Misinformation Against Trans Healthcare
In the past year alone, at least 500 anti-trans bills have been proposed or implemented throughout the US, in every state. Papers like the New York Times routinely publish articles casting doubt on the efficacy of trans healthcare, often by claiming countries like Sweden, Finland, and the UK are reconsidering gender-affirmative treatment. In the UK, Labour MP Wes Streeting proposed an indefinite ban on puberty blockers for trans youth. (Cis youth with precocious puberty continue to enjoy access to these drugs.) Many of these measures have been motivated by scientific misinformation propagated and funded by American right-wing think-tanks like Alliance Defending Freedom and The Heritage Foundation. It’s often said that it is harder to counter misinformation than it is to spread it. While it’s undeniably important to specifically address each false assertion peddled by these organizations, it’s actually surprisingly easy to rebut anti-trans misinformation concerning healthcare as a whole. This article shows you how.
One of the better known propaganda groups peddling misinformation is the Society for Evidence-based Gender Medicine (SEGM). Recognized as a hate group by the Southern Poverty Law Center, they have been involved in anti-trans legislative efforts in Florida, Texas, and many other states. Covering groups like SEGM in detail reveals how anti-trans healthcare misinformation spreads. After all, its members have even managed to insert themselves into otherwise reputable websites like Medscape and have provided testimony towards banning all youth (and adult) transitions. On April 28, 2022, the Yale School of Medicine released a report titled 'Biased Science: The Texas and Alabama Measures Criminalizing Medical Treatment for Transgender Children and Adolescents Rely on Inaccurate and Misleading Scientific Claims.'
According to this report (pg. 28), SEGM appears on the surface to be nothing more than another website. Although it claims that they’re a group of clinicians and researchers ‘concerned’ about the risks of trans-related healthcare, their actions call that into question. The original content on this site includes many statements unsupported by citations, and those citations that are provided are often unreliable, misleading, or blatant misrepresentations. The SEGM website includes a list of citations to more than 100 articles as evidence for the supposed medical risks of gender-affirming care. Yale reviewed all these articles and found a majority of them to be of low quality. Their list of citations omits studies that go against their agenda and the site neglects to mention the standards of care published by mainstream scientific organizations, which one would assume a genuine group of concerned clinicians wouldn’t do. 40% of these citations are letters to the editor (which are neither peer-reviewed nor fact-checked), opinion pieces, and case studies of meager scientific value. SEGM has repeatedly tried to pass off these letters as genuine scientific literature in court/policy discussions. Many of their criticisms betray a lack of understanding of practice within the field.
On August 5, 2022, a member of the Florida Board of Medicine, Patrick Hunter, an affiliate of SEGM, oversaw a hearing on new ‘standards of care’ for trans youth. The documents submitted for consideration at the August 5 hearing in Florida included blog posts and literature ‘reviews’ written by SEGM. Ron DeSantis appointed Patrick Hunter to the Florida Board of Medicine in June 2022, two months prior to the hearing. Court documents (pg. 284 in Eknes-Tucker v. Ivey 2022) reveal that Patrick Hunter is on good terms with Riittakerttu Kaltiala, a Finnish doctor researching trans healthcare who was, in Patrick’s own words, ‘instrumental’ in lobbying for restrictive policies against healthcare for trans youth in 2020. Kaltiala is also known to be friends with Julia Mason, one of the founders of SEGM.
SEGM seem to have no official ties to mainstream scientific organizations, and its core members can be seen on the boards of other organizations advancing unscientific content against gender-affirming treatment. These organizations include Genspect, Gender Identity Challenge, Gender Health Query, Rethink Identity Medicine Ethics, Sex Matters, Gender Exploratory Therapy Team, Gender Dysphoria Working Group and the Institute of Comprehensive Gender Dysphoria Research.
The fact that these groups have, through underhanded means, amassed the influence they have should be a cause of alarm. Documents from the United States District Court for the Southern District of West Virginia, Huntington Division on April 27, 2022 revealed that SEGM paid a researcher named Stephen Levine $5,000 to publish articles in peer-reviewed journals criticizing access to informed consent transition care for youth (pg. 9). Levine has repeatedly misrepresented the findings of studies on trans youth and has compared trans adolescents willingly transitioning to forced Nazi experiments (pg. 80 in Brandt et al. v. Rutledge et al.).
PROVIDING CONTEXT
In 2020, Keira Bell, a cis woman, challenged the Tavistock and Portman NHS Trust's Gender Identity Development Service (GIDS) in the UK High Court. A former patient, Bell claimed to regret her transition, arguing doctors didn’t challenge her enough, despite being on puberty blockers for three years. At the time, over 90% of GIDS referrals faced long delays and didn’t start puberty blockers due to extended wait times.
Regret is common in medical procedures. But regret rates in trans healthcare are lower than in other areas, so it’s strange to conclude that no one should access these procedures. Bell and her lawyers argued that individuals under 16, (the age she started blockers) cannot consent to the treatment, despite her beginning transition at 20.
Bell won her case, which mandated that court approval be required for prescribing puberty blockers to minors. The ruling misinterpreted scientific evidence, suggesting that puberty blockers act as a ‘gateway’ to cross-sex hormones. This decision privileged Bell’s regret over her adult decisions over the distress trans adolescents face, including the dysphoria caused by undergoing endogenous puberty. This reflects a transphobic double standard, which is far from the last we’ll see from the anti-trans movement.
Although the Bell ruling was eventually overturned, its impact spread across Europe, with Sweden, a country that had required sterilization of trans people prior to their legal recognition until 2013, restricting puberty blockers and hormones for trans youth under 16. Meanwhile, several US states introduced anti-trans bills citing the ruling.
‘LOW-QUALITY’ EVIDENCE
Anti-trans advocates tend to claim the quality of evidence in favor of affirming trans healthcare is low. This sentiment has been echoed by the controversial Cass Review in the UK, policy statements made by the states of Florida, Alabama, Arkansas, and Texas, and organizations like SEGM. This pronouncement is usually used to argue that affirming trans healthcare must no longer be provided and ‘extended psychotherapy’ be used instead.
Suppose the evidence in favor of trans healthcare is indeed ‘low-quality’. ‘Low-quality’ is a technical term. It doesn’t mean ‘inaccurate.’ Evidence is still evidence, and can’t be dismissed only because it is low quality in a technical sense. It also can’t be used to cease providing existing trans healthcare, since ceasing existing treatment, in this context, isn’t a neutral stance. It’s unethical to apply the adage of ‘First, do no harm’ here, since doing nothing (being unsupportive or dismissive of someone’s identity) is known to cause harm. Just as it’s unethical to force a cis adolescent girl to undergo a ‘male’ puberty, it is equally unethical to withhold pubertal suppressants and subsequent HRT to a trans adolescent girl.
‘Low-quality’ (or ‘low-certainty’) evidence refers to limited confidence in the effect estimate, meaning the true effect could differ significantly. High-quality evidence is the ideal, of course. But this standard isn’t expected in many fields of clinical practice. It’s accepted in a number of areas like cardiology, gastroenterology, cholesterol management, and even abortion care for clinicians to use their accumulated experience and discretion to appropriately treat and manage a patient’s condition. There’s also clinical need in the present, and a requirement to meet that need even if existing evidence isn’t deemed ‘high-quality’—even if there hasn’t been a perfectly designed10-year or 20-year-follow-up.
Most quality assessments favor RCTs (Randomized Controlled Trials), deeming observational studies low-quality by default, which can be limiting, especially for rare conditions or minority populations. According to Thomas Frieden, the former director of the CDC: ‘Current evidence-grading systems are biased towards RCTs, which may lead to inadequate consideration of non-RCT data.’ He also states: ‘For much, and perhaps most, of modern medical practice, RCT-based data are lacking and no RCT is being planned or is likely to be completed to provide evidence for action.’ He concludes his paper with: ‘There will always be an argument for more research and for better data, but waiting for more data is often an implicit decision not to act or to act on the basis of past practice rather than best available evidence.’
RCTs are rare in trans healthcare and many fields like atherosclerosis treatment, hormonal contraception, and routine surgeries like C-sections and cataract surgeries. In trans healthcare, RCTs are impractical and unethical because visible effects of HRT or lack of puberty blockers quickly reveal the treatment group, undermining blinding. This leads to high dropout rates, especially due to the distress of untreated gender dysphoria. Thus, the only time one may be able to obtain a control group (which will not be truly randomized) is when external factors happen to create one unintentionally, which can then be observed after the fact.
RCTs also typically require long-term follow-up to assess the sustained effects and potential risks of interventions. Although HRT and gender-affirming surgeries have lifelong implications, conducting long-term RCTs with appropriate follow-up can be challenging, as it requires extensive resources and may not be feasible within ethical and practical constraints. It can be difficult to maintain participant engagement and follow-up over extended periods, especially in a small, marginalized population facing numerous social and healthcare barriers.
The creators of the GRADE system, which is one of the commonly used quality assessment standards, have noted that: ‘Although higher quality evidence is more likely to be associated with stronger recommendations than lower quality evidence, a particular level of quality does not imply a particular strength of recommendation. Sometimes, low or very low-quality evidence can lead to a strong recommendation.’ In 2016, around 56% of the interventions evaluated under GRADE were ranked as having ‘low’ or ‘very low’ quality evidence. However, unlike gender-affirming care, it is possible for many of these interventions to be subject to a RCT.
Here’s an example provided in ‘A Critical Review of the June 2022 Florida Medicaid Report on the Medical Treatment of Gender Dysphoria’: It is accepted pediatric practice to not give aspirin to children with fevers. The basis of this practice happens to be several observational studies that showed an association between giving aspirin to children with viral fevers to a potentially fatal disease of neurological dysfunction called Reyes Syndrome. Given how flagrantly unethical it would be to conduct RCTs in this context, the strong consensus recommendation is based entirely on ‘low-quality’ studies.
Given limited resources, individual studies will inevitably have imperfections, and dismissing them for not meeting arbitrary standards is unscientific. No single study is perfect; science relies on cumulative evidence. We rely on systematic reviews and meta-analyses to assess overall evidence quality, provided that they’re well-conducted, addressing the limitations of individual studies. The current evidence base for trans healthcare, including puberty blockers and HRT, is comparable to many other medical fields. Evaluations must consider practical and ethical research constraints rather than idealized, hypothetical standards.
ANTI-TRANS ARGUMENTS ARE BASED ON CONJECTURE AND GUESSWORK
After the Bell ruling in 2020, some European institutions (Sweden and Finland) released policy statements alleging that the prescription of puberty blockers to trans adolescents ‘might be’ harmful. In 2023, the final report of the highly flawed Cass Review was released, echoing the same. The problems with that review have been extensively covered by others, and I won’t beat that dead horse here. I’ll just note that other countries that have walked down the road the UK have employed similar tactics.
In February 2022, Sweden’s National Board of Health and Welfare released a summary of recommendations for the treatment of children and adolescents with gender dysphoria, effectively limiting access to puberty blockers and hormones to many. These guidelines claim to be based on three factors: 1) the supposedly continued lack of ‘reliable scientific evidence’ regarding the efficacy and safety of transition; 2) the ‘new’ knowledge that detransition occurs among young adults; 3) the supposedly unexplainable increase in the number of care seekers and the change in the sex ratio of the patients (in recent years, AFAB patients—assigned female at birth— have become more prevalent than AMABs—assigned male at birth).
The summary goes on to recommend the prescription of puberty blockers and hormones mainly within a research context (or in ‘exceptional’ cases), and if RCTs can’t be done, robust longitudinal (long-term) research must be undertaken before offering these treatments to the broader public. Again, this standard isn’t followed in any other field of medicine and it’s unethical to withhold treatment just to wait for even more robust long-term evidence (which may take up to 20 years), especially when all the available evidence shows said treatment to be efficacious and low-risk, especially when compared to medication that is prescribed much more freely to adolescents (e.g. hormonal contraceptives). It may also be unethical to withhold potentially life-saving treatment unless and until the patient participates in a research study, which may require years, if not decades of follow-up and intense scrutiny/interrogation.
There is some evidence to suggest that there’s an approximately five-fold increase in anxiety disorders and depression for trans youth who receive treatment during later stages of puberty, compared to those who received it earlier. This suggests that while examining a study measuring the effectiveness of transition, it’s essential to observe how old the youth were when the interventions were given, since that variable can greatly affect the outcomes.
The summary also claims that ‘it is not possible to determine how common it is for adolescents who undergo gender-affirming treatment to later change their perception of their gender identity or interrupt an ongoing treatment.’ This is supported by a single study: a survey of 100 detransitioners conducted by Lisa Littman. The study asked 100 self-identified detransitioners for their reasons. But the study used a biased sampling methodology. The survey was anonymous and filled with loaded questions; participants were solicited from (among other venues) anti-trans social media forums, which means a number of participants might have detransitioned for purely ideological reasons. The study cites YouTube videos, opinion pieces by anti-trans individuals and entire Reddit communities as sources.
The existence of detransitioners was already documented by a 2014 longitudinal study conducted by Swedish researchers, which indicated that the rate among adults is very low, especially compared to other surgical interventions like knee replacement surgery. Thus, it’s odd that the board chose to use the Littman study as ‘evidence that detransition exists’. Other, less biased research suggests that in a large number of cases, detransition is likely influenced by external factors such as social pressure and might even be temporary. Only a minority of an already small number of detransitioners report detransition to be caused by fluctuations in gender identity or as a direct outcome of transition. The clinical consensus is that gender dysphoria that persists after early puberty (Tanner stage II) is almost always permanent. Medical transitions always begin after this stage.
There seems to be a clear double-standard in the summary (and other policy statements, including the Cass Review) where the benefits are unknown due to a lack of high-quality evidence (often unethical and impractical to obtain), whereas the drawbacks are known based on anecdotes about detransitioners.
It has been observed in some countries that AFAB adolescents with adolescent-onset gender dysphoria have been reporting more mental health issues in recent years. The implication is that this demographic change represents a new ‘clinically distinct presentation’ of gender dysphoria that may not be treatable by puberty blockers and transition.
But trends of clinical referrals aren’t the same as trends of prevalence. Those positing a ‘distinct presentation’ have yet to establish the existence of a ‘clinically distinct population’, in terms of meaningfully different from already understood gender dysphoric populations, in terms of the treatment approach needed, or in terms of outcomes from gender-affirming treatment and its effectiveness. There isn’t sufficient available evidence to make any of those claims. Available evidence is certainly not enough to restrict care that has been shown to help vulnerable youth.
In fact, research conducted in 2020 in the Netherlands suggests that despite the sharp increase in the number of adolescent referrals in recent years, most demographic and psychological characteristics have remained stable over time (except for the aforementioned change in the sex ratio). The increase in trans youth compared to the smaller growth in trans adults can be explained by the higher rates of acceptance/awareness among the younger generations compared with older generations where anti-trans sentiments are more prevalent. Social acceptance isn’t uniform across generations.
While some, including the Cass Review, have argued that social acceptance alone can’t explain the increase in referrals, no evidence has been offered as to why. There’s no such thing as an expected rate of social acceptance for a minority group. But the most important point to note is this: an increased rate of referrals doesn’t automatically mean people are being recklessly offered puberty blockers or hormones. This simply isn’t happening on a systemic level.
The changing sex ratio and age of onset of dysphoria can't be judged against a ‘norm’ based on past trends. Historical data were skewed by factors like marginalization, patriarchal norms, and transphobia. It's possible AMAB youth were overrepresented in clinics before, as femininity in AMABs was less socially acceptable than masculinity in AFABs. This likely pushed dysphoric AMABs towards transition, while dysphoric AFABs could more easily express their gender through socially tolerated tomboyish behavior. Moreover, the sex ratios of trans people have been shown to vary by country and aren’t very reliable owing to selection bias and small sample sizes. Also, comparisons between youth referrals at gender identity clinics and the estimated overall trans youth population suggest that the former is only a small percentage of the latter, which weakens the possibility that there has been a legitimate change in the actual sex ratio of trans youth.
As for the age of onset of dysphoria, adolescent-onset gender dysphoria is by no means a new presentation. In fact, the research into these individuals suggest that they did have gender dysphoria since childhood, except they simply didn’t express it in the same way a child with childhood-onset gender dysphoria typically does.
According to a 2012 study by Norman Spack et al.:
Most of these late-adolescent onset transgender patients indicate that they always felt different or knew that something was not right but were unable to identify it until puberty. Oftentimes these individuals report that they initially thought that their confusion was related to sexual orientation because they were unaware that transgenderism existed. Others report that they were aware of feeling like the other gender, but either thought that there was nothing that could be done about it so they tried to ignore the feelings, or they feared how others would react if they expressed their gender dysphoria. Some of these patients recall attempting to inform a parent of their cross-gender identity but feeling quickly dismissed or rejected, making it difficult to bring up again. We find it common among these patients to report little or no early body dissatisfaction as it relates to their male or female anatomy.
Furthermore, increased mental health comorbidities in AFAB adolescents could just as likely be caused by the observed general decline in mental health among all AFAB adolescents over the past decade, sometimes attributed to the widespread adoption of smartphones and social media. A study published in 2022 with 84,011 participants between ages 10 and 80 found that the relationship between social media use and life satisfaction is most negative among young adolescent girls (AFABs), compared with other demographic groups. This trend offers a far likelier explanation than the emergence of an entirely new variant of gender dysphoria that is untreatable by existing protocols.
It may take decades to fully understand changes in referral sex ratios or the rise in mental health issues among youth, and answers may never be clear. But denying current youth access to healthcare based on weak theories is unethical. While studies on trans youth often screen for mental health issues, stricter research criteria don't invalidate clinical practices. Study designs rarely match real-world cases perfectly, so stricter research criteria don’t necessarily undermine their applicability in clinical settings, which is an argument some anti-trans activists have made.
The Swedish summary also indicates that treatment eligibility will be defined on the basis of ‘distress’ rather than ‘identity’, which seems like the wrong way to go about it since the available research suggests that, especially in prepubescent youth, a strong and explicit cross-sex identification is a strong predictor of being trans, whereas distress alone could be caused by other factors. This move seems to indicate that Sweden’s official position is that being trans is a pathological phenomenon rather than an innate variance of identity, and that this may be ‘curable’ via ‘psychotherapy’. In effect, these guidelines propose an approach backed by zero evidence (gender incongruence is ‘curable’) in lieu of the gender-affirmative approach that they claim is based on weak evidence.
Finland’s policies echo the same talking points. Finnish trans youth have reported finding the treatment system in Tampere, the Finnish state clinic where Kaltiala works, to be highly critical of their gender expression, as well as dehumanizing and insulting, such as demanding to know how they masturbate. Requiring this disclosure in the course of evaluation can be seen as abusive as it implies the threat of withholding treatment. There is also no meaningful evidence to suggest that such information could lead to a different treatment pathway. Although the clinic has claimed that the reports are a ‘bending of the truth’ (they did admit that they inquire about masturbation habits), testimony from patients at Tampere calls that claim into question. Kaltiala is the lead author of a paper that claims it is unable to reproduce the beneficial mental health effects of pediatric transitions. But the paper actually shows that the ‘adolescents’ were on average 18.1 years old when they started to transition, and that all of them had completed puberty. Using post-adolescents to make arguments about pubertal transitions is dubious at best.
THE DOUBLE STANDARD
While these policy papers imply that the harms of puberty blockers are well-documented, their use of terms like ‘may,’ ‘could,’ and ‘possibly’ and the sources that they often cite suggests a lack of strong evidence. Despite presenting these concerns as serious, the provision of puberty blockers in the Netherlands stretches back to the 1990s, starting with children around age 12. Follow-up studies have tracked hundreds of participants through gender clinics, where patients are evaluated over several years by a specialized team. This allows experts to identify potential physical or cognitive impairments. To date, no substantial evidence indicates widespread adverse effects in youth receiving puberty blockers and HRT, suggesting that concerns may be overstated and not supported by clinical data.
Researchers have recognized the need for more of this research and planned for such since before 2020. Yet those with anti-trans views approach these questions in the most counterproductive manner possible. They claim that evidence of harm caused by puberty blockers and hormones already exists, despite the lack of any substantial evidence supporting these assertions. They contend it is no longer necessary to gather additional evidence, and they presume it is justifiable to completely halt access to puberty blockers and hormones for transgender youth based solely on these unverified claims. This tactic is a sleight-of-hand, manipulating the narrative and diverting attention away from the need for rigorous research and objective examination of the existing data.
Their actions show a disregard for trans youth's well-being by rejecting reliable information that could improve care and reassure families. A responsible approach requires ethical research, open-mindedness, and compassion. Investing in well-designed studies will provide crucial evidence, ensuring the focus remains on the health and well-being of trans youth, not political agendas.
The double standard is clear: anti-trans advocates harp on about the ‘low-quality’ evidence and promote outright bans on trans healthcare, but never seem to hold themselves to any standard whatsoever. Where is the robust, high-quality research on 10-year follow-up outcomes of denying trans people access to the care they seek? Where’s their iron-clad evidence that providing ‘extended psychotherapy,’ ‘exploratory therapy,’ or ‘talk therapy’ (euphemisms for conversion therapy) is effective? In fact, the existing evidence indicates that conversion therapy of any kind is substantially harmful. Even without this evidence, it would still be unethical to forcibly change someone’s identity for assimilation. ‘First, do no harm’ doesn’t apply here.
The purported ‘concern’ being expressed by these organizations and individuals is a strategic ruse, concealing an underlying conviction that individuals of any age should be prohibited from undergoing transition. We should recognize that these organizations may be utilizing this seemingly rational façade to advance their broader agenda of opposing all forms of transitioning, regardless of age or circumstances.
Featured image is Biology laboratory, by Jun Seita