“Less boobs? No boobs?”: Subjectivity, Not Science, Drives Youth Gender Medicine

As the debate around care for gender dysphoric youth intensifies, the World Professional Association for Transgender Health, self-appointed arbiter of norms in gender medicine, has come under increasing scrutiny. WPATH’s most recent Standards of Care, released in September 2022 and colloquially known as SOC8, has garnered widespread attention and critique, most notably for the chapter on the newly minted “eunuch” gender identity and the mysterious last-minute deletion of minimum age requirements for medical transition in children. A bombshell report in the top-tier British Medical Journal from March 2023 revealed that WPATH’s protocols do not actually meet the criteria for evidence-based medicine, and that those protocols at times contradict the findings of their own systematic evidence reviews.

Is WPATH a legitimately scientific organization? Is their global guardianship of gender medicine well-deserved? These questions now hang in the air, deservedly asked and yet tricky to answer, in large part because WPATH shrouds itself in secrecy. When the state of Alabama recently subpoenaed WPATH for information about how they established their guidelines, WPATH responded not with transparency, but with an unsuccessful attempt to quash that subpoena on first-amendment grounds.

Their 27th annual Scientific Symposium, held in Montreal on September 16-20, 2022, was closed to the general public and to journalists. Despite these attempts at concealment, recordings of several sessions from WPATH’s symposium were leaked. One participant, Aaron Terrell, a transgender man and representative of the Gender Dysphoria Alliance, reported being banned from the conference after asking in an online conference forum: “What are providers doing to ensure that cis children aren’t being transitioned unnecessarily?” Another attendee, researcher and writer Eliza Mondegreen, described a “total witch hunt” for journalists on the last day of the conference, when participants were encouraged to report any suspicious activity so suspected journalists could be ejected. Mondegreen says she was regarded warily for being one of the few attendees taking notes.

Mondegreen has spoken candidly about her experience at WPATH, both in interviews and in her own writing, as well as private correspondence. Her insights provide a much-needed peek behind the curtain of gender medicine and have influenced my own analyses.

A Scientific Veneer

Perhaps the fattest fly in the ointment of youth gender medicine is the absence of long-term data on its efficacy and outcomes. None of the low-certainty evidence currently available provides information about how medically transitioned children and adolescents fare over the long term. Yes, you read that correctly: there is no data on long-term outcomes.

This fact was acknowledged by researchers from the pioneering gender clinic in Amsterdam, birthplace of the famed Dutch protocol. At their WPATH panel, the Dutch researchers told attendees that they were there to present results from “the first study done to assess the long-term effects of early medical treatment in transgender youth.” The panel was titled “Transgender Care Over the Years: First Long-Term Follow-Up Studies and Exploration of Sex Ratio in the Amsterdam Child and Adolescent Gender Clinic.” It was moderated by Thomas D. Steensma, PhD, and featured a team of Dutch researchers: Frédérique B.B. de Rooy, MD; Isabelle S. van der Meulen, MD; Joyce D. Asseler, MD; and Anna I.R. van der Miesen, MD. (See the full conference program here.)

Like all studies on youth medical transition, this study has significant limitations. There is no control or comparison group, and the data comes from self-reported survey results that carry high risk of bias. To gather the data for the study, the researchers invited 205 adults who had been treated by the clinic as adolescents to complete an online survey, followed by a short phone interview.  However, only 101 (49%) of those eligible to participate actually did so. This means that for 51% of the now-adults who were transitioned as minors at this clinic, the outcomes are unknown. This study, then, only provides a snapshot of half the people in the treatment pool. Such a high loss to follow-up is significant, especially because there is some evidence to indicate that those who detransition are much less likely to maintain contact with gender clinics and report on their experience. One recent study found that only 24 percent of detransitioners informed their doctors of their decision to revert back to their natal sex.

Although the survey questionnaires covered a wide range of topics—identity labels, body image, psychological functioning, quality of life, relationships, sexuality, fertility—only the results related to gender, relationships, sexuality, and fertility were presented in the symposium. Let’s explore some of those findings.

Stability and Fluctuation in Gender Identification

For a majority of respondents (81%), gender identity remained stable over time. However, a substantial minority (19%), experienced fluidity and instability in their gender identities. Such fluctuations in gender identity were more pronounced in autistic children: 31% experienced “multiple attenuations of their gender identity” over time, meaning more than one change in gender identity. (The displayed word cloud of current gender identity descriptors included the words “fairy,” “elf,” and “moment.”) 

The researchers made much of the fact that the majority were stable in their gender identity. Yet, without a control group, there’s no way to know if the irreversible treatment protocol itself influenced the persistence of cross-sex identification. The original Dutch protocol, moreover, had fairly strict gatekeeping criteria: only young people with persistent, early-onset gender dysphoria and stable mental health were allowed to transition. Furthermore, the patients in this dataset all began transition prior to 2014—so, just on the cusp of the surge in gender dysphoria among adolescents, especially girls, across the West. The results presented, then, reflect a different cohort of young people than the ones currently showing up at gender clinics in unprecedented numbers.

Yet even within this pre-surge, early-onset, vetted group—for one in five of them, gender identity did not remain stable. (At least, one in five of those who took the time to report back.)

Fertility and the Desire to Have Children

Researcher Joyce Asseler presented results from a cohort of 89 patients who began medical treatments around the age of 15 and are currently in their 30s. All of these now-adults started their transition prior to 2014, and almost all of them (96%) underwent a gonadectomy, rendering them permanently sterile. Prior to 2014, removal of the gonads was a requirement for a legal gender change in the Netherlands.

When asked whether they had developed the desire to have children, the majority (56.2%) expressed that they had, with a further 12.4% being unsure. Only 19% of this sterilized cohort reported not wanting to have children as adults. A substantial minority, furthermore, said they would now choose to keep their gonads (14% of natal females and 17% of natal males) or are unsure about their decision (24% of natal females and 9% of natal males). 

For proponents of youth gender transition, these results should be unsettling. Medical transition—hormonal as well as surgical—unambiguously threatens fertility, and here is evidence indicating that most of the young people put on that pathway later develop the desire to have children.  

Sexual Dysfunction after Vaginoplasty

Data from a separate study presented in the Dutch session focused on “the sexual function of trans women after vaginoplasty.” This study analyzed self-reported data from 37 transgender women (natal males) with a mean age of 20 years, approximately eighteen months post-vaginoplasty. The lead presenter, Isabelle van der Meulen, made much of the fact that 76% have been able to achieve orgasm, even after early pubertal suppression.

Alongside this finding, however, van der Meulen disclosed equally high rates of recurring sexual difficulties: pain during sex (77%), lack of libido (76%), difficulty in getting aroused (62%), inability to orgasm (67%). These high rates of sexual dysfunction are even more striking when we remember that we are talking about 20-year-old natal males, who would normally be in their sexual prime. Yet, disturbingly, van der Meulen’s concluding remarks glossed over these difficulties: “My take home message to you is that, can they orgasm? Yes, they can!”

Sex Ratio Reversal in Gender Clinic Referrals

The final presentation in the symposium was by Thomas Steensma, one of the pioneering clinicians of the Dutch protocol. Steensma confirmed that the sex ratio reversal of gender clinic referrals between 2000-2019–from majority natal males to majority natal females—is most pronounced and began first within the adolescent age group, before spreading to other age groups.  

All of these results, when taken together, reveal an undercurrent of instability: for many young people, desires and identities fluctuate from adolescence to adulthood. Indeed, that observation seems obvious, a reflection of conventional wisdom about the turbulence and impulsivity of adolescence. Yet that shared wisdom is forgotten in the upside-down world of gender medicine, where young people are encouraged to make life-altering and often irreversible decisions about their bodies, identities, and fertility, before they’ve reached adulthood. 

Bizarrely, the Dutch researchers did not seem particularly troubled that the majority of the young people they sterilized later developed the desire to have children; that the majority of young males whose genitals were surgically altered now experience high rates of sexual dysfunction; and that a substantial minority of young people treated in their clinic did not maintain a stable gender identity over time. These factors all challenge early medicalization as the gold standard treatment for gender dysphoric young people. Yet the treatment pathway itself remains unquestioned. Even while presenting adverse evidence, not once did anyone ask: is this the best approach?

Subjectivity, Not Science

Among even the esteemed Dutch researchers, the world’s foremost experts on youth gender medicine, a persistent and unscientific doublethink is at work: on the one hand, a data-informed acknowledgement that desires and identity are unstable, and on the other hand, a continued endorsement of early and invasive medical interventions that seek to reshape the adolescent body according to those desires. 

This doublethink is even more pronounced in the “gender affirmative” model of care, the Dutch protocol’s reckless offspring, which keeps the invasive interventions while ditching the gatekeeping. Proponents of this paradigm argue that, rather than focusing on identity, clinicians should shift their focus toward “embodiment goals.” In another session at the WPATH conference, clinical psychologist Colt St. Amand explained this concept:

The most basic 101 way to describe this is what primary and secondary sex characteristics a person is desiring: more hair, less hair, larger boobs, less boobs, no boobs, hips, voice changes, etc. […] Historically, we have overfocused on stability and certainty of identity, and then just made the assumption that if they’re saying they’re a boy, then they’ll want “a boy’s body,” which is by its nature an endocisheteronormative framework, and it’s incredibly problematic. And so instead, we really want to focus on making sure that we’re asking the young person what their embodiment goals are, and that will lead treatment and decision making. 

Armaud seems to think that shifting from gender identity to embodiment goals will ameliorate the problem of young people who transition and then change their minds—but it doesn’t, because the embodiment goals of adolescents aren’t stable either. The concerns raised by youth transition skeptics are not about identity fluctuation, but about irreparable bodily harm. Whether that harm is facilitated by an emphasis on gender identity or on embodiment goals is irrelevant. 

In the world of transgender youth medicine, “health” is code for molding the body to subjective, shifting desires; “want” is urgently expressed as “need”; and unchecked consumerism wears the linguistic garments of science, evidence, and medical necessity—garments that would be quickly cast off, if not for the pesky gatekeeping of insurance companies and the threat of litigation.

Here, the purpose of collecting evidence on long-term outcomes is not to evaluate the effectiveness of the medicalization protocol. No, the purpose is to add more small print to the warning label. As Dutch researcher Anna van der Miesen put it: “I want to emphasize that follow-up studies should not be used to predict outcomes regarding gender identity or gender identity development over time, but should be used in the informed consent process to inform the children and the adolescents.” The ethical-sounding concept of “informed consent” disguises the sleight-of-hand taking place: the burden of responsibility shifts from the practitioner to the patient.

Eliza Mondegreen describes this as a shift from a “medical responsibility” framework to an “autonomy framework,” which allows clinicians to distance themselves from their own culpability. The blame is placed on patients who “experienced multiple attenuations of their gender,” rather than the harmful interventions and the doctors who supplied them. 

Comparing the Dutch with clinicians who base their work on adolescents’ ever-shifting “embodiment goals,” one could argue that there is a foundational instability, a widening fracture in the mantle of gender medicine, as dueling paradigms push and pull against one another like shifting tectonic plates. One could frame this as an impending collision between a scientific paradigm, in which claims and hypotheses must be tested and confirmed by objective evidence, and an identity paradigm, in which diagnoses and treatment pathways are determined by subjective and unfalsifiable self-declarations. 

In truth, however, the quake has already struck: objectivity has crumbled; the paradigm of subjectivity is the foundation of gender medicine.

Editor’s note: This piece was updated on May 15, 2023.