The Tide Goes Out on Youth Gender Medicine

As the shaky evidence base for youth gender medicine has become better known, activists have retreated to an argument from authority. Never mind the Cass Report, whose findings resulted in the closure of Britain’s leading youth gender clinic. Never mind the study by a leading American practitioner showing that the treatments she championed did not improve minors’ mental health. Never mind reports that some adolescents were being put on a medical pathway after only a single clinic visit. For advocates, the important thing to remember was that “gender-affirming care” for minors—puberty blockers and hormones, plus surgery in rare cases—was endorsed by all of the major American medical associations.

“Doctors Agree,” proclaimed the American Civil Liberties Union: “Gender-Affirming Care Is Life-Saving Care.” GLAAD declared that “every major medical association and leading world health authority supports health care for transgender people and youth.” Fired up by the Republican “war on trans kids,” and naturally deferential to institutional authority, Democrats have tended to echo this line. At a 2023 congressional-subcommittee hearing on pediatric gender medicine, the ranking Democrat, Representative Mary Gay Scanlon of Pennsylvania, declared that “gender-affirming care is safe and effective” and “supported by every major medical association”—groups that collectively count more than 1.3 million doctors as members. “It’s not up for debate,” she said. In line with this, Joe Biden’s administration lobbied to remove age minimums from the industry’s standards of care.

Today, though, the future of medical transition for minors is up for debate. On February 3, the American Society of Plastic Surgeons recommended that “surgeons delay gender-related breast/chest, genital, and facial surgery until a patient is at least 19 years old.” The next day, the American Medical Association, the country’s largest organization representing doctors, endorsed that view: “In the absence of clear evidence, the A.M.A. agrees with A.S.P.S. that surgical interventions in minors should be generally deferred to adulthood.” These statements echo what skeptics of American youth gender medicine have been saying for years: The evidence of the benefits and risks of mastectomies and other surgeries is insufficient to justify their use as treatments for gender dysphoria, and follow-up data on those who have undergone the procedures are scant.

[Helen Lewis: The liberal misinformation bubble about youth gender medicine]

More significant, the ASPS statement explicitly endorses the conclusions of the Cass Report and the evidence review commissioned by the Department of Health and Human Services last year. LGBTQ groups and gender clinicians have dismissed both of these documents as fuel for right-wing attacks on care, even though Hilary Cass was a nonpartisan retired pediatrician, and most of the HHS report authors were self-described liberals and Democrats. But the ASPS references both warmly, and bases its new guidelines on the research carried out by the official British and American inquiries. “Both the Cass Review and the HHS report emphasize that the natural course of pediatric gender dysphoria remains poorly understood,” notes the ASPS statement. “Available evidence suggests that a substantial proportion of children with prepubertal onset gender dysphoria experience resolution or significant reduction of distress by the time they reach adulthood, absent medical or surgical intervention.” Put simply, that is an American doctors’ organization acknowledging that gender dysphoria frequently resolves itself without treatment—a challenge to the idea that children’s new identities should be uncritically endorsed.

I don’t want to overstate what has happened here: The ASPS has been more cautious than other groups for many months now, and its new positions are limited in scope. Gender surgeries on minors were never offered by Britain’s health service, and only a few thousand have been performed in the United States, according to a 2023 study. The ASPS statement also cites “insufficient evidence demonstrating a favorable risk-benefit ratio” for hormone treatments, but does not explicitly recommend against them. Yet the organization’s stance still represents a shift away from the purely affirmative model, in which saying no is never a clinician’s job. Notably, the group reminds members that “plastic surgeons cannot rely on the presence of a prior medical intervention, referral, or letter of support as a proxy for surgical indication or adolescent readiness.”

This matters, because the idea of performing mastectomies on girls as young as 13 became a powerful symbol of a clique of doctors who could not be trusted to regulate themselves. The Miami surgeon Sidhbh Gallagher became known on TikTok for her catchphrase “yeet the teet,” referring to mastectomies, and for calling herself “Dr. Teetus Deletus.” The detransitioner Chloe Cole, who has testified in favor of state bans on pediatric gender medicine, received a double mastectomy at 15. Johanna Olson-Kennedy, who formerly worked at the gender clinic of the Children’s Hospital Los Angeles, was the lead author on a paper recommending that mastectomies be offered based on “individual need rather than chronologic age.” She once boasted at a seminar that she did not worry about regret: “If you want breasts at a later point in your life, you can go and get them.”

Unfortunately, things are not that simple. In a recent lawsuit in New York State, a detransitioner called Fox Varian testified that she’d had her breasts removed at 16, only 11 months after first identifying as male. She had also been diagnosed with autism and had struggled with an eating disorder and anxiety. By the time of the surgery, she had changed her name twice already. Varian asserted, according to the reporter Benjamin Ryan, who attended the trial, that her doctor “served as an enabler, repeatedly assuring her that the mastectomy she desired would greatly improve her well-being.” Varian told the court that she regretted the surgery instantly, and detransitioned three years later. She was awarded $2 million in damages. The court heard that she had been left with scarring and a lack of sensation, and would be unable to breastfeed.

Varian’s lawsuit also claimed that doctors encouraged her mother to approve the surgery by invoking the specter of suicide. As I wrote last year, the idea of youth gender medicine as “lifesaving”—for the prevention of suicide—has been key to overriding parents’ understandable concerns about these treatments. But this is another activist talking point that has begun to crumble. In front of the Supreme Court, the ACLU’s Chase Strangio conceded that there was no evidence to support the assertion that transition prevents suicide, because “completed suicide, thankfully and admittedly, is rare.” He argued that instead it reduced suicidal thoughts—a significant climbdown from the once-popular assertion that parents had to choose between “a dead son and a living daughter,” and vice versa. His concession helped expose this rhetoric as the emotional blackmail that it always was.

[Adam Serwer: The attack on trans rights won’t end there]

The tide is now going out on the affirmative approach to youth gender medicine as practiced in America. “I stopped the mutilation of children,” Donald Trump told a prayer breakfast on February 5. Twenty-seven states have placed restrictions on the medical pathway, while gender clinics in blue cities such as Los Angeles have shut down under Trump’s threat of funding cuts to their host institutions. Now the success of such a high-profile detransitioner lawsuit—one of more than two dozen currently under way, according to Ryan—will make the remaining affirmative clinicians nervous.

Frankly, they should be nervous. As the field has received more scrutiny, advocates have begun to stress the need for careful assessments, even though American providers in the 2010s largely rejected this essential feature of the Dutch protocol, the medical treatment for youth gender dysphoria developed in Europe in the 1990s. Today, when Democrats defend youth gender medicine, they tend to do so on the basis of individual freedom rather than the effectiveness of the treatments themselves. In 2024, a brief signed by 11 Democratic senators and 153 Democratic House members urged the Supreme Court not to uphold Tennessee’s ban on youth medical transition. The state law “intrudes on an individual’s decisions about their own medical care, made in partnership with their medical providers,” the signatories said.

All of this represents a clear retrenchment from the 2010s and early 2020s. The excesses of that era prompted a backlash that fueled the current MAGA demonization of gender nonconformity. The story of youth gender medicine is one of good intentions, arrogance, fear, and polarization. It is also an avoidable tragedy.