the national interest

Fight the Anti-Trans Backlash With Accountability, Not Silence

Photo: Tiffany Hagler-Geard/Bloomberg via Getty Images

A new book by Hannah Barnes describes how the Gender Identity Development Service at the Tavistock clinic, the United Kingdom’s only dedicated youth gender-identity clinic, routinely put children on puberty blockers with inadequate assessment. Barnes reports how the clinic responded to demands by activists that it quickly affirm and treat the stated gender identity of every child, rather than engage in careful diagnosis. She describes an atmosphere of fear preventing staff from voicing, or maintaining, their doubts about the soundness of its methods — a government regulator found that some staff “felt unable to raise concerns without fear of retribution.”

The foundational medical evidence for giving kids puberty blockers comes from a Dutch study whose subjects “had been heavily screened, suffered from gender dysphoria since childhood, and were psychologically stable with no other mental health issues.” But “according to almost every clinician I have spoken to,” writes Barnes, GIDS “was referring people under 16 for puberty blockers who did not meet those conditions.”

The Tavistock has been shut down by the National Health Service, and health systems in England, Finland, and Sweden are all restricting the use of chemical treatment for youth gender dysphoria after concluding there is a paucity of evidence for it.

The United States, with its fragmented, patient-driven system, lacks any unified standard of care like these European countries. I believe, as I will explain below, there is ample grounds to fear something similar is happening in the U.S. My view is that protecting trans children requires carefully following the evidence, and being willing to expose providers who are operating dangerously, in order to find scientifically defensible standards and avoid discrediting the entire field. But many American progressives seem to have drawn a very different conclusion from the experience in western Europe.

On Wednesday, a large collection of progressive journalists launched a public campaign, including a letter and a coordinated in-person demonstration by GLAAD, to protest the New York Times’s coverage of youth gender care. The letter claims the Times’s coverage is excessive, and it raises a couple attribution complaints about sources in a few of the stories to suggest the overall tenor is biased toward criticism.

The letter’s key premise is that the Times is whipping up public concern over a nonexistent phenomenon. “Puberty blockers, hormone replacement therapy, and gender⁠-⁠affirming surgeries have been standard forms of care for cis and trans people alike for decades,” explains the letter. Since nothing especially new is occurring medically (“This is not a cultural emergency”), it follows that reporters have no reason to give the matter any new attention.

But this is simply not true. Reporting in the Times, and in the other publications noted above, all show clearly that the field has undergone dramatic changes in the last decade or so. The old practice asked medical providers to diagnose gender dysphoria only in children who expressed persistent belief that they had the wrong gender identity. Many medical providers have adopted the view advocated by activists that children’s professed identity needs to be taken at face value almost immediately, with significantly less medical gatekeeping.

“I think what we’ve seen historically in trans care is an overfocus on assessing identity,” Colt St. Amand, a family-medicine physician at the Mayo Clinic told the Times. “People are who they say they are, and they may develop and change, and all are normal and okay. So I am less concerned with certainty around identity, and more concerned with hearing the person’s embodiment goals.” This is a candid description of the new theory sweeping through clinics across the country: Stop the “overfocus” on assessing the gender identity of kids, and instead take their statement at face value and proceed to helping them actualize what they say they want.

The World Professional Association for Transgender Health (WPATH) last year dropped its age guidelines for hormone use and surgeries. Some clinicians have expressed concern over the new practices. “It went so quickly that not even centers but individual clinicians, people who were not knowledgeable, were just giving this kind of treatment,” said Dr. Peggy Cohen-Kettenis, a Dutch psychologist who worked at the clinic that pioneered treatment for transgender youth, in another story in the Times. Many American gender clinics, Reuters found, prescribe puberty blockers “on the first visit, depending on the age of the child.”

At the same time as providers have sped up their protocols for transitioning children, the number of children requesting gender reassignment has risen dramatically. Within a few years, the number of young people identifying as transgender “nearly doubled,” and the number of pediatric gender clinics exploded from “a handful” to more than 60.

Unlike in past years, when “those assigned male at birth accounted for the majority,” a large majority of children questioning their gender now were assigned female at birth, reported Reuters. “Adolescents assigned female at birth initiate transgender care 2.5 to 7.1 times more frequently than those assigned male at birth,” according to WPATH. This is taking place in the context of a mental health crisis that is disproportionately affecting girls and LGBTQ+ teens. Properly assessing kids who question their gender is much more challenging when they are afflicted with serious mental health challenges. And so medical providers are diagnosing and treating kids much faster than before at a time when the patient population has become much harder to diagnose.

Whatever parallels the letter writers see to past practices — the letter cites episodes going back as far as 1394 — phenomena like a surgeon on TikTok telling teens to “Come to Miami to see me and the rest of the De Titty Committee,” as Reuters found, are new. One can defend the new practices, but it is preposterous to maintain that the field has merely continued “standard forms of care for cis and trans people alike for decades,” rather than having implemented a very sharp change.

But proceeding from the false assumption that nothing significant has changed in the field of youth-gender care, it is easy to see why progressive critics would believe the only explanation for the Times devoting significant reporting resources to the issue would be to foment a panic. And what other motives would the Times have to foment a panic besides fear and bias?

The protesters in front of the Times are demanding the newspaper “Stop Questioning Trans People’s Right to Exist.” There is no line in any of the offending stories questioning trans people’s right to exist, and indeed all the stories adopt a carefully balanced approach that acknowledges the benefits of full transition to people who have gender dysphoria.

Jo Livingstone, one of the organizers of the letter, says that the paper’s coverage is being driven by a “transphobe” high in the organization, and justified on the pretext that it attracts readership. “I would suspect that it’s coming from someone quite senior within the organization, and that their position is defensible on the grounds of traffic,” they tell an interviewer, “Honestly, if I were a transphobe at the fucking New York Times, that’s how I would do it.”

If the Times was following a secret transphobic agenda, you would expect a wave of coverage across a wider spectrum of transgender-related topics. Yet there isn’t any remotely similar reportorial attention to topics like whether people should be addressed by the name and pronoun of their choice, or use a bathroom corresponding to their gender identity. The premise that the Times is advancing a secret transphobic agenda has trouble explaining this absence, or why the area the Times has given some attention, youth-gender care, has also been covered by reporters at other prominent mainstream publications, who are not operating at the behest of a secret transphobic mastermind at 620 Eighth Avenue.

The primary harm cited by the protesters is one that arises regularly any time a reporter or commentator suggests there are problems with the new treatment practices for gender-questioning youth: They are blamed for a wave of Republican-driven laws. It doesn’t matter if the reporter or critic opposes these laws. The presumption is that anything that discredits the left automatically benefits the right. The anti-Times letter makes a great deal of the fact that Times reporting has been cited by sources like Arkansas’s attorney general, and that a conservative activist “approvingly cited the Times’ reporting and relied on its reputation as the ‘paper of record’ to justify criminalizing gender⁠-⁠affirming care.”

It is true that Republicans are passing a wave of harmful, restrictive laws on trans medical access. The blame for laws like this does not rest with the medical providers who demanded evidence for the rapidly changing protocols in their field, nor with the reporters who brought these doubts to light. It lies first with politicians and the party that pass them. But blame will rest as well with activists who were so certain they stood on the side of justice that they sought to silence all doubt until it was too late.

Of course, the whole reason leftists try to associate reporters at the Times with Republican-backed laws is precisely that their targets do not agree with the conservative position on transgender care. If they did agree with it, there would be no shame in associating them with Republican-sponsored legislation. The point is to discredit any middle position, forcing a binary choice between extremes.

The idea that reporting on failures and abuses in the system feeds a backlash strikes me as completely backward. Of course, the right is going to push for harmful laws restricting trans youth regardless of the evidence. But the degree to which those bans win support in the middle of the political spectrum depends heavily on whether there is any real abuse in the system to correct. Conservative “bathroom” bills have died out because they combatted an imaginary problem with no real or sympathetic victims. Measures that target a real problem — even if they go too far — stand a better chance of success if they can point to actual, not imagined, harm.

The official line of pro-trans activists and their allies has maintained a dogmatic insistence that such victims of the newer, faster, and more aggressive treatment of gender-questioning kids are vanishingly rare. But that insistence has often extended to reflexively denying or ridiculing trans people who come to regret their transition (as two trans researchers, Leo Valdes and Kinnon MacKinnon, explained in The Atlantic).

Refusing to acknowledge de-transitioners, and attacking even the friendliest concerns as denying trans people’s rights to exist, means refusing to face up to the risks and uncertainties of a relatively new medical regime. “People are terrified to do this research,” Dr. Laura Edwards-Leeper, a clinical psychologist in Oregon, told Reuters. The effect of this fear is to bury evidence of failure. This political culture creates a large risk of a Tavistock-like scandal in the United States.

Last week, a whistleblower named Jamie Reed published an account of the abuses she witnessed as a case manager at the Washington University Transgender Center at St. Louis Children’s Hospital. The picture she paints of the clinic’s treatment of children is ghastly. The affidavit she signed is even worse.

Reed describes herself as a queer woman, married to a trans man, with politics “to the left of Bernie Sanders,” who joined the clinic to help vulnerable populations. According to Reed, children coming to the clinic were given little or no psychiatric evaluation, even when they presented with serious mental illnesses or obvious false diagnoses. Instead, they were pushed overwhelmingly, almost automatically, into gender reassignment. Doctors underplayed the risks and side effects of the hormones and puberty blockers given to children, bullied parents into giving consent by threatening their children would otherwise commit suicide (even without the children having indicated this), and prescribed drugs even without parental consent. Staff members who sometimes disagreed with the treatments, she says, “were told to stop questioning the prevailing narrative of immediate cross-sex hormones for all by the prescribing physicians.”

“Children come into the clinic using pronouns of inanimate objects like ‘mushroom,’ ‘rock,’ or ‘helicopter,” and were given puberty blockers or cross-sex hormones. One boy had an “intense obsessive-compulsive disorder that manifested as a desire to cut off his penis after he masturbated,” and despite having “expressed no gender dysphoria” was allegedly given hormone treatment. Many of the outcomes Reed claims to have witnessed are unbearably sad: Children rushed onto hormones, or into surgery, coping with painful side effects or (in one case) asking to have their breasts back.

Of course, these are still allegations. (Washington University says it is “alarmed by the allegations” and “taking this matter very seriously and have already begun the process of looking into the situation to ascertain the facts.”) But practices very similar to those she alleges have already been proven in the United Kingdom. And her account jibes with reporting in the U.S. Reuters, The Atlantic, and the New York Times that have all revealed deep concerns within the provider community, a division over best practices, and pressure applied to skeptics. If Reed’s allegations are proved correct, it will take its place among the gravest medical scandals in modern American history.

*Correction: A previous version of this story incorrectly attributed a quote to Hannah Barnes.

Additionally this story has been updated to clarify that while an advance copy of WPATH’s revised Standards of Care lowered the age guidelines for hormone use and surgeries, the final version did away with age requirements altogether.

Fight Anti-Trans Backlash With Accountability, Not Silence