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Dr. Richard Pan’s Claims in Support of California’s SB 107 Are False and Medically Irresponsible
Pan stressed the importance of ‘talking about facts’ and ‘not exaggerating.’ I suggest he take his own advice.
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It was disappointing to hear Dr. Richard Pan, a pediatrician and California senate representative, give a fact-free endorsement of the state’s SB107. The law would effectively set up California as a sanctuary state for minors seeking “gender affirming care.” Its supporters argue that it is a necessary response to Republican states passing laws that ban or restrict the controversial protocol. Pan stressed the importance of “talking about facts” and “not exaggerating.” I suggest he start taking his own advice.
Here are his comments in full, cleaned up for readability:
When it comes to surgery, there is no recommendation for surgery…before the age of majority, when they can make decisions of their own. So that is not what is recommended by the medical profession, and I think it’s important not to exaggerate about that. Unfortunately, there are people who have done that on social media [and] that has led to a bomb threat at a children’s hospital lately… I would also make note that there actually is research…, long term studies, looking at puberty blockers. We also know that there is research that youth who are questioning their gender identity—that first of all, many of then don’t change their minds, [though] I’m not saying it never happens. But by the way most of the treatments we provide to youth of that age are reversible, for example puberty blockers. And that denial of those treatments ha[s] long-term and significant consequences, including depression and suicidality. And we know that the rates of suicide in these youth is higher than in other youth, especially if they are not accepted. So, when it comes to what our role is, here, in trying to protect the people of California, including youth, we want to be sure that we not just Google, but actually talk to experts. People in the field, people who actually work on these issues.
Let’s evaluate the truth of Pan’s claims, one by one.
The medical profession does not recommend surgery before the age of majority
The American Academy of Pediatrics, in its 2018 statement endorsing “gender affirming care,” does not rule out surgeries for minors. It recommends “top surgery” (mastectomies or breast enhancement) and “bottom surgery” (genital reconstruction) for adults as needed, but notes that these “irreversible” procedures are “occasionally pursued” for “adolescents on a case-by-case basis.” In response to our Wall Street Journal op-ed, in which we point out how the AAP has allowed activism rather than science to dictate its policy position, the AAP president insisted that the organization recommends the “exact opposite” of hormones and surgeries for “the vast majority” of children suffering from gender-related distress.
The World Professional Association for Transgender Health, whose Standards of Care (SOC v.7) serve as a guide to pediatric gender clinics in the United States, suggests that mastectomies “could be carried out earlier” than age 18, provided the candidate has undergone a full year of cross-sex hormones. Assuming no changes to the publicized draft, the 8th version of SOC, which are slated to come out this week, lowers the age limit of mastectomies to 15 and breast augmentation to 16. It even allows for “bottom surgery” from age 17.
There is ample evidence that minors subject to “gender affirming care” in the United States have in fact undergone surgeries, presumably upon the recommendation of medical professionals. The surgeon Marci Bowers has openly spoken of the surgeries she has performed on minor patients. A medical center in Seattle published findings from hysterectomies it said it performed on patients ages 16-43 in the peer-reviewed Journal of Obstetrics and Gynecology. Other journals and hospitals have said that minors have received surgeries of this nature as well. And then, of course, there are testimonies from detransitioners like Chloe Cole, who testified at the very hearing where Dr. Pan spoke, who received a double mastectomy at age 15.
In short, if Dr. Pan is right that the medical profession “doesn’t recommend” surgeries, it sure seems like that advice is being ignored.
Bomb threats to Boston Children’s Hospital
It goes without saying that threats of violence against hospitals are totally inexcusable and should be prosecuted to the fullest extent of the law. Dr. Pan’s invocation of the incident at Boston Children’s is, however, inappropriate in the context of the SB 107. First, we are yet to discover who called in the bomb threat; it is at least possible that it was a “gender-affirming” activist using this as a false flag to discredit critics. It is irresponsible of Dr. Pan to assume he knows what happened in Boston. But even if it turns out Dr. Pan is right, that is no indication that critics of SB 107 are wrong. Indeed, it has no impact whatsoever on any analysis of the scientific and therapeutic merits of “gender affirming care.” Sadly, the left-of-center media’s coverage of the Boston incident has focused almost exclusively on the threat itself, virtually ignoring the underlying reasons it may have been made (perhaps journalists believe that explaining why something happened is the same thing as justifying it).
There are long term studies looking at puberty blockers
I assume Dr. Pan means studies that find puberty blockers to be safe and effective in the context of gender dysphoria treatment. If so, I would be curious to know what studies Dr. Pan has in mind; I know of no such research.
Randomized controlled trials for puberty blockers have been done on use for precocious puberty, an entirely unrelated condition with a different etiology, diagnosis, and prognosis, and with a very different calculation of risks and benefits. For gender dysphoria, use of puberty blockers remains off-label and non-FDA-approved. Dr. Pan should know this.
Of note, the side effects of puberty blockers including cognitive impairment (Dr. Hilary Cass, who reviewed the U.K.’s Tavistock Clinic prior to its closure, expressed concern that puberty blockers can impair the very faculty for risk-assessment that allows minors to make an informed decision about whether to continue to cross-sex hormones and surgeries), decreased bone density (early osteoporosis), cardiovascular problems, diabetes, and psychological effects including anxiety and depression. Another serious risk is iatrogenesis: taking them makes gender dysphoria desistence less likely and increases the chance that the patient will go on to pursue riskier forms of medical intervention. One study found that over 98 percent of minors who were put on puberty blockers went on to cross-sex hormones. Another study reports a rate of 87 percent. Since there are no RCTs for puberty blockers in gender dysphoria, it is impossible to know whether these statistics accurately represent clinical outcomes. But they are, at the very least, red flags.
To date, studies examining the mental health benefits of puberty blockers for gender dysphoric youth have either found no correlation, statistically insignificant correlation, or negative correlation. A study from the U.K.’s Tavistock found a statistically significant increase in suicidal thoughts and self-harming behaviors following puberty suppression. Studies purporting to find mental health benefits consistently suffer from biased samples and poor controls. Since patients who get puberty blockers also get psychotherapy, it’s impossible to know which of the two is responsible for mental health improvement. A study from the University of Washington, which was touted in the media as proof that medical gender affirmation is life-saving and medically necessary, found no statistically significant improvement in depression or suicidality. When the university received questions about its misrepresentation of the study to the press, it chose to ignore them.
Most significant is the fact that Dr. Pan simply ignores what has happened in Sweden, Finland, and the U.K. Unlike in the United States, medical authorities in these countries have conducted systematic reviews of the evidence—the highest standard of evidence review, a method intended to prevent cherry-picking of evidence to support a desired result—and all have come to the same conclusion: the benefits of puberty blockers and cross-sex hormones are unclear and their risks are either unknown or known and serious. Sweden and Finland (which now considers the protocol “experimental”) have sharply curtailed the administration of hormones to minors with gender dysphoria. Sweden has banned surgeries outright. In her report for the NHS, Dr. Cass highlighted the lack of proper “safeguarding” in the “affirmative model,” which, she said, originated in the United States. It is precisely this model that California law protects.
We know that youth who are questioning their gender identity… many of them don’t change their minds
The claim is demonstrably false. Eleven studies conducted to date on prepubertal children consistently show that the vast majority (60-90 percent) desist from their cross-gender identification by adolescence. The only study to show otherwise, done earlier this year by Kristina Olson and colleagues at Princeton University, suggests that 97.5 percent of children who are socially “affirmed” persist in rejecting their body’s sex five years later. Although the study was celebrated in the media as evidence that “transgender children” “know who they are” and need to be “supported” in that way, the only way to square Olson’s study with previous findings is by assuming the iatrogenic risk of social transition. Leave a child alone or offer him psychotherapy designed to make him feel comfortable in his body, and he will very likely do so by puberty. “Affirm” his belief that he is “trapped in the wrong body,” and he will very likely persist in that belief.
Regarding adolescents, there are no long-term studies on rates of regret or detransition in the new clinical cohort of adolescent-onset (mainly natal female) gender dysphoric youth, the cohort that has come to dominate the clinical scene in virtually every Western country that has gender clinics. This is partly because this cohort is relatively new and not enough time has passed to know what the clinical outcomes will be. But it is also partly because of ethical and methodological constraints in designing studies around regret and detransition. As Lisa Littman has found in a survey of detransitioners, roughly three quarters of them did not report their regret to their doctors. Finally, given the affirmative model’s emphasis on “following the child’s lead” when it comes to diagnosing dysphoria and prescribing treatment, and given the known high rates of mental health co-morbidities in the new adolescent-onset population, it seems very likely that the rate of false positives (misdiagnosed dysphoria) will be much higher than in the previous (Dutch) studies.
In short, the factually accurate and responsible thing for Dr. Pan to say on this issue is: the vast majority of children with cross-gender identification come to terms with their natal sex, and regarding the majority of youth who nowadays seek medical transition, we have no idea how many will end up changing their minds.
Rates of suicide in gender dysphoric youth are very high, and “acceptance” [i.e. “affirming” medicine] is necessary to address this problem
Dr. Pan is correct that rates of suicidal ideation and attempt are high in youth who identify as transgender, and significantly higher than in non-transgender-identifying youth. But his second, and crucial, claim that laws like SB 107 will address that problem has no basis whatsoever in research.
As alluded to above, the studies usually cited in support of the affirm-or-suicide mantra show at best a loose correlation. These studies do not control for psychotherapy as a potential confounding factor, making it impossible to say whether counseling or hormones are responsible for improvement (assuming improvement actually happens).
The core problem is that most pediatric transitioners these days present at clinics with significant psychiatric co-morbidities, including anxiety, depression, ADHD, eating disorders, history of sexual trauma, and autism. Each of these conditions is known to increase the likelihood of suicidal behavior independent of any “gender” issues. Indeed, a focus on “gender” as the cause of other mental health problems—the assumption behind the affirmative model’s “minority stress” framework—is likely to leave patients without the psychotherapeutic support to address the true causes of their distress. According to the CDC, moreover, simplistic narratives about suicide—such as “gender is the cause of your problems” and “failure to affirm your gender identity will lead you to kill yourself”—are themselves likely to contribute to suicidality. So not only is Dr. Pan wrong, but his use of the affirm-or-suicide mantra is deeply irresponsible.
When talking about suicidality and the link to affirmative interventions, the relevant comparison is not between transgender-identified youth and non-transgender youth, but between the former and non-transgender youth with similar mental health profiles. Only this way can we begin to figure out whether hormones and surgeries, as opposed to psychotherapy, are necessary to address suicidality. A study by the Dutch researchers suggests that when this apples-to-apples comparison is done, the disparity in suicidality diminishes considerably.
Once again, the experience of European countries presumably more LGBT-friendly than the United States is instructive. Sweden and Finland do not “hate” transgender people, nor are parents and doctors in these countries indifferent to teen suicide. Rather, Swedish and Finnish experts have looked at the data surrounding suicidality and its link to “affirming” medical interventions and have found no convincing evidence of benefits. Why Dr. Pan neglects to mention this is anyone’s guess.
Policymakers should take their cues from “people in the field”
It’s not entirely clear what Dr. Pan means by this—whether, for instance, he means that only the opinions of medical professionals who work with gender dysphoric youth should count. If so, this approach is wildly out of step with how medical policy is and should be made. The input of clinicians is obviously of great value, but allowing it to guide policymaking is scientifically wrong and irresponsible. As Dr. James Cantor has noted in a recent report:
The advantages of accumulated personal experience is [sic.] its low cost and potential utility when there do not exist systematic studies of the unique combination of variables represented by some cases. The disadvantages are that it is the most subject to human biases, such as recall bias and confirmation bias, as well as to sampling biases including both self-selection biases (who decides to come into the clinic in the first place) and any variables which led to dropping out of the clinic, leaving clinicians no capacity for determining why.
For these reasons, research methodologists consider clinical experience to be on the lowest end of the quality-of-evidence scale: useful as a starting point of inquiry, but badly in need of filtration by more systematic analysis.
Regardless, many “people in the field” actually disagree with Dr. Pan. In December 2021, for instance, Dr. Laura Edwards-Leeper and Dr. Erica Anderson, both proponents of “gender affirming care,” published an editorial in the Washington Post arguing that the “mental health establishment is failing trans kids.” The crux of their criticism is essentially the same as the one Dr. Cass made of Tavistock: minors were being rushed into medical transition without proper safeguarding. The course reversal in Europe was led by “people in the field” such as Finland’s Dr. Riittakerttu Kaltiala, who writes that “Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria.” (Her study reports a reduction in “suicidality and self-harm,” but in response to my query about what exactly she meant by that she clarified that it referred to non-serious suicidal ideation and non-life-threatening self-cutting.)
It is one thing for Dr. Pan to express an opinion as an elected representative and lawmaker on SB 107. It is quite another for him to invoke his scientific and medical credentials and spread false or highly misleading information about the state of the evidence for “gender affirming care.” Dr. Pan warned against using Dr. Google instead of medical expertise, but it seems that his own views on pediatric gender medicine are heavily informed by Google and avoid any careful analysis of existing research.
The children of California deserve better. So do their parents. And so do families in other states, who are likely to be affected—very likely in negative ways—by the Golden State’s desire to become a sanctuary for minors seeking hormones and surgeries.
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