What Both Sides Are Missing About the Science of Gender-Affirming Care | Opinion

Last April, Arkansas became the first state to ban what's known as "gender-affirming care," a protocol that affirms a child's transgender identity and allows for medical transition with puberty blockers, cross-sex hormones and, in some cases, surgeries like mastectomies or orchiectomies. The ACLU, which is now suing the state on behalf of four transgender young people, their families and two doctors, noted that "Gender-affirming care is life-saving care for our clients" and that banning it "runs counter to science and medicine." There have been as many as 25 such bills floated, mostly in right-leaning states.

From the outside, it looks as if the controversies around young people with gender dysphoria—marked distress at an incongruence between biological sex and gender identity—are political: The Left fights to ensure trans kids get the care they need, and the Right bans it.

But when the politics are pulled back and the science scrutinized, a very different picture becomes clear—or rather, it becomes clear just how murky the science is, just how much dispute there is about how life-saving these medical interventions are. Absent a partisan lens, it becomes clear how ambiguous the long-term safety and efficacy is of medical intervention, and how bipartisan the concern about them.

Despite the imprimatur of groups like the American Academy of Pediatrics and articles (some of which have been corrected or amended) asserting clear benefits of gender-affirming care, there remains a "paucity of quality evidence on the outcomes of those presenting with gender dysphoria," per the Royal Australian and New Zealand College of Psychiatrists. "No consensus exists whether to use these early medical interventions," says an article in the Journal of Adolescent Health.

A review of the research by the UK's National Institute for Health and Care Excellence found that in terms of body image, psychosocial impact, satisfaction with surgery and other matters, "The quality of evidence for all these outcomes was assessed as very low certainty." Finland and Sweden have largely stopped providing such medical interventions to trans-identified youth except in carefully controlled studies, not because of politics but because among the successes are poor results, like children with osteoporosis or increasing numbers of detransitioners who medically transitioned and regret it.

Trans student rights
A Virginia judge dismissed a lawsuit challenging guidelines on policies for transgender students in public schools, saying it did not impact religious rights on Tuesday, July 27, 2021. LGBT activists and their supporters rally in support of transgender students on the steps of New York City Hall, October 24, 2018 in New York City. Drew Angerer/Getty Images

Meanwhile, the high suicide rate is likely inflated, due to that low-certainty evidence. Some research suggesting a possible connection between medical intervention and reduced suicidality, cited in the ACLU's Arkansas lawsuit, comes from a self-selected sample of adults who still identify as transgender, excluding those with bad outcomes who no longer identify that way. Its methodological flaws have been documented and its conclusions critiqued.

In reality, the UK's Gender Identity Development Service reports, "suicide is extremely rare." One Swedish study of more than 6,000 gender dysphoric people detected a 0.6 percent rate of suicide. Meanwhile, the higher estimates of suicidal ideation and suicide attempts are similar to those of young people with other mental health issues.

No one doubts that the population of children being diagnosed or self-diagnosing with gender dysphoria has exploded, and that children are suffering. But that population has radically transformed in the past 15 years all over the Western world. It was once mostly a scant few kids, mostly young boys, often without other mental health problems and with lifelong dysphoria. Now it's an explosion of mostly teen girls who experience dysphoria suddenly, often while navigating other serious mental health conditions.

There is almost no research on these young people. As one study noted, "virtually nothing is known regarding adolescent-onset GD." Most research that found positive psychological outcomes of gender reassignment was conducted elsewhere, for example, a study on older people out of the Netherlands whose own proponents worry about the rest of the world "blindly adopting" such research. Meanwhile another study found improvement in behavioral and emotional problems and global functioning but no change in anxiety, anger or—significantly—gender dysphoria, the reason for treatment.

There are studies that have found that surgeries alleviate gender dysphoria and improve psychological functioning. One found that after surgery, gender dysphoria "was alleviated and psychological functioning had steadily improved" and "well-being was similar to or better than same-age young adults from the general population." Another found "a significant increase in levels of general well-being and a significant decrease in levels of suicidality were observed"—at least in the short-term. As one trans teen in the ACLU's amicus brief avows, "Since starting transitioning three years ago, I have become more social because I feel at home in my body."

But amicus briefs from the other side cite detransitioners, young women who took testosterone and had their breasts removed, convinced—wrongly—that it would alleviate their dysphoria. "I cannot reverse any of the physical, mental or legal changes that I went through," one said. "Transition was a very temporary, superficial fix for a very complex identity issue."

That's the key: This is a very complex issue indeed with very little reliable data. Nobody knows how many kids are helped by transition and how many have been harmed. There are no regulations, no long-term follow-ups, and no one keeping track.

We do know that investigations into the makers of puberty blockers have just begun, and parents, desisters and detransitioners are organizing and sharing their stories, just as the parents of happily transitioned kids and organizations that support them are; but only the latter group are considered by most medical groups and mainstream media.

Some of the most experienced clinicians in the country, including trans people themselves, have been sounding the alarm on gender dysphoric kids rushed to medicate without proper evaluation. Many are speaking out not to ban the care but to expose the affirmation-only approach, which is anathema to a practice of medicine and psychology, based on science and inquiry.

While some people characterize the bans as based on hate, they may be a regulatory reaction to a medical and mental health community that refuses to regulate itself.

We need an apolitical and rigorous review of the evidence, and more and better research, as have happened in several European countries, which then altered their approach to treating young people with gender dysphoria. We need the medical and mental health communities to create policies that are sound, fair, and evidence-based, guided not by ideology but a complicated, underreported reality.

The politicization of this issue, on both the Left and Right, must stop. The fight should not be seen as pro- or anti-trans but rather pro-good health care and mental health care for all young people.

Lisa Selin Davis is the author of TOMBOY: The Surprising History and Future of Girls Who Dare to Be Different. She has written for The New York Times, Washington Post, Wall Street Journal, CNN and many other publications.

The views in this article are the author's own.