What’s Your Endgame?

By Sara Hertz

What do you think you are doing?

To those of you clinicians and researchers claiming that gender identity is biologically based, not malleable, that people should be affirmed or they will be harmed, that medicalization has been found to be reliably safe, effective, and prevents harm, that almost no one who embarks on medicalization regrets it, that puberty blockers are reversible and safe….

You know all of these statements do not have the evidence behind them, and that some are demonstrably false. 

You know there is no established robust biological underpinning to gender identity. If there were, one might conceive of a robust test for gender identity, but there is also no such thing.

You know gender identity does change for some people with gender dysphoria, but that social transition can prevent it from changing.  You know desisting is in fact the predominant (61%-98%) well documented outcome for childhood onset.  You know the paper you frequently quote saying otherwise was debunked immediately.¹ You know that studies which found that adolescent gender dysphoria tends to persist only referred to those with significant childhood onset.²

You know the argument that one should only affirm has numerous flaws.³ You know that ethical explorative psychotherapy is even advocated for in the papers upon which you base adolescent medical treatment, and is the traditional first line approach.⁴ Nonetheless, you often imply response options are limited to the (false) choice between affirmation and conversion therapy.

You know the classic study you quote to support adolescent and young adult medical treatments was only done on very carefully screened young people, who were nothing like the novel and rapidly exploding adolescent onset group being treated en masse right now.⁵  You know that no one knows the long term outcomes for people medicalized based upon (strikingly different⁶) affirmation. And you’re well aware it’s even unknown how the original carefully screened people did, either mentally or physically, after the honeymoon phase of a few years post surgery.⁷ 

You do know that, irrespective of the unknown mental health benefits, the physical risks of medical transition, from puberty blockers through surgery, are severe and significant.⁸

You know that the commonly quoted regret rates,⁹ used to reassure people who are considering medicalization, are not applicable to those now presenting with adolescent/young adult onset (different in symptoms, mental health, ages, treatment protocols).   You know that the relevant regret rates are entirely unknown.¹⁰ You know outcomes for some are catastrophic.

You know your one oft quoted and deeply flawed study of those who want and do not get puberty blockers only finds “associations” with lifetime suicidal ideation, not cause and effect.¹¹ In addition, that study only included those who currently identify as transgender, making it irrelevant for deciding whether to give puberty blockers to young people to “buy time”, i.e., who might desist instead.

And, although you claim it repeatedly, you know there is no study finding puberty blockers are safe and reversible for those whose bodies are starting correctly timed, not precocious, puberty. In fact, almost all who start puberty blockers continue to hormones, for these cases it is unknown how to preserve fertility (a “safe” side effect?). You know the bone density risks, and the lack of and conflicting evidence regarding mental health outcomes. 

You know that the UK, Sweden and Finland have found, via rigorous evidence reviews, that the evidence supporting medicalization is lacking, and have strongly restricted medical intervention.  You know the US Endocrine Society similarly found the evidence behind their recommendations to be almost all low quality, very low quality or ungraded,¹² and yet, do you tell people this?  

You know that these young people will not be developmentally mature until after age 25, and that they are thus less able, compared to mature adults, to estimate risk, understand long-term consequences, or predict their future interest in having children. That’s why hysterectomies, for example, are not freely available to them.¹³  

We know this.  You know this.  Your statements and articles are carefully worded, sometimes quoting “association,” not cause and effect, or saying “no genital surgery” on minors, when you know however, that breasts are cut off of 13 year olds, or mentioning suicide when discussing medical intervention, but not saying how the two are related, because the evidence isn’t there.

You inaccurately frame evidence-based scientific discussion of treatment uncertainties and dangers as transphobic and anti-science.¹⁴  Noting the above facts and uncertainties does not make someone anti-trans, any more than saying one should not perform open heart surgery for chest pain without careful consideration of risks and options means you are “anti” those who have had open heart surgery (“anti-cardiac patient”).  It’s ludicrous.

You know all this.  So do we. The public does not.  Maybe more importantly, many clinicians do not, and think they have to listen to you, and to send their patients to “experts” for which there is in fact no accreditation, on top of the poor quality of the evidence.  The patients who only hear statements such as those above are misinformed as they make serious life-changing decisions about (often irreversible) treatment.

So, what’s your endgame?

You can tell people all these things, and they will believe you. You can word it very carefully to get around your lack of supporting evidence.  

People who hear these things are acting on them.  They trust you. Vulnerable young people are starting on a lifetime of aggressive medicalization without learning there are major outcome uncertainties, dangers, and, importantly, other promising alternatives.  Young people who could have perhaps resolved their gender dysphoria by instead starting with supportive explorative psychotherapy or other mental health interventions, or who may have even simply grown out of it.

What do you think is going to happen to them?  What do you think you are doing?

Do you believe that your carefully worded insinuations about how it is helpful to permanently medicalize a young person will change the truth of whether it is appropriate for them? Even though there is no robust evidence that this helps people like them? And even though you know that those with other significant mental issues (a large fraction of currently presenting adolescents and young people) were, for good reason, carefully screened out of the studies used to justify adolescent medicalization?

You can mislead the public, your colleagues, and the people who believe you and undergo treatment, but if they are getting the wrong treatment, they are getting the wrong treatment.  

No matter how much you say “oh, I didn’t say it caused suicide, just that it was associated.”

What is going to happen to these distressed and misinformed young people, sometimes sterilized before they are even old enough to smoke or drink?  Who are being put on dangerous lifetime medication which attacks their fertility, sexual function, heart, brain, bones, and more, having their healthy bodies surgically, irreversibly, altered? Those who could have been healed with appropriate mental health support, and time? 

It doesn’t matter if you use your plausible deniability words to make it sound like lifetime medicalization is what they need.  Your words and your lies…do not change reality.  

They are going to have to live this reality, these consequences, in their medicalized bodies, for the rest of their lives.  No matter whether you were so careful when you spoke that no one can sue you.  

Have you thought about what is going to happen to them?

We have. 

We’re their parents.

References:

1. That paper seems to question whether studies to count the numbers of desisters should be done at all.
2. Only adolescents with childhood (<12) onset noticeable enough to be taken to a clinic for evaluation were studied for persistence. These studies did not include those with adolescent onset. The classic study of medicalization of adolescents and young adults required childhood onset, in fact, “lifelong extreme gender dysphoria,” to participate.
3.  Including falsely conflating gay & trans and misrepresenting the literature. An often quoted paper, also flawed, only finds “association” with poor outcomes, using a vaguely defined recalled encounter in a biased study.
4. Many mental health issues (including OCD, trauma, depression, ASD) can cause gender dysphoria, which is why many recommend addressing mental health concerns first, as this sometimes heals the gender dysphoria as well.
5. Other studies have, e.g., no longer statistically significant results (p>0.05 for all but 1 of 12 measures, CESD-R for MTF on puberty blockers) once you control for counseling & psychiatric medication, or note they can “not provide evidence about the direct benefits of puberty suppression over time and long-term mental health outcomes“ or (adults) are later corrected.
6. Here is what affirmation looks like.
7. Only one Dutch Protocol participant was followed up at least the (average time seen with screened older cohorts of) 8–10 years to regret. At 22 years later, he had “shame about his genital appearance.”   8
8. Risks to fertility, heart (and here), blood clots, bones (and here), brain (and here, here), immune system, etc.
9. Mostly with huge uncertainties from being too short term, with large loss to follow-up, etc.
10.  Some falsely claim regret is only due to discrimination, rather than regretting medicalization.  It is unknown how many detransitioners there are with each reason.  You know many may not speak up, as they report rejection because they regret.
11. “Limitations include the study’s cross-sectional design, which does not allow for determination of causation” (source is here), but readers are not told that important detail when the result is quoted.
12. GRADES: 14 low quality, 5 very low quality, 6 ungraded good practice, 3 moderate quality (counsel fertility preservation, address medical conditions which interfere with taking hormones, confirm diagnosis).
13. You know they can nonetheless access these treatments without evaluation or referral from a mental health specialist once they are over 18.
14. You know that it is both accurate and not anti transgender to point out that 1) misinformed young people are rushing into medicalization, 2) the evidence base is weak, 3) other less invasive and less dangerous treatments, which you are discouraging, are known to sometimes help, and 4) medicalizing has significant physical dangers and produces an unknown number of poor mental health outcomes. See concerns about the ability of clinicians to freely discuss treatments, described by Dr. Edwards-Leeper on 60 minutes. 

Originally published at https://pitt.substack.com/p/jaccuse reproduced by kind permission.