Is ‘social contagion’ real? Fact-checking transgender care claims in new MO restrictions

Missouri Attorney General Andrew Bailey’s emergency rule restricting access to gender-affirming health care is set to go into effect on Thursday, unless a judge blocks enforcement before then.

The ruling would require patients — both adults and minors — to complete 15 therapy sessions over 18 months, get screened for autism and other conditions, resolve all other mental health issues and follow other requirements before receiving care.

Civil rights groups including the Missouri ACLU and Lambda Legal are suing to challenge the rule before it goes into effect, with a first hearing on Wednesday.

But transgender and nonbinary Missourians are already preparing for the AG’s rule to complicate or even cut off their access to medication and other treatments.

Critics have called the 11-page emergency rule “baseless and discriminatory,” with some of its underlying claims being widely debunked.

We took a closer look at the justifications the rule uses to severely limit gender-affirming health care in the state.

Why does the ruling seek to limit transgender health care?

Gender-affirming health care is a combination of services that help people better align with their gender identity, such as talk therapy, puberty-blocking medication, hormone replacement therapy and surgeries.

The practice has recently come under fire in Missouri, especially for minors.

Bailey’s office announced in February that it was investigating the Washington University Transgender Center at St. Louis Children’s Hospital for providing gender-affirming care to children. The university has denied allegations of “substandard” care.

In light of the ongoing investigation, Bailey’s emergency ruling is based on the idea that “gender transition interventions lack a solid evidentiary foundation.” Most major medical associations disagree.

“Gender-affirming care is medically-necessary, evidence-based care that improves the physical and mental health of transgender and gender-diverse people,” said Dr. Michael Suk, a board member of the American Medical Association, in a 2021 statement.

Gender-affirming health care is also supported as a safe and evidence-based best practice by the American Academy of Pediatrics, the Association of American Medical Colleges, the American Psychiatric Association, the American College of Obstetricians and Gynecologists, the American Association of Clinical Endocrinology and many others.

What is ‘social contagion’?

Another point repeated several times in Bailey’s ruling is the idea that gender dysphoria, the disconnect between one’s gender identity and the sex they were assigned at birth, can spread between young people in a manner similar to social trends.

This theory, called “social contagion,” is widely understood to be false.

The idea stems from a single study from 2018 in the journal PLOS One wherein researcher Lisa Littman collected survey results from parents on three websites that oppose gender-affirming health care.

Citing this study, the emergency rule requires providers to screen patients of all ages for social contagion “at least annually.” The rule doesn’t detail what this kind of screening would involve, but it does require providers to share a statistic from this study with patients.

The emergency rule does not cite the extensive correction that PLOS One issued to Littman’s study in 2019, which questions its sampling methods and reliance on parental accounts rather than information gathered directly from trans people.

The ruling also neglects to cite a 2022 study in the journal Pediatrics that found no evidence of social contagion, and stated that the theory “should not be used to argue against the provision of gender-affirming medical care.”

For context, the 2018 study that popularized this theory used a sample of “256 parent-completed surveys,” while the 2022 study debunking the theory used a sample of over 100,000 adolescents.

What other misleading claims does the emergency ruling contain?

Claim: “The use of puberty blocker drugs or cross-sex hormones to treat gender dysphoria… is not approved by the Food and Drug Administration (FDA).”

Context: The FDA first approved a puberty-blocking drug in 1993 to treat precocious puberty, a condition that causes early sexual development. Sex hormones are also FDA-approved to treat a wide variety of conditions. Estradiol (estrogen) was approved in 2004, and testosterone gel was first approved in 2012.

While the FDA has not approved these medications specifically to treat gender dysphoria, they have long been used for this purpose “off label” — a widely accepted medical practice.

Claim: “The FDA has issued a warning that puberty blockers can lead to brain swelling and blindness.”

Context: A closer look at this report shows that the condition in question, called pseudotumor cerebri, was only identified in six children — and at the time of the FDA’s review, only one of them was still experiencing symptoms. The update does not report blindness, saying only that some of the children experienced “visual disturbances.”

Claim: “Researchers have suggested that allowing a child to go through puberty without medical intervention may resolve gender dysphoria, whereas puberty suppression may improperly influence and worsen gender dysphoria.”

Context: The citation for this claim is a 2020 paper by a regulatory group in Finland that “does not assess the service needs of individual patients or make decisions on their treatment.” The paper itself concludes that both puberty-blocking medication and hormone therapy can be used for minors on a case by case basis.

Research has shown that providing puberty blockers to transgender children significantly reduces suicidal ideation later in life, and that those who are supported in their gender expression have rates of depression and anxiety no higher than the average population.

“It would be unethical to allow a patient to suffer through the distress of pubertal development when we have a way of preventing the distress it causes,” concluded a 2010 paper from the American Medical Association’s Journal of Ethics. “Suppression of puberty is a safe and easy way to begin to do so.”

Do you have more questions about gender-affirming health care in Missouri or Kansas? Ask the Service Journalism team at kcq@kcstar.com.