Opinion: No strong evidence to back trans care for kids

Many laws have been proposed around the country that affect transgender people. The Kentucky Legislature just passed such a bill over Gov. Andy Beshear's veto, and the Ohio Legislature may do the same. The most contentious aspect of these laws has been preventing minors from accessing puberty blocking drugs and cross sex hormones, treatments that fall under the umbrella of gender-affirming health care.

Advocates for gender-affirming care have been vociferous in their condemnation of these laws. Multiple editorials criticizing the Kentucky law have recently been published in The Enquirer, including one by Joseph Gerth on March 25 and Hana Khalyleh on April 2.  Both make several assertions about gender-affirming care.

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Both authors take a similar line to many advocates: gender-affirming care for children works, it is proven, evidenced-based medicine, and it saves the lives of trans kids. Lawmakers who interfere in the care of transgender children do not have their best interest in mind and are inflicting harm.

The problem with this perspective is that it doesn't actually fit all of the data. Both guest editorials were an example of how not to approach the evidence for gender-affirming care. They both cherry-picked and misrepresented a few small studies and inaccurately described the overall state of the evidence.

Particularly troublesome was both authors citing a small study published in the Journal of the American Medical Association in 2022 by Diana Tordoff, et al, which they claimed showed that gender-affirming care reduced suicidality in trans youth by over 70%. This small prospective study was criticized when it was published for its methodological limitations and the unsupported conclusion its authors drew.

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In summary, this was a study of about 100 children from a single gender clinic. Over the course of a year, children who received gender-affirming care saw no change in their mental health (which was poor at baseline). They neither improved nor worsened. This was the most robust finding of the study.

The study suffered from a high dropout rate, was small to begin with, and had the limitations of any prospective study. The idea that it showed gender-affirming care reduces suicidality by 70%, as both Gerth and Khalyleh claim, is debatable.

Further, the "What We Know" review Gerth cited from Cornell suffers from similar methodological limitations, was underpowered to make any substantial claim about the efficacy of gender-affirming care in children, and has not undergone peer review as a systematic review but is rather an in-house catalogue of studies.

So what is the state of the evidence for gender-affirming care? What broad syntheses are there that might guide us? Keeping in mind that no area of medicine has perfect certainty about major treatment decisions, there are still comprehensive reviews that shed light on this question.

For instance, in 2022 the Swedish National Board of Health and Welfare published a review of literature and guidelines that found insufficient evidence to recommend medical gender-affirming care for the vast majority of gender dysphoric children. This lead to a substantial curtailment of gender-affirming care treatments for children in Sweden. It’s hard to explain nordic, secular Sweden's decision by the usual American partisan framing, and indeed the decision was based on a broad review of evidence and not some reactionary campaign.

Similarly, the United Kingdom's National Institute for Health and Care Excellence released reviews in 2021 identifying the low quality of evidence for gender-affirming care and their unknown long-term safety profile. This review was partly undertaken in response to the scandal at the Tavistock gender clinic, formerly the UK's premier gender clinic. Multiple lawsuits revealed reckless treatment practices and careless willingness to prescribe children gender-affirming care. The center has been ordered to shut down.

One of the troublesome findings highlighted in the UK review was how little evidence there is for the idea that puberty blockers are 100% reversible, a claim that is often made. In reality, while puberty blockers do delay the onset of some secondary sex characteristics, they may also have diverse and permanent neurodevelopmental consequences, may lead to permanent sexual dysfunction, and were found in the UK to probably contribute to progression to cross sex hormone therapy, which may be considered iatrogenic (or caused by the treatment) harm. Stating puberty blockers are "100% temporary," as Khalyleh did, is not supported by strong medical evidence.

I suppose someone might say, "Well, that's just the findings from Europe." Perhaps American advocates for gender-affirming care have access to high-quality evidence the Europeans do not. If so, it doesn't seem to have made it into the Endocrine Society's Gender Dysphoria/Gender Incongruence Guidelines. These guidelines, while recommending hormone regiments to older adolescents, list the level of evidence for all hormonal recommendations for children as "low" to "very low" evidence.

The gist of these various comprehensive guidelines and literature reviews from some major health authorities around the globe is that we just don't have good evidence for the efficacy of gender-affirming care in children.I hasten to add this doesn't mean that gender-affirming care has been proven to be harmful or that there's no weak evidence to support it (there is weak evidence that supports it), simply that there isn't strong evidence to support it.Medical insights are hard earned. They are very hard earned. They are especially hard earned in areas like childhood gender medicine where the best tools of evidenced based medicine, such as controlled trials, are difficult or impossible to perform.

When discussing the evidence for gender-affirming care in children, especially when critiquing public policy, one should be cautious to represent the evidence fairly and accurately. That means being honest about the lack of evidence and not projecting a false certainty. Some of what Khalyleh describes as "myths" about transgender care are actually well-substantiated concerns.

State legislation may be an imperfect way to regulate the care of transgender children. Critics have every right to argue and lobby for alternative policy. However, we would do well to keep in mind the limits of what we currently know and an appreciation that, at least in some ways, Kentucky’s law is not far from the evidence-based policies of multiple peer nations.

Christopher Wood is a neurologist who lives in Clifton.

This article originally appeared on Cincinnati Enquirer: Opinion: No strong evidence to back trans care for kids