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Adding Evidence to the Discussion of Trans Issues on Joe Rogan’s podcast

April 17, 2019

This week I had the pleasure of being a guest on the Joe Rogan Experience. On that episode, Joe brought up the question of trans children, and whether it is ethical to provide them with puberty blockers. Joe feels strongly that it is not. In my discussions with trans researchers and friends, I’ve come to understand that there are quite a lot of misconceptions about this issue, and that it’s an important one to get right. For that reason, I did my best to represent that perspective. However, since I was not aware we’d be discussing this topic before it came up, I did not have the relevant research close at hand, as I freely admitted on air. In this post, I’d like to provide it.

As a starting place, I’ve used Brynn Tannehill’s excellent book, Everything You Ever Wanted to Know about Trans, which is an exhaustive compilation of research on the subject. Tannehill is a military veteran, a researcher, and a defense analyst.

First, on the question of whether 7 year old children are being given “hormones”, which cause irreversible changes: This is not true. These drugs are not hormones: what they actually do is block the onset of puberty. These drugs are generally not given until the children are 12 or 13 (Source: FDA), and they have been used with success for many years. Tannehill writes:

One of the most commonly used drugs to block puberty in transgender children is leuprolide, and has been used on children who aren’t transgender to prevent precocious (early onset) puberty. It has been approved for this purpose by the US Food and Drug Administration (FDA) since 1993. The reason that doctors block puberty in transgender children is that forcing a transgender child to go through the wrong puberty is more or less irreversible, does permanent harm in terms of ongoing dysphoria, and results in greater difficulty living in their identified gender when they do transition later. Undoing the effects of going through the wrong puberty with surgery or hormones can be difficult, expensive, or impossible.

According to the Endocrine Society, these drugs are completely reversible. (Source.) Furthermore, they recommend that these drugs are the best course of treatment for trans children. They write:

Another reason to start blocking pubertal hormones early in puberty is that the physical outcome is improved compared with initiating physical transition after puberty has been completed (60, 62). Looking like a man or woman when living as the opposite sex creates difficult barriers with enormous life-long disadvantages. We therefore advise starting suppression in early puberty to prevent the irreversible development of undesirable secondary sex characteristics.

Regarding Joe’s question about whether or not we know what the long-term effects are: These drugs have been approved for use in children by the FDA since 1993. In other words, they’ve been prescribed to children for over 25 years, and still have been deemed safe.

Regarding the question of how many children “change their minds”: Tannehill writes that the medical protocols that are designed to treat trans children are specifically designed to ensure that no permanent steps are taken until after the age at which childrens’ gender identities become fixed:

Very few transgender youth whose dysphoria persists past 13 or so decide they wish to stop treatment. In one Dutch study, 70 transgender youth were offered puberty suppression. None of them decided to stop the treatment over the course of the multi-year study. (Source.) Only after reaching 16 are cross- gender hormones administered.

In short, the medical and mental health protocols are designed to only take permanent medical steps after everything possible has been done to ensure that this is the correct course of treatment. Until that point, everything is reversible. Along the way, however, steps are being taken to minimize potential harm to the patient whether or not they are transgender. As a recent study concluded, “most of the risks that children who socially transition and their families may experience are based on minority stress in response to unsupportive environments.” (Source.)

Regarding the claim that puberty blockers affect bone density: researcher shows that non-transgender youth who underwent puberty blocker treatment for precocious puberty recovered their bone density. Also, the most recent study of transgender youth reached a similar finding. (Source.)

[Update: Joe reached out to clarify that the point he was making regarding bone density was not about puberty blockers in trans kids, it was about hormone treatment in adult athletes. Duly noted, and my mistake; that said, I am leaving the above in case others find it helpful.]

When it comes to the concern that trans people are more likely to commit suicide after they transition: The truth is that trans youth in good environments have mental health outcomes no different from their peers. (Source 1, Source 2.)

As Tannehill writes, it is not being transgender, or receiving treatment for dysphoria that causes suicide: It’s the other way around.

Transgender people who are rejected by their families or lack social support are much more likely both to consider suicide, and to attempt it. (Source.) …

Conversely, those with strong support were 82 percent less likely to attempt suicide than those without support, according to one recent study. (Source.) Numerous recent peer-reviewed studies show that transgender youth who are supported in their gender identity by parents, schools, and their peers have significantly better mental health outcomes than those whose identities are rejected or stigmatized. (Source.) A 2018 study found that simply by using a transgender youth’s preferred name reduced suicide risk by 56 percent, and significantly improved their mental health. (Source.)

It’s for all these reasons that the American Academy of Pediatrics has issued guidelines for treatment of trans youth that support puberty blockers and gender affirmation. This is, in other words, the medical consensus.

The discussion that Joe and I had was between two non-experts in the topic; as a result, I regret that it was necessary for me to engage in this discussion without having the proper materials at hand to represent what the medical consensus actually is. I hope that this post goes some distance towards clearing the matter up for those who are curious to learn more.

Update: Brynn Tannehill wrote in to add the following regarding the question of trans athletes competing in mainstream sports:

Transgender women have been allowed to compete in the Olympics since 2004. They were required to undergo surgical transition, and transgender women were required to have been without testosterone for a year. In 2011, the NCAA instituted a similar policy, except the surgical requirement was removed, and centered on a minimum of a year of testosterone suppression. In 2016, the IOC dropped the surgical requirement, and is now has broadly similar requirements to the NCAA, with testing for testosterone levels for all athletes.

Since 2004, there have been ~22k women Olympic athletes. None were transgender. Every year there are approximately 215,000 women who compete in NCAA athletics, and you would be hard pressed to identify a dominant transgender person in NCAA athletics.

Thus, we have effectively tested the hypothesis that if transgender women were allowed to compete, it would destroy women’s athletics by setting standards for participation, allowing participation, and observing the results. Given the sample sizes involved, there is no evidence that inclusion of transgender athletes under controlled conditions has any meaningful impact on the sports.

Finally, I would remind people that anecdotes are just that: single point observations that do not capture the larger picture, and are thus a poor basis for setting policy.

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