Transgender Healthcare and Experimental Design

Access to gender-affirming medication and hormone therapy for transgender youth have been a subject of endless political debate. A recent WIRED article elaborates on research that indicates that denial of such medical services is a contributor to the estimated 40% of trans people who attempt suicide during their lifetime. However, researchers have encountered many obstacles when designing experiments to examine this connection. For one, transgender people, especially those looking for gender-affirming medication, are hard to come by, and those that have attempted suicide are even rarer. To remedy the latter problem, researchers focus on suicidality, a set of behaviors that can range from suicidal ideation to self-harm. Though this approach has its critics, research has shown that suicidality is a strong predictor of extreme psychological distress and attempted suicide.

The ideal experiment of a clinical trial testing the efficacy of a treatment is the double-blind randomized controlled trial: participants (in this case, transgender people seeking gender-affirming treatment) are randomly assigned either treatment or a placebo, and even the researchers do not know who has which treatment. This method ideally eliminates psychological, allocation, and selection biases, but giving potentially suicidal adolescents a placebo is unethical, so RCTs are out of the question. A double-blind is also practically impossible, as it will be obvious to participants and researchers if hormone therapy is taking effect. Participants will be less willing to participate in a clinical trial where they could potentially receive no benefit whatsoever.

Since the RCT is unfeasible, another model researchers can follow is the longitudinal study, where transgender people receiving hormone therapy are tracked over the years, starting at the beginning of their treatment. A series of longitudinal studies have found reductions in suicidality or depressive symptoms in adolescents upon receiving hormone treatment. One of the benefits of this model is that it controls for variance across individuals by comparing subjects with themselves. However, the inhibitory costs of longitudinal studies limit the sample size and time frame, and there is no control group – there is no way to know how these individuals would have responded without hormone treatment.

Another method is the cross-sectional study: examining a group of transgender individuals, some of whom receive gender-affirming treatment and some of whom do not, at one point in time. One cross-sectional study based on a survey of transgender adolescents found that youth who were denied puberty blockers experienced more suicidal ideation than youth who were not, though it is unclear if the ideation occurred before or after the participants would have received treatment. Moreover, it was found that hormone treatment reduced the odds of suicidal ideation and depression, although the frequency of suicide attempts was not affected. The strength of the longitudinal study is the weakness of the cross-sectional study: that participants vary individually, in aspects such as parental support and mental health at the start of treatment. Controlling for the latter is especially difficult because of the complex dimensionality of mental health, but researchers can take measures such as examining improvement in mental health.

These two types of studies have their limitations, but they complement each other. If enough researchers use both methods and produce similar results, the evidence is solid enough to support the hypothesis (the Law of Large Numbers again). RCTs may be a gold standard, but scientists have historically opted for the next best thing in times of crisis.

Ultimately, however, do we really need scientific research to tell us that being denied gender-affirming healthcare is harmful to transgender adolescents? Being misgendered or simply not feeling “right” are detrimental feelings that cisgendered people cannot imagine. Moreover,  anti-transgender legislation is a blatant societal rejection. It sends the unfiltered, explicit message that transgender people do not belong and that there is something wrong with them. In terms of experimental proof, there are plenty of studies about the negative psychological effects of discrimination in general. Even if there were widespread easy access to gender-affirming care, the intense stigma surrounding free gender self-expression would still prove a stubborn obstacle. This is, above all, an ethical argument about inclusion. And, while not 100% foolproof and decisive, science has provided us with even more urgency to address this issue.

mkahmon

I'm a high school student dedicated to stimulating conversation around mental health.

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