Lisa Jarvis: Trans kids' health care deserves a more nuanced discussion

Just a few years ago, most Americans probably didn’t think much about transgender adolescents. But in 2020, the political rhetoric began to dramatically shift.

That’s changed public opinion: In 2023, 43% of Americans supported laws that would make it a crime to provide gender-affirming health care to minors—up from 28% in 2021. That’s had real consequences for kids, families and doctors. The number of states that have passed laws restricting or banning gender-affirming care for minors has grown from 4 to 23 in the last two years. That means more than a third of transgender adolescents and teens, or about 113,000 youth, live in a state that has passed a law banning access to gender-affirming care.

But something important has been missing from the debate: nuance.

That’s what made me so glad to read Jack Turban’s thoughtful new book, "Free to Be: Understanding Kids and Gender Identity." I talked with Turban, the director of the gender psychiatry program at University of California, San Francisco, about how he and his colleagues approach treating kids; how today’s adolescents and teens approach identity; and what the evidence shows is the best way to support them.

Here’s an edited and condensed version of our conversation:

Lisa Jarvis: Some parents say they are alarmed by the sharp increase in the number of kids who identify as trans. What should people make of those statistics?

Jack Turban: Because of this heated rhetoric, it makes it sound like there’s an explosion of kids coming out as trans. It’s still a very small number — the highest estimate you'll see from the CDC is less than 2%.

On the one hand, I think there’s less stigma to come out as trans. Kids who have gender dysphoria, or extreme discomfort with their bodies, are more comfortable telling people.

We’re also seeing a rise in kids who are just describing gender in a more nuanced way, but are still falling under that transgender umbrella. [For example], I have patients who say: I don’t like the expectations placed on women in society, and as my way to reject that, I’m going to adopt they/them pronouns.

That is really vital context. People are making it sound like the rise in kids identifying as transgender means all of those kids are getting hormones. But it’s a very small fraction of those kids who are getting any medical interventions.

Q. In your book, you say that you want parents to understand that “There’s no one way to be transgender, just as there’s no one way to be cisgender. Some transgender people want medical intervention, some don’t. Some are distressed by puberty, some aren’t. The existence of one type of person doesn’t invalidate the existence of another.”

A. We've ended up in a place where you don't really hear super-nuanced, accurate information from either side of the political aisle. Everything is constantly boiled down into a one sentence sound bite that’s meant to kind of rile up emotion rather than capture the complexity of what’s going on.

Republicans are guilty of using inflammatory rhetoric that’s misleading (like “sterilizing” children, “mutilating” children). That’s one end of the extreme. But on the other end, I don’t know that I hear a lot from the left, and in particular from politicians who have big platforms, that they’ve really dived into this in a nuanced way to be able to say, “Actually, not all trans kids do want medical interventions — and the important thing is that we have comprehensive evaluations to understand the nuances of these kids.”

Q. One narrative that seems to underpin parental fears (and stoke political flames) is that kids are being given irreversible medications without much consideration.

A. There’s this misconception that care is rushed or not thoughtful. Some people even think that it’s done without parental consent, which certainly has never happened at my clinic. The guidelines are clear that you cannot do that. If you look at the WPATH [World Professional Association for Transgender Health] guidelines, and just go to the adolescent chapter, you’ll see what they say providers should be doing. Generally, medical providers follow guidelines, because if you don’t, you’re at risk of losing your license.

Q. The use of puberty blockers in adolescents has become a political lightning rod. You write that this form of therapy strikes you as being held to a different standard than other medications that are used to treat children. How so?

A. You'll hear things like, “We don’t know what people are going to be like in 10 or 20 years who get these medications.” But that that’s not a complaint with puberty blockers. That’s a complaint with medicine, right? If your standard was that you need 10 to 20 years of follow-up data, then you would have to ban every medication that was approved by the FDA in the past five years.

You’ll hear people say, “But this is off-label.” A huge swath of pediatric medicine that we prescribe is off-label use. I sometimes direct people to the statement from the American Academy of Pediatrics where they explain that off-label use does not mean improper or experimental. It just means off-label.

Also questions like, “What is the cognitive impact on these medications a decade out?” You know, I can’t answer that for most psychiatric medications.

There’s just been a phenomenon where people are taking uncomfortable truths about medicine broadly and bringing them up to scare the public. [Puberty blockers] have risks, benefits, side effects and unknowns the same way any medicine does.

Q. The scrutiny of medical intervention really came to a head in April with the release of the Cass Review — a report commissioned by the UK government. In it, British pediatrician Hilary Cass determined that the evidence on the use of gender-affirming medications was unreliable and UK policymakers responded by implementing bans. American doctors have criticized it. (This week, the main doctor’s union in the UK said it would evaluate the Cass Review over concerns “about weaknesses in the methodologies used.”) What’s your view on the Cass Review?

A. It’s very different the way it is reverberating in medicine versus in the political realm. Within medicine, people read it and I don’t know that it presented a lot of new information or ideas. But in the political realm it had this huge impact.

[The Cass Review] keeps getting translated as the United Kingdom saying, “You should ban puberty blockers. Puberty blockers are dangerous. There’s no evidence that it’s helpful.” And it’s being filtered through op-ed journalists and J.K. Rowling, and coming up in our political debates in the US, to ban medical care. But [Cass] didn’t say to ban them; she said to have it within the context of a clinical trial, but to make sure it’s still available.

[Cass] says you should have a thorough assessment and practice this medicine in a nuanced way, which really is quite similar to what our guidelines say. Not all kids are good candidates for these interventions, but some kids clearly benefit. And you should do a comprehensive mental health evaluation before offering the treatments to make sure they’re appropriate. And she said that gender-affirming hormones should be available after age 16, but there should be a very good clinical rationale for doing so. Which I think is not super-far from how I practice.

There is a firm disagreement where the Cass Report seems to think you could offer puberty blockers only in a clinical trial and American doctors think — and, you know, turned out we were right — that it wasn’t logistically feasible. And I think a lot of American doctors also have kind of ethical qualms of forcing people into a clinical trial for a medication that we have a lot of data is effective and not particularly huge concerns that it’s dangerous.

Q. Still, some people are using the report as proof that the risks of medical interventions outweigh their benefits. Where do you think the evidence sits today?

A. I think people would be reassured to know there are now 15 to 20 studies looking at gender-affirming medical interventions for adolescent gender dysphoria. Those 15-20 studies have all shown improvement.

The biggest one was published in the New England Journal [of Medicine]. Four different gender clinics in the US followed over 300 kids. They tracked improvements in anxiety, depression and positive affect (which is like positive emotions), and they found that the improvements tracked along with your body aligning with your gender identity.

All [studies] have strengths and weaknesses. But there’s nothing scary in these studies, right? The kids aren’t getting worse.

Q. What do you hope to come from this book?

A. My greatest hope is that people will try to meet a trans person or a family with a trans child to hear what their real-life experience is. I think that is so much more important than hearing what talking heads are saying.

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This column does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.