"I suspect, but cannot yet prove, that the gender affirming model is actively harmful..."
About that viral Reddit post
This Reddit post on r/medicine—written by a disenchanted psychiatrist—is worth reading in its entirety, but there are a few passages I’d like to pull out and discuss.
First up: useful insight on why some medical professionals who (mostly) know better go along, even as adverse outcomes pile up:
Therefore, for most of my career I have been in the odd position of doubting my gender-affirming colleagues, who would say "trans kids know who they are" and talk about saving lives from suicide, but also believing that they were making the best of a difficult situation. In the absence of any hard outcome data, all we had to argue about was theory and priors. I routinely saw adverse outcomes from these treatments, both people who regretted transitioning and those whose dysphoria and depression kept getting worse the more they altered their bodies, but I had to admit this might be selection bias, as presumably the success cases didn't go on to see other psychiatrists. I could be privately skeptical, but without any hard data there was no public argument to make. The gender affirming clinicians claimed that they could correctly identify which kinds of gender dysphoria required aggressive treatment (from DSMIV-TR to DSM5 the diagnosis was changed to emphasize and require identification with the opposite gender, rather than other kinds of gendered distress and nonconformity), and even when they were wrong they were appropriately trading a risk of long term morbidity for short term mortality. There was nothing to be done except wait for the eventual long term outcomes data.
The author then proceeds to take apart a 2023 article claiming to find improvements in psychosocial functioning among gender-dysphoric youth after two years of cross-sex hormones:
The problem with Chen 2023 isn't its methodological limitations. The problem is its methodological strength. Properly interpreted, it is a negative study of outcomes for youth gender medicine, and its methodology is reasonably strong for this purpose (most of the limitations tilt in favor of a positive finding, not a negative one). Despite the authors' conclusions, an in-depth look at the data they collected reveals this as a failed trial. The authors gave 315 teenagers cross-sex hormones, with lifelong implications for reproductive and sexual health, and by their own outcome measures there was no evidence of meaningful clinical benefit.
The author goes through the study in some details (see the full post, linked at the top), then lingers on the minimal improvements in mental health outcomes: “positive affect” up 0.80 on a 100-point scale, “life satisfaction” up 2.23 points, minimal decreases in depression (-1.27) and anxiety (-1.46).
These appear to be small effects, but interpreting quantitative results on mental health scales can be tricky, so I will not say that these results are necessarily too small to be clinically meaningful, but because there is no control group these results are small enough to raise concerns about whether GAH outperforms placebo. It is unfortunate that it is not always straightforward to compare depression treatments due to several scales being in common use, but we can see the power of the placebo effect in other clinical trials on depression. In the original clinical trials for Trintellix, a scale called MADRS was used for depression, which is scored out of 60 points, and most enrolled patients had an average depression score from 31-34. Placebo reduced this score by 10.8 to 14.5 points within 8 weeks (see Table 4, page 21 of FDA label). For Auvelity, another newer antidepressant, the placebo group's depression on the same scale fell from 33.2 to 21.1 after 6 weeks (see Figure 3 of page 21 of FDA label).
I won't belabor the point, but anyone familiar with psychiatric research will be aware that placebo effects can be very large, and they occur across multiple diagnoses, including surprising ones like schizophrenia (see Figure 3 of the FDA label for Caplyta). I am genuinely surprised and confused by how minimal this cohort's response to treatment was. Early in my career I thought we were trading the risk of transition regret for great short-term benefit, and I was confused when I noticed how patients given GAH didn't seem to get better. This data confirms my experience is not a fluke. I could go in depth about their anxiety results, which on a hundred-point scale fell by less than 3 points after two years, but this would read nearly identically to the paragraph above.
Here the author is striking at something that I’ve wondered about for years: why are the possible placebo effects so small? All the ingredients are there for a gonzo placebo response: an active drug (that, in the case of testosterone in particular, itself boosts mood and energy) packaged in sky-high patient expectations (this drug will help me realize my true self!), with strong social reinforcement from doctors who believe in ‘gender-affirming care’ and trans communities that celebrate every step members take toward transition. And yet!
The short-term effect of GAH is no longer an unanswered question. Its theoretical basis was strong in the absence of data, but like many strong theories it has failed in the face of data. Now that two studies have failed to report meaningful benefit we can no longer say, as we could as recently as 2021, that the short-term benefits are so strong that they outweigh the potential long-term risks inherent in permanent body modification. Some non-trivial number of patients come to regret these body modifications, and we can no longer claim in good faith that there are enormous short term benefits that outweigh this risk. The gender affirming clinicians had two bites at the apple to find the benefit that they claimed would justify these dramatic interventions, and their failure to find it is much greater than I could have imagined two years ago.
I am not unaware of how fraught and politicized this topic has become, but the time has come to admit that we, even the moderates like me, were wrong. When a teenager is distressed by their gender or gendered traits, altering their body with hormones does not help their distress. I suspect, but cannot yet prove, that the gender affirming model is actively harmful, and this is why these gender studies do not have the same methodological problem of large placebo effect size that plagues so much research in psychiatry. When I do in depth chart reviews of suicidal twenty-something trans adults on my inpatient unit, I often see a pattern of a teenager who was uncomfortable with their body, "affirmed" in the belief that they were born in the wrong body (which is an idea that, whether right or wrong, is much harder to cope with than merely accepting that you are a masculine woman, or that you must learn to cope with disliking a specific aspect of your body), and their mental health gets worse and worse the more gender affirming treatments they receive. First, they are uncomfortable being traditionally feminine, then they feel "fake" after a social transition and masculine haircut, then they take testosterone and feel extremely depressed about "being a man with breasts," then they have their breasts removed and feel suicidal about not having a penis. The belief that "there is something wrong with my body" is a cognitive distortion that has been affirmed instead of Socratically questioned with CBT, and the iatrogenic harm can be extreme.
This shows great insight into patients—and sounds almost exactly like a section of my own thesis that explores possible explanations for why the mental health of members of online trans communities seems to deteriorate over time. Basically: it’s terrible for your mental health to believe there is something fundamentally wrong with you. This likely obtains even if there is something fundamentally wrong with you, the power of positive thinking and whatnot, but especially in cases where a patient’s struggles are fairly ordinary, this is an absolutely toxic idea to take onboard. It cuts you off from your body, your real-life friends and family, and binds you to a body-modification cult.
Online trans communities promise members that transition helps. And at every stage of transition, no matter how badly transition is going, the community promises that if you just take the next step—just do it! trust us!—you will feel better.
But many people seem to feel worse—and it’s no wonder why. Participating in these communities, imbibing this belief system, you become sensitized to hundreds of new ways to feel uncomfortable in your own skin. You’re told that ordinary problems of living familiar to all humans across time and space need not be accepted: they can be cured, or sidestepped. (Remember what Ivan Illich said: “only pain perceived as curable is intolerable.”)
As the gap between how you feel on the inside and how you appear to the rest of the world widens, every encounter with the world outside the cult starts to chafe. Life itself becomes unbearable. Young people talk about feeling like imposters, fakers, liars. This is because they are in fact imposters, even though the community rushes to reassure them that they’re not, that it’s not your fault if no one understands.
Meanwhile, the community tells you the whole world is gunning for you, that anybody who rejects your wacky beliefs about gender wants you dead. This is a mentality that shows up even in the comments section of this very post, in the mouth of a trans-identified MD, who protests that “Hitler threw us into camps.” Except that that never happened.
Tell me, whose mental health wouldn’t go off a cliff?
Deep in the comments section, the author writes:
I do not think we should do nothing for these patients, only counsel them with CBT the same way we do anyone else who is unhappy with their body, and the same way that trans affirming people themselves do when patients are at the end of the transition process, or unable to proceed for other reasons. What should a therapist tell a transwoman with gender dysphoria due to inability to become pregnant? Any answer to that question can be applied to other manifestations of gender dysphoria.
Recommended reading, in case you missed it:
This psychiatrist finally lays out a key point in this whole debate that I have wanted the medical and mental health fields to go on record discussing. First, this excerpt from the original Reddit post:
“...even when they were wrong they were appropriately trading a risk of long term morbidity for short term mortality.”
The issue: that if a teen is actively suicidal or self-harming, something must be done in the short term (transition) even if it causes harm in the long term (morbidity and/or regret) because - and here’s the sticking point I’ve wanted the profession to go on record about - apparently the mental health field has no other interventions for suicidality and self harm in their tool box??
Having no other treatment options for these suicidal and self-harming teens is the underlying premise we are all being told to accept by everyone shouting “life saving care” and “would you rather have a live son or dead daughter.” But this premise this treatment model is built on and that we’re being sold is not true and the mental health profession knows that, as evidenced by the original poster deep in the comments:
“I do not think we should do nothing for these patients, only counsel them with CBT the same way we do anyone else who is unhappy with their body, and the same way that trans affirming people themselves do when patients are at the end of the transition process, or unable to proceed for other reasons. What should a therapist tell a transwoman with gender dysphoria due to inability to become pregnant? Any answer to that question can be applied to other manifestations of gender dysphoria.”
They KNOW there are other treatment options - BETTER treatment options - as evidenced in this NYT article about DBT (a type of CBT) titled “The Best Tool We Have for Suicidal and Self-Harming Teens.”
https://www.nytimes.com/2022/08/27/health/dbt-teens-suicide.html
What’s really keep about this point and DBT is that, unlike affirmation and “gender affirming healthcare,” we DO have a LOT of research on the efficacy of DBT. So why isn’t DBT or CBT the first line of treatment for these teens? (See this post for more!on that question https://pitt.substack.com/p/if-dbt-is-the-best-tool-for-teens)
We need to start asking this question and pushing on it insistently and loudly because already, this untested and unsupported ideology of affirmation only is infiltrating, taking over, and undoing the only treatments that actually have research support for their efficacy in treating depression, self-harming, and suicidality
https://psycnet.apa.org/record/2019-21621-004
"Basically: it’s terrible for your mental health to believe there is something fundamentally wrong with you."
This, this ,this, thank you for crystallizing it! I was anorexic in my late teens/early 20s because of this belief instilled in me, whether on purpose or not, by my parents, and it has taken my entire life to learn coping skills to counter it - it never completely goes away. I fear I would have been completely susceptible to gender ideology if I were a teen today.
We need to talk more about the use of social media to hammer this belief into vulnerable people, and examine the motives behind this behavior of coercion. Maybe it's not all nefarious but some of it has to be.