Response: “The Signal and the Noise”—a response to Clayton et al. (2021)

Abstract

The purpose of this response is to clarify points about the steps we took in a systematic review of the literature and to reaffirm our findings.

Full text

Response: “The Signal and the Noise”—a response
to Clayton et al. (2021)
Lynn Rew
1
, Cara C. Young
1
, Maria Monge
2
& Roxanne Bogucka
3
1
School of Nursing, The University of Texas at Austin, Austin, TX, USA
2
Dell Medical School, The University of Texas at Austin, Austin, TX, USA
3
Life Science Library, The University of Texas at Austin, Austin, TX, USA
We appreciate the opportunity to respond to the com-
mentary provided on our review of the use of puberty
blockers to treat adolescents with gender dysphoria. Our
view is that each time a systematic literature review is
conducted and published, the scientific community is
presented with additional data and analyses from which
to form conclusions. As authors of such a review, we are
responsible for the integrity of our process, but acknowl-
edge that all readers may not agree with our interpreta-
tion of the findings.
We initiated our review with a rigorous step-by-step
method of systematic review as outlined by Harris
Cooper (2017). Adherence to this method was the
strength of our study and it should be acknowledged
that we followed this method faithfully through comple-
tion with multiple investigators addressing each step in
the process. We also acknowledged the limitations of our
review, including the inclusion of only four databases.
We maintain that the databases utilized from the avail-
able institutional subscriptions were appropriate to
answer our research questions. The EMBASE data base
was not available at our university. We acknowledge that
our search terms did not identify the studies by Costa
et al. (2015), Joseph, Ting, and Butler (2019), and Klink,
Caris, Heijboer, van Trotsenburg, and Rotteveel (2015).
For this response, however, we sought and found these
publications. The Joseph et al. paper is a retrospective
chart review concerning bone density; these investiga-
tors concluded that there was a need for further study.
Klink et al. investigated bone mineral density (BMD) and
found that BMD was delayed and attenuated in adoles-
cents using GnRHa. Inclusion of these three papers
would have strengthened our review, but would not have
altered our conclusions.
The commentators wrote that “The Costa et al. study
found no significant difference in psychosocial function-
ing between a group of adolescents receiving puberty
blockers plus psychosocial support, and a group receiv-
ing only psychosocial support, at eighteen months (the
study end period)”(Clayton, Malone, Clarke, Mason, &
D’Angelo, 2021, p. 3). This selected quotation misses
other important statements written by Costa et al.
(2015). The purpose of the study by Costa et al. (2015)
was to assess the psychosocial functioning of adoles-
cents with gender dysphoria (GD), meeting diagnostic
criteria found in DSM-IV-TR across time. They hypothe-
sized that these adolescents would improve in psychoso-
cial functioning from baseline to after beginning
treatment with GnRHa. All adolescents in this study
were eligible for pubertal suppression as outlined in the
Standards of Care provided by WPATH; some were eligi-
ble immediately and others were delayed. All of these
adolescents (N=201) received psychological support
throughout the study period. Assessments were con-
ducted at baseline, and every 6 months for a total of four
evaluations over 18 months. Costa et al. reported,
“Compared with baseline, GD adolescents’psychosocial
functioning was increasingly higher at each of the follow-
ing evaluations (figure 2). In particular, CGAS scores
were significantly higher after 6 months of psychological
support (Time 0 vs. Time 1, p<.001). Also there was a
further significant improvement 18 months from base-
line (Time 1 vs. Time 3, p=.02; table 2)”(p. 2211). Costa
e al. also wrote, “Finally, global functioning improved
steadily over time in GD adolescents receiving both psy-
chological support and GnRHa.”Further, “Consistently,
these results underline the importance of puberty sup-
pression for GD adolescents’well-being.”Finally they
added, “In conclusion, this study confirms the effective-
ness of puberty suppression for GD adolescents”(p.
2212). This takeaway message is far different from the
one put forth by the commentators.
We further acknowledge that our search strategy
returned a total of 151 eligible, non-duplicated papers,
whereas 525 were identified by a review conducted by
the National Institute for Health and Care Excellence
(NICE, 2020). Because the NICE search strategies used
more search terms than those used in our review, they
yielded a larger set of search results. Ultimately, in an
evidence review, the number of studies that meet the
inclusion criteria is of greater importance than the num-
ber of studies recalled by the search strategies. Nine arti-
cles met the inclusion criteria for the NICE report, and
nine articles met the inclusion criteria for the Rew,
Young, Monge, and Bogucka (2021) report; four of these
were identical in both reports. The PubMed search strat-
egy we used found all nine of the included articles in the
NICE report, however, some of these did not meet our
inclusion criteria or failed to answer our research
questions.
In citing the work of Turban, King, Carswell, and Keu-
roghlian (2020) as well as all other studies in our review,
we did not make causal statements. We clearly wrote,
“The most recent study by Turban et al. (2020) was the
first to demonstrate that access to pubertal suppression
during adolescence was associated with decreased
©2021 Association for Child and Adolescent Mental Health.
Child and Adolescent Mental Health27, No. 3, 2022, pp. 263–264 doi:10.1111/camh.12534