WHAT SHOULD you do if a 12-year-old girl says: “I am a boy”? If the answer were simple or obvious, the question would not be so explosively controversial. A good place to start, if you are a parent, is to affirm that you love the child. It should go without saying, too, that no child should be bound by gender stereotypes. Boys can wear dresses; girls can play with cars, or become plumbers. The question gets much harder, however, when children say they hate their body and want a different one. Gender dysphoria (a feeling of alienation from one’s natal sex) is real, and the proportion of children and adolescents diagnosed with it in rich countries is rising for reasons that are poorly understood (see article). One school of thought, which has spread rapidly, is that you should agree with youngsters who identify as transgender, and offer them medical interventions, if they ask for them, to help their bodies match what they regard as their true selves.
England’s high court last week highlighted some of the problems that can flow from such thinking. The case concerned Keira Bell, who says she was rushed into life-changing medical treatment when she was 16, which she now regrets. The process began with drugs that delay puberty. These are typically described as reversible and a way to “buy time”. But at the Tavistock clinic, where Ms Bell was treated, most patients who took puberty blockers went on also to take cross-sex hormones (oestrogen for males who want to grow breasts; testosterone for females who want to develop male sexual characteristics). Many then proceeded to surgery.
Some of the effects of this are irreversible. Skipping puberty causes sterility. Ms Bell’s breasts, which were removed when she was 20, will not grow back. Those who undergo gender-reassignment treatment may never be able to have children of their own, or experience an orgasm; and the evidence of long-term benefits is extremely sketchy. The English court said it was highly unlikely that someone of 15 could understand all this well enough to give informed consent to taking puberty blockers, which it called an experimental treatment. It suggested that in the case of 16- or 17-year-olds, it might be wise for doctors to seek a court’s permission before prescribing such drugs. Once they reach adulthood, young people in England and Wales are free to seek whatever hormones or surgery they choose.
Many trans activists denounced the ruling as a travesty, or even a denial of the right of trans people to exist. Their passion is understandable. Trans people have often been appallingly treated, and it is right that societies should pass laws to protect them from discrimination, and from bullying in schools. But given the available evidence, the ruling is a reasonable attempt to set out guidelines in an area where there are as yet no good solutions. Other countries should learn from it.
Some children and adolescents who express gender dysphoria will never be happy with their natal sex. But studies suggest that 61-98% of children with gender-related distress, if allowed to go through puberty without medical intervention, will be reconciled to it. Many will realise that they are simply gay. Alas, there is as yet no way to predict these outcomes. So the possible harm of delaying transition for those who might benefit from it must be weighed against harm to the health and the emotional lives of a larger number of people. The latter harm appears worse, so the English court was right to err on the side of preventing it.
It was also right to criticise the Tavistock for several failures. The clinic could not say how many of those referred for puberty blockers had autism, which is common among those who express gender dysphoria. It did not have good data on how many move on to cross-sex hormones. Nor did it properly lay out for patients the alternatives to medical intervention.
Perhaps clinics in other rich countries do a better job of caring for the children and adolescents that attend them. But since they are often subject to less scrutiny, it would be unwise to assume so. The number of transgender clinics has shot up in several countries. In America it has risen from one to more than 50 since 2007—there are no national statistics on how many patients seek treatment. And some activists are urging rules which, though no doubt well-meaning, would make it harder to strike the right balance when treating gender dysphoric children.
Some Australian and American states have banned “conversion therapy” in relation to sexual orientation or gender identity; Canada is considering doing likewise. This conflates two issues which are not the same. It is wrong to try to talk gay people into being straight. But the same principles applied to gender identity could criminalise counselling that raises the distinct possibility that a particular trans-identifying child or adolescent might one day desist. So such laws are a bad idea. Youngsters who are trying to grapple with gender dysphoria need honest, caring therapy that sets out all the long-term options. Health services must do a better job of providing it. And before embracing invasive procedures such as those undergone by Ms Bell, the medical profession needs to gather evidence to establish the balance of benefits and harm they bring. ■
This article appeared in the Leaders section of the print edition under the headline “First, do no harm”
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