While technology enabled much-needed human connection during COVID-19, algorithm-driven social media and the residual fear and anger from the collective loss and restrictions of the pandemic have created heightened divisiveness around medical issues. Angry discourse around medical care became a daily reality as the world navigated vaccinations and safety mandates.
And yet politics and healthcare have always had an uneasy symbiotic relationship. Reproductive rights, end-of-life care, health equity, insurance coverage, and gender affirming care is a far from non-exclusive list of healthcare issues turned political over the last half century – each impacting a group of people marginalized by society: people assigned female at birth, the elderly, people of color, the under-resourced, and non-binary and transgender individuals, respectively.
Gender affirming care – for non-binary and transgender youth, in particular – is the latest third rail issue that has been pushed into the precarious intersection of politics and healthcare. The political crossfire has led to significant misunderstanding and polarisation around care including hormone replacement, puberty blockers, surgical intervention, and reassignment regret. Commentary on all these and more is rampant in many forms of media. In the U.S., legislative approaches to restrict gender-affirming care are in full swing.
Early this summer, the Texas Senate approved a bill that prohibits 30,000 trans children from receiving gender-affirming health care, and the Texas Supreme Court unanimously ruled that the state child welfare agency resume investigating parents and doctors who provide gender-affirming care for trans youth. Florida ratified the largest slate of anti-LGBTQ bills in one legislative session in its history. Under one law, a court could intervene to temporarily remove a child from their home if they receive gender-affirming treatments or procedures, the same as it would do in a case of child abuse.
Rather than discuss and address the concerns that many parents and families on all sides of the issue have, some U.S. states have hastily passed legislation to dictate their preferred course of treatment. These restrictive and potentially harmful U.S. state laws feel needlessly rushed, preventing doctors and medical professionals from doing their jobs, and placing parents in the precarious and desperate position of finding access to the medical care needed to keep their children healthy and, in many cases, alive.
Even in the policy and legal arena, there are other perspectives to consider. Federal district courts have concluded these laws violate the rights of transgender youth, their caregivers, and their medical providers under the opportunity for equal protection, the First Amendment and due process. Even still, state court battles are looming in Alabama, Florida, and Indiana with additional cases likely to follow.
In the political arena, this issue feels new. The coarse, and often inaccurate, rhetoric reflects the novelty of the issue. But in the medical community, this issue has reached a far greater level of maturity. Gender identity is acknowledged to be part of the spectrum of human experience by respected medical and mental health associations, including the American Medical Association, the American Academy of Pediatrics, the American Psychological Association and the American Academy of Child and Adolescent Psychiatry. And, medical care for transgender individuals is not new. It has been available for more than 60 years. In fact, the medications and therapies provided to transgender youth have been approved, administered and successfully tolerated for more than 40 years for other medical conditions. Access to these treatments requires rigorous multi-disciplinary assessment before a diagnosis of gender dysphoria is concluded. These standards in the U.S. are rooted in a conservative approach and have been in place for nearly 20 years. And, while less than 1% of the population experiences gender dysphoria, for the human beings that do, the consequences of going without medical treatment can be fatal.
According to a study published by the NIH, “82% of transgender individuals have considered killing themselves and 40% have attempted suicide, with suicidality highest among transgender youth.” Anecdotally, trans and non-binary youth experience increasing anxiety and a sense of isolation, especially when they experience a lack of social acceptance. The NIH study found that both intervenable risk factors (interpersonal and environmental microaggressions, internalized self-stigma, and adverse childhood experiences) and protective factors (school belonging, family support, and peer support) influenced those statistics.
Many years of clinical research and evidence-based treatment have proven that access to healthcare, including mental health resources, and a focus on a patient’s quality of life, including social and family relationships, dramatically reduce suicidality. Patients have seen excellent outcomes from these treatments, and these outcomes and standards set to achieve them have been endorsed by every major medical association in the U.S.
In fact, the Journal of the American Medical Association published a recent study that concluded that, “receipt of gender-affirming care, including puberty blockers and gender-affirming hormones, was associated with 60% lower odds of moderate or severe .depression and 73% lower odds of suicidality over a 12-month follow-up.”
While there may be little to no middle ground on the issue of gender-affirming care in the U.S., European countries, generally, are taking a different approach – providing minors and their families with access to this critical care, but much more conservatively, limiting medical interventions to clinical research settings.
As a pediatric critical care physician, the large majority of parents I meet want to understand and measure the potential outcomes of medical decisions for their child, even in the pressure cooker environment of the ED. It’s my job to talk those patients and their families through those options and potential risks, and to help ensure they understand the implications of their decisions – with care and caution. We slow down to formulate a plan, and we then proceed together.
To that end, the medical community has long-established standards of care in the U.S. for evaluating and supporting trans and non-binary youth; those standards include behavioral and mental health evaluations to determine if medical interventions are required or advised – something that qualified medical professionals do not take lightly. Again, the medical team slows down to develop a plan with the patient and their family before proceeding with therapy and treatment. This cautious, conservative, and respectful approach should be a model for how public policy is crafted on this issue.
The medical community has the expertise, research, data, standards and therapies readily available to keep kids healthy and safe. Regardless of political affiliations and inclinations, our commitment as a medical community to keep all people well – both in body and spirit – should be respected, alongside the trusted doctor/patient/family relationship that we work so hard to develop and nurture to ensure the best possible outcomes for our patients.
Rash judgment and knee-jerk legislation are not helping our kids. The health and wellbeing of children is not a game. We need to move beyond the political binary and reach a place as a society that allows us to collectively slow down and work together to determine how we provide access to the medical care and services that contribute to kids’ health, wellness, and the basic ability to “be” – all of which are human rights.
That type of work cannot be achieved through an algorithm or social media. It requires intellectual curiosity, empathy, understanding, and thoughtful, open discussion. And, rather than simply shutting down the conversation where there’s disagreement, we need to listen to and be responsive to people’s concerns. And to take the time to have open discussions around gender dysphoria with non-binary, trans kids, their families and caregivers to listen and understand their journeys before rushing to judgment and legislation.
By slowing down, relying on best practices, and engaging in human connection, conversation, and empathy – instead of rushed and divisive politics – we can work together to achieve the long-term positive health outcomes for every child. When it comes to caring for our children, slow and steady wins the human race.
Authors
Dr. Marc Harrison
Marc Harrison, M.D. is a global healthcare leader, recognized for healthcare transformation and health equity advocacy. He is a pediatric critical care physician, and is the former president and CEO of Intermountain Healthcare. Dr. Harrison is co-founder and CEO of Health Assurance Transformation Corporation (HATCo), a new business owned by the venture capital firm General Catalyst with the mission to deliver health and wellness collaboratively, compassionately, and courageously – for all people.
As president and CEO of Intermountain, Dr. Harrison led the organization to reimagine healthcare operations and champion innovation and collaboration to ensure that its 60,000 caregivers had access to the technology and tools to best reach, serve, and empower patients. In his first five years leading the organization, he executed a disciplined growth strategy with significant investments in telehealth and rural health to expand Intermountain’s service area from primarily Utah communities to serving patients throughout the Mountain West.
Under his leadership, Intermountain embraced unconventional, public-private partnerships to confront some of the most pressing systemic challenges facing communities and industry to proactively keep people well and make communities healthier. Those initiatives were a catalyst for the national movement toward value-based care, advancing clinical education, and establishing a new Digital Hippocratic Oath (developed by Graphite, a company co-founded by Intermountain) to improve hospital data interoperability and secure patient privacy rights.
During his tenure, Intermountain partnered with more than 1,000 hospitals nationwide to launch Civica Rx, a nonprofit generic drug manufacturer and distributor, to make generic medications—including insulin, which they plan to offer in 2024—more accessible and affordable. Intermountain was a founding member of the Utah Alliance for the Determinants of Health, a collaboration of community partners proactively addressing forces that affect people’s ability to stay healthy. Additionally, Intermountain partnered with an international genomics leader and more than 100,000 volunteers to advance medical breakthroughs that will help prevent and treat genetic diseases for people around the globe.
Before leading Intermountain, Dr. Harrison served as CEO of Cleveland Clinic Abu Dhabi, chief of international business development at Cleveland Clinic, and chief medical operations officer at Cleveland Clinic. Fortune recognized him as one of the Top 50 World’s Greatest Leaders in 2019, and Modern Healthcare has consistently recognized him among the Most Influential People in Healthcare. Dr. Harrison is the author of Possibility Unleashed: Pathbreaking Lessons for Making Change Happen in Your Organization and Beyond, a guide for leaders to face their fears, transcend discord and polarization, and drive positive systemic and societal change.
Dr. Harrison received his undergraduate degree from Haverford College and his medical degree from Dartmouth Medical School. He completed a pediatric residency and pediatric critical care fellowship at Intermountain’s Primary Children’s Hospital, and earned a Master of Medical Management at Carnegie Mellon University.
He is an all-American triathlete, and represented the U.S. at the 2014 World Championships. He is also a two-time cancer survivor and nine-time Ironman participant. He is a loving husband and proud father of three adult children.
Molly Gillis
Molly Gillis is a Partner and Chief of Staff at the venture capital firm General Catalyst. She has more than 20 years of experience in VC and tech, focused on operations, communications, and relationship building. In her current role, Molly provides connectivity and strategic prioritization for the firm’s chairman Ken Chenault, GC’s chairman of health assurance initiatives Ken Frazier, and CEO of GC-backed Health Assurance Transformation Corp. Marc Harrison, M.D., partnering with them on their work with the GC ecosystem, the external organizations with which they are affiliated, and mission-driven initiatives that are in service of making a positive impact on society. She also drives their executive communications, including media relations and speaking engagements.
Molly is a writer both as part of her role at General Catalyst, and in her spare time. An active member of her community, she serves as a commissioner of her town’s LGBTQIA+ Rainbow Commission to promote inclusion of LGBTQIA+ individuals and groups through affirming policies and programs, resources, advocacy, and community building. She collaborates to enable several local initiatives focused on creating greater, more consistent opportunities for access and inclusion in schools.
Declaration of interests:
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.