Medical Safety: Risk Study of Gender Medicine, Part 2

Statements that Gender Medicine is “life-saving” and addresses the suicide rate are unsubstantiated by any data here in the USA; furthermore, no effort is being made to collect this data scientifically. What data is available indicates that Gender Medicine is ineffective at impacting the suicide rate. Based on the material that I have reviewed, my education, training, and experience, I find that Gender Medicine as currently described by WPATH (2022) is hazardous. The World Professional Association for Transgender Health (WPATH) leadership is grossly incompetent. WPATH (2022) is grossly negligent in providing its assessment of suicide in Gender Medicine to practitioners using its “standards”.

In the previous part of this two-part series, I discussed how Gender Medicine was being conducted without any safety controls for this type of experimentation. This conduct would not necessarily meet the definition of “experiment”, because no results are being systematically collected to modify the hypotheses (Jensen, 2022). This part examines the claim for why this approach is appropriate: suicide (WPATH, 2022). The claim that this is necessary includes the term “life-saving” as well (Becerra, 2022).

Recall from Part 1 that I listed ways in which the Institutional Review Board safety practice could be subverted, including the misrepresentation of current research. Herein we evaluate the relevance of the claim that Gender Medicine improves suicide rates by comparing the citations in two overarching sources: (1) Levine et al. (2022) “Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults” and (2) WPATH (2022) “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8”.

Recall from Part 1 that I listed ways in which the Institutional Review Board safety practice could be subverted, including the misrepresentation of current research.

To summarize the rigorous research that has taken place into the question of whether or not Gender Medicine improved outcomes on suicide, the following quality control criteria were applied: (1) The study’s methodology was not contradicted by a peer reviewed article; (2) The study produced some form of quantifiable data on the topic; and (3) The study passed a consistency inspection on its basic statistics, logic, and calculations. If a study is not included, these numbers provide the criteria item where it failed. These are noted as “Fail #” in the text below.

Variables in Suicide

My summer sociology class at Texas A&M University (circa 1994-1998) featured studying Dirkheim’s (1897) text “Suicide”. The short summary is that he found statistical patterns to the practice after studying data across multiple countries, religions, mental health, age, sex, marriage status, etc.; for example, a single mom is less likely to commit suicide than a teenager home alone with nothing to do. Suicide is also a socially spread contagion, spread through thought rather than biology (Gould and Lake, 2013). Finally, suicide is a secondary side effect of various pharmaceuticals with depression as a side-effect (Qato et al, 2018). Note that depression is not caused by low serotonin (Moncrieff et al, 2022). When discussing approaches to address suicide, it is important to recognize that multiple factors can be involved and isolating their contribution is quite complicated.

There are two more issues relative to understanding the research into the effectiveness (or not) of Gender Medicine on suicide. The first is terminology relative to concrete evaluation. Specifically, Clayton et al (2021) states,

“There is also unclear use of the term suicidality, which exaggerates the implication of Turban et al.’s findings. Suicidality is a broad term, which is comprised of suicide attempts, plans, and ideation, and indeed this was the manner it was used by Turban et al. It is also important to note that Turban et al. made no assessment of completed suicides. Turban et al. assessed six areas of suicidality (including recent and lifetime suicide attempts, recent ideation with plans, recent and lifetime ideation) and found no association between puberty blockers and suicidality measures on five of the six areas [before AND after interventions]. The only association was with “lifetime suicidal ideation.” Of course, any suicidal ideation is concerning, but suicide attempts are generally considered of higher concern, in terms of suicide risk assessment, than suicidal ideation.”

(My additional information for the reader is in []’s.) Note that WPATH (2022) failed to include the Clayton reference in its materials.

Suicide Completion Rates

Figure 1 shows the quality of evidence in the suicide research that we will be discussing. One of the best studies cited by Levine et al. (2022) was Dhejne et al. (2011), a population-wide study from Sweden 1973-2003. The study analyzed records from more than a 30-year time span, and it found that (summary from Levine et al, 2022)

“adults who underwent surgical transition were 19 times more likely than their age-matched peers to die by suicide overall, with female-to-male participants’ risk 40 times the expected rate”

The suicide rate was 0.3% (2.7/1000 person years). WPATH (2022) cites this study only once in its “Mental Health” chapter as a supporting reference that a higher prevalence of suicidality occurs among “those requiring medically necessary gender-affirming medical treatment”. This is problematic because Dhejne et al. (2011) shows no improvement in suicides nor suicidality. The impact of gender-affirming treatment on changing the suicide rate was not measured.

Levine et al. (2022)’s second reference on the topic, Wiepjes et al. (2020), examined the charts of the population in their Amsterdam clinic and found no change in the suicide rate before, during, or after medicalization. The ratio of suicides was 0.5%.

Biggs (2022), Levine et al. (2022)’s last citation on suicide, analyzed England, Wales, and Northern Ireland children referred for Gender Medicine from 2010 to 2020; 0.03% died from suicide. Due to the extent of the wait list (2 years) for this population, the change in suicide rate prior to and after medicalization was studied, and there was no significant statistical difference. Note that in the realm of the statistics of small numbers, comparisons between data sets are complicated. Biggs (2022) discusses the Dhejne et al. (2011) and Wiepjes et al. (2020) studies in terms of suicides per 100,000 people for comparing these statistics.

Due to the extent of the wait list (2 years) for this population, the change in suicide rate prior to and after medicalization was studied, and there was no significant statistical difference.

WPATH (2022) does not discuss Wiepjes et al. (2020) nor Biggs (2022) at all. I would like to note that the Levine et al. (2022) is also not mentioned in WPATH (2022). This is concerning, because Levine et al. (2022) raised extremely serious ethics issues in current practices.

WPATH Citations

It is clear that WPATH (2022) did not provide the medical community with information that is consistent with Levine et al. (2022). In discussing the citations WPATH (2022) provided, the difference between “suicidal” and “suicide” needs to be re-emphasized. Cantor (2022) states, “Psychological research importantly distinguishes completed suicide—which occurs primarily among biological males and involves the intent to die—from suicidal ideation, gestures, and attempts—which occur primarily among biological females and represent psychological distress and cries for help.” Also refer to the discussion by Clayton et al. (2021) in this article (paragraph 3).

A search through the WPATH (2022) material for discussions on suicide brought up references such as Craig et al., 2017; Green et al., 2020; Turban, Beckwith et al., 2020 and D’Angelo et  al., 2020 in the “conversion therapy”-suicide relationship section. First of all, the American Psychological Association (2022) loosely defines “conversion therapy” as, "a highly controversial, ethically questionable, and generally discredited process intended to change individuals of same-sex or bisexual orientation to heterosexual orientation." I interpret this to mean sexual orientation relative to the individual’s being female/male, genetically; all of these details can be objectively measured. In contrast, gender identity is purely subjective.

Finding of note: Given how concentrated homosexual/bisexual people are among the gender dysphoric population (e.g. Levin et al., 2022), Gender Medicine practices could be defined as conversion therapy.

Among WPATH (2022)'s citations related to suicidality, Craig et al. (2017) is inappropriate for Table 1 as it does not actually tally any data from the survey that quotes were drawn from (Fail #2).

D’Angelo et al. (2020) questions the methodology in Turban, Beckwidth et al. (2020), so this will be left out of Table 1 (Fail #1).

Finally Green et al. (2020) is a selection-biased survey in which respondents who claim to have undergone Sexual Orientation and Gender Identity Change Efforts (SOGICE) were asked about suicidal thoughts and attempts. Table 1 in Green et al. (2020) had the following issue: 58.5% of the SOGICE respondents were "cisgender". There is a major difference between a LGB person experiencing SOGICE and a transgender person not having their identity affirmed (Stella O'Malley, 2022). Without Green et al. (2020) distinguishing suicidality between transgender and cisgender respondents in Table 2, it provides no insight into the suicidality relative to LGB SOGICE versus transgender identity non-affirmation (Fail #3). The labels in Table 3 are meaningless without "cisgender" among them to make this separation of variables possible given the extremely limited description provided of the "adjusted" logistic regression model(s) involved. Finally, it is not explained in the text why the number of respondents changed between Tables 1 and 2.

Other WPATH (2022) references include de Graaf (2022), summarized by Levine et al. (2022) as, “...suicidality of trans-identifying teens is only somewhat elevated compared to that of youth referred for mental health issues unrelated to gender identity struggles”; this reference is added to Table 1.

Keo-Meier et al. (2015) looked at adult suicidality during the 3 months after medicalization; this is temporarily beneficial so it isn’t included in Table 1 (Fail #1). Levine et al. (2022) points out,

“Clinicians working with trans-identified youth should be aware that although in the short-term, gender-affirmative interventions can lead to improvements in some measures of suicidality, neither hormones nor surgeries have been shown to reduce suicidality in the long-term.”

The Levy (2003) reference, concerned with discussing pharmaceutical effects, is not being included in Table 1 as studying suicide was not one of the article’s objectives (Fail #2).

Turban, King et al. (2020) and Rew et al. (2020) were methodologically critcized by Clayton et al. (2021). Turban, King et al. (2020) was methodologically criticized by Biggs (2020), too. Neither Turban, King et al. (2020) nor Rew et al. (2020) will be included in the table below (Fail #1). Note that WPATH (2022) failed to include both the Clayton reference and the Biggs reference in its materials.

Bauer et al. (2015)'s selection-biased survey somehow has 110 individuals that attempted suicide out of 433 total survey respondents consisting of "11.2%" of the population; it’s 25.4%. As how this was accomplished is not explained, this study is not included in the table below (Fail #3).

Finally in another selection-biased survey, Brumer et al (2015), which should read Perez-Brumer et al. (2015), somehow analyzes the sample size of 1060 individuals which is larger than the total survey group of lifetime suicide attempts (355). This indicates that the population size was too small for the analysis that was conducted, so this study is also not included in the table below (Fail #3).

Recall what I said in Part 1:

In other words, the state of the Gender Medicine practices and research has to be presented as rigorous and strong; a presentation that is false. IRB members would have to independently go through the cited materials to assess the accuracy of their citations and be sufficient experts in the field to recognize what is missing from the discussion of the hypothesis. Cantor (2022) goes in to this in detail when discussing the expert witness reports filed by Drs. Brady and Antommaria. This is probably what went wrong with the Olson IRB.

Levine et al. (2022) had superior citations to WPATH (2022), and the quality of the WPATH (2022) citations were very weak for supporting the points they were attempting to make in their "standards of care". What is the effect of WPATH (2022) misrepresenting the state of research?

Four Risk and Safety issues are relevant here:

1) It is not unusual to make policy changes to address small populations which are at risk (e.g. USDA, 2017); however, these changes are debated in terms of the expected impacts on other people (see the comments on the proposed change). In the absence of data (Jensen, 2022), my educated guess is that the number of transgender people who commit suicide is smaller than most populations on which major policy changes are directed. This is important for the upcoming safety discussion.

2) Gender Medicine does not change the suicide rate/ratio. In other words, it is not “life-saving”. The WPATH (2022) document claims the reverse and then fails to discuss the studies in Table 1 that contradict that assertion.

3) Where suicide has patterns relative to the individual, as a social contagion, and as a side effect of certain pharmaceuticals, it is impossible to isolate one versus another with the available research.

Levine et al. (2022) warns practioners,

“Providers of gender-affirmative care should be careful not to unwittingly propagate misinformation regarding suicide to parents and youths. They should also be reminded that any conversations about suicide should be handled with great care, due to its socially contagious nature.”

The necessity of this warning suggests to me that practitioners, particularly in promulgating the transition-or-die misinformation, could themselves be socially spreading suicide.

Also, Gender Medicine involves lifetime consumption of off-label use pharmaceuticals (American Medical Association, 2016). Dresser and Frader (2009) warn about the weak evidence base for these sorts of prescriptions,

“More than half the respondents in a survey of academic medical centers reported that innovative off-label prescribing raised concerns in their institutions, such as lack of data, costs, and unfavorable risk-benefit ratios. When substantial uncertainty exists about off-label applications, patients are at risk of receiving harmful or ineffective treatments.”

The side effects from Gender Medicine pharmaceuticals is not discussed here, but their off-label status and uncertainty in effectiveness in suicide cannot be dismissed.

4) The suicide completion data on these Gender Medicine patients is not being collected here in the USA (Jensen, 2022). Green (2022) makes an estimate on effectiveness by comparing pediatric suicide data against pediatric access to Gender Medicine pharmaceuticals, for example.

Conclusion

In Part 1 of this Medical Safety series, I discussed how Gender Medicine is being conducted on an experimental basis without any of the safety controls for human experimentation. In fact, the term “experimentation” is not the correct description of the practice as no effort is being made to systematically collect results and modify the hypotheses. The explanation for this approach has been that the Gender Medicine patients have extreme suicide rates. In Part 2 of this series, I examined this claim by comparing two overarching Gender Medicine publications and found that the available data suggests that the suicide rate doesn’t change.

Finding for a court of law: Statements that Gender Medicine is “life-saving” and addresses the suicide rate are unsubstantiated by any data here in the USA; furthermore, no effort is being made to collect this data scientifically.

Finding for a court of law: What data is available (Table 1) indicates that Gender Medicine is ineffective at impacting the suicide rate.

Finding for a court of law: Based on the material that I have reviewed, my education, training, and experience, I find that Gender Medicine as currently described by WPATH (2022) is hazardous.

Opinion for a court of law: WPATH leadership is grossly incompetent.

Opinion for a court of law: WPATH (2022) is grossly negligent in providing its assessment of suicide in Gender Medicine to practitioners using its “standards”.

Figure 1: Epidemiologic study designs and increasing strength of evidence (from BasicMedical Key, 2016).

Table 1: Advantages and Disadvantages of Common Types of Studies Used in Epidemiology (from BasicMedical Key, 2016) with studies of note in this article listed.

Safety Implications

Significant policy changes have been enacted to protect transgender people based on the largely unmeasured phenomena discussed above. For example, a professor at the UC Berkeley School of Law testified at the Senate Judiciary Committee, “I want to recognize that your line of questioning is transphobic and it opens up trans people to violence by not recognizing them...[asked to clarify]...I want to note that one out of five transgender persons have attempted suicide” (C-span, 2022). There is no evidence to support this assertion, and there is no intention among USA Gender Medicine community leadership to study this scientifically. So accommodations in the form of limits on free speech are being implemented because of this small, virtually unstudied risk (e.g. Meriwether, 2021). How do other policy accommodations impact safety?

First of all, there are fundamental biological differences between females and males that are critical to acknowledge in the health care setting (search “female” in American Medical Association, 2021). While the nursing home court case, Taking Offense (2021), was not concerned with patient safety insofar as receiving the correct care, this is a developing issue as sex-specific definitions fall under scrutiny (e.g. American Medical Association, 2021). Also, recall that the definition of transgender does not require any form of medicalization; it is a subjective identity. Impact sports become unnecessarily hazardous if females play against males (e.g. World Rugby, 2022). Imprisoning females with males is particularly dangerous (e.g. Chandler v CDCR, 2022). Then there are various activities, such as bathing, in which the presence of a naked male is inherently threatening (e.g. Hoyt, 2021; note it is concerning that the wider media did not follow-up on the safety issues in this incident after the suspect’s criminal history became known). These are a small sampling of the incidents, injuries, and close-calls that are being experienced by the policies intended to protect transgender people from suicide. For comparison, the USDA (2017) regulation change was based on a measured issue, worker safety for chicken farmers. It is concerning that in comparison to this USDA regulation that was not modified, Gender Identity based regulation changes are occurring across the breadth of the federal government in the absence of an objective measure of harm and to whom (e.g. Title IX, 2022).

Just as measuring the full suicide rate has not been conducted here in the USA, documentation of these safety incidents in health care, sports, prison, and facilities for partial or full-nudity are similarly under-sampled. The safety risks to females is significantly greater under these policies, but they also impact all Gender Medicine patients when it comes to health care. My educated guess is that the size of the population put at risk by these changes far exceeds the population at risk without these protections. Also note that due to the complexity of suicide, social contagion and pharmaceutical secondary side-effects in particular, there is no data suggesting that these policy changes will have any impact regardless.

Finally, current research on detransitioners, Gender Medicine’s patients who regret medicalization, found that they experience negative interactions with the LGBT community (Vandenbussche, 2022). Safety concerns that transgender people raise also apply to those who medicalized yet no longer identify as transgender; however, no policies are being developed to support this growing population.

Summary

Based on the material that I have reviewed, my education, training, and experience, I find that Gender Medicine as currently described by WPATH (2022) is hazardous. Based on the available data, the suicide risk shows no improvement for those who medicalize. I also briefly summarized the most dangerous policy accommodations which developed on these unfounded assumptions of suicide risk. The safety risks to females is significantly greater, but they also impact all Gender Medicine patients when it comes to health care.

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