August 2022
Recently, a friend confided in me that her teenage daughter, who I also know, was going through a rough time. The daughter is an adorable quirky nerd, not at ease in many social situations but who lights up when you get her talking about something she’s really passionate about. Maybe that’s why she’s so comfortable online, where she can bypass the awkwardness of real life social situations and instantly find large communities who share her enthusiasms. She immersed herself in online communities during the pandemic, and became almost obsessively involved in a friendship with an older girl who identified as transgender. Soon, my young friend was convinced she too was transgender. Her parents, faithful Latter-day Saints, were confused and distraught.
I open with this anecdote because I want to establish that my interest in this subject comes from a place of love and concern. I love this girl, I love her parents, I love other friends I have who are dealing with this issue, and I was motivated to learn what is best for them. These kids we’re going to discuss for the next hour–they are all adorable and quirky and infinitely precious, and deserve the best effort we can give to help them through their challenges. This challenge is going to confront us all in some way, either through our families or friends or service in the church, and we need to be prepared with good data, loving counsel, and courageous faith.
My presentation today is going to specifically address gender issues among children and youth. Adults who identify as transgender are in many ways very different, with a different calculation regarding medical risk and a very different issue of consent. For those adults struggling with gender issues, I love you and pray there will be some practical value for you in what I say today, but this will be targeted for the parents and leaders of children and youth.
The Church’s Counsel
The Handbook discusses transgender individuals in Sections 38 and 32.[1] I hope that everyone will read it closely. Let’s review some excerpts:
Doctrine and eternal perspective: “Gender is an essential characteristic of Heavenly Father’s plan of happiness. The intended meaning of gender in the family proclamation is biological sex at birth.” (38.6.23)
Two-way respect: “Those who attend should …[Refrain] from overt romantic behavior and from dress or grooming that causes distraction. [Also refrain from] political statements or speaking of sexual orientation or other personal characteristics in a way that detracts from meetings focused on the Savior.” (38.1.1)
Ordinances: Most Church participation and some priesthood ordinances are gender neutral. Transgender persons may be baptized and confirmed if he or she is not pursuing elective medical or surgical intervention to attempt to transition to the opposite of his or her biological sex at birth. A person who has completed sex reassignment through elective medical or surgical intervention must have First Presidency approval to be baptized. (32.2.8.10) Priesthood ordination and temple ordinances are received according to biological sex at birth. (38.6.23)
Transitioning: “Church leaders counsel against elective medical or surgical intervention for the purpose of attempting to transition. Leaders advise that taking these actions will be cause for Church membership restrictions.
“Leaders also counsel against social transitioning. A social transition includes changing dress or grooming, or changing a name or pronouns, to present oneself as other than his or her biological sex at birth. Leaders advise that those who socially transition will experience some Church membership restrictions for the duration of this transition.
“Restrictions include receiving or exercising the priesthood, receiving or using a temple recommend, and receiving some Church callings.
“Transgender individuals who do not pursue medical, surgical, or social transition to the opposite gender and are worthy may receive Church callings, temple recommends, and temple ordinances.” (38.6.23)
Medical use of hormones: “Some children, youth, and adults are prescribed hormone therapy by a licensed medical professional to ease gender dysphoria or reduce suicidal thoughts. Before a person begins such therapy, it is important that he or she (and the parents of a minor) understands the potential risks and benefits. If these members are not attempting to transition to the opposite gender and are worthy, they may receive Church callings, temple recommends, and temple ordinances.” (38.6.23) I want to interject here that the church is allowing for this prescription, but that’s not the same as the church saying “research shows this to be an effective treatment.” As we will shortly see, it is not an effective treatment. Also, some activists partially quote this passage, or deceptively refer to this passage, to imply the church endorses taking hormones with the intent to transition. This is false. It is very clear that taking hormones *with intent to transition* is NOT endorsed.
Name and pronouns: “If a member decides to change his or her preferred name or pronouns of address, the name preference may be noted in the preferred name field on the membership record. The person may be addressed by the preferred name in the ward.” (38.6.23) This section is confusing, because it brings up the issue of pronouns but then totally drops it and only talks about options for preferred name. I don’t speak for the church on this, but here’s my take, in lawyer mode as though I were trying to understand a statute. There is no “pronoun” section on church records, and there’s definitely no authorization to change a person’s sex on their church record, and this passage doesn’t specifically say that pronouns may be noted anywhere in a record or used in the ward. So hopefully it’s a good balance to courteously use someone’s preferred name, but not undermine church doctrine by noting and using wrong-sex pronouns, because that implies sex is a matter of self-definition. There’s a risk to kids who are trying to process all this, if they hear their local church leaders endorsing pronoun changes.
Counsel with authorities: “Bishops counsel with the stake president. Stake presidents and mission presidents must seek counsel from the Area Presidency.” (38.6.23) That’s mandatory. Local leaders are not allowed to freelance here, and I emphasize this because I’ve heard alarming reports that individual Bishops and Stake Presidents are failing to follow church policy by not consulting Area authorities. Out of misapplied compassion, they allow youth to socially transition at meetings and activities, and may thereby contribute to the social contagion and confusion of their youth. That should not happen at church.
Therapy: “When it comes to gender-related concerns, you should exercise great care in selecting a therapist who respects your values and does not seek to impose one particular outcome. Therapists should respect your right to determine your values and goals for your life.”[2] Find a therapist who helps you live the gospel, not one who pushes you toward transition.
Love: “Members and nonmembers who identify as transgender—and their family and friends—should be treated with sensitivity, kindness, compassion, and an abundance of Christlike love. All are welcome to attend sacrament meeting, other Sunday meetings, and social events of the Church.
Criticism of the church’s policies
When a transgender-identifying member of the church, or the parents or leaders of a trans-identifying youth, look for resources to help them understand and deal with the challenge, they’ll find many websites, podcasts, videos, social media accounts, and influencers that challenge or criticize the church’s teachings and policies. Some do so very subtly, by claiming to be faithful supporters of the church, constantly invoking Jesus and His love for those who suffer, and downplaying the difference between their ideology and the church’s teachings. For instance, many will advocate for gender transitioning, and simply not bring up that the church counsels against it. They use manipulative emotional appeals to the need to be loving and accepting like the Savior. They imply that “acceptance” means validation of transgender identity and encouragement to transition, is the church’s doctrine and policy. The cumulative effect of this deception is to convince families and leaders that church doctrine, basic common sense, and the Savior Himself are all in favor of gender transitioning. That’s false, and so harmful to these kids and parents who need truth and the Savior’s true doctrine as taught by His prophets.
A second, more strident group of critics do the opposite of pretending the church supports gender transitioning: they openly denounce the church, accuse its leaders of bigotry, and forcefully blame it for driving transgender-identifying members to commit suicide.
For someone like my friend and her daughter, the first group is likely the bigger danger. The constant emotional invocation of love and validation and equality are very appealing, and families dealing with pain and confusion may become integrated into that soothing worldview before they even realize that their new beliefs are actually contrary to the teachings of the church. When they do realize it, they are primed to conclude the church is wrong, and even dangerous to their child. If they have allowed their child to take drastic body-altering steps like puberty blockers, hormones, and surgery, they have an additional incentive not to reverse course and decide they were wrong. No one would have an easy time admitting they made a wrong decision with such terrible consequences.
The second group, the strident critics, is less alluring to faithful members, but plays an important role in the process of wedging people away from the church: its accusations regarding suicide are the hard backstop to the first group’s softer pleas for love and acceptance. It’s the dark cloud hovering over the rainbow flags that says validate your child’s transgender identity, and support his or her transition, or else he or she will commit suicide and it will be your fault.
The risk of suicide
A beloved child’s death is every parent’s worst nightmare, hands down. Telling parents that their child will commit suicide unless a certain course is taken is one of the strongest imaginable pressure tactics, and so basic decency demands that it only be used in cases of clear necessity.
But it is not clearly certain that transgender-identifying children and youth are likely to commit suicide unless they transition. They are more likely to also suffer from depression, anxiety, and other conditions, but that only causes a increase in what is still a low overall risk of suicide[3], and there is no good evidence that transitioning reduces that risk of suicide. Contrary to those who claim suicidality is the result of distress from having to “live in the wrong body,” it is just as possible, based on current evidence, that the desire to transition is a misguided attempt to feel control over their depression and anxiety which are not caused by gender dysphoria.
If you follow all this in the media and on social media, you know that what I just said is extremely controversial. I just contradicted mainstream medical societies, a lot of prominent researchers, and practically every journalist who reports on this issue. If this room were Twitter, you would all be rushing the podium to clobber me. But I’m making this claim because it’s true, and I can back that up.
Researchers, advocates, and journalists cite a lot of studies when claiming that kids must take blockers and hormones to protect against suicide. But these studies do not prove what they’re claimed to prove. When you consider a published study, you have to ask: what are the strengths and weaknesses of its design? How was the data collected? Is the analysis sound? Do the authors tweak their data or analysis in order to strengthen their results? Are the results significant, or likely to just be random chance?
When you know to ask those questions, you start to see that a lot of published research is much weaker than the headlines claim. The social sciences, including psychology, are dealing with a full-blown replication crisis, where even studies without obvious flaws cannot be verified.[4] ***So coming from a science enthusiast who believes strongly in the benefits of scientific research, the best you can do is to examine everything closely. Don’t just accept a long list of citations without investigating what the cited studies actually say. Don’t just read the headline, the abstract, and the conclusions–tackle the methods, the tables, and the data. Be suspicious of appeals to authority. And guard against accepting studies that affirm your pre-existing beliefs.
That Heritage Foundation Study (2022)[5]
For a timely example of the need for skepticism of studies that confirm our beliefs, there’s a recent study from the Heritage Foundation. Heritage is a conservative think tank whose position regarding transgenderism largely coincides with church doctrine and my own views. So a couple months ago, when they announced a new study concerning youth gender transitions and suicide risk, I was of course very interested–I had already started preparing this presentation, and this study was on-the-nose. It claims to show youth gender transition actually increases the rate youth suicides. That’s a huge challenge to the current consensus!
But if that claim is true, it is in spite of this study, because this study is no good. The research design is bad. The analysis is bad. The conclusion is unsupported. We should not cite it when making our case.
The study tries to look at two sets of state-level data: first, how easily minors in that state can access puberty blockers, cross-sex hormones, and surgery, and second, the youth suicide rate in that state. The study tries to show there is a correlation between easier access to medical gender transition and youth suicide.
There are serious problems with this. (1) The study doesn’t accurately evaluate whether a kid in a given state actually could access blockers, hormones, and surgery during the timeframe of the study. It makes dubious claims that conservative states like Utah and Texas had teenagers easily undergoing medical transitioning as far back as 2014, when both had very few doctors taking on minor patients for gender procedures. It’s just not plausible that enough kids were transitioning at that time for the effect to show up in suicide rates. (2) The Heritage study classifies several states’ laws as facilitating minors’ access to gender transition against their parents’ wishes, when actually the access is limited. Thirty-four of those states only allow minors to direct their own healthcare if they are totally emancipated from their parents or guardians. This is a very small population, not a general free-for-all for kids to transition. (3) If you filter out just one or two states with unusually high suicide rates, the study’s whole conclusion would flip. This extreme sensitivity to a few outliers is very statistically suspicious, because you could actually be seeing an effect that is unique to those locations, and not the overall causation that you’re claiming to see.
So even though you would expect someone at a conference like this to jump at the chance to say “Look! The Heritage Foundation just proved I’m right!” I can’t do that because that’s not what the data says. We have to be willing to think critically to find truth.
Major Medical Association Statements
Now let’s look at the claims and studies on the other side. This is, again, the side that is putting almost unimaginable pressure on to parents by saying “either support your child in transitioning gender, or your child will commit suicide.” Colloquially, it’s “would you rather have a dead daughter, or a live son?” or vice versa.
I feel immense sympathy for any family in this situation, because it’s not just individual doctors, researchers, and therapists who are saying this–it’s groups like the American Medical Association and the American Academy of Pediatrics. And again, it’s not a comfortable position for me to go against these organizations. I think it’s usually best to go by what mainstream professional medical organizations recommend because their recommendations are usually backed by sound science. But in this case the studies they’re citing just don’t support their conclusions.[6] Let’s dig in.[7]
The American Medical Association released a document titled “Health insurance coverage for gender-affirming care of transgender patients” in 2019.[8] It makes the strong claim that “recent research demonstrates that integrated affirmative models of care for youths, which include access to medications and surgeries, result in fewer mental health concerns than has been historically seen among transgender populations.” The footnote refers to three papers, which I read, and astonishingly, none of the three papers even address the outcomes of the treatment. Seriously. The papers merely describe the treatment protocol, patient demographics, treatment philosophy and goals, the clinical population served, common clinical and social problems, rationale for the interventions provided, and the level of gender variance and psychological distress. There’s no data whatsoever on outcome or suicidality following treatment.[9]
This is astonishing. The AMA document does cite other studies, some of which we’ll get to in a minute. But right off the bat, we have a clear example of the incredibly weak foundation for crucial claims like “your kid’s life depends on taking blockers and hormones.”
Next up, the American Academy of Pediatrics published “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents,” in 2018[10]. It was written to persuade pediatricians that they should enthusiastically support puberty blockers and hormones for youth, because, quote, “There is a limited but growing body of evidence that suggests that using an integrated affirmative model results in young people having fewer mental health concerns whether they ultimately identify as transgender.” There’s a footnote citing three articles: the exact same three papers as the AMA cited, utterly inadequate to establish the point they’re cited to support, that don’t even address the issue of patient outcomes. So now we have a second major medical body making the exact same unsupported claim. Did they copy off each other? Did they both copy from a third source? There clearly wasn’t the level of serious research and careful analysis that you’d hope to see from such influential medical associations.[11]
In 2019, the American Academy of Child and Adolescent Psychiatry released a “Statement Responding to Efforts to ban Evidence-Based Care for Transgender and Gender Diverse Youth.”[12] It’s directed at lawmakers who could outlaw puberty blockers and cross-sex hormones for minors. But it uses the same logic and the same sort of claim: “Research consistently demonstrates that gender diverse youth who are supported to live and/or explore the gender role that is consistent with their gender identity have better mental health outcomes than those who are not…These interventions may include social gender transition, hormone blocking agents, hormone treatment, and affirmative psychotherapeutic modalities.” It cites three studies in support.[13]
The first study[14] recruited 73 transgender-identifying children and their parents, along with a control group of non-transgender-identifying children, and found that the trans-identifying children whose parents supported their social transitioning had normal rates of depression and only slightly higher signs of anxiety than the non-trans-identifying group of children. The study authors promoted[15] the conclusion that if parents support kids’ social transitions, the kids won’t suffer from the mental health issues they otherwise would. And a parent who isn’t a medical researcher would read this and feel nervous about harming his child. But there are huge flaws in the study design: the study compares the group of trans-identifying kids to a group of non-trans-identifying kids, but that’s not a relevant comparison. It’s missing the essential comparison it needs, between trans-identifying kids whose parents supported their social transition, and trans-identifying kids whose parents did not. Moreover, as skeptical group of researchers pointed out in a formal comment[16], the recruited group of trans-identifying kids and their parents were unusually economically well-off, which is very relevant when you’re dealing with mental health issues. There is also a problem with how the study authors adjusted the scale for reports of mental health issues using different evaluations for different groups. This study is weak, low-quality evidence for the point it’s cited to support.
The second cited study[17] deals with a broader group of LGBT youth, which is important because treating and supporting a transgender-identifying child is very different from a gay, lesbian, or bisexual child. Only about 22 of the kids in the study were transgender-identifying, which is too small a sample size to feel confident in any conclusions you draw. The study analyzes how family acceptance of a child’s LGBT identity affects the child’s likelihood of suffering from depression, substance abuse, or suicidality. The results for transgender-identifying subjects are not statistically significant in any of the studied areas, meaning you can’t conclude any benefit was due to the variable you’re testing–family acceptance–versus random chance. Moreover, this study analyzed how family acceptance of kids’ LGBT identities affected the kids’ mental health, but it didn’t include “access to puberty blockers and cross-sex hormones” as part of “family acceptance.” The example it gives of a survey question regarding family acceptance of a trangender child is “How often did any of your parents/caregivers appreciate your clothing or hairstyle, even though it might not have been typical for your gender?” That’s something a lot of parents could do in good conscience, even while simultaneously opposing a child’s social and medical transition. So this study gives no statistically significant conclusions, and is basically irrelevant to the question of whether kids need to transition to alleviate suicidality.
The third citation is to a “Practitioner’s Resource Guide” encouraging family support of LGBT children, prepared by a federal agency.[18] It’s written by one of the authors of the second study, its recommendations are based on the second study, and doesn’t improve on any of the problems of the second study. It’s basically a duplicate citation, padding the list to make the evidence look more formidable.
So when we examine the recommendations of leading medical societies, we find a huge problem with the evidence they’re trying to use. So far, there’s no good evidence that puberty blockers and cross-sex hormones improve minors’ mental health, and it’s certainly telling that these major organizations can’t find better evidence to cite in their recent, major statements.
Other Commonly-Cited Studies
The Dutch Study (2014)
There are other studies that are often cited as evidence that gender transitioning is crucial to protect minors’ mental health and even their lives. Let’s see if those studies hold up any better than the medical association statements.
The earliest, most foundational study on transgender-identifying youth is often just called “the Dutch study.[19]” It’s one of the strongest pieces of evidence for the case that medical transitioning helps kids. But it’s not that strong, and its protocols are very different from how gender dysphoric minors are usually treated today, so its applicability to today’s debate is limited.
The Dutch study, from 2014, considers long-term outcomes for 55 transgender-identifying young adults who received puberty suppression, cross-sex hormones, gender re-assignment surgery, and other treatment and evaluation as teenagers from a clinic in the Netherlands. It concludes that they are happy and psychologically well-functioning. Advocates want you to just stop your analysis at this point, but we’re going to dig in to the details.
A 2022 critique[20] of the Dutch study notes a lot of problems with it, both on its own terms and in its applicability to today’s skyrocketing numbers of transgender-identifying youth. (1) The claimed improvements in psychological functioning were actually very small, not clinically significant because they did not move the patient into a higher category range, and often not even statistically significant. (2) The subjects in the Dutch study were heavily screened to ensure that they were not significantly mentally unwell to start with, which is nearly opposite of today’s narrative wherein trans-identifying kids are on the brink of suicide unless allowed to transition immediately. You can’t credit the transition with improvement of mental health problems that weren’t a large issue to start with, or say the Dutch study has anything to tell us about treating kids in significant mental distress. (3) The Dutch clinicians discouraged childhood social transition, because in their experience and judgment, most childhood gender dysphoria resolves on its own prior to puberty. Today, many activists, doctors and therapists promote childhood social transitioning, so they therefore cannot honestly cite the Dutch study as evidence their approach will lead to good outcomes. (4) The Dutch protocol involved ready access to psychological counseling and pharmaceuticals to help with any mental health issues that did come up, but the results didn’t control for those factors, which could explain part or all of the claimed psychological benefit from transition, or have mitigated psychological harm that would have otherwise resulted. Many minors undergoing gender transition today are not receiving nearly so much psychiatric support, and the counseling they receive is very different in that it is much more uncritically affirming of ideas like being “born in the wrong body.” (5) The principal author of the Dutch study wrote a paper in 2020[21] expressing concern that her earlier work was being mis-applied to a much different group of kids, because so many minors undergoing gender transition in 2020 had no long-term childhood history of gender incongruity/dysphoria. The Dutch study was on kids whose dysphoria was longstanding and persistent, and therefore cannot be used to advocate for transitioning teens whose dysphoria is recent, late-onset, and associated with other factors like autism, anxiety, social media addiction, and pressure from peer groups. (6) The authors claimed improvement in the participants’ dysphoria, but that’s difficult to interpret because they initially had subjects complete a survey evaluating their dysphoria based on their biological sex, and afterward for the opposite sex.
The Dallas study (2020)[22]
The Dallas study, published in 2020, evaluated 148 adolescents receiving cross-sex hormones at a clinic in Dallas. It claims to provide “further evidence of the critical role of gender-affirming hormone therapy in reducing body dissatisfaction,” as well as “modest initial improvements in mental health.” I give the authors some credit for including that term “modest,” because they reported their results rather strangely and they do not show significant benefit to the kids’ mental health.
The strange results are in Table 5, concerning suicidality, which is the most important thing we’re worried about. If you don’t read the table carefully, it actually looks like the kids in the study became more suicidal following the hormones: from 33 to 51 ideation, from 3 to 6 attempts, from 13 to 23 non-suicidal self injury. But that’s not a fair reading, because it turns out you can’t draw any conclusions from this at all because of the different time frames. The left column asks if the kids have ever in their lives, prior to assessment for this study, experienced the suicide-related events. The middle column asks if the kids experienced suicide-related events in the few months prior to assessment. The right column asks if the kids experienced suicide-related issues during the year or two they participated in the study. This can’t tell us anything useful about the severity or trajectory of suicidality, which is why they didn’t run any statistics on the numbers, but just reported them. So we might just give them the benefit of the doubt that it’s certainly good for them to try to monitor the kids’ well-being, and they probably reported it in the interests of full disclosure. However, the authors brought up the results in the study’s abstract, which is the only part of the study that 99% of influential activists and journalists are going to read (I made up that statistic). The abstract says “lifetime and follow-up rates were 81% and 39% for suicidal ideation, 16% and 4% for suicide attempt, and 52% and 18% for NSSI, respectively.” They just spent a significant chunk of their abstract, the only part many people will read, telling us the analytically worthless news that a eleven-to-eighteen month period contained fewer suicidal issues than a nine-to-fifteen year period. This is really fishy. If you don’t have good data to support the narrative that gender transitioning is crucial to preventing suicide, but you still want people to use your paper to support that narrative, this is how you’d do it.
As for the mental health issues less extreme than suicide, the study does only show “modest” improvement, and if you go by the arguably more rigorous clinician assessment rather than the kids’ self-reported mental health, even those modest benefits disappear. There’s just not any good evidence of improvement here.
Except for one: the improvement with regard to body dissatisfaction is significant. And I won’t deny that it is important to help adolescents resolve feelings of distressing dissatisfaction with their bodies. But this is just one study, and it doesn’t show the improvements couldn’t have been obtained with more conservative, less intrusive treatment. It’s very possible that kids who are excited by their recent changes from hormones will later become dissatisfied again as the side effects become more evident. And this study certainly doesn’t show that transgender-identifying kids will kill themselves unless they take cross-sex hormones.
The United Kingdom studies (2015 and 2021)
***If you follow youth transgender issues, you’ve probably heard of the United Kingdom’s Gender Identity Development Service, or GIDS, and the ongoing legal action spurred by Keira Bell. She was given puberty blockers and testosterone starting at age 16, despite significant mental, physical, and family difficulties. She won a legal case against GIDS for failing to give her adequate care[23] (the judgment was partially overturned on appeal,[24] but still spurred a high-level review of the evidence, and the closure of GIDS, which we’ll discuss later).
In 2015, GIDS researchers published a study that purports to show “Psychological support and puberty suppression were both associated with an improved global psychosocial functioning in [gender dysphoric] adolescents.”[25] But an Oxford researcher pointed out, in a formal comment published in the same journal, there’s no way the study can distinguish between improvement caused by the psychological support and improvement caused by the puberty suppression.[26]
First, this study protocol is a lot more in line with the Dutch approach–which heavily screens out kids with significant psychological problems like depression and anxiety–than most activists are advocating for today. When you’re dealing with claims that kids will kill themselves unless given puberty blockers and cross-sex hormones, you can’t support that with a study that didn’t give blockers and hormones to the group of kids with the actually elevated risk of suicide. Moreover, the study measured the kids’ scores on the Children’s Global Assessment Scale (CGAS), and found that at the beginning of the study, the control group who were not given puberty blockers were, despite their struggles with depression and anxiety, only a little bit behind on their CGAS scores from the group who were going to be given blockers. The difference was not statistically significant. And at the end of the study, to measure whether there was any benefit from the puberty blockers, the CGAS was administered to both groups again. The results? The control group scored slightly lower than the blockers group, by a slightly larger margin than at the beginning–but still too small to be statistically significant. So the control group was only behind by an insignificant margin to start with, and was only behind by a still-statistically-insignificant margin at the end. You can argue that these results are still worth reporting, but they’re weak, low-quality evidence for a very serious medical procedure. No one touting these results would accept this level of evidence for something less socially fashionable, like, say, alternative COVID treatments.
Second, the sample size for this study was small–201 kids to start with–and shrunk by 65% over the course of the study. That’s a huge attrition rate[27], and the study authors don’t offer any explanation for it. There are a lot of possibilities as to why kids dropped out that could be extremely relevant, but we have no way of knowing. Did some kids become too mentally unwell to continue? Did they suffer physical or mental side effects from the blockers that made them decide to stop? Or, to be fair, from the lack of blockers? Did their psychosocial well-being improve significantly enough that they were no longer interested in bothering with the study and contact with the clinic? We just don’t know, and it would sure be useful to know.
Third, the authors didn’t account for access to psychological counseling in their statistical analysis, so we can’t be sure any positive effect was caused by the puberty blockers and not from counseling.
Fourth, the study authors report they administered the Utrecht Gender Dysphoria scale to both the control group and the blockers group at the beginning of the study…and then don’t say if they administered it again at the end, and if so, what the results were. This is pretty puzzling, because presumably they administered it because they wanted to study whether the blockers group’s gender dysphoria improved relative to the control group. But then, nothing! You’ll forgive me a bit of cynicism that they might have left out some results that didn’t show what they wanted to see.
Overall, this is yet another weak study that doesn’t support advocates’ claims.
In 2021, some of the same researchers from the 2015 GIDS study used additional GIDS data to publish another study, again to evaluate the benefits of puberty blockers.[28] This study also did some Dutch-style gatekeeping, like only enrolling subjects whose gender dysphoria was longstanding, for at least five years. This 2021 study suffered similarly huge attrition rates, losing 68% of their subjects by the final evaluation at 3 years. And the results were absolutely no difference–positive or negative–in psychological outcomes for the kids who went on blockers (of whom, 98% went on to take cross-sex hormones). Some activists and journalists who touted the first GIDS study (despite its huge problems) did not mention the second one. Some did try to spin the second study as evidence in favor of puberty blockers based on the authors’ interviews with study subjects who said they were happy and satisfied with their treatment.[29] But it’s not surprising that the 32% of the kids who were enthusiastic enough to stay in the study were happy about it, and the interviews aren’t nearly as rigorous as the formal psychological assessments that showed no change in mental health and functioning.
The New York study (2020)[30]
***Published in 2020, this study followed 50 kids and young adults who were given both puberty blockers and cross-sex hormones, and underwent psychological assessments every six months during treatment. (The study began with 95 participants, but the rest dropped out, for a 46% attrition rate.) This study is interesting for breaking down its analysis according to whether a participant was a male taking estrogen or a female taking testosterone, which it certainly makes sense to do, because those are very different substances. It’s problematic to just lump them all together as “cross-sex hormones” and “transgender medicine.”
The study’s abstract reports as its results that “Mean depression scores and suicidal ideation decreased over time while mean quality of life scores improved over time.” This is the part advocates like to quote. But you have to continue reading: “When controlling for psychiatric medications and engagement in counseling, regression analysis suggested improvement with endocrine intervention.” Suggested? Not established, not showed. Because: “This reached significance in male-to-female participants.” Significance is a concept in statistics that conveys whether or not we can be confident it’s a real result, not just a random chance that happened to show up in your particular sample. The study’s authors are reporting that their only significant result was among males taking estrogen, and that everything else was merely “suggestive,” which is a nice way of saying “insignificant.”
Moreover, we’re already dealing with a small sample, and fully two-thirds of that sample is females taking male hormones, with no significant improvement. So the only significant result is from a sample of 17 males who took female hormones, and even with a statistically significant result, that’s still just not a strong piece of evidence when the sample is so tiny.
Moreover, when you consider the effect on suicidality specifically, the sample size is even more tiny. Again, for females taking male hormones, there is no statistically significant benefit. For men taking female hormones, yes, it’s technically correct for the authors to report in the abstract that “suicidal ideation decreased over time.” But when you look at the actual numbers, two males started out suffering from suicidal ideation, and at the end of the study, one male was still suffering from suicidal ideation. That’s not evidence. It’s an anecdote.
The Turban studies (2020 and 2022)[31]
***Jack Turban is perhaps the most prolific and prominent advocate for children and youth gender transitioning that there is. He often publishes advocacy in venues like the Washington Post, the New York Times, and Psychology Today. But his data are weak and his conclusions are unsupported no matter how often he’s quoted by sympathetic media.
His 2022 paper tries to show that minors who take cross-sex hormones have lower rates of suicidality compared to similar kids who want to take hormones but do not. His paper from 2020 considered the same question, but about puberty blockers instead of cross-sex hormones.[32] So the claim is a parent’s nightmare in a nutshell: your kid needs to take blockers and cross-sex hormones, or your kid is far more likely to die. Turban doesn’t mince words about this in his advocacy.
The studies use data from the 2015 US Transgender Survey, and that’s the first problem. The USTS is a very unrepresentative sample, and its respondents were recruited in a way that means it’s likely to lead to biased conclusions. A published critique[33] points out that the USTS used convenience sampling, meaning its participants were recruited by advocacy organizations with a vested interest in getting the responses they favored instead of an actually random sample of transgender-identifying individuals. Respondents to the survey were urged to “pledge” to promote the survey to their (presumably like-minded) friends and acquaintances. Demographically, the respondents skew much richer, younger, more educated, and politically engaged than a random sample would. A similar survey conducted by the CDC, the Behavioral Risk Factor Surveillance System (BRFSS), doesn’t suffer from these issues, and could have been used. But Turban used the USTS.
There are more problems. The USTS asks respondents to remember what treatment they’ve sought and received, and a lot of them have demonstrably bad memories: 73% of the respondents who reported taking puberty blockers reported that they did so after age 18, which is not possible. By age 18, you’ve already gone through puberty and there’s no point in blocking it; no doctor will prescribe blockers to you (prominent guidelines recommend their use no later than age 16). If the vast majority of respondents were so obviously wrong in recalling that important aspect of their treatment, how can we trust the rest of their answers? This data wasn’t verified by calling up their doctors. It’s all based on self-report and memory. And the mental health data is all self-reported, which isn’t worthless, but also isn’t going to give us a rigorous understanding of what was going on for the person in distress. This is a sketchy, unreliable data set. It shouldn’t be used to make important decisions and public policy.
Besides his choice to use the sketchy data set, Turban’s methodology has other problems. It’s a big stretch, to put it mildly, to conclude that access to puberty blockers or cross-sex hormones would have improved someone’s suicidality just because years later they indicated on a survey that they at some point “wanted” them. Was it a serious, persistent, realistic desire? Would a doctor have prescribed them, or would there have been important disqualifying issues? Did they even suffer from diagnosable gender dysphoria? Or could it have been a peer-pressure phase or an anime fad? It’s such a broad question, with no rigorous way to analyze how “wanting” really factored into the respondent’s life and health.
Moreover, observing that a survey respondent both “wanted” blockers or hormones and also suffered from suicidality doesn’t show causation, only correlation. The USTS was published in 2015, so it covers a time period when most American doctors were still more Dutch in their approach to prescribing blockers and hormones than they are today. A patient who was experiencing significant mental distress, like suicidal ideation, would likely have been screened out of transitioning and instead referred to counseling and psychiatric medication. So you can’t just conclude that causation points the way Turban says it does in the 2020 paper, that kids didn’t get blockers, which caused them mental distress. It could be that the mental distress was the reason they were denied blockers, and there’s therefore no evidence that the blockers would have helped. The 2022 study doesn’t suffer from this weakness as badly, because it focuses on suicidality only recently suffered, within a month of the survey response, instead of during the respondent’s entire life. But there are still more problems.
The survey data break down suicidality into degrees of severity: some people occasionally feel like life isn’t worth living, and to be clear, that is extremely worrisome and needs to be actively treated. But some people specifically plan out how to go about taking their life and take steps to put the plan into action, and that is a far worse situation. The 2022 paper does statistical analysis on the responses indicating more serious suicidality, and gets no result. It doesn’t show any correlation between taking cross-sex hormones and having lower levels of acute suicidality.
***And there are more problems. A critique of the study[34] by the same Oxford sociology professor who found problems with the GIDS study says that he was unable to replicate the study’s findings. He asked the authors for additional statistical information to help him, but they didn’t reply. Moreover, the Oxford critic notes that the 2022 paper controls for access to puberty blockers, and shows that “having taken puberty blockers has no statistically significant association with any outcome.” This negates the claimed findings of the 2020 paper focusing on blockers, but that possibility isn’t discussed or defended against anywhere in the 2022 paper.
And there are more problems. The Oxford critic broke down the data by respondents’ sex, and found huge discrepancies between females taking testosterone and males taking estrogen. Testosterone is known to have antidepressant effects in many cases, so it’s not surprising that many women report initially feeling better when taking it (though it causes a lot of problems, too). But estrogen is very different, and by the Turban study’s own measures, men who took estrogen suffered a higher probability of acute suicidality: planning, attempting and being hospitalized for suicide. To be clear, the point still stands that the USTS data set is unreliable and we can’t draw conclusions from it. But if one accepts the validity and conclusions of this study, one has to face the worrisome suicide data for males taking estrogen. The study’s publisher added an Editor’s Note that they’re looking into the questions raised. Stay tuned.[35]
The Seattle study (2022)[36]
Another study published in 2022 claims to establish that gender dysphoric kids who take puberty blockers and cross-sex hormones have better mental health outcomes afterwards than kids who did not. Specifically, it reports 60% lower odds of depression and 73% lower odds of thoughts of self-harm or suicide. That’s a blockbuster finding and was widely reported as such. But there are huge problems with it. In fact, it’s so thoroughly misleading that I’ll even call it false.
The study found no statistically significant mental health improvements for the kids who took blockers and hormones. Depression started at 59% and dropped to 56% after 12 months. Self-harm and suicidality started at 45% and dropped to 37% after 12 months (and the 8% drop isn’t enough to be statistically significant because of the small sample size).
But wait, how could they report the 60% and 73% lower odds? By a sleight of hand that most people won’t catch. The crucial question is: lower odds compared to what? Compared to a control group. The study followed 69 kids who took blockers and/or hormones, and 35 kids who did seek treatment for gender dysphoria, and did enroll in the study, but did not take blockers or cross-sex hormones. So the kids who did get pharmaceuticals did not improve. They had high rates of depression and suicidality to start with, and they still had high rates of depression and suicidality after 12 months of treatment. That’s not a great result.
But if the control group meanwhile plunged into worse and worse depression and suicidality, and the treatment group at least avoided that, that’s in favor of treatment, right? No. Because we’ve got a study design problem, and a huge attrition problem.
First, the study-design problem, which isn’t an accusation against the researchers, but just an important limitation of the data. This isn’t a group of kids who were randomly assigned into either the treatment group or the control group. There is no information whatsoever about why the control group kids didn’t go on blockers or hormones. That’s a really important limitation when trying to draw conclusions about their eventual outcomes.
Second, the attrition problem. The treatment group started out with 69 kids, and by the final assessment at 12 months, was down to 57 kids. That’s a loss of 17%, which isn’t terrible, especially compared to other studies we’ve seen. But the control group started out with 35 kids, and after 12 months, was down to just 6 kids. That’s an incredible 83% attrition rate. That’s enormous on its own, but the really huge problem is the difference in attrition rates between the two groups. The treatment group lost 17%, and the control group lost 83%. The groups are too unalike to draw meaningful comparisons between them. At the very least, the authors need to address what could be going on for the control kids to be dropping out so profusely while the treatment kids stay. But the authors don’t mention it at all.
We don’t know why so many of the kids dropped out of the study, but it’s quite possible that their mental health improved so much that they didn’t want to bother any more. Or perhaps they weren’t particularly badly off to start with, which means that had they stayed in the study, the results would have been radically different. If it’s true that the healthier kids are the ones who dropped out, then the remaining sample would skew comparatively unhealthy. If the healthier kids had stayed in the control group, the study conclusions would have been that puberty blockers and cross-sex hormones do not improve mental health outcomes for dysphoric kids, and even lead to as bad or even worse outcomes as the kids who didn’t take the drugs. Instead, we got headlines like “Suicide Risk Reduces 73% in Transgender, Nonbinary Youths with Gender-Affirming Care,” which is just appallingly misleading.[37] Parents are being bullied into procedures on their children on the basis of terrible evidence.
Other countries are noticing
***I’m hardly the only one to pick up on all this bad science and misleading propaganda, but in general, I think it’s fair to say Americans are being particularly gullible about all this[38]. In contrast, health officials in other countries have actually read the studies with a critical eye, noticed their glaring shortcomings, and adjusted their policies accordingly.
Last Thursday, news broke[39] that the UK’s National Health Service has ordered GIDS to close, because of its practice of rushing kids into transitioning, neglecting careful psychological evaluation and screening for comorbid conditions like autism, and not bothering with good evidence or careful follow-up.[40] In the wake of the Keira Bell case, NHS commissioned a pediatric medical researcher, Hilary Cass, to conduct a thorough review of the evidence for youth transition procedures. The full report is not yet complete, but the interim report[41] was damning enough for Cass to recommend[42] the GIDS closure and for the NHS to agree. In its place, eight smaller regional treatment facilities will be established which will emphasize more “holistic” care with “strong links to mental health services,” as well as more well-designed research and more active follow-up evaluation. It’s not yet fully clear exactly how the new “holistic” treatment protocol will differ from GIDS procedures, but based on the interim Cass report and its scathing critique of the weak state of the evidence for youth transition, it’s a fair guess that there will be a lot more counseling, a lot more “watchful waiting” to see if gender distress resolves without medical intervention, and a lot less quick starts on blockers and hormones for kids who have only recently developed a desire to transition.
Both Sweden and Finland have commissioned comprehensive reviews of the literature and have found that the quality of the evidence is very poor. The Swedish report states: “There are no definite conclusions about the effect and safety of the treatments.”[43] ***In Finland, “As far as minors are concerned, there are no medical treatments that can be considered evidence-based.” Also, “In light of available evidence, gender reassignment of minors is an experimental practice…Information about the potential harms of hormone therapies is accumulating slowly and is not systematically reported. It is critical to obtain information on the benefits and risks of these treatments in rigorous research settings.”[44] In France, the National Academy of Medicine notes there is no way to reliably diagnose durable transgender identification as opposed to transitory social contagion, and advises: “the greatest reserve is required in [the use of blockers and hormones], given the side effects such as impact on growth, bone fragility, risk of sterility, emotional and intellectual consequences and, for girls, symptoms reminiscent of menopause…It is therefore advisable to extend as much as possible the psychological support phase.”[45]
***Enough of the forest; back to the trees
This isn’t a fun topic to have spent so much time on, but I did it because of what’s so extremely important here: your child. Your grandchild. The youth in the quorum or class you lead. This issue is going to confront us all at some point. And it horrifies me to think that kids are being pushed into these mentally and physically harmful medical procedures on the basis of weak, misleading, manipulated data. It is horrifying that parents are being bullied into approving these treatments on the basis of a supposed suicide risk that the evidence simply does not substantiate. If your child is at risk for suicide, please take that extremely seriously and do all you can to help your child get treatment.[46] But it is imperative that you understand there is no evidence blockers or hormones will protect your child from suicide. It is extremely worrisome that these weak studies are being used to justify banning the treatment that does actually help: psychological counseling to help kids accept their bodies and make peace with their difficult feelings. There’s not even a lot of strong evidence that blockers and hormones help to significantly alleviate gender dysphoria and kids’ dissatisfaction with their bodies, so these kids are being left with infertility, sexual dysfunction, and other terrible side effects and life-long medical challenges[47], for no likely significant benefit.[48]
I also don’t want all of us to be constantly backed into a corner on this issue. There’s a subset of church members who are activists, who join with ex-members and other critics to accuse the church and its leaders of bigotry and to insist that church teachings and policies are responsible for kids’ suicides. There is no evidence of this. Anecdotes abound on the internet, sure, but accepting a suicidal person’s report that a single, prominent cause is driving their suicidality is dangerous and wrong in light of the well-established psychological literature on suicide.[49] Suicide is caused by mental illness, not by church doctrine. And the activists who promote a fake link between suicide risk and lack of blockers and hormones might be doing enormous harm by encouraging suicide contagion. If a mentally ill kid hears over and over “you must get blockers and hormones or else you’ll kill yourself,” and they certainly do hear that, it can become a self-fulfilling prophecy.
Let’s go back to the church’s guidelines in the Handbook: we love and welcome transgender individuals. We treat them with sensitivity, kindness, compassion, and an abundance of Christlike love. We teach the truth that gender, meaning biological sex at birth, is an essential characteristic of Heavenly Father’s plan of happiness. We advise against medical, surgical, and social transition, and in favor of counseling by a careful professional respects your beliefs and values.
This advice is perfectly sound in light of all we’ve just discussed, because there is no good evidence that blockers or cross-sex hormones are helpful for kids suffering from suicidality. This, despite years of highly-motivated researchers trying to find such evidence and misleadingly reporting the weak evidence they have gathered. And there is some evidence that social transitioning solidifies transgender identification that might otherwise have desisted, leading to unnecessary medical and surgical procedures–that’s at least an equally valid interpretation of the evidence as the narrative that social transitioning is helpful.[50] So be kind, be sensitive, be prayerful in dealing with individuals and families in difficult circumstances, but don’t accept the narrative that teaching church doctrine is killing kids. Teach the doctrine.[51] Testify of the doctrine. Don’t hide the truth under a bushel of weak studies.
———-
[1] https://www.churchofjesuschrist.org/study/manual/general-handbook/38-church-policies-and-guidelines?lang=eng#title_number118
[2] https://www.churchofjesuschrist.org/study/life-help/transgender?lang=eng
[3] https://4thwavenow.com/2017/09/08/suicide-or-transition-the-only-options-for-gender-dysphoric-kids/
[4] https://ucsdnews.ucsd.edu/pressrelease/a-new-replication-crisis-research-that-is-less-likely-be-true-is-cited-more
[5] https://www.heritage.org/gender/commentary/does-gender-affirming-care-trans-kids-actually-prevent-suicide-heres-what-the
[6] For a discussion of how one major medical society suppressed discussion of evidence regarding transgender medicine, listen here: https://gender-a-wider-lens.captivate.fm/episode/hormonal-interventions-from-fringe-to-mainstream-a-conversation-with-dr-will-malone
[7] Note: I will provide an internet link to the best version of every study and document that I discuss, but some studies are not fully available for free online. I have obtained and analyzed the full versions of those studies, even if I can only link to a partial summary.
[8] https://www.ama-assn.org/system/files/2019-03/transgender-coverage-issue-brief.pdf
[9] The three studies are:
- https://pubmed.ncbi.nlm.nih.gov/22455323/
- https://pubmed.ncbi.nlm.nih.gov/22455325/
- c) https://pubmed.ncbi.nlm.nih.gov/20063232/
[10] https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for?autologincheck=redirected
[11] Credit to science journalist Jesse Singal for reporting the identical useless citations. See here: https://jessesingal.substack.com/p/science-vs-cited-seven-studies-to
[12] https://www.aacap.org/AACAP/Latest_News/AACAP_Statement_Responding_to_Efforts-to_ban_Evidence-Based_Care_for_Transgender_and_Gender_Diverse.aspx
[13] Of note, the three studies are cited specifically to the claim that youth need to “live and/or explore the gender role that is consistent with their gender identity” deal with social transition and family support, not puberty blockers and hormones. It’s unclear whether “live and/or explore” refers exclusively to social and not medical transition. But when the statement goes on to endorse “hormone blocking agents” and “hormone treatment,” there is no citation at all.
[14] https://pubmed.ncbi.nlm.nih.gov/26921285/
[15] https://www.washington.edu/news/2016/02/26/transgender-children-supported-in-their-identities-show-positive-mental-health/
[16] https://pubmed.ncbi.nlm.nih.gov/27365308/
[17] https://onlinelibrary.wiley.com/doi/10.1111/j.1744-6171.2010.00246.x
[18] https://store.samhsa.gov/sites/default/files/d7/priv/pep14-lgbtkids.pdf
[19] https://pubmed.ncbi.nlm.nih.gov/25201798/
[20] https://www.tandfonline.com/doi/pdf/10.1080/0092623X.2022.2046221
[21] https://publications.aap.org/pediatrics/article/146/4/e2020010611/79688/Challenges-in-Timing-Puberty-Suppression-for?autologincheck=redirected
[22] https://publications.aap.org/pediatrics/article/145/4/e20193006/76951/Body-Dissatisfaction-and-Mental-Health-Outcomes-of?autologincheck=redirected
[23] https://www.judiciary.uk/wp-content/uploads/2020/12/Bell-v-Tavistock-Judgment.pdf
[24] https://www.transgendertrend.com/supreme-court-decision-keira-bell-case-is-not-a-loss/
[25] https://pubmed.ncbi.nlm.nih.gov/26556015/
[26] https://users.ox.ac.uk/~sfos0060/BiggsJSM.pdf
[27] I confirmed with two university professors of psychology that this much attrition is not normal in psychology research, and should definitely be addressed and explained by the study authors.
[28] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0243894
[29] https://www.pinknews.co.uk/2021/02/03/puberty-blockers-trans-teens-gender-identity-gids-nhs-study/
[30] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7191719/?report=reader
[31] https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0261039
[32] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7073269/
[33] https://link.springer.com/content/pdf/10.1007/s10508-020-01844-2.pdf
[34] https://journals.plos.org/plosone/article/comment?id=10.1371/annotation/dcc6a58e-592a-49d4-9b65-ff65df2aa8f6
[35] On August 3, 2022, the day before I gave this presentation, Turban published a new study in Pediatrics (https://publications.aap.org/pediatrics/article/doi/10.1542/peds.2022-056567/188709/Sex-Assigned-at-Birth-Ratio-Among-Transgender-and), purporting to debunk the existence of “Rapid Onset Gender Dysphoria,” wherein adolescents suddenly adopt a transgender identity because of peer contagion and frustration over conditions unrelated to gender like autism and low self-esteem. This new study has been specifically criticized on the same grounds as Turban’s other work: bad statistics and bad analysis. See here for in-depth analysis and links to other criticism: https://jessesingal.substack.com/p/the-new-study-on-rapid-onset-gender
[36] https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2789423
[37] https://www.hcplive.com/view/suicide-risk-reduces-73-transgender-nonbinary-youths-gender-affirming-care
[38] Except Florida. A recent, extensive, non-partisan review by the Division of Florida Medicaid concluded: “the research supporting sex reassignment treatment is insufficient to demonstrate efficacy and safety. In addition, numerous studies…identify poor methods and the certainty of irreversible physical changes. Considering the weak evidence supporting the use of puberty suppression, cross-sex hormones, and surgical procedures when compared to the stronger research demonstrating the permanent effects they cause, these treatments do not conform to GAPMS and are experimental and investigational.”
https://ahca.myflorida.com/letkidsbekids/docs/AHCA_GAPMS_June_2022_Report.pdf
The Florida Department of Health
[39] https://www.thetimes.co.uk/article/tavistock-gender-clinic-forced-to-shut-over-safety-fears-wpdx3v6nw
[40] https://segm.org/GIDS-puberty-blockers-minors-the-times-special-report
[41] https://cass.independent-review.uk/publications/interim-report/
[42] https://cass.independent-review.uk/publications/
[43] https://www.socialstyrelsen.se/om-socialstyrelsen/pressrum/press/uppdaterade-rekommendationer-for-hormonbehandling-vid-konsdysfori-hos-unga/
[44] https://segm.org/sites/default/files/Finnish_Guidelines_2020_Minors_Unofficial%20Translation.pdf
[45] https://www.academie-medecine.fr/la-medecine-face-a-la-transidentite-de-genre-chez-les-enfants-et-les-adolescents/?lang=en&utm_source=floridahealth.gov&utm_medium=referral&utm_campaign=newsroom&utm_content=article&url_trace_7f2r5y6=https://www.floridahealth.gov/newsroom/2022/04/20220420-gender-dysphoria-guidance.pr.html
[46] https://www.nbcnews.com/news/us-news/988-suicide-prevention-hotline-launch-nationwide-rcna38297?cid=sm_npd_nn_tw_ma
[47] https://segm.org/the_effect_of_puberty_blockers_on_the_accrual_of_bone_mass
https://academic.oup.com/jcem/article/100/2/E270/2814818
https://www.frontiersin.org/articles/10.3389/fnhum.2017.00528/full
https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.118.038584
https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.119.005597
[48] See the earlier-discussed Levine review of the Dutch study for a discussion of the odd way the Dutch study handled measurements of gender dysphoria, which undercuts its claims that subjects were happier with their bodies post-transition: https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2046221
[49] https://www.jaacap.org/article/S0890-8567(17)30331-3/fulltext
https://reportingonsuicide.org/research/
[50] https://segm.org/early-social-gender-transition-persistence
[51] https://publicsquaremag.org/faith/gospel-fare/teach-it-freely-unto-your-children/
