Systematic review finds “qualified support” for hormonal treatments for gender dysphoria in youth

GettyImages-694909590.jpgBy Christian Jarrett

Clinicians treating children with gender dysphoria, the children themselves, and their parents, are faced with a dilemma – early use of puberty suppressing drugs (followed later by further hormonal treatments) will likely make it easier for the young person to gender transition in due course, and the earlier that process begins, the more effective it is likely to be. However, intervening earlier comes with the possibility that the child’s feelings of gender dysphoria would have dissipated naturally, or that they may later de-transition (that is, change their mind about wanting to transition to the other gender), leaving them with potentially irreversible bodily changes caused by the hormonal treatment.

According to a systematic review published recently in the journal Pediatrics, adding to this clinical dilemma is a dearth of quality data on the physical and psychosocial effects of hormonal treatments on gender dysphoric children, teenagers and young adults. However, the limited evidence that is available does provide “qualified support” for these treatments, the review concludes.

The new findings – based on an exhaustive search of any and all relevant studies published between 1946 and 2017 – are published at a time when the medical and allied professions have shifted toward an increasingly “affirmative” approach toward gender dysphoria, one that at the extreme involves encouraging the process of transition at the very first signs of the condition.

The British Psychological Society’s own guidelines from 2012 propose offering “a series of [five] staged treatments”, to give time for the young person to consider their options, beginning with psychological exploration and escalating, if the dysphoria persists, to the use of puberty suppressing hormones and culminating in surgery.

The guidelines of the Endocrine Society (an International body based in Washington DC) are more affirmative: “We suggest that clinicians begin pubertal hormone suppression after girls and boys [diagnosed with gender dysphoria] first exhibit physical changes of puberty”.

However, the new review reveals how this well-intentioned advice is based on extremely limited evidence. When it comes to children, teens and young adults aged under 25, we simply do not yet know much about the psychosocial effects of pubertal suppressors (including gonadotropin-releasing analogs which suppress the development of secondary sexual characteristics) and further hormonal treatments (both gender-affirming hormones and cross-hormonal treatments, such as anti-androgens, which counter the effects of testosterone, and progestins, which suppress the menses).

Denise Chew at the University of Melbourne and her colleagues identified only thirteen relevant studies, and – by necessity in many cases given the context – most of these involved small samples, only two featured a control group, and none involved blinding or randomisation (the gold standard approach for medical trials).

The limited evidence available suggests that these interventions are “relatively safe” in terms of their physical side-effects, although there is no long-term data (including potential adverse effects on fertility). Where short-term side-effects occur, these can include, among others, hot flushes, fatigue, weight gain and, most concerning, changes to bone mass density.

Puberty suppressors appear to be effective at having their intended physical effect – that is, preventing pubertal changes associated with the person’s sex assigned at birth. They also have welcome emotional and behavioural benefits, such as reducing depression. However, on their own they do not appear to alleviate gender dysphoria (in fact one study found a trend in the opposite direction, and increased negative body image). The researchers said this is “probably not surprising” given that puberty suppressing drugs “cannot be expected to lessen the dislike of existing physical sex characteristics associated with an individual’s birth-assigned sex nor satisfy their desire for the physical sex characteristics of their preferred gender”.

Meanwhile, the next stage of gender affirming treatments and cross-hormonal treatments are successful, to a degree, in achieving the intended physical changes in line with the desired gender, current evidence suggests. However, these often do not match the hopes of the person with gender dysphoria – for instance, one study found oestrogen led to a degree of breast growth that most of those treated found unsatisfactory. There are some cognitive effects to consider – for instance, after taking puberty suppressing drugs, teenagers born male but seeking to transition to female, subsequently showed poorer performance on tests of executive functioning and mental rotation. Perhaps most concerning – especially given the psychological vulnerability of many teens with gender dysphoria – there is simply no data on the psychosocial effects of these treatments.

This lack of data is in the context of a growing concern among some psychologists and psychiatrists that the affirmative approach may have gone too far. For example, psychologist Dianne Berg, Co-Director of the National Center for Gender Spectrum Health in the US (which advocates an affirmative approach), told The Atlantic recently “Under the motivation to be supportive and to be affirming and to be nonstigmatizing, I think the pendulum has swung so far that now we’re maybe not looking as critically at the issues as we should be.”

One critical issue that has yet to be addressed by research at all, is what the effects are of hormonal treatments on children and teens who later de-transition. As of now, Chew and her team say there are “no known studies to date in which researchers have reported the rates and circumstances under which transgender youth cease their hormonal therapy in an unplanned manner or the risk of subsequent regret.” While the researchers say their review provides “qualified support” for the use of puberty suppressors and hormonal treatments, they conclude that more better quality and long-term research is essential, including data on the psychological effects of these interventions.

Hormonal Treatment in Young People With Gender Dysphoria: A Systematic Review

Christian Jarrett (@Psych_Writer) is Editor of BPS Research Digest

NB. On July 31, 2018 the headline to this post was changed, together with a few other minor amendments, following feedback from one of the review’s authors received via a Digest reader.

Further reading:

BPS Guidelines and Literature Review for Psychologists Working Therapeutically with Sexual and Gender Minority Clients [pdf]

Gender dysphoria [Information from NHS Choices]

When Children Say They’re Trans [recent in-depth article in The Atlantic]

Support:

Childline  [support and guidance for children and young people aged under 19]

Samaritans [support and guidance for anyone]

8 thoughts on “Systematic review finds “qualified support” for hormonal treatments for gender dysphoria in youth”

  1. Although you appear to have attempted to write a neutral essay, in effect you have given voice to those who would see medical intervention denied to transyouth. Specifically, this essay overstates several anti-interventionist talking points:

    “Weak evidence”… ummmm… yeah about that. It is considered unethical to leave untreated a patient who is suffering from a condition for which we know we have a treatment. That is to say, that no one is allowed to conduct a random study of blockers / HRT vs. placebo since we KNOW that blockers and HRT DO treat the gender dysphoria. The other issue is that the type of transgender issues found in the Western industrialized nations are comparitively rare… and highly stigmatized (and until very recently, treated as criminals / mentally ill)… so of course the clinical studies are still new. Thus, the so called ‘weak evidence’ meme is a strawman. While we have few papers, the ones we do have are quite good… and the clinical experience has been excellent.

    {{ Oh… and transyouth have been obtaining and using HRT on their own since at least the 1960s with good, if undocumented, results… }}

    “Estrogen affects executive and cognitive function” That is another BS point. While it’s true… its only true statistically as a small effect and the effect in any one individual is barely noticable. The difference is mostly found in ADULT “late transitioners” as well… NOT in youth. In other words, mixing apples and oranges on one hand, and overblowing the effect on the other. To expand a little, the fact is that men are better at mental rotation than women… by a slight amount. Adult transitioners who are given estrogen for a period of time show decreases in mental rotation ability to the point where they no longer have that very slight male edge… that is to say, that their brains become more like women’s. However, this effect does not occur in young MTF transkids because they never had that Testosterone induced edge to begin with.

    It’s important to look much deeper into these and other issues… doing a shallow glide across a deep ocean of knowledge won’t do it. Instead, look to someone who has ACTUALLY been through all the science papers and has also LIVED through these issues:

    https://sillyolme.wordpress.com/advice-to-parents-of-transkids/

    https://sillyolme.wordpress.com/2018/06/09/transphobic-propaganda-aimed-at-parents-of-transgender-kids/

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    1. There is a very important misunderstanding here.

      A scientist although neutral, does not produce neutral results. His/Her research is not neutral. Human activity is responsible for climate change and vaccines are safe. End of story. These results are not “neutral”.

      Similarly, the results regarding puberty suppressing drugs are not neutral, are negative. Puberty suppressing drugs are not working, are not alleviating gender dysphoria. Period.

      I know that this is not what the LGBT community wants to hear and I know that many in the LGBT community are hostile against science when science does not suit them. I know that many in the LGBT community want just to have their opinions served and do not care about the objective truth. Many in the LGBT community are biased. A scientist’s job is to be unbiased. I also know that many in the LGBT community will cry “homophobe” for all those unbiased scientists.

      The irony? These members of the LGBT community are working against the interests of transyouth, whereas the scientists are working in favour of those interests.

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      1. Blockers aren’t working for the simple reason that they were never going to accomplish what youngsters want… blockers only leave a body at their present state. By definition, that will NEVER alleviate dysphoria. No… blockers are NOT what young transfolk want… it is the DOCTORS who want this for two reasons, one reasonable, one not. The reasonable is fear of iatrogenic harm. The other is because of transphobic politics, because even today we live in a world where many people would rather not allow anyone, adult or adolescent, to have access to medical intervention. Puberty blockers are the compromise between what is really needed, HRT, and not doing anything at all… which would be the same as HRT, but in the opposite sense, allowing endogenous hormones to wreak their damage on a gender dysphoric child.

        https://sillyolme.wordpress.com/2011/02/28/age-of-innocence/

        You are making an odd mistake here… it appears you are lumping me into a group that denies science. Had you read my links at my blog you would have a very different understanding.

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      1. Yes, you meant to be offensive… and had you bothered to actually read them, you would have seen that they not only continued the conversation but had extensive peer reviewed reference citations at the bottom of a number of the links that fully supported the conclusions of the linked essays. THAT is “credible evidence”.

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  2. A reply based on refering to but only indirectly referencing the over one hundred essays that DO reference specific papers and studies that back up my statements… that had you bothered to follow would have shown:

    Essay w/ references regarding age of desistence and successful use of blockers / HRT:

    https://sillyolme.wordpress.com/2011/02/28/age-of-innocence/

    Bibliography w/ loads of references:

    https://sillyolme.wordpress.com/2011/02/28/age-of-innocence/

    Essay on w/ specific reference to HRT causing brain changes:

    https://sillyolme.wordpress.com/2010/02/28/the-incredable-shrinking-brain/

    About my referencing papers regarding cognitive changes due to HRT:

    Gender differences in behaviour: activating effects of cross-sex hormones. Van Goozen SH, Cohen-Kettenis PT, Gooren LJ, Frijda NH, Van de Poll NE. Psychoneuroendocrinology. 1995;20(4):343-63.

    Organizing and activating effects of sex hormones in homosexual transsexuals. van Goozen SH, Slabbekoorn D, Gooren LJ, Sanders G, Cohen-Kettenis PT. Behav Neurosci. 2002 Dec;116(6):982-8.

    Comments about the above papers available here:

    http://www.transkids.us/biblio.html#activate

    http://www.transkids.us/biblio.html#organizing

    I had suggested in my post that a DEEPER dive from some folks that actually have studied this assiduously and have lived it… please, sarcasm reflects poorly on those that are sarcastic when the target of that sarcasm is far more knowledgable than they…

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  3. Maybe you should therefore write and publish your own systematic review, if this one isn’t good enough – and doesn’t come to the conclusions you’d like?

    Like

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