Theology in the Raw - S2 Ep6: Diversity of Trans* Part 6: An Endocrinologist’s Perspective on Puberty Blockers and Cross Sex Hormones:

Episode Date: February 8, 2021

Dr. Hruz (pronounced “rooz”) is an associate Professor of Pediatrics, Cell Biology & Physiology at Washington University School of Medicine in St. Louis. He has a Ph.D. and an M.D. and specializes in pediatric endocrinology. Dr. Hruz has clinical interest in a wide range of endocrine disorders, with a special interest in diabetes mellitus. Dr. Hruz's research interests include intermediary carbohydrate metabolism, glucose transporter structure and function and mechanism of insulin action. Dr. Hruz has also become an expert in the discussion currounding puberty blockers, cross-sex hormones, and trans* teenagers seeking transition. This is what we focused on in our discussion. We looked at the health risks and benefits of blockers and cross sex hormones and some of the ideology surrounding the discussion.

Hello, friends. Welcome back to another episode of Theology in the Raw. This is the sixth and final part of our series, The Diversity of Trans. I hope you have enjoyed this series. If you've listened to all the episodes, I highly encourage that you do listen to them all. If you have only listened to one or two, I encourage you to listen to them all. That's the whole point, is that we would get our arms around a glimpse of the diversity of voices in the trans conversation. And there's no way we can capture every single kind of experience. There's just, there's way too many, way too many lived experiences and perspectives and backgrounds and foregrounds and all of the above. But I hope that these six conversations were helpful in exploring the diversity of the trans conversation. My guest for today is Dr. Paul Ruse. Paul is Associate

Professor of Pediatrics, Endocrinology, and Diabetes. If you're watching the video, you see me kind of looking around here because I'm trying to read his profile as accurately as I can. He is an associate professor at Washington University School of Medicine in St. Louis. Dr. Ruse has an MD and a PhD. He is an endocrinologist, He is an endocrinologist, and he is an expert in the medical side of the conversation about puberty blockers and cross-sex hormones, which we explained what those are in this conversation. Dr. Ruse did want to make it really clear that his views do not represent the university as a whole. He's not representing the perspective of Washington University School of Medicine in St. Louis. These are his own personal thoughts as an

endocrinologist. Also, my book Embodied has been published as of February 1st. You can get it through Amazon. The full title is Embodied Transgender Identities, the church and what the Bible has to say. So yeah, if you're listening to this episode, because you were drawn to maybe the medical discussion, the scientific discussion about cross sex hormones and puberty blockers, I do discuss this aspect of the conversation throughout the book. I'm not a medical expert, but I've had to do a lot of research in this area. And that's how I came across Dr. Ruse's, uh, very great work. Uh, what I love about Dr. Ruse is he's very level-headed. He's kind, he's compassionate. He wants the best of people. And he's also very, I think, very honest with where we are at with the science

in this really important conversation. If you would like to support the show, you can go to patreon.com forward slash theology in the raw, or just look down into the show notes. You can support the show for as little as five bucks a month and get access to the theology in the raw Patreon community without further ado. Let's welcome to the show for the first time. Do you want to know Dr. Paul Ruse? All right, I'm here with an acquaintance slash friend.

We've met only virtually a couple times. We have some mutual friends, but I'm here with Dr. Paul Ruse. That is how you pronounce your name. Is that correct? You told me. Yeah, the H is silent. The H is silent. So, Paul, thanks so much for being on.

wanted to have have you on because there's a lot of public discussion about um uh trans you know trans teenagers transitioning the efficacy of puberty blockers um the potential side effects of cross-sex hormones and then medical transition and you know this is this is something you've you've really become an expert on um and what i love about your approach is you just you know this is your specialty from a medical standpoint and so you you can just give us the facts you know i know in a day and age like today when everybody likes to claim to have the facts but i you know as i've looked at your work you really do seem to just say here's where the science is at make an informed decision decision. But if we're not giving people all the facts, then that's when it, I think, can be really unhelpful. So why don't we

start, Paul? Why don't you give us a background of your expertise and how you got into this conversation in particular? Oh, very happy to do so. And again, it is a pleasure to have this opportunity to speak in this area. I'm a pediatric endocrinologist. I'm an academic physician scientist. So I spend a lot of my time both doing basic science research and also in caring for children that have a variety of hormone diseases. Certainly, a lot of what we do is related to diabetes, but it also includes issues of abnormal puberty and disorders of sexual development and all sorts of questions related to that. And so I've been in practice for over 20 years. I've been in a large academic institution and have done a lot in my field to be able to advance science relevant to my specialty. And so that training,

I think, has really helped in asking the important questions in this particular topic related to gender dysphoria. I got involved more actively in that conversation while I was chief of our division of endocrinology at my institution. And shortly after I assumed that position, there was really a national conversation that was going on about this growing awareness of individuals that had this discordance in their gender identity and their sex. And really specifically for my specialty, there was a move to engage in treating these affected children with hormones to align the appearance of their body to conform with their gender identity. And it was in the context of that being put forward to start a clinic at my institution for that purpose that I began

exploring the scientific evidence that was available about that question and entering into dialogue. And we can talk a lot more about what I've learned over the last decade, you know, as that has been explored. And, you know, to sum it up very succinctly, there's still so much that we don't know. And so that's really, I think, that's why this conversation, I think, is so important that we have the opportunity to put out there what are the scientific facts that we know and don't know and what are the questions and concerns that are still remaining.

for an adolescent or pre-adolescent who is wrestling with gender dysphoria or experiences gender dysphoria. When did that shift in protocol happen and why did it happen? Was it based on rigorous scientific kind of discussion or was it more, I don't want to get over my skis here, or was there some ideological movement that was pushing that change? Yeah, no, that's a great question. sex was to really explore and understand some of the psychological underpinnings of where that identity came from, to be able to support them and help them in that regard. But this new approach to affirmation, rather than challenging that gender identity, it used to be referred to as gender identity disorder. It was recognized as that the underlying difficulty was arising from the thought processes that these individuals had. And I think there was a move. I think it is fair to say that there's quite a bit of ideology involved in really

thinking about that differently, making claims that really the mind is not a problem at all. It's the body itself that was not formed correctly. And again, that's not based on any science. And there's a lot that could be said about that. But this is about dating back a little over a decade ago, my professional organization, the Endocrine Society, first came out with practice guidelines in 2009, so to give you some ideas, and they revised those in 2017, and really moving away. So the traditional approach was either to try to assist affected children in realigning their gender identity with their biological sex, or merely watching and waiting. And that was based upon some longstanding data that the majority of

children that have this experience, at least when this begins before the time of puberty, will have a spontaneous realignment of the gender identity with their sex. And we're talking, you know, good estimates around 85, 90 percent. And that was how it was approached in recognizing that. That has moved drastically now to the current approach of affirming one's gender identity and then, you know, engaging in some of these medical interventions like puberty blockers and cross-sex hormones that we can talk about. And it's really moved beyond, you know, looking at the various approaches to very strongly asserting that that's the only viable option forward, the affirmation-only approach. And really with the exclusion of even investigating other ways that we can assist these individuals. You know, it's based medically on the recognition that a very significant proportion of people that have this experience will have real suffering. And I think that that's not controversial at all.

You know, markedly elevated rates of suicide, depression, eating disorders, substance abuse, of suicide, depression, eating disorders, substance abuse, all of these going on. So the change went from considering this gender identity disorder to focusing on the discomfort that one has in that experience and referring to that as gender dysphoria. And that actually came out formally in the diagnostic manual that psychiatrists use to classify psychiatric conditions, the DSM. psychiatrists used to classify psychiatric conditions, the DSM. And it really is important to recognize that there was no new science in making that transition. It was based on ideological principles. And to this day, really, there are many questions about what the underlying cause is of the condition. Again, we can talk about that as well. So that's really historically,

of the condition. Again, we can talk about that as well. So that's really historically, and it really began actually in the Netherlands. The Dutch had developed an approach, really, in older individuals for this affirmation and applying that to children. So moving toward aligning the body to conform with the gender identity. And that was brought to the United States, again, a little over a decade ago in the early 2000s. There was a prominent endocrinologist, Norm Spack at Harvard, that really was a strong advocate for this, was a strong advocate for this, but there are others as well. And I do recall when this all began at that time, at the professional meetings, there was really active discussion going on, recognizing that this was a controversial new approach. Yet the discussion that went on at that time never resolved the concerns that many of the people in my profession had about some of the

ideological assumptions that were being made and really about the very little information that we had about the success of the approach. There was a lot of focus on the immediate effects of relieving that dysphoria with virtually nothing known about the long-term outcomes and very little known about the consequences of these hormonal treatments. You know, again, in the process, and again, the process of the discussion was shut down very quickly where panels were convened to purportedly discuss this. And really, the panels were heavily biased for people supporting the affirmation approach and really shutting down the opportunity to really raise some of the questions that I've continued to raise in this

area. Real quick, I want to come back. I want to go to the explaining puberty blockers and cross-sex hormones and, you know know from a medical standpoint but um can you uh you mentioned kind of in passing i'd love for you to just maybe tease it out just briefly but the difference between um the older term gender identity disorder and in 2013 right the new dsm came out the fifth edition and now it's called gender dysphoria. So it's still listed in the manual of mental health disorders. So I would assume that it's still technically a mental health disorder, but they've removed the term disorder and now replaced it with dysphoria. Can you unpack maybe why that change in language is actually significant? Correct. Well, you know, so there are many that

would like to have that out of the manual altogether. The dilemma that one has is that one is making the ideological assertion that this is part of the normal human condition, that this represents a spectrum of human diversity. diversity. Yet at the same time, one is advocating for pretty significant medical intervention. So you need to justify why the medical profession needs to be engaged in addressing that condition. And really having it listed is the means by which it is justified that insurance companies are paid for this and that clinicians can engage in that. There really is, if you think about it from a logical standpoint, a lot of questions that can be asked about that assertion. If this is normal, you know, what is the reason for having to engage in these interventions that have very significant risks and long-term consequences? So, it is shifting the, it's really stated that it's not a disorder and that they're just addressing the discomfort. Yet, I think as

one moves forward, logistically, they're trying to figure out ways to really move away from this as even a medical condition, yet still allow patients access to these hormones. So, and again, you kind of said it in passing, but the three main approaches, I'm sure there's variations, but one would be like a psychosocial approach, right? To look at the psychological aspect of the dysphoria, what might be causing it, what might be flaring it up. And then there's the watchful waiting, which is more just hands-off,

just let's wait and see what comes about. And then there's the affirmation, gender-affirmative approach that, you know, wants to, says, you know, to align, to attempt to align the body with the gender identity through hormones and so on is the best or maybe even only way to relieve the dysphoria. Is that, did I get that largely correct? Yeah, I think that that's correct as far as the various approaches. And I think where they differ, they differ in many ways.

So they differ in what the scientific premise is, you know, in the intervention that one has, what are the assumptions that we have, and what is the goal of the intervention as well. So that in the, well, it's often referred to as the reparative approach, you know, to assist that individual of having the realignment of their gender identity with their biological sex, that would be an intended and desired goal. And again, it's, you know, based upon largely, at least in children, on the natural trajectory. But the watch and wait approach really is an unbiased approach. So it really doesn't seek any one particular outcome. It just looks at the likelihood of spontaneous realignment. And again, many people challenge that.

But when you actually look at the data, it's a consistent finding. And I think it's, you know, attempts to dismiss evidence that really is on par, if not stronger than the evidence that people use to make the counter argument. So again, the reparative approach has a desire to realign the gender identity with the biological sex. It makes sense from a medical standpoint that if that is the outcome, then one is not obligated to be tethered to the medical establishment for the rest of their life. So they're not subjected to all of the medical risks that are associated with these hormone therapies.

And so if you look at outcomes and desired outcomes, even aside from ideology, you have, you know, two groups of patients, one that are going to have increased risk of the hormones and another group that is going to be able to go on with life without, you know, that exposure. One would think that that would be a desirable outcome. And again, it's the ideology that is pushing this forward as the goal is to affirm and have them move forward with the bodily changes. And so in the watch and wait approach, it's also very important to recognize it doesn't mean do nothing, so that it means that there's not a direction as far as a desired intent of the outcome. It's to support that individual during this process, and that can include psychotherapy to address the issues of depression and anxiety and eating disorders and the other things that are going on.

That really needs to be done in these individuals. And this is the best medical practice. We would do this for any patient that walked into the door, you know, suffering from depression or anxiety or any of the other, what we call comorbidities. So, and then the affirmative approach that the premise, again, as we stated, was that this is part, this is the way it's often stated is that the patient was born in the wrong body. And the assumption is that the mind is correct and the body needs to be changed to align with that. There's a lot of underlying ideology there. a lot of things in the areas of philosophy and other implications as far as how one arrives at that understanding of the human person.

But that is why it is pushed for affirmation. Now, the other argument for affirming an individual is the data that shows that the alleviation of that dysphoria will occur in the short run for many of the individuals that are affirmed. And again, going through the different components of that intervention would be helpful. Again, without knowing what the long-term outcomes are going to be. Well, I really want to get there, the efficacy of medical intervention. But let's start with puberty blockers. For somebody that doesn't even know what that phrase is, can you explain what puberty blockers are and why they would be given to somebody who's experiencing dysphoria? Yes. So, puberty blockers are drugs that are used to halt the normal signals that come from the brain to tell the gonads to work. So, that normally,

during most of childhood, those signals from the brain, specifically the pituitary gland of the brain, are not operating. They're inactivated. And hold on a second. I'm going to. That's fine. Yeah. If you need to take the call, I'm sure you got a lot going on.

No, I'm just trying to figure out how to get it to stop making noise. I'm going to put it down here. I'm sorry. Let me start over again. So puberty blockers are a class of drugs that are used to suppress the normal signaling that comes from the brain, the pituitary gland in the brain, to tell the gonads to work. that comes from the brain, the pituitary gland in the brain to tell the gonads to work. There are drugs that have been used for many years to treat children that have undergone abnormally early puberty. So normally the signals from the brain are secreted in short pulses, and when you give them continuously, rather than stimulating the gland or the gonad, it actually shuts it off. They're also used in adults to treat

that are being treated for cancers, for example, where you want to shut down the function of the gonads to protect them from damage. And we recognize that the condition that we treat in pediatric endocrinology of precocious puberty, that puberty is happening at an abnormally early time point. That is where the drugs have been studied and where they've been approved by our Food and Drug Administration and where we have quite a bit of experience in using these medications. What is going on in the area of gender dysphoria is that they're now being used to halt normally timed puberty, so occurring at an age where a child would normally go through the bodily changes of puberty, together with the psychological and social changes

of adolescence. And the medicines themselves have not been studied rigorously in that condition. They've not been approved by the Food and Drug Administration for that purpose. We really, they're used what we call off-label, which is not unique in pediatrics. We do that in many other conditions. But we really have not investigated what the medical consequences of that are. We already know of many things that occur at the time of puberty that are very important. For example, improving the density of one's bones that'll protect them from osteoporosis later in life. It's very critical that puberty occurs

for that to happen. So the claims that are made for using puberty blockers in children with gender dysphoria are multifold. You know, the claim is made that it gives some information about in diagnosing the condition that when somebody starts going through puberty and their body is changing, some children will experience worsening of the dysphoria. It's an unwanted change for them. And that by halting that puberty, we can alleviate that discomfort that one experiences. We'll give them a little bit more time to sort through some of the issues of their gender identity. And it's also claimed that it's safe and fully reversible. And I can say quite a bit about each of those claims. I've already mentioned the safety issue because it's not been studied. So it's really erroneous to say that we know that it's safe. We don't have the information right now

to really say that. And we do have things like bone density that are clear risks. There's emerging data right now about the effects of those medications in normal brain development as well. We know that the human brain is not fully developed. By the time one reaches adolescence, it actually continues into the early 20s. There's many things that are different in the adolescent brain that lead to very clear observable behaviors that any parent would recognize as far as impulsivity and risk-taking behaviors and the like. But there's also questions about the organization of the brain and memory and spatial processing that there's really not good evidence right now about whether there

are effects there. And then, you know, the question or the statement that it's fully reversible needs to be unpacked just a little bit. And I hope we have time to do that. So, what we're talking about is a developmental process. So, what one means by saying it's fully reversible is that if you give the hormones, the puberty blockers, you'll shut the signals down. And if you stop giving that drug, those signals will resume. That part is true. Yet you're blocking a development process that is time dependent.

And so that, again, puberty is only one component of the changes from childhood to adulthood. And there's many other things that are going on socially with the peer groups and term adolescence. So if you halt that process and then resume it, you know, four or five, six years later, you can't turn back the clock. You've actually impacted the normal development of that child. And all of the consequences of that have not been fully explored. So we cannot say that it's fully safe. We cannot say that it's fully reversible. And all of these claims. And then the other concern that we have is that, again, coming back to this understanding that the majority of affected children will have a realignment of their gender identity with their sex, their biological sex. How much is this locking in by suppressing puberty, locking in that transgender identity and really actually pushing them down that path that at some point may become irreversible. And there is data out there.

There's published data in some of the few studies that have been done in this area that rather than having this usual desistance rate, in one study, for example, every single subject in that study went on to get cross-sex hormones, which is a very different outcome. And I know some people argue that the people entered into that study were well-vetted and that they were just the ones that were going to go on. But really, there is really no biochemical test or any way that we can determine of those children that experience this condition, which of them will fall into the roughly 85% that will have the

realignment of their gender identity with their sex and the small percentage that will have persistent experience of that gender identity. So again, many problems, many questions, and this really just needs from a medical, to be discussed openly and not – it's part of the normal process that we do in other conditions where we do operate in pediatrics with – sometimes with limited information. But we're always willing and really need to, as physicians and scientists, question what's being done and design the proper studies that need to be done to answer those questions and everything you've said so far say in the last five ten minutes about blockers in general is this something that would be fairly basic knowledge to anybody with a degree in endocrinology and if so um what percentage of endocrinology it's not that you have a survey you've done but i mean um if this is kind of basic endocrinology then why are is it so widespread that the blockers would be freely given i mean is i and i and i i want to weigh all the possibilities you know but one possibility

could be there's just so much ideological pressure that people who know better otherwise are just saying, well, I don't want to lose my job, my degree, you know, I'll just go with this. I'm a little, you know, deep down, I don't feel great about it. But is that, yeah, would that be, if I had 10 endocrinologists on here, would they basically say everything you're saying or would they be diversity of opinion? So it's important to note that, you know, many of my colleagues rely very heavily on the Reader's Digest versions, the synopses, you know, the recommendations of professional organizations without really critically evaluating them. I think they're operating under the presumption that they're doing good. I think that the general desire is to help these children. And what they're continually being told is that this is the only way to proceed forward or that it is beneficial and haven't had the opportunity to actually look

at the data. It's even more concerning than that when we're looking at that. So the guidelines that have been put forward consistently make these claims, you know, that it's safe, reversible. And, you know, it doesn't take a lot from a medical practitioner standpoint to recognize everything that I just said. And if it wasn't layered with the ideology, I think there would be general consensus in that area. But that people have not considered the assertions, they accept what people put forward as evidence. In the published literature, a widespread concern is that many of the papers that are being published are not of the rigor that we expect for other conditions. And even more concerning to me is that many times

in the title or the abstract of the paper, conclusions will be stated that aren't even supported by the data that's in the paper itself, or at least can be questioned. Or, you know, no study is perfect. All studies have limitations. Many times the authors will list what those limitations are. How you take that information and apply it to your medical practice is critically important. And that scientists as a whole are generally skeptical. They really constantly question what is being said. Unfortunately, the way medicine is practiced these days, that many people don't delve that deeply into the literature itself. They're not prepared to be critical or at least question what is being said. But I think as physicians, we generally want the best for our patients. That's why we do what we

do. We do want to alleviate suffering. We want to minimize risk and maximize benefit. If we're true to that calling, we have an obligation to be able to look more deeply into what's going on. And again, we do this in other areas. And the challenge is to do this in this particular area as well and be willing to have that dialogue and not be dismissive of it out front. be dismissive of it up front. Or, you know, to conduct a research study, the traditional way we do research is we try to be as unbiased as we can. I think the reality is that you have to acknowledge that there are underlying biases in everything that we do. But we start with what we call a hypothesis. And we try to look at the evidence, you know, for or against that hypothesis. And we try to look at the evidence for or against that hypothesis. In fact, the way that the research is usually stated is called the null hypothesis. We start with an assumption that there is no difference in a treatment, and we look for evidence that disproves that to show that

there is. Many of the papers that are being published in this area are starting with a conclusion and then looking for data to support that conclusion. And they're quite biased in the data and the presentation of the data that's there, even by looking how they're conducted. So again, it's a problem within our profession. I think it's a problem that could extend well beyond the condition of gender dysphoria if it's applied more broadly. It's a disservice to the patients that we treat and leads to the potential for proposing therapies that are either not helpful or may, in fact, be harmful. There actually is a very long history in medicine of things that we used to do thinking

that we're doing good. And you can look back to the examples of, you know, bloodletting and frontal lobotomies, you know, as examples. And I'm not back to the examples of, you know, bloodletting and frontal lobotomies, you know, as examples. And I'm not trying to say that these are the same conditions, but we learn as we go along and we're willing to look at the data. And we, especially in areas where we have so little information or where the quality of the information is so limited or poor, of the information is so limited or poor, we have all the more caution. And let me just emphasize this. When we talk about those endocrine society guidelines that were published in 2009 and revised in 2017, within the guidelines themselves, they acknowledge the poor quality of the evidence. They rate it on a scale, you know,

from very high quality evidence to very low evidence. And nearly all of the recommendations that were made in those guidelines were based upon very low evidence. And by definition, that means that there's a high likelihood that as new information becomes available, that the recommendations will change. Some of them are based solely on what they call expert opinion and no data at all. So that, you know, physicians should be cautious in doing this. And there's also a long history of clinical practice guidelines that have been revised and many times where the recommendations are 180 degrees different than what was previously recommended. I can give an example. You know, giving hormones to postmenopausal women, you know, is one great example of that.

So, you know, again, in that theme, I think that contributes a lot to where the medical profession stands. So just to sum up puberty blockers. So their puberty blockers might be given as young as 8, 10 years old. Is that roughly 10 to 12 maybe? And so if somebody is experiencing gender dysphoria, all the studies show that an overwhelming majority, the dysphoria relieves itself after maybe even by means of going through puberty. And yet you mentioned that even a study that people who are who go on puberty blockers, almost all of them were ones that he was like 100 percent ended up going on to cross sex hormones and pursuing medical transition. So that those are two very divergent statistics, you know. And yeah, I'm sure that's

interpreted different ways. So let's move, I guess, to cross-sex hormones. So if somebody goes on blockers, overwhelming majority will end up going on cross-sex hormones. So can you explain what cross-sex hormones are and what does the science say about the risks and benefits of that? are and what does the science say about the risks and benefits of that? Happy to do so. So what we mean by cross-sex hormones are, you know, for example, giving testosterone to a biological female that desires to have the bodily characteristics of a male or giving estrogen to a biological male that desires to appear female. male that desires to appear female. And it's important to know that both males and females have both hormones. So all men have both estrogen and testosterone, and all women have testosterone

and estrogen. It's the relative amounts of those hormones that differ. And we have many conditions that we treat as endocrinologists where those hormone levels are inappropriate for one's biological sex. A great example of that is the treatment of too much androgen or male hormone testosterone in females that have polycystic ovary syndrome. that have polycystic ovary syndrome. And very well documented that there are very significant risks as far as cardiovascular risk, metabolic risk associated with that. And the difference is, you know, what the patient's desire is. It's not the difference in what the physiological or pathophysiological effect of those hormones are going to be. So if you give testosterone to a biological female, you will have impairment of the normal functioning of the female reproductive system. So the ovaries will not function as they normally do. Fertility will be impaired. You'll

get virilization, so growth of hair in places where you are desiring to have that to occur. And you have a whole host of changes induced. So these hormones themselves act throughout the body. They don't just act on the reproductive system. Males and females genetically being determined at the time of fertilization, the differences between males and females occur in every nucleated cell of the body. And the programming of those cells is geared toward what would be expected for that biological sex. So giving testosterone to a female is not equivalent to giving that same hormone to a male and vice versa. And so, you know, as we think about the way that these hormones are given, many times, for example, in females, the desire to appear as males,

they're achieving testosterone levels that are orders of magnitude higher than they would ever see, even in conditions like polycystic ovary disease, and really reach the level that we would see in androgen-secreting tumors. So what are the consequences of that? Some of them we know, some of them we're still trying to unpack, and some of them we're very likely to discover down the road, you know, are going to be very significant. So there's clearly changes that occur. And for example, I'll just give you a couple of them. It's very well known if you give estrogen to a biological male, that you have about a five-fold increase in incidence of stroke, which people can die from, and they can have significant neurologic complications of that

that are going to be lifelong. We know that there's an increased risk of metabolic changes, including insulin resistance and diabetes, in giving these cross-sex hormones. And many of the outcomes as far as heart attacks leading to death are going to take many years. And so since we're starting these in children at a young age, we haven't even reached the point where we're going to fully understand what's going on. But already the information is coming out that they're not safe in that respect. There's a lot of desire to make the argument that they are safe, and it's not unexpected. So in any medicine that we give, there's going to be risks and benefits. Really, the question is, are the risks acceptable in relation to what the

benefit is? And the argument that's often made is that the if they don't receive these hormones, they're going to commit suicide. So then, you know, they're going to be dead. And so therefore, we can tolerate all of these other outcomes because they're not committing suicide. You know, the phrase, you know, do you want an alive daughter or a dead son? You hear that a lot, actually. I can hear somebody saying, yeah, I understand the risk, but there's things we do to fight cancer and we understand the risk. But I'd rather not die of cancer. So I don't mind having other health side effects. Can you speak to the kind of like suicidality versus the health risks and the mitigation there? This is another example of, you know, a desire, you know, to do good by not really critically evaluating what the evidence is. So really in treating children, we do not have that

long-term data. It does not exist right now. The largest study that's going on right now is what's called an observational study. So these children are being treated and they're being followed over time to see what the outcome is. They really don't have any hypothesis. They're just trying to figure out what's going to happen. Where we do have evidence is in the adult population. So people that were started later, you know, after they've gone through puberty and early adulthood or later. And there's a couple of very important studies that have come out that really need to raise questions about whether what we're doing is truly beneficial in that regard with suicide. One of the ones that is often quoted is a Swedish study that was published in 2011. The Swedish healthcare system and the government itself is

such that they collect an enormous amount of data on every single person in the country, so that it's not a biased sample, which is another problem with many of the research studies that are done. So we get a population-based sample, and they looked several decades after affirming interventions were performed, so both cross-sex hormones and with or without surgery, and looked at what the outcome was. Now, this wasn't a controlled study, so that it is not possible from that study to say whether that intervention changed what the outcome would have been otherwise. But what the data shows is that the rates of completed suicide are still 19-fold above the background population. So what one can say with confidence is that it didn't fix the problem.

There's still ongoing issues. Now, what many people will say is the reason for that is that they weren't able to socially pass as the desired sexual appearance, and they had many areas of social stigma. And those are reasonable hypotheses. We can ask those questions. But in the end, that data does not show that it fixed the problem. So, you know, this claim that it's going to prevent suicide is not supported by that information. A more recent paper came out where they looked at mental health outcomes after cross-sex hormones and surgery. And this came out just in the past year.

The conclusion of the paper as it was published, it was a paper by a lead author named Brandstrom, was that surgery, gender-affirming surgery, improved mental health. improve mental health. When the data was analyzed, it was clear that there were many problems with the way the data was analyzed. Now, even before saying that, they claimed in the paper initially and showed that the cross-sex hormones themselves didn't affect mental health. So that was already shown not to be beneficial. because of challenges by many different investigators who looked at that data. They reanalyzed the data. They didn't retract the paper. They just made the claim that they probably overstated their claims.

Were you one of the ones? I know Will Malone wrote a critique of it, and I think you did too, right? Or several endocrinologists. Several people did, and not all of them got their critiques published. But in the end, what that study showed is that the affirmative approach did not change. I talk by affirmative approach. Cross-sex hormones in gender-affirming surgeries did not alter mental health outcomes in the patients that were studied. So basically, it showed that it wasn't having the benefit that they were purporting that it had.

Now, those are only two studies. There's other studies out there as well. And there's a need, you know, to be very rigorous in looking at this data. Another interesting observation is that, again, because these are not controlled studies, comparing patients that have other issues unrelated to gender dysphoria and what is the rate of suicide by depression alone, independent of gender dysphoria or some of these other comorbidities that we have. And when you actually are objectively looking at this patient population, they're at very high risk of attempted and completed suicide just by having depression and anxiety. And so, and then, you know, trying to sort out how much of that psychological or psychiatric comorbidity preceded the gender identity. So it's not really established, you know, which is the chicken or the egg is the way that we often say it. You know, a lot of questions that can be asked about what's underlying that. And then that leads to a corollary, you know, a question, you know,

that what is the best way to approach the depression and the anxiety and the eating disorders and all these other things that are going on? And is that sufficient to be able to prevent that suicide outcome? So there's many questions that can be asked from a rigorous scientific standpoint. There's data that's already available that indicates that this whole question of suicidality is not necessarily dependent upon affirmation. There are really an absence of rigorous studies that are being done looking at modern psychological approaches. And again, one of the reasons why that is, is that there are some that make the claim that psychological approaches are harmful and they don't work.

And they make that categorically by citing papers from decades in the past using outdated psychological methods, many of them merely case reports. And many of those actual studies that they cite do show benefit for some patients. They dismiss that completely. They just say it's categorically harmful and not helpful. What has not been done is to apply modern approaches to psychotherapy. And again, I'm an endocrinologist, but know enough in treating other things like anxiety and depression in my patients with diabetes, for example, you know, to know the benefit of being able to do that. Even to go so far as to when a patient comes in requesting these interventions, to explore in detail all of the underlying psychosocial dynamics that are going on, all of the preceding components of psychological health, you know, as, you know, contributing to this desire to receive this intervention is not given the weight that it

normally would or should in these conditions. And there's, that's a great overview. And I've seen it happening, especially in Canada, in the US and in Australia and other places where any kind of psychosocial attempt or psychoanalysis, psychological attempt to address the dysphoria is being labeled as conversion therapy. labeled as conversion therapy and so you have policies being enacted i think some are even put in a place to where you'll have the phrase you know it is illegal to try to say change somebody's sexual orientation or gender identity those are two very different things um i mean another way of saying change someone's gender identity that you could say the same thing in different ways saying helping somebody to live in their body except their body which in every other field that i'm aware of is what we what we do like if somebody has some kind of body dysmorphia i know the broad category but we try to address we we try to help them live into that gender dysphoria is the only one where that i'm aware of where it's it's it's the exact opposite is is true

in some attempts you know can you i mean are you seeing that that that kind of subtle correlation between sexual orientation and gender identity change being labeled conversion therapy and i don't know how this is being passed because this is these are very it seemed very different to me but um yeah in in many respects it's not so subtle i think it's a it's a directed you know attempt um and again you know it's important to be very precise in the words that we use uh and to be accurate in what we're doing and i think this this is certainly the people that have underlying ideological desires want to be able to use that language in a way to achieve a desired outcome. You know, what is being conflated are things that were done in a different condition

in a different era. I think that when using using even using the word conversion therapy denotes many things that I think all physicians, you know, would say, you know, that that's approaches that that nobody would support. That's very different than the psychological investigation and support for people have gender dysphoria. for people who have gender dysphoria. And really, I think it is an intentional use of that word, and it's an intentional desire to conflate different conditions to be able to really suppress the conversation that needs to go on. You may know that I use the term reparative therapy. Even that is – what are we actually trying to do so that if you talk about converting, we're talking about what one's identity is of their gender, of who they are as male or female in relation to their biological sex. So one could, you know, make the argument of in the opposite direction that by altering the appearance of the body, one is converting oneself, you know, to a different phenotype or appearance. So I think there, you know, I think you touched upon things that are out there in the dialogue. And this is where from the really important scientific and medical discussion where we need to be very objective, we need to really maintain,

you know, focus on what our goals are in the area of best medical practice to really try to, at least we need to acknowledge where the biases are, but expose the ideology that's behind this, because it's not helpful in the dialogue, so that people can disagree about the nature of the human person from a philosophical or theological standpoint. But what we're talking about here is what is best medical practice? What are we going to be able to do to have the best benefit for the individual that comes for our care, minimizing the risk and maximizing benefit. We have just a couple more minutes, Paul, and I don't want to keep you past the hour, but can you give just a last word of advice to parents? I know there's probably a lot

of parents listening to this that have kids that are maybe identifying, exploring, or maybe wanting to get on hormones or whatever. What would be your advice specifically to parents who are in this situation? That's an excellent question and a very important way to kind of wrap up this discussion because very frequently parents are seeking answers. I mean parents in general, in loving their children, want to, parents are seeking answers. I mean, parents in general, in loving their children, want to do the best for them. Many of them will have very significant questions about what is being offered as far as the best treatment. They'll intuitively have reservations about that. They're often not in a position of knowledge or authority

to really challenge or question what their practitioners are telling them. I think just having the discussion that we're having today, I think is helpful to at least bring to the surface, bring to light that there are so many questions that are going on. The way it needs to be presented to parents to be very true to what we're actually doing is we're engaging in an experiment, a very large experiment with an unknown outcome. And in other areas of medicine, you know, when we engage in experimentation, we acknowledge that and try to put up safeguards, you know, to really help. Now, from the parent standpoint, you know, I can only reinforce what I think most parents will do. I mean, you know, to really, even though

they're confused, they're anxious, they're wanting to do the best for their children, to love their children, to accept them unconditionally for who they are. And as any parent would do in other areas, that doesn't mean they can do anything that they want. Parents in other areas will set very clear boundaries. They'll have conversations about what is acceptable and not acceptable within the family. They'll have conversations about what is acceptable and not acceptable within the family. There are things that parents will say no to when a child desperately desires, you know, to have, you know, still seek out help that will have long-term benefit for them. Paul, I just can't thank you enough for all of this, a lot to digest. And I'm going to post these studies in the show notes.

They are important, the ones you mentioned a few minutes ago. So, yeah, thank you so much for sharing. And many blessings on your continued work and, yeah, wisdom in this really important area. Well, it's my pleasure. And thank you.