A controversial new study suggests that gender-transition surgeries and hormone treatment may contribute to rising teen suicide rates.
When a leading transgender-health organization revealed last week that it is now recommending young teens be allowed to begin cross-sex hormone therapy and gender-transition surgeries, its alleged reasoning was hard to argue with: to improve those kids’ psychological well-being and to reduce suicides.
The updated guidance from the World Professional Association for Transgender Health, which lowered the organization’s recommended starting ages for both hormone treatments and surgeries, is based on “expert opinion” and “a review of scientific evidence,” according to an Associated Press report. The best research suggests “the treatments can improve psychological well-being and reduce suicidal behavior,” according to the AP report.
The problem: That scientific evidence is mostly bunk, according to Jay Greene, a senior research fellow with the Heritage Foundation.
Greene — an advocate for slowing the rush toward irreversible medical treatments for children with gender dysphoria — says existing research on the topic of transgender treatments and their impacts on the mental health of teenagers is “so deficient as to be worthless.”
Two days before the AP’s report, Greene released his own research on the topic that he believes offers strong evidence that making it easier for minors to undergo cross-sex medical interventions likely leads to higher rates of suicide among young people.
My new study released today by @Heritage finds that easing access to puberty blockers and cross-sex hormones has actually increased youth suicide rates, contrary to the claims of the Biden admin, advocates, and flawed prior research. 1/ https://t.co/XM4o4ioeOA
— Jay P. Greene (@jaypgreene) June 13, 2022
Greene’s report sparked an intense debate in the media, on Twitter, and among academics and trans advocates, not only over the pros and cons of hormone treatments for transgender youth, but also over the rigor of his research and the research generally on this topic. Greene’s critics alleged his research was “shoddy.” Media Matters accused him of peddling “junk science.” Meanwhile, Greene’s supporters applauded his bravery and described him as a “brilliant thinker” who won’t allow himself to be confined to “an utterly broken ivory tower.”
Lol if anyone thinks they can bully @jaypgreene into backing down from the pursuit of truth. A first rate person and brilliant thinker who is so committed to free inquiry that he wouldn’t be confined to an utterly broken ivory tower https://t.co/TpyzsK23zy
— James Paul (@james_d_paul) June 15, 2022
Greene said the resulting media storm “is as big” as any in his career or bigger, and it has left him more security-conscious. But, he said, he’s okay with the attention. “Frankly, I’m happy about it,” he said. “I think this is an issue that is important.”
In response to his critics, Greene, a former University of Arkansas department leader and education researcher, confidently claims that his research approach to the topic is “better” and “more rigorous” than previous studies, in part because it doesn’t use inherently biased treatment groups and control groups that other researchers have relied on.
Greene’s research, by contrast, doesn’t directly study transgender youth at all — a likely source of confusion for many about his report. Rather, Greene came at his conclusions about the likely effects of transgender hormone treatments indirectly, through what he calls a “natural policy experiment” that allowed him to conduct a whole population analysis.
In essence, Greene found that since 2010, when the use of puberty blockers and cross-sex hormones began ramping up in the U.S., states that make it easier for kids generally to obtain medical treatments without their parents’ consent have seen their youth suicide rates increase at a higher rate than states that don’t. “The relative increase in suicide rates only occurs after cross-sex treatments are introduced, and the trajectory of the increase matches the prevalence of these interventions,” Greene found, according to his report.
Jack Turban, a Stanford Medical School psychiatrist and LGBTQ advocate — whose own research on transgender treatments was a focus of Greene’s criticism — called Greene’s methodology and conclusions “absurd.” He accused Greene of making a “huge jump,” by attributing the increase in youth suicide rates in some states to young people getting hormones. He argued that the number of trans youth who receive medical treatments without parental consent is so small that “the logical jump made by the Heritage people doesn’t make sense.”
This is making the rounds. It’s a paper from the conservative @Heritage Foundation claiming to show gender-affirming care increases suicidality.
The methodology and conclusions are absurd, which is likely why they didn’t submit it for peer review.https://t.co/n1MsS2md2g
— Jack Turban MD 🏳️⚧️🧠🏳️🌈 (@jack_turban) June 13, 2022
Greene counters that the difference in suicides in states that allow kids access to medical care without parental consent is small — 1.6 additional suicides per 100,000 people ages twelve to 23 in 2020 — and he believes there is plenty of reason to believe access to cross-sex hormone treatments is the likely culprit. Greene also acknowledged deficiencies in his research. “It’s clearly suboptimal,” he said, “but still worthwhile.”
“Look, it’s an imperfect world we live in,” he said. “The ideal would be to have a randomized experiment. And I would urge Jack Turban and the Biden administration to conduct one. They could do it if they want. If they’re so convinced that these are life-saving interventions, they could prove it, easily, in a highly credible way.”
Emotional Blackmail
Greene said the idea for his research came earlier this year after he attended a Heritage conference on gender ideology, and heard “one horrifying story after another.”
Greene is not a medical researcher; at Heritage, he primarily studies education policy. But he said studying gender ideology and the effects of cross-sex hormone treatments on kids makes sense for him, because pharmacological gender transitions generally follow social transitions, and “that social transition is an incredibly important issue in schools right now.”
Greene said at Heritage, their approach is to empower parents to raise their children, and they believe that education is an extension of child-rearing. “These health issues that are coming up initially in schools and then spill over outside of schools, they’re also undermining the ability of parents to raise their children,” Greene said.
Greene said the supporters of providing puberty blockers and cross-sex hormones to children base their advocacy on an empirical claim that “if we don’t make these drugs widely and readily available, then kids will kill themselves.” He called this a kind of “emotional blackmail,” and said that if it isn’t true, “the whole thing falls apart.”
“The only thing that could get parents to agree to something that their natural instincts tell them might not be a good idea is if they think the only alternative is their kid’s doing to die,” he said. “If a bunch of professionals — teachers at school, guidance counselors — tell them, ‘You’ve got to get on board or your kid will die,’ then they get on board, too.”
Greene felt like he could bring something new to the table. During his career, he said, he’s become good at “detecting BS and debunking it.” When he started reviewing the existing literature examining the relationship of puberty blockers and cross-sex hormone treatments to suicidal outcomes, he found it lacking.
“The empirical research base here is incredibly thin,” Greene said, adding that shouldn’t be surprising considering the use of those treatments didn’t really start spreading in the U.S. until around 2010. There are only a few prominent studies with control groups examining the impact of the treatments on the mental health and suicide rates of young people.
Those studies have mostly relied on surveys of trans-identifying adults. Greene said those surveys draw subjects from a “convenience sample” that isn’t representative of the population.
“Largely, they go to trans activist groups and they say, ‘Give us your mailing list,’” Greene said. The problem, he said, is that people who are on the outs with those trans groups — people who are more likely to have had bad outcomes with trans treatments — are less likely to be surveyed. “They’re not finding the unhappy customers with their sampling,” he said.
The bigger problem with the studies is the systemic difference between the people in their treatment groups and their control groups, Green said. One of the requirements for receiving the treatments is that a patient is psychologically stable. So, it’s likely that the control groups — the people who wanted hormone treatments but couldn’t get them — disproportionally contain people who were disqualified for being psychologically unstable.
“Which would mean that all that they’re finding is not the effect of the drugs on later mental health, they’re just finding that people that start out with worse mental health report later having worse mental health,” Greene said, a finding he called “uninteresting and unimportant.”
A Better Approach?
Over the years, Greene said he’s tried to impart on his students an uncomfortable truth: Almost all research sucks. “Your goal,” he would tell them, “is to suck less rather than suck more.”
When designing his research into the impact of puberty blockers and cross-sex hormones on the mental health of young people, Greene said his goal was to “suck less.” He added that, “what I’m really good at is coming up with clever strategies to isolate causal effects better.”
The ideal study, he said, would be a random assignment experiment where subjects who want hormone interventions are randomly assigned to a treatment or control group. That’s not what Greene’s research is, however. His research, he said, is “quasi-experimental,” in that it attempts to approximate an experiment in important ways, though inevitably falls short.
Greene’s research is based on what he describes as “a natural policy experiment” — that 33 states, plus Washington D.C., have legal provisions that allow minors to obtain routine health care without parental consent, while 17 states do not. In states that have those legal provisions, “it is possible for adolescents to obtain puberty blockers and cross-sex hormones, at least under some circumstances, as those medical interventions have come into broader use for youth who identify as transgender,” according to Greene’s report.
Greene said the extra barrier to medical care access is “exogenous” or “effectively random with respect to this issue.” The two groups contain both red and blue states, and “it’s as if people have found themselves by chance in a state where there’s an extra barrier or not,” he said.
Greene then compared suicide rates over time in the two groups of states among young people ages twelve to 23, who would normally have entered puberty since 2010, when puberty blockers and cross-sex hormone treatments became more commonly used in the U.S.
Greene said there are three elements of chance in his research, or “exogeny” in the where (states with and without an added barrier to youth medical care), the when (before and after hormone treatments became readily available), and the who (people who experienced puberty after 2010, but weren’t already 18 in 2010). The research is “noisy” in the fact that Greene’s variation to exposure to treatment by minor consent laws is imprecise, so the fact that he was able to find any statistically significant difference between the two groups of states is important, he said.
The findings, according to Greene’s report: “Before 2010, these two groups of states did not differ in their youth suicide rates. Starting in 2010, when puberty blockers and cross-sex hormones became widely available, elevated suicide rates in states where minors can more easily access those medical interventions became observable.”
Greene believes puberty blockers and hormone treatments are the best explanation for the elevated suicide rates in states with a lower barrier to medical care for minors, though he acknowledges it’s possible there is something else at play.
“That’s just the inherent messiness of research. There are always unknown unknowns,” Greene said. But he said if there is another explanation, “it would have to be a medical intervention that comes along only in 2010, and only affecting this age group.”
Greene said he was unable to get prescription data by state for puberty blockers and cross-sex hormones that would have allowed him to run a two-stage regression analysis to better understand their effects on suicide rates.
On Twitter, journalist Jesse Singal, who has written critically of many of the leading studies on transgender medical treatments, called Greene’s study “awful.” He accused Greene of reaching “into basically the same bag of tricks” as Turban and other researchers on the pro-trans-medical-treatment side.
“The Heritage article doesn’t come close to telling us ANYTHING about the effects of youth gender medicine,” Singal tweeted. “I am not overstating this.”
Either you care about the quality of the research and claims surrounding this issue or you don't. The Heritage article doesn't come close to telling us ANYTHING about the effects of youth gender medicine. I am not overstating this. https://t.co/jrTd99Lyng
— Jesse Singal (@jessesingal) June 14, 2022
Greene said he believes Singal and other critics of his report misunderstand his research, and defended his approach in an in-depth blog post Monday.
“I’m looking at it from a kind of public health perspective as opposed to an individual treatment perspective. That is, this is not about should individual kids be getting these (treatments) or not, it’s about what policies should we have about their availability,” he told National Review. “I’m much more focused on trying to isolate causation than I am trying to answer the question whether an individual kid with dysphoria should be taking these drugs or not. They want to answer that question, and I’m not answering that question.”
“I don’t think they understand why trying to isolate causation is so important and so difficult, but it is the essence of the problem here,” Greene added. “We want to know do these drugs actually cause people to not commit suicide, or does it cause the opposite, or does it have no effect?”
On Twitter, Turban downplayed Greene’s findings by noting that his paper has not been peer reviewed. The paper hasn’t been peer reviewed, but Greene said “that doesn’t mean that it won’t be a peer-reviewed study. It will be. It’s just a matter of time.”
Greene said he intends to submit his research for peer review, and he has a journal in mind. But that process could take years, he said, and he felt it was important to put his research out now while policy decisions are being made. Media outlets report on working papers “all of the time,” he said. “These things are not secret and only done among professionals,” he said.
If Turban were really concerned about the causal outcomes from these medical treatments, “he would be advocating for a random assignment experiment,” Greene said. “And the fact that he doesn’t is incredibly damning.”
Greene acknowledges his research isn’t perfect. At the very least, he said, his findings should give pause to people who are rushing kids into potentially dangerous medical transitions.
“We don’t have random assignment experiments at all on this,” Greene said. “We’re lacking the kind of extremely strong evidence that we would normally want to have to adjudicate such an important issue.”