BMJ editor warns trans US children rushed into sex change surgery

American children with gender dysphoria are being rushed into surgery ‘without psychological support’, the editor of a prestigious medical journal has warned.

Kamran Abbasi said in an editorial in the British Medical Journal (BMJ) that the approach by doctors in the US is ‘not in line with the strength of the evidence’.

The article followed a BMJ investigation last month that laid bare an explosion in gender dysphoria cases among children in recent years, especially in America.

Dr Abbasi said European countries had taken a more cautious approach to prescribing drugs and operating on transgender minors.

‘The US, however, has moved in the opposite direction,’ he wrote, adding: ‘More and more young people are being offered medical and surgical intervention for gender transition, sometimes bypassing any psychological support.’

The above shows insurance claims for diagnoses with gender dysphoria – or a different gender to that assigned at birth – by year. These have also doubled since 2017

The above graph shows insurance claims for puberty blockers in the United States by year, which delay the onset of secondary sexual characteristics — such as facial hair and a deeper voice in boys. It shows claims have doubled since 2017

Dr Abbasi added: ‘Much of this clinical practice is supported by guidance from medical societies and associations, but closer inspection of that guidance finds that the strength of clinical recommendations is not in line with the strength of the evidence.

‘The risk of overtreatment of gender dysphoria is real.’

The BMJ probe cited data showing prescriptions for puberty-blocking drugs among under-18s have doubled between 2017 and 2021, while scripts for hormone therapies have seen a similar rise.

Influential groups like the World Professional Association for Transgender Health (WPATH), American Academy of Pediatrics (AAP) and the Endocrine Society all recommend hormonal and surgical interventions for children with gender dysphoria.

But Dr Abbasi points out that the evidence which those recommendations are based on is scant and inconclusive, and there is a lack of large-scale, long-term research. 

The lack of certainty has caused the UK, Sweden, Norway and Finland to block or issue medical guidelines opposing pharmaceutical interventions for most trans children.

But in the US, medical and surgical interventions given at early ages are becoming increasingly common. 

No national data is available, but one study found the number of mastectomies — sometimes called ‘top surgery’ — performed on girls under 18 in California had risen 13-fold in the last decade, with children as young as 12 offered the irreversible operations.

Chloe Cole says her short-lived transition to being a boy, Leo (right), was a mistake, and that years of treatment from age 13 onwards and the later reversal took a huge toll on her body 

Luka Hein spoke out about how she feels she was rushed into surgery at a young age and doctors did not take into account her poor mental state 

At the state level, however, a gradual pushback is emerging. 

Yesterday, West Virginia introduced a bill that would make it the ninth state to ban gender-affirming drugs and surgery for people under 18.

The BMJ investigation, conducted by Jennifer Block, said the discourse is more ‘polarized’ in the US than other countries. 

Dr Abbasi called for ‘a better appreciation of the evidence, as well as the limits of medicine’ in order to have a ‘more constructive dialogue’.

He said: ‘If the evidence base is weak, we must provide the necessary support to young people as well as prioritizing research to answer questions on issues that are causing a great deal of distress.’

As gender-affirming surgery becomes more popular among minors, an increasing number of ‘detransitioners’ who regret having the irreversible procedure have come forward and claimed they were not challenged enough as children.

Chloe Cole, now 18, has given spoken out about how taking puberty blockers and having surgery ‘irreversibly and painfully’ damaged her body from the age of 13.

At age 14, Ms Close began taking puberty blockers and testosterone injections, that were administered by her mother. That same year she begins going by the name Leo. 

Ms Close, from Central Valley in California, went under the knife at age 15 when she had a double mastectomy.

Almost immediately, she regretted the surgery. She was confined to her bed for the summer of June 2020 as she healed from her surgery.

She said her treatment left her unlikely to have children and unable to breastfeed if she can. 

She said she could also be at risk of certain types of cancer – such as cervical cancer – due to her invasive treatment. 

Ms Close told a hearing of Medicaid officials in Tallahassee last year: ‘No child should have to experience what I have. My consent was not informed.’

West Virginia is the latest state to introduced a bill to become the ninth state to ban gender-affirming drugs and surgery for people under the age of 18

The above shows select states where diagnoses of gender dysphoria have been heading upwards

Luka Hein, another detransitioner, was prescribed hormone treatments to transition from female to male at 15 and was just 16 when she had her breasts removed.

The Minnesotan was a young teenager when she became unsure of her true gender, but thinks doctors were too quick to nudge her in the direction of surgery and did not take her mental health issues into account.

Hein said: ‘It was presented both to me and my parents as, ‘This is your option to fix things or not. There’s not really any other choices. This is the track that you’re going to be on if you want to fix these things.’

Four years post-operation, she transitioned back to female.

Hein said: ‘I feel like dealing with some of the more underlying issues in depth would have definitely been a better place to start.

‘Seeing that I was clearly… a teenager that had mental health issues. I was on psychiatric drugs at the time for depression and anxiety.’

Doctors should have considered that her emotional state meant she could not properly consent to treatment relating to her gender, she said.

She added that doctors could have told her: ‘Just take a wait-and-see [approach] and make sure you’re healthy before anything else.’

West Virginia has become the latest state to introduce a bill to restrict gender affirming care.

It is estimated that West Virginia has more transgender children per capita than any other US state. 

If passed, the bill will prohibit hormone therapy prescriptions and even reversible medication to suppress physical puberty changes for those under 18.

Gender-affirming surgery is also banned as as part of the bill, but doctors say that this is not currently happening in West Virginia anyway.

The state joins eight others who are banning sex change surgeries and puberty blockers for children.

Utah led the charge in January when it became the first state to ban all gender-affirming care for minors. Similar bans in Alabama and Arkansas have been blocked by the courts.

Legislation restricting healthcare for transgender youth has been proposed in roughly two dozen states.

Around 1.5 percent of American teens identify as trans, the highest of any age group.

Many trans-identifying children will undergo hormone treatments, hoping to prevent themselves from developing sex-based characteristics linked to their birth gender.

These often include puberty blockers, which push back the start of the process, and medication that boosts either estrogen or testosterone levels.

Puberty blockers are used to pause puberty and consider whether they want to transition.

By stopping the body’s production of sex hormones, gendered characteristics like a deeper voice in men or the development of breasts in women can be halted.

The long-term effects of these drugs are not fully understood, but it can take years for the body to naturally start producing hormones after stopping the drugs.

The Food and Drug Administration has approved the drugs to stop precocious puberty – when a child goes through the process earlier than when is healthy – but they are used off-label for trans care.

Hormone therapy can then trigger desired sexual characteristics in a trans teen.

By giving a person born as a female testosterone, or a person born male estrogen, they will instead develop traits that match their wanted gender.

The long-term consequences of taking these drugs in youth has not yet been determined, leaving many experts fearful of the recent increase in their use.

Gender-affirming operations, often called top or bottom surgery, will either make changes to a child’s genitalia or chest to match that of their new sex. These are irreversible and can leave a person infertile. 

The success of surgery in particular is a contentious topic.

Finland’s chief psychiatrist for a state-approved pediatric center said four out of five young people who do not receive intervention from professionals will come to accept their bodies.

She warned there was a problem of ‘purposeful disinformation’ among American doctors who pressure parents into transitioning young people.

Research has shown that young people are more likely to come out as trans if they have friends who have already come out as trans, though the cause cannot be inferred from correlation.

A 2020 systematic review and meta-analysis of ‘the quality of life in people with transsexuality after surgery’, looking at 1,099 patients, found quality of life was generally better for people who underwent surgery, but that trans people remain at risk for low life quality and mental health issues.

It noted that ‘[transexuality] can convert to a source of identity crisis due to the… effects on the personality and behavioral system of the individuals as well as their social adjustment.’