If You Don't Ask, You Have to Believe (en) - TransTeens · Sorge

If You Don't Ask, You Have to Believe

How journalists fail to do their job when interviewing the most important gender expert in Germany.

It's astonishing how often German journalists fail to ask very important questions when they interview experts on the medical treatment of children, adolescents and young adults with gender dysphoria. Journalists need to do a better job.

According to BBC World advertising, journalists must not only ask questions – they must also question the answers they get. To probe interviewee’s answers, of course, they must first do their homework. This is especially so when a journalist is researching complex and controversial issues such as the medical treatment of adolescents according to 'the Dutch protocol' (which includes puberty blockers, cross-sex hormones and surgery). In daily life, media outlets often fall far short.

This becomes all too apparent when we look at two interviews in Germany's quality press: one in Süddeutsche Zeitung Magazine SZ Magazine (6/2023) and one in Der Spiegel Spiegel (4/2024). Both ran interviews with Professor Georg Romer, the director of Child and Adolescent Psychiatry at the University Hospital of Münster, where he co-founded the Centre for Transgender Health two years ago. Romer also chairs the commission that developed Germany's latest guideline on the diagnosis and treatment of gender incongruence and dysphoria in childhood and adolescence.

Unsurprisingly, journalists consider Romer an expert. What is surprising, however, is that they tend to naively accept answers they should question. As a result, they allow him to skip important issues. Here are some examples of things they should have asked after the professor gave an unsatisfying answer in view of the publicly available information at the time.

At the beginning of the SZ-Magazin 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, work for the paper’s science section, but they failed to follow up with crucial questions like these:

Romer's answer to the next question is factually incorrect. He says he and other experts and stakeholders are drafting an "S3" guideline (the highest level of evidence-based guidance) based on a "very broad expert consensus". He should have been challenged:

As we know today, an evidence-based guideline did not materialise. The recently published draft S2k guideline is consensus-based, not evidence-based, so it indeed does not meet the "highest quality level" claimed in the interview.

Asked about the "great disagreement" regarding treatment in "public debate", Romer first points out that the guideline committee has "over 100 years of proven treatment experience with adolescents". The interviewers fail to challenge this assertion and so it remains unclear what wealth of experience he is actually claiming. The drugs that are applied as puberty blockers today were only developed 40 years ago and for completely different conditions. They were approved for those purposes, but not as puberty blockers for teenagers with gender dysphoria. Even surgery in adults does not have a 100-year tradition, apart from very few - not always successful - experiments.

Uninterrupted, Romer explains that the Guideline Committee is keeping a critical eye on "the entire corpus of international studies". While acknowledging that there are individual “dissenting opinions”, he insists that it would be a “distortion of reality” to argue that experts lack consensus. These follow-up questions would have been important:

Instead of confronting Romer with specific criticism, the interviewers ask in all seriousness what the controversy is all about, allowing Professor Romer, who says he has been doing these treatments for 20 years, the opportunity to justify his practice, including early interventions. Waiting, he says, is not a "neutral option".

It would be very surprising if Romer wasn't familiar with international studies. It's a shame that Bernd and Schroeder don't have a better grasp of the subject (which Schroeder tends to cover in a rather uninformed and one-sided way in other articles too). When Romer is asked about the "scientific basis" of his work, he speaks of "findings from previous follow-up studies" based on the Dutch Protocol that, according to him, have provided more clarity. Instead of asking him what "follow-up studies" he has in mind, Bernd and Schroeder next naively want to know: "What exactly is the Dutch Protocol?"

It is, 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 has 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 do not confront him with the existing scientific criticism of this approach and the single longitudinal study. They allow him to embellish a problematic scenario. Young people in the Netherlands, he says, 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 would have been:

Romer is right when he says that the Dutch findings have made experts re-think. But he is doing so at a time when a rethink of the rethink has long since begun - even in Germany, where the medical journal Deutsches Ärzteblatt covered a controversial debate among paediatricians and psychiatrists in 2022. The interview does not clarify why Romer is not - or does not want to be - up to date. Instead, it leaves a particularly problematic assertion unchallenged: According to him, a "recent figure" from the US is that 40 % of adult trans people have attempted suicide at least once. Dutch publications, in his view, suggests that “early enough” intervention might “prevent” such attempts.

Why, one wonders, is this interview being published? Surely not to enlighten readers. When Romer is asked how often he was "wrong", how often people who transitioned in Münster wanted to reverse their transition later, he says: "We usually work with our patients for several years and to date we only know of three cases of people changing their mind out of more than 600 adolescents treated in the past ten years." The risk of detransition is also greater, he claims, if people are not treated until adulthood.

The interviewers vaguely suggest that the fast increase in young people experiencing gender dysphoria might be linked to "peer pressure". But Romer digresses and talks about children. Some clearly show a "persistent feeling of being in the opposite sex" as soon as they utter their first words. Such "clear cases" of "early transgender identity" actually "teach us" a thing or two, he says: "Gender identity is innate in these children. Learning, social factors or the internet have nothing to do with it."

Romer is not forced to explore these difficult issues. The journalists allow him to praise his work self-indulgently. Their work thus does not help families who are wondering what is 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.

That similarly can be said of the interview in Der Spiegel. This time, Georg Romer is asked whether the Cass Review, which was published shortly before, makes a difference in Germany. Since Veronika Hackenbroch, the science journalist, rarely follows up on Romer's answers, one wonders whether she is the right person for this job. Didn’t she know the Romer is among the most avid supporters of the Dutch protocol in Germany? Why didn’t she pick a less biased expert for assessing the relevance of the Cass Review, one wonders.

The first question is whether Romer should now change "his" guideline. "Not at all," he responds. He sees “many similarities” between the Cass Review and the German draft guideline. He acknowledges “gradual differences” which have been "partly exaggerated". Neither the similarities nor the differences are discussed in much detail. This is a pity. The Review differs considerably from the German draft, for example in its meticulous examination of the scientific evidence. The recommendations differ too. For example, the Cass Review only recommends medical treatment in the context of clinical research that leads to reliable data.

The publication of the Cass Review made very clear that there is no long-term evidence for the validity of treatments based on the Dutch Protocol. Hackenbroch whose previous writing already revealed a lack of proper research, now asks Romer why there are “so few” long-term studies. Romer replies that they are "costly" and require "sustained funding". According to him, "more and more" such studies are now being conducted. Next, he says that “we” have years of treatment experience, as though that were a substitute for scientific evidence. "We have been treating adolescents for 25 years and have accompanied many of them into adulthood". He claims that there have, so far, not been notable examples of "conceivable long-term damage".

The follow-up questions to this answer would take up an entire interview. Romer keeps downplaying the problems. In medicine, he says, it is quite common for "so-called 'best practice' to evolve provisionally on the basis of clinical experience, and for studies to gradually confirm - or modify - this with evidence". Medical journalist Hackenbroch is fine with this evasive response. She did not have to be.

The Cass review looked at treatment practice in England. Whether and in what respect this might be superior in Germany does not seem to interest most German journalists, not even after the publication of the Cass Review. Der Spiegel only wants to know whether Professor Romer himself is conducting scientific research. "Yes", he says, his results will be available sometime this year. Curiously, the interviewer shows no interest in what Romer is researching and how relevant it is to evidence for treatment. What a shame! We'll never know whether Hilary Cass might have to modify her review after getting a chance to read Romer's work.

Romer is also allowed to speak of “actual treatment figures” without spelling out the numbers or revealing the sources. When asked about the increasing number of children and young people who feel "uncomfortable in their own gender" (and who present with "major psychological problems"), Romer warns that a careful distinction needs to be made between young people who are "temporarily trying out queer lifestyles" and "real” treatment figures. Nonetheless, he does not indicate numbers accordingly, and the interviewer does not ask him to do so, even when he says that treatment number have increased "significantly", though "moderately" in the past ten years.

This raises questions. After all, Romer seem to deny elsewhere in this interview that the distinction matters in his clinical practice. There he points out that "every first encounter" with a patient involves an element of discrimination, and that we must move on away from the idea that doctors define who is trans. He himself addresses everybody "correctly" with the names and pronouns of their choice right from the start, he says.

Romer insists that "body-modifying gender reassignment treatment" helps with "mental health problems" in adults and that the "available” data clearly indicate "that this is also the case for adolescents". Again, adults and adolescents are blurred. Anyhow, the Cass Review (the interview supposedly focuses on) clearly does not support that claim. Germany has no data on how many minors and young people are treated with puberty blockers or hormones. The journalist does not ask for any of this and instead allows Romer to call for “more reasonable scientific debate” as a closing remark. She does not seem to notice that he is not sticking to the rules of evidence based scientific discourse.

„If you know nothing, you have to believe everything.“

That was a astute observation by novelist Marie Ebner-Eschenbach. Journalists are not supposed to replace research in favour 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.