It’s Almost 2024 And Doctors Are Still Misleading The Public About Youth Gender Medicine

A sloppy article in ‘Pediatrics’ shows, once again, that major medical institutions have failed the public on this issue

(Happy holidays, everyone! If you’re in the market for a last-minute gift, my podcast is running a giveaway contest with some arguably worthwhile prizes.)

---

I’ve written many Singal-Minded posts highlighting deficiencies in both left-of-center journalism and peer-reviewed literature on the use of puberty blockers and hormones as a treatment for gender dysphoria (also known as youth gender medicine). 

Each case of lackluster journalism or science is different, but the most common theme is omission. Peer-reviewed articles on this subject regularly omit key information about their data (such as this very important federally funded paper in which multiple important variables simply disappear) and fail to explain very basic facts like why dropout rates were so high or why some kids in a sample went on youth gender medicine and others didn’t, while articles and segments produced for popular audiences by both journalists and academics in this space routinely ignore the fact that a number of countries in Europe have found, via systematic evidence reviews, that the evidence base for youth gender medicine is lacking. 

Pediatrics just published a “Perspectives” article on youth gender medicine (an opinion piece, more or less) (update: here’s an unlocked copy) by Emily Georges, Emily C.B. Brown, and Rachel Silliman Cohen that is one of the worst offenders I’ve come across. Despite clocking in at a brisk two-and-a-half pages, not counting endnotes and a “Ways to Advocate for TGD [transgender and gender diverse youth] Youth” chart that takes up a whole page of its own, the article contains a remarkable amount of misleading information, including a disheartening number of claims that point, via endnote, to resources that don’t come close to supporting them. The fact that Pediatrics would publish this article in its current form — and I’m getting déjà vu typing these sorts of sentences over and over and over — is a really bad sign about the collapse of institutional credibility in this area. 

Now, Georges and her coauthors are clearly concerned with overly draconian reactions to the youth gender medicine controversy, some of which go as far as attempting to remove trans children from their parents’ home. But these are separate questions from whether the evidence base for youth gender medicine is good. It can both be true that all those European countries are correct that the evidence base is shoddy and that banning the treatments outright (which has not been the response in Europe) is the wrong reaction to this medical uncertainty.

Naturally, the authors don’t mention the highest quality evidence in question, which is — say it with me — the European evidence reviews. It is, and again I feel that déjà vu coming on, a shocking omission on the part of doctors writing in perhaps the most important journal of pediatrics in the world. 

Let’s get into a few examples of how misleading this paper is, because so many of the specific claims are questionable at best and clearly false at worst. For example, Georges and her colleagues argue that GOP laws seeking to restrict access to youth gender medicine “deny children access to routine health care that has been shown to decrease dramatically high rates of suicide and depression for TGD youth.” There are two footnotes at the end of the sentence.

This sentence contains two claims: one is that TGD youth have “dramatically high rates of suicide and depression.” You see this claim constantly: transgender youth have terrifying rates of completed suicide, and youth gender medicine can protect them from it. I don’t want to reiterate the argument I’ve already made that transgender youth do not, in fact, appear to have a terrifying rate of completed suicide, so click that link and search down to “The article then notes” if you’re curious about that.

As for the claim that youth gender medicine constitutes “routine health care that has been shown to decrease” these symptoms, the first citation points to the WPATH Standards of Care Version 8. This is a big document, and it’s usually a sign of less-than-tight reasoning when an academic makes a strong causal claim and then asks you to pore through a big document to find the justification for that claim. Here and there the WPATH SoC does contain claims about the supposedly salutary effects of blockers and hormones on youth gender medicine, but these claims generally reference papers like Jack Turban and his colleagues’ 2020 analysis of the 2015 United States Transgender Survey — papers that are extremely weak, methodologically speaking (click here and search down for “mental and social health” to read more about Turban’s 2020 study). But the SoC also notes that “Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood. Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible.” Methodologists disagree with this — you can still do a systematic review if there aren’t a lot of studies. But either way, if according to the WPATH SoC there aren’t enough studies to do a proper review, how can the WPATH SoC support the claim that youth gender medicine has been “shown to decrease” depression and anxiety?

The second citation points to Jason Rafferty’s policy statement for the American Academy of Pediatrics, which is a very strange document that certainly does not provide evidence that youth gender medicine has been “shown to decrease” depression and anxiety.

A bit later Georges and her coauthors write, “Although some individuals make it seem that GAC [gender-affirming care] is a new, experimental area of medicine, GAC is evidence-based.” Here there is some slippage between youth gender medicine and gender medicine more generally. Whether or not that’s intentional, it’s a serious stretch — arguably a misleading one — to call this area of medicine “evidence-based.” While definitions of that term can vary, we already know what the Europeans found about youth gender medicine, and a systematic review of adult care commissioned by WPATH itself found that, well, let me borrow from myself, writing in UnHerd:

The results, published in the Journal of the Endocrine Society in 2021, revealed that there is almost no high-quality evidence in this field of medicine. After they summarised every study they could find that met certain quality criteria, and applied Cochrane guidelines to evaluate their quality, the authors could find only low-strength evidence to support the idea that hormones improve quality of life, depression, and anxiety for trans people. Low means, here, that the authors “have limited confidence that the estimate of effect lies close to the true effect for this outcome. The body of evidence has major or numerous deficiencies (or both).” Meanwhile, there wasn’t enough evidence to render any verdict on the quality of the evidence supporting the idea that hormones reduce the risk of death by suicide, which is an exceptionally common claim.

Right after that, the authors explain that “When indicated, TGD youth may start gonadotropin-releasing hormone analogs, which have been used in pediatrics since the 1980s. They also may go on to receive gender-affirming hormones or surgical interventions, all of which are supported by a wealth of research on their safety and effectiveness.” First, “used in pediatrics since the 1980s” is exceptionally misleading, because the context there was (generally) precocious puberty, meaning that after the kids ceased blockers their natal puberty (presumably) kicked in, whereas research shows that the vast majority of kids who go on puberty blockers to treat gender dysphoria subsequently proceed to cross-sex hormones. That’s a very different use case, and one for which we have almost no high-quality evidence, so the “decades of use” argument really is a canard. Second, there is no footnote on “wealth of research on their safety and effectiveness,” which makes sense given that there isn’t a wealth of research on their safety and effectiveness in a youth gender medicine context.

Later, the authors write that youth gender medicine “decreases many negative health outcomes, including rates of depression, and improves well-being for children and adolescents.” The footnote points to this letter Texas Governor Greg Abbott wrote to another state official attempting to institute a policy of investigating instances of youth gender medicine performed in that state. This is clearly an error on the part of the authors, who definitely didn’t mean to cite this here. Next sentence: “GAC has not been shown to lead to short- or long-term negative health effects, and in fact, the benefits of GAC have been shown to far outweigh the risks.” Another strong claim, and this time the footnote points back to the SoC 8. I do not believe that document contains any language stating, conclusively, that all gender medicine is this safe and has such a lopsided benefit:risk ratio, but I could potentially be wrong. Either way, again, if someone makes a strong claim and then asks you to find the evidence for it in a haystack of a document, you should be skeptical.

A bit later on, the authors argue that youth gender medicine is not “medical child abuse,” as some conservatives have argued. I agree: for myriad reasons, that’s a really extreme claim, and the sort of overheated language that doesn’t really help get this conversation back on track. 

But again, the specifics of the authors’ argument are quite strange and ill-founded:

GAC is not MCA. Although caregivers are vital supports in a child’s gender journey, the provision of gender-affirming medical and surgical care necessitates an alignment of the child’s goals with the evidence-based treatment plan determined most appropriate by the medical team. As a testament to GAC being patient driven, studies have found that the vast majority of youth who initiated medication intervention continue these treatments when followed in adulthood.

Setting aside how odd it is to see “child’s goals” used so breezily in this context, let’s once again check the footnote. It points to this study out of the Netherlands, which indeed showed a high continuation rate. But under that protocol — and this is very well-known to anyone who studies this issue — youth seeking blockers or hormones could be excluded for a wide variety of reasons, including mental health comorbidities, insufficiently severe symptoms, unsupportive parents, and so on. It’s really not “patient driven.” This is a misdemeanor compared to some of the misleading statements and miscitations in this paper, but it’s another sign of sloppiness and what might be genuine unfamiliarity with the contours of this debate on the part of the authors.

A bit later on the authors repeat that “The benefits of GAC, most notably on mental health,

self-esteem, and development, outweigh the risks in the majority of circumstances.” No footnote at all this time, although I guess, to be fair, we’ve already been told to read the 260-page SoC to find out where this claim is supported. Then an even stronger claim: “GAC is, for many, lifesaving.” No citation. This is the top journal Pediatrics! How can such a claim be allowed with no evidence?

This next part tips over from sloppy into genuine medical misinformation:

Research highlights how transgender youth disproportionately experience negative mental health outcomes, including anxiety, depression, and suicidality.¹² However, when children are supported in their gender identities and have access to GAC, they have better mental health outcomes.^12,13 Some studies demonstrate that appropriate GAC, in the context of caregiver support, entirely mitigates the increased risk of depression and suicidal ideation for TGD youth.¹²

Footnote 12 points to “Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria,” a paper published by Joanna Olson (now Olson-Kennedy) and her colleagues in 2015. As the title suggests, it simply captures the baseline characteristics of kids who showed up to their clinic. Therefore, it definitionally can’t tell us that “when children are supported in their gender identities and have access to GAC, they have better mental health outcomes,” and it definitely can’t tell us that “appropriate GAC, in the context of caregiver support, entirely mitigates the increased risk of depression and suicidal ideation for TGD youth.” The authors have severe problems getting their citations straight throughout the paper, but this is a particularly galling instance because this miscitation communicates such a strong claim about adolescent suicide.

Footnote 13 points to Diana Tordoff and her colleagues’ 2022 study of outcomes at the Seattle Children’s Hospital gender clinic, which readers of this newsletter might remember because I wrote about it twice.

Tordoff and her colleagues at the clinic and the University of Washington–Seattle (Seattle Children’s is the teaching hospital of the UW School of Medicine’s pediatrics department) watched as a group of kids at their clinic were given blockers and/or hormones and showed no meaningful mental health improvement over the course of a year. Then, by torturing various statistics so severely it’s a miracle they weren’t dragged to The Hague, they published a study basically claiming the opposite. It was one of the more noteworthy examples of genuinely pernicious medical misinformation being published by youth gender medicine clinicians in recent years — a complete breakdown of the important barrier between researcher and activist. You can read my posts for more details, but the fact that a doctor at Seattle Children’s Hospital, Emily Georges, would lead-author a Pediatrics Perspectives piece that treats this research as solid evidence represents a serious mortgaging of trust on her and the institution’s part. It’s 2023. She must be aware of the critiques of this study and how little evidence it provides for the efficacy of youth gender medicine. 

This is not going to be an exhausting look at every claim in this piece. But I’ll leave you with one last example of how sloppy it all is:

Denying GAC not only represents medical neglect, but it is also state-sanctioned emotional abuse. In addition to the basic physical needs all people require for survival, humans have vital psychological needs. The degree to which these needs are met during childhood impact a child’s identity, capacities, and behaviors into adulthood.¹⁴ Emotional abuse involves actions, either as a repeated pattern or an extreme single incident, that thwart a child’s basic psychological needs.¹⁴ This form of abuse can be especially damaging because it undermines a child’s self-worth and psychological development.¹⁴ Policies that prohibit or limit a caregiver or physician’s ability to provide necessary GAC force caregivers and providers to perpetuate psychological distress.

The footnote points to a study that does not mention the word child or its variants, and which has nothing to do with the matter under discussion. The authors didn’t even give their paper a rudimentary proofreading to ensure the footnotes were correct before publishing it.

Of course, it isn’t just their fault. It would be quite easy for Pediatrics not to publish a Perspective this wildly off-base and disconnected from the real-world debate over youth gender medicine. It would be similarly easy for Pediatrics to insist on the rudimentary proofreading of citations. Pediatrics chose not to take these steps. This is a pattern.

---

Questions? Comments? Footnotes pointing to random drawings of cats? I’m at singalminded@gmail.com or on Twitter at @jessesingal. The image is one of ChatGPT 4’s responses to my prompt requesting “an abstract image representing the debates over gender identity.”