“Extraordinary claims require extraordinary evidence,” is a famous quote by Carl Sagan often referenced in the context of the scientific method. In healthcare, extraordinary claims also hold an extraordinary potential for harm, which is why it’s crucial that invasive or high-risk treatments are well-supported with a robust body of research. We must weigh the health risks of a medical condition against the risks of the treatment for that condition to ensure the patient achieves the best quality of life possible.
Consider the following assertions:
Some children are born into the wrong body,
the only cure for this condition is puberty blockers, cross-sex hormones, and surgical removal of healthy organs, and
allowing children and young people to undergo these interventions is the only way to prevent suicide.
These are all extraordinary claims requiring extraordinary scientific evidence to be validated.
Dr. Jack Turban is a San Francisco researcher and transition advocate whose studies have been funded in part by Arbor Pharmaceuticals and Pfizer, both manufacturers of puberty blockers (1). He argues that the existing evidence for “gender affirming care” is sufficient to justify the practice and even goes so far as to allege that any other treatment options, such as exploratory psychotherapy, are harmful “gender identity conversion efforts” which result in adverse mental health outcomes, including suicide (2).
“Gender affirming care” is a sugar-coated term for deceiving a child about the immutability of biological sex, prescribing sterilizing drugs and/or performing surgical castration, and inducing a lifetime of health complications. Puberty blockers, for instance, have been documented to interfere with accruement of bone mass, cause brain swelling and vision loss, and may interfere with normal brain development (3-6). Use of cross-sex hormones impairs reproductive function and significantly increases the likelihood of life-threatening events such as a heart attack, blood clot, stroke, and some cancers (7-11). Genital surgeries carry not only typical surgical risks, but also have unusually high complication rates, cause lifelong sexual dysfunction, and result in permanent dependence on exogenous hormones (12-14).
Parents of children suffering from gender dysphoria are wise to have reservations about signing off on starting their son or daughter down this harrowing path. Yet often when they express their concerns to a medical provider, the provider silences them with some variation of the following statement:
“Would you rather have a trans son, or a dead daughter?”
This is the suicide myth, which assumes only two options: transition or suicide. When faced with the terrifying possibility that their child could take her own life, many parents decide on what appears to be the lesser of two evils: allowing their child’s body to be permanently altered.
Transition advocates recite allegedly proven statistics, such as, “Forty-eight percent of trans youth will attempt suicide.” This figure comes from a study with a non-random sample of just 27 youth, yet its repetition has influenced both public opinion and medical practice (15).
The authors of a more rigorous study published in Pediatrics surveying nearly 121,000 adolescents asserted that having a female-to-male transgender identity or nonbinary identity heightened the risk of attempted suicide (16). Michael Biggs, associate professor of Sociology at Oxford and advisor for the Society for Evidence Based Gender Medicine (SEGM) noted that over two thirds of the subjects who identified as “female-to-male” - the category with the highest number of alleged suicide attempts - also reported being same-sex attracted (homosexual or bisexual), and that overall, same-sex attracted females, regardless of gender identity, had the highest reported incidence of suicide attempts (17). This agrees with previously known suicide statistics: females are more likely to attempt suicide than males, and homosexual people are more likely to attempt suicide than heterosexual people (18, 19).
Most studies which examine the relationship between self-reported gender identity and suicide attempts (such as the one mentioned above) ignore that the majority of children and adolescents with gender dysphoria also suffer from at least one other mental health condition and are more likely to be autistic (20-21). When the factors of homosexuality, mental illness, and autism are considered, it becomes clear that there are too many confounding factors to establish a causal relationship between trans identity and elevated suicide risk. Furthermore, documentation of attempted and completed youth suicides in the United Kingdom found that these numbers fell orders of magnitude short of what was reported in surveys (22).
Even if it was true that transgender or non-binary-identified youth were more likely to attempt suicide, the evidence that gender medicine prevents this is extremely weak.
There are currently no clinical trials or controlled studies on the use of puberty blockers as a treatment for gender dysphoria or suicidal ideation. A two-part study conducted by de Vries et. al., often referred to as “the Dutch study,” is widely considered to be the gold standard of evidence for the gender affirmation model in youth, despite only following seventy subjects, one of whom passed away from surgical complications (23, 24). The Dutch study excluded participants with debilitating mental illness, and thereby did not address the suicide question at all.
A 2020 US study by Jack Turban et. al compared levels of suicidal ideation and attempts in 3,500 trans-identifying adults who desired puberty suppression but did not receive it to just eighty-nine trans-identifying adults who had undergone puberty suppression (25). It reported that adults who had desired puberty suppression but did not receive it had higher levels of suicidality than the group who did. Given that this study was funded in part by Endo Pharmaceuticals, another puberty blocker manufacturer, the fact that its findings support the use of puberty blockers isn’t surprising (26).
In the discussion section, the authors reveal that while suicidal ideation was found to be lower in the puberty suppressed group, there was no difference in the odds of lifetime or past-year suicide attempts between the groups. It is also noteworthy that the puberty-suppressed group was comprised of younger individuals with more affluent families. Overall, the “evidence” gleaned from Turban’s study is far too weak to support its conclusion that puberty blockers prevent suicide or should be adopted as a standard of care.
Like “trans women are women”, “gender affirming care saves lives” is a religious mantra not grounded in science, logic, or medical facts. Sadly, the most dangerous aspect of the suicide myth is that impressionable youth who hear it will believe it is true. This alone may exacerbate their feelings of distress around their bodies and make them desperate to transition. It is imperative that parents, educators, pediatricians, and anyone else caring for children are aware of the misinformation and biased research fueling the suicide myth, so that it won’t be perpetuated any longer.
References
“Incomplete Financial Disclosure in a Viewpoint.” JAMA. 2021;326(1):90.
Turban, et al. “Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults.” JAMA Psychiatry. 2020;77(1):68-76.
Lee, et al. “Low Bone Mineral Density in Early Pubertal Transgender/Gender Diverse Youth: Findings From the Trans Youth Care Study.” Journal of the Endocrine Society. 2020 Sep 1; 4(9). Published online 2020 Jul 2.
Schemmel, Alec. “FDA warns puberty blocker may cause brain swelling, vision loss in children.” The National Desk. 26 July 2022.
Cass, Hilary. “Independent Review of Gender Identity Services for Children and Young People – Further Advice.” The Cass Review. 19 July 2022.
Schneider, et al. “Brain Maturation, Cognition and Voice Pattern in a Gender Dysphoria Case under Pubertal Suppression.” Frontiers in Human Neuroscience. 14 November 2017.
Hudson, et al. “Fertility Counseling for Transgender AYAs.” Clinical Practice in Pediatric Psychology. 16 March 2017.
Alzahrani, et al. “Cardiovascular Disease Risk Factors and Myocardial Infarction in the Transgender Population.” Circulation: Cardiovascular Quality and Outcomes. 5 April 2019.
Connelly, et al. “Gender-affirming hormone therapy, vascular health and cardiovascular disease in transgender adults.” Hypertension. 2019;74(6):1266-1274. doi:10.1161/hypertensionaha.119.13080.
Getahun, et al. “Cross-sex hormones and acute cardiovascular events in transgender persons.” Annals of Internal Medicine. 2018;169(4):205.
de Blok, et al. “Breast cancer risk in transgender people receiving hormone treatment: nationwide cohort study in the Netherlands.” 14 May 2019. BMJ 2019;365:l1652
van der Sluis, et al. “Double flap phalloplasty in transgender men.” Microsurgery. 2017 Nov;37(8):917-923.
Falcone, et al. “Total phallic construction techniques in transgender men: an updated narrative review.” Translational Andrology and Urology. 10 June 2021. 10(6):2583-2595
Oelschlager, A.; Kirby, A.; Breech, L. “Evaluation and management of vaginoplasty complications.” Current Opinion in Obstetrics and Gynecology. October 2017. 29(5):316-321.
Nodin, et al. “The RaRE Research Report.” 2017.
Toomey, R.;Syvertsen, A.; Shramko, M. “Transgender Adolescent Suicide Behavior.” Pediatrics. 1 October 2018. 142 (4): e20174218.
Biggs, Michael. “Attempted suicide by American LGBT adolescents.” 4thWaveNow. 23 October 2018.
Freeman, et al. “A cross-national study on gender differences in suicide intent.” BMC Psychiatry. 29 June 2017. 17, Article number: 234
Centers for Disease Control and Prevention. “Youth Risk Behavior Surveillance - United States 2017.” 15 June 2018.
Becerra-Culqui, et al. “Mental Health of Transgender and Gender Non-Conforming Youth Compared With Their Peers.” Pediatrics. 1 May 2018. 141 (5): e20173845
Warrier, et al. “Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals.” Nature Communications. 7 August 2020. 11: 3959.
Biggs, Michael. “Suicide by Clinic-Referred Transgender Adolescents in the United Kingdom.” Archives of Sexual Behavior. 18 January 2022. 51, 685-690(2022).
de Vries, et al. “Puberty suppression in adolescents with gender identity disorder: a prospective follow-up study.” The Journal of Sexual Medicine. 14 July 2010. 2011 Aug;8(8):2276-83
de Vries, et al. “Young adult psychological outcome after puberty suppression and gender reassignment.” Pediatrics. 8 September 2014. 2014 Oct;134(4):696-704.
Turban, et al. “Pubertal Suppression for Transgender Youth and Risk of Suicidal Ideation.” Pediatrics. 01 February 2020. 145 (2): e20191725.
Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2021). “Pubertal suppression for transgender youth and risk of suicidal ideation”: Erratum. Pediatrics, 147(4), Article e2020049767.