A chance to depoliticize gender-affirming care

An op-ed in The Boston Globe

I wrote this for The Boston Globe after the revised HHS Review came out. Yes, five years later, I’m still trying to speak in a way that fellow liberals—who assume this is an extension of gay rights, and that the only objectors are bigots—can hear.

Photo by Nikolas Gannon on Unsplash

A report commissioned by the Trump administration manages to look at the evidence for youth gender medicine outside of a left-right framing.

Most of my liberal friends and neighbors assume that the battle over gender-affirming care for trans kids divides neatly into left versus right. Supposedly, the left supports trans kids, and the right wants to commit genocide against them. After all, we Democrats have been told that gender-affirming care is evidence-based and lifesaving — and we’re the party of science.

But the more I studied the history of affirming a child’s subjective gender identity and sometimes changing the body to match it, the more blinding daylight I saw between what I knew to be true and what my community had been taught or believed — and the more I saw how desperately we need to depoliticize the issue.

For years, feminists, liberals, and gays and lesbians have voiced their objections to teaching children that if they do not conform to stereotypes, they may have been born in the wrong body. Detransitioners — who medically transitioned and regret it — have been trying to raise awareness among Democrats since at least 2019. Doctors, academics, and therapists have attempted to air their concerns with their colleagues and professional associations. Even some transsexual adults, as they refer to themselves, have been asserting that adolescents should not transition.

No matter which of us raise our voices, we’re rebranded as right-wing. One of the most startling examples is what happened to the Society for Evidence-Based Gender Medicine (SEGM), a nonpartisan group that calls for research on youth gender medicine to be depoliticized. The Southern Poverty Law Center disparaged SEGM’s work by labeling it a “hate group.”

The way youth gender medicine is often practiced without proper guardrails, and the redefining of sex to mean gender identity, are deeply unpopular — even among Democrats. New polls show that culture war issues, LGBT rights, and males in women’s sports are not what voters want Democrats to focus on. But since we don’t know how to pivot, this issue continues to be our party’s Achilles heel; we dig in instead of moving forward.

Now we have one more chance to depoliticize the subject, but it’s a big ask, because of the unlikely source of the off-ramp.

President Trump’s Executive Order 14187, “Protecting Children From Chemical and Surgical Mutilation,” called for the Department of Health and Human Services (HHS) to compile “a review of the existing literature on best practices for promoting the health of children who assert gender dysphoria, rapid-onset gender dysphoria, or other identity-based confusion” and to end reliance on “junk science.”

The first draft of the review, “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” was published on May 1 of this year. The authors had been given only three months to compile it, so there wasn’t time for peer review, and they were left anonymous, in part “to protect them from intimidation tactics and undue pressure campaigns,” per HHS. They promised to engage peer reviewers postpublication, and hoped readers would parse what the report said, rather than focus on who said it — let alone that Trump ordered it.

What it said was that multiple systematic reviews in such places as Sweden, Finland, and England found no proof that gender-affirming care for youth was evidence-based or lifesaving. The authors conducted an “umbrella review”— essentially, a dispassionate evaluation of other dispassionate evaluations — and concluded: “The overall quality of evidence concerning the effects of any intervention on psychological outcomes, quality of life, regret, or long-term health, is very low. This indicates that the beneficial effects reported in the literature are likely to differ substantially from the true effects of the interventions.”

The World Professional Association for Transgender Health (WPATH), which is often thought of as the leading authority on gender medicine, actually suppressed several systematic reviews it had commissioned, maintaining that research showed benefits for puberty blockers, cross-sex hormones, or surgeries to treat gender dysphoria in youth. WPATH also excluded a chapter on ethics in its latest “standards of care,” published in 2022 (but added one on “eunuch gender identity”).

The HHS report, by contrast, concentrated on the ethics of, for instance, sterilizing children to alleviate psychological distress or treating puberty as a disease. The most basic facets of medical ethics are beneficence and nonmaleficence: showing benefit and not causing harm. If there’s no definitive evidence of benefit and some risk of harm — and if parents and children don’t know this before signing on — how can these interventions be ethical?

It also raised concerns about the terminology used in gender-affirming practices, including the opaque term “gender-affirming care” itself — much different from “sex changes,” as they were once colloquially called. The field is plagued with “euphemistic and morally loaded language, which can mislead or unduly influence patients and their guardians,” the authors wrote. That includes “chest masculinization surgery” and the term “gender identity,” often explained as “a sense of one’s gender” — a circular definition.

Proponents of gender-affirming care could and should have engaged with these issues. Instead, many focused on the report’s anonymous authorship and lack of peer review as reasons to dismiss it.

As of today, those failings have been addressed. The report has been republished, and now it includes seven peer reviews solicited by the authors, two unsolicited reviews, and the authors’ responses to them — along with a list of some of the changes those reviews suggested, which are minimal. The number of studies excluded — because they focused on adults, for example, or because better versions were later published — shifted from 3,200 to 3,198. A typo was corrected, from irreversible to reversible. Citations were fixed. A sentence was deleted because it had been attributed to the American Psychiatric Association, rather than the American Psychological Association.

The commissioned peer reviews largely support the report, calling it “a comprehensive summary of the evidence base,” “a compelling historical context,” and “scientifically sound.”

One commissioned review, from Johan C. Bester, a professor of health care ethics at Saint Louis University School of Medicine, noted that existing clinical practice guidelines from WPATH and the Endocrine Society “include conflicts of interest, methodological problems, and misapplication or misrepresentation of available evidence.” He called them “unsuitable for use.”

Another reviewer, Lane Strathearn, a professor of pediatrics at the University of Iowa, pointed out that while there may be insufficient evidence of benefit, “there is also insufficient evidence to clearly understand the ‘risk of potential harm’ for some of these treatments.” Yet, he wrote, “the primary burden of evidence should be for the likelihood of benefit, especially when there is even a potential for harm.”

In contrast, the uncommissioned peer reviews, largely by gender-affirming clinicians, many of whom are members of WPATH, continue to dismiss the report.

One review called the report “a dangerous example of government incursion into the provision of evidence-based medical care,” despite the fact that the report makes no clinical recommendations. Another insisted the report was part of a “growing list of White House-endorsed harmful practices against [transgender/nonbinary] children and adolescents and their families, as well as the healthcare professionals who support them, with little regard for their civil rights and for the expertise that protects and promotes their well-being.”

Medical associations did no better at engaging with the ethics and science catalogued in the HHS report. The American Academy of Pediatrics, which has staunchly supported gender-affirming care, initially agreed to conduct a peer review but reversed course at the last minute. The Endocrine Society demurred. The American Psychiatric Association critiqued the anonymity of the authors.

Now, the authors have finally been revealed. They are a politically diverse group, headed by a center-right political scientist at the Manhattan Institute, Leor Sapir; and including liberals like MIT philosophy professor Alex Byrne and bioethicist Moti Gorin. Among the authors are doctors and psychiatrists and a research methodologist. There are true-blue liberals and at least one diehard conservative.

There is, of course, bias in this report, and a point of view; even if the team operated independently of HHS, each member had to be approved by the department.

But that doesn’t mean that those who believe deeply in the value of pediatric gender medicine shouldn’t read it and engage with its findings. It means that they should.

Because the report’s authors are politically diverse and address ethics and harms, this is the closest we’re going to get to wresting the issue from the clutches of partisan politics. Doing so is going to be hard. Some authors belong to SEGM, the nonpartisan group that’s been disparaged as hateful. Trump and HHS Secretary Robert F. Kennedy Jr. aren’t exactly towering figures of scientific integrity or bipartisanship.

But we Democrats have to push past the left/right framing, because we claim to be the party of science, and this is where the science leads — away from calling gender-affirming care for youth “evidence-based” or “lifesaving,” and perhaps away from providing these interventions at all.

“Given the lack of demonstrable benefit and concern about potential harms,” Bester wrote in his peer review, “the use of puberty blockers, cross-sex hormones, and gender transition surgery in minors with gender dysphoria cannot be ethically justified.”

That isn’t necessarily an endorsement of state bans on these treatments. It could just as well be a call for medical groups to reform their positions and their guidelines — something they’ve been unwilling to do. They rationalize, rather than being rational.

Their silence is deafening. Their refusal to engage honestly with the science is dangerous. Their unwillingness to admit that some children have been harmed by the gender-affirming model — a model that at the very least needs to be reformed — borders on malfeasance. The medical field should declare itself apolitical, beholden to science, not party. This is its chance.