Will an RCT of HRT Finally Satisfy Critics of Trans Care?
A randomized controlled trial found that testosterone significantly reduces gender dysphoria, depression, and suicidal thoughts in trans patients. At long last critics will concede this is evidence-based medicine… right?
by Evan Urquhart
Are medical transition measures, such as testosterone therapy which masculinizes the appearance of a trans person who was assigned female at birth, evidence based? Yes. OK, but really? Yes, obviously yes, there have been numerous studies, every bit of evidence that exists points to yes.
Desperate for something to confuse this very unambiguous finding in the medical literature, anti-trans ideologues have seized on a simple mantra: The evidence showing that medical transition improves patient outcomes is low quality. In the medical profession, this meant there haven’t been any randomly controlled trials, trials where patients are randomly selected to either receive treatment or not and the two groups are compared to see if the treatment did any good. In the medical field a lack of RCTs can come about in a lot of different ways, and there are situations where RCTs are unethical or impossible to conduct, but in the anti-trans political climate all that matters is throwing the words low quality around and acting as if you’ve just said something huge. That’s why the recent publication in the journal Diabetes and Endocrinology of a randomly controlled trial showing early testosterone therapy for trans patients improved outcomes over patients who had to wait a standard 3 months is such a big deal.
screenshot from Diabetes and Endocrinology
BOOM! There it is, it’s a randomized controlled trial, it shows testosterone decreased gender dysphoria, depression, and suicidality. It’s just what critics say they wanted, putting to rest the canard that gender-affirming care isn’t evidence based forever, hooray!
Alright, alright, no one thinks this single study looking at adult AFAB trans people who got testosterone 3 months earlier than the control group will silence transphobia once and for all. Nor should it! There is absolutely no reason why any single study should transform a well-established field of medicine with a robust research based.
That’s not to say the Diabetes and Endocrinology study isn’t important. Researchers were able to gain IRB approval by taking advantage of the fact that patients seeking testosterone therapy had a standard 3 month waiting period in the city of Melbourne, Australia. By randomly selecting patients to jump the line they offered a benefit to those randomly selected to receive treatment early, rather than penalizing anyone by withholding treatment longer than they’d normally have to wait. This allowed them to compare trans people who had been on testosterone therapy for 3 months with patients who’d waited without treatment for that same time. They found that after three months a significant reduction in gender dysphoria, depression, and suicidality had occurred in patients who got treatment compared to controls. This is particularly significant because a randomized controlled trial of testosterone therapy for depression in cisgender women did not find significant improvement above a placebo. Trans patients were helped, cis women were not.
Naturally this isn’t the final word on gender-affirming care, because it can’t be. This study didn’t include trans women or transfemmes. It only looked at outcomes 3 months after the start of treatment, which for most trans people who desire a cisnormative appearance wouldn’t be long enough to be fully cis-passing as male. The study didn’t include children, and there was no placebo group. These are critiques that are likely to be brought up by anti-trans activists, but they’re also perfectly valid. The Melbourne study really is only one study. It’s randomly controlled, but RCTs aren’t magic and the existence of one RCT doesn’t dramatically alter the evidence base for gender-affirming care.
The strength of the evidence for gender-affirming care rests on its depth. A large number of studies have looked at different aspects of gender-affirming care in different populations, over different time frames. Taken together, they present a clear and convincing picture of a set of treatments that improve the lives of trans people who are able to access them. From studies on puberty blockers and cross-sex hormones for adolescents to long-term follow ups 10-24 years after legal gender change to studies consistently showing very low rates of regret multiple avenues of inquiry have converged on the same basic result. Adding an RCT to the mix is a lovely complement to the research we already have, but the fundamental picture is unchanged by it because that basic picture was already so clear due to decades of careful research.