The End of Gender Medicine

Activist clinicians no longer claim that gender affirming medical treatment does any good, but they don’t care

A new article by a group of professionals working at the main gender clinic in Amsterdam has upended the debate on gender affirming treatments for children and adolescents. The article (Oosthoek et al., 2024) is entitled Gender-affirming medical treatment for adolescents: a critical reflection on “effective” treatment outcomes. Annelou de Vries, one of the founders of the “Dutch Protocol”, is a co-author. The article has been accessed over 24,000 times in less than 2 weeks and is receiving wide attention, although not the type the authors would want. An X/Twitter thread by J.K Rowling describes the article as an example of what Hannah Arendt described in The Banality of Evil. It has also been the subject of a question in the Dutch Parliament.

What the article says, in very simple terms, is that the measures of the effectiveness of gender affirming medical treatment (GAMT) which researchers have used to date, such as improvement of psychological function and absence of regret, are irrelevant. Treatments should be provided simply because young people desire them.

In order to understand the significance of the article, it is necessary to consider it in the context of the overall debate on gender affirming care. There are really two parallel debates: a medical debate and an ideological debate. The medical debate starts from the premise that the purpose of gender affirming treatments is to improve health and that the effectiveness needs to be demonstrated through research evidence. It is generally accepted that a preliminary assessment and psychological support need to be part of the process. The current debate is over the strength of the evidence for medical interventions and the role of psychotherapy in the process. The nature of the medical debate allows for nuanced positions and changing opinions. Professionals such as Laura Edwards, Leeper, Erika Anderson and Riittakerttu Kaltiala, who have in past supported GAMT now advocate for a more cautious approach.

At one time it appeared that the leadership of the Amsterdam gender clinic endorsed this cautious approach. The initial Amsterdam study had strict eligibility requirements and required ongoing psychological support. In 2022, Thomas Steensma, another co-author of the original puberty blockers study, criticized clinicians in other countries for blindly adopting the Dutch research. De Vries, at one time, cautiously suggested that the research of Lisa Littman on rapid onset gender dysphoria deserved serious consideration.

While the medical debate allows for a spectrum of opinions, the ideological debate is split into two opposing camps. One, which includes some radical feminists and most religious conservatives opposes all forms of gender affirming treatments. They argue that humans cannot change sex and that a treatment model which is based on affirming an untruth is unethical. While supporters of this belief were no doubt active in promoting the American bans on gender affirming treatments for minors, they have been relatively muted in the ensuing legal proceedings which have focused on the medical debate.

The opposing camp are transgender activists, led by scholars with backgrounds in sociology, philosophy, law, literature or other humanities, who regard access to gender affirming treatments as a human right. The medical diagnosis of gender dysphoria is rejected as “pathologizing” and the requirement for a preliminary assessment is “gatekeeping.” Any attempt to treat gender-related distress through anything other than transition is “conversion therapy.” Transition regret is irrelevant. Proponents of this view include Florence Ashley and Andrea Long Chu.

The transgender activist view has had some influence on medical practice. The definition of gender incongruence in the latest edition of the International Classification of Diseases reflects activist demands for depathologization of gender distress and Florence Ashley regularly published in medical journals. However, Ashley, Chu and many of the most vocal transgender activists are not medical doctors or clinical psychologists. Professionals who deal with actual patients, and are subject to professional regulation and the potential legal liability, need to be more cautious. While many of them clearly believe in the activist approach, it is rare to see them endorse it so clearly. This new article says plainly what many gender clinics endorse through their actual practice.

The article analyzes the 16 studies of GAMT which are cited in the WPATH SOC8 chapter of adolescents to determine how the researchers evaluated the effects of the treatments. They identify 44 different outcome measures which they divide into four themes.

These themes pertain to (1) doing bad: experiencing distress before GAMT, (2) moving toward a static gender identity and binary presentation, (3) doing better: overall improvement after GAMT, and (4) the absence of regret.

The theme of “doing bad” concerns the distress that trans and gender diverse (TGD) youth experience. The literature emphasizes that TGD youth are “are disproportionately burdened by poor mental health outcomes before receiving GAMT, including depression, internalizing disorders, behavioral problems, anxiety, and suicidal ideation and attempts.” Early intervention through GAMT is justified as a means of relieving this distress. However, the article notes that there is uncertainty around the “effectiveness” of GAMT and,

This uncertainty appears to arise from both the limited evidence base and the ambiguous ‘nature’ of the distress required to receive GAMT, reflecting broader socio-political debates about the object and objectives of GAMT for youth – that is, what GAMT aims to “treat” and “achieve” in the first place.

The second theme the article identifies is that the current research tends to assume that gender transition is linear and binary. Gender identity is assumed to be fluid and malleable in childhood and tend to stabilize in adulthood. Therefore, “a stable, persisting and (often) binary gender identity thus becomes a prerequisite for receiving GAMT.”

The third theme the article identifies is “doing better” after GAMT.

The third theme describes the multi-faceted improvements observed across various measures of TGD youths’ functioning and well-being following GAMT. These improvements include treatment outcomes spanning a wide range of constructs, from decreased gender dysphoria and body dissatisfaction, to improved global functioning, psychosocial health, mental health, and overall well-being and quality of life.

The problem here is that systematic reviews have consistently found that the evidence that GAMT leads to any improvement in these measures is low certainty. While the article does not reference any systematic reviews, many of the studies it reviewed found little or no improvement from GAMT and, in some cases, improvement might be attributable to other factors such as parental or peer support.

The fourth theme is absence of regret. This section concludes:

The topic of regret serves as a common thread within discussions of treatment outcomes in the cited literature and seems to profoundly influence considerations of eligibility for GAMT and decision-making processes. The possibility of regret is notably highlighted as a critical factor to be addressed to ensure the “effectiveness” of GAMT and feelings of regret are portrayed as “unfavorable,” indicating that the absence of regret is a “positive” result. Authors often seem to equate regret with detransition, portraying both as unambiguously “negative” outcomes, leaving little room for a more nuanced understanding of the diverse ways in which TGD individuals might experience (de)transition. As such, the cited literature stresses minimizing regret as an essential aspect of ensuring the “effectiveness” of GAMT for adolescents.

The article sums up the justification for GAMT as a “logic of improvement.” It notes that the WPATH SOC8 asserts that GAMT leads to “improved or stable psychological functioning, body image, and treatment satisfaction.” The article also notes that,

The flip side of the above is that improvement has become a norm that GAMT is required to meet in order to be justified, often operationalized by measurable, beneficial effects on the overall well-being of TGD adolescents. However, our findings indicate ambiguity regarding the objectives of GAMT for adolescents. Should its primary aim be to alleviate gender-related distress, or the improvement of general well-being and functioning in order for it to be justified?

This paragraph raises major red flags. Improvement did not “become a norm” for GAMT. It has always been the norm for all types of medical treatment. If the primary aim of a treatment is not to relieve distress and improve general well being, what could it be?

The article goes on to say:

Furthermore, the (implicit) normative expectation that GAMT should result in improvements across multiple physical, psychological, and psychosocial outcomes risks undermining the provision of this care practice. Indeed, critics often refer to the supposed failure of GAMC to result in improved psychological well-being and psychosocial functioning to question the validity of GAMT.

Once again, this is an explicit expectation in all fields of medicine. If a treatment does not lead to improvement, doctors stop using it and look for something better. However, the authors of this article do not believe that the ordinary norms of medicine apply to GAMT. The balance of the article explicitly endorses an extreme transgender activist approach.

The article quotes a 2018 piece by transgender provocateur Andrea Long Chu with the provocative title of My New Vagina Won’t Make Me Happy: And it shouldn’t have to. Chu argues in this and other articles that hormones and surgery should be made available to patients solely on the basis of their desire. Chu admits that, “I feel demonstrably worse since I started on hormones” Furthermore, Chu says, “I was not suicidal before hormones. Now I often am.” However, according to Chu, no amount of anticipated pain justifies doctors in withholding GAMT.

Chu believes that age is no barrier to accessing GAMT. In a 2024 article entitled The Freedom of Sex: The moral case for letting trans kids change their bodies, Chu argues for a “universal birthright” of freedom of sex which can be exercised at any age. According to Chu,

The freedom of sex does not promise happiness. Nor should it. It is good and right for advocates to fight back against the liberal fixation on the health risks of sex-changing care or the looming possibility of detransition. But it is also true that where there is freedom, there will always be regret. In fact, there cannot be regret without freedom. Regret is freedom projected into the past.

It is not clear how much of Chu’s writing the authors of the article have read, but they should have considered whether Chu’s obsession with sissy porn and blatantly misogynistic descriptions of womanhood disqualify Chu as a trustworthy source on any issue relating to children and sexuality.

Chu’s belief that GAMT should be provided on the basis of patient desire underlies many of the conclusions of the article. For example, the article says:

…there is a prevalent fear among TGD individuals who want to access GAMT that not showing enough distress will impact their eligibility for care. This places further tension on the provider-client relationship; TGD individuals may see their healthcare providers as gatekeepers, hindering honest communication due to a fear that it may jeopardize their care.

However, this kind of gate-keeping is routine practice in healthcare. Doctors are not supposes to prescribe any treatment without first making a diagnosis and determining if the treatment will lead to improvement. If doctors believe that patients are exaggerating their pain to get a prescription for opioids, they have a legal and ethical duty to refuse.

The article also makes the reasonable point that

… it becomes imperative for healthcare providers to engage in open conversations with TGD individuals and their families or caregivers about the possibility that GAMT may not lead to the expected or desired outcomes.

However, the authors fail to consider that, for most young patients, distress is real and the desired outcome is relief. If these patients and their parents are told that medical transition may not help them, they will start to ask what else could be done. Gender clinics do not have a good answer. Many of them do not have the resources to offer psychotherapy and the ideological approach to gender identity is an obstacle to effective therapy.

While the authors reject the “logic of improvement” they are not clear on what should take its place. They suggest that GAMT might be regarded as analogous to reproductive health care. This is an argument that has been made by Florence Ashley and has been refuted by Moti Gorin. What they are left with is a position which disregards the ethical principles of beneficence (doing good), non-maleficence (do no harm) and justice and relies solely on patient autonomy. However, even the autonomy argument is weak. The principle of autonomy allows a patient to choose between treatment options recommended by a doctor or no treatment. It does not compel doctors to provide treatments they believe will be ineffective or event harmful solely because the patient requests it.

The article seems to be driven by a strategy of desperation. They have effectively admitted that evidence does not support GAMT as presently practised but they don’t want to change. Instead, they have jettisoned the evidence-based approach entirely and thrown in their lot with the most extreme ideologues. They must be hopelessly naïve if they believe this will do anything but harm their cause.

There is ongoing litigation on the constitutionality of restrictions on GAMT in the United States and a court case in Canada is expected soon. The legal case against restrictions on GAMT has been based on the premise that it is medically necessary and even “lifesaving.” Not even the most liberal judge is likely to be convinced by an argument based on the writings of Andrea Long Chu. Lawsuits by detransitioners are moving ahead and some of the big names in gender medicine like Jason Rafferty and Joanna Olson Kennedy have both been sued. Their defence counsel will certainly not try to convince a jury that regret and pain are irrelevant. The incoming Republican administration in the U.S. is likely to reopen the question of whether gender medicine should be funded under Medicare, Medicaid and the Affordable Care Act. Congress has already approved a bill which cut funding for GAMT under the military health system. It will be very hard to make a case that taxpayers and premium payers should be compelled to fund treatments when the doctors providing them do not even care whether they do more harm than good.

The Dutch group article signals the beginning of the end of pediatric gender medicine. Clinics in some parts of the world will continue to give puberty blockers, cross sex hormones and surgeries to gender questioning children and adolescents but it is now clear that the rationale for these treatments has nothing to do with the ordinary goals of medicine.