By: Tomás Ojeda, Mariana Gaba, Isidora Paiva-Mack, Rodrigo Sierra Rosales, Débora Fernández y Alemka Tomicic
Year: 2024
This piece explores the relationship between gender-affirming interventions, particularly medical ones, and suicide mortality in the trans and non-binary community. It responds to the publication of the ‘Cass Report’, which reviews evidence about treatment of trans and gender non-conforming adolescents in the UK and the negative impact that the report has had in Chile. It critically discusses how groups opposing gender-affirming care have used the report to relativise the evidence around suicide risk in the trans community while also advocating for harmful restrictions and/or banning access to this vital care. The authors provide insights about evidence omitted in the report and analyse strategies used by the report’s proponents, which may be of interest to other mental health professionals, policymakers and activists dealing with similar issues in other locations.
INTRODUCTION
The Cass report, published in April this year, is an extensive review of evidence around gender-affirming care for trans and gender non-conforming children and adolescents. Commissioned by the National Health Service (NHS) in England, it sought to understand why the demographic profile of those consulting gender identity services has changed and to identify the best clinical approach to meet their needs. Alongside this, Dr Hillary Cass and her team reviewed the state of the evidence about the use of medical and non-medical interventions for trans and gender non-conforming children and adolescents, concluding that the level of certainty about their effects and benefits is ‘low’.
The publication of the report has had a global impact. For example, the Ministry of Health in Chile issued in June the so-called Circular No. 7. In a hasty move, it instructed the national public health service network to defer new admissions of adolescents who want to start their treatment with puberty blockers and cross-hormone therapy. Concurrently, it convened representatives of the country’s scientific societies with experience in working with transgender people and their families to set up a Panel of Experts to contribute to the development of ‘technical guidelines’ to orient the provision of gender-affirming hormone therapy for adolescents. Lastly, the Chamber of Deputies also approved the creation of an Investigative Commission to inquire into the functioning of the country’s trans health programmes. The commission, which extended its mandate until November 4, is expected to hear experts from civil society and academia, as well as testimonies from service users and their families.
While the focus of the discussion has centred around the medical aspects of gender-affirming care, another dimension of the debate has involved the mental health issues of trans people, including suicide, and their relationship to access to affirmative health care.
In the wake of the Cass report, some media outlets, columnists and activists have shared information claiming that the review allegedly did not find conclusive evidence to account for the positive impact of gender-affirming care on the well-being of trans and non-binary people. Among the sloppy and careless claims that have circulated, it has been suggested that the evidence around suicide, as a trans-specific public health issue, has been used as a ‘threat’ and a coercive strategy by ‘trans activism’ to ‘force’ or ‘push’ parents and/or family networks to support their children’s transition. Rather than contributing to a serious and careful debate on suicide, these publications cast doubt on the available evidence on the subject and the existing relationship between suicidality and various social stressors, such as lack of family support, barriers to accessing health care, discrimination and gender disaffirmation, among others.
The use and interpretation of suicide epidemiology should be evaluated based on its merits and following a case-by-case ethics. However, we are concerned that in the current discussion around gender-affirming care, the existing evidence about suicide is at risk of being disregarded. As a result, we argue, the negative impact of interventions and legislative initiatives seeking to ban, limit, or deny LGBTQIA+ people’s right to health is being underestimated, particularly for adolescents.
To contribute to a responsible and evidence-based discussion, we discuss three issues in this piece: 1) first, we review some of the existing evidence around the complex phenomenon of suicide, paying attention to the uniqueness of the experience of trans lives, a particularly vulnerable social group in Chile; 2) second, we situate this discussion vis-à-vis the Cass report, contextualising its main findings and criticisms; 3) and lastly, we analyse the relationship between gender-affirmative interventions, particularly medical ones, and suicide mortality, critically discussing some of the political uses that have been made of the evidence reviewed in the Cass report by anti-trans actors, which seek to ban or restrict access to gender-affirming care. The latter, in our view, violates the right to health of trans, non-binary and gender-diverse people, particularly adolescents.