The Reason Gender-Affirming Care is Controversial is Base Prejudice

Viewed as medicine, the treatments are remarkable only in their ability to give hope to patients with no other evidence-based treatment.

by Evan Urquhart

What if being transgender wasn’t a controversial, highly stigmatized identity? What if men in dresses had never become a staple trope of rowdy comedy? What if medical transition, when it began a century ago, was never an object of either disgust or intense fascination? Throughout history some people have lived as the opposite sex: What if no one ever had any strong opinions about that whatsoever?

These counterfactuals are hard to imagine, not because there’s something so strange about the existence of trans people, but because the historic oppression of women and the rigidity of societally imposed gender roles imparts an aura of contentiousness to everything relating to sex or gender. When the first gender surgeries were being conducted in Germany, women in America were still 50 years from having the right to open their own bank accounts. Women fought hard for equality of the sexes, but despite many gains it continues to elude them.

Gender and sex are culturally fraught, so the culture reacts when a group of people move from one position in the gender hierarchy to another. Still, just for fun, let’s imagine what gender-affirming care would look like from the perspective of a culture which didn’t have these same hang ups.

Medical transition isn’t new, which means there’s been ages to amass evidence about its efficacy. If regret was common, we would know. If it often resulted in harm to the patients, we would know. The evidence of transition’s efficacy for adults is so settled that even fringe medical figures who voice concerns about modern treatment advances don’t dispute adult medical transition for individuals diagnosed with gender dysphoria is safe and effective Instead, they say there’s not enough evidence to support treating young people. They say the evidence we have, which strongly suggests that youth treatments are beneficial, are tainted by the possibility that young people seeking treatment today might be different from youth who were studied in the past, and perhaps also from the transgender adults who have been known to benefit from treatment for many decades.

No matter how hard people try to normalize it, this is a really weird angle of criticism. Gender dysphoria, as everyone agrees, is associated with a range of negative symptoms including anxiety, depression, and even suicide. A systematic literature review conducted in 2018 is one of many sources that show how transition significantly improves these symptoms. There is no other evidence-based treatment available. It is the most natural thing in the world for the medical establishment to have started generalizing findings this robust to children with the same symptoms that adults are being successfully treated for. This movement to younger patients began slowly, it built up a research base, so now when we look at the literature we find evidence that transition helps young patients with gender dysphoria also.

“But the evidence isn’t as strong as we’d like” isn’t a normal objection to a promising medical treatment for children. Neither is “But the patients being treated now might be different, and less likely to benefit, than the patients who benefitted earlier.” Those are, at best, hypothesis to be investigated. In a normal situation, only if those bore fruit in the form of concrete evidence would they start to impact future treatment decisions.

That’s how medicine normally works. You amass evidence in adults, you generalize to children. If there are questions you investigate them, and change course once there’s evidence to support that there’s a problem. You wouldn’t normally change course because someone has raised questions because questions are an unlimited resource and anyone can raise them about anything for any reason.

In the New York Times today there was another article on gender-affirming care for youth, this time focusing on the court battles over care bans. It’s bylined by Ernesto Londoño and Mitch Smith, and it’s perfectly functional, but it does contain these two paragraphs:

screenshot from the New York Times

The field of transition care for minors is 34 years old. Prominent clinicians do disagree on the ideal timing and diagnostic criteria, as one would expect experts in any field to have their own preferred methods and small disagreements. The linked reviews of the research are an interim report from England, which was narrowly focused on the Tavistock clinic and made no final conclusions, and this one from Sweden whose conclusions don’t suggest anything has gone amiss in the treatment of gender dysphoria.

Not sure? Well, here are those conclusions:

screenshot from the Swedish Agency for Health Technology Assessment and Assessment of Social Services

Concerns, questions, and doubts about gender-affirming care are being aggressively normalized at the moment. However, the core of those concerns and doubts has nothing to do with the medical evidence. And, since it’s not based on evidence, the only reasonable conclusion is that it rests on a reluctance to accept people are trans, or that people who are trans could be helped by these treatments, which were developed slowly and painfully over so many decades.

It’s important, every so often, to stop and observe how strange these questions and concerns would look in any other context. The possibility that patients being diagnosed with cancer today might be different from patients diagnosed with cancer 10 years ago is an interesting hypothesis to float, but no one would suggest halting cancer treatments because I just floated it, before I’ve offered any evidence that the patients really are different or that the new patients aren’t being helped by the standard treatments. There’s no normal medical context where a treatment that boasted 30 years of observational studies would be banned because there’s only been one randomly controlled trial.

The treatment of gender affirming care in the mainstream, and in the press, is freaking weird. It is unusual. It is not normal, or rational. Mainstream reporters are unable to turn off their biases and approach this like any other medical story. A normal process would be to wait for the criticisms to produce evidence that something is amiss or that the outcomes aren’t as expected. Instead, for this treatment alone, mere questions are being allowed to do the work findings would be expected to. It’s not right, but it is everywhere.