Claims that scientific studies show clear mental health benefits of “gender affirming” medical treatments for trans-identifying youth are exaggerated and misleading, according to a new analysis.
Leor Sapir, a fellow at the Manhattan Institute, found that claims of causality frequently cited by news outlets are not supported by evidence, and that some of the studies commonly touted as demonstrating positive mental health outcomes show no or possibly even negative association between hormones and mental health.
In a recent article published in Reality’s Last Stand, a popular Substack dedicated to the sex and gender debate, Sapir responded to a January Psychology Today article by activist researcher Dr. Jack Turban, which is cited widely among trans activists to support the medical transition in minors. Turban’s article references 16 studies that purportedly show so-called gender affirming care for trans youth “results in favorable mental health outcomes.”
“The language of ‘results in’ can easily lead the reader to believe that hormonal interventions cause improved mental health,” said Sapir, who is concerned that activists use articles like Turban’s to chill debate on the health care needs of transgender-identified youth.
Despite being fresh out of his residency and having far less clinical experience than many other experts calling for a more cautious approach to managing gender dysphoria in youth, Turban is widely and frequently quoted by popular mainstream outlets as an authority.
“Dr. Jack Turban is one of the leading proponents of the controversial protocol known as ‘gender affirming care’ and has been outspoken in the American media promoting puberty blockers and cross-sex hormones to manage gender-related distress in youth,” said Sapir.
Sapir broke down the 16 studies Turban relied upon and determined that Turban oversold or misrepresented the strength of evidence in order to mislead his readers into embracing the controversial “gender affirmation” protocol. Several of the studies were short-term follow-ups, which by definition cannot capture long-term feelings about medical transition.
Two of the most frequently cited studies are from scientists in the Netherlands, who developed the so-called “Dutch protocol.” But the Dutch protocol differs from the American “gender affirming” model in that it involves heavily screening candidates. The American approach is designed to reduce “gatekeeping” by entreating clinicians to deferring to patients’ own self-diagnosis. In the U.S., most pediatric patients referred to gender clinics today appear to be females with no prepubertal history of dysphoria and very high rates of mental health problems.
“The more the validity of the Dutch study is played up, and by extension the selection criteria for hormones made stringent, the less applicable its findings to the majority of those who seek medical transition today,” said Sapir.
Because of their highly selective vetting process, the Dutch studies were shown to have selection bias.
“For their research on puberty blockers, the Dutch team excluded from the outset cases that would have cast doubt on the safety or efficacy of puberty blockers. It is hard to imagine a more obvious example of selection bias,” said Sapir, relying on the work of Levine, Abbruzzese and Mason.
Although the Dutch studies are characterized by Turban as following different, if overlapping groups, they actually used the same cohort and followed up after only 18 months, Sapir said.
“This time frame is hardly enough to pick up on whether the procedures are ultimately to the benefit of the patients,” said Sapir. “Two studies found that the average time to regret is around 10 years—and keep in mind that almost all the data in these studies comes from those who transitioned as adults and were gathered before the ‘affirming’ model and its hostility to safeguards became widespread.”
Another issue Sapir pointed out with the studies Turban cited is one of “confounding factors.” Many of the studies that were designed to find out whether medical transition improves mental health could not adequately do so because the patients were also receiving psychiatric medication, counseling, and coming from a supportive family environment, all things that are independently shown to improve mental health.
Replication, getting the same result when an experiment is repeated, is extremely important in science, and one of the key ways scientists build confidence in the validity of their results. The results of the Dutch studies have still never been replicated, and the only attempt to do so by researchers in the UK yielded very different conclusions. The 2021 British study results actually found increases in “internalizing problems and body dissatisfaction” following puberty suppression, according to one report.
“The fact that a team of researchers in the U.K. tried to apply the eligibility criteria and treatment protocols of the Dutch team to a cohort with similar characteristics but failed to observe the same outcome substantially weakens the claims of the original study,” said Sapir.
Turban seems to find small sample sizes to be a problem only in studies whose results weaken confidence in the gender affirming model, Sapir said.
“It appears that sample size is only flagged as an issue when results don’t support Turban’s favored conclusion— a good demonstration of his confirmation bias,” said Sapir.
“Turban also likes to say that ‘all experts agree’ with the ‘gender affirming’ model—a statement that is only true if you define ‘expert,’ in No True Scotsman-like fashion, as only someone who agrees with Turban,” said Sapir, while health authorities in Sweden, Finland, and the U.K. have unanimously concluded after systematic reviews of evidence for puberty blockers and cross-sex hormones, that the risks and uncertainties outweigh any known benefits.
A 2019 Finnish study cited by Turban was used in a WIRED article by Grace Huckins to promote the unfounded belief that “gender affirming” hormones are effective suicide-prevention methods.
But Dr. Riittakerttu Kaltiala, the lead author of that study, rejected Huckins’ interpretation.
“[Huckins’ piece] is a total mischaracterization of our research!” Kaltiala said. “We said practically the opposite: gender affirming hormones did not reduce psychiatric problems or improve the adolescents’ functional level.”
Another study Turban cited in his article was conducted by researchers at the University of Washington. But in August, it was revealed that the school deliberately withheld information that would damage its reputation and public standing. UW Medicine was caught distorting the results of a study on “gender affirming” care outcomes.
Researchers at UW Medicine found that the use of puberty blockers and hormones didn’t improve the mental health of trans-identified teens, but published a study claiming they did. Internal emails reveal that when the researchers were caught, officials at UW Medicine and Seattle Children’s Hospital advised each other against correcting the misinformation they put out.
“Thanks to the science journalists Jesse Singal and Jason Rantz, we now have confirmation that the UW knew that the study did not in fact find any causality but covered up this inconvenient fact due to the warm glow of positive media coverage,” said Sapir.
When the media tout studies that only track outcomes for a period of sometimes as low as a few months, but claim that “gender affirming” hormones and surgeries are medically necessary and lifesaving, there is ample ground for skepticism.
Short-term follow-up studies for gender-related surgeries in adults typically showing a low rate of regret (1 percent) have very short follow-up times and often ask very narrow questions. For example, they may ask questions about satisfaction with the results of the surgery, rather than satisfaction overall with the medical transition. These studies are not applicable to teenagers but are often used to dismiss requests for caution in allowing minors to medically transition.
One long-term study on adults in Sweden shows that 10 to 15 years after sex-reassignment surgery, the suicide rate of those patients was 19 times that of comparable peers. To date, no long-term studies on minors transitioned under the “gender affirming” approach exist, as it is a relatively new phenomenon.