When members of Do No Harm attended the 2023 Endocrine Society meeting, we heard from many endocrinologists who quietly expressed concerns about current standards of care in pediatric gender medicine. A recent post on the anonymous social media platform Reddit reveals that those sentiments are not unique to one specialty.
A post in the medicine Subreddit (i.e., a section of the site devoted to medical discussion) raises serious technical concerns about a New England Journal of Medicine paper used to justify medical transition of children. While the critique is astute, it is not new. The paper rightfully caught tremendous flak for concluding that medical transition is beneficial for children. Among the red flags: the study featured no comparison group, so it’s impossible to discern how changes in mental health associated with transition compared to alternative approaches. Moreover, self-reported measures of mental health barely changed once children initiated hormonal intervention, and in fact were entirely static in natal males and those who initiated puberty blockers early in puberty. The individual who posted the critique mentions these reasons among their “serious concerns about pediatric gender medicine outcomes.”
If groups like the Endocrine Society and American Academy of Pediatrics were correct that their positions are backed by consensus, then one would expect the responses to rebuke the original post as fringe opinion. Instead, the commentators nearly universally express the same concerns. Among highly upvoted comments:
- “I’m also a psychiatrist (although not CAP) [child and adolescent psychiatrist] and I agree there are significant limitations in the current evidence base supporting medical interventions for gender dysphoria, especially in minors… Often times, when this is brought up, the knee-jerk response is ‘but WPATH guidelines are the standard of care.’ Except WPATH guidelines are not grounded in robust evidence. And those who follow the organization know the changes that have happened in recent years. Former leaders being ousted because they’ve called for moderation and not jumping into blind affirmation without the evidence base to support that approach. The organization is not a neutral, professional scientific body and that major fact is often glossed over… To be blunt, psychiatry has a checkered history of too hastily adopting novel treatments without adequate study. Compassion for gender dysphoric individuals is important. Recommending irreversible medical interventions in vulnerable populations should require definitive, or at the very least probabilistic, proof of long-term benefit and minimal harm. Currently, that proof does not exist.”
- “Internist, not psychiatrist. It’s bizarre to me that this is the only condition where we take at face value that what the patient says is wrong with them is exactly what’s wrong with them. Maybe you were born in the wrong body. Or maybe you’re a teenager which means that you’re going to try on multiple identities over the course of your adolescence before you find the real one. Or maybe you have borderline personality disorder and so have an unstable sense of self and are clinging to the current socially acceptable fix for a pervasive sense of lack of belonging. This doesn’t necessarily mean that hormones for trans people are always inappropriate, but the lack of credulity with which we approach folks who state that their issue is hormonal, in comparison with our general skepticism overall as a field, is baffling to me. We don’t accept a patient’s assertion that their chest pain is a heart attack without further diagnostic testing, why do we accept the assertion that their gender dysphoria is from being born in the wrong body. The relatively short follow up time in most of these studies troubles me. If you make a major change in your life that you hope will help something, your mood will go up and your suicidality will go down. I’m more interested in outcomes 3, 5 and 10 plus years down the road.”
- “Chen 2023 [the paper cited by the original poster] should be a causing a sea change even on the skeptical side of the aisle. We should no longer be asking ‘Are the long term fertility risks and other risks worth the short term benefits of GAH?’ But rather we should be asking ‘Does GAH even work in the short term?’
- “From an Ob-Gyn perspective, it has always concerned me the lack of focus on whether or not minors can consent to medications that may severely limit or eliminate their reproductive options later in life. In any patient who I counsel regarding permanent forms of contraception, it is always a very careful process. Additionally, even just for a salpingectomy (where actually patients technically still have the ability to get IVF, so their fertility options are not completely eliminated) Medicaid requires special consent forms signed 30 days before we can even do the surgery, after which time we only have a 6 month window. This is a protective measure to prevent patient coercion. So as giving puberty blockers and then cross sex hormones which prevent sexual maturity is a decision that I am not sure a preadolescent has the ability to consent to, from a reproductive standpoint.”
- “Psychiatrist pitching in, copying over a comment from r/Psychiatry. I do not see patients who are outright MtF [Male to Female] or FtM [Female to Male] in my outpatient practice very often, and when I do it is not for their gender issues specifically, but I do see many young people these days who are gender non-conforming in some way. I have several patients who go by ‘she/they’ pronouns who are entirely unable to articulate why they prefer this to “she/her” apart from some extremely vague discomfort with entirely feminine pronouns. I am of course happy to accommodate whatever pronouns they like but it does make me wonder how much of this is social contagion combined with a generalised ‘feeling uncomfortable in your own body’ which is entirely normal for those of a certain age group or with certain other (non-gender dysphoria) mental health concerns which would simply self-terminate if not labelled and reinforced.
- “Medicine being cavalier about some new intervention for a few years then starting to beat a retreat as the harms surface is a tale as old as time. These treatments are already being curtailed in Europe, we’re firmly in the retreat stage. See you in 10 years for the next big boom and bust cycle.”
The comment with the greatest number of upvotes notes that it has become so politically taboo to even ask questions “that a meaningful discussion cannot be had.”
Doctors certainly have concerns and questions. Let’s hope the Endocrine Society and American Academy of Pediatrics change their mind about hearing them.
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