A transitioning debate

Trans Train, a 2019 Swedish documentary, introduces viewers to a woman named Sametti. She says she feels like the result of an experiment. Sametti is a detransitioned woman who regrets irreversible hormone treatments and sex-change surgeries she underwent for gender dysphoria. She speaks with a deep voice and covers her receding hairline as she expresses remorse over the drugs and surgeries she thought would fix her.

Sametti was diagnosed with gender dysphoria in 2012, in the middle of a transgender tidal wave. The number of gender dysphoria diagnoses among 13 to 17 year old girls rose 1,500 percent between 2008 and 2018, according to Sweden’s Board of Health and Welfare. In Trans Train, doctors at Sweden’s biggest gender identity center, Karolinska University Hospital in Stockholm, acknowledge a huge surge of referrals for young girls with gender dysphoria.

Karolinska administered treatments including puberty blockers, testosterone, mastectomies, and other sex-change procedures to girls as young as 14—despite severe underlying psychiatric issues and a lack of scientific evidence supporting these medical interventions.

But this month, Karolinska announced a change in course amid growing international concern over the dearth of scientific evidence behind transgender medical treatments and surgeries with lifelong and irreversible effects. (Sametti isn’t alone. One Reddit sub-thread for those who have detransitioned has more than 17,000 members. Trans Train cites one Swedish gender facility, the Lundstrom Clinic, that now offers trauma therapy for people who have detransitioned.)

As of May 1, Karolinska no longer prescribes puberty blockers and cross-sex hormones to minors except in a clinical trial setting approved by the country’s ethics review board. The new policy was enacted after a national healthcare agency found “a lack of evidence for both the long-term consequences of the treatments and the reasons for the large influx of patients in recent years.”

The policy—translated into English by the Society for Evidence-Based Gender Medicine (SEGM)—cites similar findings as the U.K. High Court ruling in December 2020 in the Keira Bell case, which forced the National Health Services to suspend hormone treatments for minors under age 16. That ruling has been appealed, and a hearing is scheduled in June.

Finland was the first nation to issue new guidelines in June 2020, citing the need to prioritize psychological therapy over medical treatment for youth with gender dysphoria.

Karolinska’s statement notes “extensive and irreversible adverse consequences” associated with puberty blockers and cross-sex hormones, including cardiovascular disease, osteoporosis, infertility, increased cancer risk, and thrombosis.

The SEGM called Karolinska’s policy change “a watershed moment,” noting the renowned hospital abandoned the so-called “Dutch Protocol,” an uncontrolled study with low-quality data supporting a gender-affirmation approach. The protocol is endorsed by the World Professional Association for Transgender Health and cited in the 2017 guidelines from the U.S.-based Endocrine Society on gender dysphoria medical treatments.

Despite worldwide scrutiny over transgender interventions, multiple doctors I spoke with said the debate in the United States remains highly politicized and driven by ideology rather than evidence-based science.

On Monday, U.S. Department of Health and Human Services issued an executive order stating it will interpret federal healthcare law as banning discrimination based on sexual identity.

Family physician André Van Mol of Redding, Calif., said the new HHS regulations threaten conscience protections for doctors. “[The Biden administration] plans to make ideology supreme over rights of conscience, religious liberty, and in this case, evidence-based medicine,” said Van Mol, co-chair of the American College of Pediatricians’ Committee on Adolescent Sexuality and the Christian Medical & Dental Association’s Sexual & Gender Identity Task Force.

Psychiatrist Miriam Grossman expressed similar concern: “Three highly respected countries have reviewed all of the scientific evidence and issued strong cautionary approaches, but here in the U.S., we are told if we don’t provide [hormone] treatments we’re violating a patient’s civil rights.”

Endocrinologist Michael Laidlaw of Rocklin, Calif., said doctors who question gender-affirming approaches are actively suppressed, marginalized, or threatened. “That means you’re not getting a good debate going here. … Very few [medical] organizations at the top are even willing to allow a debate.”

Some states are pushing back. In April, Arkansas became the first state to prohibit doctors from providing puberty blockers, cross-sex hormones, and sex-change surgeries to minors. The state’s GOP-controlled legislature overruled a veto from Republican Gov. Asa Hutchinson, who called the bill a “vast governmental overreach.” The American Civil Liberties Union indicated it will sue the state.

More than 10 other states are considering bills to prohibit doctors from giving minors with gender dysphoria hormone-altering drugs or sex-change surgeries. But the U.S. medical establishment seems stuck where Sweden and Finland were a few years ago.

In the closing scene of Trans Train, Sametti returns to the gender clinic that diagnosed her and facilitated her treatments and surgeries. “They admitted they made a mistake, so that is a start,” she said. “Regret was not supposed to happen. My problem still exists …. The surgeries and everything, they are irreversible.”