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Cracking the 'false' consensus

Florida mounts the most significant challenge yet to under-age gender transition

Bernard Lane
Jun 12, 2022
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Cracking the 'false' consensus

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The gist

Health professionals, activists and journalists are relying on the facade of โ€œeminence-based medicineโ€ to justify medicalised gender change for minors, thereby obscuring from the public the very weak evidence base for these risky, irreversible treatments.

That is the allegation by the American state of Florida, where health authorities have made the first government challenge to the authority of medical societies, particularly the American Academy of Pediatrics (AAP), responsible for transgender youth treatment guidelines and policy statements.

In the most comprehensive scientific critique yet commissioned by a U.S. state government, Floridaโ€™s Agency for Health Care Administration has issued a report advising against Medicaid subsidies for paediatric transition, backed by five expert papers on the evidence and ethics of hormonal and surgical treatments for the distress of youth gender dysphoria.

โ€œIt is the first state to request a comprehensive, independent review and assessment of the literature with respect to whether sex-affirming care is safe, effective and medically necessary by experts who study methodologies, results and standards โ€” and to place it along with other expert testimonies in the record as the basis of their decision,โ€ said former health care lawyer Jane Wheeler of the group Rethink Identity Medicine Ethics.

โ€œI think it is significant also because the state is overtly challenging the AAP and other medical associations, and called out their supportย  for โ€˜affirmativeย careโ€™ as ideological and not evidence-based.โ€ย ย ย 

Amid polarised politics, many U.S. Republican-run states are seeking to restrict โ€œgender-affirmingโ€ medical interventions with minors, claiming they are too young to give informed consent, while President Bidenโ€™s Democratic federal administration endorses gender medicine as beneficial for youth mental health and has warned the states it will litigate to maintain access to these treatments.

In April, U.S. assistant secretary for health Dr Rachel Levine, a trans woman appointed by the Biden administration, claimed that medical transition of minors had the firm foundation of โ€œevidence-based standards of careโ€, citing treatment guidelines and policy statements from the AAP, the Endocrine Society and the World Professional Association for Transgender Health.

These documents are often relied on by gender clinicians, activists and journalists when claiming a solid medical consensus for social and medical transition of minors using the โ€œgender-affirmingโ€ treatment approach.

But the June 2022 Florida Medicaid report says youth gender medicine โ€” from puberty blocker drugs through to cross-sex hormones and surgery โ€” does not constitute a standard of care, and the evidence is so weak that these treatments are โ€œexperimentalโ€ and cannot be taken as โ€œsafe and effectiveโ€ for gender dysphoria.

โ€œWhile clinical organisations like the AAP endorse [these] treatments, none of those organisations relies on high quality evidence,โ€ the report says.

โ€œTheir eminence in the medical community alone does not validate their views in the absence of quality, supporting evidence.

โ€œTo the contrary, the evidence shows that [these] treatments pose irreversible consequences, exacerbate or fail to alleviate existing mental health conditions, and cause infertility or sterility.โ€

Floridaโ€™s Surgeon-General Dr Joseph A. Ladapo has alerted the Florida Board of Medicine to the Medicaid report, as well as the stateโ€™s April 2022 Department of Health guidance against social and medical transition of minors.

โ€œI encourage the Board to review the Agencyโ€™s findings [in the Medicaid report] and the Departmentโ€™s guidance to establish a standard of care for these complex and irreversible procedures,โ€ Dr Ladapo said in his June 2 letter.

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The Florida Medicaid report may be used in test-case litigation to argue that the policies of activist medical societies do not represent a โ€œtrue consensusโ€ among health professionals, and that the low-evidence treatments of the gender-affirming model are not โ€œmedically necessaryโ€, according to Candice Jackson, a former senior lawyer for the federal government now helping the international parentsโ€™ group Genspect.

โ€œWith a specific report to point to, from a government agency โ€” I think that's going to be used far and wide,โ€ Ms Jackson told GCN.

โ€œI'd be surprised if Florida stands alone as the only [Republican] state that goes ahead and truly dives into this [gender medicine debate] in a realistic and rational and specific way like this.โ€

Ms Wheeler highlighted the decision of Floridaโ€™s DeSantis administration to involve the stateโ€™s medical board.

โ€œThe Florida Medical Board was asked to assess in light of the [Medicaid] review whether minors in Florida should get โ€˜affirmative careโ€™,โ€ she told GCN.

โ€œBy making this a matter for the medical board and conducting an independent review, the medical issues are front and centre โ€” and not so politicised as are the [other] state bans.ย 

โ€œ[President] Biden is about to propagate new regulations requiring providers and insurance to provide and cover โ€˜medically necessary gender-affirming careโ€™.

โ€œSo you can say that Florida is heading them off at the pass โ€” and setting up the court case to challenge such a requirement as โ€˜arbitrary and capriciousโ€™, given Floridaโ€™s findings.โ€

Already in an Arizona case heard by a U.S. federal court of appeals, lawyers for young biological females seeking Medicaid cover for trans mastectomy failed to meet a high standard of proof for the โ€œmedically necessaryโ€ test.

And like the 15 states which recently filed a brief in defence of Alabamaโ€™s law against paediatric transition, the Florida report cites the international trend towards greater caution, with systematic reviews of the medical literature in Sweden, Finland and the United Kingdom confirming the weak evidence base for youth gender medicine.

Dr James M. Cantor, the clinical psychologist and researcher commissioned by Florida to review the medical literature on youth gender dysphoria, told GCN that many trans rights advocacy groups โ€œhave been shockingly guilty of cherry-picking evidence, citing only the studies or even just pieces of studies that look supportiveโ€.ย 

โ€œThe objective and transparent methods used in [Floridaโ€™s project] represent a huge step beyond that, capturing all the relevant evidence.โ€

Assessing the weak and inconclusive evidence, the Florida report notes that โ€œclinical organisations [such as the AAP] that have endorsed puberty suppression, cross-sex hormones, and sex reassignment surgery frequently state that these treatments have the potential to save lives by preventing suicide and suicidal ideation.

โ€œThe evidence, however, does not support these conclusions.โ€

Twitter avatar for @kellyske
Kelly S. @kellyske
๐ŸงตErin Friday courageously testified today in Sacramento against Scott Wiener's SB 107, which would make California a Sanctuary State for families of children seeking "Gender-Affirming Health Care" I'm grateful to know her. assembly.ca.gov/media/assemblyโ€ฆ
3:21 AM โˆ™ Jun 9, 2022
1,221Likes384Retweets

The detail

Highlights

  • โ€œPublic healthcare systems throughout the world have โ€ฆ been ending the practice of medical transition of minors, responding to the increasingly recognised risks associated with hormonal interventions and the now clear lack of evidence that medical transition was benefiting most children, as opposed to the mental health counselling accompanying transition.โ€ โ€” Dr James M. Cantor, clinical psychologist, expert report for Florida

  • โ€œ[The 2018 โ€˜rapid-onset gender dysphoriaโ€™ study of researcher Dr Lisa Littman] along with [other studies] reveal that the causes of gender dysphoria are still a mystery and could have multiple biological and social elements. Because of this ongoing uncertainty, treatments that pose irreversible effects should not be utilised to address what is still categorised as a mental health issue.โ€ โ€” Florida Medicaid main report

  • โ€œGiven that the majority of surveyed detransitioners [in Dr Littmanโ€™s 2021 paper said] they were comfortable with their biological sex, [her] study indicates that gender dysphoria is not necessarily a lifelong issue. This necessarily raises doubts about whether cross-sex hormones, which cause permanent physical damage, are justified.โ€ย โ€” Florida Medicaid main reportย 

  • โ€œPerhaps the greatest failure of informed consent, and non-disclosure of human experimentation outcomes, is found in the supposedly benign use of puberty blocking agents in minors โ€ฆ [T]he development of the adolescent brain and the maturation of its rational and executive functions does not typically complete until oneโ€™s early 20s. โ€” Dr G. Kevin Donovan, ethicist and paediatrician, expert report for Florida

  • โ€œWe do not know if brain development that is halted with puberty blockers can return to full function once puberty is allowed to resume. It is very difficult to imagine ethical controlled clinical trials that could elucidate the effects of delaying puberty until the age of consent.โ€ โ€” Dr Quentin L. Van Meter, paediatric endocrinologist, expert report for Florida

  • โ€œIn the self-identified transgender adolescent, breasts are being removed on the basis of a diagnosis that is made by the patient since there are no tests with known error rates that can be used to predict who will benefit from this disfiguring and irreversible surgery.โ€ โ€” Dr Patrick W. Lappert, plastic surgeon, expert report for Florida

  • โ€œIn a year when Florida officials have already unleashed repeated, mean-spirited attacks on the LGBTQ+ community, this latest move by the DeSantis administration to deny best practice, age-appropriate, medically-necessary health care to transgender people is simply one more purely partisan attack on LGBTQ Floridians.โ€ โ€” Cathryn Oakley, Human Rights Campaign

A review of reviews

Floridaโ€™s health agency commissioned a systematic review of the medical literature from Dr Romina Brignardello-Petersen and Dr Wotjek Wiercioch, two McMaster University experts in health research methodology and the synthesis of evidence.

For their report, they took data from 75 systematic reviews of studies on puberty blockers, cross-sex hormones and trans surgery; synthesised the evidence on outcomes; and then graded the quality of that evidence.

They found some โ€œlow certaintyโ€ and โ€œvery low certaintyโ€ evidence suggesting improvements in gender dysphoria and other outcomes such as depression after these treatments. For most outcomes, these studies lacked a comparison group of patients not given these treatments, making impossible any firm conclusion about cause and effect.

โ€œDue to the important limitations in the body of evidence, there is great uncertainty about the effects of puberty blockers, cross-sex hormones and surgeries in young people with gender dysphoria,โ€ the reviewers say.

โ€œThis evidence alone is not sufficient to support whether using or not using these treatments. We encourage [clinical] decision-makers to be explicit and transparent about which factors play an important role in their decision, and how they are weighted and traded off.โ€

Caution abroad

Floridaโ€™s various reports cite official reviews and studies in Sweden, Finland, the U.K. and Australia as vindicating the turn to caution by Americaโ€™s Republican states.

Finland, June 2020: Finlandโ€™s Council for Choices in Health Care removed hormonal and surgical interventions as first-line treatments for minors, insisting that psychiatric issues and other problems be treated first. The council said: โ€œNo conclusions can be drawn on the stability of gender identity during the period of disorder caused by a psychiatric illness with symptoms that hamper developmentโ€. Finlandโ€™s new treatment guideline drew on a systematic review of the evidence, which found that โ€œgender reassignment of minors is an experimental practiceโ€.

Australia, April 2021: A study linked to the Childrenโ€™s Hospital at Westmead in Sydney reported that dysphoric patients had significantly higher rates of childhood attachment issues and โ€œadverse childhood eventsโ€ such as trauma. This suggests that mainstream psychological approaches be used rather than irreversible medical interventions, according to Floridaโ€™s main June 2022 report.

Australia, September 2021: A new position statement from the Royal Australian and New Zealand College of Psychiatrists stressed the importance of mental health assessment before any decision on medical transition. Floridaโ€™s ethics expert report notes this more cautious policy, and quotes its warning โ€” โ€œThere is a paucity of quality evidence on the outcomes of those presenting with gender dysphoria. In particular, there is a need for better evidence in relation to outcomes for children and young peopleโ€. The new RANZCP policy followed a two-year review of evidence.

Sweden, February 2022: The Swedish National Board of Health and Welfare concluded that โ€œthe risks of hormonal interventions for gender dysphoric youth outweigh the potential benefitsโ€. This policy to end routine medical interventions followed a systematic review of the evidence base.

U.K., April 2022: In an interim report, the independent Cass review of gender dysphoria treatment said โ€œgaps in the evidence baseโ€ โ€” highlighted by systematic reviews โ€” prevented any โ€œdefinitive adviceโ€ on the safety or effects of puberty blockers and cross-sex hormones for minors.

The science of gender dysphoria

In his expert report for Florida, Dr Cantor reviews the small body of prospective studies โ€” tracking outcomes over time โ€” involving dysphoric youth given puberty blockers or cross-sex hormones, and concludes โ€œthere is little evidence that transition improves the mental well-being of childrenโ€.

โ€œDespite that mental health issues, including suicidality, are repeatedly required by clinical standards of care to be resolved before transition, threats of suicide are instead oftentimes used as the very justification for labelling transition a โ€˜medical necessityโ€™,โ€ he says.

He says that what looks like adolescent-onset gender dysphoria might sometimes be the โ€œidentity disturbanceโ€ of undiagnosed borderline personality disorder (BPD), which calls for dialectical behavioural therapy, not medical transition. He says this condition, together with potentially LGB youth presenting as trans, may explain some of the elevated suicide risk attributed to dysphoric youth.

โ€œSocial media increasingly circulate demands for transition accompanied by hyperbolic warnings of suicide should there be delay or obstacle,โ€ Dr Cantor says.

He cites the anecdotal refrain of gender clinicians faced with parents sceptical about medical transition โ€” โ€˜Would you rather have a live, trans son than a dead daughter?โ€™

โ€œSuch threats are treated as the justification for referring to affirming gender transitions as โ€˜lifesavingโ€™ or โ€˜medically necessaryโ€™,โ€ he says.

โ€œSuch claims convey only grossly misleading misrepresentations of the research literature, however, deploying terms for their shock value rather than accuracy, and exploiting common public misperceptions about suicide.

โ€œIndeed, suicide prevention research and public health campaigns repeatedly warn against circulating such exaggerations, due to the risk of copy-cat behaviour they encourage.โ€

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Dr Cantor highlights the modest claims and relatively cautious approach of the Amsterdam clinic which pioneered the use of puberty blockers within what became known as the โ€œDutch protocolโ€ of gender medicine.

He says the protocol stipulates โ€”

  • no social transition before age 12 (the โ€œwatchful waitingโ€ period)

  • no puberty blockers before age 12

  • cross-sex hormones considered only after age 16

  • resolution of mental health issues before any transition

โ€œThe data from this [Amsterdam] clinic simply contain no information about the safety or efficacy of employing these measures at younger ages,โ€ Dr Cantor says.

โ€œMany other clinics and clinicians intrepidly proceeded on the basis of only the perceived positives [of the Dutch protocol], broadened the range of people beyond those represented in the research findings, and removed the protections applied in the procedures that led to those outcomes.โ€

In February 2021, a leading Dutch clinician, Dr Thomas Steensma called out gender clinics internationally for โ€œblindly adoptingโ€ the Dutch protocol treatments without researching their own different patient groups.

โ€œWe donโ€™t know whether studies we have done in the past are still applicable to today. Many more children are registering, and also a different type,โ€ Dr Steensma said.

Over the last decade, the patient profile has switched from the classic early childhood dysphoria affecting a minuscule number of boys, to an exponentially growing gender clinic caseload of adolescent girls with multiple mental health disorders, autism and other complex issues.

Dr Cantor says โ€œwatchful waitingโ€ had been the standard approach with early childhood dysphoria because of the robust research finding that the majority of these children would grow out of their opposite-sex identification, with many emerging as LGB adults.

โ€œIn sum, despite coming from a variety of countries, conducted by a variety of labs, using a variety of methods, all spanning four decades, every study without exception has come to the identical conclusion: among prepubescent children who feel gender dysphoric, the majority cease to want to be the other gender over the course of puberty,โ€ he says. This is known as โ€œdesistanceโ€.

โ€œBecause only a minority of gender dysphoric children persist in feeling gender dysphoric in the first place, โ€˜transition-on-demandโ€™ increases the probability of unnecessary transition and unnecessary medical risks.โ€

Dr Cantor says most medical society recommendations on youth gender dysphoria are more cautious than they are made out to be in todayโ€™s โ€œhighly politicised contextโ€.

At odds with activist claims, he says most of these official documents note that:

โ€ข Desistance of gender dysphoria occurs in the majority of prepubescent children

โ€ข Mental health issues need to be assessed as potentially contributing factors and need to be addressed before transition

โ€ข Puberty-blocking medication is an experimental, not a routine, treatment

โ€ข Social transition is not generally recommended until after puberty

Dr Cantor says the 2017 Endocrine Society guideline, one of the most commonly invoked in favour of paediatric transition, in fact does not endorse an โ€œaffirmation-onlyโ€ treatment approach.

He notes that a 2020 Endocrine Society position statement, created in concert with the Pediatric Endocrine Society, states that the societyโ€™s 2017 โ€œrecommendations include evidence that treatment of gender dysphoria/gender incongruence is medically necessary and should be covered by insurance.โ€

However, Dr Cantor says, โ€œthe Endocrine Society makes neither statementโ€.

His strongest rebuke is for the 2018 AAP policy, which he says is โ€œ unique among the major medical associations in being the only one to endorse an affirmation โ€˜on demandโ€™ policy, including social transition before puberty, without any watchful waiting period.

โ€œAlthough changes in recommendations can obviously be appropriate in response to new research evidence, the AAP provided none.

โ€œRather, the research studies the AAP cited in support of its policy simply did not say what the AAP claimed they did. In fact, the references that the AAP cited as the basis of their policy instead outright contradicted that policy, repeatedly endorsing watchful waiting.โ€

Dr Cantor first published his fact-check of the AAP policy four years ago. The AAP has been asked for comment a number of times but has refused.

Twitter avatar for @segm_ebm
SEGM @segm_ebm
A new study published in Pediatrics found that 98% of children who undergo early social gender transition (SGT) continue to identify as transgender in early adolescence. Majority (60%) also initiate hormonal interventions within 5 years of SGT. /1
segm.orgEarly Social Gender Transition in Children is Associated with High Rates of Transgender Identity in Early AdolescenceA recent study published in Pediatrics examined the 5-year gender identity development trajectory of transgender-identified children who underwent early social gender transition (SGT). The children were, on average, 6-7 years old at the time of SGT. Five years later, at the average age of 11-12, almโ€ฆ
3:37 PM โˆ™ May 9, 2022
223Likes104Retweets

Affirming natural puberty

โ€œThe major benefit of enduring puberty in a gender dysphoric patient is that it provides a strong likelihood of alignment of his gender identity with his natal sex,โ€ paediatric endocrinologist Quentin L. Van Meter says in his expert report.

โ€œThere is no doubt that these patients need compassionate care to get them through their innate pubertal changes.โ€

Dr ย Van Meter โ€” whose training at Johns Hopkins Hospital included exposure to the methods of Dr John Money, the pioneer of the disembodied concept of โ€œgender identityโ€ โ€” opposes puberty blockers and challenges the claim that they are fully reversible.

He says this suppression of naturally timed puberty is quite different from using the same drugs to stop โ€œprecocious pubertyโ€ occurring in girls before age 8 or boys before age 9.

โ€œ[With precocious puberty] the end of treatment is carefully timed so that resumption of puberty occurs at the average age for females (10.5 years) and males (11.5 years),โ€ Dr Van Meter says.

โ€œThis allows the necessary functions of puberty to prepare the body for reproduction and affects the bones, gonads, and brain, among other body systems.

โ€œOn the other hand, blocking puberty at the age of normal puberty [in gender dysphoria cases] prevents the needed accretion of calcium into the skeleton and prevents the maturation of the gonads.

โ€œThere is no long-term data that compares bone, gonad, and brain health in pubertal-aged patients who have had puberty interrupted and those who have not.

โ€œWithout any verifiable safety data, using the puberty blockers for interrupting normal puberty is not a sanctionable โ€˜off-labelโ€™ use of these drugs and is therefore to be considered uncontrolled, non-consentable experimentation on children.โ€

Twitter avatar for @Bernard_Lane
Bernard Lane @Bernard_Lane
"There are parents of 7-year-olds asking: When should my daughter get hormones? And when should the ovaries come out?" Munich gender dysphoria expert Dr Alexander Korte speaks about social contagion, puberty blockers that "prevent homosexuality" & law confusing sex & gender. 1/
9:45 AM โˆ™ May 3, 2022
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Ethics

In his expert report on ethics, Dr G. Kevin Donovan, a paediatrician and former director for the Center for Clinical Bioethics at Georgetown University School of Medicine, says young people with gender dysphoria have been promised โ€œholistic careโ€ while at the same time, the confused idea of a child โ€œtrapped in the wrong bodyโ€ imposes โ€œa fragmented concept of the selfโ€.

โ€œThis approach has been warmly embraced, even insisted upon, by many practitioners while viewed as nonsensical and even ludicrous by many laypersons,โ€ he says.

โ€œIn reality, we cannot be trapped in the wrong body; we are our bodies, which are an integral and inseparable part of ourselves. To assert that there is a female self inside a male body (or the reverse), is to fail to achieve a full understanding that we are embodied persons, unified body and mind, if you will. A generation ago, sex and gender were taken to be synonyms for the same phenomena.

โ€œWe must ask if [todayโ€™s gender-affirming approach] represents a shift towards being trapped in a wrong diagnosis, rather than a child being trapped in a wrong body.โ€

Dr Donovan diagnoses a โ€œheadlong rush in the past decade towards the process of gender affirming careโ€, which he concludes is an unacknowledged experiment with off-label treatments not approved for gender dysphoria.

โ€œGiven this, we must ask ourselves: how can experienced and ethical physicians so mislead others, or be so misled themselves?โ€

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Cracking the 'false' consensus

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Cracking the 'false' consensus

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for the kids
Jun 13, 2022Liked by Bernard Lane

Thank you for the fantastic summary of this review and all the context as well!!

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