A parent responds to TIME article on poorly designed Trevor Project survey

On December 14, 2021, TIME Magazine printed this article: Gender-Affirming Hormone Therapy for LGBTQ Youth Can Help Save Lives, Study Finds. The subject of the article is this study: Association of Gender-Affirming Hormone Therapy With Depression, Thoughts of Suicide, and Attempted Suicide Among Transgender and Nonbinary Youth.

As TIME asserts: “The use of gender-affirming hormone therapy (GAHT) is significantly related to lower rates of depression, suicidal ideation and suicide attempts among transgender and nonbinary youth, according to a study published in the Journal of Adolescent Health on Tuesday.”

In response, an American Genspect parent wrote this response (lightly edited here) to the journalist:

I’d like to call your attention to a problem with the Journal of Adolescent Health study by the Trevor Project; this problem plagues many of the US studies that examine the mental health of transgender young people and which is likely to plague any study that examines mental health using a convenience sample of people recruited online. 

Specifically, the Trevor study recruited youth who identify as LGBQT “via targeted ads on Facebook, Instagram, and Snapchat.” The authors compare the current mental health of young people who want hormones and received hormones with those who want but do not take hormones. The problem is that young people who identify as transgender are frequently told by other young people and others that hormones are life saving. Speaking as a parent of a young person who is both anorexic and gender dysphoric, I have noted that such young people can become very anxious and fixated on starting hormones. 

This anxiety can reverse the association between a factor associated with anxious feelings and mental health. Anorexia illustrates the association. Actively restricting as an anorexia is associated with very bad mental and physical health outcomes. Anorexia nervosa (the restricting type) has the highest mortality rate of any psychiatric condition, with mortality due to organ failure, be it suicide (brain failure), heart failure, or liver failure.  But at different points in time, active restriction and lower weight in anorexia is associated with better current mental health than not restricting or being at a healthy weight because the act of restricting or being low weight reflects an effective – but very harmful – strategy for coping with anxiety.  I give two examples of how this could play out in a convenience sample.

1. Suppose young people who are interested in losing weight are recruited via ads on social media.  The sample screens for people who screen positive for anorexic symptoms. Families of the eating disordered in treatment are advised to closely monitor internet use in case the eating disordered are accessing pro-ANA sites or other information where they access tips and encouragement to lose weight. Some of these sites on Discord were banned a few years back, but there are still plenty around. If you compare the current mental health of young anorexics in the sample who are currently restricting with those of young anorexics not currently restricting, you’re likely to find that the restricters will be less anxious and less depressed. They are coping more “effectively” than the non-restricters.

2. Eating disorder therapists warn families that as the anorexic in recovery approaches their (higher) weight target, anxiety and suicidality risks may peak – that this can be the most dangerous period. If you were to compare the mental health of anorexics in treatment who are still underweight with those approaching a healthy weight, you will find much higher rates of suicidality and anxiety in the healthy weight recovering anorexic, but no one would interpret this as meaning anorexics should not achieve a healthy weight. After one or two years following treatment, you will find that recovered anorexics at a healthy weight are likely to have lower anxiety and better overall health than those who are still at a low weight, possibly because the recovered anorexic has developed and mastered better coping strategies.   

I offer these examples to illustrate the challenges in interpreting the contemporaneous association between mental health and some factor that may elicit anxiety in sample members (like hormone treatment in a trans-identifying population). The anorexia examples may be especially relevant because identity-disrupting conditions, like anorexia and body integrity dysphoria (the intense need/desire to live in a disabled body), co-occur at very high rates with gender dysphoria.

Such poorly designed studies on trans-identifying young people are unfortunately common. Much of the evidence is also unclear because studies are often conducted on childhood-onset gender dysphoria and may not be applicable to adolescent-onset gender dysphoria. Of particular note, very few good, reliable studies have been conducted at all about detransitioners, so there is very little information about them – one way or the other.

Ideal studies would have controls, be conducted over long periods of time (ideally 8-10+ years), with a small-enough loss to follow up, unflawed study instruments, unflawed analysis, and cohorts relevant to the patients seeking care. Unfortunately, much of the available evidence so far appears to be of low quality and unreliable, frequently with huge losses to follow up, thereby introducing massive uncertainties.

The UK National Institute for Health and Care Excellence (NICE) comprehensive reviews of both puberty blockers and cross-sex hormones underscore the poor research quality of many studies.

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