Surgeons being sued after transgender regrets their life changing decision made at 15 years old.

[operaman]

We can do things like suicide risk evals but in reality we cant actually predict suicide. We can provide clearance letters but what are we saying in these letters? If gender is fluid and at one point someone identifies one that deviates from how they were born, it stands to reason they could learn more about themselves as they age and question who they are, perhaps identifying in another way. There are many people who are confused about their gender in general. There is all kinds of research out there, sure, but lets put it into a purely logical perspective. Its fine if someone wants this surgery but after informed consent they should be the ones responsible for any positive or negative consequence, which is why this may be better suited to do as an adult, where someone can accept legality. Also people make fairly impulsive choices at that age anyways. The world's smartest 15 year old is still emotionally stupid. Physicians shouldn't be scapegoats when a patient desires to change their mind on a whim.

When I was writing my posts above about wishing we had clinical trials, I was pondering what kind of endpoints you would want to power for. Suicide, attempts, inpatient psych stays, PROs, etc. It wouldn’t be easy and obviously much smarter people than me would be making those decisions.

But the thought exercise does tease at the underlying question of how we define success in these operations and how we characterize harms. Is this really a suicide prevention intervention? Is it a quality of life preserving intervention? Is it a mental health intervention?

Another fundamental issue then arises: if a medical or surgical intervention does not provide a benefit, then the only thing it can do is cause harm.

I would go a step further and argue that the proponents of any intervention bear the burden of proof to demonstrate that their intervention actually provides benefits and does so without undue harm. For transgender treatments in youth we haven’t even had a single decent trial that I can find to demonstrate any evidence that we are providing any benefit whatsoever. It’s quite possible we are helping some people, but we need to be careful and study this appropriately just like we do with any other intervention. I really think our euro friends have the right idea by confining these practice - for now - within the context of clinical trials.

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[annoyedpsychiatrist]

When I was writing my posts above about wishing we had clinical trials, I was pondering what kind of endpoints you would want to power for. Suicide, attempts, inpatient psych stays, PROs, etc. It wouldn’t be easy and obviously much smarter people than me would be making those decisions.

But the thought exercise does tease at the underlying question of how we define success in these operations and how we characterize harms. Is this really a suicide prevention intervention? Is it a quality of life preserving intervention? Is it a mental health intervention?

Another fundamental issue then arises: if a medical or surgical intervention does not provide a benefit, then the only thing it can do is cause harm.

I would go a step further and argue that the proponents of any intervention bear the burden of proof to demonstrate that their intervention actually provides benefits and does so without undue harm. For transgender treatments in youth we haven’t even had a single decent trial that I can find to demonstrate any evidence that we are providing any benefit whatsoever. It’s quite possible we are helping some people, but we need to be careful and study this appropriately just like we do with any other intervention. I really think our euro friends have the right idea by confining these practice - for now - within the context of clinical trials.

sometimes doing nothing is the right thing to do (and often the hardest), as like you said, doing something can make a bad situation worse in the long run.

 

[Dr. Anonymouss]

Transgender surgery in adolescents, is not cosmetic......it is reconstructive.

Cosmetic surgery is still reconstructive. I see many similarities. But as Operaman alluded to, determining that a minor may benefit from a rhinoplasty tends to provide better outcomes as a surgeon can see a clear defect or flaw that they can change. In the case of transgender surgery there is no objective way to determine how one will cope psychologically or if their ideas on gender are a temporary phase. It is a complex topic no doubt.

 

[nofliesonme]

No, top surgery is not cosmetic, ...it is a double mastectomy with nipple areola reconstruction. Of course, we surgeons try to make all our surgeries as aesthetically pleasing as possible. A rhinoplasty in an adolescent is not comparable to top surgery in an adolescent.

 

[wholeheartedly]

One thing I think that’s gotten lost in some of these discussions at the national level is that gender affirming care (hormone therapy and surgery) isn’t just for transgender people. Where’s the line going to be? How often are kids who aren’t trans given growth hormone or other hormone therapies or surgeries?

Opinion | How come gender-affirming surgeries like mine don’t stir up controversy

Cisgender children seek gender-affirming care without being scrutinized endlessly and demonized. Trans kids deserve the same consideration.

www.nbcnews.com

 

[operaman]

One thing I think that’s gotten lost in some of these discussions at the national level is that gender affirming care (hormone therapy and surgery) isn’t just for transgender people. Where’s the line going to be? How often are kids who aren’t trans given growth hormone or other hormone therapies or surgeries?

Opinion | How come gender-affirming surgeries like mine don’t stir up controversy

Cisgender children seek gender-affirming care without being scrutinized endlessly and demonized. Trans kids deserve the same consideration.

www.nbcnews.com

I think the key difference here again lies in that things like gynecomastia are known pathology with objectively verifiable signs. We aren’t depending solely on the undeveloped mind of a child to make the diagnosis itself.

Even so, we have rather poor data on these procedures as well, med vs surg tx, recurrence, etc. I think we as surgeons have a bad habit of automatically believing our operations are the best and of course they’re very effective.

 

[mvenus929]

One thing I think that’s gotten lost in some of these discussions at the national level is that gender affirming care (hormone therapy and surgery) isn’t just for transgender people. Where’s the line going to be? How often are kids who aren’t trans given growth hormone or other hormone therapies or surgeries?

Opinion | How come gender-affirming surgeries like mine don’t stir up controversy

Cisgender children seek gender-affirming care without being scrutinized endlessly and demonized. Trans kids deserve the same consideration.

www.nbcnews.com

We don't routinely give trans kids growth hormone...

 

[Proudfather94]

We don't routinely give trans kids growth hormone...

They're given estrogen or testosterone blockers though right? That's going to mess their development up if they are still in puberty. Where does the line end for doing things that some teens want that might effect them later on? What if this leads to other things that will help a teen now but might impact them later? I think this should only be done in extreme circumstances since this age range is a vulnerable population whose views change very often.

 

[wholeheartedly]

We don't routinely give trans kids growth hormone...

I said kids who aren’t trans.

 

[NotAProgDirector]

They're given estrogen or testosterone blockers though right? That's going to mess their development up if they are still in puberty. Where does the line end for doing things that some teens want that might effect them later on? What if this leads to other things that will help a teen now but might impact them later? I think this should only be done in extreme circumstances since this age range is a vulnerable population whose views change very often.

Does it, though? Puberty blockers delay puberty. When they are withdrawn, puberty happens. How does this "mess their development up"? The data for this question is thin, I'll admit. But my read of it is that any harm of delaying puberty is very small if any.

You know who does get harmed from denying puberty blockers? Teens who experience a sense of being trans and don't change their mind and go through puberty. Now they have often irreversible changes that need major surgery, procedures, or aren't really fixable at all.

Seems to me that the compromise is straightforward: Avoid surgery for young teens since that's completely irreversible. Allow puberty blockers since the evidence of long term harm seems thin at best, give them more time for evaluation / introspection / decision making.

Should every teen who shows up and says "give me puberty blockers" get them? Of course not. They should be evaluated and assessed.

I'd recommend that this be done by a team rather than by a single person -- much like transplant evals. A single person brings their own biases. A team tends to cancel those out although isn't perfect. Team would include a gender specialist (might be GIM or Endo), Psych, and maybe MSW at a minimum. Gender affirming care balanced by an assessment to try to minimize the impact of peer pressure, other comorbid psych issues, etc.

 

[Proudfather94]

Does it, though? Puberty blockers delay puberty. When they are withdrawn, puberty happens. How does this "mess their development up"? The data for this question is thin, I'll admit. But my read of it is that any harm of delaying puberty is very small if any.

You know who does get harmed from denying puberty blockers? Teens who experience a sense of being trans and don't change their mind and go through puberty. Now they have often irreversible changes that need major surgery, procedures, or aren't really fixable at all.

Seems to me that the compromise is straightforward: Avoid surgery for young teens since that's completely irreversible. Allow puberty blockers since the evidence of long term harm seems thin at best, give them more time for evaluation / introspection / decision making.

Should every teen who shows up and says "give me puberty blockers" get them? Of course not. They should be evaluated and assessed.

I'd recommend that this be done by a team rather than by a single person -- much like transplant evals. A single person brings their own biases. A team tends to cancel those out although isn't perfect. Team would include a gender specialist (might be GIM or Endo), Psych, and maybe MSW at a minimum. Gender affirming care balanced by an assessment to try to minimize the impact of peer pressure, other comorbid psych issues, etc.

If they go on puberty blockers and then change their mind at 16 or 18 won't they not be as tall or developed?

 

[NotAProgDirector]

My understanding is that GnRH agonists (which is what we're talking about when we consider "puberty blockers") simply delay puberty. So the growth spurt that's seen with puberty just happens later, and if blockers are withdrawn normal puberty ensues and secondary sex characteristics develop as expected. There is an oft-cited study from the UK which gets lots of spin.

Here's a news article about it: Puberty blockers 'impair height growth and bone density', data reveals States that it stunts growth.

But here's the study itself: Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK It looked at growth and Bone mineral density in these patients. There were only 44 patients in the study, and only 14 at the three year follow up -- so hard to say anything with confidence. The study shows no adverse outcomes. The news article appears to be comparing these kids height with those not on blockers -- so no surprise that they are shorter, since they have had their growth spurt delayed. You'd need to compare their eventual height - which wasn't done. If the blockers are withdrawn, or if hormone therapy is started (for those transitioning), it appears that normal puberty changes ensue.

I haven't seen any clear evidence that there's lasting harm. Even if kids end up shorter -- is that really all that bad? I'm only 5'1" tall, and I've done just fine. And I'm not certain what you're referring to as "not as developed".

We don't really know the long term outcomes here. Will kids treated with GnRH blockers have some horrible outcome 20 years down the road? Will there be some sort of impaired fertility (assuming they don't undergo transition) or osteoporosis? We can't be certain, but those kids whom are treated for precocious puberty with these drugs do not seem to run into those problems. Studying this would take 30+ years, so not practical.

 

[Proudfather94]

My understanding is that GnRH agonists (which is what we're talking about when we consider "puberty blockers") simply delay puberty. So the growth spurt that's seen with puberty just happens later, and if blockers are withdrawn normal puberty ensues and secondary sex characteristics develop as expected. There is an oft-cited study from the UK which gets lots of spin.

Here's a news article about it: Puberty blockers 'impair height growth and bone density', data reveals States that it stunts growth.

But here's the study itself: Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK It looked at growth and Bone mineral density in these patients. There were only 44 patients in the study, and only 14 at the three year follow up -- so hard to say anything with confidence. The study shows no adverse outcomes. The news article appears to be comparing these kids height with those not on blockers -- so no surprise that they are shorter, since they have had their growth spurt delayed. You'd need to compare their eventual height - which wasn't done. If the blockers are withdrawn, or if hormone therapy is started (for those transitioning), it appears that normal puberty changes ensue.

I haven't seen any clear evidence that there's lasting harm. Even if kids end up shorter -- is that really all that bad? I'm only 5'1" tall, and I've done just fine. And I'm not certain what you're referring to as "not as developed".

We don't really know the long term outcomes here. Will kids treated with GnRH blockers have some horrible outcome 20 years down the road? Will there be some sort of impaired fertility (assuming they don't undergo transition) or osteoporosis? We can't be certain, but those kids whom are treated for precocious puberty with these drugs do not seem to run into those problems. Studying this would take 30+ years, so not practical.

I read the links and while the mental health benefits are great in the short term, I think it has the potential to do great harm in the long term if the person changes their mind. If the person goes off of the GNRHa when they were on it for a few years they are missing years of their puberty. They are going to stop growing at the same age as someone not taking puberty blockers right? Sex hormones cause gene expression in so many different cells and effect so many things throughout the body, I just don't think messing with that while someone is that young is a good idea. I'm truly happy that you're okay with your height, but people are getting surgery to increase their height more often, getting insoles for their shoes to appear taller, and lying about their height on dating apps which shows its important to alot of people. I can see it being worth it if the person's qol is completely dependent on it but I wouldn't do it otherwise

 

[NotAProgDirector]

If the person goes off of the GNRHa when they were on it for a few years they are missing years of their puberty. They are going to stop growing at the same age as someone not taking puberty blockers right?

No, incorrect. If someone takes GNRHa, then puberty is delayed. When it happens, it would last the same length of time. They would complete puberty later. The length of puberty, and the length of their growth spurt, would be exactly the same. Just later.

Sex hormones cause gene expression in so many different cells and effect so many things throughout the body, I just don't think messing with that while someone is that young is a good idea.

But presumably when puberty happens (when blockers are stopped), all of those changes still happen. The person would go through puberty, just at an older age. There may be some psychological issues with that -- but that's a choice a patient makes. I don't see it as "messing" with anything.

I'm truly happy that you're okay with your height, but people are getting surgery to increase their height more often, getting insoles for their shoes to appear taller, and lying about their height on dating apps which shows its important to alot of people. I can see it being worth it if the person's qol is completely dependent on it but I wouldn't do it otherwise

Personally I think people getting surgery to increase their height are making a more controversial decision than puberty blockers..

This treatment is not common. Most people are sex/gender concordant. As mentioned, I would have anyone with gender dysphoria evaluated by a team to assess the best options and to try to avoid choices that people might regret later. Early surgery and/or hormone therapy should be avoided. This would mean that many trans patients might need to wait to go through puberty later in life, but I think a slight delay to ensure the best decision is being made is reasonable. But I can also see the other side of the argument -- that gender dysphoria is a horrible experience for patients, and that prolonging it longer than necessary causes harm. There isn't a simple answer. It's easy to dismiss this when it doesn't affect you.

 

[Proudfather94]

No, incorrect. If someone takes GNRHa, then puberty is delayed. When it happens, it would last the same length of time. They would complete puberty later. The length of puberty, and the length of their growth spurt, would be exactly the same. Just later.

But presumably when puberty happens (when blockers are stopped), all of those changes still happen. The person would go through puberty, just at an older age. There may be some psychological issues with that -- but that's a choice a patient makes. I don't see it as "messing" with anything.

Personally I think people getting surgery to increase their height are making a more controversial decision than puberty blockers..

This treatment is not common. Most people are sex/gender concordant. As mentioned, I would have anyone with gender dysphoria evaluated by a team to assess the best options and to try to avoid choices that people might regret later. Early surgery and/or hormone therapy should be avoided. This would mean that many trans patients might need to wait to go through puberty later in life, but I think a slight delay to ensure the best decision is being made is reasonable. But I can also see the other side of the argument -- that gender dysphoria is a horrible experience for patients, and that prolonging it longer than necessary causes harm. There isn't a simple answer. It's easy to dismiss this when it doesn't affect you.

Oh if they can still go through puberty at the normal length of time that's not that bad then. Yeah that would be scary to be put in that situation because on one hand you're unhappy with your own body but on the other alot of people will judge you if you change your sex. That's a rough choice to choose.

 

[operaman]

No, incorrect. If someone takes GNRHa, then puberty is delayed. When it happens, it would last the same length of time. They would complete puberty later. The length of puberty, and the length of their growth spurt, would be exactly the same. Just later.

But presumably when puberty happens (when blockers are stopped), all of those changes still happen. The person would go through puberty, just at an older age. There may be some psychological issues with that -- but that's a choice a patient makes. I don't see it as "messing" with anything.

Personally I think people getting surgery to increase their height are making a more controversial decision than puberty blockers..

This treatment is not common. Most people are sex/gender concordant. As mentioned, I would have anyone with gender dysphoria evaluated by a team to assess the best options and to try to avoid choices that people might regret later. Early surgery and/or hormone therapy should be avoided. This would mean that many trans patients might need to wait to go through puberty later in life, but I think a slight delay to ensure the best decision is being made is reasonable. But I can also see the other side of the argument -- that gender dysphoria is a horrible experience for patients, and that prolonging it longer than necessary causes harm. There isn't a simple answer. It's easy to dismiss this when it doesn't affect you.

Forgive my ignorance on this, but what’s the endgame with puberty blockers? Are some people staying on them indefinitely? Do they switch to exogenous sex specific hormone therapy later and try to mimic puberty of their desired gender while suppressing the others? If they still go through puberty when the drugs are stopped, what are we gaining them by delaying it?

Sorry for the elementary question; I hear puberty blockers discussed frequently but have yet to hear anything about how that treatment plays out when it works well.

 

[VA Hopeful Dr]

Forgive my ignorance on this, but what’s the endgame with puberty blockers? Are some people staying on them indefinitely? Do they switch to exogenous sex specific hormone therapy later and try to mimic puberty of their desired gender while suppressing the others? If they still go through puberty when the drugs are stopped, what are we gaining them by delaying it?

Sorry for the elementary question; I hear puberty blockers discussed frequently but have yet to hear anything about how that treatment plays out when it works well.

Yes to your third question. Basically you delay puberty to try and make sure the patient is truly transgender since while GnRH analogues are reversible, exogenous hormone therapy usually isn't.

 

[Angus Avagadro]

Alright, let me jump in with the stupid questions.
If puberty is delayed, are the Trans Men effectively sterile since female eggs don't mature until puberty??

Secondly, do the epiphyses remain open? If so, are they at risk for damage as in child sports? Could this lead to excessive height?

Apologies in advance
Thanks.

 

[VA Hopeful Dr]

Alright, let me jump in with the stupid questions.
If puberty is delayed, are the Trans Men effectively sterile since female eggs don't mature until puberty??

Secondly, do the epiphyses remain open? If so, are they at risk for damage as in child sports? Could this lead to excessive height?

Apologies in advance
Thanks.

No, yes, not sure, no though it can lead to getting an extra 1-2 inches of used for an extended period.

 

[Angus Avagadro]

No, yes, not sure, no though it can lead to getting an extra 1-2 inches of used for an extended period.

Thanks very much.

 

[yaboigk]

No, incorrect. If someone takes GNRHa, then puberty is delayed. When it happens, it would last the same length of time. They would complete puberty later. The length of puberty, and the length of their growth spurt, would be exactly the same. Just later.

Consistently telling a little boy he's a girl or little girl she's a boy will reinforce false beliefs. It's actually puberty that helps us fully know who we are, which is why all children need to undergo puberty normally. Studies show 80-95% of children with gender dysphoria grow out of it. In stark contrast, a dutch study pdf showed that 100% of children who were placed on puberty blockers took cross sex hormones which we all know have drastic life long consequences. If anything, instead of buying more time, it's clear giving kids puberty blockers locks them into a transgender identity. Had these kids undergone puberty as normal, a lot, perhaps even most of them would have not transitioned. Instead, they were harmed permanently by the medical community.

But presumably when puberty happens (when blockers are stopped), all of those changes still happen. The person would go through puberty, just at an older age. There may be some psychological issues with that -- but that's a choice a patient makes. I don't see it as "messing" with anything.

Scary thought!! Holy cow can you imagine how you'd feel knowing your parents and doctors failed you by putting you on puberty blockers and harming you psychologically as an adult after knowing most kids with gender dysphoria grow out of it? We actually don't even know the long term psychological effect according to the NHS in England.

Personally I think people getting surgery to increase their height are making a more controversial decision than puberty blockers..

Another scary thought. Most children outgrow gender dysphoria after puberty. https://www.transgendertrend.com/wp-content/uploads/2017/10/Steensma-2013_desistance-rates.pdf At least with an increase in height surgery we probably have a grasp on the long term consequences. Not the case with puberty blockers! treatment "Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria." According to England's government!

A large, long-term data set from Sweden released in 2019 shows: hormonal transition produced absolutely no mental health benefits for those patients. Meanwhile, the data from that study demonstrate that “the beneficial effect of surgery for transgender people is so small that a clinic may have to perform as many as 49 gender-affirming surgeries before they could expect to prevent one additional person from seeking subsequent mental health treatment.” Psychiatry Online

There simply is not enough high quality research in this field to argue we should be putting children on puberty blockers. I would argue that a lot of this field appears ideologically rather than scientifically driven.

 

[yaboigk]

There may be some psychological issues with that -- but that's a choice a patient makes. I don't see it as "messing" with anything.

You don't see it as "messing" with their psychology? This statement doesn't even make sense.

health-56601386 The National Institute of Health and Care Excellence (NICE) in England in 2021 "found it was difficult to draw conclusions from existing studies because of the way they had been designed. They were "all small" and didn't have control groups, which are used to directly compare the effect of different treatments.The review said there was "very little data" on any additional interventions - such as counselling or other drug treatments - the young people may have had alongside taking puberty blockers, and this could bias the results." Something tells me the English health services aren't transphobic. They're following the science as we all should.

 

[Mad Jack]

All true, but you should have sufficient training to determine if there is a secondary cause of gender dysphoria that if treated, will improve or alleviate the gender dysphoria without the need for any transitioning.

Almost no one else in medicine has the training or knowledge to be able to tease that out.

The issue is that we don't know. Sometimes people present with dysphoria and depression and fixing depression results in the dysphoria easing. Sometimes the depression is a secondary effect of the dysphoria. It can't really be teased out, and is further complicated by the combination of poor long-term planning/executive functioning inherent in being a teenager and the social dynamics of many of these cases, in which gender expression becomes a core part of their social identity and they feel continuing down that road is the only way to remain authentic to the image others have of them. I realistically can't assess for treatment of the dysphoria component of things, and will typically refer out because from an ethical perspective I don't feel I can reliably do no harm with my judgments. It feels more like a coin flip, and I don't like flipping coins with peoples' lives. I fully support the right of people to get gender affirming care, but I would be too devastated by even one mistake while personally making that decision of who does and does not meet criteria for treatment.

 

[Mad Jack]

Consistently telling a little boy he's a girl or little girl she's a boy will reinforce false beliefs. It's actually puberty that helps us fully know who we are, which is why all children need to undergo puberty normally. Studies show 80-95% of children with gender dysphoria grow out of it. In stark contrast, a dutch study pdf showed that 100% of children who were placed on puberty blockers took cross sex hormones which we all know have drastic life long consequences. If anything, instead of buying more time, it's clear giving kids puberty blockers locks them into a transgender identity. Had these kids undergone puberty as normal, a lot, perhaps even most of them would have not transitioned. Instead, they were harmed permanently by the medical community.

Scary thought!! Holy cow can you imagine how you'd feel knowing your parents and doctors failed you by putting you on puberty blockers and harming you psychologically as an adult after knowing most kids with gender dysphoria grow out of it? We actually don't even know the long term psychological effect according to the NHS in England.

Another scary thought. Most children outgrow gender dysphoria after puberty. https://www.transgendertrend.com/wp-content/uploads/2017/10/Steensma-2013_desistance-rates.pdf At least with an increase in height surgery we probably have a grasp on the long term consequences. Not the case with puberty blockers! treatment "Little is known about the long-term side effects of hormone or puberty blockers in children with gender dysphoria." According to England's government!

A large, long-term data set from Sweden released in 2019 shows: hormonal transition produced absolutely no mental health benefits for those patients. Meanwhile, the data from that study demonstrate that “the beneficial effect of surgery for transgender people is so small that a clinic may have to perform as many as 49 gender-affirming surgeries before they could expect to prevent one additional person from seeking subsequent mental health treatment.” Psychiatry Online

There simply is not enough high quality research in this field to argue we should be putting children on puberty blockers. I would argue that a lot of this field appears ideologically rather than scientifically driven.

There are studies that run contrary to yours.

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.

jamanetwork.com

Findings In this prospective cohort of 104 TNB youths aged 13 to 20 years, 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.

Association Between Gender-Affirming Surgeries and Mental Health Outcomes

This study evaluates associations between gender-affirming surgeries and mental health outcomes, including psychological distress, substance use, and suicide risk.

jamanetwork.com

Results Of the 27 715 respondents, 3559 (12.8%) endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses, while 16 401 (59.2%) endorsed a desire to undergo 1 or more types of gender-affirming surgery but denied undergoing any of these. Of the respondents in this study sample, 16 182 (81.1%) were between the ages of 18 and 44 years, 16 386 (82.1%) identified as White, 7751 (38.8%) identified as transgender women, 6489 (32.5%) identified as transgender men, and 5300 (26.6%) identified as nonbinary. After adjustment for sociodemographic factors and exposure to other types of gender-affirming care, undergoing 1 or more types of gender-affirming surgery was associated with lower past-month psychological distress (adjusted odds ratio [aOR], 0.58; 95% CI, 0.50-0.67; P < .001), past-year smoking (aOR, 0.65; 95% CI, 0.57-0.75; P < .001), and past-year suicidal ideation (aOR, 0.56; 95% CI, 0.50-0.64; P < .001).

As to the points about outgrowing dysphoria through puberty, that's where it's tough. Some move past gender dysphoria and some don't. Making a wrong decision for either group is devastating. Being correct in every assessment is literally impossible. So how do we approach the issue? That is the question. An outright ban on care for transgender youth would do enormous damage to the portion of individuals that would have seen benefits from that care.

 

[Mad Jack]

You don't see it as "messing" with their psychology? This statement doesn't even make sense.

health-56601386 The National Institute of Health and Care Excellence (NICE) in England in 2021 "found it was difficult to draw conclusions from existing studies because of the way they had been designed. They were "all small" and didn't have control groups, which are used to directly compare the effect of different treatments.The review said there was "very little data" on any additional interventions - such as counselling or other drug treatments - the young people may have had alongside taking puberty blockers, and this could bias the results." Something tells me the English health services aren't transphobic. They're following the science as we all should.

The UK has a notorious reputation with regard to treatment for transgender patients of any age. They're not exactly a great example of anything. We're talking about a place that didn't fully decriminalize gay sex until 2003-2009, depending on the part of the UK, and where transphobia is generally more common than not throughout society. The UK is ranked amongst the worst places in the world to be transgender for a reason.

 

[VA Hopeful Dr]

The issue is that we don't know. Sometimes people present with dysphoria and depression and fixing depression results in the dysphoria easing. Sometimes the depression is a secondary effect of the dysphoria. It can't really be teased out, and is further complicated by the combination of poor long-term planning/executive functioning inherent in being a teenager and the social dynamics of many of these cases, in which gender expression becomes a core part of their social identity and they feel continuing down that road is the only way to remain authentic to the image others have of them. I realistically can't assess for treatment of the dysphoria component of things, and will typically refer out because from an ethical perspective I don't feel I can reliably do no harm with my judgments. It feels more like a coin flip, and I don't like flipping coins with peoples' lives. I fully support the right of people to get gender affirming care, but I would be too devastated by even one mistake while personally making that decision of who does and does not meet criteria for treatment.

That's fair and I spoke poorly. I will clarify:

You have a better chance than any other specialist in parsing through everything. No idea what your batting average might be on that but it would be better than mine.

You are also more likely to have time to get into stuff like "when did you start feeling this way" and the other social dynamics you mentioned already. Its not perfect and I absolutely understand your reluctance here and my intent was not to shame any psychiatrist into doing this type of medicine, merely to point out that at baseline you're likely to have better success at this than us PCP types will.

 

[yaboigk]

There are studies that run contrary to yours.

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.

jamanetwork.com

Findings In this prospective cohort of 104 TNB youths aged 13 to 20 years, 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.

Not a good study. It only did a 12 month follow up. It says nothing about the long term implications. Listening to people who detransitioned, it was typically years later that people realized the implications of puberty blockers and HRT. You'd almost expect an initial boost in morale if you thought getting puberty blockers would conform you to your identity so I don't find this study compelling.

Results Of the 27 715 respondents, 3559 (12.8%) endorsed undergoing 1 or more types of gender-affirming surgery at least 2 years prior to submitting survey responses, while 16 401 (59.2%) endorsed a desire to undergo 1 or more types of gender-affirming surgery but denied undergoing any of these. Of the respondents in this study sample, 16 182 (81.1%) were between the ages of 18 and 44 years, 16 386 (82.1%) identified as White, 7751 (38.8%) identified as transgender women, 6489 (32.5%) identified as transgender men, and 5300 (26.6%) identified as nonbinary. After adjustment for sociodemographic factors and exposure to other types of gender-affirming care, undergoing 1 or more types of gender-affirming surgery was associated with lower past-month psychological distress (adjusted odds ratio [aOR], 0.58; 95% CI, 0.50-0.67; P < .001), past-year smoking (aOR, 0.65; 95% CI, 0.57-0.75; P < .001), and past-year suicidal ideation (aOR, 0.56; 95% CI, 0.50-0.64; P < .001).

As to the points about outgrowing dysphoria through puberty, that's where it's tough. Some move past gender dysphoria and some don't. Making a wrong decision for either group is devastating. Being correct in every assessment is literally impossible. So how do we approach the issue? That is the question. An outright ban on care for transgender youth would do enormous damage to the portion of individuals that would have seen benefits from that care.

This is a more interesting study. But is kinda unrelated because we're talking about blocking puberty in children, most of whom will outgrow their gender dysphoria (roughly 85% will after puberty). I'm assuming most of the participants in this study were fully grown adults since it talked about surgeries. I was talking about puberty blockers in children and HRT. Not surgery as the study was looking at.

The UK has a notorious reputation with regard to treatment for transgender patients of any age. They're not exactly a great example of anything. We're talking about a place that didn't fully decriminalize gay sex until 2003-2009, depending on the part of the UK, and where transphobia is generally more common than not throughout society. The UK is ranked amongst the worst places in the world to be transgender for a reason.

The Sexual Offences Act 1967 is an Act of Parliament in the United Kingdom (citation 1967 c. 60). It legalised homosexual acts in England and Wales. Regardless, are you insinuating that the researchers and physicians in the British NHS and NICE who originally promoted gender affirming care (weird for transphobes to do) reversed their conclusions through ideology? Is it possible then that perhaps the ideology in the US is impacting the research and medical decisions made following your logic?

 

[Mad Jack]

The Sexual Offences Act 1967 is an Act of Parliament in the United Kingdom (citation 1967 c. 60). It legalised homosexual acts in England and Wales. Regardless, are you insinuating that the researchers and physicians in the British NHS and NICE who originally promoted gender affirming care (weird for transphobes to do) reversed their conclusions through ideology? Is it possible then that perhaps the ideology in the US is impacting the research and medical decisions made following your logic?

You think we’ve had 50 years of gay liberation? In the UK it’s barely four | Peter Tatchell

Britain is celebrating the anniversary of the 1967 act, but in fact anti-gay laws were enforced more aggressively by the state after it was passed

www.theguardian.com

Over 100,000 men were arrested in the decades that followed the law passed in 1967. The problem is it didn't actually repeal many of the laws that criminalized sexual contact between gay men in the first place, and furthermore provided a different standard for heterosexual and homosexual intercourse (that being 21 years of age if you happened to be gay).

And yes, ideology certainly plays a part in what is happening at the NHS and NICE. If you aren't aware of their general and historical stances on the issue I'm not going to bother sourcing and giving you a history lesson, but generally they've been considered to be amongst the worst to work with in the world for transgender care and always have sought to limit services. Ideology certainly affects things here as well, and I've voiced my rather complicated feelings on such care myself elsewhere in the thread.

Not a good study. It only did a 12 month follow up. It says nothing about the long term implications. Listening to people who detransitioned, it was typically years later that people realized the implications of puberty blockers and HRT. You'd almost expect an initial boost in morale if you thought getting puberty blockers would conform you to your identity so I don't find this study compelling.

Your first study was a sample size of 70, and showed no real negative outcomes. It could be argued that perhaps they very carefully selected their candidates, as there are, per your own admission, plenty of people that do go on to transition down the line. It showed no negative outcomes, so I found an outcome study that was similar in duration and size. I was following your low-powered study with one of my own. Your second study is low-powered, again, with 127 total patients that were referred to one center in one country. If you've ever gotten a referral, you would know that a lot of them are ultimately garbage. It also clearly indicates that 37% of their study population continued to seek treatment and that there were factors that could be used to identify those more likely to persist in treatment. It supports the idea that these services should be offered but we should get better at identifying who to offer them to. Your third study was one on gender confirmation surgery not having positive outcomes. I countered it with a well-powered, long-term study that showed the opposite. Your post was the context for my post, to pick it apart in isolation is poor form.

 

[hamstergang]

But is kinda unrelated because we're talking about blocking puberty in children, most of whom will outgrow their gender dysphoria (roughly 85% will after puberty).

Studies show 80-95% of children with gender dysphoria grow out of it. In stark contrast, a dutch study pdf showed that 100% of children who were placed on puberty blockers took cross sex hormones

I'm not sure where your numbers exactly come from, but I suspect there's some fudging of the ages. That is, for the group of kids who identify as trans and then "outgrow" this, what's the average age or age range at the start of that? For the kids we start on puberty blockers, what's the average age or age range of them?

If the first answer is younger than the second answer, then that has to be taken into account when considering the true rate of unidentifying as trans amongst those who would be started on pubertal blockers.

 

[yaboigk]

Over 100,000 men were arrested in the decades that followed the law passed in 1967. The problem is it didn't actually repeal many of the laws that criminalized sexual contact between gay men in the first place, and furthermore provided a different standard for heterosexual and homosexual intercourse (that being 21 years of age if you happened to be gay).

I HIGHLY doubt any those took place recently. "The Gender Recognition Act 2004, which came into effect on 4 April 2005, gave trans people full legal recognition of their gender, allowing them to acquire a new birth certificate" "Between July and October 2018 the UK Government consulted the public on reforming the Act. As of 1 September 2020 no report from the consultation has been published. The Equality Act 2010 gave LGBT employees protections from discrimination, harassment and victimisation at work. The legislation brought together existing legislation and added protections for trans workers, solidifying rights granted by the Gender Recognition Act." Remember, in 2008 Obama and Hilary Clinton were against gay marriage but I wouldn't use that as evidence in 2022 of the US's medical agencies of being anti LGBTQ.

And yes, ideology certainly plays a part in what is happening at the NHS and NICE. If you aren't aware of their general and historical stances on the issue I'm not going to bother sourcing and giving you a history lesson, but generally they've been considered to be amongst the worst to work with in the world for transgender care and always have sought to limit services. Ideology certainly affects things here as well, and I've voiced my rather complicated feelings on such care myself elsewhere in the thread.

What's your evidence that the NHS and NICE are anti trans ideologues? Why would they originally push gender affirming care if they were transphobic? You're grasping at straws here. England's government is super pro LGBTQ. Do you have evidence to the contrary?

Your first study was a sample size of 70, and showed no real negative outcomes.

You're missing the entire point of the first study. It was to show that out of 70 children with gender dysphoria, ALL 70 went on to receive HRT. Absolutely horrifying when 80-95% of kids with gender dysphoria outgrow it with puberty. I'll reiterate my point: instead of buying more time, it's clear giving kids puberty blockers locks them into a transgender identity. I'm yet to see any evidence of children with gender dysphoria starting puberty blockers and then deciding not to move onto HRT. Scary!

Your second study is low-powered, again, with 127 total patients that were referred to one center in one country. If you've ever gotten a referral, you would know that a lot of them are ultimately garbage.

You need to bare in mind that there are so few trans kids out there that it's hard getting incredibly large sample sizes. Still, 127 is pretty decent given what we're dealing with. I'm not saying the study is perfect but this study along with others CLEARLY points to large rates of desistance in children with gender dysphoria after puberty. Here's another study I found in the Frontiers of Psychology: "Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters." This was a decades long study, not just a few years or even months. full

It also clearly indicates that 37% of their study population continued to seek treatment and that there were factors that could be used to identify those more likely to persist in treatment.

You see 37% and think that's a lot. I see 37% and think that's well over half of participants of the study who decided not to transition. I can cite you some sources on how readily kids/teens are put on puberty blockers and HRT which is terrifying when most of them will grow out of it if they go through puberty normally.

. Your third study was one on gender confirmation surgery not having positive outcomes. I countered it with a well-powered, long-term study that showed the opposite. Your post was the context for my post, to pick it apart in isolation is poor form.

I forgot to add in the other key finding from that study! My apologies: "the study found no mental health benefits for hormonal interventions in this population." I will also grant you that that study you posted is interesting and made me think. However, there are things that are overlooked in the study. For instance, there were pretty large different rates in education, salary, family acceptance, counseling in those who had surgery vs those who didn't which could be significant confounding variables that could impact why those who had the surgeries had lower mental health rates. With the surgeries, the mental health issues are still astronomically for those who receive the trans surgeries which still makes me very dubious of the overall efficacy of doing these irreversible procedures. BUT I admit these surgeries were done in consenting adults, not children. My main concern is kids hoodwinked to go on puberty blockers (locking them into HRT) when the overwhelming majority of children with gender dysphoria outgrow it with puberty.

 

[yaboigk]

I'm not sure where your numbers exactly come from, but I suspect there's some fudging of the ages. That is, for the group of kids who identify as trans and then "outgrow" this, what's the average age or age range at the start of that? For the kids we start on puberty blockers, what's the average age or age range of them?

If the first answer is younger than the second answer, then that has to be taken into account when considering the true rate of unidentifying as tandem amongst those who would be started on pubertal blockers.

A Follow-Up Study of Boys With Gender Identity Disorder I already posted this study but I'll post it again in response to this. Basically, this study was a longterm follow up and 88% of children who identified as trans did not identify as trans as adults. Other studies report similar numbers. Interesting question you ask on what age they are. Sadly, this area is pretty new so there isn't a whole lot of good data out there on this stuff. I think we can all agree more research needs to be done.

 

[hamstergang]

A Follow-Up Study of Boys With Gender Identity Disorder I already posted this study but I'll post it again in response to this. Basically, this study was a longterm follow up and 88% of children who identified as trans did not identify as trans as adults. Other studies report similar numbers. Interesting question you ask on what age they are. Sadly, this area is pretty new so there isn't a whole lot of good data out there on this stuff. I think we can all agree more research needs to be done.

Thank you. At least by skimming, this appears to be a decent study in this area which has otherwise been full of not great studies (often low sample size, poor follow up). It would be great if we had much larger samples, of course, as we could then learn a lot more about factors that predicted persistence of a trans identity, but I'm sure those are coming over the next decade.

However, this study did have the age problem I suspected. The mean age at initial assessment was 7.5 (ranging from 3 to 13). The mean age we would consider starting puberty blockers is something older, though I don't know what it actually is. And in the study, the kids who were older at the initial assessment were more likely to persist. Therefore, the persistence of a trans identity amongst those initially assessed at the age we would consider starting puberty blockers would be expected to be higher than the 12%. And, amongst those who are actually considering this treatment, I imagine it would be even higher.

Though I completely agree with your point -- I wish we had more and better data for such things now.

 

[Mad Jack]

A Follow-Up Study of Boys With Gender Identity Disorder I already posted this study but I'll post it again in response to this. Basically, this study was a longterm follow up and 88% of children who identified as trans did not identify as trans as adults. Other studies report similar numbers. Interesting question you ask on what age they are. Sadly, this area is pretty new so there isn't a whole lot of good data out there on this stuff. I think we can all agree more research needs to be done.

I HIGHLY doubt any those took place recently. "The Gender Recognition Act 2004, which came into effect on 4 April 2005, gave trans people full legal recognition of their gender, allowing them to acquire a new birth certificate" "Between July and October 2018 the UK Government consulted the public on reforming the Act. As of 1 September 2020 no report from the consultation has been published. The Equality Act 2010 gave LGBT employees protections from discrimination, harassment and victimisation at work. The legislation brought together existing legislation and added protections for trans workers, solidifying rights granted by the Gender Recognition Act." Remember, in 2008 Obama and Hilary Clinton were against gay marriage but I wouldn't use that as evidence in 2022 of the US's medical agencies of being anti LGBTQ.

What's your evidence that the NHS and NICE are anti trans ideologues? Why would they originally push gender affirming care if they were transphobic? You're grasping at straws here. England's government is super pro LGBTQ. Do you have evidence to the contrary?


You're missing the entire point of the first study. It was to show that out of 70 children with gender dysphoria, ALL 70 went on to receive HRT. Absolutely horrifying when 80-95% of kids with gender dysphoria outgrow it with puberty. I'll reiterate my point: instead of buying more time, it's clear giving kids puberty blockers locks them into a transgender identity. I'm yet to see any evidence of children with gender dysphoria starting puberty blockers and then deciding not to move onto HRT. Scary!

You need to bare in mind that there are so few trans kids out there that it's hard getting incredibly large sample sizes. Still, 127 is pretty decent given what we're dealing with. I'm not saying the study is perfect but this study along with others CLEARLY points to large rates of desistance in children with gender dysphoria after puberty. Here's another study I found in the Frontiers of Psychology: "Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters." This was a decades long study, not just a few years or even months. full

You see 37% and think that's a lot. I see 37% and think that's well over half of participants of the study who decided not to transition. I can cite you some sources on how readily kids/teens are put on puberty blockers and HRT which is terrifying when most of them will grow out of it if they go through puberty normally.

I forgot to add in the other key finding from that study! My apologies: "the study found no mental health benefits for hormonal interventions in this population." I will also grant you that that study you posted is interesting and made me think. However, there are things that are overlooked in the study. For instance, there were pretty large different rates in education, salary, family acceptance, counseling in those who had surgery vs those who didn't which could be significant confounding variables that could impact why those who had the surgeries had lower mental health rates. With the surgeries, the mental health issues are still astronomically for those who receive the trans surgeries which still makes me very dubious of the overall efficacy of doing these irreversible procedures. BUT I admit these surgeries were done in consenting adults, not children. My main concern is kids hoodwinked to go on puberty blockers (locking them into HRT) when the overwhelming majority of children with gender dysphoria outgrow it with puberty.

You continue to move around the point- whether it's 12% or 37% likely more depends on the rigor with which referrals were made more than anything. Your other study about puberty blockers was not designed to answer the question of hormonal suppression vs natural progression- there was no control group. It is entirely possible that it was a very carefully selected sample that had no individuals desist because they've got the sampling method correct or had an extremely high bar for whom they would treat. It is also possible you are entirely correct. The problem is, this is not the question the study was designed to answer, thus neither of these conclusions can be inferred. You're trying to use an entirely different study as a control group for a study with a different population, different selection criteria, and different measures of outcome. That shows a very poor grasp of understanding of basic research methodology.

My study about surgical outcomes showed profoundly improved specific mental health outcomes and had a more robust dataset with regard to mental health outcomes. It was also sufficiently powered to be applicable at the population level. Perhaps there is a difference in the populations that explains this, as they did not take place in the same country and cultural differences could be a major factor. I don't think surgeries should be done in those under the age of 18, personally, as there's still a lot of physical growth occurring that could impact surgical results down the line and for a decision this serious an adult should be making it for themselves.

I think the other major point you've demonstrated is that there is no evidence of significant harm in the literature, as shown by any measured outcomes. So bravo for that.

 

[yaboigk]

You continue to move around the point- whether it's 12% or 37% likely more depends on the rigor with which referrals were made more than anything.

All of those numbers are ABSURDLY high which is my point. I don't care which number it is.

It is entirely possible that it was a very carefully selected sample that had no individuals desist because they've got the sampling method correct or had an extremely high bar for whom they would treat.

Of course that's possible. But is it likely? I'd argue that it's not likely at all given what we already know about how quickly and easily kids are put on puberty blockers. The gender affirming care model in my opinion is very very sloppy. I've listened to a lot of detransitioners who detail their stories of how they were rushed into puberty blockers with little oversight. Many teen girls were given testosterone at planned parenthood at their first visit. This is obviously not a study but illustrates a lot of the concerns with kids going on puberty blockers and HRT. Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care
Another point: can you give me ANY examples of kids who started puberty blockers for gender dysphoria and discontinued? So many activists talk about how they're reversible. Maybe that's true (I kinda doubt it though as you said it could effect mental health) but it seems irrelevant when it seems like starting puberty blockers locks one into HRT.

My study about surgical outcomes showed profoundly improved specific mental health outcomes and had a more robust dataset with regard to mental health outcomes. It was also sufficiently powered to be applicable at the population level. Perhaps there is a difference in the populations that explains this, as they did not take place in the same country and cultural differences could be a major factor. I don't think surgeries should be done in those under the age of 18, personally, as there's still a lot of physical growth occurring that could impact surgical results down the line and for a decision this serious an adult should be making it for themselves.

I've already granted it was an interesting study. But as I've already said there were so many confounding variables-socioeconomic status, family support, access to counseling, etc- between the two groups I think that could have had a huge influence on the data. Moreover, the people who responded to the survey had to wait at least 2 years after surgery to respond. I think that may be a little too soon. Listening to detransitioners who had surgeries, it was many years later they realized their regret. Additionally, the mental health issues were insanely profound still after surgery which still leads me to questioning the efficacy. But regardless as long as their adults, it's their right to have the surgeries done.

The problem is, this is not the question the study was designed to answer, thus neither of these conclusions can be inferred. You're trying to use an entirely different study as a control group for a study with a different population, different selection criteria, and different measures of outcome. That shows a very poor grasp of understanding of basic research methodology.

Very very uncharitable statement. I OBVIOUSLY know that wasn't the point of the study. They weren't looking to study that. However, we don't have ANY data on rates of kids starting puberty blockers and going off of them. This was the only published data I could find. I just cannot for the life of me believe that all 70 of those kids would not have a single one of them grow out of their gender dysphoria. You'd expect at least a couple. I found it horrifying, as should you. I'll ask again, can you list me any examples of kids starting puberty blockers who stopped and didn't move onto HRT? I can list you numerous examples of kids who were rushed into it and regretted it down the line. I agree with England. Gender affirming care is not the correct approach.

 

[WhereMyLiberalsAt]

There are studies that run contrary to yours.

Researchers Found Puberty Blockers And Hormones Didn’t Improve Trans Kids’ Mental Health At Their Clinic. Then They Published A Study Claiming The Opposite. (Updated)

A critique of Tordoff et al. (2022)

jessesingal.substack.com

This is a great substack on your 1st JAMA paper. IMO it does a great job at breaking down everything (in painful detail.)

 

[yaboigk]

Researchers Found Puberty Blockers And Hormones Didn’t Improve Trans Kids’ Mental Health At Their Clinic. Then They Published A Study Claiming The Opposite. (Updated)

A critique of Tordoff et al. (2022)

jessesingal.substack.com

This is a great substack on your 1st JAMA paper. IMO it does a great job at breaking down everything (in painful detail.)

Wow. Fascinating read. Thanks for the share. Everyone should check this out. There's a lot of very low quality studies on puberty blockers out there but very few-if any- that are high quality.

 

[yaboigk]

This is a great substack on your 1st JAMA paper. IMO it does a great job at breaking down everything (in painful detail.)

"you’d think there’s simply no debate here whatsoever, that the science is settled, when in fact the controversy has grown so heated that major European healthcare systems have changed their policies on these treatments. Maybe they’re wrong to have done so, but it’s quite surprising to see an outlet like Science Friday completely ignore any of this, and to see clinicians so uninterested in the controversy and so willing to gloss over warning signs in their own data." Sweden, Finland, and England have changed their guidelines recently given the evidence. The science is not settled on giving puberty blockers to children, clearly.

 

[operaman]

"you’d think there’s simply no debate here whatsoever, that the science is settled, when in fact the controversy has grown so heated that major European healthcare systems have changed their policies on these treatments. Maybe they’re wrong to have done so, but it’s quite surprising to see an outlet like Science Friday completely ignore any of this, and to see clinicians so uninterested in the controversy and so willing to gloss over warning signs in their own data." Sweden, Finland, and England have changed their guidelines recently given the evidence. The science is not settled on giving puberty blockers to children, clearly.

This is exactly why I think these interventions need to be confined to clinical trials for the time being so we can gather good data and figure out how to maximize benefits while minimizing harms.

The biggest beef I have with the surgical outcomes retrospective uncontrolled survey study (aside from those things), is that you’ve pre selected only the trans people who could actually afford surgery and had the support systems to see it through.

Many of my trans patients are so isolated they can’t even get a ride to appointments, and I often have to obs them after surgeries simply because they have nobody to watch them at home. Even in my relatively small practice, the patients who make it to surgery and go through with it are wildly different than those who don’t. I don’t think there’s any way to effectively control for this in a retrospective model; if there were, we wouldn’t ever need truly randomized data.

And that’s exactly what we need here - prospective randomized data that helps us figure out what’s actually happening. My suspicion based on my anecdotal clinical experience is that simply having the support of a multidisciplinary care team provides immense benefits and that the benefits of drugs or surgeries may not reach significance in a good randomized protocol.

 

[VA Hopeful Dr]

This is exactly why I think these interventions need to be confined to clinical trials for the time being so we can gather good data and figure out how to maximize benefits while minimizing harms.

The biggest beef I have with the surgical outcomes retrospective uncontrolled survey study (aside from those things), is that you’ve pre selected only the trans people who could actually afford surgery and had the support systems to see it through.

Many of my trans patients are so isolated they can’t even get a ride to appointments, and I often have to obs them after surgeries simply because they have nobody to watch them at home. Even in my relatively small practice, the patients who make it to surgery and go through with it are wildly different than those who don’t. I don’t think there’s any way to effectively control for this in a retrospective model; if there were, we wouldn’t ever need truly randomized data.

And that’s exactly what we need here - prospective randomized data that helps us figure out what’s actually happening. My suspicion based on my anecdotal clinical experience is that simply having the support of a multidisciplinary care team provides immense benefits and that the benefits of drugs or surgeries may not reach significance in a good randomized protocol.

I would be surprised if that's true, particularly the latter part.

 

[NotAProgDirector]

I think everyone - on both sides of this discussion - would agree that the current evidence base is poor. Studies are small, timelines are often short, everything is prospective cohort without randomization or blinding. There's immense bias in whom gets active treatment or not - based upon SES, family supports, geography, and innumerable other factors. Studies try to fix this with statistical correction -- and that's very open to interpretation. It's the best data we have, but it's not very good.

And I have some bad news: I don't think a study can be done. At all. There's no way to randomize to treatment -- it's very unlikely kids/families will be willing to leave this decision to a coin toss. And there is certainly no way to blind anyone, it will be obvious to patients, families, and physicians whom is on treatment and whom not. Controls are going to be very difficult to get, population is much too small for propensity scoring and other tools. Not all questions can be answered by RCT's, and this is one of them.

As usual in these discussions, both extreme viewpoints are problematic to me. A blanket "no child gets treated for gender dysphoria" seems wrong -- there are clearly some children with severe persistent gender dysphoria who may be helped with treatment. Likewise, a pure Gender Affirmative model where any person who walks in and says they feel transgender gets put on blockers or hormones is equally bad. With all the data we do have, it seems very likely that ~30% of people who initially present with GD seem to have persistent symptoms and 70% do not. So the question is: should we treat all of them knowing that 70% will ultimately stop blockers and go through puberty with ? possible long term impacts of that (although we have NO clear data that there is any long term harm), treat none and have 30% go through puberty and be harmed by that / need more treatment long term to address it, or can we find some middle ground to help tease out those that would benefit? I would hope the solution is the middle ground -- that we adopt a Gender Supportive stance, assess patients broadly with a team, perhaps let puberty get started and see how kids are doing with it, start blockers judiciously when the team assessment agrees. This is very far outside my practice, so I don't know how realistic it may be. And likely very difficult to provide in resource poor areas and rurally.

Regarding the substack, I could only get through the start. I find their arguments not very convincing. I agree that the major issue with the study is that at 12 months, there are only six kids not getting treatment -- there appears to have been a large dropout of that group because the number on treatment stays steady. So any assessment at 12 months is impossible. But their claim that there is "no benefit" because the outcome was unchanged over time in-group and so it doesn't work makes no sense -- if without treatment things get much worse, then keeping things the same is a win. They mention similar examples -- keeping a malignancy at bay or staving off cognitive decline both for a window -- and this is similar. And you wouldn't expect that someone's mental health would get much better when they are a trans pre teen when you block puberty -- that's going to take much longer, there's still lots of issues for them, etc. And they also make vague comments about how the statistics were done in the study, that it was a "model". This is crazy -- the study is observational, so the authors have no control of when people are put on blockers if at all. So they need to address that some people were on them to start, some might start at 3 or 6 months. And the lack of randomization also needs "correction", which as I mentioned above is a very inexact science.

 

[sloop]

Thank you and well said. Not really going to expand on what I do and why since it’s not the topic of the thread really. But the big part of why I refer to psych is to help me understand if the patient has any psych condition I’m not able to diagnose and how that could play into their future psych well-being as you say (not just for legal purposes of course). I don’t deal too much with gender dysphoria, but I’m interested to hear how you specifically got that training. Was there a specific clinic for those patients, was it just by way of seeing enough patients over time with an attending who was more familiar, or some other way?

I just realized I never actually responded to your question.

My residency had a required rotation in a specialty clinic for sex and gender related issues. There were three main categories of patients we saw in that clinic: gender dysphoria, sexual dysfunction, and paraphilias. Of those, probably about 50-60 percent were gender dysphoria evaluations. We had supervision by attendings who specialized in this work. We would recommend puberty blockers, hormones, and write letters for surgery when appropriate. I also did an elective in my fourth year through this clinic, though by then I knew I was going to be a forensic psychiatrist and my focus at that time was on paraphilias.

 

[operaman]

I would be surprised if that's true, particularly the latter part.

I think you’re probably right with adults and even older adolescents. Where there is likely some gray area is the younger teens/tweens. Delayed puberty versus standard puberty with support and affirmation and potential for hormonal therapy later may have a harder time showing significance. I would guess there’s probably some age where benefits become more clear, and that age may be younger than I think.

I have to disagree with NAPD partly - I do think we can get randomized data here. Maybe not effective placebo controlled given you can’t really blind for long, but probably enough data to begin answering some of these questions. Some of the euro countries are doing this very thing just like they’ve done some other randomized studies you wouldn’t see done here either.

 

[VA Hopeful Dr]

I think you’re probably right with adults and even older adolescents. Where there is likely some gray area is the younger teens/tweens. Delayed puberty versus standard puberty with support and affirmation and potential for hormonal therapy later may have a harder time showing significance. I would guess there’s probably some age where benefits become more clear, and that age may be younger than I think.

I have to disagree with NAPD partly - I do think we can get randomized data here. Maybe not effective placebo controlled given you can’t really blind for long, but probably enough data to begin answering some of these questions. Some of the euro countries are doing this very thing just like they’ve done some other randomized studies you wouldn’t see done here either.

The trick with this is differentiating between true transgender kids and kids who have dysphoria for whatever other reasons. Kinda like how problems with attention can be caused by ADHD but can also be caused by other untreated mental illness.

 

[WhereMyLiberalsAt]

And they also make vague comments about how the statistics were done in the study, that it was a "model". This is crazy -- the study is observational, so the authors have no control of when people are put on blockers if at all.

Um… You 100% need to reread it then. He is saying they used an inferior way to calculate their data. In no way is he vague about it. The fact that this study still got published is quite surprising with the dropout rate. Also the researches will not release their data so academics can explore it further. At best it’s a “shrug off study” at worst it’s a study that misleads the layperson into thinking this is settled science. The way it’s been reported on by secondary media outlets, it might be the latter.

 

[NotAProgDirector]

Reread what? The study or the substack?

If you think there's a key portion of the substack that is important, feel free to quote it here.

I agree with you that the lay media has presented this as "clear proof" when in fact it's a study with lots of problems. Although there are problems, I wouldn't just discard their findings.

 

[WhereMyLiberalsAt]

Reread what? The study or the substack?

If you think there's a key portion of the substack that is important, feel free to quote it here.

I agree with you that the lay media has presented this as "clear proof" when in fact it's a study with lots of problems. Although there are problems, I wouldn't just discard their findings.

Can do when I have a moment… Their findings can be meaningful, even more so if the data was shared too. I should also have been more clear or picked better wording; I’m surprised it was published in such a prestigious journal. JAMA and UW give almost any study “the benefit of the doubt” treatment.

 

[Hzreio]

I agree that you could potentially consider performing trans surgery before age malpractice. But then again, if the guardians signed informed consent… tough issue