Instigator / Pro
15
1774
rating
96
debates
77.6%
won
Topic
#5216

THB in the efficacy of gender affirming care.

Status
Finished

The debate is finished. The distribution of the voting points and the winner are presented below.

Winner & statistics
Better arguments
3
9
Better sources
6
6
Better legibility
3
3
Better conduct
3
3

After 3 votes and with 6 points ahead, the winner is...

Bones
Parameters
Publication date
Last updated date
Type
Rated
Number of rounds
3
Time for argument
Two days
Max argument characters
10,000
Voting period
Two months
Point system
Multiple criterions
Voting system
Open
Minimal rating
1,762
Contender / Con
21
1761
rating
31
debates
95.16%
won
Description

Full Resolution: This house believes in the efficacy of gender-affirming care.

Gender-affirming care is a supportive form of healthcare. It consists of an array of services that may include medical, surgical, mental health, and non-medical services for transgender and nonbinary people.

Round 1
Pro
#1
Resolution: This house believes in the efficacy of gender-affirming care. 


Definitions
All gender-related definitions are from psychiatry.org.

Gender identity: One’s internal sense of self as man, woman, both or neither. 
Cisgender: Describes a person whose gender identity aligns with their sex assigned at birth
Transgender: Describes a person whose gender identity and or expression is different from their sex assigned at birth, and societal and cultural expectations around sex.

Gender dysphoria: Clinically significant distress that a person may feel when sex or gender assigned at birth is not the same as their identity. Though gender dysphoria often begins in childhood, some people may not experience it until after puberty or much later.
Gender-affirming care: a supportive form of healthcare. It consists of an array of services that may include medical, surgical, mental health, and non-medical services for transgender and nonbinary people.

Last but not least, 
Efficacy: the capacity for producing a desired result or effect. 


Preliminary:
Voters will note that the definition of efficacy is that it has the capacity to produces a result that is desired. It does not say that the results have to be deemed "good" or "succesfull" by any third party. Even if God himself said that gender-affirming care was immoral and produced bad results, that would have no bearing on it's efficacy. My job is to show that gender-affirming care more often than not produces the results that its recipients desire. 





Social Affirmation.
  • Adopting gender-affirming hairstyles, clothing, name, gender and pronouns.
  • At any age or stage
  • Reversible
Puberty Blockers
  • Using certain types of hormones to pause pubertal development
  • During puberty
  • Reversible

Hormone Therapy
  • Testosterone hormones for those who were assigned female at birth
  • Estrogen hormones for those who were assigned male at birth
  • Early adolescence onward
  • Partially reversible

Gender-AffirmingSurgeries
  • “Top” surgery – to create male-typical chest shape or enhance breasts
  • “Bottom” surgery – surgery on genitalsor reproductive organs
  • Facial feminization or other procedures
  • Typically used in adulthood or caseby-case in adolescence
  • Not reversible
For transgender and nonbinary children and adolescents, early gender-affirming care is crucial to overall health and well-being as it allows the child or adolescent to focus on social transitions and can increase their confidence while navigating the healthcare system.

I have three major arguments:
  1. Gender-affirming care succeeds in affirming gender. 
  2. Gender affirming care reduces gender dysphoria. 
  3. Gender-affirming care prevents suicides


Argument 1: Gender affirming care succeeds in affirming gender.
People that choose to apply for gender-affirming care obviously desire to get their gender affirmed. Now, does gender-affirming care fail to affirm your gender? Chosing a new name, changing your pronouns and switching up your wardrobe and hairstyle are all part of sociall affirmation. These have nigh perfect success rates, and if they still are not  can be repeated until you reach the desired outcome. Puberty blockers delay the changes to our bodies that occur during puberty. If you have gender dysphoria and take puberty blockers then it means you don't want the physical traits of your sex to become more pronounced. With supervision, these reversible drugs safeley and effectively delay a child's development until they are ready. Since puberty blockers delay that change then that counts as a desired result. This is also perfectly safe, and puberty blockers are also used by cisgender children, like 9 year olds who feel like they aren't ready to grow boobs yet. 

Normaly, at age 17 or older, a teenager and the clinic team may be more confident about confirming a diagnosis of gender dysphoria. If desired, steps can be taken to more permanent treatments that fit with the chosen gender identity or as non-binary. This usually comes in the form of cross-x hormone therapy. Basically, you use estrogen if you want your body to be more feminine, and testosterone if you want your body to become more masculine. You are going to consult with experts and take your specific circumstances into account before choosing to get hormone therapy, it is a more important decision than social affirmation. The same can be said for gender-affirming surgeries. But for those that ultimately decide that they desire to change their bodies, they get their bodies changed through these treatments.

So in conclusion, gender-affirming care has a high efficacy because they succeed in producing the results that their recipients desire. Every patient gets a highly tailored and personalized treatment plan, that allows them to allign their physical characteristics and social image with their sense of self. 


Argument 2: Gender affirming care reduces gender dysphoria.
I have demonstrated that gender-affirming care succeeds in affirming gender. It should naturally follow that gender dysphoria, a result of the strong gender-sex incongruency, should be reduced as a result. Reasearch supports this conclusion. A meta study found that gender affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. 

Research demonstrates that gender-affirming care—a medical and psychosocial health care designed to affirm individuals' gender identities—greatly improves the mental health and overall well-being of gender diverse, transgender, and nonbinary children and adolescents. Social interventions, which are considered reversible (meaning that if gender identity shifts in the future, these decisions can be adapted), are often attempted in a stepwise manner. For example, children may first begin to use a new name or pronouns in the home, and if this feels positive, they may start to do so in other environments, such as school. Social transition may also involve use of different clothing or engagement in new activities, such as transferring to a new a camp or sports league, that are more congruent with the child’s gender. Social interventions have been found to lower the rates of depression and anxiety in TGNB children.
 
Delaying puberty to promote physical development that is consistent with a child’s gender identity is associated with better mental health outcomes, improved functioning, and life satisfaction. 
 
In particular, according to a recent study in JAMA Pediatrics(link is external and opens in a new window), transmasculine adolescents who have undergone chest surgery report significant relief in dysphoria and very rare regret. [columbiapsychiatry.org]
Based on this review, there is an extremely low prevalence (<1%) of regret in transgender patients after gender affirming surgery. Out of 7928 participants in 27 studies, only 77 reported having regrets about their gender affirming surgeries. Significant improvement in the quality of life, body image/satisfaction, and overall psychiatric functioning in patients who underwent GAS has been well documented. So we know that gender-affirming care reduces gender dysphoria and increases mental health.

Argument 3: Gender affirming care prevents suicide. 
With an adjustment for temporal trends and potential cofounders, individuals were 60% less likely to experience depression and 73% less likely to experience suicidality when compared to youths who did not receive gender-affirming interventions. [hcplive.com]
By giving people access to gender-affirming care we are giving them access to a body that they actually desire to live in. This has to count as a desired result.


Summary:
The efficacy of gender-affirming care is evident when you consider that it has the results that it's recipients desire. It succeeds in alligning your physical appearance and social image with your own sense of self. It succeeds in reducing gender dysphoria, depression and low self-esteem. Lastly, it reduces suicidality.

Conclusion:
It is impossible to deny the overwhelming evidence for the efficacy of gender-affirming care.





Con
#2
Full Resolution: This house believes in the efficacy of gender-affirming care (GAC).  

Meta-Analysis

It is crucial to recognise the distinction between denying that GAC is efficient, and actively positing that it is harmful. Whereas PRO’s success in this discussion is contingent on affirming the efficacy of GAC, CON is merely required to render GAC neutral in efficiency. Given how being neutral is distinct from being effective, the resolution would fail if CON can simply demonstrate that GAC does not pass the standard which would afford it the title of exhibiting efficacy. 


Scientific literature 

Valuable research into the efficacy of GAC is highly limited. Often, research is conducted with a small control group, and within a timespan inefficient for casting a determination on the efficacy of the treatment. Particularly, those studies conducted over a short timespan do not allow for subjects to provide an insightful nor considered interpretation as to the efficacy of GAC. Nevertheless, the major studies in the field suggest that GAC is not only inefficient, but actively deleterious in the treatment of gender dysphoria. 

  1. Long-Term Follow-Up of Transsexual Persons Undergoing Sex Reassignment Surgery: Cohort Study in Sweden
    1. The merit of this study is that it a) contains a high population (324), b) utilises a population-based matched cohort, and c) was conducted over a period of 30 years. The following are some significant findings (own emphasis). 
      1. “This study found substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts, and psychiatric hospitalisations in sex-reassigned transsexual individuals compared to a healthy control population. 
      2. The cause-specific mortality from suicide was much higher in sex-reassigned persons, compared to matched controls.
      3. The overall mortality for sex-reassigned persons was higher during follow-up (aHR2.8; 95% CI 1.8–4.3) than for controls of the same birth sex, particularly death from suicide (aHR 19.1; 95% CI 5.8–62.9). Sex-reassigned persons also had an increased risk for suicide attempts (aHR 4.9; 95% CI 2.9–8.5) and psychiatric inpatient care (aHR 2.8; 95% CI 2.0–3.9). 
      4. Persons with transsexualism, after sex reassignment, have considerably higher risks for mortality, suicidal behaviour, and psychiatric morbidity than the general population.”
  2. Reduction in Mental Health Treatment Utilisation Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study
    1. This study was initially lauded by trans inclusive pundits, given it ostensibly supports the GAC thesis. Indeed, that it utilises the “Swedish Total Population Register” as the population investigated (this study has the largest dataset on patients who have undergone sex-reassignment procedures), coupled with its lengthy study period (2005-2015) meant it carried the characteristics of a sound research. Yet three years following its publications, the author issues both a correction and response to unequivocal criticism. 
    2. In their correction, it is written that
      1. “the results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations following suicide attempts in that comparison.”
    3. Further still, in response to letters, it is acknowledged that 
      1. “individuals diagnosed with gender incongruence who had received gender-affirming surgery were more likely to be treated for anxiety disorders compared with individuals diagnosed with gender incongruence who had not received gender-affirming surgery
      2. this study highlights the substantially increased risk of mental health problems among individuals diagnosed with gender incongruence, and in particular, among those in the process of receiving gender-affirming surgery 
      3. When comparing the mental health treatment outcomes between the two groups , we found no significant difference in the prevalence of treatment for mood disorders and no significant difference in the prevalence of hospitalization after suicide attempt.
  3. Long-term follow-up of individuals undergoing sex reassignment surgery:
    1. Finally, one of the last long term studies conducted on the matter (1978-2010 with over 100 gender dysphoric individuals corroborates the notion that GAC of the surgical variant is inefficient in ameliorating anxiety of ones  gender. 
      1. No significant difference in psychiatric morbidity or mortality was found between male to female and female to male (FtM)
Thus, those major studies bearing the characteristics indicative of good science suggest that GAC is not only inefficient, but actively harmful in the treatment of gender dysphoria. 

Logical incongruity

Not only is GAC an unscientific treatment within the clinic, but pure reason and statistics are sufficient in dispelling its efficacy. This can be done by issuing a simple reductio ad absurdum. 

It is often claimed that denying transgender individuals GAC entails suicide. One specific number that is commonly noted by these individuals is that 60% of trans identifying people who are denied healthcare attempt suicide.  Holistically however, the stipulation being put forth is the following - IF we allow transgender individuals gender affirming care, THEN there will be an decrease in suicide. 

Following this, it is apparent that there has indeed been an increase in transgender individuals seeking and being given GAC. Equalities Minister Penny Mordaunt of the UK has launched an investigation into the numbers provided by the Tavistock Gender Identity Development Service finding a 4,415 percent (or 1766 individuals) increase in young girls seeking GAC between 2010 and 2018.  

Now, if the trans inclusive hypothesis is correct, it should follow that of these 1766 individuals referred, 60% of them would have attempted suicide, had the Tavistock Gender Identity Development Service not been avaliable. The reason we can make this inference is because we have taken the hypothetical that providing GAC decreases attempted suicide, and so this particular instance where 1766 individuals have been provided GAC should therefore be accompanied with a decrease in suicide. Combing the hypothetical that “60% of trans identifying people who are denied healthcare attempt suicide” with the proliferation of 1766 individuals seeking healthcare, we can deduce that there should be a decrease of 1059 attempted suicides. Of course, attempted suicides ought not be conflated with completed suicides, and so taking this number and combining it with the ratio of suicide attempts to suicide death in youths being about 25:1, we can finally conclude that 42 successful suicides should have been prevented, in purview of GAC between 2010 and 2018. 

Yet, this has not occurred at all. If we consider the statistics collected by the Royal College of Paediatrics and Child Health, 2010 saw a total of 53 suicides by females under the age of 19 and 2018 saw 78. No where in these numbers is there a drastics decrease of 42 suicides that would be expected if the GAC hypothesis were truly sound. 

In anticipation that the complexity of this point may be overly confusing, consider the following encapsulation:  

  1. The hypothetical supposition is as follows - “If we allow transgender individuals to seek GAC, then their suicide will decrease”
  2. We have seen the antecedent (if statement) actualise in reality - 1766 more individuals who otherwise would not have been able to, were referred to the Tavistock clinic. 
  3. Yet, the consequent (then statement) has not actualised - despite 1766 individuals seeking supposedly life saving healthcare, the expected suicide decrease not only did not occur, but seemed to actualise in the opposite direction. If ignoring gender dysphoria were so damaging, and GAC is such an effective antidote, it should be expected that the increase in GAC availability is followed by a correlated decrease in suicide of which the treatment prevented. However, given no such correlation, the efficacy of GAC ought to be questioned. 
Syllogistically, the argument outlined would be as follows. 

P1. If allowing transgender individuals to seek it will decrease their suicide, then gender affirming care is effective. 
P2. Allowing transgender individuals to seek it will not decrease their suicide
C1. Gender affirming care is ineffective. 

Conclusion

Both scientific and logical accounts render the gender affirming care hypothesis null. On the scientific front, those studies which bear the characteristics of a good paper find GAC to be ineffective in ameliorating gender dysphoria. More damningly however, are the incongruity of the statistics found with relation to GAC accessibility and suicides. Even if PRO were to produce studies which ostensibly support GAC, the fact that the statistics objectively do not find mortality to be decreased in any ways conclusively dispels the efficacy of gender affirming care.
Round 2
Pro
#3
Thank you, Bones. 

Meta-analysis response: 
I believe that efficacy cannot be defined in ideal terms when discussing gender affirming care, because life is not a laboratory. But if we are to shoehorn in these criteria, it actually helps my case. I believe it is obvious to anyone that ideal circumstances for GAC means that the rights of transgender people to exist and express themself publicly is not constantly denied by political and public figures, that the recipients are not constantly accused of being child groomers and sport destroyers, that the transitioning are not bullied, threatened or looked down upon, that their feelings and sense of self is validated instead of being labeled a political agenda and an offence to God. That they are accepted by their own families and members of their own communities. It is very clear that under ideal circumstances, all transgenders, but especially those treated with GAC, would be far happier and healthier.


CON cannot claim that neutral long-term outcomes disproves GAC efficacy, because under ideal circumstances without transphobia these outcomes would be positive.


Rebuttals:

The first swedish study CON presented found that the 324 sex-reassigned persons had higher rates of mortality, higher risk of suicide and psychiatric inpatient care. The question then is who are they being compared to, and what is the cause of this discrepancy. It turns out that they are being compared to the general population, which is composed of cisgender people. That means that according to this study transitioned people have worse outcomes than cisgender people of their original sex and cisgender people of reasigned sex. CON is commiting the mental health equivalent of saying that crutches and wheelchairs don't have efficacy because compared to the general population, users of crutches and wheelchairs are slower. Being able to move on your own is still a desired result.

"Our findings suggest that sex reassignment, although alleviating gender dysphoria, may not suffice as treatment for transsexualism, and should inspire improved psychiatric and somatic care after sex reassignment for this patient group". 
Sex reassignment does alleviate gender dysphoria -- and that is the desired results. A treatment can have efficacy without being sufficient.



The second swedish study CON presented showed an association between gender-affirming surgery and reduced likelihood of mental health treatment. The conclusion "lends support to the decision to provide gender-affirming surgeries to transgender individuals who seek them". CON brings up a later correction. But said correction only talks about some limitations of the methodology of the study, and one minor math error. Thus the conclusion of the original study was stated too strongly. The authors themselves have clarified that their study did not measure the effects of GAC on mental health, but rather the prevalence of mental health problems among trans people in Sweden, which is influenced by many factors beyond medical care, such as social stigma, discrimination, and violence.

“[those] who had received gender-affirming surgery were more likely to be treated for anxiety disorders compared with [those] who did not.
CON cites some lines from the response to letters as though they are bearing the characteristics indicative of good science. That is not true. "The group diagnosed with gender incongruence not receiving surgery is a heterogeneous group, including those with no intention to seek surgery, that would be inappropriate as a comparison group for those receiving surgery". This comparison they were asked to make retroactively is of very low quality according to the writers of the letter, and has no academic weight. 


Finally, one of the last long term studies conducted on the matter (1978-2010 with over 100 gender dysphoric individuals corroborates the notion that GAC of the surgical variant is inefficient in ameliorating anxiety of ones gender. 
The study CON is refering to this time does not even mention gender dysphoria or "anxiety of ones gender", and it never claims that SRS is inefficient or lacks efficacy. 


Adressing CON's syllogism:

If allowing transgender individuals to seek it will decrease their suicide, then gender affirming care is effective. 
What is implied here is false. The purpose and desired result of GAC is to reduce gender dysphoria. It is not a suicide prevention clinic. The recipients of GAC report satisfaction with the treatment and minimal regret, and those doctors and psychologists also report in their research that results are desirable. As a third party CON cannot impose on transgender patients his own criteria for what constitutes a desirable result from them undergoing GAC. I already mentioned this in R1.

we can finally conclude that 42 successful suicides should have been prevented, in purview of GAC between 2010 and 2018. 
This premise is ripe with methodological problems:
  • CON straw mans by assuming that suicide attempts are predicted to always fall from 60% to 0% if they receive GAC. 
    • The 60% figure is only a statistic. You cannot use it to say that excactly 60% of any given transgender group denied GAC will attempt suicide.
    • It's also bad methodology to apply a general American statistic to a specific British group.
    • The reduction in suicidality as a result of GAC is consistently observed across the board, but always to different degrees, and no study claims a 100% reduction.
    • The 1:25 ratio of successfull to failed suicide attempts is also a statistic from America, not a universal rule.
If we consider the statistics collected by the Royal College of Paediatrics and Child Health, 2010 saw a total of 53 suicides by females under the age of 19 and 2018 saw 78.
CON's other premise is also based on easily detectable errors and faulty logic:
  • There is no reason to assume that all the averted suicides would have occured in 2018. If some girls made use of access to social affirmation at age 6 in 2015, it makes no sense that this would prevent a suicide that would have occured specifically in 2018 or any year before that.
  • CON is looking at the overall number of suicides and making unwaranted assertions about transgender suicides. He does not take into considerations other factors that influence the frequency of suicides, and he does not falsify the null hypothesis, that is prove that random fluctuations cannot be a valid cause.
  • According to CON's source: "Over the past 15 years, the UK rate of suicide among 15-24 year olds has gradually fallen, but rose again in 2018 – although this could be partly due to a change in coronial standards rather than a true rise." In 2013 for example, the number was 31. CON cherry picked the year 2018.
So it is wrong to say that 42 suicides should have been prevented if GAC has efficacy, and it is also wrong to say that 42 suicides weren't prevented. 




My own syllogism:
P1. IF a treatment doesn't produce desirable results, THEN it produces regret.
P2. Gender affirming surgery does not produce regret. 
C: GAS produces desirable results

Premise 1 is obvious. Undergoing surgery is a big undertaking, and nobody is goint to say "whatever" after getting results that aren't positively satisfactory. 
Premise 2 is backed by lots of evidence. I extend that a study found that less than 1% of 7928 patients regret having undergone gender affirming surgery. 
So the conclusion holds. Sex reassignment surgery does produce desirable results, and thus has efficacy. 


Summary:

Conclusion:
There is an extensive scientific consensus that GAC has efficacy, that it reduces gender dysphoria and has minimal rates of regret. The resolution holds true. 


Con
#4
Meta analysis

The operative term of this debate is efficacy - whether GAC can produce a desired effect. Given the proportions of what GAC is (a treatment which is often life altering and semi-permanent), whether it truly yields a “desired effect” ought to take into consideration the livelihood (as opposed post surgical deliberations) of those gender dysphoric individuals. If someone created an anti-depressant which made patience temporarily happy, but drastically increased their future suicidal ideations, PRO's method would deem the medication valuable, as they have not provided a single reason supporting the longevity of GAC. 

Scientific literature 

PRO claims that because the first study only compares the mental well being of transgenders to the general population and not the trans individuals themselves, and that an inference therefore cannot be made because of extraneous values. This is false for various reasons. 

  1. Misleadingly false:  In science, a control group is the standard to which comparisons are made in an experiment - such individuals are matched for statistically relevant characteristics and ought not be flippantly discounted as the "general population" by PRO. A control population can be statistically considered an "identical" of those being studied, and so when researches finds that transgender individuals have "substantially higher rates of overall mortality, death from cardiovascular disease and suicide, suicide attempts", it is a variation of which they would not have experienced had GAC not been offered. 
  2. Empirically false: Even if PRO's analysis of control group is correct, they are still substantively incorrect because the study does analyse the progress of transgender individuals. If you consider figure 1, transgender mental experiences a sharp decline following their transition. Indeed, when being denied GAC, the figures show their mental health situation to be identical to their cis-gender counter part, yet a few years following GAC, their mental health starkly drops. How can PRO explain that the divergence occurs after 10 entire years? Any post hoc justification they have for why there was divergence in the 2nd and 3rd decade (asserting that these individuals were bullied, were not accepted by their community or family) can be refuted by asking why these effects, which were present in the first 10 years, did not result in such stark suicides? 
PRO critiques the second study is that the correction was minor, as opposed to explaining the damning critiques that there is "no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care". PRO states that a correction is not good science - yet the correction merely amends the very much good science which constitutes the original study. CON also cites some lines about the control group being inappropriate as a response to there is no  significant difference in the prevalence of treatment for mood disorders. This is extraordinarily bad faith - what PRO quotes is the admission of fault in the original study (which supported GAC). Immediately following, the authors seek to be "responsive" to these critiques, amend their use of control groups and only then do we get the correction that GAC doesn't treat mood disorders. PRO has confused the order of which the admission of fault occurs. 

Regarding the third, PRO makes no address, claiming that gender anxiety wasn't considered whilst ignoring the title"psychiatric morbidity and mortality", flippantly disregarding the three decade long study. If what PRO calls "gender anxiety" causes "no significant difference in psychiatric morbidity or mortality", that speaks more to the shortcomings of what "gender anxiety" really is. 

Logical incongruity

PRO claims that the purpose of GAC isn't to reduce suicide, but to amend gender dysphoria. This makes zero sense. If gender dysphoria were amended, then suicidal ideations would be removed - clearly, GAC is not working.

PRO's primary critique is that CON is too harsh - that they expect a drop from 60% to 0% in suicides. This is blatantly false. CON is entirely willing to afford a margin of error, whereby a non 0 digit would still function in their argument. If we compare the periods between 2010 and 2018, we can see the following: 

  • 2010 - 53 suicides, 1766 people denied GAC, 42 predicted suicide. 
  • 2018 - 78 suicides,  1766 people allowed GAC, 42 predicted decrease in suicide. 
Contrary to PRO's characterisation, CON can offer a huge margin of error and still be correct, as the predicated suicides are so absurdly high they constitute more than half of all youth suicides (note "predication" is derived from the GAC hypothesis only)

PRO hypothesises that CON cherry picked 2018 (couldn't be because the gender clinic didn't provide number for 2019 as they were amidst a class action lawsuit). Even if they are true, CON can just take the statistics for 2017 (63 total suicides) and substitute it into the above argument with no issues. Further, PRO takes issue with using cross nation inferences - they must provide a symmetry breaker as to why suicides in Britain and USA would be statistically significant. 

PRO then poses their own syllogism which hinges on the study they presented in the opening, the science of which is thoroughly refuted below. 

Rebuttal

1. Gender-affirming care succeeds in affirming gender

PRO’s first claim, that “with supervision, children can take reversible drugs safely and effectively delay a their development until they are ready” is blatantly and unequivocally untrue. Scientifically, the American College of Pediatricians outright claim that there exist “no evidence that Transgender interventions are safe for children”, and that “puberty blockers may cause permanent physical harm”. Combined with the fact that the FDA has not approved of puberty blockers in teens, independent analysis of statistics from the CDC, Centers for Disease WISQARS, “"State Laws on Minor Consent for Routine Medical Care," hand book find that suicide rates of those in states with provision which allow minors to seeks hormonal GAC have increased following the treatments avaliability. This is because puberty motivates exclusive changes to the body. When such drugs are used in adolescents, bone density growth flatlines irreversibly, which could lead to heightened risk of debilitating fractures

Indeed, that many nations in the UN (Norway, Finland, Sweden, UK) are adopting caution with regards to allowing GAC further rejects PRO’s acceptance of the experimental treatment

2. Gender affirming care reduces gender dysphoria

PRO puts forth a systematic review (was also used in their syllogism in the second round) finding that there is an extremely low prevalence (<1%) of regret in transgender patients after gender affirming surgery. The study they chose is hugely problematic. Firstly, the authors elect to overlook numerous studies, including the largest one which dispels their findings, lending prima facie considerations towards the possibility of bias. Further, the authors themselves admit to “lack of controlled studies, incomplete follow-up, and lack of valid assessment measures,”. Because most studies considered postsurgical periods of 1 or 2 years, they do not account for how the average number of years for regret to manifest is 8 years. Although the author admits to “moderate-to-high risk of bias in some studies”, “some” really refers to 23 of the 27 studies. The majority of included studies ranged between “poor” and “fair” quality: with only 3 percent receiving higher quality ratings - of which had participant drop out rates ranging from 28% to more than 40%, including loss through death from complications or suicide, negative outcomes potentially associated with regret. From a simply logical perspective, those with regret would be far more unlikely to return than those without it because of shame and stigmatisation. 

Likewise, PRO’s claim that gender affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress is likewise contingent on a single source which carries much the same difficulties. Its small sample size and lack of adjustment for confounders limits the ability for causal inferences to be made. 

3. Gender-affirming care prevents suicides

As a general refutation, refer CON’s first round, 2nd argument, which illustrates the incongruity between the alleged dire consequences of denying GAC, and the reality of the unchanging suicide rates. 

PRO presents a single study to affirm the matter. Immediately, it faces issues given it surveyed participants over a single year. The reason a short time period is unacceptable can be understood colloquially - suppose you make a purchase of your dream house which you have been aspiring to own for years. To understand whether a purchase of this magnitude positively impacts your mental well being, I cannot simply ask you whether you are satisfied a year after the matter - this is because purchasing and paying off a house is a process which spans over decades, and so asking if someone is satisfied after a single year does not sufficiently capture all contingencies. This is likewise in the case of GAC - it is understandable that immediately following treatment, these individuals will be ostensibly satisfied. However, as GAC affects one's whole life, valuable insight would be obtained if we had a long term understanding of these individuals' satisfaction later on in life. Various studies (as I have presented in the opening), find that diversion of mental welfare occurs after 8 to 10 years - something PRO simply cannot account for. 

Conclusion

When transgender mental health improves, PRO says it is because of GAC. When transgender mental health improves, PRO says it is in spite of GAC and a consequent of public treatment. 
Round 3
Pro
#5
Thank you, Bones.

Meta-analysis:
As per CON's own definition, efficacy in medicine means the capacity of an intervention or drug to produce a desired result in expert hands under ideal circumstances.

If gender dysphoria were amended, then suicidal ideations would be removed
There is a huge body of research affirming that transgenders' mental health after receiving GAC is negatively impacted by stigma, discrimination, harassment, physical assault and ostracization. So it is incorrect and bad faith to assert that after GAC has alleviated their gender dysphoria that they would automatically have good mental health. I uphold that the efficacy of GAC is far higher than it's efficiency for this very reason. 

Scientific literature from CON's R1:
CON claims that "transgender mental experiences a sharp decline following their transition" with no evidence. He also says "when being denied GAC, the figures show their mental health situation to be identical to their cis-gender counter part", which is ridiculous. His own source says that "It is generally accepted that transsexuals have more psychiatric ill-health than the general population prior to the sex reassignment". Post-GAC mental health isn't worse than Pre-GAC mental health.

CON repeats that there is no advantage from GA surgery, citing a line from the correction to a the swedish study. I will let the authors of the correction correct CON:
this comparison was performed retrospectively and was not part of the original research question given that several other factors may differ between the groups. they would be inappropriate as a comparison group for those receiving surgery  [Correction][Response to letters]
So the very authors he is citing are denying the usefullness of this comparison that CON keeps going back to. I will also reiterate that the correction did not actually retract the findings of the long term swedish follow up study which were that the likelihood of being treated for a mood or anxiety disorder was reduced by 8% for each year following the last gender-affirming surgery, for up to 10 years. I also extend that the third study of his measures psychiatric morbidity in general, not gender dysphoria specifically like CON is insinuating. 

None of the studies or corrections or letters CON cited in R1 concluded that the data dispells the efficacy of GAC. To the contrary, they all affirm nearly verbatim in their conclusions that GAC alleviates gender dysphoria. So while CON may elect to interpret them differently, those sources do support the efficacy of GAC. 


CON's syllogism refuted again:
I extend that it is false to deny that GAC reduces depression and suicidality based only on incredibly flawed analysis of cherry picked data. CON says that he has can afford a margin of error. Of the 1766 individuals he mentioned many were young and would never had commited suicide during the period 2010-2018. CON has also not discounted the null hypothesis or other factors that could influence the ammount of suicides. The numbers in the middle of the period were much lower than in 2010, in 2013 there were 31 suicides by young females. Take his number 42 and shave off 22 because no study claims a 50% reduction in suicide attempts. Now we predict 20 prevented suicides. How can CON prove that these did occur? He has no data on the actual suicide rates of the 1766 individuals that seeked GAC in 2018. 

 CON has not made a reductio ad absurdum argument, he has made an absurd and reductive argument.


Social affirmation
Chosing a new name, changing your pronouns and switching up your wardrobe and hairstyle are all part of sociall affirmation. These have near perfect success rates, and if you still are not fully satisfactory you just repeat the process until you reach a desired outcome. A study finds that socially transitioned children have average mental health outcomes, in stark contrast to children with GID who continue living as their natal sex and have terrible mental health. When someone chooses to receive further GAC that proves that they found the results of social affirmation desirable, because if they didn't they would have instead returned to living as their natal sex. 


Puberty blockers
The primary source that CON uses to make puberty blockers out to be ineffective or harmfull is the American_College_of_Pediatricians. That's about the lowest quality source you can find for this kind of debate. They have been labeled a fringe anti-LGBTQ hate group pushing junk science by the Souther Poverty Law Center. What they write is not peer reviewed, and the page that CON is linking to makes sweeping claims with no references or named author. However I do agree with CON's other source that states with easier access by minors to cross-sex medical interventions without parental consent is associated with higher risk of suicide. However, my BoP is that GAC produces desirable results in expert hands under ideal conditions, where parrents are consenting.  

Puberty blockers do not cause permanent changes to the body. And you can stop taking them at any time. If you decide to stop taking puberty blockers and did not take hormone therapy, your body will go back to the  puberty that had already started. The FDA has declared that these medications are safe when used as prescribed. [healthline.com]
According to Mayoclinic.org, posible benefits of puberty blockers for transgender and gender-diverse youth include:
  • Improve mental well-being.
  • Ease depression and anxiety.
  • Improve social interactions with others.
  • Lower the need for future surgeries.
  • Ease thoughts or actions of self-harm.
Hospital Cedars Sinai has this to say: "While puberty blockers have been scrutinized by some due to their use in caring for transgender children, these drugs have been in use since the 1980s and are overwhelmingly safe if used appropriately. Side effects such as bone health risks typically only occur with prolonged use past the age of puberty."

Countries have a right to be cautious, but politics does not dictate how we should interpret the research. It is inaccurate to say that puberty blockers are an experimental treatment.


Hormone therapy:
CON mentions bone mass reduction as a harm of HT. The authors of the study he cites  concluded that GnRHa treatment may delay or reduce the attainment of peak bone mass, which is the highest level of bone mass that a person can achieve. But they also found that gender-affirming hormone treatment may restore or improve bone mass, especially in transboys. This is consistent with the latest reserach. A recent study tracked the bone mineral density and BMD z-scores of 50 transmen and 25 transfemales the period 1978-2010. Each of them had received GnRH before age 18 and had subsequently received cross-x hormones for 9 years. The researchers found that the patients had similar pre- and post-treatment bone mineral density after receiving puberty blockers and gender affirming hormone treatment.

Forty-six relevant journal articles (six qualitative, 21 cross-sectional, 19 prospective cohort) were identified. Gender-affirming hormone therapy was consistently found to reduce depressive symptoms and psychological distress. 

Research tends to support the evidence that hormone therapy reduces symptoms of anxiety and dissociation, lowering perceived and social distress and improving quality of life and self-esteem in both male-to-female and female-to-male individuals. Overall, this review demonstrates that cross-sex hormonal treatment has definite effects on mental health, generally ameliorating gender dysphoria individuals’ well-being at different levels. 


Gender surgery.
CON mentions "numerous studies" dispelling the findings that GAS recipients have high satisfaction and low regret rates. But he does not present any research papers that reports high or even moderate regret rates. He claims that the average time for regret to manifest is 8 years, but the study CON linked to that figure is not very usefull for his case. They studied 95% of transgenders in the Netherlands who received GAC between 1972 and 2015 and yet "Only 0.6% of transwomen and 0.3% of transmen who underwent gonadectomy were identified as experiencing regret.". Table 4 catalogues the information about the 14 cases of regret. 5 cited "social acceptance" as their reason for regret, while 2 cited "feels nonbinary". So in the results from a study with 43 years of data found a grand total of 7 people  who reported "true regret" about sex reassignment surgery. Similarly, over a 50 year period in Sweden covering 767 recipients of GAS, there were only 15 regret applications corresponding to a 2.2% regret rate for both sexes. Both of these studies conclude that the percantage of regret was always small but did decrease with time. This makes sense since surgeries improve over time. 

One study of transgender men showed that participants had lower self-esteem than cis-gender men and that a mastectomy improved their body image, self-esteem and self-worth.  A  40-year follow up study on 97 patients found that Gender-affirming surgery is a durable treatment that improves overall patient well-being. High patient satisfaction, improved dysphoria, and reduced mental health comorbidities persist decades after GAS without any reported patient regret"Another study analysed the 2015 American survey of 20 000 transgenders and found that those who had received a gender affirming surgery more than 2 years prior "had significantly lower odds of past-month psychological distress, past-year tobacco smoking, and past-year suicidal ideation" compared with transgenders that were denied gender affirming surgery. Recipients of GAC were 60% less likely to experience depression and 73% less likely to experience suicidality.


CON has not provided a single study that reports high rates of regret. He relies entirely on claiming that the precise regret rates are hard to figure out. But my case does not require a perfect precision in these studies. Even if we assume very liberaly that 90% of regret was unreported or not developed yet when collecting data for the meta-study of 8000 GAS recipients, that still leaves us with less than 10% regret, and much of that would be because of social acceptance rather than true regret.

The CON position cannot adequately explain why research CONSISTENTLY shows positive results for GAC and extremely low regret rates regardless of size or duration.



My syllogism:
Low rates of regret would be a solid proof of the efficacy of GAC. CON dropped this, I extend.
So if voters find my evidence for low regret rates more convincing than his evidence for high regret rates, then my syllogism holds and proves the efficacy of GAC. 


Conclusion:
Research consistently shows that gender affirming care is effective in alleviating gender dysphoria. Studies repeatedly find that GAC has numerous benefits on mental health. The positive results would have been even greater and more pronounced had it not been for the overwhelmingly negative impact of transphobia. GAC definately has the capacity to produce desirable results in expert hands under ideal circumstances. Thus it has efficacy. I have fullfilled my BoP and the resolution holds true.
Con
#6
Meta analysis 

Repeatedly, PRO has attempted to construe the debate into a win-win circumstance for themself. When gender dysphoria seems to be alleviated, they assert this is because of GAC. When gender dysphoria doesn't seem to be alleviated, this is in spite of GAC, and in fact because of social pressure. Substantively, the "social pressure" ad hoc manoeuvre is false - as has been argued, if such a variable is responsible for deleterious mental health, why is it that suicidal ideations deviate from the control decades later, particularly, in 2003 as opposed to the 1980's? Throughout the entire debate, PRO has not accounted for such a late divergence. 

Scientific literature 

Regarding the first study, PRO's assertion that there isn't a stark decline in mental health is factually untrue - refer to the provided table. PRO quotes a segment of the study finding that "transsexuals have more psychiatric ill-health than the general population prior to the sex reassignment", in an attempt conclude that the mental health deviation were already present. Yet, they fail to show how such a statement is incompatible with the sentiment that psychological deterioration occurred following GAC. Again, if such mental health difficulties were equally present prior to GAC, PRO must explain why there is a consistently stark divergence decades following GAC. Furthermore, PRO has entirely resigned refuting the plethora of effects found in this study, namely, that patients of GAC have higher death from suicide, psychiatric morbidity,  death from cardiovascular disease and general risk for mortality. 

Regarding the second study, PRO repeats their prior critique, which CON has already thoroughly dispelled, quoting a single line which asserts that the method of the study is inappropriate. Because PRO is unresponsive to my charge that they have completely confused the order of the quotes, I am forced to present it in full. 

The group diagnosed with gender incongruence not receiving surgery is a heterogeneous group, including those with no intention to seek surgery, that would be inappropriate as a comparison group for those receiving surgery [PRO's quoteHowever, to be responsive to some of the letter writers’ interest in comparing individuals with a gender incongruence diagnosis who received and did not receive gender-affirming surgery, we have created a matched group of individuals with a gender incongruence diagnosis who have not received surgery. These individuals were each matched to an individual with a gender incongruence diagnosis who had received gender-affirming surgery by age, legal gender, education, and country of birth. When comparing the mental health treatment outcomes between the two groups (Table 1), we found no significant difference in the prevalence of treatment for mood disorders and no significant difference in the prevalence of hospitalization after suicide attempt.
PRO has quoted the studies admission that their former findings (the ones which support GAC) were false, and taken it to be an admission that the new revision is false. As this has already been explained, CON is forced to take it as a bad faith reading. 

PRO has also resigned answering to the third study and perhaps most important study, so can presume they accept the conclusion "no significant difference in psychiatric morbidity" following GAC. 
 
On the basis of these studies alone, it is evident that the longest, most comprehensive and population rich studies all find that GAC is not a treatment with long term success in alleviating gender dysphoria. 

Logical incongruity

PRO's response has regressed from their last rebuttal, now asserting that "other factors" could have effected CON's finding. Claims are not evidence. PRO has resigned to hypothesising what could have, should have, and would have happened, without committing to an actual position. I am therefore compelled to reiterate my argument in the simplest terms. 

  1. The GAC hypothesis is as follows: IF we allow transgender individuals to seek GAC, THEN their suicide will decrease
    1. Such a statement now commits you to a causal prediction - IF, X, THEN Y. 
  2. Luckily, the IF statement has occurred, in the form of those 1766 individuals seeking GAC. These individuals, who were formally prohibited, now get to seek care. 
  3. Given the commitment to causal prediction, we can see if the THEN statement has actualised. But we ought be more specific than just seeing if "suicide will decrease". Pro trans positions find denying GAC results in approximately 60% of them attempting suicide. Of attempted suicides, approximately 4% are successful. Thus, the THEN statement can be amended to "their will be a suicide decrease of approximately 42". To this, PRO priorly asserted that you cannot use exact number. In response, I charge that claim as a being a straw man. Because the total suicide of this population was 78, CON simply has no need to expect a precise decrease. The numbers are so absurd that a margin of error amounting to 50% would not effect the soundness of CON's argument
Thus, the GAC hypothesis makes a prediction which it does not fulfil. despite any study PRO may produce, it remains a fact that GAC has little to no effect on the suicidal ideation of gender dysphoric individuals. 

Rebuttal

PRO introduces a huge plethora of new studies here, without defending the many ones they introduced in the opening, and second round. As a side note, this blitzkrieg tactic of throwing sources in hopes that one sticks is usually done when the instigator recognises that their sources are of low quality, and must instead substitute it with volume (12 is the counted number). Overall, CON is not compelled to issue a response to every new source, just as how PRO does not bear that burden to reciprocate. 

PRO has three major claims here: 

The first regards the efficacy of of puberty blockers. Outside of issuing an ad hominen attack on the  American_College_of_Pediatricians, no efforts are made to address the various sources which were unpacked by PRO. To recall, the following was presented as points of rebuttal, excluding those from the ACP: 

  1. The FDA has not approved of puberty blockers in teens,
  2. States with provision which allow minors to seeks hormonal GAC have increased following the treatments avaliability (WISQARS, CDC) 
  3.  Bone density in children's growth flatlines irreversibly,
    1. Leads to heightened risk of debilitating fractures
Admittedly, PRO does attempt to address the issue of bone growth. I would like to note that they however ignore the two studies [1][2] presented by CON to prove the case. However, their response has absolutely no relevance to the point being made. Linking for CON a study on the effects on bone density in post pubescent adults, they completely miss the initial point, being that puberty blockers have deleterious impact on children. We must take it that they therefore forfeit the outrageous claim they made in the opening - that GAC does not negatively effect a child's development. 

The second claim regards gender surgery, which they begin by attacking the source CON provided on how regret manifests 8 years following surgery. In refutation of the point, they curiously never address the three primary studies CON provided, all of which were conducted over 30 years and prove the point, instead opting to issue more new sources in the closing round. However, as the sources are poor, CON issues a short rebuttal of them each. 

  1. Sweden study with 767 members - the study writers "regret rate isdefined as the number of sex reassigned individuals at the timeperiod when they did their first application that will later applyfor reversal to the original sex". There are many reasons people may regret but not apply for reversal to original sex eg, financial hardship, embarrassment, inconvenience, none of which PRO account for. 
  2. "One study of transgender men... improved body image" - recycled from the first round, CON already noted of it that it contained a small sample size and lack of adjustment for confounders and period of research was too short. 
  3. 40-year follow up study on 97 patients - 82 of 97 from the initial pool did not wish to respond to follow up - hence the admission that there existed "selection and recall bias".
  4. 2015 American survey of 20 000 transgenders -first issue being it was literally a single survey. Obviously, people happy with their treatment are more likely to report their experience than those who are not and feel shame. Second, there is no defined period one must have been a transgender for eg they could have received their surgery a month prior to the study and still be feeling rapid onset dysphoria. 
Thus, even with the impressive plethora of sources, PRO is unable to find a single one which substantively supports GAC. 

PRO's syllogism

Warrants little response - the source they used propping up the entire argument was thoroughly debunked in in r2. 

Conclusion

Even whilst blitzkrieging their way to the finish line, analysis of the source bomb wouldn't yield you a single study of longevity which simply assert - "GAC is beneficial in the long run". Contrary to this, CON has provided three major sources, as well as a contemporary analysis of why suicide ideations are not impacted by GAC. As mentioned in my opening GAC effects ones whole life, and thus analysis of its efficacy too ought to consider ones whole life. No such considerations are offered by PRO. 

Thank you Ben for an enjoyable debate.