“Confirmation bias, as the term is typically used in the psychological literature, connotes the seeking or interpreting of evidence in ways that are partial to existing beliefs, expectations, or a hypothesis in hand.”

Confirmation Bias: A Ubiquitous Phenomenon in Many Guises, by Raymond S. Nickerson,  Tufts University

In this post, I will look at two recent survey studies (i.e., patient questionnaires and demographic data culled from medical records) conducted by Dr. Johanna Olson and colleagues at the The Center for Transyouth Health and Development at Children’s Hospital, Los Angeles. These studies do not look at the medical effects or potential harms of hormone treatments and/or sterilization of prepubescent children and adolescents. Rather, they consist of self-reported characteristics and demographic data, with no questioning of the key “hypothesis in hand”: that medical transition is the treatment of choice for self-identified “transgender youth.”

A hypothesis in hand also can bias the interpretation of subsequently acquired data, either because one selectively looks for data that are supportive of the hypothesis and neglects to look for disconfirmatory data or because one interprets data to be confirmatory that really are not.

In looking at the work and public statements of Dr. Olson, there are a number of biases and assumptions that can be easily seen:

• Children and adolescents who label themselves as “transgender,” or who claim to be the opposite sex, are a priori “transgender,” even though there is no hard scientific data that a “transgender child” actually exists.
• The reason for depression and suicidal ideation in youth who identify as transgender is lack of access to medical transition (i.e., hormones and/or surgery) and/or lack of parental support for such treatments.
• Comorbid mental health issues are not explored as possible causes for gender dysphoria or suicidal ideation.
• Parental, clinician, internalized, or societal homophobia is not mentioned as a possible contributing factor in the diagnosis of “transgender youth.”
• It is a foregone conclusion that the psychological stress experienced by a young person believing they are “actually” a member of the opposite sex cannot be addressed via supportive psychotherapy to help resolve such feelings.
• Permanent adult sterility, the usual consequence of puberty blockers followed directly by cross-sex hormones, is an acceptable and tolerable outcome for prepubescent “transgender children.”
• Further, despite overwhelming scientific consensus that judgment, decision-making, and awareness of future risks and rewards does not reach maturity in the human brain until the early 20s, prepubescent children facing irreversible sterility are capable of understanding and choosing this consequence.
• The possibility of future patient regret (a completely unknown factor at this time) is insignificant in comparison with the urgent need to treat children NOW with hormones and (possibly) plastic surgeries.

Now to the two survey studies. First, let’s look at “Parental Support and Mental Health Among Transgender Adolescents” by Simons et al, examining the impact of parental support on the mental health of 66 self-identifying “transgender” youth ages 12-24. What’s the main conclusion?

 Parental support is associated with higher quality of life and is protective against depression in transgender adolescents.

What is meant by “parental support” in the context of the 66 youths included in the survey? The “limitations” section of the study tells us it wasn’t well defined:

The parental support measure did not delineate whether the subject was referring to one or more parents, differentiate between parents and other guardians or caregivers, or explore the impact of other sources of support on mental health. Also, it did not distinguish between general parental support versus support specifically for gender identity, or assess particular parental qualities or actions constituting support.

Readers who have been with me for awhile know that my idea of “support” for my erstwhile trans-identifying  teenager did not include agreeing to hormone or surgical treatments. Judging by the vague criteria in the survey, my daughter and I might have presented to Olson’s clinic, with my teen rating me as “supportive” even if, in the end, we left without a prescription for testosterone or a recommendation for “top surgery” (two interventions my teen, at the time, insisted she wanted).

Here is how the study defined parental “support.” The 66 patients

completed a survey assessing parental support (defined as help, advice, and confidante support)

Help, advice, and confidante support? You better believe I provided that to my kid.

Regarding the young people who were surveyed in the study:

Before meeting with medical staff, participants underwent mental health assessment by a provider with knowledge of gender nonconformity in youth to identify major mental health concerns and provide a recommendation that hormone therapy would benefit the participant in their transition process.

But the paper doesn’t provide any hint whether “identify[ing] major mental health concerns” might have included psychotherapy or some other exploration of how these concerns might contribute to the young person identifying as transgender. Nor do we know specifics of what these concerns might be.  All we know is that “hormone therapy” was recommended, and it is assumed that a “transition process” was a desirable outcome. In my own personal family case, finding a supportive therapist who was willing to explore other thorny psychological concerns was extremely important and led to a reduction in my child’s desire to medically transition.

Moving on, another limitation noted by the authors is

Findings were based on self-report and may be open to self-presentational biases.

In other words: Like the diagnosis of “transgender” itself, the survey data is based on subjective thoughts and emotions. While the researchers acknowledge this as a “limitation” of their study, why don’t they acknowledge that the “self report” of being the opposite sex (in contravention to objective biological reality) is itself a “limitation” of the entire enterprise of the medical transition of minors? The diagnosis of “transgender children”  as opposed to just letting kids be kids, however they “identify,” is the mother of all confirmation biases.

Dr. Olson is listed as the first author of the 2nd study, still in press: Baseline Physiologic and Psychosocial Characteristics of Transgender Youth Seeking Care for Gender Dysphoria. The subjects were 101 youth (approximately 50/50 male and female), ages 12-24, who had indicated the “desire to undergo puberty suppression or phenotypic gender transition” at Olson’s clinic from 2011-2013.

What were some key psychological findings these young people self-reported? (Of note, physiological characteristics did not differ from other similar-aged youth.)

• suicidal ideation: 50%
• suicide attempt: “nearly 1/3”
• depression: mild-moderate 35%, severe 11%
• drug use: alcohol (75.5%), tobacco (58%), cannabis (61.5%,), other drugs (43%)
• gender dysphoria experienced since approximately age 8
• revealed their transgender identification to family at a mean age of 17.1 years [Remember this one]

What do Olson et al conclude from their survey?

…transgender youth are aware of the incongruence between their internal gender identity and their assigned sex at early ages. Prevalence of depression and suicidality demonstrates that youth may benefit from timely and appropriate intervention. All participants expressed a desire to begin hormonal intervention to assist in bringing their physical bodies into better alignment with their internal gender identity.

Seems to me there are several assumptions and confirmation biases in operation here:

• “Timely and appropriate intervention” apparently does not include anything other than “bringing their physical bodies into alignment” with internal identity. No suggestion is made that psychological treatement aimed at helping youth feel comfortable in their bodies should even by considered.
• The assumption appears to be that depression and suicidality are caused by gender dysphoria–or at the very least, the correlation of  suicidal ideation with gender dysphoria–can only be solved through medical transition.
• Suicidality rates for other psychological problems (apart from gender dysphoria)  are not mentioned or compared in this study, only those of “normal” adolescents  (6.7% for ages 12-17, 10.9% ages 18-24), even though there is research (see here, and here for examples) indicating that some disorders may occur at higher rates in people with gender dysphoria. Nothing in the survey or study design indicates any knowledge of these comorbidities, whether there was an attempt to control for them, or the fact that increased suicidality is associated with some of them.
• And again, the key assumption: “Identifying” as transgender is a priori a reliable diagnosis, as opposed to a psychological problem that could possibly be exacerbated by some combination of peer pressure, societal trends,  or online social media.

But enough of my criticisms. What limitations do the authors of this study see?

…these data describe those who are able to access care related to gender dysphoria and desire medical intervention for gender transition. These results may not be generalizable to transgender youth who are not receiving care or to those who do not desire a phenotypic transition with cross-sex hormones…

…Lastly, data collected about early childhood gender nonconforming feelings or behaviors are subject to potential recall bias. Ideally, this information could be collected in a cohort of younger children currently experiencing gender nonconformity.

“Recall bias” means the adolescent or young adult may not be remembering his or her childhood experiences accurately. Also, and even more to the point: if most of the youth in this study “knew” they were trans at 8-years old, but didn’t “come out to family” until about age 17, how are they “truly transgender?”  The phenomenon of young kids insisting they are the opposite sex is often touted as proof of some innate brain-based gender. And as anyone who has raised a child knows, 8-year-old children don’t generally hide their true feelings from their parents. If these young people profess to have “known” they were the opposite sex as 8-year-olds, why didn’t they voice this realization earlier? Why did they wait until they were 17?

I have to wonder: given that the patients who completed the survey for this study had managed to secure hormone treatments at Olson’s clinic; and given the ready availability on the Internet of the list of requirements to qualify for hormone therapy, it’s not much of a stretch to think that many likely knew that reporting a long history of identifying as transgender would be helpful in actually qualifying for treatment.

And here comes the final caveat:

Although there are guidelines and recommendations for the treatment of transgender-identified youth with puberty suppression in early adolescence followed by appropriate hormone therapy, there remain fundamental questions about when to start puberty suppression with gonadotropin-releasing hormone analogues, when to add cross-sex hormones, and how young is too young for gender confirmation surgery.

Dr. Olson has repeatedly  gone on record as promoting early cross-sex hormones, stating in a recent NPR interview that it is “ridiculous” to make an adolescent wait until age 16, as the current WPATH standards prescribe. (Some might counter that it’s more absurd to permanently destroy a child’s fertility.) Interestingly, Olson et al seem to almost concede that point in their last-but-not least limitation to the current study:

Finally, the trajectory of gender nonconformity among peripubertal youth is still difficult to predict, creating serious concerns for providers and families about the possibility of future regret in response to more permanent aspects of hormone therapy, such as breast development and voice deepening. The data we have begun to collect are an attempt to understand the transgender youth population and follow them over time, tracking the safety and efficacy of medical intervention as well as the impact of intervention on quality of life, high-risk behaviors, suicidality, depression indices, gender dysphoria, and potential regret in response to early medical intervention. We will continue to publish our follow-up data as they are collected,

So once again, as I chronicled in an earlier post, providers of medical transition tell us, “We just don’t know.” The implications of this cannot be overstated.  These providers are, by their own admission, essentially experimenting on children and adolescents with treatments that have permanent consequences, and they have no idea what the rate of future regret will be. Let’s listen again:

“… the trajectory of gender nonconformity among peripubertal youth is still difficult to predict, creating serious concerns… about …future regret…in response to early medical intervention.”

There it is, folks, in black and white, in a peer reviewed journal. We don’t know, but we’re going to find out–after it’s too late to take any of it back.

It is not my intention to demonize Dr. Olson. In fact, to give Dr. Olson a heaping helping of Benefit of the Doubt, it’s quite possible she is operating from compassion for the suffering of the youth and families who visit her clinic. (I realize more cynical observers might say she and her fellow “gender specialists” are only in this field for profit, but I am not prepared to assign sociopathic greed at this juncture).

Might Dr. Olson be suffering from pathological altruism—a particular brand of confirmation bias?

A working definition of a pathological altruist then might be a person who sincerely engages in what he or she intends to be altruistic acts but who (in a fashion that can be reasonably anticipated) harms the very person or group he or she is trying to help

…such as the substantial percentage of her young patients who, without her intervention, would have been allowed to grow up to be gay, lesbian, or simply “gender nonconforming” adults, their fertility fully intact, without the need for an expensive lifelong medical condition treated by endocrinologists and surgeons.

or a person who, in the course of helping one person or group, inflicts reasonably foreseeable harm to others beyond the person or group being helped

That might be, in the case of the steadily increasing numbers of young women being transitioned, the harm to the lesbian community, particularly the “butch” and “gender nonconforming” lesbian community. And then there is the damage to families–parents, siblings, other relatives–whose doubts and concerns are dismissed as “transphobic.” Their prior knowledge of their loved one; their possibly correct hunch that the young person is not actually in need of such extreme intervention. Their opinions are never considered or legitimized in any research or media story I’ve seen, but brushed aside,  as they watch their loved one step on the conveyer belt of puberty blockers-cross-sex hormones-surgery, to be changed forever.

Dr. Olson and the other purveyors of pediatric medical transition are certainly reasonably intelligent human beings; obtaining an MD or PhD is no mean feat. But (again from the above linked article, Concepts and implications of altruism bias and pathological altruism by Barbara A. Oakley)

 Intelligence is no safeguard regarding these confirmation bias-related issues. Highly intelligent people, for example, do not reason more even-handedly and thoroughly; they simply are able to present more arguments supporting their own beliefs.