Hi, I'm Wendy Zuckerman and you are listening to Science Versus.
Before we get started, this episode discusses suicide and self -harm a little bit.
So please take care while you're listening and we'll put some resources in the show notes.
Today on the show, kids who are transgender.
It's a topic we've covered before, but there's new research and you battle amongst researchers, and a new election, Which is all putting transgender health care into the spotlight like never before.
Texas, now the largest state to block gender -affirming care for transgender...
Good morning. Idaho and Indiana are officially banning gender -affirming care for transgender youth.
So called gender -affirming care, ridiculous.
If you're forcing a trans child to go through puberty when they are trans, that is tantamount to torture.
Some politicians even want to make it harder for kids to do things like changing their pronouns or names to fit their gender.
And they say that all of this talk of being trans, it's just a phase that they'll grow out of.
And so all of this politics has been bubbling away.
But then, just a few months ago, a nearly 400 page scientific report for the UK government called the CAS Review came out.
And it kind of sounds like it agrees with many of those politicians.
It said that supporting a kid who's trans could actually be harmful for them, and that the evidence behind medicines like puberty blockers or hormones, which are sometimes given to trans teens, is basically garbage.
Well, they called the evidence remarkably weak.
The report has found no good evidence for giving puberty blockers to adolescents.
These clinicians gave puberty blockers to these children, but what is that if not experimenting, it is a medical scandal.
In the UK, the government just announced an emergency ban on puberty blockers.
So today on the show, we are diving back into this topic to find out what is going on, And what is the new science telling us about, one, if your kid says that they want to use different pronouns or change their name, what should you do?
Two, is the evidence behind puberty blockers and hormones actually crappy?
And three, what's the chance that this is just a phase that your kid will grow out of?
With more and more kids coming out as trans and gender diverse, the stakes of getting this right a higher than ever, and it's all coming up just after the break.
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Welcome back. Today on the show, we are asking, when a kid is trans, what is the best thing that we can do for them?
Should we let them change their name and pronouns, give them medicines?
To help us wade through the research here, we have Senior Producer Beryl Hord. Hey Beryl.
Hey, Wendy. Oh, my gosh.
When this cast report first came out, you know, this scientific report, I pretty much called you right away, right?
And I guess I'm just like, did we get the science wrong here?
Because last time when we reported on this several years ago, I mean, we were basically saying the exact opposite thing of what this report has found, right?
I know. It was like, what?
We got this all wrong?
What did they, like, in a nutshell, you read that 400 page report?
I didn't read, like, all of Appendix 6, but I read a lot of it.
Did you read, did you read Appendix 5?
I think I may have. I think that was a good one.
Okay, good, good, good, good.
All right. So as you were reading, as you were reading, what did strike you?
Well overall they just kept saying that, you know, the evidence is really weak for all of this stuff, for puberty blockers, for hormones, that we just like don't have good research on a lot of this stuff.
Okay. So, so let's start, not with medicines, like puberty blockers and hormones, we're going to get into all of that.
But first, let's start with actually kind of the first thing that your kid might need to do.
It's called social transitioning.
So this is a situation where you've got a kid saying, you know, don't call me by a girl's name because I'm a boy.
Don't put me in a dress.
Don't use the pronouns.
She, I'm a boy, use he.
And when we talked about this last on the show, it seemed like the science was pretty clear.
Like, that if your kid wants to do this, you should support them in doing that.
Yeah. Okay. But it's been a couple of years, so what is the research telling us now?
Yeah, so this was something that really surprised me when I read the cast review, because they were basically like the science here is mixed.
And they even pointed to some research that really seemed to show that if you let your kid do this, that it can actually make things worse for them.
It could be harmful to their mental health.
Oh, wow. And that was just really different, like you said, from what we thought when we last looked at this.
Yeah, so what's the truth here?
What do you think the science is?
Yeah, so they really kind of pointed out one study in particular, which seemed to show that this could be bad for kids, so I wanted to start there.
So what these researchers did, is they surveyed thousands of trans and gender -diverse adults, and then they asked them about when they socially transitioned and also about their mental health.
And what they found was that for the people who said, like, I socially transitioned when I was an adolescent, they were more likely to have attempted suicide at some point in their lives, compared to people who socially transitioned as adults.
And the caste review says that this basically means that social transitioning could be bad for adolescents.
And that's what the study concluded, or the caste review?
Well, what was weird was that when I looked at the actual study, they said it wasn't actually the social transitioning itself that was making these kids feel crappy.
It was the bullying that can come along with that.
Oh, so they could tell from the data that it was the kids who got bullied more.
They were the ones who were more likely to be attempting suicide years later.
That's what was driving this increased risk in suicide attempts.
The paper, so they said, social transition itself is not harmful.
But, if you're getting harassed, because of it, then that is the thing that can make you feel horrible.
And I actually talked about this with professor Stephen Russell.
He's at the University of Texas in Austin.
Yeah. What that study suggests is that the critical factor there is discrimination and stigma.
We know like a lot of trans kids do face a lot of bullying and this can be really brutal, like especially if you're trying to figure out all this stuff when you're, when you're pretty young like around like middle school.
That's scary being the target of homophobia and transphobia not when you're 24 but when you're 14.
And you've got to deal with that, which is a totally different story than when we used to come out when we were in our 20s and 30s, and figure it out then.
We're all our nastiest little turds when we're in middle school, right?
Yeah, exactly. And so I talked to Steven about what we make of all of this.
How does it make you feel when you see that kind of study being used to say, you shouldn't let your kid socially transition when they're young, because then they'll get bullied more that will increase their suicide risk." Yeah.
Well, there are so many layers of that, and I understand the anxiety.
I understand where it comes from.
I totally get it. I raised a gay kid.
I was not interested in someday's safety for him.
I was interested in safety that afternoon, like sending him to school that morning and him being safe then.
So all of my great ideas about averages and statistical properties and who cares.
What about my kid today?
I bet there are a lot of parents who have this anxiety, and now we have this study, sort of suggesting like if a kid does want to socially transition they should wait, until you know, at least after middle school, maybe after high school when it's less likely that they'll get bullied, what do you think?
I mean, that's the question, right?
Like would it be better to kind of discourage this or should we just like support kids anyway.
and Steven actually did this study that really helps answer this.
It focuses on this one specific part of social transitioning which is changing your name.
So this is like, if your parents named you Michael but you're realizing that like no actually I am a girl, you probably want to change your name, right?
And so this can be a big step and Steven wanted to look at what might happen after someone decides to do this.
So he did this study a few years ago.
And so, this was before we were talking about pronouns, even, and so I just thought, well, we should just ask about whether kids can use the name they want.
Oh, so how did he study this?
Alright, so he surveyed almost 130 trans and gender nonconforming teens and younger adults, and he asked them, do you have a preferred name that's different from the name that you were given at birth.
And if they said yes, then the survey asked them, and this is the important part, how many people in your life actually use that name?
It's like, well, are you able to use that at home, at school, at work, and with your friends?
And he also asked them about their mental health.
And he wanted to know if there are people in the person's life that are using that name, is their mental health better?
And he wasn't really expecting that he'd see much in the data, but then his colleague knocked on his door.
She came in with the results and was like, Steven, yeah, I can believe this.
Oh my gosh. Oh my gosh.
It worked. It's like it's real.
The people who said, yes, I get called my chosen name in at least just one place, that lowered their risk of suicidal behavior by 56%.
Oh my gosh. 56%. I talked to Steven about that.
Yeah, it's dramatic.
So it could mean the difference between life and death for someone?
Well, yes, absolutely.
Absolutely. The more people in their lives used the person's chosen name, the more their risk for suicidal behavior dropped.
That's so... that's such a dramatic finding.
I... I... like... I don't know.
It's been surprising.
I don't think it is, actually.
Like, like, Stephen was like, no, this makes sense.
I feel like it's that amazing possibility to be seen or heard, like, and maybe for the first time.
You know, it's so deep when you think about it that you can imagine that if you're a trans kid that feels like Susan is not who you are but Steven is, and you get to, there's at least one place where people will call you Steven, it's gotta be amazing.
When kids can use their name, it transforms them.
Another study has actually since backed that up.
They found something really similar.
And then we also have a study that looks at younger kids who socially transitioned when they were around seven years old.
And that one also found that the kids had better mental health after they socially transitioned and the researchers thought that this would just, like, generally be true of kids that are in support of families.
So, like, zooming out, it really feels like for a kid who's decided to socially transition and that's what they want to do, the studies say that you should support them.
So then, I mean, it feels like, other than the messiness with the bullying study, It feels like the research is...
isn't that mixed? That it's really pointing to, like, if your kid is transitioning, you should support them.
Why was the cast review so...
so down on this? I mean, they did seem to put a lot of stock in that bullying study.
Um, like, th... th...
that was kind of their big conclusion.
They said that, like, look, when kids get called by their chosen name, it helps them, but then there's the study that finds that suicide attempts go up.
It was almost like those all canceled each other out, and so we just don't know what to do.
I mean, it feels like the actual answer is try to stop bullying and then support your kids to socially transition.
Yeah, exactly, and also this idea of waiting until you're out of high school to come out as trans, for some kids, it's just not really an option.
Here's Steven. And I think that what so many transgender diverse people will tell us, just like so many, you know, LGB people will tell us, just like many straight people would tell us.
If we told them not to be straight and just wait, they would tell us, I can't just wait.
It's inauthentic and it's undermining my well -being to just put an entire part of myself on hold for five, 10, 15 years.
After the break, puberty blockers and hormones.
We're giving them to some trans kids, but is it the right move?
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Welcome back. Today we're looking at the new science on transgender health care.
And now we're going to go to the most controversial part of this debate.
We brought Ada Chung into the studio to discuss it.
She is an endocrinologist and head of the Trans Health Research Group at the University of Melbourne.
Alright, we're going to jump right into the controversy.
We've been looking at your Twitter and it seems like you're a Swifty.
Oh yes, of course. So what do you think of the new album?
I love it. Um... Yeah I unashamedly love Taylor Swift. I can't get into it.
I love that people love it, but I cannot get through it all.
Wendy, how do you not tell her Swift?
Come on. She's fine.
I feel nothing in my soul when I listen to it.
So, Meryl and I chatted with Ada together and we're here to talk about some of the medicines that we're using for trans kids.
Now, Ada treats trans adults.
So she gives them hormone therapy, but she knows a lot about this space in general.
And so let's start by talking about the first medication that a trans kid might go on.
And I talked with Ada about the basics here.
Okay, so these are called puberty blockers.
So they might start these when some of the first signs of puberty kick in.
So think when the kid is like around 11.
What they do is they block the pituitary gland hormones so that it pauses puberty so it's temporary it's a pause so the idea is that you temporarily stop your body from going through puberty because if you're, let's say, a trans girl assigned male at birth you may really not want to go through male puberty that would mean growing hair on your face having your voice drop on the other hand in a trans boy we can prevent the development of breasts that otherwise might require invasive surgery down the track to correct.
OK, so in our past episodes on puberty blockers, we've mainly talked about the side effects.
And these drugs are pretty safe.
They've actually been used for decades for something called precocious puberty, which is when kids go through puberty early.
And we've never really dug into this question of, do they improve mental health or not?
So Merril, what did that Big Science Report from the UK say about this?
Yeah, they did not think the evidence was great.
They came down pretty hard on puberty blockers.
They said that, like when it came to whether or not being on puberty blockers helps kids' mental health, the results were insufficient and inconsistent.
So what is the evidence?
Why did they think that?
So, okay. One of the things that they point out is that like, we don't have the highest quality of evidence for puberty blockers.
So like we all know what you'd really like is a randomized controlled trial, so that's where you get a group of people, split them into two groups, one gets the drug, one group doesn't at random, and then you compare the two.
Love a randomized controlled trial.
Yeah, right? Love them, but a lot of researchers have said that that would basically be impossible for this area because there's no kids that would want to sign up for a trial where they might get a puberty blocker or they might get a placebo and then their bodies will go through all these irreversible changes.
But like we do have these other studies, so like observational studies that look at kids who get puberty blockers and then checks like what happens to their mental health after they go on them.
But what the CasReview noticed is that the results are kind of mixed.
Oh. And that's true.
So some of the studies will find that when they look at like trans -adolescence mental health after they go on puberty blockers, it'll get better.
But then other studies don't find an improvement.
I can see then why people have been questioning these meds.
Yeah, I mean, that's what I thought too when I first looked at this.
But then I spoke to researchers about it, like Cal Horton.
So they're a research fellow at Oxford Brooks University in the UK, and they've done a bunch of studies on trans kids and their families, so I asked them about puberty blockers.
One of the things that surprised me when I read it was this idea that there's not good evidence that they improve mental health.
So the purpose of puberty blockers is to block puberty.
They are very successful and effective at blocking puberty.
what they're meant to do is stop wellbeing decreasing.
So they're preventing something from happening, and what we would hope to see is just a kind of keeping on the same even, just mental health being as it was before puberty.
Yeah, so okay. It feels like what the CAS report is saying is that they're kind of expecting kids to get this big boost to their mental health after they've gotten puberty blockers, and sometimes we do see that.
But the thing is like what you really want to know is like what happens when people don't get puberty blockers at all right?
Yes, because that's ultimately what would lead To potentially depression right like if you don't get the blockers And you start growing boobs or getting a period and you are a boy yeah people, you know yes Okay, so do we have a study then that?
Looks at the kids who did not get them like and what happened to their mental health?
We have a study like that Oh, OK.
Great. So, OK, they looked at mental health of over 200 trans kids who were around 14 years old and they were not on puberty blockers.
So probably had started to go through, you know, some some puberty that they didn't want.
OK, and they had pretty terrible mental health compared to like just cisgender kids who were around the same age from the same population.
They had more stuff like self -harm, suicidality, depression, anxiety.
It looked like they were really struggling.
Yeah, that's awful.
So from that, like, we could see that kids, trans kids who are not on puberty blockers, their mental health is not great.
And then if you look at the kids who were on the puberty blockers, they were doing better, like they were doing better than the kids that didn't get them.
And in fact, they were actually doing basically as good as the kids who weren't trans.
Okay, so all of this seems to be saying that if you don't let kids access puberty blockers, like the exact situation that is happening in more and more states around the US and now in the UK as well, those kids have the worst mental health compared to everyone.
Yeah. That's where we're at.
Yes. This stuff really matters.
So, now on to perhaps the most controversial side of all this, which is giving hormones.
So, for lots of trans folks, after they go on puberty blockers, if they want to then physically transition, they might take hormones.
Right, yeah. A lot of trans people might go on to take testosterone or estrogen to help their bodies match their gender better.
Yes. Yes, exactly. And so hormones, that's actually a big part of Ada Chung, our Swifty and Endocrinologists research. So she just did this randomized political trial.
Yes. So she got more than 60 trans and gender diverse folks who were mostly in their early 20s.
And she gave half of them testosterone therapy immediately while the others were on a waitlist. And then, after three months, she looked to see what was going on with their mental health.
So did the group that got hormone therapy do better?
And here's what she found.
We found a marked reduction in depression and, most significantly, this marked reduction in suicidal ideation.
So half the people had complete resolution of their suicidal ideation.
Whoa! From a result of testosterone therapy.
yep from that first three months of testosterone therapy.
That's huge! Huge! How did you feel like?
It was really affirming because this is mirroring what we're seeing clinically.
Testosterone therapy for someone who has the agenda dysphoria can you know save lives.
And I can just sort of see the um I don't really like the emotion in your eyes which I don't get from when I talk to most academics about most things um can you tell me a little more about how you're feeling as you're thinking about your patients.
You know, I see patients who, um, have quite severe mental health conditions.
I see people who are struggling, you know, in hospital with various conditions and then they affirm their gender and then I see people thrive.
People are happy and it is a pure joy when I see people so well.
And although ADA's research was on people who were mainly in their 20s, there is another study which involved more than 150 trans teens getting testosterone therapy.
And it also found that their depression and anxiety scores dropped after the treatment, which ADA says is exactly what you'd expect.
Right. I personally, I actually think the effects of testosterone on a 22 -year -old compared to an 18 -year -old are pretty similar, or even a 16 -year -old, like it causes the same physiological effects.
So I would expect similar effects of testosterone therapy on gender dysphoria, on psychological functioning, on suicidality.
It's also important to point out that some of the benefits that Ada saw in her study We might have been due to the placebo effect because there wasn't a placebo control.
And also, Ada's study was specifically on people taking testosterone, right?
So Merill, what do we know about trans women taking estrogen?
We do know that with estrogen the effects on the body might be a little bit more slow or subtle, at least in the beginning.
Because like with testosterone, you can start getting facial hair pretty much like, you within months, pretty quickly, but with estrogen, it could take years to grow breasts.
Yes, I remember my own, those titties don't grow out of nowhere.
No, exactly, it takes like years.
You got that awkward budding thing going on.
Okay, so do we have research on estrogen and trans teens?
Yeah, there is some, so there's this study that looked at like young trans feminine people, So basically, teens taking estrogen and they tracked them for two years and still didn't see like clear improvements to their mental health.
Oh, right, right. And the researchers said it could be because they just didn't follow them long enough.
Like, maybe they were actually still in that like awkward budding phase.
And we're not really sure like why it didn't help them because we do have a handful of studies in adults that has shown that estrogen therapy can help.
Even in the Cass report's review on hormone therapy most of those studies showed mental health benefits to younger kids, adolescents, taking hormones.
OK, so the last thing that we want to look at, which is this big question that's kind of like sitting like an elephant in all of this talk around trans kids and how to best help them, which is this idea that they're going to regret any medicine that they've been on, that this is just a phase.
Yeah. I remember from previous episodes that we've done on this, we would talk about how there are these strands of evidence pointing to an answer here, but we really wanted more data in this space.
Yes. Now it feels like we finally have studies on this question of how many people identify as trans and then stop identifying that way later on, including one that just came out a couple weeks ago by this guy.
Hi there. Steven Russell.
So he just did this study where they followed hundreds of people.
They were 15 to 21 years old for over three years and they asked them again and again and again like, how do you identify to see whether their gender identities shifted over time.
And what he found was that it was actually super common to see all sorts of things.
people going from cis to trans to cis, just all sorts of different things.
And I was like, oh my gosh, that's amazing.
And who knew? I'm constantly amazed by the data that tells me how old I am or how out of touch. That there's that much change happening in gender.
And so were you surprised when you saw that there were a big chunk of kids who identified as trans at one point but then ultimately identified as cis by the end of the study?
Yeah, I was. I wasn't expecting as much change.
So, if you took everyone who identified as trans at the start of the study and then looked at what happened, half of them still identified as trans by the end of it, but half of them identified as cis.
Oh, interesting. So then I guess then what does this mean for this big fear that kids are going to be on medicines that they don't need to be on.
Like, is that happening?
Right, yeah. So that's the question, right?
But Stephen looked at that.
He asked everybody whether they were on hormones or puberty blockers.
Great. He saw that while most of the people who identified as trans the whole time were taking hormones, it was actually really rare for the people who started identifying as trans and then later switched to identifying as cis.
it was really rare for them to be taking hormones.
It was actually only one person out of 32.
Oh, interesting. And none of them are on puberty blockers.
And the results from Steven's study were actually remarkably similar to another study looking at this, which came out earlier this year.
So that one was from a pediatric gender clinic in Western Australia.
So in that study, there were 29 people who switched from identifying from trans to cis, and only two of them were on any kind of medication.
I mean, it is fascinating because it does show that when people say things like, you know, oh, they're just kids, this is just a phase.
I mean, for some kids, there is kind of, there is some truth in that.
I mean, saying it's just a phase might feel derogatory, but they're just exploring who they are.
But then what the data is telling us is to take that argument further and to say, like, therefore we should not allow any trans kids to be on medication.
That is wrong. Right, like according to these two studies, at least, that we have, the trans kids that are going on medications far and away, they're not in that exploratory phase.
Like, they are sticking with that identity.
Yeah, exactly. And then, like if we do look at that group of people who are changing things like identifying as transverse and then cis, the vast majority of them are not taking any of these meds, over 90 % of them.
Right. Right. And while that study was on teens, there is actually data from younger kids that seems to show that if you socially transitioned when you're around eight years old, you're much less likely to be switching up your identity.
So, yeah, the data does not seem to be backing up this idea that there's all these people who are, you know, taking these meds and then later not identifying as trans anymore.
Yeah. Yeah. Okay. So then, you know, I feel like the cast review might have highlighted some places where we want more research. More research is always good, but it still feels like if you look at the data that we have it is supporting social transitioning puberty blockers and the use of hormones that's what it looked like to me by the way I reached out to the cancer people to ask them about why it seemed like they like overlooked a bunch of the stuff that we talked about today And they never got back to me.
But the thing is, and so what it feels like to me is that the CasterView has set this really high bar of evidence that we need to show that affirmative care works.
And it's good to demand good quality evidence, but then they kind of ignore the fact that if you don't do any of this stuff, a kid could really suffer.
I mean, that's what we see in the data.
Like when kids don't get puberty blockers, their mental health is worse.
That's right. That's right.
I mean, that's what these...
when people make these arguments of like, the evidence base isn't perfect, so let's do nothing.
Like, they're not able to acknowledge that doing nothing is doing something.
Like you're actively saying no to a child.
You're actively saying like, no, we will not support you.
We will not give you the medicines that you need.
And, and we have evidence that that is harmful.
Yeah, and, and now as a result of this report there are these huge implications for all these kids.
Um, so like, here is Cal Horton there, the UK researcher that we heard from earlier.
It's, it's really disheartening, disheartening is the wrong word. I was kind of, you know, pretty much unable to function for like a week afterwards.
And, and I speak to trans people and I speak to parents of trans kids around the country.
And, you we've all been absolutely devastated by the impact of the cash report, because it was a car crash we could see coming, but we're unable to in any way influence.
The impact it's already having are devastating, and the impacts it's going to have are just heartbreaking, and knowing and caring about trans kids, it's devastating that we've got to where we are, and it's devastating that this harm is being veiled in a banner of evidence -based policy that really cuts to my core because it's not evidence -based.
Yeah and it's not just Cal, other big science -y groups in the space have looked at all this and said, if you follow the evidence, it still leads to gender -affirming care being the best thing for kids, like the American Academy of Pediatrics and the Endocrine Society.
And so yeah, when it comes to this argument that the evidence here is weak, here is, here's what Steven thinks.
I mean we really, we have just started and, you know, for what it is we have really good data.
Rich community samples that follow kids over time.
Using multiple methods from different areas of the world and the country, asking similar questions to come up with the same kind of results, It's insulting to say that it's weak.
It's not weak. So we know a lot.
Thanks, Meryl. Thanks, Wendy.
That's science verses.
And how many citations are in this week's episode?
We have 81 citations.
And if people want to see them, where should they go?
To our show notes. And then follow the links to the transcripts.
And we'll also put a link there to our last episode that we did on trans kids healthcare.
And that one, we go in some more detail about stuff like the side effects of puberty blockers and hormones.
Yes, and on Instagram this week, which is science underscore V S we're going to have a video of me chatting to Dr. Aida Chung.
I also pop it on my TikTok, which is at Wendy Zuckerman.
See you, Meryl. Bye Wendy.
This episode was produced by me, Merrell Horne and Wendy Zuckerman with help from Michelle dang and Rose Rimmler.
We're edited by Blyth Tyrell.
Fact checking by Iva Dasher, consulting by Rebecca Clang, mix and sound design by Bobby Lord. Music written by Bobby Lord, Bumi Hidaka, and Peter Lenard. Thanks so much to all the researchers.
We spoke to for this episode, including Blake Cave, Dr. Doug Vanderlin, and Dr. Quinnitucket Maclemore, and a very special thanks to all of the trans folks and their families that we spoke to.
Christopher Souter, the Zuckerman family, and Joseph Laval Wilson.
Science Verse is a Spotify Studios original.
Listen for free on Spotify, or wherever you get your podcasts.
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See you next week.
