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Biden administration divided on 'gender affirming' care for minors as other countries pull back

HHS wants to force doctors to treat children with puberty blockers, even as FDA warns of severe side effects for girls. "Unqualified" office developed affirming guidance with no FDA involvement, FOIA response suggests.

Published: August 10, 2022 2:42pm

Updated: August 12, 2022 11:43pm

As medical authorities and regulators worldwide warn against rushing gender-confused youth into puberty blockers and cross-sex hormones and sharply restrict the practice, the U.S. is divided not only between state and federal governments but among the feds themselves.

Last month, the Food and Drug Administration added a warning to "gonadotropin-releasing hormone (GnRH) agonists" based on their "plausible" connection to spontaneous increases in intracranial pressure in girls, reaffirming years of warnings about Lupron and undermining the feds' top transgender official.

That didn't stop the Biden administration from asking the 5th U.S. Circuit Court of Appeals Aug. 4 to reinstate a Department of Health and Human Services mandate requiring doctors to perform gender transitions on children and some private insurers and employers to cover them.

Medicare and Medicaid weren't covered, though. Religious liberty law firm Becket, which is representing religious healthcare providers, noted HHS declined to issue a "National Coverage Determination" on sex-reassignment surgery in 2016, citing conflicting study results on benefits versus harms.

The FDA's response to a Freedom of Information Act request suggests the agency wasn't even consulted when HHS's Office of Population Affairs drafted guidance that claims "early gender affirming care is crucial to overall health and well-being," blockers are "reversible," and hormones are "partially reversible."

The March guidance prompted alarm from a former FDA official, who wrote in Newsweek that his colleagues were "circumvented on transgender clinical pharmacology recommendations by an obscure, obviously unqualified HHS office."

FOIA officer Meredith Schlaifer told former Department of Education lawyer Hans Bader the FDA had no communications between the commissioner's office, media affairs and the Center for Drug Evaluation and Research on the drafting and publishing of the OPA guidance.

In a Liberty Unyielding essay Tuesday, Bader said the agency responded only after he sued the FDA and HHS, which has yet to respond to a similar request.

HHS and FDA didn't respond to queries on Bader's characterizations.

"The American stance is at odds with a growing consensus in the West to exercise extreme caution when it comes to transitioning young people," journalist and "Tomboy" author Lisa Selin Davis wrote in the Common Sense newsletter last month.

Scandinavian countries have sharply restricted "gender affirming" treatments in the past two years, with Sweden limiting youth transitions to "exceptional cases" and Finland banning "irreversible treatment" for this "experimental practice" of gender reassignment.

The National Health Service is closing the U.K.'s central gender-identity clinic for youth, known as Tavistock, following a high-profile lawsuit by a former patient, Keira Bell, and an independent review by Hilary Cass, former president of the Royal College of Paediatrics.

Cass' interim report on Tavistock this spring found "major gaps in the research base underpinning the clinical management" of youth, now predominantly girls "first presenting in adolescence with gender-related distress." Staff said they felt pressured to "adopt an unquestioning affirmative approach" at odds with the process for "all other clinical encounters." 

A diagnosis of "gender distress" also led to "diagnostic overshadowing" of other healthcare issues children were having, Cass said. The Times of London reported the clinic's services will be farmed out to regional children's hospitals, with an emphasis on mental health services and "holistic care."

Cass shared her July 19 letter to NHS recommending an ongoing research program to study the "pause" rationale for puberty blockers now that adolescent girls are the predominant patients. These drugs may disrupt "maturation of the part of the brain concerned with planning, decision making and judgement." 

The French National Academy of Medicine warned this year that "the greatest reserve is required" for the use of blockers and hormones in children and adolescents, "given the side effects such as impact on growth, bone fragility, risk of sterility, emotional and intellectual consequences and, for girls, symptoms reminiscent of menopause."

It emphasized there is "no test to distinguish a 'structural' gender dysphoria from transient dysphoria in adolescence" and the rising number of detransitioners shows "the risk of over-diagnosis is real."

The Royal Australian and New Zealand College of Psychiatrists updated its position on gender dysphoria last fall to recognize that "evidence and professional opinion is divided" on the affirming approach versus talk therapy, given the "paucity of quality evidence on the outcomes" for gender-confused youth and particularly the "long-term effects of medical and surgical affirming treatment."

Even as gender-affirming advocates try to tarnish the "social contagion" explanation for the explosion in gender-confused adolescent girls, the justification for their treatment is under the microscope.

Responding to law professor Khiara Bridges' congressional testimony claiming "one in five" transgender people attempt suicide due to transphobia, Manhattan Institute fellow Leor Sapir said the "affirm-or-suicide mantra" that's popular in the Biden administration has little basis in research.

It's based on a "small handful of deeply flawed studies that, at most, find loose correlations between 'affirming' interventions and improved mental health," Sapir wrote in evolutionary biologist Colin Wright's newsletter.

Surveys of transgender-identified youth (TIY) "do very little to vet respondents when they say they 'attempted' suicide" and compare apples to oranges, he said. TIY "exhibit extraordinarily high rates of mental health problems" apart from gender distress that confound comparisons with non-TIY.

This is particularly the case with rapid-onset gender dysphoria, whose adolescent sufferers are "known to have very high rates of anxiety, depression, history of sexual trauma, anorexia, and eating disorders, all of which typically precede their gender-related distress."

Sapir pointed to a January study in European Child and Adolescent Psychiatry that examined suicidality in transgender adolescents, with a median age of 16, at specialty clinics in Toronto, Amsterdam and London. By comparing apples to apples — similar mental health profiles in TIY and non-TIY — "the disparities in suicidal behavior reduced considerably," he said.

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