RUTHFULLY YOURS

The United States has become the world’s most adamant promoter of what is called “gender-affirming care” for children and adolescents who identify as being other than their sex. This approach ranges from “social affirmation” (the use of preferred pronouns, for example) and “medical affirmation” such as puberty blocking to radical “surgical affirmation,” meaning mastectomies, facial feminization or masculinization, cosmetic procedures, and, in a few cases, even genital removal and refashioning.

Beginning to “transition” kids while they are still immature remains intensely controversial. But the increasingly woke medical establishment claims that the gender-affirming approach is “settled science” and the only efficacious approach to treating these children. “Protecting Transgender Health and Challenging Science Denialism in Policy,” a recent column published in the New England Journal of Medicine, denigrated legislative efforts to restrict medical and surgical affirmation as “science denialism”:

A virulent brand of science denialism is emerging in the U.S. legal system, as states enact bans on gender-affirming health care. Misused clinical research and disinformation have provided legal cover for bans on essential treatments for transgender and gender-expansive (TGE) people.

Corporate media echo this view, ubiquitously labeling such legislation as “anti-LGBT” or “transphobic,” and stories generally describe the science behind gender-affirming care as uncontroversial. Even more potently, the Biden administration is all-in for the gender-affirming approach. United States Assisted Secretary for Health Rachel Levine — who is a transitioned transgender person — recently asserted that “there is no argument among medical professionals — pediatricians, pediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, etc. — about the value and the importance of gender-affirming care.”

This unnuanced view has also been advocated in litigation by the Department of Justice. For example, the DOJ recently intervened in a lawsuit seeking to invalidate a new Tennessee law that bans medical and surgical gender affirmation. In its legal brief, the DOJ argued,

Studies indicate a general improvement in the lives of transgender adolescents who, following careful assessment, receive medically necessary gender-affirming medical treatment. Conversely, allowing irreversible puberty to progress in adolescents who experience gender dysphoria may have immediate and lifelong harmful effects for the transgender young person.

(National Review’s Dan McLaughlin recently provided an in-depth analysis of the DOJ’s legal intervention.)

The Pushback against Gender-Affirming Care

That all sounds sincere and convincing — until you dig an inch beneath the surface and discover countervailing facts that these gender ideologues somehow forget to mention. It turns out that countries such as Great Britain, Sweden, France, and Finland — not exactly Bible Belt nations—have disembarked from the gender-affirming train. Why? According to these nations’ respective health authorities, the scientific data do not unequivocally support the gender-affirming approach, gender incongruence in youth is often transitory, and, further, medical interventions such as puberty-blocking and surgeries may cause more harm than good.

Sweden’s national board of health just updated its guidelines to reject the kind of blanket gender-affirming approach advocated by the Biden administration, stating:

Several factors have pointed toward increased caution in offering hormonal and surgical treatment: insufficient scientific evidence, a yet-to-be-explained increase in the number of people being diagnosed, especially 13–17 years old and with registered sex female at birth, less uniform experience-based knowledge among participating experts than in 2015, and the documented prevalence of de-transition. [Google translation, italics are mine.]

(More on the “detransition” phenomenon below.)

A recent British Medical Journal analysis similarly noted that the evidence supporting gender-affirming care was “low or very low,” further reporting that “without an objective diagnostic test,” the “demand for services has led to a ‘perfunctory informed consent process’ . . . in spite of two key uncertainties: the long-term impacts of treatment and whether a young person will persist in their gender identity.”

A New Study Casts More Doubt on Gender-Affirming Care

In the midst of this growing unease about gender affirmation, an important peer-reviewed analysis of relevant studies (93 citations) about the effects of transitioning — both in youth and adults — was just published in the professional journal Current Sexual Health Reports. Authored by Case Western Reserve Clinical Professor of Psychiatry Stephen B. Levine and E. Abbruzzese, a scholar at the Society for Evidence-Based Gender Medicine, the paper details the paucity of reliable data establishing the benefits of beginning gender transitioning during a patient’s youth. The authors also outline potential significant harms.

The paper doesn’t limit its analysis to the care of children. Adult gender transitions have been studied for decades, so, as a way of extrapolating potential outcomes for youth, Levine and Abbruzzese review the literature to see what benefits or harms have accrued among patients who have previously transitioned.

The news is not good: “Long-term data do not show that hormonal and surgical transitions result in lasting mental health improvements in transgender-identified individuals, and some evidence even suggests the possibility of treatment-associated harms.” They continue (citation numbers omitted throughout):

A well-known 30-year Swedish follow-up study compared medically transitioned individuals to cisgender age-matched peers on key measures of morbidity and mortality. The study found sharply elevated rates of suicide among transitioned adults (19 times higher than controls overall, and 40 times higher for female-to-male individuals) and significantly elevated all-cause morbidity and mortality, with survival curves between transitioned adults and their cisgender matched controls markedly diverging at the 10-year mark and beyond.

A more recent Swedish study “also failed to find that either hormones or surgery improved long-term mental health outcomes of gender-dysphoric adults.” A long-term Dutch study “concluded that ‘suicide death risk is higher in trans people than in the general population’ and that suicide deaths occurred during every stage of transitioning.” Moreover, “two recent U.S. based publications highlighted high rates of mental health problems including depression, anxiety, substance abuse disorder suicidality, cardiovascular disease, obesity, cancer, and sexually transmitted infections such as HIV, HPV, syphilis, and hepatitis C.”

Levine and Abbruzzese note that gender-affirming care in youth is designed to improve on these adverse outcomes by preventing the development of secondary sex characteristics and/or permitting the physicality of the gender-dysphoric child to be surgically refashioned to match their subjectively identified gender at an earlier age. But at what potential cost?

Here are examples from each danger category associated with medical gender transition: sexual dysfunction and infertility; shortened lifespan due to increased medical morbidity; difficulties in romantic partnerships; substance abuse and addiction.

What about the hoped-for benefits? Contrary to what gender ideologues assert, at best, the jury is still out:

Unlike the risks of transition-associated harms that have been demonstrated, avoidance of future harms by undergoing a medical transition in adolescence remains at best an unproven theory. Blocking puberty at Tanner stage 2 not only removes the possibility of fertility preservation but also greatly complicates future genital surgeries due to insufficient tissue.

Not only that, but patient satisfaction from gender-affirming procedures and interventions may not last:

Initially, a high level of satisfaction is expected as desired changes such as softened skin or, conversely, facial hair appear. Surgery can further improve appearance and satisfaction, although its rate of complications is significant, and it does not clearly improve mental health. However, at some point, the interventions reach their limit. While the face, chest, and/or genitals can be surgically altered, overall skeletal size or hand size will continue to appear incongruent, and dysphoria may persist.

The authors also explore the “detransition” phenomenon, in which transgender patients seek to restore their appearance to match their sex. Most famously in this regard, a detransitioner named Chloe Cole has sued Kaiser Hospitals for blocking her puberty at age 13 and performing a double mastectomy at age 15. Now 18, Cole travels the country warning against the dangers of youth gender-affirming care.

Advocates for gender-affirming care claim that detransitioning is very rare, amounting to perhaps only 1 to 2 percent of transitioned patients. But Levine and Abbruzzese’s analysis found that statistic to be wildly understated:

Detransition has become much more visible in recent years. However, it was only recently that the rates of detransition began to be quantified. According to recent UK and US data, 10–30% of recently transitioned individuals detransition a few years after they initiated transition.

To say the least, these findings would seem to refute current gender-affirming orthodoxies. Curious as to why that might be, I reached out to Levine for his opinion on the reasons promoters of gender-affirming care, such as the American Academy of Pediatrics and the World Professional Association for Transgender Health (WPATH), work so hard to squelch open debate about this crucial issue. He replied: “The authors of these policies assume that medical/surgical transition is the best treatment possible. They cherry-pick studies that support their treatments and ignore or dismiss contrary ones as having poor methodologies.” Also, perhaps most relevantly, “they are financially invested in these treatments.”

I also asked Levine about the Biden administration’s attempt to define gender-affirming care “as an issue of civil rights.” He responded:

I think it is misinformed as it presumes that any trans identity is permanent, biologically caused, and helped by transition. It is not aware or caring about the unanswered questions, the medical and psychological harms, and the systematic review of evidence of five independent commissions, nor has it mentioned what is happening in Europe. . . . Their thinking is that a trans identity of any age should [receive] trans-affirmative care. This is political rhetoric. Science has to do its work without such powerful institutional sway.

So should government. But alas, the Biden administration remains curiously incurious about the mounting data that runs contrary to its ideological preferences.

The Levine/Abbruzzese study of studies does not prove — nor does it attempt to— that gender-affirming care offers no benefit to young patients. But when its findings are added to similar conclusions by health authorities in Sweden, the U.K., Finland, and France — as well as the British Medical Journal study quoted above — it is clear that the science on gender-affirming care is far from settled, and indeed, efforts by ideologues to push affirmation as the exclusive approach is not only unscientific, but ill-advised. At the very least, this heterodox perspective belongs at the center of our ongoing discussions about how to best care for anguished children who believe that their “true self” is other than their sex.