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It's worth pointing out that Blue Tribe is crowing about how this story has been debunked, because an unverified twitter account claiming to be the child in question is saying, despite all the facts in the article being correct, that they don't place the same emotional valence or cause and effect on it that the mother in the story does. They especially and annoyingly split hairs in that they admit the doctors said trans teens kill themselves without treatment, but the doctors never said they would specifically. See, totally no longer pressuring the parent! And it goes on and on with more of the same.
Of course my favorite, and typical, reaction is here at The Hill. Robby Soave, who seems to have made a career out of being insulted by irate leftist for plainly stating correct facts gets the typical reaction you'd expect when he brings up that children are being sterilized. I wish we could see the look Brie gives him when he brings that up, but the camera isn't on her. We can assume it was a helluva stink eye from how you can see her face turning before the camera turns away, and from how quickly Robby tries to ameliorate whatever offense she shows she took.
Ah yes, the regulators don't let us to tell you your kid will kill himself if not put on puberty blockers, but since we can't tell you your kid will kill himself we can tell you other kids, who are totally not your kid, kill themselves all the time, but we're not talking about your kid, because the regulators would not allow us that. So, no pressure, totally your decision whether you want your kid to kill himself or not, we have no idea what'd happen, or at least we're not allowed to tell you what's happen, only that all other kids who are completely not your kid, did kill themselves, so you can choose anything you like. Also please sign here that we totally didn't pressure you about anything like telling you your kid would kill himself.
I think this proves too much.
Consider bariatric surgery on an obese patient. It's elective, and it has risks and benefits. It's shown to cut the risk of cardiovascular events like heart attacks and strokes in half. If your doctors tells you, look, we can't tell you that you will die of a heart attack, but people who don't get this surgery die of heart attacks all the time, so no pressure, it's your decision whether you want to have a heart attack, we have no idea if that'll happen, at least we can't tell you whether it'll happen or not because the regulators won't let us, so you can choose anything you like, and please sign here that we totally didn't pressure you about anything like telling you that you'd have a heart attack.
If you think that puberty blockers don't actually reduce the risk of suicide, then that's a real objection, a matter of fact, and someone is right and someone is wrong.
But in the world where puberty blockers do significantly reduce the risk of suicide in teenagers with gender dysphoria, what's the right thing to do? Not tell their parents about it? Informed consent is complicated, but communicating the risks and benefits of an elective procedure has to be part of it.
The objection is that it is an experimental treatment, and that they're using the risk of suicide to push it, even though they have no evidence that it reduces the risk. There's place for experimental treatments, but you shouldn't scare people into trying them out.
Okay, that's fair! So, to be clear, this is a question of fact, and if the best estimate we currently have says that puberty blockers are, in particular circumstances, linked to a lower risk of suicide, then you wouldn't have an objection?
I'm aware of Turban et al. (2020) and Tordoff et al. (2022). Note that as of 2018, a literature review concluded that "the psychosocial effects of gender-affirming hormones in transgender youth have not yet been adequately assessed". So at that point, the right thing to tell patients and parents would be different. But it looks like you can reasonably say that puberty blockers are indicated in certain circumstances, and not using them carries an increased risk.
So as promised here's my links.
In 2019 the Swedish Agency for Health Technology Assessment and Assessment of Social Services published it's review of the literature on gender dysphoria in children and adolescents concluding there's little evidence (and no randomized controlled trials of children and adolescents). The review resulted in a change in policy on how blockers are administered, first at the Karolinska Hospital, and later nationally. The National Board of Health and Welfare concluded that the risks of puberty blockers currently outweigh the benefits, and they should only be administered under a research framework and in exceptional cases.
In 2020 UK's National Institute for Health and Care Excellence published a review of the literature on puberty blockers. The report concludes that to the extent there's evidence for good or bad impacts of blockers, the quality of the evidence is rated at "very low certainty". The review was used in the Cass Report resulting in the shutdown of Tavistock's gender dysphoria clinic.
In 2023 the Norwegian Healthcare Investigation Board published their report on Patient safety for children and young people with gender incongruence. They similarly conclude there's not enough evidence to routinely prescribe blockers to children with gender dysphoria, declared blockers experimental, and recommended that the Ministry of Health revise their national guidelines to restrict the administration of blockers.
There's been similar noises out of France and Belgium, but I've only heard about scientists raising an alarm, rather than an official report being published.
Thanks! I'd previously seen the difference between the Swedish model and WPATH recommendations, and kinda dead-ended there, because I'm not a researcher, just a layman trying to do my homework. (For example, I don't know how you could ethically do an RCT on puberty blockers in children and adolescents.)
I do notice that the NICE report excludes Turban et al. (the strongest evidence I'm aware of that puberty blockers reduce the risk of suicide) with the explanation "Intervention – data for GnRH analogues not reported separately from other interventions". (I don't understand why the criteria were set to exclude nearly every study.) On page 19 and following, it relies entirely on de Vries et al. (2011), which is a prospective study of seventy people, to conclude that "This study provides very low certainty evidence that treatment with GnRH analogues, before starting gender-affirming hormones, may reduce depression." So, in plain terms, it looks promising, but we don't have enough information to have a strong opinion.
It looks like the state of evidence is different now than it was in 2018. These questions are, generally speaking, answerable, and it looks like the best information we have indicates that puberty blockers reduce the risk of suicide in adolescents with gender dysphoria. Perhaps a good use of time would be to develop better diagnostic tools so that dysphoric adolescents who will likely not pursue transition aren't offered puberty blockers, and those who likely will, are.
Why is it ethical to RCT every other medication before it gets approval?
On that one in particular, I'd read some of the comments at the bottom of your link:
I don't think studies at "very low certainty" can be considered promising. From what I understand we're still in the midst of a replication crisis, so between that and publication bias, "positive finding at very low confidence" should probably default "it's probably just noise".
It might be answerable eventually, but the question is too complex to settle on the basis of the latest paper. Keep in mind we're not talking about the optimal way of setting a broken bone, or even about the best therapy for cancer, which has a lot more pitfalls. We're talking about psychiatry, a field that spent years prescribing SSRIs for depression only to go "oops, they might actually be no better than a placebo". With things like suicide in particular, we know there's a significant social contagion component, where even a silly Netflix show for teenagers can trigger a wave of suicides. So with ubiquitous messaging about trans healthcare saving lives, "would you rather have a happy daughter or a dead son?" etc, you don't even know if you're measuring the impact of the puberty blockers, or the impact of the messaging.
Finally, there being a positive signal in the literature that blockers may reduce suicide risk does not justify scaring the parents into allowing blockers for their kids. Far more confidence is needed to make such statements ethically.
You're right; I'm not sure what I was thinking. I guess you'd enter adolescents with gender dysphoria into a study, and either give them puberty blockers or a placebo, would be hard to keep secret from the patients. But I'm reminded of AIDS patients desperately trying to beat the blinding system in the AZT trials. ("There were also stories of patients from the 12 centers where the study was conducted pooling their pills, to better the chances that they would get at least some of the drug rather than just placebos.") And a story I can't find right now about a teenager who stole HRT from their mother back in the sixties or seventies.
My concern is less that people are ignoring the evidence we have (as you point out, the best we have is an uncontrolled retrospective study), and more that the people fighting the use of puberty blockers in teenagers have no interest in answering these questions. I see this in the pre-emptive excuse-making; if we did do an RCT and puberty blockers saved lives, maybe the whole thing is still social contagion?
And here we're back to the beginning. If you say, "a massive uncontrolled retrospective study found that kids who present with the symptoms your kid is presenting with were less likely to commit suicide when given this treatment", are you "scaring the parents into allowing blockers for their kids"?
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