2023-09-16 15:07:12
The clinic for transgender minors in St. Louis was overwhelmed last year by an influx of new patients. The requests for appointments were so numerous that his two psychologists struggled to keep up. At the same time, emergency room doctors were seeing transgender teenagers arriving every day in crisis. They took hormones, but had no psychological follow-up.
Opened in 2017 at Washington University Children’s Hospital in St. Louis, the clinic has been welcomed by many families as a blessing. It was the only place for hundreds of miles where distressed teenagers could consult experts for help with their gender transition.
But the demand was such that the establishment was quickly overwhelmed and found itself at the heart of a political storm. Jamie Reed worked there as a case manager. In February, she publicly accused doctors at the clinic of prescribing hormones with long-lasting effects to minors suffering from serious psychological difficulties.
How far should we push the psychological evaluation?
His statements put the Saint-Louis clinic at the center of a war opposing two camps. Missouri’s attorney general, a Republican, opened an investigation, and lawmakers in Missouri and other states used his accusations to ban gender transition care for minors. LGBTQI rights advocates, for their part, have cited accounts from parents who dispute Jamie Reed’s allegations, as well as a Washington University study concluding that his claims “could not be corroborated”.
The turmoil in Saint-Louis brings to the fore one of the most thorny questions about the care of transgender minors: how far should we push the psychological evaluation before initiating medical treatment?
Inspired by ideas born in Europe, several specialized clinics have opened in the last ten years in the United States to accommodate the growing number of minors wanting to begin a gender transition. According to testimonies from patients and parents, the care provided at the Saint-Louis clinic was indispensable: it helped adolescents feel good in their bodies for the first time in their lives, and allowed some to escape from the Depression.
But demand increased, and more and more patients with complex psychological profiles presented themselves. The caregivers had to search for the best way to help them, which highlighted a crucial question: was gender dysphoria the primary cause of their psychological problems or was it a temporary consequence?
A fledgling specialty
With its psychologists’ appointment books overflowing, the clinic called on external workers, some of whom had little experience in gender issues, to determine whether the young candidates were suitable to begin the transition process. Doctors prescribed hormones to those who were given the green light, even though some had a medical history justifying an unfavorable opinion. Many subsequently stopped identifying as transgender.
Several clinics around the world have reported the same type of difficulties. The management of transidentity in pediatrics is an emerging specialty. There are few studies of how patients change over time, making it difficult for doctors to determine when transitioning will be beneficial.
In several European countries, medical authorities have limited – but not banned – transitional medical treatment for minors, and strengthened mental health care until more data becomes available. Health organizations in the United States approved “gender-affirming” treatments, even as their European counterparts became increasingly cautious. In more than 20 U.S. states, conservative lawmakers have taken the radical step of banning or severely restricting all transitional treatment for minors.
Washington University has established an oversight committee responsible for producing a weekly report on the activities of the gender clinic. According to its investigation, none of the 598 patients on hormonal treatment reported any “undesirable physical reactions”. “Doctors treated patients in accordance with current protocols,” says the university.
But, in St. Louis as elsewhere, doctors are faced with ever-changing guidelines and conflicting scientific evidence, while having to deal with political pressure and the mental suffering of young people.
The “affirmative” approach
The first American center for the treatment of pediatric gender dysphoria opened in Boston in 2007. Its founders, Norman Spack, an endocrinologist, and Laura Edwards-Leeper, a child psychologist, had seen Dutch doctors prescribe drugs that delayed puberty in order to prevent physical changes that increased young people’s distress. The goal was to give teens time to think before starting estrogen or testosterone treatment.
Transgender children have high rates of anxiety, depression and suicide attempts. The Dutch found that, in adolescents who did not suffer from serious psychiatric disorders and had experienced gender dysphoria since childhood, the symptoms
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