A paper published last month in the Archives of Sexual Behavior makes an important point about the environment in which “gender-affirming” drugs and surgeries are offered to minors. Positive outcomes from hormonal interventions, argues psychiatrist Alison Clayton, the article’s author, may be attributable to placebo effects generated by clinical encounters and the social context in which they take place, rather than to the underlying psychotropic effects of the drugs themselves.
Clayton’s basic intuition makes sense. If you take a teenager in emotional distress and tell her that drug X will solve her problems, while treatment Y will make them worse, and then bring her to a clinical setting where medical professionals repeat that message, it should come as no surprise that the teenager experiences emotional relief when you give her X, or distress when you give her Y—regardless of the psychotropic effects of X. The patient may regard the giving of X symbolically as adults listening to her and empathizing with her inner turmoil. “The ‘Hawthorne effect,’” writes Clayton, “describes the phenomenon where clinical trial patients’ improvements may occur because they are being observed and given special attention. A patient who is part of a study, receiving special attention, and with motivated clinicians, who are invested in the benefits of the treatment under study, is likely to have higher expectations of therapeutic benefits.”
It is indeed the case that promoters of “gender-affirming care” have created what Clayton calls “a perfect storm for the placebo effect.” In the left-of-center media, puberty-blockers, cross-sex hormones and (less frequently) surgeries are hailed as “medically necessary” and suicide-preventing measures for teens in distress, supposedly over having been wrongly “assigned” their sex at birth. Skeptics of these interventions are denounced as cruel deniers of life-saving medicine to youth at high risk of suicide. Meantime, alternatives to drugs and surgeries (e.g., psychotherapy) are denigrated as harmful “conversion therapy,” setting the stage for a nocebo (harmful) effect on those who receive psychotherapy but not drugs.
Clayton helpfully distinguishes between placebo effects in research versus clinical settings. There is nothing inherently wrong about relying on placebo effects in clinical settings, where the wellbeing of individual patients is paramount. The problem is when drugs or procedures that produce placebo effects also carry significant risk for adverse side-effects. In the case of gender-affirming drugs and surgeries, these risks are thought to include, among other things, loss of fertility and sexual function, increased risk for heart disease and cancer, bone-density deficiencies, and cognitive impairment. Understanding both the likelihood and severity of these outcomes is precisely what research is for. Yet the placebo/nocebo effects described by Clayton make it harder for researchers to ascertain the causal mechanisms involved, and therefore the true medical necessity of drugs and surgeries.
If all this was disclosed to distressed teenagers and their anxious parents within an honest informed-consent process, that would be one thing. But parents are frequently told that their choice is between “a live son or a dead daughter,” and that puberty blockers are safe and “fully reversible.” Teenagers, meantime, get told that any questioning of their gender self-identification constitutes a metaphysical act of aggression against their very person and dignity. This makes evidence-based medicine exceedingly difficult. “A medical profession that does little to distinguish placebo effects from specific treatment effects,” observes Clayton, “risks becoming little different from pseudoscience and the quackery that dominated medicine of past times, with likely resulting decline in public trust and deterioration in patient outcomes.”
In effect, gender-affirming doctors and their allies in the media are creating a problem for which only they have a solution. If around 2 percent of teenagers today identify as trans and even half have gender dysphoria, and if, as we sometimes hear, around 40 percent of those with dysphoria are at serious risk for suicide, we would expect to have seen a shocking epidemic of teenage suicides in the years before gender-affirming care was on offer. That didn’t happen. Thus, assuming gender-affirming doctors and researchers are right about their predictions over youth suicide, it’s at least possible, and perhaps likely, that the cause of this danger is the promise, not the denial, of these drugs and surgeries.
Clayton highlights the fundamental bias in the world of gender-affirming research. The “clinical environment” created by gender-affirming doctors and their allies “maximizes the placebo effect,” yet it is this “same environment in which the [gender-affirming] clinicians are researching [gender-affirming therapy’s] efficacy.” In other areas of medical research, such biases would be openly discussed and raise concerns among medical journal reviewers and editorial boards. But transgender medical research, we have come to learn, operates under exceptional circumstances.
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