One of the main public relations strategies of “gender-affirming care” advocates is to deny that the model of treatment being used in American clinics differs in any significant way with the one now used in European clinics. Over the past two years, and following systematic reviews of evidence, health authorities in Sweden, Finland, and the U.K. have agreed that no evidence exists that the benefits of puberty blockers and cross-sex hormones outweigh the risks. All three countries have since imposed measures to reduce drastically the accessibility of these drugs to teenagers.
Just two weeks ago, the World Professional Association for Transgender Health (WPATH)—a U.S.-based promoter of “gender affirmation” that now recognizes “eunuch” as a valid childhood “gender identity”—was still insisting that Europe’s only change was a decision by health authorities to conduct “more studies” and gather data. But with evidence of the actual changes increasingly hard to deny, WPATH has now finally had to reckon with reality. On November 25, it chose to air its grievances—and tacitly concede its previous disinformation campaign—about Europe’s change of direction when it criticized England’s National Health Service.
Back in October, the NHS released draft guidance based on a February report by the former president of the Royal College of Paediatrics and Child Health. In that report, physician Hilary Cass noted the “affirmative” model, which “originated in the USA,” as likely responsible for insufficient child “safeguarding” at the now-discontinued Tavistock clinic gender service. Tavistock staff, Cass wrote, “have told us that they feel pressure to adopt an unquestioning affirmative approach and that this is at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.” The NHS’s draft guidance calls for a restoration of careful and lengthy mental-health assessments before prescribing drugs.
In its November 25 statement, WPATH condemned the NHS in terms that reveal the organization’s strong preference for the affirmative model. The NHS, it complained, is emphasizing “careful exploration of a child or young person’s co-existing mental health, neuro-developmental and/or family or social complexities,” which WPATH deemed an “alarming” practice of “outdated gatekeeping.”
You might think that every rational American would support “careful exploration” of a distressed teenager’s state of mind before prescribing powerful drugs. But public confusion about gender-affirming care arises from the slippery definition of this protocol and how it differs from the more cautious Dutch approach that European nations are now implementing. Both models assume that gender-identity discordance—that is, the experiencing of one’s gender as different from one’s sex—is a natural, normal, and healthy variation of human development. The main difference between them concerns their assumptions about when and how gender identity can be known and what to do about it. Three points of divergence are especially important.
The first concerns childhood social transition—the use of new names and pronouns, as well as access to restrooms and sports teams. According to the affirmative model, as clarified by the American Academy of Pediatrics in 2018, gender identity is knowable from a very early age, and once declared, a child’s gender identity calls for immediate and uncritical “affirmation” by parents, peers, clinicians, and teachers.
This contrasts starkly with the Dutch model, which, drawing on decades of research, acknowledges that gender dysphoria in children is very likely to desist by adolescence or early adulthood, in many cases resolving into homosexuality. Moreover, research published in recent years strongly suggests that if a child’s cross-gender feelings are affirmed as evidence of a wrongly “assigned” sex at birth, that child is far more likely to persist in his dysphoria and seek puberty suppression. It is in light of the high likelihood of desistance that the Dutch model recommends “watchful waiting,” not affirm-first. Indeed, the Dutch team did not even recommend social transition (“real life experience” in the felt gender) in the early stages of puberty, but only after the teenager tried living as his true sex and found it too distressing. Social transition was seen as something to be done cautiously and incrementally, in conjunction with pharmaceutical puberty suppression, which the Dutch team thought of as part of the diagnostic rather than treatment phase. In its new draft guidance, England’s NHS strongly advises against childhood social transition and recommends it for adolescents only, based on informed consent and with a diagnosis of gender dysphoria.
Behind these differing recommendations on social transition are diverging assumptions about the etiology of gender identity—the second point of disagreement. Proponents of the affirmative model tend to believe that it has a strong neurological component. No evidence supports this. Studies on brain structure and functioning are notoriously inconclusive, mainly because they cannot control for homosexuality or for the effects of synthetic hormone use and gender-role change on the brain.
Several reasons, however, require advocates of the affirmative approach to believe in the neurological explanation. First, it allows for a politically potent analogy to gay rights (“born that way”), which in turn helps facilitate the capture of mainstream gay rights institutions and their repurposing—without arousing public suspicion—toward transgender issues. Second, if gender identity is not innate and fixed at a young age, there would be no good reason to transition a minor medically. When Jack Turban, a leading pro-affirming psychiatrist, tweeted that gender is “fluid” and not “fixed,” one of his critics asked “then why the f**k we [sic] cutting up kids, Jack?” to which he promptly responded by deleting the tweet. Finally, in American jurisprudence, a trait’s supposed immutability has direct relevance for a court’s willingness to afford it higher judicial protection. In a lawsuit filed by the ACLU on behalf of a transgender-identifying student, the Court of Appeals for the Fourth Circuit based its judgment against a school district on the supposition, endorsed in an amicus brief by medical groups, that being transgender is “as natural and immutable as being cisgender.”
Those adhering to the Dutch model tend to be agnostic on the question of etiology. Consistent with the contemporary standard in psychiatry, they are content to focus on classification of symptoms and believe that the cause of mental pathology may be less important, clinically speaking, than the contours, tenacity, and severity of its presentation. As the Dutch researchers themselves put it just over a decade ago, “the (patho-) biological basis of [gender dysphoria] is still poorly understood, and its diagnosis relies totally on psychological methods.”
No new research has emerged to challenge this basic insight. Less willing to allow popular narratives to cloud their judgment, practitioners of the Dutch model have been more open to recognizing the importance of social influences on identity formation in youth. The likely possibility that many teens were identifying as transgender and seeking irreversible medical interventions because of social influences prompted European health authorities to conduct evidence reviews and scale back the administration of hormones. Among U.S. practitioners of gender-affirming care, however, social-influence-based explanations remain strictly verboten. In their amicus brief for Eknes-Tucker v. Marshall, the lawsuit challenging Alabama’s ban on affirmative drugs and surgeries, 18 American medical groups wrote that there is “no reliable evidence” supporting the social influence hypothesis. Oddly, however, in its updated standards of care, WPATH acknowledges “susceptibility to social influence” as potentially relevant to “a select subgroup of young people” in forming a sense of self, though it clarifies that this should not be a barrier to social or medical transition.
The third key point of divergence between the affirmative and Dutch protocols concerns how to understand and what to do about co-occurring mental-health problems in clinically referred adolescents. In recent years, Western countries have observed a change in the main cohort presenting at their gender clinics. In the Dutch study, most of the minors were boys. Candidates were eligible for puberty suppression only if they had early-onset “gender identity disorder,” supportive families, and no serious co-occurring mental-health problems. In contrast, most referrals to pediatric gender clinics over the past decade have been teenage girls with no prepubertal history of dysphoria and with high rates of such mental-health problems as anxiety, depression, ADHD, and autism.
The Cass report, for instance, found that about one-third of the adolescents referred to Tavistock’s gender identity service for treatment had autism or some other neuroatypical condition. Finland’s Council for Choices in Healthcare reported that “psychiatric disorders and developmental difficulties may predispose a young person to the onset of gender dysphoria.” One plausible explanation for why transgender-identified teenagers exhibit such high rates of suicidal ideation and behavior, then, is that minors—specifically teenage girls—with preexisting mental health problems including suicidality are more likely to identify as trans.
Affirmative-model proponents argue that co-occurring mental-health problems should always be presumed as secondary to—meaning, caused by—unaffirmed gender identity and lack of social acceptance for transgender people. This belief system is known as the “minority stress” model, and it is important to clarify that, as with many other claims made on behalf of gender identity and medicine, it is borrowed from research on homosexuality. Practitioners of the Dutch approach, by contrast, argue that the causes of mental-health problems should be investigated and treated prior to gender transition, on the view that these might be causing the gender issues rather than the other way around, and that a less invasive psychotherapeutic approach is likely to be less risky than drugs and surgeries.
Not only are co-occurring mental-health problems not a red flag for medication, according to the affirmative model, but if anything, their presence makes “gender-affirming” drugs even more urgent. As Diana Tordoff, lead author of a controversial study done earlier this year at Seattle Children’s Hospital, admitted in response to a critic, “the only instances when it would have been appropriate to delay initiation of [puberty blockers and cross-sex hormones] is if there was a concern that a patient did not have the capacity to provide informed consent (which is exceedingly rare in adolescence). Therefore, youth who reported moderate to severe depression, anxiety, or suicidal thoughts were not precluded access to [these drugs], especially since initiating [them] is known to improve or mitigate these symptoms.” This was a remarkable thing for Tordoff to say, considering that the point of her study was to discover whether “gender affirming” drugs are needed to “mitigate these symptoms.”
Back in August, in response to our criticism of its anti-scientific approach, the American Academy of Pediatrics assured the public that “the vast majority” of gender dysphoric minors need “the exact opposite” of drugs and surgeries. According to the data published in Tordoff’s study, however, two-thirds of the youth referred to Seattle Children’s for gender issues were put on hormones. While it is possible that this sample is non-representative of how local teenagers with gender issues are treated, it is potentially a sign that Seattle Children’s does not follow the advice of the AAP. Assuming it does not, this would not constitute a violation of gender-affirming care but a fulfillment of its promise: patients should be in the driving seat of their own medical “treatment.”
Why do advocates of the affirmative approach publicly deny that their assumptions and methods depart from those of the Dutch? One likely answer has to do with an all-too-familiar feature of American life. Like most policy debates, the one over gender-affirming care has been framed in the language of “rights” and litigated primarily in the courts. Organizations like the ACLU regularly tell federal judges that because Republican state bans on pediatric gender transition go farther than in Europe (which is true), striking them down means preserving a well-accepted model practiced in Europe (which is false). Because judges are nonexperts whose busy schedules and institutional constraints force them to rely on partisan witnesses appointed by winning-focused lawyers, they have proved amenable to the false dichotomy.
At a Florida medical boards hearing last month, Aron Janssen, a child psychiatrist, claimed that Dutch clinical data are “the best we have” and that American gender clinics follow the Dutch model. Yet a recent investigation found that not a single interviewed provider at 18 pediatric gender clinics nationwide “described anything like the months-long [psychiatric] assessment” the Dutch clinicians require before putting a minor on hormones. Thomas Steensma, one of the Dutch researchers, himself observed that “the rest of the world is blindly adopting our research,” warning that most patients seeking medical transition are significantly dissimilar to the original Dutch cohort. Annelou de Vries, who spearheaded youth medical transition, also stressed the potential inapplicability of the Dutch data in the American Academy of Pediatrics’ peer-reviewed journal.
Another star witness supporting the affirmative model at the Florida medical boards hearing, Meredith McNamara of the Yale School of Medicine, denied any meaningful change had taken place in Europe. “I disagree that international guidelines are more conservative” and don’t “see any substantive differences” between American and European pediatric gender medicine, she said. England’s National Health Service, she insisted, is merely “gather[ing] evidence moving forward.” As with Janssen, it is not clear whether McNamara is ignorant of the realities of pediatric gender medicine in the U.S. or being dishonest.
It should be emphasized that while the Dutch approach is more cautious than the affirmative one and allows for more safeguarding of vulnerable minors, it is far from clear that even the Dutch model is based on good evidence. The systematic reviews done by European health authorities concluded that the Dutch study was subject to significant bias and methodological limitations and that the certainty of evidence it yields is “very low.” We are likely to see more evidence emerge about this patient cohort’s long-term clinical outcomes. But whether the Dutch study withstands the increasing scrutiny it is now receiving (it seems that things were not as clearly beneficial for the youth treated in the Dutch clinic), it is clear that the U.S. is not following even this supposedly more cautious approach.
In the Wild West of U.S. gender medicine, and consistent with the affirmative model’s hostility to any questioning of a minor’s asserted identity, the only criteria for the “medical necessity” of drugs and surgeries for minors are the wishes of teenage patients. The stronger the wish, the greater the medical “necessity.” McNamara illustrated this thinking in her response to the Florida board doctors. When pressed to explain how she determines when a teenage girl “needs” a double mastectomy and why (as she claimed) she’s never referred a patient for this procedure, McNamara could only say: “I’ve never had a patient express that they desire top surgery.”
McNamara’s latest commentary, in the prestigious New England Journal of Medicine, calls for legal and medical “experts” to fight for unfettered access to hormones and surgeries for youth. She strongly implies that legal coercive power could be used to stop “science denialism,” by which she means efforts to get the U.S. to conduct systematic reviews of evidence and base medical care on the findings of those reviews. Virtually every sentence of her short NEJM article is false or misleading. But that is almost beside the point. The main purpose of articles such as these is to continue cluttering medical journals with pro-affirming pieces in the hope that unsuspecting judges and journalists will regard the sheer number of them as evidence of a substantive medical consensus. Coverage of studies by Tordoff and Turban this year alone show how much traction egregiously misinterpreted results can gain in the public debate, and how hard it is to correct the public record once misinformation spreads.
Sooner or later, though, this house of cards will collapse. McNamara’s ominous call for legal authorities to be concerned about “science denialism”—of which her own writings and testimonies offer a good example—suggests desperation. When a movement is unable to defend its position using good faith and rational, evidence-based arguments, its only recourse is force and fraud. Meantime, WPATH’s admission that England has in fact become more cautious is a welcome, if sadly belated, development.
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