Nothing Is Clear

Excerpts from scientific studies to make your head spin

Flickr/creative commons

Earlier this week, The New York Times published a story about Sarah Palin’s libel lawsuit against the paper, which had spread misinformation by linking her rhetoric to a mass shooting, though it corrected it soon after. Immediately upon reading it, I turned to Twitter to ask, “Are there implications for this for those of us concerned about the way the media, especially the NYT, reports about gender dysphoric youth? How should we hold them accountable for spreading misinformation?”

But I didn’t actually tweet it because: Twitter. Don’t have the stomach for it.

While the Times did recently publish a shockingly more-than-one-sided piece about treating adolescents with gender dysphoria, it was also riddled with inaccuracies and omitted a lot of important information, and I am beginning to wonder if anyone at the science section has actually read the science, or considered it. Many young reporters have been convinced that it’s their job to combat information that disrupts a narrative, rather than investigate it.

What does the body of the science show? All kinds of different and competing stuff! That little of the past research applies to the teens identifying as trans, or self-diagnosing with gender dysphoria, today. That positive outcomes were based on kids who weren’t socially transitioned and had lifelong childhood gender dysphoria, no other mental health problems, and were rigorously evaluated—meaning, some kids were dissuaded from pursuing the medical path, so what would have been their poor outcomes weren’t included. That the great bulk of kids with childhood GD desisted, and most were later same-sex attracted. That we have almost no long-term research on those who are socially or medically transitioned young, but social transition is likely to increase gender dysphoria at puberty. That detransition is on the rise. That short-term self-reports of self-selected participants show improvement, but that such research is so low quality we shouldn’t put much stock in it—yet it is almost the only research that gets written up. Most of the research shows some improvements and some deprovements, but you rarely hear about the latter.

Even this week, Psychology Today printed an article asserting that research on gender-affirming care clearly shows that medical interventions work and are necessary. The author did this by homing in on select outcomes. Here’s an excerpt:

"Study 1: 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.

This study from the Netherlands followed 70 transgender adolescents and measured their mental health before and after pubertal suppression. Study participants had improvements in depression and global functioning following treatment."

Here’s what the study actually says: 

"Feelings of anxiety and anger did not change between T0 and T1. While changes over time were equal for both sexes, compared with natal males, natal females were older when they started puberty suppression and showed more problem behavior at both T0 and T1. Gender dysphoria and body satisfaction did not change between T0 and T1. No adolescent withdrew from puberty suppression, and all started cross-sex hormone treatment, the first step of actual gender reassignment."

There were some improvements, some things got worse, some things didn’t change. Notably, gender dysphoria—the very reason for the treatment—did not improve. And, as hopefully people know by now, even though kids weren’t really getting better on puberty blockers, ALL OF THEM went on to cross-sex hormones, disrupting the idea that they are a “pause button,” as opposed to a first step in a path to lifelong medicalization.

I’m pleased to say that after I reached out to the editors, they made two corrections to the article, though they were stealth edited (they had to take out the assertion that people on Twitter claiming the research doesn’t hold up were bots, and they amended this entry). More changes may be forthcoming as the article’s claims are further scrutinized. Please, as always, write to editors and reporters when you see studies being misrepresented and ask for corrections. So few people are properly educated about this issue, in part because the publications educating them have it wrong.

Here are just a few excerpts to show you how confusing the research really is, and to provide you with some information the media has kept out of stories.

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“There is a lack of consensus demonstrated as to the exact nature of the condition. Questions remain for psychiatrists regarding whether gender dysphoria is a normal variation of gender expression, a social construct, a medical disease or a mental illness. If merely a natural variation, it becomes difficult to identify the purpose of or justification for medical intervention.”

Griffin, L., Clyde, K., Byng, R., & Bewley, S. (2021). Sex, gender and gender identity: A re-evaluation of the evidence. BJPsych Bulletin, 45(5), 291-299. doi:10.1192/bjb.2020.73

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“…no reliable data derived from randomized controlled trials, or longitudinal cohort studies give confident estimates of the risks and benefits of various gender-affirming interventions… Long-term patient outcomes are uncertain, partly due to high losses to follow up.”

Boyd, I.; Hackett, T.; Bewley, S. Care of Transgender Patients: A General Practice Quality Improvement Approach. Healthcare 2022, 10, 121. https://doi.org/10.3390/healthcare10010121

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“The overall mortality for sex-reassigned persons was higher during follow-up (aHR 2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0–3.9). Comparisons with controls matched on reassigned sex yielded similar results. Female-to-males, but not male-to-females, had a higher risk for criminal convictions than their respective birth sex controls.”

Dhejne C, Lichtenstein P, Boman M, Johansson AL, Långström N, Landén M. Long-term follow-up of transsexual persons undergoing sex reassignment surgery: cohort study in Sweden. PLoS One. 2011 Feb 22;6(2):e16885. doi: 10.1371/journal.pone.0016885. PMID: 21364939; PMCID: PMC3043071.

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“Puberty blockers used to treat children aged 12 to 15 who have severe and persistent gender dysphoria had no significant effect on their psychological function, thoughts of self-harm, or body image, a study has found.

However, as expected, the children experienced reduced growth in height and bone strength by the time they finished their treatment at age 16.”

Dyer C. Puberty blockers do not alleviate negative thoughts in children with gender dysphoria, finds study BMJ 2021; 372 :n356 doi:10.1136/bmj.n356

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“…failure to address relevant psychological issues can result in trans people making unnecessary, permanent changes to their bodies, without adequate scientific justification for doing so.”

Withers, R. (2020) Transgender medicalization and the attempt to evade psychological distress. J Anal Psychol, 65: 865– 889. https://doi.org/10.1111/1468-5922.12641.

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“Key challenges faced by the clinicians included the following: the effects of increasingly dominant, polarized discourses on daily clinical practice; issues pertaining to patient and clinician safety (including pressures to abandon the holistic [biopsychosocial] model); the difficulties of untangling gender dysphoria from comorbid factors such as anxiety, depression, and sexual abuse; and the factual uncertainties present in the currently available literature on longitudinal outcomes.”

Kozlowska, Kasia & McClure, Georgia & Chudleigh, Catherine & Maguire, Ann & Gessler, Danielle & Scher, Stephen & Ambler, Geoffrey. (2021). Australian children and adolescents with gender dysphoria: Clinical presentations and challenges experienced by a multidisciplinary team and gender service. Human Systems: Therapy, Culture and Attachments. 1. 70-95. 10.1177/26344041211010777.

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“Larger studies are clearly required to delineate the positive outcomes in psychosocial functioning and quality of life and the long-term effects of pubertal suppression and gender-affirming hormone therapy on metabolism, on the growing skeleton, and on brain development and cognition.”

Kyriakou A, Nicolaides NC, Skordis N. Current approach to the clinical care of adolescents with gender dysphoria. Acta Biomed. 2020 Mar 19;91(1):165-175. doi: 10.23750/abm.v91i1.9244. PMID: 32191677; PMCID: PMC7569586.

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“According to the original Dutch protocol, one of the criteria to start puberty suppression was ‘a presence of gender dysphoria from early childhood on.’… This raises the question whether the positive outcomes of early medical interventions also apply to adolescents who more recently present in overwhelming large numbers for transgender care, including those that come at an older age, possibly without a childhood history of GI.

Prospective longer-term follow-up studies of clinical samples…are needed to inform clinicians so that an individualized approach can be offered that differentiates who will benefit from medical gender affirmation and for whom (additional) mental health support might be more appropriate.”

Annelou L.C. de Vries; Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents. Pediatrics October 2020; 146 (4): e2020010611. 10.1542/peds.2020-010611

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“At follow-up, gender identity/dysphoria was assessed via multiple methods and the participants were classified as either persisters or desisters. Sexual orientation was ascertained for both fantasy and behavior and then dichotomized as either biphilic/androphilic or gynephilic. Of the 139 participants, 17 (12.2%) were classified as persisters and the remaining 122 (87.8%) were classified as desisters. Data on sexual orientation in fantasy were available for 129 participants: 82 (63.6%) were classified as biphilic/androphilic, 43 (33.3%) were classified as gynephilic, and 4 (3.1%) reported no sexual fantasies…. Boys clinic-referred for gender identity concerns in childhood had a high rate of desistance and a high rate of a biphilic/androphilic sexual orientation.”

Singh Devita, Bradley Susan J., Zucker Kenneth J. A Follow-Up Study of Boys With Gender Identity Disorder.” Frontiers in Psychiatry, 12 ; 2021; 10.3389/fpsyt.2021.632784

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“One other predictive factor of importance for the persistence of gender dysphoria, especially in boys, showed to be, at least partially, a childhood social transition to the preferred gender role. Although transitioned boys reported more gender dysphoria and cross-gender behaviors, which could indicate that transitioning is an indicator of the intensity of gender dysphoria, one may wonder whether a childhood transition has an effect by itself and influences the cognitive gender identity representation of the child and/ or their future development.”

Steensma TD, McGuire JK, Kreukels BP, Beekman AJ, Cohen-Kettenis PT. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013 Jun;52(6):582-90. doi: 10.1016/j.jaac.2013.03.016. Epub 2013 May 3. PMID: 23702447.

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“There is a paucity of quality evidence on the outcomes of those presenting with gender dysphoria. In particular, there is a need for better evidence in relation to outcomes for children and young people.”

Recognising and addressing the mental health needs of people experiencing Gender Dysphoria / Gender Incongruence, position statement by the Royal Australian and New Zealand College of Psychiatrists.

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“The guidelines recommend the use of gonadotropin-releasing hormone agonists in adolescence to suppress puberty. However, in actual practice, no consensus exists whether to use these early medical interventions.”

Lieke Josephina Jeanne Johanna Vrouenraets et al., “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study,” Journal of Adolescent Health 57, no. 4 (October 1, 2015): 367–73, https://doi.org/10.1016/j.jadohealth.2015.04.004. https://www.jahonline.org/article/S1054-139X(15)00159-7/fulltext

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“After the article “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study” by Richard Bränström, Ph.D., and John E. Pachankis, Ph.D. (doi: 10.1176/appi.ajp.2019.19010080), was published online on October 4, 2019, some letters containing questions on the statistical methodology employed in the study led the Journal to seek statistical consultations. The results of these consultations were presented to the study authors, who concurred with many of the points raised. Upon request, the authors reanalyzed the data to compare outcomes between individuals diagnosed with gender incongruence who had received gender-affirming surgical treatments and those diagnosed with gender incongruence who had not. While this comparison was performed retrospectively and was not part of the original research question given that several other factors may differ between the groups, the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts in that comparison.”

Correction to Bränström and Pachankis, American Journal of Psychiatry2020177:8,734-734 Published Online:1 Aug 2020https://doi.org/10.1176/appi.ajp.2020.1778correction

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I could go on, but by now I hope you get the point.