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On the American Medical Association and Endocrine Society’s painfully inaccurate new statement on youth gender medicine
Sometimes I feel like I’m writing the same post over and over and over. But it’s important to call out misinformation on high-stakes subjects when powerful institutions spread it.
Earlier this week the American Medical Association announced that its House of Delegates had “passed the Endocrine Society’s resolution to protect access to evidence-based gender-affirming care for transgender and gender-diverse individuals.”
Anyone who keeps even one eye on this issue will, upon reading this document, see that it is larded with nonsense.
Let’s go through it quickly:
Due to widespread misinformation about medical care for transgender and gender-diverse teens, 18 states have passed laws or instituted policies banning gender-affirming care. More than 30 percent of the nation’s transgender and gender-diverse youth now live in states with gender-affirming care bans, according to the Human Rights Campaign. Some policies are even restricting transgender and gender-diverse adults’ access to care.
These policies do not reflect the research landscape. More than 2,000 scientific studies have examined aspects of gender-affirming care since 1975, including more than 260 studies cited in the Endocrine Society’s Clinical Practice Guideline.
I remain opposed to these bills for reasons I’ve expressed consistently for years, but factually speaking, this is a terrible argument against them.
The average layperson might see that phrase, “2,000 scientific studies,” and be impressed. But setting aside the fact that quantity does not equal quality when it comes to medical research — even transgender medicine for adults doesn’t hold up well, evidence-wise, when subjected to appropriately rigorous scrutiny (more details here) — those who follow this issue closely know that there is a major difference between studies of adult versus youth gender medicine. That’s because there are obvious and important distinctions between giving hormones to a not-fully-developed adolescent and to an adult, and because there is an entire process, the blocking of puberty, that occurs in youth but not adult gender medicine. So defending the evidence for youth gender medicine by pointing to the existence of “2,000 scientific studies” on “aspects of gender-affirming care” is an act of misdirection, fundamentally a non sequitur. It is designed to fool the easily fooled.
It’s remarkable that the AMA and Endocrine Society published this claim mere days after the UK’s National Health Services announced that going forward, as the BBC put it, “Puberty blockers will only be prescribed to children attending gender identity services as part of clinical research.” The NHS made that shift largely because of the disastrous lack of research underpinning the use of blockers in this context — a decision echoing similar ones made in Finland, Sweden, and Norway.
That BBC article also notes that the NHS is going to conduct a clinical trial on blockers and transgender youth “which aims to be up and running in 2024,” as an NHS spokesman put it. So, you know, more than a decade after the Tavistock study that was supposed to offer a ringing endorsement for blockers, only for it to turn out that whoops, there was no evidence to support the idea that blockers helped improve patients’ mental health.1
I want to make a morbid joke about starting to rigorously evaluate a medical intervention for kids only, like, a decade and a half after you started administering it to them in earnest — seems like you might want to flip the order there — but we Americans haven’t a leg to stand on since the situation over here is so much more pathetic and divorced from scientific integrity. At least in the UK they are making an honest effort to allow science rather than politics to dictate policy.
Pediatric gender-affirming care is designed to take a conservative approach. When young children experience feelings that their gender identity does not match the sex recorded at birth, the first course of action is to support the child in exploring their gender identity and to provide mental health support, as needed.
This is just. . . more nonsense. Everyone who follows this issue closely knows that there is no reality-based sense in which affirming care is “designed to take a conservative approach.” In fact, the affirming approach grew out of a competing and more conservative approach: watchful waiting, which was pioneered by Dutch researchers and clinicians. This approach is very much out of vogue in the United States. As Reuters reported last year, it’s now routine for gender clinics here to prescribe blockers or hormones during a first visit, which is anything but “conservative.”
Medical intervention is reserved for older adolescents and adults, with treatment plans tailored to the individual and designed to maximize the time teenagers and their families have to make decisions about their transitions. Major medical organizations also agree on waiting until an individual has turned 18 or reached the age of majority in their country to undergo gender-affirming genital surgery.
I cannot overstate the level of rank dishonesty in that first sentence. Youth gender medicine interventions are not “reserved for older adolescents and adults.” Everyone knows this. It’s an absolutely baffling claim, contradicted by the Endocrine Society’s own past statements — “puberty blocking medications could be considered once an experienced clinician confirms the start of puberty.” Some kids go on hormones as young as 12 or get double mastectomies as young as 13. Maybe even younger, in outlying cases — here I’m relying on published studies from one of the top gender clinics in the country, not comprehensive reporting on what is going on at random, smaller clinics.
If there’s no real debate here, why do the AMA and Endocrine Society have to spread falsehoods about the nature of these treatments?
This line, meanwhile, isn’t quite as bad, but is rather misleading: “Major medical organizations also agree on waiting until an individual has turned 18 or reached the age of majority in their country to undergo gender-affirming genital surgery.” That’s true in some cases, but the most influential organization when it comes to this conversation, the World Professional Association for Transgender Health, removed all age guidelines from its Standards of Care shortly after it was published. Seems a pretty big omission, no? There’s in fact serious disagreement about age guidelines, because WPATH doesn’t believe there should be any at all.
Here’s the worst part:
Gender-affirming care can be life saving for a population with high suicide rates. For example, a 2020 study analyzed survey data from 89 transgender adults who had access to puberty-delaying medication while adolescents and data from more than 3,400 transgender adults who did not. The study found that those who received puberty-delaying hormone treatment had lower likelihood of lifetime suicidal ideation than those who wanted puberty-delaying treatment but did not receive it, even after adjusting for demographic variables and level of family support. Approximately nine in ten transgender adults who wanted puberty-delaying treatment, but did not receive it, reported lifetime suicidal ideation.
Cross “Jack Turban study” off your bingo card. I am not going to debunk this study for the nth time. Click here and search down to “It is, to phrase things bluntly, not serious research” for the concise version. I stand by that description completely — this study offers no useful evidence about puberty blockers and suicide. It’s very, very bad that the AMA and Endocrine Society are publicly claiming otherwise. Adolescent suicide is a frightening subject that demands scrupulous research.
It’s important to remember that organizations like the AMA and Endocrine Society aren’t designed, as some institutions are, to make recommendations based on scientific evidence and scientific evidence alone. They are fundamentally political — they have to be, because they represent specific constituencies, have political goals, spend tens of millions of dollars on lobbying (in the case of the AMA), and so on. So on this and other issues, there have been past, similar incidents of baffling science-communication failures. For me, the most memorable one will always be the American Academy of Pediatrics’ disastrous 2018 “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents,” which read as though it had been authored by a recent graduate of Tumblr University, not by a committee of MDs. It was that bad, and it led to one of those moments where, as someone with some knowledge of the relevant issues, I had to ask myself: Is there any reason I can trust the AAP on this issue, going forward? It’s a frustrating question to have to ask given how epistemically confusing — and exhausting — the world already is. You’d like to think major professional organizations can ease some of the burden by being trustworthy enough to earn our deference.
Alas. The fundamental problem, going back to the AMA/Endocrine Society nonsense, is that most people don’t know much about this issue. So the average person is going to see a statement like this one and, well, believe it. Those are very impressive-seeming organization names!
I’d argue the American Medical Association and Endocrine Society have a fundamental obligation to, at the very least, not spread outright nonsense. It is not a high bar to clear to, for example, not lie about the age at which youth gender medicine is often first administered, or to understand that you cannot make causal medical claims about suicide based on a self-report survey administered at youth LGBT organizations. I’ve heard these organizations have a lot of scientists working for them, and scientists, in theory, are supposed to be good at this sort of thing.
But highly respected institutions, like these organizations and like countless media outlets, do keep spreading misinformation on this subject. At a certain point, if you’re just trying to figure out the truth about these subjects, why wouldn’t you give up on the AMA or the Endocrine Society or the AAP or Scientific American or Science Vs? Seriously. Once it’s established that these institutions are much more interested in coming down on the “right” side of a hyper-politicized debate than in making a good-faith effort to communicate the truth — once they’ve shown, over and over and over, that they only deploy the full powers of their reasoning and skepticism selectively — what is the point of trusting them?
I’m not totally blackpilled. These organizations all still have good people working for them and are capable of solid work. I would still trust The New York Times or even Science Vs over the countless maniacs spreading conspiracy theories on YouTube. But I’m gaining a better and better understanding of how said maniacs gain a foothold. When someone comes to me and complains that they just can’t trust mainstream institutions anymore, what can I do, knowing what I know, other than shrug?
Folks like Alex Jones will always have some influence, unfortunately, even in otherwise healthy epistemic landscapes. Humans are imperfect and our brains are easily hijacked by charismatic madmen. But why make it such a cakewalk for the Joneses of the world? Why give people easy excuses to abandon mainstream sources of knowledge?
Don’t complain when you dislike where those disillusioned folks eventually end up, is all I’m saying.
Image: WATERBURY, CONNECTICUT - SEPTEMBER 21: InfoWars founder Alex Jones speaks to the media outside Waterbury Superior Court during his trial on September 21, 2022 in Waterbury, Connecticut. Jones is being sued by several victims’ families for causing emotional and psychological harm after they lost their children in the Sandy Hook massacre. A Texas jury last month ordered Jones to pay $49.3 million to the parents of 6-year-old Jesse Lewis, one of 26 students and teachers killed in the shooting in Newtown, Connecticut. (Photo by Joe Buglewicz/Getty Images)
I’ve been criticized in the past for describing the finding this way when the kids did self-report positive experiences on blockers. But I’m sorry — if you go zero-for-everything when it comes to validated psychological measures, you can’t then point to kids saying they liked going on blockers as evidence they work, given the fraught nature of this sort of self-report.