Disentangling the arguments behind the gender care bans for minors: "Protecting children" or protecting political power?

I've worked in three multidisciplinary gender clinics in three Top 10 Children's hospitals (Boston, Chicago, and Columbus) over a 16 year period and so I may know a thing or two about the ethics of gender care for minors. I'll start by saying that this should be a debate about how to do the care, and not whether to do the care.

I'll start by saying that this should be a debate about how to do the care, and not whether to do the care.

But logic and nuance seem to be attributes low on the political totem pole of priorities these days, and so here we are left with an obligation to be outspoken against the injustices of an extremist era.

In Ohio, providers have been navigating the complexity of gender care bans ever since the first iteration of the gender care ban was introduced into legislation back in November 2021. Now, the entire country is experiencing what we in Ohio (and half of the other States) have been facing, and the cruel impact is leaving thousands of families scrambling to get their kids' clinical needs met. I speak to this from firsthand direct clinical experience serving hundreds of families in this timeframe.

In order to know how to best counter the arguments that supports of bans are using, it is important to know what those arguments are. I will break them down here.

Argument 1: Gender is an ideology.

We are hearing about "gender ideology" all over the place, and the term itself is ideological. Referring to gender as an ideology dismisses the very real notion that ones' gender (also referred to as gender identity) might not match with ones' sex traits (the physical characteristics that arise from being male or female, the two main typical categories of sex that a large majority of the population fall into). This is simply not true. People who have experienced a misalignment between gender and sex traits have always existed, across cultures and historical periods. In my previous post, I explained sex development and how variations in sex development do occur, not infrequently, and this can include variations in ones' gender-sex trait alignment.

Of course if gender were an ideology, and not a real thing, then technically one would not need treatments to "correct" the misalignment. For those arguing that gender is an ideology who are also arguing for more mental health care for young people, they are saying that other mental health issues are invariably at the root of why a person feels as though they are another gender (again referring to this as gender ideology), and that addressing those mental health issues will lead to a resolution of one feeling differently about their gender. This a priori search for a reason why one is transgender, with the goal of this resolving the person's gender experience, is what falls under the category of conversion therapy (https://www.aacap.org/aacap/Policy_Statements/2018/Conversion_Therapy.aspx).

On another note- and one that is deserving of its own LinkedIn article on its own- exploring the function of gender for a given child/adolescent before making any irreversible decisions, without any preconceived goal of any preferred gender, would not be considered conversion therapy. And this is where nuance is often lost.

Argument 2: The evidence is bad/weak.

The science on the efficacy of gender care treatments (blockers, hormones, and sometimes even surgeries) has been deconstructed and criticized time and time again as being too weak. Those against the care will claim the following:

• Not many studies exist, especially longitudinal ones.
• They are no double blind randomized control trials.
• The ones that do exist have significant methodological limitations.

The challenge is that there are elements of truths behind these statements, however those truths are not often contextualized into a bigger picture. And many will immediately dismiss these elements of truth since those who resort to repeating these truths are often ideologically-driven (wanting to ban the care) parading as science-focused. Therefore, acknowledging the truths and contextualizing them is extremely important.

1. True, there are not many longitudinal studies. But how could there be? Puberty suppression (for gender dysphoric youth) was first done in the late 90's in Amsterdam and hasn't been widely available until the late 2000's, even at which point it only started to be more available in other countries. In a relatively new field of practice, we wouldn't expect to have longitudinal studies, however there are a handful of longitudinal studies (including the main long-term one in Pediatrics, the 2014 de Vries et al study out of Amsterdam that did track youth over a several period period through three time points). The handful of studies, including some shorter longitudinal studies do show- at least preliminarily- that care leads to psychological benefit by reducing gender dysphoria.
2. True, there are no randomized control trials. The challenge with this is that there would be no way to do a double blind randomized control trial, since A. it is impossible to blind patients to treatment vs no treatment groups when the treatments lead to clearly visible characteristics and B. It would be unethical to randomize subjects to a non-treatment group when the benefits of treatment are slowly emerging. But the main reason why this is misleading is because there are so many other areas of medicine where there are no double blind randomized control trials, and yet there are no calls to ban those treatments.
3. True, there are significant methodological limitations with the existing studies. And while some of the studies have questionable contributions to the literature- at least per my own review of them- there seems to be a universal dismissal of all the studies on the grounds that there are methodological limitations. Every study has methodological limitations and there is unfortunately a push-pull in this field where individuals hold up studies that they like and tout how impressive the methodology is while putting down the studies that they don't like and dismissing on the grounds of methodological limitations. This is a problem, because we cannot have inquisitive conversations about the issues and generalizability of the study in question.

In truth, the treatment intervention studies are only one aspect of the overall evidence base to treatment. Clinical consensus, clinical experience of those with profound expertise, and supporting evidence around the ideal timing of pubertal changes in presumed cisgender youth (early and late pubertal changes lead to poor longterm psychological functioning) are other aspects of the evidence that need to be taken into account as well. Another post for another time.

Argument 3: They are all going to regret it.

Yes, there are individuals who regret their decision to take medications with irreversible effects. Welcome to medicine. If we are banning treatments (that help a significant amount of people) because some people regret them, then we should be banning a lot more treatments.

If we are banning treatments that help a significant amount of people because some people regret them, then we should be banning a lot more treatments.

Using the youth/young adults who have regretted their treatments by parading them around State Capitols hurts both the trans and detransition communities. By focusing in on regret in adolescence, proponents of the gender care bans are using the experiences of those who claim to be harmed by the medical system for political gain. They prevent people who do feel regret from being able to seek help and support for their experiences, since they do not want their experience to be weaponized against an entire group of people who do in fact need the care.

Regret experiences, in and of themselves, are complex. There is a difference between outcome regret (the effects of the intervention) and decisional regret (the decision to move forward with the intervention). We can, and do, prevent decisional regret by being upfront with our patients about the A. Impact of the treatments; B. Non-impact of the treatments; C. Evidence for the treatments; D. Who the evidence can & cannot be generalized to; E. Discussion of the harms, both short-and-long-term; and F. Ensuring our patients understand the concept of regret and experiences of those who have regretted their treatment.

Argument 4: Other countries are banning it too.

This is now commonly being used to justify banning gender care bans in the United States, particularly as the United Kingdom and some of the other European countries (particularly in Scandinavia) have implemented policy changes that are decreasing access to gender care for minors drastically. The Cass report from the UK has been cited as a reason to ban treatment based on its recommendation to de-centralize the care away from one major center in the United Kingdom (formerly GIDS at the Tavistock Center) and to re-establish programs around the country. Some of these countries are requiring patients/families to enroll in research protocols in order to move forward with treatment.

The response:

1. Who is to say that there aren't political and ideological motivations behind some of the bans in these other countries? Proponents of banning care in the other countries are pointing at the trend in the United States, and vice versa, yet few are questioning the ideological movements behind the efforts in those other countries as well.
2. The treatments aren't being fully banned per se. There are major hoops families have to go through in order to get the care, but these countries are not criminalizing those who provide this care to families. They are severely restricting it.
3. Requiring participation in a research protocol in order to access care has its own ethical misgivings. This is coercion. Families and patients who need these treatments should not have to be forced into a research protocol in order to access the treatment.

The Cass report touches on the challenges of a service serving one aspect (gender) of a very hetereogenous group of patients (range of psychological and psychiatric profiles) that has presented in exponentially increasing numbers over time without the simultaneous exponential increase in resources needed to meet the individualized needs of the patient population. Of course there needed to be a look at the delivery of care system with an eye for revamping it. The Cass Review does not recommend banning care. Yet it is pointed to as a reason why care bans should exist.

In summary, no matter where you stand on the issue of adolescents making decisions with irreversible consequences, these gender care bans for minors are dangerous, harmful, politically and ideologically motivated, and they hurt far more people than meets the eye.

When the pendulum swings back to center, history will judge those whose policies are harming countless children and families (in the name of "protection"). Hopefully we can return to a conversation about how to do the care instead of whether to do the care.