Constructive Criticism for Psychology Today

Written by a Genspect parent

A recent article in Psychology Today about using hormones and puberty blockers on young people with gender dysphoria (“The Evidence for Trans Youth Gender-Affirming Medical Care”) discussed 15 studies. It is extremely useful to have this list of studies and their individual summaries in one place. This article can go much further, though, by reporting how well one expects these studies to reliably estimate medical outcomes and by locating treatment with hormones and puberty blockers within context—that is, in relation to other supportive treatments for gender dysphoria currently also recommended by experts.

For starters, a general reader of Psychology Today might not understand the implications of these 15 collected studies.  The medical profession uses evidence assessments such as GRADE, which characterize how a study-based estimate of effects compares with the likely true effects.  For GRADE, there are 4 ratings.

  • High quality: “very confident that the true effect lies close to that of the estimate”
  • Moderate quality: “moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different”
  • Low quality: “confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect”
  • Very low quality: “very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect”

It would be useful for the readers to know that seven of the 15 studies were found to be “very low certainty” with modified GRADE, and one was “low quality” GRADE. Of those studies which were not yet assigned a GRADE, five could not show cause and effect (for instance, improved mental health outcomes) because of design (four explicitly use the term association or associated), and the two others did not show benefit of treatment. (1) So these 15 studies do not allow one to reliably estimate that positive mental health outcomes will result from administering puberty blockers and hormones.

Perhaps related to this fact, all of these drugs are off-label with the FDA for treating gender dysphoria, that is, the FDA has not determined that “the benefits of using the drug for a particular use outweigh the potential risks,” which the article should mention.

One might want to try to combine these studies to try to get stronger results, but, as I used to  hear growing up, “three bad arguments do not add up to a good argument.” More seriously, combining medical studies requires a careful procedure such as PRISMA (an “evidence-based minimum set of items for reporting in systematic reviews and meta-analyses”) to account for the biases and quality (e.g., GRADE) of each individual study, plus the consequences of combining them (for instance, new biases might occur as studies are combined).  Once evidence quality has been assessed for the rest of the 15 studies, it would be interesting to see what results when they are combined. 

There is, however, a statement made with reference to the absence of randomized control trials for these medicines, which is incorrect:

“There is a general consensus in the field that such a trial would be unethical given the body of literature we have so far indicating that those in the control group would be likely to suffer adverse mental health outcomes compared to those randomized to the treatment groups.” 

First of all, it has not been established that controls are “likely” to suffer adverse mental health outcomes compared to those given medical intervention; as described above, the results from the 15 studies are too limited. The paucity of data to guide treatment is not a secret among professionals.  And (consequently?) consensus in this field is notably lacking with regards to medical intervention, with some advocating for the non-exploratory affirmative model, others using assessments before considering medicalization, others only treating people within clinical studies, and others calling for even more caution. In fact, instead of considering medical intervention immediately, many clinicians and researchers worldwide are calling for psychotherapeutic support (in particular, exploratory therapy) to be first line. For these reasons, I think this statement needs revision in the Psychology Today article.

The Psychology Today article also should give more context for gender dysphoria treatments, including, in particular, the non-medical, supportive approaches which have helped some resolve their gender dysphoria. It is extremely relevant that the majority of those with childhood onset (2) have been seen in studies to outgrow their gender dysphoria by the end of puberty. (3) And that for others, exploratory psychotherapy has sometimes been seen to resolve gender dysphoria – the desire to transition, for some, has been observed as secondary to other mental health conditions. In addition to there being no clinical test to determine whose gender dysphoria will improve from non-medical intervention alone, there are serious physical consequences (4) to medicalization. In addition, an increase in detransitioners has been seen: the article currently does not mention them or that no one knows how many there are (since long-term outcomes are not being tracked). And it doesn’t mention that more than a few detransitioners have reported being misinformed before they started medical intervention, regret at having medicalized, and wish they’d had access to exploratory therapy – that is, psychotherapeutic support – instead.

In sum, it is excellent that summaries of these different medical intervention studies have been provided for Psychology Today readers.  Adding more information and context to the article will help readers understand there are important limitations to using these study outcomes for predicting outcomes in practice.  With more context, including descriptions of different ways of supporting gender dysphoria (i.e., the benefits, risks and unknown aspects of each), readers will be able to learn that many experts are pushing for psychotherapeutic support as first line, and/or differential diagnosis, because of their track record for helping gender dysphoria resolve without requiring these hormones for life (and without incurring the risk of detransition).  The issues being raised in the current debates between experts should also be reported in this article or in another one in Psychology Today, so that people understand where the serious medical disagreements are arising and why.  

Without this context, there is a very real concern that Psychology Today readers, including young people with gender dysphoria and their families, might mistakenly and dangerously conclude that experts agree (they don’t) that medical intervention has been established to be beneficial (it hasn’t), and that medical intervention is the only option for treatment (it isn’t), if one develops gender dysphoria.

NOTE: If there are corrections that appear to be needed for this essay, please send them to [email protected] so they can be taken into account.

Image credit: Marco Verch, Flickr

END NOTES

(1)  Seven of the 15 studies in this Psychology Today essay were part of the UK National Institute for Care and Excellence (NICE)  formal evidence reviews, for puberty blockers (studies 1 & 3)  and hormones (studies 4, 5, 6, 8, 9),  for young people under 18.  They found: “The critical outcomes for decision making are the impact on gender dysphoria, mental health and quality of life. The quality of evidence for these outcomes was assessed as very low certainty using modified GRADE.” (boldface mine).  Study 2 was evaluated to be low quality GRADE evidence for treating gender dysphoria with puberty blockers and hormones and, relevant for this topic in particular, study participants were required to be “psychologically stable” to participate.  For the other studies,  study 7 says their results can “not provide evidence about the direct benefits of puberty suppression over time and long-term mental health outcomes,” studies 10, 12, 14, and 15 had cross-sectional design, which did not allow determination of causation (i.e., that an intervention caused a certain outcome).  Studies 11 and 13 did not show benefit (study 15 also has data which associates greater suicidality with hormones, but again, not cause and effect).

(2) Using an older definition of gender dysphoria (the newer definition is only nine years old).

(3) In contrast, those on puberty blockers, in studies, almost always instead continue to hormones.

(4) Hormones chemically castrate MTF, as do puberty blockers, and are a high dose of steroids for FTM: on top of their severe consequences for sex organs and fertility, other risks include impacts on the brain and significantly increased likelihoods of heart attacks and strokes.

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