In 2015, the National Institutes of Health launched the Sexual and Gender Minority Research Office. Its purpose: to rectify the absence of health data on this cohort by prioritizing research and improving data collection. While the new office (SGMRO) does not have grantmaking authority on its own, its wide sphere of influence shapes the nature of the grants being considered for funding and the overall spirit of research on sexual and gender minorities (SGM). Moreover, the SGMRO and its associated working group and coordinating committee function as connective tissue linking the NIH’s various institutes, centers, and offices, allowing them to spread their understanding of the health of “individuals who identify as lesbian, gay, bisexual, asexual, transgender, non-binary, Two-Spirit, queer, and/or intersex.” While many of the SGMRO’s priorities are laudable and in principle worthy of scientific inquiry, in practice they have enshrined activist assumptions about the nature of “gender identity,” “gender-affirming care,” and the causes of “health inequities” at NIH.
The catalyst for establishing the new office was a 2011 report commissioned by the NIH to survey the known research on “LGBT” health. Conducted by what is now the National Academy of Medicine, the report stated, “All aspects of the evidence base for transgender-specific health care need to be expanded.” The authors noted a need for more research on how treatment for gender dysphoria should be managed “under the new paradigm of greater diversity of gender identities” and on both the benefits and harms of sex-trait modification procedures, particularly related to hormone use.
With the benefit of hindsight, the 2011 report contains signs of things to come—for instance, recommendations to consider “intersectionality” and “minority stress” as guiding principles. But in many ways the document reads like a relic from a bygone era of scientific discourse, full of genuine humility and a desire for more scientific data on LGBT health more broadly. The report concluded that overall data on LGBT health was so sparse that a substantial research program was needed. In 2012, what is now known as the Sexual and Gender Minority Research Coordinating Committee issued a report that accepted the 2011 findings and recommendations, culminating in the founding of the SGMRO in 2015.
The ultimate triumph of SGMRO’s incoherent worldview can be seen in a glossary of gender terms provided by the NIH’s office of Equity, Diversity and Inclusion. From it, we learn that, on the one hand, “gender” is a “set of socially constructed roles, behaviors, activities” and, on the other, that “affirmed gender” is innate and reflects “an individual’s true gender,” as opposed to his or her “gender assigned at birth.” The glossary uses sex-based language to assert that male and female are “gendered” rather than biological categories. This lack of scientific precision extends to obscurantist or redundant definitions for terms such as “gender expansive,” “genderqueer,” “gender nonconforming,” and “gender variant.”
A review of the SGMRO’s resources suggests that the office is part of a fundamentally ideological project that adopts the most controversial—and least useful—aspects of the 2011 report, while using them as a pretext to build gender ideology into all the NIH’s institutes, centers, and offices. The SGMRO thus represents a missed opportunity to prioritize the principles of evidence-based medicine. Its current activities are highly unlikely to win over a public increasingly losing faith in our scientific institutions and in the scientific process.
Under its mandate to improve health for sexual and gender minorities, the SGMRO has essentially built gender-identity data collection into NIH-funded research, added SGM research “experts” to study review panels and sections, and indoctrinated employees on the necessity of pronouns and the dubious premise that sex and gender exist on a spectrum.
Notably, the research office treats SGM as a monolithic category despite the broad range of differences between and within groups, particularly when it comes to trans-identified individuals. Moreover, it is one thing to study “gender identities” through the prism of sociology and another to formalize these concepts as natural categories within a “gender diversity” paradigm, lending them an unearned veneer of scientific credibility.
The crux of the SGMRO’s research framework—and a justification for much of its gender-identity initiatives—stems from the 2011 report’s assumption that “the main commonality across these diverse groups is their members’ historically marginalized social status relative to society’s cultural norm of the exclusively heterosexual individual who conforms to traditional gender roles and expectations.”
The NIH’s adoption of an explicitly ideological research framework to make sense of SGM “health disparities” is its fundamental scientific flaw. The framework presupposes that elevated rates of psychopathology or other disparities in health stem from societal stigma or discrimination. Making this assumption virtually unfalsifiable, the SGMRO redefines discrimination and stigma to include circumstances in which they exist entirely in the mind of the subject—namely, “internalized, perceived, or anticipated” forms of bias.
In 2016, the National Institute on Minority Health and Health Disparities (NIMHD) formally designated sexual and gender minorities as a population “experiencing health disparities for research purposes.” This special designation enhances research funding opportunities. Investing federal funds in understanding SGM health disparities is a worthwhile scientific endeavor, but the NIMHD research framework suggests a ready-made answer before even investigating the nature of the problem.
“Progress has been made in recent years, with gains in legal rights and changing social attitudes,” the NIMHD writes. “However, stigmatization, hate-violence, and discrimination are still major barriers to the health and well-being of SGM populations.” This contested understanding of health disparities is baked into the NIMHD’s definitions of “minority health” and “health disparities,” which presuppose from the outset that populations with such disparities are “socially disadvantaged due in part to being subject to racist or discriminatory acts and are underserved in health care.”
Revealingly, as part of its announcement the NIMHD cited a single paper to justify its conclusion that “sexual and gender minorities who live in communities with high levels of anti-SGM prejudice die sooner—12 years on average—than those living in more accepting communities.” The NIMHD later updated its announcement to acknowledge that this paper had been retracted because of an “error” that, once corrected, erased the statistically significant association between prejudice and mortality.
This is not an isolated incident. The SGMRO adopted a modified version of the NIMH’s health disparities research framework, which again presupposes that these problems can be attributed to “minority stress” and “structural stigma.” The adapted model suggests that “gender-affirming therapies,” “culturally competent care,” and “affirming patient-provider relationships” can combat health disparities, though the efficacy of these interventions remains hotly debated.
Even as the U.K.’s Cass Review mounts the most definitive challenge to date to the claim that “gender-affirming care” is medically necessary, the NIH is funding grants to train nursing students on the “affirmative model” based on the World Professional Association of Transgender Health’s (WPATH) SOC-8 guidelines. The Cass Review deemed these guidelines lacking in developmental rigor and fundamentally unsuitable for implementation into clinical practice. This is without even getting into WPATH’s evidence-suppression scandal, in which the organization commissioned, and then suppressed, systematic reviews of evidence after the findings undermined its mission to expand access to minors.
Since the SGMRO launched, how successful has the NIH been in filling the knowledge gap on subjects like the risks and benefits of hormone therapy and puberty blockers? Despite NIH’s spending well over $1 billion researching SGM health since 2015—which, admittedly, covers a lot more than transgender research—we’re no better off in answering the most pressing questions.
Take the controversial four-site, NIH-funded Youth Care Study, which includes both a puberty-blocker cohort and a cohort of youth taking cross-sex hormones. Though the study launched in 2015, data from its puberty-blocker portion has yet to be published. Physician and primary investigator Johanna Olson-Kennedy told the New York Times that her team feared their findings would be used to buttress the legal arguments adopted by states that have passed laws regulating “affirming care” for minors. This public admission prompted the House Committee on Oversight and Accountability to launch an investigation into the circumstances surrounding the unpublished data. Kennedy is also being sued by a former patient for medical negligence.
Data from the hormone portion of the study has been published, but it has its own problems. As journalist Jesse Singal documented last year, the study authors’ claims were overstated and misleading. Investigator Diane Chen told attendees of a recent NIH workshop about the benefits of “affirming” care for anxiety, depression, “appearance congruence,” and life satisfaction. But she and her coauthors have not reported findings for six of the eight outcome measures preregistered in their study protocol, including findings for gender dysphoria, trauma symptoms, self-injury, suicidality, body esteem, and quality of life. This curious omission raises suspicions that the authors retroactively changed their study hypothesis after the findings clashed with it.
Moreover, the study was also plagued by many confounding variables, including access to psychotherapy. Even for the study’s positive findings, male study participants failed to show improvements in mental health, and while female participants saw modest improvements that reached statistical significance, the gains were unlikely to be clinically significant. Most damning of all, however, is the fact that two of the 315 participants died by suicide after initiating hormone treatment—even though the eligibility criteria excluded participants with the most severe psychiatric issues.
The politicization of the SGMRO is a warning sign of deeper issues within the National Institutes of Health. While President-elect Donald Trump’s nominee to lead the agency, Jay Bhattacharya, has his work cut out for him, he and his team also have an enviable opportunity for reform. Overhauling the SGM health disparities framework, restoring scientific and sex-based language across NIH institutes, centers, and offices, and adding “detransitioners” to the SGM umbrella would be a good start. Other priorities should include encouraging research into the etiology and epidemiology of dysphoria, diagnostics, and the efficacy of psychosocial interventions as a treatment model for dysphoria. Under Bhattacharya’s stewardship, the NIH can recommit itself to evidence-based principles. In doing so, it can also restore public faith in American scientific institutions, which should be the envy of the world.
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