Opinion: The Utah Legislature and governor did the right thing on transgender youth bill
Activist organizations recently wrote an open letter to The New York Times, opposing a practice many Americans take for granted: the open discussion of critical issues affecting young people, including medical transition treatment for trans-identifying youth. The same core complaint shows up in recent public criticism of the Utah Legislature and governor for enacting SB16, a bill placing a sensible moratorium on puberty blockers, cross-sex hormones and transgender surgeries for trans-identifying youth while a systematic review of the evidence is conducted.
These youth deserve our compassion and love. How best to support them is a question deserving a high-quality conversation involving different perspectives. Yet one recent essay signed by a group of Utah psychotherapists sharply derides the Utah governor and legislature, implying that medical transition of gender-questioning minors has uncontested value, with little left to discuss. Transition treatment for trans-identifying youth — whose numbers have exploded over the past decade — is described as “essential,” “lifesaving” and “spectacularly” beneficial, “dramatically improving their mental health.”
These professionals undoubtedly care about their gender-questioning clients. However, the medical procedures in question are quite new. And rather than being settled, most of the research remains contested. We wish no harm to transgender-identifying youth. On the contrary, we wish to protect and help them in the best possible way.
A closer look at the research
Medications used to block puberty have not been approved by the FDA for the treatment of trans-identifying children and have never undergone rigorous, controlled trials. Risks of these and other transition treatments that are known are often not fully communicated to minors and their parents. For instance, puberty blockers may reduce bone density and thus increase the risk for fractures and osteoporosis. And despite puberty blockers being promoted as a benign “pause button” that gives youth time to decide what gender they will align with, almost all who start that treatment go on to take cross-sex hormones and are expected to continue these drugs indefinitely. Over the long term, these hormones may contribute to cardiovascular problems, compromise fertility and fuel emotional instability.
Following a groundbreaking lawsuit against the U.K.’s Tavistock gender clinic by a young woman who felt she had been harmed by the treatment she received there, England initiated a systematic review of the evidence supporting medical transitioning treatment. Like Sweden and Finland, which had performed systematic reviews of their own, England found the supportive evidence for this kind of treatment to be poor and decided to shut down the clinic. In all three of these countries, medical transition used to be the treatment of choice but is now increasingly used only as a last resort, and only under carefully controlled conditions. Norway has proposed a similar path following a closer look at the research. Notable medical organizations and experts in France, Australia, New Zealand and Belgium have also issued strong cautions.
But these developments are almost entirely overlooked by those advocating gender-transition services for youth in the U.S. and Canada, who instead highlight a select group of studies that have serious methodological limitations or other flaws.
One such study, from the journal Pediatrics, claimed to find that gender-questioning teens who took puberty blockers and cross-sex hormones had 73% lower odds of suicidality and 60% lower odds of depression compared with those who did not take these medications. But a closer investigation by journalist Jesse Singal found no statistically significant improvements in mental health among these youth.
Related
Advocates also cite Cornell University’s “What We Know” project, which looked at 55 studies and claimed to find “no studies concluding that gender transition causes overall harm.” But a separate report titled “What We Don’t Know” comprehensively challenges those claims, demonstrating significant weaknesses in much of the research.
The burden of proof usually applied in medical science is reversed in the Cornell team’s phrasing — with skeptics left to prove new, experimental treatments are unsafe before they can be withdrawn, rather than awaiting a body of clear evidence appraising risks and benefits before widely introducing a new intervention. “Medical science is not supposed to work this way,” underscores The Economist in a recent article calling the available evidence for these procedures “worryingly weak.”
The need to pause
Our vulnerable youth have the most to lose if we don’t get this right. Because institutions that typically require treatments to be proven safe before broad dissemination have not done so here, legislators are wise to step in and allow experts to look more deeply at the issue.
This watching and waiting parallels the wisdom of many parents and health professionals who have helped youth navigate these issues in years past. Studies before 2014 found that 60%-90% of kids who experienced gender dysphoria before puberty did not continue to have these feelings once they reached adulthood. A more recent study indicated nearly all participating children continued to identify as transgender five years after socially transitioning. However, these children were not followed into adulthood, and within our fast-changing social environment today, it’s difficult to say how many other trans-identifying youth will continue to identify that way beyond age 18. This data may suggest that many parents and healthcare professionals who are acting more quickly today on children’s earliest declarations about a transgender or nonbinary identity might increasingly be foreclosing the possibility for later developments among their youth.
Bottom line: more time and space can help us figure out how to better support young people in these complicated situations. This is especially true where depression and suicidal ideation are involved.
Effective support for suicidal youth
Suicidal teens need our compassion and support. But how do we best provide this? Strikingly, there is no good empirical evidence that medical transition reduces suicide. Indeed, suicides have increased even while the number of pediatric gender clinics in the United States has grown from virtually none to at least 100 in the past 15 years, along with additional hundreds of Planned Parenthood clinics providing easy access to cross-sex hormone prescriptions.
It’s critical that parents know that there are alternatives to medical transition. Yet rather than being presented with various options, families too often are given, ironically, a binary choice: support your child and help them transition, or deprive them of “life-saving” treatments. In this way, worried parents often feel pressured into believing they have no other option than medical transition.
Let’s not forget that suicide is impacted by social contagion and that dramatic rhetoric involving grievance, suspicion and accusation can inflame the problem. Respected guidelines urge media outlets to avoid overstating the problem of suicide or “oversimplifying or speculating on the reason for suicide.”
The recent essay asserted that “as of Jan. 24, 2023” — the day after SB16 was passed — “depression and suicidality are immediately on the rise,” a claim that is at best unproven.
The essay also highlighted Utah Gov. Spencer Cox’s “awareness that 56% of transgender youth have attempted suicide.” We can find no support for this figure. In 2022 the Trevor Project reported that 56% of transgender and nonbinary youth surveyed in Utah “seriously considered suicide” over the previous year (a number that included youth who already transitioned). This is concerning, but considering suicide is far different from attempting. Again, no study has conclusively shown that medical transition reduces suicide.
The same Trevor Project survey actually indicated that 22% of transgender and nonbinary youth in Utah attempted suicide. Any suicide attempts should be taken seriously — with a robust and compassionate conversation about what more we can do to help. As part of that, it should be understood that many trans-identifying youth have coexisting developmental or mental health conditions associated with heightened suicidality such as autism, borderline personality disorder, eating disorders and body dysmorphic disorder. Our youth are better served by treating all of these issues holistically and encouraging them to wait until after their brains and bodies have matured to make decisions that permanently affect their futures.
Listening to detransitioners
As a part of hearing all perspectives on how to best support our youth, the lived experiences of detransitioners themselves need to be considered. Growing numbers of young people who undertook medical treatments to transition, but then stopped and chose to identify with their biological sex, have testified before state legislatures regarding the irreversible harm that has been done to their bodies. Increasingly they are speaking out on social media and in other public forums.
Detransitioners lament gender-affirming therapists urging them on a course that left them with permanently changed bodies, lifelong medical challenges and the inability as adults to have normal sexual functioning, conceive or father children, or breastfeed. Several groups of detransitioners in the United States have initiated lawsuits against their medical providers, including one young woman who underwent a double mastectomy at age 13.
These voices deserve to be heard. We can do that while also acknowledging that many gender-affirming therapists are well intentioned, earnestly wanting what is best for their clients. They may not be aware of all the contested research on this subject, the wealthy advocates who profit from the transition industry or how their efforts may further other causes they do not necessarily support.
When we fall into inflammatory rhetoric, it can only serve to exacerbate feelings of alienation among an already vulnerable population — perpetuating the damaging impression that politicians deliberately want trans teens dead. Far better to acknowledge an honest disagreement about how to most effectively support (and not cause further harm to) a population that everyone agrees needs help.
A society’s moral stature may be evaluated by how it treats its most vulnerable citizens. Evidence is accumulating that medical transition treatments are harmful to minors and that there are gentler, less invasive ways to support these youth. We encourage all stakeholders — not only lawmakers but also medical providers, psychotherapists, parents, teachers, and others — to look carefully and critically at the relevant research, which is exactly what Utah’s SB16 was designed to encourage. The future of these precious young people depends upon it.
Rebecca Taylor is a psychotherapist practicing in Sandy, Utah. Jeff Bennion is a marriage and family therapist practicing in Murray, Utah. Chelsea Johnson is an associate marriage and family therapist practicing in St. George, Utah.
This essay is also signed by Dr. David R. Boettger, a board-certified pediatrician and fellow in the American Academy of Pediatrics who practices in Sandy, Utah; Jennifer Roach, a therapist licensed in Utah, Washington, and Idaho; Thurmon Thomas, a licensed marriage and family therapist and clinical director of Ascend Counseling and Wellness in Hurricane and Delta, Utah; Christian Anderson, a Utah-based social worker practicing for over 40 years; Dr. Lili De Hoyos Anderson, a Utah-based individual, marriage, and family therapist; Jeffrey J. Ford, a marriage and family therapist and court mediator in St. George, Utah; Dr. David M. Haralson, a licensed marriage and family therapist and owner of Oasis Family Therapy in Bountiful, Utah; Dr. David A. Nelson, a professor of human development in the School of Family Life at Brigham Young University.
