https://www.washingtonpos(...)trans-supreme-court/quote:
Look to science, not law, for real answers on youth gender medicine
The Supreme Court will rule on Tennessee’s puberty blocker ban. Science should have settled the issue first.
December 15, 2024 at 2:18 p.m. ESTYesterday at 2:18 p.m. EST
The Biden Justice Department on Dec. 4 challenged before the Supreme Court a Tennessee law that bans the use of puberty blockers and hormones for gender-transition treatments in minors on the grounds that it unlawfully discriminates based on sex.
The court’s decision will be consequential in the 24 states with these restrictions, but it won’t resolve the crux of the debate over pediatric gender medicine: whether, as the plaintiffs argued, the treatments can be lifesaving or, as some global health authorities have determined, the evidence is too thin to conclude that they are beneficial and the risks are not well-understood.
This unresolved dispute is why Tennessee has a colorable claim before the court; it would be ludicrous to suggest that patients have a civil right to be harmed by ineffective medical interventions — and, likewise, unconscionable for Tennessee to deny a treatment that improves patient lives, even if the state did so with majestic impartiality. The issue is subject to legal dispute in part because the medical questions have not been properly resolved.
Multiple European health authorities have reviewed the available evidence and concluded that it was “very low certainty,” “lacking” and “limited by methodological weaknesses.” Last week, Britain banned the use of puberty blockers indefinitely due to safety concerns.
“Children’s healthcare must always be evidence-led,” British Health and Social Care Secretary Wes Streeting said in a press release. “The independent expert Commission on Human Medicines found that the current prescribing and care pathway for gender dysphoria and incongruence presents an unacceptable safety risk for children and young people.”
The uncertainty is the result of scientists’ failure to study these treatments slowly and systematically as they developed them. Early studies from a Dutch clinic seemed to show promising results, but the research started with only 70 patients (dropping to 55 in a follow-up study) and no control group. Treatment results that look impressive in small groups often vanish when larger groups are studied. That’s why the Food and Drug Administration generally requires large, randomized controlled trials of drugs: to ensure that encouraging initial results aren’t mere statistical noise.
Conducting gold-standard medical research on gender-transition treatment was never going to be easy; it would have been obvious to those in any control group that they were getting placebos, making it impossible to conduct a “double-blind” study. Yet researchers could and should have used randomized control groups, gradually expanding a patient population enrolled in systematic clinical research, to rigorously assess effectiveness, refine treatment protocols, and — crucially — improve their ability to tell which patients benefit, since at least some patients who transitioned later experience regret and suffer the fate the treatments were supposed to avoid: a body that doesn’t match their gender identity.
Yet as other doctors began copying the Dutch, clinical practice outraced the research, especially as treatment protocols rapidly evolved. A British study attempting to replicate the Dutch researchers’ success with puberty blockers “identified no changes in psychological function” among those treated.
Some clinicians appear reluctant to publish findings that don’t show strong benefits. The British lackluster results were published nine years after the study began, after Britain’s High Court ruled that children younger than 16 were unlikely to be able to form informed consent to such treatments. Internal communications from the World Professional Association for Transgender Health suggest that the group tried to interfere with a review commissioned from a team of researchers at Johns Hopkins University.
Johanna Olson-Kennedy, medical director of the Center for Transyouth Health and Development at Children’s Hospital of Los Angeles, told the New York Times that a government-funded study of puberty blockers she helped conduct, which started in 2015, had not found mental health improvements, and those results hadn’t been published because more time was needed to ensure the research wouldn’t be “weaponized.” Medical progress is impossible unless null or negative results are published as promptly as positive ones.
The failure to adequately assess these treatments gives Tennessee reason to worry about them — and legal room to restrict them. We have serious reservations when states make decisions about minors’ medical care, rather than leaving them to parents. But in the absence of clear data — and with the possibility of significant publication bias or researchers massaging their results — parents might not have adequate information.
No matter how the court rules, though, the federal government should supply the missing evidence at the heart of this dispute. Randomized trials would be best, though harder to pull off now, since children who are placed in a control group might drop out and seek blockers and hormones elsewhere. Congress should nevertheless fund new research of maximum possible rigor, overseen by scientists who are not gender medicine practitioners. Those studies should set timetables and specify the outcomes to be studied in advance to avoid the risk that researchers will pick and choose what to show the public. Children with gender dysphoria deserve clearer answers.
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