On January 28, President Trump signed an executive order titled “Protecting Children from Chemical and Surgical Mutilation.” The order’s most important provision defunds health-care and medical education institutions that engage in or facilitate sex-trait-modification procedures for adolescents 18 or younger. Within a week, at least ten hospitals in states where these procedures are still legal announced that they were changing their practices. The list includes some of the top pediatric gender clinics.
On February 4, the American Civil Liberties Union announced a lawsuit challenging the executive order. Joining the ACLU in the suit are other transgender advocacy groups and two law firms, which together represent two trans-identified 18-year-olds and five trans-identified minors and their families; they also represent PFLAG National, an LGBT organization with nearly 350 chapters nationwide, and the named plaintiffs.
The suit alleges that the executive order exceeds Trump’s Article II powers by directing “public funds to advance the President’s policy preferences, rather than those of Congress.” It argues as well that the EO discriminates based on sex—a claim also made against Tennessee’s ban on pediatric “gender-affirming care,” which the Supreme Court is considering in U.S. v. Skrmetti—and violates plaintiffs’ constitutional rights to equal protection and due process under the Fifth Amendment. Finally, and most surprisingly, it alleges that the order violates Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination because of disability in federally funded programs. Gender dysphoria, the ACLU claims, is a disability of the kind protected by this law.
On February 13, a federal district court in Baltimore blocked the executive order’s defunding provision from going into effect for a period of 14 days, at which point the court will reassess. The Department of Justice is expected to appeal these injunctions to the Fourth Circuit and, possibly, to the Supreme Court.
The ACLU’s case contains an unusual feature. One of the plaintiffs, Cameron Coe (pseudonym), is a 12-year-old New York–area resident who received a puberty-blocking injection in 2024. Cameron was scheduled for a puberty-blocking implant at NYU Langone the day after the executive order went into effect. Unlike plaintiffs in similar suits, however, Cameron does not identify as a boy or a girl. When Cameron was born, “they [sic] were designated as male. From the age of four, Cameron communicated to their parents that they were neither a boy nor a girl. They began to express their nonbinary identity in the fourth grade.”
The suit never defines the term “nonbinary.” Instead, it lists “nonbinary” as a “gender identity,” which it defines as “a person’s internal sense of belonging to a particular gender.” The complaint does not define “gender,” either, or explain how a “particular gender” can include no “particular gender,” which is presumably the substance of a “nonbinary” identity.
People across time and civilizations have felt that they did not fit into their society’s sex-role expectations. Contemporary therapeutic culture, empowered by novel medical technologies and theories from the postmodern academy, has recast this enduring human experience as an innate “identity” corresponding to a distinct type of human. Girls who once would have been referred to as “tomboys” are now “nonbinary” and part of the “LGBTQIA+ community.”
Nonbinary is the “fastest growing” gender category among adolescents and young adults, according to the U.K.’s Cass Review. As Jean Twenge reports in Generations, according to U.S. Census data, by 2022 more than 3 percent of those born in the 2000s identified as transgender and nearly 5 percent identified as nonbinary, representing a rise of 48 percent and 60 percent, respectively, from 2021. The U.S. Transgender Survey of 2015 found that close to one-third of its nearly 28,000 adult respondents identified as nonbinary, 80 percent of whom were female. By 2022, 38 percent of 92,329 respondents identified that way, with similar female overrepresentation.
The phenomenon of (mostly female) celebrities “coming out” as nonbinary, adopting “they/them” pronouns, and receiving instant media attention has become familiar to many in the West. This would likely be of less public interest if not for the fact that kids who embrace the nonbinary label are being offered irreversible medical interventions on that basis.
In its legal filing against the Trump executive order, the ACLU appeals to medical “guidelines” supported by “[d]ecades of clinical experience and a large body of scientific and medical literature.” The ACLU doesn’t specify which “guidelines” it has in mind, likely because it is referring to the now-discredited World Professional Association for Transgender Health’s “Standards of Care,” Version 8.
SOC8 introduced several innovations on SOC7, among them chapters on “eunuchs” (a “gender identity” that WPATH claims even children can have) and on nonbinary identity. WPATH states that nonbinary identity “first emerged in approximately the late 2000s.” The term
includes people whose genders are comprised of more than one gender identity simultaneously or at different times (e.g., bigender), who do not have a gender identity or have a neutral gender identity (e.g., agender or neutrois), have gender identities that encompass or blend elements of other genders (e.g., polygender, demiboy, demigirl), and/or who have a gender that changes over time (e.g., genderfluid).
WPATH writes that nonbinary “may communicate a specific consciously politicized dimension to a person’s gender” but also that it “functions as a gender identity in its own right.” Rather than explain the tension, WPATH reverts to cliché: “the same identities can have different meanings for different people, and the use of terms can vary over time and by location.”
Further:
A non-linear spectrum indicates differences of gender expression, identity, or needs around gender affirmation between clients [missing word?] should not be compared for the purposes of situating them along a linear spectrum. Additionally, the interpretation of gender expression is subjective and culturally defined, and what may be experienced or viewed as highly feminine by one person may not be viewed as such by another. . . . [Health care providers] benefit from avoiding assumptions about how each client conceptualizes their gender and by being prepared to be led by a given client’s personal understanding of gender as it relates to the client’s gender identity, expression, and any need for medical care.
The expectation, standard in gender medicine, that clinicians be “led by their patients” is never more applicable than when treating individuals whose “gender” and “embodiment goals” have no parallel in nature.
WPATH recommends various procedures to help those who feel neither male nor female align their bodies with their “internal sense of gender.” These include surgeries like “penile-preserving vaginoplasty” and hormone micro-dosing. Unlike male-to-female or female-to-male “transitions,” where the end goal is to resemble the opposite sex, nonbinary medicine lacks defined objectives. It is entirely dependent upon the patient’s subjective, idiosyncratic (or as WPATH puts it, “particularly diverse”) goals.
Nonbinary is both the result and a likely cause of gender medicine’s drift away from a clinical model, which at least pretended to care about evidence-based medicine, toward an autonomy-focused framework that deems cosmetic procedures “medically necessary,” for insurance purposes. The autonomy model discourages “gatekeeping” and insists that physicians’ proper role is to counsel “clients” (“patients” is too stigmatizing) on the technical possibilities and limitations of drugs and surgeries. If a male wants “softening of skin and reduction in facial hair growth” but not “breast growth,” WPATH says, the doctor must explain that estrogen will inevitably result in the latter. If a female patient wants testosterone for “facial hair development,” she should be told that this comes with “genital growth” (i.e., clitoral growth that can result in chronic, painful chafing). Gender surgery centers across the U.S. now offer clients a range of a la carte procedures catered to their individual “embodiment goals.”
If you are wondering what any of this has to do with medicine, you’re not alone.
What of the ACLU’s claim that the Trump executive order negates “[d]ecades of clinical experience and a large body of scientific and medical literature”? According to SOC8, “The most robust longitudinal evidence supporting the benefits of gender-affirming medical and surgical treatments in adolescence” comes from the Dutch studies that launched the field. Considered the “gold standard” of evidence for such treatments, the initial outcomes of the Dutch pseudo-experiment were reported in two papers, published in 2011 and 2014. Lurie Children’s Hospital gender clinician Aron Janssen, who has served as an expert witness in gender-medicine lawsuits, attested in a 2022 Florida hearing that the Dutch data are “the best . . . we have.”
The Dutch first proposed early intervention as a possible solution to a problem that they observed in their adult patients: “subjective well-being of the transsexuals has increased, whereas an ‘improvement’ in their actual life situation is not always observed.” The Dutch clinicians theorized that their patients’ difficulty passing, a problem they attributed to the irreversible effects of puberty on the body, was a key reason for their psychosocial dysfunction. The problem, in short, was “wrong puberty”—that is, a puberty that a kid doesn’t want—and the solution, for adolescents in these situations, was the administration of puberty-blocking hormones.
Showing at least superficial awareness of the ethical problems involved, the Dutch devised what they thought were strict eligibility criteria. Only adolescents with documented history of gender distress arising in childhood and who had a strong desire to be of the opposite sex were considered. Crucially, what we today call nonbinary was seen as a contraindication—a sign that an adolescent’s sense of self was unstable. Such youths were ineligible for medical intervention. As the Dutch clinicians wrote: “adolescents… whose wish for sex reassignment seems to originate from factors other than a genuine and complete cross-gender identity are served best by psychological interventions” (emphasis added).
The Dutch approach quickly “escaped the lab,” was grafted onto a nascent transgender-rights movement, and became entrenched as the standard of care shorn of its original safeguards in multiple Western countries. Rates of transgender identity and gender dysphoria in youth skyrocketed, partly because “being transgender” was popularly redefined such that it was indistinguishable from regular gender nonconformity or puberty-related angst. Adolescent girls, most with mental-health challenges and no documented history of gender non-conformity in childhood, became the primary demographic identifying as trans and being referred to gender clinics.
Society’s shifting conceptualization of sex and gender coincided with a change in the rationale for early intervention. No longer was it about trying to detect future (mostly male) transsexuals and help them pass. No longer were puberty blockers envisioned as diagnostic tools that would allow patients “time to think.” The goal was now to help “trans kids” who “know who they are” to realize their autonomy and achieve their unique “embodiment goals.” The “child’s sense of reality,” explains the lead author of the American Academy of Pediatrics’s statement on gender medicine, is the “navigational beacon to . . . orient treatment around.” And that sense of “sense of reality” need not be binary. All individuals now had a right to “gender euphoria,” regardless of age, mental-health status, or comfort with the sex binary.
One of the architects of this new way of thinking is UC San Francisco’s Diane Ehrensaft. “[N]othing less than a gender revolution is going on,” the Bay Area child psychologist gleefully declared in her 2016 book, The Gender Creative Child. “Who is leading this revolution? Children who are nimbly pushing the boulders around, creating an ever-shifting terrain as we try to grasp ‘What’s your gender’?”
In a 2017 interview with Tomboy author Lisa Selin Davis, Ehrensaft said that she had “kids as young as four or five” telling her that they are neither boys nor girls but rather “a boy-girl” or “just a rainbow kid.” It “just shakes the foundations of what we think gender is,” she said. “We have a number of gender nonbinary kids coming to the clinic, asking for, for example, a touch of testosterone. They would just like to have a little bit of a deeper voice and a little bit of peach fuzz and then stop the testosterone.”
Yesterday’s tomboy wore baggy clothes and rode skateboards. Today’s nonbinary girl micro-doses on testosterone to grow peach fuzz.
In a 2018 US Professional Association for Transgender Health symposium titled “Outside the Binary—Care for Nonbinary Adolescents and Young Adults,” Johanna Olson-Kennedy, a leading U.S. gender clinician, expressed a similar sentiment. “I don’t like the word ‘pass’ at all,” she explained. “Passing as a member of the other sex is not a criterion for treatment, whereas achievement of personal comfort and well being are.” The role of the physician is “to work with [a] person to determine what it is that they’re interested in.”
The clearest demonstration of how the goalposts have moved came in December 2024, when the lead author of the Dutch studies, Annelou de Vries, coauthored a peer-reviewed article arguing that the field should no longer concern itself with whether “gender-affirming care” is “effective,” or results in mental-health “improvement” (the article places these words in quotation marks). Drawing on the theoretical framework of “trans negativity,” which “critiques” the notion that “negative affect” in trans-identified people is “a problem to be resolved through medical intervention,” de Vries promptly abandoned the clinical reasoning that she had defended so vigorously throughout her career. In this schema, doctors are reduced to highly educated vendors of consumer services.
I asked Laura Edwards-Leeper, the psychologist who helped establish the first pediatric gender clinic in the country at Boston Children’s Hospital, whether her clinic saw kids with nonbinary identities in the early days and, if so, how they treated such patients. “There wasn’t even a term for it back then,” she told me. “All the kids we saw were straightforward binary adolescents”—meaning, they identified as either male or female—“with severe dysphoria, with some indication since childhood.” The nonbinary phenomenon among clinic-referred teens emerged in the late 2010s, she added, “but it was rare. Doctors were very hesitant to do anything medically” with these kids “because they said, ‘there was no research.’”
There are still no long-term studies on the impacts of using hormones this way, not for binary transitions and certainly not for nonbinary ones.
Blocking the puberty of boys like ACLU plaintiff Cameron at Tanner stage 2—the earliest stage of physical puberty—and placing them on estrogen therapy will result in lifelong sterility. They will have undeveloped penises and suffer from sexual dysfunction. Those lucky enough to have passed through Tanner 2 will still be exposed to a range of negative health effects, including cardiovascular disease and cancer.
Gender clinicians like de Vries, who abandon the pretense that they care about evidence-based medicine, appeal to the value of personal choice as the sole ethical consideration. As evidence that their “clients” are choosing autonomously, they argue that regret from pediatric gender transition is vanishingly rare, at less than 1 percent. The main piece of evidence furnished in support of this claim is a deeply flawed “systematic” review published in 2021. Notably, of the more than five thousand of patients documented in the review,only one identified as nonbinary.
Summarizing the findings of her multiyear review of youth gender medicine, Hilary Cass wrote that “This is an area of remarkably weak evidence,” and when it comes to nonbinary-identifying children in particular, “we know even less about the outcomes for this group.”
The ACLU’s decision to include Cameron and his parents in its lawsuit may prove to be a strategic mistake. But this would be on brand for the organization, which has thrown its institutional weight behind the most radical and unpopular campaigns for transgender rights. The ACLU’s star attorney, Chase Strangio, is a controversial figure even within the nonprofit, according to a source with high-level knowledge of LGBT movement politics. Strangio, who has used “they/them” pronouns, once tweeted that “Stopping the circulation of [Abigail Shrier’s] book [Irreversible Damage] and these ideas is 100% a hill I will die on.”
In 2020, Strangio told The New Yorker that she and a group of lawyers had asked trans-identified male inmates whether they wanted to integrate into women’s prisons or have a separate trans section in a male prison. An extremely high percentage of trans-identified male inmates are convicted of sexual crimes, and their placement in women’s prisons puts incarcerated women at risk. The inmates “all said that they wanted a trans unit,” but they were overruled by Strangio and the others. A separate unit, Strangio reportedly believed, would be “stigmatizing, and only served to perpetuate the prison system.”
Like other gender-medicine apologists, Strangio seems willing to say whatever the moment demands. For example, she once said that she “sort of regret[s] the emergence of gender identity as this entire separate thing from sex” and that assumptions about the reality of sex, not only of gender, “are socially, culturally, and politically contingent”—that is, they “take on meaning as we talk about them and interface with systems of power.” Yet when arguing before the Supreme Court in U.S. v. Skrmetti, Strangio accepted that while “gender identity” may be “fluid,” it nevertheless is an “immutable characteristic” deserving of constitutionally protected status because, as she argued, it has “a strong biological basis.”
“I am a civil rights and constitutional lawyer,” Strangio said in a 2019 interview, “who fundamentally doesn’t believe in the Constitution and the legal system.” Rest assured, she will now call upon that system and its Constitution to protect her favorite client, the gender industry.
Photo by Rory Doyle for The Washington Post via Getty Images
