Does Gender-Affirming Medicine Help Trans-Identifying Youth?

The issue of gender-affirming medicine (GAM) for trans-identifying youth has been an issue of concern for parents, policymakers, and trans advocates. GAM may involve a range of interventions, but at most concern are those involving medical interventions such as puberty blockers, cross-sex hormones, and surgery. Opinions on when and what care is appropriate vary.

Policy on GAM should be driven by evidence from research, though, at the moment, we don’t have a clear body of data to make informed decisions. My suspicion is that some youth who identify as trans indeed have gender dysphoria and would benefit from medical interventions. At the same time, a rigorous psychological evaluation process may also identify some youth with borderline personality disorders or autism who may erroneously assume gender dysphoria is the root of their anxieties and would not benefit from medical intervention.

The more modern “believe youth” approach to GAM can be contrasted against the “Dutch Protocol” which involved a rigorous assessment process. Under the Dutch Protocol, regret rates are very low, but it’s not clear yet that this applies to the modern variant of GAM, which deemphasizes “gatekeeping.”

In January, a new research article got widespread attention. On its surface, the article appeared to claim that modern GAM was associated with improvements in mental health among youth. However, the article also provoked controversy, suggesting, perhaps, the results were not as useful as advertised.

The article, by Diane Chen, Johnny Berona, and colleagues, published in the New England Journal of Medicine, called itself a longitudinal study, though, as the predictor variable has no real variance (the study only followed youth receiving GAM over time), it’s better conceptualized as a single-group pre-test/post-test design. This kind of design is actually a weak research design, as it’s impossible to determine why people’s behaviors change if they do. If youth are happier at post-test, we don’t know if it’s because they received GAM, or simply because they got older, their families had time to adjust to their new identities and became more supportive, etc. There was no control group, thus, any changes cannot be ascribed to the treatment with certainty (in fairness, early- and late-puberty patients were compared in some analyses, albeit not randomly assigned). Nonetheless, in their abstract, the researchers use causal language inappropriate to such a design, “…GAH improved appearance, congruence, and psychosocial functioning.”

The authors published their analysis plan in advance of collecting data. This is typically a great method in research, as it makes the study more transparent. However, in their analysis plan, they promise to measure a variety of outcomes that do not appear in the final publication. Granted, the published analysis plan is a bit more vague than I’d like, but it raises the possibility that the authors simply failed to mention some outcomes that failed.

This made me curious to see the data myself. I reached out to both Chen and Berona, requesting their raw data, including for any outcomes in the analysis plan that they didn’t report in the final report. I did not hear back from either of them. After a few weeks, I reached out to the editors of the New England Journal of Medicine with my concern about data transparency. I heard back from Deputy Editor Julie R. Ingelfinger, who said that data transparency is required only for randomized controlled experimental trials. “For papers that are not concerning prospective trials, this is neither posted nor required,” she wrote.

This means that because the Chen, et al., paper is of a weaker design, no data transparency is required. Thus, we have a weak research design with no data transparency that may have a significant impact on policy related to GAM.

To be clear, I am not taking the position that the modern variant of GAM is wrong. Further evidence may prove that it is effective, and, if so, I will be happy to defend it. I do, however, call on researchers in this area to improve the rigor of their field and eagerly await the results of strong research.