Progressives have cultural power and yearn for more political power. Conservatives have political power and long for more cultural power. The left uses its cultural power to affect mores, and the right responds with laws. In the battles that ensue, there is no room for nuance or mutual understanding. Transgender controversies are where these clashes become particularly ruthless.
Gov. Greg Abbott of Texas recently used his executive authority to declare that puberty blockers, cross-sex hormones, and surgeries for those under 18 meet the legal standard for child abuse in Texas, a ruling that authorized the Department of Family and Protective Services to investigate parents who had sought such treatment for their children. (A court has issued a stay.) That kind of click-baity use of government power is a gross overreach, and it’s also counter-productive. There are many reasons that our society needs to reconsider its wholesale embrace of the “affirmation” model in treating kids with gender dysphoria, and malice from Republicans makes it that much harder.
Progressives, for their part, have deployed their cultural power to anathematize anyone who questions the new orthodoxy about gender. Talk to a random group of journalists and they will admit, off the record, that they are more wary of venturing wrongthink about transgender issues than any other. Arguably, more people have been canceled for running afoul of the transgender police than for any other perceived transgression.
One side uses the heavy hand of state power to stifle dissent and the other uses the cudgel of opprobrium for the same purpose and we get dumber by the minute. Not to go all kumbaya, but it just might be the case that both sides in these controversies have valid perspectives. Maybe we should seek to make arguments rather than score points.
Progressives are right that transgender people used to be treated with some contempt. It’s important to correct that. Everyone deserves to be treated with dignity. But conservatives are right that we’ve rushed into radical approaches to medicating children with gender dysphoria because the medical establishment and large parts of the opinion-shaping commentariat have treated this as a social justice matter rather than as a question of what’s best for kids. An NBC Think piece gives the flavor of the progressive approach: “We Should be Celebrating Lia Thomas Like We Did Jackie Robinson.” Meanwhile, gender ideology—that it’s common for people to be born into the wrong body—is creeping into schools. In Connecticut, the curriculum for first grade includes titles like Jacob’s New Dress and Are You a Boy or a Girl?, a story about a child who’d rather not say. A 2017 California law made it a criminal offense for healthcare workers not to use a patient’s preferred pronouns. (The progressives sometimes use state power too.)
Over the past couple of decades, the percentage of kids identifying as transgender has skyrocketed. A recent survey found that 1.8 percent of children under the age of 18 identify as trans, which is twice the number from 10 years earlier. Abigail Shrier reports in Irreversible Damage that starting in 2006, gender dysphoria cases went through the roof throughout the developed world. Whereas in the past, gender dysphoria was almost exclusively found among natal males (and usually presented in early childhood), after 2006, the ratio flipped and the majority of cases were natal females who did not have any early childhood history of gender dysphoria but began to exhibit symptoms in adolescence. “In 2016,” Shrier writes, “natal females accounted for 46 percent of all sex reassignment surgeries. A year later, it was 70 percent.”
Brown University public health researcher Lisa Littman published a study speculating that peer contagion was part of the reason groups of teenage girls were coming out as trans, and Shrier’s book followed up with insights into the social media influencers on YouTube and Tik Tok who encourage unhappy kids to consider that path.
LBGTQ advocates vigorously oppose the group contagion theory, but it’s obvious that behavior and mental health are affected by social cues. Emil Durkheim showed that suicide was contagious more than 100 years ago, and other mental health issues like eating disorders and cutting are associated with particular groups (white, middle-class females). Positive behaviors like volunteering and charitable giving are also influenced by group dynamics.
While we can’t rule out the possibility that trans people are coming out of the closet for the same reasons that gay people did in previous decades—declining stigma—there are reasons to be more cautious about the trans trend.
First, there is the complicated matter of why people seek to transition. Studies have shown that the majority of youth with gender dysphoria who go through natural puberty become lesbian, gay, or bisexual nontransgender adults. Surely clinicians have a duty to help young people explore their sexuality before prescribing hormones and other body- and brain-altering treatments.
Second, recognizing one’s sexual orientation doesn’t entail the risks of surgery or infertility, while gender therapy does. The “gender affirmation” model of treatment, the nearly univeral approach of American gender clinics, requires that children who express gender dysphoria be recognized by family, friends, and teachers as the other sex. They are encouraged to dress, style their hair, change their names and pronouns, and conduct themselves in every way as the other sex. They are given puberty blocker drugs to retard the onset of puberty until they are “ready” to decide what they really want to be. And thereafter they are prescribed cross-hormone treatments (lifelong) along with surgery if desired.
Advocates say puberty blockers and other early treatments are fully reversible, but that’s debatable. Psychologically, it would be hard for a child who has acted and been treated as Sam from age 3 to reverse polarity and decide at age 15 to be Susan after all, and nearly 100 percent of those given puberty blockers go on to cross-hormone treatments and surgery. As the New York Times noted, few studies have followed adolescents receiving these drugs into adulthood. Puberty blockers impede bone development, and if administered early in puberty, cause permanent infertility. Some of the changes, like deepening of the voice and growing facial hair, can be permanent, and of course, surgeries like double mastectomy preclude the possibility of nursing if someone decides to detransition.
Children know how they feel, but they are not equipped to understand the long term consequences of the whole trans regimen. It is the rare 16 year old who can predict how he or she will feel about infertility at the age of 30 or 35. Besides, children go through stages, and it seems ill-advised to make decisions about treatment that will have irreversible effects or put children on a conveyor belt toward gender transition that is very difficult to exit once begun.
Studies of patients who have detransitioned after hormone or surgical treatment or both reveal that most feel they received inadequate counseling before being prescribed hormones. A quarter said they realized as adults that their discomfort with being gay drove them to transition, and 38 percent said that trauma, abuse, or other mental health issues caused them to transition. “Carol,” a detransitioned lesbian told the Economist that she worries about butch lesbian girls who are now being encouraged to think that they are in fact straight men. She thinks it’s a new kind of homophobia.
Clearly, children who have true gender dysphoria need sensitive and compassionate care and full respect. In some cases, it may be best to adopt aspects of the gender affirming approach. But interfering with their bodies and brains before they reach maturity seems drastic, particularly when surgeries are performed on teens younger than 18.
Two psychologists, Laura Edwards-Leeper, the founder of the first pediatric gender clinic in the United States, and Erica Anderson, a transgender woman, published a Washington Post essay in November 2021 decrying the poor care that has become the norm in the United States. They opened with the story of Patricia:
At 13, Patricia told her parents she was a transgender boy. She had never experienced any gender dysphoria—distress at a disconnect between gender identity and the sex assigned at birth—she said. But a year earlier, she’d been sexually assaulted by an older girl. Soon after this trauma, she met another older girl who used they/them pronouns and introduced her to drugs, violent pornography and the notion of dissociation from her body. Her lingering psychic wounds, coinciding with a raft of new and unsettling ideas, plunged her into depression and anxiety. Patricia’s parents took her to a therapist so she could talk through her shifting identity and acute mood swings.
The job of the therapist here, they wrote, was clear. Establish how long Patricia had these feelings about her body, assess her mental health and life history thoroughly, and investigate whether her recent trauma might have contributed to her self-diagnosis. Instead, the therapist told the parents to affirm Patricia’s new identity, warning that 40 percent of transgender teens attempt suicide. Would they “rather have a dead child or a trans one?” Patricia’s parents sought another opinion, and the second therapist offered counseling. A year later, Patricia stopped binding her breasts and wearing boys’ clothing.
This rush to gender affirmation without psychological counseling is common, Edwards-Leeper and Anderson write:
We find evidence every single day, from our peers across the country and concerned parents who reach out, that the field has moved from a more nuanced, individualized and developmentally appropriate assessment process to one where every problem looks like a medical one that can be solved quickly with medication or, ultimately, surgery. . .the treatment pushed by activists, recommended by some providers and taught in many training workshops is to affirm without question.
Many teens who arrive at gender clinics are prescribed hormones after just one visit. Edwards-Leeper and Anderson quote a pediatrician at Children’s Hospital in Los Angeles who gives hormones to kids as young as 12 and explained, “I don’t send someone to a therapist when I’m going to start them on insulin.” Planned Parenthood clinics follow the “informed consent” model and stress that no evaluation by a mental health professional is required before starting hormones for those 18 and older. Younger patients are referred to other practitioners.
Dr. Will Malone, an endocrinologist and founder of the Society for Evidence-Based Gender Medicine, objects that “Cognitive maturity doesn’t occur until the age of 25,” and notes that it’s very unusual for a woman under 25 to be given a hysterectomy other than for life-threatening conditions, even if she requests it, because doctors don’t consider people that young to be fully capable of making an informed decision.
Other nations have begun to rethink their approach. In 2020, Finland revised its treatment guidelines out of concern that the hormone and surgery approach was not well-supported. Practitioners now focus more on psychological therapy and draw distinctions between early-onset dysphoria and the adolescent variety. Sweden, Australia, and New Zealand have likewise moved to require thorough mental health evaluations for young gender dysphoria patients. In Great Britain, Keira Bell, a destransitioner who says she was prescribed testosterone and underwent a mastectomy without proper psychological counseling, won her case in Britain’s high court, which resulted in a ruling that young people under 16 could not give informed consent for puberty blockers.
The World Professional Association for Transgender Health has also endorsed a more cautious approach. A new chapter of their guidelines stresses that adolescents presenting with gender dysphoria must undergo psychological assessments and must have questioned their sexual identity for “several years” before being treated with puberty blockers or hormones.
Progressives have created a stampede to treat transsexuality as a civil rights issue before medical science has had a chance to measure what’s really going on and how best to respond. Conservatives are responding with cruelty—how else to describe the Texas law that sics child protective services on parents who are trying to do what’s best for their kids? We need to slow down and learn more.