As promised, this is my second newsletter covering Week 8 of the 2023 legislative session.
On Thursday, Feb. 23 the House Government Oversight Committee, of which I am a part, questioned Dr. Katie Imborek, Professor of Family Medicine and Co-Director of the University of Iowa LGBTQ+ Clinic, and Dr. Dave Williams, Chief Medical Officer for UnityPoint Health. They were questioned on issues related to transgender surgeries, procedures and treatments for patients under the age of 18 performed at their institutions.
Representative Brooke Boden, Chair of the Committee, also inquired with Mercy One and Broadlawns, but neither organization performs these procedures or treatments on minors.
University of Iowa LBGTQ+ Clinic performs mastectomies for female minors wishing to transition to male. The clinic’s services also include cross-sex hormone therapy and puberty blockers for children. It is important to note that this is all done with parental consent. The clinic does not perform genital surgeries on minors.
UnityPoint Health does not perform any transgender surgeries on minors. It does provide hormone therapy and puberty blockers to minors with parental consent.
Questions from Republican members of the Committee focused on several themes:
· First, Republicans questioned whether providing gender transition to minors violates the first duty of medicine: do no harm. Cross-sex hormones have long-term irreversible side effects such as infertility, type 2 diabetes, cardiovascular disease and risk of stroke. Puberty blockers are described as completely reversible, yet they come with the risk of sterilization, osteoporosis and decreased growth spurts. Surgical procedures are irreversible. If a minor female has her breasts removed and then realizes it was a mistake, she cannot have her breasts reattached.
· Second, while parental consent is required for these procedures and therapies, Republicans questioned if it is truly informed consent. Minors are not old enough to get a tattoo, buy cigarettes, or drink alcohol. The prefrontal cortex – the part of the brain responsible for rational decision-making is not fully developed until age 25. As a society, we have already determined that minors are not mature enough to make many life-altering decisions, yet current practice allows teens to make these irreversible determinations on therapies and procedures, including the removal of healthy body parts.
· Third, Republicans advanced the belief, supported by mountains of information, that the data and evidence simply do not support the safety or effectiveness of gender transition services. The British Medical Journal (https://www.bmj.com/content/380/bmj.p382) ran an article on February 23rd, 2023, which contained the following important facts:
“Sweden’s National Board of Health and Welfare, which sets guidelines for care, determined last year that the risks of puberty blockers and treatment with hormones “currently outweigh the possible benefits” for minors. Finland’s Council for Choices in Health Care, a monitoring agency for the country’s public health services, issued similar guidelines, calling for psychosocial support as the first line treatment.
Medical societies in France, Australia, and New Zealand have also leant away from early medicalization. And NHS England, which is in the midst of an independent review of gender identity services, recently said that there was “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” even of the risks of social transition.
Sweden conducted systematic reviews in 2015 and 2022 and found the evidence on hormonal treatment in adolescents “insufficient and inconclusive.” Its new guidelines note the importance of factoring the possibility that young people will detransition, in which case “gender confirming treatment thus may lead to a deteriorating of health and quality of life (i.e., harm).”
In 2022 the state of Florida’s Agency for Health Care Administration commissioned an overview of systematic reviews looking at outcomes “important to patients” with gender dysphoria, including mental health, quality of life, and complications. Two health research methodologists at McMaster University carried out the work, analyzing systematic reviews and concluding that “there is great uncertainty about the effects of puberty blockers, cross-sex hormones, and surgeries in young people.” The body of evidence, they said, was “not sufficient” to support treatment decisions.”
Further supporting our deep concerns as to the efficacy of these procedures is this perspective from Roger Hiatt, Jr., M.D., a child and adolescent psychiatrist with more than thirty years of experience working with thousands of troubled youth, including hundreds struggling with the issue of Gender Dysphoria: “Suicidality is a close companion of transgender identity throughout the life cycle. Despite all medical and surgical efforts, the suicide rate among transgender individuals is documented to be about 19 times higher than for those who embrace their chromosomal sex. The only outcome that actually results in decreased suicidality is “desistance,” or a return to gender identity consistent with biological reality. The pivotal event leading to children abandoning a transgender identity is the onset of puberty. Puberty blockers thus adversely impact the probability of the very outcome with the most favorable prognosis. While 80-90% of affected kids will desist without these interventions, almost all who initiate puberty blockers will continue to identify as the opposite sex into adulthood. Efforts to medicalize this psychiatric disorder rob otherwise healthy youth of the opportunity to rediscover their innate biology and instead doom them to a lifetime as medical patients in pursuit of an impossible dream: a change in biological sex.”
Dr. Hiatt’s statement that most children that reach puberty will return to gender identity consistent with their biological sex is echoed by the American College of Pediatricians. Its studies show that 80-95 percent of children who experience gender dysphoria will accept their biological sex by late adolescence. However, if puberty is blocked by medication, this obviously changes the outcome, and not in a good way.
It must also be noted in this discussion, as some doctors demand that they be allowed to continue these procedures, and that legislation should not interfere with the doctor-patient relationship, that the history of medical science is replete with disproven interventions once held in high regard by the medical establishment. These include leeches, frontal lobotomies, and physician tested and approved cigarette brands, just to name a few.
Just recently (08/2020), The American Journal of Psychiatry was compelled to retract a study erroneously affirming that hormones and surgery yielded significant improvement in mental health for gender incongruent patients, stating, “Our conclusion based on the findings at hand in the article, which used neither a prospective cohort design nor a randomized controlled trial design, was too strong.”
Due to the lack of conclusive evidence that these therapies and surgeries are ultimately effective, and the unacceptably high risk of doing harm to our children, based a growing collection of evidence, I authorized House Study Bill 214 to move forward. This legislation will prohibit the use of hormone therapy, puberty blockers and irreversible surgeries on children (minors under age 18) in Iowa. I am floor-manager of this legislation, and it passed out of Judiciary Committee at the end of Week 8. It is now eligible for debate by the full House.
I am hopeful we will move quickly to pass these important protections for our young people.
