A National Institutes of Health-funded study published Jan. 19 in the New England Journal of Medicine claimed to find that cross-sex hormones caused improvements in psychosocial functioning for transgender and nonbinary adolescents. However, two participants committed suicide while another 11 developed suicidal ideation, according to the study.

Among 315 transgender and nonbinary participants aged 12 to 20, two committed suicide during the two-year study, and biological males saw no improvements in depression, anxiety or life satisfaction, researchers reported. The researchers claimed to find a causal relationship between cross-sex hormones and psychosocial improvements, but the research was based on an observational study rather than a randomized trial, and it lacked a control group, meaning it wasn’t possible to determine whether the hormones or something else had caused any improvements in patients’ mental health.

In 2020, the suicide rate for people aged 15-14 was 14.24 per 100,000, according to the American Foundation for Suicide Prevention; at two out of 315, this study had a suicide rate of 634.9 per 100,000.

“Overall, our results provide evidence that [gender-affirming hormones] improved appearance congruence and psychosocial functioning in transgender and nonbinary youth,” the study’s conclusion read.

The study did find that patients’ average mental health scores — determined by several surveys participants completed — improved slightly over the course of two years; of 27 participants who started with depression scores in the severe range, 18 had a depression score in the minimal or moderate ranges at 24 months, according to the study. Of 33 participants with moderate depression at the study’s start, 21 had minimal or moderate depression at 24 months.

Depression among participants, on average, started in the mild range and decreased to the subclinical level by 24 months, according to the study, which found that those improvements correlated with improved sense of “gender congruence,” a sense of alignment between one’s gender identity and physical appearance.

Dr. Annelou L.C. de Vries, the researcher behind the famous Dutch studies which became the foundation of modern pediatric gender medicine, expressed concern about the study’s shortcomings in an editorial published in the same journal, the New England Journal of Medicine, Jan. 11. The new study failed to account for the possibility that mental health care or other interventions may have been the cause of improved mental health, rather than hormones or the sense of gender congruence hormones can inspire.

“Social support has been hypothesized as explaining why Dutch transgender adolescents have better psychological function than those in other countries,” she wrote. “Understanding additional factors that influence outcomes should help to determine which components of care and support other than GAH might improve the lives of transgender adolescents.”

The study also failed to provide further information on the six individuals who withdrew from the study, she wrote; it’s unclear if they detransitioned, were unhappy with the treatments or stopped taking them because they were satisfied. She also said that any supposed benefits of cross-sex hormones should be weighed against their negative side effects.

“Benefits of early medical intervention, including puberty suppression, need to be weighed against possible adverse effects — for example, with regard to bone and brain development and fertility. At present, studies involving young adults from the Dutch adolescent transgender cohort show that accrual of bone mineral decelerates during puberty suppression but increases during GAH treatment,” she wrote.

Dr. Steven Levine, a psychiatrist and clinical psychiatry professor at Case Western Reserve University School of Medicine, told the Daily Caller News Foundation the study was stronger than most others in the field of transgender medicine since it had a relatively large sample size, high retention rate and was prospective (meaning researchers chose participants in advance and observed them over time rather than analyzing data on patients who had already undergone care). He also pointed to weaknesses in the study, such as the lack of control groups and its inability to determine causality, and stressed that the study couldn’t determine long-term outcomes.

“The study measures the central role of happiness about one’s appearance,” he said, referencing the study’s “appearance congruence” measure. “I don’t think it measures much else about psychosocial functioning. It certainly does not address the issue that I think is the major issue facing this trans population: are they going to be able to negotiate life in their 20s and 30s and deal with the developmental tasks that all young adults face, which is having a stable vocation and having a stable, satisfying intimate relationship with another person.”

He supports further research into the efficacy of cross-sex medical interventions and told the DCNF he doesn’t know the answer to the best treatment for children with gender dysphoria, particularly given the lack of data about their long-term effects.

“I’m a little skeptical of the use of hormones for teenagers and I think we need to be more truthful about what is known and what is not known,” he said. “All other psychiatric problems in teenagers are dealt with by thorough evaluation and investigation about the cause of their symptoms … but for some reason transgender symptoms in adolescents, especially rapid onset, have been treated as an exception, and there are all these rationalizations doctors use to rapidly medicalize these kids … no psychiatrist, no psychologist, can spend 50 minutes with a kid and know the best thing to do.”

Despite the study’s shortcomings, media outlets parroted the researchers’ conclusions uncritically, largely failing to note the suicides, the lack of efficacy for male participants or the study’s inability to determine causality.

“Gender-affirming care for trans youth improves mental health: Study,” an ABC News headline read. The article did not mention the study’s flaws, but did cite unnamed activists who were stoking fears that state-level restrictions on childhood sex changes were a danger for children.

NBC News published a similar story under the headline “Hormone therapy improves mental health for transgender youths, a new study finds.” The article pointed to the potential dangers of restricting child sex change procedures but also acknowledged that mental health scores didn’t improve for natal males.

The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health. The federal government has spent at least $17.5 million since 2008 funding studies examining the impacts of transgender medical procedures on patients’ health.

WPATH, the NIH, ABC News, NBC News and Diane Chen, the lead researcher in this study, did not respond to the DCNF’s request for comment.

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