On July 21st The Hamilton Spectator published the letter Unwillingness to challenge partisan paradigms in Canadian gender affirmation research. It is a clear example of the rhetoric and tactics that modern anti-trans movements use to dehumanize trans people and strip them of human rights.
In the face of organized anti-trans actors targeting the gender affirmation of all trans youth, it is critical to learn to recognize and call out anti-trans narratives. The July 21st letter is anti-trans disinformation. It attempts to delegitimize the most basic, fundamental practices for supporting trans youth under the guise of concern and debate. This is harmful to trans youth and to the wider Hamilton trans community. This kind of disinformation has permeated mainstream Canadian media and we are saddened to see direct local impacts.
Why respond?
We do not want to legitimize the intellectually dishonest talking points in the original letter by engaging in debate with a piece that so clearly manipulates basic information about trans youth and gender affirmation. Instead, we will turn this into a learning opportunity for everyone who wants to build a safer world for gender diverse youth.
This statement shows how anti-trans disinformation is presented as legitimate or evidence-based, to slowly create doubts and questions about trans people. Those who promote anti-trans disinformation rely on their audience accepting what they claim without critical analysis or fact-checking. This is harmful to gender diverse people, the people who love them, their healthcare providers, and the very disciplines of science and medicine.
The letter blatantly misrepresents the data in the single study it references to imply that access to gender-affirming care causes suicidality in trans youth. This assertion is false, as evidenced below. The letter uses this argument to fearmonger about the existence of trans youth and social and medical transition.
The Spectator presents the central argument of the letter with this summary: “the claim that children have fewer negative outcomes following gender affirmation is simply untrue”. Children do have fewer negative outcomes following gender affirmation, this is widely evidenced in the research. To attempt to subvert this fact, the letter cites Psychosocial Functioning in Transgender Youth after 2 Years of Hormones (2023) in the New England Journal of Medicine (NEJM). A review of the article shows that the research supports no such claim. This is a study that analyzed the psychosocial functioning of youth (12-20 years old) after two years of gender-affirming hormone therapy. The conclusion of the study, in its entirety, was “In this 2-year study involving transgender and nonbinary youth, GAH [gender-affirming hormones] improved appearance congruence and psychosocial functioning”. This study does not analyze the impact of social transition or gender affirmation as a whole and is patently unsuitable as evidence for any such general assertion of the effect of gender affirmation.
What does the evidence say?
The reality is that many studies have examined different components of gender affirmation, social transition and the mental health of trans youth. In these studies, acceptance of gender and access to social transition correlate with improved mental health for trans youth. These include:
Using a study about the impact of medical transition to fearmonger about all affirmation of trans youth is not the only issue with the single citation in the letter. The letter cherry-picks results from the NEJM study to make an obviously unsubstantiated claim. The letter reads:
A paper published in the New England Journal of Medicine in January of this year disclosed that of 312 children given gender-affirming care in a multi-centre study in the US, there were two suicides within the first 18 months of the start of medications. Suicide in children, regardless of mental health diagnoses or gender non-conformity, is extremely rare. In any other area of medicine, such a negative outcome in a medical intervention would have led to a suspension of the study.” (Emphasis added.)
Using the loaded term “disclosed” implies providing information that was previously hidden or unknown. The NEJM study authors make no secret that two youth in their sample died by suicide; they state it clearly at the beginning of their article. Additionally, the study does not present data or speculate about the cause of either suicide or suicidal ideation in their sample population. The letter provides no evidence for its unsupported claim that access to gender-affirming hormone therapy caused suicide.
The letter conveniently leaves out the very findings of the NEJM study:
During the study period, appearance congruence, positive affect, and life satisfaction increased, and depression and anxiety symptoms decreased. Increases in appearance congruence were associated with concurrent increases in positive affect and life satisfaction and decreases in depression and anxiety symptoms.
The study also finds:
Youth who had initiated GAH [gender-affirming hormones] in early puberty had higher scores for appearance congruence, positive affect, and life satisfaction at baseline and lower scores for depression and anxiety at baseline than those who had initiated GAH in later puberty.
In other words, access to gender-affirming hormone therapy showed tangible benefits to trans youth in the study.
The letter dismisses essential context about suicidality and trans communities. The NEJM study found suicidal ideation in 11 youth or 3.5% of their sample. Neither the NEJM study nor the letter address the evidence that trans youth typically experience disproportionately high rates of suicidal ideation and suicide attempts for reasons that include minority stress, lack of affirmation and affirming care, experiences of discrimination, and the distress associated with experiencing gender dysphoria. Trans Pulse Canada (2019), Clark et al. (2014), and Perez-Brumer (2017) all found higher rates of suicidality than the youth in the NEJM study who had access to gender-affirming hormone therapy.
Furthermore, studies have consistently demonstrated correlations between access to requested medical transition care and improvements in mental health and well-being for trans youth. These include:
Major medical organizations in the US and Canada have published statements in support of trans youth and gender-affirming care. In Canada these include the Canadian Paediatric Society, Canadian Association of Social Work Education & Canadian Association of Social Workers, Children’s Healthcare Canada (with a quote from the President of McMaster Children’s Hospital), and the Greater Hamilton Health Network. In the US, this includes the American Academy of Pediatrics, American Medical Association, Endocrine Society & Pediatric Endocrine Society, and American Psychiatric Association.
What can I do?
Two common anti-trans disinformation tactics targeting youth are employed in the letter. Parents, health-care providers, allies, and everyone invested in bodily autonomy should be able to recognize these tactics.
The first tactic is claiming that something happening elsewhere in the world is evidence for why access should be restricted here in Canada. This is often framed as, ‘[European country] has banned gender-affirming care for youth after listening to the latest evidence, therefore we should too’. This is generally a misrepresentation of what is happening in different countries, often taking advantage of a language barrier. It intentionally downplays the active anti-trans movement in the named countries to imply that any restriction on care access is ‘evidence-based’ and not tied to an anti-trans political movement. For more information on this tactic, check out Alex Koren’s article The GOP’s War on Trans Kids Relies on Myths about a “Progressive” Europe (2023).
The second tactic is to call the evidence for gender-affirming care ‘low quality’. Evidence demonstrating that gender affirmation and gender-affirming care improves outcomes for trans youth is dismissed through this label without engaging honestly with the complexities of human-focused research. This, again, takes something that is true and completely misrepresents the context underpinning it to push an agenda against trans youth.
A majority of the extensive evidence in support of affirmation and gender-affirming care for youth and adults alike receives a ‘low quality’ label under the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework for evaluating scientific evidence. Under this framework, the primary type of study that can receive a ‘high quality’ rating is a randomized controlled trial (RCT). In an RCT, participants are divided into a control group and a treatment group. The control group receives no treatment and is compared against the group that did receive treatment. This type of study is highly unethical for gender-affirming care; it would require denying medical care to trans youth for the purposes of a control group. RCTs also use blinding or masking, where participants do not know which group they have been randomized into, to mitigate potential bias. However, physical changes to the body are a primary goal of medical transition (either the pausing of puberty or the onset of secondary sex characteristics), and the mental health benefit of medical transition hinges on these changes. This makes it impossible to mask who receives medical transition between a control and treatment group; all participants would figure out if they had been given the medical care they needed.
Interest groups peddling anti-trans disinformation rely on the ‘low quality’ technical label and a lay misunderstanding of research ethics to delegitimize the evidence for a type of healthcare they want to restrict and eliminate. It’s actually common and necessary for medical guidelines, especially in pediatric medicine, to be based on evidence that GRADE rates as ‘low quality’. For more information on gender-affirming care, RCTs, GRADE, and evidence-based medicine, check out Florence Ashley’s Randomized-controlled trials are methodologically inappropriate in adolescent transgender healthcare (2023).
Successful disinformation campaigns present an avalanche of half-truths and manipulations at once, to overwhelm readers and the impacted community, while constantly moving the goal posts. Attacks against trans youth are increasing in the media. Everyone can and should learn to apply critical analysis to these narratives.
#HamiltonForAll
It is egregious that this letter used the very real issue of suicidal ideation in the trans youth community and the deaths of two trans youth by suicide to fearmonger about the very healthcare that decreases suicidality for trans youth. We are appalled that this was published.
Trans youth are real. They know their genders and identities. Social affirmation and medical transition, when requested, are solidly evidence-based methods of ensuring their best health outcomes. There will always be letter writers, academics, providers, and media personalities that find personal value in pushing anti-trans disinformation to fearmonger about our community’s youth and healthcare. We will continue fighting for a world where all gender diverse people can live their lives freely, on their own terms.
Hamilton Trans Health Coalition
Endorsements and public support for this statement
Greater Hamilton Health Network
"The GHHN supports the @hamtranshealth statement in response to a recent letter published in the Hamilton Spectator on July 21st. We must work together to fight against disinformation that harms our youth. Anti-trans rhetoric directly harms the wellbeing of trans youth. ..." —@GHHN_TheNetwork
St. Joseph's Healthcare Hamilton
"St. Joe’s supports the @hamtranshealth statement in response to an opinion letter published in the Hamilton Spectator. Spreading misinformation about trans and gender diverse individuals is harmful and unacceptable. ..." —@StJoesHamilton
Hamilton Community Legal Clinic
"Trans youth are real. They know their genders and identities. Social affirmation and medical transition, when requested, are solidly evidence-based methods of ensuring their best health outcomes. Access to evidence-based healthcare is a matter of access to justice." —HCLC Statement
The Hamilton Social Medicine Response Team
"#HAMONT MUST READ. An important and thoughtful collective community response to local anti-trans rhetoric that has real, harmful impacts for trans youth and their families and loved ones." —@HAMSMArTeam