Some Limitations of “Challenges in the Care of Transgender and Gender-Diverse Youth: An Endocrinologist’s View”

J COHN – 24 December 2022 – SEGM

Discussion

Currently, there is a dramatic rise in the number of young people seeking help for gender dysphoria and/or reporting trans-identification. There is a dearth of understanding of both gender dysphoria and how to best support young people dealing with it; Rosenthal (2021) rightly recognizes there are “gaps in knowledge” (p. 589). Given the accompanying significant expert disagreements (including how to distinguish transient gender dysphoria), and one treatment option offering serious lifelong medical intervention with unclear outcomes and often irreversible consequences, decisions about treatment are fraught and ethical informed consent is crucial. Levine et al. (2022) discuss how properly informed consent for the care of gender dysphoric and trans-identified young people is currently impeded by “erroneous professional assumptions; poor quality of the initial evaluations; and inaccurate and incomplete information shared with patients and their parents.”

These erroneous professional assumptions are in part caused by the many inaccurate or unsupported statements which have appeared in the peer-reviewed research literature, which often then get repeated and distorted (Clayton et al., 2021). For example, Cantor (2020) found that Rafferty et al. (2018) misrepresented their cited evidence in order to support the adoption of the affirmative model by the American Academy of Pediatrics. Above, many omissions and limitations in the Nature review by Rosenthal (2021) are discussed. These issues undercut the five key points upon which his review rests and could lead to inaccurate estimates of risks and benefits of medical intervention and a lack of awareness of (possibly more appropriate and less invasive) non-medical or psychiatric alternatives.

Many similar omissions and limitations are present in another review currently available only in preliminary form by Lee and Rosenthal (2023). This second review quotes additional references for evidence of benefit, including a double mastectomy study with a too short (1–5 year) follow up time, high loss (28%) to follow up and an unvalidated scale, for improvement of “chest dysphoria.” In support of mental health improvement with medicalization, the second review quotes two additional recent papers which cannot show cause and effect (Green, DeChants, Price, & Davis [2022] and Turban, King, Kobe, Reisner, & Keuroghlian [2022], see Biggs, et al. [2022a] for discussion of further limitations of Turban et al. [2022]).

Beyond this second review, many of the issues highlighted in Rosenthal (2021) are in common with statements and policies espoused by others who also emphasize medical intervention (sometimes along with social transition). The US HHS office of Population Affairs (2022) and the American Academy of Pediatrics (Rafferty et al., 2018) also both fail to note that mental health or other noninvasive interventions may help gender dysphoria resolve even in the absence of medical intervention or social transition. Rosenthal’s (2021) inaccurate claims that studies demonstrate mental health benefit of medical intervention are echoed widely (e.g, see the US HHS office of Population Affairs, [2022] and AusPATH, [2022]; the latter was rebutted by Clayton, et al., [2022]). The Endocrine Society (2020) position statement also downplays or omits many of the known serious physical dangers of medical intervention and also inaccurately claims evidence “demonstrating a durable biological element underlying gender identity” (see Malone, Hruz, Mason, Beck, et al. [2021] for a rebuttal of many of its points). The regret and detransition rates are also inaccurately claimed to be low in section 5.7 of WPATH’s new version 8 guidelines (Coleman et al., 2022). These new version 8 WPATH guidelines also do not mention the NICE (2020a; 2020b) evidence reviews, similar to Rosenthal (2021); they also omit the Swedish (Swedish National Board of Health & Welfare, 2022) and Florida (Brignardello-Petersen & Wiercioch, 2022) evidence reviews appearing after Rosenthal (2021) and state: “Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible. A short narrative review is provided instead” (Coleman et al., 2022, p. S46).

This direct comparison of evidence in the research literature with Rosenthal (2021), a review containing omissions and limitations also found in other prominent sources, may make it easier for practitioners, patients and their families to understand the current state of knowledge, including where uncertainties and controversies exist. In addition, it is hoped that more awareness of these uncertainties will increase support for follow-up studies of the large number of young people who have already begun lifetime medicalization, in order to capture outcomes at or beyond the observed average regret times, which range from 3 to 10 years in studies of different cohorts. Systematic outcome studies are badly needed. Similarly, the resolution of gender dysphoria via psychological intervention for some, who then avoid lifetime medicalization including risks to fertility, sexual function, and longevity, motivates support for studies to improve understanding and improvements to these non-medicalized and psychiatric approaches, and increased access to practitioners skilled in these methods (which may require increased training as well). And importantly, the substantial needs of detransitioners, a rapidly growing community, call for research as to how to help them, including psychological, medical and financial resources and community recognition and support.

There are serious challenges in deciding how to best support those currently suffering gender dysphoria, given how little is known about this complex condition. Accurately describing what the evidence currently says and does not say, and what further evidence is needed, is crucial.

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