A Transgender Controversy

The world of gender and sex has become more complicated. In earlier times, the person delivering the baby could announce “It’s a boy” or “It’s a girl,” and that was that. Everyone could easily tell a boy from a girl. No longer. Today, more and more people are self-identifying as LGBTQ (Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning). In a 2020 Gallup poll, 5.6% of respondents reported themselves as belonging to this group; 54.6 percent of these self-identified as bisexual, 24.5 percent as gay, 11.7 percent as lesbians, 11.3 percent as transgender and 3.3 percent said they used another term to describe their identity (for instance same-gender loving). In another recent study 0.6% of American adults self-identified as transgender. That figure is double the estimates from a decade earlier and is higher in younger people. LGBTQ doesn’t include people who are intersex or born with ambiguous genitalia or are hermaphrodites with organs of both sexes or who are asexual and have no interest in sex.

Transgender individuals have experienced gender dysphoria. They were acutely uncomfortable with their natal sex and were strongly motivated to adopt the appearance, dress, and lifestyle of the opposite gender.  

Society is changing; it has become more accepting of people it once disparaged as sick, immoral, or defective. Same-sex marriage is legal in many jurisdictions and prisons have authorized medical treatments so transgender inmates can transition. A boy who announced that he is a girl trapped in the wrong body or a girl who claims she is really a boy is readily believed and encouraged to use the names and pronouns they prefer. They are offered affirmative treatment, puberty-blockers, and sex hormones; and the majority of those so treated go on to have surgeries which may include removal of breasts or male genitalia, or creation of an artificial vagina (vaginoplasty) or penis (phalloplasty).

What should have been decided by the scientific evidence has degenerated into a political battle between transgender activists and those they paint as transphobic. The Week magazine called it “the controversy over transgender teens.” It started when Lisa Littman coined the term “Rapid Onset Gender Dysphoria” (ROGD) in a 2018 study published in PLOS One. She had become aware of a disturbing trend: an increasing number of teenage girls who had not expressed discomfort with their natal sex in childhood suddenly self-identified as transgender in their teen years. She thought some of them may have been unduly influenced by their peer group or through the internet. Her study was disparaged as poor science because she relied on parental reports instead of talking to the transgender teens themselves. The term ROGD has not been accepted. It is not recognized by any professional medical or psychological organization. But many observers have noticed a similar trend.

If Littman’s article provided the spark, journalist Abigail Shrier fanned it into a fire. Her 2020 book, Irreversible Damage: The Transgender Craze Seducing Our Daughters, won awards in some quarters but elsewhere was characterized as transphobic and harmful to the transgender community. She argued that ROGD was a real phenomenon, that some adolescent girls had not been adequately evaluated to rule out psychological problems, and that some girls were being subjected to potentially dangerous and irreversible medical and surgical interventions before they had reached the legal age of consent.

Detransitioners

Some have regretted it and detransitioned. Thousands of detransitioners have joined online forums, but we don’t know what percentage that represents. Littman published a study in the Archives of Sexual Behavior in October 2021 titled “Individuals Treated for Gender Dysphoria with Medical and/or Surgical Transition Who Subsequently Detransitioned: A Survey of 100 Detransitioners.” It used a convenience sample of subjects recruited via social media; they submitted anonymous questionnaires. It did not answer the question of prevalence. It was essentially just more anecdotal evidence, but it did provide some valuable insights. It explored the experience of detransitioners and their reasons for detransitioning.

69% of the sample were natal females; 31% were natal males. The reasons they gave for detransitioning:

  • Experiencing discrimination (23%)
  • Becoming more comfortable with their natal sex (60%)
  • Concerns about potential medical complications from transitioning (49%)
  • Coming to realize that their gender dysphoria was caused by something specific such as trauma, abuse, or a mental health condition (38%)

23% reported homophobia or difficulty accepting themselves as lesbian, gay, or bisexual. The majority (55.0%) felt that they did not receive an adequate evaluation from a doctor or mental health professional before starting transition and only 24.0% of respondents informed their clinicians that they had detransitioned (perhaps this explains why transgender clinicians think detransition is rare). Average age of detransition was 21.9. Steps taken included reverting to former pronouns, stopping cross-sex hormones (95%), and getting surgery to reverse the changes from transition (9%).

These self-reports are no substitute for good, objective scientific evidence, but they tend to validate the concerns raised in Shrier’s book.

Is Shiloh transgender?

Angelina Jolie and Brad Pitt’s daughter Shiloh has always dressed in boys’ clothing and apparently wanted to be called John. Is she transgender? It’s hard to glean the true details from social media and tabloids, but I haven’t seen any evidence that she was prescribed puberty blockers or male hormones, or that she is considering mastectomy or other gender transition surgeries. And recently she seems to have traded her boyish short hair for long hair done up in a bun. She has been seen in public wearing dresses and other feminine clothing, including her mother’s designer gowns. Did she experience gender dysphoria? Did she identify as transgender? Did she really think she was a boy? Did she change her mind?  We’ll never know for sure, but then it’s really none of our business. What if she is just a creative, independent child with her own unique fashion sense? Her parents have always been very accepting of whatever their children chose to do. If she is not transgender, it’s easy to imagine how readily she could have been influenced to proclaim herself a boy born into the wrong body and to accept treatments that would be difficult or impossible to reverse.

A forbidden topic?

I reviewed Shrier’s book for Science-Based Medicine (sciencebasedmedicine.org), I said that while it was mostly based on anecdotes, I thought it raised serious concerns that cried out for good scientific studies. As one of the three editors on that website, I was shocked when the other two editors took the unprecedented step of deleting my book review, the first time an SBM article had ever been retracted in the 14 years of its existence. Michael Shermer promptly republished it online, where it can still be read. The reactions to my article were mixed: many respected skeptics (including a former SBM editor) thought it was fair and should not have been retracted, but many commenters called me a trans-phobe who had caused irreversible harm to the trans community.

Some researchers have faced reprisals and loss of jobs. Some are reluctant to question transgender medical interventions because activists have created a climate of fear. The word “woke” originally meant being aware of racial and social issues, but its meaning has become distorted to where it now interferes with rational discourse and scientific inquiry. It was Scientifc American’s “woke” thinking that led it to fire Michael Shermer from his long-running column. Should any subject be out of bounds? Shouldn’t skeptics be free to ask for evidence to support any claim?

Transgender experts speak out

Dr. Marci Bowers is a world-renowned surgeon who has performed over 2000 vaginoplasties. Erica Anderson is a clinical psychologist at the University of California San Francisco’s Child and Adolescent Gender Clinic. Both have treated thousands of transgender patients. Both are on the board of WPATH (The World Professional Association for Transgender Health, which sets the standards for transgender care), and Bowers is WPATH’s President Elect. Both Bowers and Anderson are themselves transgender women.

Children with gender dysphoria were once treated with “watchful waiting” (nonintervention and waiting to see if some of them might outgrow it with time as they learned to accept their bodies). It has been replaced by the current practice of “affirmative care.” Some claim that affirmative care prevents suicides, but others say the evidence is not robust. Doctors and families are expected to corroborate the child’s belief that they are trapped in the wrong body and to give them puberty blockers, cross-sex hormones, and surgery (which is supposed to wait for the age of consent but sometimes happens earlier). Bowers and Anderson think the new orthodoxy has gone too far; they are seeing more adolescent girls who seem to fit the ROGD description, and they are concerned that currently sloppy healthcare work may lead to more regrets and detransitioners. There are concerns about brain development, impaired fertility, and the inability of puberty-blocked patients to ever experience orgasm. And patients who don’t go through puberty may not develop adequate penile tissue for surgeries like vaginoplasty.

When Anderson submitted a co-authored op-ed to The New York Times warning that many transgender healthcare providers were treating kids recklessly, the newspaper rejected it with the lame excuse that it was “outside our coverage priorities right now.” I guess their priorities don’t include protecting children. Bowers said, “There are definitely people who are trying to keep out anyone who doesn’t absolutely buy the party line that everything should be affirming, and that there’s no room for dissent,…I think that’s a mistake.”

The bottom line

The science supporting transgender diagnosis and treatment is far from settled, especially for adolescent girls. Unanswered questions remain that can only be answered through good science. If experts could predict which individuals are likely to regret gender transition, irreversible damage might be avoided.

This article was originally published in Skeptic Magazine.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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