The Trump administration’s policymaking apparatus is often a chaotically uncoordinated mess. The White House issued a well-designed road map for American dominance in artificial intelligence, and then the Defense Department launched a quixotic attack on Anthropic, one of the nation’s frontier AI firms. Immigration and Customs Enforcement went back and forth on workplace raids after the Agriculture Department secretary said that rounding up farm laborers would make it hard to deliver the lower food prices President Donald Trump promised on the campaign trail.
But there’s one policy area where the administration is united and monomaniacally on-task: the war on pediatric medical transition (PMT). From Trump’s executive order titled “Protecting Children from Chemical and Surgical Mutilation” to the recent Federal Trade Commission lawsuit against the World Professional Association for Transgender Health, the administration has done everything in its power — and some things that weren’t — to halt these treatments.
True conservatives regard these efforts with uncomplicated glee. But we more libertarian-minded skeptics have something of a quandary. On the one hand, some of the administration’s actions have been novel — and dubiously legal — expansions of regulatory power. On the other hand, as the medical nonprofit Do No Harm wrote, “WPATH deserves it.”
I’ve been covering this issue for four years with growing dismay at the shoddy research and obvious confirmation bias of clinicians who insisted, based on thin observational studies, that these treatments were “evidence-based, medically necessary care.” I was stunned when doctors claimed that it would be unethical to do randomized controlled studies that might have provided proof of effectiveness, because how can we deny the control group treatments that are the standard of care?
Then some of WPATH’s internal deliberations became public via leaks and lawsuits, and gosh darnit, I am running out of synonyms for “absolutely gobsmacked.”
WPATH seems to have axed minimum-age guidelines at the request of a Department of Health and Human Services official in the Biden administration. The official, who is a pediatrician and a transgender woman, argued that setting minimum ages might spur “devastating legislation.”
The group also apparently sought to block the publication of systematic reviews WPATH commissioned from Johns Hopkins University. The head of the gender clinic at Children’s Hospital of Los Angeles offhandedly admitted that she’d delayed publishing research with disappointing results because she didn’t want her work to be “weaponized.”
This is not how serious medical professionals behave. It is not how science works. It is activism dressed up in a lab coat.
Is it a deceptive business practice, though?
I can make the argument: WPATH members earn quite a lot of money from these interventions, and the FTC lawsuit alleges that the organization crafted its guidelines to maximize insurance reimbursement, “including by replacing objective criteria with provider discretion, removing age minimums, and issuing broad ‘medical necessity’ declarations for nearly every medical-transition intervention.”
However, I don’t think they’re misinforming the public for fun and profit. I think they are convinced these treatments work, and that confirmation bias and groupthink led them to behave like political activists rather than dispassionate scientists. It deserves a reckoning, but it shouldn’t come from the FTC. Because this topic has been so politicized, cracking down in this way comes uncomfortably close to free speech restrictions. False confidence isn’t the same thing as false advertising.
And where, the skeptics might justly ask, will that reckoning come from? They believe that PMT amounts to grotesque medical experiments on children. It will be the “next lobotomy,” I have been told many times since I wrote a column on the sordid history of that medical horror story.
I have sympathy for those who believe PMT is a disastrous medical mistake. That practitioners seem to ardently believe in their interventions doesn’t mean they work: Medical history’s most destructive quacks weren’t charlatans selling snake oil, but people who believed with all their heart that they could cure patients by dunking them in ice baths or scarring the prefrontal regions of their brains. Given how little we know, I can’t rule out this becoming another one of those episodes.
That said, medical history also contains pioneers who were wrong about small things and nonetheless right about something important: The 19th-century Hungarian doctor Ignaz Semmelweis didn’t understand the germ theory of disease, but he was still absolutely correct that doctors should wash their hands before touching patients. Gender clinicians may turn out to be prematurely confident in treatments that eventually prove out, rather than grievously wrong.
In the meantime, government overreach isn’t the answer. The administration’s belligerent stance on all trans issues will convince many patients, and their parents, that this is an ideological attack. It undercuts the good work the administration has done, such as last year’s careful HHS report on the uncertain state of the science.
For many patients, that report is simply part of the administration’s war on trans people, and they will ignore the questions it raises about whether these interventions help. If the administration blocks them from getting hormones or surgery here, they might go abroad or buy bootleg drugs on the internet.
The cure for bad science is better science, not lawsuits. Yet of all the frenetic action, the one thing the administration has not done is to fund serious clinical trials with long-term follow-up to provide answers patients need. Instead, the government canceled grants for youth gender research. Perhaps those studies were shoddy, and grants for better-controlled trials are forthcoming. But they should have been the first resort, not the last.
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