By now only the most committed ideologues will have failed to notice that pediatric “gender affirming” care—the practice of using puberty blockers, cross-sex hormone injections, and mastectomies to treat gender dysphoria in minors—is not always in a child’s best interests. Recently, notable proponents and practitioners of affirmative therapy have begun publicly to express reservations about its use.
Last November, the Washington Post published an op-ed by Laura Edwards-Leeper, founder of the first American clinic to offer medical transition to minors, and Erica Anderson, a transgender psychologist, titled “The Mental Health Establishment is Failing Trans Kids.” Edwards-Leeper and Anderson raise alarm bells about the “skyrocketing” number of teens seeking hormones and the clinicians who provide them with “sloppy, dangerous care” out of misguided compassion. Though the authors still “enthusiastically support” the affirmative model, they express concern over a political climate that treats any denial of hormones on the basis of a child’s “trans self-diagnosis” as cruel and bigoted.
Edwards-Leeper and Anderson had apparently first contacted the New York Times, but the newspaper deemed their submission not newsworthy. Two of the nation’s top experts and leading advocates of affirmative care believe that hundreds if not thousands of American children are likely being fast-tracked to unnecessary mastectomies and future infertility, but the Times did not think this significant enough to deserve the attention of its readers.
Is the newspaper having second thoughts? In January of this year, it took the unusual step of conceding that a debate exists among medical professionals dedicated to the mental health of gender-distressed youth over the merits of “affirmative” care. This marks a welcome departure from its previous approach. Yet the article continues to make claims that, if not outright false, are highly misleading without the appropriate context and qualifications. Four stand out in particular.
First is the identification of those seeking hormones as “transgender teenagers.” The problem with this terminology is that whether gender-distressed minors who seek hormones are in fact transgender is precisely what is at issue. Just as not all people who self-identify as transgender have gender dysphoria (severe distress associated with discomfort in one’s sex), not all who have (or appear to have) gender dysphoria are transgender. Even the Dutch experts at the Free University in Amsterdam who pioneered pediatric transition recognized that “80 to 95 percent” of prepubertal children who exhibit dysphoric behavior will desist on their own by puberty. Most, in fact, will come out gay or lesbian, a fact that has led researchers to conclude that cross-gender behavior is a far better early predictor of same-sex attraction than of being “born in the wrong body.”
In developing its protocol, the Dutch team recognized the risk of false positives and the ethical dilemmas involved in allowing immature individuals to make potentially life-altering decisions. It recommended careful vetting—including “lengthy” screenings for psychological comorbidities such as a history of sexual trauma or autism, which is unusually common among gender-dysphoric youth and tends to coincide with rigid thinking and unrelenting obsessions. In addition, candidates’ parents would have to consent to and be supportive of the medical transition process, not just for legal reasons but because parents can supply the clinician with vital information about the changing needs of their child.
It is this emphasis on the need for caution and gatekeeping that the Times characterizes as the more conservative—and presumably less “affirming”—approach. On the other side are mental-health professionals such as Alex Keuroghlian, the psychiatrist who directs the Massachusetts General Hospital Psychiatry Gender Identity Program—who argue against any screening requirements for teenagers seeking hormones. Over the past two decades in the United States, pediatric gender transition has evolved well beyond, and even against, the original intentions of the Dutch experts. American-style affirmative care has taken on all the trappings of our therapeutic-oriented, pharmaceutical-driven, individualistic culture.
Bay Area psychologist Diane Ehrensaft, another Times interviewee and opponent of prescreening, qualifies as the face of American-style gender affirmation. She argues that children as young as three “know who they are,” that adults should “follow their lead,” that parents who refuse to do so might not love their children enough, and that clinicians should perform a gatekeeping function only in the most extreme of circumstances. When parents raise concerns over the loss of their child’s future fertility, she insists, they are simply manifesting a selfish desire for grandchildren. Ehrensaft agrees that gender dysphoria may coincide with other mental-health issues, such as past sexual trauma or autism, but she believes that these should not be an obstacle to gender transition. In fact, she suggests that transition may be a “treatment” for these problems. Gender socialization, for Ehrensaft, is largely a process in which the authentic voice of nature within each of us is suppressed under the weight of external—and thus illegitimate—authority.
Until the 2010s, pediatric referrals to gender clinics were extremely rare. Most were for natal males before or at the cusp of puberty. As transgender identity became a subject of mainstream fascination, clinics across the West began seeing a dramatic change in the number of referrals as well as in the age and sex ratios of their patient populations. In the U.K., the National Health Service’s Gender Identity Development Service recorded a 4,000 percent increase in referrals between 2009 and 2018, with three-quarters being teenage girls.
In the United States, data are unfortunately harder to come by—a serious problem in itself—but clinicians like the authors of the Washington Post piece who practice affirming care have given firsthand reports of a massive influx of teenage-patient referrals, also heavily favoring girls. Girls who transition and later regret it regularly comment on the bewildering ease with which they got hormones. One de-transitioner recently wrote that she was given testosterone on her first visit to a Planned Parenthood. There is surely irony in the fact that an organization that purports to be a bastion of “women’s health” is helping distressed girls escape womanhood.
Advocates of affirmative care argue that the explosion in teenagers opting for transition is the result of warming social attitudes toward transgender people. As trans people become more socially visible and accepted, the argument goes, more young people are finding it acceptable to come out as trans. But if society now has a more flexible view of gender variance and expression, shouldn’t the number of those seeking medical transition—which is expensive, risky, and painful—go down rather than up? If the body has nothing to do with one’s gender, why change it? As clinicians who work with gender-distressed people know, those who opt for medical transition do so because they experience visceral aversion to their bodies, not because they reject prevailing gender norms. Is the implication therefore that as society becomes more welcoming to transgender people, more children will come to hate their bodies and agree to sacrifice their future fertility and sexual function? If so, is this progress?
Feminists and gay rights advocates argue that medical-transition culture is driven by decreasing tolerance for gender non-conformity and more rigid policing of gender boundaries. Boys (or girls) who do feminine (or masculine) things are no longer non-conforming boys (or girls), but potentially girls (or boys) “trapped in the wrong body.” The Diagnostic and Statistical Manual of Mental Disorders explicitly lists having desires and preferences for behaviors “stereotypically” associated with the other sex as signs of gender dysphoria. This is why for some gay rights advocates, gender-affirming therapy is really gay conversion therapy in a new and seemingly more progressive guise.
Better explanations exist for the surge in referrals. Hormone therapy promises adolescents a technological quick fix for the self-doubts and anxieties that accompany puberty, which is when most kids begin to experience gender-related distress. Declaring a transgender identity can bring immediate positive attention to those who feel dismissed or ignored. Clinicians have noted that it can be a symptom of unresolved depression and anxiety or a response to past sexual abuse. In a 2018 article, Brown University’s Lisa Littman found that girls were coming out as trans boys in clusters at 70 times the rate one would expect, given the prevalence of gender dysphoria in the general population. In the typical scenario, these girls declared themselves trans boys after a prolonged period of social isolation and exposure to social media. Abigail Shrier, who has devoted a book to this phenomenon, finds that the primary factor behind girls seeking hormones and mastectomies is “social contagion.”
In short, gender dysphoria is a real and documented condition, but to believe, as gender-affirming “experts” do, that a “consistent, persistent, and insistent” declaration of cross-gender identity is proof of having been “assigned” the wrong sex at birth requires either breathtaking naivete or deep immersion in ideology (assuming there is a difference between the two). One must be willing to ignore just about everything that we have come to know about childhood development.
There is another simple, overlooked truth here: the more you encourage a certain behavior, the more of that behavior you will get. If you tolerate crime, you’ll see it rise. If you condone open-air drug markets, they will proliferate. If you implement affirmative action for “people of color,” sophisticated white people will find ever more ways to enlist themselves into that category. And if you celebrate transgender identity while vilifying gender “conformity” and making hormones easily accessible, you’ll get more teenage girls who interpret their adolescent distress as trans-ness and demand hormones and mastectomies. The Times’s use of the term “transgender teenagers” to describe all those seeking medical transition obscures the fact—recognized by all but the most radical affirmers—that it is very difficult for pediatric clinicians to distinguish genuine cases of lifelong dysphoria from temporary (if acute) gender distress.
This brings us to the Times’s second misleading claim, that de-transition is “thought to be quite rare.” By whom, exactly, it is so thought, the Times doesn’t say.
Whether de-transition is rare depends, of course, on how one defines the phenomenon and which patient populations one includes within its scope. Consider, for example, that transgender advocates now enjoin parents, teachers, and clinicians to “affirm” children as young as three who reject the sex they were “assigned at birth.” Given the documented evidence that the vast majority of prepubertal children with dysphoric symptoms will feel comfortable in their bodies by puberty, by activists’ own definition most transgender children de-transition.
“Rapid onset gender dysphoria”—Littman’s term for what she was observing in adolescent girls—is a new phenomenon, and it will take some years before researchers have a sense of how many later regretted and tried to undo their decision. But given the growth in online forums for the wrongly transitioned and the sociological realities against which young people are making such decisions, that number is growing. It is only a matter of time before the wrongly transitioned take legal action.
The Times’s third misleading claim is that puberty blockers are “reversible” interventions. Gonadotropin-releasing hormones, or “GnRH analogues”—so called because they stimulate the pituitary gland responsible for pubertal processes without actually triggering these processes—were first used in children who experienced early-onset, “precocious” puberty. The idea was to delay puberty until the child was more or less at the same developmental stage as his or her peers, the assumption being that puberty is a complex and dynamic psychosocial process, not just a biological one. In the 1990s, clinicians in the Netherlands pioneered an off-label use for this drug in youth with gender dysphoria. They argued that puberty blockers were “fully reversible” and created a “window of time” for users to reflect on their identity before deciding—autonomously, one may presume—on next steps. Mental-health outcomes would improve for those with genuine gender dysphoria if they could “pass” as the other sex. Especially for natal males, bypassing puberty would make physical transition technically easier, less risky (with less need for invasive surgeries later), and more affordable.
Yet the studies on which the reversibility claim is based were done on precocious puberty, not gender dysphoria. These are two very different clinical conditions with different etiologies and developmental trajectories; any inference from one to the other is a matter of speculation. Puberty blockers do tend to bring immediate relief for many teenagers who take them, but their longer-term effects are unknown. Some evidence links drugs like Lupron to developmental impairments in cognitive ability and bone density.
No less important, puberty suppression may itself contribute to the persistence of gender dysphoria. In 2020, a U.K. court was surprised to discover that the NHS’s Tavistock Clinic, which refers minors for hormone therapy, had kept no record of the desistence-versus-persistence rates of minors who received puberty blockers. Relying on what it said was the only peer-reviewed study on the matter, the court found that 98 percent of children who begin puberty blockers go on to cross-sex hormones, which are known to cause infertility, sexual dysfunction, and other long-term health risks, including increased likelihood of cancer and hypertension. The court’s skepticism of the ability of minors to give consent to puberty suppression was subsequently overturned, albeit in a decision that dealt more with the propriety of judges interfering with the discretion of clinicians than with the underlying medical debate over pediatric transition. Still, the initial court’s instinct was sound: either clinicians have the uncanny ability to pick out the truly dysphoric from among all children presenting with dysphoric-like behaviors, or, what is more likely, pubertal suppression “puts the young person on an inexorable path to taking [cross-sex hormones].”
How do these insights connect to affirmative therapy’s deeper philosophical beliefs? American affirmers define transgenderism as nonconformity with social expectations and “cisgenderism” as conformity with those expectations. They regard nonconformity not just as normal and healthy, but in some sense as morally superior to and more socially valuable than conformity. If puberty blockers are “fully reversible interventions,” then wouldn’t the logic of their belief system dictate that all children take them? If they pose no harm and offer at least the possibility of a better, more authentic life, why allow the body’s biological processes to dictate one’s gendered fate? The elimination of gatekeeping turns out to be the result not of medical insight but of philosophical assumptions about what the good life is and what makes for a just society.
The “window of time” thesis adopted by advocates illustrates what happens when academic theories begin to dominate thinking about human sexual development. Adolescents are not islands. They are acutely attuned to the physical development of their peers and how it compares with their own. Sexual development is a dynamic process involving the complex interplay of psychological, social, and physical forces. By the time he reaches age 15, a boy who has suppressed his puberty will look and sound more like girls than other boys his age. A girl who has suppressed her puberty will be as flat-chested as the boys and will not have experienced menstruation like the rest of her female peers. Both will have insisted that others refer to them as members of their claimed gender identity. Depending on where they live and how plugged-in they are to online trans forums, both may have been celebrated as courageous by adults and other teenagers. And both will doubtless feel profound embarrassment to admit that they were wrong in their gender self-declaration, especially to those who stood up for them.
But the “window of time” hypothesis fits nicely with the hyper-individualistic bent of the gender identity movement, which understands sex (or gender) as a private experience or feeling wholly independent of the reproductive capacities and erotic longings that make humans interconnected and interdependent beings. The natural course of the body’s development is seen as having no ontological weight of its own, as taking no priority over the feelings and desires of an authentic self. As the World Professional Association for Transgender Health, whose decision to revise its Standards of Care provided the occasion for the Times piece, puts it, “Neither puberty suppression nor allowing puberty to occur is a neutral choice.” Only someone accustomed to thinking about human life in these terms can believe that puberty blockers place their users in a state of autonomy-enhancing gender purgatory. Once again, assertions by affirmative-care advocates about medicine and mental health are grounded in deeper, often unexamined, moral and metaphysical beliefs.
The political climate that even committed gender-affirmers like Edwards-Leeper and Anderson now say is hostile to ethical, evidence-based treatment did not emerge out of nowhere. It was created by activists (inside and outside of the medical establishment) and sympathetic journalists at places like the New York Times who have fueled a moral panic over identity. A newly published paper by Swedish researchers sympathetic to affirmative treatment illustrates how the media shape the realities of pediatric medical transition. Comparing referral rates before and after the release of a Swedish documentary The Trans Train and Teenage Girls, which highlights stories of transition regret and raises concerns “about whether gender-conforming treatments are based on sufficient evidence,” the authors found that referrals dropped by between one-quarter and one-third. They conclude that “negative” media coverage of pediatric transition—by which they mean coverage that discusses the risks and drawbacks of transition—should be limited. But if Edwards-Leeper and Anderson are right, it should be increased.
By far the most potent argument for affirmative care has been that failure to affirm a teen’s gender identity will cause him or her to commit suicide. Parents of gender-distressed teenagers have been warned, “You can either have a trans child or a dead child.” Those who question the merits of affirmative therapy, its supporters argue, are responsible for kids killing themselves. In its article, the Times cites the CDC on transgender suicidality and mentions that “preliminary studies have suggested that adolescents who receive drug treatments to affirm their gender identity have improved mental health and well-being.” Repeating the affirmation-or-suicide mantra is the Times’ fourth misleading claim.
Rates of suicidal ideation, attempt, and completion are indeed alarmingly high for transgender people: more than one in three, according to some reports. The problem is one that parents, medical experts, and policymakers cannot afford to ignore. But the relevant question is whether failure to affirm a child’s gender identity is causing this troubling trend. Existing studies, including by leading advocates of affirmative therapy, show that suicidality and gender dysphoria are co-occurring phenomena, but they fall short of being able to draw any definitive causal links.
A common flaw of these studies is that they compare gender-dysphoric adolescents, who almost always present with other mental-health problems like anxiety and depression, to “cisgender” adolescents in general, rather than to non-gender-dysphoric adolescents with similar mental-health profiles. When the latter are used as a point of comparison, disparities in suicidality go down dramatically. In a 2020 paper, the Dutch pioneers of affirmative therapy themselves noted that “adolescents diagnosed with [gender dysphoria] have, on average, a greater number of behavioral and emotional problems in general when compared to non-referred adolescents, but relatively similar to adolescents seen clinically for other types of mental health issues.” Numerous other studies over the past five years have reached a similar conclusion.
If teenagers who undergo affirmative therapy are less likely to contemplate or attempt suicide, that could be because affirmative therapy coincides with other forms of mental-health intervention and support that address more serious risk factors. The point is that researchers aren’t sure what is causing the high rates of self-harm among gender-distressed teens and are far from reaching a consensus on when, if ever, affirmative therapy is an appropriate response. For its insinuation that affirmation prevents suicide, the Times relies on research almost a decade old by the Dutch experts while ignoring their more recent and nuanced findings.
Like other proponents of affirmative therapy (including its Dutch inventors) who are trying to put the brakes on what is shaping up to be a serious medical scandal, Edwards-Leeper and Anderson deserve credit for their courage. But it would be a mistake for critics of affirmative therapy to seize on these instances of whistle-blowing without regard for the delicate politics of gender medicine. A more prudent approach would see proponents and opponents of affirmative therapy agreeing to limit its use only to those rare cases in which, after prolonged and rigorous psychological vetting in cooperation with parents, no other course of treatment seems viable. That alone would greatly reduce the workload of the transition-industrial complex. Opponents of affirmative therapy should do their best to slow the proliferation of victims from the medical establishment’s misguided compassion.
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