As a physician who came of age in the former Soviet Union, I view with deep concern the widespread efforts by governments at various levels across the United States to ban best practice medical care for transgender youth and adults. Even more concerning and eerily familiar to me is the support these efforts have received from some local medical boards.
The Danger of Physicians’ Collusion with Government in the Abuse of Medicine
It is well documented that in the U.S.S.R., some physicians colluded with government in the widespread, systematic abuse of medicine, specifically psychiatry, for political purposes. The KGB—the internal security agency in the Soviet Union—regularly “treated” political dissidents in cooperation with “prominent” psychiatrists. Several thousand people (including some of my personal friends) were “diagnosed” with mental illness—“sluggish schizophrenia” was the most commonly used fictional diagnosis—and incarcerated in psychiatric hospitals. As the U.S. Congress noted in landmark hearings on this issue, “Psychiatric abuse is a technique that perverts medicine in order to destroy law.”
In Russia today, this abuse of medicine is ongoing: as of July 1, a Russian health ministry order signed by President Vladimir Putin will require clinics to be staffed with “sexologists to help patients ‘overcome’ homosexuality and various sexual ‘mental disorders’”—despite Russia’s removal of homosexuality from its list of mental disorders in 1999.
Meanwhile, many lawmakers in the U.S. are engaging in extreme, coordinated political attacks in an ideological quest to deny appropriate gender affirming medical care to people who are transgender. According to the Movement Advancement Project, legislators in 20 states have moved to ban medically necessary medication, surgery, or both for transgender youth and in some cases adults. Perhaps most striking were the rules-based bans first initiated by the Florida Boards of Medicine and Osteopathic Medicine, and by the Missouri Attorney General. (The Florida Board of Medicine notes, “The practice of medicine is a privilege granted by the state.” The Florida Board of Osteopathic Medicine notes, “The Florida Board of Osteopathic Medicine was legislatively established.”) These developments threaten access to quality healthcare, which is already challenging. As the Williams Institute at UCLA has found, “Medicaid beneficiaries who are transgender face a patchwork of policies across the U.S. that leave many of them without access to coverage for gender-affirming care.” Access to quality healthcare is critical, given just “3% of transgender people at high risk of HIV infection currently take PrEP” and “people who regularly tested for HIV and people who experienced affirmation of their gender identity were more likely to use PrEP.”
The Efficacy of Best Practice, Gender Affirming Care
The field of transgender medicine is relatively new and, as in most fields, additional research is needed. However, currently available data clearly demonstrate the efficacy of gender affirming healthcare in reducing depression and the risk of suicide in transgender individuals, including youth.
A recent study in The Journal of the American Medical Association found 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.” The American Academy of Child & Adolescent Psychiatry has stated, “Many reputable professional organizations, including the American Psychological Association, the American Psychiatric Association, the American Academy of Pediatrics, and the Endocrine Society, which represent tens of thousands of medical professionals across the United States, recognize natural variations in gender identity and expression and have published clinical guidance that promotes nondiscriminatory, supportive interventions for gender diverse youth based on the current evidence base.”Further, the American College of Physicians “strongly opposes restrictions on health care for transgender individuals, who already may face extreme barriers to accessing care, and strongly objects to any unnecessary government interference with any health care services.”
Resisting Bans on Best Practice Care
Physicians have an ethical duty to resist efforts to ban best practice medical care. The ethical demands of the medical profession—rooted in oaths that have served as the basis of medical codes of conduct around the world for centuries—have, as their central component, the primary duty of a physician to serve the patient. All other considerations are secondary.
As Jesse Ehrenfeld, M.D., the new president of the American Medical Association stated in a recent interview, “This is new territory for us. We have just never seen laws that criminalize the provision of medical care... Our obligation is to respect the law. We don’t advocate for physicians breaking the law,” but “we also stand up against bad laws that put physicians in untenable situations … where they have an ethical obligation to patients that is no longer permissible because of an action by a lawmaker.”
The Texas Medical Association’s amicus brief in Doe v Abbott is a positive example of how physicians can mobilize to resist government interference with medically necessary, gender-affirming care, and oppose the criminalization of such treatment.
Additionally, the American Medical Association’s House of Delegates recently passed the Endocrine Society’s resolution to protect access to evidence-based gender-affirming care for transgender and gender-diverse individuals, noting “ The Endocrine Society’s resolution was co-sponsored by The American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Urological Association, the American Society for Reproductive Medicine, the American College of Physicians, the American Association of Clinical Endocrinology, GLMA: Health Professionals Advancing LGBTQ+ Equality, and AMA’s Medical Student Section.
Centering Human Rights in Medical Decision-Making
Medical decisions should be made as a result of thoughtful dialogue between the patient (represented and supported by a parent or guardian, if the patient is a minor) and their physician or other medical providers. Government has no role to play in this relationship. We must not embark on the dangerous path of medical subservience to political pressures.
As a physician who provides evidence-based gender affirming healthcare, I view the ongoing attacks on the transgender community with deep concern. Yet I do believe that we are living through a period of progress, and that transgender rights are finally being recognized as human rights. Physicians should participate in this struggle: when advocating for our patients and resisting inappropriate government pressure, we are on the right side of ethics - and history.
Dr.Leonid Poretsky, Professor, Feinstein Institutes for Medical Research, founded the Friedman Transgender Program for Health and Wellness at Lenox Hill Hospital/Northwell Health, where he is also Chief of Endocrinology. He co-edited Transgender Medicine: A Multidisciplinary Approach (Springer International Publishing, April 2019).