Girl with a vase of flowers (1902), Stanislaw Wyspianski. Public Domain.

The New Free to Be Might Make You Long for the Seventies

Free to BeYou and Me is a wildly successful 1972 album, with a 1974 companion book and TV special, conceived by the actress Marlo Thomas. The book, Thomas wrote in the Foreword, has “stories and poems and songs that would help boys and girls feel free to be who they are and who they want to be.” Even if you weren’t around in the 1970s, you can guess the message, delivered at the high watermark of second-wave feminism. One of the songs is “William’s Doll,” in which a five-year old boy gets his dream toy, a doll from his wise grandma, over the reservations of his dad. As you can also guess, his grandma doesn’t mention that William might be transgender (or gay, for that matter).

Fast forward fifty years to the new Free to Be, a book by the child and adolescent psychiatrist Dr. Jack Turban. Turban, who directs the Gender Psychiatry Program at UC San Francisco, is perhaps the country’s leading public proponent of “gender affirming” healthcare for children. According to the activist Charlotte Clymer’s cover endorsement, Free to Be is “an excellent guide on why this necessary health care has been a miracle for millions of trans youth and their families.” Although Turban wouldn’t reflexively label the old Free to Be’s gender-nonconforming William a “trans girl” and put him on the waiting list for puberty blockers and cross-sex hormones, the new Free to Be certainly recognizes diagnostic possibilities that the 1970s version did not.

But Free to Be does not discuss practical medical issues until chapter five. Before that, Turban sets the theoretical stage, with disquisitions on sex, the all-important notion of “gender identity,” the biological basis of being transgender, and the myth (as he sees it) that “social media makes kids transgender.”

Turban’s book crystallizes orthodox thinking in the US about the treatment of youth with “gender dysphoria” (distress at one’s sexed body). There are some sins of commission, and many of omission. Although ordinary readers will have no idea of what Turban has elided, his selection of citations to the medical literature is one-sided, and critics are generally ignored. However, even taking Free to Be at face value, it leaves the reader wondering. Is the current enthusiasm for placing gender dysphoric youth on a medical pathway that leads to infertility really as evidence-based as Turban makes out?

The Current State of Pediatric “Gender-Affirming Care” in the United States

For those only dimly aware of the debate, some background will be useful. According to psychologist Diane Ehrensaft, a colleague of Turban’s at UCSF and another leading figure in the gender-affirmative movement, the purpose of pediatric gender-affirming healthcare is to “aid children in affirming their authentic gender,” helping them to “discover and fortify their true gender selves.” She once claimed that a one-year-old “assigned male” who unsnapped his onesie “to make a dress” was sending a “pre-verbal communication about gender.” Turban, Ehrensaft, and their likeminded colleagues maintain that if a child of any age wants to undergo a “social transition” to live as the opposite sex (changing their name, pronouns, clothing, etc.), then they should be allowed to do so.

Puberty blockers (drugs that prevent the brain from signaling to the gonads, with the effect of suppressing puberty) are the first in a series of approved medical interventions. These are followed by cross-sex hormones (testosterone for girls and estrogen for boys). The final step, if desired, is “gender-affirmation” surgery. This might involve “top surgery” (a double mastectomy) for adolescent girls with some breast growth before taking blockers, and a vaginoplasty for adolescent boys.

The traditional approach to treating children with gender dysphoria is much more cautious: social transition is avoided, and the emphasis is on talk therapy rather than medicalization. Clinicians in the Netherlands introduced puberty blockers as an option in the 1990s, but patients were very carefully screened. Since blockers came to the US in 2007, the guardrails of the “Dutch protocol” have been removed, and the child-centered affirming model has prevailed. As Turban notes, “every major medical organization has said… that gender-affirming care should be available to adolescents,” including the American Medical Association and the American Academy of Pediatrics.

Nonetheless, more than twenty states have passed laws banning or limiting gender affirming healthcare for minors, many of which are tied up in court challenges. Some states have responded with “shield laws” to protect gender-affirming providers and their patients. In the US, the division between those who support more conservative approaches and those who defend the gender-affirming model tends to split along Republican/Democratic lines. In the UK, the division is not so partisan.

Replacing Sex with “A Transcendent Sense of Gender”

Free to Be begins with Turban’s own childhood, growing up gay in rural Pennsylvania with a father who once remarked that “gay people don’t deserve to live.” “Having suffered the psychological trauma of being told that being gay—something so fundamental about myself—was wrong,” Turban writes, “I was fascinated by the diversity of human identities and the stigmas attached to them.” It’s easy to see where Turban is coming from, and his compassion for his patients is palpable throughout the book.

It’s also easy to see why other gay men have landed at the opposite pole. In his recent book Gay Shame, the British screenwriter Gareth Roberts, himself gay, recognizes this divide. “Strange as it may seem,” he says, gay men “are responsible for a lot of the spread of genderism, which from its redefinition of sex onwards is blatantly, obviously homophobic. This is an ideology which says that there is something wrong with camp little boys and butch little girls and that they need to be fixed.”

Put this way, “strange” is an understatement. But, as we’ll see, Turban wouldn’t say that camp or effeminate boys need fixing. Rather, he thinks, some of those whom Roberts would count as camp boys are, in fact, not boys. They are girls—transgender girls, not the usual cisgender variety. Transgender girls can look just like boys, admittedly, but experts such as Turban can supposedly tell them apart.

Predictably, Turban is down on “biological sex.” The problem, he claims, is that it has many competing “scientific definitions.” For example, by saying that someone is “male,” one could mean that they have XY chromosomes. Or one could mean that they have a male “neurological sex—referring to the sex of a person’s brain.” Turban gives some other definitions and thinks that there’s no choosing between them, which is why he takes the phrase “biological sex” to be confusing and not worth the trouble. (Consulting some biologists might have helped.) Turban allows that “sex” may be used as “shorthand” for “sex assigned at birth,” but Free to Be carefully avoids using the word with its ordinary meaning. With the disappearance of sex, same-sex attraction makes no sense, and sexual orientation must be reconceptualized. Turban says that “we generally use someone’s gender identity as the reference point”: “transgender women attracted to other women” are now accordingly lesbians.

The subtitle of the book is “Understanding Kids & Gender Identity,” indicating the importance of “gender identity” to the entire theoretical enterprise. So, what is that, exactly?

Gender identity, Turban explains, is “one’s psychological understanding of oneself in terms of masculinity, femininity, a combination of both, and sometimes neither.” The number of gender identities is “nearly infinite,” although he concedes that for practical purposes “male” and “female” can crudely approximate the gender identities of most people. Free to Be’s glossary tells us that a transgender person is someone whose “gender identity does not align, based on societal expectations,” with the person’s “sex assigned at birth.” But then wouldn’t a stereotypical butch lesbian be transgender? She understands herself as masculine, so presumably has a male gender identity, which does not align with her sex assigned at birth.

However, it turns out that gender identity is considerably more intricate and elusive than Turban’s initial definition suggests. “On one level,” he writes, gender identity is “something deeply felt… one’s transcendent sense of gender. You simply feel a certain gender.” Transcendent sense of what, though? What are these “genders” that one may feel? The glossary entry for “Gender identity” gives a few examples of genders: “male, female, nonbinary,” while implying that there are many more. By “male” Turban doesn’t seem to mean the male sex, but precisely what he does mean is unclear. In any event, our butch lesbian is evidently supposed to have a transcendent sense of her female gender; this is why she is not transgender.

The effect of all this complexity is to shroud the notion of being transgender in a dense fog.

The “Biological Basis” of Transness

In Turban’s assessment, a large body of evidence shows that “transness has an innate biological basis.” He rejects the idea that the social environment—distant mothers, trauma, TikTok videos—has any kind of influence. But he does not provide a balanced picture of the scientific literature.

One piece of Turban’s “strong evidence” for an “innate biological factor” comes from the study of twins. Twin studies are often used to examine the effects of genes on the distribution of traits in a population. Identical twins share their genes, while fraternal twins share half, the same as regular siblings. If identical twins differ in a trait, that difference must be entirely due to the different effects of their environments, not to differences in genes. For fraternal twins, the difference might be due to both genes and environments. (“Environment,” it should be emphasized, includes the environment of the womb.) The heritability of a trait, the extent to which its variation in a population is due to genes, can be estimated by comparing identical and fraternal twins.

Turban cites a 2012 review that collated information on 44 twin pairs (identical and fraternal), in which at least one twin had “gender identity disorder,” an older term for gender dysphoria. The review found that one identical twin was about 40 percent likely to have gender dysphoria if the other twin did, while all the fraternal pairs had one unaffected twin. Turban takes this to show that “whether we are cisgender or transgender” is “deeply rooted in…our genes.”

But he does not cite a 2022 study from Sweden that examined a larger number of twin pairs (67) and found very different results. In this study, there were ten fraternal pairs in which both twins had gender dysphoria. This time, all the identical pairs had one unaffected twin. Turban’s confidence in the importance of genetic factors is misplaced: given the small samples and other methodological limitations, no firm conclusions can be drawn.

Even if we set aside the omission of the more recent study, Turban’s discussion is still misleading. First, the 2012 review (as well as the Swedish study) is about the heritability of gender dysphoria, not transness. Turban does obliquely acknowledge this in a footnote, and he emphasizes elsewhere in the book that “gender dysphoria and being transgender are not the same thing.” (As he also notes, dysphoria in young children usually abates before puberty.) Second, and more importantly, it would be very surprising if gender dysphoria (or transness, however this is explained) were not to some significant degree heritable. Practically everything is significantly heritable (the “first law of behavior genetics”). Personality is heritable. Sexual orientation is heritable. Eating disorders are heritable. Even political ideology is heritable. Third, also importantly, the last two examples show that there can be social influences on heritable traits. Anorexia is well-known to be transmitted between peers, despite being heritable.

That brings us to one of Turban’s bogeymen, “the blaming of social environments for gender diversity,” in its modern incarnation of “Rapid-onset gender dysphoria” (ROGD).

ROGD and the Role of Social Influences

In 2018, a physician and researcher at Brown University called Lisa Littman published a paper in the journal PLOS One, “Rapid-onset gender dysphoria in adolescents and young adults: A study of parental reports.” She defined ROGD as gender dysphoria that begins “suddenly during or after puberty in an adolescent or young adult who would not have met criteria for gender dysphoria in childhood.” Two forms of gender dysphoria were previously recognized: early-onset, affecting young children with marked cross-gender behavior, and late-onset, almost always affecting heterosexual men. The TV reality star Jazz Jennings, another endorser of Free to Be, is a classic example of the early-onset kind. An example of late-onset is the assistant secretary of health, Rachel Levine. If ROGD is real, this would be a type of gender dysphoria quite unlike the other two.

Littman analyzed detailed survey results from 256 parents. More than 80 percent of the children described were girls. Their trajectories, Littman wrote, “were not consistent with the narrative of discovering one’s authentic self and then thriving.” Her lengthy paper concluded with two “emerging hypotheses”: that ROGD was driven by social contagion, and that it is a “maladaptive coping mechanism,” a way to avoid distressing emotions while ignoring the source of the problem.

Trans activists responded by unleashing total war. Littman’s paper was subjected to a highly unusual post-publication review, and the revised paper was republished the following year as “Parent reports of adolescents and young adults perceived to show signs of a rapid onset of gender dysphoria.” The results were essentially unchanged, and Littman herself was remarkably gracious about the whole affair, which must have been personally upsetting.

Turban finds Littman’s paper to be worthless and harmful: “deeply flawed,” “pseudoscience,” a “fringe idea” that “became a full-fledged conspiracy theory.” “The single most glaring issue with the study,” Turban says, “was that Dr. Littman did not interview any of the kids.” Here, Turban cleverly hands the microphone to Katie, a transgender girl from a Southern state: “When I sat down with Katie and told her about the study, she rolled her eyes: ‘That’s the most bullshit thing ever.’” Yet this “glaring issue” was explicitly acknowledged in the original title: “A study of parental reports.” Parental reports are useful sources of data, and many papers have been based on them. And as Littman pointed out, there has been an explosion of referrals to child and adolescent gender clinics, starting around 2014, with adolescent females accounting for most of the increase. Littman’s work on ROGD was prompted by this significant shift—which Free to Be conspicuously fails to mention.

Turban gives the impression that Littman’s paper was a tinfoil-hat outlier, not corroborated by anything else. But in 2015 Finnish gender clinicians gave this description of their adolescent referrals: “most of the adolescents [87% female] first presented with gender dysphoria and cross-gender identification well after the onset of puberty, and the vast majority suffered significant psychopathology and broader identity confusion than gender identity issues alone.” And this is based on information from the adolescents themselves. Similarly, in 2019, Kenneth Zucker, a world-authority on gender dysphoria, wrote that, in his opinion, ROGD “is a new clinical phenomenon.” Zucker and Turban have been co-authors, but the “gray-bearded, bespectacled psychologist” is portrayed in Free to Be as “a man who firmly believed that young transgender children could—and should—be made cisgender.” A less-loaded description would be that Zucker thinks that gender-distressed children should be given every opportunity to feel comfortable in their own skins.

It’s hardly implausible that some adolescent girls, a population especially vulnerable to mental health issues, would interpret their psychological distress as a sign of being transgender. Even if most of the allegedly rapid-onset group somehow concealed their dysphoria and cross-sex wishes from a young age, wouldn’t we expect a few to fit the ROGD mold? Turban is unwilling to concede a single case. Discussing a teenage girl who reportedly desisted from a transgender identification, he thinks it’s “much more likely” that she’s a transgender boy who went back into the closet. You can read an essay by her here, and judge for yourself. 

Meredith, Kyle, and Sam

That’s enough about Turban’s theoretical framing. Now, on to practice. The stories of three composite patients are woven throughout Free to Be. Turban first encounters the trans boy Kyle when the sixteen-year-old turns up in the emergency room after a suicide attempt. Meeting the trans girl Meredith is less dramatic: Turban drives his elderly Subaru Forester into an “expansive driveway” in a New England town and finds fourteen-year-old Meredith in the doorway, wearing “blue tights and an oversize hot-pink T-shirt.” Like Jazz Jennings, Meredith was very feminine from a young age.

Meredith socially transitions at the start of middle school and is given puberty blockers at Tanner Stage 2 (when the first physical signs of puberty appear). Meredith “desperately wanted to take estrogen so that she could be on the same timeline as her peers,” so is duly prescribed cross-sex hormones and has a vaginoplasty the summer after high school graduation. There is a strong association between boyhood femininity and homosexuality, so it’s unsurprising that the “assigned male” Meredith is sexually attracted to men. After a bout of depression in college, a boyfriend arrives on the scene and, happily, Meredith’s life is going well.

Kyle’s story is more troubled. Kyle’s parents resist the female child’s gender nonconformity. Despite “constant screaming and tears” Kyle is put in dresses and enrolled in a dance class. Kyle becomes depressed and anorexic during puberty. With parental support, Kyle starts testosterone therapy a year after the suicide attempt. A month before turning eighteen, Kyle has a double mastectomy—the “removal of chest tissue for people assigned female at birth.” Kyle’s mental health and family relationships have both improved.

Meredith and Kyle are familiar stereotypical “trans kids,” but the story of Turban’s third composite patient is quite eyebrow-raising. A feminine boy who likes nail polish, Sam is sent to Turban’s clinic after his mother wonders whether he needs puberty blockers, after watching a TV segment on transgender kids. When an endocrinologist asks the seven-year-old about his pronouns, he sensibly says “I don’t care; use whichever you want.” Since the boy is only at Tanner Stage 1, it’s too early for blockers, and instead he is referred to Turban. Remember: there is absolutely nothing wrong with Sam. He has no gender distress and is otherwise healthy. He tells Turban that he “kind of feels like both” a boy and a girl, which prompts Turban to oscillate between “he” and “she” when describing their first meeting in Free to Be.

During a remote appointment three months later, Turban uses the Zoom whiteboard to explain Sam’s pubertal choices—the regular “testosterone puberty” or the “girl puberty” instead. Not that Sam was asking! He’s having fun at school and is unperturbed when Turban draws a beard on his whiteboard person, showing what boy puberty is like. The reader naturally wonders what Turban would have done if the seven-year-old had decided that girl puberty sounded nicer. At the end of Free to Be, Sam is “transgender” (specifically, nonbinary), fortunately unmedicalized, but coping with Obsessive-Compulsive Disorder. He may be gay; at any rate, he is “hoping to work in theater in the future.” No one seems to have told Sam that he exemplifies one of the myriad ways boys can be.

The Risks of “Gender-Affirming” Interventions

One merit of Free to Be is that Turban is forthcoming—in large part—about the risks, limitations, and consequences of gender-affirming treatments. Puberty blockers reduce bone density and, in females, can induce menopause-like symptoms. Their effect on cognitive development, Turban admits, “has only been preliminarily studied.” (This year, the neuropsychologist Sallie Baxendale wrote a review on the topic, concluding that “critical questions remain unanswered.”) Turban notes the “strong theoretical risk that going straight from pubertal suppression to gender-affirming hormones (estrogen or testosterone) will result in infertility.” He says that “most adolescents” on blockers proceed to cross-sex hormones. That seriously lowballs it: the figure is around 95 percent. Fertility preservation may not be possible for females; even for males, Turban tells us, it is costly and has other drawbacks. In effect, Meredith made the decision not to have biological children by taking puberty blockers at twelve.

Breast growth in males who take estrogen is often poor. Testosterone therapy in females can cause vaginal atrophy. Mastectomies can result in “loss of nipple sensation,” will leave “large scars,” and (of course) prevent “chestfeeding,” a possibility Kyle foreclosed at seventeen. Because of Meredith’s early pubertal suppression, there was not enough penile growth for a standard vaginoplasty; an alternative is to construct the neo-vaginal canal from the membrane lining the abdomen. The surgery carries “rare but serious risks,” and as preparation Meredith required “months of hair removal.” Meredith’s recovery was lengthy, and dilating the neo-vagina “is generally something one needs to do for life.”

What about the effect of blockers on sexual pleasure? Turban alludes to “comments in the media that trans women who have a vaginoplasty after early pubertal suppression had lack of sensation and could not orgasm,” and Meredith wants “readers to know that this was not the case for her.” Turban tactfully omits the fact that the source for these “comments in the media” is Marci Bowers, Jazz Jennings’ surgeon and the president of the World Professional Association for Transgender Health (WPATH). Bowers is thanked in Free to Be’s acknowledgements. She expressed concern about blockers impairing sexual function in a 2021 interview with Abigail Shrier. And in an online symposium in 2022, Bowers said that every male child “who was truly blocked at Tanner Stage 2, has never experienced orgasm. I mean, it’s really about zero.” Meredith was very lucky.

Pushing Parents Toward Medicalization

Without knowing anything about controversies over gender medicine, the reader might well ask why such extraordinarily drastic interventions on young healthy bodies are better than the alternatives. Wouldn’t it have been advisable for Meredith to wait until adulthood?

For Turban, the alternatives are not on his radar, because he is convinced that Meredith is a girl with a “transcendent sense” of her own female gender. Once Meredith’s status as transgender is settled, the only thing left is to ask her what social arrangements or medical procedures she wants, in the light of the pros and cons. If she wishes to preserve her penis, fine; if not, also fine. But if the situation is described accurately, other possibilities become more salient.

A young boy has gender dysphoria that persists into puberty. Completing puberty may well be tough, but it keeps his options open. It’s not going to kill him: before puberty blockers were available, there was no rash of deaths due to enduring the “wrong” puberty. If our boy does decide to medically transition as an adult, at least he’ll have had a chance for some sexual experience beforehand. To be sure, “passing” as a woman will be more difficult after a male puberty, but there is a long track record of reasonably successful adult transitions. Alternatively, he might be content living as a man—very likely a gay one—with his body intact, his fertility preserved, and no commitment to a lifelong entanglement with the healthcare system. To eliminate this unmedicalized option at age twelve seems imprudent.

Perhaps most importantly, a more cautious approach avoids placing children and families in a compromised position. Once puberty blockers are offered, a choice needs to be made. Blockers must have some advantages, parents will reason, otherwise physicians would not put them on the table. The situation is familiar: you go to the doctor with a serious complaint, and the authority figure in the white coat tells you that treatment X might help, but it comes with side effects. As Turban says, “there are risks, benefits, and unknowns for all medications.” There’s a temptation to do something, so if it’s treatment X or nothing, you’ll probably go for the treatment. And if it’s your child who’s suffering before your eyes, the temptation can be overwhelming.

Meredith’s story vividly illustrates how contact with gender-affirming clinicians can nudge level-headed and well-informed parents to put their child on the medical pathway. In retrospect, Meredith’s journey has an air of inevitability, starting with a social transition in middle school. The possibility that social transition makes subsequent medicalization more likely is a real concern, which is why the earlier Dutch protocol recommended against it.

Hillary vs. Chelsea, Cass vs. Turban: Which Side Will America Choose?

If we look outside the pages of Turban’s book, the gender-affirming model seems far from “necessary health care,” let alone a “miracle,” as Charlotte Clymer’s endorsement has it.

In April of this year, the final report of the UK’s Cass Review was published, the most comprehensive examination to date of pediatric gender medicine, led by the distinguished pediatrician Hilary Cass. Cass commissioned eight systematic reviews (studies at the very top of the evidence-based medicine pyramid) from the University of York. The systematic review of puberty blockers concluded:

There is a lack of high-quality research assessing puberty suppression in adolescents experiencing gender dysphoria/incongruence. No conclusions can be drawn about the impact on gender dysphoria, mental and psychosocial health or cognitive development. Bone health and height may be compromised during treatment. More recent studies published since April 2022 until January 2024 also support the conclusions of this review.

Free to Be has a front-cover blurb from Chelsea Clinton: “A must-read for anyone seeking to better understand how we can truly help all our children thrive.” That may be true, although not in the way Clinton intended. Her mother has a close connection with the original Free to Be: Hillary helped cut the ribbon at the opening of the Marlo Thomas Center for Global Education in 2014.

In an interview with the UK’s Sunday Times, the former Secretary of State and her daughter were asked “if someone with a beard and penis can ever be a woman.” As recounted by the interviewer—from TERF Island, obviously—“Chelsea peers at me as if I’ve just asked if the sun rises in the east. ‘Ye-esss. Yes.’” Hillary, apparently playing J.K. Rowling to Chelsea’s Emma Watson, “is looking uneasy. ‘Errr. I’m just learning about this. It’s a very big generational discussion, because this is not something I grew up with or ever saw…’”

With European countries pulling away from the gender-affirming model, the US is at an inflection point. Will we side with Hillary and return to the 1970s Free to Be, updated with the acknowledgement that the doll-loving William might be gay? Or will we follow Chelsea and embrace the ideology of “sex assigned at birth” and “chestfeeding,” guided by our transcendent sense of gender?

To readers of a certain age, with no adherence to any side in the gender wars, Turban’s new Free to Be will invoke nostalgia for the old one.