We know from Olson-Kennedy's presentations at WPATH and USPATH conferences that her research group planned to gather at least five years of follow-up data on their study cohorts, which they recruited between 2016 and 2018. And yet all we have are papers on a maximum of two years of follow-up for the group on hormones. It's been three years since the first of those papers, Chen et al, was published. So where are papers on longer follow-up times? And given the team got a renewed grant in 2020, it's entirely possible they kept following these youth past the five-year mark. https://benryan.substack.com/p/in-2021-dr-olson-kennedy-was-eager
This lines up with the adult gender clinics in England refusing to share their data with Hilary Cass, even after a way was created for them to do it without compromising patient privacy.
It doesn't seem like the behavior of clinicians who are confident that all their patients are getting better.
Yes, and they only reported on 6 of the 8 psychological outcomes they hypothesized would improve. As Jesse pointed out at the time.
A psychiatrist pointed out that the biggest problem with Chen et al is its strength. They barely found anything. For mtf those 2 outcomes didn't improve. And two surely got very much worse as there were 2 completed suicides.
One key point, which I have made (in at least 1 LTTE about Chen et al) is the terrible loss-to-follow-up. In Chen et al (about the GAC arm of Cohen-Kennedy NIH study), they started with 313-318 cases (amazingly and shockingly, not everyone in the study responded to all study measures at baseline), and at 2Y, they had about 225 cases - this is LTFU of 30%. This is not found in other medical studies - LTFU in clinical research is usually 2-3%, and is considered a serious threat to any kind of conclusion if LTFU > 5%. How many of these cases died? How many desisted? How many had other problems?
There is also a wider and serious nocebo effect. All these young people are being told they need these "life-saving" interventions in order to thrive, which was directly criticized after a UK study in response to the claims:
"The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide."
" However, an excessive focus on an exaggerated suicide risk narrative by clinicians and the media may create a damaging nocebo effect (e.g., a “self-fulfilling prophecy” effect) whereby suicidality in these vulnerable youths may be further exacerbated (Biggs, 2022; Carmichael, 2017). This type of risk has been discussed in other similar situations involving youth (Abrutyn et al., 2020; Canetto et al., 2021; Shain & AAP COMMITTEE ON ADOLESCENCE, 2016)."
That is, patients who get these drugs might think they were saved from this risk.
And patients who don't get them might be made even more anxious--a big problem right now in US states where these interventions are not available for minors, and where the **MDs** treating them still believe that this means "lifesaving care" is being denied. The doctors pushing the "lifesaving" narrative are, in my opinion, doing harm to these kids by suggesting suicide is a natural response to having gender dysphoria and that gd can only be alleviated with these medications. It appears to me to be encouraging despair and fear, based on falsehoods.
Olson-Kennedy said at the 2023 USPATH conference: “I asked our person at the NIH if there was a prize for the grant that got the most FOIA requests, and she said, ‘No, but even if there was, you would still be behind Covid and fluoride.'"
This is an obstruction to calling "gender medicine" science, but the obstruction to calling it medicine is deeper. No control on your design can change the fact that we cannot independently verify the complaint. No diagnosis is involved. The same principle applies to "pain management", and, of course, psychiatry. I think the "pain as the fifth vital sign" movement is underreported as the cause of the opioid epidemic.
Medicine has an epistemology problem that runs deeper than RCTs can address.
"No control on your design can change the fact that we cannot independently verify the complaint. No diagnosis is involved."
This is really important.
It's also a weakness of Jesse's reporting and commentary on this whole ecosystem of issues. I'm a financial support of Barpod and a big fan overall of Jesse's work. But Jesse consistently avoids the question "What is 'trans'?" and avoids the obvious and likely possibility that "trans" is not a natural feature of human existence and is instead just a late 20th century outgrowth of mental illness + homophobia + misogyny + sexual fetish that was made into an identity by the effects of social media and cell phones. That view deserves a fair hearing because the prior on its being true is very high: there are are no "trans kids", humans don't have gender souls, they can't change sex, and no one is born in the wrong body.
‘Trans’ does seem to have existed for ages. That does not mean it isn’t a response to the factors you suggest. No reason to assume “ mental illness + homophobia + misogyny + sexual fetish” haven’t been around for ages. We’ve just got better communications about it now
There is exactly 0 evidence for the statement "‘Trans’ does seem to have existed for ages. " The meaning of trans is very very new. What did exist, and is well documented is the interest and willingness of persons to live under the illusion of the other sex. Women enlisted as soldiers pretending to be men, a well-known case of a woman acting as a man to be a physician, etc. These all had to do with the inability of women to have a professional life prior to about 1940. But there is no evidence whatsoever of the "trans notion" of "being in the wrong body". That started in the 1950s with the "Danish girl" and with "Renee" Richards.
If they clearly state the goals of treatment, those can be used. But this group did that and then hid most of the outcomes. Most outcomes still have not appeared for hormones.
While I agree that hiding the outcomes of your poorly conceived studies is bad behavior, and should be reported on, there is a deeper problem.
For a concrete example, which is far from the only realization of this problem, how do you control for cohort effects? How does an RCT account for the differences in the boys from the dutch protocol and the boys who have left wing influencer parents? There's no way to build a study around this question.
On the other end, how do you account for the clinical relevance of "never being able to achieve orgasm"? Katie makes this point a lot, and I would phrase it as boys cannot report dissatisfaction via a counterfactual that they cannot imagine. Failure to ever gain the function of orgasm is not an outcome that can be collected through patient satisfaction reporting alone.
These are not isolated problems. These are structural, philosophical problems with abandoning the medical model as the basis of medicine.
"No diagnosis is involved" - that is slightly incorrect. There certainly is a diagnosis, but the "diagnostic criteria" are completely subjective. If a person says "I am trans" that is considered the diagnosis. Jack Turban has stated that no other diagnostic criteria are needed. Thus, the "dysphoria" diagnosis is simply indistinguishable from any other form of delusion. It has just been given the "special status" of being immediately believed with no need for any form of verification or validation.
Once you see the pattern in this field of “we say whatever we need to say at the time to reach a short term goal even if it’s incoherent with what we say otherwise” you can’t unsee it. We said we expected there to be mental health improvements but didn’t find any? Well we actually never said that was the point in the first place, it’s just embodiment goals. We will talk about all of the uncertainties and unknowns to take public research funds but if you bring them up in clinical or policy discussions you are an evil transphobe. We hold conference presentations that stigmatize exploration, assessment and try to disabuse clinicians of the “right to know” why someone wants to transition but we will send in our incoming WPATH president to testify against you for quickly affirming and facilitating surgery and not clarifying comorbidities or identity stability. If this field ever seriously self-reflects about why people who are accepting and tolerant of individuals who transition are suspicious of the “gender medicine establishment” they will find this to be a major factor. Maybe the general public is quite empathetic to the plight of these patients but can’t stomach the constant contradictions, obfuscations, and lying from the leaders and institutions.
Alchemy, the belief that one could turn stuff into gold, seems operative here. If you believe it, it will come true. We’ll just do some more studies, and tinker some more, and soon we’ll have pure gold.
It's so hard to see someone suffering, especially a child, and not want to alleviate the suffering. Unfortunately, the adults let their empathy overcome their responsibility to the scientific method.
Literally hundreds of medical guidelines are published, many or most from specialty societies. Many recommendations are based on relatively weak evidence. The AUA and PSA screening; AHA and statins for primary prevention of heart disease. The American Society for Gastrointestinal Endoscopy and endoscopy for reflux. The Endocrine Society and Vitamin D screening (withdrawn) and pre-diabetes. This typically amounts to self-serving intellectual bias.
This accounts partly for guidance in youth gender medicine. Yet the entire basis is shaky, based in ideology, not biology or psychology. Dysphoria is a psychological issue. Why treat it with hormones and hormonal manipulators when there is a 100% normal phenotype?
Evidence Based Medicine as practiced in the US is imperfect, but better than what it replaced- eminence- based medicine. There's no excuse for Olson-Kennedy, Hack, WPATH, or members of the Endocrine Society should understand these matters; and any MD, especially a trialist, should understand the multiple sources of systematic error (aka bias) when conducting research. Countless sound, good ideas in the past have failed when tested rigorously. Contrary to Olson- Kennedy's statement regarding fear that it "would be weaponized by conservatives seeking to ban youth gender medicine", it might be employed by those who want high quality studies and those concerned for the welfare of minors.
I have served on national peer reviewed panels for decades, and I have received several million dollars in peer reviewed funding over the years. Not saying to brag, but just to ground by authority both as someone who has seen and written any number of submissions and resubmissions of grants
1) effusive and uncritical letters of support from stakeholders for any grant application are exceedingly common, if not universally seen for any grant application for any disease or condition.
2) in 2015, There would’ve been a 0% chance of getting funding for a randomized control trial to study puberty, blockers, or any other aspect of gender affirming care.
The evidence base, as Singal establishes, was very sparse at the time; prospective longer term follow up of treated participants would provide better estimates around other important aspects of care,
These would include knowing the evolution of benefits and harms over time, and understanding which clinical and demographic factors may be predictive of those outcomes
3) In the grants review process, it is up to the applicants to make the best possible case to justify their Request for funding, it is up to the reviewers to make the best possible criticisms of the application, and for granting agency to make decisions that they believe are in the best interest of the populations they are hoping to serve
4) In 2013 to 2015, when this grant was written, It would not have been unusual to be highly concerned about the suicide rate and trans youth who did not have access to therapy.
We now know through higher quality studies that there is not a clear benefit for gender affirming care in decreasing the suicide risk. But this would not have been known at the time of the grant’s writing
And there almost would have been sufficient clinical concern around the increased risk of self harm with restricting access to GAC that no IRB in the US would approve any study where that was a possibility, unless the suicide risk was definitely shown to be marginal
Given the evolution on the evidence base around suicide risk that has taken place since 2015, it is far more likely an IRB would approve such a study today.
It was cut and paste from a draft. And I was working from my phone and I must’ve missed cutting that last bit at the end when I was moving around. I’ve since fixed it up
As for your actual question, Even though there was no proven causal link between suicide risk and access to gender affirming care, this does not mean there was no concern about a causal link. Given that suicide is a highly consequential outcome, it would not be remarkable that a risk minimization decision would be entertained
Don't we have a significant number of kids who got blockers already? Why can't we do a study of their outcomes relative to the outcomes of people who only got hormones, hormones and surgery, or desisted later? What am I missing?
Jesse is writing about a study that was proposed back in 2014 when there were not a lot of kids who had gotten these treatments. In general, a well-executed prospective observational study is going to produce better quality information than retrospective studies for many of these questions of interest unless you have access to very complete databases, ways to identify and control for confounds, and very standardized systems for screening and follow up (which the US does not generally have). How to measure “their outcome” is not a simple matter and you cannot do certain things retrospectively that you could prospectively.
What many people overlook is that the control group already exists, or rather, already existed: it consists of patients treated when gender "medicine" was in its infancy and uncommon.
The most serious difficulty with such examinations of retrospective cases lies in the inability to answer basic questions. If "depression" is a key variable, did everyone get a before- and after-treatment depression evaluation, using some standard measure of depression? No, of course not. Similar for all other variables - for some, these are assessed but not for all and with different scales and at different time points.
One challenge would be adjusting for confounding variables: for instance if the decision to use puberty blockers was more common in kids who developed gender dysphoria earlier. Ideally you would be able to adjust for this but in other contexts I've seen some weird grouping so that the investigators get the answer they want. As in, grouping adult ages with the cutoff of ages ending in 3 or 8. The other challenge is that data on the confounding variables may not have been collected which would make it impossible to control for them.
1) Given the concerns about the potential association between increased suicide risk and withholding access to gender affirming care at that time, the likelihood of any IRB in the US approving a trial or prospective study where GAC was potentially withheld would have been close to zero
"potential association" - what crap. EVERY objective study has completely NOT supported the suicide myth. The Swedish study, the Finnish study - all show either NO suicidality or show that suicide is much higher AFTER treatment. I do agree that these studies have come along much after 2015. However, it is time to stop talking about "potential associations" - no such association exists.
Actually the 2024 Ruuska and paper should approx 4-5x the suicide risk among the dysphoric kids who did not receive gender interventions compared to those who did, though because of small numbers of suicides (1 in the GR group, and 5 or 6 in the no GR group) it was not powered to assess an effect
And my point is is in 2015, there was no published data on the suicide risk in young people.
it was known to be significantly elevated among adult transitioners, so it was reasonable to believe that forcing people to wait until adulthood to transition increased their suicide risk.
So it was often framed not as a way to prevent child suicide, but to prevent adult suicide
It is a little worrisome that you haven't supplied links to the FOIA letters you collected. I'm very sorry if I'm saddling you with a lot of extra work but ... can't you dump it all into a google docs sort of place? (Heck, you could ask people to request access with their email address.) I image these might be fruitfully mined by others researching this topic. And the absence of full disclosure creates doubt about whether you did some cherry-picking yourself.
“That is question-begging,” is the evergreen line that encapsulates this entire phenomenon.
Anecdotally, I know far too many – not anywhere near the majority but enough to deeply concern me – within healthcare who cannot grok what begging the question is.
The statement "“Non-intervention in adolescents with Gender Dysphoria has been demonstrated to result in harmful physical and psychological outcomes, especially at the onset and during pubertal development,” is key.
What are the PHYSICAL OUTCOMES? We know that these studies measure and report depression, anxiety, suicidality (usually a single question already reported under anxiety), and body satisfaction. These are dreadful outcomes to base treatment on. Who is not depressed occasionally? If you want to "cure" depression, shoot up the patients with ketamine or heroin.
But what are the PHYSICAL OUTCOMES? No such outcomes were reported in Chen et al, Tordoff et al, the preprint on the PB arm of the Cohen-Kennedy study.
This is a horrible weak point of all of this stuff. No OBJECTIVE measures. When you have a staph infection, the infection is evaluated using cultures of suspect locations. When you have a broken leg, the outcome is measured by imaging techniques. These are objective - patient beliefs and desires are not only ignored, but are considered problematic (speak to a pediatrician about anti-biotics for URIs).
We know from Olson-Kennedy's presentations at WPATH and USPATH conferences that her research group planned to gather at least five years of follow-up data on their study cohorts, which they recruited between 2016 and 2018. And yet all we have are papers on a maximum of two years of follow-up for the group on hormones. It's been three years since the first of those papers, Chen et al, was published. So where are papers on longer follow-up times? And given the team got a renewed grant in 2020, it's entirely possible they kept following these youth past the five-year mark. https://benryan.substack.com/p/in-2021-dr-olson-kennedy-was-eager
This lines up with the adult gender clinics in England refusing to share their data with Hilary Cass, even after a way was created for them to do it without compromising patient privacy.
It doesn't seem like the behavior of clinicians who are confident that all their patients are getting better.
Yes, and they only reported on 6 of the 8 psychological outcomes they hypothesized would improve. As Jesse pointed out at the time.
A psychiatrist pointed out that the biggest problem with Chen et al is its strength. They barely found anything. For mtf those 2 outcomes didn't improve. And two surely got very much worse as there were 2 completed suicides.
https://www.reddit.com/r/medicine/comments/15hhliu/the_chen_2023_paper_raises_serious_concerns_about/
The argument that there is no equipoise is still quoted, unbelievably.
One key point, which I have made (in at least 1 LTTE about Chen et al) is the terrible loss-to-follow-up. In Chen et al (about the GAC arm of Cohen-Kennedy NIH study), they started with 313-318 cases (amazingly and shockingly, not everyone in the study responded to all study measures at baseline), and at 2Y, they had about 225 cases - this is LTFU of 30%. This is not found in other medical studies - LTFU in clinical research is usually 2-3%, and is considered a serious threat to any kind of conclusion if LTFU > 5%. How many of these cases died? How many desisted? How many had other problems?
🤷♂️
There is also a wider and serious nocebo effect. All these young people are being told they need these "life-saving" interventions in order to thrive, which was directly criticized after a UK study in response to the claims:
https://www.gov.uk/government/publications/review-of-suicides-and-gender-dysphoria-at-the-tavistock-and-portman-nhs-foundation-trust/review-of-suicides-and-gender-dysphoria-at-the-tavistock-and-portman-nhs-foundation-trust-independent-report
"The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide."
This is also discussed by Clayton:
https://link.springer.com/article/10.1007/s10508-022-02472-8
" However, an excessive focus on an exaggerated suicide risk narrative by clinicians and the media may create a damaging nocebo effect (e.g., a “self-fulfilling prophecy” effect) whereby suicidality in these vulnerable youths may be further exacerbated (Biggs, 2022; Carmichael, 2017). This type of risk has been discussed in other similar situations involving youth (Abrutyn et al., 2020; Canetto et al., 2021; Shain & AAP COMMITTEE ON ADOLESCENCE, 2016)."
That is, patients who get these drugs might think they were saved from this risk.
And patients who don't get them might be made even more anxious--a big problem right now in US states where these interventions are not available for minors, and where the **MDs** treating them still believe that this means "lifesaving care" is being denied. The doctors pushing the "lifesaving" narrative are, in my opinion, doing harm to these kids by suggesting suicide is a natural response to having gender dysphoria and that gd can only be alleviated with these medications. It appears to me to be encouraging despair and fear, based on falsehoods.
Olson-Kennedy said at the 2023 USPATH conference: “I asked our person at the NIH if there was a prize for the grant that got the most FOIA requests, and she said, ‘No, but even if there was, you would still be behind Covid and fluoride.'"
Congrats to Jesse for making them number 3.
https://www.compactmag.com/article/how-gender-medicine-set-itself-up-for-disaster/
This is an obstruction to calling "gender medicine" science, but the obstruction to calling it medicine is deeper. No control on your design can change the fact that we cannot independently verify the complaint. No diagnosis is involved. The same principle applies to "pain management", and, of course, psychiatry. I think the "pain as the fifth vital sign" movement is underreported as the cause of the opioid epidemic.
Medicine has an epistemology problem that runs deeper than RCTs can address.
"No control on your design can change the fact that we cannot independently verify the complaint. No diagnosis is involved."
This is really important.
It's also a weakness of Jesse's reporting and commentary on this whole ecosystem of issues. I'm a financial support of Barpod and a big fan overall of Jesse's work. But Jesse consistently avoids the question "What is 'trans'?" and avoids the obvious and likely possibility that "trans" is not a natural feature of human existence and is instead just a late 20th century outgrowth of mental illness + homophobia + misogyny + sexual fetish that was made into an identity by the effects of social media and cell phones. That view deserves a fair hearing because the prior on its being true is very high: there are are no "trans kids", humans don't have gender souls, they can't change sex, and no one is born in the wrong body.
‘Trans’ does seem to have existed for ages. That does not mean it isn’t a response to the factors you suggest. No reason to assume “ mental illness + homophobia + misogyny + sexual fetish” haven’t been around for ages. We’ve just got better communications about it now
There is exactly 0 evidence for the statement "‘Trans’ does seem to have existed for ages. " The meaning of trans is very very new. What did exist, and is well documented is the interest and willingness of persons to live under the illusion of the other sex. Women enlisted as soldiers pretending to be men, a well-known case of a woman acting as a man to be a physician, etc. These all had to do with the inability of women to have a professional life prior to about 1940. But there is no evidence whatsoever of the "trans notion" of "being in the wrong body". That started in the 1950s with the "Danish girl" and with "Renee" Richards.
Agreed. Most important of all, no one can change their sex. If the goal cannot be achieved, no pathway to achieve said goal is valid
If they clearly state the goals of treatment, those can be used. But this group did that and then hid most of the outcomes. Most outcomes still have not appeared for hormones.
While I agree that hiding the outcomes of your poorly conceived studies is bad behavior, and should be reported on, there is a deeper problem.
For a concrete example, which is far from the only realization of this problem, how do you control for cohort effects? How does an RCT account for the differences in the boys from the dutch protocol and the boys who have left wing influencer parents? There's no way to build a study around this question.
On the other end, how do you account for the clinical relevance of "never being able to achieve orgasm"? Katie makes this point a lot, and I would phrase it as boys cannot report dissatisfaction via a counterfactual that they cannot imagine. Failure to ever gain the function of orgasm is not an outcome that can be collected through patient satisfaction reporting alone.
These are not isolated problems. These are structural, philosophical problems with abandoning the medical model as the basis of medicine.
Agree!
"No diagnosis is involved" - that is slightly incorrect. There certainly is a diagnosis, but the "diagnostic criteria" are completely subjective. If a person says "I am trans" that is considered the diagnosis. Jack Turban has stated that no other diagnostic criteria are needed. Thus, the "dysphoria" diagnosis is simply indistinguishable from any other form of delusion. It has just been given the "special status" of being immediately believed with no need for any form of verification or validation.
Once you see the pattern in this field of “we say whatever we need to say at the time to reach a short term goal even if it’s incoherent with what we say otherwise” you can’t unsee it. We said we expected there to be mental health improvements but didn’t find any? Well we actually never said that was the point in the first place, it’s just embodiment goals. We will talk about all of the uncertainties and unknowns to take public research funds but if you bring them up in clinical or policy discussions you are an evil transphobe. We hold conference presentations that stigmatize exploration, assessment and try to disabuse clinicians of the “right to know” why someone wants to transition but we will send in our incoming WPATH president to testify against you for quickly affirming and facilitating surgery and not clarifying comorbidities or identity stability. If this field ever seriously self-reflects about why people who are accepting and tolerant of individuals who transition are suspicious of the “gender medicine establishment” they will find this to be a major factor. Maybe the general public is quite empathetic to the plight of these patients but can’t stomach the constant contradictions, obfuscations, and lying from the leaders and institutions.
Alchemy, the belief that one could turn stuff into gold, seems operative here. If you believe it, it will come true. We’ll just do some more studies, and tinker some more, and soon we’ll have pure gold.
I’ve essential made the same point in the past, this is to biology ans astrology is to astronomy, alchemy to chemistry.
Isn't all this Jesse a repeat of the Recovered Memory Syndrome problems from the 1990s?
Ian
It's so hard to see someone suffering, especially a child, and not want to alleviate the suffering. Unfortunately, the adults let their empathy overcome their responsibility to the scientific method.
It doesn’t help that the same adults have introduced incoherent ideas and foisted those ideas upon impressionable kids.
Literally hundreds of medical guidelines are published, many or most from specialty societies. Many recommendations are based on relatively weak evidence. The AUA and PSA screening; AHA and statins for primary prevention of heart disease. The American Society for Gastrointestinal Endoscopy and endoscopy for reflux. The Endocrine Society and Vitamin D screening (withdrawn) and pre-diabetes. This typically amounts to self-serving intellectual bias.
This accounts partly for guidance in youth gender medicine. Yet the entire basis is shaky, based in ideology, not biology or psychology. Dysphoria is a psychological issue. Why treat it with hormones and hormonal manipulators when there is a 100% normal phenotype?
Evidence Based Medicine as practiced in the US is imperfect, but better than what it replaced- eminence- based medicine. There's no excuse for Olson-Kennedy, Hack, WPATH, or members of the Endocrine Society should understand these matters; and any MD, especially a trialist, should understand the multiple sources of systematic error (aka bias) when conducting research. Countless sound, good ideas in the past have failed when tested rigorously. Contrary to Olson- Kennedy's statement regarding fear that it "would be weaponized by conservatives seeking to ban youth gender medicine", it might be employed by those who want high quality studies and those concerned for the welfare of minors.
I have served on national peer reviewed panels for decades, and I have received several million dollars in peer reviewed funding over the years. Not saying to brag, but just to ground by authority both as someone who has seen and written any number of submissions and resubmissions of grants
1) effusive and uncritical letters of support from stakeholders for any grant application are exceedingly common, if not universally seen for any grant application for any disease or condition.
2) in 2015, There would’ve been a 0% chance of getting funding for a randomized control trial to study puberty, blockers, or any other aspect of gender affirming care.
The evidence base, as Singal establishes, was very sparse at the time; prospective longer term follow up of treated participants would provide better estimates around other important aspects of care,
These would include knowing the evolution of benefits and harms over time, and understanding which clinical and demographic factors may be predictive of those outcomes
3) In the grants review process, it is up to the applicants to make the best possible case to justify their Request for funding, it is up to the reviewers to make the best possible criticisms of the application, and for granting agency to make decisions that they believe are in the best interest of the populations they are hoping to serve
4) In 2013 to 2015, when this grant was written, It would not have been unusual to be highly concerned about the suicide rate and trans youth who did not have access to therapy.
We now know through higher quality studies that there is not a clear benefit for gender affirming care in decreasing the suicide risk. But this would not have been known at the time of the grant’s writing
And there almost would have been sufficient clinical concern around the increased risk of self harm with restricting access to GAC that no IRB in the US would approve any study where that was a possibility, unless the suicide risk was definitely shown to be marginal
Given the evolution on the evidence base around suicide risk that has taken place since 2015, it is far more likely an IRB would approve such a study today.
"It would not have been unusual to be highly concerned about the suicide rate and trans youth who did not have access to therapy"
Except no such causal link has been clearly demonstrated. Also, whatsup with the copy and pasting your own writing twice? Very strange.
It was cut and paste from a draft. And I was working from my phone and I must’ve missed cutting that last bit at the end when I was moving around. I’ve since fixed it up
As for your actual question, Even though there was no proven causal link between suicide risk and access to gender affirming care, this does not mean there was no concern about a causal link. Given that suicide is a highly consequential outcome, it would not be remarkable that a risk minimization decision would be entertained
Don't we have a significant number of kids who got blockers already? Why can't we do a study of their outcomes relative to the outcomes of people who only got hormones, hormones and surgery, or desisted later? What am I missing?
Jesse is writing about a study that was proposed back in 2014 when there were not a lot of kids who had gotten these treatments. In general, a well-executed prospective observational study is going to produce better quality information than retrospective studies for many of these questions of interest unless you have access to very complete databases, ways to identify and control for confounds, and very standardized systems for screening and follow up (which the US does not generally have). How to measure “their outcome” is not a simple matter and you cannot do certain things retrospectively that you could prospectively.
What many people overlook is that the control group already exists, or rather, already existed: it consists of patients treated when gender "medicine" was in its infancy and uncommon.
https://cabrerae.substack.com/p/trans-identity-fixed-or-transient
The clear result of these studies is that the best remedy for gender dysphoria is acceptance of one's own identity without any medical interventions.
The most serious difficulty with such examinations of retrospective cases lies in the inability to answer basic questions. If "depression" is a key variable, did everyone get a before- and after-treatment depression evaluation, using some standard measure of depression? No, of course not. Similar for all other variables - for some, these are assessed but not for all and with different scales and at different time points.
One challenge would be adjusting for confounding variables: for instance if the decision to use puberty blockers was more common in kids who developed gender dysphoria earlier. Ideally you would be able to adjust for this but in other contexts I've seen some weird grouping so that the investigators get the answer they want. As in, grouping adult ages with the cutoff of ages ending in 3 or 8. The other challenge is that data on the confounding variables may not have been collected which would make it impossible to control for them.
1) Given the concerns about the potential association between increased suicide risk and withholding access to gender affirming care at that time, the likelihood of any IRB in the US approving a trial or prospective study where GAC was potentially withheld would have been close to zero
"potential association" - what crap. EVERY objective study has completely NOT supported the suicide myth. The Swedish study, the Finnish study - all show either NO suicidality or show that suicide is much higher AFTER treatment. I do agree that these studies have come along much after 2015. However, it is time to stop talking about "potential associations" - no such association exists.
Actually the 2024 Ruuska and paper should approx 4-5x the suicide risk among the dysphoric kids who did not receive gender interventions compared to those who did, though because of small numbers of suicides (1 in the GR group, and 5 or 6 in the no GR group) it was not powered to assess an effect
And my point is is in 2015, there was no published data on the suicide risk in young people.
it was known to be significantly elevated among adult transitioners, so it was reasonable to believe that forcing people to wait until adulthood to transition increased their suicide risk.
So it was often framed not as a way to prevent child suicide, but to prevent adult suicide
And it remains an open question as to whether adolescent transition prevents adult suicide.
Sorry! I see them now. My apologies.
It is a little worrisome that you haven't supplied links to the FOIA letters you collected. I'm very sorry if I'm saddling you with a lot of extra work but ... can't you dump it all into a google docs sort of place? (Heck, you could ask people to request access with their email address.) I image these might be fruitfully mined by others researching this topic. And the absence of full disclosure creates doubt about whether you did some cherry-picking yourself.
I linked to both letters, no?
“That is question-begging,” is the evergreen line that encapsulates this entire phenomenon.
Anecdotally, I know far too many – not anywhere near the majority but enough to deeply concern me – within healthcare who cannot grok what begging the question is.
The statement "“Non-intervention in adolescents with Gender Dysphoria has been demonstrated to result in harmful physical and psychological outcomes, especially at the onset and during pubertal development,” is key.
What are the PHYSICAL OUTCOMES? We know that these studies measure and report depression, anxiety, suicidality (usually a single question already reported under anxiety), and body satisfaction. These are dreadful outcomes to base treatment on. Who is not depressed occasionally? If you want to "cure" depression, shoot up the patients with ketamine or heroin.
But what are the PHYSICAL OUTCOMES? No such outcomes were reported in Chen et al, Tordoff et al, the preprint on the PB arm of the Cohen-Kennedy study.
This is a horrible weak point of all of this stuff. No OBJECTIVE measures. When you have a staph infection, the infection is evaluated using cultures of suspect locations. When you have a broken leg, the outcome is measured by imaging techniques. These are objective - patient beliefs and desires are not only ignored, but are considered problematic (speak to a pediatrician about anti-biotics for URIs).