Don’t Let Gender-Affirming Care Be the New Abortion

An op-ed for liberal media

I pitched this in various iterations over the past couple of months to multiple liberal outlets. It’s written for liberals—those with just a tiny bit of openness to another point of view about gender-affirming care—to share with one another. This post is free so please share!
-LD

Photo by Jasmine on Unsplash

On Wednesday, December 4, the U.S. Supreme Court heard the case of U.S. v Skrmetti, which concerns itself with whether bans on “gender-affirming care” for young people amounts to a form of sex discrimination. If you can give puberty blockers and hormones to one sex, per the challengers, you should be able to give them to the other.

Some 23 red states have enacted such bans on gender-affirming care for young people. Less known are the sanctuary state laws in blue states, which indemnify gender clinicians who treat patients from those red states, and protect access to those treatments for residents and those who cross state borders to procure them.

In the wake of the Supreme Court’s dismantling of Roe v. Wade, many states passed “shield laws” or constitutional amendments, linking gender-affirming care under the mantle of bodily autonomy. Oregon’s HB2002 protects “providers of and individuals receiving reproductive and gender-affirming health care services.” Illinois, Colorado, and Washington State, among others, passed similar bills. A few red states, like Nebraska, took a similar tack, but in the opposite direction—conflating abortion with gender affirming care, and restricting access to both.

In other words, American politicians linked gender-affirming care for youth—psychological and physical interventions to match one’s body and/or social category to one’s internal gender identity—to abortion, treating them the same way: as left versus right issues.

We need to unlink them. Though they seem to some liberals to both relate in some way to bodily autonomy, they are fundamentally different. Abortion is about politics. The safest, most effective way to treat gender dysphoric youth—that’s about science.

When we debate abortion, we’re parsing morals, belief systems, the rights of women versus the unborn babies they carry. Being pregnant is a physical condition, and terminating a pregnancy—or, if you’re against it, taking the life of a fetus—isn’t about shifting the body to match an internal identity. Having an abortion doesn’t preclude the possibility of procreating later, nor is the science behind it particularly contested.

Gender dysphoria, on the other hand, is a psychological condition. How to treat it is the stuff not just of robust debate but a vicious culture war. In some countries, trans people were once required to be sterilized before transitioning—a violation of their human rights. But going straight from blockers to cross-sex hormones, and of course removing ovaries or testicles, causes infertility, forfeiting young people’s human right to an open future.

There are many reasons—medical, emotional, financial—women might choose abortion, and it can be both medically-necessary and life-saving. There are many reasons, too, that a person might partake of gender-affirming care, and some of them overlap: to pursue what they believe will be a better life, for instance.

But while many American medical associations, government agencies, and NGOs claim that gender-affirming care is medically-necessary and life-saving, the evidence simply doesn’t back them up. Countries like Sweden, England, and Finland conducted systematic evidence reviews—the most robust method of evaluating medical research—and all came to the same conclusion: the evidence for these interventions is generally of low or very-low quality. That means, for instance, that when a study suggests that social transition, puberty blockers, cross-sex hormones, and/or gender surgeries lead to improved mental health, the actual outcome could be the opposite. The results shouldn’t be counted on, or mapped onto the larger population outside of the study. As the most comprehensive document ever produced on the subject, the Cass Review Final Report, found: “The reality is that we have no good evidence on the long-term outcomes of interventions to manage gender-related distress.”

The only state to conduct such a review in America was Florida. That document, too, found a lack of reliable research. But it was dismissed by supporters of gender-affirming care as partisan, rather than impartial. A major advocacy group creating guidelines for gender-affirming procedures, the World Professional Association for Transgender Health, actively suppressed several systematic reviews they’d commissioned, because “evidence-based review reveals little or no evidence and puts us in an untenable position in terms of affecting policy or winning lawsuits.”

In America, we’ve politicized the evidence, rather than listening to it.

Gender-affirming clinicians themselves have been among those most guilty of this behavior. A recent study by researcher Kristina Olson showing low rates of regret among young people receiving gender-affirming care concluded: “Our hope is that these data…will contribute to continued updating of decisions regarding the provision of gender-affirming care to adolescents.” That is, the conclusion was: don’t ban gender-affirming care. A political conclusion to a scientific paper.

Just after, Dr. Johanna Olson-Kennedy—no relation—admitted that she’d declined to publish data gathered from an almost $10 million NIH-funded study “because of the charged American political environment.” She didn’t want to share that puberty blockers had not led to improved mental health—because to do so might support bans.

But the bans, contrary to popular belief among Democrats, are filling a regulatory vacuum. Supporters of gender-affirming care haven’t offered to heavily regulate the industry. They’ve doubled down, rather than modifying based on scientific evidence.

Polls show that even though a slim majority of adults do not support gender-affirming care, most people do not want it banned outright. We must presume that they want what many of us want: for gender-distressed kids to get the highest-quality, safest, most effective care they can.

Nobody knows what that is. Nor can they find out in this polarized environment, where rational discussion makes determining the best way to help gender dysphoric youth impossible.

To continue to link abortion and gender affirming care is block offramps for Democrats, wanting to walk back unyielding faith in these treatments, aware that supporting them played some role in the Democrats’ massive defeat on Election Day. To link them is to make it hard for people anywhere on the political spectrum to object to or support one without endorsing or rejecting the other, when these issues don’t break down neatly along party lines. There are anti-abortion Republicans who support gender-affirming care, and pro-choice Democrats wary of it. To link them is to prevent us from achieving comprehensive, evidence-based guidelines for treating gender-distressed youth.

This framing leaves us with a patchwork of hard-edged policies, rather than a comprehensive set of guidelines. We need to discard this binary framework, and evaluate—and regulate—gender-affirming care and abortion separately, considering costs and benefits, responding compassionately to competing stakeholders. We need an environment in which asking questions and dissenting are seen as crucial to divining better treatments, not as heresy. What we don’t need is a moral crusade—on either side.