Gender-affirming treatment up for minors; the why is debatable

(The Center Square) – A new database shows the prevalence of gender-affirming care among minors in Pennsylvania and across the country over the last five years.

Overall, treatment has risen significantly. The reasons why are less concrete and up for debate. The efficacy even more so.

Do No Harm, a medical advocacy group critical of the pediatric field’s embrace of the interventions, says physicians are too quick to prescribe puberty blockers and perform gender-affirming surgeries, causing irreversible damage to bone strength, fertility and brain maturity.

The database , launched on Oct. 8, compiles claims from private and public insurers – apart from Kaiser Permanente and the Department of Veterans Affairs – that have been cross-referenced to ensure the procedures covered are for gender-affirming care specifically.

Doing so, according to Do No Harm External Relations Manager Beth Serio, means the group is “highly confident” that children undergoing mastectomies, breast reductions and other sex-related treatments for conditions other than gender dysphoria are excluded from the database.

After a press conference in Harrisburg with state legislators, Serio told The Center Square that families that pay out of pocket aren’t captured in the data. This, combined with the group’s methodology, this means the total number of procedures is undercounted.

It’s a notable distinction given research from the Harvard T.H. Chan School of Public Health published in June that indicates 97% of breast reductions performed on minors in 2019 were for cisgender males. The term cisgender describes people who do not identify as the opposite sex.

Researchers, who similarly scoured insurance claims, said the procedure was chosen for analysis because it’s one of the few covered surgeries for children and adults diagnosed with gender dysphoria.

In a news release describing the study, co-author Elizabeth Boskey, an instructor in Harvard’s Department of Social and Behavior Sciences, said the data illustrates the rarity of surgeries performed on transgender, or TGD, minors, backing up “that U.S. surgeons are appropriately following international guidelines around assessment and care.”

Lead author Dannie Dai, a research data analyst in the Department of Health Policy and Management, said legislation in 25 states that bans gender-affirming care isn’t about protecting children, but rather “is rooted in bias and stigma against TGD identities and seeks to address a perceived problem that does not actually exist.”

Dr. Stanley Goldfarb, chairman of Do No Harm, begs to differ, saying the “first-of-its-kind project” paints a different picture.

“While this data represents the tip of the iceberg, this is the first step in holding the medical establishment accountable for participating in, and often times promoting, predatory and unscientific medical interventions for vulnerable children,” he said.

According to data provided by the group, between 2019 and 2023, insurance companies covered 558 claims for puberty blockers and 321 surgeries for more than 800 minors. Of the latter, managed Medicaid approved 125 of the procedures, while commercial companies handled the remaining 196.

That translates to just under $5.9 million submitted hospital claims; $469,592 for puberty blockers, and for surgeries, $2.9 million from private insurers and $2.5 million from managed Medicaid.

Nationally, the database claimed just under 14,000 minors received gender-affirming care, totaling more than $119 million.

The group also named Children’s Hospital of Philadelphia and UPMC Children’s Hospital of Pittsburgh as two of 12 institutions across the country that report the most gender-affirming care interventions for minors.

The Center Square was unsuccessful attempting to contact the Gender and Sexuality Development Program at the Children’s Hospital of Philadelphia.

In an interview published in June 2020, Dr. Linda Hawkins, co-director of the hospital’s Gender and Sexuality Development Clinic, said her interest in the field grew out of treating HIV-diagnosed youth. She realized transgender children, in general, lacked access to appropriate medical care.

The “one-stop shop” offers medical, behavioral, nutritional, psychological, legal and educational support for transgender and nonbinary children, she said. Since the clinic’s doors opened in 2014, its caseload had grown from 40 families to more than 1,500 in the tristate area. Some patients come from as far as Germany and Saudi Arabia.

In the same interview, Dr. Nadia Dowshen, co-founder of the program, said she prioritizes research to better guide patients through “challenging” decisions.

“From early on, we developed a registry where we’re tracking psychosocial and biomedical outcomes for all the young people who are seen in our clinic,” she said. “We’re constantly working on that ongoing project.”

Dowshen referenced a study published in the Journal of Adolescent Health that concluded transgender patients and their families “did not find having biological offspring important” and were unwilling to delay gender-affirming care as a result. A child’s discomfort with existing reproductive anatomy, as well as personal wishes, factored into parental support, according to the analysis.

Do No Harm and its supporters say consent “is not possible” given the young age of patients involved. Nor is the claim that transgender youth have no interest in having children.

Eighteen-year-old Chloe Cole, a patient advocate for the group, said she began taking puberty blockers at 13 and underwent a double mastectomy two years later – all without coaching from parents or teachers.

Instead, she learned about it from the internet. Medical interventions began just months after her diagnosis of gender dysphoria. Only one doctor, an endocrinologist, refused to treat after warning Cole about the potential long-term consequences of hormone therapy on brain development.

“It destroyed me,” she said. “It destroyed parts of my body. It destroyed my health. It’s absolutely not for kids. No kid can consent to this.”