By Helen Lewis
Sunday, June 29, 2025
Allow children to transition, or they will kill
themselves. For more than a decade, this has been the strongest argument in
favor of youth gender medicine—a scenario so awful that it stifled any doubts
or questions about puberty blockers and cross-sex hormones.
“We often ask parents, ‘Would you rather have a dead son
than a live daughter?’” Johanna Olson-Kennedy of Children’s Hospital Los
Angeles once explained
to ABC News. Variations on the phrase crop up in innumerable
media
articles
and public statements by influencers,
activists, and LGBTQ groups. The same idea—that the choice is transition or
death—appeared in the arguments
made by Elizabeth Prelogar, the Biden administration’s solicitor general,
before the Supreme Court last year. Tennessee’s law prohibiting the use of
puberty blockers and cross-sex hormones to treat minors with gender dysphoria
would, she said, “increase the risk of suicide.”
But there is a huge problem with this emotive
formulation: It isn’t true. When Justice Samuel Alito challenged the ACLU
lawyer Chase Strangio on such claims during oral arguments, Strangio made a
startling admission. He conceded that there is no evidence to support the idea
that medical transition reduces adolescent suicide rates.
At first, Strangio dodged the question, saying that
research shows that blockers and hormones reduce “depression, anxiety, and
suicidality”—that is, suicidal thoughts. (Even that is debatable,
according to reviews of the research
literature.) But when Alito referenced a systematic review conducted for the
Cass report in England, Strangio conceded the point. “There is no evidence in
some—in the studies that this treatment reduces completed suicide,” he said.
“And the reason for that is completed suicide, thankfully and admittedly, is
rare, and we’re talking about a very small population of individuals with
studies that don’t necessarily have completed suicides within them.”
Here was the trans-rights movement’s greatest legal
brain, speaking in front of the nation’s highest court. And what he was saying
was that the strongest argument for a hotly debated treatment was, in fact, not
supported by the evidence.
Even then, his admission did not register with the
liberal justices. When the court voted 6–3 to uphold the Tennessee law, Sonia
Sotomayor claimed in her dissent that “access to care can be a question of life
or death.” If she meant any kind of therapeutic support, that might be
defensible. But claiming that this is true of medical transition
specifically—the type of care being debated in the Skrmetti case—is not
supported by the current research.
Advocates of the open-science movement often talk about “zombie
facts”—popular sound bites that persist in public debate, even when they
have been repeatedly discredited. Many common political claims made in defense
of puberty blockers and hormones for gender-dysphoric minors meet this
definition. These zombie facts have been flatly contradicted not just by
conservatives but also by prominent advocates and practitioners of the
treatment—at least when they’re speaking candidly. Many liberals are unaware of
this, however, because they are stuck in media bubbles in which well-meaning
commentators make confident assertions for youth gender medicine—claims from
which its elite advocates have long since retreated.
Perhaps the existence of this bubble shouldn’t be
surprising. Many of the most fervent advocates of youth transition are also on
record disparaging the idea that it should be debated at all. Strangio—who
works for the country’s best-known free-speech organization—once tweeted that
he would like to scuttle Abigail Shrier’s book Irreversible Damage, a
skeptical treatment of youth gender medicine. Strangio declared, “Stopping the
circulation of this book and these ideas is 100% a hill I will die on.” Marci
Bowers, the former head of the World Professional Association for Transgender
Health (WPATH), the most prominent organization for gender-medicine providers,
has likened
skepticism of child gender medicine to Holocaust denial. “There are not two
sides to this issue,” she once said, according to a recent episode of The
Protocol, a New York Times podcast.
Boasting about your unwillingness to listen to your
opponents probably plays well in some crowds. But it left Strangio badly
exposed in front of the Supreme Court, where it became clear that the
conservative justices had read the most convincing critiques of hormones and
blockers—and had some questions as a result.
***
Trans-rights activists like to accuse skeptics of youth
gender medicine—and publications that dare to report their views—of fomenting a
“moral panic.”
But the movement has spent the past decade telling gender-nonconforming
children that anyone who tries to restrict access to puberty blockers and
hormones is, effectively, trying to kill them. This was false, as Strangio’s
answer tacitly conceded. It was also irresponsible.
After England restricted the use of puberty blockers in
2020, the government asked
an expert psychologist, Louis Appleby, to investigate whether the suicide rate
for patients at the country’s youth gender clinic rose dramatically as a
result. It did not: In fact, he did not find any increase in suicides at all,
despite the lurid claims made online. “The way that this issue has been
discussed on social media has been insensitive, distressing and dangerous, and
goes against guidance on safe reporting of suicide,” Appleby reported. “One
risk is that young people and their families will be terrified by predictions
of suicide as inevitable without puberty blockers.”
When red-state bans are discussed, you will also hear
liberals say that conservative fears about the medical-transition pathway are
overwrought—because all children get extensive, personalized assessments before
being prescribed blockers or hormones. This, too, is untrue. Although the
official standards of care recommend thorough assessment over several months,
many American clinics
say they will prescribe blockers on a first visit.
This isn’t just a matter of U.S. health providers
skimping on talk therapy to keep costs down; some practitioners view long
evaluations as unnecessary and even patronizing. “I don’t send someone to a
therapist when I’m going to start them on insulin,” Olson-Kennedy told The
Atlantic in 2018. Her published research
shows that she has referred girls as young as 13 for double mastectomies. And
what if these children later regret their decision? “Adolescents actually have
the capacity to make a reasoned logical decision,” she once told an industry
seminar, adding: “If you want breasts at a later point in your life, you can go
and get them.”
***
Perhaps the greatest piece of misinformation believed by
liberals, however, is that the American standards of care in this area are
strongly evidence-based. In fact, at this point, the fairest thing to say about
the evidence surrounding medical transition for adolescents—the so-called Dutch
protocol, as opposed to talk therapy and other support—is that it is weak and
inconclusive. (A further complication is that American child gender medicine
has deviated significantly from this original protocol, in terms of length of
assessments and the number and demographics of minors being treated.) Yes, as
activists are keen to point out, most major American medical associations
support the Dutch protocol. But consensus is not the same as evidence.
And that consensus is politically influenced.
Rachel Levine, President Joe Biden’s assistant secretary
for health and human services, successfully lobbied
to have age minimums removed for most surgeries from the standards of care
drawn up by WPATH. That was a deeply political decision—Levine, according to
emails from her office reviewed by the Times, believed that listing any
specific limits under age 18 would give opponents of youth transition hard
targets to exploit.
More recently, another court case over banning blockers
and hormones, this time in Alabama, has revealed that WPATH members themselves
had doubts about their own guidelines.
In 2022, Alabama passed a law criminalizing the
prescription of hormones and blockers to patients under 19. After the Biden
administration sued to block the law, the state’s Republican attorney general
subpoenaed documents showing that WPATH has known for some time that the
evidence base for adolescent transition is thin. “All of us are painfully aware
that there are many gaps in research to back up our recommendations,” Eli
Coleman, the psychologist who chaired the team revising the standards of care, wrote
to his colleagues in 2023. Yet the organization did not make this clear in
public. Laura Edwards-Leeper—who helped bring the Dutch protocol to the U.S.
but has since criticized in a Washington
Post
op-ed the unquestioningly gender-affirmative model—has said that the
specter of red-state bans made her and her op-ed co-author reluctant to break
ranks.
The Alabama litigation also confirmed
that WPATH had commissioned systematic reviews of the evidence for the Dutch
protocol. However, close to publication, the Johns Hopkins University
researcher involved was told that her findings needed to be “scrutinized and
reviewed to ensure that publication does not negatively affect the provision of
transgender health care.” This is not how evidence-based medicine is supposed
to work. You don’t start with a treatment and then ensure that only studies
that support that treatment are published. In a legal
filing in the Alabama case, Coleman insisted “it is not true” that the
WPATH guidelines “turned on any ideological or political considerations” and
that the group’s dispute with the Johns Hopkins researcher concerned only the
timing of publication. Yet the Times has reported that at least one
manuscript she sought to publish “never saw the light of day.”
The Alabama disclosures are not the only example of this
reluctance to acknowledge contrary evidence. Last year, Olson-Kennedy said
that she had not published her own broad study on mental-health outcomes for
youth with gender dysphoria, because she worried about its results being
“weaponized.” That raised suspicions that she had found only sketchy evidence
to support the treatments that she has been prescribing—and publicly advocating
for—over many years.
Last month, her study finally appeared as a preprint,
a form of scientific publication where the evidence has not yet been
peer-reviewed or finalized. Its participants “demonstrated no significant
changes in reported anxious/depressed, withdrawn/depressed, somatic complaints,
social problems, thought problems, attention problems, aggressive behavior,
internalizing problems or externalizing problems” in the two years after
starting puberty blockers. (I have requested comment from Olson-Kennedy via
Children’s Hospital Los Angeles but have not yet heard back.)
The reliance on elite consensus over evidence helps make
sense of WPATH’s flatly hostile response to the Cass report in England, which
commissioned systematic reviews and recommended extreme caution over the use of
blockers and hormones. The review was a direct challenge to WPATH’s ability to
position itself as the final arbiter of these treatments—something that became
more obvious when the conservative justices referenced the British document in
their questions and opinions in Skrmetti. One of WPATH’s
main
charges against Hilary Cass, the senior pediatrician who led the review,
was that she was not a gender specialist—in other words, that she was not part
of the charmed circle who already agreed that these treatments were beneficial.
Because of WPATH’s hostility, many on the American left
now believe that the Cass review has been discredited.
“Upon first reading, especially to a person with limited knowledge of the
history of transgender health care, much of the report might seem reasonable,”
Lydia Polgreen wrote
in the Times last August. However, after “poring over the document” and
“interviewing experts in gender-affirming care,” Polgreen realized that the
Cass review was “fundamentally a subjective, political document.”
Advocates of youth gender medicine have reacted furiously
to articles in the Times and elsewhere that take Cass’s conclusions
seriously. Indeed, some people inside the information bubble appear to believe
that if respectable publications would stop writing about this story, all the
doubts and questions—and Republican attempts to capitalize on them
electorally—would simply disappear. Whenever the Times has published a
less-than-cheerleading article about youth transition, supporters of gender
medicine have accused
the newspaper of manufacturing
a debate that otherwise
would not exist. After the Skrmetti decision, Strangio was still describing
media coverage of the issue as “insidious,” adding: “The New York Times,
especially, has been fixated on casting the medical care as being of an
insufficient quality.”
***
Can this misinformation bubble ever be burst? On the
left, support for youth transition has been rolled together with other
issues—such as police reform and climate activism—as a kind of super-saver
combo deal of correct opinions. The 33-year-old democratic socialist Zohran Mamdani
has made
funding gender transition, including for minors, part of his pitch to be New
York’s mayor. But complicated issues deserve to be treated individually: You
can criticize Israel, object to the militarization of America’s police forces,
and believe that climate change is real, and yet still not support
irreversible, experimental, and unproven medical treatments for children.
The polarization of this issue in America has been deeply
unhelpful for getting liberals to accept the sketchiness of the evidence base.
When Vice President J. D. Vance wanted to troll the left, he joined Bluesky—where
skeptics of youth gender medicine are among the most blocked users—and
immediately started talking about the Skrmetti judgment. Actions like
that turn accepting the evidence base into a humiliating climbdown.
Acknowledging the evidence does not mean that you also
have to support banning these treatments—or reject the idea that some people
will be happier if they transition. Cass believes that some youngsters may
indeed benefit from the medical pathway. “Whilst some young people may feel an
urgency to transition, young adults looking back at their younger selves would
often advise slowing down,” her report concludes.
“For some, the best outcome will be transition, whereas others may resolve
their distress in other ways.”
I have always argued against straightforward bans on
medical transition for adolescents. In practice, the way these have been
enacted in red states has been uncaring and punitive. Parents are threatened
with child-abuse investigations for pursuing treatments that medical
professionals have assured them are safe. Children with severe mental-health
troubles suddenly lose therapeutic support. Clinics nationwide, including
Olson-Kennedy’s, are now abruptly closing because of the political atmosphere.
Writing about the subject in 2023, I
argued that the only way out of the culture war was for the American
medical associations to commission reviews and carefully consider the evidence.
However, the revelations from Skrmetti and the
Alabama case have made me more sympathetic to commentators such as Leor Sapir,
of the conservative Manhattan Institute, who supports the bans because American
medicine cannot be trusted to police itself. “Are these bans the perfect
solution? Probably not,” he told
me
in 2023. “But at the end of the day, if it’s between banning gender-affirming
care and leaving it unregulated, I think we can minimize the amount of harm by
banning it.” Once you know that WPATH wanted to publish a review only if it
came to the group’s preferred conclusion, Sapir’s case becomes more compelling.
Despite the concerted efforts to suppress the evidence,
however, the picture on youth gender medicine has become clearer over the past
decade. It’s no humiliation to update our beliefs as a result: I regularly used
to write that medical transition was “lifesaving,” before I saw how limited the
evidence on suicide was. And it took another court case, brought by the British
detransitioner Keira Bell, for me to realize fully that puberty blockers were
not what they were sold as—a “safe
and reversible” treatment that gave patients “time
to think”—but instead a one-way ticket to full transition, with physical
changes that cannot be undone.
Some advocates for the Dutch protocol, as it’s applied in
the United States, have staked their entire career and reputation on its safety
and effectiveness. They have strong incentives not to concede the weakness of
the evidence. In 2023, the advocacy group GLAAD drove a truck around the
offices of The New York Times to declare that the “science is
settled.” Doctors such as Olson-Kennedy and activists such as Strangio are
unlikely to revise their opinions.
For everyone else, however, the choice is still open. We
can support civil-rights protections for transgender people without having to
endorse an experimental and unproven set of medical treatments—or having to
repeat emotionally manipulative and now discredited claims about suicide.
I am not a fan of the American way of settling political
disputes, by kicking them over to an escalating series of judges. But in the
case of youth gender medicine, the legal system has provided clarity and
disclosure that might otherwise not exist. Thanks to the Supreme Court’s oral
questioning in Skrmetti and the discovery process in Alabama, we now
have a clearer picture of how youth gender medicine has really been operating
in the United States, and an uncomfortable insight into how advocacy groups and
medical associations have tamped down their own concerns about its evidence
base. Those of us who have been urging caution now know that many of our
ostensible opponents had the same concerns. They just smothered them, for
political reasons.
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