Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults, JAMA Psychiatry, September 2019, Turban, J. L. et al.

Study Description & Claims: Based on responses to the 2015 USTS, researchers tried to determine if “gender identity conversion efforts” (GICE)—counseling that attempts “to change one’s gender identity from transgender to cisgender”—are associated with poor mental health in adulthood.

The authors claim that the transgender adults who could recall exposure to GICE, particularly at age 10 or younger, were more likely to have experienced severe psychological distress in the month prior, as well as lifetime suicide attempts when compared with transgender adults who had “discussed gender identity with a professional but who were not exposed to conversion efforts.”

Of the 27,715 respondents to the 2015 USTS survey, 19,751 said they discussed their gender identity with a professional. Of those, 3,869 said their therapists engaged in GICE, with 206 respondents reporting exposure to GICE before the age of 10. Turban uses the study’s findings to support the idea that mental health professionals should affirm but never explore a patient’s transgender identity.

Study Flaws:

• Biased selection of study participants or cohort: See Summary above.

• Inconsistent or inappropriate measurement instruments: To determine which survey respondents experienced distress when recalling exposure to GICE, researchers used the K-6 scale, a common tool for distinguishing between distress and serious mental illness. A score of 13 or higher predicts being diagnosed with a major mental health condition like schizophrenia or bipolar disorder. The study reports that those who recalled exposure to GICE scored 13 or higher on the K-6 scale—meaning that they were more likely to have a severe mental illness than those who could not recall GICE, not that the exposure to GICE itself caused distress.

• Confounding: The association between poor mental health and recalling exposure to GICE could be explained by a therapist being less likely to affirm a patient’s transgender identity if the patient also had a serious mental illness. According to the critique below, “In fact, failure to control for the subjects’ baseline mental health makes it impossible to determine whether the mental health or the suicidality of subjects worsened, stayed the same, or potentially even improved after the non-affirming encounter.”

• Correlation vs. causation: See Summary above. Additionally, the researchers reported that the subjects in the GICE-recalling group were more likely to attempt suicide. However, the number of total suicide attempts in the prior year and the number of suicide attempts requiring hospitalization—which is considered more serious—were not significantly different between the GICE-recalling respondents and others. This means we can’t know whether exposure to GICE caused suicidal ideation.

• Other: The study relies on an unproven assumption that transgender identities are immutable. Also, the authors conclude that any therapy in which a counselor seeks to understand the source of a patient’s transgender identity is conversion therapy, and that the only ethical approach is to affirm without exploration. However, it’s common for people who identify as transgender to have other mental health diagnoses which might, in fact, be the source of their distress, their trans identification, or both. Instead of calling for more research, the authors used the study’s flawed findings to call for legislative bans of GICE. The Journal of the American Medical Association (JAMA) did not allow any debate regarding this study. As a matter of fact, JAMA Psychiatry’s Editor rejected all of the letters that documented the study’s issues, although some letters appeared later as comments in the online publication. Study critics conclude, “given the absence of robust long-term evidence that the benefits of biomedical interventions outweigh the potential for harm, especially among young people (Heneghan & Jefferson, 2019), it is self-evident that the least-invasive treatment options should be pursued before progressing to more risky and irreversible interventions. To the extent that psychological treatments can help an individual obtain relief from gender dysphoria without undergoing body-altering interventions, ensuring access to these interventions is not only ethical and prudent but also essential.”

Rebuttals:

Singal, J. (2022) "Science Vs" Cited Seven Studies To Argue There’s No Controversy About Giving Puberty Blockers And Hormones To Trans Youth. Let’s Read Them. Singal-Minded (see Study #1)

D’Angelo, R., Syrulnik, E., Ayad, S. et al. (2021) One Size Does Not Fit All: In Support of Psychotherapy for Gender Dysphoria. Archives of Sexual Behavior 50, 7–16.

Pubertal suppression for transgender youth and risk of suicidal ideation, Pediatrics, February 2020, Turban, J. L. et al.

Study Description & Claims: Based on responses to the 2015 USTS, researchers analyzed self-reported desire for, or use of, puberty blocking drugs during adolescence and “examined associations between access to pubertal suppression and adult mental health outcomes, including multiple measures of suicidality.” Researchers concluded that there was an association between adolescents that took puberty blockers and good adult mental health outcomes.

Study Flaws:

• Biased selection of study participants or cohort: See Summary above.

• Inconsistent or inappropriate measurement instruments: 73% of respondents who reported having taken puberty blockers (which are administered at the start of puberty) said they started on them after age 18 (after puberty). The study authors concede that respondents may have confused blockers with opposite-sex hormones, and therefore respondents who claimed taking blockers at age 18 years or older were eliminated from the analysis. Further, the sample was limited to people who were 17 years old or younger in 1998 because they would, the authors thought, have had access to blockers. However, blockers weren’t widely used in the US prior to 2009. This means the sample group included people who wouldn’t have had access to blockers so their responses shouldn’t have been used.

• Small number of participants: Of the 20,619 responses that matched the established criteria, after then eliminating those who claimed to take puberty blockers at or after age 18, only 89 reported actually taking puberty blockers at age 17 or younger (and this number, as noted above, is likely an overcount because it includes people who probably didn’t have access to blockers). Authors tested nine mental health related metrics and found only one to be statistically significant—a result which could have occurred entirely by chance. The 89 respondents who reported taking puberty blockers were less likely to have thought about killing themselves than were the respondents who reported wanting blockers but not obtaining them. This is not a large enough sample size to show an association much less to allow conclusions to be made.

• Confounding: Youth with psychological problems would have been less likely to be prescribed puberty blockers (at that time). Some youth may have received both blockers and psychotherapy, and there is no way to distinguish which intervention reduced the odds of suicidal ideation.

• Placebo effect: Youth who received puberty blockers may have been more likely to report improved mental health because they received something they wanted. This doesn’t prove that the puberty blockers themselves improved mental health.

• Correlation vs. causation: See Summary above.

• Other: According to Oxford Professor Michael Biggs, though the authors state that the study doesn’t allow causation to be determined, this “was not conveyed in many news reports generated by the study. ‘Puberty blockers reduce suicidal thoughts in trans people’ ran a typical headline (LGBTQ Nation, 2020).” Biggs further notes that the New York Times published an article by Turban on the study’s implications as related to attempts by South Dakota to ban puberty blockers for gender dysphoria implying that the evidence supporting the use of blockers is well-established.

Rebuttals:

Biggs, M. (2020) Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior 49, 2227–2229.

Sapir, L. (2022) The Distortions in Jack Turban’s Psychology Today Article on ‘Gender Affirming Care’. Reality's Last Stand (see Study #10).

Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults, PLoS One, January 2022, Turban, J. L. et al.

Study Description & Claims: Based on responses to the 2015 USTS, this study examined “associations between recalled access to gender-affirming hormones (GAH) during adolescence and mental health outcomes among transgender adults in the U.S.” Researchers found that 77.9% of respondents reported wanting GAH at any time, and of these: 8,860 (41.0%) never accessed GAH, 119 (0.6%) accessed GAH in early adolescence, 362 (1.7%) accessed GAH in late adolescence, and 12,257 (56.8%) accessed GAH in adulthood. The authors conclude that access to GAH is associated with favorable mental health outcomes compared to wanting but not accessing GAH. Specifically, they claim that GAH were associated with lower odds of past-year suicidal ideation and severe psychological distress. (Note: The authors published a correction in June 2023 (https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0287283) that they claim does not affect the original study conclusions.)

Study Flaws:

• Short follow-up times: The study looked at suicidal ideation during the year prior to the survey and severe psychological distress during the month prior to the survey. Whether respondents accessed GAH, looking back a month or even a year is too short a time for any conclusions to be drawn since suicidality or mental distress could be temporary.

• Biased selection of study participants or cohort: See Summary above.

• Inconsistent or inappropriate measurement instruments: A reanalysis of the study data by Oxford Professor Michael Biggs revealed that male respondents who did not access opposite-sex hormones had better mental health outcomes than those who took estrogen. In fact, Biggs found that males who took estrogen were almost twice as likely to have attempted suicide than those who didn’. Further, compared to males that reported wanting hormones (whether or not they got them), males who reported not wanting hormones were much less likely to suffer mental distress. This reanalysis demonstrates that the study tools weren’t robust, calling other findings into question.

• Confounding: Clinicians may have declined to prescribe hormones to patients that had poor mental health to begin with. It can’t be known, based on the available data, whether hormones would have improved poor mental health. Also, the study admits that puberty suppression is a confounding variable, but doesn’t report the result. Biggs’ reanalysis found that puberty blockers had no statistically significant effect on mental health, contrary to the claims of Study #2 above.

• Placebo effect: Those that wanted, and then received GAH, may have experienced an improvement in their mental health by simply getting what they wanted. The study offers no proof that taking GAH itself improves mental health.

• Correlation vs. causation: See Summary above.

• Other: Access to GAH during adulthood was associated with a 20% increase in the likelihood of past-month binge drinking and a 70% increase in the likelihood of lifetime illicit drug use when compared to desiring but never accessing GAH.

Rebuttals:

Biggs, M. (2022) Reader comments: Estrogen is associated with greater suicidality among transgender males, and puberty suppression is not associated with better mental health outcomes for either sex. PLoS One.

Singal, J. (2022) "Science Vs" Cited Seven Studies To Argue There’s No Controversy About Giving Puberty Blockers And Hormones To Trans Youth. Let’s Read Them. Singal-Minded (see Study #6).

Age of realization and disclosure of gender identity among transgender adults, Journal of Adolescent Health, June 2023, Turban, J. L. et al.

Study Description & Claims: Based on responses to the 2015 USTS, the study attempts to disprove the existence of Rapid Onset Gender Dysphoria (ROGD), a hypothesis that seeks to describe and explain the recent rise in trans identities among adolescents and young adults, mostly females, with no history of gender dysphoria. The study “evaluated components of ROGD by (1) estimating the prevalence among TGD [transgender and/or gender diverse] adults of first realizing one's TGD identity after childhood [before or after age 10, framed as “early realization” or “late realization”], and (2) assessing the median time between realizing one's gender identity and disclosing this to someone else.” Researchers found that the time between realizing and disclosing was about 14 years and, based on this finding, concluded that gender dysphoria wasn’t rapid onset but rather that TGD individuals didn’t share the realization with others until long after they first experienced it.

Study Flaws:

• Biased selection of study participants or cohort: See Summary above.

• Inconsistent or inappropriate measurement instruments: The many problems with this study are detailed in the Rebuttal below. Among the most serious: survey respondents were adults who would have self-identified as TGD long before the recent group of trans-identifying adolescents/young adults came of age. To capture those to whom the ROGD hypothesis applies, only respondents aged 18 to 24 years should have been included; responses from older respondents should have been eliminated from the analysis but were not.

The survey question that researchers relied upon to assess the age of “realization” was: “about what age did you begin to feel that your gender was ‘different’ from your assigned birth sex?” In response to this question, researchers found the median age to be 8 years old. But “gender” is an ambiguous term. In the context of the question, it could be understood to mean that you feel like you were born in the wrong body (“gender dysphoria”) or it could mean that you don’t feel happy with the societal norms for your sex. There is no way to know how individual respondents interpreted the question. The survey had a separate question: “At about what age did you start to think you were trans (even if you did not know the word for it)?” If researchers had used answers to that question instead of the first, they would have found that the median age was 15 which supports, rather than refutes, the ROGD hypothesis.

In fact, for the 18-24 year old respondents, late realization (83%) was nearly five times more common than early realization (17%). Using answers to the second question instead of the first, the time from realization to disclosure is much shorter for the 18-24 year old respondents than for the early realization group, which again supports the ROGD hypothesis. By including all respondents rather than those in the 18-24 year old group, researchers also misrepresent the large proportion of females in the late realization group. But even if they hadn’t, 63.2% of the respondents in the late realization group were female, supporting the ROGD hypothesis. For respondents aged 18-24, that percent goes up to 75.2%.

• Correlation vs. causation: See Summary above.

Rebuttals:

Sapir, L; Littman, L; Biggs, M (2023) The U.S. Transgender Survey of 2015 Supports Rapid-Onset Gender Dysphoria: Revisiting the “Age of Realization and Disclosure of Gender Identity Among Transgender Adults,” Archives of Sexual Behavior (letter to the editor).