JAMA: Trans Kids Receiving Health Care Happy, Actually
Who knew that helping kids would help them?
The Journal of the American Medical Association published several articles from Saturday to today related to trans health care. The most obviously relevant was research finding that gender affirming care for youth is associated with positive outcomes and low regret rates and published in JAMA Pediatrics. (Sadly but accurately, JAMA found the study necessary to file in the category “Health and the 2024 US Election.”) In addition, however, is a raft of articles that are part of a review of the World Medical Association’s 1964 Declaration of Helsinki (below “8th review” or “2024 declaration”) which determines the ethical framework in which decisions are made about when medical research can be performed and (to some extent) when a doctor is ethically justified in offering a particular treatment. It was developed in the aftermath of World War II and the many medical abuses committed by Nazis and others during the period. From JAMA:
The declaration represents the foundational ethical document addressing the design, conduct, and reporting of medical research, a document referred to internationally. Since the World Medical Association (WMA) first adopted the declaration in 1964, the 2024 declaration represents its eighth revision, synthesizing more than 2 years of global consultation, international meetings, and public input. The significant changes reflect a growing appreciation of global ethical challenges, fair and responsible inclusivity in research, community and local engagement, and the complexity of current interdisciplinary research.
The Cass Review has frequently belittled the state of research on trans health care, and minimizing the value of what we know has been an important part of the Cass/Tory strategy to attack the provision of care under the NHS to the UK’s trans citizens and permanent residents. But a good deal of what Cass proposed to be done may reasonably be considered unethical. The 2024 declaration will have broad impact on how the Cass Review’s methodology holds up over time.
Importantly, Barbara E. Bierer’s JAMA editorial summarizing areas updated by the 8th Review states:
The 2024 declaration permits the use of placebo only under carefully controlled conditions in which there is no safe and effective alternative but otherwise requires the “best proven” intervention. A comparator other than the best proven is allowable only if necessary to demonstrate safety or efficacy and if participants are not exposed to additional serious risks of harm.
While the Tories and America’s Republicans would like to avoid the admission, the “best proven” interventions for trans persons seeking medical assistance are the ones already described in the WPATH v8 standards of care. Under the 2024 declaration, research on the effectiveness of alternative treatments favoured by Cass and her ilk (such as psychological conversion therapies) could not ethically be used to deny access to existing treatments, which include explorative but affirming talk therapy, social transition (including name, pronoun, and clothing changes), puberty blockers, hormone therapies, and, for older teens and adults, chest reconstruction, breast reduction, breast augmentation, and eventually genital and/or reproductive tract surgeries.
Because “best proven” does not mean, “proven to every standard of satisfaction,” it will become harder under the 2024 declaration to deny gender related health care to trans and non-binary youth. That does not mean that it will become impossible to deny such care, of course, and it certainly doesn’t mean that theocrats and trans haters won’t try. Nevertheless, the change in the landscape of ethical evaluations will clearly affect implementation of the Cass Review, where the NHS is moving to deny care outside of research protocols, and to limit care within them.
Of course the ethical guidance from international standards cannot overcome local laws, and if Keir Starmer’s government chooses to take harsher action in legislation, they could certainly overwhelm and override the protections of the 8th review of the Declaration of Helsinki. In the US where health care is overseen by states rather than at the national level, there are already numerous laws restricting trans health care. The Supreme Court of the United States has scheduled a December 4th hearing on one case challenging such laws, US v. Skrmetti. It’s not entirely clear how the 2024 declaration would affect that case, but other research published today would be more directly relevant.
This research carrying the oddly clear title, “Levels of Satisfaction and Regret With Gender-Affirming Medical Care in Adolescence,” measured satisfaction and regret with gender affirming medical care.
Re-questioning teenagers and young adults initially recruited between 2013 and 2017, new data was collected in 2023 from 220 subjects. Originally 269 persons were screened for long term followup so this response rate represents relatively small percentages lost to followup compared to other studies. Responses were accepted directly from youth or from a parent. Of the 220 in this study, 211 expressed no regrets. 4 who expressed regret with either puberty blockers or hormones had ceased all treatment, 4 had some regret but continued and intended to continue indefinitely, and 1 had some regret and though currently continuing treatment expected to discontinue in the future. Overall this represents 96% expressing no regret with treatment, 98.2% continuing treatment, and 97.7% intending to continue treatment indefinitely.
The 2024 declaration should help clarify what are and are not “experimental” treatments and the satisfaction/regret study directly adds to the evidence that gender affirming care is helpful to youth. Together, these publications should inform the SCOTUS decision in US v. Skrmetti, especially considering that one supposed justification for care bans is that trans health care is experimental (especially but not only as applied to adolescents) and without proven benefit. Unfortunately the current makeup of the court gives little reason to trust its majority to make rational decisions based on known facts.
It’s more likely that the 2024 declaration and satisfaction/regret study will be useful in the longer term than in Skrmetti or even in the current NHS actions implementing the Cass Review and beginning a new review of adult gender affirming care. The adult review will be led by Dr. David Levy, an oncologist with no experience or interest in the field of gender-related medicine. He studied brain tumours, though I don’t think he’s likely to excise cissexism from the public mind so that seems largely irrelevant. While we can’t know for sure until later, it seems likely that he’ll follow the pattern of Hilary Cass and exclude research showing positive outcomes for supportive care, recommend their discontinuation on the basis of little research of “high quality” and then recommend instead that the NHS provide treatments with no research successes at all.
It’s also likely that cissexist bigots in the US will use Levy’s (likely predetermined) findings to bolster anti-trans efforts on this side of the pond. One Los Angeles Blade article earlier this year summed up the foreseeable (but not yet inevitable) consequences of the Cass, Levy, and related efforts this way:
[W]e’re going to see roughly 25 states eventually ban health care for trans adults the way they did to trans youth.
The mass migration of trans people will become a stampede. They will flee either to blue states or seek asylum elsewhere. Transgender people will go back to the bad old days of self-medication, buying drugs from Vanuatu, and back-alley orchiectomies. The trans community won’t disappear merely because of this, but it’s part of the overall plan to “eradicate transgenderism” in the United States.
Even so, it’s vital that medical progress moves forward. The JAMA Pediatrics study provides good information and documents like the Cass Review force bigots to put specific claims and assertions on paper where they can be quoted and rebutted. As low a bar as it may seem, the idea that transphobes have to have a reason to ban our care or discriminate against us in housing, employment and benefits is actually quite a large step forward from where society was in the 1990s when I began my activism.
Trans people deserve the chance to make informed decisions about our own care, and while this new JAMA information will not immediately benefit trans people in the UK or in red states, the research and the 2024 declaration can benefit some youth in some places now, and also can form the basis of the arguments that will overturn today’s hateful and dangerous laws and rebut Cass-like “studies” in the future.
We can only hope that as more and more research consistently finds trans people happier and healthier when receiving affirming care, the theocratic right will get tired of hitting their heads against facts and turn to some other scare tactic which they can portray as a brand new and dangerous trend.
PREVIOUSLY IN TRANS HEALTH:
Crip Dyke also writes for the delightfully cussmouthed Wonkette!
You could also follow me on BlueSky. Pretty sure that would make you cool or something.
Found out one of my old friends from a vidya game transitioned recently. I'm in a trans friendly guild in the main game I play (FFXIV) so all I said was, "Oh hey cool, congratulations! I like your new name."
I didn't even blink. I'm just happy so many of my old friends are figuring out who they really are.
In the meantime, Mr. Anzu leads a local 20s-30s anime club at the library, and it's earned a rep as a trans friendly hangout, so we've adopted a crew of trans adults and turned into their surrogate parents.
Ta, CD. Trans rights are human rights, even when the humans are minors.