In 2013, the number of children treated annually at the Doernbecher Children's Hospital gender clinic at Oregon Health & Science University in Portland was 16. In 2021, the number was 724 - a rise of about 4500 percent.
This is far from unusual. Across the United States and Europe, the number of children and adolescents with gender dysphoria is exploding. No one really knows why. But many specialised gender clinics are offering them life-changing medical treatment - puberty blockers, sex change hormones, and even "gender affirming" surgery.
This puzzling rise in a poorly understood phenomenon has prompted some providers and European authorities to urge caution because of a lack of strong evidence.
In a new report from The BMJ Investigations Unit, an American women's health journalist, Jennifer Block, looked into the evidence base behind this surge in treatment. The BMJ [British Medical Journal] is one of the world's leading medical journals. Its misgivings cannot be dismissed as conservative fear-mongering.
Block begins by showing that more teens with no history of gender dysphoria are presenting at gender clinics. For example, a recent analysis of insurance claims found that nearly 18,000 US minors began taking puberty blockers or hormones from 2017 to 2021, the number rising each year.
The number of US private clinics focused on providing hormones and surgeries have grown from just a few a decade ago to more than 100 today.
American medical professional groups are aligned in support of "gender affirming care" for gender dysphoria, which may include hormone treatment to suppress puberty and promote secondary sex characteristics, and surgical removal or augmentation of breasts, genitals, and other physical features.
Three organisations in particular have had a major role in shaping the US approach to gender dysphoria care: The World Professional Association for Transgender Health (WPATH), the American Academy of Pediatrics, and the Endocrine Society, all of which have guidelines or policies that support early medical treatment for gender dysphoria in young people.
These endorsements are often cited to suggest that medical treatment is both uncontroversial and backed by rigorous science, but Block notes that governing bodies around the world have come to different conclusions regarding the safety and efficacy of certain treatments.
The most recent country to slam on the brakes is Norway, which has also seen an exponential growth in gender dysphoria and treatment. On March 9, the Norwegian Healthcare Investigation Board (UKOM) declared that puberty blockers, cross-sex-hormones and surgery for children adolescents are experimental treatments and that the current "gender-affirming" guidelines are not evidence-based and must be revised.
Last year, for example, Sweden's National Board of Health and Welfare, which sets guidelines for care, determined that the risks of puberty blockers and treatment with hormones "currently outweigh the possible benefits" for minors.
And NHS [National Health Service] England, which is in the midst of an independent review of gender identity services, recently stated that there is "scarce and inconclusive evidence to support clinical decision-making" for minors with gender dysphoria, and that for most who present before puberty it will be a "transient phase," requiring clinicians to focus on psychological support and to be "mindful" of the risks of even social transition.
Experts are also questioning the evidence underpinning these guidelines.
Professor Mark Helfand at Oregon Health and Science University identified several deficiencies in WPATH's recommendations, such as lack of a grading system to indicate the quality of the evidence, while Professor Gordon Guyatt at McMaster University found "serious problems" with the Endocrine Society guidelines, including pairing strong recommendations with weak evidence.
Helfand explains that calling a recommendation "evidence-based" should mean a treatment has not just been systematically studied, but that there was also a finding of high quality evidence supporting its use.
Despite these concerns, WPATH recommends that youth have access to treatments following comprehensive assessment, stating "the emerging evidence base indicates a general improvement in the lives of transgender adolescents."
Eli Coleman, lead author of WPATH's Standards of Care and former director of the Institute for Sexual and Gender Health at the University of Minnesota, told The BMJ that WPATH's new guidelines emphasise "careful assessment prior to any of these interventions" by clinicians who have appropriate training and competency to assure that minors have "the emotional and cognitive maturity to understand the risks and benefits."
But without an objective diagnostic test, others remain concerned, pointing to examples of teenagers being "fast-tracked to medical intervention" with little or no mental health involvement.
And in her interim report of a UK review into services for young people with gender identity issues, Professor Hilary Cass noted that some NHS staff reported feeling "under pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters."
For Guyatt, claims of certainty represent both the success and failure of the evidence-based medicine movement. "When there's been a rigorous systematic review of the evidence and the bottom line is 'we don't know,'" he says, then "anybody who then claims they do know is not being evidence based."
Across the Atlantic, in the United States, a transgender orthodoxy reigns. Rachel Levine, the most senior transgender official in the Biden Administration, has strongly defended transgender medical treatment for American children. "There is no argument among medical professionals - pediatricians, pediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, et cetera - about the value and the importance of gender-affirming care," she told National Public Radio last year.
However, the conventional wisdom has been shaken by shocking stories from a whistleblower at a gender clinic in St Louis, Missouri. Last month, in a blistering, sometimes stomach-churning, essay in The Free Press, Jamie Reed, a case manager at The Washington University Transgender Center at St. Louis Children's Hospital, raised serious issues.
Reed is not a disgruntled conservative. She describes herself as "a 42-year-old St. Louis native, a queer woman, and politically to the left of Bernie Sanders". She is married to a transman and is raising two biological children from a previous marriage and three foster children.
She has lodged an official complaint with the Missouri Attorney-General. It took her a long time to take this step, partly because anyone who complained was labelled a transphobe. Here are some of her comments based on observations of a thousand adolescent patients:
It's an unsettling article. Anyone interested in trans teenagers should read it. Together with The BMJ report, it makes a persuasive argument that the changes in European transgender policy cannot arrive in the United States quickly enough.