CCBI News: Gender Dysphoria – Part 2

November 24, 2023

Dear Friends of CCBI,

Gender Dysphoria – Part 2

Since 2011, two Dutch studies have been regarded by many in transgender medicine as providing the ‘gold standard’ for treating young people seeking help with gender dysphoria and perhaps seeking transition. Treatment methods include the use of puberty blockers and cross-sex hormones. Other practitioners have consistently warned of the dangers of claims of improvement, unverified by long term studies. Nevertheless, not only some medical societies but also school boards and governing bodies accepted these standards, despite being cautioned that undue haste and lack of proof could end badly for the young people concerned.

In our previous NEWS I wrote that these standards have been challenged and have been rejected, for example by Finland, Sweden and the UK, which have in the main stopped administering puberty blockers and hormone treatments and have returned to psychotherapy as primary treatment. Many in the field now demand more evidence-based treatments, having found claims such as the Dutch studies exaggerated and not borne out upon re-evaluation.

One analysis (E. Abbruzzese et al, 2023, p. 673) claims that, “…a false narrative has taken root. It is that gender affirming medical and surgical interventions for youth are as benign as aspirin, as well-studied as penicillin and statins, and as essential to survival as insulin for childhood diabetes.” The authors aver that this narrative has ‘failed to withstand scientific scrutiny internationally, with public health authorities in Sweden, Finland and England doing a U-turn in the last 24 months.” Their analysis shows that the foundational Dutch studies are gravely flawed, to the extent that they should never have been relied upon in the first place!

These authors demand rigorous clinical research before procedures involving puberty blockers, cross-sex hormones and surgery are used, lest they do more harm than good. The authors of the Dutch studies, deVries et al, have dismissed these challenges to the authenticity of their work, but more clinicians are now rejecting it, coupled with the major challenge to its efficacy shown in the numbers of young people who want to de-transition.

Flaws in Practices; Ethical Factors

In this week’s NEWS, we want to emphasize the flaws in practices still in use, e.g., in Canada and in the United States, that were originally embraced wholeheartedly by many practitioners and activists, seemingly without doubt but also without proof of success. I find that approach unethical and inexcusable, whether in medicine, in law, in logic, in philosophy or in scientific research. Political advocacy and a morality based on individual relativism (‘choice’) ignore the logic that tells us that not everything we choose is right or good for us, and that we should be aware possible consequences before we take any action. An important ethical factor that should always be considered, also in the gender dysphoria field. is that young people are not capable of fully understanding some situations nor of evaluating consequences over the long haul. Their consent is undermined by lack of knowledge due to their age, further clouded by their need to have their wishes about gender change fulfilled. As children, they rely on adults to guide them by providing information otherwise inaccessible to them, then helping them to understand that information. They are deemed ‘minors’ in society and in law so that adults will protect and guide them. The tail should not wag the dog!

Challenges to The Dutch Studies

Abbruzzese and co-authors are painstaking in their dissection of de Vries’ work, concluding with six pages of references. Their main objections are:

1. Bias in method. This is the primary challenge to existing protocols based on the Dutch studies: the number of adolescents suffering from gender dysphoria at the time of the studies beginning in the 1990s was small, and at the time evidence showed that transitioning in the late teens and as adults did not obtain good results in resolving the condition. An idea took hold that if transitioning were to begin earlier, results would be better. Puberty blockers would be used, followed later by cross-sex hormones. Since this amounted to ‘innovative practice’ with no studies to back it up, the ethical requirement is, “…to move into high quality clinical research capable of demonstrating that the benefits outweigh the risks.” (Abbruzzese, P. 675) What happened, however, was that ‘affirmative’ treatment with hormones and surgery entered clinical practice, more or less worldwide, without the necessary high-quality research having been done.

It was not shown that “…the benefits were substantial enough to outweigh the burdens of lifelong dependence on medical interventions, infertility and sterility and other health care risks.” (Abbruzzese, P. 675). One should ask why these factors were rarely mentioned by those in favour of early transitioning?

The other factor that was consistently downplayed, rejected or denied, is that statistics show that most young people, about 80%, revert to acknowledging their biological sex and gender IF these medical and physical interventions do not take place. That was current knowledge before studies such as deVries’ took hold, and it is difficult to understand why the results of those studies superseded existing medical practices without real proof and longer-term studies. It can be observed, however, that rights-activist groups often make a big impression on society, including on some in the Roman Catholic community who embraced these new treatment protocols, presumably to help children relieve their distress, yet despite the teachings of the Catholic Church on accepting our God-given bodies and perhaps without fully realizing what treatment would entail.

The Dutch studies did show that hormonal and surgical interventions can successfully change the phenotypical appearance of secondary sex characteristics of adolescents and young adults, but what they failed to show is that these physical changes resulted in meaningful psychological improvements significant enough to justify the adverse effects of the treatment—including the certainty of sterility. Despite these drawbacks, they continue to inform the work of medical groups such as the Endocrine Society and the World Professional Association for Transgender Health, although, as noted, many other societies and countries have re-evaluated and disavowed them, moving to an evidence-based, psychotherapeutic regime.

2. A second major finding of analysis of the Dutch studies’ standards shows incompleteness of evidence and information regarding physical health risks for those who transition, including the possibility of sterility. Young people need to know and understand the implications of possible adverse effects of hormonal interventions on their bones and brains before making any decisions about treatment. Just as studies began to show problems in administering liberal doses of estrogen to women in some situations, so there is a likelihood of problems for those who transition, who must remain on hormone treatment for the rest of their lives. Indefinite hormone treatment cannot be as ‘benign as taking aspirin,’ as the Abbruzzese paper remarked.

3. The third major challenge to the Dutch studies is their poor generalizability to cases now, in the 2020’s. What might have been valid in the 1990’s and early 2000’s is not necessarily so today. Most youth diagnosed now suffer from post-pubertal onset of gender dysphoria coupled with significant mental illness—two clinical presentations that were explicitly disqualified from the Dutch studies.( Abbruzzese, P. 677) As such, the Dutch findings are inapplicable to most of the youth seeking treatment today.

DeVries disputed the charge of bias but did not respond to the other two charges, and it is uncertain whether she agrees or disagrees with them since she has not yet produced countering evidence. Their studies were supposed to evaluate the use of puberty blockers for gender dysphoria and therefore should have started at puberty, not at the age when they could receive cross sex hormones, which at that time was age 16. Some of the original subjects, however, were not ready for many reasons to begin cross-sex hormones and were then left out of the study. Since the original study subjects were not all subjects of the continuing study, its conclusions were skewed in favour of best outcomes, the problem statistics having been omitted. This was not noted or discovered by researchers analyzing the statistics originally. Also, some of the young people were aged 15-16 and had reached a different level of physical maturity. Attempts to replicate studies on younger age groups did not have the same success. (Carmichael et al, 2021).

The Dutch studies also confounded results of puberty blocking and post surgical results into a single set of outcomes, making it almost impossible to evaluate the benefits or otherwise of the effects of the separate use of cross-sex hormones. The inability of the Dutch research to elucidate the outcomes of cross-sex hormone treatments (separate from surgery) was noted by the British National Institute for Health and Care Excellence (NICE), which “…appropriately excluded the 2014 Dutch study from its systematic review of evidence, 2020,” i.e., about outcomes in treatments for youth with gender dysphoria. (Abbruzzese, P. 679)

Invalidation of Measurement of Outcomes

The Utrecht Gender Dysphoria Scale purports to measure the resolution of gender dysphoria, and an indicator of this is when the measuring tool results are low post-surgery. DeVries showed results at the lowest end of the scale, but according to later investigators, this was achieved by switching the scale from female to male versions (and vice versa) before and after treatment, prompting a reversal in the scoring. This abuse of method alone invalidates the conclusion of resolution of gender dysphoria and the Abbruzzese paper states: “We think it is vitally important for the scientific community to recognize that the UGDS scale use was not merely “not ideal”—but that it entirely invalidated the Dutch study’s main finding.” (Abbruzzese, P.680) This is an extremely candid statement in a scientific paper and is clearly meant to be cautionary, to say the least. The accusation of unethical practice is substantiated in that methods were used to justify results in favour of medical interventions for gender dysphoria in youngsters that are invalid. The outcomes are similarly invalid and these ‘standards’ should no longer be applicable.

More to come!

Added to their conclusions and my remarks in Part 1 about the closure of the Tavistock Clinic in England, signalling a move away from puberty blockers and cross-sex hormones as standard treatment, Finland and other countries have also reversed their protocols.

Next time we will look into the reasons for this major shift, and also explain ‘social contagion’ as a factor making many jurisdictions question their existing protocols. As late as the late 1990’s, only a very small number of young children presented with gender dysphoria. One Finnish researcher describes patients as now arriving in ‘droves,’ noting that while earlier patients had nearly all been young boys, the vast majority now are teenage girls. Such a dramatic shift demands an examination of the reasons for this, added to the myriad other challenges, moral, psychological and medical, associated with gender dysphoria.

References

E Abbruzzese ¹, Stephen B Levine ², Julia W Mason ^{3 “} TheMyth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed” Journal of Sex and Marital Therapy, 49:6, 673-699. DOI: 10.1080/0092623X.2022.2150346

Carmichael, et al. “Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK.” PLoS One. 2021 Feb 2;16(2):e0243894.

Doi: 10.1371/journal.pone.0243894. eCollection 2021.

Pope Francis’ Intentions for November

For Pope Francis

We pray for the Holy Father; as he fulfills his mission, may he continue to accompany the flock entrusted to him, with the help of the Holy Spirit.

Moira and Bambi