Ending the Gender Affirming Care Model

Trump’s Executive Order Won’t Do It

President Trump’s recent executive order Protecting Children From Chemical and Surgical Mutilation has been widely promoted as the end of gender affirming medicine for children. However, its impact is much less than its title suggests. 4thWaveNow, which has been leading the opposition to child gender medicine for the last ten years was cautious:

But people need to understand that Trump didn't (and can't) unilaterally "ban" pediatric transition with an executive order. What he did do: Ended the blatant federal-agency peddling of those practices, and began the process of slowing down taxpayer funding of them.

In the United States, regulation of health care and education is a matter for the states. This leaves the country in a position where half the states can pass laws that ban medical transition of minors and the other half can threaten parents who will not agree to transition with loss of custody. However, the federal government can influence policy at the state level by attaching conditions to federal funding. This is how previous administrations promoted gender medicine and Trump is now reversing the process.

The threat to cut off federal funding to hospitals and universities which engage in medical transition of minors is already having an effect. Major teaching hospitals in Democrat controlled states have announced that they will no longer provide puberty blockers, hormones or gender transition surgery to minors. Clinics which employ major figures in gender medicine such as Johanna Olson Kennedy and Jason Rafferty have been affected. However, the actual effect on availability of treatment will be less dramatic. Many clinics are still treating existing patients and, with time, treatments can be provided in doctors’ offices or smaller hospitals which do not receive federal funding.

The Executive Order may have broader impact by cutting off the funds which pay for procedures. Congress has already approved changes which would cut off funding for medical transition of minors covered under the United States military health plan. The Executive Order also proposes to cut funding under the health insurance plans for federal employees, Medicare and Medicaid. It also refers to a review of section 1557 of the Patient Protection and Affordable Care Act, which is now interpreted as requiring private insurers to cover medical gender transition.

It will take months or even years to determine the overall impact of the Executive Order. Some parts of the Order may require regulatory changes, which entail complex procedures. Most provisions contain the qualifier “in accordance with applicable law.” A lawsuit has already been started to challenge the constitutionality of the Executive Order. Fifteen state attorneys general (Rhode Island, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, New Jersey, New York, Nevada, Vermont, and Wisconsin) have issued a joint statement that they believe the Executive Order is unlawful and that they will continue to enforce state laws protecting access to gender affirming care. Medical transition of minors will be less common, but it will continue for the foreseeable future, at least where the state government supports it.

Neither the Executive Order nor the state level treatment bans will end the ongoing medical scandal of gender medicine. None of the health care professionals engaged in gender medicine are likely to change their minds and they will change their practices only to the minimum extent necessary to stay within the law. Gender confused young people will still be “affirmed” in their new identity, encouraged to transition socially and kept in a holding pattern until they are old enough legally to start hormones. While a delay of even one or two years may give some children time to come to terms with their bodies, the fact remains that cognitive capacity, and in particular risk assessment and long-term planning ability, continues developing until around age 25. There are many detransitioners who did not start on hormones until their early twenties.

The problem is not simply that patients are being started on medical transition too young, but that they are not receiving adequate psychological assessment before they start and are often continued on hormones even as their mental and physical health worsens. This problem does not go away at age 18 or 19. Indeed, young adults may be at greater risk than minors because their parents are no longer able to look out for them.

The problems are built into the gender affirming model of care which is not compatible with science or ethical medical practice. The gender affirming model starts from the dogmatic belief that everyone has a gender identity which is not connected to any other developmental or psychological process. Co-morbid mental health conditions such as depression or eating disorders or neurodevelopmental conditions are viewed as irrelevant to the formation gender identity. The only appropriate response is affirmation and medical transition to the extent the patient desires. According to the WPATH SOC8, even active psychosis is not necessarily an obstacle to medical transition. The WPATH Files describe a case in which a WPATH member explained that he was able to provide gender affirming surgery to a patient with Dissociative Identity Disorder (formerly known as multiple personality disorder) because he had obtained consent from all seven of the patient’s “alters.”

The gender affirming model detaches medical transition from the normal medical concerns about accurate diagnosis and appropriate treatment. There is no clear diagnostic criteera except self-declared gender identity. Systematic reviews have consistently found that the evidence of benefit from gender affirming treatments is low or very low certainty. The risks are considerable and include sterility, loss of sexual response, early onset osteopororis and increased risk of heart attacks and strokes.

Advocates of the gender affirming model have responded by moving the goal posts so that evidence of risk and benefit are irrelevant. The goal of gender affirming treatment, they now claim, is simply to fulfil the patient’s self-determined embodiment goals.

The obvious dangers of applying this model to minors has triggered a political and legal response. However, the whole model is inappropriate for patients of any age. It needs to be discarded and replaced with an evidence-based model. This is a scientific and medical matter, which cannot be resolved by politics.

One legal and political obstacle to replacing the gender affirming model which the Executive Order will not overcome is conversion therapy legislation. At least 25 states have some form of legislation which prohibits health care providers from attempting to change the sexual orientation or gender identity of a minor. The scope of these laws and the extent of exemptions vary considerably. Many laws do have broad exemptions for exploratory therapy. However, many therapists who question the gender affirming model cannot afford to risk professional sanctions and prefer to avoid treating cases of gender dysphoria or limit their practice to adults. The uncertainty created by the laws deters academic research and publishing on non-medical responses to gender distress. Conversion therapy laws are a state matter in the United States and the President or even Congress cannot do much about them.

There is also a need for re-education of health care professionals on non-medical approaches to gender distress. Many healthcare providers are simply not aware that there are any other options for treating a gender distressed young person other than a referral to a gender clinic for puberty blockers and hormones. The rise of gender dysphoria among young people over the last ten years paralleled the rise of transgender activism in the health care professions and universities. Prior to 2014 transgender identification in young people was rare and treatment was a very small sub-specialty. Since then, clinicians who used to advocate for a cautious wait and see approach have been pushed aside and clinicians have been indoctrinated in the belief that the gender affirming model is the only acceptable one.

Groups like Therapy First, Society for Evidence Based Gender Medicine and Genspect are working to educate health care professionals on an approach to gender distress which prioritizes psychotherapy but the process has been slow. Supporters of gender affirming care are well entrenched in hospitals and universities and resist any change. They are supported by noisy activists.

Executive Orders will not change minds on contested medical and scientific issues. The immediate impact of Trump’s intervention will be further to inflame an already bitter partisan debate. At this point, it would be best if Trump lost interest in the issue. The language in some of Trump’s Executive Orders is overtly hostile to transgender people. The Executive Order on military service says “adoption of a gender identity inconsistent with an individual’s sex conflicts with a soldier’s commitment to an honorable, truthful, and disciplined lifestyle, even in one’s personal life.” While Trump has not shown any marked hostility to the LGB community, he is notoriously unreliable and this could change. Vocal support from Trump will only make the task of getting needed change in Democrat controlled state legislatures and professional governing bodies even more difficult.

Trump’s overall agenda will also slow down change and reform. His policies have already seriously disrupted federally supported research with reckless funding freezes. He has signalled his intentions to slash spending and keep the rest under tight partisan control. There is very little hope that there will be any federal agency left standing that could bridge the partisan divide with an American equivalent of the Cass Review. Nor is there likely to be much federal support for research on detransition and non-medical approaches to gender distress.

But reversing the Biden administration’s dogmatic support for gender ideology is a positive change. Without the backing of the federal government, supporters of gender ideology will not be able to maintain the kind of hegemony they have gained in the academic world. Without federal research money, supporters of gender ideology will not have the same attraction to graduate students or influence with boards of governors. Their ability to threaten the careers of dissidents will be weakened. Eventually, change will reach the peer-reviewed journals. Research articles on medical transition will get more rigorous peer review and some of the more questionable studies may even be retracted or reanalyzed.

Trump has not ended the gender affirming care model but has at least created conditions in the United States where a productive debate is possible. The federal government is not likely to offer much help but at least it is no longer a biased adversary.