Transgender issues and discussions

[Jeff Lebowski]

We need a dedicated thread. I am never sure where to put this stuff.

Interesting op-ed piece in the WSJ today signed by 21 doctors and clinicians from various European countries including Finland, Sweden, Norway, Belgium, UK, France, etc. They essentially say that the US model of "gender-affirming care" (hormones, surgery) for trans youth is not supported by evidence and many European countries are pulling back from that approach.

Every systematic review of evidence to date, including one published in the Journal of the Endocrine Society, has found the evidence for mental-health benefits of hormonal interventions for minors to be of low or very low certainty. By contrast, the risks are significant and include sterility, lifelong dependence on medication and the anguish of regret. For this reason, more and more European countries and international professional organizations now recommend psychotherapy rather than hormones and surgeries as the first line of treatment for gender-dysphoric youth.

On suicide prevention:

Dr. Hammes’s claim that gender transition reduces suicides is contradicted by every systematic review, including the review published by the Endocrine Society, which states, “We could not draw any conclusions about death by suicide.” There is no reliable evidence to suggest that hormonal transition is an effective suicide-prevention measure.

It may be behind a paywall, but you can get a decent summary in this thread:

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[Flystripper]

Thank you for sharing that. Not much to add here, but anecdotally there are a couple of loved ones in my life who have experienced significant body dysmorphia, which has let to them feeling some gender dysmorphia. For a preteen/teenager there is so much going on in their their body and phycological development that the introduction of surgery/hormone treatment would be like adding gasoline to a fire that is already raging. Go slow! Therapy has been helpful for those I love, but what has been most helpful is consistent expression of love and acceptance and participation in their therapy journey from their close inner circle who loves them and knows them the best.

[Moliere]

I'm no expert on any of this but it does seem that we are probably a couple years behind Europe and likely will end up in a similar place as them, which is probably a good thing. I do really like Bari Weiss' new podcast "Honestly" and would recommend this very recent episode on how the UK's NHS has recently made changes to their recommendations for gender-affirming care.

Latest Episodes | Honestly Podcast

[Shaka]

Spencer Cox actually had something to say on Face the Nation about how the data in the United States because the AMA etc. had become politicized.

https://www.youtube.com/watch?v=lrs9e6jzaNg

[Northwestcoug]

If anyone finds a free link to the opinion piece I'd like to see it. I'm going to be pretty skeptical until I see something more than an opinion piece claiming American standards of care are not following the science. Especially when it's pretty easy to see it's been cherry picked. According the the snippet Jeff posted:

Every systematic review of evidence to date, including one published in the Journal of the Endocrine Society, has found the evidence for mental-health benefits of hormonal interventions for minors to be of low or very low certainty. By contrast, the risks are significant and include sterility, lifelong dependence on medication and the anguish of regret. For this reason, more and more European countries and international professional organizations now recommend psychotherapy rather than hormones and surgeries as the first line of treatment for gender-dysphoric youth....

Dr. Hammes’s claim that gender transition reduces suicides is contradicted by every systematic review, including the review published by the Endocrine Society, which states, “We could not draw any conclusions about death by suicide.” There is no reliable evidence to suggest that hormonal transition is an effective suicide-prevention measure.

Is taken from an abstract, which states very clearly that:

Hormone therapy was associated with increased QOL, decreased depression, and decreased anxiety. Associations were similar across gender identity and age

They were up front with the inability to assess benefit with regards to suicide, and it's in the abstract.

Here's a recent consensus paper published by JAMA. You will find similar papers published by the national pediatrics and other associations.

1. Primary care
   • Transgender and gender diverse patients should receive nonjudgmental care from appropriately trained health care professionals. Gender-affirming primary care includes preventive care, mental health and substance use disorder screening, hormone therapy, and education about nonmedical/nonsurgical gender-affirming interventions.
2. Assessment of transgender and gender diverse persons
   • When the adult patient desires gender-affirming medical and/or surgical treatment (GAMST) that aligns physical characteristics with gender identity, this care should be offered when there is a marked and sustained difference between sex assigned at birth and current gender; there is capacity for informed consent; physical and/or mental health conditions that may be affected by GAMST have been assessed; and reproductive implications and options have been discussed.
   • Children and adolescents require a multidisciplinary approach, which considers developmental stage, neurocognitive function, language skills; offers mental health support; discusses risks and benefits of social transition; and includes parental/guardian involvement in GAMST in almost all situations.
3. Mental health
   • Any qualified health professional with the ability to identify gender incongruence may assess patients for GAMST. No more than 1 letter of recommendation is required for GAMST in adults.
   • Psychotherapy is not required before GAMST, although therapy may be helpful for some.
   • Therapy to change gender identity or expression is associated with increased suicide risk and should not be offered to transgender and gender diverse patients.
4. Medication
   • To improve psychosocial functioning and quality of life, clinicians should assess, and if appropriate, initiate and continue hormone therapy for eligible transgender and gender diverse people when it is required.
   • Eligible adolescent transgender and gender diverse patients may be offered hormone suppression after pubertal onset (Tanner stage 2) and menstrual suppression for eligible adolescents assigned female at birth, when testosterone is not yet indicated.
5. Surgery
   • Clinicians should counsel transgender and gender diverse patients seeking surgical options about associated risks and benefits unless surgery is contraindicated.
   • Qualified surgeons should have training and continuing education in gender-affirming procedures and should track their surgical outcomes.
6. Education
   • The health care workforce should receive transgender and gender diverse cultural awareness continuing education.
   • Health care training programs should include competencies in transgender and gender diverse health.

https://jamanetwork.com/journals/jam...rticle/2805345

I'm sure most will disagree with statement #4. But it is based on the literature. Go ahead and peruse the consensus paper. It is up front with the potential harms of gender affirming care. But the recent science is showing benefits for care, even in the adolescent population.

If there is a significant difference between the US and Europe wrt gender affirming care, I hope it's given the attention it deserves and doesn't get forgotten in an opinion piece.

[Jeff Lebowski]

It turns out the the op-ed in the OP of this thread is part 3 in series of letters to the editor of the WSJ. There is some back-and-forth going on with some doctors claiming that the Endocrine Society has gotten far too political and that their analysis of the data is politicized and incorrect. Stephen Hammes, president of the Endocrine Society, responded.

These are short, so I will just include them. Here is the first one that kicked everything off:

https://www.wsj.com/articles/the-endocrine-societys-dangerous-politicization-endocrinologists-gender-affirming-care-arkansas-dac768bd?mod=article_inline

The Endocrine Society’s Dangerous Transgender Politicization
Members we spoke with take exception to the group’s guidelines on ‘gender-affirming care.’

A federal court last week struck down an Arkansas law banning the provision of sex-change procedures—off-label “puberty blockers,” opposite-sex hormones and surgery—to minors. In the June 20 ruling, Judge James M. Moody Jr. repeatedly cited the Endocrine Society, the professional organization of physicians who specialize in hormones. He wrote that the society has “published widely-accepted clinical practice guidelines for the treatment of gender dysphoria” that “were developed by experts in the field” and “are recognized as best practices.”

In truth, over the past decade transgender activists have co-opted the Endocrine Society and other professional organizations to promote such treatments for adolescents and even young children. Their guidelines are based on flimsy evidence, giving the appearance that invasive and irreversible treatments are beneficial for young patients despite a growing body of evidence to the contrary. The guidelines have been used by lawmakers in states such as California and New York to endanger children—and now by judges to block state efforts at protecting youngsters.

A few days before Judge Moody’s ruling, we attended the annual meeting of the Endocrine Society, of which one of us (Dr. Eappen) is a member. We found that endocrinologists are aware of the society’s failings and rue its elevation of transgender activism over medical expertise and patient needs.

The Endocrine Society endorsed medical “transition” for young people in 2017. It published the “clinical practice guidelines” for the “treatment of gender-dysphoric/gender-incongruent persons” that Judge Moody cited. At the time, there was little good research on this issue, and the Endocrine Society admitted the guidelines were largely based on evidence of “low” or “very low” quality. The society nonetheless recommended that some children receive a “hormone regimen that will suppress the body’s sex hormone secretion, determined at birth and manifested at puberty.”

At this year’s meeting, we had frank and fruitful discussions with endocrinologists who provide hormonal treatments to kids with gender dysphoria, as well as some who don’t. Without exception, they acknowledged that the society’s evidence base for pediatric gender transition is weak, at best. Yet while they’re aware of the guidelines’ shortcomings, they’re afraid to voice their concerns. The society’s full-throated endorsement of gender-affirming care implied condemnation of anyone who holds differing views. Medical professionals are being cowed into silence and coerced into providing treatments they know are dangerous to children.

Perhaps the most telling interactions were with European endocrinologists, who were there to discuss the latest research and treatments in the specialty. Those we spoke with expressed surprise that the U.S. hasn’t banned, or at least severely restricted, such treatments for adolescents and children.

England, Sweden and Finland have all taken this path, and Norway is likely to follow. Belgium, France, Ireland and Italy are also raising concerns. These countries are following the science, which shows that the claimed benefits of hormonal intervention for young people fail to outweigh the risks.

Most disturbing, endocrinologists on all sides of this debate told us that practitioners aren’t complying with the precautions set forth in the society’s guidelines. Despite the document’s call for careful mental-health screening and its acknowledgment that most cases of childhood gender dysphoria naturally resolve during puberty, endocrinologists recognize that some of their peers are rushing young patients to irreversible hormonal treatments. Every endocrinologist we spoke with supports doing more to ensure that these guardrails are enforced, and many favor erecting new ones.

Judge Moody’s ruling cites the Endocrine Society’s guidelines in a lengthy section titled “Findings of Fact,” which is essentially a recitation of transgender ideology. A trial judge’s findings of fact are all but unreviewable on appeal. By allowing ideologues to hijack their organization, endocrinologists are making themselves complicit in a scientifically baseless movement that inflicts serious harm on children’s physical and mental health.

Dr. Eappen is a practicing endocrinologist in Montreal and a senior fellow at Do No Harm. Mr. Kingsbury is Do No Harm’s research director.

Here is the response by the president of the Endrocine Society:

https://www.wsj.com/articles/trans-gender-affirming-care-endocrine-society-evidence-fdb8562c?mod=article_inline

Endocrine Society Responds on Gender-Affirming Care
It improves the well-being of transgender and gender-diverse people.

Roy Eappen and Ian Kingsbury’s op-ed “The Endocrine Society’s Dangerous Transgender Politicization” (June 29) ignores scientific evidence and the conclusions reached by the American Medical Association, the American Academy of Pediatrics and other reputable medical organizations. More than 2,000 studies published since 1975 form a clear picture: Gender-affirming care improves the well-being of transgender and gender-diverse people and reduces the risk of suicide.

Based on this evidence, the Endocrine Society developed our clinical-practice guideline through a rigorous process adhering to the Institute of Medicine’s highest standards of trustworthiness and transparency. All 18,000 members had an opportunity to be heard during our extensive vetting process. Based on much of the same evidence, federal judges in Tennessee, Kentucky and Florida have joined the Arkansas judge in striking down bans on lifesaving gender-affirming care.

Do No Harm, the organization with which Messrs. Eappen and Kingsbury are affiliated, produced model legislation used to ban gender-affirming care in Arkansas and two other states, according to the Associated Press. It seeks to keep in place bans fueled by misinformation. It is quite clear who is motivated by politics and who relies on scientific evidence.

Stephen R. Hammes, M.D.
President, Endocrine Society

And finally, here is the response by the groups of doctors/clinicians in Europe:

https://www.wsj.com/articles/trans-gender-affirming-care-transition-hormone-surgery-evidence-c1961e27

Youth Gender Transition Is Pushed Without Evidence
Psychotherapy, not hormones and surgery, is increasingly the first line of treatment abroad.

As experienced professionals involved in direct care for the rapidly growing numbers of gender-diverse youth, the evaluation of medical evidence or both, we were surprised by the Endocrine Society’s claims about the state of evidence for gender-affirming care for youth (Letters, July 5). Stephen Hammes, president of the Endocrine Society, writes, “More than 2,000 studies published since 1975 form a clear picture: Gender-affirming care improves the well-being of transgender and gender-diverse people and reduces the risk of suicide.” This claim is not supported by the best available evidence.

Every systematic review of evidence to date, including one published in the Journal of the Endocrine Society, has found the evidence for mental-health benefits of hormonal interventions for minors to be of low or very low certainty. By contrast, the risks are significant and include sterility, lifelong dependence on medication and the anguish of regret. For this reason, more and more European countries and international professional organizations now recommend psychotherapy rather than hormones and surgeries as the first line of treatment for gender-dysphoric youth.

Dr. Hammes’s claim that gender transition reduces suicides is contradicted by every systematic review, including the review published by the Endocrine Society, which states, “We could not draw any conclusions about death by suicide.” There is no reliable evidence to suggest that hormonal transition is an effective suicide-prevention measure.

The politicization of transgender healthcare in the U.S. is unfortunate. The way to combat it is for medical societies to align their recommendations with the best available evidence—rather than exaggerating the benefits and minimizing the risks.

This letter is signed by 21 clinicians and researchers from nine countries.

FINLAND
Prof. Riittakerttu Kaltiala, M.D., Ph.D.
Tampere University
Laura Takala, M.D., Ph.D.
Chief Psychiatrist, Alkupsykiatria Clinic

UNITED KINGDOM
Prof. Richard Byng, M.B.B.Ch., Ph.D.
University of Plymouth
Anna Hutchinson, D.Clin.Psych.
Clinical psychologist, The Integrated Psychology Clinic
Anastassis Spiliadis, Ph.D.(c)
Director, ICF Consultations

SWEDEN
Angela Sämfjord, M.D.
Senior consultant, Sahlgrenska University Hospital
Sven Román, M.D.
Child and Adolescent Psychiatrist

NORWAY
Anne Wæhre, M.D., Ph.D.
Senior consultant, Oslo University Hospital

BELGIUM
Em. Prof. Patrik Vankrunkelsven, M.D. Ph.D.
Katholieke Universiteit Leuven
Honorary senator
Sophie Dechêne, M.R.C.Psych.
Child and adolescent psychiatrist
Beryl Koener, M.D., Ph.D.
Child and adolescent psychiatrist

FRANCE
Prof. Celine Masson, Ph.D.
Picardy Jules Verne University
Psychologist, Oeuvre de Secours aux Enfants
Co-director, Observatory La Petite Sirène
Caroline Eliacheff, M.D.
Child and adolescent psychiatrist
Co-director, Observatory La Petite Sirène

[Jeff Lebowski]

One of the letters above mentioned:

England, Sweden and Finland have all taken this path, and Norway is likely to follow. Belgium, France, Ireland and Italy are also raising concerns. These countries are following the science, which shows that the claimed benefits of hormonal intervention for young people fail to outweigh the risks.

It looks like Norway has changed its guidelines:

https://www.forbes.com/sites/joshuac...h=3ce49c277efb

Increasingly, European nations are adopting a more cautious approach to gender-affirming care among minors. In March, for example, the Norwegian Healthcare Investigation Board announced it would revise its current clinical recommendations with respect to “gender-affirming care” for minors. The updated guidelines would restrict the use of puberty blockers, cross-sex hormones and transition-related surgery to clinical research settings. Norway joins other European nations, such as Finland, Sweden and the U.K., in introducing limits on the provision of gender-affirming care to minors.

But caution with respect to gender-affirming care for minors may be warranted, as European experience indicates. A series of Europe-based systematic reviews of evidence for the benefits and risks of puberty blockers and cross-sex hormones have shown a low certainty of benefits. Specifically, longitudinal data collected and analyzed by public health authorities in Finland, Sweden, the Netherlands and England have concluded that the risk-benefit ratio of youth gender transition ranges from unknown to unfavorable.

As a result, across Europe there has been a gradual shift from care which prioritizes access to pharmaceutical and surgical interventions, to a less medicalized and more conservative approach that addresses possible psychiatric comorbidities and explores the developmental etiology of trans identity.

In turn, this has brought about the imposition of restrictions in Europe on access to hormones. Currently, minors in most European countries can access puberty blockers and cross-sex hormones, but only if they meet stringent eligibility conditions. And, this is increasingly done in the context of a tightly controlled research setting.

[LVAllen]

Medical professionals are being cowed into silence and coerced into providing treatments they know are dangerous to children.

We talked to Endocrinologists who agree with us. You wouldn't know them, though. They practice in Canada.

[Northwestcoug]

It turns out the the op-ed in the OP of this thread is part 3 in series of letters to the editor of the WSJ. There is some back-and-forth going on with some doctors claiming that the Endocrine Society has gotten far too political and that their analysis of the data is politicized and incorrect. Stephen Hammes, president of the Endocrine Society, responded.

These are short, so I will just include them. Here is the first one that kicked everything off:

https://www.wsj.com/articles/the-endocrine-societys-dangerous-politicization-endocrinologists-gender-affirming-care-arkansas-dac768bd?mod=article_inline

Here is the response by the president of the Endrocine Society:

https://www.wsj.com/articles/trans-gender-affirming-care-endocrine-society-evidence-fdb8562c?mod=article_inline

And finally, here is the response by the groups of doctors/clinicians in Europe:

https://www.wsj.com/articles/trans-gender-affirming-care-transition-hormone-surgery-evidence-c1961e27

Here is the important context for the first letter. It is signed by doctors from 'Do No Harm', a medical society with a clear agenda. The first 2 questions on their FAQ page are "What is critical race theory?" and "What is anti-racism?". If you head on over to their podcast page, episode 9 is "Standing up to Woke Ideology". Their media page has links to Townhall and Daily Wire articles.

https://donoharmmedicine.org

So let me be clear, they may be clearly 'right' and advocating a needed course correction, but their bias has to be taken into account. I also want to make sure I'm clearly understood. I'm skeptical of the claim that the US is clearly out of best practices within the developed world. The relevant medical societies here have taken responsible positions, maybe way more left than what the electorate is comfortable with but they are based on published literature. In fact, here's the consensus statement of the society that the first letter was directed towards, the Endocrine Society:

• Diagnosing clinicians, mental health providers for adolescents, and mental health professionals for adults all should be knowledgeable about the diagnostic criteria for gender-affirming treatment, have sufficient training and experience in assessing related mental health conditions, and be willing to participate in the ongoing care throughout the endocrine transition
• Gender-dysphoric/gender-incongruent persons should receive a safe and effective hormone regimen that will suppress the body’s sex hormone secretion, determined at birth and manifested at puberty, and maintain levels of sex steroids within the normal range for the person’s affirmed gender.
• Hormone treatment is not recommended for pre-pubertal gender-dysphoric /gender-incongruent persons;
• For the care of youths during puberty and older adolescents, an expert multi-disciplinary team comprised of medical professionals and mental health professionals should manage treatment;
• For adult gender-dysphoric/gender-incongruent persons, the treating clinicians (collectively) should have expertise in transgender-specific diagnostic criteria, mental health, primary care, hormone treatment, and surgery, as needed by the patient;
• All individuals seeking gender-affirming medical treatment should receive information and counsel on options for fertility preservation prior to initiating puberty suppression in adolescents and prior to treating with hormonal therapy in both adolescents and adults;
• Removal of gonads may be considered when high doses of sex steroids are required to suppress the body’s secretion of hormones, and/or to reduce steroid levels in advanced age; and
• During sex steroid treatment, clinicians should monitor, in both transgender males (female to male) and/or transgender females (male to female), prolactin, metabolic disorders, and bone loss, as well as cancer risks in individuals who have not undergone surgical treatment

I could be persuaded to believe that since the US healthcare is less regulated than countries with socialized medicine, that some clinics may have been pushing too far with gender affirming care with minors, and that once some problems arose the relevant medical societies put out responsible guidelines. But I have no evidence of that one way or the other. Also notice that not all European countries are 'banning' the most consequential aspects of minor gender affirming care. Many of them are just restricting it to research institutions.

[Jeff Lebowski]

Here is the important context for the first letter. It is signed by doctors from 'Do No Harm', a medical society with a clear agenda. The first 2 questions on their FAQ page are "What is critical race theory?" and "What is anti-racism?". If you head on over to their podcast page, episode 9 is "Standing up to Woke Ideology". Their media page has links to Townhall and Daily Wire articles.

https://donoharmmedicine.org

So let me be clear, they may be clearly 'right' and advocating a needed course correction, but their bias has to be taken into account. I also want to make sure I'm clearly understood. I'm skeptical of the claim that the US is clearly out of best practices within the developed world. The relevant medical societies here have taken responsible positions, maybe way more left than what the electorate is comfortable with but they are based on published literature. In fact, here's the consensus statement of the society that the first letter was directed towards, the Endocrine Society:[/LIST]I could be persuaded to believe that since the US healthcare is less regulated than countries with socialized medicine, that some clinics may have been pushing too far with gender affirming care with minors, and that once some problems arose the relevant medical societies put out responsible guidelines. But I have no evidence of that one way or the other. Also notice that not all European countries are 'banning' the most consequential aspects of minor gender affirming care. Many of them are just restricting it to research institutions.

Bias noted.

The most significant thing to me is how many European countries (liberal ones in fact) are pulling back on medical/surgical care for adolescents. You say "just restricting it to research institutions" as if that minimizes what they are doing. And nobody is claiming that there should not be any form of gender-affirming care for kids. This entire discussion is about the "most consequential aspects". I.e., a lifetime of extreme medicalization, surgical removal of body parts, loss of ability to have children, etc.

[Northwestcoug]

The most significant thing to me is how many European countries (liberal ones in fact) are pulling back on medical/surgical care for adolescents. You say "just restricting it to research institutions" as if that minimizes what they are doing.

No. I am referring to the politicization of it all. The comparison of European countries is being used as a cudgel to drive politics here. I'm being more clear than 'Europe is banning all gender affirming care for minors/adolescents'. Countries are restricting it, yes. A more truthful statement would be European countries are being more cautious now. But as far as I can tell most have not baked it outright.

And nobody is claiming that there should not be any form of gender-affirming care for kids. This entire discussion is about the "most consequential aspects". I.e., a lifetime of extreme medicalization, surgical removal of body parts, loss of ability to have children, etc.

I know what you are saying here, but yes there are absolutely people claiming exactly that. Look at the states that have rapidly banned gender affirming care, with laws so vaguely written that they are undoubtedly a feature, not a bug. Florida (and I'm sure others) ban 'social gender transition':

https://www.cnn.com/2023/06/06/politics/states-banned-medical-transitioning-for-transgender-youth-dg/index.html

[Jeff Lebowski]

No. I am referring to the politicization of it all. The comparison of European countries is being used as a cudgel to drive politics here. I'm being more clear than 'Europe is banning all gender affirming care for minors/adolescents'. Countries are restricting it, yes. A more truthful statement would be European countries are being more cautious now. But as far as I can tell most have not baked it outright.

I know what you are saying here, but yes there are absolutely people claiming exactly that. Look at the states that have rapidly banned gender affirming care, with laws so vaguely written that they are undoubtedly a feature, not a bug. Florida (and I'm sure others) ban 'social gender transition':

https://www.cnn.com/2023/06/06/polit...-dg/index.html

This feels like nitpicking and semantics.

[Green Monstah]

Bias noted.

The most significant thing to me is how many European countries (liberal ones in fact) are pulling back on medical/surgical care for adolescents. You say "just restricting it to research institutions" as if that minimizes what they are doing. And nobody is claiming that there should not be any form of gender-affirming care for kids. This entire discussion is about the "most consequential aspects". I.e., a lifetime of extreme medicalization, surgical removal of body parts, loss of ability to have children, etc.

I wonder if the fact that those countries all have national healthcare systems creates an economic motivation to pump the brakes.

I have a few trans friends that I taught in sunday school. My only real concern is that they don't do anything permanent without first ensuring it's what they want done and that it's in their best interest long term.

[Bo Diddley]

Sexually provocative shows on military bases are ok as long as you're not misrepresenting your gender at birth.

https://www.military.com/daily-news/...-show-ban.html

Nevermind that we have a problem with sexual harassment and sexual assault in the military, let's go ahead and objectify women to perpetuate the problem.

[YOhio]

So I’ve seen the WPATH leaks floating around here and there on Twitter the last week or so, but spent some time looking into it today and it’s pretty disturbing. Shellenberger does a good job at bringing the receipts.

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