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Youth gender medicine has become a hall of mirrors

Despite the certainty projected by medical institutions about the ‘affirming’ model of care, some pioneering practitioners worry it may have gone too far.

Michael Woloschinow for The Boston Globe

In August, a Missouri law went into effect that limits gender treatment for minors to counseling. Such laws, which have passed in 22 states to date, can be particularly cruel. Minors already on puberty-suppressing drugs or cross-sex hormones are being effectively cut off. Trans adults on Medicaid who’ve been taking hormones for years may find their prescriptions are suddenly unaffordable. And often these laws are tied to overt acts of culture war — like a ban on drag shows in Tennessee.

This wave of legislation is unfortunate for another reason. A lot of fair-minded, thoughtful people may question whether hormones and surgery are appropriate for the growing number of young people who are distressed about their biological sex. But given all the campaigns in red states, many progressives are instead biting their tongues and trusting that doctors know what they’re doing.

The problem is that as more kids identify as transgender than ever before, it’s still worth asking whether “gender-affirming care” is the right model for them. Despite the certainty advocates project that this is an open-and-shut case, it wasn’t long ago that this “affirming” approach for children was simply an idea — a hypothesis informed by experience, but an idea nonetheless. Yet in less than a decade, it became the standard of care and is now practically gospel in the United States, even as other countries are redirecting services toward psychotherapy and social support.

A natural response on the left to bills restricting or even outlawing gender-related medical treatment is “keep your laws off my body.” As a vocal supporter of abortion access, I’m sympathetic. But it’s a mistake to conflate these two causes. Abortion is a thoroughly vetted, one-time procedure, and denying access to it reduces a woman to an incubator. That’s quite different from a relatively new hormonal protocol in children that can lead to major, irreversible, long-term impacts.

The practice of medicine doesn’t have perfect checks and balances, but it does have a history of proving itself wrong (for the latest episode, see: cold medicine). So when a new approach for children and adolescents involves powerful medications and surgeries, people aren’t necessarily misguided (or “anti-trans”) to voice concerns. Yet journalists, parents, researchers, and clinicians who have raised questions about the evidence have been ensnared in a conversation about identity and rights. Now it seems all we can hear are the loudest and most reactionary voices, echoing in statehouse rotundas.

Loaded terms

For as long as gender roles have existed, there have been people whose inner compass, even at an early age, felt unaligned with their bodies. What’s new today is the ability to medically address that mismatch in adolescence, before puberty has fully had its say.

And since about 2016, the number of young people receiving what are called “puberty blockers” — drugs that suppress the signal to the pituitary to release the hormones that transform tweens into sexually mature adults — has grown. An analysis by health technology company Komodo found that the number of kids between the ages of 6 and 17 in the United States who began suppressing puberty to treat gender-related distress rose every year between 2017 and 2021 and leveled off in 2022. Komodo counted more than 6,000 children in that category in that time span, although that number is likely an undercount because it only represents treatments covered by insurance. Massachusetts is among the top five states, generating 6 percent of claims.

At least 14,700 minors with a gender dysphoria diagnosis began taking prescription estrogen or testosterone from 2017 through 2021, according to Komodo’s analysis — especially testosterone, as female-born teens now outnumber males 3 to 1 in many clinics. And a recent study found that gender-related surgeries, such as breast removal, nearly tripled between 2016 and 2019, including among 12- to 18-year-olds.

Meanwhile, European countries, including those that pioneered early intervention for children with gender dysphoria, have generally limited gender-related surgery to adults.

“Puberty blockers,” “hormone therapy,” and “top surgery” fall under the umbrella of “gender-affirming care.” These are loaded terms, fraught with as much activism and obfuscation as “pro-choice” and “pro-life,” yet they were validated by medical sources like the 2018 American Academy of Pediatrics (AAP) statement in support of the “gender affirmative care model.”

This document informs clinicians that “many medical interventions can be offered to youth who identify as transgender and gender diverse,” including drugs that suppress pubertal development, cross-sex hormones, and, “on a case-by-case basis,” surgeries. These kids, even before puberty, “know their gender as clearly and as consistently as their developmentally equivalent [cisgender] peers,” the statement says. An approach of “watchful waiting” to see how a young patient’s identity develops is “outdated” and “does not serve the child because critical support is withheld.”

The statement presented the affirmative approach as settled consensus based on evidence. However, this past August the AAP — under pressure by several members — announced that it would commission an independent systematic review of the evidence. That’s typically the first step in developing what the National Academy of Medicine calls “trustworthy guidelines,” so that patients and providers can make decisions informed by a thorough, unbiased evaluation of the available research. But the AAP hadn’t done that before releasing its 2018 statement. The AAP did not respond to requests for comment other than to reaffirm its 2018 statement.

Existing systematic reviews have prompted Sweden, Finland, and England to restrict treatments for minors, because the evidence that they are likely to result in more benefit than harm is of low quality. But unlike US states that have taken legislative action, these countries are allowing hormonal treatment in select cases, and they are ensuring that researchers follow the recipients over time so the evidence base gets stronger.

The case for watchful waiting

Not only do red-state gender laws tend to lack the humanity and room for inquiry seen in Europe, I think they also distract progressives from fully absorbing what the people they’re marching with are actually chanting. The argument for early treatment is not just a medical one — it is a metaphysical one. It holds that gender identity is something that exists deep inside a person’s psyche and that this diagnosis, essentially, will be revealed to the clinician even by young children. That is a radical interpretation of patient-centered care.

When I spoke with the AAP statement’s lead author, Jason Rafferty, a child and adolescent psychiatrist in Providence, he reiterated that this model of care is fundamentally about “affirming and validating the child’s sense of identity from day one through to the end.” Its main principle is that when a patient says, “‘I’m X,’ we operate under the assumption that what they’re telling us is their truth, that the child’s sense of reality and feeling of who they are is the navigational beacon to sort of orient treatment around.”

Joshua Safer, director of the Mount Sinai Center for Transgender Medicine and Surgery and a coauthor of the Endocrine Society’s practice guideline — another influential document — told me, “I know that kids who are talking that way when they are 9 years old are overwhelmingly consistent in their thought processes,” and thus giving such patients puberty blockers “would save them from surgery” down the road.

But when I spoke to the Dutch clinician and researcher Thomas Steensma — who joined the team that pioneered the early treatment model that migrated to the United States — he distanced himself and his colleagues’ practice from the current American iteration. In brief, he said, “That’s not our approach.”

In the Dutch clinics, he said, young patients undergo a “long, focused” process of assessment, and even social transition is not a given. “It’s not necessarily true that a child who feels gender dysphoria or incongruence will grow up with [those feelings],” he explained. “Our approach is to make developmentally informed decisions with the child, with the family,” and through counseling to explore what might help. “Identity is not the strongest force in providing medical treatment” because it becomes more fixed during puberty. “It’s common sense,” he said, that the brain matures with the body and that one gains greater capacity to “reflect on your body and about your identity.”

In 2016 — while the AAP statement was being drafted and reviewed — Steensma coauthored a review of 10 studies of gender-incongruent and dysphoric youth. Among 317 kids, 85 percent resolved their identity distress “around or after” puberty. The review also found that most dysphoric kids turned out to be same-sex attracted, lending credence to the concern that enthusiastically affirming kids may mean “transing away the gay.” The article made clear that “there is currently no general consensus about the best approach to dealing with the (uncertain) future development of children with gender dysphoria,” even social transition. In its 2015 guidelines, the American Psychological Association also said there was no consensus.

Steensma’s article explains that in the model of “watchful waiting” — what the AAP derided in its 2018 statement — children are neither discouraged from nonconforming behaviors nor counseled to accept their natal sex (denounced by critics as “reparative” or “conversion” therapy, historically the term used to describe the widely condemned practice of trying to “convert” same-sex-attracted adults). Rather, families are encouraged to allow their child to explore their feelings and given counseling “to bear the uncertainty of the child’s psychosexual outcome.” There’s an effort to “find a balance between an accepting and supportive attitude toward gender dysphoria while at the same time protecting the child against any negative reactions and remaining realistic about the chance that [dysphoric] feelings may desist in the future,” wrote the authors.

This is different from what has become the dominant approach in the United States, in which children’s sense of identity is supposed to be accepted as true and real by care providers and medically treated accordingly. Not affirming, by this interpretation, is tantamount to conversion therapy. But in the approach Steensma describes, children are in an unpredictable process of self discovery, and thus care providers must follow closely and exercise caution in treating. “We do think puberty suppression can be a good intervention for adolescents struggling with gender incongruence,” Steensma told me. But “you have to be very careful.” “We say, don’t make certain decisions where you close developmental pathways. Watch and see what happens with the identity.”

These competing approaches — one proactive, one restrained — could have been treated with equivalence by the AAP and other entities as they continued to evaluate the evidence. Instead, tens of thousands of pediatric providers, including the therapists charged with assessing prospective patients, were essentially told to trust their young patients in determining whether to recommend potentially life-altering treatment.

A risk-benefit calculation

In the mid-2000s, Boston Children’s Hospital became a satellite for the Dutch early treatment approach. Pediatric endocrinologist Norman Spack, now retired, told me what motivated him to pitch this to his higher-ups was years of witnessing young adult trans patients struggling. Even with hormones and surgery they couldn’t easily pass as their felt gender, they had little support from family or society to express themselves, and many were fighting addiction, homelessness, and suicidality. Spack wanted to pilot a strategy of early detection, because it was at puberty when “they started to fall apart,” he told me recently. The idea was to catch these patients before “their bodies escaped from that neutral space of pre-puberty.”

Dr. Norman Spack in 2011, when he headed the Gender Management Service clinic at Children's Hospital Boston.Suzanne Kreiter

Seeing the suffering of a population is often the impetus for a preventive treatment. Obstetricians began using electronic fetal monitors in the 1970s in the hope of preventing cerebral palsy and stillbirths. Physicians began screening men for prostate antigen in the hope of catching and curing deadly cancers. These were solid rationales, but what happened was an epidemic of overdiagnosis and overtreatment. Strapping laboring patients to beeping machines initially succeeded in tripling the rate of cesarean surgeries without any concomitant improvement in infant outcomes (and added harm to their mothers). PSA testing increased the rate of prostate surgeries without an overall survival benefit — and a not insignificant amount of resulting urinary and sexual dysfunction.

Spack told me that the evidence for early intervention was “the many, many years of nontreatment for transgender youth waiting until they were adults to do anything medically for them” and seeing where that led.

But what if he was only seeing a sliver of the population — the minority who continued to feel distress and seek treatment, rather than the bigger picture that included those who may have felt a mismatch in childhood and then realigned during puberty? Imagine only studying cases of emergency cesareans and drawing policy conclusions based on those births rather than everyone who gave birth in a particular year. I ran that comparison by Gordon Guyatt, a research methodologist at McMaster University and one of the founders of evidence-based medicine. Earlier intervention is a “reasonable hypothesis,” he said, but if the population you’re observing is “a subpopulation that is unrepresentative and you make inferences about the entire population, you’re in trouble.”

Spack said the suicidality among his trans patients, even kids under 12, “was so strong that I felt we had to do something.” And he saw many kids “flourish” with treatment. Research does suggest that LGBTQ youth are at higher risk for depression and suicide, but the World Professional Association for Transgender Health’s own systematic evidence review makes clear that it can claim no definitive relationship between hormonal treatment and mental health outcomes, especially in adolescents, and that it’s “impossible” to say what impact hormonal treatment has on suicide. Long-awaited research funded by the National Institutes of Health — Spack was one of the original lead investigators — recently published in the New England Journal of Medicine reported some improvements among 315 youths receiving treatment in university-based gender clinics, but there were also two suicides. “Sometimes you have to bite the bullet, and go with more than a hunch” based on “smaller numbers and not being able to answer all the questions at once,” said Spack.

By 2011, the Dutch had published on the outcomes of a cohort of 70, which seemed reassuring, though the findings had limitations and haven’t been replicated elsewhere. Steensma told me he and his colleagues have never thought of their work as “scientific proof” that their model would work everywhere. “We always have said, ‘This is what we can provide from evidence, but you have to do your own studies.’”

In a new analysis of the mental health outcomes of the first 44 recipients of gender-related puberty suppression at the UK’s Tavistock clinic, roughly a third got better, a third got worse, and a third did neither. The National Health Service has ordered the Tavistock clinic to close after a review found the care “inadequate.”

Like the Dutch, the Boston clinic didn’t take kids at their word without psychological assessment. In fact, the staff used tools the Dutch had designed. Laura Edwards-Leeper, the clinic’s original psychologist, told me that extensive, exploratory talk therapy was historically part of the model. But lately she’s been outspoken about her concerns that “more providers do not value the mental health component, largely because they believe if the young person says they’re trans, they’re trans,” she told me.

The dramatic rise in young people presenting for treatment, especially genetically female teens, and the number of clinics that have sprung up with little to no emphasis on assessment, all make Spack “anxious.” “I run into so many people who tell me they have a child or grandchild or niece who’s trans. And I always say, ‘Well, who made that determination and when?’”

The clinic in the UK's Tavistock Centre that specializes in gender issues in young people has been ordered to close.Dan Kitwood/Getty

The logic of affirmation

I’ve spent the last year reporting on pediatric gender medicine and policy for The BMJ, one of the oldest medical journals. Like other journalists in this space, I’ve been accused of transphobia, hate, bias, and worse. Some of the rhetoric is extremely hostile, but the underlying logic is apparent: If people need medical treatment to exist in their identity, and kids know who they are, then anything that might impede access is an existential threat. Politicians who simultaneously target pride parades and library books and “groomers” only reinforce that terror and turn up the political heat. That’s even more reason for journalists to keep cooler heads and stay true to our duty: to hold authorities to account.

The most important question is one that the Europeans and Americans seem to be answering differently: What if it’s possible that there are kids who identify as trans who indeed know who they are at very early ages — younger versions of the adult patients who haunted Spack — and there are also kids who identify as trans for a finite period of time? And what if there’s no sure way to tell them apart?

Before he stopped returning my calls and emails, Rafferty acknowledged that children are in a “process of discovery” and may understand themselves one way at the onset of puberty and another way five years later, but that uncertainty shouldn’t preclude medical treatment. “It needs to be an ongoing, flexible, dynamic approach that we understand from the beginning may change over time, and so we need to bring in interventions when they seem their most appropriate from our medical perspective,” he told me. “If we’re wrong, then we need to back up and say, ‘What do we need to do differently?’”

And what if a kid has taken hormones that caused permanent hair growth or vocal changes or damaged their sexual function and came to regret these effects? In a recent Zoom meeting — footage of which has been shared on social media — Marci Bowers, a California gender surgeon and president of the World Professional Association for Transgender Health, shared a startling observation: Adult patients who transitioned from male to female couldn’t have orgasms if they had been “blocked” at the earliest signs of puberty and went directly on to estrogen. Bowers told me she was sharing a hypothesis, but that it was “a wake-up call for those who counsel this group of patients.” Safer told me “there’s some discussion about adjusting the timing of some of these treatments” to achieve more optimal function. “If you come to our meetings, that’s what we’re discussing. Nobody is worried about puberty blockers for a year or two.”

Yet data suggest that more than 95 percent of the children who begin puberty blockers continue on to cross-sex hormones. “The most difficult question,” the UK pediatrician Hilary Cass wrote in her interim report on a national review of gender health services, which led to the order to close the Tavistock clinic, “is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway . . . by impeding the usual process of sexual orientation and gender identity development.” In 2020, following a systematic review, the UK’s National Health Service removed language that called the blockers “fully reversible” and replaced it with “little is known about the long-term side effects.”

There are an unknown number of people whose identity shifted and who feel they’ve been irreparably harmed by medically transitioning. Corinna Cohn, who was born male, began hormones at 16 and had genital surgery at 19. Now, at age 48, Cohn testifies in support of laws restricting treatments in minors. “The thing that I’m most convinced of right now is that the longer somebody puts off medicalization, the more opportunities they’ll have to really clarify in their mind whether transition is actually good for them,” said Cohn, for whom “transition was a way out of having to deal with puberty. But I’m sort of stuck in a state of arrested development, because I never completed the adjustment to my body as it was becoming an adult body.”

Bowers pointed out that “you can always find someone who is going to regret” and warned me not to “single out transgender care” when one in five people regret their knee surgery, for example. “People have to take some responsibility in making those decisions,” she said.

But how can young people and their families make informed decisions without strong evidence it will make them better? How can children who’ve never experienced sexual intimacy consent to treatment that may limit their ability to have it in the future?

Edwards-Leeper believes some children do benefit from early treatment. “But to the general question of how can a young kid consent to something like this, it is a huge ethical dilemma . . . because honestly, they can’t,” she told me. “The responsibility falls on the parent.”

Rafferty told me patients who live with harms or regrets do not signal a failure of the affirmative care model. If a child or patient doesn’t like the effects of an intervention, or begins to feel different in their identity, then the provider continues to affirm by discontinuing treatment. “They’re not treatment failures if that’s what’s affirming,” he said.

In other words, the logic of affirmation seems to ensure only successful outcomes, circumventing questions of risk and benefit entirely. If parents and providers find this untenable, they are rejecting an argument — not trans people.

Jennifer Block is an investigative journalist, most recently for The BMJ, and the author of “Everything Below the Waist: Why Health Care Needs a Feminist Revolution.” Follow her @writingblock.