Over the past few years there has been a dramatic increase in children and adolescents being diagnosed with gender dysphoria, gender incongruence or gender distress.
This phenomenon has been noted both internationally as well as in South Africa and is an issue that concerns parents, the medical profession, the Department of Education and other sectors of South African society. The best approach to providing care for these vulnerable children and adolescents has been fiercely contested.
A vocal sector of the medical community, locally and internationally, has presented a “gender affirming” approach as the standard of care. This approach assumes that children and adolescents who self-report that they wish to adopt a gender role different from their sex are “transgender”, and that they should be “affirmed” in this, meaning they are socially supported by parents, extended family, educators and broader society in adopting the gender of their choice.
This starts with “social transition” including change of name and pronouns, adopting certain clothes and hairstyles and use of different toilets. The next step is medical interventions where drugs such as puberty blockers and cross-sex hormones are prescribed if requested. Finally, if they choose, they are provided with surgical procedures such as mastectomies and genital surgery.
This relatively new approach gained international popularity after the publication of two Dutch studies in 2011 and 2014. The approach is foundational to the management guidelines promulgated by the World Professional Association for Transgender Health and has fallaciously been presented as the global standard of care for “transgender health”.
However, there is now emerging scientific consensus that the two Dutch studies, as well as several other subsequent studies, suffer from serious methodological problems. These include a high risk of bias due to small sample sizes, lack of control groups, confounding factors and poor study design.
Further, attempts to replicate the Dutch studies at the Tavistock Gender Identity Development Services in the UK, the world’s largest paediatric clinic, failed to demonstrate the psychological improvements reported by the Dutch.
The uncritical adoption of gender-affirming management strategies for children with gender dysphoria is not aligned with the best medical evidence.
Four major systematic reviews of the medical evidence supporting gender-affirming care have been conducted in Finland, Sweden and the UK. All of the reviews concluded that social transition and puberty blockers in children and adolescents could not be recommended as the benefits they sought to achieve were not realised and that clear harm could be demonstrated. A letter published in the Wall Street Journal on 13 July 2023, and signed by 21 clinicians from nine countries, including some authors of this article, summarises these findings as follows:
“Every systematic review of evidence to date... has found the evidence for mental health benefits of hormonal interventions for minors to be of very low certainty. In contrast, the risks are significant and include sterility, lifelong dependence on medication, and the anguish of regret. For this reason, increasing numbers of European countries and international professional organisations now recommend that psychotherapy rather than hormones and surgeries should be the first line of treatment for gender-dysphoric youth.”
These systematic reviews of medical evidence have shown previously published guidelines that encouraged a gender-affirming approach to be unreliable. Further, proponents of the gender-affirming approach commonly claim that the interventions reduce suicide risk.
However, these reviews show that this claim is not supported by the published scientific evidence. As noted in the Wall Street Journal letter, this makes claims of increased suicide risk in children not receiving gender-affirming care both unfounded and irresponsible.
In recent years, it has been difficult for people to challenge the gender-affirming approach, both internationally as well as in South Africa. There has been a lack of respectful dialogue about an issue that affects vulnerable young people in profound ways. Many of those who have questioned the gender-affirming ideology have been labelled “transphobes” – a common and pejorative way to shut down the discussion and intimidate those with different perspectives.
Internationally, a growing number of public health authorities recognise that less medically invasive approaches, such as exploratory psychotherapy, should be the first-line treatment for young people with gender distress. These include the traditionally liberal Scandinavian countries like Sweden and Finland, as well as Australia, New Zealand and the UK. The Finnish National Health service guidelines on the management of gender dysphoria recommend:
“In adolescents, psychiatric disorders and developmental difficulties may predispose a young person to the onset of gender dysphoria. These young people should receive treatment for their mental and behavioural health issues, and their mental health must be stable prior to the determination of their gender identity.”
The immediate side-effects related to puberty blockers and cross-sex hormones (reproductive sterility and loss of bone density) are well understood. However, there are few long-term studies examining the long-term impact on mood, memory, learning and psychosexual maturation. This raises serious questions about the ability of children to understand the implications of these interventions over a long time and so to provide true informed consent for gender-affirming care.
A holistic management approach, centred on watchful waiting is being proposed. This includes psychotherapy as well as the management of a wide range of common coexisting disorders such as anxiety, depression, ADHD, psychosis, eating disorders, suicidal ideation, self-harm and autistic spectrum disorders.
While much attention has been focused on the impact of puberty blockers and cross-sex hormones, it must be understood that social transition is not a neutral action – a key finding in the NHS Cass review.
In the vast majority of cases, gender dysphoria in children will resolve once they have gone through puberty. However, social transition results in up to 97% of these children having persistent gender dysphoria and many proceeding to puberty blockers and cross-sex hormones.
Where to now?
Over the past few years there has been a significant increase in the number of countries rejecting social transitioning, puberty blockers and cross-sex hormone therapy as the de facto “standard of care” for children with gender distress.
Rather, a holistic management approach, centred on watchful waiting is being proposed. This includes psychotherapy as well as the management of a wide range of common coexisting disorders such as anxiety, depression, ADHD, psychosis, eating disorders, suicidal ideation, self-harm and autistic spectrum disorders.
This contrasts with recent publications in South Africa, which include a guideline by the South African HIV Clinicians Society and the Professional Association for Transgender Health South Africa that advocate a gender-affirming approach in children and adolescents.
The safety and protection of children should be one of the highest priorities in any society. It is crucial that any social, psychological or medical interventions provided to children do not cause harm and should increase their well-being. Due to children’s inherent vulnerability, their rights need to be promoted and protected by all sectors of society.
The South African Constitution states: “A child’s best interests are of paramount importance in every matter concerning the child.” As noted in the United Nations Convention on the Rights of the Child, childhood is a special, protected time in which children must be allowed to grow, learn, play, develop and flourish with dignity.
As such, we call on members of the medical profession and others in South Africa to “first do no harm” when faced with vulnerable children and adolescents. The uncritical adoption of gender-affirming management strategies for children with gender dysphoria is not aligned with the best medical evidence and is out of step with international developments and an increasing number of national regulatory authorities.
First Do No Harm SA is a voluntary association of South African professionals who are advocating for evidence-based care of children and adolescents with gender distress. Anyone who would like to know more can email info.fdnhsa@gmail.com. DM
This article is signed by the following professionals, who are members or supporters of FDNHSA: Dr Janet Giddy: Family Physician, Cape Town; Assoc Professor Reitze Rodseth: Anaesthesiologist & critical care specialist, Pietermaritzburg; Dr Tygie Sidhambaram Nadesan: Family Physician, Durban; Prof WJ Steinberg: Family Physician, Bloemfontein; Dr AK Lutakwa: General Surgeon, Durban; Dr Martin Bac: Family Physician, Gauteng; Dr M Gounder: Urologist, Durban; Dr Erika Drewes: Family Physician, Cape Town; Dr Ami Muller: General Practitioner, George; Dr Jonathon Pons: Eye Surgeon, Eswathini; Dr Jolanda Niemann: General Practitioner, Gauteng; Dr Allan Donkin: General Practitioner, Western Cape; Dr Albu van Eeden: General Practitioner, KZN; Dr Francois Potgieter: Child Psychiatrist, North West; Dr Hein Pohl: Surgeon, Western Cape; Dr Frances Scholtz: General Practitioner, Western Cape; Dr Maria Rossouw: Medical Officer in Endocrinology, Bloemfontein; Dr Caroline Armstrong: Emergency Care doctor, Pietermaritzburg; Dr Jon Larsen: Obstetrician, KZN; Melindie Pretorius: Researcher & medical student, Western Cape; Jaco van Zyl: Clinical Psychologist, South African in Ireland; and Vincent Deboni: Counselling Psychologist. South African in Sweden.