Dispatches from Deutschland: If You Know Nothing, You Will Believe Everything (Part 1)
TransTeensSorgeBerechtigt on how journalists failed to do their job when interviewing the most important gender expert in Germany.
It is a maxim of journalism that it is not enough to simply ask questions; an effective journalist must also question the answers they receive. This means they must first do their homework, especially when the topic is as complex and controversial as the medical treatment of adolescents under "the Dutch protocol”, which includes puberty blockers, cross-sex hormones, and surgery. However, media outlets often fall short of this standard in practice. We can see this lack of curiosity in two interviews in Germany's quality press.
Süddeutsche Zeitung Magazine (June 2023)
Süddeutsche Zeitung Magazine is a weekly magazine supplement of the Süddeutsche Zeitung, one of Germany's largest and most influential daily newspapers. As one of the most lauded publications in Germans, with a reputation for journalism that generates socially important debates, their interview with Professor Georg Romer, director of Child and Adolescent Psychiatry at the University Hospital of Münster and co-founded the Centre for Transgender Health seemed promising. Moreover, Romer’s position as chair of the of the commission that developing Germany's latest guidelines on diagnosing and treating gender incongruence and dysphoria in children and adolescents meant that there was no higher authority.
While it was unsurprising that SZ-Magazine journalists regarded Romer as an expert, what is unexpected was their willingness to naively accept answers they should have questioned and to allow him to sidestep critical issues. At the beginning of the SZ-Magazine interview, Romer says: "Given what we know now, we have good reason to believe" that a body dysmorphic disorder (a condition where a person worries about perceived flaws in their appearance) is a "health condition" in which "the longing for optimisation" doesn't go away even after surgery has been performed. By contrast, "we observe exactly the opposite" with gender incongruence. In these cases, Romer claims, only once the body is made to "align" with an individual's experienced gender is a "normally healthy life" possible. The two interviewers, Christina Bernd and Vera Schroeder, who work for the paper’s science section, failed to follow up with crucial questions like these:
Who exactly is the "we" that asserts body dysmorphic disorder and gender incongruence are two entirely different conditions?
Can you provide empirical studies that compare body dysmorphic disorder and gender dysphoria?
Are you suggesting that there is a definitive endpoint to medical transition?
Are you referring to adults or adolescents? Identity development is a key challenge for teenagers, whose sense of identity continues to evolve.
How can you be certain that irreversible changes made now will benefit adolescents in the future?
What do you mean by "align" and "normally healthy"? Doesn't this trivialize the serious medical and surgical procedures involved?
Romer's response to the next question was factually incorrect. He claimed that he and other experts are drafting an "S3" guideline (the highest level of evidence-based guidance) based on a "very broad expert consensus." Had Bernd and Schroder done their homework they might have responded with critical follow-up questions like these:
- Consensus alone is insufficient for systematically developed S3 guidelines; evidence must be critically appraised. Did you conduct this appraisal?
- How does the Guideline Commission reach a consensus position, especially given the growing number of critical voices among doctors, scientists, and parents? To what extent were these critical voices represented in the Commission?
As we now know, an evidence-based guideline did not materialize. The recently published draft S2k guideline is consensus-based, not evidence-based, and thus fails to meet the "highest quality level" claimed in the interview.
When asked about the "great disagreement" surrounding treatment in the "public debate," Romer asserts that the guideline committee possesses "over 100 years (!!) of proven treatment experience with adolescents." The interviewers incredibly failed to challenge this claim or establish what specific experience he is referencing. Was he referring to the drugs used as puberty blockers which were developed only 40 years ago for entirely different conditions and were not approved for treating teenagers with gender dysphoria in any case? Surely, surgical interventions in adults lack a century's worth of tradition, with very few sometimes unsuccessful experiments.
Romer continued to assert that the Guideline Committee maintained a critical perspective on "the entire corpus of international studies." While acknowledging individual dissenting opinions, he insisted that it is a "distortion of reality" to claim a lack of consensus among experts. Important follow-up questions might have included:
- Doesn't Hilary Cass's interim report, published in 2022, indicate a "lack of consensus," including regarding the definition of the rapidly growing phenomenon of adolescent gender dysphoria? Does this not imply that there can also be no consensus on appropriate clinical responses?
- Aren't scientists and doctors—the experts—pointing out the insufficient evidence for treating adolescents with puberty blockers and hormones?
Critics argue that the long-term benefits and risks of treatment have not been adequately researched. The Cass interim report, referencing work by the National Institute for Health and Care Excellence (NICE) from 2020, highlights a lack of empirical evidence. Are you suggesting that the systematic reviews provided by NICE, for example, amount to nothing more than isolated opinions?
Instead of confronting Romer with specific criticisms, the interviewers inquired about the controversy, granting him the opportunity to justify his practice, including early interventions. Romer then claimed that waiting was not a "neutral option."
It is disappointing that Bernd and Schroeder did not demonstrate a stronger grasp of the subject matter. When they asked Romer about the "scientific basis" of his work, he referred to "findings from previous follow-up studies" based on the Dutch Protocol, which he claimed have provided greater clarity. Instead of inquiring about which "follow-up studies" he was referencing, the journalists naïvely asked, "What exactly is the Dutch Protocol?"
It was, of course, the paradigmatic approach that originally involved the use of puberty blockers (from the age of 12), cross-sex hormones (from the age of 16), and surgery (from the age of 18). It had spread around the world, particularly since the results of a single longitudinal study in the mid-2010s suggested that participants were apparently doing well psychologically after treatment. The journalists let Romer off the hook. They did not confront him with the existing scientific criticism of this approach and the single longitudinal study. They allowed him to embellish a problematic scenario. Young people in the Netherlands, he said, had received "qualified" hormone treatment, and when "the group was followed up and examined at the age of 25 and over", "mental health problems" were found to be no more common than in the average population. Relevant questions might have been:
Are you suggesting there was long-term data on early treatment patients who were later interviewed as adults? In the well-known Dutch study from the 2010s, none of the respondents were older than 23.
We do not know of any studies that assessed groups of young people who were treated under 16 and examined at 25 or above. Did you have any? Could you be referring to academic papers that NICE considered too low quality to merit consideration?
Romer implied that the Dutch findings had prompted experts to re-think the watchful waiting approach in which treatment is delayed. But he was doing so at a time when a rethink of the rethink had long since begun - even in Germany, where the medical journal Ärzteblatt covered a controversial debate among paediatricians and psychiatrists in 2022. The interview did not clarify why Romer was not - or did not want to be - up to date. Instead, it left a particularly problematic assertion unchallenged: According to him, a "recent figure" from the US was that 40 % of adult trans people had attempted suicide at least once. Dutch publications, in his view, suggested that “early enough” intervention might “prevent” such attempts. Again, the interviewers failed to ask critical questions such as:
Are you saying early medical treatment under the Dutch protocol could prevent suicide attempts or even suicide itself? Notably, the American sociologist Michael Biggs found no such evidence in support of this theory when he analyzed the statistics of the largest counseling service for minors, the English GIDS.
The 40 % figure was from a 2015 online survey of adults. How appropriate is it to apply such findings to the many minors who now attend gender clinics like yours? We still know little about these young people, except that they differ from earlier cohorts in many ways. Many of them did not experience gender dysphoria before they reached puberty. Why is it mainly girls and how do you explain that these teenagers, moreover, came with other issues such as distress, anxiety, and depression?
Why, one wonders, was this interview published? Surely not to enlighten readers. When Romer was asked how often he had been "wrong", how often people who transitioned in Münster wanted to reverse their transition later, he said: "We usually worked with our patients for several years and to date we only knew of three cases of people changing their mind out of more than 600 adolescents treated in the past ten years." The risk of detransition was also greater, he claimed, if people were not treated until adulthood.
But a cursory look at the literature would have revealed that there is no such data. Which studies on detransitioned patients was he referring to with his "better treat early" theory? To put the figures into context: How many of his 600 patients was he still in contact with? How many of them were treated, and in what ways? And how many were asked about their satisfaction with their treatment and tracked over what periods of time?
None of these points were raised. Instead, the interviewers vaguely suggested that the fast increase in young people experiencing gender dysphoria might be linked to "peer pressure". Then Romer digressed and talked about children. Some clearly showed a "persistent feeling of being in the opposite sex" as soon as they uttered their first words. Such "clear cases" of "early transgender identity", he claimed, actually "taught us" a thing or two: "Gender identity was innate in these children. Learning, social factors, or the internet had nothing to do with it." A proper follow up might have asked:
Wasn't the key issue with the rapid increase in the number of cases in recent years that so many of the teenagers concerned did not suffer from gender dysphoria in their early childhood?
And didn't some people who cross-dressed as children or even expressed gender dysphoria at that age later turn out to be homosexual? Was it possible to clearly distinguish one group from the other? And if it wasn't possible, didn’t that create a danger of assigning a trans identity to homosexuals even before puberty and, in the worst case, medicalizing them?
Romer was not forced to explore these difficult issues. The journalists allowed him to praise his work self-indulgently. Their work thus did not help families who were wondering what was suddenly going on with their teenager. Perhaps this extensive SZ interview was not meant to be informative at all, but to give the professor a platform.
The novelist Marie Ebner-Eschenbach once astutely observed:
"If you know nothing, you will believe everything.”
Journalists are not supposed to replace research in favor of beliefs. Not asking but believing is especially improper when dealing with a subject as precarious as this one. The stakes are high for children and young people. They and their parents have a right to honest and comprehensive information.In this case, S-Z Magazine failed them and the public.
Original interview in Süddeutsche Zeitung Magazine (6/2023)
The above text was originally published in German at the website of TransTeensSorgeBerechtigt
TransTeensSorgeBerechtigt is a parents network and interest group. It runs a website to inform parents about ROGD but also tries to make decision makers aware of the problems with the medicalisation of ROGD youth.
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