Traduction de l’article de Jesse Singal, A Critique Of Scientific American’s Recent Article, “What Are Puberty Blockers, and How Do They Work?” : Singal-Minded, Substack, 7 mai 2023
(DeepL)
It has been published in one of the leading international scientific journals, and it has some major problems.
I blame the editors, for whom this is a habit, far more than the author herself. I won't name her, as I don't intend to cause lasting damage to a young journalist's Google reputation, but obviously her name won't be hard to find. I promise you, despite the criticism that follows, that when I was a young journalist, I wrote far worse things than she has written here. She's in a tough spot, trying to write about a subject where there's so much manipulation and politicization that it's impossible not to step on a minefield unless you're very, very careful. His editors weren't careful. At all.
Let's start there:
Hormonal drugs called gonadotropin-releasing hormone agonists (GnRHas), often referred to as "puberty blockers", temporarily halt the production of the sex hormones testosterone, estrogen and progesterone with minimal side effects. They can interrupt puberty, giving transgender children and their caregivers time to consider their options.
We don't know if side effects are "minimal" when these drugs are used in young people with gender dysphoria. This is one of the reasons for the controversy, and this wording dismisses that controversy in a way that is far too paternalistic.
Similarly, the term "cooling-off period" is highly contested at this stage. Data from the Tavistock Clinic, in particular, call it into question, as almost all the children treated there with blockers went on to use the opposite sex hormones. Time to think" is a common activist argument that sees puberty blockers as a common-sense measure to buy time, but this may not be accurate. Many researchers believe that early puberty can have the effect of resolving gender dysphoria. From a scientific point of view, therefore, the question remains open as to whether blockers really do give children time to think in a neutral way, or whether they contribute to the persistence of gender dysphoria by interrupting a natural developmental process and setting the child on a different path. For more information, see Hannah Barnes' book, Time to Think, or my interview with her.
Other excerpt from the article:
These drugs are well studied and have been used safely since the late 1980s to interrupt puberty in adolescents with gender dysphoria. They have been used regularly for even longer in children who enter puberty too early, and in adults suffering from a range of other medical conditions.
The phrase "since the late 1980s" is technically and narrowly true, since the very first young people with gender dysphoria had their puberty blocked "around 1987", as Emily Bazelon put it, but it's quite misleading because :
widespread use of blockers for this purpose didn't begin until much later
to date, we have virtually no studies that have followed children with gender dysphoria who took blockers over a significant period of time to see how they evolved.
It is therefore absolutely false to claim that these drugs are "well studied" for this type of use.
As for the second sentence, it deals with a certain confusion that often recurs in this debate - a confusion that, in my opinion, is intentional in some cases. Yes, puberty blockers have been used to treat precocious puberty for longer than they have been used to treat gender dysphoria, and are better studied in these circumstances. But these are very different situations.
In the latter case (for gender dysphoria), there's a good chance (based on the data we have) that the child will then switch to opposite sex hormones, meaning that he or she won't go through the natural puberty that would otherwise cause his or her body and brain to develop in a certain way. Can opposing sex hormones provide an equivalent form of development, without negative consequences for the adolescent's physical or cognitive development? The simple answer is that we don't know yet, because we have virtually no medium-term data and no long-term data on the young people who have undergone this protocol. That's why we can't confuse the two. In addition, there are questions about the safety of using puberty blockers to buy time for children suffering from precocious puberty. Scientific American makes no mention of this.
You don't have to believe me when I say that we don't have sufficient evidence to use puberty blockers to help transgender children. Here's an excerpt from the Standards of Care (version 8) of the otherwise very pro-transition World Professional Association for Transgender Health: "Despite the growing body of evidence for the efficacy of early medical intervention, the number of studies is still small and there are few outcome studies that follow young people into adulthood. Consequently, it is not possible to conduct a systematic review concerning treatment in adolescents." I don't agree with the first half of this sentence, as many recent studies are quite weak and/or present mixed results (more on this soon), but if WPATH thought there was solid, high-quality evidence in favor of blockers, it's obvious they would have brought it to light.
All government-funded studies of the evidence for puberty blockers have come to the same conclusion: the quality of the existing literature is so low that no one really knows whether these drugs are safe and effective for young people with gender dysphoria. The Finnish and Norwegian health systems have gone so far as to call these treatments "experimental", as has the Swedish team behind a major systematic review just published. The UK's National Health Service didn't go quite so far, but in October 2022 proposed new guidelines [updated in June 2023] based in part on the evidence base, which would advocate a much more cautious approach to the administration of blockers and opposing sex hormones (again, see Barnes' book for more on this).
You wouldn't know any of this from Scientific American's article on puberty blockers. And frankly, that's what makes this article so lacking in scientific rigor. Of course, the existence of these studies alone doesn't solve the question of exactly what we should think about these drugs, let alone what national policies should be towards them. Health care decisions for a vulnerable young person sometimes have to be made in conditions of scientific uncertainty. But this uncertainty is an absolutely crucial element, a major detail that must be communicated by journalists writing about this subject.
It's disconcerting and frustrating that in 2023, the magazine's editors feel comfortable allowing their publication to assert that there is solid evidence that puberty blockers help children with gender dysphoria, and to conflate two such different uses of the drug. This is an extremely misleading and potentially dangerous claim to disseminate to parents trying to make an extremely delicate medical decision.
The article goes on to note that:
Half of transgender people ages 13 to 24 have seriously considered suicide [The Trevor Project, 2023] in the past year, according to a national survey conducted in 2023 and published May 1 by The Trevor Project, a nonprofit organization focused on suicide prevention among LGBTQ+ people.
This is one of the more subtle criticisms I'm going to level at this article, but I think it's an important one, because it concerns one of the worst kinds of misleading claims about gender medicine for young people: claims about suicide.
It's true that the Trevor Project asked its respondents whether they had attempted or considered suicide in the past year, and the number of responses was alarmingly high. In its report on the survey, the organization notes that it obtained similar figures to those from a more representative sample: the subset of LGBT teens surveyed as part of the Centers for Disease Control and Prevention's Youth Risk Behavior Survey (YRBS) :
Fortunately, these are almost certainly significant overestimates of the prevalence of serious suicidal ideation and suicide attempts in the LGBT population. At least, that's what suicide researchers think. The excerpt below is from a Williams Institute report entitled "Suicide Attempts among Transgender and Gender Non-Conforming Adults: Findings of the National Transgender Discrimination Survey (NTDS)" (2014), which reveals that an astonishing 41% of transgender people surveyed said they had ever attempted suicide :
Although the NTDS provides a wealth of information on the experiences of transgender and gender non-conforming people, the survey instrument and methodology posed certain limitations to this study. Firstly, the NTDS questionnaire included only one question on suicidal behavior: "Have you ever attempted suicide?", with dichotomous responses (yes/no). Researchers have found that the use of this single question in surveys can inflate the percentage of affirmative responses, as some respondents may use it to communicate self-injurious behavior that is not a "suicide attempt", such as seriously considering suicide, planning suicide or engaging in self-injurious behavior without intending to die (Bongiovi-Garcia et al., 2009). The National Comorbidity [sic] Survey, a nationally representative survey, found that asking about intent to die in face-to-face interviews reduced the prevalence of lifetime suicide attempts from 4.6% to 2.7% of the adult sample (Kessler et al., 1999; Nock & Kessler, 2006). In the absence of such surveys, we were unable to determine to what extent the 41% of NTDS participants who reported having attempted suicide might be overestimating the true prevalence of attempts in the sample.
I think the same logic applies to simply asking someone if they've "seriously considered suicide" out of the blue. It's part of a wider phenomenon often seen in opinion polls, where respondents endorse extreme sentiments at seemingly alarming rates, unless and until you're more specific in your follow-up questions. The "lizard constant" is the most extreme (and entertaining) example of this.
Transgender youth may be at increased risk of suicide, but these figures are often presented in an alarmist and exaggerated manner. Better, more conservative ways of measuring suicidality, such as using tools validated in clinical settings, yield different and somewhat less catastrophic results.
As Australian psychiatrist Alison Clayton, affiliated with the Society for Evidence-Based Gender Medicine, explains in an excellent article ["Gender-affirming treatment of gender dysphoria in youth: a perfect storm environment for the placebo effect"] recently published in Archives of Sexual Behavior:
The suicidality of young people with gender dysphoria presenting to child and adolescent gender clinics, while significantly higher than that of non-referred samples, has been reported to be relatively similar to that of young people referred to generic child and adolescent mental health services (Carmichael, 2017; de Graaf et al., 2022; Levine et al., 2022). A recent study reported that 13.4% of patients referred to a large gender clinic were assessed as being at high risk of suicide (Dahlgren Allen et al., 2021). This is much lower than the often-quoted figure of 50% suicide attempts among transgender youth (Tollit et al., 2019). A recent analysis found that, although higher than population rates, transgender youth suicide (at England's CAGS) remained rare, with an estimated rate of 0.03% (Biggs, 2022).
Here and there, as in this Belgian clinic and in a study we'll look at shortly, rather alarming rates of suicidality and suicide are observed (there are in fact virtually no studies of transgender youth measuring completed suicide), but context is very important here: even if we select the most frightening studies, there's no reason to think that 40% or 50% of transgender youth are at serious risk of suicide.
It's unfortunate that the discourse on gender medicine among young people often claims the opposite, because the constant dissemination of the meme "large numbers of transgender children will kill themselves if they don't have easy access to blockers or hormones" causes unnecessary fear and could potentially contribute to the contagion of suicide. That's why experts are urging journalists and others to be very, very careful when publishing articles on this subject. The Scientific American article is (very) far from the worst, but it illustrates a common problem that could exacerbate the risk for transgender children.
After mentioning the appallingly high risk of suicide among transgender children, the article continues:
Gender-affirming hormone therapy can reduce this risk. A recent study published in the New England Journal of Medicine, for example, showed that hormone therapy significantly reduced symptoms of depression and anxiety in transgender youth [Chen et al., January 2023]. Another study showed that transgender adolescents who received gender-affirming care were 73% less likely to self-harm or have suicidal thoughts than those who did not [Tordoff et al., JAMA, February 2022].
It's really, really frustrating that SciAm spreads these messages. Remarkably, not only do none of the articles cited in this passage demonstrate a reduction in suicidality (which is distinct from depression and anxiety) in children who have taken blockers or hormones, but there is reason to believe that both results offer evidence that these treatments do not reduce suicidality.
If you're a regular reader, we've covered this topic before.
● Chen et al, NEJM, January 2023
Let's start with the NEJM study, which was published by a team of gender clinicians as part of a very ambitious federally-funded ongoing research effort. As I've pointed out before [see J. Singal's review of this study in French], the Diane Chen et al. study failed to account for six of the eight variables mentioned by the authors in their main, preregistered hypothesis, including suicidality - which strongly suggests that they didn't find what they wanted to find. And while the carefully selected variables that were reported included anxiety and depression, these results weren't promising either: there was no statistically significant improvement for trans girls (natural males) on either front, and the overall average decreases (the researchers didn't provide specific figures by natural gender) were of questionable clinical significance: over a two-year period, depression decreased by only 2.54 points out of 63, while anxiety decreased by only 2.92 points out of 100. Furthermore, as the researchers did not control access to medication or therapy, there is really no reason to attribute these improvements to hormones rather than to these factors, the placebo effect, other influences or a combination of any or all of these. None of the experienced, critical readers of this type of research should be convinced that the authors have established the causality they claim to have established when they write that hormones "improved appearance congruence and psychosocial functioning." (I remain surprised that the NEJM allowed this wording to slip into the article, given that the authors ticked virtually none of the boxes required to make such a claim. It's far from a foregone conclusion).
With regard to suicides, the authors note that there were two suicides in a sample of 315 children. Although (as I noted in my original article) a rate based on a small number of crude events should be interpreted with caution, this is undeniably a high rate, especially given that this sample was screened, at the start of the study, for serious psychological problems, including suicidality.
Thus :
1. The authors of a major study, in their pre-recorded protocol, describe that they will measure suicidality in a sample of children taking hormones.
2. They mysteriously omit this variable, except to note, almost as an aside, that there were two suicides - meaning that the sample had a high suicide rate. Several other key variables are also missing, without explanation.
3. In short, the study provides no evidence that, in this sample of transgender youth, access to hormones reduced suicidality.
4. Scientific American cites this study as evidence that hormones reduce suicidality in transgender youth.
You can understand how frustrating that is, can't you? Can you understand why I keep writing articles about it?
● Tordoff et al, JAMA, February 2022
As for the SciAm article's assertion that "another study found that transgender adolescents who received gender-affirming care were 73% less likely to self-harm or have suicidal thoughts than those who did not," it's simply remarkable that this study is still being cited in 2023. I wrote about it in a previous article (April 6, 2022): Diana Tordoff and her colleagues found no evidence that the children they followed who took blockers and hormones (again, regardless of medication or therapy) experienced any improvement in their mental health over time. They then claimed the opposite.
How did they achieve this feat? First of all, they used a very strange statistical technique, which was described to me as "a pretty poor way of handling [this type of data]" by James Hanley, the statistician who co-authored what I believe is the most cited article about this technique. They also ignored the fact that 80% of the group who didn't receive the blockers and hormones had dropped out by the end of the study, leaving only six children at the end, compared with a much lower percentage for the group who received the treatment, meaning that it's more or less impossible to make a meaningful comparison between the two groups.
See my article for details, but the fact is that no informed, bona fide person is able to make a meaningful comparison between the two groups, and could claim that this study found that "transgender teens who received gender-affirming care were 73% less likely to self-harm or have suicidal thoughts than those who didn't" - at least not without a lot of hesitation and throat-clearing - and I'll gladly repeat myself in saying that it's immoral [article translated into French] to disseminate this kind of statement in this kind of context.
It wouldn't be hard for Scientific American to be a little more skeptical about all this. But I think the same thing is happening here as with Science Vs [article translated into French]: because these claims about blockers and hormones are considered politically urgent, the ability to criticize is disabled in the service of the apparently noble goal of getting the message across. SciAm would never show this level of credulity to a scientific claim promoted by conservatives.
Let's continue:
Puberty has a long natural window, usually occurring between the ages of 8 and 14 and lasting from two to five years. Blockers are usually prescribed when puberty has already begun, and the process involves evaluations by several physicians, including mental health practitioners, explains Stephen Rosenthal, a board member of the World Professional Association for Transgender Health (WPATH) and a pediatric endocrinologist at Benioff Children's Hospital, University of California, San Francisco.
If you're going to call Rosenthal, co-author of the NEJM study, why not ask him what happened to those six missing variables? It seems like a missed opportunity.
In any case, Scientific American seriously simplifies matters. The protocol used by American clinicians for young people is more or less derived from a protocol known as the "Dutch Protocol" (I'm delighted that the book The Dutch Approach has just been published), which originated in a world-famous (for nerds) Amsterdam clinic and involved very careful and thorough assessments. Under this protocol, children were monitored for months and carefully assessed for psychological comorbidities, before being allowed to take blockers or hormones, or undergo (later) surgery.
I don't know if things have loosened up a bit since then, but traditionally, children simply weren't allowed to transition if their other mental health issues weren't under control, if they didn't have supportive parents, or if they didn't have a long history of gender dysphoria in childhood. Some of the only valid research we have comes from this very specific clinical context, although even this research is not as straightforward as many (myself included) have previously assumed, at least according to the article The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence (2022) by Oxford sociologist Michael Biggs, and the review The Myth of "Reliable Research" in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed (2023) by E. Abbruzzese, Stephen Levine and Julia Mason.
Stephen Rosenthal describes a process that sounds Dutch. Is this what happens in American gender clinics? Probably not, at least in many cases. Here's what Reuters had to say about it in October 2022 [As more transgender children seek medical care, families face many unknowns] :
In interviews with Reuters, doctors and other staff from 18 gender clinics across the country described their patient assessment process. None described anything like the months-long assessments that [eminent Dutch clinician Annelou] de Vries and her colleagues adopted as part of their research. In most clinics, a team of professionals - usually a social worker, a psychologist and a doctor specializing in adolescent medicine or endocrinology - first meets with the parents and child for two hours or more to get to know the family, its medical history and treatment goals. They also discuss the benefits and risks of treatment options. Seven clinics said that if they don't see any red flags and the child and parents agree, they don't hesitate to prescribe puberty blockers or hormones on the first visit, depending on the child's age.
What's more, many of the children presenting to gender clinics today have no history of childhood gender dysphoria, which means they wouldn't have been eligible for transition under the Dutch protocol, and which also means that any honest clinician would have to admit that there's far less evidence to justify prescribing blockers and/or hormones for these children.
De Vries herself raised some concerns about this in Pediatrics in 2020 [Challenges in Timing Puberty Suppression for Gender-Nonconforming Adolescents] :
According to the original Dutch protocol, one of the criteria for starting puberty suppression was "the presence of gender dysphoria since early childhood". Prospective follow-up studies evaluating these Dutch transgender adolescents showed improved psychological functioning. However, the authors of case studies and a study of parent reports argue that gender identity development is diverse, and that a new developmental pathway is proposed for young people with a history of transidentity that emerged after adolescent puberty. These young people have not yet participated in the first evaluation studies. This raises the question of whether the positive results of early medical interventions also apply to adolescents who, more recently, are presenting in very large numbers for gender-affirming care, including those arriving at an older age, possibly without a history of gender dysphoria in childhood. Caution is also called for, as some case studies illustrate the complexities that can be associated with transgender adolescents who present later, and describe that some of them end up detransitioning.
In my opinion, a person reading SciAm's description of the evaluation process will be unaware that :
this clearly doesn't happen in many American gender clinics,
many of the children presenting at these clinics bear no resemblance to their Dutch predecessors, which means that the little research we have cannot be applied to them,
One of the heads of the Dutch clinic spoke out in the pages of Pediatrics to express her concerns about the treatment of this new cohort.
It's disconcerting and frustrating that in 2023, Scientific American's editors don't hesitate to leave out so much. It's disconcerting and frustrating that in 2023, Scientific American editors don't hesitate to omit so much from a complicated story, opting instead for an oversimplified account.
The article also originally stated that "the World Professional Association for Transgender Health (WPATH) standards of care recommend waiting until adulthood for gender-affirming surgeries," which is not true. The document SciAm originally linked to, a WPATH FAQ on its most recent standards of care, stated that:
Standards Of Care [SOC 8] guidelines recommend that patients reach adulthood, which can vary depending on where the trans person lives or seeks care, to be a candidate for gender affirmation surgery. These guidelines are designed to help providers individually assess when and for whom a procedure is age-appropriate, and they exist to ensure that patients receive the individualized care they need, as is the case in medicine as a whole.
It's going to sound strange, but WPATH... misrepresents its own guidelines. In fact, a few hours after the release of SOC 8, a "fix" was published that removed all age guidelines. The current version of SOC 8 therefore contains no age restrictions. At the time, this caused quite a stir, as some people, such as Ron DeSantis' deputy press officer, noticed the change and expressed their outrage.
This sentence jumped out at me in the same way it would jump out at anyone who followed this issue, as the removal of age restrictions was considered a major event at the time. I emailed the editor of Scientific American to ask the question and, to her credit, the text has since been updated and now refers to SOC 8 proper rather than this strange FAQ (although the change is footnoted rather than in the text, which is a pet peeve of mine as hardly anyone reads an article all the way to the bottom). But I can't help pointing out that this is a mistake that wouldn't have happened if the people involved in the process of publishing this article knew the context of this debate and its evolution over the last few years. (I also emailed WPATH to verify, and received in return a statement from Marci Bowers, WPATH President, confirming the absence of age requirements, which I will place in a footnote1).
After SciAm reminds us that puberty blockers have been used to treat other pathologies over the years, the article continues with further oversimplifications:
According to Simona Giordano, bioethicist at the University of Manchester, England, this multitude of beneficial clinical uses and data, dating back to the 1960s [Horton, 2022], shows that puberty blockers are not an experimental treatment, as they are sometimes wrongly described. Among patients who have received the treatment, studies have highlighted extremely low regret rates [Brik et al., 2020) and minimal side effects [Giordano and Holm, 2020), as well as mental and social health benefits [Turban et al., 2020].
● "dating back to the 1960s [Horton, 2022)"
The chronology is simply inaccurate. Gonadotropin-releasing hormone wasn't discovered until 1971, and its agonist wasn't first used to treat precocious puberty until ten years later. This is another case of SciAm linking to a document that says something true and taking it as gospel. The link inserted in "back to the 1960s" is a document that claims that "puberty blockers have been used to delay precocious puberty in children since the 1960s", but the quote at the end of that sentence says no such thing. I'm not very familiar with this story, and would have missed it if someone else hadn't pointed it out to me, but I'll say it again.... it's Scientific American. If they can't answer such basic questions as "When was this hormone discovered?", that begs the question.
The question of whether puberty blockers are an "experimental treatment" for other pathologies is completely different from the question of whether they are an "experimental treatment" for gender dysphoria in young people. The fact is, we have virtually no quality evidence regarding the safety and efficacy of puberty blockers in the latter case. Why is Scientific American hiding all this from its readers?
● "extremely low regret rates [Brik et al., 2020)"
As for the claim about "extremely low regret rates", it is unjustified and fails to take context into account. The claim refers to a single study from a Dutch clinic that carried out a careful diagnostic assessment of all its patients before putting them on blockers: "This assessment usually consisted of about six visits (more if necessary) of the adolescent with a mental health professional within 6 to 12 months, in addition to interviews with parents/guardians." Of these carefully selected children, 3.5% regretted taking puberty blockers, and a handful more discontinued blockers for health reasons, although this group mostly subsequently pursued gender affirmation treatment of one kind or another.
It's good that the rate is low, but what would that figure be if these children hadn't been carefully evaluated? If they had taken blockers after just one clinic visit? If they hadn't benefited from the Dutch healthcare system, but from the American one? We have no studies on regret or discontinuation rates for puberty blockers in an American context. It is therefore misleading to assert that these treatments have "extremely low regret rates" on the basis of a single study conducted in a single foreign clinic, which takes a much more restrictive approach than seems to be the case in the USA. It's a basic principle of scientific writing and editing not to extrapolate from most single studies, and the editors of Scientific American are certainly very familiar with it.
● "minimal side effects [Giordano and Holm, 2020)"
The cited link does not claim that puberty blockers have "minimal side effects", but rather that there are unknown medium- and long-term side effects, but that they should not be considered sufficient evidence to consider the treatments "experimental". The authors themselves state that "the questions still to be answered concern the medium- and long-term effects of delayed puberty" and that "if it can be proven in larger studies that peak bone mass is affected by GnRHa treatment, this will obviously become an important consideration in the overall risk/benefit calculation before proposing this treatment". It's simply inaccurate to present this article - which is an editorial anyway, rather than a research paper, review or meta-analysis - as evidence that blockers have "minimal side effects", because the authors themselves don't even assert that!
● "mental and social health benefits [Turban et al., 2020]"
The link is one of the studies by Jack Turban and his team. To put it bluntly, this is not serious research. It relies on a flawed self-reported dataset known as the 2015 United States Transgender Survey (USTS), which, among other problems, excludes people who have undergone detransition - click here ["Science Vs." translated into French] and go to page 29 ["There are many reasons to be skeptical") if you're not sure why work based on the USTS is often untrustworthy. To interpret these data as Scientific American does is also to overlook the possibility that poor mental health is the cause of a lack of access to transitional care, rather than the other way around (as some clinicians and medical guidelines consider good mental health a prerequisite for the use of blockers or hormones). What's more, the researchers found only one statistically significant correlation out of three, in their best-controlled model. According to their own methodology and argument, in this model, access to blockers had no statistically significant impact on severe psychological distress in the previous month, or on suicidal ideation in the past year. Even in their simpler, so-called "univariate" model (i.e. one that did not control for other potentially confounding variables), there was no correlation between access to blockers and more severe forms of recent suicidal ideation.
If blockers are as wonderful and effective as their advocates claim, why is this so?
See Michael Biggs's letter ["Puberty Blockers and Suicidality in Adolescents with Gender Dysphoria," Archives of Sexual Behavior, 2020] for a complete and concise denial of this study. No one should make decisions about a child's or adolescent's health care on the basis of this type of study, and to be clear, my argument is that we probably can't draw any solid conclusions from a study published on the basis of USTS 2015.
More generally, even if the data set were less fragmented, it's simply not possible to determine whether a medical treatment is effective using this type of investigation - too many things can go wrong. It would be hard to find a less convincing type of medical evidence, given what we know about the difference between good and bad medical research ["What is GRADE?", BMJ].
It's baffling and frustrating that in 2023, the editors of Scientific American feel comfortable publishing such misleading arguments, are so unfamiliar with the many criticisms leveled at a study first published more than three years ago, and completely refuse to engage with such an approach. It's not very scientific.
The final quote from Scientific American:
Meanwhile, the increase in suicide rates among people who don't receive gender-affirming care is well documented.
We've moved from assertions about suicidal ideation and suicide attempts to assertions about completed suicides. It would be hard to find a more serious claim than "If you don't give your child this medication, you increase the likelihood that they will commit suicide", and as regular readers know from this article ["Science Vs", translated into French] that I wrote in response to Science Vs' version of this argument, it is not corroborated by the evidence. It is irresponsible to say this to parents - or to children or teenagers considering gender medicine.
Let's review the two links:
● "Good."
This link is to a MedPage article ludicrously titled "Gender-affirming drugs have drastic impact on suicide risk in transgender youth". It's paid for, but shhh, and if you click on that link, you'll see that it's an article favorable to the Tordoff study. The Tordoff study did not measure the number of completed suicides. I sincerely hope that no one in their cohort committed suicide, but if they did, the researchers didn't see fit to inform us. Leaving aside the many other problems with this study, it simply cannot be used to prove that denying children access to gender medicine increases their suicide rate.
● "documented"
This article links to a Time magazine article on a study [Green et al., 2021] based on survey data from the Trevor Project. Once again, SciAm confuses itself (and its readers) by mixing up suicidal ideation, suicide attempts and completed suicides, which are crucial distinctions for researchers in this field. Obviously, a survey study can say nothing about completed suicides. But beyond this simple observation, this study is structured similarly to some of the work of Turban and his team - it compares people who reported ever receiving hormones to those who reported wanting them but not receiving them - and suffers from the same major obstacles to establishing any causal link. Here again, the data could be partly explained by the exact opposite of what is claimed: having a mental illness makes young people less likely to have access to hormones.
The Scientific American article also deals with bone health topics that I'm less familiar with, so I can't comment on its quality without doing some research that I don't have time to do right now, but in light of the above, I'll just say that the article isn't very convincing. Let's say my default position would be skepticism. I wouldn't take anything in this article at face value, without rigorous fact-checking - checking that should have taken place before the article was published.
I'll leave it at that. It seems appropriate to summarize as follows: a major scientific magazine makes a very serious claim about suicide - that a specific intervention is "well established" as reducing the number of suicides. This sentence refers to reports of two studies, neither of which even measured the number of suicides, let alone proved that the intervention in question reduces the likelihood of suicide. This is how scientific studies are presented in the mainstream media.
1 "Throughout the process of developing and updating Standards of Care 8, we made adjustments to ensure consensus within the scientific and medical community based on the latest research. Instead of specifying rigid age limits for certain types of healthcare, SOC-8 provides a detailed framework to help providers assess the needs of patients at different stages of life. We don't want age-appropriate care guidance to be misinterpreted as being so rigid that patients can't receive care that meets their unique needs. We want to ensure that every transgender person receives individualized, age-appropriate care that best suits their needs."
For what it's worth, I'm not sure it's accurate to say there's a "consensus within the scientific and medical community based on the latest research" that there shouldn't be age guidelines dictating the pace of gender medicine in young people - in my opinion, there's more evidence to support the idea that activist pressure caused this last-minute publication. Emily Bazelon's New York Times article gives good background on the tension within WPATH over issues of assessment and deadlines.