The Problem with the "Trans Child," Part 3 of 3

Youth gender medicine lacks standards

Snake oil and other infamous elixirs

A study published days ago on Gender-affirming medical treatment for adolescents in the peer-reviewed journal Biomed Central (BMC) makes a startling claim—that “improvement” is an inappropriate metric by which to measure the success of gender transition.

That’s right: This field of medicine, which has so often claimed to prevent suicide, rescue youth from despair, and facilitate wholeness and well-being, now excuses itself from such “normative” standards of measurement. Instead, it intends to “center the voices” of patients, leaning into whatever “negative feelings” may arise “after, or even because of” transition.

To restate: Gender medicine need not confer any benefit whatsoever to retain its legitimacy, now, even if it goes horribly wrong. “The experience of regret [is] inherent to all lives,” state the study’s authors.

The claim comes, unsurprisingly, on the heels of a number of systematic reviews concluding that “insufficient evidence” exists to support these treatments.

If this claim is startling, it’s not unprecedented for this field.

John Hopkins University, which pioneered transgender sex reassignment, deemed gender medicine a failure way back in 1979 and stopped doing it. Research by psychiatrist Jon K. Meyer, who screened patients for surgery, had shown that “persons who were operated on… were no better adjusted afterward than those denied the surgery.” Chief of psychiatry Paul McHugh concurred, fearing gender medicine amounted to “cooperating with a mental illness.” Thirty-eight years later the hospital resumed performing surgeries, not because better evidence had arisen, but amid pressures to promote “LGBTQ+ Equity.”

Earlier, sexologist John Money theorized that sexed personality traits are purely a product of socialization, and would prove completely malleable in a child raised as the opposite sex from a young age. He got his chance to test this theory when he oversaw the transition of David Reimer, an infant whose penis was destroyed in a botched circumcision. Money reported his experiment a success, though Reimer preferred rough-and-tumble play, was attracted to girls, and felt continually tormented by his dissimilarity to his female peers. After Reimer (and his twin brother) endured years of Money’s sexually inappropriate “therapy,” the boy discovered what had happened to him and promptly reclaimed a male identity. But the damage was done. Later, he committed suicide and his brother died of an overdose.

Even earlier, surgeon Kurt Warnekros performed the first sex reassignment surgeries on painter Lili Elbe (born Einar Wegener). These included castration, penis removal, and a uterus transplant which led to organ rejection and the patient’s death. Ostensibly, the operation was meant to facilitate pregnancy, though Warnekros failed to test or fully plan for that objective. Even today that surgery remains elusive and would result in a barely functional organ—requiring embryo implantation, caesarian section, and later removal of the transplant.

These failures have not slowed the medical industry’s fervor for performing sex reassignment, but they have resulted in ever-changing justifications for its continuance—culminating in this recent disregard for favorable outcomes altogether.

In part one of this series, I showed that gender medicine is unnecessary, as it confers no known benefit. In part two, I showed that these treatments are harmful, as well.

In part three, I will show the utter lack of standards that characterize this branch of medicine:

• No standard diagnostic criteria

• No standard range of treatment options

• No achievable treatment objectives

No Standard Diagnostic Criteria

Proponents of gender affirming care love to cite the “Dutch protocol,” a series of studies from 1988 to 2014 that comprise the basis for today’s youth gender medicine. There’s a lot to say about this protocol, so I may soon dedicate a whole article to it. For now, here’s what you need to know¹:

• Three studies were performed: one on a cohort of adults in 1988, one on a cohort of children in 2011, and a follow up on the same cohort of children in 2014.

• The studies have been widely criticized for their poor design, lack of clinically significant favorable outcomes, low certainty, and failure to replicate. They were plagued with a high dropout rate: 38% in one study and 70% in another.

• The first study employed a strict screening criteria, treating only young adults “with long, persistent histories of childhood gender dysphoria” with supportive families on board and no “major problems with mental or physical health.” That’s because this group of researchers was “very concerned” with minimizing regret. Today, however, cohorts of children “explicitly disqualified” from the Dutch protocol are treated. More on this below.

• Despite this strict screening, results of the first study were lackluster. While many self-reported satisfaction, those reports were not correlated with treatment; in other words, those contemplating hormones were as happy as those who’d completed surgeries. This prompted researchers to suspect “wishful thinking.” Additionally, participants scored poorly on quality of life measures such as “employment, partnership, [and] sense of loneliness.”

• Poor results in the adult cohort nonetheless inspired additional research on children, to test whether earlier intervention would work better. This was initiated after a psychologist from the Dutch team was moved to a children’s ward. There she met a 12-year-old girl whose Italian father disapproved of the girl’s “masculinity” and same-sex attraction. The psychologist, who admitted she “had faith” in the protocol, transitioned the child with the help of an endocrinologist friend who’d recently begun prescribing puberty blockers for another condition. The child became youth gender medicine’s “patient zero.”

• “High rates of suicide attempts” were observed in the studies on children. One participant died as a direct result of treatment.

• Data were apparently manipulated. Questionnaires measuring self-reported happiness were used inconsistently, so that natal boys were asked if they “hate menstruating” and other such nonsense. An entire study was discarded. Patients who developed diabetes, became obese, detransitioned or dropped out—as well as the patient who died—were excluded from final analysis, skewing results.

These studies are used to justify youth gender medicine. The criteria supposedly used to diagnose today’s “transgender children” hint at the criteria used in the Dutch studies, but vary from clinic to clinic and in practice are seldom consulted at all.

Take “gender dysphoria,” for example. Described as “discomfort” with one’s “sex or sex-related physical characteristics,” it was once absolutely crucial for receiving gender related treatment. This plastic surgery clinic still requires it, though they seem motivated by insurance reimbursement. But the Society for Evidence Based Gender Medicine notes that recent guidelines remove the “distress criterion” associated with “gender dysphoria,” allowing treatment for mere “gender incongruence.”

Per the Dutch criteria, treatment should also be reserved for those whose gender dysphoria presented early, in childhood. But whistleblower Jamie Reed, while working as a case manager at The Washington University Transgender Center, recalls seeing young patients “with no previous history of gender distress.” Physician Lisa Littman coined the phrase “rapid onset gender dysphoria” to describe the experience of a new cohort of adolescent girls whose sudden transition plans seem influenced by peers.

Some modern criteria list “consistent, insistent, and persistent” as indicators of longstanding dysphoria. But as discussed in part one, children as young as 2, 3 and 4 are diagnosed transgender with startling frequency. How “persistent” can they be? Planned Parenthood dispenses hormone therapy after one visit, precluding any monitoring of symptoms over time.

Good mental health was required by the Dutch protocol, but that’s been openly abandoned. The BMC study admits that transgender youth are “disproportionality burdened” by “depression, internalizing disorders, behavioral problems, anxiety, and suicidal ideation and attempts,” though it considers these no barrier to treatment. Manhattan Institute reporter Christina Buttons has researched the oft-observed link between gender distress and autism. Researcher Andrew Amos warns that “psychosis” is the “undeniable” cause of some patients’ gender confusion.

Reed saw children with “many comorbidities: depression, anxiety, ADHD, eating disorders, obesity,” children who claimed to have Tourette’s or multiple personalities, and one who was “sexually abusing dogs.” One young patient’s “intense obsessive-compulsive disorder… manifested as a desire to cut off his penis after he masturbated.” All were funneled into transition, often after one or two perfunctory visits with a therapist.

Researcher Mia Hughes, along with journalist Michael Shellenberger, uncovered similar stories from within the World Professional Association for Transgender Health (WPATH). Clinicians discuss patients with “mood disorders” and “schizophrenia,” note a “high prevalence of eating disorders” and speak of “developmentally delayed” patients who aren’t in the “brain space” to consent. Nonetheless, these kids were transitioned, too.

Another Dutch protocol that’s been abandoned is a supportive family structure. The news is rife with custody battles related to parental consent for treatment, while “sanctuary states” and bills intercept “child removal requests, extraditions, arrests or subpoenas related to gender-affirming health care.”

As alluded to above, the demographics of patients accepted for treatment have changed since the Dutch studies, too. “Three times as many men as women” sought transition in the past, and feminine males who could pass as women were considered the best candidates. Today, females outnumber males, and younger and younger cohorts of both sexes seek treatment.

No Standard Range of Treatment Options

Unlike other medical treatments, interventions for gender dysphoria are “client led” and bespoke.

Gone are the days when men sought to look like women, or women sought to look like men. Identities have proliferated, and so have the ways to express them.

Men and women who opt for cross-sex hormones but no surgeries have become commonplace.

“Microdosing” estrogen or testosterone facilitates “more subtle changes” for those who aren’t ready to commit to an opposite-sex identity, who need to manage contraindicated “pre-existing medical conditions” (also excluded by the Dutch protocol) or who simply want to save money.

“Top surgery” is no longer limited to breast removal. For “nonbinary” individuals—an identity I argue is a political statement rather than a natural orientation—a nipple-free chest is all the rage (a 13-year old post-op girl standing nipple-less beside her mother made the rounds on Twitter/X a couple of years ago). Even incision sites and areola size can be customized for a desired look.

For men who identify as eunuchs, which is now apparently a thing, the fruit can go while the veg stays.

For men and women who want a little “something extra,” phallus-preserving vaginoplasty and vagina-preserving phalloplasty allow the old parts to live in harmony with the new.

And for those who hate all sex organs, nullification surgery, which removes everything, can provide a “Barbie-doll crotch” (in the words of fictional malpractice victim Hedwig). No trauma could possibly enter into such a decision, right? Nor does regret loom large for those razing off sections of their body in the name of a neo-gender—we hope. No studies have been performed to evaluate satisfaction with these procedures, of course, since they were invented yesterday.

Even the comparatively traditional vaginoplasty comes in a myriad of methods (using genital, colonic, intestinal and/or peritoneal tissue), largely because of a philosophical conflict among gender-affirming medical personnel. Endocrinologists want to administer puberty blockers and hormones to boys while they’re young, to prevent the masculinizing effects of puberty. But surgeons want fully-intact adult males to work with, so they’ll have sufficient penile tissue with which to sculpt a neovagina. Surgeon Marci Bowers, after performing a complex vaginoplasty on Jazz Jennings that required peritoneal tissue grafts and three corrective revisions, is thus “not a fan“ of early puberty blockade.

This type of conflict among medical personnel is common in the field, where clinicians have admitted to “flying the plane while building the plane.” Do these sound like proper conditions for modifying the bodies of children?

No achievable treatment objectives

This has been covered in bits and pieces, but let’s collect it here.

Gender affirming care doesn’t do anything.

It doesn’t prevent suicide, and may increase it.

It doesn’t improve mental health, and may make it worse.

It doesn’t improve body image or alleviate gender dysphoria.

It doesn’t result in “positive measurable outcomes” or improved quality of life indicators such as “employment, partnership,” or alleviation of “loneliness.”

It may lock in a trans identity in kids who would have otherwise grown out of it.

It’s a clear case of “medicine” that’s driven not by efficacy, but by activism.

Norway, Finland, the Netherlands, Sweden, the UK, France, and Denmark have limited gender-affirming care for minors in light of recent systematic reviews that failed to uncover evidence for its efficacy. The U.S. remains “out of step.”

Why such variation in approaches? Where are the standards?

1. Credit for this research belongs to Zhenya Abbruzzese, Stephen B. Levine and Julia W. Mason, who authored The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed. Abbruzzese speaks further on the issue here.