The Gig’s Up

The emperor has no clothes

Dear University Health Services, University President, University Development Officers, and University Donors,

The gig’s up. You know that science being taught over in the biology department? It's real. And the scientific method, about how to compare hypotheses to evidence? Maybe you also know about evidence based medicine, where you “GRADE” the studies to see how reliable they are?

Well, the evidence behind the medical interventions you are giving out freely to trans-identified and gender dysphoric young people (which some of you are also eagerly encouraging) has been rigorously reviewed. Those interventions have been found to be standing on unreliable (low and very low quality or certainty) studies, unproven assumptions, and in some cases, things which are outright not true. Alarms are being raised widely about the “risk of overtreatment.” Consistently, the FDA also has not found that the benefits exceed the risks for any medicine treating gender dysphoria; as the drugs are all off-label, the drug companies conveniently bear no responsibility. The legal liability for any of the (sometimes devastating) harm is with you.

It is now recognized that your approach is not evidence-based medicine. The guidelines you are following? You might claim you were just using the “WPATH Standards of Care.” Are you aware that they aren’t “standards of care,” just practice guidelines (and poor ones at that, being prone to bias and not evidence based)? (But if you claim you are following WPATH, are you actually doing so? Involving parents,¹ for instance? Do you ensure that “Other possible causes of apparent gender incongruence have been identified and excluded”? How? In particular, what studies do you have to show you can reliably do this identification and exclusion? No one else has any: if you have a method with moderate or high quality evidence to support it, please make it available.) Note this is the same WPATH which both recommends serious irreversible interventions for adolescents and claims that “a systematic review regarding outcomes of treatment in adolescents is not possible”! (Nevermind that several systematic reviews of these interventions for adolescents appeared prior to the WPATH guideline release, with findings described as “the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits.”)  

WPATH also subscribes to the Endocrine Society's guidelines, but don't expect those to legally back you up either, check out their unusual disclaimer² at the end.

But maybe you don’t follow WPATH, you “affirm”. This is on even weaker ground. Word is getting out about the unreliable evidence base for these recommendations; you’re standing on quicksand.

And relevantly for the students in your “care,” the outcomes for the college aged people who had surgery in the (more restrictive) Dutch protocol study are not encouraging either;³ the results from that key study more generally are falling apart. Ignorance is no excuse, you’ve just been informed, right here.

For more reports of harm, you can also go to r/detrans; since 2020 that subreddit has been gaining about 1000 people a month. Do you tell the students you're medicalizing that no one knows how often gender dysphoria is temporary and that non-invasive therapy or time (in some cases therapy for the very frequently observed comorbidities) is sometimes the key to having gender dysphoria resolve? No lifelong hormones/surgery/sterility required. Do you offer them exploratory therapy? (Do you know what exploratory therapy is or that it helps resolve some kinds of gender dysphoria?) Were they informed that your affirmative model means you just believe them (reminiscent of another medical scandal); that they didn’t receive even an attempt at differential diagnosis? Do you tell them that some people who were once very very certain are now detransitioning and/or regretting, but that their numbers are unknown because doctors aren't bothering to keep track carefully enough? Do you mention the severe pain some detransitioners report? (How welcoming are your health services to detransitioners, by the way? Do you encourage detransitioners publicly the same way you trumpet "are you trans" all over campus?) Do you tell young people about the many known, some long term, associated harms (do you know what they are?), taking into account this age group is not considered mature enough to appropriately weigh the dangers of smoking? Do you inform them that long term mental health benefit has not been shown, even for adults?

If not, it seems the young people in your clinic did not give informed consent for medical intervention, as you did not accurately provide them with the risks, benefits and alternatives (including how poorly they are known). It’s on you.

If you didn't already know the above facts, you're misinformed and should not have been entrusted with the care of these vulnerable young people. If you did know…no words.

The UK's central pediatric gender clinic is also finding out it is liable, with over 1000 young people now eligible to sue. In the US, lawsuits are underway with those who had interventions as minors and as adults. (Some others have settled already.) Shocking US practices are coming to light. Those being named in the suits include the mental health practitioners as well as the doctors, that is, your health services. Of course, the young people harmed will only get money, not their young bodies the way they were prior to harm by your “medicine”. 

Many of these young people worked really hard to be able to go to your college, and many of us parents also invested a lot–time, money, our dreams for our children – and look at what is happening to them at your school! By encouraging, prescribing, or even offering these unproven dangerous interventions, you’ve recklessly and irresponsibly bet the futures of these trusting young people, who came to you for help.

It's not supporting trans-identified kids to give them lies, and unnecessary and harmful drugs and surgeries whose impact they'll suffer for the rest of their lives.  It's criminal.

See you in court.

1. The new WPATH guidelines, by the way, note that parents for young adults should be involved: "For clarity, this chapter applies to adolescents from the start of puberty until the legal age of majority (in most cases 18 years), however there are developmental elements of this chapter, including the importance of parental/caregiver involvement, that are often relevant for the care of transitional-aged young adults and should be considered appropriately." (p. S44) Do you involve parents in your evaluation and treatment of their college aged children for this poorly understood condition?

2. ”The guidelines should not be considered inclusive of all proper approaches or methods, or exclusive of others. The guidelines cannot guarantee any specific outcome, nor do they establish a standard of care. The guidelines are not intended to dictate the treatment of a particular patient.” The disclaimer is only in the PDF downloadable from the article’s journal web page, not displayed on the journal web page.

3. "Nearly a quarter of the participants have felt that their bodies were still too masculine, and over half have experienced shame for the “operated vagina” and fearful their partner will find out their post-surgical status—despite registering low “gender dysphoria” UGDS scores (Steensma et al., 2022).[...] the reported relationship difficulties reported by Asseler, with over 60% of individuals in their early to mid-30’s still single, also deserve serious consideration. The apparent sexual difficulties reported by male-to-female transitioners by van der Meulen (around 70% have problems with libido, have pain during sex, or have problems with achieving orgasm), combined with reproductive challenges, may be contributing to this outcome."

"the rate of cross-sex identification was not as stable as originally expected, with a sizable percentage reporting one or more instances of identity changes after treatment completion, especially among the individuals on the autistic spectrum (Steensma et al., 2022)."