care but were not able to access it attempted suicide in the past year, compared to 5% who did. Anti-transgender legislation in the U.S., which has rapidly increased in the past several years, seems very likely to harm transgender people instead of helping.
To me, it’s less important that you agree with me and more important that you too believe in engaging in dialogue with the other side, viewing all people as equals and acknowledging that there’s a possibility, even if improbable, that you may be wrong. If so, aren’t we on the same side after all?
Jess Jiang is a Trinity senior. Their column typically runs on alternate Wednesdays.
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