Redesigning gender identity services: an opportunity to generate evidence

A recent feature in The BMJ implied that new services are all that’s needed to improve transgender healthcare.1 Providing timely, sensitive services for all, including those who decide to not pursue treatment or detransition, is important.2 But the article did not question the steep rise in referrals of mainly young women or the potential harms of medical overdiagnosis and overtreatment, given the lack of comprehensive evidence of better outcomes after major surgery and taking lifelong hormones. Additionally, the proposed terminology misleads: biological sex is not “assigned” but determined at conception and observed at birth, whereas gender is a fluid, social construct. Although subjective gender identity, legal status, and external appearance can be realigned, biological sex cannot. Diagnosis is depicted as a straightforward application of criteria. General practitioners are portrayed as reluctant to engage, yet the BMA is clear they should not be expected to provide “bridging” prescriptions for those who have self started medication.3

Good medical practice requires doctors to discuss uncertainties about the effects of treatments. We disagree with the claim of Action For Trans Health (a campaign group quoted in the piece) that “the continued existence of gender identity clinics amounts to wilful abuse.”6 People who question their identity or self define as trans should have access to high quality, joined-up, and person centred healthcare based on good evidence.

Regulated medical practitioners should follow a framework of evidence, not simply respond to client expectations. Creating that evidence to inform quality standards is an ethical imperative. We need research to explore the interplays between gender identity, mental health and neurodevelopmental problems, sexual orientation, autogynephilia, and unpalatable gender roles.45 The national reconfiguration is an opportunity to establish research, including trials for key uncertainties such as approaches to assessment and supportive wait-and-see versus intervention strategies. This is a vital opportunity to establish an ongoing cohort for all those referred, so that outcomes can be monitored.