West Coast shuts parents out of 'gender affirming' decisions as Swedish research urges caution

Bills would deny parents notice of runaway children seeking hormones, surgery, gender identity counseling. Treatment should be limited to clinical trials, Sweden-commissioned review says.

Published: April 23, 2023 11:03pm

America's West Coast is separated by a continent and an ocean from Europe. Their policy gap on "gender affirming care" for minors — including puberty blockers, cross-sex hormones, and breast and genital removal — is becoming similarly wide.

Washington is on the verge of denying parents notice that their runaway children are living in licensed shelters if the children are seeking "protected health care services," defined as gender affirming care and "reproductive health care" such as abortion and contraception.

SB 5599 cites these circumstances as "compelling reasons" that shelters can instead notify the Department of Children, Youth, and Families. They are "not limited" to these examples when deciding whether to withhold parental notice, however.

A legislative summary of opposition to the bill describes it as "legalized kidnapping." The bill passed the House and Senate and now awaits action from Gov. Jay Inslee (D).

The California Assembly approved legislation this month (AB 665) that would let children 12 and up in the Medi-Cal program "consent to mental health treatment or counseling on an outpatient basis, or to residential shelter services," if the "attending professional person" believes they are "mature enough to participate intelligently" in the services. Legal experts told the Associated Press that would cover gender identity counseling.

The bill removes a section of existing law that requires a consenting minor to "present a danger of serious physical or mental harm to self or to others without the mental health treatment or counseling or residential shelter services" or "is the alleged victim of incest or child abuse."

Mental health counselors can exclude "parental involvement" — notification and consent — if they believe that "would be inappropriate," but shelter providers would still have to "make their best efforts to notify the parent or guardian of the provision of services."

A lengthy and confusing Oregon bill on reproductive healthcare and gender-affirming care (HB 2002) appears to let minors 15 and up consent to gender-affirming care without parental consent.

State law already lets 15-and-up consent to "[h]ospital care, medical or surgical diagnosis or treatment." The bill adds "gender-affirming treatment" to the law, defined as "a procedure, service, drug, device or product" prescribed to treat "incongruence" between gender identity and sex. It goes even further for abortion and contraception, letting a minor "of any age" consent.

By contrast, Scandinavian countries and the U.K. have led Europe in ratcheting back drugs and surgery for gender-confused minors in recent years, let alone minimizing parents in treatment decisions.

In a new "systematic review" of research on hormone treatment for gender-confused children in the peer-reviewed Acta Paediatrica, Swedish researchers commissioned by the country's Agency for Health Technology Assessment and Assessment of Social Services found so little evidence on its effects that they recommended a ban except for clinical trials. 

Florida regulators approved a similar ban with a trials carveout on the same grounds last fall, and the state Senate approved a legislative ban for minors that would also prohibit public funds from covering gender-affirming care this month.

Missouri Attorney General Andrew Bailey issued an "emergency regulation" taking effect next week that claims state law already prohibits treatment for minors "in the absence of substantial guardrails that ensure informed consent and adequate access to mental health care." Among his dozen such guardrails: disclosure that Sweden has said the risks of treatment "currently outweigh the possible benefits."

Children's Mercy Hospital sued Bailey this month to halt dozens of investigative demands for records and testimony on its practices, including "prescriptions for hormone blockers as well as surgeries for transgender patients," the Kansas City Star reported.

The Swedish researchers claimed theirs was the first systematic review despite growing demand for treatment among minors, particularly "an exponential rise among children born female." They wanted to assess the treatment's effects on "psychosocial and mental health, cognition, body composition, and metabolic markers." 

From a pool of nearly 10,000 potentially relevant English-language studies based on abstracts, they could find only three dozen that were relevant, a third of which were then excluded due to "high risk for bias." The two-year process couldn't find any randomized controlled trials (RCTs), the strongest form of scientific evidence.

"Gonadotropin-releasing hormone analogues" were given to adolescents "typically" between ages 11 and 15 in 21 studies, and the other three studies looked at cross-sex hormones without prior GnRHa treatment, "rarely" given below age 15.

The studies were all over the map on psychosocial and mental health, "hampered by small number of participants and substantial risk of selection bias," so the researchers concluded they couldn't evaluate long-term effects. 

Only one study looked at cognitive outcomes of GnRHa treatment, with no differences found between either treated and untreated transgender children or treated children and controls. Because it lacked "before-after GnRHa therapy analyses," the Swedish researchers couldn't investigate treatment effects. 

The strongest findings concerned bone health. GnRHa treatment "delays bone maturation and bone mineral density," while cross-sex hormone patients had "partially recover[ed]" bone health when they were studied at age 22.

The existing research generally suffers from "group level" analyses "sensitive to selection bias," rather than analyzing "intra-individual changes," and fails to account for "puberty stage and biological age," they said. 

The lack of long-term studies is "worrying" because the patients start young and will remain on cross-sex hormones for their entire lives, according to the paper. Studies that track minors "until at least age 30 are urgently needed."

RCTs "may be the only way to address biases" they found in the research literature, the researchers concluded. They said GnRHa treatment for minors "should be considered experimental treatment of individual cases rather than standard procedure."

The weak research base hasn't stopped advocates for treating minors from portraying legislative and legal challenges as threats to gender-confused children's lives.

The first transgender member of the Montana Legislature, Zooey Zephyr, told colleagues supporting the successful minor ban that "forcing a trans child to go through puberty ... is tantamount to torture" and they will have "blood on your hands," the Montana Free Press reported. 

Zephyr also claimed another successful bill to define sex as a binary was like trying to "legislate that the Earth is flat," The New York Times reported.

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