The Problem with the “Trans Child,” Part 1 of 3
Youth gender medicine is unnecessary
This article is inspired by conversations between myself and real-life friends—liberal, LGBT-allied friends like me. What exactly is my concern? they wonder, after coming across snippets of my work. But that conversation hasn’t lent itself to two-minute snatches of time amid friendly chatter at the craft brewery. As it turns out, it hasn’t even lent itself to a standalone article. So here we are.
In this three part series, I will show comprehensive evidence that gender medicine in its current practice is:
Unnecessary and ineffective
Harmful
Not standardized like other medicine
To note, much of Europe (including Norway, Finland, the Netherlands, Sweden, the UK, France, and Denmark) has already reached these conclusions and has scaled back gender-related care for youth as a consequence—leaving the U.S. “out of step” with the “developed world” on this issue.
This topic is big, but I’m going to do my best to cover the major issues high-level, without getting in the weeds, and let links and footnotes (which I may continue to update over time) fill in the gaps.
What’s at Stake
Let’s start here: Kids are dumb. They can barely count or read. They believe in Santa Claus, they run into traffic, they wet their pants. They think “princess” and “cowboy” are realistic career aspirations. Left to their devices, they’d eat Sour Patch Cherry Blasters for dinner.
Because kids are dumb, they are vulnerable. They can’t be trusted with alcohol, drugs, adult entertainment, or decisions about sex. They have parents and guardians because they need parents and guardians.
To be clear: I’m not concerned with what adults do. I’m an old-school liberal who believes in unfettered individual freedom to the extent that permits peaceful societal coexistence. Do I have opinions? Sure, I have a few. Adults do all sorts of inadvisable things, like getting ugly tattoos or reaching for that third slice of cake. But I don’t make that my business.
Kids are another story, because kids are vulnerable.
In recent years, unprecedented numbers of boys and girls are being diagnosed transgender. In the U.S., transgender identification has “tripled” in children and “nearly quintupled" in young adults. Canada has seen “exponential” growth. The U.K. and Denmark have seen a 4515% and 8700% increase in referrals to youth gender clinics, respectively.
Once diagnosed, these kids are set on a path which will permanently alter their bodies and the trajectory of their lives. As a consequence of now-common medical interventions for this group, many will become infertile, lose the ability for future orgasm, and become dependent upon prescription hormone replacement for life—and these are merely the known and expected tradeoffs. Complications1 are common in gender medicine and can be heinous, debilitating, and sometimes fatal.
This should not be taken lightly.
I know what you’re thinking. Kids young enough to believe in Santa aren’t the ones being offered gender medicine. You would be wrong, though.
This article mentions 382 grade schoolers referred to one gender clinic in the past few years, 70 of whom were under the age of 4. Jackie Green was deemed trans at 18 months. Noella McMaher, whose parents are both trans, was 2 years old. Other “trans” preschoolers in the news include Danni McFayden, Avery Jackson, Stormy Stubbings, Jackie Carter, Gracie Robinson, Shane Bliss, Kai Shappley, Charlie Lloyd, Jacob Lemay, Ellie Ford, Robin Bradbury, Riley Grant, Izzy Straton, Jayden Rogers, April He-van Zijl, Sadoka Frank, and Ronja Sif Magnúsdóttir.
How are these children diagnosed? Jazz Jennings, the most famous of these kids, was deemed trans when mother Jeannette overanalyzed the toddler’s fidgeting with the snaps on a onesie. Most are diagnosed by their parents based on sex stereotypes. But when parents aren’t diagnosing them, kids are diagnosing themselves. In the U.S., a National Sex Education Guide (page 18) recommends introducing “gender identity” to kids in kindergarten through second grade.
In light of their vulnerability, we should think twice before permanently modifying the bodies of children at all, much less on insufficient evidence. We should demand a high standard of proven benefit before accepting any given intervention.
What’s Happening
Instead, we are giving kids who express gender confusion puberty blockers, hormone injections, and/or surgeries, often starting treatment after one visit to a clinic.
One database created by a child advocacy group shows 13,994 American minors received gender-related medical treatment over a five-year period, including “5,747 surgeries,” “8,579 [who] received puberty blockers or hormone replacement therapy,” and “60,000 prescriptions issued.” Similar trends exist in other countries that still perform youth gender medicine.
But Isn’t It Necessary?
Consider this handful of facts:
The vast majority of kids with gender dysphoria or incongruence will grow out of it if left alone (some estimates: 85%, 85%, 87.8%, 80%-95%)2
There are no accurate diagnostic criteria or tests to determine which kids will persist (more on this in part 3)
Early social3 or medical4 transition may actually prevent gender confusion from resolving on its own, permanently locking in the trans identity
Despite what you may have heard, transition does not prevent suicide, and may increase it5
Likewise, transition does not improve mental health, and may make it worse6
This information, alone, shows that treating children for gender incongruence is inadvisable. Most kids will grow out of their distress. We can’t predict which ones won’t. And even the supposedly “ideal” candidate won’t be helped by medical intervention.
How is this possible? you may ask. Surely the U.S. hasn’t gotten it this wrong.
Yes, it’s hard to believe. But tell me—is it easier to believe that Norway, Finland, the Netherlands, Sweden, the UK, France, and Denmark have gotten it wrong, while the U.S. has gotten it right?
The medical industry, like everything else, gets some stuff wrong. I present for your consideration three of its many missteps: the nobel prize-winning lobotomy, the psychologist-led Satanic Panic, and the physician-facilitated opioid crisis. Some say the U.S. profit motive keeps us from facing unprofitable truths, as Europe has socialized medicine. I don’t know. But I do know that people are fallible and the march of “progress” has always zigged and zagged.
Gender Medicine Is Ineffective
“Neither hormones nor surgeries have been shown to reduce suicidality in the long-term,” writes veteran psychiatrist Stephen P. Levine, who has worked with transsexual patients since the seventies. Indeed, some studies (see footnote 5) find an increase in suicidality with transition, and at least one finds it remains consistent through every “stage,” from “pretreatment” to “post-transition follow up.”
For centuries, “transition” did not exist, so the gender dysphoric could neither pine for it nor consider it a condition for survival. Indeed, youth suicide has actually increased in the time frame that it’s been widely accessible. If transition decreased suicidality, we should expect to see evidence in both past and present statistics. Instead, we see the opposite trend.
Nor does gender medicine improve mental health. Researchers Bränström and Pachankis found “no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations.” That study is linked in the footnotes, alongside others highlighting the ineffectiveness and/or harms of puberty blockers and hormone injections. Check them out. I put them there to keep this thing short and readable.
More recently, a number of systematic reviews7 of existing studies on transgender medicine have concluded that insufficient evidence exists to support the effectiveness of gender-affirming care. It is these that have led those European countries to reverse course.
Maybe the thought is that gender medicine should not be expected to improve mental health, but merely deliver desired changes in appearance. In that case, it isn’t “life saving care,” as it’s so often called, but cosmetic surgery—something we’ve never offered to children nor covered with insurance.
Transition is even ineffective on that front. The fact is, the vast majority of medically transitioned people do not pass as the opposite sex. Even when patients achieve the desired physical results—which is rare—hand size, foot size, shoulder width, waist to hip ratio, height, and voice give them away, and that’s before the pants come off.
Let’s Recap
Kids are young and dumb. When they question their identity, they’re experiencing “a developmentally-appropriate phase” they’ll grow out of. We can’t predict which rare kid will continue to experience gender distress as they age, and even if we could, we don’t have effective treatments for those kids.
Offering medical intervention to gender-questioning kids risks interrupting the natural process of identity consolidation, locking in a trans identity in those who might have desisted—and for no verifiable benefit. Once delivered, it interferes with kids’ natural development, alters their genitals, complicates their future love lives, compromises their physical health in myriad ways (to be discussed in part 2), and chains them to a medical pathway for life.
As many studies have concluded, gender medicine for kids is “experimental” (footnote 7) and should be limited to clinical trials. Many first-world European countries we consider among the most liberal and enlightened have heeded these results and altered course accordingly.
So why on earth would giving this treatment to kids ever be appropriate?
Good health—mental and physical—is always better than compromised health. Less invasive is better than more invasive. Caution is better than haste, especially when dealing with kids.
All medical interventions pose risks. Here, the risks of harm are high—from medical injury to social difficulty—and they aren’t balanced by the alleged benefits.
“The large majority (about 85%) of prepubertal children with a childhood diagnosis did not remain GD/gender incongruent in adolescence.” Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. Hembree et al, citing Steensma. link
“80–95% of the prepubertal children with GID [gender identity disorder] will no longer experience a GID in adolescence.” The Treatment of Adolescent Transsexuals: Changing Insights. Cohen-Kettenis, Delemarre-van de Waal, Gooren. link
In “the largest sample to date of boys clinic-referred for gender dysphoria… at follow-up… (87.8%) were classified as desisters.” A Follow-Up Study of Boys With Gender Identity Disorder. Singh, Bradley, Zucker. link
In a study of girls, “approximately 85%… came to identify as a sexual minority [lesbian or bisexual] without GID [gender identity disorder] in adolescence or adulthood.”; A Follow-Up Study of Girls With Gender Identity Disorder. Drummond, Bradley, Peterson-Badali and Zucker. link
With use of puberty blockers, “young people are left in a state of ‘developmental limbo’ without secondary sexual characteristics that might consolidate gender identity.”; “Gender dysphoria may resolve once puberty begins.” Gender-affirming hormone in children and adolescents, Heneghan et al, link
“Those who had socially transitioned at an earlier age and/or prior to being seen in clinic were more likely to proceed to a medical pathway.” The Cass Review, called “the most thorough scientific review of the evidence for [gender treatments] ever undertaken.” link
”If children have completely socially transitioned, they may have great difficulty in returning to the original gender role upon entering puberty”; “Social transition… has been found to contribute to the likelihood of persistence.“ Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons. Hembree et al, citing Steensma et al. link
“The effects of puberty suppression on emotional and cognitive development… could potentially affect the capacity to consent to cross-sex hormones and surgery.” Stephen P. Levine, link
“Without medication, most will desist… yet over 90% of those treated with puberty blockers progress to cross-sex hormones and often surgery“; “Blocking puberty… may be preventing the role of hormonal changes in the usual pattern of desistance.” Puberty Blockers for Children: Can They Consent? Latham. link
“Youth… are in the midst of a developmentally-appropriate phase of identity exploration and consolidation… the potential for puberty blockers to alter the natural course of identity formation should give pause to all ethical clinicians.” - Society for Evidence Based Gender Medicine. link
“98%” of kids taking puberty blockers “proceeded to masculinising or feminising hormones.“ The Cass Review, link
“A longitudinal study from Sweden that covered more than a 30-year span found that adults who underwent surgical transition were 19 times more likely than their age-matched peers to die by suicide.” Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults. Stephen P. Levine, citing Dhejne et al. link
“The overall mortality for sex-reassigned persons was higher during follow-up… than for controls of the same birth sex, particularly death from suicide.” Dhejne et al. link
A “key longitudinal study from the Netherlands concluded that suicides occur at a similar rate at all stages of transition, from pretreatment assessment to post-transition follow-up.” Stephen P. Levine, citing Wiepjes et al et al. link
“Lifetime suicide attempts and suicidal ideation in the ‘past year’ was higher among those who had socially transitioned as adolescents.” The Cass Review, link
In this study of hormone treatment in 315 young people, “The most common adverse event was suicidal ideation… death by suicide occurred in 2 participants.“ Psychosocial Functioning in Transgender Youth after 2 Years of Hormones, Chen et al. link
On the “pressure to support a medical pathway based on widespread reporting that gender-affirming treatment reduces suicide risk”: that connection is “not supported” by the review. The Cass Review, link
“Among 963 TGD [transgender and gender diverse] youth… using gender-affirming pharmaceuticals, mental healthcare did not significantly change… and psychotropic medications increased.” Mental Healthcare Utilization of Transgender Youth Before and After Affirming Treatment. Hisle-Gorman et al. link
”There were no statistically significant changes reported in gender dysphoria or mental health outcome measures whilst on puberty blockers”; “37-70% experience no reliable change in distress across time points, 15-34% deteriorate and 9-29% reliably improve.” The Cass Review, link
“Results demonstrated no advantage of surgery in relation to subsequent mood or anxiety disorder-related health care visits or prescriptions or hospitalizations.” Correction to Bränström and Pachankis. link
"Kids who took puberty blockers or hormones experienced no statistically significant mental health improvement during the study," a finding the study’s authors “confirmed.” Journalist Jesse Singal’s analysis of the study Mental Health Outcomes in Transgender and Nonbinary Youths Receiving Gender-Affirming Care. link
An “early intervention study” failed to show “positive measurable outcomes”; “There is a lack of high-quality evidence to support recommendations for puberty suppression or hormones for masculinisation or feminisation in children/adolescents experiencing gender dysphoria or incongruence… Robust research is needed to address the significant gaps in our understanding.” The Cass Review, link
“Significant problems with [studies] prevents definitive conclusions to be drawn… treatments for under 18 gender dysphoric children and adolescents remain largely experimental.” Gender-affirming hormone in children and adolescents, Heneghan et al, link
Available studies are “small, uncontrolled observational studies, which are subject to bias and confounding, and all the results are of very low certainty” and “suggest little change with [puberty blockers] from baseline to follow-up.” Evidence Review: Gonadotrophin Releasing Hormone Analogues for Children and Adolescents with Gender Dysphoria. National Institute for Health and Care Excellence, link
“The quality of evidence for all these outcomes was assessed as very low certainty.“ Evidence review: gender-affirming hormones for children and adolescents with gender dysphoria, National Institute for Health and Care Excellence, link
“Studies on long-term effects of gender affirming treatment in children and adolescents are few… No relevant randomised controlled trials in children and adolescents were found.” Gender dysphoria in children and adolescents: an inventory of the literature; A systematic scoping review. Swedish government, link
“We found insufficient evidence to determine the efficacy or safety of hormonal treatment approaches.“ Antiandrogen or estradiol treatment or both during hormone therapy in transitioning transgender women, Haupt et al, link
Additional series of systematic reviews: link
Thanks for providing such a cogent summary. I can point to it instead of sputtering incoherently.
Excellent piece, thank you! I would love to read more from you on social transition. I see this as the starting point, when the parents and other adults start lying to themselves and the child that sex can be changed. This can happen years before any medication is started, but is more harmful as it can lock everything in. I cringe when neighbors use the word “trans” when talking about the little boy down the road who wears skirts sometimes. We all need to say NO to any hint of accepting that a child could be trans.