Pediatricians Say Study Approving Puberty Blockers for Adolescents Is Flawed

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Two pediatricians say data from a study published at the official journal of the American Academy of Pediatrics (AAP) actually reveals the opposite of what its authors conclude – that puberty blockers are linked to positive mental health outcomes in youth claiming to be transgender.

In the February issue of Pediatrics, Drs. Jack L. Turban, Dana King, Jeremi M. Carswell, and Alex S. Keuroghlian, asserted that “pubertal suppression for transgender adolescents who want this treatment is associated with favorable mental health outcomes.”

“There is a significant inverse association between treatment with pubertal suppression during adolescence and lifetime suicidal ideation among transgender adults who ever wanted this treatment,” the authors concluded from their data.

Two pediatricians, however, both board members of the American College of Pediatricians, which has posted a position statement on child gender dysphoria and the consequences of puberty blockers and cross-sex hormone treatments, said the data actually reveal the opposite of what Turban and his associates claim.

“Given the controversy surrounding the practice of puberty suppression for gender dysphoric adolescents, the article by Turban et al creates more confusion than clarity,” wrote Drs. Scott Field and Den Trumbull in a comment responding to the journal article.

The authors of the study used a cross-sectional survey of 20,619 transgender adults between the ages of 18 and 36. They examined the adults’ self-reported history of puberty blocking drugs during adolescence and then studied “associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality.”

The researchers found that 90 percent of the transgender adults who wanted, but were unable to obtain, puberty blockers experienced suicidal thoughts. However, 75 percent of transgender adults who received puberty blocking drugs experienced the same suicidal thoughts.

Turban and his colleagues reported 16.9 percent of those adults surveyed self-reported they “ever wanted” to take puberty blockers. Of these participants, 2.5 percent received the drugs.

The authors concluded:

After adjustment for demographic variables and level of family support for gender identity, those who received treatment with pubertal suppression, when compared with those who wanted pubertal suppression but did not receive it, had lower odds of lifetime suicidal ideation.

In examining the data, however, Field and Trumbull addressed several problems with the study:

The authors imply causal evidence for a reduction in suicidal ideation with transgender adolescents who received puberty suppression (PS), yet they fail to acknowledge the exceedingly high rates in both groups of suicide ideation (75% and 90%) and suicide attempts (42% and 51%).

The pediatricians observed flaws in the design of Turban et al’s study:

The cross-sectional design using online survey data is insufficient to validate the efficacy of such a life-altering therapy. Because the data was collected by survey, there is no way of knowing how many would-be participants in either group actually succumbed to suicide. The so-called “lifetime suicidal ideation” is misleading, since at the time of the survey, the PS treatment group was significantly (p=001) younger (mean age 21.7 years) than the “ever wanted” PS control group (mean age 23.4 years), and the total age range of survey participants was 18 to 36 years. With mean age of hormone treatment initiation being 15.7 years in the PS group and 22.5 in the control group (p<0.001), it is obvious that the follow-up time for both groups was far too brief to assess “lifetime suicidal ideation.” The control group was not appropriately matched to the treatment group by age at time of survey or by age when hormone therapy was begun. Since there were over 30 controls for each PS case, they could have been selectively trimmed to be better matched.

Field and Trumbull then noted the outcome is actually the opposite of what the authors claim:

What is more disturbing is that the PS treated group actually had double (45.5% versus 22.8%) the rates of the control group for serious (resulting in inpatient care) suicide attempts in the year preceding the data collection.

The pediatricians identified another study that found adolescents who identify as transgender, as well as those who identify as lesbian, gay, and bisexual, are increasing at “extraordinary rates,” specifically, doubled between 2009 and 2017.

“[T]hese adolescents are almost four times more likely than their heterosexual peers to commit suicide,” Field and Trumbull noted. “The same study found that over 35% of adolescent suicide attempts in 2017 came from sexual minorities, who comprised only 14% of the adolescent population.”

According to the pediatricians, there are no long-term studies proving puberty blockers, cross-sex hormones, or “gender-confirming surgery” are either safe or effective. They added these treatments “potentially render recipients sterile, physically altered, and sexually dysfunctional,” and, therefore, should be considered “experimental” until longitudinal studies can prove otherwise.

“The prevailing narrative that these interventions are necessary to prevent suicide is without reasonable evidence,” Field and Trumbull asserted.

Turban said in January that his findings add to the “growing evidence base suggesting that gender-affirming medical care for transgender youth is associated with superior mental health outcomes in adulthood,” reported NBC News.

“It certainly argues against the misguided notion that gender-affirming care is inherently harmful and should be legislatively banned,” he added, apparently referring to several bills introduced in states attempting to ban transgender drugs and surgeries for children.

Turban is a psychiatrist who was nominated for NBC Out’s #Pride30 list by producer Andy Cohen, who praised the psychiatrist’s efforts to “bring the stories of transgender youth to the general public” and “build empathy and support” for the trans community.

“I’m a cisgender, gay white man,” Turban told NBC Out. “I recognize my privilege. We’ve made so much progress in LGB health, but the T was left behind.”

Turban’s co-authors, King and Keuroghlian, are affiliated with the Fenway Institute, an interdisciplinary center for research, training, education, and policy development regarding LGBT individuals.

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