Wednesday, April 24, 2019

Eureka - Another crackpot physician

Where else but Witherspoon's pseudo-intellectual blog?
Dr. Monique Robles
via Charlotte Lozier Institute
Tuesday, Dr. Monique Robles wrote: Understanding Gender Dysphoria and Its Treatment in Children and Adolescents. If only she provided text consistent with her title. She chose a conservative Catholic outlet to promote her “understanding.” In that venue, she allowed dogma to prevail over medical science.

Robles is intellectually dishonest. She has a religious objection to transgender people which compels her to find everything wrong with adolescent gender affirmation. This places her at odds with her own professional association.

As a doctor, Robles knows perfectly well that medical care is always a balance causing doctors to ask: Do the benefits outweigh the concerns? Can we achieve the same results with less risk? Throughout, Robles answers neither compulsory question. She writes:
As a pediatric critical care physician, I became interested in the topic of gender dysphoria while pursuing further studies in bioethics. Gender dysphoria was not a topic I encountered during my medical school and residency training. I began to wonder: how have over forty gender identity clinics associated with children’s hospitals appeared in just over a decade?
Dr. Robles is board certified but her profile indicates that her current location is “private.” I am finding references to her practicing in Indianapolis, Dallas and Houston. She is also associated with the Charlotte Lozier Institute, a conservative Catholic anti-choice organization.

As for the paragraph above, her rhetorical wonderment about gender clinics is immaterial to anything important to the welfare of children. Robles is suggesting something nefarious — a conspiracy of clinicians to mistreat children. Sure. Where are all the malpractice suits? Universally, the religious warriors, doctors opposed to gender affirmation, have no experience actually treating gender dysphoria. On this subject, as is typical, Dr. Robles is both unqualified and inexperienced.
The diagnosis of gender dysphoria was previously known as gender identity disorder, categorized with sexual dysfunctions and paraphilias. The new term was introduced in DSM-5, which was published in 2013. Gender dysphoria is described as a distressing conflict the individual experiences between one’s biological sex and the gender with which he or she identifies. Gender dysphoric individuals often experience depression, anxiety, and suicidal ideations.
In children, gender dysphoria diagnosis involves at least six of eight criteria and an associated significant distress or impairment in function lasting at least six months.
Troublingly, the defining criteria are all subjective, based on a child’s preferences, desires, or dislikes. The diagnostic criteria have really produced an even greater dichotomy between male and female stereotypes.
Troublingly, a physician does not understand the difference between objective and subjective (observation, the centerpiece of scientific knowledge, is objective when done properly). Moreover, her description of the criteria is deliberately misleading. At least six of the following are required. (It involves very careful questioning of the child and parents by highly trained and experienced clinicians):
  • A strong desire to be of the other gender or an insistence that one is the other gender
  • A strong preference for wearing clothes typical of the opposite gender
  • A strong preference for cross-gender roles in make-believe play or fantasy play
  • A strong preference for the toys, games or activities stereotypically used or engaged in by the other gender
  • A strong preference for playmates of the other gender
  • A strong rejection of toys, games and activities typical of one’s assigned gender
  • A strong dislike of one’s sexual anatomy
  • A strong desire for the physical sex characteristics that match one’s experienced gender
The objective of religious conservatives is to scare parents away from knowledgeable clinicians as a way of preventing gender affirmation. These ideologues spread the myth that seeing a gender specialist automatically means that your child will become transgender and have surgery. Nothing could be further from the truth.
The proposed treatments for gender dysphoria are off-label and not FDA-approved. Yet, they are legal and promoted as the standard of care. These include puberty-suppressing hormones, also known as Gonadotropin-Releasing Hormone agonists. Such hormones are classified as fully reversible, and they are used to prevent the development of unwanted secondary sex characteristics.
The above is reasonably accurate.
However, calling them “fully reversible” is simply not accurate. These hormone treatments arrest bone growth and decrease its density, prevent normal pubertal organization and maturation of the adolescent brain, and prevent sperm and egg development. They are started with the intent of further treatment with high-dose cross-sex hormones, which are classified as partially reversible. This second round of hormones is used to trigger the development of the secondary sex characteristics of the desired gender.
The above is a half-truth — which is a lie. A description of side effects should be accompanied with duration and incidence. I am not a doctor, let alone an endocrinologist. Robles is not an endocrinologist. However, the Endocrine Society knows a thing or two about puberty blockers. According to them:
Hormone treatment to halt puberty in adolescents with gender identity disorder does not cause lasting harm to their bones, a new study finds. The results were presented Saturday at The Endocrine Society’s 95th Annual Meeting in San Francisco.

“Hormonal interventions to block the pubertal development of children with gender dysphoria are effective and sufficiently safe to alleviate the stress of gender dysphoria,” said the study’s lead author, Henriette Delemarre-van de Waal, MD, PhD, a professor of pediatric endocrinology at Leiden University Medical Center, Leiden, The Netherlands.
Furthermore, according to the full prescribing information the most common adverse reaction is injection site reaction affecting about 9% of patients.

More importantly, Dr. Robles, What do you suggest as an alternative? Adolescent gender dysphoria creates a serious risk of self-harm which is greater than any risks associated with puberty blockers. What is the recommended substitute?
The final stage of treatment for gender dysphoria is sex-reassignment surgery. Such surgery is irreversible and not recommended until a patient reaches the legal age of majority. However, in California, mastectomies are being performed on underage girls as young as thirteen.
She means gender confirmation surgery. The development of breast tissue in transgender boys (not “girls”) can cause enormous distress. This could be avoided, perhaps, with the early administration of puberty blockers which the religious cranks do not approve of. Perhaps they should stop spreading religious dogma disguised as medical advice. Moreover, no underage patient receives surgery without parental consent. Again, what is the recommended alternative? I already know the answer: Don't be transgender in the first place because God doesn't like it.

Following Robles' flimsy attempt to discredit the gender-affirming care model promoted by the American Academy of Pediatrics:
The Academy says watchful waiting is “outdated,” and it is negligent in addressing concerns expressed by many parents of transgender youth. Just after the AAP statement came out, for example, a letter was written by members of the Gender Critical parent forum criticizing the AAP’s stance, its diagnostic methods, its view of the associated mental health problems, its choice to ignore the realities of desistance and detransition, and the Academy’s failure to apply clinical science.
Right. An open letter at iPetitions from a group of anonymous parents which may, or may not, really exist is very compelling. For all Robles knows it is really a Catholic prelate. It could very possibly be Ryan T. Anderson, another Christian warrior. The letter uses the same idiotic talking points. Moreover, they should be content to make medical decisions for their own children. What is their agenda? Why do they even have an agenda?
Robles needs a new kitchen sink:
Nor is the AAP adequately addressing the phenomenon known as Rapid-Onset Gender Dysphoria. This late-onset form of gender dysphoria primarily occurs in peer groups of adolescent females, in a way similar to eating disorders, suggesting that gender dysphoria can function as a social contagion, being spread from peer to peer.
Does Dr. Robles not know that the lone study suggesting the existence of ROGD had to be corrected by the journal editors six months after publication? That supposed “phenomenon” lacks real evidence of existence. The journal not only corrected the study but it apologized. If Robles knows about this then she is dishonest. If she doesn't know then she is negligent. Lisa Littman, the researcher, relied on some of the same anonymous parents (or whoever they really are) previously referred to by Robles.
The obligatory and irrelevant desistance rate:
After attempting to discredit the recommendations of the Endocrine Society, Robles writes:
Prospective follow-up studies reveal that nearly 85 percent of children diagnosed with gender identity disorder do not remain gender dysphoric in adolescence.
I am not sure what a prospective follow up study is. However, as Kristina Olson (UW - TransYouth Project director) points out from her research that desistance occurs prior to social transition. More importantly, according to research, transgender children supported in their identities show positive mental health. Dr. Robles is promoting just the opposite. It seems safe to assume that the results will also be the opposite: Suffering children. Children should be in misery to satisfy religious dogma? Does any rational person think that makes sense?
A 2011 study evaluated seventy young people between the ages of twelve and sixteen who went on puberty blockers. Of the seventy individuals, not a single one withdrew from puberty suppression, and all went on to begin high-dose cross-sex hormones.
What Robles is dishonestly projecting is the idea that puberty blockers made the kids transgender. She wants to scare parents away from appropriate medical treatment. So which is it Dr. Robles: high desistance rates cited in a different paragraph or low desistance rates cited above? Which is the problem? I doubt that Robles has even read the cited study. She is just repeating from the religious echo chamber.
Hoof-beats; think horses not zebras:
Isn't the more likely explanation the simple fact that these children were properly diagnosed in the first place? Furthermore, if they ceased to have gender dysphoria while on puberty blockers then they would reverse their transition. Otherwise they would suffer from an induced form of gender incongruity and be in considerable distress. Again I must ask: What is the medically appropriate alternative?
The kitchen sink is already gone. Now she is tossing toilets:
No other diagnosis in medicine poses such a serious threat to our society. We must ask, “Who are we helping, and who is benefitting [sic]?” Think of individuals with the diagnosis of body identity integrity disorder who desire amputations.
The rhetoric is always the same crap. Gender dysphoria is not comparable to body integrity disorder. The logical fallacy is called a straw man. Again I must ask: What is the medically appropriate alternative to gender affirmation?
The dignity of these individuals is violated, and the root cause of their suffering is not addressed.
Oh, there she goes. Root cause? Perhaps we should try some form of conversion therapy. If that fails the fall-back is an exorcism. The root cause could be many things, most of which will not respond to therapy. If gender identity is influenced by environmental factors that does not mean that discovering those factors makes the condition reversible.
Why is this area of medicine allowed so much leniency in regard to ethical standards? Why are children and parents not provided fully informed consent? They should be educated about benefits and risks of each intervention, informed of alternative therapies, and given the option of doing nothing. Parents are being misled by fear and coerced into affirming their children’s gender dysphoria.
I am trying very hard to stay dignified. Nevertheless, where                         does she get the idea that parents are not fully informed? In addition to a diagnosis she knows perfectly well that psychiatrists evaluate the severity of the condition and might very well recommend doing nothing. Coerced? As I wrote earlier, as a Defender of the Faith, Robles' objective is to scare parents away from getting proper care for their children.
These polemics write themselves:
In an era of evidence-based medicine, gender dysphoria is somehow exempt. There are no randomized, controlled studies looking at the potential benefits and harms of these puberty blockers and cross-sex hormones on children. There are no studies looking at psychiatric interventions.
That is untrue. For FDA approval these drugs undergo rigorous testing. On-label, puberty blockers are used to treat precocious puberty and hormones have an abundance of applications. The reason that they are prescribed is irrelevant to the safety testing. The cause of gender dysphoria remains unknown. Genes, hormones in the birth mother's womb and environmental factors are all suspected.
You knew this was coming:
Well-renowned clinicians such as Dr. Paul McHugh and Dr. Kenneth Zucker, after taking care of the mental health of those who identify as transgender for decades, have been scrutinized and denounced for their focused efforts on treating the mental illness rather than the mutilating of genitals.
That's the alternative? Where                         is their literature substantiating their success rates? McHugh, nearing 90, hasn't practiced in decades. Zucker collected data on children with gender dysphoria for 20 years. Where is the cite to his study showing success rates? And by the way, Zucker supports gender affirmation. He has published over 100 papers. Which of those have influenced Robles? She does not say but Zucker is at odds with every mainstream medical association.

Robles goes into the whole panoply of religious distress including sex education, accommodations for transgender and gender nonconforming students and the “conscience rights” of physicians. In the last regard she is transforming anti-choice issues to the treatment of children for gender dysphoria.
Arriving at a conclusion:
Treatments for gender dysphoria should address the underlying mental health issues and concerns that lead these children and adolescents to identify as transgender. Thankfully, some compassionate therapists are spending time with their patients and the parents working through histories and experiences, addressing the whole of the individual. In this way, the body, mind, and soul can be brought together, as they were meant to be.
What Robles is trying to do is to promote the idea that gender specialists (usually psychiatrists) do not fully investigate the mental health of their patients with adolescent gender dysphoria. That is untrue. If there are underlying conditions they will be addressed. In spite of her assurances otherwise, these clinicians do not have an agenda. Mind, body and soul is religious rubbish.

Dr. Monique Robles, a professional Catholic, simply provides another dose of dogmatic nonsense. It is an expression of the confusion between faith-based dogma and evidence-based science (although she erroneously claims that trans children are not being treated according to evidence-based medicine). Fortunately, Robles is not a specialist in this area and will not have the potential to damage vulnerable children and their deeply concerned parents.

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