Meredithe McNamara is arguably the leading physician advocating for on-demand availability of medical “gender transition” for youth in the United States. An adolescent medicine physician and assistant professor of pediatrics at the Yale School of Medicine, McNamara has become a top expert witness in lawsuits challenging state age-minimum laws. She has testified before Congress, given television interviews, and published academic articles in support of “gender-affirming care” for minors.
The young, charismatic, and polished McNamara appeared seemingly out of nowhere about two years ago, just in time to serve as a well-paid expert witness in lawsuits against states seeking to regulate the Wild West of gender medicine by imposing age minimums. Her ascent has relied on three rungs. First, she emphasizes her clinical experiencing in working with trans-identifying youth and treating them for their gender dysphoria. McNamara casts medical professionals who typically do not practice “gender-affirming care,” or who believe it is not well-supported by evidence, as incompetents lacking the relevant clinical experience to opine on such matters. Second, McNamara claims to be an expert in “scientific disinformation” when it comes to gender medicine research and principles of evidence-based medicine (EBM). From this perch, she launches ad hominem attacks on critics. To help her achieve these two goals, McNamara employs a third tactic: enlisting the reputation of her employer, Yale University, to bolster her credibility. McNamara is cofounder of Yale’s Integrity Project, an Orwellian-named initiative at Yale Law School whose mission is to bridge “the legal and medical communities” in pursuit of “health justice.”
McNamara’s name recently came to light again as lead author of a new white paper from the Integrity Project titled “An Evidence-Based Critique of ‘The Cass Review’ on Gender-Affirming Care for Adolescent Gender Dysphoria.” The paper takes aim at the findings of a four-year review process commissioned by the National Health Service of England to examine and restructure care for youth who experience gender dysphoria. The Cass Review concluded that the practice of youth gender medicine is based on remarkably weak evidence, and that it has operated outside the scientific and ethical norms of medicine. The Review’s findings have been endorsed by both major U.K. political parties, with the Labour government agreeing that puberty blockers should be banned for routine use in minors with gender dysphoria.
Serving as expert witness can be financially lucrative, but it also has a potential downside: experts must testify under oath. On April 4, as part of her role as expert witness in Boe v. Marshall, a lawsuit challenging Alabama’s age-restriction law, McNamara submitted to an eight-hour deposition. The transcript of that deposition reveals that McNamara’s many public and under-oath statements about her clinical experience are fundamentally misleading, if not outright false—and even perjurious.
As it turns out, McNamara admits that she does not perform or provide any of the “gender-affirming care” that is implicated in these state laws. She admitted that she “generally” does not perform diagnoses or assessments for gender dysphoria in minors and has never prescribed puberty blockers for this purpose (though she has prescribed them for other conditions). She has never been appointed as a member of any gender clinic. Since arriving at Yale School of Medicine in 2021, McNamara referred a total of two minors to its pediatric gender clinic. Neither of these patients had undergone medical “transition” as of the time of her deposition; one had not even been seen. McNamara also confessed that she had no idea how patients fared after referral to the Yale gender clinic. She did not know what percentage of patients referred to that clinic end up on a medical pathway or how many ultimately desist or detransition. And she has no firsthand knowledge of how that clinic operates—for instance, she admitted that she has never reviewed the informed-consent documents that are given to parents, so it is hard to see how she could know what kind of information is conveyed to parents as part of the informed-consent process, and whether that information is accurate or comprehensive.
In other words, McNamara is guilty of the very flaw she ascribes to her critics. If only clinicians who practice and have firsthand knowledge of “gender-affirming care” are experts on such care, as McNamara and her allies have said or implied, then by her own definition she is no expert.
The deposition also revealed McNamara’s lack of familiarity with the research in the field and with basic concepts of evidence-based medicine (e.g., she confessed to not knowing what an intellectual conflict of interest is). These are troubling revelations, considering her self-description as an expert in “scientific disinformation,” and they will have to be addressed in another article.
McNamara’s public and under-oath statements in which she says or strongly implies that she treats trans-identified or gender dysphoric minors with “gender-affirming care” are well-documented.
Consider:
- In testimony before the Florida medical boards in 2022, McNamara said that she “provide[s] clinical care for youth ages 12 to 25, which includes transgender and gender expansive youth.” When asked by one of the medical board members about her experience referring minors for gender surgery, McNamara responded: “I’ve never referred a patient for surgery because a patient has never desired surgery who[m] I’ve cared for. It’s all about what the patients wants, [and] how that fits into the informed consent model . . . None of my patients had desired that surgery at that moment in time. We discuss [it] openly.”
- In an interview with Chris Cuomo on NewsNation in December 2022, McNamara described herself as “deeply ingrained in this professional community.” When Cuomo asked how she manages the concerns of parents, McNamara responded that she “invite[s] parents to be a part of every single conversation in every stage of it . . . And, we say . . . one thing that I like to say is, ‘what does it cost you, to just affirm who they say they are?’”
- A 2022 report McNamara coauthored with colleagues at Yale School of Medicine and the University of Texas Southwestern introduced the authors as medical professionals who “all treat transgender children and adolescents in daily clinical practice” (emphasis added). Later in the report, when the authors dispute the credibility of the Society for Evidence-Based Gender Medicine (SEGM), McNamara and her coauthors emphasize that “none [of SEGM’s members] currently treat patients in a recognized gender clinic.”
- In a medical journal article titled “Combatting Scientific Disinformation on Gender-Affirming Care,” McNamara and her coauthors characterize themselves this way: “All [are] clinicians [who] treat transgender youth and practice in jurisdictions of GAC bans.”
- In the Georgia lawsuit Koe v. Noggle, in which she is an expert witness, McNamara declares in her expert report: “I provide full spectrum clinical care to youth aged 12-25 years, which includes youth experiencing gender dysphoria.”
- In a Boston Globe op-ed from March, McNamara called herself “a pediatrician who serves youth with gender dysphoria” and “who cares for transgender youth.” She writes that “one thing in common that I see universally in the care of transgender youth” is that “decisions on whether, when, and how to pursue medical interventions are slow-moving, rigorous, and individualized.”
Considered collectively, these statements suggest that McNamara not only sees minor patients with gender dysphoria or trans identities but also works with them on their gender issues and plays an active and perhaps even supervisory role in their “gender-affirming” medical treatments. The statements also suggest that McNamara has extensive experience doing so. McNamara has entered this debate in the first place to defend medical interventions, which are being challenged. The most that can be said about McNamara’s clinical experience is that, perhaps due to her proximity to the Yale gender clinic, she sees youth with diagnosed gender dysphoria but doesn’t herself diagnose or treat them for that condition. Perhaps McNamara believes that being “socially affirming” (using a patient’s preferred name and pronouns) is part of “gender-affirming care.” But that is not what is at issue in these laws and lawsuits, and that is not the issue around which she has formed her national role as an experienced expert. Thus, she appears to have misled the public, the medical profession, and judges about her own clinical experience.
McNamara’s misrepresentation of her clinical experience suggests a conundrum. In EBM, having direct clinical experience in an area of medical treatment is typically seen as a conflict of interest (intellectual and potentially financial). When the question is how to apply a standard of care to a particular patient, clinical experience is obviously relevant; but when the question is whether a standard of care is evidence-based, clinical experience introduces bias. Considering that the central issue in lawsuits over youth gender medicine is whether sufficient evidence exists to justify this clinical approach, why would McNamara misrepresent her own experience? Why not state honestly that she isn’t personally involved in this area of care, an admission that would reduce the potential for conflict of interest and bias?
The answer has much to do with the nature of the U.S. legal system. Americans are known for turning every political and policy question into a legal one; litigiousness is an enduring part of American political culture. But because judges have busy schedules and lack the scientific competence to second-guess expert witnesses, especially on highly technical matters such as gender medicine research and evidence-based medicine, they are inclined to use proxies to decide who among the competing experts is a more credible source of knowledge.
In EBM, clinicians with personal involvement in an area of treatment whose evidence base is at issue are said to have conflicts of interest. These conflicts can be financial (the clinicians derive payment from administering the treatment) or intellectual (the clinicians have published articles in support of the treatment or tethered their professional reputation to them by advocating for them in public). But under Rule 702 of the Federal Rules of Evidence, which governs the admissibility testimony by expert witnesses (and the equivalents in most state courts), having “experience” can qualify one as an expert in the eyes of a court. U.S. judges are thus inclined to see personal involvement not as a source of bias but of credibility.
This problem comes up in litigation over youth gender medicine. In the initial phase of the Boe litigation, for instance, Judge Liles Burke, a Donald Trump-appointed federal judge, gave “very little weight” to the testimony of Alabama’s expert witness, James Cantor, a Canada-based psychologist with deep knowledge of the history and research of youth gender medicine. Cantor, the judge explained, “had never provided care to a transgender minor under the age of sixteen; . . . had never diagnosed a child or adolescent with gender dysphoria; . . . had never treated a child or adolescent for gender dysphoria; [and] had no personal experience monitoring patients receiving transitioning medications.”
Compare this with NHS England’s justification for appointing Hilary Cass to lead its review of the Gender Identity Development Service. Cass was appointed not despite but precisely because she was “a senior clinician with no prior involvement or fixed views in this area.” In other words, NHSE, likely recognizing the relevance of intellectual conflicts of interest (a concept McNamara admitted she was not familiar with), was trying to minimize the risk of bias that comes from such conflicts.
McNamara seems to have absorbed the message. In her white paper criticizing the Cass Review, she and her coauthors boast of having “86 years of experience in caring for more than 4800 transgender youth and [of] publish[ing] 278 peer-reviewed studies, 168 of which are in the field of gender-affirming care.” This stands in contrast, they say, to “[m]ost of the Review’s known contributors,” who “have neither research nor clinical experience in transgender healthcare.” McNamara and her coauthors write, “Expertise is not considered bias in any other realm of science or medicine, and it should not be here.” (The issue is not whether “expertise” is bias but whether personal involvement with treatment is bias.)
This example illustrates the quandary McNamara finds herself in. To win lawsuits and perform her duty as a paid expert witness, she must misrepresent bedrock EBM principles, on the assumption that this will be more persuasive to judges. If judges had a better understanding of EBM principles to begin with, or if they interpreted “experience” in Rule 702 to mean experience in evidence evaluation as opposed to direct clinical experience, perhaps McNamara would have more of an incentive to tell the truth about her experience.
The fundamental nature of McNamara’s role as a legal advocate rather than an EBM expert also explains why she appears to have improperly used Yale’s name to confer further credibility on her white paper. On July 11, almost two weeks after the paper came out, a disclaimer appeared in it notifying readers that the views expressed were the authors’ own and did not reflect the official views of Yale. McNamara conveniently forgot to add the disclaimer when the paper first appeared and when she submitted it into evidence in Boe. Despite the added disclaimer (mandatory in such circumstances), advocates of “gender-affirming care” in the U.S. and abroad continue to refer to the critique of the Cass Review by “the world-class Yale School of Medicine,” though Yale’s Integrity Project is actually housed at the law school. McNamara, it’s not unreasonable to think, hoped for this outcome.
The argument that only practitioners of “gender-affirming care” can legitimately opine on such matters is, of course, a No True Scotsman fallacy. Clinicians who believe “gender-affirming care” lacks an appropriate evidence base or ethical framework will almost certainly not practice it themselves. Gender medicine activists’ definition of “expertise” conveniently confers that title only on clinicians who happen to agree with them. U.S. judges may be waking up to this problem, but it’s still a long road ahead. For now, it is an expedient fallacy for hired legal guns like McNamara, who use medical credentials and institutional affiliation as a cover for attacking their more cautious and scientific-minded critics—expedient, that is, until the inevitable moment of deposition arrives, and the deposing attorney comes well-prepared.
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