On March 31st, Joe Biden’s White House issued a lengthy “fact sheet” claiming that science has spoken in favour of puberty-blocking drugs—lifelong synthetic hormones for young people who identify as transgender or non-binary and seek medicalised gender change. What used to be called “sex-reassignment” is now the more seductive “gender-affirming care.” We also have the leader of the free world boldly “confirming the positive impact of gender-affirming care on youth mental health.”
“Confirming” is the new asserting, and the Biden-Harris administration is also “confirming that providing gender-affirming care is neither child maltreatment nor malpractice.” It’s a small step from confirming to enforcing, and so the federal Justice Department has written to state attorneys-general warning them that if they deny minors the benefits of gender-affirming medical science, they will fall afoul of constitutional and statutory guarantees of equality, not to mention funding rules tied to grants from Washington. The first state under federal fire is Alabama, where a new law would impose up to 10 years’ prison time on clinicians taking anyone under 19 on a medicalised gender journey. The White House is even taking the fight offshore, pledging to uphold trans health rights with its foreign policy and overseas aid programs.
Biden’s blizzard of initiatives was unleashed on Transgender Day of Visibility. Timing matters in politics, and Biden’s may be a little off. Americans are starting to get their first glimpse of gender medicine as an intensely contested field; it’s nowhere near settled science. For several years, big left-leaning media outlets have told a simple story in which the medicalised gender-affirming approach is lifesaving, at least for those kids who say they can’t live without it. It follows, we’re told, that any restriction is a suicidally dangerous denial of health care, there being supposedly no alternative to hormonal and sometimes surgical interventions.
But there was a story-rewriting change already underway back in 2015, when Barack Obama became the first president to name-check trans rights in a state-of-the-union address. The explosion in young people declaring themselves trans or non-binary was predictably celebrated as a plus for identity politics and proof of a more welcoming society. Less noticed by an increasingly woke media was a flip in the patient profile. For decades, it was a minuscule proportion of boys in early childhood who became severely distressed about their birth sex. The vast majority grew out of it, without medication, and many emerged as gay or bisexual. But sometime around 2015 (it varied country to country), teenage females became the patients typically being diagnosed with the bodily distress now known as gender dysphoria.
Thanks to experiments conducted in the 1990s at a famous Amsterdam clinic, there was the novel option of hormone-suppression drugs to fend off the unwanted onset of puberty. The soothing rationale was that trans teenagers would be spared distress, and granted time to consider whether or not they were ready to commit to lifelong, irreversible treatment with cross-sex hormones, possibly followed by surgery (such as a mastectomy). Known as the Dutch protocol, this three-stage treatment from puberty blockers to hormones and surgery has been promoted by clinicians in affluent cities around the world. America, for instance, went from having one specialised children’s hospital gender clinic in 2007 to more than 50 today.
With this expansion has come a new breed of aggressive and dogmatic trans activism. What these activists see as fragile progress in trans health has sparked a mobilization among a loose, below-the-radar coalition of dissident clinicians, parents, non-woke teachers and academics, new LGB groups subtracting the radical Q and the medicalised T, conservatives, Christians, old-school transsexuals, and young adult “detransitioners” who come to believe that gender drugs and surgery were harmful mistakes distracting them from other, often deeper issues in their lives.
The very fact that the White House is in strident “confirmation mode” points to its concern about this pushback, which has generally been under-reported except to such extent as it can be cast as transphobic. Acting on the right wing of America’s deeply polarised political landscape, Texas and Florida have been among the Republican states seeking to shut down medicalised gender change for teens, on the basis that the treatments are unproven, and minors are unable to give informed consent. And thanks mostly to independent journalism and social media, Americans are beginning to hear about an international trend towards caution in gender medicine, a shift that makes for a stark contrast with the cavalier operation of some US clinicians and the insouciance of virtue-signalling medical organisations.
For all its “affirming” and “confirming,” the White House fact sheet contains a discordant reference to an announcement by the National Institutes of Health in regard to more funding for research “to further develop the evidence base for improved standards of care.” Surely, it’s already the gold standard? Perhaps not. We are told that NIH “research priorities include a more thorough investigation and characterisation of the short- and long-term outcomes on physical and mental health associated with gender-affirming care.” But if everyone knows that gender-affirming care is lifesaving, a treatment with no serious rivals, who needs more thorough investigation? (I couldn’t find any substantive online detail about this potentially important research agenda, and my email to the NIH communications team went unanswered.)
While media outlets have bumped up transphobia headlines at the merest whisper of scepticism about “trans health care,” experts in Sweden, Finland, the United Kingdom, Australia, and New Zealand have carried out systematic reviews of the medical literature on hormonal and surgical treatment for youth gender dysphoria. Their findings are sometimes hedged with identity-politics sloganeering to forestall activist attacks, but the common conclusion is that the evidence base for these treatments is weak; very weak.
Sweden’s shift to caution appears to be the most complete to date. It involves prestigious and independent organisations, including the medical powerhouse of the Karolinska Institute, whose Nobel Assembly annually awards the Nobel Prize in Physiology or Medicine. And it’s a socially progressive country, meaning that even the most strident trans activists will struggle to portray its health authorities as Scandinavian sock puppets for America’s religious Right (which is, laughably, said to funnel secret money to gender-sceptical feminists in the UK, otherwise known to gender ideologues as “TERF Island,” after the acronym for the derogatory label, “Trans Exclusionary Radical Feminist”).
In May 2021, Sweden’s biggest youth gender clinic at the Astrid Lindgren Children’s Hospital in Stockholm—part of the Karolinska Institute complex—opted to stop routine use of puberty blockers and cross-sex hormones, confining them to strictly controlled clinical trials. The new Karolinska policy suggests that even within clinical trials it would be difficult for minors under the age of 16 to provide informed consent to these treatments, given their risks and uncertainties. This ranked as significant international news, though it went unreported by most mainstream media outlets in the English-speaking world.
In February, a similarly cautious approach became official government policy in Sweden, with the National Board of Health and Welfare urging “restraint” in the under-18 use of such hormone interventions, and warning that the risks appear to outweigh the benefits. A crucial factor was a systematic review of the evidence carried out by the independent Swedish Agency for Medical and Social Evaluation. Also significant was the fact that well-known medical experts—including one of the world’s leading neuropsychiatry researchers, Christopher Gillberg—were willing to go public with their concerns, and the Swedish media allowed them a platform. (In 2019, Gillberg told me he believed that unproven treatment of trans-identifying children was “possibly one of the greatest scandals in medical history.”)
Another Swedish ingredient, missing in many countries, is serious and sustained investigative journalism. The country’s high-profile television program Mission: Investigate has dedicated its multi-part Trans Train series to the troubling surge in gender-clinic caseloads, the promotion of medicalisation with misleading statistics on suicide risk, the emergence of regretful “detransitioners,” and children suffering harm and injury while on (supposedly safe) puberty blockers.
Finland does not cast as big an international shadow as Sweden in this area, but it is another well-educated, liberal country, and a leader in the youth-gender field. Whereas in Sweden, it seems to have been concerned hospital managers who were behind the Karolinska’s shift to caution, in Finland it was clinicians themselves. They were puzzled that hormonal treatment following the famous Dutch protocol was not giving their teens the mental-health benefits promised by the medical literature. They also detected the above-described and now widely noted flip in patient profiles: Most of the new referrals to Finland’s two specialist gender clinics were teenage girls, many with serious mental-health problems predating their gender issues. The success claimed by the Dutch has been attributed to screening out patients with major psychiatric problems, and transitioning only that minority of teens whose childhood gender dysphoria was still strong at puberty. This group, it was thought, would be more likely to have a stable trans identity; no responsible clinician wants patients to end up regretting irreversible changes to their bodies.
But the Finnish contribution goes further than highlighting the fact that the Dutch studies do not apply to the new wave of gender-clinic patients. In a recent podcast, Finnish psychiatrist Riittakerttu Kaltiala, a specialist in adolescent care before she set up the youth gender service at Tampere University Hospital, explained how the novelty of trans declarations by teenagers at first made health and education professionals hesitate to apply traditional interventions to deal with all the other problems facing these children—from mental-health issues to substance abuse to difficulties at school and with peer groups.
In its more activist mode, the gender-affirming approach implies that social, legal, and medical validation of a child’s trans identity can solve all these other problems. It may also serve to insist that a teen’s self-identification as trans should be taken as gospel, rather than possibly a changeable, crowd-sourced role created on the path to adulthood. In this way, the very idea of the “trans child” seems at odds with mainstream psychology, in that the celebration of a fixed identity pre-empts consideration of normal adolescent development.
(At first blush, a newly published US study would appear to confirm the proposition that we should trust even quite young children when they pronounce themselves trans or non-binary. According to survey data collected by the Trans Youth Project—and reported by the New York Times under the headline, “Few Transgender Children Change Their Minds After Five Years”—the vast majority of 317 US and Canadian kids who “socially transitioned” to a new trans identity at an average age of 6.5 were still living their “truth” five years later. But, as is typical of gender-affirming research, there was no comparison group. What would have been the outcome for a group of gender non-conforming kids who did not socially transition? The study may in truth confirm the view of Canadian psychologist Ken Zucker, a global authority on youth gender dysphoria, that early social transition may lock in the bodily distress that might otherwise resolve as a child grows into maturity, and thereby encourage children to stay on a path toward medicalisation.)
The Finns did their own research, and concluded that gender issues should not be invoked so as to overshadow the standard challenges of identity development facing teens, nor to put off tried and tested interventions to help them with non-gender-related problems, such as depression and peer-group difficulties. “Our message,” said Prof Kaltiala, “is that you shouldn’t think that simply changing gender will solve all these problems.” She also said Finland’s systematic review showed that “the evidence base for medical gender reassignment starting during developmental years [in adolescence] is minimal—actually non-existent.”
Finland’s 2020 national guidelines insist that psychiatric and developmental issues must be dealt with first, because they may predispose a child to gender distress, and so make it risky to assume that a teen’s trans identity is a stable foundation for irreversible medical intervention. Finland’s first-line treatment for gender dysphoria is now psychological and social support, backed up with exploratory therapy and mental-health treatment if needed.
This stands in dramatic contrast with the advice contained in the first gender-affirming treatment guideline specific to children and adolescents, issued in 2018 by the Royal Children’s Hospital (RCH) in Melbourne, Australia. The authors of this document, praised by the Lancet in an unsigned editorial, conclude that conditions such as depression, anxiety, and psychosis “should not necessarily prevent medical transition” (although the guideline concedes that associated treatment decisions would be rendered more complex).
Skyrocketing patient numbers at the RCH clinic were cited (and in fact understated) by the French National Academy of Medicine in its February 2022 statement alerting clinicians to the “epidemic-like” spread of gender dysphoria, with clusters diagnosed in school peer groups. The academy instructed parents to be vigilant for “the addictive role of excessive engagement with social media,” blaming this for “a very significant part” of the exponential increase in teen gender distress. French physicians were urged to take “the greatest caution” in the use of puberty blockers and cross-sex hormones, keeping in mind side-effects “such as the impact on growth, bone weakening, risk of sterility, emotional and intellectual consequences and, for girls, menopause-like symptoms.”
The academy’s intervention vindicates the 400-plus clinicians, academics, intellectuals, and lawyers who have put their names to an open letter issued by the gender watchdog group The Little Mermaid. The letter expresses deep misgivings about the rise of medicalised gender change, the capacity of minors to consent, and the attempt to shut down any sceptical debate as “transphobic.”
There is an extra cultural dimension in France, where some view the gender-affirming treatment model as an American globalised product that disrupts a more insightful French psychological tradition. But unlike Sweden and Finland, France has not yet adopted a new national policy of caution, as the National Academy of Medicine’s authority is moral, not legal. The outlook may be clearer once a state agency, the French National Authority for Health, finalises its update of the 2009 medico-legal guideline entitled, “The medical care of transsexualism.” Meanwhile, critical media coverage is sparse, and the trans rights lobby is strong. On April 29th, activists armed with a “Transphobia Kills” banner invaded a conference at the University of Geneva that featured discussion of a new book, The Manufacture of the Transgender Child (La Fabrique de l’enfant transgenre), written by two French psychoanalysts, Céline Masson and Caroline Eliacheff.
While Sweden’s new national policy of caution is the most comprehensive, the United Kingdom’s contribution may prove the most influential in the long run. The first serious international scrutiny of gender clinics began with litigation by Keira Bell, a young woman who had lived as a man under the name Quincy (after the musician Quincy Jones). She was prescribed puberty blockers at age 16 by the National Health Service’s Tavistock gender clinic in London. She began testosterone at 17, and had a double mastectomy at 20. She soon realised that none of this could make her a man; she stopped taking hormone drugs and “detransitioned.” Looking back, Bell recognised herself as a troubled girl incapable of giving informed consent to this medicalisation, and in need of exploratory psychotherapy that was not offered.
Bell’s initial courtroom success against the Tavistock clinic made headlines around the world. Many people had never before heard the term “detransitioner,” nor had any idea that young people alienated from their birth sex are considered mature enough to consent to chemical interruption of puberty, lifelong opposite-sex hormone drugs, or irreversible surgery. The 2020 judgment in Bell’s favour was later reversed by a higher court not because the Tavistock’s treatment model had somehow been vindicated, but because of demarcation rules governing the judicial, political, and medical spheres. On May 6th, the UK Supreme Court declined to hear a final appeal in Bell’s case, and so the focus now shifts to political accountability and clinical responsibility. Gender clinicians have been warned by senior judges that they must “take great care” before treatment decisions or risk medical-negligence claims.
In the governmental realm, Bell’s litigation has already set in motion a cascade of consequences. Britain’s National Health Service now provides more accurate advice to families about the unknowns associated with puberty blocking; there is more oversight of treatment decisions at the Tavistock clinic; systematic reviews have highlighted the weak evidence base for hormonal drug treatments; there has been a damning assessment of standards of care at the Tavistock clinic; and retired paediatrician Hilary Cass has been put in charge of an independent treatment review.
Keira Bell’s case has been closely followed internationally, including by Thomas Steensma, a leading expert at VU University Medical Center, Amsterdam’s pioneering gender clinic. Dr. Steensma has rebuked gender clinics around the world for not doing their own research, and for “blindly” mis-applying the more cautious Dutch protocol to a different, more troubled group of young people.
This litigation is one of several recent legal actions targeting the influence of gender ideology across UK society, from activist capture of school policies, through corruption of official data, to workplace discrimination. This testifies to a further advantage that has marked the British approach: multiple volunteer groups working behind the scenes on policy, while effective professionals are willing to carry the debate publicly, despite the inevitable attempts by trans activists to smear them and ruin their careers. “TERF Island” also has been able to draw upon a critical mass of brave journalists who channel the traditionally bolshie, independent spirit of the British media. (Trans activists like to present themselves as the underdog when it comes to these arguments; but in truth, they have represented the establishment voice for years now.)
All this helps explain why the UK has pulled back from the brink of two demands of gender-affirmation activists: legal gender change enabled by a mere act of self-declaration (sometimes known simply as “self-ID”), and a deceptively branded “conversion-therapy” ban likely to entrench medicalised trans identities. Real conversion therapy, which thankfully has been discredited for many years, was based on the pseudoscientific and homophobic notion that gay individuals could be turned straight by “therapeutic” means. In the idiom of gender activists, however, the term “conversion therapy” has been recklessly expanded so as to potentially impugn virtually any psychotherapeutic exploration of underlying non-gender issues in a way that might ease a patient’s distress in their birth sex.
Also in Britain’s favour is the centralised National Health System, which creates an expectation that proper data is available, and offers a clear line of political responsibility. To his credit, UK Health Secretary Sajid Javid has reportedly said that “far too many public figures have been avoiding [gender clinic issues] for too long.” In Australia, by contrast, federal Health Minister Greg Hunt expressed some concern about gender clinics, but referred inquiries to his state counterparts, who are in charge of children’s hospitals; the result of this more devolved approach is a total absence of transparency. In 2021, the Royal Australian and New Zealand College of Psychiatrists, which once endorsed RCH Melbourne’s gender affirming treatment guideline, noted the “paucity” of good evidence and the fact of expert disagreement on whether the affirmative approach should even be used with children.
All of which is to say, the big picture is not a simple contrast between reckless US gender medicine and the rest of the world coming to its senses. In fact, the handful of European nations already on the uneven road to caution owe a debt to key US figures, whose contribution has been somewhat obscured by activist and media misrepresentation. In particular, the Finns, Swedes, French, and British have all drawn on the work of US public-health researcher Lisa Littman, whose hypothesis of “rapid-onset gender dysphoria” has been recognised as credible by thoughtful clinicians in many countries. A 2017 paper titled Outbreak: On Transgender Teens and Psychic Epidemics by Philadelphia-based Jungian analyst Lisa Marchiano has also found an international audience. As has the work of American journalist Abigail Shrier, whose 2020 book Irreversible Damage: The Transgender Craze Seducing Our Daughters was chosen as a book of the year by the London-based Economist and Times. Shrier has exerted indirect pressure on woke U.S. media enterprises such as the New York Times and Washington Post to finally fess up to the reality of expert disagreement about transitioning minors. And it was on Bari Weiss’s Common Sense Substack platform that Shrier last year broke the news of two of America’s top gender affirming clinicians, both transwomen, harbouring concerns about risks and substandard care in the medical transition of minors. At first ignored by mainstream media in the United States, this story was picked up by the mass-readership Daily Mail in the UK.
Notwithstanding their dogmatic insistence that the affirm-and-confirm approach to gender dysphoria has been conclusively vindicated, members of the Biden administration are no doubt perfectly aware of domestic and international dissent in this area. What, then, to make of the statements by US Assistant Secretary for Health Rachel Levine, who claims that gender-affirming care is lifesaving, and “well-established medical practice” based on “decades of study.” Levine, a transgender woman and paediatrician, delivered this sermon on April 30th at Texas Christian University, wearing an admiral’s uniform. She sought to cast out evil forces “attacking our LGBTQI+ community” and perverting the language of medicine and science “to drive people to suicide.”
One particular devil of the moment is the Republican state of Florida, where health authorities issued an April 20th guidance advising against puberty blockers, cross-sex hormones, and surgery for minors. This announcement, like the White House’s March 31st “Fact Sheet,” has a sharp political edge. But the state health guidance was on firmer ground in citing systematic reviews showing the weak nature of the evidence that minors benefit from transition. Florida’s Surgeon General, Joseph Ladapo, played the international-caution card, saying: “Countries such as Sweden, Finland, France, and the United Kingdom are currently reviewing, reevaluating, stopping, or advising caution on the treatment of gender dysphoria in children and adolescents.”
In an April 29th interview with National Public Radio, Levine shifted the defence from evidence to authority, pointing out that gender affirming care enjoys the support of treatment guidelines and policy statements from august-sounding medical societies, including the Endocrine Society, the World Professional Association for Transgender Health (WPATH), and the American Academy of Pediatrics. WPATH is a special case, being a hybrid club for gender clinicians and trans activists, but it’s arguable that many mainstream medical organisations have allowed good intentions and identity politics to infuse their policy prescriptions with an air of certainty not warranted by the weak evidence base.
One claim by Levine stands out as betraying reckless disregard for the truth: “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.” As discussed above, there is plenty of argument on the public record, even among gender-affirming clinicians who disagree on the limits and risks associated with this treatment model.
The Biden administration shouldn’t assume that judges will be as incurious about the superficial appearance of medical consensus as journalists have been. In 2020, a US federal appeals court upheld a constitutional challenge to yet another of the world’s many, suddenly urgent bans on “conversion therapy”—this one in Florida, as it happens.
In the Florida case, the kind of virtue-signalling voice of authority relied upon by Levine—including the American Psychological Association (APA)—sprang to the defence of these neo-conversion-therapy bans and filed sombre resolutions and task force reports against this practice. The court majority was not impressed: “When examined closely, these documents offer assertions rather than evidence, at least regarding the effects of purely speech-based [conversion therapy].” Nor did the judges warm to the argument that even if the evidence of harm was lacking, they should take into account the fact that the APA and other professional bodies had all in unison denounced “conversion therapy.”
“It is not uncommon,” the judges said,
for professional organizations to do an about-face in response to new evidence or new attitudes, but one example stands out as we consider this case. In the first three printings of the Diagnostic and Statistical Manual of Mental Disorders, the American Psychiatric Association considered homosexuality a paraphilia, disorder, or disturbance. Only in 1987 was homosexuality completely delisted from the Manual. The Association’s abandoned position is, to put it mildly, broadly disfavored today. But the change itself shows why we cannot rely on professional organizations’ judgments—it would have been horribly wrong to allow the old professional consensus against homosexuality to justify a ban on counseling that affirmed it.
This leaves us with the question: How will history judge gender-affirming care if professional groupthink has in fact served to improperly justify the medicalisation of vulnerable minors with no good evidence to confidently predict the effect on their welfare?