Depending on whom you ask, the Arkansas state legislature is filled with either devils, dupes, or diligent lawmakers who did their duty to protect minors despite enormous pressure to capitulate. After all, they reversed their own Republican governor’s veto of a bill that would prohibit persons under age eighteen from receiving certain surgeries and hormone treatments for diagnosed gender dysphoria.
Last Tuesday, the Arkansas House of Representatives voted 72-25 to overturn Governor Asa Hutchinson’s veto, while the Senate did so by a vote of 25-8. While these margins are hardly narrow, the way forward will be widely contested by media mischaracterizations, deep-pocketed medical organizations’ proclamations, and the growing reach of corporate threats.
Hutchinson’s veto was predicated on the idea that it was legislative overreach to obstruct the doctor-patient (and family) relationship, while the legislature’s primary narrative revolved around longstanding objections to medical experimentation on minors. Both notions have merit to them. But the legislature knows something the governor apparently does not: hormonal treatment of adolescent gender dysphoria continues to yield little demonstrable benefit across samples and studies, save perhaps for idealized self-image—a subjective outcome once considered unworthy of dramatic intervention. Critics will claim otherwise (they already are), and will seek to weaponize the risk of suicide in a manner long considered dangerous and unethical.
Just last month, a pair of reports commissioned by the UK’s National Health Service was released, revealing yet again little evidence to suggest that puberty-blocking and gender-affirming hormonal treatments improve the mental health and psychosocial functioning of minors. The “clinical effectiveness, safety, and cost-effectiveness” of such treatments just aren’t there, the National Institute for Health and Care Excellence (NICE) report found.
The evaluation was commissioned in the wake of the scandal at Tavistock—Britain’s only clinic serving transgender youth—which had witnessed not only a 4,400-percent increase in demand for its services, but a growing chorus of whistleblowing clinicians, and complaints about informed consent, quality of care, and subpar research protocols. The NICE assessment offers another refrain in the growing litany of reasons to be far more cautious about treating underage persons in a way that permanently alters bodies as a response to problems of the mind.
The evaluation does not break new ground—it’s a review—but instead examines a series of studies published since 2010. The authors conclude that the data “suggest little change with GnRH analogues from baseline to follow-up,” meaning that invasive treatment of youth doesn’t result in a confident determination of demonstrable success. Those studies “that found differences in outcomes could represent changes that are either of questionable clinical value, or the studies themselves are not reliable and changes could be due to confounding, bias, or chance.” The studies “all lack appropriate controls who were not receiving GnRH analogues,” a longstanding criticism of many clinicians and researchers’ position that it is unethical to fail to offer treatment to those who want it. In other words, such clinicians and researchers maintain that this inherent flaw in research design is a limitation that must be accepted because to use control groups would necessitate “withholding an effective treatment from those who need it.” The question remains—effective at what?
Contrast this with the untold number of cancer drug trials, whose very efficacy and credibility is staked on a randomized design in which some participants receive the experimental treatment while others receive a placebo—that is, the existing standard of care. It’s why lives are risked—including those of children—because without this, it is unknowable whether the protocol ought to change. Could it be that the largest and most influential pediatric societies in the United States—the American Academy of Pediatrics, along with the World Professional Association for Transgender Health and the Endocrine Society, all of which endorse experimental treatments—don’t really want to know the answer? It is an unconscionable thought.
Not all medical societies ignore such cautions. But the mainstream ones are captured, one-sided, and so silencing of all but “affirmative care” voices that alternative professional groups are forced to form. For instance, the Society for Evidence Based Gender Medicine notes in its coverage of the UK report that “the irreversible nature of the effects of cross-sex hormones, and the potential for puberty blockers to alter the natural course of identity formation should give pause to all ethical clinicians.” But to recommend (or actually offer) counseling services that might conclude that the patient is better served by “watchful waiting,” especially given that transgender “desisters” outnumbered “persisters” by a 7-to-1 margin in a just-released longitudinal study, is an approach that invites trouble. Clinicians are being bullied into writing a radical prescription based on fear and groupthink in clinical environments in which objections are socially difficult to raise. This is not how medical research and clinical operations are supposed to work.
That all of these new publications have been released to little media attention, save a short announcement about the NICE report in the BBC, hints at the wide lack of interest in null findings not simply in science but particularly in the science of transgender medicine. Sometimes, however, even trumpeted conclusions actually turn out to be null. A study appearing in the October 2019 edition of the American Journal of Psychiatry declared that “gender-affirming” surgery was associated with reduced demand for subsequent mental health treatment in a sample of Swedish adults diagnosed with “gender incongruence.” Although that conclusion eventually succumbed to a correction of the authors’ overreaching claims about the efficacy of surgical treatment on subsequent use of mental health services, the original version had already observed no effect of time since initiating hormone treatment on the likelihood of subsequently receiving mental health treatment. After the correction, the authors admitted that surgeries did not yield the anticipated benefit, either.
As I noted at the time, given the surge in interest, demand, and supply of hormonal therapies to self-identified transgender persons today, you would think that it is a solution that pays obvious benefits in reduced subsequent need—over time—for treatment of mood or anxiety disorder or hospitalization after a suicide attempt. In fact, the confidence intervals in the AJP study actually reveal a nearly significant aggravating effect of hormonal treatment on subsequent mental health needs.
It’s not as if more time and data have changed things, either. A study released last month in the Journal of Sexual Medicine revealed that while just over 10 percent of a group of 1,212 adult “transmasculine” patients elected to undergo genital reconstruction surgery, those 129 patients reported 281 complications—more than two per patient, on average—requiring 142 “revisions.” The three most common complaints? Urethral fistulas or strictures, and worsened mental health. The only documentable benefit? A surge in their “genital self-image.”
The field of transgender medicine continues to be exceptional. Recent research on growth hormones shows that medical interventions on children can have negative effects that aren’t revealed for years and even decades into the future. Transgender youth medicine involves numerous known and serious risks that are already identifiable for the young people involved, while the long-term effects and possible harms of these off-label drug uses are completely unknown. These troubled young people are indeed being “treated like an experiment”—but with no control group to discern actual efficacy. No wonder people desperate to prevent harm revert to lawsuits and legislative action.
In the coming weeks, the Arkansas legislature will be pummeled by external actors—politicians, media, athletes, and woke pediatricians. Corporate threats will be leveled. But what nobody has at their disposal are the results of the kind of rigorous clinical trials that Americans have long benefited from in every other branch of medical research—except this one.