Should the “gold standard” of randomized controlled trials really be the standard for transition treatment?

Zinnia JonesThe standards we choose to set for the kinds of evidence that we consider valid and acceptable for a given purpose are something that can be wielded selectively or in bad faith for motivated purposes. Such maneuvers are sometimes attempted in anti-trans discourse, with clinical studies of transition treatment and its beneficial effects on trans people being labeled as inadequate due to their methodology and thus insufficient to demonstrate that transitioning is beneficial or necessary in the treatment of gender dysphoria. For instance, Hruz, Mayer, & McHugh (2017) assert:

Though there is very little scientific evidence relating to the effects of puberty suppression on children with gender dysphoria — and there certainly have been no controlled clinical trials comparing the outcomes of puberty suppression to the outcomes of alternative therapeutic approaches . . .

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Large study of trans youth on HRT finds zero incidents of thrombosis

Zinnia JonesOne of the most serious side effects of feminizing hormone therapy can be the development of thrombosis, a blood clot which blocks the normal circulation of blood, leading to potentially fatal conditions such as pulmonary embolism, heart attack, or stroke. While this has been a known risk since the initial development of HRT, the nature and extent of that risk has been a matter of lengthy debate. Prior to the adoption of bioidentical estradiol in trans women’s HRT regimens, conjugated equine estrogens or the synthetic estrogen ethinylestradiol were typically used, and ethinylestradiol is associated with an elevated likelihood of developing blood clots; route of administration may also be a factor, and injectable or transdermal estradiol may carry less thrombotic risk than oral estradiol. However, even including earlier studies in which synthetic estrogens were used, a meta-analysis by Khan et al. (2019) found that the risk of thrombosis among trans women on HRT was not higher than the risk among cis women taking oral contraception. And thrombosis is not considered to be a risk associated with testosterone treatment as part of masculinizing HRT (Hembree et al., 2017), although a case has been reported in a 17-year-old trans boy who was taking both testosterone as well as an ethinylestradiol-containing oral contraceptive (Stanley & Cooper, 2018).

Khatchadourian, Amed, & Metzger (2014) found that among 63 trans girls and boys receiving cross-sex hormone therapy in adolescence, no cases of serious side effects such as thrombosis were reported. A recent abstract of a study by Kowalczyk Mullins et al. (2020) at the Cincinnati Children’s Hospital Medical Center reports the frequency of thrombosis observed among 635 trans adolescents and young adults aged 13-24 receiving estrogen or testosterone treatment. How many experienced thrombosis during this treatment? Zero.

None of the 635 patients developed clinically significant thrombosis. One patient experienced recurrent superficial thrombophlebitis associated with peripheral intravenous catheters.

Three patients had a history of previous thrombosis and two were on prophylactic anti-clotting treatment; another three were started on anti-clotting treatment upon initiating HRT due to risk factors for thrombosis. Nonetheless, neither these patients nor any others experienced thrombosis during cross-sex hormone therapy. The authors recommend:

Clinicians should 1) obtain a careful and detailed personal and family history of risk factors for and history of thrombosis and consider referral to a hematologist to discuss the risks associated with GAHT, and 2) counsel about modifiable risk factors such as tobacco use and obesity.

At a time when multiple state legislatures are moving to prohibit the administration of puberty blockers and cross-sex hormones to trans adolescents, studies such as these are essential to establishing the basic safety of these treatments. Medical transition in adolescence is beneficial to trans youth, necessary for their well-being, and, as this latest study indicates, low-risk and safe.

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Puberty blockers can be beneficial for trans girls even in late adolescence

Zinnia JonesGuidelines for the treatment of trans adolescents with puberty blockers and cross-sex hormones recommend that puberty blockers should be initiated once the first physical changes of natal puberty, Tanner stage 2, have begun (Hembree et al., 2017). However, in practice, many trans adolescents do not begin treatment until the final pubertal stages of 4 or 5, after having already experienced many of the undesired physical changes associated with their birth-assigned sex. For instance, Tack et al. (2016) report using the androgenic progestin lynestrenol instead of GnRH analogues for trans boys who have already reached stage 4 or later of their natal puberty, while Tack et al. (2017) note the substitution of the antiandrogen cyproterone acetate as a puberty blocker for trans girls who begin treatment at stage 4 or later. Continue reading

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Once more, with peer review: Transitioning is not anti-gay conversion therapy

Zinnia JonesFor years now, anti-trans activists have made the contention that the availability of gender-affirming care for trans youth, including social transition and medical transition with puberty blockers and cross-sex hormones, functions as a form of anti-gay conversion therapy in which youth who would supposedly grow up to be cisgender and gay are instead somehow induced to be transgender via this treatment, resulting in a heterosexual orientation. The anti-trans group 4thWaveNow offers a representative example of this argument:

What’s more, a side effect of this pediatric transition propaganda is the proactive conversion of same-sex attracted young people into surgically and hormonally manufactured heterosexuals. It has been well known for decades that the vast majority of “gender dysphoric” young people resolve those feelings and grow up to be gay and lesbian.

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Progesterone may not be only beneficial or ineffective for trans women – for some, it can be actively harmful

Disclaimer: I am not a medical professional and this is not medical advice.

Zinnia JonesEver since I came out and started HRT in 2012, I’ve found it important to document and share my experiences as a trans person with every aspect of this process, not only to aid in cis people’s understanding of our lives but to offer other trans and gender-questioning people points of similarity and comparison with which to identify themselves. This has included experiences which haven’t been documented extensively or at all in official literature on what to expect, such as pre-transition chronic depersonalization that remits upon transition, but which turn out to be shared by many trans people once we begin comparing notes on our lives. In keeping with that tradition, I find it necessary to share the results that I and other trans women have seen from a much-debated element of HRT: progesterone. Continue reading

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