Dr. Peters

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Nikki Haley: A Leader of Courage and Conviction

I was already inclined to support her, but after last night’s debate, I am firmly behind the candidacy of Nikki Haley. In addition to her executive experience as the Governor of South Carolina and her foreign policy knowledge as the United States Ambassador to the United Nations, Haley strikes me as the most balanced, the most adult, of the remaining GOP candidates.

Haley was a popular and effective Governor of South Carolina. Her tenure was perhaps most notable for her courageous and correct decision to remove the Confederate flag from the State House in the aftermath of the race-motivated shooting at the Emanuel African Methodist Episcopal Church in 2015. Her successful tenure as governor laid the foundation for her subsequent role as the United States Ambassador to the United Nations, and the first Indian-American to serve in a presidential cabinet.

In the international arena, Haley has been a loyal supporter of Ukraine against Russian aggression, and of Israel since long before the barbaric attack by Hamas on October 7th. She supported the decision to withdraw from the Iran Treaty, and called out Iran for its support of Hamas, Hezbollah, and the Houthi rebels in Yemen who have been attacking commercial and U.S. warships in the Red Sea recently.

Haley has been a staunch defender of human rights, to include opposing the persecution of Rohingya Muslims in Myanmar and Uyghurs Muslims in China. Yet, she also opposed a Muslim immigration ban, stating, “we should ever ban anyone based on their religion”. Perhaps being raised a Sikh, and converting to Christianity following her marriage, has given her a broader perspective on religion than many of us have.

At a time when the world is witnessing a concerning rise in antisemitic sentiments, Haley remains an outspoken defender of the Jewish community. Haley has also been a consistent supporter of women. She has called out sexual violence against women in Myanmar, China, and most recently, by Hamas in Israel.

Haley has strong military connections in her family, which makes me feel that she will be a responsible commander-in-chief, unlikely to send U.S. service members into harm’s way without careful deliberation. Her husband is an officer in the South Carolina National Guard and her eldest brother is a retired U.S. Army combat veteran. Haley’s husband was deployed to Afghanistan during her first term as Governor, and has just been deployed to the Horn of Africa.

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Nikki Haley’s track record of experience, good judgement, and decisive leadership, from the statehouse to the global stage, underscores her qualifications for the highest office in the land. Her more centrist views and pragmatic approach make her a compelling choice for Republicans, Democrats, and independents alike.

In a political landscape marked by divisive figures, Haley emerges as a candidate who can bridge the gap. Her even temperament, courage, and commitment to common-sense values position her as the ideal candidate to lead our nation forward. If you’re looking to break the cycle of low-approval candidates, Haley is a worthy consideration for a brighter political future.

Sex, Doubt, and Regret

Despite a lack of evidence, it is possible that some youths who undergo gender-affirming care find themselves in an improved condition. But, certainly not all are. Those who begin an early stage of transitioning, but don’t proceed to the next step, are known as “desisters”, as opposed to those who do, the “persisters”. Detransitioners proceeded further with transitioning, to include puberty blockers and/or cross-sex hormones, and frequently gender reassignment surgeries, but then decide to revert back to their biological gender.

Keira Bell’s story is compelling. Born a female, she transitioned to a male through the U.K.’s Tavistock Clinic (GIDS). She began puberty blockers at sixteen years of age, a year later she began receiving testosterone, and when she was twenty years of age, underwent a double mastectomy. She has since realigned with her biological gender, but with “possible infertility, loss of my breasts and inability to breastfeed, atrophied genitals, a permanently changed voice, facial hair”, in her words. In 2020, Keira sued the Tavistock clinic and won. While that verdict was overturned on appeal, the concerns of people like Keira, as well as current and former Tavistock staff, ultimately led to a ban on transgender youth care outside of a research setting, as I noted in my last post, and will discuss further, shortly.

Persuasion, 2021: Keira Bell: My Story

Chloe Cole is the equivalent of Keira on this side of the Atlantic. Suffering from anxiety and depression, she began identifying as a male at age 12. At 13, she was started on puberty blockers and cross-sex hormones. Two years later, when she was only 15, she underwent a double mastectomy. Again echoing Keira, Chloe is now suing Kaiser Permanente, the healthcare system through which she received her care, alleging medical malpractice. I know my citations below for Chloe come from right-leaning media sites, the Daily Signal and the New York Post; but, try finding a story about Chloe on CNN, Reuters, or The Associated Press. I couldn’t.

The Daily Signal, 2023: Why Chloe Cole Deserves the Jazz Jennings ‘Trans’ Treatment – and More

New York Post, 2022: ‘I Literally Lost Organs:’ Why Detransitioned Teens Regret Changing Genders

Keira and Chloe are not alone in their concerns, as many other detransitioners have come forward in the past several years. Jackie, another natal female, decided to reverse her transition just before she underwent “top surgery” (a double mastectomy). In what I think is an insightful reflection on the double-speak so common in this area, Jackie said; “Everybody says that gender is a social construct, but we also act like it’s somehow an innate part of a person’s identity, “I started to think the whole concept of transitioning was regressive.”

The Stranger, 2017: The Detransitioners: They Were Transgender, Until They Weren’t

The Free Press, 2022: The Testosterone Hangover

Even admitting that desisters and detransitioners exist, and suggesting they should be considered relevant to the discussion of the efficacy of care provided, can be problematic. There exists a kind of bigotry from some within the transgender community; that such individuals are something akin to traitors. Kinnon MacKinnon, a transgender man and assistant professor of social work in Canada dedicated to the care of sexual and gender identity health, provides one such example. He was previously dismissive of detransitioning and reports of patient regret; but, after he and his team of researchers talked to 40 detransitioners in the United States, Canada and Europe, he has changed his opinion.

Reuters, 2022: Why Detransitioners are Crucial to the Science of Gender Care

The Atlantic, 2023: Take Detransitioners Seriously

Lisa Littman, a physician who is somewhat notorious in the transgender community for proposing the existence of rapid-onset gender dysphoria (ROGD), particularly among adolescent females (which I think has some validity), also a performed a survey of 100 detransitioners. It was an online survey, so may not be generalizable to all detransitioners, but I think her findings are still interesting. A slight majority, 55%, did not feel that they had received an adequate evaluation by a physician or mental health professional before beginning to transition. And, only 24% of those surveyed had informed their clinicians that they had detransitioned, which seems likely to have skewed results coming from gender identity clinics, as these patients simply would have been listed as “lost to follow up”.

For both natal females and natal males, the top reason given for detransitioning was “I became more comfortable identifying as my natal sex”. Other frequently endorsed reasons for detransition included realizing that their gender dysphoria was related to other issues, health concerns due to transitioning, observing that transition did not help their dysphoria, and that they found other ways to deal with their dysphoria.

Archives of Sexual Behavior, 2021: Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners

MacKinnon, the transgender man and Canadian social worker, is increasingly being joined by others in the transgender care providing community voicing their concerns, to include several who, like him, are also transgender. Marci Bowers, a gynecologist and a specialist in gender reassignment surgeries, is a transgender woman and the the current president of the World Professional Association for Transgender Health (WPATH). She is perhaps best known for having operated on Jazz Jennings, a trans-female, of the reality-television show “I Am Jazz”. Bowers has raised concerns that puberty blockers are being given too early, that there may exist a contagion effect behind the rapid rise in female adolescents presenting with gender dysphoria, and that some adolescents are being offered affirmative medical care without appropriate assessments and safeguards.

Jennings, who started on puberty blockers at the age of 11, has reported that she has no libido and cannot orgasm. Jennings’ surgeon, Bowers, acknowledges that “every single child … who was truly blocked at Tanner stage 2 (an early stage of puberty at which blockers are commonly prescribed), has never experienced orgasm. I mean, it’s really about zero”. Given her early use of puberty blockers, Jennings didn’t have adequate penile and scrotal skin for a vaginoplasty, so a section of stomach had to be used; this ruptured postoperatively, requiring emergency surgery to repair.

“I’m not a fan of blockade at Tanner Two anymore, I really am not”, says Bowers. “The idea all sounded good in the very beginning.” “Believe me, we’re doing some magnificent surgeries on these kids, and they’re so determined, and I’m so proud of so many of them and their parents. They’ve been great. But honestly, I can’t sit here and tell you that they have better – or even as good – results. They’re not as functional. I worry about their reproductive rights later. I worry about their sexual health later and ability to find intimacy.” To be transparent, Bowers has walked back some of her comments more recently, I suspect due to pushback from her colleagues at WPATH, but I think her earlier comments are likely more authentic views.

The Free Press, 2021: Top Trans Doctors Blow the Whistle on ‘Sloppy’ Care

Erica Anderson, a clinical psychologist and transgender woman, co-authored a remarkably nuanced article in the Washington Post with the founding clinical psychologist of the first pediatric gender clinic in the U.S., Laura Edwards-Leeper. Early in this opinion piece, they state, “This is an era of ugly moral panic about bathrooms, woke indoctrination and identity politics in general. In response, we enthusiastically support the appropriate gender-affirming medical care for trans youth, and we are disgusted by the legislation trying to ban it.”

But, they go on to admit that, “A flood of referrals to mental health providers and gender medical clinics, combined with a political climate that sees the treatment of each individual patient as a litmus test of social tolerance, is spurring many providers into sloppy, dangerous care. Often from a place of genuine concern, they are hastily dispensing medicine or recommending medical doctors prescribe it – without following the strict guidelines that govern this treatment.”

The Washington Post, 2021: The Mental Health Establishment is Failing Trans Kids

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Other staff at gender clinics in the U.K. and U.S. have also raised concerns, attempted to steer their services in more prudent directions, were rebuffed or ignored, and some became whistleblowers. The earliest I could find was from David Bell, a former staff governor at the Tavistock and Portman NHS Foundation Trust (GIDS), who sent an internal report to its leaders in 2018, urging them to suspend all experimental hormone treatment for children who wished to change gender until there was better evidence of the outcomes. He was joined by multiple other staff members, to include Sue Evans, a clinical nurse therapist, and her husband, Marcus, a psychoanalyst and a senior staff member at Tavistock.

The Times, 2020: David Bell: Tavistock Gender Clinic Whistleblower Faces the Sack

The Free Press, 2022: How Tavistock Came Tumbling Down

The Spectator, 2021: Tavistock Gender Clinic Whistleblowers have been Vindicated

In 2021, Bernadette Wren, a former clinical psychologist at GIDS, validated many of the concerns raised by David Bell, and Sue and Marcus Evans, in a thoughtful post titled Epistemic Injustice. Towards the end, she writes, “If a whistle-blowing report on GIDS was needed, I wish I’d written it myself. It would have highlighted the isolation of a group of conscientious clinicians who were trying to cope, in the absence of adequate support, funding and external expertise, with complex clinical, empirical, legal and procedural challenges while an upheaval in cultural narratives of sex and gender took place across the country.”

London Review of Books, 2021: Epistemic Injustice

In the U.S., Jamie Reed, a former case worker at the The Washington University Transgender Center at St. Louis Children’s Hospital is another recent whistleblower of note. She refers to herself as a “queer woman, and politically to the left of Bernie Sanders”, who “did a lot of gender questioning myself”, and is married to a trans-man.

“I Want My Breasts Back”

“One of the saddest cases of detransition I witnessed was a teenage girl, who, like so many of our patients, came from an unstable family, was in an uncertain living situation, and had a history of drug use. She was put on hormones at the center when she was around 16. When she was 18, she went in for a double mastectomy, what’s known as “top surgery.”

“Three months later she called the surgeon’s office to say she was going back to her birth name and that her pronouns were “she” and “her.” Heartbreakingly, she told the nurse, “I want my breasts back.” The surgeon’s office contacted our office because they didn’t know what to say to this girl.”

The Free Press, 2023: I Thought I Was Saving Trans Kids. Now I’m Blowing the Whistle.

I’m including Reed’s report for completeness, but will note that other providers at the St. Louis clinic, and of its some patients and their parents, have disputed her claims, and a review performed by the center concluded that her claims were “unsubstantiated”. Yet, another parent subsequently came forward, detailing her experiences at the center with her son, who was placed on a puberty blocker, experienced mental and physical health deterioration, expressed suicidal ideation, was briefly hospitalized, and placed on several psychiatric medications. Missouri’s attorney general announced an investigation into care at the center, and also announced restrictions on transgender care, not only for youths, but also for adults. So, this is an evolving story.

Missouri Independent, 2023: Washington University Inquiry Found Allegations Against Transgender Center ‘Unsubstantiated’

Missouri Independent, 2023: Former Employee of St. Louis Transgender Clinic Reaffirms Allegations of Misconduct

The Free Press, 2023: ‘I Felt Bullied’: Mother of Child Treated at Transgender Center Speaks Out

Associated Press, 2023: Missouri to Limit Gender-Affirming Care for Minors, Adults

Here in the U.S., apart from state-by-state restrictions on gender-affirming care, we have yet to see significant signs of caution or slowing down. Reuters interviewed doctors and staff at 18 gender clinics across the country, who described their processes for evaluating transgender youths. None reported “anything like the months-long assessments (that Dutch researchers) adopted”. At seven of the clinics, staff said that “if they don’t see any red flags and the child and parents are in agreement, they are comfortable prescribing puberty blockers or hormones based on the first visit, depending on the age of the child.”

Reuters also interviewed the parents of 39 youths who had undergone evaluation at a gender identity clinic, and the parents of 28 of those children said they “felt pressured or rushed to proceed with treatment.” One parent reported that, “after an initial one-on-one consultation of little more than an hour with the teen, a psychiatrist said he was a good candidate for puberty blockers”, and that “an endocrinologist recommended the same after talking with the family for 15 minutes.” This parent reflected that “the message was, let your kid drive the bus. Wherever they lead you, that’s what you should do.”

Reuters, 2022: As More Transgender Children Seek Medical Care, Families Confront Many Unknowns

Meanwhile, in the Netherlands, where this journey began, we are seeing more cautionary warnings. Annelou de Vries is a child and adolescent psychiatrist whose early work emphasized the importance of careful assessments before beginning medical transitioning. She is concerned about the growing number of youths seeking treatment, but is more concerned about moving too fast; prescribing puberty blockers and hormones when they may not be appropriate. She also told Reuters there is no evidence that “providing care immediately leads to a decline in self harm or would prevent suicide.”

“The existential ethical dilemma in transgender care is between on one hand the (child’s) right for self-determination,” de Vries said. “On the other hand, the do-not-harm principle of medical intervention. Aren’t we intervening medically in a developing body where we don’t know the results of those interventions?” In the United States, in particular, she said, “the transgender right or child’s right seems to be put forward more strongly.”

If you have time for only one or two references to read, I highly recommend the following, from the New York Times, and the one cited just above, from Reuters. Both are nicely nuanced in their discussion of a topic in which there are more unknowns than knowns. Personally, I agree with some of what is written in each, while at the same time disagreeing with other points. To me, that means they have struck a reasonable balance. It is very easy to cherry-pick one’s sources when no unimpeachable data exists, but it’s much harder to admit uncertainty in the same circumstance, especially given our current politically polarized environment.

The New York Times Magazine, 2022: The Battle Over Gender Therapy

To conclude this series on youth transgender care, I will restate my premise: Since we have no conclusive overall benefit, and clear instances of individual harm, we should not allow gender-affirming youth care to be pursued, at least not outside of a rigorously controlled scientific environment with careful oversight. On one side, we have anecdotal reports of possible benefit; while on the other, we have clear instances of patient regret, parental alarm, and provider doubt. For now, that’s evidence enough for me that we should seek a different path until better data is made available.

Sex and Science

The modern era of medical transitioning for transgender youths began in the Netherlands sometime in the late 1980s, when a 13 year old natal female, FG (identified as B in the medical literature), who identified as male, became the first adolescent to be treated with a puberty blocker for gender dysphoria (then known as gender identity disorder). FG continued on puberty suppression until 18 years of age, when testosterone was started, and he ultimately underwent surgical transitioning procedures at 20 and 22 years of age. This first case study appeared in the scientific literature in 1998.

European Child & Adolescent Psychiatry, 1998: Pubertal Delay as an Aid in Diagnosis and Treatment of a Transsexual Adolescent

A gradual increase in experience with a small number of similar patients, led to the development of the “Dutch Protocol”, introduced in 2006, which I outlined in my last post. The Dutch model was initially adopted in Boston in 2007, at which time the total accumulated published experience from the Netherlands consisted of only 54 patients.

An initial request to adopt the Dutch protocol at The Gender Identity Development Service (GIDS) in the U.K. was rejected by the NHS Research Ethics Committee in 2009, “on the grounds that it was not a proper randomized trial and therefore could not yield valid results”. The proposal was revised, arguing that a randomized trial was not practical, and submitted to a different Research Ethics Committee in 2010. The GIDS began a trial of the Dutch protocol under the guise of an experiment in 2011, at which time the published Dutch experience had increased to merely 70 patients. In 2014, the Dutch protocol was adopted as general policy at GIDS by the NHS, despite the fact that they had not published any results of their promised experiment.

Meanwhile, in the U.S., the Dutch protocol eventually morphed into the more aggressive “Gender Affirmative Model”, introduced in 2013, which has since been exported to other countries, to include back to the U.K.

This was a remarkably rapid progression, from introduction of the Dutch protocol in 2006 to the rollout of the gender affirmative model in 2013, just seven years later, especially given the limited research upon which it was based. And in the decade since, there has been a rapid rise in the number of youth referrals to gender identity clinics, an increase of anywhere between 1000% and 4000%, depending upon which country or clinic is considered, with a particularly marked rise in the number of natal females compared to natal males, and little in the way of new original research.

The earliest comprehensive critique I have found comes from a group of Australian scientists and published in the influential journal, The Lancet, in 2017. They state that “there is a dearth of research to inform evidence-based practice. Few studies have examined the ability of puberty-suppression treatments to alleviate the distress that might have been experienced by children and adolescents with a transgender identity. Similarly, very few studies have assessed physical and cognitive function during treatment.”

The Lancet, 2017: Puberty Suppression in Transgender Children and Adolescents

Similarly, a group of U.S. researchers, note that “despite the precedent of years of gender-affirmative care, the social, medical and surgical interventions are still based on very low-quality evidence. A U.S. psychologist concurred, stating, “It is obvious that our state of knowledge regarding appropriate and timely gender transition … and its consequences is not where we would like it to be.”

Journal of Sex & Marital Therapy, 2022: Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults

Journal of Sex & Marital Therapy, 2022: Commentary on Levine et al: Festina Lente (Rush Slowly)

Due to concerns raised by a detranstioner and whistleblowers in the U.K., who we will return to next in this series, the National Health Service (NHS) recommended a review be conducted by the National Institute for Health and Care Excellence (NICE), which found that, “The key limitation to identifying the effectiveness and safety of gender-affirming hormones for children and adolescents with gender dysphoria is the lack of reliable comparative studies. All the studies included in the evidence review are uncontrolled observational studies, which are subject to bias and confounding and were of very low certainty.”

National Institute for Health and Care Excellence (NICE), 2020): Evidence Review: Gender-Affirming Hormones for Children and Adolescents with Gender Dysphoria

In response, the NHS to called for an independent investigation supervised by Hilary Cass, a former President of the Royal College of Paediatrics and Child Health. The review was critical of the clinical approach, the suppression of dissent, and the lack of systematic data collection at the GIDS. Among other conclusions from the Cass review: “Evidence on the appropriate management of children and young people with gender incongruence and dysphoria is inconclusive both nationally and internationally. Internationally as well as nationally, longer-term follow-up data on children and young people who have been seen by gender identity services is limited…” and “there has been research on the short-term mental health outcomes and physical side effects of puberty blockers for this cohort, but very limited research on the sexual, cognitive or broader developmental outcomes.”

The Cass Review, 2022

So many critiques have appeared in the scientific literature in the past few years that my main problem is not finding them, but deciding which to include and which to exclude. I’ll limit myself to just four more. The first two cited below come from Oxford University sociologist Michael Biggs who published thorough critiques of the original Dutch research and the experience in the U.K. The second two come from Australian psychiatrist Alison Clayton, which are especially interesting to read. In addition to broader critiques, both articles provide examples of regretful past medical practices based on poor evidence, to include lobotomies for psychiatric patients and prone sleeping position for infants, likely contributing to tens of thousands of deaths due to SIDS.

Oxford University, Department of Sociology, 2019: The Tavistock’s Experiment with Puberty Blockers

Journal of Sex & Marital Therapy, 2022: The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence

Archives of Sexual Behavior, 2021: The Gender Affirmative Treatment Model for Youth with Gender Dysphoria: A Medical Advance or Dangerous Medicine?

Archives of Sexual Behavior, 2022: Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect – The Implications for Research and Clinical Practice

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So, is anyone paying attention to these concerns? Fortunately, the answer is yes, but not so much here at home, at least not now. As The Economist put it in their cover story this week, “On different sides of the Atlantic, medical experts have weighed the evidence for the treatment of gender-dysphoric children and teenagers, those who feel intense discomfort with their biological sex. This treatment is life-changing and can lead to infertility. Broadly speaking, the consensus in America is that medical intervention and gender affirmation are beneficial and should be more accessible. Across Europe several countries now believe that the evidence is lacking and such interventions should be used sparingly and need further study. The Europeans are right.”

The Economist, 2023: What America has got Wrong About Gender Medicine

In response to the NICE report and the subsequent Cass review, the NHS announced that it is restructuring its youth gender identify services. For all youth, psychosocial counseling will be a primary emphasis. Social transitioning will not be encouraged. No medical transitioning will be offered to prepubescent children. And, for adolescents, puberty blockers and cross-sex hormones will only be made available in the context of a formal research protocol.

Sweden, Finland, and Norway have all taken comparable significant steps away from gender affirmative care, emphasizing the paucity of good data to support such care, encouraging a more cautious approach to care with a particular focus on mental health care, and generally restricting the use of medical transitioning care to research centers.

Sweden’s National Board of Health and Welfare “currently assesses that the risks of puberty blockers and gender-affirming treatment are likely to outweigh the expected benefits of these treatments. Finland’s Council for Choices in Health Care acknowledges that “research data on the treatment of dysphoria due to gender identity conflicts in minors is limited”, and that there is also a “need for more information on the disadvantages of procedures and on people who regret them.” The Norwegian Healthcare Investigation Board (NIHB) “recommends that puberty blockers and hormonal and surgical gender confirmation treatment for children and young people are defined as experimental treatment.”

France has not yet restricted access to gender affirmative care, but its Académie Nationale de Médecine urges that “great medical caution must be taken in children and adolescents, given the vulnerability, particularly psychological, of this population and the many undesirable effects, and even serious complications, that some of the available therapies can cause”. It also acknowledges social contagion as a cause of the rapid rise in referrals, stating “whatever the mechanisms involved in the adolescent – overuse of social networks, greater social acceptability, or example in the entourage – this epidemic-like phenomenon results in the appearance of cases or even clusters in the immediate surroundings.”

NHS, 2022: Interim Service Specification for Specialist Gender Dysphoria Services for Children and Young People – Public Consultation

Socialstyrelsen, 2022: Care of Children and Adolescents with Gender Dysphoria

Palveluvalikoima, 2020: Medical Treatment Methods for Dysphoria Associated with Variations in Gender Identity in Minors – Recommendation

Ukom, 2023: Pasientsikkerhet For Barn Og Unge Med Kjønnsinkongruens

Académie nationale de médecine, 2022: Medicine and Gender Transidentity in Children and Adolescents

And, notably, returning to the Netherlands, Thomas Steensma, a psychologist at the Center of Expertise on Gender Dysphoria in Amsterdam, has raised concerns about the increase in number of presenting youths, particularly the increase in natal females, and the paucity of data used to support treatment, most of which has come from his country.

“We don’t know whether studies we have done in the past can still be applied to this time. Many more children are registering, and also a different type. Suddenly there are many more girls applying who feel like a boy. While the ratio was the same in 2013, now three times as many children who were born as girls register, compared to children who were born as boys.”

“Little research has been done so far on treatment with puberty blockers and hormones in young people. That is why it is also seen as experimental. We are one of the few countries in the world that conducts ongoing research about this. In the United Kingdom, for example, only now, for the first time in all these years, a study of a small group of transgender people has been published. This makes it so difficult, almost all research comes from ourselves.”

Algemeen Dagblad, 2021: More Research is Urgently Needed into Transgender Care for Young People: “Where Does the Large Increase of Children Come From?”

Given the current insistence on the benefits of gender affirmative care here at home, I was pleasantly surprised to find that scientific researchers in the U.S. had taken an even earlier interest in the uncertainties regarding such care. The NIH asked the Institute of Medicine to convene a consensus committee to conduct a review “assessing the state of the science on the health status” of LGBT population writ large, and their report was published way back in 2011.

Focusing only on transgender youth, some of their findings include, “a relatively small percentage of gender-variant children may develop an adult transgender identity”, and “while GnRH analogs may be used to alleviate gender dysphoria among adolescents, a paucity of empirical data exists concerning how these medical interventions affect overall physical health and well-being” (GnRH analogs is the more proper medical name for puberty blockers). They go on to argue “there is a need for more research on the health implications of hormone use (e.g., randomized controlled trials of puberty-delaying hormones, masculinizing and feminizing hormone therapies, and the consequences of long-term hormone use).”

National Academies Press, 2011: The Health of Lesbian, Gay, Bisexual, and Transgender People

In 2015, the NIH authorized a comprehensive study to examine the mental health and other outcomes for gender dysphoric youths treated at four gender identity clinics in the U.S. But, don’t get your hopes up; long term results will take years to accumulate, and still will not adequately address the concerns raised by the multiple government agencies and scientific panels cited above. Although this study has more participants than the Dutch studies, over 400 as of the most recent report, it is the same type of observational study, rather than the randomized control trial recommended to the NIH by the Institute of Medicine.

JMIR, 2019: Impact of Early Medical Treatment for Transgender Youth: Protocol for the Longitudinal, Observational Trans Youth Care Study

In the last published follow up I have found, FG was 35 years old and reportedly generally satisfied with his decision to transition, though he was not happy with the results of his metoidioplasty (the creation of penis-like structure out of the clitoris and labia). “He did not like its size and shape and he could hardly urinate in a standing position. He was able to have orgasms, but he could not have sexual intercourse. Because of his desire to have more convincingly male appearing external genitals and his wish to be able urinate in a standing position, he considered having a phalloplasty” (a much more complicated produce to create a penis-like structure utilizing donor tissue from elsewhere on the body).

Archives of Sexual Behavior, 2011: Puberty Suppression in a Gender-Dysphoric Adolescent: A 22-Year Follow-Up

The Dutch researchers obviously consider FG’s results a success, but compared to what? One has to wonder how FG might be now, if she had undergone normal female puberty; perhaps worse, but perhaps better. This is the fundamental problem with all of the youth transgender studies performed to date; there is no comparison group against which to measure success or failure. In the absence of such comparative studies, advocates for such care cannot prove they are right. The flip side is also true, however; I cannot definitively prove they are wrong, either.

Sex and Youths

If the care of transgender youths seems like a new issue, that’s because it is. And, if it feels as if it has also been a rapidly growing one, that’s because that is also true. In part because of this newness and rapid expansion, but also due to a lack of scientific rigor in the gender identity clinics caring for these children and adolescents, we have not established an adequate knowledge base of how best to care for these youths. Due to all these factors, newness, rapidity, and inadequate knowledge, pushback was inevitable, and long overdue.

I think the critiques of politicians and activists should be set aside, as they may have other motives for speaking out. But, there are three more credible sources of resistance: the scientific community, itself; concerned current and former transgender care providers; and those youths and adults who have regretted their prior decisions and realigned with their biologic gender, the desisters and detransitioners. I will present those counterpoints in my next post, but I first want to review a bit of history, as I think it is informative.

The modern era of the care of transgender youths began in the Netherlands in the 1980s and 1990s, and the “Dutch Protocol” was formally introduced in 2006. For children with gender dysphoria, counseling was performed, but it was not focused on the gender dysphoria, itself. Parents were encouraged to adopt an attitude of watchful waiting, as it was known that most gender dysphoric children would resolve their feelings of gender disparity by or during adolescence. Social transitioning was generally discouraged, because such decisions can lead to more social obstacles for the later adolescent to realign with his or her biological sex. This cautious approach to gender dysphoric children seems entirely appropriate to me.

For adolescents with persistent gender dysphoria, puberty blockers might be offered at the onset of physical changes associated with puberty, possibly followed by cross-sex hormones at around age 16. Gender reassignment surgeries were typically not offered until age 18. Unlike with the watchful waiting approach to gender dysphoric children, where there is scientific support, there isn’t good research to justify this care of gender dysphoric adolescents. As an aside, some of the early Dutch research was supported by the pharmaceutical manufacturer of the puberty blocker used in those studies; that isn’t necessarily wrong, but I still find it bothersome.

European Journal of Endocrinology, 2006: Clinical Management of Gender Identity Disorder in Adolescents: A Protocol on Psychological and Paediatric Endocrinology Aspects

Journal of Sexual Medicine, 2023: Children and Adolescents in the Amsterdam Cohort of Gender Dysphoria: Trends in Diagnostic and Treatment Trajectories During the First 20 Years of the Dutch Protocol

The first dedicated clinic for gender dysphoric American youths was established at Boston Children’s Hospital in 2007; today, we have more than 60 such clinics. While U.S. centers initially adopted the Dutch protocol, a “Gender Affirmative Model” was introduced in 2013. The authors didn’t lay out a specific guideline of care, but rather a philosophy of their approach to gender dysphoric and non-conforming youths, to “allow time and space for exploration and self-acceptance within an infinite variety of authentic gender selves”. This model takes the claims of even very young children at face value, and does not embrace the watchful waiting approach of the Dutch protocol. Near the end of the editorial, the authors ask multiple questions for which they agree we need answers, to include the consequences of receiving puberty blockers and cross-sex hormones; I found that paragraph refreshingly honest.

We didn’t have answers to those questions in 2013, and still do not. While there have been dozens of reports published in support of this protocol or that model, none have been scientifically rigorous, in the sense of proving or disproving a hypothesis, with adequate sample sizes, control groups, and treatment randomization. Instead, most are simply observational reports. These are perfectly acceptable, even necessary, but their primary purpose is to generate hypotheses that might later be verified or falsified. And, that has yet to be done.

Human Development, 2013: The Gender Affirmative Model: What We Know and What We Aim to Learn

American Psychological Association, 2018: Introduction to the Gender Affirmative Model

Hormone Research in Paediatrics, 2022: The Evolution of Adolescent Gender-Affirming Care: An Historical Perspective

large_2 disclosing gender-biased social norms

During this time, there was also a shift in how the medical community, and especially the psychiatric community, began to view gender issues. Transvestites became transexuals, and then transgender. Gender identity disorder, previously a mental health disorder, became gender dysphoria, now a personal identity rather than a psychiatric condition, and dysphoria, a feeling of discomfort with one’s own body, became less of a criteria for pursuing gender transitioning. A wonderful, almost metaphysical review of gender, sexuality, and psychiatry, is cited below, and well worth a read.

Cambridge University Press, 2020: Sex, Gender and Gender Identity: A Reevaluation of the Evidence

In addition to the unanswered questions of how best to care for gender dysphoric and non-conforming children and adolescents, we have seen a rapid increase in referrals to gender identity clinics around the world in the past decade. Although there have been many hypotheses advanced, to include the impact of mainstream media, the influence of online communities such as YouTube and Tumblr, and the possibility of social contagion within friend groups (especially biologic females), this phenomenon remains largely unexplained and concerning for many.

Reuters, 2022: A Gender Imbalance Emerges Among Trans Teens Seeking Treatment

I could not find a comparable graph for referrals in the United States overall, but individual reports suggest a comparably rapid rise in the past decade has been experienced here, as well. The following citations give proof to this claim.

Reuters, 2022: Putting Numbers on the Rise in Children Seeking Gender Care

Williams Institute, 2022: How Many Adults and Youth Identify as Transgender in the United States?

The youth transgender movement is relatively new, it is growing rapidly, and we don’t have good data upon which to base care decisions. Still, from what we do know, I think we can make several safe assumptions to inform what our approach might be.

First, and perhaps most importantly, is how we should deal with gender dysphoric children. Here, I believe we should embrace the watchful waiting approach of the Dutch protocol, recognizing that the majority will desist by adolescence. We should not encourage social transitioning, as that can lead to more social obstacles should the child later realign with their natal sex. And while I think schools have a role to play in encouraging children to be more accepting and less inclined toward bullying generally, I don’t think they should be addressing issues of gender identity. This is especially true of primary school students, who are probably not capable of understanding these issues in a meaningful manner, anyway.

For children and adolescents alike, we should treat the whole of the person before us, not focus only on the gender dysphoria on non-conformity. Many of these youths have mental health problems, such as anxiety, depression, attention deficit disorders, autism spectrum disorders, and substance use disorders. They have a much higher incidence of suicidal ideation and self-inflicted injuries. Many have a history of sexual abuse or other adverse childhood experiences. From some reports, which we will get to in my next entry, it appears that these other issues, which may be the underlying reason for the purported gender dysphoria, are sometimes ignored, while the dysphoria is treated. Especially for female adolescents, counselors should consider the impact of social media, the possibility of social contagion within friend groups, and the understandable apprehension of becoming a woman in our overly sexualized culture.

We should avoid prescribing puberty blockers to prepubescent and adolescent youths. We don’t have clear data on the long term effects of preventing puberty to proceed naturally, and even studies of the purported benefits of puberty blockers to the mental health of gender dysphoric adolescents has been mixed. Apart from external bodily changes, brain maturation is an important part of puberty, and we don’t know how that is being affected. It is argued, but not proven, that puberty blockers are “totally reversible”, but this is almost certainly not the case. And, based upon observational reports, the majority of youths who receive puberty blockers will later proceed with cross-sex hormones, which have undeniably irreversible effects. Some youths treated with puberty blockers and cross-sex hormones will be made permanently infertile, and some may never experience an orgasm.

One downside of allowing puberty to proceed naturally is that transgender adults will have to deal with the persistence of secondary sexual characteristics of their biologic sex, such as facial hair or a deeper voice for transgender females. That’s not nothing, but still might be overall preferable to the challenges experienced by detransitioners, who have to deal with even greater changes, especially those who have undergone surgical transitioning. Furthermore, for those who remain comfortable with their decision to transition, the use of puberty blockers and cross-sex hormones in adolescence can make some surgical transitioning procedures more difficult later.

Surgical transitioning is something that I believe should only be performed on adults, and never on youths of any age. So called “top surgery”, mastectomy for natal females, and breast implants for natal males, are common. Removal of sexual organs, such as the uterus and ovaries for natal females and the testicles of natal males are also common. More advanced “bottom surgery”, creating a penis-like structure from the clitoris of natal females and a vagina-like structure from the penis and scrotum of natal males, is less common, due to the complexity of the procedures and associated complications.

It’s not at all clear to me how youths faced with such choices as puberty blockers, cross-sex hormones, or surgical transitioning can ever give truly informed consent. Many will have never experienced an orgasm or given much thought to being a parent or wanting to breastfeed one day. And, we know from other research that the human brain doesn’t fully mature until 23 to 25 years of age. These are hefty decisions we’re leaving to immature young people and to their concerned parents who want the best for their children, but may passively accept the advice of the clinician in the white coat.

Are we on the right path? Personally, I don’t think so, and I am certain that we don’t have good evidence to establish that we are. In my next installment, we’ll hear from the broader scientific community, current and former transgender care providers, and those who have regretted their decisions, the desisters and detransitioners.

Neuropsychiatric Disease and Treatment, 2013: Maturation of the Adolescent Brain

The Lancet, 2017: Puberty Suppression in Transgender Children and Adolescents

The New Atlantis, 2017: Growing Pains

Reuters, 2022: As More Transgender Children Seek Medical Care, Families Confront Many Unknowns

Sex is Messy

Transgender issues are a hot political topic these days, and I think that is both understandable and appropriate. The first time I remember thinking much about this issue was in 2016, when I first ran for Congress, and bathroom bills were a particularly pressing concern. Since then, this brave new world has expanded exponentially, and, I think, haphazardly. The GOP-lead Iowa legislature has proposed a number of statutes that would address various aspects of transgender care as it applies to our youth, and I am supportive of some of those efforts; not as former politician, but as a physician and parent.

About two years ago, I began reading reports of transgender care providers speaking out against questionable care they observed being provided in their clinics, and hearing tragic stories of youth who had received “gender-affirming” care, now regretting their choices, and opting to return, in as much as possible, to their birth sex. I decided to do a deep dive into the scientific literature, eventually reviewing dozens of reports, probably close to one hundred, from the foundational studies on transgender care, to more recent, and more critical, analyses.

What I found was disturbing, with the literature providing what I believe is next to no support for much of our current “gender-affirming model” of care. Such care is currently being advocated by various governmental and medical institutions, from the Centers for Disease Control and Prevention, to the America Medical Association, the American Academy of Pediatrics, and the American Psychiatric Association. Still, in all the studies I have reviewed to date, I simply find no good justification for much of the care that is being rendered to our youth, to include puberty blockers, hormone therapy, and surgical procedures.

It’s not that studies purportedly supporting such treatment don’t exist; there are in fact many, but all are compromised by numerous shortcomings. None are randomized, in which similar patients randomly receive different treatments, and results are compared. None include a suitable control group with which to compare the efficacy of any treatment versus supportive care only. Most are compromised by small sample sizes, which inhibits the ability to draw statistically meaningful results. Some exhibit obvious bias in the reporting of their results, emphasizing the positives, however small, while downplaying or ignoring any negatives.

The “gold standard” of research would be a randomized, double-blinded, controlled trial. What this means is that researches would intake a bunch of subjects, in this case, youth presenting with gender dysphoria, would randomly separate them to receive different treatment regimens, with participants and researchers “blinded” (as much as possible, at least) to which participants were in which treatment or control groups. For example, some participants could receive supportive psychiatric care only, some with psychiatric care and social transitioning (wearing clothing of their chosen gender and going by different names and pronouns), and some with both of the above, plus puberty blockers and hormone treatment, when older and if appropriate.

If such a study were done, combining participants from multiple centers in multiple countries to ensure an adequate sample size, we might have a better idea of how best to care for our youth with gender identity concerns. No such study has been performed to date, however, and it has been argued that it would be unethical to perform such a study now, based upon the purportedly positive results of the research performed to date, which is a conclusion that I cannot comprehend.

Still, there are some conclusions we can reach with reasonable confidence based upon the research which that has been reported. First, for prepubescent youth who present with gender dysphoria, most will resolve that discrepancy before or during puberty, will accept their biologic sex, and will go on to be healthy adults. Therefore, for any children who present with complaints of gender dysphoria, I think the “watchful waiting” approach initially advocated in the “Dutch model”, where the modern era of transgender care originated in the 1980s and 1990s, is appropriate.

Second, we know from multiple studies that youth who present with complaints of gender dysphoria, particularly as adolescents, have a much higher incidence of mental illnesses than the general population, to include anxiety, depression, oppressive-compulsive disorders, autism-spectrum disorders, suicidality, and non-suicidal self-harm. Are these psychiatric conditions being misdiagnosed as gender dysphoria, such that if they were adequately treated, the dysphoria would resolve? Does the presence of gender dysphoria increase the likelihood of mental illness, especially anxiety and depression, due to family or social disparagement? Either option seems possible, at least in some circumstances, but neither has been proven.

Here, I support legislation from Iowa GOP lawmakers who have proposed mandating that parents be informed should their children and adolescents wish to present as a different gender, whether by dress, name, or pronouns. Sure, not all parents will be as supportive of their gender questioning youth as others might like; but, it should not be the decision of those unnamed others, or of school officials, who are not as intimately, legally, and morally responsible for their children, that matters, here. Furthermore, given the increased risk of suicide among youth with gender dysphoria, I can’t imagine why school districts would wish to accept potential legal liability by withholding such information from parents.

There also exists suggestive, but I don’t think conclusive, observations from the studies done to date. For example, in the past decade or so, there has been a marked increase in the number of youths presenting with complaints of gender dysphoria; and, while this could be due simply to greater awareness and acceptance, there also exist suggestive findings of a media effect, reported adverse influences of social media, and the possibility of a “social contagion effect”, particularly among peer groups of biological girls.

The most disturbing thing to me, however, has been the increasingly frequent stories of “detransitioners”, or those who received some degree of medial and/or surgical “gender reassignment”, now regret those decisions, and are attempting to return, to the degree that might be possible, back to their biological sex. A frequent refrain from these patients is that they had been suffering from various mental health concerns which were not addressed, and that they were instead diagnosed with gender dysphoria, and encouraged to pursue “gender-affirming” care as the solution to their problems.

While it is frequently claimed that such care is “totally reversible”, in fact, it frequently is not. Although not proven, it is thought that puberty blockers are not harmful, and the effects are largely reversible, if used only for a few years during puberty. But, if puberty blockers are followed by the administration of “cross-sex hormones”, androgens for biological females and estrogen for biological males, the results are no longer totally reversible. Some possible effects can include infertility, inability to experience orgasm, and a possible increased risk of various medical diseases, to include some cancers. And, obviously, gender-affirming surgical procedures are largely irreversible.

So, we know there are harms to gender-affirming care. Granted, there may be net benefits to such gender-affirming care, in that we are helping more than we are harming, but that has not been established. It also might be that there are some youth with gender dysphoria who would best treated with gender-affirming care, and others who might be best managed with watchful waiting, but that hasn’t been delineated, either.

As we know some of our children and adolescents are being harmed by gender-affirming care, and that the net benefit of said treatment has not been proven, I also support Iowa’s GOP-lead legislature’s proposal to ban gender-affirming care for our youth. Such a ban can always be revisited down the line, if high-quality scientific studies eventually confirm the benefit of such care. In other words, this ban is fully reversible, but the care some of our youth would otherwise receive might not be. Personally, I think that is a good trade, and is in keeping with a phrase that all doctors have learned, “first, do no harm”, or primum non nocere, in Latin.

I will conclude by pointing out that we are increasingly seeing push back within the gender care movement, itself. A queer (self-described) woman, married to a trans-man, who worked as a case manager at the gender clinic at Washington University in St. Louis, recently became a whistle-blower. Physicians and therapists long been involved in transgender care, are raising alarms, and frequently being criticized by advocates inside and outside of the clinical setting. And, several European countries, to include the U.K., Sweden, and Finland, are pausing or reviewing gender care in their countries, based upon concerns such as those highlighted above.

One of my favorite sayings from my first surgical residency was; “When it comes to medical innovations, never be the first one on the bandwagon, or the last one off.” I think that would be good advice here, too.

Chris

NB: In this post, I am focusing only on gender dysphoric youth, not transgender adults, and that I’ve attempted to address this issue from a purely scientific viewpoint, not an ideological one. The ideology versus knowledge aspect is important, and I plan to address that in future installments, particularly as it relates to medical care and education. Furthermore, this interesting area of study has impacts into other subjects, such as women’s rights, female sports, and the humanity of those rare individuals who are don’t clearly fall into either of the usual biologic sex binaries. I plan to be back with more, to include a curated list of useful references.

Happy Birthday, America!

Like many Americans, I greatly enjoyed Top Gun: Maverick. Apart from the acting and the action, which I thought were quite good, I appreciated the sense of optimistic patriotism, of a can-do Americanism, that the movie inspired. And, it appears I was not alone in recognizing this sentiment. Furthermore, this appreciation largely seems to have crossed our partisan divides, which doesn’t happen often. There were a few exceptions, but most of the reviews I read, both from official reviewers and from friends of mine, and both from the political left and the political right, touched on this inspirational sentiment.

As with the responses to the movie, I sense that many Americans are interested in rediscovering that optimistic patriotism, regardless of preexisting political persuasions. If one imagines a normal distribution, the bell curve we all learned about in school, most Americans hold views which are broadly in the center. Some may be left-of-center, and some may be right-of-center, but we share more in common than we are led to believe. It simply doesn’t seem so, because the extreme “tails” of the bell curve are so amplified in our current environment.

The typically moderate Republican-leaning voters in Johnson County, where I live, mostly accept that the 2020 election wasn’t stolen or that COVID-19 was hoax. They think the Capitol riot on January 6th, 2021 was inexcusable, and they’ve received their vaccinations. Similarly, most of my Democratic-leaving friends here dismiss proposals to defund the police, and are concerned about aspects of the transgender rights movement. They recognize that a lessened police presence would have an especially negative effect on minority neighborhoods, and are uncomfortable with children being encouraged to question their gender at a young age.

I’m not describing all Republican-leaning and Democratic-leaning voters in the above paragraph, of course. The extremes still exist, and have an exaggerated influence on our political discourse. But, I do think I am accurately depicting the broad center of American political beliefs, what I will call the “true silent majority” of our current era.

From the Memorial Day celebration in Julie’s hometown of Whittemore, Iowa.

This broad center is our path forward, I think. The label I would apply is “radical centrism”. Radical, in the sense of fundamental, or root, and centrism in emphasizing where most Americans stand. As a democracy, I think we should govern from the center, and that we have not been doing. As a republic, I believe we should emphasize fairness and the rule of law, and we have not been doing that, either.

As some have argued, we are in the midst of a class war and a new political realignment. I’ll return to this topic in more detail in a future post, but I’m largely convinced they are right. We have a dominant class, of primarily college-educated elites who are influencing much of our economic, cultural, and political lives, and another class, some of which are college-educated and some not, but who are typically less influential in those spheres.

In the presidential primaries of 2016 and 2020, voters without a college degree largely supported one of two candidates, either Donald Trump or Bernie Sanders, not the establishment candidates of Hilary Clinton or Joe Biden. And, despite what some on the political left might argue, the shift that we may be seeing is not based upon racism or misogyny. Trump received 28% of Hispanic votes in 2016, and 38% in 2020; he marginally increased his vote share among Black voters from 6% in 2016 to 8% in 2029; and, his share of support from women increased from 39% in 2016 to 44% in 2020.

Pew Research Center 2021: Behind Biden’s 2020 Victory

If we are in the midst of a class war and a new political realignment, I believe that our focus should be on reestablishing the American Dream, which has been lost to many our fellow citizens. We need to ignore the political extremes, and concern ourselves with the broad center of silenced Americans. I’d like to know that every elected official wakes up each day and thinks, “How can I make life better for the working and middle classes, not those who will donate to my reelection?”. We’re not there yet, of course, but that is where we should aim.

I’ll close by wishing America a happy 246th birthday, today, and Julie and I an equally happy 28th anniversary, yesterday. I fervently believe that we and America remain full of great potential, and will continue to work to see those realized!

People jumping over the hurdles during obstacle course

Healthcare Reform Obstacles

Every time I write about healthcare reform, I receive at least one comment about the need to get the government out of healthcare entirely. I’m not unsympathetic to this argument, but it’s unrealistic.

It is true that industries which have seen the largest increases in costs over the past few decades, such as healthcare and higher education, are also some of those most highly impacted by government interventions. Since 1965, when the federal government got seriously involved in healthcare with the establishment of Medicare and Medicaid, inflation-adjusted per-capita spending on healthcare has increased more than six-fold, to an average of over $12,000 per person today.

Source: Center for Medicare & Medicaid Services

Some of this increase is undoubtedly due to newer technological innovations, which are more costly. For example, CT scans did not enter commonplace medical practice until the 1970s, and MRI scans until the 1980s; less-invasive surgical techniques did not become widespread until the 1990s, and robot-assisted surgery until the 2000s. Furthermore, it’s impossible to prove that government interventions were even partly responsible for these increased expenditures, anyway. Conversely, it’s arguable that we might have seen more than a six-fold increase in expenditures without Medicare/Medicaid, Medicare Part D, and the Affordable Care Act. I’m doubtful, but it is arguable.

Most importantly, however, Americans need to be aware of the obstacles to healthcare reform, and there are many. On the patient side, will those over the age of 65 willingly surrender their Medicare cards, or will veterans give up on the Veterans Administration? On the provider side, we are accustomed to the reimbursements we receive, most of which are somewhat tied to Medicare reimbursement rates. We might wish for higher payments, but the uncertainty of what change could bring will be a barrier for many.

Finally, we have the institutional actors, from the Pharmaceutical Research and Manufacturers of America (PhRMA) to America’s Health Insurance Plans (AHIP), and from the American Medical Association (AMA) to the American Hospital Association (AHA). These organizations might ultimately benefit from changes to our healthcare system, but they have also all lobbied extensively for the protections they currently enjoy; they are quite comfortable with the status quo.

All of the healthcare reform debates I have seen in my career, dating back to the efforts of the Clinton administration in the 1990s when I was still in my Army general surgery residency, have failed to seriously consider the political and economic forces which will resist any reform. The Affordable Care Act, passed during the Obama administration in 2010, was more limited than had been promised because of those same forces. Subsequent Republican efforts to “Repeal and Replace” went nowhere, for the same reason.

In short, we’ve reached something of a stalemate. Government is involved in healthcare policy and will remain involved for the foreseeable future. Too many actors are habituated to the current system, making radical change, barring a catastrophic failure, likely impossible. Our best hope is to offer incremental changes, those which benefit most players, and proceed one step at a time.

My overall guiding vision as to where those incremental changes might lead us is twofold.

Market forces are our most potent means of producing beneficial innovations and driving down costs. We should encourage and embrace market economics in healthcare reform as much as possible.
Government can provide essential backup roles, to include some needed regulation, and especially in the provision of a safety net for those in need.

We don’t need to eject government from our healthcare system, but we do need to limit it to those spheres of influence in which it can be most beneficial. We also need to allow space for market forces to deliver better outcomes and lower prices whenever possible. As in most (perhaps all) sectors of the economy, there is a role for both government and markets to play; it’s all a matter of finding the right balance.

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A Time To Live

Last night, I listened to Matthew McConaughey’s speech from the White House this week regarding the the mass shooting at Robb Elementary in Uvalde, Texas, and thought it was quite powerful. If your immediate response to that sentence was, “liberal Hollywood actor wants to take away our guns”, then think again.

Like me and many of you, McConaughey is a gun owner. He also generally agrees with Republican points of view regarding mental health, family values, and school safety as root causes of many mass shooting incidents, as do I. He doesn’t want to gut the 2nd Amendment, but does emphasize the importance of responsible gun ownership, and I don’t think many would disagree with that emphasis.

Uvalde is his hometown, so this tragedy, in which nineteen elementary school students and two teachers were killed on May 24th, struck McConaughey particularly hard. He said his mother taught kindergarten less than a mile away from Robb Elementary. He also said that Uvalde is where he first learned the fundamentals of responsible gun ownership.

McConaughey says, “In a bit of shock, I drove home, hugged my children a bit tighter and longer than the night before, and then the reality of what had happened that day in the town I was born in set in.” The morning after the tragedy, McConaughey, his wife, Camila, and their children, drove to Uvalde. There, they met with survivors, relatives of victims, first responders, morticians, and funeral directors.

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In his speech, McConaughey went on to highlight many of the children lost in the tragedy, focusing on their extinguished dreams and the brave resilience of their families. As one example, he mentions Maite Rodriguez, a nine-year-old who dreamed of becoming a marine biologist. Camila McConaughey was holding a pair of green Converse tennis shoes during the speech, and reportedly these were the only clear evidence that could identify Maite immediately after the shooting.

Roy Guerrero, a pediatrician in Uvalde, reports seeing after the shooting, “Two children, whose bodies had been so pulverized by bullets fired at them, decapitated, whose flesh had been ripped apart, that the only clue as to their identities was blood-spattered cartoon clothes still clinging to them. Clinging for life and finding none.”

In testimony before Congress this week, eleven-year-old survivor Miah Cerrillo described the shooter saying “good night” before shooting one of her teachers in the head; how she saw several of her friends and classmates killed; and how she smeared herself with his blood and pretended to be dead.

McConaughey went on to suggest a few reforms which might garner bipartisan support, to include expanding background checks, raising the minimum age to purchase an AR-15 rifle to 21, imposing a waiting period for such rifles, and instituting red flag laws. Personally, I would support some of these reforms, and object to others depending upon the details, but the specifics of any gun reform proposals are beyond the intent of this post.

While it was a really powerful speech, I think McConaughey missed one opportunity. In 1996, he achieved breakthrough status as a serious actor in the movie adaptation of the John Grisham novel, A Time To Kill. In that film, he plays lawyer Jake Tyler Brigance, charged to defend an obviously guilty killer, Carl Lee Hailey, played by Samuel L. Jackson.

To make a long story short, Hailey’s daughter, Tonya, had been beaten, raped, and left for dead by two white men. Hailey (Jackson), knowing the two would likely be set free in the white-dominated Mississippi of the day, kills the two perpetrators in full view of many witnesses. Brigance (McConaughey) can’t discount what happened, but makes an emotional appeal to the all-white jury in his summation.

“I want to tell you a story. I’m going to ask you all to close your eyes while I tell you the story. I want you to listen to me. I want you to listen to yourselves. Go ahead. Close your eyes, please.” He goes on to recount how Tonya was walking home from a grocery store, was grabbed by two men in a pickup truck, taken to a nearby field, tied up, raped, beaten, urinated upon, endured a failed lynching, and then thrown in a creek and left for dead.

At the end of his summation, he says, “Can you see her? Her raped, beaten, broken body soaked in their urine, soaked in their semen, soaked in her blood, left to die. Can you see her? I want you to picture that little girl. (Long pause.) Now imagine she’s white.” In this happy ending, Hailey is judged innocent.

For Uvalde, McConaughey might have concluded his speech in the same manner. “I want to tell you a story. I’m going to ask you all to close your eyes while I tell you the story. I want you to listen to me. I want you to listen to yourselves. Go ahead. Close your eyes, please.”

“There were nineteen children dead, and two of their teachers. Two children were so pulverized by bullets, that the only clue as to their identities was blood-spattered cartoon clothes. One child could only be identified by their green Converse tennis shoes. Another child only survived by smearing themselves with the blood of classmates and pretending to be dead. (Long pause.) Now, imagine those were your children.”

We will, and should, scrutinize the details of any proposed gun reforms. What we should not do is begin with the reactionary pronouncements of the left or right in deciding which path to take. Begin in the middle, as McConaughey does. And, like McConaughey, I think we responsible gun owners should take the lead.

I would support some prudent gun reforms, but also think that most of those which might be politically possible will not make a huge difference. I definitely believe that we need to make a much greater investment in mental health care. Even more important, I think, is creating a healthier society. This includes working to narrow our economic and cultural divisions, healing the loneliness and sense of disconnection many are feeling, and generally being more kind and helpful to one another.

Again, imagine those were your children.

USA Today: McConaughey’s Full Speech on Gun Violence

Healthcare Models Around the Globe

Our current healthcare system is so costly, and access to care and coverage so unequal, that I think simple continuation of the status quo is indefensible. At the same time, I believe that simplistic approaches to reform, such as Medicare for All, are unrealistic and would prove inadequate.

At this point, my friends on the political left, having agreed with my first sentence, will respond to my second with a cry of, “But, we’re the only developed country that doesn’t have universal healthcare!” To which, I might reply, “Okay, that’s true enough, but which type of universal healthcare would you prefer?” Oftentimes, that response draws a momentary blank stare, but it’s an important question.

Every other developed country does have a form of universal (or nearly so, in most cases) healthcare, but they are not all alike. Some are radically different from each other, in fact. Four models of healthcare are commonly identified, the Bismarck model, the Beveridge model, the National Health Insurance Model, and the Out-of-Pocket model. Many countries combine two or more portions of each model in their healthcare systems, and we in the United States incorporate pieces of all four.

The Bismarck model was established in the newly formed German Empire by Otto von Bismarck in 1893. While it has since been modified and expanded, it was initially a system limited to coverage of workers and their families through joint contributions by employers and employees. Echoes of that model are still seen today in most of western Europe, Japan, and among many working-age citizens in the U.S.

The Beveridge model, designed by British economist William Beveridge, and instituted in 1948, led to the creation of the U.K.’s National Health Service (NHS). In this model, coverage is provided by the government, in a single-payer system, funded by general taxes. Most hospitals are owned and run by the NHS, though there are a few private facilities. Most hospital-based physicians are employed by the NHS, though those in private hospitals, and many general practitioners are self-employed. In the U.S., we utilize a similar model in the care of most of our active duty military, veterans, and Native Americans.

The National Health Insurance model developed gradually in Canada. Now known as Canadian Medicare, it began with hospital-based care in the province of Saskatchewan in 1947, expanding to the rest of the country by 1957, and was later extended to cover outpatient costs in 1966. It’s a universal single-payer model, like the NHS in the U.K., but most hospitals are privately-owned, and physicians are not government employees, unlike in the U.K. In this sense, Canadian Medicare is very similar to our Medicare, though ours is limited to elderly Americans. Its overall model is also comparable to our Medicaid, with costs shared between the provinces (states, in our case) and the national government.

The Out-of-Pocket model is what is left when there is no overarching plan in place. You pay for what you need if you can afford to do so. It is the predominant model in most of the less developed countries, but is also what is left available to people who cannot obtain coverage in developed countries, including the U.S. Although partially subsidized, the ACA marketplace plans also fall somewhat into this category. This model is frequently derided as the only option available to the desperate. It is important to realize, though, that is also sometimes the preferred choice of the global wealthy, and it is the primary model used for many elective healthcare choices worldwide. This model actually helps to drive down prices and improve quality. So, I think it is not a model that should be entirely dismissed out of hand.

None of these models is perfect alone, and no country has combined portions of any of these models to create the perfect healthcare system for their citizens. In the United States, we are stymied by unequal access to care and high costs. Other countries have provided more equal access to care, but are faced with with long wait times and/or economically depressed physicians and hospitals. All developed countries are struggling with rising healthcare prices and aging demographics.

However, one thing all these models share is that they were adopted in bits and pieces to address the concerns of the citizens in their respective countries. They all tried, to a greater or lesser extent, to work within the existing healthcare infrastructure in their home countries, while recognizing the political and economic forces which might prevent wholesale change.

I think this is where we should begin. To address our current healthcare problems, we should look to other countries for ideas, while looking within our own country to see what is possible. Then we can create a uniquely American solution for our citizens.

As a reminder for those who missed my last piece, consider checking out the 2008 PBS Frontline documentary with correspondent, T.R. Reid, Sick Around the World, and Reid’s book, published in 2010, The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.

Sick Around the World

The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care

It’s Time for a Healthcare Reform Checkup

It is impossible for me to imagine that we will see any meaningful healthcare reform in the near future. Nothing substantive has been offered by the Biden administration, despite earlier declarations that “Obamacare” would be extended as “Bidencare”. And, given the logjam in the Senate, thanks in large part to Senators Manchin and Sinema, any proposal which is unlikely to be offered in the next few months seems equally unlikely to pass.

Furthermore, Republicans will likely retake the House following the midterm elections less than eight months away, and there’s at least an even chance that they will retake the Senate, as well. If either or both happens, that would mean no chance for any substantive changes in healthcare policy for the remainder of Biden’s first term.

How about after the 2024 general election? That’s far too in the future for me to forecast, honestly. But, my guess is that the Republican nominee will likely be either Trump, or someone catering to his political base. Whether Biden wins or loses against any Republican challenger in 2024, I don’t see much hope for any serious healthcare reform.

Since the Affordable Care Act passed in 2010 under the Obama administration, the GOP has not offered anything of value when it came to healthcare reform, in my opinion. “Repeal and Replace” didn’t go anywhere, and I don’t suspect that’s likely to change unless, and until, we see a significant realignment of our political compass.

I think that realignment is coming, sooner or later, and we need to prepare for whatever opportunities might arise for all Americans, from the political right to the political left, in the future.

I have written extensively about healthcare reform in this and other venues. It is perhaps the most complicated domestic policy issue we face, so I have decided to return to the subject and break it down in a new way. This is my introduction to a series which will explore the fundamentals of our healthcare system, step-by-step. This will get a bit “deep in the weeds” for some, but I’ll try to make these entries relatable and interesting.

Each installment will focus on one or two key points that I believe are important to bear in mind when considering our overall healthcare system, and the measures we might adopt to improve it. The reasons I think a fundamental understanding of our healthcare system is important are twofold. First, I believe our current system is so expensive and unequal as to be indefensible; we need a change. Second, all the proposals advanced to date would not adequately address the underlying problems I see in our healthcare infrastructure. We’ll turn to some of those in later installments.

So, where to turn? I suggest we begin by looking at which healthcare systems have been implemented in other countries. For homework, which is more enlightening and less tedious than you might remember from your school years, I’ll ask you to check out a PBS Frontline documentary featuring correspondent, T.R. Reid, titled Sick Around the World. It’s a bit dated, having come out in 2008, at the outset of the healthcare debate leading to the ACA. But, honestly, not much has really changed. Reid also has a book, published in 2010, called The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care, which echoes the same points as the documentary.

I’ll be back next time to explore the four primary models of healthcare around the globe.

Sick Around the World

The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care