Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect-The Implications for Research and Clinical Practice

Critiques of the Cass Review: Fact-Checking the Peer-Reviewed and Grey Literature

The Cass Review's final report, published in April 2024, made recommendations to the UK's National Health Service regarding structuring of services for minors with gender-related distress. It recommended cautious use of hormonal interventions in this population and use of research protocols. Some clinician-researchers disagree with the Cass Review's recommendations and have written critiques. A critique of the Cass Review posted on Yale Law School's website in July 2024 has received extensive media coverage. Its references identified three other critiques. In these papers, there were multiple claims that were incorrect or that lacked essential clarification/contextualization. These claims involved (1) the Cass Review's contents and processes; (2) the pediatric transgender healthcare evidence base; (3) existing clinical practice guidelines, including claims that there is international medical consensus; (4) evidence-based medical practice and guideline development; and (5) conclusions regarding the validity of the Cass Review's findings. The Cass Review's careful, balanced investigations and judgments were a comprehensive, evidence-based response to the controversies in this pediatric clinical arena. Recently-published critiques of the Review have contained incorrect or inadequately contextualized claims. Because accurate information about medical interventions is essential to informed consent, it is important to correct errors in potentially influential publications.

Timing of puberty suppression in transgender adolescents and sexual functioning after vaginoplasty

BACKGROUND

Sexual function in transgender adolescents after puberty suppression has been a topic of recent clinical and scientific questions.

AIM

This study aimed to explore the long-term effects of early treatment with puberty suppression on sexual functioning of transfeminine individuals after vaginoplasty.

METHODS

This retrospective cohort study included 37 transfeminine individuals treated with a gonadotropin-releasing hormone agonist (puberty suppression), estrogen, and vaginoplasty (penile inversion technique or intestinal vaginoplasty) at the Center of Expertise on Gender Dysphoria in Amsterdam, the Netherlands, between 2000 and 2016.

OUTCOMES

Experiences regarding sexual functioning and difficulties were assessed with a self-developed questionnaire ~1.5 years after genital gender-affirming surgery and compared between early (Tanner stage G2-3) and late (Tanner stage G4-5) treatment with puberty suppression.

RESULTS

Following surgery, 91% of transfeminine individuals was able to experience sexual desire, 86% experienced arousal, and 78% could attain an orgasm. Seventy-five percent of transfeminine individuals who had not experienced an orgasm pre-surgery were able to experience one post-surgery. Of all participants, 62% reported having tried penile-vaginal intercourse post-surgery. The majority reported the presence of one or multiple sexual challenges. There were no significant differences in postoperative sexual function or sexual difficulties between groups treated with early versus late puberty suppression.

CLINICAL IMPLICATIONS

With these findings, more adequate and tailored information on the expected effects of early endocrine gender-affirming treatment (including puberty suppression) can be given by healthcare professionals.

STRENGTHS AND LIMITATIONS

This is the first study that has assessed sexual functioning of transgender individuals treated with puberty suppression, and has differentiated between the pubertal stage at treatment initiation. Limitations were the small cohort size and retrospective study design. This study focuses on sexual functioning, however, it is important to realize sexual wellbeing is multifactorial and encompasses more than genital functioning or the ability to have certain sexual experiences.

CONCLUSION

This study found that post-vaginoplasty transfeminine individuals after both early and late suppression of puberty have the ability to experience sexual desire and arousal, and to achieve orgasms. Outcomes are comparable to previous findings in those who started treatment in adulthood.

Paediatric gender medicine: Longitudinal studies have not consistently shown improvement in depression or suicidality

AIM

Systematic literature reviews have found the evidence for hormonal interventions in paediatric-age patients with gender dysphoria is of low certainty. Studies in this field have all been observational, and generally of low quality. Nevertheless, some experts assert that the observational studies in this field have consistently found improvement in mental health, and therefore constitute sufficient evidentiary basis for hormonal interventions. The present review sought to characterise results of the longitudinal clinical research studies that have reported depression and suicidality outcomes.

METHODS

The present review collated, from examination of six existing reviews, 14 longitudinal clinical research studies that have specifically investigated depression and/or suicidality outcomes.

RESULTS

Significantly positive depression outcomes were reported in six studies, and significantly positive suicidality outcomes in two studies. Outcomes were negative in the largest study. Notably, some studies articulated positive conclusions about hormonal interventions even in the setting of insignificant, small or negative findings.

CONCLUSIONS

Analysis of longitudinal clinical research in this field showed inconsistent demonstration of benefit with respect to depression and suicidality. This analysis suggests that, contrary to assertions of some experts and North American professional medical organisations, the impact of hormonal interventions on depression and suicidality in this population is unknown.

Puberty Suppression for Pediatric Gender Dysphoria and the Child's Right to an Open Future

In this essay, we consider the clinical and ethical implications of puberty blockers for pediatric gender dysphoria through the lens of "the child's right to an open future," which refers to rights that children do not have the capacity to exercise as minors, but that must be protected, so they can exercise them in the future as autonomous adults. We contrast the open future principle with the beliefs underpinning the gender affirming care model and discuss implications for consent. We evaluate claims that puberty blockers are reversible, discuss the scientific uncertainty about long-term benefits and harms, summarize international developments, and examine how suicide has been used to frame puberty suppression as a medically necessary, lifesaving treatment. In discussing these issues, we include relevant empirical evidence and raise questions for clinicians and researchers. We conclude that treatment pathways that delay decisions about medical transition until the child has had the chance to grow and mature into an autonomous adulthood would be most consistent with the open future principle.

Taking the Long Way Around: Towards A Depathologized Ethical Framework of Gender-Affirming Care for Trans Youth

Political debate regarding trans youth's access to gender-affirming care (GAC) has pushed many to advocate for GAC by pointing to tragic, pathological outcomes of non-treatment, namely suicide. However, these pathologized arguments are a harmful ethical "shortcut" which should be replaced by a meaningful engagement with the ethics of providing GAC to youth.

European Academy of Paediatrics statement on the clinical management of children and adolescents with gender dysphoria

Gender issues have become a polarised and political subject in modern paediatrics and indeed, in broader society. These include the management of infants with disorders of sex development and transgender sports participation, but especially recently regarding the management of gender dysphoria. The European Academy of Paediatrics (EAP) acknowledges that there are deeply held beliefs about this issue based on conscience and social norms. Several European countries, led by the UK, have recently reviewed the management of gender dysphoria in children and young people. Recognising the need for far more research into treatments such as pubertal suppression and cross-sex hormones in children and young people, we review the current ethical and legal dilemmas facing children with gender dysphoria, their families and the clinical teams caring for them. We suggest an approach that maintains the child's right to an open future whilst acknowledging that the individual child is the crucial person affected by decisions made and must receive appropriate support in decision-making and care for any associated mental health or psychological issues. Noting that national approaches to this vary and are in flux, the EAP advocates a child-centred individual rights-based analytical approach.

Gender dysphoria: Reconsidering ethical and iatrogenic factors in clinical practice

OBJECTIVE

To examine the treatment of gender dysphoria described in Bell v Tavistock (UK 2020). Bell documents the treatment and sequelae of a 16-year-old adolescent referred to the Tavistock with gender dysphoria. Her case highlights contrasts between gender affirming care and comprehensive care.

CONCLUSIONS

Consistent with other western centres, in the 2010s, the Tavistock began treating patients with gender dysphoria under the 'Dutch protocol' for gender affirming care. Bell reveals concerning lapses of clinical governance influenced by activists and linked to patient harm. The recent suspension of a senior child psychiatrist from an Australian public hospital service after questioning the evidence base and ethical foundation of gender affirming care underlines the need to resolve these uncertainties to address the crisis in the treatment of gender dysphoria.

"On Suggestion" by John Bostock, 1923: A comparison with twenty-first century understandings of the placebo effect

OBJECTIVES

This paper describes Australian psychiatrist John Bostock's 1923 concept of suggestion and compares it to our understandings, in 2023, of the placebo effect.

CONCLUSIONS

Bostock's 1923 article on "suggestion" gives us a glimpse of the history of Australian psychiatry. It also stimulates thought about the current understandings of the placebo effect. Now, as then, placebo effects can play a critical role in patient outcomes. However, careful consideration is required to ensure contemporary ethical standards are met and harm is not done.

In vitro fertilization outcomes in a mouse model of gender-affirming hormone therapy in transmasculine youth

OBJECTIVE

To investigate in vitro fertilization (IVF) outcomes in an adolescent transmasculine mouse model mimicking gender-affirming hormone therapy in prepubertal youth, both on testosterone (T) and after T washout.

DESIGN

Experimental laboratory study using a validated mouse model.

SETTING

University-based basic science research laboratory.

ANIMAL(S)

A total of 80 prepubertal 26-day-old C57BL/6N female mice were used in this study.

INTERVENTION(S)

Animals (n = 10/group) were implanted subcutaneously with gonadotropin-releasing hormone agonist at 3.6 mg or received sham surgery. After 21 days, they were implanted with silastic tubing containing either T 10 mg or placebo for 6 weeks. After 6 weeks, a group of animals were superovulated for immediate IVF, and another group had the implant removed and went through superovulation for IVF after 2 weeks (washout IVF). The total number of oocytes yielded, oocyte maturity rate, fertilization rate, and numbers of 2-cell embryos, 4-8-cell embryos, morula, blastocysts, and hatching blastocysts were recorded.

RESULT(S)

Testosterone treatment negatively impacted IVF outcomes in animals stimulated when receiving T, but not after T washout. Pretreatment with gonadotropin-releasing hormone agonist did not affect IVF outcomes.

CONCLUSION(S)

Although current T had a negative impact on IVF outcomes compared with controls, animals were still able to produce viable oocytes for fertilization and develop into blastocysts. Future efforts to study the impact of long-term T exposure on oocyte quality, especially aneuploidy rates, pregnancy outcomes, and live birth rates, are necessary.

The Myth of "Reliable Research" in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies-and research that has followed

Two Dutch studies formed the foundation and the best available evidence for the practice of youth medical gender transition. We demonstrate that this work is methodologically flawed and should have never been used in medical settings as justification to scale this "innovative clinical practice." Three methodological biases undermine the research: (1) subject selection assured that only the most successful cases were included in the results; (2) the finding that "resolution of gender dysphoria" was due to the reversal of the questionnaire employed; (3) concomitant psychotherapy made it impossible to separate the effects of this intervention from those of hormones and surgery. We discuss the significant risk of harm that the Dutch research exposed, as well as the lack of applicability of the Dutch protocol to the currently escalating incidence of adolescent-onset, non-binary, psychiatrically challenged youth, who are preponderantly natal females. "Spin" problems-the tendency to present weak or negative results as certain and positive-continue to plague reports that originate from clinics that are actively administering hormonal and surgical interventions to youth. It is time for gender medicine to pay attention to the published objective systematic reviews and to the outcome uncertainties and definable potential harms to these vulnerable youth.

Commentary on Levine et al.: A Tale of Two Informed Consent Processes

This commentary compares two recently published informed consent recommendations for gender dysphoria. One key difference identified is in their assessment of the strength of the evidence base for the gender affirming treatment model. An evaluation of both authors' citations supports the claims of a weak evidence base for the use of puberty blockers and gender affirming hormonal treatments in youth with gender dysphoria. This commentary then reflects on the implications of this. In particular, it asks whether it would be best practice to provide gender affirming treatments for youth only under clinical research conditions, rather than as routine clinical practice.