The researchers use a cross-sectional approach to examine differences in self-reported mental health and behaviour problems, poor peer relations, and suicidality in three groups: 651 adolescents from the general population, 272 adolescents with gender dysphoria at the start of their assessment at the clinic, and 178 adolescents under the care of the clinic and taking puberty blockers.
This paper is from VU University in the Netherlands, the institution that produced Vries et al. (2011) and Vries et al. (2014). We note a shift in language in this field over the last decade: in Vries et al. (2011) the participants are "adolescents with gender identity disorder"; in most other studies from the middle of the decade participants are described as "adolescents with gender dysphoria" (Staphorsius et al., 2015; Costa et al., 2015); in the current study they have become "transgender adolescents" in the study title.
The previous emphasis on a mental health condition, gender dysphoria, was neutral in regards to ultimate causes. Authors were open to the possibility that dysphoria could arise from co-morbid mental health conditions, such as autism (Vries et al., 2011). By shifting the headline language to transgender, authors seem to have decided that there is a single cause for the adolescent's distress: a fixed internal aspect incongruent with their sexed body. Without explanation or presenting evidence, researchers have de-emphasised questions regarding underlying issues, and non-medical treatments which would address these issues first (such as psychotherapy).
Study Design and Results
The study has some of the same problems that affect the majority of earlier studies: a lack of control, a confounding with psychosocial support, and a subjective outcome measure.
Mental health problems, poor peer relations, and suicidality were all lower in the treated group. Externalising problems and suicidality were lower in the treated group than in the general population, and internalising problems (e.g. anxiety, depression) were significantly lower.
That 3 out of 4 outcome measures in the treated group were the same or healthier compared to the general population raises questions about the influence of social expectations and other confounds on these subjective self-reported outcomes. Supposedly, blockers not only reduced distress but reduced it to the extent that the typical gender-dysphoric adolescent under puberty suppression has superior mental health when compared to the general adolescent population without gender dysphoria.
There are several reasons to believe that other factors explain part or all of the reported differences.
First, a medical intervention pathway may act as official recognition of a transgender identity. The recognition, not the blockers, may improve the adolescent's mental health.
To illustrate, the treated group reported better peer relations compared to the untreated group. The researchers constructed their measure of peer relations from three questions:
- “I don’t get along with other kids.”
- “I get teased a lot.”
- “I am not liked by other kids.”
It is unclear how puberty suppression decreases teasing incidents or improves relationships. The authors emphasise, and we agree, that peer relationships are primarily a product of the adolescent's social environment:
A framework for understanding [gender dysphoria] and the associated mental health disparities is offered by the minority stress model that posits that sexual minorities experience chronic stressors related to the stigmatization of their identities... Psychological functioning is better when there is more acceptance of [gender dysphoria] by the youth and their environment, including better peer relations.
If the problem lies in the adolescent's social environment, then how is a drug given to an individual justified?
We could speculate that a reduction in distress associated with pubertal development gave the adolescent greater capacity to establish relationships. However, there are other, more likely explanations. For example, by beginning medical intervention pathway, the adolescent may believe they have achieved "official" (i.e. medically recognised) status as transgender. If status acquisition occurs alongside a peer support network for trans-identified adolescents, then an "officially transgender", "protected" status may help the adolescent establish relationships. In this hypothetical case, it would not be the puberty blockers, but the official recognition granted by medical authorities that led to improved peer relationships.
Second, self-report measures are particularly susceptible to bias when the answer confirms a belief about the subject's identity (Brenner and DeLameter, 2016). If adolescents arrived at the clinic primed to believe that blockers are the "real" treatment that "true" transgender adolescents receive to avoid suicide, then it does not surprise when subsequent self-reports confirm these beliefs. Erikson (1968) explicitly frames adolescence as an "identity crisis". The authors' conception of the pursuit of medical intervention as "affirming" the adolescent's innate gender stands apart from well-established theories of social-context-driven social identity formation.
Third, the same effect could exaggerate the reported mental health problems of the comparison group who had not yet received treatment. The adolescent will know that initially reporting elevated mental health issues will increase their chances of gaining official recognition of their transgender status.
Fourth, the severity of the treated group's gender dysphoria is unclear. Unlike surgery and cross-sex hormone treatment, puberty suppression does not modify the adolescent's sex characteristics. The treatment only maintains sex characteristics at their current stage of development. If the adolescent has distress with their body's sex characteristics, then we would expect anxiety and depression to remain elevated above normal levels during puberty suppression. That self-reported internalising problems were significantly less, even in comparison to the general population, suggests that subjective bias and factors other than puberty suppression influenced this measure. The authors need to clarify the severity of gender dysphoria in the treated group. Either the dysphoria was mild or misdiagnosed, and a treatment program that was not designed to eliminated associated mental health issues - in which case further interventions would be questionable, or confounding factors and reporting bias influenced the subjective outcome measures.
With no control, confounding with psychosocial support and aging, and the possibility of biased self-reports, we cannot attribute reported improvements to blockers. The authors appear to operate in a vacuum where well-established social psychology perspectives on adolescent identity development have no bearing on their decisions to pursue medical treatment.