Florida’s reluctance to unequivocally adopt recommendations from health officials has consistently made national headlines in the US. Most recently the culture wars pertained to Covid vaccination in children, but media attention is returning to treatment for gender dysphoria, an issue of contention since last year when House bill 211 (HB211) proposed to criminalize gender reassignment treatment or surgery on minors. The bill died in committee but the state is proceeding with other actions to limit medical intervention.
In April, the Florida Department of Health, led by Surgeon General Joseph Ladapo, M.D., Ph.D., responded to a fact sheet issued by the U.S. Department of Health and Human Services on the treatment of gender dysphoria. The guidelines assert that gender reassignment surgery should not be a treatment option for children or adolescents due to the “unacceptably high risk of doing harm.” In addition, due to “the lack of conclusive evidence, and the potential for long-term, irreversible effects,” the guidelines advise against social gender transition, puberty blockers and hormone therapy for those under 18. The guidelines recommend that children and adolescents be provided social support and counseling from a licensed provider and closes with references to similar international guidelines.
Transgender guidelines released in 2020 by Finland urge providers to progress through the treatment pathway only if three conditions are met: 1) significant and prolonged suffering in everyday situations; 2) concomitant psychiatric symptoms have been identified and addressed; and 3) the person has the capacity to demand an evaluation. A scoping review commissioned by the Swedish government reached a similar conclusion regarding the dearth of evidence regarding the epidemiology of gender dysphoria and its treatment. Guidelines from the French National Academy of Medicine urge caution in the use of puberty blockers and hormones, noting an “…epidemic-like phenomenon…” and the influence of social networks. Finally, an interim report to the UK’s National Health Service acknowledges that international evidence is inconclusive while striving to address the distress caused by service capacity issues.
In June 2022, the Florida Department of Health and the Agency for HealthCare Administration (AHCA) announced the initiation of rule-making on Medicaid coverage for the treatment of gender dysphoria. The accompanying report summarized the findings of five medical experts who found that the hormonal treatment of young people is subject to “low-quality evidence, small sample sizes, and a medium to high risk of bias.” The AHCA report concluded that transgender treatments lacked sufficient medical evidence to warrant reimbursement through the state’s Medicaid program. To qualify for coverage, treatments must meet Florida Administrative Code Rule 59G-1.035—sex reassignment must be “consistent with generally accepted professional medical standards (GAPMS) and not experimental or investigational.”
In the media release, Agency cited a review article on gender dysphoria in childhood which reported 80% of those seeking transgender treatment ultimately desist in their desire to identify with opposite sex. The literature on desistance is murky, though. Another frequently-cited study reporting that 80% desist included those whose parents had not responded to a survey as well as those who were “subthreshold”—didn’t meet the criteria for gender dysphoria. Thus, the proportion of young people who desist is subject to methodological variations, such as who meets criteria for the denominator and how many are lost to follow-up.
Advocacy groups frame the Agency’s position as an assault on the rights of transgender children. Even worse, by rolling back Medicaid coverage the state is restricting access to care among the poorest citizens. Further exacerbating tension around protecting this vulnerable group, the Fairness in Women’s Sports Act went into effect on July 1, banning transgender female athletes from playing on girls’ teams in public high schools, colleges and universities. Florida is the seventh state to issue this ruling, and Governor DeSantis’ position is that the law supports the rights of female athletes to compete on a level playing field.
While Florida’s refusal to fund medical intervention is widely perceived as extremist, the state’s policy is consistent with Dr. Ladapo’s stance on pediatric Covid vaccination. In March 2022, the Department released guidance on pediatric COVID-19 vaccines, recommending that “children with underlying conditions are the best candidates for the COVID-19 vaccine.” When the under-5 vaccines were authorized in June 2022, the Department’s guidance stated that there was “insufficient data to inform benefits and risk” of COVID-19 vaccines for these infants and young children. Dr. Ladapo went on to explain that the state expects “…to have good data that the benefits outweigh the risks of any therapies or treatments before we recommend those therapies or treatments to Floridians.”
Although puberty blockers are perceived by some to be a benign treatment—a way to pump the brakes on gender transition—the medications are not harmless. The FDA released a warning on July 1 regarding the risk of pseudotumor cerebri—a surge of cerebrospinal fluid into the skull causing excess pressure and symptoms resembling a brain tumor—accompanying the use of gonadotropin-releasing hormone (GnRH). Six cases among girls were reported, ages 5 through 12; five were using GnRH for early puberty and one was undergoing treatment for gender dysphoria.
It would be an understatement to say that the topic of gender is complex, influenced by the interactions between one’s own biology, development, family, social experiences and social media. The American Academy of Pediatrics (AAP) issued a policy statement describing the epidemiology, treatment options and considerations around medical intervention, but ultimately advocates for affirmation vs. watchful waiting, advising that using puberty blockers allows children and families time to transition socially before proceeding to irreversible cross-sex hormones and surgery.
The AHCA report provides a counterpoint to the AAP push for affirmation, raising important questions regarding the strong correlation in the literature with autism spectrum disorders, the “fracturing” of the definition of gender dysphoria, and whether co-occurring issues such as substance abuse, eating disorders, compulsivity stress, anxiety, depression and suicidal ideation have been adequately addressed. The report concludes that “puberty blockers, cross-sex hormones and sex reassignment surgery do not conform to generally accepted professional medical standards and are experimental and investigational.” While this caution appears justified, the UK’s Cass Report is crafted with more inclusivity, engagement, and sensitivity to the distress of the adolescents and their families while refraining from offering advice on the use of hormone treatments due to “gaps in the evidence base.”