Gender affirming care - a magical treatment that significantly reduces suicides?

[borne_before]

That title is a bit editorialized. But, I was having a discussion with a friend's spouse about some the gender stuff. I don't want to crudely summarize or strawman their perspective but in short, they seem to think that transition, along with gender affirming care, is a bit of a panacea when it comes to this population, it it comes down to dichotomy between gender affirming care or death.

This kind of got me thinking about how the general public views gender affirming care and it also got me thinking about the research on gender affirming care that might clarify my own thinking on the issue.

• Like what is the evidence for gender affirming care?
• What is the effect size of treatment?
• Does social transition do worse than medical transition?
• Does how well someone passess as the opposite sex affect outcomes?
• What's the effect size of puberty blockers on outcomes?
• How many detransitioners exist?
• How many suicides does it prevent?
• What is the increase/decrease in disability adjusted hours (I think that's a metric the effective altruists use)?
• If you could design a perfect study that would put an end to this debate, what would it look like?
• Are there any non-affirming treatments that may have efficacy?
• Does Blanchard's classification lead to different outcomes?
• Do transwomen and transmen have different outcomes in suicidality?

Perhaps it would best to stratify the above. What other questions might be useful?

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[R. Matey]

 

[psych.meout]

• How many detransitioners exist?
• Are there any non-affirming treatments that may have efficacy?
• Does Blanchard's classification lead to different outcomes?

 

[BuckeyeLove]

How many suicides does it prevent?

This is the one that I haven't seen adequately addressed with any sort of cross validation.

 

[Shiori]

Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.
Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Suicidality and well-being among transgender youth after gender-affirming medical interventions. Clinical Practice in Pediatric Psychology.
Cantu, A. L., Moyer, D. N., Connelly, K. J., & Holley, A. L. (2020). Changes in anxiety and depression from intake to first follow-up among transgender youth in a pediatric endocrinology clinic. Transgender Health, 5(3), 196-200.
Chew, D., Anderson, J., Williams, K., May, T., & Pang, K. (2018). Hormonal treatment in young people with gender dysphoria: a systematic review. Pediatrics, 141(4).
Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The journal of sexual medicine, 12(11), 2206-2214.
De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.
De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The journal of sexual medicine, 8(8), 2276-2283.
Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).
Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3).
Sorbara, J. C., Chiniara, L. N., Thompson, S., & Palmert, M. R. (2020). Mental health and timing of gender-affirming care. Pediatrics, 146(4).
Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., & Ahrens, K. (2022). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA network open, 5(2), e220978-e220978.
White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender health, 1(1), 21-31.

A reading list! There was more, but this is a good place to start digging into the literature.

 

[borne_before]

Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.

Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results - PubMed

Endocrine intervention may improve mental health in transgender youths in the US. This effect was observed in both male-to-female and female-to-male youths, but appears stronger in the former.

pubmed.ncbi.nlm.nih.gov

Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Suicidality and well-being among transgender youth after gender-affirming medical interventions. Clinical Practice in Pediatric Psychology.

https://core.ac.uk/download/pdf/211081666.pdf (dissertation version)

Cantu, A. L., Moyer, D. N., Connelly, K. J., & Holley, A. L. (2020). Changes in anxiety and depression from intake to first follow-up among transgender youth in a pediatric endocrinology clinic. Transgender Health, 5(3), 196-200.

Changes in Anxiety and Depression from Intake to First Follow-Up Among Transgender Youth in a Pediatric Endocrinology Clinic - PubMed

Monitoring acute distress in transgender youth initiating gender-affirming care is important given their increased risk for significant mental health symptoms. The current study examined changes in anxiety, depression, and suicidality from initial appointment to first follow-up in 80 youth, ages...

pubmed.ncbi.nlm.nih.gov

Chew, D., Anderson, J., Williams, K., May, T., & Pang, K. (2018). Hormonal treatment in young people with gender dysphoria: a systematic review. Pediatrics, 141(4).

Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review - PubMed

Low-quality evidence suggests that hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact are generally lacking. Future research to address these knowledge gaps and improve understanding of the...

pubmed.ncbi.nlm.nih.gov

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The journal of sexual medicine, 12(11), 2206-2214.

Sci-Hub | Psychological Support, Puberty Suppression, and Psychosocial Functioning in Adolescents with Gender Dysphoria. The Journal of Sexual Medicine, 12(11), 2206–2214 | 10.1111/jsm.13034

De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.

Sci-Hub | Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. PEDIATRICS, 134(4), 696–704 | 10.1542/peds.2013-2958

De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The journal of sexual medicine, 8(8), 2276-2283.

Wa waaa

Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).

Body Dissatisfaction and Mental Health Outcomes of Youth on Gender-Affirming Hormone Therapy

This study examines changes in youth body dissatisfaction and mental health after gender-affirming hormone therapy and explores the impact of demographic and treatment variables.

publications.aap.org

Olson, K. R., Durwood, L., DeMeules, M., & McLaughlin, K. A. (2016). Mental health of transgender children who are supported in their identities. Pediatrics, 137(3).

Sci-Hub | Mental Health of Transgender Children Who Are Supported in Their Identities. Pediatrics, 137(3), e20153223 | 10.1542/peds.2015-3223

Sorbara, J. C., Chiniara, L. N., Thompson, S., & Palmert, M. R. (2020). Mental health and timing of gender-affirming care. Pediatrics, 146(4).

https://publications.aap.org/pediatrics/article/146/4/e20193600/79683/Mental-Health-and-Timing-of-Gender-Affirming-Care

Tordoff, D. M., Wanta, J. W., Collin, A., Stepney, C., Inwards-Breland, D. J., & Ahrens, K. (2022). Mental health outcomes in transgender and nonbinary youths receiving gender-affirming care. JAMA network open, 5(2), e220978-e220978.

Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care

This cohort study investigates whether gender-affirming care is associated with decreased depression, anxiety, and suicidality among transgender and nonbinary youths.Is gender-affirming care for transgender and nonbinary (TNB) youths associated with changes ...

www.ncbi.nlm.nih.gov

White Hughto, J. M., & Reisner, S. L. (2016). A systematic review of the effects of hormone therapy on psychological functioning and quality of life in transgender individuals. Transgender health, 1(1), 21-31.

A Systematic Review of the Effects of Hormone Therapy on Psychological Functioning and Quality of Life in Transgender Individuals

Objectives: To review evidence from prospective cohort studies of the relationship between hormone therapy and changes in psychological functioning and quality of life in transgender individuals accessing hormone therapy over time.Data Sources: MEDLINE, ...

www.ncbi.nlm.nih.gov

 

[borne_before]

This is the one that I haven't seen adequately addressed with any sort of cross validation.

I mean this has to be researchable, right?

How would one go about this?

Would Bayes theorem be applicable?

 

[gohogwild]

2nding

 

[borne_before]

OOOH here's another one:

• In transmen taking exogenous testosterone, it would be important to control for the reinforcing effect of taking testosterone, and to possibly parse out the benefits of that.

This one comes from my wife who works in the infertility field. She gets a lot of men who come in with really poor sperm quality, but are unwilling to go off testosterone treatments. She uses the term "addicting" but perhaps reinforcing might be better. "low T treatment can make men feel more alert, energetic, mentally sharp, and sexually functional." - common marketing.

Reinforcing aspects of androgens - PubMed

Are androgens reinforcing? Androgenic-anabolic steroids (AAS) are drugs of abuse. They are taken in large quantities by athletes and others to increase performance, often with negative long-term health consequences. As a result, in 1991, testosterone was declared a controlled substance...

pubmed.ncbi.nlm.nih.gov

 

[borne_before]

Why?

From Julia Galef, who collects unpopular ideas "Even though I disagree with many of these ideas, I nevertheless think it’s valuable to practice engaging with ideas that seem weird or bad, for two reasons: First, because such ideas might occasionally be true, and it’s worth sifting through some duds to find a gem."

Her lists are pretty interesting: Unpopular ideas about social norms

 

[SomeGreatNotion]

Why?

From Julia Galef, who collects unpopular ideas "Even though I disagree with many of these ideas, I nevertheless think it’s valuable to practice engaging with ideas that seem weird or bad, for two reasons: First, because such ideas might occasionally be true, and it’s worth sifting through some duds to find a gem."

Her lists are pretty interesting: Unpopular ideas about social norms

If the idea is a dud or bad/harmful, then engagement could have the unintended consequence of legitimizing that idea or shifting the Overton window.

 

[tr]

If the idea is a dud or bad/harmful, then engagement could have the unintended consequence of legitimizing that idea or shifting the Overton window.

How will you know if the idea is dud/bad/harmful if you exclude a priori any possibility of collecting relevant evidence?

 

[PikminOC]

Gender dysphoria is rising—and so is professional disagreement | BMJ

More children and adolescents are identifying as transgender and offered medical treatment, but some providers and European authorities are urging caution because of a lack of strong evidence.

www.bmj.com

 

[SomeGreatNotion]

How will you know if the idea is dud/bad/harmful if you exclude a priori any possibility of collecting relevant evidence?

That assumes no evidence gathering. I can look at the available evidence and can determine that Blanchard's, detransitors, and non-affirming care have no place in a thread about the efficacy of gender-affirming care. Individuals are free to bring these up but those same individuals shouldn't be surprised by the invalidating response it receives/deserves.

 

[futureapppsy2]

Gender dysphoria is rising—and so is professional disagreement | BMJ

More children and adolescents are identifying as transgender and offered medical treatment, but some providers and European authorities are urging caution because of a lack of strong evidence.

www.bmj.com

That article (really, letter to the editor) has a profound lack of data. For example, it somehow concludes that adolescents going to gender dysphoria treatment centers "have no history of gender dysphoria."

 

[borne_before]

If the idea is a dud or bad/harmful, then engagement could have the unintended consequence of legitimizing that idea or shifting the Overton window.

It's just an idea, dude. Please resist the urge to censor, it's creepy.

 

[borne_before]

Regarding puberty blockers and testosterone:

• Given that testosterone is pretty bad for a developing brain, how much of the impact of puberty blockers is due to reduction of testosterone vs the other rationale for them.

 

[PikminOC]

That article (really, letter to the editor) has a profound lack of data. For example, it somehow concludes that adolescents going to gender dysphoria treatment centers "have no history of gender dysphoria."

So then everything else in this long article is incorrect also?

 

[R. Matey]

Would Bayes theorem be applicable?

Generally speaking, if the prior is unknown, Bayes wouldn't really apply.

 

[futureapppsy2]

So then everything else in this long article is incorrect also?

That article is very short and doesn't really cite actual studies but rather consensus documents and likely selectively so.

 

[PikminOC]

That article is very short and doesn't really cite actual studies but rather consensus documents and likely selectively so.

Likely or for sure? Is it possible physicians think differently about this? It was good enough to get published in bmj.

 

[ClinicalABA]

So then everything else in this long article is incorrect also?

I commented on this article in the other thread. It is a position statement, not a research article. I'm not saying that the position is good or bad, just that it is a position statement, not a research article.

 

[ClinicalABA]

So then everything else in this long article is incorrect also?

If you think this is "long" think that medical professionals and psychologists have a different view of what "long" means in reference to journal articles. I cut and pasted it into WORD, and it's 2 pages, double-spaced. 701 word count. I think my reply to it on the other post may have been longer!

Regardless of where it's published, it's journalism- not research. That doesn't mean it's bad or good, but it is what it is.

ETA- I also don't see an author listed or a byline, other that "BMJ Newsroom." The article cites "Jennifer Block, investigations reporter" but it doesn't make it clear where who is actually writing what we are reading.

 

[SomeGreatNotion]

It's just an idea, dude. Please resist the urge to censor, it's creepy.

Not censoring. As I mentioned:

Individuals are free to bring these up but those same individuals shouldn't be surprised by the invalidating response it receives/deserves.

 

[PikminOC]

If you think this is "long" think that medical professionals and psychologists have a different view of what "long" means in reference to journal articles. I cut and pasted it into WORD, and it's 2 pages, double-spaced. 701 word count. I think my reply to it on the other post may have been longer!

Regardless of where it's published, it's journalism- not research. That doesn't mean it's bad or good, but it is what it is.

ETA- I also don't see an author listed or a byline, other that "BMJ Newsroom." The article cites "Jennifer Block, investigations reporter" but it doesn't make it clear where who is actually writing what we are reading.

You're right. I had a much longer article and didn't realize this wasn't it. I will try to look for the one that is actually long 😁

 

[PikminOC]

I think this is the longer one. Gender dysphoria in young people is rising—and so is professional disagreement

 

[texanpsychdoc]

 

[The Cinnabon]

https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf

Most people that detransition do so on a temporary basis. The rates of gender affirming care regret, as a result of gender dysphoria being miss DXed, are still being reported as being pretty astronomically low.

Fact of the matter is, with the data we have right now, gender affirming care is displaying pretty solid clinical results with non-ordinarily low regret rates. Most surgeons would blush at some of these treatment regret rate stats, of course you're not finding people going out in the streets and protesting against emergency colon surgery for having higher regret rates (Decisional Regret Among Patients Undergoing Colectomy : Diseases of the Colon & Rectum).

I guess my bigger question is when does the burden of proof begin to fall on the "other-side" for finding evidence to be against gender affirming care? I get the need for contradictory evidence and ideas, but at what point are you the equivalent of being one of the 5 climate scientists that are calling BS on global warming?

To be clear I don't think we're at the last example quite yet, but I'd be shocked if we weren't in as little as 10 years. I'm sure we'll have more official studies done on this but I think the "more trans kids" thing can be explained the same way we saw higher rates of gay people as the social climate became more accepting.

 

[tr]

I guess my bigger question is when does the burden of proof begin to fall on the "other-side" for finding evidence to be against gender affirming care? I get the need for contradictory evidence and ideas, but at what point are you the equivalent of being one of the 5 climate scientists that are calling BS on global warming?

This is a caricature. I don't think any serious professionals are "against gender affirming care". The devil is in the details: what sort of care, and at what time, for which individuals?

Gender affirming care spans a gamut from supportive mental health care through temporizing measures like puberty blockers, to invasive, irreversible surgical and/or endocrinological interventions that will commit the patient to a lifetime of exogenous hormone treatment, which comes with other long term health risks, to maintain.

Any of these interventions can be appropriate for some individuals, but how to determine which individuals need which type of care at which time is nontrivial.

The whole issue is made very sticky by the fact that adolescence is a critical choice point for some irreversible commitments one way or the other, but also represents a time of shifting self-concepts and experimentation with identity across the board, not only with respect to gender.

I don't think a 'one size fits all' approach is useful here. The fact that detransitioners have unfortunately been used as a political football is not a reason to ignore the important questions of how best to identify which individuals would benefit most from which types of care and, critically, at which developmental time points.

 

[Shiori]

I think it may be important to present broad categories of gender affirming care. These are purely my thoughts:

Social: Many folks who identify as trans or non-binary stay in this category their whole life. No hormone therapy. No surgery. They use other signifiers of gender like their pronouns, clothing, makeup, etc. Professionals can create a welcoming environment by not making assumptions about pronouns/using appropriate pronouns, having bathroom policies that aren't antagonizing, training staff to be knowledgeable about health disparities, etc. You may also be asked to help with getting some legal documents changed, but some of these have to be signed off by medical doctors. If you're unwilling to do that, know who does, so they're not left having to start the process of finding a provider from scratch.

Hormone therapy: This can look a few different ways, but basically folks can block certain hormones or increase hormones. We do this across all kinds of folks, trans and cis. If a kiddo starts puberty super early, they can be prescribed puberty blockers. If a kid is small, they can be given growth hormones. Psychology is rarely involved here. We get called in more often when there is a discussion around gender dysphoria and identity struggles. We assess for gender dysphoria, evaluate other mental health difficulties, etc. Typical assessment/psychotherapy stuff. Psychology probably isn't going to be asked to do much beyond this. In younger folks, you're mostly going to run into puberty blockers and social transitioning. You might get asked to sign a support letter for an insurance company who doesn't want to pay for it without a sign-off from a professional, but this can be pushed off to their medical provider or someone else if you're uncomfortable. Again, just know who to refer to if you don't feel competent. Support letters basically attest to a person's ability to make informed decisions and meeting criteria for gender dysphoria. You'll also be asked to briefly summarize mental health history and if they're stable. If you've done any transplant/bari evals, this isn't much different.

Gender confirming surgery: Almost always adults! One, it's expensive. Two, there is a long waitlist at most places who are open to doing them. It is rare for someone to have access to surgery and many people don't want to do surgeries at all. Psychology gets asked to do assessments, support letters, psychotherapy, etc. I work with the LGBTQ+ community regularly and rarely get asked to do this. I'm more than happy to, but it doesn't come up a ton.

ETA: clarifying for the types of surgery. You would run into chest-related surgeries more often because more folks will do them. Surgery on genitals is a more complicated procedure and that is where the waitlists come in.

There are people who are comfortable doing none, some, or all of these categories. Just like every psychologist will not do a bariatric assessment for their client, psychologists don't have to do all parts of gender affirming care. Know what you're comfortable with and find compassionate ways to get clients what they need when you're uncomfortable.

 

[PikminOC]

I think it may be important to present broad categories of gender affirming care. These are purely my thoughts:

Social: Many folks who identify as trans or non-binary stay in this category their whole life. No hormone therapy. No surgery. They use other signifiers of gender like their pronouns, clothing, makeup, etc. Professionals can create a welcoming environment by not making assumptions about pronouns/using appropriate pronouns, having bathroom policies that aren't antagonizing, training staff to be knowledgeable about health disparities, etc. You may also be asked to help with getting some legal documents changed, but some of these have to be signed off by medical doctors. If you're unwilling to do that, know who does, so they're not left having to start the process of finding a provider from scratch.

Hormone therapy: This can look a few different ways, but basically folks can block certain hormones or increase hormones. We do this across all kinds of folks, trans and cis. If a kiddo starts puberty super early, they can be prescribed puberty blockers. If a kid is small, they can be given growth hormones. Psychology is rarely involved here. We get called in more often when there is a discussion around gender dysphoria and identity struggles. We assess for gender dysphoria, evaluate other mental health difficulties, etc. Typical assessment/psychotherapy stuff. Psychology probably isn't going to be asked to do much beyond this. In younger folks, you're mostly going to run into puberty blockers and social transitioning. You might get asked to sign a support letter for an insurance company who doesn't want to pay for it without a sign-off from a professional, but this can be pushed off to their medical provider or someone else if you're uncomfortable. Again, just know who to refer to if you don't feel competent. Support letters basically attest to a person's ability to make informed decisions and meeting criteria for gender dysphoria. You'll also be asked to briefly summarize mental health history and if they're stable. If you've done any transplant/bari evals, this isn't much different.

Gender confirming surgery: Almost always adults! One, it's expensive. Two, there is a long waitlist at most places who are open to doing them. It is rare for someone to have access to surgery and many people don't want to do surgeries at all. Psychology gets asked to do assessments, support letters, psychotherapy, etc. I work with the LGBTQ+ community regularly and rarely get asked to do this. I'm more than happy to, but it doesn't come up a ton.

ETA: clarifying for the types of surgery. You would run into chest-related surgeries more often because more folks will do them. Surgery on genitals is a more complicated procedure and that is where the waitlists come in.

There are people who are comfortable doing none, some, or all of these categories. Just like every psychologist will not do a bariatric assessment for their client, psychologists don't have to do all parts of gender affirming care. Know what you're comfortable with and find compassionate ways to get clients what they need when you're uncomfortable.

What years are you referring to where people remain trans their whole life?
The numbers have increased exponentially in the last few years so we don't have data on that yet

 

[Shiori]

I have trans clients who served in Vietnam.

 

[futureapppsy2]

I think it may be important to present broad categories of gender affirming care. These are purely my thoughts:

Social: Many folks who identify as trans or non-binary stay in this category their whole life. No hormone therapy. No surgery. They use other signifiers of gender like their pronouns, clothing, makeup, etc. Professionals can create a welcoming environment by not making assumptions about pronouns/using appropriate pronouns, having bathroom policies that aren't antagonizing, training staff to be knowledgeable about health disparities, etc. You may also be asked to help with getting some legal documents changed, but some of these have to be signed off by medical doctors. If you're unwilling to do that, know who does, so they're not left having to start the process of finding a provider from scratch.

Hormone therapy: This can look a few different ways, but basically folks can block certain hormones or increase hormones. We do this across all kinds of folks, trans and cis. If a kiddo starts puberty super early, they can be prescribed puberty blockers. If a kid is small, they can be given growth hormones. Psychology is rarely involved here. We get called in more often when there is a discussion around gender dysphoria and identity struggles. We assess for gender dysphoria, evaluate other mental health difficulties, etc. Typical assessment/psychotherapy stuff. Psychology probably isn't going to be asked to do much beyond this. In younger folks, you're mostly going to run into puberty blockers and social transitioning. You might get asked to sign a support letter for an insurance company who doesn't want to pay for it without a sign-off from a professional, but this can be pushed off to their medical provider or someone else if you're uncomfortable. Again, just know who to refer to if you don't feel competent. Support letters basically attest to a person's ability to make informed decisions and meeting criteria for gender dysphoria. You'll also be asked to briefly summarize mental health history and if they're stable. If you've done any transplant/bari evals, this isn't much different.

Gender confirming surgery: Almost always adults! One, it's expensive. Two, there is a long waitlist at most places who are open to doing them. It is rare for someone to have access to surgery and many people don't want to do surgeries at all. Psychology gets asked to do assessments, support letters, psychotherapy, etc. I work with the LGBTQ+ community regularly and rarely get asked to do this. I'm more than happy to, but it doesn't come up a ton.

ETA: clarifying for the types of surgery. You would run into chest-related surgeries more often because more folks will do them. Surgery on genitals is a more complicated procedure and that is where the waitlists come in.

There are people who are comfortable doing none, some, or all of these categories. Just like every psychologist will not do a bariatric assessment for their client, psychologists don't have to do all parts of gender affirming care. Know what you're comfortable with and find compassionate ways to get clients what they need when you're uncomfortable.

Great post! Also, bottom surgeries have a lot more risks (of course, no surgeries are risk-free) and more variable outcomes than top surgeries, so a fair number of trans people skip or wait on them, because the cost-benefit ratio isn't right for them.

 

[PsychPhDone]

If you think this is "long" think that medical professionals and psychologists have a different view of what "long" means in reference to journal articles. I cut and pasted it into WORD, and it's 2 pages, double-spaced. 701 word count. I think my reply to it on the other post may have been longer!

Regardless of where it's published, it's journalism- not research. That doesn't mean it's bad or good, but it is what it is.

ETA- I also don't see an author listed or a byline, other that "BMJ Newsroom." The article cites "Jennifer Block, investigations reporter" but it doesn't make it clear where who is actually writing what we are reading.

Rare off topic reply from me: someone remind me to stop reviewing articles for psychology journals. The manuscripts are so long. Nope.

 

[futureapppsy2]

Rare off topic reply from me: someone remind me to stop reviewing articles for psychology journals. The manuscripts are so long. Nope.

I was once asked to review a manuscript where the author appeared to have literally just submitted their unedited dissertation--the introduction alone was about 30 pages. I noped out of that.

 

[borne_before]

@Heist could an explanation of the positive impact of affirming exogenous hormone administration also be ascribed to antipsychotic effect of estrogens?

 

[smalltownpsych]

Watched a documentary on David Bowie the other day. He made challenging gender norms cool. Those were the good old days. All this political stuff is just so non-entertaining. If gender affirming care just means supporting an individual in the process, then I’ve been doing that for years. I think some people are concerned that it will mean a mandate to begin medical transition when an adolescent expresses that desire. The ability to appraise risks and benefits on the long term as shiori was discussing is something I have seen in my adult patients and not so much in the younger ones who are usually pushing hard to get it done and upset that there are any obstacles.

 

[Shiori]

I really recommend sitting down with the WPATH recommendations if the process is concerning. It is very thorough about caveats, necessary competencies for providers, etc. If a child or teen (or adult) expresses that they are trans, the first step is not medical transition.

The recommendations start on page 45/S43 for adolescents.
https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644

I found another article! I like it because it's from a referral center for sex hormone therapy and they give concrete numbers showing the increase of patients since they started in the 90s.
Changing Demographics in Transgender Individuals Seeking Hormonal Therapy: Are Trans Women More Common Than Trans Men?

 

[zestyzigzagoon]

Watched a documentary on David Bowie the other day. He made challenging gender norms cool. Those were the good old days. All this political stuff is just so non-entertaining. If gender affirming care just means supporting an individual in the process, then I’ve been doing that for years. I think some people are concerned that it will mean a mandate to begin medical transition when an adolescent expresses that desire. The ability to appraise risks and benefits on the long term as shiori was discussing is something I have seen in my adult patients and not so much in the younger ones who are usually pushing hard to get it done and upset that there are any obstacles.

The same people who now have qualms about gender-affirming care were (for the most part) the same people who ridiculed cis people for challenging gender norms. Make it make sense.

 

[R. Matey]

I was once asked to review a manuscript where the author appeared to have literally just submitted their unedited dissertation--the introduction alone was about 30 pages. I noped out of that.

For real? Your editor must've been too busy with their golf game to bother with desk rejection.

 

[borne_before]

https://onlinelibrary.wiley.com/doi/epdf/10.1111/apa.16791

 

[zestyzigzagoon]

https://onlinelibrary.wiley.com/doi/epdf/10.1111/apa.16791

More research is always better but the fact that there are no RCTs isn't that surprising considering you have to take into account equipoise and the ethics of clinical research. It would be unethical to have a group of control participants be refused hormone therapy considering the risk it would present to their mental well-being. I'm not even talking about suicidality. Simply having gender dysphoria is painful and allowing a child to go through that unnecessarily sans intervention is unethical.

 

[borne_before]

Here's an interesting comparison of Sweden's model vs WPATH 8 (which, to their credit, is always updating):

Personally, from a policy perspective, I think Sweden's is probably a better move.

 

[ClinicalABA]

Here's an interesting comparison of Sweden's model vs WPATH 8 (which, to their credit, is always updating):

Personally, from a policy perspective, I think Sweden's is probably a better move.

Do you mind sharing where this screenshot is from?

Does anyone know if the WPATH SOC8 is available for free (it cost 55 bucks on their website). I'm particularly curious about the WPATH SOC8 summary statement on the document @borne_before posted stating that "patient desire is the ultimate eligibility criterion." This statement is presented parallel to the Swedish Position summary statement regarding eligibility for hormonal treatment, which implies that it is the WPATH SOC8 positions on hormonal treatment. Is that really the WPATH SOC8 on hormonal treatment? That seems unlikely to me.

ETA- found the link (the 55 bucks was for a printed copy). Link is here: https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644

I'm curious to check out the source and see if the summary statements in @borne_before screenshot are representative of the actual WPATH standards of care.

 

[Shiori]

It's super long, but SBM did a piece on SEGM vs WPATH.

Cutting through the Lies and Misinterpretations about the Updated Standards of Care for the Health of Transgender and Gender Diverse People

The title gives you a look into the premise and their perspective. The authors do give links to both viewpoints though. I have always liked SBM's approach. They make a post as long as it needs to be to be thorough.

 

[borne_before]

Do you mind sharing where this screenshot is from?

Does anyone know if the WPATH SOC8 is available for free (it cost 55 bucks on their website). I'm particularly curious about the WPATH SOC8 summary statement on the document @borne_before posted stating that "patient desire is the ultimate eligibility criterion." This statement is presented parallel to the Swedish Position summary statement regarding eligibility for hormonal treatment, which implies that it is the WPATH SOC8 positions on hormonal treatment. Is that really the WPATH SOC8 on hormonal treatment? That seems unlikely to me.

https://www.tandfonline.com/doi/pdf/10.1080/26895269.2022.2100644 wpth8
Summary of Key Recommendations from the Swedish National Board of Health and Welfare (Socialstyrelsen/NBHW) -table

 

[borne_before]

It's super long, but SBM did a piece on SEGM vs WPATH.

Cutting through the Lies and Misinterpretations about the Updated Standards of Care for the Health of Transgender and Gender Diverse People

The title gives you a look into the premise and their perspective. The authors do give links to both viewpoints though. I have always liked SBM's approach. They make a post as long as it needs to be to be thorough.

Dude... in the first paragraph they completely misrepresent a position

How did they get "Published in 1998, the HBIGDA SOC5 were developed in part by then-Chairman of the Standards of Care Committee, Dr. Stephen Levine, a vocal opponent of informed consent. " from this: Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults ?

I'm not so sure that SBM is the neutral bastion of science here.

EDIT: there is almost no attempt to act objectively here, they label and throw out so much personal attacks, it's astounding.

 

[Shiori]

Sorry! I didn't mean to make it seem like they are objective. I meant that they present links to different positions. If they make an assertation that someone said something, they will provide a link, etc. They don't attempt to be objective regarding individuals. I should have made that clear. I have followed the blog off and on for years and many of them have been a part of the "skepticism" movement. They run in spaces with people like Michael Shermer, Richard Dawkins, and Penn & Teller. I don't follow the skepticism movement as much, but it introduced me to this blog. Steve Novella has been a regular commentator as well.

 

[ClinicalABA]

I encourage you all to, on your own, compare the SEGM characterization of the WPATH SOC8 with the position as actually stated in the WPATH SOC8 document. Regardless of the "rightness" or "wrongness" or empirical support/lack of for either position, I believe that you will find that the SEGM summaries mischaracterize (and in some cases grossly so) the WPATH positions on many/most of the issues. Given my biases and what I know about SEGM, I personally believe they (or he- if it is all coming from William Malone) do so intentionally, hiding an activist group with a political and moral agenda behind a "sciency" sounding name. I may be incorrect on the latter position (i.e., intent), but I think I'm pretty spot on with my former one (i.e., the WPATH position is mischaracterized).

I'll also add that the WPATH SOC8 is a comprehensive document that includes the methodology for arriving at their conclusions, clear definitions of terms- including population labels, and an appendix with more detailed methodology and definitions. It also included a very comprehensive reference section citing 100s (1000s? I lost count) of primary sources. Their methodology includes multiple checks of procedures from independent (i.e., not directly affiliated with WPATH or otherwise involved with the SOC8 project). The linked source from SEGM is a web page which does not include even an authors name and has no references. As such, we are not privy to who is summarizes the WPATH SOC8 positions, or their methods or rationale for developing those summaries. We are also not clear why they have focused exclusively on Sweden, rather that summarize the positions of similar countries boards of health.

I have not reviewed the Swedish NBHW positions in detail, but can say that the SEGM summary statement that " Hormonal interventions should be restricted to research settings" is somewhat misleading, if not an outright mischaracterization. The NBWH position is that, yes, hormonal therapies with "young people" should be "provided within a research context", but they clarify that this does not mean an RCT (randomized clinical trial). Further, they state that "Until a research study is in place, the NBHW deems that treatment with GnRH-analogues and sex hormones may be given in exceptional cases, in accordance with the updated recommendations and criteria described in the guidelines." Those guidelines include criteria of "an early (childhood) onset of gender incongruence, persistence of gender incongruence until puberty and a marked psychological strain in response to pubertal development is among the recommended criteria." That is not quite the same a saying it should be restricted to research settings. If this is how SEGM summarizes/characterizes the NBHW point on this one issue, it brings into question the accuracy of their/his characterization their other positions.

 

[aim-agm]

Apologies if this is already addressed in one of the articles posted, but is anyone aware of studies of hormonal interventions in patients that are born female and effects on schizophrenia development/severity?

The thought occurs because of the higher rates of GDD in patients on the schizophrenia spectrum, and the protective effect of estrogen from schizophrenia. The potential clinical significance would be assessing for schizophrenia risk and including in discussion of risks/benefits with born-female patients before starting hormonal interventions, and whether increased monitoring for signs/symptoms of developing schizophrenia are warranted after starting intervention.