Dr. Crystal Beal's Response to Legislative Bans on Youth Gender Affirming Medical Care

Dear Legislators:

My name is Crystal Beal, MD. In medical school, I was taught the principles I was expected to uphold as a physician:

• Beneficence
• Non-maleficence   
• Autonomy
• Justice

I learned that beneficence was my duty to act for the benefit of the patient¹. I was taught that non-maleficence meant to do no harm to the patient, which includes not depriving others of the goods of life, that the practical application of non-maleficence is for me to weigh the benefits against burdens of all interventions and treatments, to eschew those that are inappropriately burdensome, and to choose the best course of action for the individual patient in front of me¹. Medical school taught me that all persons have intrinsic and unconditional worth and, therefore, should have the power to make rational decisions and moral choices, and each should be allowed to exercise their capacity for self-determination as the concept of autonomy¹. Lastly, medical school helped me learn about justice as the fair, equitable, and appropriate treatment of all persons¹. My school centered shared decision making and patient-centered care which are well-respected models of care supported by SAMSHA, CMS, AHRQ, and the AMA to name a few.

My medical school trained me well. I am forever grateful for my time there and my education. I am now a Board Certified Family Medicine physician with four full state licenses and a Florida Telemedicine license. I speak from a place of significant training and practice experience when I say this proposed legislation will cause physicians to violate our oath to do no harm and force us to act against the principles of medical ethics we all hold dear. It will remove the ability for physicians to center their patients in care and will disallow shared decision making.

Current and high quality research indicates that desistance among trans youth who access gender affirming medical care is less than 2%^{5, 6, 16, 22}. Studies of 10s of thousands of trans youth show receipt of gender-affirming medical care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe depression and 73% lower odds of suicidality over a 12-month follow-up in youth who desired such care³⁰. Studies also show lower odds of lifetime suicidal ideation for young people who wanted gender affirming medical care and received it versus those who wanted it and were unable to access it.

This legislation is in direct opposition to the current evidence-based medical practices.

29 major medical associations have policy statements indicating the medical necessity of gender affirming care. These 29 associations are well-respected organizations with long histories and prolific memberships. They have published guidelines in other areas of care that constitute national standards of care, such as the Clinical Practice Guideline for the Diagnosis, Evaluation, and Treatment of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents or Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. These organizations include, but are not limited to:

• American College of Physicians
  • Founded January 8, 1915
  • Number of members: 160,000
• American Medical Association
  • Founded May 7, 1847
  • Number of members: 240,359 as of 2016
• American Osteopathic Association
  • Founded April 19, 1897
  • Number of members: more than 168,000
• American Psychiatric Association
  • Founded October 16, 1844
  • Number of members: 37,400
• American Academy of Pediatrics
  • Founded 1930
  • Number of members: 67,000
• The Endocrine Society
  • Founded 1916
  • Number of members: over 18,000
• The Pediatric Endocrine Society
  • Founded 1972
  • Number of members 1,500
• American Public Health Association
  • Founded 1872
  • Number of members: 25,000
• American Academy of Child and Adolescent Psychiatry
  • Founded 1953
  • Number of members: more than 10,000
• American Academy of Family Physicians
  • Founded 1947
  • Number of members: 127,600
• American College of Obstetricians and Gynecologists
  • Founded 1951
  • Number of members: 60,0000

The medical organizations stating opposition to gender affirming care are small organizations with limited membership and history including:

• American College of Pediatricians
  • Founded 2002
  • Number of members: 500
• American Association of Physicians and Surgeons
  • Founded 1947
  • Number of members: 5,000

They have no publications that are widely read, nor treatment guidelines that have been adopted as national standards of care. 

The current body of evidence indicates that the benefits of medical gender affirming care for youth who meet the criteria for gender dysphoria and desire medical intervention outweigh the risks. When you combine the numbers of individuals studied it totals over 10s of thousands of subjects. Here is the summary of some overviews to make the evidence easier to parse:

• A 2021 meta-analysis of 9 qualifying studies (one which was considered “excellent” quality, five considered “good”) on the effects of GnRHa found that the common benefits among them were decreased suicidality in adulthood, improved affect and psychological functioning, and improved social life³.
• A comprehensive literature review of 16 studies examining the benefits of puberty blockers and gender-affirming hormones in trans youth revealed that 13 of the 16 showed blockers and hormones resulted in statistically significant improvements in mental health, and none of them showed a decline. Two of these three studies found an improvement, but did not reach the level of statistical significance due to small sample sizes⁴. 
• The most recent study released earlier this year in the New England Journal of Medicine shows improvements in psychosocial functioning after 2 years of gender affirming medical care in youth.²⁹
• To be clear, the current literature suggests that access to gender affirming medical care is LIFE-SAVING which is supported in many of the policy statements of the 29 aforementioned medical organizations.

In fact, the current evidence is so overwhelmingly positive that no Institutional Review Board is likely to allow randomized controlled studies in gender affirming care as often mentioned by opponents of this care. Almost, if not all, IRBs, would find non-treatment unethical based on the current body of existing literature in the field of youth gender affirming medical care. As to the common concern that youth gender affirming care is experimental, not even the district court of Alabama could find evidence of such. In May of this year Judge Liles Burke enjoined a prohibition on puberty blockers, hormones, and hormone antagonists, stating “Defendants produce no credible evidence to show that transitioning medications are ‘experimental’. While Defendants offer some evidence that transitioning medications pose certain risks, the uncontradicted record evidence is that at least twenty-two major medical associations in the United States endorse transitioning medications as well-established, evidence-based treatments for gender dysphoria in minors.” Furthermore, Judge Burke stated that “there is a substantial likelihood that Section 4(a)(1)-(3) of the Act is unconstitutional.” (Eknes-Tucker v. Marshall, 2:22-cv-184-LCB: M.D. Ala. May. 13, 2022)

Puberty blockers were first used in 1988 for the treatment of gender dysphoria and prior to that they were used to treat precocious puberty. Some of the first recipients of care with puberty blockers were in the Netherlands. The Dutch trials published a follow-up of their original cohort in 2014 which found that “after gender reassignment, in young adulthood, the gender dysphoria was alleviated and psychological functioning had steadily improved. Well-being was similar to or better than same-age young adults from the general population. Improvements in psychological functioning were positively correlated with postsurgical subjective well-being.”⁵ Further, the Dutch clinic published a review of 6,793 patients seen at their clinic from 1972-2015 which is 95% of the gender care done in the Netherlands which found only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret⁶. 

Some other common concerns around puberty blockers for gender affirming care include loss of bone strength, loss of sexual pleasure, and loss of cognitive development. Bone mineral density (BMD) issues with puberty blockers which are similar to issues with BMD seen in the use of depo-provera, a contraceptive option that is included in standard practice for adolescents in the United States. Similar to depo-provera treatment, BMD recovers after discontinuation of puberty blockers or administration of hormones to levels appropriate for current gender identity (in this publication they compare patients administered estradiol to cis boys scores which provides context for the lower Z-scores seen in transgirls) ⁸. Early GAT (including puberty suppression, affirmative hormones, and surgeries) may provide young transgender adults with the opportunity to increase their romantic and sexual experiences^{9, 10}. A study looking at Tower of London performance scores suggested that pubertal suppression with puberty blockers is not associated with a detrimental effect to these scores describing higher-order cognitive process¹¹. A study in patients treated with puberty blockers for precocious puberty indicated patients treated with puberty blockers performed similarly in the domains examined, including auditory and visual memory, response inhibition, spatial ability, behavioral problems, and social competence¹². 

Another common misuse of out-dated data in opposition of adolescent gender affirming care is the citation that “it is well known that 80-85% of children who experience gender dysphoria “change their mind” upon reaching puberty”. This statistic comes from four small studies^{13, 14, 15, 16} with a total of 254 youth in all of the four studies who meet the now outdated criteria for Gender Identity Disorder from the DSM-IV. To be clear these children would not necessarily meet today’s actively used criteria for gender dysphoria in children. All that was required by the DSM-IV was:

Manifestation by four (or more) of the following:

(1) repeatedly stated desire to be, or insistence that he or she is, the other sex

(2) in boys, preference for cross-dressing or simulating female attire; in girls, insistence on wearing only stereotypical masculine clothing

(3) strong and persistent preferences for cross-sex roles in make-believe play or persistent fantasies of being the other sex

(4) intense desire to participate in the stereotypical games and pastimes of the other sex

(5) strong preference for playmates of the other sex

Currently used is the DSM-5-TR which defines gender dysphoria in children as a marked incongruence between one’s experienced/expressed gender and assigned gender, lasting at least 6 months, as manifested by at least six of the following (one of which must be the first criterion):

1. A strong desire to be of the other gender or an insistence that one is the other gender (or some alternative gender different from one’s assigned gender)
2. In boys (assigned gender), a strong preference for cross-dressing or simulating female attire; or in girls (assigned gender), a strong preference for wearing only typical masculine clothing and a strong resistance to the wearing of typical feminine clothing
3. A strong preference for cross-gender roles in make-believe play or fantasy play
4. A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
5. A strong preference for playmates of the other gender
6. In boys (assigned gender), a strong rejection of typically masculine toys, games, and activities and a strong avoidance of rough-and-tumble play; or in girls (assigned gender), a strong rejection of typically feminine toys, games, and activities
7. A strong dislike of one’s sexual anatomy
8. A strong desire for the physical sex characteristics that match one’s experienced gender

As with the diagnostic criteria for adolescents and adults, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.

These studies are misquoted as they are no longer applicable to today’s diagnostic criteria or standards of care. The bulk of the children in that study were not transgender but cisgender children who happened to like toys or clothes of the “opposite sex”. As some of your cis female legislative members have been photographed in pants, they may have been considered gender discordant by that study.

A further body of larger research has indicated that young people who have worsening of dysphoria with the onset of puberty have persistence of their transness into adulthood at rates of 96-97.5%^{17, 18, 19, 20}. Further, UK GIC clinicians conducted a records review of 3,398 transgender patients at the Charing Cross, Tavistock, and Portman clinics. They found only two individuals (.06%) who had detransitioned due to regret or deciding that they were not actually transgender²¹. Similarly, a Dutch study of 6,793 patients who medically transitioned found only seven (.1%) who regretted transition because they decided they were not transgender⁶. Among those few adolescents who detransition, including those who have undergone hormonal interventions, research indicates that most do not regret having been given the opportunity to explore their gender. A 2021 study of youth who ceased puberty suppression found that many were glad to have had puberty suppression available because it safely offered them time and space to explore their gender identity²². Conversely, approximately 5% of cisgender women who undergo breast reduction experience regret this procedure, and this is considered by plastic surgeons to be an extremely low rate of regret²³.

Additionally, it is important to note that none of our current guidelines or practicing clinicians recommend providing ANY medical interventions until patients are in puberty. There are NO recommended medical interventions for youth diagnosed with gender dysphoria while they are children. Puberty blockers are NOT administered until a patient is IN puberty. It is important to note that very few if ANY of the children quoted in the 80-85% or the even higher number would have received medical treatment or intervention for their childhood gender exploration. Opponents to adolescent gender affirming care often say that surgeries and medical interventions are enacted on young children, but this is simply not true.

According to WPATH SOC8 and the Endocrine Society, gender affirming care is not universal or occurring in stages. It is a plethora of options available to youths and their families with options chosen by families, youth, and a care team that are appropriate for that individual patient’s goals and values. It is exceedingly rare for a minor to undergo any form of gonadectomy as most insurance companies and surgeons require an age of 18 for gonadectomy. While some minor patients are able to access gender affirming chest reconstruction, the initial research indicates positive outcomes with self-reported regret near zero^28,29. Further cis gender patients are also able to access gender affirming chest surgeries with parental consent as minors as well, such as, breast augmentation or gynecomastia chest tissue removal. 

The existing body of literature and research which involves 10s of thousands of trans and gender diverse patients is often dismissed by legislators pandering to the religious and conservative vote in favor of four studies with less than 300 patients, three of which are more than 10 years old and one of which is 9 years old, all of which use outdated criteria. In crafting and moving this legislation forward, you have ignored the medical necessity statements of 29 major medical organizations with over 700,000 members and favored the recommendations of two organizations with less than 6000 members. If you pass this legislation, you will further minoritize transgender youth. This will lead to an increased risk of suicidal ideation, attempts, and completed deaths. By enacting this legislation against the advice of 29 major medical organizations and 800,000 clinicians and the existing literature, you will have those deaths on your hands. 

Please feel free to contact me with questions. 

Sincerely,

Crystal Beal, MD

Board Certified Family Medicine Physician

drcrystalbeal@queerdoc.com

References:

1. Varkey B: Principles of Clinical Ethics and Their Application to Practice. Med Princ Pract 2021;30:17-28. doi: 10.1159/000509119
2. Founding dates and membership rates of medical organizations taken from each individual organization website.
3. Rew, L., Young, C.C., Monge, M. and Bogucka, R. (2021), Review: Puberty blockers for transgender and gender diverse youth—a critical review of the literature. Child Adolesc Ment Health, 26: 3-14. https://doi.org/10.1111/camh.12437
4. Turban, J. (2022 January 24). The Evidence for Trans Youth Gender-Affirming Medical Care. Psychology Today. https://www.psychologytoday.com/us/blog/political-minds/202201/the-evidence-trans-youth-gender-affirming-medical-care 
5. de Vries AL, McGuire JK, Steensma TD, Wagenaar EC, Doreleijers TA, Cohen-Kettenis PT. Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics. 2014 Oct;134(4):696-704. doi: 10.1542/peds.2013-2958. Epub 2014 Sep 8. PMID: 25201798.
6. Wiepjes CM, Nota NM, de Blok CJM, Klaver M, de Vries ALC, Wensing-Kruger SA, de Jongh RT, Bouman MB, Steensma TD, Cohen-Kettenis P, Gooren LJG, Kreukels BPC, den Heijer M. The Amsterdam Cohort of Gender Dysphoria Study (1972-2015): Trends in Prevalence, Treatment, and Regrets. J Sex Med. 2018 Apr;15(4):582-590. doi: 10.1016/j.jsxm.2018.01.016. Epub 2018 Feb 17. PMID: 29463477.
7. Michael Biggs (2022) The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence, Journal of Sex & Marital Therapy, DOI: 10.1080/0092623X.2022.2121238
8. Schagen SEE, Wouters FM, Cohen-Kettenis PT, Gooren LJ, Hannema SE. Bone Development in Transgender Adolescents Treated With GnRH Analogues and Subsequent Gender-Affirming Hormones. J Clin Endocrinol Metab. 2020 Dec 1;105(12):e4252–63. doi: 10.1210/clinem/dgaa604. PMID: 32909025; PMCID: PMC7524308.
9. Bungener SL, Steensma TD, Cohen-Kettenis PT, de Vries ALC. Sexual and Romantic Experiences of Transgender Youth Before Gender-Affirmative Treatment. Pediatrics. 2017 Mar;139(3):e20162283. doi: 10.1542/peds.2016-2283. PMID: 28242863.
10. Bungener SL, de Vries ALC, Popma A, Steensma TD. Sexual Experiences of Young Transgender Persons During and After Gender-Affirmative Treatment. Pediatrics. 2020 Dec;146(6):e20191411. doi: 10.1542/peds.2019-1411. PMID: 33257402.
11. Staphorsius AS, Kreukels BP, Cohen-Kettenis PT, Veltman DJ, Burke SM, Schagen SE, Wouters FM, Delemarre-van de Waal HA, Bakker J. Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology. 2015 Jun;56:190-9. doi: 10.1016/j.psyneuen.2015.03.007. Epub 2015 Mar 11. PMID: 25837854.
12. Wojniusz S, Callens N, Sütterlin S et al.  Cognitive, emotional, and psychosocial functioning of girls treated with pharmacological puberty blockage for idiopathic central precocious puberty. Front Psychol. 2016; 7: 1053
13. Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90. doi: 10.1016/j.jaac.2013.03.016. Epub 2013 May 3. PMID: 23702447.
14. Drummond, Kelley & Bradley, Susan & Peterson-Badali, Michele & Zucker, Kenneth. (2008). A Follow-Up Study of Girls With Gender Identity Disorder. Developmental psychology. 44. 34-45. 10.1037/0012-1649.44.1.34.
15. Wallien MS, Cohen-Kettenis PT. Psychosexual outcome of gender-dysphoric children. J Am Acad Child Adolesc Psychiatry. 2008 Dec;47(12):1413-23. doi: 10.1097/CHI.0b013e31818956b9. PMID: 18981931.
16. Steensma TD, Biemond R, de Boer F, Cohen-Kettenis PT. Desisting and persisting gender dysphoria after childhood: A qualitative follow-up study. Clinical Child Psychology and Psychiatry. 2011;16(4):499-516. doi:10.1177/1359104510378303
17. van der Miesen, Anna & Steensma, Thomas & Vries, Annelou & Bos, Henny & Popma, Arne. (2020). Psychological Functioning in Transgender Adolescents Before and After Gender-Affirmative Care Compared With Cisgender General Population Peers. Journal of Adolescent Health. 66. 10.1016/j.jadohealth.2019.12.018. 
18. Brik, T., Vrouenraets, L.J.J.J., de Vries, M.C. et al. Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Arch Sex Behav 49, 2611–2618 (2020). https://doi.org/10.1007/s10508-020-01660-8
19. Clara De Castro, Mireia Solerdelcoll, Maria Teresa Plana, Irene Halperin, Mireia Mora, Laura Ribera, Camil Castelo-Branco, Esther Gómez-Gil, Angela Vidal, High persistence in Spanish transgender minors: 18 years of experience of the Gender Identity Unit of Catalonia,Revista de Psiquiatría  y Salud Mental, 2022,ISSN 1888-9891, https://doi.org/10.1016/j.rpsm.2022.02.001 
20. Olson KR, Durwood L, Horton R, Gallagher NM, Devor A. Gender Identity 5 Years After Social Transition. Pediatrics. 2022 Aug 1;150(2):e2021056082. doi: 10.1542/peds.2021-056082. PMID: 35505568.
21. Lieke J.J.J. Vrouenraets, Martine C. de Vries, Irma M. Hein, Marijn Arnoldussen, Sabine E. Hannema & Annelou L.C. de Vries (2022) Perceptions on the function of puberty suppression of transgender adolescents who continued or discontinued treatment, their parents, and clinicians, International Journal of Transgender Health, 23:4, 428-441, DOI: 10.1080/26895269.2021.1974324
22. Turban JL, Carswell J, Keuroghlian AS. Understanding Pediatric Patients Who Discontinue Gender-Affirming Hormonal Interventions. JAMA Pediatr. 2018;172(10):903–904. doi:10.1001/jamapediatrics.2018.1817
23. Gonzalez MA, Glickman LT, Aladegbami B, Simpson RL. Quality of life after breast reduction surgery: a 10-year retrospective analysis using the Breast Q questionnaire: does breast size matter? Ann Plast Surg. 2012 Oct;69(4):361-3. doi: 10.1097/SAP.0b013e31824a218a. PMID: 22964671.
24. Thornton KGS, Mattatall F. Pregnancy in transgender men. CMAJ. 2021 Aug 23;193(33):E1303. doi: 10.1503/cmaj.210013. PMID: 34426447; PMCID: PMC8412429. 
25. A Stangl T, M Wiepjes C, Defreyne J, Conemans E, D Fisher A, Schreiner T, T’Sjoen G, den Heijer M. Is there a need for liver enzyme monitoring in people using gender-affirming hormone therapy? Eur J Endocrinol. 2021 Apr;184(4):513-520. doi: 10.1530/EJE-20-1064. PMID: 33524005.
26. Cuccolo NG, Kang CO, Boskey ER, Ibrahim AMS, Blankensteijn LL, Taghinia A, Lee BT, Lin SJ, Ganor O. Mastectomy in Transgender and Cisgender Patients: A Comparative Analysis of Epidemiology and Postoperative Outcomes. Plast Reconstr Surg Glob Open. 2019 Jun 12;7(6):e2316. doi: 10.1097/GOX.0000000000002316. PMID: 31624695; PMCID: PMC6635198.
27. Olson-Kennedy J, Warus J, Okonta V, Belzer M, Clark LF. Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatr. 2018 May 1;172(5):431-436. doi: 10.1001/jamapediatrics.2017.5440. PMID: 29507933; PMCID: PMC5875384.
28. Kuper LE, Rider GN, St Amand CM. Recognizing the Importance of Chest Surgery for Transmasculine Youth. Pediatrics. 2021 Mar;147(3):e2020029710. doi: 10.1542/peds.2020-029710. Epub 2021 Feb 3. PMID: 33536331.
29. Chen D, Berona J, Chan YM, Ehrensaft D, Garofalo R, Hidalgo MA, Rosenthal SM, Tishelman AC, Olson-Kennedy J. Psychosocial Functioning in Transgender Youth after 2 Years of Hormones. N Engl J Med. 2023 Jan 19;388(3):240-250. doi: 10.1056/NEJMoa2206297. PMID: 36652355.
30. Tordoff DM, Wanta JW, Collin A, Stepney C, Inwards-Breland DJ, Ahrens K. Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Netw Open. 2022 Feb 1;5(2):e220978. doi: 10.1001/jamanetworkopen.2022.0978. Erratum in: JAMA Netw Open. 2022 Jul 1;5(7):e2229031. PMID: 35212746; PMCID: PMC8881768.