If popular opinion is to be believed, living as if one were the opposite sex is simply a healthy variant on a spectrum rather than a mental disease in need of serious treatment. What transgender individuals need, the thinking goes, is not to be told that they are delusional and in need of psychotherapy; it is for society to accept them as they are, and for medical and psychological professionals to help them “transition” to their “true gender.”
There is precious little evidence to support such a claim. Yet there seems to be a determined campaign, waged by activists and politicized medical officials, to suppress or otherwise ignore any dissent on the matter, even within the medical and psychiatric professions.
The “misalignment” of one’s body and one’s gender identity is one of the core tenets of transgender ideology. Most (though not all) transgender individuals feel the need to alter their physically healthy bodies—with genital surgery, with hormones, with breast augmentation or elective mastectomies—in order to reflect their “true” identities.
What drives so many doctors, psychiatrists, and therapists to affirm transgenderism rather than deny it? Where is the evidence to support such bizarre clinical practice?
Where's the Evidence?
You might be surprised to learn that the evidence is sorely lacking. We have been led to believe that there is a scientific consensus on this issue: that gender affirmation and “transitioning” have been scientifically proven to be the correct approaches to dealing with transgenderism in both children and adults. This appears to be largely false.
A few years ago, the medical consultation company Hayes, Inc., released several overviews of the numerous medical and scientific studies that have been performed on transgender populations. Hayes, which bills itself as promoting “better healthcare decisions using fiercely unbiased evidence,” is a low-profile but longstanding player in the medical evidence field. Since its founding in 1989, Hayes “has become an industry leader in providing unbiased, timely, clinically focused, evidence-based research and analysis to health plans, insurers, hospitals, healthcare systems, ACOs and government agencies.”
The Hayes reports are the damning indictments of the transgender industry that you’ve never heard of. Getting my hands on the reports entailed some difficulty; Hayes, Inc., did not respond to my requests for them, and indeed they did not respond to any of my inquires at all, leaving me to seek them out elsewhere. Eventually a sympathetic doctor offered me some copies. What they revealed was, to put it mildly, rather shocking.
The reports, released between May 9 and May 19, 2014, survey the three major types of medical treatment most often sought by transgender individuals: “sex reassignment surgery,” “hormone therapy,” and “ancillary procedures and services.” The reports draw from the literature of peer-reviewed publications over the span of at least a decade’s worth of studies and concern themselves with outcomes ranging from “psychological well-being” and “sexual function and satisfaction” to “safety outcomes” and “quality of life.”
Though the surveys note certain positive post-treatment changes in patient populations—say, an improvement of quality of life for some individuals who underwent “sex reassignment surgery,” and a reduction in anxiety and depression in some patients subject to “hormone therapy”—the overall “quality of evidence” for every category of treatment was rated “very low.”
The low-quality ratings were given for a variety of reasons: “limitations of individual studies,” “lack of randomization of patients to treatment groups,” “failure to control for confounders,” “unknown or short follow-up intervals,” “variable follow-up duration,” “possible recall bias and selection bias,” “lack of objective and validated outcome measures,” “lack of blinded outcome assessments,” “lack of baseline data for self-rated outcome measures,” and many others. In other words, there appears to be very little evidence to support the treatment plans proposed by the modern medical transgender zeitgeist.
Gender Dysphoria in Children
This troubling dearth of evidence would be alarming enough if this phenomenon were limited solely to adults. But in recent years, transgender activists have set their sights on encouraging children to embrace transgender identities.
The Endocrine Society, a professional medical organization based in Washington, DC, recently stipulated that children under sixteen years old can safely begin hormone treatment therapy, even though its own research indicates that there are insufficient data to support its recommendations. In a recent “Clinical Practice Guideline” surveying the state of “Endocrine Treatment of Gender-Dysphoric/ Gender-Incongruent Persons,” the Endocrine Society laid out a “Summary of Recommendations” detailing how physicians and mental health professionals should treat individuals who experience gender dysphoria. The Society rates each of its recommendations on a four-point scale of quality of evidence: “very low,” “low,” “moderate,” or “high.”
Not a single one of the guidelines is backed by “high” quality evidence. Of the twenty-eight recommendations, only three scored “moderate.” The rest were either “low” or “very low.”
Among the recommendations that scored “low” are those that adolescents experiencing gender dysphoria should “undergo treatment to suppress pubertal development;” that sixteen-year-olds should be allowed to undergo “partly irreversible” hormone therapy; and that children younger than sixteen should be allowed to receive hormone therapy in some cases. Some of the very low ratings include permitting individuals to undergo “genital surgery” and “breast surgery.”
The guidelines also make several ungraded recommendations for which “direct evidence . . . was either unavailable or not systematically appraised and considered out of the scope of this guideline.” Among those ungraded statements: the suggestion that clinicians consider whether or not hysterectomies (the removal of the uterus) and oophorectomies (the removal of the ovaries) are “medically necessary” as part of “gender-affirming surgery.” That is to say, the Society does not even give the lowest possible grade on its evidentiary scale for a surgical medical directive that renders women permanently, irreversibly sterile.
This past June, the American College of Pediatricians released a policy statement titled “Gender Dysphoria in Children” that asserts that there is a “vigorous, albeit suppressed, debate among physicians, therapists, and academics regarding what is fast becoming the new treatment standard for GD [gender dysphoria] in children.” Disputing the growing trend of using hormone therapy to treat children with gender dysphoria, the College states that “a review of the current literature suggests that this protocol is founded upon an unscientific gender ideology, lacks an evidence base, and violates the long-standing ethical principle of ‘First do no harm.’”
“There is not a single large, randomized, controlled study,” the College points out, “that documents the alleged benefits and potential harms to gender-dysphoric children from pubertal suppression and decades of cross-sex hormone use. Nor is there a single long-term, large, randomized, controlled study that compares the outcomes of various psychotherapeutic interventions for childhood GD with those of pubertal suppression followed by decades of toxic synthetic steroids.”
Noting the proliferation of transgender clinics and transgender-affirming doctors across the country in recent years, the College notes the staggering levels of persistent gender dysphoria among young patients placed on puberty blockers:
In a follow-up study of their first 70 pre-pubertal candidates to receive puberty suppression, de Vries and colleagues documented that all subjects eventually embraced a transgender identity and requested cross-sex hormones. This is cause for concern. Normally, 80 percent to 95 percent of pre-pubertal youth with GD do not persist in their GD. To have 100 percent of pre-pubertal children choose cross-sex hormones suggests that the protocol itself inevitably leads the individual to identify as transgender. There is an obvious self-fulfilling nature to encouraging a young child with GD to socially impersonate the opposite sex and then institute pubertal suppression. Given the well-established phenomenon of neuroplasticity, the repeated behavior of impersonating the opposite sex will alter the structure and function of the child’s brain in some way—potentially in a way that will make identity alignment with the child’s biologic sex less likely…
“The treatment of GD in childhood with hormones,” the College declares, “effectively amounts to mass experimentation on, and sterilization of, youth who are cognitively incapable of providing informed consent.”
Branding Heterodoxy as Hate
Dr. Michelle Cretella, the president of the American College of Pediatricians and the lead author of the above-cited policy statement on gender dysphoria in children, says that the deck is stacked against professionals who wish to speak out against the current fashionable stance on transgenderism. “Not only is there a profound lack of diversity of philosophical worldviews among medical school faculty and professional medical guilds,” she told me, “but also, staunch transgender physician activists—some of them trans-identified—[have] achieved positions of authority allowing them to craft the current standards of care.” In this environment, Cretella argues, “no one is free to dissent without being punished. Such punishments range from being “passed over for promotions” to “demoted from Chairmanship positions” to suffering “loss of research funding” and being subject to “severe harassment by peers [and] death threats from activists.”
“And this censorship continues,” she says, “even as those ‘expert’ physicians admit that their recommendations have no long term scientific evidence to back them.”
Consider the example of Paul McHugh, a renowned physician who has been put through the wringer for his stance on gender dysphoria. Dr. McHugh, who is a distinguished professor of psychiatry at Johns Hopkins Medical School, was for twenty years the Psychiatrist in Chief at Johns Hopkins Hospital. By his own account, he has had extensive experience in observing and interacting with individuals identifying as transgender. In 1979 he shut down the gender identity clinic at Johns Hopkins, claiming that the treatments it offered were ineffective for helping people with gender dysphoria.
McHugh’s ongoing heterodoxy on transgender ideology—he has been outspoken in his belief that it is deeply flawed and misguided—has earned him the unrelenting ire of progressive activists across the country. The Human Rights Campaign devotes an entire website to “exposing” McHugh, accusing him of providing “junk science” to “anti-LGBT activists.” The Daily Beast directly accused McHugh of being “anti-LGBT.” ThinkProgress claimed that “social conservatives depend on [McHugh] to justify anti-transgender hate.” Slate called him “a dinosaur” with “outdated, anti-LGBTQ views.” The Huffington Post accused McHugh of “endanger[ing] the lives of transgender youth.”
“They try to stop you in any way they know how,” McHugh told me over the phone when I asked about the often vicious criticism directed toward him. “They’ll brand you a hate person. They’ll try to get your university downgraded.” McHugh claims there are many more professionals who believe as he does on the subject of transgenderism who are keeping their mouths shut. “There are lots of people who agree with me,” he says, “but who don’t want to be brought forth. They fear the difficulties aren’t worth it.”
That is not an unreasonable fear. Take the case of Dr. Kenneth Zucker. For several decades Zucker ran Toronto’s Child Youth and Family Gender Identity Clinic (GIC). The clinic was the subject of some controversy due to its cautious approach to identifying and treating gender dysphoria: rather than go full steam ahead when a child experienced gender dysphoria, psychiatrists and clinicians at the GIC were more circumspect, mindful of the possibility that an overwhelming majority of children end up “desisting,” or abandoning their transgender identity.
By reliable accounts, the GIC under Zucker was a warm, welcoming, therapeutic environment. But the clinic’s wary approach to transgender affirmation earned it the ire of activists; an external review of the clinic eventually led to Zucker's being fired from his long-held position there, to the delight of transgender partisans. Yet in a fantastic piece at New York Magazine last year, Jesse Singal detailed the utterly shoddy and tissue-thin charges on the basis of which Zucker was publicly smeared and eventually dismissed. The external review itself ended up being a slapdash, largely unverified document that took the accusations against Zucker at face value without verifying any of them.
Beyond such smear campaigns and professional ramifications, there is a quiet but critical effort underway to criminalize professional dissent on the matter of gender identity—not simply as a matter of public debate but as a matter of private practice. The Therapeutic Fraud Prevention Act, put forward in April of this year in Congress, would expressly forbid mental health professionals from attempting to “change another individual’s . . . gender identity.” If the TFPA passes, medical professionals who try to offer psychological treatment to patients with gender dysphoria to help them accept their bodily identity will be treated like criminals by the federal government of the United States.
Cause for Optimism?
Yet Paul McHugh is optimistic—more optimistic, anyway, then you would expect from a man who has spent many recent years being slandered as some kind of Nazi devil-doctor. “This has happened before,” he told me. “This isn’t the only psychiatric craze I’ve been involved in. The ‘recovered memories’ of child sex abuse from the 1990s had exactly the same kind of pressure behind it. People insisted you’d better not speak against it, because then you’d be considered a champion of pedophilia.”
In the past, McHugh points out, activists have “seized on psychiatry to defend things that are indefensible.” Psychiatry, he says, “goes into a craze once every twenty to twenty-five years. They always do it for the same reasons . . . You had the eugenics business with [the support of] Oliver Wendell Holmes, frontal lobotomies that won the Nobel Prize, the psychoanalysis craze with the influx of European psychoanalysts . . . and now this one.”
These crazes do not go on forever, McHugh says. “They last for ten or fifteen years. Eventually they fall apart. And that’s what will happen here.”
He is probably right. But the damage that transgender ideology can wreak in ten or fifteen years—the hormones, the surgery, the irreversible decisions, the mutilated bodies—is considerable. When this ideological zeitgeist collapses, we will be left with thousands and thousands of individuals whose lives will have been forever altered by a passing fad. What will we say to them then? And what will the promoters and enablers of this fad say to themselves?
Daniel Payne is an assistant editor at The College Fix, a daily higher education news website that trains young student reporters in the craft of journalism. His work has appeared at The Federalist, National Review Online, Reason, Front Porch Republic and elsewhere. He lives in Virginia and he blogs at Trial of the Century.