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.
Is it your position, then, that a 16-year old doesn’t know themselves well enough to know if they feel better on hrt, or that they can’t make that choice because they aren’t legally competent?
If the former, how do you propose we assess legal minors in psychiatric context, you’ve just said they can’t judge how they feel? Or just in the case of your ordinary appendicitis?
If the latter: why is a 16-year old legally competent to make the choice whether or not to become a parent? Those choices are sometimes made with less reflection, less support from a mental health professionals and they always severely impact a third party, the child.
What have you personally done to criminalise all genital mutilation of minors, sometimes called female or male circumcision? That is a body modification without any therapeutic benefit to the child, completely irreversible and done without even the less full consent a child can give. If well-being of children and not doing irreversible stuff to kids they can’t competently consent to is your concern, we’re talking sun vs moon in scale here.
I am the parent of a 16-year-old about to turn 17-year-old who identifies as transgender. Yes, I do doubt their judgement. Unlike the more clear cut cases where a child has clearly shown transgender traits since early childhood, my teen has only started feeling that they are transgender about 7 months ago.
If we do get approved for hormones, I do worry about my child having short-term feelings of life getting better at the expense of long-term happiness. It’s the age-old parental concern that my teen might feel like something makes them happy but they don’t have the long-term perspective. Anyway, we are practicing “watchful waiting” and trying to do the right thing. Our teen will be 18 soon, and legally an adult, although we would still be the ones paying for treatments and insurance after 18.
I would like to see studies that go beyond checking back on children on hormones only one or two years later. I would like to see long-term data, but that’s hard when the first teens in the recent surge are still in college and haven’t yet launched into the real world.
In short, this is my precious child and I would like solid medical evidence guiding their treatment, not politics or ideology.
No, my position is that actual doctors assessing evidence recognise that GAC on minors can have irreversible effects long-term (such as sterility) which minors may find difficult to assess against other questions in the moment. This is why the Cass Review suggests thorough exploration of such minors' understanding of effects through talking therapy.
And what have I done about FGM? I've voted for parties which have made it illegal in the UK. I haven't so far been asked to go out on any raids against those carrying it out, but those invitations don't seem to be extended to ordinary members of the public. What an oversight, denying me my human rights.
Re male circumcision, the health effects are minimal though long-term studies suggest male circumcision has notable health benefits (lower risk of HIV and STI transmission) and may lead to increased pleasure for sexual partners, so it doesn't seem like something to campaign against. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684945/
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.
"It may not be robust, but it exists". No. If it's not robust, then it can be simply the result of chance outcomes and/or bad study designs. The reason to restrict treatments that will certainly have irreversible long-term detrimental effects (sterility among others) when you're uncertain of the benefits should be self-evident.
There is no evidence at all to show that cis children are erroneously given these treatments.
The number of those who receive them all minors and later change their mind is minuscule, far too low to suggest any systematic problem.
At the same time, there is real, actually observable harm being caused to transgender children who are denied care.
Being forced to go through the wrong puberty also causes irreversable damage. It causes severe distress and can lead to suicide.
Even in the best case it sets someone up for a long and painful journey of having to correct these outcomes latet.
The theoretical harm to those theoretical children, that has never been demonstrated to exist cannot and must not be used to excuse causing actual harm to transgender children.
Why are people so concerned about the former kind of harm, but happy to accept the latter as collateral damage?
“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.
Dhejne’s papers or, even better, her doctoral dissertation as a whole, is a good place to start. But you won’t even Google scholar search for her papers. And if you do, you’ll come back saying that you can’t access the research because you don’t have access to scientific journals. You’ll then say that we haven’t shown you the literature unless we break the terms of service and send you a copy of the paper. You won’t have dug deep enough that you’d have realised that Dhejne’s dissertation is freely available.
Thanks for pointing me to the name, Dhejne. I’ll look it up.
And it is quite arrogant of you to assume everything you say in every sentence after that. Like I said, I’m not here to argue. I’m here to learn. Maybe you could learn how to have conversions with people.
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.
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.)
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
Right, so we're now on to moving the goalposts. From your initial post (above) "with no comparison group". It seems that what you have moved the goalposts to is a randomized double-blind placebo controlled trial, which is a completely different discussion.
Can we agree that your initial objection was at the least poorly-phrased?
You’re the one who said the majority of the literature had a “control group.” In fact, most don’t even have comparisons to patients with the same diagnosis. I don’t think you necessarily need a double blind RCT. However, you absolutely need some kind of meaningful comparison group. This could be as straightforward as kids of parents who do not consent to biological treatments. It could be as easy as a waitlist control group, although ideally with longer follow up than three months. What I think you’re missing is that these studies have no meaningful comparison group *at all.*
Imagine a wizard transports you to a parallel universe just like ours, except in this universe you can be certain that I am right and gender affirming care does not work. In this universe, would you expect the results of these studies to be any different? The point I am making is that you would not, because these results are completely explainable by the placebo effect.
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.
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.
Health nerd dissected a fresh (2024) paper from Finland where the abstract said transition isn’t helping but the numbers show a difference. Don’t remember the name of the first author but Kaltiala is the last author so it’s partially anti-trans tripe, as you’d expect from someone in open collaboration with SEGM and genspect. So that’s the easiest way to find the most relevant Finnish paper: check the articles here :)
I think Dhejne would have been at least a co-author of the Swedish paper im thinking of and that’s one of the papers where they find low, low, rates of surgery regret.
You might not know it but people actually regret elective routine surgeries at a pretty high rate! The 1% — anything less than 5%, really — rate is phenomenally low.
And yes, it is reasonable to believe that the long wait times before surgery contribute to the low rate of regret.
But then, you meet people who’ve been on hormones for 3 or 5 or 10 years and they still don’t know if they want it. And people who know from day 1 and are just doing time until the earliest possible date.
This is very much a branch of medicine where stats can be useful but can also be super misleading. Clinical evaluation and follow-up to see how the patient is doing plus therapy to cope with the changes (the earlier the transition the less to process as a rule of thumb) and so on.
I do agree that if you’re not trans, then hormones can be at best an illuminating experience, but to us, it’s iatrogenic harm, even if you learn something valuable from how it feels to have messed up hormones.
I wish we’d invest in refining the brain imaging methods so we could differentiate between different aetiologies and fast-track those whose life trajectory is most impacted by early transition while giving time to reflect for those who are better served by that. As it is, it’s one size fits all, which is not optimal. (But cost optimisation says we go with 1size4all! Gotta love new public management in health care!)
For the Dhejne one you are thinking of I think I saw the one where they compared regret rates with plastic surgeries (actually, I’d already seen that one), but I thought it wasn’t the one you intended. If I understood correctly the first time I looked at the study, it compares regret rates for gender-affirming plastic surgeries to other types of plastic surgeries. That is, it didn’t look at regret for non-cosmetic surgeries such as vaginoplasty. I might have misread it.
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.
Remember that trans adults were trans kids once.
The percentage of us who were able to access and received gender-affirming care and minors and then went on to transition is overwhelmingly high.
Regret rates for minors are low.
There are now trans people in their 40s who transitioned as minors.
This has never been a problem.
The countries that are now making it harder or impossible to access such care are doing so for political reasons, not medical ones.
Is it your position, then, that a 16-year old doesn’t know themselves well enough to know if they feel better on hrt, or that they can’t make that choice because they aren’t legally competent?
If the former, how do you propose we assess legal minors in psychiatric context, you’ve just said they can’t judge how they feel? Or just in the case of your ordinary appendicitis?
If the latter: why is a 16-year old legally competent to make the choice whether or not to become a parent? Those choices are sometimes made with less reflection, less support from a mental health professionals and they always severely impact a third party, the child.
What have you personally done to criminalise all genital mutilation of minors, sometimes called female or male circumcision? That is a body modification without any therapeutic benefit to the child, completely irreversible and done without even the less full consent a child can give. If well-being of children and not doing irreversible stuff to kids they can’t competently consent to is your concern, we’re talking sun vs moon in scale here.
I am the parent of a 16-year-old about to turn 17-year-old who identifies as transgender. Yes, I do doubt their judgement. Unlike the more clear cut cases where a child has clearly shown transgender traits since early childhood, my teen has only started feeling that they are transgender about 7 months ago.
If we do get approved for hormones, I do worry about my child having short-term feelings of life getting better at the expense of long-term happiness. It’s the age-old parental concern that my teen might feel like something makes them happy but they don’t have the long-term perspective. Anyway, we are practicing “watchful waiting” and trying to do the right thing. Our teen will be 18 soon, and legally an adult, although we would still be the ones paying for treatments and insurance after 18.
I would like to see studies that go beyond checking back on children on hormones only one or two years later. I would like to see long-term data, but that’s hard when the first teens in the recent surge are still in college and haven’t yet launched into the real world.
In short, this is my precious child and I would like solid medical evidence guiding their treatment, not politics or ideology.
No, my position is that actual doctors assessing evidence recognise that GAC on minors can have irreversible effects long-term (such as sterility) which minors may find difficult to assess against other questions in the moment. This is why the Cass Review suggests thorough exploration of such minors' understanding of effects through talking therapy.
And what have I done about FGM? I've voted for parties which have made it illegal in the UK. I haven't so far been asked to go out on any raids against those carrying it out, but those invitations don't seem to be extended to ordinary members of the public. What an oversight, denying me my human rights.
Re male circumcision, the health effects are minimal though long-term studies suggest male circumcision has notable health benefits (lower risk of HIV and STI transmission) and may lead to increased pleasure for sexual partners, so it doesn't seem like something to campaign against. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684945/
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?
"It may not be robust, but it exists". No. If it's not robust, then it can be simply the result of chance outcomes and/or bad study designs. The reason to restrict treatments that will certainly have irreversible long-term detrimental effects (sterility among others) when you're uncertain of the benefits should be self-evident.
There is no evidence at all to show that cis children are erroneously given these treatments.
The number of those who receive them all minors and later change their mind is minuscule, far too low to suggest any systematic problem.
At the same time, there is real, actually observable harm being caused to transgender children who are denied care.
Being forced to go through the wrong puberty also causes irreversable damage. It causes severe distress and can lead to suicide.
Even in the best case it sets someone up for a long and painful journey of having to correct these outcomes latet.
The theoretical harm to those theoretical children, that has never been demonstrated to exist cannot and must not be used to excuse causing actual harm to transgender children.
Why are people so concerned about the former kind of harm, but happy to accept the latter as collateral damage?
“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?
Dhejne’s papers or, even better, her doctoral dissertation as a whole, is a good place to start. But you won’t even Google scholar search for her papers. And if you do, you’ll come back saying that you can’t access the research because you don’t have access to scientific journals. You’ll then say that we haven’t shown you the literature unless we break the terms of service and send you a copy of the paper. You won’t have dug deep enough that you’d have realised that Dhejne’s dissertation is freely available.
Is it the study discussed in this article, where Dhejne looked at how many people in Sweden applied for surgery to detransition back to their original assigned sex? https://www.sciencenordic.com/forskningno-gender-sweden/few-swedes-regret-sex-reassignment-surgery/1448218
Thanks for pointing me to the name, Dhejne. I’ll look it up.
And it is quite arrogant of you to assume everything you say in every sentence after that. Like I said, I’m not here to argue. I’m here to learn. Maybe you could learn how to have conversions with people.
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.
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.)
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
Right, so we're now on to moving the goalposts. From your initial post (above) "with no comparison group". It seems that what you have moved the goalposts to is a randomized double-blind placebo controlled trial, which is a completely different discussion.
Can we agree that your initial objection was at the least poorly-phrased?
You’re the one who said the majority of the literature had a “control group.” In fact, most don’t even have comparisons to patients with the same diagnosis. I don’t think you necessarily need a double blind RCT. However, you absolutely need some kind of meaningful comparison group. This could be as straightforward as kids of parents who do not consent to biological treatments. It could be as easy as a waitlist control group, although ideally with longer follow up than three months. What I think you’re missing is that these studies have no meaningful comparison group *at all.*
Imagine a wizard transports you to a parallel universe just like ours, except in this universe you can be certain that I am right and gender affirming care does not work. In this universe, would you expect the results of these studies to be any different? The point I am making is that you would not, because these results are completely explainable by the placebo effect.
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.
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.
Not a mention of the leaked WPATH files.
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”?
Health nerd dissected a fresh (2024) paper from Finland where the abstract said transition isn’t helping but the numbers show a difference. Don’t remember the name of the first author but Kaltiala is the last author so it’s partially anti-trans tripe, as you’d expect from someone in open collaboration with SEGM and genspect. So that’s the easiest way to find the most relevant Finnish paper: check the articles here :)
I think Dhejne would have been at least a co-author of the Swedish paper im thinking of and that’s one of the papers where they find low, low, rates of surgery regret.
You might not know it but people actually regret elective routine surgeries at a pretty high rate! The 1% — anything less than 5%, really — rate is phenomenally low.
And yes, it is reasonable to believe that the long wait times before surgery contribute to the low rate of regret.
But then, you meet people who’ve been on hormones for 3 or 5 or 10 years and they still don’t know if they want it. And people who know from day 1 and are just doing time until the earliest possible date.
This is very much a branch of medicine where stats can be useful but can also be super misleading. Clinical evaluation and follow-up to see how the patient is doing plus therapy to cope with the changes (the earlier the transition the less to process as a rule of thumb) and so on.
I do agree that if you’re not trans, then hormones can be at best an illuminating experience, but to us, it’s iatrogenic harm, even if you learn something valuable from how it feels to have messed up hormones.
I wish we’d invest in refining the brain imaging methods so we could differentiate between different aetiologies and fast-track those whose life trajectory is most impacted by early transition while giving time to reflect for those who are better served by that. As it is, it’s one size fits all, which is not optimal. (But cost optimisation says we go with 1size4all! Gotta love new public management in health care!)
For the Dhejne one you are thinking of I think I saw the one where they compared regret rates with plastic surgeries (actually, I’d already seen that one), but I thought it wasn’t the one you intended. If I understood correctly the first time I looked at the study, it compares regret rates for gender-affirming plastic surgeries to other types of plastic surgeries. That is, it didn’t look at regret for non-cosmetic surgeries such as vaginoplasty. I might have misread it.
Thanks, I will add Health Nerd’s review of the Finnish research to my list of things to read.
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.