I’m guessing that some day historians will look back at the mishigass surrounding “affirmative care” and wonder what the deuce was going on in America in the 2020s.
Now let me say at the outset that I have no objection to people with “gender dysphoria” changing their gender using drugs and surgery. But I also think that transitioning should not be allowed until after puberty, and for two reasons. First, we don’t know eough about the safety of “puberty blockers” used to stop the process while adolescents figure out their sexual identity, and second, because children who are too young to make mature judgments should not be allowed to make irreversible decisions about their bodies. Eighteen seems to me to be an appropriate age to begin a medical process of transitioning.
My objection to “affirmative care” is not that we shouldn’t treat young people repectfully when they have with a sincere desire to transition, or fail to support them. But in the U.S., and previously in the UK, the default option was “affirmative care”, with no real psychological probing to dissect the roots of gender dysphoria and see if it was a form of distress that might resolve into a child becoming gay. “Affirmative care”, in its most extreme form, pronounces children who question their sexuality as transsexuals, deems them ready to change sex, and encourages them to go on puberty blockers and then hormone therapy. (There are few adolescents who, once on blockers, decide to stop them and “de-transition.”)
I’m cautious because the huge rise in the number of adolescents who declare themselves transsexual (particularly biological women who want to change gender) could have a number of causes: a relaxation of the stigma against transsexuality, an increase in the genetic propensity to change gender (that’s impossible given the rate of the rise), or—as Abigail Shrier argues in her book Irreversible Damage, a sort of social contagion—a sense among young people that it’s far more cool to be trans than to be gay, and because such people get a lot of props and attention. (Shrier doesn’t claim that transition is always prompted by social contagion.)
Only the first and second hypotheses are supportable, and I think both are at play, but to deny that social contagion hypothesis plays any role in the temporal changes shown below is to deny reality. There are simply too many cases of seeing “detransitioners” (“desisters”) discuss the social pressure they were under, and of others seeing it at play in real life.
Below is an article by writer Lisa Davis you should read (click the screenshot). It’s on Bari Weiss’s site (and I don’t want to hear that Weiss is “alt-right” so that you can ignore it), and explains how several European countries, including the UK, Sweden, France, and Finland, are changing course on affirmative care, replacing it not with a refusal to let people transition, but with a more compassionate and psychologically-oriented inquiry into the roots of gender dysphoria.
The change in Europe comes from a realization of the weakness of the evidence supporting two assertions of trans activists: that puberty blockers are completely harmless and can be completely reversed if someone changes their mind, and that allowing medical transitioning reduces the rate of mental illness and suicide among those with gender dysphoria. We now know that the evidence for the first claim is wrong, and for the second is plagued by methodological weaknesses. We simply need a lot more data, and the Europeans are being cautious while Americans ignore the counterevidence. That’s unwise given the drastic and irreversible nature of many transitions.
Here’s a graph from the article above showing the increase in referrals to the gender-affirming Tavistock clinic, and this is just between 2009 and 2017 (original source here). Both the proportion of and the increase in biological females (compared to males) referred to the clinic for affirmation have increased substantially. If your hypothesis is that the rise reflects purely the de-stigmatizing of transsexuality, this discrepancy between the sexes must be explained. Of course, it also has to be explained if you hold a “social contagion” hypothesis.
I completely agree with Andrew Sullivan in his Friday column section called “Yes, the trans madness is real” when he says this:
I recall a few years ago having a heated conversation with some well-meaning trans activists who appeared completely aghast when I voiced some worries about the treatment of kids with gender dysphoria. What if the kid is gay, I asked? How do we know for sure if a pre-pubescent child really is trans and not just experimenting with gender the way many gay kids do? And are these nine-year-old children really mature enough to make life-long decisions that could make them permanently sterile, keep them on drugs for the rest of their lives, or permanently remove their capacity to have an orgasm? How could pre-pubescent kids even know what an orgasm was?
My activist friends were shocked. It seemed to me as if they had never previously been asked these questions. They were all very-well intentioned, and not entirely wrong — in a few extreme cases, there might be a reason to permanently change a child’s sex. But they assured me that no such errors were ever made, that the process was entirely ethical, and that all medical authorities backed it. They insisted that puberty blockers were harmless and fully reversible. The bubble is real.
I think it’s better to give kids with gender dysphoria extensive psychological counseling—NOT affirmative from the outset, i.e., not “affirming” that children who say they’re of another gender must be right—before giving them irreversible medical treatment, treatment that we now know can render people sterile, unable to enjoy sex, and, in the case of puberty blockers, cause other medical damage. Sullivan, who experienced dysphoria himself, says that many adolescents go through a period of confused sexuality, and perhaps would become gay were it not more fashionable to change gender.
Both articles detail some big changes in Europe about how to treat gender dysphoria. I’ll summarize what most of us know already (the first article above gives links):
- Sweden has revised its guidelines for treating gender dysphoria in adolescents, arguing that gender-affirming treatment may be more harmful than good, and claiming that affirmative treatment “should be offered only in exceptional cases.”
- Finland, using an evidence-based approach showing that many young people seeking transitioning had severe psychiatric problems, that there were risks to using puberty blockers (see below), both physically in in terms of sexuality, changed its protocol for treating gender dysphoria:
(From Davis’s piece): In Finland, for patients who fit the profile of participants in the Dutch study, after a prolonged period of evaluation, and with a multidisciplinary team including a psychiatrist, psychologist, social worker and nurse, puberty blockers may be started near the onset of puberty, and cross-sex hormones may be possible starting at age 16. Assessments take place at two gender identity clinics; gender surgeries are offered only at one center. Both Finland and Sweden now stress gathering data and extensive follow-up.
My own view is that giving puberty blockers “near the onset of puberty”, or at age 16, is too young.
- The National Academy of Medicine in France has urged caution in proceeding with drugs and surgery in cases of gender dysphoria since some of it may be due to social contagion. It recommends more extensive psychological counseling of those with gender dysphoria.
- The Tavistock clinic in London (a notorious place for affirmative therapy) is to be closed, replaced by a number of regional clinics practicing a different brand of care. This is the result of a critical review headed by Dr. Hillary Cass, commissioned to review Tavistock and its practices. Their recommendations, which the government accepted, was to de-centralize the clinics, adopt more “holistic care”, and ratchet back on the use of puberty blockers, which now appear to have possibly severe medical consequences.
- The medical consequences of puberty-blocking drugs like Lupron, which according to Sullivan have been known for a while, include brain swelling and loss of vision, possible bone damage, and other irreversible effects. In fact, these blockers are used for other conditions, and I understand are always prescribed by doctors treating gender dysphoria “off label”, i.e., they’re not specifically recommended by the FDA for stalling puberty while a child ponders its gender.
This month the FDA added brain swelling to the warning labels of puberty blockers. The sample size is small, and these problems appear only in biological females (the most common sex experiencing gender dysphoria), but an FDA warning is nothing to take lightly. Here’s a tweet about the dichotomy between the American use of blockers willy-nilly in American “affirmative care”, and the warnings on drug labels. Clearly, more research needs to be done (that’s what Sweden and Finland concluded) before blockers are used so readily. But, in contrast to the caution about other new remedies, like Covid-19 vaccines, the standards for usage are very lax in the U.S., and were in the UK as well:
The US Food and Drug Administration, which is run by Rachel Levine's Department of Health and Human Services, revealed on July 1 that it had identified that pubery blockers carry a risk of brain damage to children. Levine, a few days later, called for more children to take them pic.twitter.com/OuZCpdcUhI
— ripx4nutmeg (@ripx4nutmeg) July 30, 2022
Nevertheless, as both Sullivan and Davis point out, the U.S., urged on by the Biden Administration, is going full steam ahead with affirmative care.
In the US, however, as many states move in the European direction, the left is pushing harder. California has a bill offering sanctuary for any child seeking a sex change. The Biden administration still insists that “every major medical association agrees: gender-affirming care is life-saving, medically necessary, age-appropriate and a critical tool for health care providers.” The absolute certainty, compared with the second thoughts in Europe, is striking.
Davis, referring to Finland and Sweden’s revised guidelines in comparison to America’s (my emphasis):
Both guidelines starkly contrast with those proffered by the Illinois-based World Professional Association of Transgender Health, an advocacy group made up of activists, academics, lawyers, and healthcare providers, which has set the standard when it comes to transgender care in the United States. WPATH will soon issue new standards that lower recommended ages for blockers, hormones and surgeries. (WPATH did not respond to a request for comment.)
WPATH’s position is in keeping with an array of U.S. medical associations and activist groups across the country that insist gender-affirming care is “life-saving.” Assistant Secretary of Health Rachel Levine, who is herself a transgender woman, recently asserted that there is a medical consensus as to its benefits. Some activists and gender clinicians in the U.S. feel that WPATH doesn’t go far enough, asserting that any child who wants puberty blockers should get them, for instance, or claiming that a teenager who later regrets having her breasts removed can just get new ones.
In Sweden and Finland, this issue has been primarily a question of health and medicine. Here in the U.S. it is a political football.
Why the ignoring of evidence and lack of caution in the U.S. as opposed to Europe? Why are we not following the examples of countries that take an evidence-based approach to medical policy about gender dysphoria? Surely one of the reasons is “wokeness”: the idea that changing gender is to be admired as an act of courage, and that transgender people, or those who wish to become so, should be valorized as members of stigmatized minorities. And, sadly, the Biden administration has bought into the pronouncements of the extreme Left, which include unquestioning approbation for “affirmative care.”
Yes, there’s some stigma about transgender people, and yes, we should help those who, after intensive medical and psychological examination, are deemed to be serious about their gender misindentification rather than confused about their sexuality. And yes, we should treat transgender people in nearly all respects as equals to members of the biological sex they assume. But what we should not do is, in the interests of seeming virtuous, rush children and adolescents into very serious and irreversible medical procedures without proper vetting.