Should Texas be allowed to administer “gender-affirming care” to minors? That’s the question at the heart of Senate Bill 14 / House Bill 1686, which seeks to ban it. Proponents of the controversial practice argue that “legislatures shouldn’t be practicing medicine.” But recent testimony from pro-affirming medical professionals before the Texas legislature suggests the need for just such oversight. Delivering false or misleading testimony about minor surgery, mental health, and the evidence backing gender medicine, opponents of the ban inadvertently proved that it is justified.
Start with the question of whether “gender-affirming” surgeries are performed on minors. Last week, physician Cody Miller Pyke assured Texas state senators that “children under the age of eighteen in this country do not have gender reassignment surgery. There isn’t a single case. . . . The rhetoric of mutilating children with scalpels is just fictitious.” Louis Apel, president of the local chapter of the American Academy of Pediatrics, and Jessica Zwiener, a Houston-based endocrinologist, testified that “surgeries are not part of the standard of care for minors.” Zwiener also insisted that “[n]o one is touching these kids’ genitals. There’s not surgery done on minors.”
These physicians are wrong. The World Professional Association for Transgender Health (WPATH), whose Standards of Care are commonly cited as the most authoritative in the field, considers both genital surgeries and mastectomies part of the standard of care for treatment of gender dysphoria in minors (Statement 13.7, SOC-8). WPATH recently did away with all age minimums for medical interventions, including surgeries.
Last year, a Reuters investigation found evidence for “56 genital surgeries, including vaginoplasty and other procedures, among patients ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021. That doesn’t include surgeries not covered by insurance.” A 2017 peer-reviewed article titled “Age is Just a Number” found WPATH-affiliated surgeons reporting “a definite increase in the number of minors” seeking vaginoplasty. The Biden administration’s Department of Health and Human Services has said that both double mastectomies and genital surgeries are “typically used in adulthood or case-by-case in adolescence.”
When confronted with these facts, advocates of “gender-affirming care” usually pivot to saying that surgeries are “incredibly rare,” as Colt St. Amand, a physician and psychologist, testified at hearings conducted by the Texas House Public Health Committee. But it’s worth noting that at least three times as many kids got genital surgeries between 2019 and 2021 as the number of students killed in school shootings during the same time period (19)—a problem that no one believes is too “rare” to warrant public concern.
Double mastectomies are also rising. The number of these procedures increased thirteen-fold between 2013 and 2020, and by 50 percent to 100 percent annually—or from 100 to 500 procedures—between 2016 and 2019. This is almost certainly an undercount, because “gender-affirming” mastectomies are often paid for out of pocket. Assuming the same annual rate of increase remained steady between 2019 and 2022, the estimated number of teenage girls who received gender-related mastectomies in 2022 is in the low thousands.
Data published by gender-affirming researchers confirm that teenage girls undergo these procedures aged as young as 12. Laura Kuper, who helped write the “nonbinary” chapter in WPATH’s latest Standards of Care and who also testified in the House hearing, argues that because black girls go through puberty and develop breasts earlier than white girls, “equity” requires that mastectomies be made available to them at even younger ages—presumably around ten or 11.
Another key issue on which opponents of the Texas ban were either misinformed or dishonest concerns mental-health assessments. Last August, the president of the American Academy of Pediatrics assured the public that for the “vast majority” of youth with gender dysphoria “gender affirming care . . . recommends the opposite” of “medical treatments or surgery.” Zwiener agreed with the Texas House bill’s sponsor, Tom Oliverson, that it is “appropriate” for minors to undergo at least six months of psychotherapy before any decision is made to give them hormones, as per the Dutch protocol.
Both Zwiener and the AAP seem to be dangerously out of touch with realities on the ground. The Reuters investigation from last year found that “none” of the staff at 18 pediatric gender clinics across the country “described anything like the months-long assessments” the Dutch “adopted in their research.” Though Reuters did not say whether any of these clinics was in Texas, it’s reasonable to assume that the Lone Star State does not stand alone. A study published last year on patients at Seattle Children’s Hospital reported that two-thirds of children referred to the hospital’s gender clinic were put on puberty blockers or cross-sex hormones within a year. And in her sworn affidavit, whistleblower Jamie Reed has said that families who turned to the gender clinic at St. Louis Children’s hospital were misled into believing their children would get comprehensive psychological evaluations. In practice, even children with severe underlying mental conditions were being rushed into medical transition.
Zwiener claimed that she couldn’t recall any patients of hers who had mental-health counseling for less than a year. She did not indicate, however, if these kids got “affirmative” therapy, in which case their asserted gender and desire for transition would have been “affirmed” rather than seen as a reason to do more exploration.
When gender-affirming advocates insist that “comprehensive” and “multidisciplinary” mental-health assessments are conducted, what they mean is that psychologists are not simply rubber-stamps for medicalization, but instead perform the gatekeeping role of determining whether a minor is a good candidate for hormonal interventions. But how stringent is the gatekeeping?
At the Texas Senate hearing, Megan Mooney, president of the Texas Psychological Association, was asked whether she believes every child, even a 12-year-old, who comes to her and says “I’m trans.” Without hesitation, Mooney said she did. She was then asked whether she could recount a single instance in which she declined to write a letter of recommendation for medicalization for a child who said “I’m trans” and wanted hormones. This was an easy chance for Mooney to demonstrate that she does differential diagnosis; even a single instance of refusing to write a recommendation letter would indicate that approval for medicalization is not based solely on the wishes of her pediatric patients. But Mooney could not—or would not—say that she ever said no to patient who wanted hormones.
In her 2022 report to England’s National Health Service, physician Hilary Cass, a former president of the U.K.’s Royal College of Paediatrics and Child Health, noted the problem of “diagnostic overshadowing,” in which “many of the children and young people presenting have complex needs, but once they are identified as having gender-related distress, other important healthcare issues that would normally be managed by local services can sometimes be overlooked.” The American affirmative model is especially vulnerable to this problem because of its reliance on a “minority stress” approach to understanding the extraordinarily high rates of mental health comorbidities among trans-identified minors. The net result is that differential diagnosis, which requires exploratory therapy, is not only made exceedingly difficult, but is cast as unethical “conversion therapy.”
Oliverson asked Mooney whether the kids she sees in her practice “who present with GD [gender dysphoria] also present with other issues.” Mooney’s answer illustrates the minority stress approach. Trans-identified kids experience high levels of “PTSD, anxiety, [and] depression,” she suggested, because they are constantly “harassed.” Oliverson pressed on, citing research showing that roughly three-quarters of gender-clinic-referred adolescents have psychiatric diagnoses prior to being referred for gender issues. Could Mooney be confusing the causal relationship between gender dysphoria and other mental-health problems? Mooney replied that while she “wouldn’t dispute” the study or that the “timeline” for complex mental-health presentation “matters,” a patient’s history of psychiatric diagnoses is “not the only thing that determines my treatment.”
The massive overrepresentation of autism among gender dysphoric patients has received a lot of attention in the wake of the collapse of the Tavistock clinic in the U.K., where up to a third of patients had autism or neuroatypical conditions. According to one study, up to 80 percent of girls with autism are not diagnosed until adulthood, creating the risk for their autism to be misdiagnosed and mistreated as another condition (i.e., “diagnostic overshadowing”). The causes of autism’s overrepresentation among gender-distressed youth are not fully known, but some theorize that autistic people tend to fixate on “special interests” (social media has allowed the world of gender to become an all-consuming special interest) or use a “born in the wrong body” narrative to make sense of their social maladjustment and hold out hope that it can be fixed.
Mooney confirmed that she was seeing more and more autistic kids in her practice. As to why this is, she admitted that there isn’t good research on the issue but suggested that there might be “genetic links” between the two conditions and that “the creative thinking we see in autism spectrum disorders” might facilitate “creative thinking about gender identity.” Neither theory has support in the clinical literature. Mooney’s demonstrated lack of curiosity about the autism-gender connection was another red flag at the Texas hearing.
Zwiener and Mooney were both asked about “rapid onset gender dysphoria” (ROGD), and both dismissed it out of hand. After calling ROGD a “diagnosis” (an admittedly common mistake even among supporters of the theory), Zwiener said that it is based on a single study with a “very biased sample.” In fact, physician and researcher Lisa Littman has shown that the methodology she used in her 2018 study is consistent with studies supporting “gender affirming care.” At the hearing, Zwiener herself cited two studies that rely on similar methodology.
In 2020, a group of researchers and clinicians in the U.K. said that “Littman’s description resonates with our clinical experiences from within the consulting room.” Other researchers have noted the rise of the clinical presentation associated with ROGD—predominantly female, comorbid psychiatric problems, no childhood history of gender issues—in gender clinics in multiple countries. In 2021, Littman published a study on detransitioners in which she found that a significant number cited psychosocial influences as motivating their decision to pursue transition. Another study published a few weeks ago lends further support to Littman’s 2018 methodology and findings. Yet despite all this, when asked to explain the rapid rise of minors seeking “gender affirming care,” Mooney suggested that it was because “centers and providers [had] become known for [offering] good care.”
To be sure, ROGD is not settled science. But the clinical presentation associated with ROGD is by now internationally recognized and is the main reason that health authorities in other countries have backed away from the affirmative model of care. Zwiener’s and Mooney’s flippant dismissal of ROGD raises serious concerns about whether they read the scientific literature with an open mind. More importantly, it calls into question their commitment to performing thorough mental health assessments and differential diagnosis.
After testifying in the House that “medical transition is recommended as the gold standard for treatment for gender dysphoria by every major medical body in this country,” an apparent contradiction of the AAP’s August statement, Zwiener was asked whether medicalization is “always the answer.” “In my experience,” she said, “it’s almost always the answer.”
This is hardly the first time that gender-affirming clinicians have admitted that they do not do, or do not approve of, thorough assessments. Jack Turban, for instance, has argued that there shouldn’t be any gatekeeping for minors who desire hormones, only “informed consent” (though given the affirmers’ deeply misleading claims about the reversibility of drugs, their safety, and the risk of suicide for those who don’t get them, one can legitimately doubt how informed the consent really is). Bioethicist Florence Ashley has denounced medical gatekeeping on the grounds that teenagers should enjoy unfettered autonomy to treat their bodies like “gendered art pieces.”
Gender-affirming advocates contradict themselves frequently on this question simply because they have no choice. Given their beliefs that gender identity is innate and fixed from a very young age, that “trans kids know who they are,” and that withholding affirmation from “trans kids” amounts to “conversion therapy,” these advocates must assure activists that they refrain from gatekeeping. At the same time, though, the notion of doctors effectively handing the prescription pad over to minors, especially teenagers with psychiatric problems that typically precede their gender issues, is plainly unpalatable to most of the public, and probably also to most medical professionals. And so, reluctantly, gender-affirming advocates are forced to speak out of both sides of their mouth.
A third example of distortion in the Texas legislative hearings came when Zwiener and St. Amand explained not just what studies on the link between “gender-affirming” interventions and mental health found, but how the scientific process itself works and how evidence informs clinical practice. At the House hearing, Rep. Oliverson asked Zwiener whether “these treatments reduce suicide in these adolescents.” Zwiener answered in the affirmative. Oliverson asked if she could cite corroborating studies, to which Zwiener replied:
I can. And one thing is to know what studies. I mean, you know this you’re a physician, but the way we come to know the truth in science is complex. I know we don’t like that word, but every study is different and we look at the accumulation of evidence. There are small studies that show no effect on the suicide rate, but when you look at the studies in aggregate and compare that with clinical experience.
This is a gross misunderstanding of how science works. First, the sum of several “small studies that show no effect on the suicide rate” is not evidence that hormones reduce the suicide rate. In the U.K. between 2010 and 2020, the number of suicides among clinically referred minors already receiving treatment at the Gender Identity Development Services was the same as the number of suicides among clinically referred minors who were not receiving treatment. A 2011 study from Sweden showed that 30 years after full sex reassignment surgery, transsexual patients were 19 times more likely to commit suicide than population-matched controls.* In a study recently published in the New England Journal of Medicine, two out of 315 subjects committed suicide within the first year of treatment—a figure far higher than the rate of suicide in the general population for the same age group. Finally, systematic reviews of evidence have found no reliable evidence that hormones make suicidality less likely.
The studies and systematic reviews mentioned above are sufficient to demonstrate the fallacy in Zwiener’s understanding of scientific corroboration. In her testimony, Zwiener was asked what studies specifically show that “gender-affirming care” reduces suicide. She cited two by Jack Turban. Even setting aside the profound weaknesses of Turban’s suicide research, discussed in peer-reviewed journals, and his lack of professional integrity, Turban himself admits that his 2020 study’s “cross-sectional design . . . does not allow for determination of causation.” As I’ve written, claims about “gender-affirming care” being “life-saving” rely on public ignorance about the scale of suicide in this population as well as on confusion of correlation and causation. Finland’s top gender-medicine expert has called such claims “purposeful disinformation” and their dissemination “irresponsible.”
Second, Zwiener is wrong to think that comparing the (null) results of many small studies with “clinical experience” changes this picture in any meaningful way. In evidence-based medicine, a doctor’s clinical experience-based expert opinion constitutes the lowest level of information in the hierarchy of knowledge.
Zwiener may have experience seeing teenage patients who are less suicidal following administration of hormones. But several factors could explain this outcome apart from the hormones themselves: psychotherapy, psychotropic drugs (e.g., antidepressants), regression to the mean, placebo effects, or any combination thereof. It’s exactly for this reason that observational studies, randomized controlled trials, and systematic reviews of evidence represent, in increasing degrees, higher levels of confidence that an intervention causes an observed effect. A single randomized controlled trial can in theory invalidate the “clinical experience” of dozens of doctors.
A more accurate statement than the one given by Zwiener is this: clinical expertise is relevant to, but not decisive in, the establishment of evidence-based practices, and should ideally guide the application of evidence-based knowledge in particular cases. Democrats’ claim that only the opinions of doctors should matter when it comes to medical regulation makes intuitive sense to the lay public, but it’s not how evidence-based medicine works.
Oliverson, the bill’s sponsor and a doctor himself, seemed to appreciate this key point. The difference between him and Zwiener was only superficially about “gender-affirming care.” At a deeper level, it was about the relationship between intellectual humility and professionalism in the practice of medicine.
Later in the hearing, Oliverson asked St. Amand to comment on the fact that systematic reviews of evidence have consistently found that the evidence base for “gender-affirming care” is extremely weak. St. Amand’s response was that, unlike the observational studies he believes (incorrectly) confirm the benefits of hormones and surgeries, systematic reviews are not peer-reviewed. Indeed, St. Amand also dismissed my 52-minute testimony on the grounds that, unlike him, I do not have peer-reviewed publications to my name.
Even if both statements are true, they are beside the point. What gives systematic reviews their status at the top of the information hierarchy in evidence-based medicine is how they are done, not where they are published. Systematic reviews are most authoritative because their methodology is best suited to detect bias and other methodological problems in the studies being evaluated and, using the GRADE system, rank the reliability of their findings. In theory, any two researchers using the methodology of a systematic review should be able to arrive at exactly the same conclusions. And indeed, that is what has happened in pediatric gender medicine.
St. Amand and Zwiener might be highly intelligent physicians with deep empathy for their patients. But when it comes to understanding the link between evidence and clinical practice, they are either dishonest or badly misinformed.
Faced with such admissions of incompetence by doctors defending their practice, what are Texas lawmakers to do?
At minimum, states like Texas have the authority, and some would say the duty, to exclude from their standards of care medical interventions, such as puberty blockers for gender dysphoria, that are not bona fide medical practices but rather fall within the purview of a medical experiment. If advocates of “gender affirming” drugs and surgeries wish to see states incorporate these procedures within approved medical practice, they should demonstrate their safety and efficacy through FDA-approved clinical trials. Of course, this would require advocates to admit that “gender affirming care” is not, as they repeatedly claim, “settled science.”
Democratic complaints about Republicans “practicing medicine” are not just woefully misinformed. They are also hypocritical. When doctors operated OxyContin pill-mills, legislatures in red and blue states alike “practiced medicine” by imposing restrictions on what, when, and how physicians could prescribe powerful painkillers. Advocates of “gender-affirming care” have themselves supported legislatures “practicing medicine” in the form of 20 state bans on gender dysphoria “conversion therapy,” the strategically misnamed practice of trying to help kids in distress feel comfortable enough in their bodies to avoid the feeling that they need life-altering drugs and surgeries (or as activists call it, “forcing trans kids to be cis”). They have done so despite the lack of good evidence showing the superiority of medicalization to psychotherapy—and despite European health authorities’ recognizing this paucity of evidence and recommending psychotherapy as the first line of treatment.
It is becoming increasingly clear, even to left-of-center Americans, that activists have hijacked the scientific process and that some measure of regulation and accountability is badly needed in pediatric medicine. Though many remain understandably skeptical of Republican bans, the case for banning rather than restricting access to “gender-affirming” drugs and surgeries becomes harder to dismiss as more evidence emerges that those practicing these interventions are unwilling or unable to regulate themselves.
Until the American medical establishment comes to its senses, lawmakers have no choice but to do their best to protect the health of children and teenagers—even from those sworn to “do no harm.”
* Editor’s note: The author originally wrote, “remained 19 times more likely,” and wants to clarify that the study’s design makes it impossible to know what the suicide rate would have been without the sex-change procedures; accordingly, the possibility exists that the suicide rate would have been even higher than 19 times that of matched controls if not for the sex-change procedures.
Photo by Julia Robinson for The Washington Post via Getty