Science Corner: When Normal Isn’t Normative

Although my public health training focused on infectious diseases, I care about a wide range of public health issues. My job cuts across domains, and also personally I want people to be comprehensively healthy and not merely free from contagions. So when I saw that health-improving and potentially life-saving interventions were being labeled as child abuse and used as the sole grounds for investigating parents, I was baffled and dismayed. I don’t understand how providing treatments which have demonstrated health benefits can be considered abuse. And now some states want to make providing those treatments a felony.

Now, before we get into the details, let me remind you that I am not a clinician. I am not recommending any particular course of treatment for any individual. Such decisions are best made between patients and healthcare providers familiar with their history and condition, with input from parents or other caregivers where appropriate. I am a public health scientist trying to reconcile the evidence of improved health outcomes from these treatments with the allegation that they constitute abuse.

We often discuss recent research findings here, so let’s look at this paper published a couple of weeks ago. A cohort of transgender and nonbinary youths were surveyed regarding their mental health symptoms, including suicidal thoughts and symptoms of depression. They were then followed for one year and asked the same questions again at 3 month intervals. During that year, some of them received one or more treatments known collectively as gender-affirming care; these treatments include puberty blockers and hormone therapies. The treatments were not randomized; the researchers recorded who received which treatments as part of their care outside of the study. Youths who received gender-affirming care were significantly less likely to report symptoms of depression and suicidal thoughts afterwards.

This is not the first study to look for and find mental health benefits of these treatments. The paper itself has a number of references; there was also a larger study published last year looking specifically at surgical therapies which found benefits including reduction of suicidal thoughts. From what I can gather, the most notable aspect of this latest study is how quickly the benefits are realized. And that strikes me as particularly relevant to the news from Texas. If treatments are being delayed or suspended, even temporarily, out of concerns over legal actions, that means in the short term there will be people experiencing more depression and more suicidal thoughts than they would have otherwise, which can mean long-term or even permanent harm.

After all the public scrutiny of randomized clinical trials in the past 2 years, these nonrandom survey studies may raise questions about methodology. Surveys are widely used tools in public health. Still, self-reporting and nonrandom treatments make it more difficult to eliminate all possible sources of bias and confounding. For example, perhaps the youths who received gender-affirming care have better overall access to healthcare or differences in their support networks compared to those who did not receive the treatments. When multiple studies show the same effect, that reduces the likelihood that there are unidentified effects which are the true causes. Still, if questions about the methodology remain, the answer should be to design more rigorous studies rather than criminalizing treatments which the evidence suggest lead to improved outcomes.

I am also aware that there are instances of individuals who have received some of these treatments and later regretted them, possibly because these mental health benefits were not realized for them. It is a lamentable reality that the benefits of many if not all of our therapeutics are not apportioned equally to every person who receives them. Results vary with everything from acetaminophen to the latest SARS-CoV-2 retrovirals. If one concludes from that observation that we need better, more discerning diagnostics so that we can better predict who will benefit from which gender-affirming therapies and who will be best served by other treatments, I agree. But I cannot see how we can conclude that therapies which have reduced harm for many are actually abusive just because they have not benefited every recipient.

In conversations around this topic, I have seen concerns about disrupting the normal course of puberty. While I can understand why that might sound concerning, I do not think it negates the observed benefits of puberty blockers and other gender-affirming therapies. For one thing, the onset of “normal” puberty has gotten earlier in recent decades, and varies between populations. But more substantively, in a strict sense all healthcare interventions represent a deviation from what would occur normally or naturally. That is why they are called interventions. There is nothing natural about cracking open a person’s ribcage and removing their heart to replace it with another. Disrupting the normal cell cycle of growth and division sounds deleterious, but as chemotherapy it can treat various cancers. There is no question these are life-saving procedures. That is the standard we apply to healthcare therapies–do they demonstrate a net improvement in health?

There also seems to be concerns about the new-ness of gender-affirming care, a term that has less than a decade of history in Google Trends. Compared to some healthcare interventions, gender-affirming care for transgender and nonbinary individuals is a more recent concept; at the same time, puberty blockers and hormone therapies have a history of use for treating other conditions. In light of that recency, I certainly don’t oppose careful consideration of options for each individual in consultation with knowledgeable clinicians and in conjunction with clear consent processes for any treatments. After all, like many pharmaceuticals they can have side effects which need to be weighed against the potential benefits. As with all such decisions, we use the available evidence while acknowledging the remaining uncertainty.

Of course, there are also religious concerns that are raised about affirming transgender identification. In addition to not being a clinician, I’m also not a theologian, so I don’t expect to have a definitive take on that front either. I should also acknowledge that I don’t really expect the Bible to enumerate all the varieties of the human experience, so the most commonly cited verses on this topic are not as clearly relevant to me as they seem to be to some. Still, for whatever it’s worth, I find myself thinking about Paul writing about ensuring that his body serves him, not the other way around. Obviously he was addressing a very different context. Nevertheless, I can’t help but wonder if the principle is more broadly relevant. When gender-affirming care is opposed with reference to genetics, is that prioritizing someone’s genome over their mental health? And is that the right ordering?

I’d also observe that life is a profoundly robust phenomenon. By that I mean that life persists in a wide variety of contexts, in the face of numerous disruptions and perturbations. We can recover from or survive with divers injuries, maladies and afflictions. For that, we can be grateful that God has created life to be so tenacious. As a result of that robustness, there can be and will be many different ways to be alive and to be human. Variations are to be expected. So perhaps we should consider being thankful for those variations as well as the robustness that makes them possible, rather than trying to normalize the most common configurations.