FLDOH anti-trans guidance attacks “low-quality evidence” for gender-affirming care, citing low-quality evidence for conversion therapy
In their 2022 document “Treatment of Gender Dysphoria for Children and Adolescents”, the Florida Department of Health writes:
Systematic reviews on hormonal treatment for young people show a trend of low-quality evidence, small sample sizes, and medium to high risk of bias.
Hruz (2019) is not a systematic review
The linked “systematic reviews” is actually one four-page article by Paul W. Hruz (2019) in the Catholic Medical Association’s journal The Linacre Quarterly, and it is not a systematic review. It broadly encompasses the spectrum of gender-affirming care across all ages and does not specifically focus on “hormonal treatment for young people”. The journal has published it as a “research article”, and it is an unorganized continuous wall of text:
It does not possess any of the expected features of a systematic review, such as a specific research question or discussion of search criteria for inclusion of studies (Robertson-Malt, 2014). The FLDOH has erred in labeling this a “systematic review”.
In the same issue of The Linacre Quarterly, Kissell (2019) describes assisting with abortions as a cooperation with evil, McTavish (2019) lists “gender confusion” among “areas for pediatricians specifically to exercise their prophetic task as physicians and relative to medicine”, Williams (2019) argues for the inferiority of same-sex parents and for a slippery slope toward “polyamorous families”, and Reno (2019) describes suffering as “clarifying” and asserts: “We are often dead to spiritual things, and sometimes it takes the looming threat of suffering and death to awaken us.”
The norms of this journal are likely to inform the standards and values that journal contributor Hruz applies in his assessment of the adequacy of gender-affirming care for transgender and gender-questioning youth. Do those have the potential to include positions such as transness as “confusion”, the pediatrician as Catholic “prophet”, judgment of same-sex couples as potentially harmful to children, and suffering as spiritually beneficial?
The FLDOH’s choice to cite a low-quality article in a Catholic medical journal as informing state health policy and recommendations has raised these questions unnecessarily (assuming higher-quality evidence from less-biased sources was available). What is the quality of this evidence? What is the risk of bias? Is it low, medium, or high?
Hruz incorrectly cites Cohen-Kettenis & Kuiper (1984) as supporting gender identity change efforts (conversion therapy)
Hruz writes:
Since the widespread adoption of interventional strategies directed toward affirming transgender identity, efforts to identify psychological approaches to mitigate dysphoria, with or without desistance as a desired goal, have largely been abandoned. The WPATH has rejected psychological counseling as a viable means to address sex–gender discordance with the claim that this approach has been proven to be unsuccessful and is harmful (Coleman et al. 2012). Yet the evidence cited to support this assertion, mostly from case reports published over forty years ago, includes data showing patients who benefited from this approach (Cohen-Kettenis and Kuiper 1984). Although largely unstudied, cognitive behavioral therapy in particular may have significant benefit to this patient population by reducing social anxiety (Busa, Janssen, and Lakshman 2018).
However, coauthor Peggy Cohen-Kettenis made clear in chapter 6 of Smith (2002) that her 1984 review did not support gender identity change efforts over gender-affirming care:
In 1984, Cohen-Kettenis and Kuiper reviewed the existing case studies at that time. They concluded that the evidence for complete and long-term reversal of cross-gender identity by means of psychotherapy was not convincing for the following reasons. Firstly, in each report gender identity was operationalized differently. Consequently, treatment success was assessed on the basis of various, and sometimes unspecified, criteria. Secondly, some patients reported a disappearance of the wish for SR, when no psychotherapy was given. However, some applicants who refrain from SR may reapply many years later. So even the few claimed cures might have been postponements of SR. Thirdly, patients in these studies were highly motivated to “change“ their gender identity, which is rarely encountered in most applicants for SR. The authors did confirm, that in some cases psychotherapy had brought the transsexual to renounce their wish to undergo SR (i.e., two of the three cases from the Barlow et al. studies, 1973, 1979). In view of the scarce data available on the long-term effects of psychotherapy however, the authors considered it to be quite uncertain to conclude whether the results were manifestations of a fundamental change in cross-gender identity, or of a temporary distancing from, or perhaps suppression of the gender identity conflict. In conclusion, psychotherapy might be helpful for individuals who are merely gender confused or who’s wish for SR seems to originate from factors other than a genuine and complete cross-gender identity. Whether genuine transsexualism can be effectively resolved by means of psychotherapy still requires more conclusive evidence. Psychotherapy or counseling for purposes other than changing a cross-gender identity is also an option for SR candidates. They may, for instance, want to overcome anxieties concerning the future or need support when “coming-out“, when dealing with personal loss, or when trying to adjust to their changing life situation (Cohen-Kettenis and Gooren, 1999; Meyer et al., 2001).
This makes clear that the authors found anti-trans conversion therapy approaches to be broadly ineffective, and concluded that psychotherapy should be limited to supporting trans people in their identities and throughout any transition. Smith et al. continue:
In a recent study five cases were described of adults who were diagnosed with gender identity disorder and who showed occasional remission in gender dysphoria (Marks et al., 2000). Remission had occurred with or without treatment and in response to various life events and co-morbid psychopathology. Some of the subjects had consciously tried to suppress or control their gender dysphoria because of pressure from their partner or because circumstances did not allow for addressing the gender issue (e.g., one subject felt only minimally gender dysphoric while taking care for his aged and ill parents). Remission was documented at up to ten years. The authors concluded that, if evaluated over many years, a cross-gender identity could be less fixed than is often thought. Their implications for the clinician were that such applicants require a long trial period of cross-gender living prior to any surgical interventions. We suppose that these individuals with an apparently “less fixed” cross-gender identity might have gained from psychotherapy in coping with their gender and nongender problems. However, resolution of their gender identity conflict as a consequence of psychotherapeutic treatment seems highly unlikely, since remission of the gender dysphoria in these cases, apparently, was temporary. The fact of the matter is that the gender dysphoria in all of the five cases described in the study had returned to such an extent that the subjects had resumed cross-gender living, and all but one had started or resumed hormone treatment.
Again, the authors find it unlikely that use of psychotherapy will cause a trans person’s gender identity to resolve in the direction of cisgender identification. These reported cases of remission were rare and clinically diverse, and do not support any specific gender identity change efforts as being effective or even broadly applicable to the general gender-dysphoric transgender population. (Busa, Janssen, & Lakshman (2018) reviewed only treatment for social anxiety in transgender youth populations; disidentification as trans or remission of gender dysphoria did not even appear as subjects in that review.)
Hruz cites Zucker et al. (2012), who support gender affirmation for adolescent trans kids
Hruz states:
The pioneering work of Zucker established that many but not all patients who received psychological counseling and support were able to manage and resolve conflicts arising from discordant gender identity, particularly in affected children (Zucker et al. 2012).
This statement neither favors nor disfavors gender-affirming care, it simply describes co-occurring conflicts being addressed regardless of whether these children would go on to identify as cisgender or transgender. However, Zucker et al. (2012) write explicitly in favor of gender affirmation for adolescent trans youth, including social and medical transition, as they consider trans adolescents unlikely to begin spontaneously identifying as cis or experiencing remission of gender dysphoria:
From a developmental perspective, we take a very different approach when we work with adolescents with GID than when we work with children with GID. This is because we believe that there is much less evidence that GID can remit in adolescents than in children. Whether this is due to different populations of clients seen in adolescence versus childhood or whether this is due to a narrowing of plasticity and malleability in gender identity differentiation by the time of adolescence is open to debate. But, if the clinical consensus is that a particular adolescent is very much likely to persist down a pathway toward hormonal and sex-reassignment surgery, then our therapeutic approach is one that supports this pathway on the grounds that it will lead to a better psychosocial adaptation and quality of life (Zucker, Bradley, Owen-Anderson, et al., 2011). Because the treatment literature is lacking in terms of rigorous comparative evaluations (e.g., Treatment X vs. Treatment Y or Treatment X vs. no treatment, etc.), one has to rely on a patchwork of empirical evidence about natural history. Thus, for example, natural history data suggest, to date, a much higher rate of desistance of GID in child samples than in adolescent or adult samples (Zucker et al., 2011).”
This contradicts the FLDOH guidance against social transition, puberty blockers or hormone therapy for anyone under 18. Zucker et al. are also deliberately ambiguous and qualitative in their descriptions of treatment “success” or “failure” or “in between”, and openly question whether resolution in favor of cisgender identity is even a successful outcome:
If one goal of treatment is to reduce the gender dysphoria, then, by definition, a successful outcome would be its remission and a failure would be its persistence. If, however, a successful outcome also takes into account a child’s more general well-being and adaptation to various developmental tasks, then the definitions of success and failure must be broader. Consider, for example, the vignette described earlier of the 7-year-old girl who had an extremely strained relationship with her father. Six years after therapy commenced (and still continues), the GID has fully remitted and there has been a lessening of the sensory sensitivities and rituals. Although this now young adolescent girl functions reasonably well at school and has friends, parent-child relations remain severely strained and there continues to be substantial parental psychopathology (in each parent and in their marriage). Success? Failure? In between?
This does not support even the insinuation by Hruz that lasting resolution toward a cis identity is possible or desirable.
Zucker’s work with gender-questioning children is not benign and enforces distressing behavioral gender-role conformity
Ken Zucker has been reported as promoting a clinical approach to childhood gender dysphoria or gender-questioning that can involve discouraging activities and behaviors stereotyped as reflective of a cross-gender identification, as well as discouraging transgender identification directly. Bailey (2003) describes Zucker as encouraging families to tell a child they must be cisgender and cannot transition:
First, he thinks that family dynamics play a large role in childhood GID—not necessarily in the origins of cross-gendered behavior, but in their persistence. It is the disordered and chaotic family, according to Zucker, that can’t get its act together to present a consistent and sensible reaction to the child, which would be something like the following: “We love you, but you are a boy, not a girl. Wishing to be a girl will only make you unhappy in the long run, and pretending to be a girl will only make your life around others harder.” . . . The second prong is therapy for the boy, to help him adjust to the idea that he cannot become a girl, and to help teach him how to minimize social ostracism.
This extends to taking toys away from children:
The third prong is key. Zucker says simply: “The Barbies have to go.” He has nothing against Barbie dolls, of course. He means something more general. Feminine toys and accoutrements—including Barbie dolls, girls’ shoes, dresses, purses, and princess gowns—are no longer to be tolerated at home, much less bought for the child. Zucker believes that toleration and encouragement of feminine play and dress prevents the child from accepting his maleness.
Imposing requirements such as these for gender-conforming play have been reported as causing significant distress in Zucker’s child patients (Spiegel, 2008):
So, to treat Bradley, Zucker explained to Carol that she and her husband would have to radically change their parenting. Bradley would no longer be allowed to spend time with girls. He would no longer be allowed to play with girlish toys or pretend that he was a female character. Zucker said that all of these activities were dangerous to a kid with gender identity disorder. . . .
By the time Bradley started therapy he was almost 6 years old, and Carol had a house full of Barbie dolls and Polly Pockets. She now had to remove them. To cushion the blow, she didn’t take the toys away all at once; she told Bradley that he could choose one or two toys a day. . . .
As his pile of toys dwindled, Carol realized Bradley was hoarding. She would find female action figures stashed between couch pillows. Rainbow unicorns were hidden in the back of Bradley’s closet. Bradley seemed at a loss, she said. They gave him male toys, but he chose not to play at all. . . .
“He was much more emotional. … He could be very clingy. He didn’t want to go to school anymore,” she says. “Just the smallest thing could, you know, send him into a major crying fit. And … he seemed to feel really heavy and really emotional.” Bradley has been in therapy now for eight months, and Carol says still, on the rare occasions when she cannot avoid having him exposed to girl toys, like when they visit family, it doesn’t go well. “It’s really hard for him. He’ll disappear and close a door, and we’ll find him playing with dolls and Polly Pockets and … the stuff that he’s drawn to,” she says.
This treatment is described as inducing forms of distress in the child that did not previously exist:
In particular, there is one typically girl thing — now banned — that her son absolutely cannot resist.
“He really struggles with the color pink. He really struggles with the color pink. He can’t even really look at pink,” Carol says. “He’s like an addict. He’s like, ‘Mommy, don’t take me there! Close my eyes! Cover my eyes! I can’t see that stuff; it’s all pink!'”
The enforcement of gender-conforming behavior and identification instead pushed this very young child toward expressing their gender only through a “double life” concealed from their disapproving parents:
“I mean, he tells us now that he doesn’t dream anymore that he’s a girl. So, we’re happy with that. He’s still a bit defensive if we ask him, ‘Do you want to be a girl?’ He’s like ‘No, NO! I’m happy being a boy. …’ He gives us that sort of stock answer. … I still think we’re at the stage where he feels he’s leading a double life,” she says. “… I’m still quite certain that he is with the girls all the time at school, and so he knows to behave one way at school, and then when he comes home, there’s a different set of expectations.”
This is the distressing treatment of children approvingly cited by Hruz in the pursuit of “Success? Failure? In between?” The enforcement of gender conformity as a treatment approach is at odds with both the gender-affirmative approach and the more conservative watchful-waiting approach, which have been adopted in leading medical guidelines around the world (Ashley et al., 2019).
Hruz relies on discredited source Paul McHugh
Hruz writes:
There are a few relatively small studies that have demonstrated improved sense of well-being and reduced dysphoria in adolescent transgendered youth who receive puberty-blocking drugs (de Vries et al. 2011, 2014), but there are also significant concerns related to associated risks (Hruz, Mayer, and McHugh 2017).
His citation of Hruz, Mayer, & McHugh (2017) in the non-peer-reviewed The New Atlantis, founded by the “Judeo-Christian” conservative Ethics and Public Policy Center, highlights a significant credibility issue with his coauthor Paul McHugh. McHugh has repeatedly claimed in recent years that under his leadership at Johns Hopkins, he closed the clinic providing gender-affirming care on the basis of findings that transition care did not improve outcomes for trans patients (McHugh, 2016).
However, that 1979 study relied on an ad hoc “adjustment score” that evaluated patients’ outcomes as better if they were exclusively heterosexual and if they did not receive any of the followup psychological support which is now recommended as the standard of care in transition (Meyer & Reter, 1979). Contemporary replies identified possible numerical irregularities in the published results of the study (Fleming, Steinman, & Bocknek, 1980). McHugh would later admit his true intentions for the Johns Hopkins gender clinic under his leadership (McHugh, 1992): “It was part of my intention, when I arrived in Baltimore in 1975, to help end it.” The reliance on such sources in the course of FLDOH’s own attempt to obstruct access to transition care on the basis of misrepresentations is doubly inappropriate. (Johns Hopkins has since resumed providing comprehensive gender-affirming medical treatments via their Center for Transgender Health.)
Hruz calls for more randomized controlled trials for transition, but does not understand that this requires active controls
Hruz states:
The limitations of the published studies in the growing field of transgender medicine are many. They include a general lack of randomized controlled trial design, small sample sizes, high potential for recruitment bias, questions regarding the precision of measured parameters, nongeneralizable population groups, relatively short follow-up, high numbers of patients lost to follow-up, and frequent reliance upon “expert opinion” alone. Limitations of the existing transgender literature include general lack of randomized prospective trial design, small sample size, recruitment bias, short study duration, high subject dropout rates, and reliance on “expert” opinion.
But this does not properly contextualize how randomized controlled trials of gender-affirming care would likely be conducted and what this would be intended to accomplish. A Cochrane Library systematic review of HRT for adult trans women, cited in the FLDOH guidance, offers recommendations for more rigorous research on transition care and outcomes (Haupt et al., 2020):
Against this background, methodological problems such as inconsistent and missing comparison groups, uncontrolled confounding factors, small sample size, short follow-up time and difficulties in recording and evaluating a broad spectrum of health outcomes (physical and mental health, social functioning and QoL) have become apparent in hormone therapy (Deutsch 2016b). The performance of RCTs is controversial, especially with regard to placebo studies, and ethical and methodological objections have been raised (e.g. violation of the principle of equipoise, Miller 2003). However, the positive research potential of active-controlled RCTs is acknowledged, in order to compare different types, dosages and methods of administration of active treatments. Overall, there is a trend in the discussion to favour not only RCTs and quasi-RCTs, but also high-quality cohort studies conducted in a network of health centres, hospitals and practices (Deutsch 2016a; Deutsch 2016b).
An active-control RCT could, for example, give cross-sex hormone therapy both to the test and the control group while only varying the dosage. It is not intended to measure the effects of withholding all treatment, but to avoid the need to withhold all treatment from one group as part of a randomized controlled trial of gender-affirming care, which would be unethical or even impossible. In this case, obtaining sample sizes large enough to perform subgroup analyses by medication, dosage, route of administration, and other variables would require studies to begin enrolling many more participants to receive gender-affirming care. This would provide actionable clinical knowledge on the optimal way to provide effective hormone therapy. And it’s precisely how to obtain higher-quality evidence with a lower risk of bias – the very qualities FLDOH seeks. ■
Next: The FLDOH guide to parenting: Ignore a child’s issues, and just hope it all goes away
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