Allow children to transition, or they will kill themselves. For more than a decade, this has been the strongest argument in favor of youth gender medicine—a scenario so awful that it stifled any doubts or questions about puberty blockers and cross-sex hormones.
“We often ask parents, ‘Would you rather have a dead son than a live daughter?’” Johanna Olson-Kennedy of Children’s Hospital Los Angeles once explained to ABC News. Variations on the phrase crop up in innumerable media articles and public statements by influencers, activists, and LGBTQ groups. The same idea—that the choice is transition or death—appeared in the arguments made by Elizabeth Prelogar, the Biden administration’s solicitor general, before the Supreme Court last year. Tennessee’s law prohibiting the use of puberty blockers and cross-sex hormones to treat minors with gender dysphoria would, she said, “increase the risk of suicide.”
But there is a huge problem with this emotive formulation: It isn’t true. When Justice Samuel Alito challenged the ACLU lawyer Chase Strangio on such claims during oral arguments, Strangio made a startling admission. He conceded that there is no evidence to support the idea that medical transition reduces adolescent suicide rates.
At first, Strangio dodged the question, saying that research shows that blockers and hormones reduce “depression, anxiety, and suicidality”—that is, suicidal thoughts. (Even that is debatable, according to reviews of the research literature.) But when Alito referenced a systematic review conducted for the Cass report in England, Strangio conceded the point. “There is no evidence in some—in the studies that this treatment reduces completed suicide,” he said. “And the reason for that is completed suicide, thankfully and admittedly, is rare, and we’re talking about a very small population of individuals with studies that don’t necessarily have completed suicides within them.”
Here was the trans-rights movement’s greatest legal brain, speaking in front of the nation’s highest court. And what he was saying was that the strongest argument for a hotly debated treatment was, in fact, not supported by the evidence.
Even then, his admission did not register with the liberal justices. When the court voted 6–3 to uphold the Tennessee law, Sonia Sotomayor claimed in her dissent that “access to care can be a question of life or death.” If she meant any kind of therapeutic support, that might be defensible. But claiming that this is true of medical transition specifically—the type of care being debated in the Skrmetti case—is not supported by the current research.
Advocates of the open-science movement often talk about “zombie facts”—popular sound bites that persist in public debate, even when they have been repeatedly discredited. Many common political claims made in defense of puberty blockers and hormones for gender-dysphoric minors meet this definition. These zombie facts have been flatly contradicted not just by conservatives but also by prominent advocates and practitioners of the treatment—at least when they’re speaking candidly. Many liberals are unaware of this, however, because they are stuck in media bubbles in which well-meaning commentators make confident assertions for youth gender medicine—claims from which its elite advocates have long since retreated.
Perhaps the existence of this bubble shouldn’t be surprising. Many of the most fervent advocates of youth transition are also on record disparaging the idea that it should be debated at all. Strangio—who works for the country’s best-known free-speech organization—once tweeted that he would like to scuttle Abigail Shrier’s book Irreversible Damage, a skeptical treatment of youth gender medicine. Strangio declared, “Stopping the circulation of this book and these ideas is 100% a hill I will die on.” Marci Bowers, the former head of the World Professional Association for Transgender Health (WPATH), the most prominent organization for gender-medicine providers, has likened skepticism of child gender medicine to Holocaust denial. “There are not two sides to this issue,” she once said, according to a recent episode of The Protocol, a New York Times podcast.
Boasting about your unwillingness to listen to your opponents probably plays well in some crowds. But it left Strangio badly exposed in front of the Supreme Court, where it became clear that the conservative justices had read the most convincing critiques of hormones and blockers—and had some questions as a result.
Trans-rights activists like to accuse skeptics of youth gender medicine—and publications that dare to report their views—of fomenting a “moral panic.” But the movement has spent the past decade telling gender-nonconforming children that anyone who tries to restrict access to puberty blockers and hormones is, effectively, trying to kill them. This was false, as Strangio’s answer tacitly conceded. It was also irresponsible.
After England restricted the use of puberty blockers in 2020, the government asked an expert psychologist, Louis Appleby, to investigate whether the suicide rate for patients at the country’s youth gender clinic rose dramatically as a result. It did not: In fact, he did not find any increase in suicides at all, despite the lurid claims made online. “The way that this issue has been discussed on social media has been insensitive, distressing and dangerous, and goes against guidance on safe reporting of suicide,” Appleby reported. “One risk is that young people and their families will be terrified by predictions of suicide as inevitable without puberty blockers.”
When red-state bans are discussed, you will also hear liberals say that conservative fears about the medical-transition pathway are overwrought—because all children get extensive, personalized assessments before being prescribed blockers or hormones. This, too, is untrue. Although the official standards of care recommend thorough assessment over several months, many American clinics say they will prescribe blockers on a first visit.
This isn’t just a matter of U.S. health providers skimping on talk therapy to keep costs down; some practitioners view long evaluations as unnecessary and even patronizing. “I don’t send someone to a therapist when I’m going to start them on insulin,” Olson-Kennedy told The Atlantic in 2018. Her published research shows that she has referred girls as young as 13 for double mastectomies. And what if these children later regret their decision? “Adolescents actually have the capacity to make a reasoned logical decision,” she once told an industry seminar, adding: “If you want breasts at a later point in your life, you can go and get them.”
Perhaps the greatest piece of misinformation believed by liberals, however, is that the American standards of care in this area are strongly evidence-based. In fact, at this point, the fairest thing to say about the evidence surrounding medical transition for adolescents—the so-called Dutch protocol, as opposed to talk therapy and other support—is that it is weak and inconclusive. (A further complication is that American child gender medicine has deviated significantly from this original protocol, in terms of length of assessments and the number and demographics of minors being treated.) Yes, as activists are keen to point out, most major American medical associations support the Dutch protocol. But consensus is not the same as evidence. And that consensus is politically influenced.
Rachel Levine, President Joe Biden’s assistant secretary for health and human services, successfully lobbied to have age minimums removed for most surgeries from the standards of care drawn up by WPATH. That was a deeply political decision—Levine, according to emails from her office reviewed by the Times, believed that listing any specific limits under age 18 would give opponents of youth transition hard targets to exploit.
More recently, another court case over banning blockers and hormones, this time in Alabama, has revealed that WPATH members themselves had doubts about their own guidelines.
In 2022, Alabama passed a law criminalizing the prescription of hormones and blockers to patients under 19. After the Biden administration sued to block the law, the state’s Republican attorney general subpoenaed documents showing that WPATH has known for some time that the evidence base for adolescent transition is thin. “All of us are painfully aware that there are many gaps in research to back up our recommendations,” Eli Coleman, the psychologist who chaired the team revising the standards of care, wrote to his colleagues in 2023. Yet the organization did not make this clear in public. Laura Edwards-Leeper—who helped bring the Dutch protocol to the U.S. but has since criticized in a Washington Post op-ed the unquestioningly gender-affirmative model—has said that the specter of red-state bans made her and her op-ed co-author reluctant to break ranks.
The Alabama litigation also confirmed that WPATH had commissioned systematic reviews of the evidence for the Dutch protocol. However, close to publication, the Johns Hopkins University researcher involved was told that her findings needed to be “scrutinized and reviewed to ensure that publication does not negatively affect the provision of transgender health care.” This is not how evidence-based medicine is supposed to work. You don’t start with a treatment and then ensure that only studies that support that treatment are published. In a legal filing in the Alabama case, Coleman insisted “it is not true” that the WPATH guidelines “turned on any ideological or political considerations” and that the group’s dispute with the Johns Hopkins researcher concerned only the timing of publication. Yet the Times has reported that at least one manuscript she sought to publish “never saw the light of day.”
The Alabama disclosures are not the only example of this reluctance to acknowledge contrary evidence. Last year, Olson-Kennedy said that she had not published her own broad study on mental-health outcomes for youth with gender dysphoria, because she worried about its results being “weaponized.” That raised suspicions that she had found only sketchy evidence to support the treatments that she has been prescribing—and publicly advocating for—over many years.
Last month, her study finally appeared as a preprint, a form of scientific publication where the evidence has not yet been peer-reviewed or finalized. Its participants “demonstrated no significant changes in reported anxious/depressed, withdrawn/depressed, somatic complaints, social problems, thought problems, attention problems, aggressive behavior, internalizing problems or externalizing problems” in the two years after starting puberty blockers. (I have requested comment from Olson-Kennedy via Children’s Hospital Los Angeles but have not yet heard back.)
The reliance on elite consensus over evidence helps make sense of WPATH’s flatly hostile response to the Cass report in England, which commissioned systematic reviews and recommended extreme caution over the use of blockers and hormones. The review was a direct challenge to WPATH’s ability to position itself as the final arbiter of these treatments—something that became more obvious when the conservative justices referenced the British document in their questions and opinions in Skrmetti. One of WPATH’s main charges against Hilary Cass, the senior pediatrician who led the review, was that she was not a gender specialist—in other words, that she was not part of the charmed circle who already agreed that these treatments were beneficial.
Because of WPATH’s hostility, many on the American left now believe that the Cass review has been discredited. “Upon first reading, especially to a person with limited knowledge of the history of transgender health care, much of the report might seem reasonable,” Lydia Polgreen wrote in the Times last August. However, after “poring over the document” and “interviewing experts in gender-affirming care,” Polgreen realized that the Cass review was “fundamentally a subjective, political document.”
Advocates of youth gender medicine have reacted furiously to articles in the Times and elsewhere that take Cass’s conclusions seriously. Indeed, some people inside the information bubble appear to believe that if respectable publications would stop writing about this story, all the doubts and questions—and Republican attempts to capitalize on them electorally—would simply disappear. Whenever the Times has published a less-than-cheerleading article about youth transition, supporters of gender medicine have accused the newspaper of manufacturing a debate that otherwise would not exist. After the Skrmetti decision, Strangio was still describing media coverage of the issue as “insidious,” adding: “The New York Times, especially, has been fixated on casting the medical care as being of an insufficient quality.”
Can this misinformation bubble ever be burst? On the left, support for youth transition has been rolled together with other issues—such as police reform and climate activism—as a kind of super-saver combo deal of correct opinions. The 33-year-old democratic socialist Zohran Mamdani has made funding gender transition, including for minors, part of his pitch to be New York’s mayor. But complicated issues deserve to be treated individually: You can criticize Israel, object to the militarization of America’s police forces, and believe that climate change is real, and yet still not support irreversible, experimental, and unproven medical treatments for children.
The polarization of this issue in America has been deeply unhelpful for getting liberals to accept the sketchiness of the evidence base. When Vice President J. D. Vance wanted to troll the left, he joined Bluesky—where skeptics of youth gender medicine are among the most blocked users—and immediately started talking about the Skrmetti judgment. Actions like that turn accepting the evidence base into a humiliating climbdown.
Acknowledging the evidence does not mean that you also have to support banning these treatments—or reject the idea that some people will be happier if they transition. Cass believes that some youngsters may indeed benefit from the medical pathway. “Whilst some young people may feel an urgency to transition, young adults looking back at their younger selves would often advise slowing down,” her report concludes. “For some, the best outcome will be transition, whereas others may resolve their distress in other ways.”
I have always argued against straightforward bans on medical transition for adolescents. In practice, the way these have been enacted in red states has been uncaring and punitive. Parents are threatened with child-abuse investigations for pursuing treatments that medical professionals have assured them are safe. Children with severe mental-health troubles suddenly lose therapeutic support. Clinics nationwide, including Olson-Kennedy’s, are now abruptly closing because of the political atmosphere. Writing about the subject in 2023, I argued that the only way out of the culture war was for the American medical associations to commission reviews and carefully consider the evidence.
However, the revelations from Skrmetti and the Alabama case have made me more sympathetic to commentators such as Leor Sapir, of the conservative Manhattan Institute, who supports the bans because American medicine cannot be trusted to police itself. “Are these bans the perfect solution? Probably not,” he told me in 2023. “But at the end of the day, if it’s between banning gender-affirming care and leaving it unregulated, I think we can minimize the amount of harm by banning it.” Once you know that WPATH wanted to publish a review only if it came to the group’s preferred conclusion, Sapir’s case becomes more compelling.
Despite the concerted efforts to suppress the evidence, however, the picture on youth gender medicine has become clearer over the past decade. It’s no humiliation to update our beliefs as a result: I regularly used to write that medical transition was “lifesaving,” before I saw how limited the evidence on suicide was. And it took another court case, brought by the British detransitioner Keira Bell, for me to realize fully that puberty blockers were not what they were sold as—a “safe and reversible” treatment that gave patients “time to think”—but instead a one-way ticket to full transition, with physical changes that cannot be undone.
Some advocates for the Dutch protocol, as it’s applied in the United States, have staked their entire career and reputation on its safety and effectiveness. They have strong incentives not to concede the weakness of the evidence. In 2023, the advocacy group GLAAD drove a truck around the offices of The New York Times to declare that the “science is settled.” Doctors such as Olson-Kennedy and activists such as Strangio are unlikely to revise their opinions.
For everyone else, however, the choice is still open. We can support civil-rights protections for transgender people without having to endorse an experimental and unproven set of medical treatments—or having to repeat emotionally manipulative and now discredited claims about suicide.
I am not a fan of the American way of settling political disputes, by kicking them over to an escalating series of judges. But in the case of youth gender medicine, the legal system has provided clarity and disclosure that might otherwise not exist. Thanks to the Supreme Court’s oral questioning in Skrmetti and the discovery process in Alabama, we now have a clearer picture of how youth gender medicine has really been operating in the United States, and an uncomfortable insight into how advocacy groups and medical associations have tamped down their own concerns about its evidence base. Those of us who have been urging caution now know that many of our ostensible opponents had the same concerns. They just smothered them, for political reasons.
The post The Liberal Misinformation Bubble About Youth Gender Medicine appeared first on The Atlantic.
