This post is a pastiche of various articles that you can find linked below.
Puberty blockers is a very vague description and many articles about trans children don’t mention what they actually are. There is no drug called “puberty blockers”. But there are drugs used AS puberty blockers. These drugs are known as Gonadotropin-Releasing Hormone Antagonists/Agonists, known more conveniently as ‘GnRHa’. Lupron and Triptolerin are two such drugs. These drugs bind to the gonadotropin receptors, effectively causing a suppression of sex hormones. In adolescents this stops the progression of puberty. For women, this causes the rapid and artificial onset of menopause. GnRHa drugs were originally intended to treat terminal prostate cancer patients and then women with endometriosis, but their use has proliferated into a huge variety of uses, including in children with precious puberty and children with gender dysphoria. The crucial detail is that they are NOT approved for children with gender dysphoria by the U.S. Food and drug administration. This is an off label use.
It’s worth noting now, in clinical trials, the most common side effects of Lupron, occurring in >10% of patients, include hot flashes/sweats, headache/migraine, decreased libido, depression/emotional lability, dizziness, nausea/vomiting, pain, vaginitis, and weight gain. The FDA has reported over 20,000 adverse reactions to Lupron in their FDA Adverse Event Reporting system. These adverse reaction reports include cases that resulted in death.
Several medical associations and advocacy groups have endorsed puberty suppression. They attempt to justify their position with a number of arguments, some I’ve already addressed.
One claim that you’ll see repeatedly is that this treatment is “fully reversible”. This literature review by Stephen Rosenthal, who, as previously discussed, has a financial relationship with AbbVie as a consultant (this is disclosed as a conflict of interest within the paper.) tells us:
Based on pioneering work form[sic] the Netherlands, the Endocrine Society (ES) guidelines and WPATH SOC endorse the use of pubertal blockers using gonadotropin releasing hormone (GnRH) agonists at Tanner stage II/III in individuals experiencing a significant increase in gender dysphoria with onset of puberty3,4,44,45,46,47).
This treatment is fully reversible and allows additional time for gender exploration without the pressure of ongoing pubertal development.
This is contradicted by the fact that GnRH agents are currently the subject of multiple investigations for causing irreversible bone health problems. A recent news article in Kaiser Health News found that many patients who had received Lupron in their formative years suffered numerous side effects. One woman had a hip replacement in her early twenties.
For years, Sharissa Derricott, 30, had no idea why her body seemed to be failing. At 21, a surgeon replaced her deteriorated jaw joint. She’s been diagnosed with degenerative disc disease and fibromyalgia, a chronic pain condition. Her teeth are shedding enamel and cracking.
A 20-year-old from South Carolina was diagnosed with osteopenia, a thinning of the bones, while a 25 year-old from Pennsylvania has osteoporosis and a cracked spine. A 26 year-old in Massachusetts needed a total hip replacement. A 25-year-old in Wisconsin, like Derricott, has chronic pain and degenerative disc disease.
The bone thinning effects are also mentioned in the ‘Important safety information’ leaflets that accompany Lupron and extended use is not recommended in people with pre-existing bone thinning conditions.
In a report submitted by TAP Pharmaceuticals (Lupron’s original manufacturer) to the FDA in April 1998, researchers wrote that “they were ‘concerned’ because more than one-third of the women they studied who took Lupron did not ‘demonstrate either partial reversibility’ or ‘a trend toward return’ of bone mass in the six months after they stopped taking the drug. Further, the researchers noted some women lost as much as 7.3 percent of their bone density during treatment — more than twice the amount the drug’s packaging lists in its warnings. The researchers concluded, ‘A more complete assessment of the effects of Lupron on [bone density] can only be made with longer term follow-up of these patients.’” But the company never invested in that follow-up research, and the FDA hasn’t yet required it to.
Rosenthal admits to this later on, saying:
The primary risks of pubertal suppression in gender dysphoric youth treated with GnRH agonists include adverse effects on bone mineralization, compromised fertility, and unknown effects on brain development.
Is that fully reversible? Or did Rosenthal contradict himself?
What Rosenthal means by “compromised fertility” is that failure to experience puberty means the gonads never mature. Immature gonads, with immature gametes are never fertile. These children will grow up to be sterile.
You think I’m exaggerating? Diane Ehrensaft admits to supporting sterilizing children:
Another critical task for the medical-mental health team is the necessary discussion of fertility implications for each of these interventions. Although advances are being made in reproductive medicine to preserve immature gametes or reproductive tissues for later reproduction, at this point in history a child who begins puberty blockers at Tanner Stage 2 and proceeds directly to cross-sex hormones will be rendered infertile.
From the horse’s mouth. Infertile. No gonads. Castrated. No sexual development.
Olson-Kennedy agrees. She explains to parents at Gender Odyssey that not only are emotional lability and significant behavioral changes frequent and serious side effects of blockers (29:15) but another reason these kids are “doing so bad” is because blockers put them in menopause. “Menopause is bad enough when you’re menopause-age, but when you’re fourteen and you’re having hot flashes, memory problems, insomnia, and you feel like crap, it is really terrible. This is really common” she says, of the current treatment protocol. “What happens when you put a fourteen year old in menopause?” she asks the audience. “You’re shutting down their ovaries,” she answers herself (Olson-Kennedy, Gender Odyssey, 8/25/17, 30:25). I appreciate her candor.
The organs responsible for fertility are also those responsible for sexual function. In a study performed by the Prostate Cancer Outcomes Study of the Surveillance, Epidemiology and End Results program, it was shown that 69% of the men who were potent before androgen deprivation therapy lost their potency after treatment and the proportion of men reporting no sexual interest increased from 28% to 67% after orchiectomy and from 32% to 58% after LHRH agonists.
Not much research has been done on the effects of puberty blockers on sexual function of transgender teenagers. What we know is that GnRH agonists suppress 95% of all sex hormone production. For a “vagina-haver,” low levels of estrogen, LH, and FSH can mean vaginal atrophy, or life with a potentially very dry, possibly itchy, thin-walled vagina of a prepubescent child, that is more prone to bacterial infections, bleeding during sexual activity, and urinary incontinence, among other annoying-to-serious health issues. How will they impact an already dysphoric teen’s feelings about her body, about her sexuality?
How will parallel health issues impact Jazz Jennings, trans protagonist of I Am Jazz (recently renewed for a sixth season)? In an episode of the series, he visits a surgeon and has a discussion about sexual function. Jazz (age 17) states: “I haven’t experienced any sexual sensation.” Regarding orgasm, he says: “I don’t know, I haven’t experienced it.” From interviews with Jazz’s surgeons, one can deduce the almost certain loss of sexual function, because the sexual development of his genitalia has not been allowed to occur and never will occur under the current circumstances.
As for the “brain development” bit. Sex hormones sculpt neural circuits during adolescence, a time of dramatic rewiring of the nervous system. One study on women taking GnRHa’s to treat endometriosis found that many of them suffered memory disruption while taking the drug, which was taken over twenty-four weeks. Nearly half of the women reported moderate to marked impairment compared to ‘community norms’ while taking the drug. The memory problems resolved after discontinuing use of the drug. That was when used for six months — what happens if you use the drug for years on end as an adolescent?
Another study found that use of GnRHas in children going through early puberty suffered an average seven to eight point drop in IQ while using the drug.
Intelligence The IQ levels for the whole group decreased significantly, from 100.2 (12.7) at T1 to 93.1 (10.5) at T2 (p = 0.002)
This study on effects of puberty blockers on 12-year-old shows IQ drop of 9 points.
A Global IQ reduction is observed. At the end of 28 months of treatment, speed processing and memory remain lower than before GnRHa treatment.
Transgender children will spend years taking these drugs. How will it affect academic performance?
Rosenthal’s literature review also lets us know about the status of the research:
There are currently only limited outcomes data to support the ES and WPATH recommendations for care of transgender youth.
These people are castrating children based on limited outcome data. This may or may not work as a treatment. Who knows, really? This isn’t settled science.
Here is a sampler of quotable quotes from some of the big guns in the pediatric transgender world.
Eli Coleman, a psychologist who heads the human-sexuality program at the University of Minnesota Medical School, chaired the committee that, in November 2011, drafted the latest guidelines of the World Professional Association for Transgender Health, the leading organization of doctors and other health-care workers who assist trans patients. The committee endorsed the use of puberty blockers for some children, but Coleman told me that caution was warranted: “We still don’t know the subtle or potential long-term effects on brain function or bone development. Many people recognize it’s not a benign treatment.”
“The bottom line is we don’t really know how sex hormones impact any adolescent’s brain development,” Dr. Lisa Simons, a pediatrician at Lurie Children’s, told FRONTLINE. “We know that there’s a lot of brain development between childhood and adulthood, but it’s not clear what’s behind that.” What’s lacking, she said, are specific studies that look at the neurocognitive effects of puberty blockers.
“We do know that there is some decrease in bone density during treatment with pubertal suppression,” Finlayson said, adding that initial studies have shown that starting estrogen and testosterone can help regain the bone density.
Finlayson said there isn’t enough research on whether someone who was on puberty blockers will regain all their bone strength, or if they might be at risk for osteoporosis in the future.”
“While transgender adults have taken hormones sometimes for years, the generation growing up now is among the first to start taking hormones so young. Since most people who start hormones take them for life, doctors say there also isn’t enough research into the long-term impact of taking estrogen or testosterone for what could end up being 50 to 70 years.”
“There are so many unanswered questions around the long-term consequences, and whether your health risk profile really becomes that of a male or female,” Garofalo says. “If we start testosterone today, will you have the cardiac risk profile of a male or female as you grow older? Will you develop breast cancer because we’re administering estrogen?
“I think those are the unanswered questions that really trouble me and can only be answered with long-term follow-up studies.”
Not troubled enough to halt what you’re doing until there is some actual evidence that you are not doing irreparable harm, ah Dr. Garofalo?
Sooner or later….we just don’t know enough….there is a tremendous need…
This isn’t science. This is a grand experiment, on children who are overwhelmingly more likely to grow up to be gay than transgender. There isn’t a scientific basis for the hundreds of millions of dollars poured into the transgender movement and the children it supposedly protects. No one has any idea of the long-term effects, bar the fact that one hundred per cent of children that go through this ‘treatment’ will be completely sterile.
Questioned on whether it shouldn’t be regarded as unethical to sterilize 11-year-olds at a conference event in Santa Cruz (California) in 2016, Dr. Ehrensaft argued:
The answer to that is: We don’t think twice about instituting treatments for cancers for children that will compromise their fertility. We don’t say, we’re not going to give them the treatment for cancer because it’s going to compromise their fertility.
For some of the youth, having the gender affirmation interventions is as life-saving as the oncology services for children who have cancer.
Is it? Really? I guess in Ehrensaft’s perverse logic it is, because if we do not castrate these children right not, they will commit suicide, wont’t they?
At this juncture, let me repeat what I’ve said many times before: there is no evidence that troubled youth will desist from self harm if their parents are terrified into paying for irreversible medical interventions. A broad overview of all the medium and long-term studies into transition as a treatment show, at best, highly concerning results. Suicide rates seem to increase after transition, and quality of life remains low (more on this below).
There is no evidence, historical or otherwise, that a child will kill themselves if prevented from medically transitioning. If experiencing strong gender dysphoria made most such children feel life was not worth living, the clinical literature from the time before pediatric transition became so heavily publicized and promoted would show that. There would be multiple accounts of young people insisting that living in the wrong body was intolerable, and that they planned to end their lives because of it. I will dare to suggest that at least some of these attempted and completed suicides we are now seeing are the result of young, impressionable, gender nonconforming people who –yes—are subject to bullying and depression–being encouraged in the idea that they must either transition or die.
The list of understudied risks and side effects is neverending. Cross-sex hormones are associated with cardiovascular complications, including a fourfold increased risk of heart attacks in biological females, and a threefold increase in the incidence of venous thromboembolism in biological males (Alzahrani et al., 2019; Nota et al., 2019). Getahun et al also found higher rates of strokes and VTEs in transwomen relative to reference women and men, and found that the risk increases over time. In the words of the authors “Transfeminine participants had a higher incidence of VTE, with 2- and 8-year risk differences of 4.1 (95% CI, 1.6 to 6.7) and 16.7 (CI, 6.4 to 27.5) per 1000 persons relative to cisgender men and 3.4 (CI, 1.1 to 5.6) and 13.7 (CI, 4.1 to 22.7) relative to cisgender women.”
There is suggestive evidence indicating that hysterectomies, which a lot of trans men get, put women at a much higher risk of cardiovascular health problems and metabolic issues. As quoted in this study, here “women who underwent hysterectomy at age ≤35 years had a 4.6-fold increased risk of congestive heart failure and a 2.5-fold increased risk of coronary artery disease.”
Disturbingly, this study (using a Swedish database of women who underwent hysterectomy) found that women who had a hysterectomy had an increased risk for thyroid and brain cancer later in life. This study using the same Swedish database & by the same researchers found that the overall risk of renal cell carcinoma after hysterectomy was consistently increased, and recent population‐based studies suggest that hysterectomy is associated with several adverse outcomes including an increased risk for pelvic organ prolapse, urinary incontinence and pelvic organ fistula disease.
In the Danish study Hysterectomy, oophorectomy and risk of dementia: a nationwide historical cohort study, women who underwent hysterectomy with bilateral ovarian conservation had a 38% increase in risk of dementia with onset at ages 40–49 years. Hysterectomy with unilateral oophorectomy (surgical removal of an ovary or ovaries) increased the risk by 110%, and hysterectomy with bilateral oophorectomy increased the risk by 133%. In the words of the authors, “Premenopausal bilateral oophorectomy is associated with a higher risk, suggesting a dose effect of premature estrogen deficiency on dementia. The age-dependent effect suggests that the younger brain is probably more vulnerable to estrogen deficiency.”
This study observed an increased risk of cognitive impairment or dementia in women who underwent bilateral oophorectomy before the onset of natural menopause (70% increased risk for oophorectomy before age 49 years). The risk increased with younger age at the time of oophorectomy, was independent of surgical indication, and was partly offset by estrogen therapy after oophorectomy.
Radial forearm free flap phalloplasty (RFFP) is the current standard of care for most FTM gender confirmation surgeries. This procedure is associated with a rate of urethral stricture as high as 51%, which falls only to 23-35% even among the most experienced contemporary surgeons. In cases of urethral stricture, urethroplasty is required in 94-96% of patients.
In males, obviously, there are parallel complications. As I said, male transgender adolescents are being treated with gonadotropin-releasing hormone analogues and subsequently cross-sex hormones at early or mid-puberty, with vaginoplasty as the presumed final step in their physical transition.
And note that, despite the minimum age of 18 years defining eligibility to undergo this irreversible procedure, anecdotal reports have shown that vaginoplasties are being performed today on minors by surgeons in the United States, thereby contravening the World Professional Association for Transgender Health (WPATH) standards of care (SOC).
Now typically, surgery for trans-identified males involves dissecting the penis, turning the skin inside out, and placing it into a surgically created cavity to create a false vagina. After surgery, a dilator has to be placed in this artificial cavity to keep it from collapsing.
But kids who’ve been on puberty blockers since the age of 12 have a problem. Since they still has a small child-sized penis (because they weren’t allowed to go through puberty), they do not have enough skin to line the false vagina. Potential remedies include sewing in a section of intestine along with the penis skin to make the false vagina.
From this piece, brand-new in the Journal of Sexual Medicine:
Of the 20 (anonymous) surgeons surveyed in the Milrod-Karasic article, 11 admitted to operating on boys under the age of 18. The article emphasizes some surgeons’ belief that minors should have the procedure done while still in high school so that their parents can ensure compliance; even be “active” in the dilation routine required to keep the neovagina open to “maintain the vaginal depth involved” before the teen becomes distracted by college.
The co-authors admit that the growing trend of operating on minors is out of compliance with the current WPATH Standards of Care (SOC 7). But it’s evident from this and other writings that both are interested in changing those standards for the next version (SOC 8). And they are not alone; lowering the age for genital surgery is a very popular topic among top gender clinicians like Johanna Olson-Kennedy and others.
One surgeon cited in a footnote is Dr. Gary Alter, who in 2014 performed vaginoplasty on a 16-year-old.
Dr. Gary Alter first removed the testicles and inserted a tissue expander (similar to an internal balloon) in the scrotum several months prior to the final sex change. The expander was progressively filled with fluid through a port during several follow-up visits in order to stretch the scrotal skin and yield enough skin as a graft to line the neovagina. The expander thus enabled the patient to avoid taking skin harvested from the flanks with the resulting unsightly scars. After 2.5 months, the expander was removed during the vaginoplasty and clitoral creation.
Indeed, several Dutch studies can be found in the literature that discuss advantages of intestinal vaginoplasty for patients who have been on puberty blockers for many years. Arresting puberty seems to have spawned a whole new specialty for Dutch surgeons. In this 2016 article, Primary Total Laparoscopic Sigmoid Vaginoplasty in Transgender Women with Penoscrotal Hypoplasia,” the, authors report generally good outcomes, apart from the fact that 1 of 42 subjects died from septic shock and multiorgan failure, and 17.1 percent suffered “long-term complications that needed a secondary correction.”
This “treatment” can kill. Kids, who would have been exponentially more likely to grow up to be gay than transgender if left alone, can die in their quest for their “true identity”. I guess that’s worth dying for.
This study claims that “Male-to-female surgery can achieve excellent cosmetic and functional results.” Excellent meaning that,
Major complications during, immediately and some time after surgery occurred in nine of the 66 patients (14%), including severe wound infections in six, a rectal lesion in three, necrosis of the glans in three and necrosis of the distal urethra in one. Minor complications, e.g. meatal stenosis in seven patients, occurred in 24 (36%) of patients.
The study is misleadingly titled Male-to-female transsexualism: a technique, results and long-term follow-up in 66 patients, but of the original 66 test-subjects, only 31 completed the follow-up questionnaire (almost a 50% loss to follow-up). And the “long-term”? Study length was only 5 years (“from April 1995 to July 2000”).
Remember that pubertal blockade for gender dysphoric youth was pioneered in the Netherlands. In the US, the first doctor to use it was Norman Spack, a Harvard-affiliated pediatric endocrinologist at Boston Children’s Hospital, who leads one of the first and biggest hormone programs for young teenagers in the United States and whose infamous statement about his enthusiasm for the practice was captured in the New York Times:
Dr. Spack recalled being at a meeting in Europe about 15 years ago, when he learned that the Dutch were using puberty blockers in transgender early adolescents.
“I was salivating,” he recalled. “I said we had to do this.”
Are you scared yet?
Rosenthal’s aforementioned literature review references another Dutch study done in 2014. Says Rosenthal:
A report from the Netherlands assessed mental health outcomes in 55 transgender adolescents/young adults (22 MTF, 33 FTM) at 3-time points: Before the start of GnRH agonist treatment, at initiation of cross-sex hormones (average 16.7 years at start of treatment), and at least 1 year after “gender reassignment surgery” (average age 20.7 years)
This study represents the first long-term follow-up of patients managed according to currently existing clinical practice guidelines for transgender youth, and underscores the benefit of the multidisciplinary approach to care.
The study was a survey study of 55 young transgender adults, which reported positive outcomes from treatment.
First, this study is about young people, many of whom initially presented to the clinic as prepubescent children. 100% of them had childhood-onset gender dysphoria (no adolescent-onset gender dysphoria cases). Most of these children were socially transitioned by their parents prior to their arrival at the clinic, thereby disrupting the chance that they may have had to experience a typical childhood.
By the time these children reached the point of choosing to delay their puberty, they had been living as the other gender for years –in some instances possibly half of their young lives. By the time it came to choose whether or not to imbibe cross-sex hormones, it is no surprise that none of these children chose to revert to living as their own sex. How does a child who has basically reordered their family’s lives by their insistence that they are actually the other sex back down from such claims? How do they tell their friends? We are not talking about adults, here, after all.
Second, 94% of the males in this study were either same-sex attracted or bisexual (87.9% SSA, 6.1% BI) and 100% of the females (89.2 SSA, 10.8% BI) were same sex attracted. Are we really expected to believe that social and parental attitudes in regards to homosexuality played no part in either the formation of the children’s understandings of what constitutes “feeling like the other sex”?
It’s interesting to note from the information in this paper that during the time between starting hormone blockers and their choice to be put on cross-sex hormones, these kids –especially the girls –actually experienced greater levels of “gender dysphoria.” I think it’s important to ask ourselves why that is. These kids were not facing the risk of further development of secondary sexual characteristics. They were living as their chosen gender. Why wouldn’t they be at least somewhat relieved of their dysphoria?
The likely possibility is that living as fully socially transitioned children, their awareness of not physically “matching” their chosen gender while assuming that role actually worsens the sense of being wrong-bodied. In other words, telling someone that you are actually a boy or a girl when you clearly are not increases self-awareness of and discomfort with your actual sex. The very fact that they are attempting to live as the other gender may very well increase the dysphoria that assuming such a role is meant to lessen.
As far as the “positive outcomes” this study purports, there are numerous problems.
Fifteen of the cohort of 55 had “some missing data” which we are assured resulted in “no significant differences” on the pre-treatment tests. I think, too, that when considering the outcomes of these children, it would be remiss to ignore the 15 members of the original cohort of 70 who did not participate in follow up: six had not met the one year gender reassignment surgery anniversary for this study and were, therefore, excluded. Two refused to complete the assessment, and two did not return their questionnaires. (Why?) Three had health problems which prevented them from undergoing gender reassignment surgery, one “dropped out of care” (no clarification) and 1 died from complications from surgery. (How does one weigh such a loss against “positive outcomes?”).
Given the fact that all of these children had what is in essence a “gender obsession” since childhood and had been socially transitioned for years, it comes as no surprise that they experienced relief at finally accomplishing their goals. Research has shown that gender non-conforming children and adolescents are at higher risk for PTSD due to abuse and bullying because of being different, and the prospect of “fitting in” provided by merely initiating action towards this goal certainly provides a degree of psychological relief- regardless of the actual physical changes that have yet to take place. This is evidenced by the “significant quadratic effect” that commences immediately upon initiation of cross-sex hormones, well before significant physiological effects of the hormones could possibly have occurred.
Would body image and psychological well-being have improved in these children had they been allowed to experience a natural childhood and identity formation without medical intervention? We don’t know, because the study had no control group. No study evaluating the Dutch Protocol has.
Sadly, the ultimate result of medicalized disruption of identity formation –which would have included their whole selves, bodies included –creates an identity which is dependent upon exogenous substances, conscious gendered performance, and the willingness of others to deny their own perception in order to validate it. As such, the identity is not sustainable without significant degrees of external support and remains more highly vulnerable to what are perceived as being threats to self when it is not validated. As a result, they may be “at increased risk for the development of narcissistic disorders…as a consequence of the inevitable difficulties they face in having their cross-gender feelings and identities affirmed by others.”
Perhaps the greatest hindrance to accurately critiquing this study is related to the ages and the timing of this so-called “long-term” study: it was completed after only a minimum of one year after gender reassignment surgery. A significant portion of them were still living at home with their supportive parents and attending school. Their lives as fully transitioned adults were just beginning, and the difficulties of navigating sexual relationships and the hardships that entails for those not of their natal sex were in their infancy.
Because of the failure of the Dutch authors to denote significant variables among these youths, their study inspires more questions than it provides answers. Have these children been harmed by the parental and medical reification of childhood fantasy and desire? We have primarily their own self-reports to rely on –the reports of young adults who never were given the opportunity to experience childhood or adolescence as one would experience their own actual sex. They have nothing with which they can compare their current experienced “gender.” They will not know what it’s like to have sex in their natural bodies, nor be loved as such.
We do not know how the difficulties of living as transgender people will affect them. We do not know if the long-term effects of injecting artificial cross-sex hormones will damage them physically (or mentally). We will never know whether they might have resolved their gender dysphoria, as others have, and pressed on through life, because they were never given the chance to find out.
Part of the problem, admittedly, is the lack of good, reliable data. Studies on transition are fraught with study design problems including convenience sampling, lack of controls, low sample sizes, short study lengths, and enormously high drop-out rates. Very few studies on transition evade these issues.
Two of the largest issues are study length (or time since treatment) and loss-to-follow-up rates. It is well recognized in the literature that the year after medical transition is a “honeymoon period” which “does not represent a realistic picture of long-term sexual and psychological status.” Complicating study lengths is the issue of loss-to-follow-up. Many researchers state that at 20% loss-to-follow-up there are significantly detrimental effects to the reliability of a study. And yet studies on transition have loss-to-follow rates that reach 75%.
Patients lost to follow-up have a worse outcome than those who continue to be assessed. Consequently, a survival analysis that does not take into account such patients is likely to give falsely optimistic results. And where did all those “lost” people go? They need medication for the rest of their lives. Are the ones in van de Grift 2018, for example, lost somewhere in the Netherlands? How does that happen in a high-tech society? What percentage of the lost to follow-up have since detransitioned? How many suicides are contained within the groups that are lost to follow-up? To these and other questions there are few answers.
Three studies have addressed the problem of follow-up loss by taking a look at objective measures available in registry data in their countries. Due to this methodology these studies have either no loss or extremely low loss to follow-up and are able to supply what may be missing in many of the other studies.
Asscheman 2011 (Netherlands) considered the outcomes of 1331 post-HRT transsexuals with an 18.4yr average length since beginning of treatment.
total mortality was 51% higher than in the general population, mainly from increased mortality rates due to suicide, acquired immunodeficiency syndrome, cardiovascular disease, drug abuse, and unknown cause.
The timing of the suicides also provides some important information. None occurred within 2 years of treatment, consistent with the “honeymoon period” mentioned so often in the literature. However, “there were six suicides after 2–5 years, seven after 5–10 years, and four after more than 10 years of cross-sex hormone treatment”.
Dhejne 2011 (Sweden) found a suicide rate 19 times higher among the transsexuals than among a non-transsexual control group. 10 out of 324 transsexuals (i.e., 3.1% of the group) committed suicide. Another 29 of 324 (8.9%) receiving SRS in that period had made documented suicide attempts. Pyschiatric hospitalization was 2.8 times higher, even after adjusting for prior psychiatric morbidity. The median follow-up time was of over 10 years. Among the findings,
Transsexual individuals had been hospitalized for psychiatric morbidity other than gender identity disorder prior to sex reassignment about four times more often than controls.
Sex-reassigned transsexual persons of both genders had approximately a three times higher risk of all-cause mortality than controls, also after adjustment for covariates.
The poorer outcome in the present study might also be explained by longer follow-up period (median >10 years) compared to previous studies. In support of this notion, the survival curve (Figure 1) suggests increased mortality from ten years after sex reassignment and onwards
This study found substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalisations in sex-reassigned transsexual individuals compared to a healthy control population.
In October 2019, the American Journal of Psychiatry published a paper titled, “Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study.” The data come from the Swedish Total Population Register, a massive, longitudinal survey effort that collected information from over 9.7 million Swedes, or about 95 percent of the country. The authors tracked respondents over time and assessed their use of mental health treatment (for a mood or anxiety disorder) in 2015, as well as other related measures (such as hospitalization after a suicide attempt), as a function of time since gender-affirming hormone and surgical treatment.
The study found no mental health benefits for hormonal interventions in this population. There is no effect of time since initiating hormone treatment on the likelihood of subsequently receiving mental health treatment.
Compared with the general population, individuals with a gender incongruence diagnosis were about six times as likely to have had a mood and anxiety disorder health care visit, more than three times as likely to have received prescriptions for antidepressants and anxiolytics, and more than six times as likely to have been hospitalized after a suicide attempt. Years since initiating hormone treatment was not significantly related to likelihood of mental health treatment (adjusted odds ratio=1.01, 95% CI=0.98, 1.03).
It did claim, however, that after having had sex-reassignment surgeries, a patient was less likely to need mental health treatment.
However, increased time since last gender-affirming surgery was associated with reduced mental health treatment (adjusted odds ratio=0.92, 95% CI=0.87, 0.98).
Post-surgical mental health treatment hovers stably around 35 percent among those in their first nine years after surgery, and then drops to only 21 percent of those patients who are in their tenth (or higher) year since their last surgery. However, of the individuals who underwent surgery (n=1,018), fewer than 2% had surgery 10 or more years ago (n=19), while over 75% had surgeries within the past three years (n=772). This means the study is not, in fact, a 10-year-follow-up but effectively a single-year, short-term outcome study. And that the apparently helpful overall effect of surgery is driven by this comparatively steep drop in mood/anxiety treatment among only 19 patients.
It’s unclear why the researchers only identified a total of 19 patients who underwent surgeries before 2005, since the aforementioned Dhejne 2011 using the same national registry found 324 patients in the years prior to 2004 (13). It’s surprising that the reasons for such a large discrepancy were not addressed by the study authors, especially since both studies were conducted by the Karolinska Institute and they studied the same population.
It’s highly problematic if over 90% of postoperative gender dysphoria subjects were lost to follow-up. Where are these patients? How many completed suicide, died of other related causes, or emigrated from Sweden prior to the study timeline? We just don’t know, because the study tracks neither completed suicides nor detransitioners nor all-cause mortality for this sample.
Besides, the modest effect of surgery hinges on a handful of cases from an earlier era (10 or more years ago) when very few gender dysphoric patients pursued surgery at all. The population transitioning in recent years is qualitatively different from predecessor cohorts. For one thing, many of those now transitioning are much younger. In the UK, there was an increase of more than 1,000 percent in the annual rate of natal male children and adolescents seeking specialist gender services from 2009 to 2019, with a 4,400 percent increase among natal female children and adolescents—from 40 in 2009-10 to more than 1,800 a decade later. When the Gender Identity Development Service (GIDS) opened at London’s Tavistock Clinic in 1989, it received two referrals over the course of the year. In 2018-19 it received 2,590 referrals. Similar increases have been noticed in other Western countries.
We have no cohort of trans people in their 40s or 50s who were transitioned as adolescents and can tell us how it has impacted their life. We won’t have it for many decades to come.
After the study was published, many researchers and scientists (including some SEGM advisors) alerted the AJP to multiple serious methodological problems that challenged the study’s conclusion. In response, the AJP editor requested an independent statistical review of the data. The independent expert concurred with the concerns raised, and recommended that the answer to the key study question – whether surgeries improve mental health outcomes – should be clarified by creating a control group and reanalyzing the data. The study authors then created two equally-sized groups of patients diagnosed with gender dysphoria, the “surgery” and the “no-surgery” groups, which were matched on key demographic characteristics. When the two groups were compared, no significant differences were found in any of the mental health utilization measures used as a proxy for overall mental health.
In the words of the authors,
the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts.
In 2016, the Centers for Medicare and Medicaid revisited the question whether sex reassignment surgery would have to be covered by Medicare plans. Despite receiving a request that its coverage be mandated, they refused, on the ground that we lack evidence that it benefits patients. Here’s how the June 2016 “Proposed Decision Memo for Gender Dysphoria and Gender Reassignment Surgery” put it:
Based on a thorough review of the clinical evidence available at this time, there is not enough evidence to determine whether gender reassignment surgery improves health outcomes for Medicare beneficiaries with gender dysphoria. There were conflicting (inconsistent) study results—of the best designed studies, some reported benefits while others reported harms. The quality and strength of evidence were low due to the mostly observational study designs with no comparison groups, potential confounding and small sample sizes. Many studies that reported positive outcomes were exploratory type studies (case-series and case-control) with no confirmatory follow-up.
The final August 2016 “Decision Memo for Gender Dysphoria and Gender Reassignment Surgery” pointed out that
Overall, the quality and strength of evidence were low due to mostly observational study designs with no comparison groups, subjective endpoints, potential confounding (a situation where the association between the intervention and outcome is influenced by another factor such as a co-intervention), small sample sizes, lack of validated assessment tools, and considerable lost to follow-up.
The majority of studies were non-longitudinal, exploratory type studies (i.e., in a preliminary state of investigation or hypothesis generating), or did not include concurrent controls or testing prior to and after surgery. Several reported positive results but the potential issues noted above reduced strength and confidence. After careful assessment, we identified six studies that could provide useful information. Of these, the four best designed and conducted studies that assessed quality of life before and after surgery using validated (albeit non-specific) psychometric studies did not demonstrate clinically significant changes or differences in psychometric test results after GRS [gender reassignment surgery].
Sources:
- Inauthentic Selves: The modern LGBTQ+ Movement Is Run By Philanthropic Astroturf And Based On Junk Science
- A Republican Billionaire Is Funding the Trans Movement and Conversion Therapy Junk Science. Here’s the Who, and the How.
- The New Homophobic Bridge To Nowhere: Child Transition.
- Kingpins of pediatric transition confess: We have no idea what we’re doing
- Gender-affirmative therapist: Baby who hates barrettes = trans boy; questioning sterilization of 11-year olds same as denying cancer treatment
- Does prepubertal medical transition impact adult sexual function?
- “The money is flowing” to “suck people in:” Vaginoplasty & the case of Jazz Jennings
- Age is just a number when it comes to neovagina surgeries
- The trans-kid honeymoon is sweet—while it lasts
- http://womanmeanssomething.com/transition-as-treatment-the-best-studies-show-the-worst-outcomes/
- https://4thwavenow.com/2018/12/19/the-theatre-of-the-body-a-detransitioned-epidemiologist-examines-suicidality-affirmation-and-transgender-identity/
- https://quillette.com/2020/01/02/thehttps://quillette.com/2020/01/02/the-ranks-of-gender-detransitioners-are-growing-we-need-to-understand-why/-ranks-of-gender-detransitioners-are-growing-we-need-to-understand-why/
- https://www.segm.org/ajp_correction_2020#
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