i appreciate the source. but speaking of politics and money driving medical policy, the author of this study, alison clayton, is associated with the society for evidence-based gender medicine (SEGM), a small group of anti-trans activists and medical professionals who promote their own method,
gender exploratory therapy (indistinguishable from conversion therapy) as a replacement for gender affirming care for anyone under 25. there are currently, to my knowledge, zero studies about the efficacy of gender exploratory therapy, but nevertheless its promoters gain financially and politically from casting doubts upon the evidence base for gender affirming care. in-depth explanation of the various connections within anti-gender affirming care lobbying
here. so just keep that in mind with stuff like this ;]
i'm not gonna go through the whole paper simply because that's a massive time sink but i do have a few thoughts
providing psychosocial care
replaced by
GAT
The previous “common practice” of providing psychosocial care only to
those under 18 or 21 years (Smith et al., 2001) has largely been
replaced by the gender affirmative treatment approach (GAT), which for
adolescents includes hormonal and surgical interventions (Coleman et al., 2022).
this sentence is very bizarre. the smith et all study was a follow-up study comparing the outcomes of treatment vs. non-treatment of "adolescent transsexuals". their findings state "Postoperatively the treated group was no longer gender-dysphoric
and was psychologically and socially functioning quite well. Nobody
expressed regrets concerning the decision to undergo sex reassignment.
Without sex reassignment, the nontreated group showed some improvement,
but they also showed a more dysfunctional psychological profile." their conclusions state "Careful diagnosis and strict criteria are necessary and sufficient
to justify hormone treatment in adolescent transsexuals." so obviously psychosocial care only wasn't always provided to those under 18 or 21 because her own source literally states that this wasn't the case, and those that received medical treatment had better outcomes than those who only received psychosocial care? clayton then cites the WPATH standards of care version 8, which exhaustively layout a process for careful diagnosis of gender dysphoria and strict criteria for treatment in minors, including psychosocial care, but uses this to support her claim that psychosocial care has been replaced by GAT. like what?
Placebo Effect
at no point in this entire article does she actually provide evidence for the notion that gender affirming care has a placebo effect on gender dysphoria, she just argues that it
could, and that that's
bad. but one fact that she chooses to leave out entirely is that it is literally impossible to demonstrate a placebo effect for GAC because the changes are physical and visibly noticeable, which is the point. you can not have a placebo effect or placebo-based trial when it becomes clear right away who is receiving the placebo and who is receiving the treatment, which is yet another reason why randomized control trials are virtually impossible for GAC, alongside the ethical concerns i explained earlier. the placebo effect is most noticeable and documented in psychiatric treatment where treatment involves altering brain chemistry, and you don't know if your brain chemistry is actually being altered, all you know is you're taking a pill and the pill is supposed to make you feel better. she goes over this fact in the article but fails to explain how a treatment that is necessarily physical/visual can also constitute a placebo effect.
Low evidence for the use of GAT to treat GD
as i've said multiple times before, not having RCTs and relying primarily on observational studies and cohort studies is not really uncommon for medicine but it is presented as if it is morally outrageous and a massive medical scandal.
"In fact, the record shows that less than 15 percent of medical treatments are supported by “high-quality evidence,” or in other words that 85 percent of evidence that guides clinical care, across all areas of medicine, would be classified as “low-quality” under the scale used by Defendants’ [the Defendants being the state of georgia] experts. [...] According to the GRADE Working Group, high-quality evidence is derived from randomized controlled trials and low-quality evidence is derived from observational study designs. [...] In this respect, then, the fact that only “low-quality” evidence is available to support hormone therapy reveals little in itself. The Endocrine Society has produced clinical recommendations based on “low quality” or “very low quality” evidence in several areas, and such evidence supports other treatments that are uncontroversial. For example, the Endocrine Society guidelines regarding treatment of “various aspects of the care of primary adrenal insufficiency, central hypopituitarism, pheochromocytoma and paragangliomia,” are supported by “low-quality” or “very low-quality” evidence, and the same grade of evidence supports treatments like the use of steroids to treat a child with croup and the use of puberty blockers in female cancer patients to preserve fertility while they undergo chemotherapy."
"Dr. Hruz suggested that the Court should disregard the body of research showing benefits of gender-affirming medical care for adolescents because it is low-quality research, and the studies have methodological limitations such as lack of a control group or cross-sectional design. The Court declines to do that. The Court finds that the quality of the evidence supporting gender-affirming medical interventions for adolescents with gender dysphoria is comparable to the quality of evidence supporting many other medical treatments minors and their families may pursue. And while the Court recognizes that the studies on gender-affirming medical care for adolescents, like studies in all areas of medical research, have strengths and weaknesses, it does not credit Dr. Hruz’s assessment that the entire body of research is, therefore, meaningless. The body of research, taken as a whole, shows these treatments provide significant benefits to adolescents with gender dysphoria."
-- from the legal findings in the court decisions to overturn the GAC bans in
georgia and
arkansas.
it also bears repeating that, while the evidence for GAC may be low-quality in this scale, the evidence to alternative treatments for gender dysphoria has significantly less evidence. previous common practices for GD treatment were not, as this article implies, well-researched and well-evidenced practices that were suddenly replaced by experimental procedures with no evidence. the majority of research about GAC has come out within the last 20 years.
Risks and concerns of Gender Affirming Medical and Surgical
Treatments
all of this is well-documented and this information is available in literally every single refill of my testosterone prescription i get. it also is not placed within context. for example:
- "Cross-sex hormones are associated with cardiovascular health
risks, such as thromboembolic, coronary artery, and cerebrovascular diseases" leaves out that trans people have higher risk of heart attack and stroke regardless of whether they take hormone therapy or not, so these health risks are likely partially due to minority stress, and that risk varies with the hormone (estrogen vs. testosterone) and the administration method (transdermal vs. oral). some of these risks are also just due to the hormone itself regardless of who is taking it (e.g. testosterone increases cholesterol, as well as hemoglobin and thus chances for blood clots)
- "Increase risks of certain cancers" leaves out that this is true for any hormonal treatment, not just cross-sex hormones, because sex hormones drive cell division.
it also fails to mention that many cancer risks for cis people taking HRT do not exist for trans people. for example, estrogen increases the risk of cervical cancer, but trans women do not have cervixes. additionally, cross-sex hormones also significantly decrease the risks for certain cancers. androgen blockers significantly decrease the risk of prostate cancer, and testosterone causes the endometrium to atrophy which reduces the risk of endometrial cancer.
- "Studies done on animals indicate that puberty blockers may
impact the brain development & long-term memory deficits" leaves out that other studies on animals showed no effects at all or only effects on sex-typical behavior
- "Risks to sexual function for capacity of arousal and orgasm, testosterone may lead to vaginal atrophy and dyspareunia and for males there is concern for there being lack of genital tissue development if blockers were given early on." leaves out that rates of sexual dysfunction in trans women are similar to that of cis women (10-40%),
vaginal atrophy and dyspareunia
in trans men can be effectively managed using physical therapy and/or topical estrogen cream, and that there are methods of sex reassignment surgery for trans women who took puberty blockers. this article mentions the success of those procedures.
and so on.
The Dangers of an Exaggerated Suicide Narrative
claims of exaggeration are mostly based on people referring to GAC as "life-saving" and there supposedly not being enough evidence to back up the fact, as well as the fact that youth trans suicide is "rare". it is rare because suicide is rare. it is still markedly higher than the general population and overall risk for suicidal behavior is even higher. the article acknowledges that
any elevated risk of suicide is a problem, but then goes on to condemn "excessive" focus on "exaggerated" suicide risk. and to that i ask, when there are consistent reports of
40-50% past suicide attempts, and 80-90% past suicidal ideation, what would be an appropriate level of focus?
Framing any non-affirming treatment approaches as harmful, ineffective, and unethical
clayton claims "It is important to note that psychotherapeutic approaches for this group of patients are also based on limited evidence" which is a laughable way to word it. gender-exploratory therapy (which she recommends, surprise surprise) has zero studies. there are only a total of 15 studies on using psychotherapy alone for treatment of gender dysphoria. the majority of them are at least 40 years old, only 4 of them have sample sizes of more than 20, and all of them use outdated diagnostic criteria that lumped gender-nonconforming people with trans people. "success" at resolving gender dysphoria was very inconsistent. studies overview is
here. keep in mind that this overview was put together by an anti-trans advocacy group and it was still the best they could come up with. but this is deliberate and ideologically motivated framing; if you say that GAC has limited evidence, and then say that alternative approaches also have limited evidence, it seems like a level playing field when that could not be farther from the case. people also do this with climate change.
Clinicians’ Media and Social Media Promotion of Gender Affirmative Treatment
this section is primarily supported by the idea that gender dysphoria is a social contagion, a phenomenon termed rapid onset gender dysphoria (ROGD). ROGD as a concept was based on a questionnaire filled out by parents of gender dysphoric children who were recruited from gender-critical/transphobic online communities who claimed that their children's dysphoria was because of the internet. the theory has been
condemned by most major medical organizations and the journal that published the article retracted it and apologized. the majority of trans children begin questioning their gender 2+ years before they tell someone, let alone seek treatment. there is
literally no evidence for the social contagion theory.
anyway, thanks for the source! this type of engagement and discourse is good!
