The Trouble With Texas, Part 1
What Paxton and Abbott Are Doing Is Terrible
Last week, Texas Attorney General Ken Paxton did a bad thing. He recommended that the medical procedures of gender-affirming care—puberty blockers, cross-sex hormones and sometimes surgeries like double mastectomies or penectomies—be counted as child abuse under section 261.001 of the Texas Family Code.
Paxton asserts that allowing kids with gender dysphoria—marked distress at an incongruence between biological sex and sense of self as boy, girl or neither—to medically transition may cause “mental or emotional injury that results in an observable and material impairment in the child’s growth, development, or psychological functioning” or “physical injury that results in substantial harm to the child,” among other misdeeds. Texas Governor Greg Abbott sent a letter to the Texas Department of Family and Protective Services suggesting that gender-affirming doctors, nurses, teachers and parents be investigated.
Parents have the Constitutional right to decide their children’s medical path. Labeling those who choose the gender-affirmative model child abusers, and terrorizing those who are trying to help their suffering kids—or the clinicians who are following what the vast majority of medical and mental health organizations and advocacy groups avow as medically necessary and life-saving interventions—is heinous and unconscionable. Full stop.
In fact, many people on the Left likely believe that withholding these procedures is child abuse, because “failing to seek, obtain, or follow through with medical care for a child,” is also child abuse under that same Texas code. Supporters of gender-affirming care often assert that children know themselves and that desistance—ceasing to identify as transgender before medicalizing—and detransition—regretting medical gender change and returning to living as one’s natal sex—are rare. Criminalizing or demonizing the gender-affirmative model, they believe, is anti-trans and born of hate. The Washington Post asserted that “Republicans are obsessed with harassing transgender kids.”
I believe that both those interpretations are wrong (and later this week I’ll send a post about what I really think is behind the move). While I condemn Paxton’s and Abbott’s actions, which are likely illegal and unenforceable, my condemnation is not because gender-affirming care is the silver bullet so many activist organizations (and the media) claim it is—or because Paxton is wrong about the science. Rather, we need to create an environment where we can dispassionately evaluate the evidence and listen to those who have been helped and those who have been hurt by this approach to treating gender dysphoria. They’re making that impossible, exacerbating the already poisonous political atmosphere around this subject.
But let’s look at other countries that have nixed the gender-affirmative model for non-political reasons—as anyone reporting on the situation in Texas should.
Just two days after Paxton’s announcement, Sweden made an announcement, too: new guidelines for gender dysphoric youth. “Uncertain science and new knowledge mean that the National Board of Health and Welfare now recommends restraint when it comes to hormone treatment,” they reported, adding, “There are no definite conclusions about the effect and safety of the treatments.”
Contrary to what mainstream media, medical groups and advocacy organizations avow, the gender-affirming approach is actually deeply controversial from a scientific and ethical perspective. The “new knowledge” the Board of Health and Welfare referred to includes kids who in fact have experienced observable and material impairment. A Swedish news program, Mission: Investigate, found increasing numbers of detransitioners as well as minors with “healthcare-related injuries,” such as constant pain from osteoporosis.
Finland also altered its approach to gender dysphoric youth, asserting therapy as the best treatment, creating strict guidelines for medicalization. In the U.K., an evidence review of puberty blockers’ and hormones’ impact on gender dysphoria, mental health and quality of life were “assessed as very low certainty.” They also found that suicide was “extremely rare.”
These shifts in approach to care, from affirming to evaluative and cautious, had nothing to do with politics. Rather, they had to do with science, and the fact that earlier studies that did show positive outcomes were conducted on a very different population.
Over decades, there had been few kids diagnosed with gender dysphoria, the majority male, with lifelong dysphoria. They were not socially transitioned, and cleared for medical interventions during early stages of puberty if they weren’t suffering from other serious mental health struggles and if their dysphoria didn’t resolve on its own, as it has historically for the vast majority of children.
Today, there has been an exponential increase of adolescent girls (and many more adolescent boys) seeking treatment, most with late-onset gender dysphoria and other mental health problems. They have appeared all over the Western world, as the model switched from evaluative—based on the older studies, with careful screening—to affirmative, in which most children are accepted as trans and sometimes quickly cleared for medical procedures. The only research done on them was so heavily politicized—by the Left—that most medical groups have declared it moot, making it impossible to study them and how best to treat them. Paxton notes the high rate of desistance in childhood dysphoria. Most kids grow out of it. But adolescent gender dysphoria? We know very little about it because it was hardly ever seen until a decade or so ago.
The truth is, we have little idea how safe, efficacious or ethical these gender-affirming treatments are, especially for this never before studied cohort. What does the science say, and what does Paxton say about the science?
In his letter to Rep. Matt Krause, Chair of the House Committee on General Investigating, Paxton notes that “the use of these chemical procedures [puberty blockers] for this purpose is not approved by the federal Food and Drug Administration and is considered an ‘off-label’ use of the medications.” This is true.
He writes, “the procedures you inquire about can and do result in sterilization.” Not totally clear, but definitely seems that way. But guess what? In many places, sterilization—for adults—used to be a requirement of what was then called sex-change surgery. Let’s not forget that the adults who wanted to make these changes used to have to go through brutal hoops to get them.
He writes, “Children and adolescents are promised relief and asked to ‘consent’ to life-altering, irreversible treatment—and to do so in the midst of reported psychological distress, when they cannot weigh long-term risks the way adults do, and when they are considered by the State in most regards to be without legal capacity to consent, contract, vote, or otherwise.” I’d call that an accurate depiction, though critics argue endogenous puberty is also irreversible.
He writes, “The prevalence of gender dysphoria in children and adolescents has never been estimated, and there is no scientific consensus that these sterilizing procedures and treatments even serve to benefit minor children dealing with gender dysphoria.” The lack of scientific consensus is indeed true, though many advocacy medical groups like the AAP and APA endorse it. Last week, as Sweden announced a radical shift, another American study came out showing an association between puberty blockers/cross-sex hormones and improved mental health in young people. But that shouldn’t surprise us. Young people been told that these medical interventions will cure their distress, and they got the interventions they wanted. Research like this shows correlation but can’t establish causation.
What this new study doesn’t show us is how many are happy and how many regret—though alongside those asserting gender-affirming care is life-saving are the growing number of detransitioners—people who underwent gender-affirming medical procedures and regret them, realizing they weren’t trans. Many feel the affirmative model failed them by not properly evaluating or attending to other struggles, and rushing to medicate. There are no long-term studies in the U.S. and few clinics follow up with clients years later.
Bans and declarations of child abuse—horrendous as they may be—may be a reaction to this approach, but what we actually need is good research and long-term follow-up with every young person who goes through these procedures. Paxton’s war on practitioners and parents makes it impossible to conduct rational, nonpartisan and evidence-based evaluation of the data, or an incentive to collect more, as is desperately needed. We need to put the fires out, not fan the flames. For parents to make good decisions, they need to have all the evidence, and Paxton makes that even harder.
Ideology has no place in science or medicine, on the Right or Left, and neither refusing these medical interventions nor partaking of them is child abuse. We need to listen to those who are happy and those who’ve been harmed and, like Finland and Sweden, tailor our approach to this new generation of gender dysphoric youth.