Healthcare providers have a duty to uphold their oath — first, do no harm — and approach care from the lens of treating the entire individual. For example, we cannot effectively treat diabetes without addressing a patient’s psychological and emotional relationship with food, barriers to exercise, genetic predisposition, preferences, and social determinants of health. The challenge and complexity of successfully addressing all of these variables often necessitates prescribing medication because the alternative is the risk of severe morbidity and mortality. The medication becomes lifesaving.
The management of gender nonconforming youth is no different. The role of the provider, as part of shared decision-making, is to engage patients in a collaborative discussion about risks versus benefits of potential interventions without bias, whether pharmaceutical or non-pharmaceutical. When a risk is identified, it should be mitigated to whatever extent possible. Clinicians and healthcare leaders have an obligation to speak out against the perils of non-clinical advice and advocate for more research when needed. The hot button issue at hand here: transgender care.
We’ve recently seen a slate of articles and heard extensive political discussion centered on the concern that puberty blockers increase risks for bone density loss. However, the narrow perspective and underlying message of these discussions are harmful to gender nonconforming children and adults who are at high risk for self-harm and extreme violence.
Healthcare providers have a duty to advocate for the most vulnerable in our society, and to approach care from the lens of treating the entire individual. Discussion of risks and benefits is incomplete if it excludes patients’ cultural beliefs, physical comfort, emotional well-being, values, cultural traditions, and preferences — this is the definition of patient-centered care. This collaborative care model is endorsed by the World Health Organization, Centers for Medicare & Medicaid Services, CDC, National Quality Forum, American Medical Association, Joint Commission, and more.
While it’s reasonable to advance research on concerns such as bone density loss, it’s equally important to recognize that there are side effects to all medications. This includes some of the most commonly prescribed classes such as antihypertensives, antidepressants, antipsychotics, and antihyperglycemics. These drugs all have long lists of side effects and potential adverse reactions ranging from mild to severe, as any keen viewer of their regular advertisements on television could tell you. Focusing on a single side effect of medical treatment — as many have done for bone density in regards to the treatment of gender nonconformity — may magnify specific issues for spurious political reasons.
Many critics also fail to adequately address the most concerning risk factor — one that experts in this field are keenly aware of — which is the risk of suicide. Upwards of 82% of trans youth have experienced suicidal ideation and roughly 40% have attempted it. Risks extend beyond potential physiologic events or somatic symptoms, and the risks of not offering a treatment or intervention are just as relevant as potential adverse events during therapy. Any discussion about treatment is incomplete without acknowledging this fact.
It is well known that many studies described in the medical literature have limitations — implicit bias, insufficient sample sizes, lack of diversity in study populations, limited analytic models and funding sources, or influence from special interest groups. We saw the devastating impact of these limitations during the height of the COVID-19 pandemic, when several ineffective and potentially harmful therapies, that were based on poorly designed non-peer reviewed research, were pushed as a result of political pressure. The increasing interference of media and politics in medical practice is of grave concern to healthcare providers and poses great risk to the provision of safe and effective care in our country. In fact, prior to the pandemic, in 2019, the American Academy of Family Physicians, representing 560,000 physicians across disciplines and medical students, put out a statement calling for politicians to end political interference in the delivery of evidence-based medicine.
Human beings are complex and the health of an individual is intersectional. Our physical, mental, and emotional health are deeply interconnected. Western medicine is evolving and now acknowledges that these dimensions cannot be disaffiliated.
It’s the job of trained medical professionals, who are experts in their respective fields, to counsel and collaborate with parents on the best course of treatment for their children. In this case, those experts are pediatricians, pediatric endocrinologists, psychologists, social workers, and child and adolescent psychiatrists. Like any other treatment, the care plan for these children should be individualized and centered on the whole person’s needs.
Protecting basic human rights through evidence-based medical care is a cornerstone of ethical and compassionate care in this country. For this vulnerable population, that care is lifesaving and must be presented as such. We must protect the healthcare rights of gender nonconforming children, challenge the role of media and politics in our medical practice, and encourage those without depth of knowledge to seek understanding of these complex issues, rather than rush to judgment.
Dianna Jacob, PA, MBA, is the chief operating officer at NYC Health + Hospitals/South Brooklyn Health. Theresa Madaline, MD, is the chief quality officer at NYC Health + Hospitals/South Brooklyn Health.