The Lukewarm Perjury of Jack Turban

These are my notes on Jack Turban’s Declaration in Support of Plaintaiff’s Motion for a Preliminary Injunction in Brandt et al. v Rutledge et al. in the United States District Court for the Eastern District of Arkansas — or just the “Arkansas case” for short. This is a case where medical transition of minors has been legislatively banned and the whole matter has been brought to the courts to sort out. Jack has been brought in to offer his views on the topic and attempt to respond to the claims made by the state’s experts.

Some of these documents are now made public here should you wish to read along yourself. An extract containing only the most interesting points of this text is available here.

I have served as a manuscript reviewer for numerous professional publications including The Journal of The American Medical Association (JAMA), JAMA Pediatrics, The Journal of The American Academy of Child & Adolescent Psychiatry, Pediatrics, The Journal of Adolescent Health, and The American Journal of Public Health.

And we are all astonished at this fact. Perhaps a larger portion of the blame for the poor quality of research in this field should be placed at Jack’s feet.

I have never testified as an expert at trial or in deposition. I am being compensated at an hourly rate of $250 per hour for preparation of expert declarations and reports, and $400 per hour for time spent preparing for or giving deposition or trial testimony. My compensation does not depend on the outcome of this litigation, the opinions I express, or the testimony I provide.

Future opportunities for you to do so, however, probably do.

First, in the realm of pubertal suppression, there have been eight studies. The first was a longitudinal study of 55 transgender adolescents that found a statistically significant decrease in depression following pubertal suppression.

This is de Vries et al., 2014,¹ which was technically a study of 70 children diagnosed with Gender Dysphoria (of which only 32 have their depression scores investigated) rather than “transgender children”, in other words Jack is equivocating. That’s not technically lying, but it’s not a good start. Bringing up the borderline statistically significant depression scores is also quite misleading. Scores went from the “minimal” range to… well, there is no range below “minimal”, so they went from not being depressed to not being depressed.

He could also have brought up that this was an uncontrolled study, meaning that these small improvements could easily have been attributable to other factors, and that causation thus could not be established, or that the finding was only statistically significant for one sex. Or that one of the kids died as a result of medical transition. You could argue this is lying by omission, but I think he gets away with this one.

The second was a longitudinal cohort study of 70 adolescents who received pubertal suppression that found improvements in internalizing psychopathology (anxiety and depression), externalizing psychopathology (e.g., disruptive behaviors), and global functioning. Of note, some of the patients in this study appear to have also been included in the first study.

This is de Vries et al., 2011,² which is the same cohort as de Vries et al., 2014. The same issues as with the later paper were inherent in the study design: the relationship could not be established to be causal, nor were the findings particularly impressive. The findings reported in the paper are that the children went from “minimally depressed” to “minimally depressed” and from “generally functioning pretty well” to “generally functioning pretty well”. Why he brings up the anxiety scores at all is unclear to me, as the anxiety-specific measurement did not change to a statistically significant degree, let alone a relevant one.

With that said, let’s focus on the interesting part of Jack’s statement. He seems surprised and finds it noteworthy that the two studies of the same cohort has “some” of the same individuals. It is explicitly stated in the later paper that these are the same cohort. The only option I see is that Jack hasn’t actually understood the fundamentals of the papers he is citing.

It’s just very revealing about Jack’s self-identified “expertise”.

The third was a study that compared 89 transgender adults who had accessed pubertal suppression during adolescence to 3405 transgender adults who wanted but were unable to access pubertal suppression during adolescence. After adjusting for a range of potentially confounding variables, it found that those who accessed pubertal suppression had a statistically significant lower odds of lifetime suicidal ideation.

Speaking of Jack’s expertise, this is Turban et al., 2020,³ a particular slice of salami in Jack’s ever growing catalog of attempts to launder the 2015 USTS which has already been thoroughly torn apart. For example it has been pointed out that Jack made a number of fundamentally incorrect assumptions, incorrectly cleaned the data and failed to consider major confounding variables⁴.

The findings are weak, and Jack himself is well aware that the study “does not allow for determination of causation”. The fact that Jack, under ideal circumstances and with his finger on the scale, only found one statistically significant improvement out of nine measurements is quite telling. The saying goes “if you torture the data it will confess” and that appears to be what was attempted with this paper.

The fourth was a study that compared 272 adolescents who had not yet received pubertal suppression with 178 transgender adolescents who had already been treated with pubertal suppression. Those who had received pubertal suppression had statistically significant lower “internalizing psychopathology” scores (a measure of anxiety and depression) than those who had not received pubertal suppression.

This is van der Miesen et al., 2020,⁵ which is a very interesting study. It’s another cross-sectional survey where puberty blockers could not be established as the cause of the very modest improvements in internalizing scores that were found. Reverse causation is a considerable question in these studies, and the authors explicitly state that it “can’t provide evidence”, and urge “extreme caution” in drawing conclusions about potential benefits.

An interesting side note to this paper is that it strongly supports the notion that Dutch gender clinics are quite different from others. The children were largely untroubled, or rather very similar to the general population, which is completely different from what is seen elsewhere, like the UK and Canada.⁶ This poses the question of why these children would need medical intervention at all, as they do not appear to be suffering much relative to their peers.

The fifth was a longitudinal cohort study of 50 adolescents who received pubertal suppression, gender-affirming hormones, or both, and that found a statistically significant decrease in depression for transgender females following pubertal suppression.

This is Achille et al., 2020,⁷ and it is where Jack starts taking some real liberties with the truth. One of these is that only 47 of the 50 had hormonal treatment, Jack is possibly confusing the number of participants with the number who received treatment. Although very minor, this was a false statement by Jack which could have been avoided had he been more familiar with the literature.

The rest of the statement is misleading, but not outright false. Jack sneakily focuses on only one out of twelve measurements. Eleven did not improve to a statistically significant degree, directly contradicting some of the previously mentioned studies.

The sixth study was a longitudinal cohort study of 148 adolescents who received gender-affirming hormones, pubertal suppression, or both. When examining all participants together, it found improvements in body dissatisfaction, depressive symptoms, anxiety symptoms. It appeared to be underpowered to detect differences for individual interventions.

This is Kuper et al., 2020.⁸ It is indeed a longitudinal cohort study, although its uncontrolled design and mixed interventions makes it fairly useless when discussing any single treatment. As an example they do not take into account increased use of psychiatric medication. If someone reports lowered anxiety it’s quite important to isolate whether they are receiving anxiolytics before attributing their improvement to something else.

The body dissatisfaction improvement, which is by far the most impressive in the study, was actually followed up on for 96 of the original cohort of 179 (of which 148 had some kind of follow-up). This is an endemic problem with these studies, which Jack completely overlooks. In de Vries et al., 2014, we know that the loss to follow-up includes a death, several cases of severe morbidity and drop-outs.

The seventh was a longitudinal cohort study of 44 patients that appeared to be underpowered to detect improvements in mental health. However, on qualitative interviews, participants tended to have improved mood following treatment.

When talking about Carmichael et al., 2021,⁹ it’s findings should be comparable to some of the other studies Jack cites. For example, Achille et al., 2020, had 47 children (with mixed hormonal treatments) followed up at 12 months compared to the 39–43 children (on a single hormonal treatment) followed up at the same length of time in Carmichael et al.

Jack speculates on why it failed to find what Jack knows is there, but I can’t help but to think that perhaps it’s because it wasn’t actually there. The main difference is that Jack likes the findings of one, and not of the other.

As for the interviews, these are of course subject to all sorts of issues and biases, especially since the researchers jobs and court proceedings would be impacted by the findings of the study. As Jack carefully notes for us, it’s “following treatment” rather than “due to treatment”.

The eight was a study of 201 transgender adolescents in which 100 received pubertal suppression along with psychotherapy and 101 received psychotherapy alone. The study found a statistically significant increase in global functioning for those who received pubertal suppression. Additionally, patients receiving pubertal suppression had greater improvements in global functioning compared to those who did not receive pubertal suppression, though this difference was not statistically significant, likely due to the study being underpowered.

This is Costa et al., 2015,¹⁰ which Jack has gotten himself confused about. While there were a total of 201 adolescents diagnosed with Gender Dysphoria, Jack has gotten the two groups confused (101 were in the immediately eligible group). However, he has also misunderstood the format, as not all 101 received puberty blockers as part of the study, only 60 did.

In this particular case I have to put a large amount of blame on the authors, who after concluding they could not find a statistically significant benefit to puberty blockers still declared their study “confirms the effectiveness of puberty suppression”, in other words simply making up something contradictory to their data.

I’m not sure why Jack didn’t do some basic double checking of his numbers, it would have saved him from having factual errors in a document which he has sworn to a court is true and correct. Whether this is worth calling a lie, I can’t tell. My personal belief is that Jack simply does not know the literature anywhere near as well as he thinks he does and that he is out of his depth.

One additional study, Staphorsius et al. 2015 Psychoendocrinology, measured Child Behavior Checklist scores and found that adolescents on pubertal suppression had lower scores than those receiving pubertal suppression, suggesting better mental health for those receiving pubertal suppression. However, as this study was primarily focused on cognition, it did not conduct statistical comparisons between the two groups and thus I did not include it here.

Jack appears to have made a mess of the first sentence there, but it’s not very important. This is a fair exclusion criteria, although for the reader it may be interesting to note that this study did find that puberty suppression was associated with lower IQ. As with all of these studies, a causal link could not be established, and in this particular case the sample size was tiny, but it’s another example of the arbitrary nature of what Jack deems relevant.

To my knowledge, these are all of the studies to date that have examined the impact of pubertal suppression on the mental health of transgender adolescents. Taken together, these studies strongly indicate that pubertal suppression improves the mental health of transgender adolescents.

Jack has done a serviceable job gathering this material, and he has caught all the main studies on the topic of puberty blockers and mental health outcomes. There are also a few case studies, which are reasonable to skip, and some tangential papers regarding potentially reduced cognitive ability which, while obviously relevant to the larger question, are also fine to skip here. That said, he has done a poor job of describing the papers, including factual errors, falsehoods and firmly misrepresenting the strength of his argument.

Eight papers covering seven studies, five of which were longitudinal, is not nothing. However, due to their uncontrolled nature, mixed interventions and uniformly severe (if not critical) risk of bias, this is by any common definition an extremely low quality base of evidence. None of these studies were designed or able to show a causal link. The only direct comparison of puberty blockers against no puberty blockers showed no statistically significant difference.

In the realm of gender-affirming hormone treatment (e.g., estrogen or testosterone), there have been six studies to date. The first was the study by deVries et al. mentioned above. In addition to examining the impact of pubertal suppression, this study of 55 transgender adolescents found that before and after gender-affirming hormones and surgery, participants had a statistically significant decrease in internalizing psychopathology (i.e., anxiety and depression).

The main problem with de Vries et al., 2014, is that they explicitly excluded those who had the worst outcomes from their sample. It is quite easy to find positive outcomes when you get to ignore the person who died from your treatment, as well as those who developed severe morbidity. This is not a serious way to conduct research, for obvious reasons, as it is essentially the authors lying by omission.

It is also noteworthy that when Jack states that internalizing psychopathology decreased, this is not entirely true. It is true that it decreased on the CBCL (parent-report) however it increased on the YSR (self-report), and the separate measurements for anxiety (the STAI) and depression (the BDI) did not significantly change.

The second study was a longitudinal cohort study of 47 transgender adolescents and found a statistically significant decrease in suicidality following gender-affirming hormone treatment.

This is Allen et al., 2019.¹¹ On its own it says very little, as its design does not allow a causal link to be inferred. As major confounders were left unaddressed it’s hard to say much at all about the role of medical transition, and since the samples relationship to the population isn’t very clear, applicability is a major concern. With that said, what Jack said about it is correct.

The third study was the study by Kuper et al. mentioned above, a longitudinal cohort study of 148 adolescent who received gender-affirming hormones, pubertal suppression or both. When examining all participants together, it found statistically significant improvements in body dissatisfaction, depressive symptoms, and anxiety symptoms. It appeared to be underpowered to detect differences for individual interventions.

We covered Kuper et al., 2020, before and noted the many significant limitations it has. One interesting, but not significant detail, is that suicidal ideation, attempts and self-harm were all much higher during the follow-up period than in the months before assessment. As these time spans are of different length, we can’t make a direct comparison, but it doesn’t really line up with previous study Jack mentioned, Allen et al., 2019.

The fourth was the study by Achille et al. mentioned above, which found statistically significant improvements in depression for all participants (pubertal suppression and gender-affirming hormones) but appeared to be underpowered to detect differences for individual interventions.

This is another mixed intervention we covered before, Achille et al., 2020. Here Jack completely ignores the regression analysis they performed which found that, when controlled for counseling and psychiatric medications, the benefits of cross-sex hormones disappeared into statistical insignificance.

The fifth was the study by Lopez de Laura et al. of 23 adolescents who received gender-affirming hormones and found a statistically significant decrease in anxiety and depression.

This is López de Lara et al., 2020,¹² and Jack describes it correctly. No causal link could be established in it, nor is enough detail provided in the paper to put it in any relevant context. They note their sample is a convenience sample, but we’re not told how bad. It’s simply a terrible paper, although I’m not sure why Jack felt the need to butcher the lead authors name as they very much appear to be intellectual peers.

The sixth was the study by Kaltiala et al. of 52 adolescents who received gender-affirming hormones and found a 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%).

The findings of Kaltiala et al., 2020,¹³ are interesting as the Finns have been aware of the demographic shift for quite some time, and they have taken it into account in their national approach. Jack specifically mentions three areas where need for specialist level psychiatric treatment decreased, but does not mention that there was no statistically significant change overall.

This was due to a reduction for some people, but a new need emerging in an equivalent number. This is why the authors are very cautious in their conclusions, and specifically state that “medical gender reassignment is not enough to improve functioning”. Jack neglecting to mention that the situation worsened for a significant number of patients is interesting to say the least.

As for the overall evidence regarding cross-sex hormones in youth, six studies, some of which are of dreadful quality, that occasionally disagree with each other, with no ability to infer causality nor much in the way of controls is simply very weak evidence.

The state’s experts have focused on a Cochrane review abstract from 2020 examining gender-affirming hormone therapy among transgender women. All this abstract revealed was that there are no randomized-controlled trials (RCT) examining gender-affirming interventions for transgender women.

This is accurate, and in general I think that the Cochrane review¹⁴ is a weak argument. Those of us who follow this topic in detail already know that the evidence regarding safety is quite weak. This does not mean anything to people like Jack, because they apparently consider evidence irrelevant. They seem to have made their mind up about the answer they would like, and if you‘re already sure of the answer there is no need to investigate it.

As Dr. Antonmarria noted in his statement, it would be unethical to conduct a randomized-controlled trial of gender-affirming medical interventions for transgender adolescents, giving the principle of equipoise, which dictates that one may not randomize a patient to placebo when there is strong evidence that the intervention being offered to the treatment arm is superior. No Institutional Review Board (IRB) would approve such an RCT in this field.

I do not believe this is true. This assumes a strength of evidence which is not there. Several countries have already identified the evidence as very weak, which would mean the reason not to doesn’t exist. There are also governmental review boards that could and possibly would approve such research. Even the recent WPATH study for SoC8¹⁵ concluded that the strength of the evidence was low, and even insufficient or non-existent for some areas.

Dr. Regnerus’s assertion that “[there] would be no obstacle to randomized trials without placebo groups to compare different types, dosages, and methods of administrations of active treatments” is irrelevant, as such a trial would only tell investigators if one dose or administration of an intervention were superior to another.

This is not actually true, both because such information would be extremely interesting both if they found significant differences (in which case Jack would be proven right, and we could improve care overall) or if they did not find significant differences (in which case the effect may not be tied to the intervention and the placebo effect becomes a very relevant question).

It seems unlikely that Jack would consider the first scenario a bad thing, but the second one could certainly be threatening to him. If the dosage does not impact the outcome then you’ve essentially reinvented homeopathy. This would of course be hard to measure since the treatment comes with very noticeable effects, especially in the case of testosterone, but you could investigate the effect by offsetting the starting point in a crossover format.

The point is that there would certainly be ways to explore this issue even if Jack was correct, but he does not seem interested in them, nor is he interested in investigating whether he is correct in the first place.

Jack spends some time discussing criticism of his 2020 paper, which is mostly him being obtuse and missing the point of the arguments, but two of his comments are interesting to consider.

In reference to the same study, Dr. Levine states, “it has been rigorously criticized for not emphasizing that… more children on these drugs were hospitalized for suicidal plans than the untreated.” This statement reflects a basic misunderstanding of statistics: one does not draw conclusions from raw frequencies when no statistically significant differences are present.

This is a very near miss of the point, which is that Jack chose to single out one positive finding and ignore the eight that did not change or insignificantly worsened. The plain fact of the study is that Jack failed to find a statistically significant improvement in current suicidal ideation, planning or attempts.

Dr. Hruz goes on to present an unusual conspiracy theory, that “a handful of political advocates could have faked the entire study.” For this to be possible, these presumed “political advocates” would have needed to fill out the over 27,000 responses to the study used. They would also need to be privy to the study design for a study that was conducted 4 years after they completed the survey. They also would have needed to realize that the questions that were asked during remote portions of the survey would later be linked for analysis.

I don’t think you were supposed to take Paul Hruz’s example of the extreme range of implications seriously, but it’s actually an interesting thing to discuss. I don’t see any reason to think it was completely made up, and the strongest argument is really that if you were to make it up then you would probably make it support your argument.

Jack seems confused about how you would go about faking such a survey, when he suggests you would manually fill out the form 27,000 times. You would actually just set the desired results and then have your computer generate those entries for you in a fraction of a second. Possibly Jack does not understand this or perhaps he is being deliverately obtuse in an attempt to create a point where none exists.

Jack also seems to confuse the USTS, the survey itself, with his own work trying to data dredge it. It’s an online convenience sample recruited via advocacy groups, it doesn’t matter that you couldn’t make it say what you wanted it to, let it go Jack. It will rightly never be considered serious evidence.

Dr. Hruz criticizes deVries et al. 2011 by stating, “It is also important to note that gender dysphoria itself did not diminish in study subjects.” When he states, “gender dysphoria,” he is referring to the Utrecht Gender Dysphoria Scale, which measures one’s discordance between their gender identity and their sex assigned at birth (e.g., “I wish I had been born as my affirmed gender”). It would not be expected to decrease following treatment.

The argument for puberty blockers put forth is the “pause button” narrative and there is an interesting tight-rope Jack has to walk. What he must not say is that the role of puberty suppression is to facilitate later medical transition. If reducing anxiety and depression were his actual goals, he would simply recommend existing psychotropics and move on with his life. But Jack is a man of faith, and the question is not of minimizing suffering but of a gendered soul.

All existing published data, along with clinical experience from around the world, point to the fact that gender-affirming medical interventions improve mental health for transgender adolescents. To take these treatment options away from families and their physicians is unconscionable and dangerous.

This is not actually true, both because Jack equates “transgender adolescents” with “gender dysphoric adolescents”, but also because a number of studies, generally larger and at less risk of bias ones, do not show benefits. There is also suggestion that benefits may be temporary. Jack is simply factually wrong when he categorically states “all”. If he instead said “a not insignificant number of short term, low quality studies”, he would be correct.

The state’s experts have incorrectly asserted that gender-affirming medical interventions result in a range of adverse outcomes. They asserted that gender-affirming medical interventions negatively impact sexual functioning when, in reality, research has shown that sexual functioning (along with romantic development) improves.

For this Jack offers Bungener et al., 2020.¹⁶ It does suggest that an encouraging amount of people who have received treatment continue developing, both romantically and sexually. That said, among those excluded were a number of refusals to take part, having been medically ineligible for surgery and also having died from medically transitioning, something generally considered bad for your sexual development.

Everyone in the study was rendered infertile, which has upsides and downsides. It is by definition loss of sexual function, but many young people will be very happy that they can not become or make someone else pregnant. This is something which often, but not always, changes with age.

They note that pubertal suppression resulted in delayed bone mineralization; however, a recent peer-reviewed article in the journal Pediatrics calculated the actual risk of an adverse clinical outcome from this (e.g., a fracture) to be extremely low (1–2% over 5–10 years and only with prolonged use of pubertal suppression past what is generally recommended by current guidelines).

The literature is quite consistent on the results here, which is why Jack does not dispute the outcomes itself, but instead chooses to downplay what it means. For this he offers Pang et al., 2020,¹⁷ a single case report of a fifteen year old male, where we can read the following: “This calculator is based on data from older adults who have gone through puberty; hence, how long density affects EF’s actual risk of fractures is unknown.” The authors note that “EF’s bone density has already fallen to the lowest 2.5 percentile. It can be expected to continue falling.”

The duration of treatment at the time of study was well within the “current guidelines”, under the assumption that these are the guidelines from WPATH¹⁸ and the Endocrine Society¹⁹. If so, then this is an outright falsehood from Jack.

They claim that pubertal suppression and hormone therapy result in infertility, but such a categorical declaration is demonstrably untrue. Pubertal suppression does not impair fertility; research has shown that patients who received pubertal suppression for another pediatric indication, precocious puberty, had no impaired fertility.

To start off with, this directly contradicts studies Jack has previously cited, but most notable is the attempted bait and switch. What Jack states, rewritten more clearly, is that “Research has shown that under different conditions and different dosages, there was no impaired fertility.”

I would not want Jack anywhere near any patients if this is his actual understanding of the matter. He might just kill a patient by arguing that for another indication, chemotherapy is the correct answer. If we get to apply outcomes for different conditions and different dosages we could just as easily say that because these drugs are used in chemical castration they sterilize in 100% of cases — it’s a nonsensical argument.

It is in fact especially ironic that the drugs used in puberty suppression are used for chemical castration. Regardless of the irony, it is an incredibly weak argument. The usage in central precocious puberty will allow the child to enter puberty normally. The child then develops normally. Jack’s usage is the opposite, to prevent puberty from occurring when it should, with the child developing abnormally.

Similarly, a 2019 study for that fertility was similar between transgender men who had been on testosterone treatment and cisgender women.

This is incredibly disingenuous by Jack. These were not random “cisgender women” off the street, these were patients at a fertility clinic as Leung et al., 2019,²⁰ makes very clear: “Another limitation of our data is the selection of patients with infertility as our comparison group.”

Dr. Levine has also made some unusual and frankly offensive statements including, “transgender individuals commonly become strongly narcissistic, unable to give the level of attention to the needs of another that is necessary to sustain a love relationship” that are not substantiated by extant research.

I’m not sure why Dr. Levine has decided to put Jack Turban in the position to make a strong and valid point, but I will certainly agree. While there are certainly a number of cases where identity and narcissism have reinforced each other, this statement is needless, irrelevant and crude.

The state’s experts also stated that estrogen treatment for transgender women increases cardiovascular risk. However, a 2021 scientific statement from The American Heart Association noted that this risk is not established, “The use of gender-affirming hormone therapy may be associated with cardiometabolic changes, but health research in this area remains limited and, at times, contradictory.”

This is an excellent example of Jack’s selective amnesia. The association between cardiovascular risk and estrogen treatment in males is actually far more certain in the research literature than the one Jack proposes for mental health benefits.

The statement from The American Heart Association²¹ appears to be written by people who are under the impression that there is something physiologically different for this group of people, as they occasionally spurt out nonsense like “although estrogen and testosterone treatment, in general, are associated with enhanced endothelial function and reduced large elastic artery stiffness (or increased arterial compliance) in adults who are cisgender, limited data are available regarding vascular function in adults who are TGD”.

The idea that estrogen will have different arterial effects depending on if the individual believes they should have it is not very serious, and says something about the state of this organization.

The state’s experts report that gender-affirming medical care increases breast cancer risk. Studies have shown that transgender men (assigned female at birth) actually have lower incidences of breast cancer than cisgender women (also assigned female at birth) […] however, a second larger study did not detect an increased risk of breast cancer among transgender women compared to cisgender men. Of note, these studies did not examine whether study participants were taking gender-affirming hormones.

I don’t know what the original claim was, but de Blok et al., 2019,²² does report quite alarmingly increased rates among males treated with estrogen, and decreased rates among females who had been on testosterone. This is not surprising as, for obvious reasons, females who have had mastectomies are at lower risk of breast cancer.

The second study, Brown et al., 2015,²³ which Jack describes as “larger” initially seems comparable in size at 49,956 person-years versus 48,874. However, when we look at the data on page 195 that Jack claims doesn’t exist, we find that in terms of cross-sex hormones, the size is actually 17,247 person-years, or just above a third of the size of the “smaller” study.

The first study, which found an incidence ratio 46.7 times larger than expected, was both larger and much longer. Jack has previously (somewhat dubiously) called studies underpowered when they fail to find what he knows is there. To illustrate what an underpowered study actually looks like, this second study is a good example.

Jack’s claims about the two studies are plainly and (more importantly) verifiably false, and his desire to downplay a severe increase in breast cancer cases for males is worrying.

The state’s experts assert that pubertal suppression adversely impacts brain development; however, research has shown that pubertal suppression does not negatively impact executive functioning. Additionally, a 2020 systematic review and meta-analysis concluded that “current evidence does not support an adverse impact of gender-affirming hormone therapy on cognitive performance in birth-assigned either male or female transgender individuals”.

There is a very significant difference between saying that research has not shown that pubertal suppression negatively impacts executive functioning, which is true, and “research has shown that pubertal suppression does not negatively impact executive function”, which is a lie and also happens to be the option Jack went with.

The study he cites for this, Staphorsius et al, 2015,²⁴ does not have the ability to establish whether a causal link exists, so it can not support the claim that Jack makes. It is also a strange choice to bring up by Jack, as it found the suppressed group had significantly lower IQ than the unsuppressed group, but due to the design of the study, no real conclusions could be drawn.

The second citation, Karalexi et al., 2020,²⁵ has nothing to do with puberty suppression of children, and I am not sure why he brought it up. All but one of the studies it looked at were of adults, usually around the age of 30, and investigated their cognitive abilities after a very short amount of time, finding little difference. It doesn’t make sense to bring up this study for this claim, but I suppose Jack was getting desperate.

Every decision in medicine involves weighing risks and benefits of treatment. […] To take away gender-affirming medical interventions as options for these families is dangerous and unethical. For many transgender adolescents, gender-affirming medical interventions are life-saving.

Jack does not offer any citations for this “life-saving” claim, and the evidence he has presented so far simply does not support it. However, the interesting part of this paragraph is the first sentence. Jack has consistently overstated the benefits and understated the risks, something which is common in this field. When Jack describes it as “unethical” to restrict access, it must be recognized that he is somewhat of an expert in terms of “unethical” behaviour.

Though the terms “children” and “adolescents” are sometimes used synonymously in common parlance, it is vital that the court understand that these terms have specific and distinct meanings in the context of child and adolescent psychiatric research. In this field, “child” and “children” refers to a child who has not yet reached the earliest stages of puberty.

This is generally true, and the distinction is relevant. Jack skips through all the nuance, for example the question of whether someone who has had their puberty suppressed fits. Their physiological development will be stunted, but they will have continued to develop to various extents in other ways. However, Jack is correct here and this builds towards a good point which needs emphasis.

The state’s experts inappropriately applied studies of prepubertal children (who are not candidates for gender-affirming medical interventions under any existing clinical guidelines) with studies of adolescents (who, depending on age and other factors, may be candidates for various forms of gender-affirming medical interventions).

I have not gone over the state’s full evidence in detail, so I don’t know how hard they pushed this, but there is a definite likelihood that they have overstated their case. The evidence regarding desistance among children at gender clinics is similar in strength to most evidence in this field: it is weak and uncertain. The applicability point that Jack makes is solid, although Jack is unlikely to bring up the reason for this which is that the populations that have been studied have very little in common with the current demographic.

These studies have been criticized for a range of methodological limitations, but most importantly here, they do not apply to transgender minors who have reached the earliest stages of puberty (i.e., “adolescents”). Once a transgender youth reaches the earliest stages of puberty, it is extremely rare for them to later identify as cisgender.

This is where Jack crashes out on this point, as he offers no evidence at all to support his claim about the “extreme rarity” of this scenario. The expected trajectory is almost completely unknown in the scientific literature, and making claims of such certainty is as negligent and irresponsible as what Jack accuses the state of doing.

Dr. Levine cites a paper by Dr. James Cantor in The Journal of Sex & Marital Therapy that criticized The American Academy of Pediatrics policy statement regarding the treatment of transgender youth. However, the paper does not criticize the use of pubertal suppression, gender-affirming hormones, or gender-affirming surgery for transgender adolescents.

Since Jack has no actual response to Cantor tearing the AAP a new one²⁶, he must argue it is irrelevant. However, Jack has previously argued that the AAP policy statement²⁷ itself is relevant. But now verifying its accuracy is irrelevant. Which way is it?

The paper is focused only on the treatment of prepubertal children, who are not candidates for gender-affirming medical interventions under any existing guidelines.

It seems Jack does not understand the problem the proposed legislation is aimed at dealing with. These guidelines are not standards of care, they are not law, and they are not followed. In a survey of WPATH surgeons²⁸, 55% did not follow the WPATH age recommendations. This is misdirection from Jack, distracting from the real problem and pretending it doesn’t exist.

The state’s experts spend a considerable portion of their statements discussing social transition. This refers to when a transgender child or adolescent takes on a gender expression (i.e., a name, pronouns, clothes, etc.) that matches their gender identity. This is a non-medical intervention that is irrelevant to Arkansas’s SAFE Act.

While it’s true that the SAFE Act²⁸ is not about non-medical interventions, the question of social transition is actually relevant. Jack has previously brought up the “Dutch model” as evidence for the efficacy of medical transition. A key criteria in that process was to not encourage early social transition because this is expected to change the trajectory of the child’s development and would interfere with the diagnostic process²⁹.

The reason for bringing up social transition is one of applicability, and if the population does not match the sample, you can not generalize the findings to it. The plaintiffs in this case are explicitly ineligible under the protocol of the study used to argue for their treatment. This is clearly not irrelevant to the case as a whole.

However, it is worth noting that the assertions made by the state’s experts are false, including this statement from Dr. Levine: “In contrast, there is now data that suggests that encouraging social transition dramatically changes outcomes and often ‘locks in’ a patient’s journey into a life course of dependence on experimental hormone ‘treatments.’

It sounds like Dr. Levine has overstated the case somewhat. There is data that suggests an association, not necessarily a causal link. The most prominent study of this is Steensma et al., 2013,³⁰ which is the study that was brought up.

This assertion is premised on the presumption that a social transition will make a child identify more strongly as transgender. However, recent research has shown that this is false — gender identification is not significantly different before and after a social transition. This research highlights that the state’s experts have misinterpreted the results of Steensma et al., which showed that “persistence” of a transgender identity is associated with a prepubertal social transition.

Jack initially correctly identifies that the link is not determined to be causal. However, he once again confused “not shown to be true” with “shown to be false”. His citation for this is Rae et al., 2019,³¹ which is an extremely low quality study, featuring a small convenience sample, recruited via advocacy groups.

Like Steensma et al., it did not have the ability to show a causal link, and Jack seems to ignore that the respective ages of the children make the comparison nonsensical: Steensma et al. followed children through adolescence, for a mean of 6.8 years, while Rae et al. followed them for a mean of 2.1 years.

The state’s experts proceeded to point to studies showing that over 98% of transgender adolescents who start pubertal suppression go onto gender-affirming hormones, again suggesting that pubertal suppression increased the adolescent’s gender incongruence.

The numbers themselves are not in dispute, the same trend is seen in every pediatric gender clinic that has published their rates. There are really only two realistic options: either there is a causal link or gender clinics became experts at figuring out false positives overnight after being unable to for half a century. Perhaps there is actually only one realistic option there.

However, they make the same mistake again — the high percentage of adolescents going onto gender-affirming hormones indicates that these adolescents had a strong transgender identity to begin with. It is a logical fallacy to state that 98% of adolescent on puberty blockers proceeding onto gender-affirming hormones is evidence that puberty blockers increase the likelihood of persistence; rather all existing evidence suggests that the adolescents who started pubertal suppression to begin with were the those who were, through medical and mental health screening, determined, prior to starting pubertal suppression, to have a low likelihood of future desistence.

I’ve previously considered Jack’s ability to write in a way that a fifth grader could understand to be a strength, and that his main weakness is the fact that his own understanding is at that same fifth graders level. This second sentence is not a good example of Jack’s usual writing ability. It is also not good to accuse someone else of a logical fallacy when you’re committing the very same logical fallacy yourself.

If a higher number of these adolescents did not go onto gender-affirming hormones, these same experts would surely express concern that the evaluation protocols prior to starting pubertal suppression were insufficiently thorough.

It’s certainly possible that they would, although I don’t really see the problem here. The natural process would be one of gradual improvement in diagnostic accuracy, with complaints along the way.

The state’s experts assert that a large number of adolescents who undergo gender-affirming medical or surgical interventions go on to regret treatment; however, this assertion is not backed up by extant evidence. In 2018, Amsterdam’s VUMC Center of Expertise on Gender Dysphoria published the rates of regret among their cohort of 6,793 transgender patients who had undergone gender-affirming medical and/or surgical interventions.

This is Wiepjes et al., 2018,³² which is notoriously poorly written, so I’m not sure how much blame I can put on Jack for not understanding it, and how much belongs to the authors. Even extracting the raw numbers from it is a complex process, for example 6,793 patients did not undergo “gender-affirming medical and/or surgical interventions” as Jack states. What Jack can be blamed for is pretending he does understand it, when he does not.

Among transgender women who underwent gender-affirming surgery, 0.6% experienced regret. Among transgender men who underwent gender-affirming surgery, 0.3% experienced regret. Several of those who experienced regret were classified as having “social regret” rather than “true regret,” defined in the study as still identifying as transgender but deciding to reverse their gender-affirming surgery due to factors like “the loss of relatives [being] a large sacrifice.”

This study was a medical records search for keywords related to regret, and only in cases of gonadectomy, not any “gender-affirming surgery”. However, only the records of people who had medically detransitioned (off CHT and on HRT) via the same clinic were investigated for regret. Anyone outside of those parameters was simply ignored. The authors note an enormous uncertainty in the form of 36% loss to follow up despite the result of gonadectomies being life-long medical dependency.

When Jack says 0.6% and 0.3% “experienced regret” he is simply saying something false. He may be doing this because he doesn’t know better and doesn’t understand the literature, but the alternative, that he is perjuring himself, certainly seems realistic as well.

In a second study of 143 transgender adolescents who started pubertal suppression, 5 (3.5%) decided not to proceed with further gender-affirming medical treatments. […] There was no indication that any of these adolescents regretted pubertal suppression.

This is Brik et al., 2020,³³ which is a very strange study. The median age of start of puberty suppression was 15 for males and 16 for females, meaning that puberty suppression began after puberty was already over for a large number of participants. They would have very little in terms of the negative side effects associated with preventing development, and as such limited reason for regret.

It’s noteworthy that Jack does not mention one specific case which is discussed in the paper. During puberty suppression, a female developed mood swings, and after a year became unwell enough to be unable to go to school. Continuing the treatment, after two years they “developed severe nausea and rapid weight loss for which no cause was identified.” but gradually recovered over the next two years. Jack overlooks the possibility that people who continued transitioning could regret individual treatments.

Cases of initiating then discontinuing gender-affirming hormones like estrogen or testosterone continue to be at the case report level, suggesting that this is a rare occurrence.

I can think of studies where this has been documented, even relatively early in the literature, for example Smith et al., 2005,³⁴ where this occurred in 34 (15.3%) of cases. Perhaps, if Jack spent less time on Twitter blocking detransitioners, he might have known that this is the main reason that the commonly cited figures are unlikely to be accurate.

In a peer-reviewed manuscript that was named Best Clinical Perspectives Manuscript of the year by The Journal of The American Academy of Child & Adolescent Psychiatry, Dr. Alex Keuroghlian and I created a framework for understanding transgender adolescent patients who discontinue gender-affirming medical interventions.

This is Turban & Keuroghlian, 2018.³⁵ I can’t actually find any record of this award Turban claims for it, but on the assumption that it is correct, I can’t imagine it would be given based on the content of the paper as it contains factual errors and also features Jack’s trademark misunderstanding of what a convenience sample can and can’t tell you. Presumably this award would be similar to his 2020 Pediatrics award which was based on reader interaction, the click count.

Our team later published a study highlighting that a substantial number of currently identified transgender people (13.1%) have “de-transitioned” at some point in their life, with the majority (82.5%) citing external factors like family rejection, societal stigma, or harassment.

This is Turban et al., 2021,³⁶ When Jack speaks about this paper, he usually leaves out the words “currently identified”. This is because he knows that they give pause, undermining his point. The fact that he, when there could be legal consequences, makes sure to focus on them proves intent when he otherwise leaves them out, much like fleeing the scene of a crime shows understanding.

Like pretty much all of Turban’s work, this is another slice of the 2015 USTS, a sample which explicitly excluded people who no longer identified as trans, and given it’s nature as an advocacy group recruited online survey it’s not a generalizable source of information. His attempt to frame detransition as primarily something trans identifying people do because they are forced to reveals his willingness to throw those harmed by medicalization under the bus.

Given that these people currently identify as transgender, it highlights that many people who “de-transition” choose to transition again in the future. This harkens to the history of the “ex-gay” movement in which many homosexual individuals reported that they were “cured” of their homosexuality, only to later reveal that they were still homosexual but felt pressured by their communities to say for many years that they were not.

There is no real argument here, but as an aside, I believe Jack makes (rather than has, as it is not the one he intended to make) a point here. Specifically, that the word “detransition” is already overloaded and prone to misinterpretation. While it can be divided into categories like “social”, “medical”, “legal”, one of the main aspects is usually neglected (or assumed, as we’ll see both Jack and the state’s experts are guilty of) — is the reason to transition in the first place still there?

Dr. Levine does not cite the landmark study by Wiepjes showing that regret following gender-affirming interventions is rare. Instead, he cites a study that he falsely claims, “identified 16,000 case reports world wide on the Internet.” If one reads the cited manuscript closely, they will see that this is not the case.

Jack spends a paragraph correctly lecturing Levine and Hruz on the fact that not everyone on r/detrans can be assumed to have detransitioned, nor what their reasons for doing so would be. This is a clear error by the state’s experts, and they should rightly be called out for this. This error is more egregious than anything Jack has done so far, and is a blight on their statements.

While I don’t wish this to be full of side notes, the actual paper³⁷ discussing this is very interesting and covers some of the issues inherent in simplifying an extremely broad and complex issue into a single word, “detransition”.

In fact, in reading r/detrans, one will find posts expressing concern that the group has been dominated by members who have not actually detransitioned but rather by “people who are wanting to prey on their vulnerabilities and use them as political pawns.”

Presumably Jack is as confused as the state’s experts are about how Reddit works, as he claims that r/honesttransgender is the same as r/detrans. The quote Jack cites is from the account “therapythrowaway1205”, and they offer no evidence at all of this. Jack simply cited an anonymous account saying something on Reddit.

What a shitshow on all sides.

The state’s experts cite a second paper that recruited participants from r/detrans. Though the state’s experts imply that this study of 237 individuals was of minors who medically transitioned, only 65% of those in the study had transitioned medically, and only 25% had medically transitioned as minors.

This is Vandenbussche, 2021,³⁸ which recruited from r/detrans but also from their website, on Facebook, Instagram and Twitter. Online surveys of convenience samples are generally of very low quality which Jack has apparently selectively become aware of. This is of course one of the main criticisms against his own recent work, which presents a severe double standard.

It’s important to additionally note that this was an anonymous survey recruited on this r/detrans social media group in which there has been expressed concern that members of the group are not people who have detransitioned but rather people who wish to use detransition narratives for political motivations, such as removing access to gender-affirming medical care for transgender adolescents.

“Expressed concern”, specifically by an anonymous account who has been active in a brigading forum aiming to get r/detrans banned. It’s a pathetic argument, but since the state’s experts explicitly brought up that Turban’s study could be a hoax, I think returning the favor is acceptable.

There is undoubtedly a small number of people who start gender-affirming medical interventions and later stop them. A minority of these appear to regret the treatment. However, it is of course not reasonable to outlaw an intervention that helps the vast majority of people because a small minority will regret treatment.

Turban describes a level of certainty that is both unwarranted from the studies available, and even if the number was certain, applicability would not be. He has not offered evidence that the intervention helps a vast majority of people. His desire to downplay the suffering of those who disagree with him is not particularly becoming of him.

Two people recently shared their stories of this in Slate, comparing the experience to the “ex-gay” movement of the past in which people were forced by external pressures to report they were no longer gay, but later came out as still identifying as gay.

The Slate piece had a lot of errors and misinformation in it, but the most interesting piece to me was that there didn’t seem to be an actual “there” there. Even if we look past such nonsense as “detransitioners may be a small group — even the highest estimates are in the hundreds”, the stories told by the two people interviewed don’t actually offer any ways in which they are similar to the “ex-gay” movement. The writer themselves appears to be an avid campaigner against detransitioners.

In summary, all existing research suggests that regret following gender-affirming medical interventions is rare. As with all medical interventions, gender-affirming medical interventions cannot claim a 100% success rate. However, for the vast majority of adolescents, these interventions improve mental health.

In summary, Jack has offered a single study he did not understand, which also has no relevance to the SAFE Act. His own paper, based on data from an advocacy group recruited online survey, explicitly excluded the outcome being discussed. He chose to ignore another advocacy group recruited online survey based on an anonymous Reddit post.

The actual research literature on this topic is at least 50 papers, so exactly how bringing up one deeply flawed paper is supposed to represent “all existing research” is unclear. It is possible that Jack is simply unaware of this.

The state’s experts repeatedly claim that the “watchful waiting” model of treating gender dysphoria involves not offering gender-affirming medical interventions to transgender adolescents. This is false. The “watchful waiting” model refers to the treatment of pre-pubertal youth, who are not offered gender-affirming medical interventions under any existing medical guidelines. In fact, the “watchful waiting” model was first described by clinicians at The Center for Expertise for Gender Dysphoria at VUMC in Amsterdam, the very first clinic that first developed the use of pubertal suppression for transgender adolescents.

Watchful waiting is a fairly broad term, which has been used in different ways for a long time. The term does not originate in this field, but has been used to describe some approaches to childhood gender dysphoria, centered around non-intervention.

When Jack says “this is false” he is simply incorrect. He mentions the Dutch model as an early form of it, but seems to miss the fact that gender-affirming medical interventions were only offered to post-pubescent adolescent, based on the age limit of 16 and that simply “adolescents” were not offered gender-affirming medical interventions.

Furthermore, the “watchful waiting” approach is not generally practiced in the U.S. Nor do clinicians in the U.S. “push” children into social transition. Rather, the approach in the U.S., which has increasingly become the most common approach for treating prepubertal transgender children, is to allow a child to direct their own gender exploration without any push from clinicians or parents toward any one gender identity (cisgender, transgender, or otherwise).

It is true that “watchful waiting” is not generally practiced in the US. What is in fact seen in a worryingly large number of clinics is maximum medical affirmation, with puberty suppression as young as possible, as early as 8 years old, with cross-sex hormones and surgery administered with little regard for the patients long-term well being.

At this point there are countless reports of mastectomies as young as 12, published papers about them for heavily comorbid 13 year-olds, surveys of WPATH-affiliated surgeons indicating a majority operate on minors, with neo-vagina construction vaginoplasty as young as 15.

This is the reality of the situation in the US, but to acknowledge this would mean to admit that the SAFE Act has serious merit, that there is a problem. Jack’s efforts to obscure this and pretend it does not happen makes him culpable.

There is now a substantial body of literature showing that transgender identity has a strong innate biological basis. However, the state’s experts omit much of this research and misrepresent other elements of the existing literature. For example, Dr. Hruz proposes that, “Identical twin studies where siblings share genetic compliments and prenatal environmental exposure but have differing gender identities” have argued against the strong biological basis for transgender identity.

Twin studies are excellent for certain things, and one of them is to determine the existence of a genetic component to whatever you’re studying. The argument goes, roughly, that because the rate of cooccurrence in twins is relatively low, there is no biological basis but rather a biological component or predisposition. I would say that there is not actually sufficient evidence to say either way, but both side’s experts argue their case on this matter.

On the contrary, twin studies have been some of the strongest pieces of evidence showing that gender identity has a strong biological basis. Researchers have examined identical twins (with the same DNA) and fraternal twins (with different DNA) and found that identical twins of transgender people are far more likely to be transgender people than fraternal twins of transgender people, pointing to a strong genetic link.

For this Jack offers Coolidge et al., 2002,³⁹ which does not actually deal with “transgender people”. Not just because it largely predates that linguistic shift, but also because out of the sample of 314, only 7 scored in the clinically significant range of their unvalidated GID scale.

The error in thinking that Jack has made is to assume that small differences that are clinically irrelevant, for example an increased preference for playmates of the other sex, is that this person is truly meant to be the other sex. I would consider this view to be regressive nonsense, and I suspect that Jack actually has the level of self-reflective ability required to think this through if he wanted to.

When comparing it to the findings for things like autism or even sexual orientation, the twin-study argument appears quite weak — for something with a strong innate biological basis you would expect a much higher rate of concordance.

Functional neuroimaging studies have shown that transgender adolescents have patterns of brain activation more similar to those of their gender identity that those of their sex assigned at birth.

This is Burke et al., 2014.⁴⁰ Some differences were noted although they are overstated here, although what Jack neglects to mention is that this study was not controlled for sexual orientation, which the paper explicitly mentions as a confounding factor. It mentions a study where homosexuals were found to have similar patterns to cross-sex controls, which Jack is presumably aware of since he cites this paper. This would mean that Jack already knows that there is an obvious and strong rebuttal to his claim yet he still made it.

Sophisticated gene sequencing studies have suggested that genes involved in estrogen processing play a role in the development of gender identity among transgender people.

This is Theisen et al., 2019,⁴¹ which appears to be a study of little certainty, however as I am not a geneticist I am underqualified to discuss the mechanisms and implications. I do note what seems like a large number of methodological limitations and that the authors themselves describe it as preliminary at best.

Jack has also taken some major liberties with his phrasing here, as the authors describe using a very small sample and heavy filtering to find what they speculate to be relevant. In doing this they identified certain genetic pathways they believe “constitute a reasonable avenue for investigation into the genetic contribution to gender dysphoria in humans”.

Though the precise etiology of gender identity has yet to be identified, these studies together all establish that there is a strong innate biological basis for gender identity among transgender people.

This is simply incorrect. Very limited investigation, not controlled for major confounding factors, identifying a possible genetic component is not a “biological basis” by any means. Had the evidence existed, this would have been the time to present it.

This is all rather academic, of course, as Jack cannot under any circumstances be specific, as if a measurable and innate biological basis existed it could then be used for gatekeeping purposes. For this reason Jack would not actually make a strong case here even if the evidence existed.

The state’s experts claim that the “error rate” for gender-affirming surgery is unknown. However, as described above, a large cohort study from The Netherlands showed that rates of regret following gender affirming surgery are low (0.3–0.6%), and many of these cases do not represent “true regret” as explained above.

And as explained above, this study shows nothing of the sort. Jack’s fundamental lack of understanding of what this study can and can’t say is worrying, as the implications of misusing it to make an erroneous point can be quite severe.

To illustrate this, in the format of the study anyone who committed suicide would not be considered for regret, despite being an obvious candidate for investigation. There is actually a related paper⁴² on this, from the same clinic, which Jack may or may not be aware of.

The state’s experts also spend a considerable amount of time discussing a paper in The American Journal of Psychiatry by Bränström and Pachankis. This paper is not particularly relevant, as the majority of the surgeries described in the paper are not surgeries offered to minors under any existing medical guidelines (i.e., genital surgery, hysterectomy, laryngeal surgery, etc.). The results are thus not of particular value to discussion of the Arkansas SAFE Act, which applies only to minors.

Jack has already cited studies to support his case where these guidelines were not followed, which means he knows that the guidelines are not followed. He might also be aware of Milrod and Karasic, 2017,⁴³ which found that a majority of surveyed WPATH-affiliated surgeons had performed genital surgery on minors. By referring to what guidelines recommend Jack tries to distract from what actually takes place, a form of cover-up which I would argue makes him culpable.

As for who the state’s experts focus heavily on Bränström and Pachankis, 2020,⁴⁴ and the letters and corrections to it, this is because it was initially cited and promoted as being high quality evidence for the benefits of gender-transition. This turned out to be unsupported by the data. I also note that Jack read and promoted the original paper, yet did not spot any of the issues and errors which generated the letters and the correction.

In addition, the state’s experts all failed to mention a recent study in JAMA Surgery that addressed a major limitation of the analysis Bränström and Pachankis published in their response to letters to the editor critiquing their original study. Namely, the JAMA Surgery paper by Almazan & Keuroghlian used a proper control group.

This is Almazan and Keuroghlian, 2021,⁴⁵ which is another slice of the 2015 USTS. The usual advocacy group-recruited online survey which Jack appears to think is an oracle of divine truth. This is not comparable in quality or generalizability to the Swedish national healthcare system data for a wide range of reasons.

However, the point that the correction’s attempt at control was insufficient is correct. This was only one of many issues with the original paper, but it is enough to say that any claims that the study proves no benefit to surgery is unsupported. What it shows, however, is that erroneous information being published and promoted is a real problem in this field.

However, it appears that Dr. Lappert did not read the discussion of the Dhejne paper he cites, which states that “the results should not be interpreted such as sex reassignment per se increases morbidity and mortality. Things might have been even worse without sex reassignment. As an analogy, similar studies have found increased somatic morbidity, suicide rate, and overall mortality for patients treated for bipolar disorder and schizophrenia. This is important information, but it does not follow that mood stabilizing treatment or antipsychotic treatment is the culprit.”

This is Dhejne et al., 2011,⁴⁶ which as Jack mentions can not establish a causal link to the negative outcomes it found. However, it is also worth mentioning that the authors make an unsupported analogy which is actually contradicted by the two papers they cite for it. Their desire to excuse their findings plays into a larger pattern of confirmation bias which is endemic in this field.

Dhejne and her team have a history of publishing misleading research, including an often discussed paper (Dhejne et al., 2014⁴⁷) which relies on equivocation to present favorable findings. Her gender clinic has also failed to comply with local law regarding the handling of patient suicide, although from what I can tell nothing came of this.

In some ways it’s a perfect example of what passes as “science” in this field. An activist researcher with legal and financial conflicts of interests publishes research of dubious quality and attempts to phrase it in a favorable light despite finding nothing but things to be concerned about.

Gender-affirming chest surgery for transgender adolescents is not considered lightly. Parents and adolescents work extensively with their physicians to carefully weigh the potential risks and benefits of surgery. Existing medical guidelines note that this is only considered for transmasculine patients and only after ample time living as their identified gender.

This is generally false, as we’ll discuss later, but the thing to note is that Jack really does not want to discuss the specifics of the papers he is about to cite, as the literature on masculinizing chest surgery for minors is full of examples of rushing into things and hoping for the best.

There have been two studies examining the impact of gender-affirming chest surgery on the mental health of transgender adolescents specifically. The first was a case series of 68 transmasculine adolescents and young adults that found a reduction in scores on a novel unvalidated chest dysphoria scale.

This is not true, there are actually at least four papers that match the criteria Jack sets here. Presumably Jack simply does not know the literature very well as this would be a very silly thing to perjure yourself about.

The paper here is Olson-Kennedy et al., 2018.⁴⁸ It featured a wide range of ages and is notable for not really following any guidelines. For example, two 13 year-olds had mastectomies which seems completely incompatible with the extensive caution Jack described.

It is also worth noting that the paper found that youth receiving cross-sex hormones steadily increased on the unvalidated chest dysphoria scale, a possible association which is completely neglected in all research on the topic. The idea that masculinizing treatment may make remaining feminine characteristics stand out more seems obvious to investigate and consider for future research.

The second was a series of qualitative interviews with 30 adolescents and young adults that identified themes of improved chest dysphoria and quality of life.

This is Mehringer et al., 2021,⁴⁹ which does describe themes of improved chest dysphoria and quality of life, although they also describe the same theme of worsening chest dysphoria on testosterone, meaning it’s difficult to tell how this compares to the situation before medical transition.

Though this intervention is not appropriate for all transgender adolescents, for some with severe chest dysphoria that persists despite other interventions, it can dramatically improve mental health. It would be dangerous to take this option away from families and their physicians.

Thankfully Jack is brief on the topic of mastectomies, although it is worth noting that his premise is false here. The evidence he has shown actually suggests an interesting hypothesis: that these “other interventions”, specifically testosterone, actually worsen chest dysphoria.

While I do not wish to overstate the extremely limited research, a case could certainly be made that in some cases this is an iatrogenic issue where amputation is the proposed treatment for known side-effects of previous interventions.

The state’s experts also misrepresent the way in which gender-affirming medical and surgical care are provided to transgender adolescents. Dr. Hruz, for example, states “By demanding the immediate and uninvestigated ‘affirmation’ of a sex discordant gender identity patient’s requests for so-called ‘transitioning’ — without conducting a detailed, proper, medical assessment of alternative hypothesis — the gender transition industry is attempting to enforce and institutionalize the methodological failure of ‘confirmation bias.’” Though it is somewhat unclear to what he is referring with phrase “gender transition industry,” it appears he is referring to physicians and other medical providers who provide gender-affirming medical care.

Presumably Hruz wants to highlight the fact that an enormous business opportunity is available for the generally unscrupulous medical industry. In the US, we’re talking about tens of thousands of surgical procedures annually, and lifelong dependency of medical intervention for patients. A single child on Lupron, a common GnRHa, will bring in five digits every year.

You would think Jack might know a thing or two about the money involved since he has received a $15,000 grant from the industry, which he has neglected to disclose as a conflict of interest in his published work. There may not be sufficient information to know what role the considerable sums of money plays, but there is no denying that an industry exists today that simply did not exist a decade ago.

Such medical providers do not “[demand] immediate and uninvestigated” provision of gender-affirming medical or surgical interventions. The WPATH Standards of Care, for instance, highlight that, “before any physical interventions are considered for adolescents, extensive exploration of psychological, family and social issues should be undertaken.”

Jack spends two whole pages on this topic, even though not even WPATH members follow the WPATH guidelines. Bringing them up here is a red herring and irrelevant to the SAFE Act which has to take into account the situation as it exists in reality.

When discussing this line of reasoning, there are a number of studies that I usually bring up. One of them Jack has already cited, Olson-Kennedy et al., 2018, where about half the female patients who had surgery did so under the age of 18, with about a quarter being under 16. Two were 13. The lead author is a WPATH member and on the USPATH board of directors.

Another is Marinkovic & Newfield, 2018,⁵⁰ where a number of adolescents were medically transitioned within two months of their first visit, even if they had no history of gender dysphoria. Most notably a bipolar 13 year-old on antipsychotics (who is also listed as adolescent onset gender dysphoria) was given a double mastectomy in this study. Both authors are WPATH members.

Yet another is the previously mentioned and incredibly titled paper by Milrod & Karasic, 2017, which surveyed 20 US-based, WPATH-affiliated surgeons and found that 55% performed vaginoplasty on minors. Those surgeons “perceived the SOC as purposely ‘vague’ and more as ‘inherently flexible guidelines’”, which is a fair reading of them.

Although not from the US, the paper by Khatchadourian et al., 2013,⁵¹ also reflects the way some gender clinics approach treatment of gender dysphoria, as it states “The median time between the first visit to our clinic and initiation of GnRHa was 0.2 month (range 0–3.2 months), with 12 of 27 patients (44%) receiving treatment at their first visit to our clinic.” In addition, several patients started cross-sex hormones at 13, at least one had a double mastectomy at 14 and at least one had their womb, Fallopian tubes and ovaries removed at 16. Two of the authors are WPATH members.

This is the reality of the situation that the SAFE Act seeks to address. It has nothing to do with Jack’s fantasy scenario, and him spending two pages trying to mislead people about this is extremely tasteless. Bringing up the WPATH guidelines is a very obvious red herring.

The state’s experts repeatedly label gender-affirming medical interventions for adolescents “experimental.” In ascribing this term to gender-affirming medical interventions, they primarily rely on the fact that pubertal suppression and gender-affirming hormones do not have FDA indications for gender dysphoria specifically, but rather for other indications.

Jack notes that the state’s experts “primarily” relies on this, which is not really true. It is one of the things they bring up, and the only one Jack will discuss, but there are plenty of reasons to consider them experimental. When Jack describes “other indications”, he neglects to mention that these indications are for the other sex. There are no indications where you would administer female levels of estrogen to a male, or male levels of testosterone to a female.

Prescribing FDA approved medications without specific FDA indications for the condition being treated is common in pediatrics. It is referred to as “off-label” prescribing. The American Academy of Pediatrics has explained that “it is important to note that the term ‘off-label’ does not imply an improper, illegal, contraindicated, or investigational use.” They go on to explain that “off-label use of medications is neither experimentation nor research.”

While it is true that off-label prescriptions are not uncommon, Jack is quoting this AAP statement⁵² out of context. This is a great way of determining ignorance from malice, as the act of leaving out parts that disagree with you shows that you are aware of them.

The exact sentence is “In most situations, off-label use of medications is neither experimentation nor research” which is followed by advice on how to handle the situation. It discusses sound medical evidence (which does not exist here, as a small number of uncontrolled studies that disagree with each other certainly does not constitute sound evidence), and risk-benefit analysis (which for this use are both unknown).

The state’s experts repeatedly imply that “rapid-onset gender dysphoria” is an accepted phenomenon and that “social contagion” is a driver of gender dysphoria. For instance, Dr. Levine states, “the post-pubertal onset of what is now commonly referred to as rapid onset gender dysphoria or post-pubertal gender dysphoria seems to be heavily influenced by social and internal development forces. This is a fringe view not supported by evidence.”

Of course, we had to discuss ROGD. Is it even a discussion about trans if it isn’t mentioned? Whether or not the demographic shift is due to social contagion is really not actually in question. The DSM-V⁵³, from 2013, states an expected prevalence for gender dysphoria of between one in ten thousand and one in a hundred thousand. WPATH’s SOC7, from 2011, which describes trans identification rather than gender dysphoria also falls into this range.

In a recent survey⁵⁴, 9.2% of surveyed high school students identified as trans. Let’s use rough numbers to work out the growth. The expected prevalence was one in ten thousand, and what was found was one in ten. That’s a thousand times more common in this age group, a pattern that is not seen elsewhere. The “social contagion” discussion is over, this is a social epidemic — the only argument that can remain is one where it’s a social epidemic which happens to be true.

The term “rapid-onset gender dysphoria” entered the literature through a publication by Dr. Lisa Littman. As the state’s experts note, a correction was later published on this article. However, the state’s experts did not highlight the content of the correction, which noted, “Rapid-onset gender dysphoria is not a formal mental health diagnosis at this time. This report did not collect data from the adolescents and young adults or clinicians and therefore does not validate the phenomenon.”

“Rapid-onset gender dysphoria” did enter the literature via Littman’s paper⁵⁵. However, the explosive growth which it sought to explain did not. Nor did the terms “adolescent onset gender dysphoria”, “post-pubertal onset gender dysphoria”, “postpuberty adolescent-onset transgender histories” which others have used to describe the same phenomenon which has been observed in countless gender clinics — a large number of adolescents, especially teenage females, wanting to transition without prior notice.

Nowhere in the original paper did it suggest that this was a validated phenomenon, and the correction (which was a clarification, as no substantive changes were made) is largely irrelevant to bring up by the state’s experts as they don’t imply that it is a formal health diagnosis — they explicitly say “what is now commonly called rapid-onset gender dysphoria” making it clear they are not discussing a formal diagnosis.

I disagree with their use of it as shorthand for the demographic shift, but I also note that Jack’s objection to it is inaccurate and that his willingness to ignore an explosive growth of three orders of magnitude in a few years is simply inexplicable.

The Littman study was an anonymous online survey of the parents of transgender youth, recruited from websites where this notion of “social contagion” leading to transgender identity is popular.

It is accurate to say that Littman’s study is an advocacy group recruited anonymous online surveys of parent’s reports. Jack has already used several advocacy group recruited anonymous online surveys to support his own case, making this somewhat of a double standard. The only difference is that the ones he wanted to keep supported him and the ones he did not want to keep did not.

I’m personally fine with throwing out all low quality evidence, or with keeping it and not attributing any certainty to it. Only keeping the low quality evidence you like and disregarding the low quality you don’t like, however, is — as the state’s expert argues — a perfect example of confirmation bias.

As detailed above, there is no evidence that gender dysphoria or transgender identity are results of “social contagion”. It is true that there has been an increase in referrals to gender clinics over the past few decades. This has coincided with increased visibility of transgender youth in the media.

There has not been an increase “over the past few decades” but rather in one decade. The GIDS in the UK reported a 4400% increase in less than ten years among young females, with staff noting what they were hearing sounded “rehearsed”. I’ve heard from multiple clinicians, including from GIDS, who have used words such as “scripted” for it — it’s quite distinct in conversation with such youth. The difference from year to year before the previous decade can be counted on one hand. This pattern has been seen in every gender clinic that has published this sort of data.

Edit: This originally simply stated “The GIDS in the UK reported a 4400% increase in ten years.”, which is the female only number, which makes sense in the context of Turban spending the last 6 pages talking about females, but without reading both documents at the same time, that may not be clear to the reader. It’s also “less than 10 years”, so while I’m at it, might as well fix that too.

Whereas parents in the past may have had limited literacy regarding gender diversity in adolescents, today most Americans, as well as people abroad, have greater understanding of the experiences of transgender youth. This has undoubtedly dramatically increased the number of parents bringing their adolescents for evaluation. Additionally, insurance coverage of gender-affirming medical and surgical interventions has improved drastically, meaning that more families are able to afford care, which results in an increase in referrals for evaluation.

He doesn’t provide any citations for any of this, not even for the parts that should have numbers attached (for example the insurance argument). But let’s think about what Jack is saying. It’s not a social contagion, it’s just an increased awareness spread via media. So it’s not a social contagion, it just spreads socially.

I would personally also argue that the ideas around trans do not represent “gender diversity”, but rather the opposite. Medicalization of gender non-conforming behaviour is not progressive to me, it actually sounds like something out of the 1950s.

Of note, not all adolescents who present for treatment ultimately go on to receive gender-affirming medical or surgical interventions. In fact, in a large study from The Netherlands, the percentage of transgender people who presented for evaluation who actually started any kind of gender-affirming treatment decreased over time.

This is Wiepjes et al., 2018, again, which Jack simply does not understand. The suggestion of the authors that this may relate to media attention and the internet is quite silly as the rate has stayed roughly the same since 1990, the decrease Jack mentions really only exists from 1975 up to the 1990s. If you were to start from the year 2000, the rate has actually increased.

Dr. Regnerus additionally states that if decreased stigma were driving the higher rate of adolescents openly identifying as transgender, “we should be witnessing a parallel in documentable rise in gender dysphoria among, say, middle-age adults.” However, transgender middle-aged adults have endured decades of stigma for their transgender identities that, despite improvements in contemporary social attitudes, make them fare less likely to come out as transgender.

Jack brings up the “minority stress” model, and suggests “internalized transphobia”, neither of which really offers a satisfying answer to the question of why the phenomenon is so centered on teenagers and young adults. It really seems that he want it both ways, you’ll kill yourself if you don’t transition, but you’ll also live a long life not being “transgender” anymore. Jack’s argument, when extended, suggests that conversion therapy actually works, which is really quite a strange thing to have him say.

Some clinics have noted that they are seeing more birth-assigned females than males in recent years, often referred to as a change in the “sex ratio.” There have been a number of explanations for this, including the fact that in the past, transgender men could push the barriers of gender presentation further than transgender women could, due to gender non-conformity being more accepted among birth-assigned females than among birth-assigned males.

I haven’t seen a single clinic not have a reversal in the sex ratio, but Jack leaves out a few parts. The shift has not just been in sex ratio, but from males with childhood onset gender dysphoria and limited psychiatric comorbidity to females with adolescent onset gender dysphoria and heavy psychiatric comorbidity. It is a population which is the inverse of the previous, a full demographic shift.

Greater acceptance of gender diversity and transgender identity for both sexes would be expected to thus shift the ratio towards birth-assigned females, as some clinics have noted. This impact of societal acceptance impacting sex ratio has been noted in the past. A 2013 study compared the child sex ratio in two countries: Canada and The Netherlands. The sex ratio in Canada, where gender diversity is less socially accepted was 4.5:1 in favor of birth-assigned males. In The Netherlands, where gender diversity is more socially accepted, the ratio skewed much further toward birth-assigned females, 2:1.

This is Wood et al., 2013.⁵⁶ What Jack does not mention is that the 4.5:1 ratio was for the lifetime of the Canadian clinic, which started considerably earlier than the Dutch, and also that it saw children much younger than the Dutch, which was where most of the difference was. This is why the paper does not attribute this to the differences in culture but simply the difference in time and age.

I would like to quote a different aspect of the paper and consider whether this resembles something Jack recently called “fringe”. It states “another parameter that has struck us as clinically important is that a number of youth commented that, in some ways, it is easier to be trans than to be gay or lesbian. […] To what extent societal and internalized homonegativity pushes such youth to adopt a transgendered identity remains unclear and requires further empirical study.”

It continues, “Along similar lines, we have also wondered whether, in some ways, identifying as trans come to occupy a more valued social status than identifying as gay or lesbian in some youth subcultures. Perhaps, for example, this social force explains the particularly dramatic increase in female adolescent cases in the 2008–2011 cohort.”

Putting further nails in Jack’s argument, they go on: “Another factor that has impressed us in accounting for the increase in adolescent referrals pertains to youth with gender identity disorder who also have an autism spectrum disorder. As noted by others (de Vries et al., 2010), many clinicians are now reporting a co-occurrence of these two conditions.”

Exactly why Jack previously chose to describe these ideas as “fringe” despite being well established in the literature, including things he himself cites, is up to the reader to speculate on. My own theory is that he’s simply so full of shit that he has reached a point of no return.

While the state’s experts would lead the court to believe that a sex ratio in favor of birth-assigned females is unprecedented, this is not the case. It is not new to see sex ratios that favor birth-assigned females. This has been seen many times in the past, including in the 1970s and 1980s in then-Czechoslovakia and Poland, where sex ratios were as high as 5.5:1 in favor of birth-assigned females. This was prior to the existence of the internet or social media.

The two papers brought up are Brzek & Sipová, 1983⁵⁷, and Godlewski, 1988⁵⁸. I’m not convinced Jack has actually read these papers (since when does Jack speak German?), but it does not really make a difference— whether a single doctor or single clinic saw more females than males in the 1980s does not matter. The trend is overwhelming and irrefutable, which is why Jack is trying to distract from it.

In summary, the current scientific consensus is that the increase in referrals to gender clinics is due to decreased stigma towards transgender people in recent years, along with an increase in awareness among the general population that gender-affirming medical interventions for transgender adolescents exist, and an increase in insurance coverage for these interventions.

This is a strange thing to write, because not only is this not the “scientific consensus” at large, it’s not even the consensus among the papers that Jack has cited.

The American Academy of Child & Adolescent Psychiatry offers a clear definition of conversion therapy,”’Conversion therapies’ are interventions purported to alter same-sex attractions or an individual’s gender expression with the specific aim to promoted heterosexuality as a preferable outcome. Similarly, for youth whose gender identity is incongruent with their sex anatomy, efforts to change their core gender identity have also been described and more recently subsumed under the conversion therapy rubric.”

I don’t think Jack understands what a “clear definition” is. The first half makes no sense after they shoved “gender identity” in there. What does it even mean for a gender expression to promote heterosexuality? This is incredibly subjective and clearly unworkable from a legal or even medical perspective.

In a recent paper from our team published in JAMA Psychiatry, we found that, after adjusting for a range of potentially confounding variables, exposure to gender identity conversion efforts was associated with greater odds of attempting suicide.

This is Turban et al., 2020,⁵⁹ which is another slice of that advocacy group recruited anonymous online survey Jack likes so much. The range of “potentially confounding variables” for suicide did not include baseline mental health. It’s a ridiculous paper, and the fact that it made it through peer review and to publication says a lot about the state of JAMA Psychiatry.

Some have pointed out that this study was not a randomized-controlled trial, but rather a cross-sectional study. In the realm of scientific evidence, this level of evidence is less conclusive than a randomized-controlled trial.

What are you talking about, Jack? If you build a bridge that collapses, saying “some people complained that it wasn’t pretty enough” isn’t a normal response. You took a terrible sample and P-hacked until the cows came home, the complaint isn’t that it’s not an RCT, it’s that it looks like borderline academic fraud.

Jack goes on to mention specific interventions like CBT. This would allow him to make a very clear distinction, for example whether using CBT to reduce distress over obsessive thoughts over ones chest dysphoria should be considered conversion therapy? Jack would never answer such a question, because once he is pinned down his position falls apart.

In general, any discussion about therapy in this realm develops rapidly into a linguistic mess of talking past each other, and it does not interest me much.

Dr. Hruz cites a paper by Rider et al. as showing that racial minoritized adolescents are more likely to access gender-affirming medical care. However, this study did not examine access to gender-affirming medical care, but rather visits to the school nurse’s office, preventative medical check-ups, and dental visits. Studies that have examined access to gender-affirming medical care for transgender adolescents have found that racial minoritized patients are under-represented among those who access care.

Jack seems to fundamentally misunderstand the point Hruz is making, which is that in the high quality sample of Rider et al., 2018,⁶⁰ ethnic minorities were overrepresented as trans-identifying. Not whether they visited a school nurse more or less often. This is a very strange response to Hruz’s argument.

The paper Jack mentions is Lopez et al., 2018,⁶¹ which deals with a specific medical intervention at a small number of clinics, for a trans-identifying sample of about a hundred. The intervention is also by far the most expensive one, which would skew results away from ethnic minorities. Jack really hasn’t thought this one through.

Dr. Hruz states that “There are no reliable radiological, genetic, physical, hormonal, or biomarker tests that can establish gender identity or reliably predict treatment outcomes.” This is true of nearly all psychiatric conditions. If Arkansas were to use this standard to outlaw medications, it would outlaw selective-serotonin reuptake inhibitors like Prozac, Lexapro, and Zoloft for major depressive disorder and generalized anxiety disorder. It would also outlaw all anti-psychotic medications for schizophrenia. This is an unreasonable standard that would leave essentially all patients with mental health conditions without medical care.

Somewhat unexpectedly Jack included an actual straw man argument, completely wasting everyone’s time. At no point did Hruz propose this as a standard to outlaw any treatment, and even if he had, the comparison is nonsensical since those medications are supported by high quality research, meaning they have multiple legs to stand on.

Dr. Hruz states that, “NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system” to imply that the mental health field has moved away from using self-report measures in diagnosis and treatment measures. This is not true. RDoC includes over 100 self-report measures.

It’s hard to prove exactly what Hruz intended to imply, although from the context it appears that he is talking about the difference in how we think about diagnoses between other areas of medicine and the DSM. Why Jack thinks it is about self-report measures is unclear to me. Rather than a straw man this appears to be Jack’s Don Quixote-inspired windmill.

Dr. Hruz claims that “gender dysphoria or gender identity disorder is a logical subcategory of body dysmorphic disorder.” This is not true. Body dysmorphic disorder falls under the category of OCD and related disorders and involves an obsessive preoccupation with a perceived abnormally formed specific body part and frequent checking behaviors of that body part. Gender dysphoria, in contrast, does not focus on a specific body part but rather gender broadly.

It could certainly be argued that obsessive preoccupation to the point of dysphoria with a set of body parts is contained within the larger concept of BDD. It’s a bit of an irrelevant discussion, however, as “gender dysphoria” as a diagnosis is already on its way out.

Dr. Lappert asserts that “since the abandonment of frontal lobotomies in 1967, there has been no other psychological-psychiatric condition for which surgery is performed.” This is not true. Vagal nerve stimulators are FDA approved for surgical implantations in patients with treatment-refractory major depressive disorder. An anterior capsulotomy is a neurosurgical procedure for refractory obsessive-compulsive disorder that is considered safe, well-tolerated, and efficacious.

This is correct, there are a handful of devices that can be surgically implanted, and Lappert was clearly incorrect in his categorical statement. It’s a bit of a technicality, the point is not that much weaker for it, but you need to come correct to this sort of thing.

All of these surgical procedures for psychiatric conditions are major interventions not to be taken lightly. In each instance, as with the decision to offer gender-affirming top surgery for an adolescent, a physician must carefully weigh the potential risks of the treatment with the potential benefits of the treatment.

As we’ve already discussed, this is not what is actually happening. It would also be interesting to have Jack explain how weighing the potential risks with the potential benefits works when both sides of the equation are unknown.

Defendant’s experts cite reports from the U.K., Sweden and Finland that they claim support their opinions about gender-affirming medical care for adolescents. The state’s experts cite two reports from the U.K.’s National Institute for Health and Care Excellence. These reports were not peer-reviewed but were meant to present a review of the evidence on the efficacy and safety of pubertal suppression and gender-affirming hormones to treat gender dysphoria in adolescents.

The fact that these reviews lack external academic peer-review is not that relevant. They are generally of much higher quality and much more transparent than those in the academic literature.

The first report, which addressed pubertal suppression, critiqued the research on this treatment as having substantial limitations, which is not unusual in medical research, but it’s important to note that the analysis omitted important studies. For example, the NICE report cited a lack of comparative studies (i.e., studies with control groups), but omitted discussion of two such studies.

It’s not unusual to have very limited studies in medical research, but it is highly unusual to administer treatments that sterilize the kids based on such weak evidence. This nuance apparently escaped Jack.

It did not include Van der Miesen et al. 2020 Journal of Adolescent Health, which was a large comparative study comparing 272 adolescents who presented to a gender clinic but had not yet received pubertal suppression with 178 adolescents who had received pubertal suppression, and found that those who received pubertal suppression had statistically significant lower rates of internalizing psychopathology (anxiety and depression) than those who did not receive pubertal suppression.

We covered this study earlier, and why it does not show what Jack claims it does. Why it was not included in the NICE review⁶² however, I do not know. Their search strategy is sound, and it looks like it would have matched it. The only thing that comes to mind is that it was released shortly before the search took place and may not have been correctly added to the queried databases yet.

The NICE report also erroneously excluded a second comparative study, Turban et al. 2020 Pediatrics, mistakenly stating that pubertal suppression was not reported separately from other interventions in this study.

Jack appears to be confused about what reporting separate from other interventions means. It does not mean using multivariable logistic regression to try to isolate puberty suppression. It just means reporting separate from other interventions, which Turban et al., 2020, did not do. He could argue that the original data could do this, but it’s not what he did in his paper.

The second NICE report addressed the evidence regarding gender-affirming hormones. This report concluded, “results from 5 uncontrolled, observational studies suggests that, in children and adolescents with gender dysphoria, gender-affirming hormones are likely to improve symptoms of gender dysphoria, and may also improve depression, anxiety, quality of life, suicidality, and psychosocial functioning.

This is an accurate quote from the report⁶³ but it’s taken out of context, something Jack would be well aware of. The statement is immediately followed by the caveat “All results were of very low certainty using modified GRADE.” — in other words, the studies reported positive findings, but the process to ensure the findings were reliable showed they were not.

It also states “Any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments in children and adolescents with gender dysphoria.” which Jack also chose to leave out.

The state’s experts also cite a report from Finland’s Council for Choices in Health Care in Finland, which is “a subordinate of the country’s Ministry of Social Affairs and Health that provides recommendations on which healthcare methods should be funded by the public sector.” This report is not peer-reviewed and reports on only three studies of gender-affirming medical care for adolescents, ignoring the additional studies I cited above.

It’s slightly dishonest of Jack to not mention that the reason those papers were not included is that they were not published at the time of the review. Jack mentions a number of those later papers, but also de Vries et al., 2014, seemingly not noticing that it doesn’t report data relevant to their question unlike the earlier paper de Vries et al., 2011, which was included.

It states that effects of pubertal suppression on the central nervous system is “unknown,” despite these medications being used for precocious puberty for decades and a recent peer-reviewed systematic review and meta-analysis finding that “current evidence does not support an adverse impact of gender-affirming hormone therapy on cognitive performance in birth-assigned either male or female transgender individuals” and found “a higher performance in verbal working memory in treated assigned males.”

The report⁶⁴ speaks explicitly about the use of GnRHa to suppress normally timed puberty, which Jack seems to intentionally misunderstand in order to offer his stock defense based on conflating different uses of a medication. I do not see any possibility that Jack does not understand that blocking precocious puberty is not the same as blocking a normally timed puberty.

The systematic review and meta-analysis he mentions is Karalexi et al., 2020, which we have already covered. Why Jack thinks short term studies on adults are relevant to the question of adolescent development remains unclear — especially research on a different medical intervention.

To clarify what Jack attempted here, his response to a statement about “pubertal suppression” (for children) was to falsely equate “pubertal suppression” with “gender-affirming hormone therapy” and then cite research on cross-sex hormones (for adults). It’s a bait-and-switch which is very easy to spot. I can’t imagine what this would be other than a poor, and malicious, attempt at deception.

The state’s experts also cite another non-peer-reviewed report from Sweden’s Statens Beredning for Medicinsk Och Social Utvardering (SBU), which translates to The Swedish Agency for Health Technology. The report only examined studies published prior to September 19, 2019. It thus did not review a number of key studies, described above, that found gender-affirming medical interventions for transgender adolescents improve mental health, including Turban et al. 2020 Pediatrics, Van der Miesen et al. 2020 Journal of Adolescent Health, Achille et al. 2020 International Journal of Pediatric Endocrinology, and Kuper et al. 2020 Pediatrics.

Not content to just butcher authors names, Jack decided to drop the umlauts from this agency’s name, they’re actually called Statens Beredning för Medicinsk och Social Utvärdering (which copies and pastes just fine from their website). It also does not translate to that as their website makes clear — it’s the “Swedish Agency for Health Technology Assessment and Assessment of Social Services”.

For this report⁶⁵, he seems to have identified a rough date when the search was performed, although he states “September 19, 2019” while the report itself says “6 September 2019”. It’s largely inconsequential but it does say something about how serious Jack is about this, seemingly not double checking anything.

It also failed to review a key paper that was published prior to 2019 that found improvement in internalizing psychopathology (anxiety and depression) externalizing psychopathology (e.g., disruptive behaviors), and global function that I note above, namely de Vries et al. 2011 Journal of Sexual Medicine.

The report explicitly states their reasoning for this in the report, which was that the same cohort (which Jack is apparently unaware of, suggesting he simply does not understand what the papers say) was included in the 2014 paper, which in turn was included in the review and report.

Since the report is in a language Jack does not speak, it seems plausible that he did not even attempt to understand it, but simply searching for “de Vries” in the document shows that the later paper was included. Potentially Jack thinks that if you report on the same findings multiple times, it counts double. That would certainly explain his approach to the 2015 USTS.

It appears The Karolinska Institute’s Astrid Lindgren Children’s Hospital has, based on this report, a misinterpretation of the Bell v Tavistock ruling, and a lack of knowledge of the AC v CD and Others decision, limited gender-affirming medical interventions at its institutions to patients over age sixteen and limited treatment to clinical trial settings. This decision, made on faulty and incomplete evidence, was clearly ill-advised.

The policy document⁶⁶ does mention Bell v Tavistock, and the SBU report, although “a lack of knowledge of the AC v CD and Others decision” makes rather a lot of sense since the original policy document predates that court decision. Jack does not specify which evidence was faulty. Presumably this is based on his prior misunderstanding.

As for the actual policy, it does not really match Jack’s description of it. It is actually exactly what Jack suggests should take place — an evaluation of the evidence with a risk/benefit analysis. It found that the evidence is of an unacceptably low quality compared to the extensive set of well documented adverse consequences.

It is also worth noting that this is a decision by one hospital, not a government ban all gender-affirming medical care for minors. In summary, the SBU report is outdated and omits key studies. I do not recommend relying on its conclusions.

It is true that the policy document is from one hospital, although reportedly⁶⁷ other clinics in Sweden have followed this. We’ve already covered the erroneous claim of omitted studies, but Jack is correct that the report — being from 2019 — does not include a number of recent studies which he likes. The problem for him is that those studies do not change the situation at all — the quality remains very poor, the long term outcomes remain unclear, the explosive growth remains unexplained, and the adverse consequences have not disappeared.

In summary, the state’s experts’ references these non-peer-reviewed reports from the U.K., Finland and Sweden do not support their assertions that gender-affirming medical interventions are ineffective or unsafe or should be taken away from transgender adolescents and their families in Arkansas. The state’s experts have inflated the importance of these reports, and as noted above, all relevant major medical organizations in the United States disagree with their assessments.

As a final double standard, Jack discredits others non-peer-reviewed findings in favor of non-peer-reviewed findings he agrees with. What the court case should come down to is a simple concept. Medicine doesn’t work on the principle of “I’m right until you prove me wrong”.

¹ de Vries, A. L. C., McGuire, J. K., Steensma, T. D., Wagenaar, E. C. F., Doreleijers, T. A. H., & Cohen-Kettenis, P. T. (2014). Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics, 134(4), 696–704. https://doi.org/10.1542/peds.2013-2958

² de Vries, A. L. C., Steensma, T. D., Doreleijers, T. A. H., & 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. https://doi.org/10.1111/j.1743-6109.2010.01943.x

³ 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), e20191725. https://doi.org/10.1542/peds.2019-1725

⁴ Biggs, M. (2020). Puberty Blockers and Suicidality in Adolescents Suffering from Gender Dysphoria. Archives of Sexual Behavior, 49(7), 2227–2229. https://doi.org/10.1007/s10508-020-01743-6

⁵ van der Miesen, A. I. R., Steensma, T. D., de Vries, A. L. C., 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. https://doi.org/10.1016/j.jadohealth.2019.12.018

⁶ de Graaf, N. M., Cohen-Kettenis, P. T., Carmichael, P., de Vries, A. L. C., Dhondt, K., Laridaen, J., Pauli, D., Ball, J., & Steensma, T. D. (2018). Psychological functioning in adolescents referred to specialist gender identity clinics across Europe: A clinical comparison study between four clinics. European Child & Adolescent Psychiatry, 27(7), 909–919. https://doi.org/10.1007/s00787-017-1098-4

⁷ 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), 8. https://doi.org/10.1186/s13633-020-00078-2

⁸ 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), e20193006. https://doi.org/10.1542/peds.2019-3006

⁹ Carmichael, P., Butler, G., Masic, U., Cole, T. J., De Stavola, B. L., Davidson, S., Skageberg, E. M., Khadr, 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. https://doi.org/10.1371/journal.pone.0243894

¹⁰ 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. https://doi.org/10.1111/jsm.13034

¹¹ 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), 302–311. https://doi.org/10.1037/cpp0000288

¹² López de Lara, D., Pérez Rodríguez, O., Cuellar Flores, I., Pedreira Masa, J. L., Campos-Muñoz, L., Cuesta Hernández, M., & Ramos Amador, J. T. (2020). Psychosocial assessment in transgender adolescents. Anales de Pediatría (English Edition), 93(1), 41–48. https://doi.org/10.1016/j.anpede.2020.01.004

¹³ 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. https://doi.org/10.1080/08039488.2019.1691260

¹⁴ Haupt, C., Henke, M., Kutschmar, A., Hauser, B., Baldinger, S., Saenz, S. R., & Schreiber, G. (2020). Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.CD013138.pub2

¹⁵ Baker, K. E., Wilson, L. M., Sharma, R., Dukhanin, V., McArthur, K., & Robinson, K. A. (2021). Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review. Journal of the Endocrine Society, 5(4), bvab011. https://doi.org/10.1210/jendso/bvab011

¹⁶ Bungener, Sara. L., de Vries, A. L. C., Popma, A., & Steensma, T. D. (2020). Sexual Experiences of Young Transgender Persons During and After Gender-Affirmative Treatment. Pediatrics, 146(6), e20191411. https://doi.org/10.1542/peds.2019-1411

¹⁷ Pang, K. C., Notini, L., McDougall, R., Gillam, L., Savulescu, J., Wilkinson, D., Clark, B. A., Olson-Kennedy, J., Telfer, M. M., & Lantos, J. D. (2020). Long-term Puberty Suppression for a Nonbinary Teenager. Pediatrics, 145(2), e20191606. https://doi.org/10.1542/peds.2019-1606

¹⁸ Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., Fraser, L., Green, J., Knudson, G., Meyer, W. J., Monstrey, S., Adler, R. K., Brown, G. R., Devor, A. H., Ehrbar, R., Ettner, R., Eyler, E., Garofalo, R., Karasic, D. H., … Zucker, K. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People, Version 7. International Journal of Transgenderism, 13(4), 165–232. https://doi.org/10.1080/15532739.2011.700873

¹⁹ Hembree, W. C., Cohen-Kettenis, P. T., Gooren, L., Hannema, S. E., Meyer, W. J., Murad, M. H., Rosenthal, S. M., Safer, J. D., Tangpricha, V., & T’Sjoen, G. G. (2017). Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism, 102(11), 3869–3903. https://doi.org/10.1210/jc.2017-01658

²⁰ Leung, A., Sakkas, D., Pang, S., Thornton, K., & Resetkova, N. (2019). Assisted reproductive technology outcomes in female-to-male transgender patients compared with cisgender patients: A new frontier in reproductive medicine. Fertility and Sterility, 112(5), 858–865. https://doi.org/10.1016/j.fertnstert.2019.07.014

²¹ Streed, C. G., Beach, L. B., Caceres, B. A., Dowshen, N. L., Moreau, K. L., Mukherjee, M., Poteat, T., Radix, A., Reisner, S. L., Singh, V., & on behalf of the American Heart Association Council on Peripheral Vascular Disease; Council on Arteriosclerosis, Thrombosis and Vascular Biology; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Hypertension; and Stroke Council. (2021). Assessing and Addressing Cardiovascular Health in People Who Are Transgender and Gender Diverse: A Scientific Statement From the American Heart Association. Circulation, 144(6). https://doi.org/10.1161/CIR.0000000000001003

²² de Blok, C. J. M., Wiepjes, C. M., Nota, N. M., van Engelen, K., Adank, M. A., Dreijerink, K. M. A., Barbé, E., Konings, I. R. H. M., & den Heijer, M. (2019). Breast cancer risk in transgender people receiving hormone treatment: Nationwide cohort study in the Netherlands. BMJ, l1652. https://doi.org/10.1136/bmj.l1652

²³ Brown, G. R., & Jones, K. T. (2015). Incidence of breast cancer in a cohort of 5,135 transgender veterans. Breast Cancer Research and Treatment, 149(1), 191–198. https://doi.org/10.1007/s10549-014-3213-2

²⁴ Staphorsius, A. S., Kreukels, B. P. C., Cohen-Kettenis, P. T., Veltman, D. J., Burke, S. M., Schagen, S. E. E., Wouters, F. M., Delemarre-van de Waal, H. A., & Bakker, J. (2015). Puberty suppression and executive functioning: An fMRI-study in adolescents with gender dysphoria. Psychoneuroendocrinology, 56, 190–199. https://doi.org/10.1016/j.psyneuen.2015.03.007

²⁵ Karalexi, M. A., Georgakis, M. K., Dimitriou, N. G., Vichos, T., Katsimpris, A., Petridou, E. Th., & Papadopoulos, F. C. (2020). Gender-affirming hormone treatment and cognitive function in transgender young adults: A systematic review and meta-analysis. Psychoneuroendocrinology, 119, 104721. https://doi.org/10.1016/j.psyneuen.2020.104721

²⁶ Cantor, J. M. (2020). Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy. Journal of Sex & Marital Therapy, 46(4), 307–313. https://doi.org/10.1080/0092623X.2019.1698481

²⁷ Rafferty, J. (2018). Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics, 142(4), e20182162. https://doi.org/10.1542/peds.2018-2162

²⁸ Arkansas House Bill 1570, the “Save Adolescents From Experimentation Act”, https://www.arkleg.state.ar.us/Bills/Detail?id=HB1570

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³⁰ Steensma, T. D., McGuire, J. K., Kreukels, B. P. C., Beekman, A. J., & Cohen-Kettenis, P. T. (2013). Factors Associated With Desistence and Persistence of Childhood Gender Dysphoria: A Quantitative Follow-Up Study. Journal of the American Academy of Child & Adolescent Psychiatry, 52(6), 582–590. https://doi.org/10.1016/j.jaac.2013.03.016

³¹ Rae, J. R., Gülgöz, S., Durwood, L., DeMeules, M., Lowe, R., Lindquist, G., & Olson, K. R. (2019). Predicting Early-Childhood Gender Transitions. Psychological Science, 30(5), 669–681. https://doi.org/10.1177/0956797619830649

³² Wiepjes, C. M., Nota, N. M., de Blok, C. J. M., Klaver, M., de Vries, A. L. C., Wensing-Kruger, S. A., de Jongh, R. T., Bouman, M.-B., Steensma, T. D., Cohen-Kettenis, P., Gooren, L. J. G., Kreukels, B. P. C., & den Heijer, M. (2018). The Amsterdam Cohort of Gender Dysphoria Study (1972–2015): Trends in Prevalence, Treatment, and Regrets. The Journal of Sexual Medicine, 15(4), 582–590. https://doi.org/10.1016/j.jsxm.2018.01.016

³³ Brik, T., Vrouenraets, L. J. J. J., de Vries, M. C., & Hannema, S. E. (2020). Trajectories of Adolescents Treated with Gonadotropin-Releasing Hormone Analogues for Gender Dysphoria. Archives of Sexual Behavior, 49(7), 2611–2618. https://doi.org/10.1007/s10508-020-01660-8

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³⁶ Turban, J. L., Loo, S. S., Almazan, A. N., & Keuroghlian, A. S. (2021). Factors Leading to “Detransition” Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis. LGBT Health, lgbt.2020.0437. https://doi.org/10.1089/lgbt.2020.0437

³⁷ Expósito-Campos, P. (2021). A Typology of Gender Detransition and Its Implications for Healthcare Providers. Journal of Sex & Marital Therapy. https://www.tandfonline.com/doi/abs/10.1080/0092623X.2020.1869126

³⁸ Vandenbussche, E. (2021). Detransition-Related Needs and Support: A Cross-Sectional Online Survey. Journal of Homosexuality, 20. https://doi.org/10.1080/00918369.2021.1919479

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⁴⁰ Burke, S. M., Cohen-Kettenis, P. T., Veltman, D. J., Klink, D. T., & Bakker, J. (2014). Hypothalamic Response to the Chemo-Signal Androstadienone in Gender Dysphoric Children and Adolescents. Frontiers in Endocrinology, 5. https://doi.org/10.3389/fendo.2014.00060

⁴¹ Theisen, J. G., Sundaram, V., Filchak, M. S., Chorich, L. P., Sullivan, M. E., Knight, J., Kim, H.-G., & Layman, L. C. (2019). The Use of Whole Exome Sequencing in a Cohort of Transgender Individuals to Identify Rare Genetic Variants. Scientific Reports, 9(1), 20099. https://doi.org/10.1038/s41598-019-53500-y

⁴² Wiepjes, C. M., den Heijer, M., Bremmer, M. A., Nota, N. M., Blok, C. J. M., Coumou, B. J. G., & Steensma, T. D. (2020). Trends in suicide death risk in transgender people: Results from the Amsterdam Cohort of Gender Dysphoria study (1972–2017). Acta Psychiatrica Scandinavica, 141(6), 486–491. https://doi.org/10.1111/acps.13164

⁴³ Milrod, C., & Karasic, D. H. (2017). Age Is Just a Number: WPATH-Affiliated Surgeons’ Experiences and Attitudes Toward Vaginoplasty in Transgender Females Under 18 Years of Age in the United States. The Journal of Sexual Medicine, 14(4), 624–634. https://doi.org/10.1016/j.jsxm.2017.02.007

⁴⁴ Correction to Bränström and Pachankis. (2020). American Journal of Psychiatry, 177(8), 734–734. https://doi.org/10.1176/appi.ajp.2020.1778correction

⁴⁵ Almazan, A. N., & Keuroghlian, A. S. (2021). Association Between Gender-Affirming Surgeries and Mental Health Outcomes. JAMA Surgery. https://doi.org/10.1001/jamasurg.2021.0952

⁴⁶ Dhejne, C., Lichtenstein, P., Boman, M., Johansson, A. L. V., Långström, N., & Landén, M. (2011). Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden. PLoS ONE, 6(2), e16885. https://doi.org/10.1371/journal.pone.0016885

⁴⁷ Dhejne, C., Öberg, K., Arver, S., & Landén, M. (2014). An Analysis of All Applications for Sex Reassignment Surgery in Sweden, 1960–2010: Prevalence, Incidence, and Regrets. Archives of Sexual Behavior, 43(8), 1535–1545. https://doi.org/10.1007/s10508-014-0300-8

⁴⁸ Olson-Kennedy, J., Warus, J., Okonta, V., Belzer, M., & Clark, L. F. (2018). Chest Reconstruction and Chest Dysphoria in Transmasculine Minors and Young Adults: Comparisons of Nonsurgical and Postsurgical Cohorts. JAMA Pediatrics, 172(5), 431. https://doi.org/10.1001/jamapediatrics.2017.5440

⁴⁹ Mehringer, J. E., Harrison, J. B., Quain, K. M., Shea, J. A., Hawkins, L. A., & Dowshen, N. L. (2021). Experience of Chest Dysphoria and Masculinizing Chest Surgery in Transmasculine Youth. Pediatrics, e2020013300. https://doi.org/10.1542/peds.2020-013300

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⁵² American Academy of Pediatrics Committee on Drugs. (2014). Policy Statement: Off-label use of drugs in children. Pediatrics, 133(3), 563–567.

⁵³ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

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⁵⁸ Godlewski, J. (1988). Transsexualism and anatomic sex ratio reversal in Poland. Archives of Sexual Behavior, 17(6), 547–548. https://doi.org/10.1007/BF01542342

⁵⁹ Turban, J. L., Beckwith, N., Reisner, S. L., & Keuroghlian, A. S. (2020). Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults. JAMA Psychiatry, 77(1), 68. https://doi.org/10.1001/jamapsychiatry.2019.2285

⁶⁰ Rider, G. N., McMorris, B. J., Gower, A. L., Coleman, E., & Eisenberg, M. E. (2018). Health and Care Utilization of Transgender and Gender Nonconforming Youth: A Population-Based Study. Pediatrics, 141(3), e20171683. https://doi.org/10.1542/peds.2017-1683

⁶¹ Lopez, C. M., Solomon, D., Boulware, S. D., & Christison-Lagay, E. R. (2018). Trends in the use of puberty blockers among transgender children in the United States. Journal of Pediatric Endocrinology and Metabolism, 31(6), 665–670. https://doi.org/10.1515/jpem-2018-0048

⁶² Evidence review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria https://arms.nice.org.uk/resources/hub/1070905/attachment

⁶³ Evidence review: Gender-affirming hormones for children and adolescents with gender dysphoria https://arms.nice.org.uk/resources/hub/1070871/attachment

⁶⁴ National guidelines, translated by SEGM https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors

⁶⁵ Description and search methodology available at https://www.sbu.se/307e

⁶⁶ Internal policy document, translated by SEGM https://segm.org/Sweden_ends_use_of_Dutch_protocol

⁶⁷ Swedish medical journal article, available via SEGM https://segm.org/Swedish_pediatric_gender_clinics_adopt_cautious_stance