Red flag

Something is wrong when doctors are unfazed about sterilising minors

Social media, smart phones and peer influence are suspected drivers of gender distress. Photo by ROBIN WORRALL on Unsplash

Washington DC | Sterilisation of children is an immediate “red flag” raised by enthusiasm for puberty blockers, according to endocrinologist William Malone, co-founder of the Society for Evidence-Based Gender Medicine (SEGM).

“Anyone who has dealt with children in any medical scenario understands their degree of understanding of these complex topics is very, very limited,” he said.

Early suppression of naturally timed puberty, followed by cross-sex hormones, is thought likely to sterilise a gender-distressed child.

For Dr Malone, this outcome is not in the same category as sterilisation caused by potentially lifesaving chemotherapy for a child with cancer, for example, or the surgery required for a catastrophic genitourinary malformation.

So, he was shocked when the Endocrine Society promoted its new guidelines for gender dysphoria—encouraging puberty blockers and cross-sex hormones without any high-quality evidence—at the society’s Chicago meeting in March 2018. It was Dr Malone’s first encounter with the campaign for paediatric medical transition.

“I understood—as most of the people in the room would—that these interventions were sterilising,” he told GCN.

“That’s just a red flag in medicine.”

Dr Malone and colleagues with similar concerns decided to challenge the new treatment guideline in the Journal of Clinical Endocrinology & Metabolism, the society’s own platform.

Their letter, published in November 2018, states that, “Childhood gender dysphoria is not an endocrine condition, but it becomes one through iatrogenic puberty blockade and high-dose cross-sex hormones.

“The health consequences of GAT [gender-affirmative therapy] are highly detrimental, the stated quality of evidence in the guidelines is low, and diagnostic certainty is poor.”

The response of the guideline authors confessed ignorance about the causes of gender dysphoria, acknowledged the risks of “suboptimal physical outcomes and of regret”, and protested that their guideline was “transparent about the [poor] quality of the evidence supporting its recommendations”.

Even so, the authors said “we believe physicians would fall short in their duty of care if they withheld hormonal treatment of gender dysphoria/incongruence in pubertal youth, when indicated, given the existing state of knowledge, imperfect though it is”.

The disconnect between the guideline authors’ concessions and their unaffected enthusiasm for treatment came as a disturbing surprise for Dr Malone.

This was the moment that led him, together with health researcher Zhenya Abbruzzese and paediatrician Dr Julia Mason, to found SEGM in 2019.

Origin story

From March 2020 coverage of SEGM in The Australian newspaper:

Many mainstream doctors are simply unaware that children’s hospital gender clinics carry out invasive medical treatments based on low-quality evidence, according to a new global watchdog body.

“We want to find the best treatments for these young people and we believe the answer should be found through scientific study, investigation and open debate,” said US physician William Malone, the spokesman of the new Society for Evidence-Based Gender Medicine.

“Even among endocrinologists and mental health professionals, let alone the rest of the medical community, I think there is a great lack of knowledge about what’s occurring [in the youth gender clinics],” he said.

After eight months’ organisation, SEGM has broken cover with more than 100 health and medical practitioner members at a time when scrutiny of the pro-trans “affirmative” treatment model is intensifying, and inquiries or reviews are underway in Australia, the UK, Sweden, Brazil and Germany.

On Thursday in Washington DC, SEGM opened its conference dedicated to Rethinking Youth Gender Medicine.

Dr Malone said that in its early days, SEGM saw the need to fully understand the evidence base through independent systematic reviews, then facilitate a conversation about the results and the best response to gender dysphoric youth.

Like systematic reviews in various jurisdictions around the world, the SEGM-commissioned studies conclude there is no high-quality evidence of benefit to justify these drastic hormonal interventions with minors.

“There’s much more conversation now about the evidence. I think we were able to change the quality of the discussion about the evidence,” Dr Malone said.

Today he highlights the positive response to SEGM’s published papers and its annual conferences; the Washington meeting is the fourth. He says more medical colleagues are reaching out to SEGM and there is less “reactiveness” in discussion.

However, apart from the American Society of Plastic Surgeons, which reviewed the evidence and adopted a policy discouraging gender procedures under the age of 19, mainstream medical organisations in the US are yet to urge practitioners to be more cautious.

“The other organisations have been very rigid and unmoving in their positions, and that’s been the most frustrating and disheartening part of this entire process,” Dr Malone said.

“I think large organisations, in general, are slow to adjust, especially if they’ve made mistakes.”

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Medical fashions

“Medicine, unfortunately, has this pattern of enthusiasm about new interventions, and sometimes treatment recommendations can get ahead of the data,” Dr Malone said.

He cites the book Great and Desperate Cures: The Rise and Decline of Psychosurgery and Other Radical Treatments for Mental Illness published in 1986 by neuroscientist Elliot Valenstein.

And he recalls the relatively recent opioid scandal.

“If you weren’t prescribing opioids to your patient, who just had surgery in the hospital, for not just hours or a day, but for an extended period of time, you were an insensitive doctor. You were opioidphobic,” Dr Malone said.

As for gender medicine, he says a shift to caution will require a change in the treatment guidelines for minors.

“I rely on guidelines for lots of medical conditions, but in this particular instance [of gender dysphoria] the guidelines did not reflect good-quality data,” he said.

“A correction would be a shift in the guidelines that reflects the current lack of high-quality evidence, and a lot of reflection on the ethics of interventions that sterilise children.

“These children are not in a position to understand the consequences of what’s been done to them. It’s really up to the adults to be guiding them and have their best welfare in mind.

“And so that’s what I would look for—a guideline put together by adults that is genuinely looking out for the welfare of children with gender dysphoria.”