The Distortions in Jack Turban’s Psychology Today Article on ‘Gender Affirming Care’

Turban's public statements on pediatric gender medicine have been less than honest.

Image credit: master1305

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For those not following the debate over pediatric gender medicine, Dr. Jack Turban is one of the leading proponents of the controversial protocol known as “gender affirming care” and has been outspoken in the American media promoting puberty blockers and cross-sex hormones to manage gender-related distress in youth. He is quoted widely and frequently by mainstream, left-of-center outlets including the Washington Post and the New York Times. This, despite the fact that he is fresh out of his residency and has far less clinical experience than many of the experts with whose more cautious approach to managing gender dysphoria in youth he disagrees.

One of Turban’s most widely cited articles is the one published by Psychology Today back in January of this year. The article, it should be noted, was published after health authorities in Sweden, Finland, and the U.K. had conducted systematic reviews of evidence for puberty blockers and cross-sex hormones and concluded, unanimously, that the risks and uncertainties outweigh any known benefits. Sweden and Finland have already severely limited the practice, and the U.K. seems to be moving in the same direction following the damning Cass Report. Medical authorities in France and New Zealand have also sounded the alarm, with France’s National Academy of Medicine now urging “the greatest caution” when using hormones to treat gender-related distress in minors.

Turban has thus far chosen to ignore these developments. In the case of the U.K., he has misleadingly suggested that the decision to shut down the country’s gender clinic (which was also the largest gender clinic in the world at the time) was prompted only by concern over long wait times and that the NHS was still on board with the “affirmative” model of care. Even a cursory reading of the Cass Report shows that this is demonstrably false. Cass explicitly cites the “affirmative model,” which “originated in the USA” and pressures clinicians not to question a minor’s gender self-identification and desire for transition, as a probable reason behind the lack of child “safeguarding” and the rushing of minors to medicalization.

This fits a broader pattern of Turban spreading misinformation and, at times, demonstrating ignorance about the basic facts of studies he cites. For example, as an expert witness on behalf of the ACLU in Brandt et al v. Rutledge et al, which challenged Arkansas’ ban on the use of hormones and surgeries for minors, Turban testified that there are two Dutch studies, consisting of two distinct, if overlapping, cohorts. He says something similar in his Psychology Today article. In fact, however, there was only one cohort of Dutch patients from which two studies were produced. Not just “some” (as Turban says in Brandt) or “many” (as he says in Psychology Today), but all participants in the second study participated in the first study—a fact the significance of which will be discussed shortly.

Why the misleading statement? Perhaps Turban thinks that the higher the number of studies, the more likely a judge is to rule against state efforts to regulate gender medicine, and the more likely readers of Psychology Today are to agree with his conclusions. Regardless, either Turban is unaware of the Dutch study’s details, or he has deliberately misled a federal judge.

According to Turban’s Psychology Today article, “sixteen studies to date have examined the impact of gender-affirming medical care for transgender youth” and the evidence from these studies “suggests that gender-affirming medical care results in favorable mental health outcomes.” The language of “results in” can easily lead the reader to believe that hormonal interventions cause improved mental health. As I go through these studies one by one, I’ll show not only that such claims of causality are not supported by the evidence (as made clear, at times, by the authors themselves), but also that some of the studies Turban cites actually show no or even negative association between hormones and mental health.

Study 1 & 2: 

De Vries, A. L., Steensma, T. D., Doreleijers, T. A., & Cohen‐Kettenis, P. T. (2011). Puberty suppression in adolescents with gender identity disorder: A prospective follow‐up study. The Journal of Sexual Medicine, 8(8), 2276-2283.

De Vries, A. L., McGuire, J. K., Steensma, T. D., Wagenaar, E. C., Doreleijers, T. A., & Cohen-Kettenis, P. T. (2014). Young adult psychological outcome after puberty suppression and gender reassignment. Pediatrics, 134(4), 696-704.

According to Turban, the 2011 study showed “improvements in depression and global functioning following treatment,” but not in “feelings of anxiety and anger, gender dysphoria, and body satisfaction.” The 2014 study “found that psychological functioning steadily improved over the course of the study and by adulthood these now young adults had global functioning scores similar to or better than age-matched peers in the general population.”

Both articles are reports from the famous Dutch study. That study, however, suffers from serious internal difficulties, and even if these are ignored, its findings are almost certainly inapplicable to the majority of cases presenting at gender clinics nowadays. For good treatments of the problems on both fronts, I recommend this peer-reviewed article by Levine et al, who first categorized the Dutch study’s weaknesses, and this one by Michael Biggs, which explores the problematic origins of the practice. Because the Dutch study is still regarded as the gold standard in this area of medical research, it is worth describing some these problems in greater detail.

Regarding the study’s internal limitations, I will mention five. First, as noted by Levine et al, the only metric on which the researchers observed clinically significant improvement was alleviation of gender dysphoria (and related body image). But this finding rests on a sleight of hand. The Dutch team used the Utrecht Gender Dysphoria Scale, which has different questionnaires for males and females. They gave male-to-female transitioners the male questionnaire at the beginning of their transition but the female questionnaire at the end. As Michael Biggs points out, after transition “[a] boy who wanted to become a girl… would be rating agreement with the statement ‘I hate menstruating because it makes me feel like a girl’ and satisfaction with ‘ovaries-uterus.’” That a biological boy who transitioned to the female role does not “hate menstruating” would yield the minimum gender dysphoria score, leading to a meaningless finding of “resolved” dysphoria.

Second, the 2014 study, the final of the two studies of the same patient cohort, relied on only 1.5 years of follow-up after subjects had completed their transition. This time frame is hardly enough to pick up on whether the procedures are ultimately to the benefit of the patients. Two studies found that the average time to regret is around ten years—and keep in mind that almost all the data in these studies comes from those who transitioned as adults and were gathered before the “affirming” model and its hostility to safeguards became widespread. Increasingly, we hear testimonies of detransitioners that confirm that there is a period of time immediately after completion of some or all of the transition where the individual experiences euphoria. As even Peggy Cohen-Kettenis, one of the Dutch researchers who co-authored the 2011 study, would later observe, “a truly proper follow-up needs to span a minimum period of 20 years.”

Third, the study could not reliably distinguish the effects of hormonal and surgical interventions from those of psychotherapy. As we shall see, this is a consistent problem in studies on the link between hormones and mental health: not only did candidates (at least until recently) have to demonstrate a stable state of mind and absence of psychological counterindication (co-occurring conditions) to receive puberty blockers or cross-sex hormones in the first place, but once receiving them, they were continuously seen by therapists who (presumably) worked to address their underlying mental health problems (anxiety, depression, etc.).

Fourth, as Levine, Abruzzesse, and Mason observe in a forthcoming peer-reviewed article, de Vries and her coauthors carefully selected patients for participation in their study—so carefully, in fact, as to moot the clinical significance of their findings. To be eligible for the study on puberty blockers, participants would already have had to be enrolled for cross-sex hormones, which, given eligibility criteria, meant that their use of puberty blockers did not yield any seriously negative results. Put another way, for their research on puberty blockers, the Dutch team excluded from the outset cases that would have cast doubt on the safety or efficacy of puberty blockers. It is hard to imagine a more obvious example of selection bias. 

Fifth, the only effort to replicate the Dutch research to date has failed. Replication is essential to scientific research because researchers can never be sure if the results they observe are due to confounding factors which they may not have fully recognized at the time and for which they did not adequately control. The fact that a team of researchers in the U.K. tried to apply the eligibility criteria and treatment protocols of the Dutch team to a cohort with similar characteristics but failed to observe the same outcome substantially weakens the claims of the original study.

Setting these five difficulties aside, the study’s other big problem concerns its applicability to today’s scene. To be eligible for medical transition, all candidates in the Dutch protocol had to have early-onset gender dysphoria that persisted (and often intensified) into adolescence. This was crucial, according to the Dutch researchers, because the vast majority of gender dysphoric children desist on their own by puberty and many come out as gay. Candidates also had to have no serious psychological counterindications, strong familial support, including for their decision to transition, and a good understanding of the fact that they cannot truly change sex—what they are changing is their appearance and gender role. Being firmly in touch with biological reality was thought to be essential to eventual happiness by creating more realistic expectations, which include daily maintenance of the new appearance (trans females have to dilate their neovaginas so they don’t close like a surgical wound tends to; both sexes need ongoing administration of sex hormones, even, in many cases, when a person decides to reverse the transition).

By contrast, most of the pediatric patients referred to gender clinics today are females with no prepubertal history of dysphoria and very high rates of mental health problems. One would think that this should serve as a major red flag, and for some prominent practitioners of “gender affirming care” it is. Yet the point of the “affirmative” model of care, as it has been explained and promoted by transgender advocacy groups and politicians in the United States, is precisely to reduce the very “gatekeeping” that the Dutch deemed necessary. As Dr. Thomas Steensma, one of the authors of the Dutch papers, put it in 2021, by dispensing with the rigorous mental health assessments to screen candidates for medical transition, other countries were “blindly adopting our research.” This creates a paradox for advocates of “gender affirming care” like Jack Turban: the more the validity of the Dutch study is played up (and by extension the selection criteria for hormones made stringent), the less applicable its findings to the majority of those who seek medical transition today. 

Turban acknowledges the modest nature of the Dutch findings, but fails to disclose to readers the Dutch experiment’s—to call it anything else is disingenuous—serious internal flaws and applicability problems. It is surely relevant to our debates over medical treatment of youth that the most significant study to date on “affirming” hormonal interventions is of exceptionally low quality.

Study 3:

Costa, R., Dunsford, M., Skagerberg, E., Holt, V., Carmichael, P., & Colizzi, M. (2015). Psychological support, puberty suppression, and psychosocial functioning in adolescents with gender dysphoria. The Journal of Sexual Medicine, 12(11), 2206-2214.

Turban admits that there was no statistically significant improvement for the cohort that received hormones and psychotherapy as compared to the group that received only psychotherapy. But he says that this was “likely due” to the study’s “small sample size” of 35. It is worth noting that Turban readily and without qualification infers robust positive effects from hormones on mental health from other studies that have roughly the same or even smaller sample sizes. See Studies #2 (55 participants), #6 (23), #8 (50), #12 (19), and #16 (6, but see explanation below).

It appears that sample size is only flagged as an issue when results don’t support Turban’s favored conclusion—a good demonstration of his confirmation bias.

Study 4:

Allen, L. R., Watson, L. B., Egan, A. M., & Moser, C. N. (2019). Well-being and suicidality among transgender youth after gender-affirming hormones. Clinical Practice in Pediatric Psychology, 7(3), 302.

Turban claims that this study “found statistically significant increases in general well-being and a statistically significant decrease in suicidality.” The claim is true as stated, but the crucial detail Turban leaves out is that all those who received hormones also received psychotherapy, making it impossible to determine which of the two interventions (or both together) was responsible for the improvement.

Study 5:

Kaltiala, R., Heino, E., Työläjärvi, M., & Suomalainen, L. (2020). Adolescent development and psychosocial functioning after starting cross-sex hormones for gender dysphoria. Nordic Journal of Psychiatry, 74(3), 213-219.

According to Turban, this study “found statistically significant decreases in need for specialist level psychiatric treatment for depression (decreased from 54% to 15%), anxiety (decreased from 48% to 15%), and suicidality or self-harm (decreased from 35% to 4%) following treatment.”

In fairness to Turban, the authors do report a statistically significant drop in “suicidality/self-harm” among those who received hormones: from 35 percent to 4 percent (p < 0.001). However, the authors also clearly indicate that “[t]hose who did well in terms of psychiatric symptoms and functioning before cross-sex hormones mainly did well during real-life,” while “[t]hose who had psychiatric treatment needs or problems in school, peer relationships and managing everyday matters outside of home continued to have problems during real-life,” thus raising the question of why initiate hormonal interventions in the first place.

More damningly for Turban, the authors describe the clinical significance of their findings this way: “Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria. Appropriate interventions are warranted for psychiatric comorbidities and problems in adolescent development.”

Given the tension between their findings on “suicidality/self-harm” and this last statement, one would expect a careful researcher to contact the authors for clarification.

That is exactly what I did, following the use of this study by Grace Huckins in a WIRED article (that relied heavily on Turban) to promote the unfounded belief that “gender affirming” hormones are effective suicide-prevention methods. Here is what the lead author, Dr. Riittakerttu Kaltiala, who presides over one of Finland’s two state-approved pediatric gender clinics, told me in an email:

[Huckins’ piece] is a total mischaracterization of our research! We said practically the opposite: gender affirming hormones did not reduce psychiatric problems or improve the adolescents’ functional level.

When I asked her to clarify what she and her coauthors meant by “suicidality/self-harm,” she wrote:

Self-harm/suicidality in our study refers mainly to self-cutting. We did not have patients with recent history of severe suicide attempts or severe suicidal ideation. During the real-life (hormone treatment) the adolescents needed specialist level psychiatric treatment equally commonly as before, but it was less often explicitly recorded as being due to self-cutting or other self-harming behaviour. 

I cannot claim that my research would have shown that gender affirming hormonal treatment reduces suicidality. 

In short, Turban and Huckins may be forgiven for their interpretation of the study, but that interpretation is still wrong inasmuch as it promotes the idea that hormones are “medically necessary” and “life-saving.” It bears mention that Kaltiala is one of the Finnish experts who first sounded the alarm over the potential inapplicability of the Dutch protocol to the new (“rapid onset”) patient cohort Finland’s clinics began seeing during the 2010’s. Medical authorities in Finland have since conducted a systematic review of the evidence and, concluding that the risks are serious and the benefits unproven, sharply curtailed the use of hormones in treating gender dysphoric teenagers.

Study 6: 

de Lara, D. L., Rodríguez, O. P., Flores, I. C., Masa, J. L. P., Campos-Muñoz, L., Hernández, M. C., & Amador, J. T. R. (2020). Psychosocial assessment in transgender adolescents. Anales de Pediatría (English Edition), 93(1), 41-48.

According to Turban, the transgender-identified participants “who received gender-affirming hormones had statistically significant improvements in several mental health measures, including anxiety and depression,” as compared to the non-transgender control group.

This is true, but the study had a very small sample size (only 23 in the hormone cohort), relied on a convenience sample, and did not control for other (non-pharmaceutical) possible contributors to the positive outcome. Eligibility guidelines for participating in this study adhered to some, but not all, of the Dutch standards: candidates were not required to have had early-onset dysphoria persisting into adolescence, but they did need to exhibit no psychological counterindications, understand the risks and benefits of hormones, and have a “highly supportive family environment.” The authors note that nearly all participants had a “highly supportive” family environment and that that environment “could explain the highly favorable outcomes observed at 1 year of treatment.”

The study also utilized the Utrecht Gender Dysphoria Scale in the same problematic way that the Dutch had done, so its finding that “every trans participant had gender dysphoria at [the beginning of the study] and none had gender dysphoria at [the end of the study]” should be taken with a huge grain of salt.

Study 7: 

van der Miesen, A. I., Steensma, T. D., de Vries, A. L., Bos, H., & Popma, A. (2020). Psychological functioning in transgender adolescents before and after gender-affirmative care compared with cisgender general population peers. Journal of Adolescent Health, 66(6), 699-704.

According to Turban’s interpretation of this study, “those who received pubertal suppression had better mental health outcomes than those who did not receive pubertal suppression.”

Once again, the authors did not control for confounding psychotherapy. They acknowledge this themselves: “The present study can, therefore, not provide evidence about the direct benefits of puberty suppression over time and long-term mental health outcomes.” Thus, while Turban’s language is technically correct if it simply points to correlation, throughout his article (and in other statements he has made to the press) he creates the impression of causality.

Study 8: 

Achille, C., Taggart, T., Eaton, N. R., Osipoff, J., Tafuri, K., Lane, A., & Wilson, T. A. (2020). Longitudinal impact of gender-affirming endocrine intervention on the mental health and well-being of transgender youths: preliminary results. International Journal of Pediatric Endocrinology, 2020(1), 1-5.

Turban: “Over the course of the study, there was a statistically significant decrease in depression scores.”

This was a small (n=50), convenience sample study of 33 FtM and 17 MtF participants. 90 percent of participants were in counseling and one-third were on psychiatric medication. The authors attempted to control for these confounding variables, though apparently not very well, as the U.K.’s National Institute for Health and Care Excellence (NICE) excluded the study in its 2020 systematic review of the research due to “data for [puberty blockers] not reported separately from other interventions.”

Achille et al found a statistically significant improvement in depression, but only for male-to-female transitioners (who were only one-third of the studied group, and the minority of adolescents referred to gender clinics today) and then only for puberty blockers but not cross-sex hormones. A second depression test, found no statistically significant improvement in either male-to-female or female-to-male transitioners. These qualifications are highly significant in light of the current realities of pediatric gender medicine, yet Turban mentions none of them.

Study 9: 

Kuper, L. E., Stewart, S., Preston, S., Lau, M., & Lopez, X. (2020). Body dissatisfaction and mental health outcomes of youth on gender-affirming hormone therapy. Pediatrics, 145(4).

Turban: “When examining all participants together, the study found statistically significant improvements in body dissatisfaction, depressive symptoms, and anxiety symptoms.”

It’s worth noting that NICE rated this study’s findings as being of “very low certainty.” Regardless, the findings themselves were modest. For example, the authors recognized four categories of depression (“not elevated,” “mild,” “moderate,” and “severe”) and the mean score (based on self-report) was 9.6 at baseline and 7.4 at follow-up, meaning only marginal improvement, and all within the “mild” category. The results further showed “small reductions” in anxiety and larger reductions in body dissatisfaction, though given the very short follow-up time (less than 11 months) it is hard to make much of even this finding.

Suicidal ideation and attempt and non-suicidal harm actually increased throughout the study, but without adequate statistical analysis it’s hard to know whether this finding is significant. According to a recent report on the literature by Dr. James Cantor, Achille et al “found no statistically significant changes in the group undergoing puberty suppression on any of the nine measures of wellbeing measured, spanning tests of body satisfaction, depressive symptoms, or anxiety symptoms.”

Study 10: 

Turban, J. L., King, D., Carswell, J. M., & Keuroghlian, A. S. (2020). Pubertal suppression for transgender youth and risk of suicidal ideation. Pediatrics, 145(2).

Turban: “After adjusting for potentially confounding variables, access to pubertal suppression was associated with a lower odds of lifetime suicidal ideation.”

Turban’s summary is misleading. While he and his coauthors adjusted for some confounding variables, they did not adjust for (arguably) the most significant one, which is psychotherapy. As with the Achille study, the U.K.’s NICE did not include this one in its systematic review for this very reason.

The Turban 2020 study on puberty blockers has other serious flaws. It is a cross-sectional study that relies on a 2015 survey of self-report, which, as Jesse Singal has pointed out, seems itself to be skewed toward a younger, more politically engaged population of transgender-identified people. Moreover, participants’ answers were unreliable. For instance, almost three-quarters of those who reported having taken puberty blockers said they began the drug regime after age 18. Though Turban and his coauthors omitted this group from their final analysis, they did not mention the more general problem of unreliable responses.

Most importantly, Turban’s convenience sample and cross-sectional design did not allow for controlling for psychotherapeutic intervention. As Michael Biggs noted in his critique of the paper, “a negative association [between puberty blockers and suicidal ideation] found many years after treatment is compatible with three scenarios: puberty blockers reduced suicidal ideation; puberty blockers had no effect on suicidal ideation; puberty blockers increased suicidal ideation, albeit not enough to counteract the initial negative effect of psychological problems on eligibility.” Turban himself acknowledges this: “the study’s cross-sectional design… does not allow for determination of causation.” So, yes, assuming we are willing to ignore the other problems in the study, puberty blockers may be “associated” with reduced suicidal ideation, but that association may in fact have nothing to do with receiving puberty blockers.

Study 11: 

Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., ... & Viner, R. M. (2021). Short-term outcomes of pubertal suppression in a selected cohort of 12 to 15 year old young people with persistent gender dysphoria in the UK. PLoS One, 16(2), e0243894.

Along with the Costa study, Turban includes this as one of the two that showed no statistically significant improvement in mental health. He says, however, that this is “likely due to their low sample size” (between 14 and 44 patients). To recall, Turban is willing to count as credible evidence studies with low or even lower sample sizes, provided they find positive correlations between hormones and improved mental health. He offers no explanation for this obvious double standard.

It should also be noted that the Carmichael study is the one that attempted to replicate the Dutch study and failed. The British study actually found increases in “internalizing problems and body dissatisfaction” following puberty suppression, according to one report. Another report from the researchers who conducted the study showed no improvement in “the prevalence of measures of disturbance” or in “deliberate self-harm.” These findings, however, went unpublished. As Michael Biggs has pointed out, outcomes for natal females—who comprised the vast majority of referrals to Tavistock during this period—receiving hormones actually showed deterioration in some mental health indices.

Study 12: 

Grannis, C., Leibowitz, S. F., Gahn, S., Nahata, L., Morningstar, M., Mattson, W. I., ... & Nelson, E. E. (2021). Testosterone treatment, internalizing symptoms, and body image dissatisfaction in transgender boys. Psychoneuroendocrinology, 132, 105358.

Turban: “The adolescents who were receiving testosterone treatment had lower scores on measures of generalized anxiety, social anxiety, depression, and body image dissatisfaction.”

This study relied on a very low sample size (19) of transgender-identified boys (i.e., females) and a control group of 23 individuals. The researchers chose females only because they wanted to measure the effects of testosterone. “All participants were receiving gender affirming behavioral health support for gender dysphoria and had not been prescribed pubertal blockers prior.” Statistically significant improvements were recorded for anxiety and depression, though not for suicidality. The authors continuously qualify that their study has a very small sample size, lacks randomization, and is cross-sectional (as opposed to a higher quality cohort/longitudinal study) and so little can be reliably inferred from it. 

No less important, participants were carefully screened for eligibility. “A diagnosis of gender dysphoria was obtained after several months of extensive assessments of mental health and gender dysphoria. Multidisciplinary team discussions were held prior to initiation of GAH treatment to ensure longstanding gender dysphoria and appropriateness for the intervention.” It is unclear, then, whether this study is applicable to many youth seeking hormones today. According to some first-hand reports by detransitioners and mental health clinicians, these teenagers can receive hormones with very little prior mental health evaluation. In short, the Dutch study paradox applies here too: the more valid the findings, the less applicable to most adolescents currently seeking transition.

Study 13: 

Hisle-Gorman, E., Schvey, N. A., Adirim, T. A., Rayne, A. K., Susi, A., Roberts, T. A., & Klein, D. A. (2021). Mental healthcare utilization of transgender youth before and after affirming treatment. The Journal of Sexual Medicine, 18(8), 1444-1454.

According to Turban, “[t]he mean age of starting any gender-affirming medical care was 18.2 (so this study may not technically qualify for our review of studies of adolescents). Their outcomes of interest were number of mental healthcare visits after gender-affirming medical care and number of days taking a psychiatric medication after starting gender-affirming medical care.” The authors, Turban continues, found “no change in number of annual mental healthcare visits and an increase in days taking psychiatric medication from a mean 120 days per year to a mean 212 days per year. It’s difficult to make firm conclusions based on this study, given the unusual outcome measure of number of days per year taking a psychiatric medication.”

The study’s authors suggest a number of explanations for why “mental healthcare visits were not significantly changed and psychotropic medication use rose following gender-affirming pharmaceutical treatment after adjusting for potential confounders.” Among them, the follow-up period was too short (1.5 years median) to draw conclusions. Follow-up periods in studies Turban uses as evidence for “gender affirming care” tend to be even shorter (e.g., 11 months in the Kuper study).

Study 14: 

Green, A. E., DeChants, J. P., Price, M. N., & Davis, C. K. (2021). Association of gender-affirming hormone therapy with depression, thoughts of suicide, and attempted suicide among transgender and nonbinary youth. Journal of Adolescent Health.

Turban: “After adjusting for potential confounding variables, access to gender-affirming hormones was associated with lower odds of recent depression and suicide attempts when compared to those who desired but did not access gender-affirming hormones.”

The researchers, who are affiliated with the LGBTQ advocacy organization Trevor Project, conducted a cross-sectional study that relied on a convenience sample of youth recruited for this purpose. For the overall sample (ages 13-24), depression and serious suicidal ideation improved. For ages 13-17 specifically, depression improved, but improvement in serious suicidality did not reach statistical significance and improvement in suicidal attempt approached, but did not meet, statistical significance. As the authors note: “causation cannot be inferred due to the study’s cross-sectional design. It is possible that those who historically have higher rates of depression and suicidal thoughts and behaviors are also less able to seek or obtain [gender-affirming hormone therapy].”

Study 15: 

Turban, J. L., King, D., Kobe, J., Reisner, S. L., & Keuroghlian, A. S. (2022). Access to gender-affirming hormones during adolescence and mental health outcomes among transgender adults. PLoS One, 17(1), e0261039.

Turban: “We found that regardless of age of initiation, accessing gender-affirming hormones was associated with lower odds of past-year suicidal ideation and past year severe psychological distress. We also found that access to gender-affirming hormones during adolescence was associated with a lower odds of these same adverse mental health outcomes when compared to not accessing gender-affirming hormones until adulthood.”

Jesse Singal has done a comprehensive critique of Turban’s claims in his study—and the way he has been selling his study to an eager and uncritical media environment. Michael Biggs has pointed out that by Turban’s own method, it might actually be the case that male-to-female transitioners (who take estrogen) show a significantly higher association of hormone use with suicidality. Because testosterone is known to have antidepressant properties, it is possible that all Turban and his coauthors really discovered is that people who take antidepressants are, well, less depressed while they take them.

Both Singal and Biggs contacted Turban and his coauthors to see their data and the publishing journal (PLoS ONE) to get more information about the study. Both were largely stonewalled. This unwillingness by major peer-reviewed journals to subject studies that pronounce favorably on “gender affirming care” to serious scrutiny is by now standard fare.

Study 16: 

Tordoff, D. M., Wanta, J. W., Collin, A., Stephney, C., Inwards-Breland, D. J., Ahrens, K. (2022). Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. JAMA Network Open, 5(2), e220978.

Turban: “After adjusting for temporal trends and potential confounders, [the authors] found lower odds of depression and suicidality among young people who had started gender-affirming medical care, when compared to those who did not.”

This is technically true but highly misleading. The Tordoff study was conducted by two graduate students at the University of Washington who followed a cohort of patients at Seattle Children’s Hospital and wanted to know how hormonal interventions affected depression, anxiety, and suicidality up to one year after initiation of treatment. The study’s authors, as it turns out, overstated their conclusions, but these overstatements were themselves modest in comparison to how the UW promoted the study to the media, claiming that GAC “caused rates of depression to plummet.” This is simple, clean, causal language, but wholly inaccurate and misleading.

Those who received hormones in the study experienced no statistically significant reduction in any of the assessed mental health problems. Depression went from 57 percent to 56 percent, anxiety from 57 percent to 51 percent, and “self-harm or suicidal thoughts” from 43 percent to 37 percent. The stated benefits of hormones were inferred, instead, from the fact that the mental health of those who didn’t get them declined. There is an obvious difference between saying that hormonal interventions improve mental health and saying that those who did not receive hormones saw a deterioration. But even this turned out to be too strong a conclusion: almost all the non-hormone participants were lost to follow up, with only six out of ninety-two assessed at the end of the study, making any inferences about causality or even correlation highly irresponsible.

Thanks to the science journalists Jesse Singal and Jason Rantz, we now have confirmation that the UW knew that the study did not in fact find any causality but covered up this inconvenient fact due to the warm glow of positive media coverage. The full story surrounding this study and its publication has to be read to be believed. It stands as yet another example of the research-institution-to-mainstream-media misinformation pipeline that has formed in recent years to create the impression of a consensus in support of “gender affirming care.” As with other studies of this nature, non-findings are mischaracterized as strong evidence, sold to a gullible and ideologically-driven media establishment, and no one bothers (or cares much) to follow up when the truth eventually comes out.

From his assessment of the sixteen studies, Turban concludes that “these interventions result in favorable mental health outcomes.” Here is what Turban should have said, had he written as a scientist rather than an activist:

To date, some studies have shown positive correlations between receiving hormones and improved mental health, but the improvements tend to be modest and regardless, there is no ability to know whether they are because of the hormones or some other factor (such as psychotherapy of familial support). Other studies have shown no or even a negative association between hormones and mental health. Given the gravity of these interventions and their known and believed side-effects, there is an urgent need to know more about the risks and benefits of hormonal interventions for adolescents who experience gender-related distress. It is time for the United States to follow its European counterparts and conduct a systematic review of the evidence, meantime putting all hormonal interventions on hold.

Turban's public statements on pediatric gender medicine policy in the United States have been less than honest. In the main, he has ignored developments in Scandinavia while assuring his readers that those who disagree with “gender affirming care” (as he defines it) wish to adopt blanket bans on all hormonal and surgical interventions for minors. While Turban is correct that this is the approach favored by some Republican states, his statement is hardly an accurate characterization of the wider debate over pediatric gender medicine in the United States. I suspect that Turban knows this but finds engagement with critics who favor a more incremental retrenchment inconvenient. Turban also likes to say that “all experts agree” with the “gender affirming” model—a statement that is only true if you define “expert,” in No True Scotsman-like fashion, as only someone who agrees with Turban. 

Flawed articles like the one by Turban in Psychology Today should be the basis of debate, not a reason for shutting it down. Unfortunately, activists use these articles to argue that when it comes to the health care needs of transgender-identified youth, there is no room for debate. Current efforts underway to use the federal government to crack down on “disinformation” surrounding pediatric gender medicine are dangerous. They undermine the basic conditions for scientific inquiry and put evidence-based medicine beyond reach.

Organizations to Support

• Sex Matters

• Parents Defending Education

• Transgender Trend

• Genspect

• Foundation for Individual Rights and Expression (FIRE)

• Women’s Liberation Front (WoLF)

• LGB Alliance

• Fair Play for Women

• Society for Evidence-Based Gender Medicine

• Counterweight

• The Free Speech Union

• Heterodox Academy