Commentary on Levine et al.: A Tale of Two Informed Consent Processes

Clayton, Alison

doi:10.1080/0092623x.2022.2070565

Cited by 6 publications

(6 citation statements)

References 25 publications

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“…Some professional organizations and leading GAT clinicians, in publicly available communications to GD youth, the public, and policy makers, appear to overstate the certainty of GAT’s benefits and provide inadequate discussions of risks (Clayton, 2022a ; Cohen, 2021a , b ; Olson-Kennedy, 2015 , 2019 ; Telfer, 2019 , 2021 ). For example, GATs have been described in such communications as “absolutely life-saving” (Olson-Kennedy, 2015 ) and being underpinned by “robust scientific research” (Telfer, 2019 ).…”

Section: Gender-affirming Treatment For Youth With Gender Dysphoria: ...mentioning

confidence: 99%

“…However, as a recent review concluded, evidence on the appropriate management of youth with gender incongruence and dysphoria is inconclusive and has major knowledge gaps (Cass, 2022 ). Previous papers have discussed that the weaknesses of the studies investigating the efficacy of GAT for GD youth mean they are at high risk of bias and confounding and, thus, provide very low certainty evidence (Clayton, 2022a , b ; Levine et al, 2022 ). To date, however, there has been little discussion of the inability of these studies to differentiate specific treatment effects from placebo effects.…”

Section: Introductionmentioning

confidence: 99%

“…GAT can achieve some of the desired masculine or feminine appearance outcomes, but the main arguments used to support the use of these treatments in GD youth are that they improve short- and long-term mental health and quality-of-life outcomes. However, this claim is only underpinned by low-quality (mostly short-term, uncontrolled, observational) studies, which provide very low certainty evidence, complemented by expert opinion (Clayton, 2022a ; Hembree et al, 2017 ; NICE, 2020a b ; Rosenthal, 2021 ). No randomized controlled trials (RCTs), including none using the previous treatment approach as a comparative, have been undertaken.…”

Section: A Brief Introduction To the Gender-affirming Treatment Model...mentioning

confidence: 99%

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Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice

Clayton

2022

Arch Sex Behav

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Section: Gender-affirming Treatment For Youth With Gender Dysphoria: ...mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: A Brief Introduction To the Gender-affirming Treatment Model...mentioning

confidence: 99%

See 1 more Smart Citation

Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice

Clayton

2022

Arch Sex Behav

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“…Amid the ongoing controversies involving interventions for GD [52,[67][68][69][70][71], the Gender Service at the Sydney Children's Hospitals Network has tried to follow a cautious, carefully considered, individually tailored approach. As an initial step, the young people who presented to our service from December 2013 to November 2018-typically in an effort to obtain gender-affirming medical interventions-were assessed for GD and then, on that basis, became eligible or not to proceed with puberty suppression with GnRHa through our Gender Service.…”

Section: Discussionmentioning

confidence: 99%

Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study

et al. 2023

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This prospective case-cohort study examines the developmental pathway choices of 79 young people (13.25–23.75 years old; 33 biological males and 46 biological females) referred to a tertiary care hospital’s Department of Psychological Medicine (December 2013–November 2018, at ages 8.42–15.92 years) for diagnostic assessment for gender dysphoria (GD) and for potential gender-affirming medical interventions. All of the young people had attended a screening medical assessment (including puberty staging) by paediatricians. The Psychological Medicine assessment (individual and family) yielded a formal DSM-5 diagnosis of GD in 66 of the young people. Of the 13 not meeting DSM-5 criteria, two obtained a GD diagnosis at a later time. This yielded 68 young people (68/79; 86.1%) with formal diagnoses of GD who were potentially eligible for gender-affirming medical interventions and 11 young people (11/79; 13.9%) who were not. Follow-up took place between November 2022 and January 2023. Within the GD subgroup (n = 68) (with two lost to follow-up), six had desisted (desistance rate of 9.1%; 6/66), and 60 had persisted on a GD (transgender) pathway (persistence rate of 90.9%; 60/66). Within the cohort as a whole (with two lost to follow-up), the overall persistence rate was 77.9% (60/77), and overall desistance rate for gender-related distress was 22.1% (17/77). Ongoing mental health concerns were reported by 44/50 (88.0%), and educational/occupational outcomes varied widely. The study highlights the importance of careful screening, comprehensive biopsychosocial (including family) assessment, and holistic therapeutic support. Even in highly screened samples of children and adolescents seeking a GD diagnosis and gender-affirming medical care, outcome pathways follow a diverse range of possibilities.

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“…[1•]. Such questions have provoked an intensity of divisiveness within and outside of medicine rarely seen with other clinical uncertainties [18][19][20][21][22]. This passion reflects decidedly different prioritization of scientific evidence, medical ethics, and social values.…”

Section: Introductionmentioning

confidence: 99%

Current Concerns About Gender-Affirming Therapy in Adolescents

Levine

Abbruzzese

2023

Curr Sex Health Rep

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Purpose of Review Results of long-term studies of adult transgender populations failed to demonstrate convincing improvements in mental health, and some studies suggest that there are treatment-associated harms. The purpose of this review is to clarify concerns about the rapid proliferation of hormonal and surgical care for the record numbers of youth declaring transgender identities and seeking gender reassignment procedures. Recent Findings Systematic reviews of evidence conducted by public health authorities in Finland, Sweden, and England concluded that the risk/benefit ratio of youth gender transition ranges from unknown to unfavorable. As a result, there has been a shift from “gender-affirmative care,” which prioritizes access to medical interventions, to a more conservative approach that addresses psychiatric comorbidities and psychotherapeutically explores the developmental etiology of the trans identity. Debate about the safety and efficacy of “gender-affirming care” in the USA is only recently emerging. Summary The question, “Do the benefits of youth gender transitions outweigh the risks of harm?” remains unanswered because of a paucity of follow-up data. The conclusions of the systematic reviews of evidence for adolescents are consistent with long-term adult studies, which failed to show credible improvements in mental health and suggested a pattern of treatment-associated harms. Three recent papers examined the studies that underpin the practice of youth gender transition and found the research to be deeply flawed. Evidence does not support the notion that “affirmative care” of today’s adolescents is net beneficial. Questions about how to best care for the rapidly growing numbers of gender-dysphoric youth generated an intensity of divisiveness within and outside of medicine rarely seen with other clinical uncertainties. Because the future well-being of young patients and their families is at stake, the field must stop relying on social justice arguments and return to the time-honored principles of evidence-based medicine.

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Commentary on Levine et al.: A Tale of Two Informed Consent Processes

Cited by 6 publications

References 25 publications

Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice

Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice

Developmental Pathway Choices of Young People Presenting to a Gender Service with Gender Distress: A Prospective Follow-Up Study

Current Concerns About Gender-Affirming Therapy in Adolescents

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