One thing that bothers me is that there is still this idea that cis people are best placed to name decisions for us.
If the science is weak, but shows since evidence that gender-affirming care improves outcomes for trans people, shouldn't it be up to us and the parents of trans children to make an informed decision?
Why would someone who has never experienced dysphoria or the effects of going through the wrong puberty be able to make that decision for all trans people in one feel swoop?
We need less from Hillary Cass and her ilk and more informed consent.
I don’t understand referring to Cass as being part of an “ilk”. She is a well-respected pediatrician with a long career and past positions of leadership of pediatric organizations.
Isn’t it better to make substantial critiques of the review she headed, or the laws that have been passed in UK.
If the science is weak, then it doesn’t support any specific path. Children are not competent to make these sorts of decisions, and parents may be underinformed or easily led but not medically informed - we have seen this in more dramatic cases such as Charlie Gard.
We don’t require oncologists to have had cancer. Medicine is about what works, not necessarily what someone thinks they want. It’s why anorexics are encouraged to eat, not to keep starving themselves.
Multiple countries are reversing their positions on GAC for children (which is the discussion here; don’t divert to the adult situation, which is different for reasons of competence). If you truly think that the number of medical associations equates directly to how “correct” the treatment is, you should logically now be having serious second thoughts.
If you aren’t, then your trust isn’t about facts, but about ideology.
But in those “other areas” we are also informed by evidence-based medicine. We don’t give ivermectin for Covid, even if the patient thinks it’s great.
I think you’ll find plenty of treatments that have been carefully examined down the years. And it’s medical regulatory agencies which do the examination.
And you’re diverting the discussion from GAC for minors, which is what Cass is about.
“The authors of the Cass review believe that the data isn’t good enough to show a benefit, that there are possible harms, and therefore we should not use these therapies until someone does a series of high-quality studies proving that they work.”
Could this be because they are giving a lot of weight to “first do no harm”, as in leave nature alone unless you know what you solidly are doing, while many others seem to be judging the evidence by “first intervene medically to decrease possibility of suicide”.
One of the biggest regrets of trans people is having been forced to endure the wrong kind of puberty though. It irreversibly changes the body in ways modern medicine cannot correct.
Intervene or not, you cause permanent effects. Considering how rare regrets are and how compliance is a huge problem in medicine — patients forget to take their heart meds and their post-transplant immune suppressants!!! — getting someone to consistently take hrt that isn’t helping them would be a small miracle and internists everywhere want to hear your secret!
I’m but here for an argument. I’m a parent of a transgender-identifying teen trying to learn. May I ask, when you say “considering how rare regrets are” what are you basing that assertion on?
And I know it’s super dissatisfying to read that! I’m sorry! But, even if you read what many trans these days consider insulting and bigoted works of researcher/sexologists from the 80s & 90s, the thing that comes through is that the variance doesn’t go away. Some people repress for decades to save their parents the shame. The downside is, they don’t get to live their own life, and I don’t think I’d want my child to wait for my passing so they can start living.
Could it be your child has some other issues and they are just using transness as a cope? Yes, it’s possible. But have you had a friend or close relative who suddenly went from normal sex hormone levels to rock bottom? It feels like shit. Like aging 20 years over a fortnight.
Even the now-lambasted J. Michael Bailey says, trying to cite from memory, something like ‘after she was put on hormones, the sullen, shut-in, person disappeared and she became extroverted and bubbly young woman’ which also describes my experience with normal and rock-bottom hormone levels. As an aside, The Vajenda here on Substack is a great stack on all things (peri)menopause.
More concretely, some people will just take naturally to having more, deeper, truer, feelings and having less of a drive to do stuff, while others are more themselves when they feel like they need to be chasing stuff all the time and don’t mind having few if any feelings. It’s sexist and it’s old-fashioned, but talk to enough trans men and women and see if you don’t start believing in Obsolete Ancient Gender Prejudice (tm) ;)
The only way to put it in condensed form is: experience, what I hear from people who’ve worked in the field, and scientific literature.
Desisting seems to be usually connected to — or caused by — social punishment or dissatisfaction with realities of dating post-transition. Say you mandated capital punishment for speeding — you’d see fewer speeders in traffic. Punishments and rewards change behaviour.
Doing nothing when a distressed transgender teen asks for help to avoid going through the wrong puberty is doing harm.
It is the same as telling someone with a broken leg to "walk it off".
They may get help later, but their outcomes will be worse and they will have suffered in the meantime.
It is true that more research would be great. But until we have that, the lack of regret or any other widespread negative consequences in those who do receive care should be enough to warrant caring.
But do we even have research that clearly support the often-repeated assertion that there is lack of regret? What is that research. I have had several people quote a number, “only 1%”, but can’t say where that number comes from.
I’m frustrated by your refusal to take the placebo effect seriously. If we replace “gender affirming care“ with “homeopathic silver potions“ in those five studies, would you conclude that there is reasonably strong evidence that homeopathic silver improves gender dysphoria? I’m not being sarcastic, I find your credulity baffling. Almost every controlled mental health study ever done shows a massive placebo effect, and you simply disregard it when you take studies with no comparison group at face value.
You seem to be intent on misrepresenting my work. I have not taken any studies at face value, and am very clear in the piece about the limitations of the evidence. There are also a number of studies - which I discuss - that include comparison groups, including two RCTs. Unlike homeopathy, which is both impossible from a chemical and physics perspective and has been disproven for decades, treatment of transgender teens is an emerging field with few studies. That is certainly a weakness, which I discuss.
Comparing such therapies to homeopathy seems to be more an indication of ignorance than of understanding.
You acknowledge the weakness of the evidence, but you still use Language that is far too credulous when describing the outcomes of these studies: “Every study that examined mental health outcomes of children given gender-affirming hormone treatment showed improvements.” these improvements are entirely attributable to time alone, or to regression to the mean. you write things like “improved after one year on hormones“ as though the vast majority of teenage mental health distress does not resolve after one year regardless of treatment.
You make a good point about homeopathy being physically impossible. It was a bad choice on my part. I should have used either chai tea as an example or perhaps a solution of aluminum that was diluted but had enough metal to have theoretical biological effects.
I think this may be the crux of the issue: I believe the medical literature is full of seemingly large effects that vanish when compared to a placebo control group. Therefore, I see no reason to believe that the relatively modest effects of gender affirming care will be any different. do you agree or disagree with this?
As I've noted, several of the studies have control groups. Indeed, the majority of the literature cited here has a control group. I am not certain why you are pursuing this red herring, nor why you are asking a leading question of me.
This is just strange. There are zero adolescent studies with a control group. A random comparison group (cis teens) is not the same thing as an experimental control group. Even in adults there is really only the one recent waitlist control group that you mentioned
If we assume all kids are equally biased when responding to the BDI, then the reported benefits of GAC would vanish. Your credulity relies on believing that the response bias must be *much smaller* in gender treatment. (your first paragraph kind of implies that we need to be maximally agnostic about response bias when we don’t have a control group, but if you are agnostic about the response bias then you must also be agnostic about whether the positive result is bigger than response bias/placebo effect, so it is a bit self-defeating)
And yet, nobody is suggesting we ban homeopathic remedies, even though there is some evidence that they actually can cause harm by avoiding or delaying effective treatment.
Someone we trust people to make and live with their own decisions.
The evidence for gender-affirming care is actually better, because there is no indication of harm.
Even if the self-reported outcomes were purely due to placebo (they are not), then these patients are still happier than they were before.
So even if you were right, you'd still have the uphill battle of proving actual harm in the treatment ahead of you before you'd be justified in calling for a ban.
I agree I wish they would keep laws out of what should be between parents, patient, and doctors.
One thing about that isn’t always discussed is that a lot of transgender-identifying teens have two parents. And the parents don’t necessarily see eye to eye. In our family, I have doubts while my wife has certainty that US medical and psychological associations have deep evidence bases for their current policies. It has exacerbated pre-existing communication problems and we are now in couples counseling.
Currently, we are taking our 17-year-old to a gender clinic at our local hospital system but they have not yet approved the hormones our teen wants because they aren’t clearly showing the level of “persistent, consistent” behavior that the endocrinologist would like to see before proceeding.
I think I lost my point, which is: it is really important in our family’s scenario that all the US medical and psychological associations really try to get it right because that is what my wife goes by.
Anyway, when you have two parents who don’t agree, outlawing hormones doesn’t help. It just leads to our now having to worry about our kid trying to get black market hormones, and complications of going out of state for treatment.
The thing I find frustrating about these reviews is what the evidence regarding hormones implies about the evidence regarding blockers. If hormones work, then why would blockers not? Especially since the diagnosis of gender dysphoria is partly based on increasing distress as puberty is imminent. Here is the logic of the Cass Review: "X causes extreme distress. We have a medicine that stops X. But since no study proves that stopping X helps the distress," we just have to conclude that we have no way of knowing anything about this." That is illogical.
Also missing from the Cass Review is the fact from Finlayson's book (pages 33, 80) is that transwomen who received blockers need lower doses and can take safer forms of estrogen, which otherwise causes DVTs, strokes, and cancer (safer forms comes with no added risks - see Randolph, et al. 2018, Schatzel, et al. 2016). No one mentions this. It is a logical fallacy to privilege "do nothing" until "do something" is proven. We must compare probabilities of risks and benefits of both choices; if do nothing causes them to be 17 times more likely to die 40 years later of DVTs, etc., then do nothing is very, very risky. Not to mention the added need for surgical reversal of effects of puberty.
Also see Grinspon 2013 for a study of the safety of treating infants-toddlers with blockers for a decade. It is a very small study, since this would be treating a rare condition. But in general, when blockers have been proven safe for decades, why would medical safety be any different for gender dysphoric youth? It would have to be some thought that treating a kid from 8-11 is physically different in the body from treating a kid 13-15. Maybe, but they do not say that. Instead they say, we have no evidence, and that is misleading. It is like saying, well we know that X treatment works for children in Sweden, but since we haven't studied it in Germany, we can't say for sure that it would work in Germany, when country of origin is not likely to be a moderating factor in the safety-efficacy of a treatment. If age during treatment is not a moderating factor, then it is a fallacy to say evidence of safety for gender dysphoric youth is inconclusive.
The combination of likely immediate and long-term risks of forcing a kid to go through puberty, which we know for a fact is distressing, plus the known safety of the treatment, plus the long-term medical risks of high doses of oral estradiol needed to reverse effects of puberty, it is just not a fair conclusion to say that blockers are not recommended.
I have learned a lot here - and I thank you very much for doing this needed fair-minded review.
That 2021 systematic review has a gigantic caveat in its Conclusion: “Certainty in this conclusion is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions.” In addition, only 3 of the 20 studies found worth examining were on teenagers.
Once again, this is what the Cass Review and associated SRs criticised: using low-quality studies which show some effects and extrapolating beyond what they bear to suggest everything is good.
(Thank you btw for opening comments to non-subscribers. This is a very positive step for discussion.)
im certain you will likely delete this comment, but your explanations are exactly the kind of non scientific information that evidence reviews are designed to filter out. systematic reviews evaluate evidence of long term benefit. cass looked at 100s of studys and found most of such low quality they cant be used to claim anything. for example the baker study that you claim showed gender meds help. this study didnt find that. their study head line claimed they did. but their actual findings were only "low" and "insufficient" evidence. baker also is affiliated with WPATH indicating its participants were likely activists whose goal is to skew the results. then you say nolan study showed gender meds help. but that was only a 90 days and had only 64 participants. systematic reviews evaluate if there maybe any long term any benefit. we know gender meds provide a short term placebo. thats why most gender biz studys end at 12 months and many are only 30 days. they seek to capture that golden hour when vulnerable ppl are experiencing a placebo effect from a perceived new community, attn, an affirming therapist whose telling them they are a magic person from mars. many people telling them all of the normal problems and some may have had really terrible trauma, all of this was due to one simple thing. they are magic. but after a while it all fades and ppl learn it was a scam. in any case this environment has nothing to do with gender meds. but gender biz try to capture this placebo in their short term "studys". then you go on to quibble about the same stuff everyone knows are lies. for example, any information based on online polls, like the transgender survey. these online polls have anonymous participants, most are likely allies and no cookies to prevent repeat poll takers. its likely some participants took the poll 100s of times. yet you want cass to consider this "evidence". its not . its activism. the polls are even run by activists groups. the systematic reviews that claim gender meds really dont help anything dont have any legit evidence to oppose their findings. no legit systematic reviews found gender meds help. WPATH started to do a systematic review but had to stop it when it found gender meds dont help. Biden gave activists Olsen Kennedy $10 million to find evidence gender meds help kids. she found they didnt. this is a scam. a magic idea that progressives have latched onto and i wish they would stop harming vulnerable ppl with this fraud.
This is such an excellent, open-minded review. The evidence for the impact of hormone therapy on mental health-- clearly positive-- makes me wonder whether any work has been done on hormone supplementation-- perhaps on smaller non-transitioning amounts-- in depressed adolescents outside of the context of trans-gender care? There is a rich literature on the role of decreasing estrogen and rising anxiety/depression in cisgender women in menopause. In same vein, anxiety, irritability, depression, and other mood changes are common in people (both men and women) with low testosterone, and although the mechanism is not exactly clear, testosterone is thought to be related to serotonin reuptake in the brain.
There is a new German study about gender dysphoria persistence. It would be a good one for Health Nerd to cover. It’s in German, so all I’ve been able to see are other people’s takes on it:
The methodology was apparently looking at insurance records and changes of gender on government documents. Not sure if I got that right or if it’s a valid methodology.
Another thing I thought of. Considering how the people most prone to arguing against all transition with children used as the wedge issue… (and when they say children they mean 16-year old who are old enough to be prosecuted and punished as adults in some jurisdictions! Old enough to work full time and create families if you trust the very same conservatives!)
…Are also the people who love to underline how difficult it is to ‘pass’ after puberty even with surgeries, with the implication that being such an unusual person is horrible …
…are they not arguing that
1. HRT cant change who ‘you are really’ even superficially— where is the harm, then, in handing out such obviously weak and impotent chemical that the human body produces every day anyway? Oooor that
2. Going through the right puberty the first time is really important?
Either way, they end up confirming the importance of timely intervention.
The conservative position, then, seems to be aimed at maximising the suffering of purple based on an accident of birth. I say accident because given the choice, who wants to wait in line for years before their problems are looked at?
I’m not sure about going through the right puberty, but one of the issues the Cass Review raises is that there are important physiological developments that occur during puberty that are outside sexual characteristic development, so going through some kind of puberty plays an important role in healthy growth of the body and brain.
So, original thought that just occurred to me that I’ve never heard anyone else come up with: instead of blocking puberty, medical researchers should figure out how to give the child the puberty of the desired sex. It would be better than blocking.
But inducing the puberty of the desired sex would just be giving actual hrt. Testosterone or anti androgens and oestrogen. Well, there’s also progesterone that you’d probably want to introduce down the line. But it’s not like we don’t know how to do it.
In fact, it’s easy enough that teens regularly do it themselves with FAQs from the internet.
And they have to, because nowadays NOT doing DIY HRT raises the suspicion that the patient isn’t really serious about the whole thing.
Like so: ‘If you’re REALLY of the opposite sex, why have you been content to stay on the wrong hormones when grey market and black market suppliers will sell you the preparations you’d get with a script?’
I predict we will see in 5-10 years studies showing that the patients who transitioned early have highest life satisfaction. Easiest time finding a spouse and least difficulty ‘passing’. (Yes I’m a filthy binary gender conservative, I feel that we’re men and women, biology varies endlessly* but culture created two gender roles. I just can’t with the enbies and queers, in my private life.)
I’m personally conflicted — my sympathy/empathy tells me we should do it, but if I imagine myself actually initiating hrt regime on a 12-year old… would I have the confidence that we really have the correct diagnosis?
* I’ve been drawn to generic sexology work recently and a problem I’ve thought about is: how do we — ethically!!!! — draw the line between least female woman and most female intersex person? Who is the poor woman who loses her female-ness if we expand the intersex category one click so that one fewer person qualifies as female and is now just intersex?
By the way, in my own teen’s case, most of puberty is already over and the gender clinic isn’t even considering puberty blockers at this point. It would be too late.
But when it comes to administering puberty blockers to a younger child, there is a trade-off between making it easier to pass later in life and alleviate gender dysphoria vs not experiencing important non-sexual aspects of pubertal growth.
(By the way, there is one way puberty blockers can work against future transition: for AMAB, if the child’s penis doesn’t grow to a certain size it can be hard to perform a satisfying vaginoplasty later on.)
Genspect or SEGM or just a troll? Your talking points are copypasta from an anti trans site.
You know just as well as I do that, read honestly, the Swedish and Finnish studies speak loudly for low regret rates and, all in all, are evidence for the benefits of transition rather than against. You are commenting on one of the better Substacks going over the literature.
If you really wanted to know, I can not direct you to a better source, accessibility considered, than health nerd’s series on the Cass report. If I have you pub med id numbers, you’d gripe about paywalls that scientific journals put up.
You’re throwing out a cloud of bullshit speculation and rhetoric, this very post explains why ‘your sincere concerns’ are just strategic interference, meant to muddy the waters.
We are both commenting on Part 6 of Health Nerd’s series in the Cass Review, so neither one of us needs to direct each other to the series. We are here.
What “talking point” have I made? We are in the comment section of a series about something the Cass Review, and I brought up a concern the Review raised. That sure seems to me like my staying on topic.
Maybe engage in conversation rather than throwing the accusation, “anti-trans”, at the parent of a transgender child.
It seems to me that they have the hormone treatment thing backwards.
Shouldn't boys who want to be a girl be given testosterone to make them feel more like what they really are -- i.e., a male? Why are the doctors enabling a delusion?
It is considered unethical to explore by many/most transgender rights advocates and medical associations because it would be based on judging transgenderism as an undesirable outcome, and be analogous to past attempts at gay conversion therapy.
Still, has it been tried, say, in experiments many years ago? I can’t find any cases of it’s ever having been tried but it is hard to search because search engines return hits about testosterone being administered to AFAB persons.
By the way, this critique of the Cass Review was just released. Just passing it along, not recommending or not recommending it as I haven’t had a chance to read it yet: https://osf.io/preprints/osf/uhndk
One thing I didn’t know until taking my own teen to a gender clinic is that hormones are often administered in conjunction with puberty blockers, to make the hormones more effective. So, that is context to keep in mind while learning about puberty blockers and hormones.
You’ve made me more sceptical of the evidence. But, since we see it works in many or most cases, I now believe being careful about watching how the patient responds — as with any psychiatric pharmaceuticals — is the correct way, rather than just throwing away the treatment altogether.
Not that different from treating somone with ulcerative colitis with a biological and observing to see if they are a non-responder.
Clinical judgment and this individual patients best is the word here.
I have always said that the best place to make decisions about someone's medical treatment is between the patient and their physician.
That is true for trans people just like anybody else.
Doctors need to be free to make the decisions that are right for their patients and patients need to be free to find doctors that will have their best interests at heart.
What we doing need is government intervention and blanket bans based less on science and more on ideology.
This series continues to be excellent. Thank you so much for doing it
I will be referring to your work on The Cass Report in my own podcast, Butterfly Arose, in the future. That you for your hard work and honesty.
One thing that bothers me is that there is still this idea that cis people are best placed to name decisions for us.
If the science is weak, but shows since evidence that gender-affirming care improves outcomes for trans people, shouldn't it be up to us and the parents of trans children to make an informed decision?
Why would someone who has never experienced dysphoria or the effects of going through the wrong puberty be able to make that decision for all trans people in one feel swoop?
We need less from Hillary Cass and her ilk and more informed consent.
I don’t understand referring to Cass as being part of an “ilk”. She is a well-respected pediatrician with a long career and past positions of leadership of pediatric organizations.
Isn’t it better to make substantial critiques of the review she headed, or the laws that have been passed in UK.
If the science is weak, then it doesn’t support any specific path. Children are not competent to make these sorts of decisions, and parents may be underinformed or easily led but not medically informed - we have seen this in more dramatic cases such as Charlie Gard.
We don’t require oncologists to have had cancer. Medicine is about what works, not necessarily what someone thinks they want. It’s why anorexics are encouraged to eat, not to keep starving themselves.
This is why in other areas we trust doctors and patients to work out the right plan together
No treatment other than gender-affirming care has every been scrutinised and banned by governments so much, despite there being no evidence of harm
Thousands of trans people can tell you how massively gender-affirming care has improved their lives
Regret rates are lower than for pretty much any other medical intervention
It is not any government's place to tell them and their doctors that they cannot go down that route
Let us not forget here that the overwhelming majority of medical practitioners and their regulatory bodies support gender-affirming care.
They have seen the evidence and they have seen it with first-hand.
Multiple countries are reversing their positions on GAC for children (which is the discussion here; don’t divert to the adult situation, which is different for reasons of competence). If you truly think that the number of medical associations equates directly to how “correct” the treatment is, you should logically now be having serious second thoughts.
If you aren’t, then your trust isn’t about facts, but about ideology.
Can you cite the basis of your saying, “Regret rates are lower than for pretty much any other medical intervention”?
I am not well-versed with the literature to do so myself, but there are people out there who can.
Maybe even the author of the post below which we're having this lovely conversation.
But in those “other areas” we are also informed by evidence-based medicine. We don’t give ivermectin for Covid, even if the patient thinks it’s great.
I think you’ll find plenty of treatments that have been carefully examined down the years. And it’s medical regulatory agencies which do the examination.
And you’re diverting the discussion from GAC for minors, which is what Cass is about.
The evidence that gender-affirming care for children is beneficial is there. It may not be robust, but it exists.
There is no evidence indicating that it is useful.
If a treatment is safe and might work, has been shown to work in many people, then why restrict it?
“The authors of the Cass review believe that the data isn’t good enough to show a benefit, that there are possible harms, and therefore we should not use these therapies until someone does a series of high-quality studies proving that they work.”
Could this be because they are giving a lot of weight to “first do no harm”, as in leave nature alone unless you know what you solidly are doing, while many others seem to be judging the evidence by “first intervene medically to decrease possibility of suicide”.
One of the biggest regrets of trans people is having been forced to endure the wrong kind of puberty though. It irreversibly changes the body in ways modern medicine cannot correct.
Intervene or not, you cause permanent effects. Considering how rare regrets are and how compliance is a huge problem in medicine — patients forget to take their heart meds and their post-transplant immune suppressants!!! — getting someone to consistently take hrt that isn’t helping them would be a small miracle and internists everywhere want to hear your secret!
I’m but here for an argument. I’m a parent of a transgender-identifying teen trying to learn. May I ask, when you say “considering how rare regrets are” what are you basing that assertion on?
And I know it’s super dissatisfying to read that! I’m sorry! But, even if you read what many trans these days consider insulting and bigoted works of researcher/sexologists from the 80s & 90s, the thing that comes through is that the variance doesn’t go away. Some people repress for decades to save their parents the shame. The downside is, they don’t get to live their own life, and I don’t think I’d want my child to wait for my passing so they can start living.
Could it be your child has some other issues and they are just using transness as a cope? Yes, it’s possible. But have you had a friend or close relative who suddenly went from normal sex hormone levels to rock bottom? It feels like shit. Like aging 20 years over a fortnight.
Even the now-lambasted J. Michael Bailey says, trying to cite from memory, something like ‘after she was put on hormones, the sullen, shut-in, person disappeared and she became extroverted and bubbly young woman’ which also describes my experience with normal and rock-bottom hormone levels. As an aside, The Vajenda here on Substack is a great stack on all things (peri)menopause.
More concretely, some people will just take naturally to having more, deeper, truer, feelings and having less of a drive to do stuff, while others are more themselves when they feel like they need to be chasing stuff all the time and don’t mind having few if any feelings. It’s sexist and it’s old-fashioned, but talk to enough trans men and women and see if you don’t start believing in Obsolete Ancient Gender Prejudice (tm) ;)
The only way to put it in condensed form is: experience, what I hear from people who’ve worked in the field, and scientific literature.
Desisting seems to be usually connected to — or caused by — social punishment or dissatisfaction with realities of dating post-transition. Say you mandated capital punishment for speeding — you’d see fewer speeders in traffic. Punishments and rewards change behaviour.
As far as scientific studies, are there ones that you can cite that support how rare regret is?
Doing nothing when a distressed transgender teen asks for help to avoid going through the wrong puberty is doing harm.
It is the same as telling someone with a broken leg to "walk it off".
They may get help later, but their outcomes will be worse and they will have suffered in the meantime.
It is true that more research would be great. But until we have that, the lack of regret or any other widespread negative consequences in those who do receive care should be enough to warrant caring.
But do we even have research that clearly support the often-repeated assertion that there is lack of regret? What is that research. I have had several people quote a number, “only 1%”, but can’t say where that number comes from.
I’m frustrated by your refusal to take the placebo effect seriously. If we replace “gender affirming care“ with “homeopathic silver potions“ in those five studies, would you conclude that there is reasonably strong evidence that homeopathic silver improves gender dysphoria? I’m not being sarcastic, I find your credulity baffling. Almost every controlled mental health study ever done shows a massive placebo effect, and you simply disregard it when you take studies with no comparison group at face value.
You seem to be intent on misrepresenting my work. I have not taken any studies at face value, and am very clear in the piece about the limitations of the evidence. There are also a number of studies - which I discuss - that include comparison groups, including two RCTs. Unlike homeopathy, which is both impossible from a chemical and physics perspective and has been disproven for decades, treatment of transgender teens is an emerging field with few studies. That is certainly a weakness, which I discuss.
Comparing such therapies to homeopathy seems to be more an indication of ignorance than of understanding.
You acknowledge the weakness of the evidence, but you still use Language that is far too credulous when describing the outcomes of these studies: “Every study that examined mental health outcomes of children given gender-affirming hormone treatment showed improvements.” these improvements are entirely attributable to time alone, or to regression to the mean. you write things like “improved after one year on hormones“ as though the vast majority of teenage mental health distress does not resolve after one year regardless of treatment.
You make a good point about homeopathy being physically impossible. It was a bad choice on my part. I should have used either chai tea as an example or perhaps a solution of aluminum that was diluted but had enough metal to have theoretical biological effects.
I think this may be the crux of the issue: I believe the medical literature is full of seemingly large effects that vanish when compared to a placebo control group. Therefore, I see no reason to believe that the relatively modest effects of gender affirming care will be any different. do you agree or disagree with this?
As I've noted, several of the studies have control groups. Indeed, the majority of the literature cited here has a control group. I am not certain why you are pursuing this red herring, nor why you are asking a leading question of me.
This is just strange. There are zero adolescent studies with a control group. A random comparison group (cis teens) is not the same thing as an experimental control group. Even in adults there is really only the one recent waitlist control group that you mentioned
If we assume all kids are equally biased when responding to the BDI, then the reported benefits of GAC would vanish. Your credulity relies on believing that the response bias must be *much smaller* in gender treatment. (your first paragraph kind of implies that we need to be maximally agnostic about response bias when we don’t have a control group, but if you are agnostic about the response bias then you must also be agnostic about whether the positive result is bigger than response bias/placebo effect, so it is a bit self-defeating)
And yet, nobody is suggesting we ban homeopathic remedies, even though there is some evidence that they actually can cause harm by avoiding or delaying effective treatment.
Someone we trust people to make and live with their own decisions.
The evidence for gender-affirming care is actually better, because there is no indication of harm.
Even if the self-reported outcomes were purely due to placebo (they are not), then these patients are still happier than they were before.
So even if you were right, you'd still have the uphill battle of proving actual harm in the treatment ahead of you before you'd be justified in calling for a ban.
I agree I wish they would keep laws out of what should be between parents, patient, and doctors.
One thing about that isn’t always discussed is that a lot of transgender-identifying teens have two parents. And the parents don’t necessarily see eye to eye. In our family, I have doubts while my wife has certainty that US medical and psychological associations have deep evidence bases for their current policies. It has exacerbated pre-existing communication problems and we are now in couples counseling.
Currently, we are taking our 17-year-old to a gender clinic at our local hospital system but they have not yet approved the hormones our teen wants because they aren’t clearly showing the level of “persistent, consistent” behavior that the endocrinologist would like to see before proceeding.
I am sorry you are struggling. Coming to terms with a child realising they might be trans and figuring out the best way to support them is hard.
The reality is that both intervention and doing nothing lead to irreversable outcomes. There is no neutral option.
The best you can do is try and work with your child to understand which outcomes are more likely to allow them to live a happy and fulfilled life.
I hope you will find a way forward and that your child finds what's right for them.
I think I lost my point, which is: it is really important in our family’s scenario that all the US medical and psychological associations really try to get it right because that is what my wife goes by.
Anyway, when you have two parents who don’t agree, outlawing hormones doesn’t help. It just leads to our now having to worry about our kid trying to get black market hormones, and complications of going out of state for treatment.
The thing I find frustrating about these reviews is what the evidence regarding hormones implies about the evidence regarding blockers. If hormones work, then why would blockers not? Especially since the diagnosis of gender dysphoria is partly based on increasing distress as puberty is imminent. Here is the logic of the Cass Review: "X causes extreme distress. We have a medicine that stops X. But since no study proves that stopping X helps the distress," we just have to conclude that we have no way of knowing anything about this." That is illogical.
Also missing from the Cass Review is the fact from Finlayson's book (pages 33, 80) is that transwomen who received blockers need lower doses and can take safer forms of estrogen, which otherwise causes DVTs, strokes, and cancer (safer forms comes with no added risks - see Randolph, et al. 2018, Schatzel, et al. 2016). No one mentions this. It is a logical fallacy to privilege "do nothing" until "do something" is proven. We must compare probabilities of risks and benefits of both choices; if do nothing causes them to be 17 times more likely to die 40 years later of DVTs, etc., then do nothing is very, very risky. Not to mention the added need for surgical reversal of effects of puberty.
Also see Grinspon 2013 for a study of the safety of treating infants-toddlers with blockers for a decade. It is a very small study, since this would be treating a rare condition. But in general, when blockers have been proven safe for decades, why would medical safety be any different for gender dysphoric youth? It would have to be some thought that treating a kid from 8-11 is physically different in the body from treating a kid 13-15. Maybe, but they do not say that. Instead they say, we have no evidence, and that is misleading. It is like saying, well we know that X treatment works for children in Sweden, but since we haven't studied it in Germany, we can't say for sure that it would work in Germany, when country of origin is not likely to be a moderating factor in the safety-efficacy of a treatment. If age during treatment is not a moderating factor, then it is a fallacy to say evidence of safety for gender dysphoric youth is inconclusive.
The combination of likely immediate and long-term risks of forcing a kid to go through puberty, which we know for a fact is distressing, plus the known safety of the treatment, plus the long-term medical risks of high doses of oral estradiol needed to reverse effects of puberty, it is just not a fair conclusion to say that blockers are not recommended.
I have learned a lot here - and I thank you very much for doing this needed fair-minded review.
That 2021 systematic review has a gigantic caveat in its Conclusion: “Certainty in this conclusion is limited by high risk of bias in study designs, small sample sizes, and confounding with other interventions.” In addition, only 3 of the 20 studies found worth examining were on teenagers.
Once again, this is what the Cass Review and associated SRs criticised: using low-quality studies which show some effects and extrapolating beyond what they bear to suggest everything is good.
(Thank you btw for opening comments to non-subscribers. This is a very positive step for discussion.)
im certain you will likely delete this comment, but your explanations are exactly the kind of non scientific information that evidence reviews are designed to filter out. systematic reviews evaluate evidence of long term benefit. cass looked at 100s of studys and found most of such low quality they cant be used to claim anything. for example the baker study that you claim showed gender meds help. this study didnt find that. their study head line claimed they did. but their actual findings were only "low" and "insufficient" evidence. baker also is affiliated with WPATH indicating its participants were likely activists whose goal is to skew the results. then you say nolan study showed gender meds help. but that was only a 90 days and had only 64 participants. systematic reviews evaluate if there maybe any long term any benefit. we know gender meds provide a short term placebo. thats why most gender biz studys end at 12 months and many are only 30 days. they seek to capture that golden hour when vulnerable ppl are experiencing a placebo effect from a perceived new community, attn, an affirming therapist whose telling them they are a magic person from mars. many people telling them all of the normal problems and some may have had really terrible trauma, all of this was due to one simple thing. they are magic. but after a while it all fades and ppl learn it was a scam. in any case this environment has nothing to do with gender meds. but gender biz try to capture this placebo in their short term "studys". then you go on to quibble about the same stuff everyone knows are lies. for example, any information based on online polls, like the transgender survey. these online polls have anonymous participants, most are likely allies and no cookies to prevent repeat poll takers. its likely some participants took the poll 100s of times. yet you want cass to consider this "evidence". its not . its activism. the polls are even run by activists groups. the systematic reviews that claim gender meds really dont help anything dont have any legit evidence to oppose their findings. no legit systematic reviews found gender meds help. WPATH started to do a systematic review but had to stop it when it found gender meds dont help. Biden gave activists Olsen Kennedy $10 million to find evidence gender meds help kids. she found they didnt. this is a scam. a magic idea that progressives have latched onto and i wish they would stop harming vulnerable ppl with this fraud.
This is such an excellent, open-minded review. The evidence for the impact of hormone therapy on mental health-- clearly positive-- makes me wonder whether any work has been done on hormone supplementation-- perhaps on smaller non-transitioning amounts-- in depressed adolescents outside of the context of trans-gender care? There is a rich literature on the role of decreasing estrogen and rising anxiety/depression in cisgender women in menopause. In same vein, anxiety, irritability, depression, and other mood changes are common in people (both men and women) with low testosterone, and although the mechanism is not exactly clear, testosterone is thought to be related to serotonin reuptake in the brain.
There is a new German study about gender dysphoria persistence. It would be a good one for Health Nerd to cover. It’s in German, so all I’ve been able to see are other people’s takes on it:
https://www.aerzteblatt.de/archiv/239555/Stoerungen-der-Geschlechtsidentitaet-bei-jungen-Menschen-in-Deutschland-Haeufigkeit-und-Trends-2013-2022
The methodology was apparently looking at insurance records and changes of gender on government documents. Not sure if I got that right or if it’s a valid methodology.
Another thing I thought of. Considering how the people most prone to arguing against all transition with children used as the wedge issue… (and when they say children they mean 16-year old who are old enough to be prosecuted and punished as adults in some jurisdictions! Old enough to work full time and create families if you trust the very same conservatives!)
…Are also the people who love to underline how difficult it is to ‘pass’ after puberty even with surgeries, with the implication that being such an unusual person is horrible …
…are they not arguing that
1. HRT cant change who ‘you are really’ even superficially— where is the harm, then, in handing out such obviously weak and impotent chemical that the human body produces every day anyway? Oooor that
2. Going through the right puberty the first time is really important?
Either way, they end up confirming the importance of timely intervention.
The conservative position, then, seems to be aimed at maximising the suffering of purple based on an accident of birth. I say accident because given the choice, who wants to wait in line for years before their problems are looked at?
I’m not sure about going through the right puberty, but one of the issues the Cass Review raises is that there are important physiological developments that occur during puberty that are outside sexual characteristic development, so going through some kind of puberty plays an important role in healthy growth of the body and brain.
So, original thought that just occurred to me that I’ve never heard anyone else come up with: instead of blocking puberty, medical researchers should figure out how to give the child the puberty of the desired sex. It would be better than blocking.
But inducing the puberty of the desired sex would just be giving actual hrt. Testosterone or anti androgens and oestrogen. Well, there’s also progesterone that you’d probably want to introduce down the line. But it’s not like we don’t know how to do it.
In fact, it’s easy enough that teens regularly do it themselves with FAQs from the internet.
And they have to, because nowadays NOT doing DIY HRT raises the suspicion that the patient isn’t really serious about the whole thing.
Like so: ‘If you’re REALLY of the opposite sex, why have you been content to stay on the wrong hormones when grey market and black market suppliers will sell you the preparations you’d get with a script?’
I predict we will see in 5-10 years studies showing that the patients who transitioned early have highest life satisfaction. Easiest time finding a spouse and least difficulty ‘passing’. (Yes I’m a filthy binary gender conservative, I feel that we’re men and women, biology varies endlessly* but culture created two gender roles. I just can’t with the enbies and queers, in my private life.)
I’m personally conflicted — my sympathy/empathy tells me we should do it, but if I imagine myself actually initiating hrt regime on a 12-year old… would I have the confidence that we really have the correct diagnosis?
* I’ve been drawn to generic sexology work recently and a problem I’ve thought about is: how do we — ethically!!!! — draw the line between least female woman and most female intersex person? Who is the poor woman who loses her female-ness if we expand the intersex category one click so that one fewer person qualifies as female and is now just intersex?
By the way, in my own teen’s case, most of puberty is already over and the gender clinic isn’t even considering puberty blockers at this point. It would be too late.
But when it comes to administering puberty blockers to a younger child, there is a trade-off between making it easier to pass later in life and alleviate gender dysphoria vs not experiencing important non-sexual aspects of pubertal growth.
(By the way, there is one way puberty blockers can work against future transition: for AMAB, if the child’s penis doesn’t grow to a certain size it can be hard to perform a satisfying vaginoplasty later on.)
Genspect or SEGM or just a troll? Your talking points are copypasta from an anti trans site.
You know just as well as I do that, read honestly, the Swedish and Finnish studies speak loudly for low regret rates and, all in all, are evidence for the benefits of transition rather than against. You are commenting on one of the better Substacks going over the literature.
If you really wanted to know, I can not direct you to a better source, accessibility considered, than health nerd’s series on the Cass report. If I have you pub med id numbers, you’d gripe about paywalls that scientific journals put up.
You’re throwing out a cloud of bullshit speculation and rhetoric, this very post explains why ‘your sincere concerns’ are just strategic interference, meant to muddy the waters.
What are “the Swedish and Finnish studies”?
We are both commenting on Part 6 of Health Nerd’s series in the Cass Review, so neither one of us needs to direct each other to the series. We are here.
What “talking point” have I made? We are in the comment section of a series about something the Cass Review, and I brought up a concern the Review raised. That sure seems to me like my staying on topic.
Maybe engage in conversation rather than throwing the accusation, “anti-trans”, at the parent of a transgender child.
It seems to me that they have the hormone treatment thing backwards.
Shouldn't boys who want to be a girl be given testosterone to make them feel more like what they really are -- i.e., a male? Why are the doctors enabling a delusion?
I once wondered the same thing.
It is considered unethical to explore by many/most transgender rights advocates and medical associations because it would be based on judging transgenderism as an undesirable outcome, and be analogous to past attempts at gay conversion therapy.
Still, has it been tried, say, in experiments many years ago? I can’t find any cases of it’s ever having been tried but it is hard to search because search engines return hits about testosterone being administered to AFAB persons.
By the way, this critique of the Cass Review was just released. Just passing it along, not recommending or not recommending it as I haven’t had a chance to read it yet: https://osf.io/preprints/osf/uhndk
One thing I didn’t know until taking my own teen to a gender clinic is that hormones are often administered in conjunction with puberty blockers, to make the hormones more effective. So, that is context to keep in mind while learning about puberty blockers and hormones.
You’ve made me more sceptical of the evidence. But, since we see it works in many or most cases, I now believe being careful about watching how the patient responds — as with any psychiatric pharmaceuticals — is the correct way, rather than just throwing away the treatment altogether.
Not that different from treating somone with ulcerative colitis with a biological and observing to see if they are a non-responder.
Clinical judgment and this individual patients best is the word here.
I have always said that the best place to make decisions about someone's medical treatment is between the patient and their physician.
That is true for trans people just like anybody else.
Doctors need to be free to make the decisions that are right for their patients and patients need to be free to find doctors that will have their best interests at heart.
What we doing need is government intervention and blanket bans based less on science and more on ideology.