Response to First Do No Harm: Why we treat gender diverse youth

As the Professional Association for Transgender Health South Africa (Pathsa) and the Southern African HIV Clinicians Society (SAHCS), we write to express our dismay at the recently published Daily Maverick opinion piece by FDNHSA (First Do No Harm South Africa) titled “A call on SA medical professionals to heed evidence on child and adolescent gender distress”. 

Pathsa and SAHCS acknowledge the complexities highlighted in the op-ed and appreciate the opportunity for constructive dialogue.

Gender dysphoria is the psychological distress experienced due to a mismatch between an individual’s sex assigned at birth and their gender identity. This incongruence can lead to significant distress, impacting social interactions, performance at work or school, and overall functioning in daily life.

Considering the wealth of evidence that gender dysphoria is real and has negative consequences for trans youth, the ethical principle of “first do no harm” should recognise that delaying care can, in itself, be a form of harm.

Contrary to the view put forward by FDNHSA, that the gender-affirming healthcare approach is “uncritical” and that there is “a lack of respectful dialogue” on vulnerable young people, Pathsa and SAHCS, are deeply committed to honest, transparent engagement based on the latest and most robust evidence that exists. 

We advocate for constructive dialogue, welcoming diverse perspectives in order to achieve informed and optimal outcomes for those we serve.

In our response to the article by FDNHSA, we would like to clarify several key points raised, including the nature of gender-affirming care, the timing of interventions, social transitioning, issues related to puberty blockers, the growing number of trans and gender diverse (TGD) youth seeking care, and the perceived absence of scientific evidence to support these practices.

We will identify some logical inconsistencies in the FDNHSA article and offer additional references to encourage further thought and discussion in the spirit of scholarly exchange and good faith.

Addressing the FDNHSA article, it is important to note the straw man fallacy – a logical misstep where, in this case, gender-affirming healthcare is oversimplified or misrepresented and therefore easily contested.

The article portrays a false divide between psychotherapy and medical treatments, overlooking the multidisciplinary, holistic care model that includes a contextually appropriate informed consent process, psychological support, social affirmation and medical interventions as needed.

This care involves healthcare professionals, families and affected individuals, ensuring informed decisions that respect the individual’s exploration of their gender identity and dignity. (Turban et al., 2020; Tomson, 2018).

“Affirming” in this context is about validating and supporting youths’ exploration of their gender identity, ensuring that they have the guidance and understanding necessary to navigate their identity with confidence and curiosity, rather than pushing them towards a predetermined outcome.

The “watchful waiting” strategy recommended by some can, paradoxically, be harmful in cases of gender dysphoria.

Delaying gender-affirming care can exacerbate psychological distress (depression and anxiety, low self-esteem, eating disorders and substance abuse, to name a few), leading to social isolation and poor quality of life (Turban et al., 2020). 

Timeous, thoughtful intervention is often essential for those experiencing severe gender dysphoria.

Social transition, including changes in name, pronouns and appearance, offers a reversible, non-medical path for youth to explore their gender identity. 

A supportive environment that fosters this exploration without enforcing rigid gender norms is crucial, as it alleviates pressure on children to prematurely settle on an identity, commit to a decision or prove something (Tyni et al., 2023).

The suggestion that social transitioning invariably leads to medical interventions and then to regret is wrong. It assumes a direct progression from one action to a series of other (perceived negative) outcomes without sufficient evidence for such a deterministic chain of events.

The assumption that all TGD youth want medical interventions is incorrect – for example, many non-binary youth opt for a more “ambiguous” expression of their gender identity, albeit unsettling for the cis-hetero-normative hegemony.

The FDNHSA’s interpretation of statistics on social transitioning is misleading. The Olsen et al. (2022) study shows that 97% of socially transitioned youth continued to identify as transgender. This rate highlights social transitioning’s role in allowing transgender youth to authentically express themselves, without evidence suggesting it prolongs gender dysphoria.

Other studies support the understanding that only a minority of trans youth will retransition to a cisgender identity (Durwood et al., 2022; Van der Loos et al., 2022). 

Pathsa champions non-judgemental support for any individual who wants to retransition, recognising the ethical principle of autonomy (Allen et al., 2024).

Puberty blockers, which have been used for decades to manage conditions like early onset puberty, offer a reversible, short-term option for trans youth to delay puberty-related changes, allowing time for thoughtful and empowering exploration. 

These interventions, recommended from the second to third stages of puberty, are tailored to each child’s unique circumstances.

Concerns about their effects on fertility and bone health, while noted, are often overstated, and the benefits far outweigh potential risks. The treatments’ reversible nature allows for typical sexual development to resume once they are discontinued (Bertelloni et al., 2000; Heger et al., 2006).

There is a growing body of research that supports their safe, evidence-based use, emphasising benefits and risk management strategies such as nutritional supplementation for bone health (Lee, 2023; Navabi et al., 2021). 

The positive impact of these treatments for transgender youth is well-documented (Ramos et al., 2021).

Puberty guarantees irreversible changes. Puberty blockers do not.

The increase in gender dysphoria diagnoses should be seen as a positive development and not a trend induced by the availability of gender-affirming care. Instead, it signifies improved awareness and acceptance of diverse gender identities.

Suggesting that the uptick in diagnoses is directly attributable to the growing prevalence of gender-affirming care mistakenly infers causality from sequence without adequate evidence to substantiate a direct causal link.

The critique that gender-affirming care lacks robust evidence and citing the absence of randomised-controlled trials (RCTs), overlooks the complexities of transgender healthcare research. RCTs are not always feasible or ethical for this field (Ashley et al., 2023). They face challenges including participant adherence and broad applicability of findings.

Nevertheless, substantial research demonstrates the positive impact of gender-affirming care on trans youths’ mental health (Achille et al., 2020; Green et al., 2022; Kuper et al., 2020). 

Furthermore, the FDNHSA article’s selective emphasis on studies with perceived methodological limitations in order to dismiss the entirety of gender-affirming care research is a hasty generalisation that unjustly extends critique from specific instances to an entire body of evidence.

SAHCS published the first SA gender-affirming guideline in 2021 (Tomson et al, 2021) after a robust process of considering the evidence. The World Professional Association for Transgender Health (WPATH) published updated guidelines in 2022 (Coleman et al, 2022) that are based on the best available current evidence, and the World Health Organisation is currently in the process of developing guidelines.

Pathsa and SAHCS encourage scholarship rooted in the South African context to inform our practice in a culturally sensitive manner which accounts for our unique challenges and possibilities. 

We implore collaboration between healthcare providers, researchers and the media to accurately translate academic research to the public because it is clear that we’re not all on the same page (Delli & Livas, 2021). 

Gender-affirming care is sadly being delivered amidst a backdrop of unjust moral panic, with transgender youth, their caregivers and healthcare providers finding themselves in the crosshairs of intense socio-political debates (Carswell et al., 2022; Redfield et al., 2023).

We understand that for many medical professionals, treating gender dysphoria in youth can be a challenging and unfamiliar territory – this should not be a barrier to providing care, but instead a call to action for training and education.

Pathsa champions ethical, evidence-based practices (Allen et al, 2024). 

This commitment was exemplified in our recent annual symposium where sessions such as “The ethics of informed consent in transgender and gender diverse children and youth” by bioethicist Dr Yoshna Kooverjee took centre stage. 

This presentation was a master class in “uncertainty”, never prescribing any one direction without carefully scrutinising its alternative. This is how ethical, evidence-based medicine should proceed.

We call for further honest dialogue and a recognition that, in this fraught terrain, we all want the best for gender-questioning youth. 

We must not shy away from asking difficult questions and should continue to remain open to the possibility of being wrong.

This should not lead to inaction, but rather to measured, thoughtful care for the young people whose lives matter. DM

Pathsa Board members: Rev Chris McLachlan, clinical psychologist; Mx Jenna-Lee de Beer-Procter, clinical psychologist; Dr Robin Dyers, public health specialist; Prof Elma de Vries, family physician; Dr Sakhile Msweli, clinical psychologist; Pierre Brouard, clinical psychologist;  Prof Mershen Pillay, audiologist and speech therapist; Dr Arianne Spitaels, paediatric endocrinologist; Dr Allanah Wilson, psychiatrist; Luh Cele, clinical nurse practitioner; and Dr Camilla Wattrus on behalf of SAHCS.

References:

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Allen, L. R., Adams, N., Ashley, F., Dodd, C., Ehrensaft, D., Fraser, L., Garcia, M., Giordano, S., Green, J., Penny, J., Rachlin, K., & Veale, J. (2024). Principalism and contemporary ethical considerations for providers of transgender health care. International Journal of Transgender Health, 1–19. https://doi.org/10.1080/26895269.2024.2303462

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Ashley, F., Tordoff, D. M., Olson-Kennedy, J., Restar, A. J., Ashley, F., Tordoff, D. M., & Olson-Kennedy, J. (2023). Randomized-controlled trials are methodologically inappropriate in adolescent transgender healthcare. International Journal of Transgender Health, 0(0), 1–12. https://doi.org/10.1080/26895269.2023.2218357

Bertelloni, S., Baroncelli, G. I., Ferdeghini, M., Menchini-Fabris, F., & Saggese, G. (2000). Final height, gonadal function and bone mineral density of adolescent males with central precocious puberty after therapy with gonadotropin-releasing hormone analogues. European journal of pediatrics, 159, 369-374. https://link.springer.com/article/10.1007/s004310051289

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