Sex is Messy
Transgender issues are a hot political topic these days, and I think that is both understandable and appropriate. The first time I remember thinking much about this issue was in 2016, when I first ran for Congress, and bathroom bills were a particularly pressing concern. Since then, this brave new world has expanded exponentially, and, I think, haphazardly. The GOP-lead Iowa legislature has proposed a number of statutes that would address various aspects of transgender care as it applies to our youth, and I am supportive of some of those efforts; not as former politician, but as a physician and parent.
About two years ago, I began reading reports of transgender care providers speaking out against questionable care they observed being provided in their clinics, and hearing tragic stories of youth who had received “gender-affirming” care, now regretting their choices, and opting to return, in as much as possible, to their birth sex. I decided to do a deep dive into the scientific literature, eventually reviewing dozens of reports, probably close to one hundred, from the foundational studies on transgender care, to more recent, and more critical, analyses.
What I found was disturbing, with the literature providing what I believe is next to no support for much of our current “gender-affirming model” of care. Such care is currently being advocated by various governmental and medical institutions, from the Centers for Disease Control and Prevention, to the America Medical Association, the American Academy of Pediatrics, and the American Psychiatric Association. Still, in all the studies I have reviewed to date, I simply find no good justification for much of the care that is being rendered to our youth, to include puberty blockers, hormone therapy, and surgical procedures.
It’s not that studies purportedly supporting such treatment don’t exist; there are in fact many, but all are compromised by numerous shortcomings. None are randomized, in which similar patients randomly receive different treatments, and results are compared. None include a suitable control group with which to compare the efficacy of any treatment versus supportive care only. Most are compromised by small sample sizes, which inhibits the ability to draw statistically meaningful results. Some exhibit obvious bias in the reporting of their results, emphasizing the positives, however small, while downplaying or ignoring any negatives.
The “gold standard” of research would be a randomized, double-blinded, controlled trial. What this means is that researches would intake a bunch of subjects, in this case, youth presenting with gender dysphoria, would randomly separate them to receive different treatment regimens, with participants and researchers “blinded” (as much as possible, at least) to which participants were in which treatment or control groups. For example, some participants could receive supportive psychiatric care only, some with psychiatric care and social transitioning (wearing clothing of their chosen gender and going by different names and pronouns), and some with both of the above, plus puberty blockers and hormone treatment, when older and if appropriate.
If such a study were done, combining participants from multiple centers in multiple countries to ensure an adequate sample size, we might have a better idea of how best to care for our youth with gender identity concerns. No such study has been performed to date, however, and it has been argued that it would be unethical to perform such a study now, based upon the purportedly positive results of the research performed to date, which is a conclusion that I cannot comprehend.
Still, there are some conclusions we can reach with reasonable confidence based upon the research which that has been reported. First, for prepubescent youth who present with gender dysphoria, most will resolve that discrepancy before or during puberty, will accept their biologic sex, and will go on to be healthy adults. Therefore, for any children who present with complaints of gender dysphoria, I think the “watchful waiting” approach initially advocated in the “Dutch model”, where the modern era of transgender care originated in the 1980s and 1990s, is appropriate.
Second, we know from multiple studies that youth who present with complaints of gender dysphoria, particularly as adolescents, have a much higher incidence of mental illnesses than the general population, to include anxiety, depression, oppressive-compulsive disorders, autism-spectrum disorders, suicidality, and non-suicidal self-harm. Are these psychiatric conditions being misdiagnosed as gender dysphoria, such that if they were adequately treated, the dysphoria would resolve? Does the presence of gender dysphoria increase the likelihood of mental illness, especially anxiety and depression, due to family or social disparagement? Either option seems possible, at least in some circumstances, but neither has been proven.
Here, I support legislation from Iowa GOP lawmakers who have proposed mandating that parents be informed should their children and adolescents wish to present as a different gender, whether by dress, name, or pronouns. Sure, not all parents will be as supportive of their gender questioning youth as others might like; but, it should not be the decision of those unnamed others, or of school officials, who are not as intimately, legally, and morally responsible for their children, that matters, here. Furthermore, given the increased risk of suicide among youth with gender dysphoria, I can’t imagine why school districts would wish to accept potential legal liability by withholding such information from parents.
There also exists suggestive, but I don’t think conclusive, observations from the studies done to date. For example, in the past decade or so, there has been a marked increase in the number of youths presenting with complaints of gender dysphoria; and, while this could be due simply to greater awareness and acceptance, there also exist suggestive findings of a media effect, reported adverse influences of social media, and the possibility of a “social contagion effect”, particularly among peer groups of biological girls.
The most disturbing thing to me, however, has been the increasingly frequent stories of “detransitioners”, or those who received some degree of medial and/or surgical “gender reassignment”, now regret those decisions, and are attempting to return, to the degree that might be possible, back to their biological sex. A frequent refrain from these patients is that they had been suffering from various mental health concerns which were not addressed, and that they were instead diagnosed with gender dysphoria, and encouraged to pursue “gender-affirming” care as the solution to their problems.
While it is frequently claimed that such care is “totally reversible”, in fact, it frequently is not. Although not proven, it is thought that puberty blockers are not harmful, and the effects are largely reversible, if used only for a few years during puberty. But, if puberty blockers are followed by the administration of “cross-sex hormones”, androgens for biological females and estrogen for biological males, the results are no longer totally reversible. Some possible effects can include infertility, inability to experience orgasm, and a possible increased risk of various medical diseases, to include some cancers. And, obviously, gender-affirming surgical procedures are largely irreversible.
So, we know there are harms to gender-affirming care. Granted, there may be net benefits to such gender-affirming care, in that we are helping more than we are harming, but that has not been established. It also might be that there are some youth with gender dysphoria who would best treated with gender-affirming care, and others who might be best managed with watchful waiting, but that hasn’t been delineated, either.
As we know some of our children and adolescents are being harmed by gender-affirming care, and that the net benefit of said treatment has not been proven, I also support Iowa’s GOP-lead legislature’s proposal to ban gender-affirming care for our youth. Such a ban can always be revisited down the line, if high-quality scientific studies eventually confirm the benefit of such care. In other words, this ban is fully reversible, but the care some of our youth would otherwise receive might not be. Personally, I think that is a good trade, and is in keeping with a phrase that all doctors have learned, “first, do no harm”, or primum non nocere, in Latin.
I will conclude by pointing out that we are increasingly seeing push back within the gender care movement, itself. A queer (self-described) woman, married to a trans-man, who worked as a case manager at the gender clinic at Washington University in St. Louis, recently became a whistle-blower. Physicians and therapists long been involved in transgender care, are raising alarms, and frequently being criticized by advocates inside and outside of the clinical setting. And, several European countries, to include the U.K., Sweden, and Finland, are pausing or reviewing gender care in their countries, based upon concerns such as those highlighted above.
One of my favorite sayings from my first surgical residency was; “When it comes to medical innovations, never be the first one on the bandwagon, or the last one off.” I think that would be good advice here, too.
Chris
NB: In this post, I am focusing only on gender dysphoric youth, not transgender adults, and that I’ve attempted to address this issue from a purely scientific viewpoint, not an ideological one. The ideology versus knowledge aspect is important, and I plan to address that in future installments, particularly as it relates to medical care and education. Furthermore, this interesting area of study has impacts into other subjects, such as women’s rights, female sports, and the humanity of those rare individuals who are don’t clearly fall into either of the usual biologic sex binaries. I plan to be back with more, to include a curated list of useful references.
