Yesterday, President Biden signed an executive order instructing his administration to examine what steps it could take to end “conversion therapy” for minors who identify as transgender. According to the White House press release:
President Biden is charging HHS with leading an initiative to reduce the risk of youth exposure to this dangerous practice. HHS will explore guidance to clarify that federally-funded programs cannot offer so-called “conversion therapy.” HHS will also increase public awareness about its harms, provide training and technical assistance to health care providers, and expand support for services to help survivors. President Biden is also encouraging the Federal Trade Commission to consider whether the practice constitutes an unfair or deceptive act or practice, and whether to issue consumer warnings or notices.
The order itself sweeps much broader than pediatric gender medicine, but that is surely its most controversial element. It should put to rest any remaining doubts over whether the medical scandal of deforming and sterilizing children in order to validate their “internal sense of gender” goes all the way to the top of the American power structure. It undoubtedly does.
The term “conversion therapy” was initially used by gay rights advocates to describe efforts by mental health professionals to make same-sex attracted people heterosexual. In recent years, transgender activists have appropriated the term to target the use of psychotherapy as a measure of first resort for helping minors with gender-related distress to feel comfortable with their bodies. Critics of this approach argue that the only ethical treatment for “gender dysphoria” is “affirmation”—that is, agreeing with a minor’s self-diagnosis. They insist that any effort to explore whether a teenager’s transgender self-identification might result from some other factors—say, a combination of past sexual abuse and depression—is scientifically proven to be deeply harmful. “I have no room in my heart for hatred and I have no time for intolerance,” said HHS Assistant Secretary for Health Rachel Levine, who is transgender, “but we don’t live in a world where everyone feels that way, and this administration understands that more action is needed.”
The idea that it is unscientific and unethical to use psychotherapy as the default treatment for gender dysphoria is demonstrably wrong. The original Dutch Protocol, which laid the foundations for pediatric gender transition, insisted on lengthy psychological prescreening of candidates before prescribing them puberty-blocking drugs. What the Dutch experts knew then, and what researchers know now with even greater confidence, is that minors seeking transition tend to have extraordinarily high rates of mental-health problems, including anxiety, depression, attention-deficit and eating disorders, and autism. The intuition here is simple: if kids are going to give consent to puberty blockers and cross-sex hormone injections, they should first be determined to be mentally stable and competent. The psychological co-morbidities clinicians across the West are used to seeing in (mostly female) teenagers who show up for gender-transition procedures typically precede cross-gender identification and are thought to be in themselves the main causes of suicidality—the dreaded outcome that proponents of the affirm-only approach believe justifies allowing minors to consent to life-altering medical interventions. Existing studies provide no evidence that affirming reduces suicidality, and a new study shows limited evidence that it might worsen the problem.
Affirm-only advocates like to say that their approach has the endorsement of “all major medical associations.” As critics have pointed out, however, the statements of these associations against psychotherapy are based on an egregious misreading of the evidence. For example, when the American Academy of Pediatrics denounced non-affirming approaches as “conversion therapy” in 2018, it based that conclusion entirely on studies done on homosexuality and omitted all relevant studies on youth gender dysphoria. It even interpreted one study as supporting the affirm-only approach, despite the fact that that study explicitly recommended “watchful waiting” (psychotherapy). No one with even superficial familiarity with the politics of gender medicine can take seriously the claim that there is an evidence-grounded consensus in favor of affirmation.
Not only that, but over the past two years medical authorities in Australia, Finland, France, the U.K., and Sweden have recommended severe limitations on affirming therapy, insisting that the evidence for this approach is tenuous at best. The Biden administration is strengthening its commitment to affirming therapy at precisely the moment when the world’s most progressive welfare states are becoming more restrained about the practice.
It’s perhaps no coincidence that on the same day the Biden administration made its announcement, the New York Times Magazine ran a long article acknowledging, for the first time, that affirm-only therapy is controversial among medical experts. The article was by no means as rigorous or as fair as it could have been. Its author, Emily Bazelon, characterizes all opposition to affirming therapy as “right wing,” even as objections have come from feminists, gay rights advocates, and even transgender activists themselves. She acknowledges the role that “social influence” might play in shaping teen identity but vastly underestimates the findings of recent years in regard to “social contagion.” She also understates the growing skepticism within the research community over the safety and reliability of “social transition” and puberty blockers.
Still, Bazelon’s article marks a welcome departure from the newspaper’s previous approach, which framed the debate over pediatric transition as one between enlightened experts and knuckle-dragging bigots. It emphasizes that the World Professional Association for Transgender Health (WPATH) is slated to revise its Standards of Care this summer by adding, among other things, a requirement for psychological prescreening of adolescents prior to giving them puberty blockers. Because the premise of the affirm-only approach is that prescreening means questioning the veracity of a minor’s identity, even the WPATH seems to be moving to the right of the White House.
The sense of betrayal over the Times piece among gender-affirming trans activists is palpable—and revealing. These activists regard dissemination of their ideology by the nation’s leading public opinion organs as an entitlement; they have zero tolerance for dissent. As Bazelon reports, when transgender doctor Erica Anderson voiced concerns about how the affirm-only approach is driving “sloppy, dangerous care” and agreed to speak to Abigail Shrier, author of Irreversible Damage, the U.S. branch of WPATH censured her and imposed a month-long moratorium on speaking to the “lay press” (read: those who are not mouthpieces for the gender-affirming cohort). In preparation for her article, Bazelon sought an interview with Jack Turban, a medical doctor, zealous partisan of affirm-only, and author of two (largely debunked but still widely cited) studies purporting to show that puberty blockers are suicide-prevention measures. Turban declined, however, claiming through his spokesperson that he “didn’t have time to talk.”
Twenty-four states now ban or limit “conversion therapy,” effectively requiring mental-health experts to affirm, affirm, affirm. In California, and probably other places, parents whose teenage daughters suddenly and unexpectedly declare themselves trans and seek virilizing hormones have virtually no option to see a non-affirm-only therapist unless they go out of state. Therapists like Miriam Grossman and Stephanie Winn who disagree with the affirm-only approach believe that their field has ceded almost all grounds to affirm-only activist-practitioners—despite the absence of any evidence that affirm-only is superior to “watchful waiting” (the Dutch Protocol). The WPATH’s proposed revisions are themselves efforts to get medical experts to withhold affirming until a more robust psychological assessment can take place. Regardless, measures restricting gatekeeping for gender transition in state law tend to get smuggled in by grouping “gender identity” with “sexual orientation”—a reflection of trans activism’s deliberate effort to piggyback off the public’s warming attitudes toward homosexuality. The acronym “LGBT,” never mind its more elaborate extensions (the Biden order uses “LGBTQI+”), is surely one of the most successful marketing ploys by political entrepreneurs in recent decades.
The Biden administration’s move is supposedly a reaction to Republican states trying to ban pediatric transition, investigate parents who put their children through transition procedures, and limit government coverage of transition costs. It is possible that HHS will take a more reasonable course of action, for instance by focusing on pushing back against Texas’s parental-investigation initiative (currently held up in the courts), which may do more harm than good. But that is not likely. The president himself, as I have written, seems utterly clueless when it comes to the details of this complicated issue. Like many (but by no means all) Democrats, he seems guided more by unchecked compassion and cues from the party’s activist wing than by reason and common sense. Perhaps he is simply deferring to young progressive staffers or to HHS’s Admiral Levine, who seems intent on using federal power to ensure that every last American agrees with her that she is a woman. Whatever the reason, Biden’s executive order is a blight on his presidency and on the nation.
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