Debunking Common Myths About Youth Transition

Six college students wrote shared their thoughts on gender-affirming care for youth with the Wall Street Journal. Only one of them demonstrated a basic grasp of the issues.

by Evan Urquhart

On the far right, misinformation about trans issues often comes in the form of outrageous falsehoods. For example, right wing news outlets falsely reported that a young woman who complained about seeing a trans woman in a YMCA locker room saw a penis: In reality the young woman glimpsed an innocent trans woman from behind, and the trans woman had no such organ. Right wing outlets also routinely repeat the lie that puberty blockers are sterilizing. Most people understand that the most extreme content from the far right is untrustworthy. However, in attempt to locate their position in the reasonable middle, they often fall victim to subtler forms of propaganda and wind up believing less extreme falsehoods.

An example of this was found in the Wall Street Journal yesterday, in an item consisting of letters sent into the Journal by college students discussing their opinions about the provision of gender-affirming care to minors. The letters selected were largely thoughtful, careful, earnest fare… and showed signs that the young people had been exposed to propaganda or misleadingly framed stories, resulting in students who lacked a basic understanding of the issue they were writing in about. The myths in these letters are incredibly common, and often held by people who believe themselves to be supporters of the transgender community. We thought we’d take a look at some of them and highlight the ways well-meaning, thoughtful people can go wrong on this issue.

Myth: Medical transition is necessary for some kids, but it’s currently being offered too quickly, to too many children.

Ahmad believes that treatment for gender dysphoria involve risks, and shouldn’t be entered into lightly. He thinks that therapy is the best first step, and that youth need a balanced approach that involves their parents and ensures informed consent is present for minors who are likely to benefit from treatment.

What Ahmad Nelson of UVA seems not to realize is that he’s actually describing the status quo, not proposing a solution. There have been repeated claims that clinics rush youth into transition, there’s never been any evidence that this actually happens. The most significant and well-publicized allegations, by former clinic staff member Jamie Reed, has been refuted multiple times and seems to have been a politically motivated fabrication.

Nelson may be demonstrating one of the classic side effects of misinformation clogging the landscape: When lies are debunked, the debunking is seen by fewer people than the original story. The successful effort to seed coverage of gender-affirming care with false and misleading information has resulted in a widespread misperception of what such care involves and how it is conducted.

Myth: Mainstream gender-affirming care puts children in the driver’s seat, allowing them to diagnose themselves and prescribe their own treatment.

This letter, from a student at the conservative Christian Hillsdale College, shows clear signs of a student whose information has been filtered through far-right sources. In addition to the myth we’re addressing, Evalyn Homoelle repeats the false claim that puberty blockers and hormone treatments are sterilizing, claims without any evidence that the medical principles of informed consent and parental involvement are “often ignored,” and injects a misleading claim that most cases of gender dysphoria resolve by the onset of puberty into an argument against treatments that are only available after the onset of puberty. In all of this she is likely copying the conservative propagandists who have been obsessively repeating similar talking points for years now.

One claim that may not have been addressed previously, however, is that gender-affirming healthcare is “the only area of medicine where patients make their own diagnosis and prescribe their own remedy.” This is a plain falsehood that relies on people not thinking critically about how diagnosis works for other conditions.

When a patient goes to a doctor they start by describing their symptoms. Although in some cases there are lab tests to narrow down the diagnosis, for a huge number of conditions the patient’s description of their symptoms, and their answers to their doctor’s questions, is the test. Gender dysphoria is no different.

Doctor’s diagnose migraines by listening to patients describe their headaches. Doctors diagnose depression by listening to patients describe their moods. Doctors diagnose gender dysphoria by listening to patients describe their feelings about their bodies and gender. This student has been confused by propaganda that makes it sound as if something different is going on when doctors diagnose gender dysphoria, but the process is much like other diagnostic processes.

Myth: The existence of people who detransition proves that the criteria to transition aren’t stringent enough.

This is a confusing letter, because it argues that the guidelines for gender dysphoria aren’t strict enough, but offers no evidence that the current guidelines are too lax. Daniel Holguin, a medical student, also seems to recognize at the end that it would be impossible to develop guidelines for this or any other condition where the success rate was 100 percent.

There are people who come to feel that transitioning was a mistake, and a small number of them have become engaged in activism to ban transition for everyone. This makes no sense. The rate of regret for transition-related procedures is low, and in fact it seems to be lower than the regret rate for most other medical treatments.

In order to argue that the criteria for youth to transition should be stricter, the starting place should be with evidence that the current criteria are too lax, and too many people are transitioning inappropriately. This is a question for medical researchers: What guidelines result in the most benefit for most patients?

A system that allows fewer transitions overall would inevitably result in fewer cases of regret, but in order to maximize positive outcomes for patients you also need to look at how many patients who would have benefitted from treatment are prevented by stricter gatekeeping. If you stop 1 case of regret at the cost of 100 patients who would have benefitted from treatment the cost of the stricter screening is too high. If, on the other hand, you can stop 100 cases of regret and only make a mistake on one patient who would have benefitted, the stricter screening is warranted. As usual, this is all just describing how medicine normally works: No treatment is 100 percent effective, every treatment has risks and side effects. By calling for stricter guidelines without explaining how that benefits patients, this student is assuming that would lead to better outcomes. The medical evidence is more supportive of the opposite position.

Myth: We need higher quality evidence before allowing youth to transition.

If there’s been a theme to this debunking, it’s that well-meaning people go wrong when they’re exposed to propaganda that paints commonly-accepted medical practices in all other areas as ominous or unusual in the context of gender-affirming care for minors. This last letter is no exception.

Gender-affirming treatments are neither rudimentary nor experimental: They’ve been used for decades in both adults and children, and the earliest modern procedures go back a full century. The quality of the evidence for them is similar to the quality of the evidence for a vast number of other treatments that have not been the subject of a moral panic. Most treatments, for most conditions, are tested first on adults. When the results in adults are positive and clinicians develop experience treating them, younger people with the same condition begin to be treated with the same medications or procedures (often with reduced doses to reflect their smaller body size). Many such treatments are never specifically tested in children. That has happened in this case, and more slowly than it would normally be expected due to the widespread prejudice and reluctance in the medical establishment to have children transition.

Often, critiques of this type hyperfocus on whether or not the available evidence is in the form of randomly controlled trials. However, randomly controlled trials rely on blinding the patient and their doctor to who has been given the real medication and who has received a placebo. For medications that works by producing observable physical changes, like hormone therapy, or suppressing them (like puberty blockers) patients and doctors could never be blinded. In addition, given the large amount of evidence that transition medicine works, arbitrarily denying it to some patients for the purposes of getting better data would be unethical.

Nevertheless, one randomly controlled trial of testosterone for transgender adults has already been conducted, and it was added to the mountain of studies that have shown benefits to transgender people who access transition. While it is always possible to add more evidence, better evidence, medicine does not typically wait for absolute certainty before deciding that the evidence is sufficient to recommend a treatment to patients. That’s because there’s a huge risk to not treating a condition, an obvious enough fact that people often forget when it comes to this area. Trans people who don’t get to transition don’t become cis people, they suffer with the painful, debilitating, sometimes even life-threatening effects of untreated gender dysphoria.