A flawed agenda for trans youth

Children need protecting. Most people would agree, but the implications vary wildly. On April 6, 2021, amid a flood of new bills to curb the rights of transgender and gender diverse (trans) youth in the USA, Arkansas became the first state to prohibit doctors from providing youth (<18 years) with gender-affirming treatment: puberty blockers, hormone therapy, and gender-affirming surgery. 20 other US states have introduced similar bills, while 31 states have introduced bills to limit trans youth participation in sport. However, what the bills seek to protect appears to be traditional gender norms, using a vulnerable group in a protracted culture war. The bills' socially conservative advocates create fear by focusing on emotive issues, honing the same messaging around protecting women and children that was used in earlier campaigns against abortion and same-sex marriage. As clinicians, it is important to use evidence to debunk the false claims being made.

Disproportionate emphasis is given to young people's inability to provide medical consent, a moot point given that—like any medical care—parental consent is required. Supplanting parents with the law for this decision presumes that a parent living alongside their child cannot grasp what is best for them, despite often witnessing many years of struggle. Driving this consent narrative is the anxiety evoked by focusing on the minority who regret transition (estimated as 1% of adults who had gender-affirming surgery as adolescents). However, in any situation when medical treatment will alter a person's identity, no one can know whether post-treatment regret will occur; therefore what matters ethically is whether an individual has a good enough reason for wanting treatment. Regardless of law makers' stance on identifying with a gender other than one's birth-assigned sex, the autonomy for this decision lies with young people and their parents.

More fear is stoked by rhetoric about a malevolent threat to children. Social conservatives in the USA, UK, and Australia frame gender-affirming care as child abuse and medical experimentation. This stance wilfully ignores decades of use of and research about puberty blockers and hormone therapy: a collective enterprise of evidence-based medicine culminating in guidelines from medical associations such as the Endocrine Society and American Academy of Pediatrics. Puberty blockers are falsely claimed to cause infertility and to be irreversible, despite no substantiated evidence. The dominance of the infertility narrative, usually focused on child-bearing ability, perhaps reveals more about conservatives' commitment to women's role as child-bearers. Puberty blockers are framed as pushing children into taking hormones, whereas the time they provide allows for conversations with health providers and parents on different options. Gender transition involves many decisions over a long time, and those who take hormones do so because they are trans. Contrary to claims of a new phenomenon, trans youth have always existed; historians show they have sought trans medicine since it became possible: the 1930s in the USA.

Focusing on potential harms ignores the fact that wellbeing is broader than physical health alone. The harms to wellbeing posed by prohibiting care are huge. Being a marginalised group (<2% of US youth), trans youth already experience the stress of discrimination and stigmatisation. They have high rates of depression, anxiety, and suicide: almost double the rates of suicide ideation of their cis peers. As Laura Baams discusses in her Comment, puberty blockers reduce suicidality. Removing these treatments is to deny life. Moreover, whereas the bills focus on medical treatments, the care trans youth receive is far wider in scope. Those seeking care typically also see social workers and psychiatrists, and much of health providers' work involves listening, talking, and setting up support in their families, schools, and communities. Health providers also discuss with them the idea that gender is something we “do” in social practice and can take many forms. Indeed, some choose social transition without medical treatment, and it is useful to remember that the notion of gender dysphoria perpetuates the historical pathologisation of gender diversity. Challenging the current social construction of male–female will undoubtedly ease trans youths' lives, reducing the pressure of rigid definitions. But alongside these social aspects is a pressing need for medical care.

While those pushing the legislation claim to protect children, their arguments lack the voices of trans youth and their health providers. Trans youth seek gender-affirming care because they are trans, and they have the same right to health and wellbeing as all humans.