Drop the suicide trope

Ken Zucker on that landmark Finnish study; Italy sends inspectors into a gender clinic; Europe's paediatricians stand up for a child's 'open future'; and a new systematic review from Germany

Photo by Juliana Malta on Unsplash

GCN in brief

It is “time to bury the ‘trans kid or dead kid’ trope,” Dr Ken Zucker, a leading international authority on youth gender dysphoria, has advised.

He was commenting on a landmark study from Finland which found that suicide was rare among dysphoric youth; that medical transition did not appear to reduce suicide risk; and that the elevated suicide risk among gender clinic patients was explained by their psychiatric co-morbidities, not by gender dysphoria itself.

“There is a trope that has been around now for a number of years—‘Would you rather have a trans kid or a dead kid?’,” said Dr Zucker, who is a Toronto-based clinical psychologist, researcher, and editor of the journal Archives of Sexual Behavior. (He chaired the DSM-5 diagnostic work group which supplanted the condition “gender identity disorder” with the depathologised term gender dysphoria in 2013.)

“It has been said that this [‘trans kid or dead kid’] trope is used to engender fear and anxiety in parents who are uncertain what the best therapeutic approach should be in helping an adolescent with gender dysphoria,” Dr Zucker told GCN.

He said the Finnish paper on suicide represented “a very important study.”

“At least based on the time interval that was available for follow-up, [the study by Ruuska et al] suggests a very, very low rate of completed suicide among transgender youth and young adults,” he said. (The median follow-up time was just under six years.)

“Although any suicide is heart-breaking for both families and clinicians, this is very good news. It is now time to bury the ‘trans kid or dead kid’ trope.”

“Although we know that adolescents and adults with gender dysphoria report suicidal ideation and suicide attempts at a rate higher than non-clinical populations, the rates are, by and large, similar to what one sees in many mental health conditions.”

More—

The Society of Evidence-based Gender Medicine says the Finnish study undercuts the suicide-prevention argument for hormonal and surgical interventions.

The New York Post has reported the study.

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Dear readers,

In the field of gender clinics, new developments are coming thick and fast across the globe (thanks for all the news tips!). “GCN in brief”—shorter items, bundled together—is my attempt to keep up.

An update on GCN. Total subscribers stand at 3,917; there are 174 paid subscribers; my thanks to everyone. Most articles now get more than 4,000 page views; some have registered well over 7,000 views. There is a lot of sharing of articles, which is exactly why I decided not to put any of my reporting behind a paywall.

I believe there are many more readers yet to discover GCN.

We are witnessing a remarkable social process, mostly unreported by mainstream media, whereby new organisations are emerging, driven by volunteers, and in turn those organisations are reaching out to, and engaging with, many otherwise isolated individuals.

Genspect and the LGB Alliance are two well-known examples, with distinct missions and overlapping concerns, but there are plenty of other groups at work that did not exist five years ago.

Much organisational work has been done; information and resources have been marshalled; there has been a lot of publishing and lobbying to open up and inform debate. The landscape is dramatically different today, compared with 2019, when I first fell down this rabbit hole.

And as this social process of mobilisation, inquiry and dialogue continues, it lights sparks of interest and motivation in yet more individuals, day after day. All this is starting to exert an enlightening influence in sections of the mainstream media, politics and myriad institutions.

In some jurisdictions, there have been pronounced shifts in public opinion and policy; in other jurisdictions the conditions for potential changes are being established. It will be an uneven, unpredictable process complete with pushback.

Best wishes, Bernard Lane

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Under investigation

Some children at the Careggi hospital in Florence have been given puberty blocker drugs without the preliminary psychotherapy that is recommended, according to the Italian media outlet ANSA.

ANSA reported a leaked early finding from the expert team sent last month to investigate the hospital by Italy’s Health Minister Orazio Schillaci, a nuclear medicine specialist who serves in the populist-right administration of Prime Minister Giorgia Meloni.

“[The inspection is] just a check of what has been done and whether the regulations have been followed—it is absolutely not a punitive gesture,” Mr Schillaci said.

In December, the Senate leader of the party Forza Italia, Maurizio Gasparri, had questioned the use and rationale of the puberty blocker drug triptorelin, reportedly given to children as young as age 11 at the Florence hospital’s gender clinic. Others had also appealed to the minister for action, including the lawyer Annamaria Bernardini de Pace, an expert in family law and child protection.

The Health Ministry has asked both the National Bioethics Committee (CBN) and the Italian Medicines Agency (AIFA) to reassess the off-label use of triptorelin with gender dysphoria; the ministry has also sought data on the drug’s usage across Italy’s regions.

A lawyer’s complaint, according to an article in Breaking Latest News, “raises questions about the operations of the Careggi [gender clinic] and the use of the drug that blocks puberty. It also calls into question the diagnosis and multidisciplinary approach required before administering the drug, as well as the authorisation process for its off-label use.”

The article said: “Minister Schillaci has vowed to put an end to the ‘Wild West’ approach to the issue and is working on drafting guidelines to ensure the scientific, supportive, and diligent operation of dysphoria centres. As the investigation unfolds, the focus remains on ensuring the safety and well-being of the minors receiving treatment at the Careggi [gender clinic] in Florence.”

A spokesperson for the parents’ group, GenerAzioneD, welcomed news of the minister’s intervention, telling GCN: “We feel it is important that the topic of puberty blockers has been brought to public awareness.”

In an interview touching on the Careggi investigation, the prominent psychoanalyst Sarantis Thanopulos, claimed that the Florence gender clinic “says one thing and does another.”

“According to the protocol approved by the AIFA, there should be an appropriate period of psychotherapy, but this does not happen. Psychotherapy is in fact expelled,” he said.

“The suspension of puberty to allow time for the allegedly dysphoric subject to constitute his gender identity is an oxymoron. Pubertal development is necessary for the constitution of gender identity. How can this identity be explored and defined if developmental arrest is used? It is not surprising that in almost all cases the blockage of puberty leads to the transition/affirmation of a transgender identity.”

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Keep the future open

Poorly evidenced puberty blockers, given in the name of child autonomy, may in fact afford these patients less choice, according to a new position statement from the European Academy of Paediatrics.

“[Puberty blocker] use may irrevocably lead to the use of trans-sex hormones and surgical transition, so it may arguably compromise rather than facilitate freedom of choice,” the statement said.

The academy stresses the importance of a child’s right to “an open future.” The statement does not argue for a blanket prohibition on puberty blockers for gender dysphoria, but notes areas of doubt and concern.

“Treatments that delay endogenous puberty may impact later fertility. Children may be reluctant to stop puberty-suppressing agents, and once stopped, gamete production can be slow to resume,” the statement said.

“It is important to discuss fertility risks and fertility preservation options with transgender individuals and their families prior to initiating treatments that may compromise future reproductive function. Despite routine counselling, few [gender dysphoric] youths opt for gamete harvest.

“Several of the national European reviews [as in Finland, Sweden and the United Kingdom] concluded that the few limited quality studies on puberty blockers [and outcomes in] mental health and quality of life provide a very low certainty of efficacy. The recognised ethical and practical difficulties of performing controlled trials do not preclude the need for either appropriate comparator studies or long-term follow-up research.

“The fundamental question of whether biomedical treatments (including hormone therapy) for gender dysphoria are effective remains contested.”

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Systematic as ever

Psychotherapy and mental health problems should be the priorities for treatment of minors with gender dysphoria, given the lack of any good evidence supporting the use of puberty blockers or cross-sex hormones.

Such is the conclusion of a new German systematic evidence review updating the 2020-21 reviews by the UK National Institute for Health and Care Excellence (NICE) and confirming that the “gender-affirming” medical model rests on a very weak evidence base.

The NICE systematic reviews found the evidence for hormonal interventions to be of “very low certainty.” This finding, in conjunction with the interim report of the Cass review, led to draft NHS policy that puberty blockers would be restricted to clinical trials, given their experimental nature.

Independent systematic reviews in Finland and Sweden have led to a similar policy shift away from routine medicalisation, instead favouring traditional psychosocial interventions.

The German review team, which included child and adolescent psychiatrist Florian D Zepf of Jena University Hospital, found no new puberty blocker studies satisfying NICE criteria, and only two recent studies on cross-sex hormones eligible for review. Those two studies failed to provide “any new robust findings.”

“The currently available studies on [puberty blockers and cross-sex hormones] in minors with [gender dysphoria] show significant conceptual and methodological flaws,” the review paper said.

“The current body of evidence is very limited, based on very few studies with small samples and problematic methodology and quality. Adequate and meaningful long-term studies are equally lacking.

“Current evidence does not clearly suggest that [gender dysphoria] symptoms and mental health significantly improve when [puberty blockers or cross-sex hormones] are given to minors with [gender dysphoria].

“Children and adolescents with [gender dysphoria] should therefore primarily receive psychotherapeutic interventions that address and reduce their experienced burden [of mental health disorders and gender distress].”

The research team recommended that Germany follow the cautious example set by England and the Nordic countries. However, a draft medical guideline for minors in Germany has been heading in the opposite, “decidedly trans-affirmative” direction, according to the Munich-based child and adolescent psychiatrist Alexander Korte.

Dr Korte, a expert clinician with a long history of treating children who present with gender distress, fears that Germany’s proposed law allowing self-declared gender change will “drive up” the rate of children whose gender dysphoria persists, thereby making lifelong medicalisation more likely.

From 2020-2022, Dr Zepf was a member of the steering group working on Germany’s new medical guideline—titled “Sex-incongruence and gender dysphoria in children and adolescents: Diagnosis and treatment”— but resigned in protest.

In the new German review paper, Dr Zepf cited “professional and ethical doubts and concerns” about the draft guideline and concern about its effect on “the protection of health in children and adolescents.”

The guideline is expected to be published soon.

The German systematic review paper from Dr Zepf and colleagues highlights the risk of infertility if blockers are followed by cross-sex hormones.

“Despite the medical possibility of prior cryopreservation—i.e., obtaining and freezing eggs or sperm [before cross-sex hormones], there are currently no established standards for fertility counseling for minors with [gender dysphoria] in Germany,” the paper said.

The research team acknowledges the view that early access to puberty blockers and cross-sex hormones allows children “to develop and live in their preferred gender identity.”

“However, it is argued on the other hand that starting treatments too early may suppress homo-, bi- or heterosexual developments. Moreover, physiological changes may cause regret if improvements in well-being are insufficient and infertility is permanent,” the paper said.

“Given the bioethical considerations and the potential for suppression of homosexuality or for a desire to have children in later adulthood, the significant consequences of potentially irreversible treatments initiated too early deserve critical appraisal.

“The question of a potential ‘psychosocial reversibility’ of the medical and psychosocial consequences after stopping [puberty blockers] remains unanswered. The assumption that the use of [puberty blockers] is completely reversible, as often communicated in the media, currently lacks evidence, and potential long-term effects are unclear.”

The paper said there was “no evidence” that hormonal interventions were more effective in minors with gender dysphoria “when compared to one or more psychosocial interventions, social transition to the preferred gender or no intervention.”

“Primary interventions for minors should therefore be psychosocially based, including psychoeducation and psychotherapy, with the main aim of reducing the burden associated with the perceived incongruence and improving the overall global functioning and well-being of affected individuals.

“It is argued that clinical practice should be open to evaluating all developmental psychological and psychosocially appropriate options for children and adolescents with perceived gender-specific incongruence.” [This openness to ethical, non-medical treatment is at risk in many jurisdictions with deceptive laws against ‘gender identity conversion therapy.’—GCN.]

“It should be considered that [gender dysphoria] can be a temporary phase, particularly in prepubertal children. In this context, it is stressed that an early social transition has risks, such as children and adolescents having difficulties later following their own wish to return to their initial gender role.”