Endocrine groups: Evidence-based policies needed to support transgender health care access

Two professional endocrine societies are formally opposing legislative efforts to block transgender people from accessing gender-affirming medical and surgical care, after dozens of state bills threatened to criminalize such therapies.

Legislators across 17 states have proposed more than two dozen bills barring medical and surgical treatments for transgender and gender-diverse youths and adults in the past 3 years, according to a recent count from the Endocrine Society. Many of these bills reflect widespread misinformation about the nature of evidence-based gender-affirming medical care, according to experts. The consequences of such legislation are already being felt in the transgender community, where fear of accessing care remains high.

“During the past year, we’ve seen several state-level policies introduced regarding the care of transgender and gender-diverse individuals in the United States,” Abby Walch, MD, clinical fellow in the department of pediatrics at the UCSF Benioff Children’s Hospitals, and a co-chair of the Pediatric Endocrine Society’s Transgender Special Interest Group Advocacy Subcommittee, told Healio. “These policies appear to have been developed without the involvement of experienced medical providers who care for this population and without evidence-based clinical practice guidelines on the care of transgender individuals. We know that, if enacted, these policies would not only restrict access to health care, in some cases they could even criminalize the provider. We felt it was important to raise awareness among our colleagues regarding the proposed legislation and to reflect on it in light of our society’s position statement on transgender health.”

In December, the Endocrine Society and the Pediatric Endocrine Society released a joint policy perspective, published in The Journal of Clinical Endocrinology & Metabolism, affirming the need for evidence-based policies that include physician input.

Implications for care

A recent case involving transgender health care to gain wide media attention occurred Dec. 1, when three high court judges in the United Kingdom ruled that minors aged 16 years or younger likely could not give informed consent for pubertal suppression. On Jan. 29, the high court granted permission for a coalition of LGBTQ+ and medical organizations, including the Endocrine Society, to intervene in an appeal of its decision.

“The media attention impacts the stress levels of my patients,” Sean Iwamoto, MD, assistant professor of medicine in the division of endocrinology, metabolism and diabetes at the University of Colorado School of Medicine and Rocky Mountain Regional VA Medical Center, and co-chair of the Endocrine Society’s Transgender Research and Medicine Special Interest Group, told Healio. “They already deal with daily societal discrimination: misgendering, denial of health services and more. This can lead to delayed access to care, which has its own implications for overall health and wellness.”

Pubertal suppression, which is fully reversible, is offered to adolescents who meet diagnostic and treatment criteria and are requesting care for gender dysphoria or gender incongruence after they exhibit physical changes of puberty, according to an Endocrine Society clinical practice guideline. For adolescents who are gender questioning, intervention with a pubertal blocker can provide needed time for the youths to fully explore their gender identity, with proper support, without experiencing changes brought on through puberty, Walch said. Professional societies do not recommend any medical treatment for young, prepubertal children who may be gender questioning.

“This is really important because [treatment] can expand the diagnostic phase, which gives the adolescent more time to explore options and live in their experienced gender before making a decision to proceed with hormone therapy or surgery down the line,” Walch said.

“Early intervention also prevents the adolescent from experiencing full, endogenous puberty and the irreversible development of undesirable secondary sex characteristics that may interfere with their psychological function and well-being and can only be corrected down the line with invasive, expensive surgeries. Initiating treatment with pubertal blockers improves outcomes compared with initiating physical transition after puberty. It helps to remove the barriers that these individuals face.”

Iwamoto, an adult endocrinologist, said he has seen firsthand the mental health consequences of experiencing the “wrong” puberty.

“When I have my initial visit with patients about gender-affirming hormone therapy, we often discuss gender history, which can lead to discussions surrounding puberty and what that felt like,” Iwamoto said. “We know there are mental health disparities in terms of higher rates of depression, anxiety and suicidality, and that may come around the time of puberty, when things become more intense and negative, or later in life. I have also talked with many patients about internalized transphobia — how going through the ‘wrong’ puberty or other significant life events may lead to internal hatred that can persist long term.”

 The policy perspective notes that eliminating such interventions will detrimentally affect transgender and gender-diverse individuals who face a disproportionately high rate of suicide, while also potentially punishing providers who provide such care with felony charges, revocation of professional medical licenses, monetary fines and imprisonment.

“The Endocrine Society and the Pediatric Endocrine Society firmly believe that health care treatment should be evidence-based and doctor-patient determined without politicization that is not based on science,” the researchers wrote.

Closing knowledge gaps

Iwamoto said all endocrinologists can play a role to convey a simple, but key message: All patients, regardless of gender identity, deserve care in a comprehensive, compassionate and affirming manner.

“We hope to encourage more endocrinologists, specifically, to promote this,” Iwamoto said. “To form a cohesive group to combat discrimination in health care, we also need increased funding dedicated to transgender health research, across ages. Data from high-quality research is a priority. Hopefully, that will increase all providers’ knowledge as well as confidence in providing gender-affirming care without fear of some kind of consequence from the state or federal level.”

Walch said endocrinologists and other providers should have a seat at the table for any discussion on health care policy affecting transgender and gender-diverse people.

“We would like to see health care experts at the table as contributors to health care policy that impacts our patients,” Walch said. “We also would like to see increased funding for research to close the gaps in knowledge regarding the medical care of transgender and gender diverse individuals, which may in turn help inform health policy, as well as coverage for these interventions for individuals who are seeking therapy. To make these changes happen, we need ongoing awareness and education of the broader public, in addition to ongoing research.”

For more information:

Sean Iwamoto, MD, can be reached at sean.iwamoto@cuanschutz.edu.

Abby Walch, MD, can be reached at abby.cobb-walch@ucsf.edu; Twitter: @walch_abby.