Spoiler One of the biggest changes in scores was a 9-pt increase in the “global functioning” (CGAS). Yet the score remained in the same range of 71-80 (see below). Does such a result justify the use of interventions that rendered 100% of the youth sterile? Since the youth in the study had good function at baseline, one could argue there was little room to improve. That's why another study finding—the elimination of gender dysphoria/GD—purports to be proof that the treatment worked. Yet a closer examination signals more problems. At baseline, females rated their gender dysphoria on the female version of the GD scale, but after surgery, they were given the male scale (and vise-versa). A cursory review of the questions betrays how switching the scales post-surgery can artificially reduce the GD score. Although the Dutch used the only available scale to them at the time and undoubtedly did not mean to mislead, the significant problems arising from the switching of the scales call for a reexamination of the study's main claim that the interventions resolved gender dysphoria. These profound limitations of the Dutch protocol are not discussed w/ patients & families, the authors argue. Nor are the families made aware that the entire body of evidence in gender medicine is of very low quality, which means the hoped-for benefits are highly uncertain./ The authors also point to problems with utilizing the emotive “dead son or live daughter” argument to rush families into transition. Recent research estimated the rate of suicide in trans-identifying youth at 0.03% over 10 years, similar to youth with mental health problems. The authors point out that treating suicidality in trans-identifying youth with transition is not an appropriate response. Gender dysphoric youth struggling with suicidality deserve access to evidence-based suicide-prevention protocols, just like all other struggling youth. The authors observe that the rapid rise in demand for gender reassignment in youth can pressure even the most well-meaning clinicians to bypass a thorough evaluation and provide the desired medical & surgical interventions following a “check the box” informed consent process. A central concept that is not communicated to patients and caregivers is the highly uncertain persistence of gender dysphoria in a young person. Undergoing "gender-affirming" interventions before maturity increases the risk of permanently medicalizing a transient identity. The authors urge clinicians to slow down and ensure that accurate and unbiased information about not just the benefits, but the significant risks & uncertainties of transition. These include issues related to bone health, brain development, cardiovascular issues, and regret. The authors recommend that information is shared in a way that promotes comprehension, and should extend to all stages of transition, incl. social transition. Because transition involves the entire family, family should participate even if the young person can legally consent. The authors concede, however, that given the young age of the patients, and the durable nature of the interventions, even the most comprehensive information sharing may not be sufficient for true informed consent, posing ethical dilemmas that clinicians cannot resolve.
Spoiler April 2022: Last week, the U.S. Department of Health and Human Services issued an official document, "Gender-Affirming Care and Young People." In a recent blog, SEGM fact-checked this important document and found an alarming number of errors and misrepresentations. SEGM also reflects on gaps in the process used by HHS to arrive at the conclusion that “gender-affirming” care must be scaled widely—at precisely the same time that a growing number of public health authorities (Sweden, UK, Finland) have come to the opposite conclusion. July 2022: Yesterday, the UK shut down the world's biggest pediatric clinic, GIDS. The reasons for the shut-down were not mere operational failures. The entire model of care provided by GIDS, "gender-affirming care," was deemed unsafe for gender dysphoric youth. The changes signal recognition of two key facts. First, the evidence to justify the general use of hormonal interventions in gender dysphoric youth is poor. Second, gender dysphoria is not an encapsulated condition, but one that must be treated in the context of other issues. September 2022: The wave of teens seeking gender transition in the UK continues to grow. According to the most recent data released by #GIDS and its new referral service, after a COVID dip, referrals doubled 2021-22, for a total of 5,000+ referrals. Teen girls continue to dominate this trend. October 2022: The NHS has ended "gender-affirming care" in England for <18s, according to the newly-released draft guidance. Psychotherapy will be the first & usually only line of treatment. Puberty blockers will be confined to research settings. November 2022: Why Europe is hitting the breaks on pediatric gender transition is clear. The evidence for benefits is highly uncertain. The risks are real. Infertility & sterility are a biological certainty. A better question is, why are the U.S. medical societies going full-steam ahead? November 2022: "GIDS" is the largest pediatric gender clinic in the world in the UK. Its graph was the first to demonstrate the recent sharp rise of gender dysphoria in youth (esp. teen females). GIDS is set to shut down in 2023 in large part due to failures of the "affirmative care model." [/URL] November 2022: A new article by The Economist explains England's move away from the affirmative care model, "which accepts patients’ self-diagnosis as the starting-point for treatment." As England is "tiptoeing away from a medical scandal," the U.S. is doubling-down. The U.S. gender medicine establishment has shown little curiosity about Europe's recent changes. The NHS guidance makes it clear that the model of "gender affirmation" has been rejected. Children with gender dysphoria are no longer viewed as "transgender children." Psychotherapy will be first line of treatment, hormones will be last. And yes, there will be data gathered. [/URL] December 2022: Yesterday, the Swedish Board of Health and Welfare published new treatment guidelines for youth with gender dysphoria. The guidelines explicitly instruct medical providers that psychosocial support should be the first line of treatment. The youth gender dysphoria treatment guidelines by the Swedish Health Authority explicitly advise: “Psychosocial support that helps the young person live with the body's pubertal development without medication needs to be the first option when choosing care measures.” (p. 33). Unlike Sweden’s prior guidelines which relied on WPATH’s “Standards of Care 7,” the new guidelines no longer rely on “Standards of Care” 7 or 8. Sweden appears to have parted with WPATH’s medical “affirmative care” model, in favor of a much more cautious treatment approach. The Swedish Health Authority “deems that the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases.” The English language summary lists three key reasons for the change: 1. Lack of reliable scientific evidence; 2. evidence of detransition (citing Littman’s 2021 research) and 3. unexplained sharp rise in prevalence of youth gender dysphoria (esp.female). The number of Swedish pediatric gender clinics will shrink from 6 to 3. Puberty blockers & cross-sex hormones will be provided only in research settings, to those with “classic” childhood onset of clear cross-sex identification, and only in exceptional cases. January 2023: In 2022, the movement to safeguard gender-dysphoric youth made pivotal ground. Sweden & England followed Finland in sharply curbing the provision of hormones & surgery. The year ended with a leading Dutch newspaper questioning the Dutch gender clinic. Sweden, Finland, England are now following the principles of evidence-based medicine.
Do you consider anything pertaining to "Pride" to be "sexualized"? This seems to be a stark dividing line amongst the culture warriors.
Spoiler March 2023: The Norwegian Healthcare Investigation Board, (NHIB/UKOM) has deemed puberty blockers, cross-sex-hormones & surgery for children & young people experimental, determining that the current “gender-affirmative” guidelines are not evidence-based and must be revised. Under the current Norwegian guidelines, youth may receive puberty blockers at tanner stage 2, cross-sex-hormones at 16, and surgeries at 18. The report noted that these widely available interventions are irreversible, carry many risks, and rest on insufficient evidence. The report criticized Norway’s current "gender-affirmative" guidelines as inadequate, noting a lack of specificity regarding assessment & determination of medical necessity of risky and irreversible interventions provided to youth whose identities are still forming. The Norwegian Healthcare Investigation Board noted several worrying trends: the rapid rise of gender dysphoria in adolescents (esp. females), the high burden of mental illness (75%) & a high prevalence of neurocognitive conditions (ADHD/autism, Tourette) in the affected youth. The recommendations by the Norwegian Healthcare Investigation Board (NHIB/UKOM) align Norway with the changes among the growing number of European countries (Sweden, Finland, England) which aim to safeguard youth from harm by sharply restricting youth gender transitions. However, unlike Sweden, Finland and England, Norway explicitly calls out the group of young adults whose development is still ongoing and who are at risk for erroneously undertaking gender transitions. The report notes that the age of consent for sterilization in Norway is 25. NHIB/UKOM notes that the right to medical care does not include the right to experimental treatments. As an experimental intervention, gender transitions will be subject to heightened scrutiny around informed consent, eligibility criteria, and outcomes evaluation. Norway's proposed model appears to resemble the model of care outlined in the Cass review. Gender dysphoric youth will receive care for their distress in local primary care settings with multidisciplinary support. Youth gender transitions will be an exception, not the rule. April 2023: Last week, @TheEconomist published a briefing that warns readers that “the evidence to support medicalized gender transitions in adolescents is worryingly weak.” The article reflects on the exploding numbers of gender dysphoric youth, the growing evidence of harm of youth gender transitions, and on the divergent views on the gender transition of minors between the growing number of European countries and the US. While most American medical associations support youth gender transition, they’re increasingly out of step with developments in Europe, where England, Finland, France, Norway and Sweden have reviewed the evidence and changed course. Finland warned that youth gender transition was “experimental,” while Sweden reported that the risks “currently outweigh the possible benefits.” All countries are now pumping the brakes, and shifting their focus from pharmaceutical and surgical interventions to psychotherapy. The Economist article also touches on a thorny ethical issue: the possibility that "gender-affirmation" inadvertently works as a form of "conversion therapy" for gay youth. In the foundational Dutch research, nearly all the youth were same-sex attracted, and all became sterile. It also quotes SEGM's Dr. Malone, who observes just how far the practice of youth gender transitioned has drifted from the original "Dutch Protocol." Severe mental health problems, common in dysphoric youth, went from a contraindication, to the main indication for transition. The article concludes that the American approach of gender transitioning youth at scale is not defensible: “it is impossible to justify the current recommendations about gender-affirming care based on the existing data.” An accompanying editorial from The Economist reflects on the politicization of healthcare for gender-dysphoric youth the US. Its title is: "What America has got wrong about gender medicine: Too many doctors have suspended their professional judgment." April 2023: A new article, Current Concerns About Gender-Affirming Therapy in Adolescents, provides an overview of the current state of evidence about gender transition in youth in the Western world and discusses the debates surrounding this controversial practice. The key challenge is the unknown long-term outcomes of gender-transitioning youth. Since transitioning minors was uncommon before 2015, systematic reviews of evidence of youth outcomes are limited by short-term followup. Long-term studies of adults, however, signal problems. In fact, the disappointing psychological outcomes of adult transitioners were used as the justification to begin the "intervention" earlier. This point is clearly made in the study of the first 22 adolescents transitioned by the Dutch clinicians. The UK, Finnish, and Swedish systematic reviews of evidence have all deemed the evidence of benefits of youth transitions as highly uncertain. The Swedish review from Feb 2022, just now published in a peer-reviewed English language journal, concluded: In response to the problematic findings from systematic reviews, a growing number of European countries are sharply curbing the practice of youth transitions. Yet, the U.S. narrative that "gender-affirming care is proven, safe and effective" has been remarkably immune to facts. The authors identify 10 key unproven or disproven assumptions that have allowed the practice of youth gender transitions to unduly proliferate in the West: The authors note an unusual "intensity of divisiveness" in the field of youth gender medicine, as the field attempts to answer the key question: "just because we can, should we?” The authors acknowledge that professionals on both sides of this debate believe they are acting in the best interest of the patient. They note that ultimately, the disagreement comes from a clash in value systems: The authors examine the claims of "low transition regret," noting that regret has been defined too narrowly by the current studies. Regret is a complex phenomenon, which can coexist with acceptance. They also point to the growing medical detransition rates, now at 10-30%. The authors reflect on the politicization of clinical questions relating to care for gender dysphoric youth, especially in the U.S. They urge the field of gender medicine to stop relying on social justice arguments and recommit to the principles of evidence-based medicine.
Spoiler April 2023: A systematic evidence review by the Swedish health authority has just been published in an English-language peer-reviewed journal. It concluded that puberty blockers & cross-sex hormones in <18s are not a medical treatment but experimental procedures. The review analyzed 24 relevant studies. The effects of puberty blockers & hormones on psychological health could not be ascertained due to the poor quality of the studies. Their review found problems with bone health, which partially resolved by age 22. The review's conclusion are sobering: the long-term effects of hormonal interventions on psychological and physical health are unknown, and there is evidence of adverse effects of puberty blockers on bone maturation. The review noted a number of problems in current studies: 1. A lack of quality study designs, which precludes reliable conclusions; 2. High dropout rates, which create selection bias and can mask adverse outcomes, especially when the results are aggregated; 3. Reliance on biological age, since puberty blockade stops biological maturity in adolescents; 4. Lack of long-term data for an intervention that is intended to be life-long; 5. Lack of information about the outcomes of youth who stop puberty blockers and detransition; The authors note that a number of the studies are old. They also opine that the methodological instruments typically used to critically appraise the studies and certainty of findings suffer from limitations when it comes to applying them to studies in youth gender medicine. The authors noted that they did not factor in what is known about GnRHA's (puberty blockers) effects for diagnoses other than gender dysphoria (e.g., precocious puberty, cancer, endometriosis). Nor did they consider known adverse effects such as hair loss from testosterone use. Another noted limitation is that the authors did not conduct an updated literature search after November 9, 2021. As a result, they are missing several studies, including an NIH-funded study by Chen et al. However, the results of that study would not change the conclusions. The authors note that the NIH study had data on only 162 of 315 original participants, echoing problems with high rates of dropout identified in other studies. The strongest finding was "a moderately improved appearance congruence," while other results were mixed. The authors make suggestions for improving the quality of research in gender medicine. They suggest that followup must continue to age 30. The authors also note that randomized trials are both needed and can be ethically done, as randomization doesn't need to rely on placebos. The authors propose several ethical research frameworks that allow for generating reliable information. One randomizes participants with respect to hormones but provides psychotherapy for all. Another creates comparison groups based on start dates of hormonal interventions. Like other Western countries, Sweden has seen rapid growth in youth gender dysphoria. The conclusion that youth gender transitions are not standard procedures but "experimental treatment of individual cases" positions psychotherapy as the main treatment modality for youth. As public health authorities work to curb on-demand youth gender transitions, Sweden's conclusion that youth gender reassignment is an experimental intervention will likely be widely adopted. This puts the pressure on those tasked with designing ethical research protocols. The fact that the public health authority in Sweden—the first country in the world to recognize the legal status of transgender adults—has called for randomized controlled trials of puberty blockers and cross-sex hormones for gender dysphoric youth is a watershed moment. Clarification: The SBU—which conducted this systematic evidence review, deemed puberty blockers and cross-sex hormones in <18s to be "experimental procedures" for "individual cases," and called for randomized controlled trials of these interventions—is Sweden’s state agency that assesses evidence and makes recommendations. It is up to the NBHW (Sweden’s NHS) whether to implement SBU's recommendations. Alright, I’m done. I think…
I just found the article very balanced and gives me confidence that we can reach some sort of common middle ground. I am not a fan of states putting doctors in prison.
It is my observation. There are a lot of white people that have very strong opinions on this topic. I don’t see the same energy on other issues or minority groups. Opponents are having some success causing issues between LGB and the TQ+ part of the alliance. I suppose that should be expected with such a wide net of people.
I'm gonna go out on a limb here and guess that the number of gay racial minorities lags behind as well, but is rising over time.
So in all of these studies it basically says that we should take things slow, start with psychiatric care/therapy and the perhaps move on to hormone therapy/surgery. They are not saying it isn't real and should not be treated. They say we should be more cautious and start with thereapy. I think most people agree with this. That is according to the studies coming out of Europe. Let's contrast to the right wing in the U.S. No gender affirming care and let's throw the parents in jail. Let's also compare the medical care in Europe vs the U.S. Profit gives one hell of a motive for hormones and surgery.
The entire premise of the right attacks on these doctors is that this methodical approach doesn't exist and these doctors approve lobbing dicks off like pot doctors handing out pot prescriptions in medically legal only states.
The WHO thinks differently, that it IS beneficial overall. Either way, male circumcision isn’t nearly the same as female circumcision.
There are doctors and clinics that are starting hormone treatment after a single visit - and that is ethically questionable. The article I posted discusses that there are doctors that are either overly profit motivated of overly zealous. This is all new terrain and it will take awhile before we have it all figured out.
HIV and also decrease in UTI’s. Someone that regularly cleans themselves, has active medical care and partakes in safe sex has only a small increase in medical concerns not being circumcised…. My friend who is a doctor said the issue they are running into is that a lot of boys and men do not properly clean or groom themselves and the foreskin is causing issues…. But ultimately circumcision should be voluntary and I suspect will be rare in 50-100 years.
Because the patient said they were and some doctors likely chose the path of least resistance. I mean if you were a skeptical doctor, directed the patient to more counseling, and the patient committed suicide...There will likely be hell to pay on your end even if you were performing due diligence. Maybe it doesn't go that far, rather a slanted tweet begins a downward chain of events. Changing a kid's life when there remains a reasonable doubt is pretty ****ed up. Some kids might need prescription drugs to function, but not likely in the millions prescribed for ADHD or depression today. Another major issue is that if the minority of the minority decides to detransition after doing GAC during puberty, all the king's horses and all the king's men can't put Humpty's eggs back together again. Better slot some freezer space kiddos... Even without bottom surgery, those puberty blockers are doing a huge number on them.
