Why We Need a Serious Debate About Healthcare For Transgender Youth

Improving the quality of care begins with understanding the nuance of the issues.

(Image via Getty)

by Dr Erica Anderson

As a clinical psychologist for more than 40 years and a transgender health expert, I have helped many transgender people, including hundreds of young people, to transition. I’m a former President of the United States Professional Association for Transgender Health (USPATH), and a former board member of the World Professional Association for Transgender Health (WPATH). For some years I worked at the Child and Adolescent Gender Center at the University of California San Francisco. I am also a transgender woman.

In recent years, I’ve watched with concern as the controversies have swirled about trans youth care. Some people have questioned when or whether to support a young person in their identity, including social transition (changing names and pronouns), the deployment of puberty blockers, cross-sex hormones or gender affirming surgeries. Legislators in red states have sought to limit or even block such care altogether. I have consistently and vehemently condemned such efforts, and I applaud those standing up to proposed bans on trans youth healthcare in their states.

But it is also vital that we have nuanced debates about trans youth healthcare. In recent months, I was quoted in The New York Times in a number of articles on topics including gender therapy, hormone treatments and parental rights. These articles were condemned in two highly publicized open letters in February. The first letter was by contributors and other journalists who asserted that the newspaper’s recent coverage of trans youth issues was unfair and unbalanced, and that it hurt the plight of trans people. In a separate (though coordinated) letter, the Gay & Lesbian Alliance Against Defamation (GLAAD) offered a parallel criticism.

Having been quoted in the aforementioned pieces, and being steeped in the issues surrounding trans healthcare, I would like to offer my view on both.

First, the accusations of bias and transphobia against journalists at the Times are unconvincing. Each of the journalists with whom I spoke (in some cases multiple times) stressed their intention to illuminate the complexities of the issues. Their motivation was to cover the issues with accuracy, clarity and compassion. They were clearly trying to understand all the nuances of the issues and stressed that they were talking to many people representing a diverse range of views. In each case we discussed the precise language to be used in the articles.

The Times did the right thing by responding quickly with a full-throated defense of the pieces and their journalists. As executive editor Joe Kahn suggested, while the open letters were coordinated by activists whose mission is to advocate for a cause—in this case, the rights of transgender persons, particularly trans youth—the Times has a different mission: namely, the coverage of important issues as fairly and humanely as possible.

I would also note that writing about these topics is extremely difficult. If one seeks to discuss the nuanced aspects of trans medical treatments, it is even more difficult. As recently as two years ago, many journalists admitted to me that they were afraid to cover transgender healthcare at all, let alone weigh in on the substance and particulars of the issues. In America it would seem that one is cast as either pro-trans or transphobic. Part of the problem is the kind of reactiveness displayed by the letters. One of the journalists who signed bragged that she received the invitation at 11:02 PM and agreed to sign at 11:04 PM. That timing strikes me as reflex rather than reflection.

This unwillingness to deal with nuance is hugely problematic, and lately I have been appealing for more light and less heat. The truth is that nothing is binary about gender. In particular, a false narrative has emerged about one of the most contentious issues: the status of research on trans youth, and the rigor behind current guidelines.

Major medical organizations agree that gender affirming care for youth is necessary and appropriate. Some people have taken this to mean that all the issues surrounding such care are settled. But this is not the case. A recent British Medical Journal investigation notes that the research evidence for certain forms of care has come under question in several Western European countries—countries known to be progressive and motivated to help gender-questioning youth. A full systematic review by the Swedish health authority, for example, concluded that the evidence for medicines like puberty blockers and cross-sex hormones for youth is currently weak, and that the risks currently outweigh the benefits. Sweden’s health authority has updated their recommendations to severely curtail the use of puberty blockers for those under 18, pending further systematic study. They did not do this because they are transphobic: they did it because they are responsible.

Meanwhile, a minority of overzealous practitioners in the United States have blurred activism with responsible professional conduct. Youth presenting at gender clinics represent a heterogeneous population of young people, but many parents have told me directly about their experience of providers who eschew the standard of practice requiring an individualized comprehensive biopsychosocial evaluation prior to initiating the deployment of medicines with minors. Such an evaluation, as described by the WPATH Standards of Care, entails multiple interviews over time assembling a clinical picture of the child’s development, family dynamics, history of psychiatric issues, autism spectrum disorder, and trauma. I’ve called such abdication “sloppy,” and for this I have been criticized. But the fact remains some medical providers have launched into a discussion with minors about puberty blockers or hormones from the very first interaction, obliterating any distinction between gender questioning/incongruent and gender dysphoric youth.

Finally, there is the issue of students socially transitioning in school by presenting as a different gender. I want every child to get what they need, and for teachers to support gender questioning youth by using their preferred names and pronouns. It’s vital that parents are supportive, even if the gender questioning of their child takes them off guard.

But some school districts have instructed staff to hide the social transition from parents if the child requests it. This is another example of activism which may have started out with good intentions, namely creating safe places for kids, but which has gone too far. By condoning deception as a tactic, some districts operate as though teachers, not parents, are responsible for the upbringing of children. Changing names and pronouns at school is a simple step, but the gender journeys of many of today’s youth are highly complex, and parents need to be involved. Unless there is evidence of abuse at home, teachers should not engage in deception.

There are those who would prefer not to talk about these issues at all, and who characterize any attempt to do so as transphobic. Having personally helped hundreds of gender-questioning youth, however, I’m afraid it’s not that easy.

Dr. Erica Anderson is a clinical psychologist and a former board member of the World Professional Association for Transgender Health (WPATH).¹

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1. Dr. Anderson has filed amicus briefs in legal challenges to Maryland and Massachusetts district policies that would allow schools to withhold information of children’s gender identity from their parents.