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.
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.
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.”
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.
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.
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.
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.”
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.
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.”
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.”
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.
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.”
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.
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.