Scottish Prime Minister Nicola Sturgeon says that she resigned because she was exhausted by the pandemic. Others think that the battle over gender politics contributed to her decision to step down. But the pandemic is over. And the battle over gender politics is heating up.
Relevant background: After a long and acrimonious debate, the Scottish Parliament amended their 2004 law regarding official recognition of gender identity. They made it easier for people to officially change their gender identity. The new law lowered the age at which gender recognition certificates could be granted (from 18 to 16), removed the need for a medical or psychiatric diagnosis of gender dysphoria, and shortened the time period during which a person would have to have lived in their acquired gender from 2 years to 3 months. This approach is supported by the UN and many international courts which all recommend a similarly simple legal process, based on self-identification, and not requiring medical certification.
Then the British Parliament then overturned the Scottish law using an arcane law that has rarely been used and was designed to be used only in matters of defense and foreign affairs. That law had never before been used. A few weeks after the British veto, Nicola Sturgeon resigned as Prime Minister. She accused the British government of unconscionably “using trans people as a political weapon.”
Sturgeon denied that those debates are the reason why she stepped down. Instead she claimed that she was exhausted by the pandemic. But gender issues were clearly tearing her party apart. Some members threatened to leave the party rather than support the legislation.
In the US, meanwhile, the professionals who make such determinations have been under attack. South Dakota enacted a law making it illegal to prescribe puberty-blocking medication or perform sex reassignment surgery for minors. Texas deemed such treatments child abuse and ordered state child protection services to investigate cases of their use. Many other states have either implemented or are considering such prohibitions.
The divisiveness of the issue tends to obscure two key facts: First, while the number of children and teens who experience gender dysphoria is rising, it is still a tiny percentage of all youth. In 2021, there were 42,167 children (ages 6-17) diagnosed with gender dysphoria in the United States. Of those, 1390 (3%) received puberty-blocking medication. To put those numbers in perspective, there are about 50,000,000 children and teens between 6-17 in the US. Fewer than 1/100,000 kids are actually receiving gender-affirming hormones. (This according to a survey by Reuters). This is not a crisis. Second, non-treatment can be dangerous. Transgender youth are at high risk for mental health problems and suicide. Some studies suggest that gender-affirming treatment reduces mental health problems. But we need better studies.
Sweden offers a model that balances patients’ rights, political concerns, and the need for better data. Sweden was on the road to changes similar to those proposed in Scotland. In 2018, the ruling Social Democrat government proposed a law like Scotland’s that would have reduced the minimum age for sex reassignment surgery from 18 to 15, removed any need for parental consent, and allowed children as young as 12 to change their legal gender. After backlash from both the public and the scientific community, the government withdrew their proposal and commissioned a review by the Swedish National Council on Medical Ethics.
The Council’s excellent report was issued in 2022 and recommended that gender-affirming treatments only be offered in the context of research protocols. The goal was not to limit access to such treatments but to ensure that we could both treat patients and gather scientific data to answer important questions about the safety and efficacy of such medical interventions. In Sweden, the government could mandate that treatment take place only in designated research centers.
Careful study of outcomes would channel funding, allow access, improve monitoring and safety, and identify unanswered questions. In the long run, it would allow better treatment for current and future teens. It would be much preferable to the approach taken in six states that have made such treatment illegal.
That Swedish approach is a careful compromise. I recommended a similar approach a few years ago. The approach would be difficult to implement in the United States’ decentralized health care system but, with professional leadership, most minors who seek such treatment could be offered enrolment in clinical studies. As noted by the Swedish council, these would not need to be randomized trials. But they should be designed for careful monitoring and long-term follow-up.
Outlawing or prohibiting treatment is not the answer. Better research is.