the national interest

Helping Trans Kids Means Admitting What We Don’t Know

Transgender teenager Gabriel Diaz de Tudanca, 18, waits to be taken to the operating room to have his female to male chest reconstruction surgery in Madrid, Spain, October 26, 2016. Photo: Susana Vera/REUTERS

Last month, the New York Times published an investigative report on the medical treatment of children who question their gender identity. The findings were decidedly mixed. The reporters showed that many patients benefit from puberty-blocking drugs, which help them transition to a different gender, but that doctors also fear puberty blockers have long-term side effects, and that the treatment locks at least some children into escalating medicalization before they have figured out their gender identity.

The response on the left was as if the newspaper had committed a hate crime. “It is playing into the ongoing manufactured and weaponized conservative panic about trans existence,” asserted a Slate podcast. “Wild how normalized it is for journalists on this ‘beat’ to be aligned with straight-up hate groups and rely on anti-trans activists to link them with sources,” tweeted left-wing journalist Michael Hobbes.

This interpretation that the Times had contributed to an atmosphere of hatred against trans people was repeated so often and so stridently that within the left, it came to seem almost obvious. A week later, when a murderer opened fire in an LGBTQ nightclub in Colorado Springs, NPR’s On the Media interviewed NBC Out reporter Jo Yurcaba, who explained that the murder resulted from “rhetoric that labels LGBTQ people as grooming children,” including “coverage, for example, in the New York Times that paints gender-affirming care for minors as something that is debatable.”

There is a familiar pattern here in the way left-wing activists shut down internal criticism by treating any criticism of their position as either identical to, or complicit with, the far right. Extremists on the right, of course, use the same method to shut down their critics on the center-right. To the radical, the easiest way to win a debate is to insist that the only choice is between opposing poles. If you oppose any element of their argument, you have endorsed the enemy. If the criticism is tempered and credible, this only makes them regard it as more dangerous.

But this absolutist mind-set has had an especially pernicious effect on the issue of youth gender medicine. This is because the science is genuinely murky and embryonic, making the struggle to identify a humane and effective solution both difficult and necessary. The left has thrown itself behind a crusade to define such a position out of existence.

The key thing to understand about this issue is that there are two distinct debates going on at the same time. The one between Democrats and Republicans in the political arena concerns whether to respect the basic rights of transgender people. Within the medical community, the debate is over exactly how to treat children who question their gender identity. The former matter is clear and simple. The latter is murky.

The question of how to treat children has many sources of uncertainty. There has been a huge explosion in cases of children questioning their gender identity, and a large majority of the patients are assigned female at birth. The stages of treatment generally begin with social transition (using different name and clothing), proceed to drugs that delay puberty, and culminate in surgery. Experts don’t agree on the correct age at which to begin these treatments. One problem is that kids and teens often have a fluid grasp of their own identity and gender, and need time to form a stable identity. Another is that puberty blockers have undetermined long-term risks.

Both sides of this debate within the medical community agree that trans people do require medical and social support without stigma. The disagreement lies in the process and speed of the appropriate treatment. The treatment regimen supported by most of the trans-activist community calls for “gender-affirming” care that puts kids on the process to transition in relatively rapid order, highly aware of the risk of going too slow: that transgender children will be denied care they need and grow despondent or even suicidal. More traditional treatment models call for more cautious progression to medicalization and surgery, focused on the risk of moving too fast: that children will be mistakenly diagnosed with gender dysphoria and will have long-term side effects from treatment that they later come to regret.

Progressive activists have not just embraced the gender-affirming care model; they have begun treating any disagreement with it as hateful denial that trans people exist. Indeed, they have frequently denied that any debate exists within the medical community at all.

The purpose of their rhetorical strategy is to conflate advocates of more cautious treatment of trans children with conservatives who oppose any treatment for trans children. This campaign has met with a great deal of success. Much of the coverage in mainstream and liberal media has followed this template — ignoring or denying the existence of the medical debate, and presenting anti-trans Republican politicians as the only alternative to gender-affirming care. This has been the theme not only of progressive infotainment like Jon Stewart and John Oliver, but also mainstream organs like Politico and CNN, where coverage of the issue often treats progressive activists as unbiased authorities and dismisses all questions about youth gender treatment as hate-driven denial of the medical consensus.

Over the last half-decade, as more and more reporting has revealed a persistent divide inside the medical community, the attempts on the left to deny its existence have grown increasingly strained. Rather than acknowledge the debate within the medical community and the genuine sources of concern, activists have continued to wish away its existence and attack those journalists who try to report on it.

In 2018, Jesse Singal — a liberal former New York colleague who has enraged progressives by regularly criticizing the left — published a cover story in the Atlantic headlined “When Children Say They’re Trans.” The story’s thesis was this: “The best way to build a system that fails fewer people is to acknowledge the staggering complexity of gender dysphoria — and to acknowledge just how early we are in the process of understanding it.” Singal’s story explained that transgender activists have good reasons to oppose gatekeeping by the medical community, which until recently had often dismissed or pathologized their identity altogether. But it also explained that many practitioners who did recognize the need to help children with gender dysphoria to transition also believed that some children were being pushed into a transition too quickly:

The concerns of the detransitioners are echoed by a number of clinicians who work in this field, most of whom are psychologists and psychiatrists. They very much support so-called affirming care, which entails accepting and exploring a child’s statements about their gender identity in a compassionate manner. But they worry that, in an otherwise laudable effort to get TGNC [transgender and gender-nonconforming] young people the care they need, some members of their field are ignoring the complexity, and fluidity, of gender-identity development in young people. These colleagues are approving teenagers for hormone therapy, or even top surgery, without fully examining their mental health or the social and family influences that could be shaping their nascent sense of their gender identity.

The response from the left was volcanic. The stream of published articles, with headlines like “Atlantic cover story is a loud dog whistle for anti-transgender parents” and “What’s Jesse Singal’s Fucking Deal?” were merely the surface expression of a campaign to discredit him that has gone on for years. GLAAD put him on a list of anti-LGBTQ bigots; activists tried to get him fired and pressured other journalists to renounce him.

It is difficult to say precisely how successful this campaign was — a smear campaign is not the kind of phenomenon that can be easily quantified. But there was a relative dearth of high-profile reporting on the divide inside the medical community on how to support gender-dysphoric children for several years.

That began to change this year. In June, Emily Bazelon reported a story for The New York Times Magazine that reached the same general conclusions as Singal, explicating both sides of the debate and the substantial grounds for uncertainty. Bazelon also noted the intense pressure activists were exerting within the medical community. One longtime doctor who had practiced more gradual care for gender-dysphoric teens, Kenneth Zucker, had been targeted with a string of personal accusations and driven out of his Toronto clinic. (Singal previously covered the episode, which resulted in the accusations being disproven and Zucker receiving an apology and a $450,000 settlement.) “After that controversy,” Bazelon noted, “other providers were on notice that Zucker’s methods were no longer acceptable.”

Bazelon’s reporting predictably triggered a torrent of outrage. “New York Times faces searing backlash for publishing ‘harmful’ anti-trans ‘propaganda: ‘Do better,’” said PinkNews. “This article consistently casts reactionary backlash as legitimate debate about transition care,” thundered Hobbes. (The truth was just the opposite: Bazelon carefully distinguished between the reactionary backlash against trans people and the legitimate debate within the medical community, while left-wing activists conflated the two.)

The response to Bazelon was insistent that the divide she reported among medical providers was a pure figment of her imagination. (Texas Observer: “THERE IS NO LEGITIMATE ‘DEBATE’ OVER GENDER-AFFIRMING HEALTHCARE.” Teen Vogue: “Trans healthcare is not actually a debate.”) Representative Rashida Tlaib created a petition to “tell the New York Times to stop providing a dangerous platform for transphobic hate.”

Last month, Reuters also ran a long story describing “a split among gender-care specialists: those who urge caution to ensure that only adolescents deemed well-suited to treatment after thorough evaluation receive it, and those who believe that delays in treatment unnecessarily prolong a child’s distress and put them at risk of self-harm.” The story reported both on kids who had benefited from their transition and cases where “clinicians swiftly affirmed their children’s transgender identities and recommended medical intervention without fully assessing whether other potential underlying causes of distress were present.” Disturbingly, it reported surgeons advertising directly to teens on TikTok and Instagram (“Come to Miami to see me and the rest of the De Titty Committee”).

Shortly after that, the Times ran a report about the potential risks of puberty blockers, by Megan Twohey (whose reporting on Harvey Weinstein is featured in the film She Said) and Christina Jewett. It found “emerging evidence of potential harm from the drugs, including possible long-term effects on patients’ bones and brains” and “concerns that blockers could lock adolescents into a path of medical intervention before they are certain of their identity” within the medical community. The reporting was careful and balanced, which is precisely what enraged the critics. The New Republic’s Melissa Gira wrote, “The NYT enabling anti-trans politics isn’t really them trying to appeal to the right, I think, but trying to make ‘just asking questions’ a mainstream position.”

“Just asking questions” is a shorthand the left has used to mock Singal’s journalism. It is a sneering term that can describe the way some edgelords teasingly try to legitimize absurd and offensive claims. But it’s been used by the left to denigrate the very idea of asking questions at all — at least, if those questions are being directed at their own positions.

One of the more revealing admissions of this mentality came from Diane Ehrensaft, a developmental and clinical psychologist and an advocate of gender-affirming care. “We have wolves at the door,” she told Bazelon. “Conversations among us get aired as controversy and confusion. You end up eating your own instead of making the wolves go away.” Any admission of doubt or disagreement within the medical community would give ammunition to Republican politicians to attack all forms of treatment for gender dysphoria.

The impulse to close ranks and suppress all internal doubts — an impulse that dominates conservative-movement politics, and which supporters of the progressive movement wish to emulate — disables any mechanism for correcting errors. It is an especially dangerous mentality to apply to medical or scientific questions. The scientific method requires openness to critique and revision, and testing claims rigorously, regardless of whether the answer aligns with the position held by your allies. The demand to suppress doubt for fear of stoking a political backlash would make it difficult or impossible for doctors to actually determine best practices.

The U.K., France, Sweden, and Finland have all recently reviewed the evidence of youth gender treatment and imposed some restrictions. Progressive activists insist these countries are all capitulating to right-wing anti-trans panic. At some point, they need to recognize that denying any grounds for debate or concern and calling anybody who questions their position a bigot is not a sustainable strategy. Helping trans children means developing effective and safe treatments that can withstand scrutiny. Suppressing the debate in order to head off a backlash only creates more abusive cases — more therapists rushing children into conversion, more shady doctors peddling lucrative surgery online — and creates the risk of a larger backlash.

Helping Trans Kids Means Admitting What We Don’t Know