Great job, Jesse. Your stuff is always very thorough and fair-minded.

My child came out as trans about two and a half years ago. My wife and I were pressured to socially transition him by a therapist. We were very concerned about suicide and were told this was the best path to avoid that, so we went along with it. By the time we realized that the evidence that gender-affirming care had a positive impact on mental health wasn't so clear, we had been affirming his gender identity for over a year, and felt that reversing course would have created a very contentious situation. Our child is almost 19 now - maybe we would have stopped affirming his gender identity if he were younger at the time.

We did not ever feel pressured to medically transition him, so we never went down that path while he was living at home. However, as soon as he got to college, he went to the university medical clinic and obtained a prescription for hormones, without consulting us.

It's all been a very frustrating experience, as finding reliable information on how to handle the situation has been difficult. You've helped in that regard, and I appreciate your hard work.

Expand full comment

As a Biological Psychologist and research scientist, I agree with your (detailed) analysis. However, in some sense it's beside the point (with which, I think, you probably agree). People see what they want to see in data, especially data that deal with fuzzy psychological concepts, or which can be spun to support an ideological agenda.

However, probably the most important issue, from my perspective, is the fact that you cannot simply manipulate anatomy and physiology to change a person into something they would like to be (or you would like them to be). Biology doesn't work like that. Further, we have known the deleterious effects of cross sex hormones and blockers for over half a century (ever since the drugs were first synthesized). It amazes me that people are now "debating" their effects. Except in the rarest of instances will traumatic hormonal manipulation help someone who is suffering from a psychological or psychosocial condition. I discussed some of that in "There is "Biological Evidence for Gender Identity..." but it’s not what you think."


Interestingly, much of the back-and-forth about "gender identity," its associated issues and their putative amelioration is driven by misconceptions about biological causation, biological malleability, and fundamental misunderstandings of neuroscience on both sides of the debate. In some ways, it's become like the debate over abortion:, misconceived by people on both sides of the issue, and subject to a perpetual attempt to win the argument by presenting progressively larger bodies of "facts".... with no one making a fair and honest assessment of their "opponents" point of view.

To be clear, I agree with your analysis. I'm just not sure if it's going to make much of a difference until people decide to more carefully — and objectively — consider the fundamental biological and psychological aspects of this issue. Everything is biology, after all.

Thanks for a great read, Frederick

Expand full comment
Feb 7·edited Feb 7

I know that no amount of compliments can take your mind off the criticism but let me just throw a compliment on the pile because what the hell.

Thank you, Jesse Singal, you are doing great work and you are winning.

Expand full comment
Feb 7·edited Feb 7

Hi Jesse,

I only ever seem to comment or tweet you when I want to disagree so first of all I have to state what great work you do and how much I appreciate it.

But with every write up like this that I read, I less understand your position on supporting hormones for *some* children as a better solution than, say, leeches.

Have you written about the positive research or the persuasive arguments that have led to this position? About which are the cases you can definitively make such a prescription for? If not, would you? Please.

Thanks again

Expand full comment

Regarding the redundant scale items (I'm a social psychology PhD) - There are different approaches to making scales. Sometimes what you want *is* to ask the same exact thing in slightly different words.

Every response has some error associated with it. By asking the same question multiple times and averaging together, you average away the error.

For instance, a commonly used measure of "extraversion" asks people whether they are "hard to get to know" and, separately, whether they "keep others at distance." By averaging these very similar items (and others) together you get a more accurate score.

[Very technical addendum: These items are specifically for the "negative keyed" sided of the "enthusiasm" aspect of extraversion. Other "aspects" will ask somewhat different questions -- but they, too, will do so in very similar ways within themselves. So the full measure of extraversion with all its "aspects" includes both clearly different items and items that resemble each other. For instance, the "assertiveness" aspect asks whether you "take charge," which is different from the "enthusiasm" items however you slice it.]

Expand full comment

Thanks Jesse Singal for signing your name to this piece and writing these articles that are helpful and can’t be easy to take the heat. I guess nobody can call you chicken sheiße 🐔.

Expand full comment

Thanks for looking at this. In my own view, these studys are likely to have high participation bias. Why are the participants involved in the study? why do they want this care? have the participants and their families been told that most kids grow out of gender dysphoria without social transition and gender meds? have they been lied to regarding dysphoric youth suicide rates as is so common? have the participants and their familys been told about the long term downsides of gender meds? or that their child may have issues that arent related to gender at all, as many detransitioners report in retrospect. my apologies if this was covered. i assume the participants and their families are full believers of many of the common inaccurate gender biz catch phrases regarding this care. considering the celebratory and non critical ideation of gender care in many communities, participant feelings about this care is likely to be influenced by many factors other than the care itself.

also, i dont understand why a control group cant be used. in a previous study i read that a control group cant be used becuase not using these meds would put the control participants at risk. given these results it would seem they wouldnt be at any risk at all

Expand full comment

The article doesn't fully address two big problems with the study:

1) The authors assume that avoiding medicalization would have led to worse outcomes. This assumption is particularly inappropriate given evidence that the majority of children who don't medicalize do desist; they come to accept their bodies. (In other words, the implications of there being no control group need to be articulated more clearly.)

2) The 2 year timeline is ridiculously short. There can be euphoria after taking action one fervently believes will help, especially as schools and peers lavish praise on a child for their "bold" "courageous" "authentic" living. As time goes on, as the problems underlying rejecting one's bodies remain unsolved, as the medical consequences of messing with one's previously-healthy body become more evident, and as a child matures....bad feelings can mount. There is evidence of depression and regret, and also suicide, happening after more time has passed. (See the big Swedish study, for example.)

I would also like to state for the record that the concept of a child having been born in the wrong body is as mystical and anti-science as it gets. And that it is an outrage that doctors mislead children into believing they can become the other sex...that the hormonal and surgical measures imposed on their previously healthy bodies will in any way enable them to have the body and experiences of someone of the opposite sex. Analyzing the obviously biased studies of the Gender faithful as if this were any other medical treatment evaluation, is a cop-out. How did it come to be that people fear they will be seen as unreasonable if they point out that the whole basis of any of this is madness?

"Gender affirmation" medicine is premised on everyone agreeing to the anti-science redefining of vital words like woman and man, rendering those words absolutely meaningless. Going along with that doesn't just subject kids to a medical scandal of horrific proportions. It also fuels other unacceptable consequences in our world: men in women's prison cells, lesbians chastised for insisting on same sex relationships, females and males alike losing the right to sex-based privacy, women losing female-only sports, the reification of vile sexist stereotypes, and more. I, for one, do NOT agree to that redefinition or to the forfeiture of rights that goes with it. Most people don't. Any discussion of pediatric "gender affirmation" medicine must acknowledge the definitional sleight-of-hand upon which it is based.

Expand full comment

>A tiny bit of political throat-clearing before we start: If you write critically about youth gender medicine, you will hear from a lot of people who are aghast that you could do so given the threats trans people in the United States (adults and children alike) face.

I find this attitude absolutely infuriating. Yes, noting that the evidence base isn't great might leave medical interventions vulnerable to fearmongering, lies and hysteric reactionary responses by bad faith actors. But you know what also leads to that? Attempts to suppress any criticism at all on patently absurd claims of 'harm' to trans people.

I'm in Australia and there's an upcoming vote on constitutional change to create an indigenous 'Voice' to the parliament - effectively an advisory body comprised of indigenous people, to raise issues with the government, guaranteed to exist into the future.

Because it's a constitutional change the actual wording is vague as to the composition of the entity, how it operates, etc etc., and people understandably are asking for detail. However, the government is ducking these questions, instead asking citizens to vote on the principle, and to trust that the parliament will set out the specific details later. Unsurprisingly, this doesn't wash with everybody, but the response has been to either imply that voters asking questions are doing so in bad faith, or ignorance (some activists have told questioning voters to read a 300 page report on the Voice that the government hasn't even endorsed as the model it wants), or that detail isn't something that is needed on a constitutional question.

The vote might succeed on principle alone, but I find it disturbing how many advocates of change reflexively believe that any questions being asked to derail the 'right thing to do'. Some people might be acting in bad faith, and there's a risk that the debate could be bogged down in insignificant minutiae, but even so, it shouldn't be that difficult to give the public a TL;DR and respond effectively to misconceptions. Frankly, the unwillingness to engage on anything but the 'principle' smacks of laziness and arrogance, and could sink the entire campaign.

Expand full comment

"I am opposed to the sorts of policies Trump is proposing — . . . to codify into federal policy a ban on even adults changing their legal sex."

Jesse, I color my hair, stay out of the sun, and follow a strict diet and exercise regimen that enables me to pass for a woman ten or more years younger than my chronological age of 70. My "authentic self" is not that of an old crone cashing her Social Security check, but that of a woman enjoying late middle age.

Should I insist that Medicare pays for my next facelift? Should I be able to change the birth date on my driver's license and birth certificate?

If you don't think so? Why not?

Expand full comment

Well the research on Prozac was extremely thorough not like this garbage it was well done had a control group and a total 4400 pediatric participants.

And the test group had a reported 2% increase in suicidal ideation and Prozac got a block box label...these researchers had 2 completed suicides seriously...dudes?

Why didn’t researchers just give the kid’s cognitive behavioral therapy and appropriate psychotropic meds like a friggin SSRI? And no cross sex hormones? I know WPATH 8 isn’t great but that is the new recommendation for adolescents.

They could have tried that...you know like how Dr. Erica Anderson recommends extensive psychotherapy to address other psychiatric co- morbidities that almost 100% of these kids have...before any discussions about medical interventions like cross sex hormones. She is really at telling kids about the side effects of cross sex hormones even though she’s a clinical psychologist not a physician. The physicians I’ve had to deal say “they don’t know the side effects”. Seriously bros you did go to med school straight up say the side effects to parents and kids. I’m sick drs passing the buck.

Dr. Anderson says it can take sometimes years of therapy with a skilled clinician before a kid should go on hormones or get surgery...to make sure there aren’t false positives (kids who aren’t really trans getting fast tracked to hormones and surgery).

I’m going to hypothesise that these kids would have had better mental health without the hormones and if the researchers had just stuck with appropriate psychotherapy as an intervention from an expert not some dimwit who thinks all gender diverse teen problems will be solved with some T & E.

These researchers do NOT care about false positives and pretend Detransioners don’t exist, it’s not going fly forever but it’s working right now $$

Can we please get an American version of the Swedish Trans Train documentary? First stop Joanna Olsen-Kennedy investigation. Anyone who gets the results stands make serious change in American medical SOCs for trans kids.

These researchers-hucksters will be riding that “self ID’d trans train from Timbuktu to Kalamazoo before they admit a flaw in their theories, these are activists not scientists.

I just want to point out that the most prestigious gender clinics in the country don’t offer psych support or mental health screenings they just “treat ‘em and street ‘em”. The kids...that’s my experience and I’ll even name names:

1. Stanford



4. OHSH ( to be clear the Portland gender clinic is in strip mall in Clackamas...a different town than pediatric psychiatric department...) see Reuters on OHSU.

The psychiatric department thinks they are doing great screenings bc gender clinic employees lie. They lied to me and I know bc the pediatric psychiatrists and paediatricians believe they are great doing psych evaluations...how would they know it’s just a friendly social worker, who has a tsunami of kids to see and they will NOT say “we scrapped the screenings we were trained to do” bc we’ve got too patients post Covid. And now PC docs are doling out hormones to kids in my town and they probably do less of a screening than the gender clinics. My OBGyn told they are giving AGAB kids T and hysterectomies and she doesn’t do it but the other practice does bc at 15 in Oregon kids get to make these decisions without parental consent.

I would certainly love to hear some parent who thought their gender diverse kid got great therapy and a great psych evaluation/ screening at a gender clinic...that wasn’t some “hey you know who you are” and let’s throw in some weaponised empathy to get parents to go along with our pediatric sterilization program. It’s psychological manipulation to tell parents it’s hormones or suicide. I’ve met at least 50 parents with trans ID’d and zero thought their kids got good mental health unless they were already fast tracked to hormones...then the kids might get some DBT or if they end up in psych ward they might get some adequate therapy.

The parents might have been biased but they were almost accross the board overly educated liberal parents who care very much about their kids and were fighting tooth and nail to get good therapy and most everyone was traumatized by the lackadaisical affirm without question model.

I don’t think these researchers deserve as much as good faith as you give them...where in the world is the suicidality scale and why did they leave it out...if it showed a statistically significant increase in suicidality...and (the “experts” purposely left it out we’ve got potentially scandal of malpractice and unethical research situation like the Milgram Study but worse...

We, the parents, kids, physicians and general public deserve to know all the information from the missing scales STAT reported by the most prestigious medical journal in the US, the New England Journal of Medicine.

I guess the NEJM medicine needs to be reminded that correlation does not equal causation....especially when there were 2 completed suicides.

To this guy...

“Sure, I’d even be ok with ‘a depression researcher who’s too chickenshit to be named…’😅

I get it why he won’t go on record it’s not safe but there is a serious problem when scientists are to scared to speak out on something as serious as pediatric related care especially when potential side effects include possible sterilization.

When are drs going to find their moral courage to speak up about these bad studies... as you said in an undergrad class this would not be considered proof of anything except we need a control group (won’t happen bc what if there is actual mental improvement and the control group doesn’t get helpful treatment) but at this point I think this study actually made the point that a control is definitely needed.

So we’ve got 2 suicides and they didn’t stop the study? Who’s in charge of an ethics review here?

Gender diverse kids deserve better than this sheiße. Looking forward to my kids’ pediatric well check on Wednesday where I have to show the pediatrician AGAIN this study. I printed it out I hope he takes the time to read it with his own eyeballs.

Poor Eunice Kennedy-Shriver has her name attached to this “research”.

Expand full comment
Feb 8Liked by Jesse Singal

"Take items like “My outward appearance represented my gender identity” and “My physical appearance adequately expressed my gender identity.” For one thing, these items are so similar that I’m surprised they’re both on the scale — they seem truly redundant..."

Jesse, I'm surprised that you're surprised. Clearly you haven't been subjected to a lot of psychological questionnaires, which are rife with this kind of redundancy. Often these sets of questions are preceded by a statement like "Many of the questions may appear similar, but please answer them all." The two you cite don't appear as similar as some I've seen. There are subtle differences between "outward appearance" and "physical appearance" and not-so-subtle differences between "expressed" and "represented," not to mention that sneaky adverb "adequately."

There are good reasons to doubt the importance of this scale, but the redundancy is par for the course in psychological testing. I just did some quick searching to try to find out what the purpose of it might be, and I found a couple of sources that mention redundant questions as a way to weed out people who aren't paying attention or who aren't taking the questionnaire seriously (or robots perhaps). It seems unlikely that this was the case here though.

Expand full comment

Thanks for taking the enormous amount of time to evaluate this “study.” It is discouraging that this will be used to justify pushing kids into gender transition. Don’t give up on this issue. We need same people to keep pushing back.

Expand full comment

If we want to actually know whether these hormone treatments work, someone is going to need to bite the bullet and run a randomized trial. Randomize the participants to usual mental health treatment or usual mental health treatment with hormones. It's probably going to be controversial because there will be researchers who insist that it's unethical to randomize kids when we "already know" that the hormones work. Except that we don't have enough information to know if they work and medicine is littered with treatments that we were certain we knew worked but were abandoned when high quality evidence showed that they were either useless or caused more harm than good. There's a serious ethical problem with refusing to do high quality studies on a treatment that doesn't have good evidence one way or another.

Expand full comment

Your post is wonderful, and nuanced, and the comments are germane. If I were a NEJM reviewer I'd have easily rejected the Chen et al article (and I'm pretty chickenshit).

It would have been enough for /me/ with a point you barely touched on -- the numbers of those in each category of the Beck's scale are in /all/ cases substantially lower after 24 months than at the inception of the study. The researchers are not following a consistent cohort! It's as though they have no clue that there are ways of handling cohort loss. What would the breakdowns be if we followed the group who completed the inventory in all cases? What is the breakdown of cases -- and what are the changes -- among the approximately one-third who are missing at the end?

It's magical thinking to conclude /anything/ based on such numbers. Yet the NEJM -- one of our flagship journals -- let it get past peer review, blustery conclusions and all.

One commenter said you're winning, Jesse. But you're not. We're not. One powerful institution after another falls. Enough.

Expand full comment

Thank you, as always, for all this work. I sincerely hope that someone, somewhere is currently engaged in an extensive study of this, including controls with placebos, gender dysphoric kids who do not go the hormone route, and a comparison of mental health with kids that do not have gender dysphoria. I hope in 2-5 years we have the results of such a study that is rigorous, unbiased and has the interests of all children at heart.

Expand full comment