(2023-04-05) The Evidence To Support Medicalised Gender Transitions In Adolescents

The evidence to support medicalised gender transitions (transgender) in adolescents… In October supporters and critics of gender-affirming care held rival, rowdy protests outside a meeting of the American Academy of Paediatrics

Komodo’s data suggest around 5,000 teenagers were prescribed puberty-blockers or cross-sex hormones in America in 2021, double the number in 2017.

A Finnish review, published in 2020, concluded that gender reassignment in children is “experimental” and that treatment should seldom proceed beyond talking therapy. Swedish authorities found that the risks of physical interventions “currently outweigh the possible benefits” and should only be offered in “exceptional cases”.

The transitioning of teenagers has its roots in a treatment protocol developed in the Netherlands in the 1980s and 1990s. It is built on three pillars: puberty-blockers (formally known as GnRH antagonists), cross-sex hormones and surgery

In 2020 the National Institute for Health and Care Excellence (NICE), a British body which reviews the scientific underpinnings of medical treatments, looked at the case for puberty-blockers and cross-sex hormones. The academic evidence it found was weak, discouraging and in some cases contradictory. The studies suggest puberty-blockers had little impact on patients. Cross-sex hormones may improve mental health, but the certainty of that finding was low, and NICE warned of the unknown risks of lasting side-effects.

For both classes of drug, NICE assessed the quality of the papers it analysed as “very low”, its poorest rating. Some studies reported results but made no effort to analyse them for statistical significance. Cross-sex hormones are a lifelong treatment, yet follow-up was short, ranging from one to six years. Most studies followed only a single set of patients, who were given the drugs, instead of comparing them with another set who were not. Without such a “control group”, researchers cannot tell whether anything that happened to the patients in the studies was down to the drugs, to other treatments the patients might be receiving (such as counselling or antidepressants), or to some other, unrelated third factor.

Reviews in Finland and Sweden came to similar conclusions.

One justification for puberty-blockers is that they “buy time” for children to decide whether to proceed with cross-sex hormones or not. But the data available so far from clinics suggest that almost all decide to go ahead. A Dutch paper published in October concluded that 98% of adolescents prescribed blockers decide to proceed to cross-sex hormones

The reassuring interpretation is that blockers are being prescribed very precisely, given only to those whose dysphoria is deep-rooted and unlikely to ease. The troubling one is that puberty-blockers lock at least some children in to further treatment

Perhaps the biggest question is how many of those given drugs and surgery eventually change their minds and “detransition”, having reconciled themselves with their biological sex

Once again, good data are scarce. One problem is that those who abandon a transition are likely to stop talking to their doctors, and so disappear from the figures. The estimates that do exist vary by an order of magnitude or more. Some studies have reported detransition rates as low as 1%. But three papers published in 2021 and 2022, which looked at patients in Britain and in America’s armed forces, found that between 7% and 30% of them stopped treatment within a few years.

the original studies seem to have inadvertently cherry-picked patients for whom the treatment was most effective. The researchers started with 111 adolescents, but excluded those whose treatment with puberty-blockers did not progress well.

Newer longitudinal studies have been published since, but they have drawbacks, too.

What is more, whatever the merits of the Dutch team’s original research, the patients passing through modern clinics are strikingly different from those assessed in their papers. Twenty years ago the majority of patients were pre-pubescent boys; in recent years teenage girls have come to dominate (see chart 2).

The Dutch protocol excludes those with mental-health problems from receiving treatment. But 70% or more of the young people seeking treatment suffer from mental-health problems, according to three recent papers looking at patients in America, Australia and Finland. Despite the protocol’s caution, says Will Malone of the Society for Evidence-Based Gender Medicine, an international group of concerned clinicians, the reality is often the reverse, especially in America, with mental-health issues becoming a reason to proceed with transitions, rather than to stop them. “We are now told that if we don’t address young people’s mental-health problems caused by dysphoria with transition, they will kill themselves.”

The possibility that many teenagers presenting as trans could instead be gay has long been discussed

in America in particular the charged atmosphere has made it very difficult to separate the science from the politics.

it is impossible to justify the current recommendations about gender-affirming care based on the existing data