The bad science behind trans healthcare bans - The Verge

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Conservative legislators and special interest groups are using scientific studies as a cudgel in their attempts to limit children’s access to gender affirming healthcare. One of the biggest battles is taking place in Arkansas.

“We can’t act like these studies don’t matter,” Arkansas state Senator Alan Clark said on March 29th, arguing in support of HB 1570, a ban on gender affirming healthcare for minors in Arkansas. Clark was referring to cherry-picked research that depicted various treatments as dangerous, experimental, and unsafe for children.

After a vote, Arkansas became the first state to pass such a bill into law.

The ACLU filed a lawsuit against Arkansas in May challenging the constitutionality of the law. A judge temporarily blocked the ban on July 21st, days before it was set to go into effect. “We were able to show that these laws are irrational,” said ACLU attorney Chase Strangio at a press conference, “we’re going to keep arguing that up through the court system.”

Arkansas is one of 20 states to attempt bans on gender affirming medical care for young people in the last year. All of the bills try to weaponize science — in the form of questionable, outdated, or misinterpreted research — against trans children and their parents while willfully ignoring both the experiences of trans people and the expert opinion of many groups of scientists, scholars, and doctors.

“They’re saying they’re doing science, but they’re ignoring what all the scientific associations are saying,” says Florence Ashley, a transfeminine jurist and bioethicist who studies the ways science and legal systems affect trans youth. The American Medical Association, the American Psychological Association, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, the Endocrine Society, the World Professional Association for Transgender Health (WPATH), and others have consistently opposed the bills.

HB 1570 shares nearly identical language with proposed trans healthcare bans that are making their way through legislature in other states. That’s because they’re copy-paste bills based on “model legislature” from a coalition backed by anti-LGBTQ hate groups. Here’s a breakdown of why the arguments presented in these bills don’t hold up to scrutiny.

HB 1570: “For the small percentage of children who are gender nonconforming or experience distress at identifying with their biological sex, studies consistently demonstrate that the majority come to identify with their biological sex in adolescence or adulthood, thereby rendering most physiological interventions unnecessary.”

The idea that many trans kids will grow out of it is referred to in research as desistance. The term comes from criminology, where it describes the process of ceasing criminal behavior. The concept of desistance is often used to remove children’s agency in discussions of their own identities, painting them as confused or going through a phase. It’s also used to advocate for “reparative” conversion therapies, which, unlike gender affirming care, are unethical and dangerous.

The most frequently cited desistance statistic is that around 80 percent of kids who experience gender dysphoria will go on to be cisgender adults. This percentage is usually attributed to four studies, published from 2008 to 2013, which looked at young children at gender identity clinics in Canada and the Netherlands. There are a number of problems with how those studies were carried out and how their findings were interpreted.

All of the studies included children who had not actually expressed gender dysphoria and had instead been deemed gender-nonconforming by their parents. Labeling those children as desistant drastically inflates the percentage. In three of the studies, participants who didn’t follow up with the researchers in adolescence or adulthood were assumed to be desistant, again inaccurately raising the desistance percentage. The methodological issues are further discussed in an article by researchers and in several articles by trans writer and biologist Julia Serano.

The desistance myth is also beside the point because it refers to children younger than those who would be eligible for the physiological interventions listed in the bills. “It’s just not relevant,” says Ashley. “This is a prepubertal population. It’s not the group that’s being offered puberty blockers. Those being offered puberty blockers are the ones that have already not desisted.”

HB 1570: “Even among people who have undergone inpatient gender reassignment procedures, suicide rates, psychiatric morbidities, and mortality rates remain markedly elevated above the background population.”

This line is likely referencing a 2011 study conducted in Sweden, which sponsors of the bill have mentioned specifically in their arguments. That study did find that adult trans participants had higher rates of mental illness, suicide attempts, and death by suicide than cisgender people of the same age.

What the senators failed to mention is that the researchers also acknowledged that gender affirming surgeries alleviate gender dysphoria, and that their findings should inspire better care for trans people after surgery. The researchers state explicitly that their results should not be interpreted to say that gender affirming surgeries increase mortality. The study is also limited in several ways; most notably, its focus was trans people who were treated in the 1970s and ‘80s, and significant improvements in treatment, from mental health care to surgical techniques, have been made since then.

Avery Everhart, a trans medical and legal geographer who studies trans healthcare access, points out another issue with these kinds of studies — it’s difficult to directly compare the mental health of cis and trans kids because there are so many variables to take into account. “It’s not ideal to compare to cisgender, mentally healthy, well-adjusted, youth of the same age, instead you should be comparing to other youth who also experience comorbid issues.”

Trans youth aren’t more predisposed to mental illness and other problems simply by nature of being trans, Everhart says. Living in a transphobic society, where children may not have family support and lawmakers are trying to restrict their rights, is bound to have negative effects on mental health.

“In biomedical research, in general, there’s an assumption that it is better to pathologize the individual,” says Everhart, “as opposed to diagnosing the society that gave them suicidality, that caused them to be depressed, that may have led them to have substance abuse issues.”

HB 1570: “The prescribing of puberty-blocking drugs is being done despite the lack of long-term longitudinal studies evaluating the risks and benefits of using these drugs for the treatment of such distress or gender transition.”

“Puberty blockers have been around a long time, and weren’t invented for trans children,” says Jules Gill-Peterson, trans historian and author of Histories of the Transgender Child. There’s plenty of evidence that they do what they’re supposed to do: delay puberty. They’ve been prescribed for decades for cis children who enter puberty at particularly young ages, and are approved by the FDA for that use. The blockers used for trans and cis children are the same, are only used temporarily, and their effects are reversible.

A lack of long-term studies doesn’t equate to a lack of knowledge about puberty blockers’ risks or benefits for trans children. The use of puberty blockers for trans children is in line with the WPATH Standards of Care and the Endocrine Society’s guidelines. A 2017 review of available evidence determined that puberty suppression is reasonably safe and is associated with improved psychological health. Preliminary results from a longitudinal study in the US suggest lowered depression and suicidal ideation in trans youth on hormone treatments, including puberty blockers.

HB 1570: “Healthcare providers are also prescribing cross-sex hormones for children who experience distress at identifying with their biological sex, despite the fact that no randomized clinical trials have been conducted on the efficacy or safety of the use of cross-sex hormones in adults or children for the purpose of treating such distress or gender transition.”

The lack of randomized clinical trials isn’t really a smoking gun here. It would be unethical to run studies where hormones were given to some people and withheld from others. Like puberty blockers, hormone therapies are prescribed to cisgender people for a variety of reasons. For example, anti-estrogen drugs are recommended for teen cisgender boys with persistent gynecomastia (breast enlargement) who experience psychological distress, though they’re not approved by the FDA for that use. There are no randomized clinical trials for such treatments for cis children. Lawmakers seemingly have no objections to hormone therapies unless they’re used for trans children.

Minors are prescribed hormones after careful consideration and discussion between healthcare providers, children, and their caregivers. There are plenty of barriers and gatekeeping to gender affirming care, and researchers argue that young teens are often capable of making their own decisions about when to start hormones. WPATH, the Endocrine Society, and other medical associations consider hormone therapy safe and beneficial for trans youth.

HB 1570: “It is of grave concern to the General Assembly that the medical community is allowing individuals who experience distress at identifying with their biological sex to be subjects of irreversible and drastic nongenital gender reassignment surgery and irreversible, permanently sterilizing genital gender reassignment surgery, despite the lack of studies showing the benefits of such interventions outweigh the risks.”

Very few minors undergo gender affirming surgeries of any kind, especially genital surgeries. Those who do are usually at least 16 years old and have already been socially and medically transitioning for some time with the guidance of healthcare providers. The WPATH Standards of Care recommend waiting until the age of majority, and having been on hormones for at least a year. It’s also worth noting that the use of puberty blockers can prevent trans children from needing many surgeries later in life.

The vast majority of trans youth do not get any surgeries until they’re over 18, but there is growing evidence that there are benefits to having certain procedures done at a younger age. One study noted that transfeminine patients were more likely to keep up with vaginoplasty aftercare while at home with family members, as opposed to recovering while away at college. Another study of transmasculine people who had chest surgery earlier in life found very low rates of regret, as well as significantly lower dysphoria.

People who oppose trans healthcare rely on fear-mongering language around gender affirming surgeries, using words like “irreversible” and “sterilizing” and making comparisons to mutilation. But bodies go through irreversible changes all the time, from puberty and aging to appendectomies and tonsillectomies.

“It’s a fantasy that the cis body is some sort of organic, naturally developing body that just perfectly unfolds according to nature’s plan, and never undergoes any sorts of significant changes,” says Gill-Peterson. “The human body is fundamentally biologically plastic.”

“Irreversibility makes a couple of assumptions when we see it talked about this way, that it’s a zero sum that something either is or is not reversible, as opposed to on a spectrum,” says Everhart, “some things will return to their previous state, but maybe not fully, others will totally reverse.”

HB 1570: “Gender transition procedures” do not include: (i) Services to persons born with a medically verifiable disorder of sex development including a person with external biological sex characteristics that are irresolvably ambiguous [...] (ii) Services provided when a physician has otherwise diagnosed a disorder of sexual development that the physician has determined through genetic or biochemical testing [...]”

The bill bans surgeries for trans youth, but specifies that the ban doesn’t apply to procedures on intersex people. This exception leaves room for healthcare providers to continue the traumatizing practice of operating on intersex children of all ages without their consent or knowledge. “They’re going to force intersex people to endure the things that they’re withholding from trans people,” says Gill-Peterson.

Unlike medical treatments that trans youth seek out to affirm their identities, procedures done on intersex children, often during infancy, do cause irreversible physical and psychological harm. Medical opinion has shifted away from promoting intersex surgeries as medically necessary, and intersex activists are still calling on hospitals across the country to stop performing them.

“That’s the tell. That’s how you know none of these bills have anything to do with science and are purely ideological,” says Gill-Peterson. “[It’s] all the same medicine for cis, trans, and intersex people. They’re just treated entirely differently now under the law, and I think that’s really, really disturbing.”

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