Trans Kids’ Health Care: Are We Getting it Wrong?

Podcast episode: 

https://open.spotify.com/episode/4OeWIOZ4RL4WKusiXiAbjf?si=_5Ds5gM2QWi5ZcDGLAwlWA

This podcast episode unpacks some of the UK’s recent Cass review of gender affirming care research. This episode sorts through the science with Professor Stephen Russell, Dr. Cal Horton, and Dr. Ada Cheung whose work is referenced in the Cass review. All resources and connecting podcast episodes found in episode notes.

Overview of this episode (refer to episode notes for sources):

Names/Pronouns

The Cass review says science is mixed, and points to some research showing using chosen names/pronouns could be harmful to trans youth’s mental health. One study in particular surveyed thousands of trans and gender diverse adults; It found that the ones who socially transitioned during adolescence were more likely to have attempted suicide at some point in their lives compared to people who socially transitioned as adults. 

The Cass review’s conclusion says this means social transitioning through the use of chosen names and pronouns is bad for adolescents, however the actual study found it wasn’t the transitioning that made kids feel bad, it was the bullying they experienced from it. The bullying was driving the suicide attempts. Critical factor in suicide attempts in this study was discrimination and stigma, NOT transitioning. 

One study surveyed 130 trans and gender non-conforming teens and younger adults who socially transitioned using their chosen names. The study asked; is there someone in your life who is using your chosen name? It found that the overall risk of suicidal behaviour for the teens who got called by their chosen name in at least one place dropped by 56%. The more their chosen name was used, the lower their risk for suicide dropped. There are two other studies to back this up. 

Conclusion: Correlation is not causation. Bullying, stigma and discrimination drive suicidality, not name and pronoun changes. 

Puberty blockers & hormones: Do they improve mental health or not? 

The purpose of puberty blockers is to pause puberty, and it’s a temporary pause. These drugs have been used for decades for precocious puberty and are safe. 

The Cass review states there is insufficient and inconsistent evidence to support improvement of adolescents' mental health through using puberty blockers and hormone therapy. The evidence for puberty blockers isn’t the highest quality  because you can’t do randomized control trials: no kid would want to sign up for a chance to get a placebo instead of the puberty blocker. Observational studies do exist (but aren’t considered as strong as randomized clinical trials). The Cass review noted mixed results, with some studies finding mental health improvement, and others not. Note that puberty blockers are not a psychiatric medication. The purpose of blockers is to block puberty and stop well-being from DEcreasing. 

What about when kids don’t get puberty blockers at all? A study looking at 200 trans kids who were around 14 yrs old and not on puberty blockers. They had poor mental health compared to cis gender kids of the same age and population, and suffered more self-harm, depression, and suicidation. This study found that trans kids who were on blockers were doing better, basically as well as the kids who were cis. 

Conclusion: Puberty blockers are not a psychiatric medication, but data supports their efficacy in supporting better mental health in trans youth.

Hormone Therapy and Detransitioning

One randomized clinical trial looked at more than 60 trans and gender diverse people in their early 20s. Half got testosterone therapy immediately, while the other half were on a wait list. After 3 months the researcher looked at the mental health of those on testosterone therapy and found a marked reduction in depression and suicidal ideation. Half of those on testosterone therapy had a complete resolution of their suicidal ideation, mirroring what is being seen clinically. Another study showed more than 150 trans teens’ depression and anxiety scores dropped after testosterone therapy.

When looked at estrogen therapy, the effects on the body can be slow or subtle, especially compared to testosterone. One study looked at trans feminine adolescents, and after two years still didn’t see an improvement to their mental health. Suggested that maybe they weren’t followed long enough. Studies in adults have shown that estrogen can help. Even in Cass study, it finds research supports estrogen therapy for adolescents.

One study followed hundreds of people ages 15-21 over three years and asked them repeatedly how they identity in terms of gender to see if their identity shifted over time. It was very common to see a lot of fluidity with gender identity. Half still identified as trans at the end of the study, but half identified as cis. Most of the ppl who identified as trans the whole time were taking hormones, and only 1 out of 32 people who identified as cis at the end of the study had been taking hormones. None were on puberty blockers. In another study, 29 people switched from trans to cis and only two were on medication. The vast majority of those who are gender fluid are not taking any medications. 

Conclusion: Detransitioning in the context of puberty blockers and hormone therapy has an extremely low incidence rate.

Further learning:

Supporting CBC article that further explains some of the limitations of the Cass review: 

https://www.cbc.ca/news/health/puberty-blockers-review-1.7172920 

More on the Cass review: https://open.spotify.com/episode/03iIVqpbARRr2EpfW2Ht21?si=JfxdinBqT9K2_AYxNne7mA

Shared by the Revolve team.