American culture is prone to psychological and medical contagions. An idea catches fire, seeming to be a plausible and important explanation of a familiar problem — depression, anxiety, eating disorders, sexual dissatisfaction. The idea outruns evidence. Experts emerge to treat people suffering from the problem, exploiting the most credulous. They open clinics. They give prestigious lectures and write books. They make fortunes. They blur the diverse possible origins of a person’s difficulties, attributing them all to the latest explanation.
Throughout the 1980s, the hot explanation was childhood sexual abuse: you have an eating disorder? Your father (or grandfather, or uncle, or close family friend) probably molested you. You don’t remember that? You repressed the memory. In the 1990s, it was Multiple Personality Disorder: your other personality remembers the bad stuff; let me give you a little sodium amytal to bring it out. In the 2000s, it was PTSD (Post Traumatic Stress Disorder), said to apply to all traumatic experiences from war to an unwanted touch on the shoulder. Tearful sufferers tell horrific personal stories, and who could doubt them? Who wants to be accused of being misogynist, antifeminist, or simply cold and heartless?
In the case of the recovered-memory epidemic, for example, many state legislatures, confronted with countless stories of repressed memories of sexual abuse, began expanding the statute of limitations, permitting lawsuits to be filed against alleged perpetrators from years since the abuse occurred to years since the victim remembered the abuse. The door was thus opened for people to sue their fathers, priests, teachers, and neighbors 20, 30, and even 40 years later, and they swarmed through. “We didn’t know there was another side,” said an Illinois legislator, explaining the haste to extend the statute of limitations. There was.
I am old enough to have lived through too many of these social contagions, seeing how they rise, generating more and more believers and patients while trampling skeptics and doubters; and how, over time, as patients’ symptoms worsen, as cases of family devastation escalate, as recanters begin telling their stories, we start hearing the other side — from researchers, practitioners, and intrepid journalists.
Today, once again, the public is hearing only one side of an emotionally compelling issue: the transgender story. Once again, distinctions are ignored, this time between people for whom identification with the other sex began in early childhood and those whose rapid onset gender dysphoria started during adolescence. Yet the difference between the two groups is itself a fascinating and puzzling phenomenon. Historically and cross-culturally, it is not uncommon for some very young children, mostly boys, to reject their natal sex early on and grow up to be gay or to live in an official, socially accepted category, a “third sex,” such as berdache among Native Americans (the term is now “two-spirit”), hijra in India, muxe in southern Mexico. But the last decade has seen an explosion of rapid onset gender dysphoria, which is occurring mostly among adolescent girls who are unhappy with their bodies and their sexuality and are persuaded that this discomfort is a sign they might be transgender.
Adolescence is rarely an easy time, but life for most American teenagers now is more difficult than it has ever been, as rising rates of depression, anxiety, and body dysmorphia indicate. In a world where “gender identity” has become such a dominant theme, infusing language, art, and politics, where young people struggle to decide if they are cis, gay, other, pan, a-, or some combination, no wonder it has become the explanation du jour of the difficult miseries of adolescence — anxieties exacerbated by COVID, climate change, the economy, school costs, and uncertain futures. Saying you suffer from “gender dysphoria” is cool and common, just as saying you were sexually abused in your youth once was. It explains everything. It gets attention and support. Sometimes gender dysphoria is the explanation; statistically, given the tiny percentage of actual transgender people in the population, far more often it isn’t.
So let’s consider the story that isn’t being told. The public hears trans people tell how their lives were saved, their misery ended when they transitioned, their relief to be in the right body at last. The public hears that without the legal and medical opportunity to transition, young people are at high risk of suicide. Reporters cover tragic, infuriating stories of the hateful bigotry and violence that many trans people endure — and make no mistake, they do. Supporting “gender affirming” clinics therefore seems so obvious, so morally right, so sex-positive. What could go wrong, what could be wrong with offering unhappy children and teenagers this option, even if they are just entering puberty? Countless parents agonize over this question, wanting to be liberal and tolerant, wanting to do the right thing — but not knowing what that is.
An August 6, 2021 episode of WNYC’s “On the Media” illustrates the problem: the hosts focused on efforts “to block access to medical care for trans kids,” the “politics and propaganda behind the recent wave of anti-trans legislation,” and “what the science tells us about gender affirming care in adolescence.” But “On the Media” did not tell the full story. The usually thorough reporters did not invite a cultural historian to wonder why “gender affirming” clinics have proliferated, from only one in 2010 to more than 400 today, offering puberty blockers and hormones to facilitate the change, including helping teenage girls have “top surgery” to remove offending breasts; or why the sex ratio of transgender claims has changed so dramatically. “On the Media,” of all programs, did not even consider the role of the media in generating and perpetuating social contagion effects.
In its most glaring omission, “On the Media” said not a word about the “desisters,” a term often used for those who make a social transition (changing their names and pronouns) but do not persist in having surgery and hormones or changing their gender identity, and often change back; or about the many (possibly thousands of) “detransitioners” who now regret that they had medical procedures. Many of them are bitter and angry that they have had irreversible voice and hair growth changes, underwent surgical procedures that cannot be corrected, and have become infertile. Elie Vendenbussche, in the Faculty of Society and Economics, Rhine- Waal University of Applied Sciences, Kleve, Germany, did an international on-line survey of 237 male and female detransitioners, who reported “a major lack of support” from the medical and mental-health systems and from the LGBT+ community.
The results were illuminating. Fully 45 percent of them said they had not been fully informed about the “health implications of the accessed treatments and interventions before undergoing them.” (An additional one-third felt “partly informed.”) They also suffered serious psychological problems — “gender dysphoria, comorbid conditions, feelings of regret and internalized homophobic and sexist prejudices.”1 “On the Media” did not contact any of the support and advocacy groups that have proliferated — Detrans Voices, Post Trans, and the Detransition Advocacy Network among them. (I had no idea how many of these groups now exist; our leading news media don’t report on them.) But the available research on the harms of premature life-long medical interventions is why Finland and the Karolinska Institute in Sweden have stopped routine hormonal treatment of youth under age 18, and put psychological interventions and social support ahead of medical interventions, particularly for adolescents who have no childhood history of gender dysphoria.
The fundamental problem, a sure sign that we are in the midst of a social contagion based on pseudoscience and not the emergence of a science-driven medical advance, is that researchers and professionals who want to raise any questions or concerns have been silenced with vehement and often ugly accusations of transphobia and bigotry, their work shut down, some of them fired. Many gender professionals have marginalized, bullied, and tormented their colleagues who disagree. Politically organized “transactivists” protest that any research on, say, factors contributing to the rise of cases of gender transition, the potentially negative consequences of transitioning, or the importance of counseling and treatment before transitioning are indications of the unacceptable idea that gender transition is a pathological problem or disorder. Their second silencing tactic is to conflate psychological interventions with “conversion therapy,” a long-discredited effort to “cure” gay people and turn them straight. Conversion therapy for gay people is cruel and it doesn’t work, which is why it is illegal in many states. But providing psychological counseling before providing irreversible medical procedures for adolescents who are questioning their gender identity is not remotely comparable, especially when the vulnerable young person is also suffering from comorbid conditions, as the vast majority are, including depression, anxiety, and, evidence is now suggesting, autism.
Research is desperately needed, and if transactivists truly care about the mental and physical health of trans people, they should be demanding it—not shutting it down.
Transactivists also cite as a main reason for “gender affirming” approaches the scary statistic that if young people are denied the means of transitioning early, nearly 41 percent will attempt suicide, and many will succeed. That’s an astonishing number — virtually an impossible number — but it generates the sense of urgency to perform interventions as soon as possible. Parents understandably panic — ”oh my God, if I don’t allow this now, my child might die.” Therefore the number warrants careful consideration. The 40.4 percent statistic is from one study done seven years ago, the 2015 U.S. Transgender Survey, based on a sample of transgender adults. About 82 percent reported ever seriously thinking about suicide in their lifetimes, while 48.3 percent had considered suicide in the past year; 40.4 percent reported attempting suicide at some point in their lifetimes, and 7.3 percent reported attempting suicide in the past year. A sad picture, to be sure, but the research did not determine whether the suicidal thoughts originated before or after transition, or for that matter had anything to do with transgender concerns, or at what age.2 “Transgender people have many of the same risk factors for suicidality as found in the U.S. general population, such as depression, substance use, and housing instability,” the report noted, and indeed the trans people most likely to report thinking about suicide were those who were in serious psychological distress, in poor general health, and who reported heavy alcohol or illicit drug use. They were also more likely to have a disability, been homeless in the past year, or been arrested for any reason. Are these problems independent of having transitioned, a cause, a consequence, or all of the above? Research is desperately needed, and if transactivists truly care about the mental and physical health of trans people, they should be demanding it — not shutting it down.
But we may, at last, be entering a new phase. As usual, we can thank the first wave of writers who have refused to be cowed or bullied — Abigail Shrier in Irreversible Damage, Kathleen Stock in Material Girls, Helen Joyce in Trans: When Ideology Meets Reality. Detransitioners are growing in numbers, blowing the whistle on the unregulated gender-identity medical clinics that have sprung up overnight (reminding me of all the Multiple Personality Disorder clinics that likewise mushroomed across the country, until malpractice lawsuits shut them down). Those who study cultural contagions advise us to follow the money. And indeed, these clinics and a new legion of specialists are making plenty of money off every aspect of transitioning: offering to harvest a teenage girl’s eggs so she can have children later, when she is a he; voice therapists, offering their services to those wanting to transition and to those detransitioning, who want their old voices back; cosmetic surgeries, of course. No wonder they support the “gender affirming” belief that all of this is best for the child. No wonder they object to asking crucial questions, such as at what age are teenagers mature enough to give informed consent to treatments and interventions that may be irreversible and destroy their fertility: 13? 16? 18? And who makes the decision? The teenager? The parent, often risking the anger of their child, who demands hormones now (or else … suicide)? The clinic, eager to hand out hormones and puberty blockers without the pesky delay of psychological counseling?
Finally, though, gender specialists are breaking into media venues that once would have blocked the door to anyone questioning transactivist beliefs. In November, 2021, Laura Edwards-Leeper and Erica Anderson, two psychologists whose practice has been devoted to offering transgender patients ethical, evidence-based treatment, wrote an editorial in the Washington Post. Their trans-supporting credentials are flawless. One was the founding psychologist of the first pediatric gender clinic in the U.S.; the other is a transgender woman. They have held leadership positions in the World Professional Association for Transgender Health (WPATH). They vigorously asserted their support for “appropriate gender-affirming medical care for trans youth, and … are disgusted by the legislation trying to ban it.” But they are alarmed by the “skyrocketing” number of adolescents requesting medical care: “Now 1.8 percent of people under 18 identify as transgender, double the figure from five years earlier.” They are horrified by the rise in gender clinics that have spurred “many providers into sloppy, dangerous care … . We find evidence every single day,” they wrote, “from our peers across the country and concerned parents who reach out, that the field has moved from a more nuanced, individualized and developmentally appropriate assessment process to one where every problem looks like a medical one that can be solved quickly with medication or, ultimately, surgery. As a result, we may be harming some of the young people we strive to support — people who may not be prepared for the gender transitions they are being rushed into.” Tragically, they added, the informed treatment they call for is in short supply: “the demand for competent care has outstripped the supply of competent providers.”3
Read that again: “Nuanced, individualized and developmentally appropriate assessment” has yielded to a rush to medical intervention. That’s where the money is. That’s where the panic is — no time to waste! That’s where the social contagion is. And “competent providers”? How, where to find them, as the demand that they be “gender affirming” supersedes a staggering absence of empirical research?
By now, medical historians have enough information to give us the larger picture. In “The Gender Affirmative Treatment Model for Youth with Gender Dysphoria: A Medical Advance or Dangerous Medicine?” Alison Clayton traces the 20th-century rise of medical advances and “dangerous medicine,” which is “invasive, risky, and lacking a rigorous evidence base,” yet catches hold of physicians and the public. Over time, as people become more skeptical, the dangerous practices suddenly are seen as “not being as beneficial as claimed and as causing more harm than acknowledged. It comes to be mostly seen as misguided, occasionally even criminal.” In thinking about the gender affirmative treatment approach for youth with gender dysphoria, including the prevalence of masculinizing chest surgery, she asks: “Is this approach a medical advance or is it a contemporary example of dangerous medicine?”4
For me, the answer is clear. The pattern repeats: vulnerable patients flock to an explanation; experts exploit many of them; dissenters are silenced. Eventually, as the “other side” starts telling their stories, the bubble bursts, the contagion slows. It’s happened before in medical history; perhaps it will happen again.
