After Supreme Court Hearing, Epidemiologist Weighs In On Gender-Affirming Care And Its Effects On Transgender Kids
Uncloseted Media’s editor-in-chief Spencer Macnaughton interviews epidemiologist and scientific fact-checker Gideon Meyerowitz-Katz about what we can learn from research about trans healthcare.
Video edited by E E Oliver
This week, the debate surrounding gender-affirming healthcare (GAC) for trans kids took center stage after The Supreme Court seemed very likely to uphold Tennessee's ban on GAC for minors. For roughly two and half hours on Wednesday, lawyers offered oral arguments, and the justices debated whether states could prevent trans kids from using puberty blockers and hormone therapy. The conservative justices, 6 of 9 of whom lean conservative, repeatedly suggested that laws surrounding GAC for minors are best left in the hands of state legislatures.
Since the arguments, dozens of protesters on both sides of the debate have rallied outside the courthouse in Washington, D.C.
One of the key moments from the arguments was when Chief Justice John Roberts—who has been described as a more moderate conservative—said, “It seems to me that it is something where we are extraordinarily bereft of expertise.”
As the media reacted to the news, countless talking heads with little to no experience in the science and research arena of trans healthcare started popping up on cable news and social media to weigh in. Coleman Hughes, a fellow at the conservative think tank The Manhattan Institute for Policy Research, who has very little experience studying trans issues, was invited to opine about the science on CNN News Night with Abby Phillip. In a lead segment, he debated with trans advocates and cited studies, where he was positioned as the other side of the debate.
The vast majority of Americans are deeply uneducated on the nuances of gender-affirming healthcare. Many cannot define it or think that it solely means bottom surgeries (which are very rarely performed on trans youth).
To help our audience better understand what we know (and don’t know) about what the research says regarding GAC and trans kids, we called fellow Substacker Gideon M-K: Health Nerd, an epidemiologist and scientific fact-checker who has done deep reporting and analysis of the research that exists in this area. Watch the full interview above.
Full Transcript:
Spencer Macnaughton: Hi, everyone. Spencer MacNaughton here. I'm the founder and editor in chief of Unclosed Media. I am here with Gideon Meyerowitz-Katz, Senior Research Fellow at the University of Wollongong, and an epidemiologist who writes a substack called the Health Nerd. After the Supreme Court heard oral arguments about the ban on gender-affirming healthcare for minors in the state of Tennessee, we wanted to get Gideon's perspective from an epidemiological point of view on what we know and don't know as it relates to the science and research behind gender-affirming care as it relates to kids. Gideon, thank you so much for chatting with us. You know, to a lot of Americans and people beyond there, they hear gender-affirming healthcare as kind of almost like a buzzword, but couldn't really define it if they tried, right? Could you possibly tell our audience what is gender-affirming healthcare exactly for kids?
Gideon Meyerowitz-Katz: It is any care provided by clinicians to people who are questioning their gender or having issues with their gender assigned at birth. And that can span, or it does span, everything from just counseling to recommendations for social transition to medication and, for adults, sometimes surgical interventions as well.
SM: Like, broad strokes, what do we know about gender-affirming healthcare for kids and what do we not know? What do we have left to learn?
GMK: So that's a really complicated question. There are some aspects of gender-affirming care where we basically don't know anything. So there's no data currently on whether psychological interventions are beneficial. There are very, very few studies on whether counseling actually does anything per se. It's really hard to know just because — we assume that such things are helpful, but it's very hard to know because we haven't really studied it. The field as a whole is very new. Almost all of the studies have been published since 2010, and that's in part because the definition of, the clinical definitions changed quite substantially in 2013. So prior to 2013, a clinician would diagnose someone with Gender Identity Disorder, and that was a very strict diagnosis and it was also a mental health issue, was seen as a mental health problem. And in the noughties, there was a big shift away from that and it moved to a gender dysphoria as the clinical problem, and gender dysphoria has no bearing on someone's identity. It is simply about whether the gender that they feel themselves to be matches the gender that they are presenting at, presenting as rather. But things that we have more evidence for are the impact of puberty blockers and hormone therapy. So puberty blockers are usually given to children around the ages of 12 or 13 who are experiencing parts of puberty, irreversible aspects of puberty, like deepening of the voice or growing breasts, and who don't want to experience those things and who experience having significant discomfort from those aspects of puberty. And they are a reversible pause.
SM: Completely reversible, right?
GMK: There are some questions in terms of completely because it does to some extent depend on your definition, but broadly reversible, yes. If you stop taking the drugs, you can continue puberty as normal. The question about reversibility becomes more complex when you take into account the further treatment. So if you go on puberty blockers and then you go on hormones, hormones are largely or substantially irreversible. Some aspects of hormone therapy are reversible, but some are not. And if you've taken puberty blockers, then the changes up till then would not be reversible. So it's a somewhat complex question, but broadly speaking, if you take puberty blockers for a year and then you stop taking them, yes, just go back to having a pretty normal puberty.
SM: In the US, you know, we have a lot of people who, you know, a lot of far right or, you know, right wing, even President-elect Donald Trump, who will equate, you know, puberty blockers with essentially kind of like surgeries, like, equating those things as the same thing, really, right? But I know that Chase Strangio, he's the first openly trans lawyer who argued in the Supreme Court case. He argued that puberty blockers, for example, are for the most part, like you say, completely reversible, but B. they've been used for decades on teen girls or tween girls assigned female at birth for things like precocious puberty, like these are not new drugs, puberty blockers. Is that fair to say?
GMK: That's very true, yes. So there are some arguments against using puberty blockers that say we have no idea what their long term impact on neurological development is. And that makes very little sense to me because, yes, we have been using them for decades for children with precocious puberty, and if they had these extremely negative impacts on neurological development, that would probably show up. We would know about that. So, yeah, we know a fair bit about the risks: there are some relatively minor issues with bone health, when you take puberty blockers, that you have to be aware of, and there are a few other side effects. Some people get headaches. But broadly speaking, we do know pretty much what the drugs do and how they work.
SM: And then a lot of, you know, folks — again, politicians a lot of the time in the U.S. — say that, you know, kids are going for sex changes, gender confirmation surgery, bottom surgeries, really, right? But that is not happening all that much, if really at all. Do you know much about that?
GMK: So as far as I'm aware, particularly in the US, the numbers don't support that argument. There are vanishingly few surgeries on people under the age of 18. The number of children for whom there is any surgery recorded, any genital surgery recorded, is fewer than 50. And where there are potentially surgeries happening, they are almost exclusively limited to teenagers who are aged 17.
SM: You published a series of articles about the Cass Review, which is, as you know, many of us know, the biggest and perhaps most controversial review of healthcare for trans kids. Trans healthcare groups like WPATH have argued that its recommendations could severely restrict access to physical healthcare for trans youth, while some groups, including medical organizations and advocacy groups, have praised some parts of the report while criticizing others for drawing too far-reaching conclusions. Curious, like, how do you, as an epidemiologist who really dug in there, how do you summarize the findings?
GMK: I think it's a very interesting document because, as I wrote in my articles about the Cass Review, the primary findings, the argument in the Cass Review, is that there is insufficient evidence to recommend things like puberty blockers and hormones, and that instead the government of the United Kingdom should rely on the psychological treatment until they run randomized clinical trials investigating puberty blockers and hormones for younger people. The stuff about puberty blockers and hormones was a very significant departure from what the UK had been doing up till then. And I think the issue that I had when I looked into the Cass Review in detail was basically that there were kind of two standards for evidence. Evidence that supported gender-affirming care was given a very, very careful interrogation, was treated very harshly. That evidence was considered to be suspect and they focused really deeply. But evidence that did not support gender-affirming care was pretty much just passed through and then entered into the document. So one example is that there was someone who theorized — a single psychiatrist in Germany wrote an opinion piece, essentially an academic op-ed, saying that they thought that pornography could be influencing cisgender girls to become transgender boys. The document doesn't cite any evidence. It's just some one person's opinion, one German person's opinion. And that person works for an anti-treatment organization. So they identify themselves as someone who is recommending against treatment. That document is cited uncritically in the Cass Review. The Cass Review simply says that some clinicians believe that pornography may be influencing people's decision to be trans. So where it comes to evidence that kind of doesn't support gender-affirming care, the Cass Review basically just says any evidence will do, but the evidence for puberty blockers, that has to be interrogated. Every single study is carefully pulled apart. They were very, very harsh on that sort of evidence.
SM: And what do you attribute that to? I mean, as an epidemiologist, when you get in the weeds of them interrogating one part of it really intensely, but not so much the other part. How do you explain that out? Why does that happen?
GMK: I don't like to talk about people's motivations. All I can say is that if you read the document, you find that the recommendations don't line up with the evidence in many respects. If you read the document, the implicit recommendation is that children in the United Kingdom should not get any medical care for transition, they should only get psychological care. But psychological care was the part of transgender healthcare that the reviewers themselves, the actual people working on this, found to be the least convincing in terms of evidence, had the fewest studies of any area. So it's this weird juxtaposition where they say we have to rely on evidence except when it comes to actual treatment decisions.
SM: So the recommendations per the Cass Report don't line up with what we know from the studies and the research that exists right now in terms of what's effective when it comes to gender-affirming healthcare.
GMK: Yeah. And more importantly, I suppose, it doesn't line up with the evidence that they themselves put together.
SM: So interesting. And another controversial topic, right, you know, detransitioning, and a lot of folks will say, who are against gender-affirming healthcare, will say that, you know, social contagion on YouTube and progressive teachers and different forces like this are, you know, creating a social contagion that's causing more kids to falsely say they are trans, right? What do we know about that?
GMK: Yeah, I think if you look at the data, detransition or detransition and regret are complex because people, detransition is defined in many different ways. It's defined sometimes as people who stop identifying as transgender, but sometimes it's defined as people who stop identifying as trans but identify as non-binary are sometimes included, but sometimes not included in the definition. When you are doing a research project, you have to define it relatively specifically so that you can know what you're talking about. And in the research, yeah, detransition is defined in many different ways. So I think what the data suggests is firstly, detransition is very uncommon. Depending on the study you're looking at, the highest estimate anywhere is 30%, and that's from a study in the United States. That study found that 30% of adults — it was about 34% of adults and about 28% or 26% of children who were taking puberty blockers or hormones, getting them through their parents’ or partners’ healthcare stopped getting those medications through their healthcare.
SM: That's a high number.
GMK: So that's relatively high. The thing about it, though, is it's not really an estimate of detransition, because there are many reasons why people may stop using their parents’ or partners’ healthcare even when it's free. They may move away. They may split up. They may fall out with their parents. They may decide that they just want to, even though it's more expensive, they want to break out on their own and pay for their own healthcare. They may want a different plan or want medications that aren't covered by that plan. You know, there's, yes, some portion of that is probably people who stopped taking the meds because they didn't want to anymore, but there's also many other reasons why they may have stopped taking the meds. There's a study in the Netherlands where they followed children who were taking puberty blockers up as adults up to their mid-twenties. And they found that nearly all, it was about 95%, of those children continued taking puberty blockers and then hormones as adults. So I think we can say with a fair deal of certainty that at least as far as medical treatment goes, the majority of children who medically transition at this point in time do not detransition as adults. And then regret, which is the other side of the coin, is complex. So if you ask people whether they regret their transition, somewhere between 10 and 20% will say they do. But if you hone in on that number, there was a study by Jack Turban and some colleagues where they analyzed a large dataset of survey responses from transgender people. And if you look at that study, the main reasons that people give for regretting their transition are related to factors that are external to themselves. So they transitioned and they lost their job, they transitioned and their parents didn't support it and that was very problematic for their mental health. And I think, so the Turban study found, I think, 13.8% said that they regretted transitioning to some extent, and most of those people regretted because other people were not supportive.
SM: Factors that we don't even know exist, probably. I mean, I feel like in 2024, we're so far from having, you know, respect and acceptance of trans people in general, at least in American society, right? So if you think about gay guys, or gay people, right, you know, 30 years ago, a lot of people run back into the closet, right? So that could be even another factor that could play into that maybe.
GMK: Yeah, it's, I mean, that's basically I think what the Turban study showed, is that when people talk about regretting their transition, the majority of the regret seems to come from what other people say about it and not so much from the changes that happened to them or how they feel about themselves.
SM: How much do you think misinformation is playing into people's understandings as it relates to gender-affirming healthcare for trans kids right now?
GMK: Oh, I think quite a lot. I mean, the rapid onset gender dysphoria issue is a rather remarkable case. I mean, the entire idea of rapid onset gender dysphoria is based on a handful of surveys of people who inhabit anti-trans Reddit forums and websites. And it is the only attempt at establishing a diagnosis that I'm aware of where we, where people have interviewed anonymous Internet trolls to try and figure out what is some sort of medical problem. The fact that that is, even that it's a term that's even discussed, is remarkable, especially given how terrible the scientific papers on this question are. So, yeah, I think misinformation does play into it quite a lot.
SM: What is rapid onset gender dysphoria and how did it become mainstream? Because it is relatively a mainstream term now.
GMK: So rapid onset gender dysphoria is the concept that children who have, teens primarily, who have never before had any experience of gender dysphoria and never expressed, specifically expressed to their parents a desire to be a different gender, all of a sudden, after going online, decide that they are trans. One of the things that makes rapid gender dysphoria pseudoscientific, in my opinion, rapid onset gender dysphoria rather, is that there is no definition of what the word “rapid” means. Usually that would be the, you know, the first part of defining a condition like this. We say “acute onset X” means that it's happened quickly. And we usually define that as like within a week. The acute period of Covid-19 is usually defined as the first month or two of Covid. So there's specific time periods that you would expect “rapid” to be. But it's not. It's just the parents think that it was quick. And the way that, so the idea of rapid onset gender dysphoria is basically that this social contagion idea that you touched on, they're not trans and they go online, they meet people online who convince them that they're trans, they go on Tumblr or TikTok or whatever. There is no evidence that this happens. The only evidence for the diagnosis of ROGD is a series of papers where the authors posted links to surveys on the r/detrans subreddit, and there are a few anti-transgender websites, websites that say that transgender people don't exist, so they posted links on those websites to recruit people who claim to be the parents of transgender teens and who claim that sometimes this transition was rapid. There are so many holes in that process. Firstly, they're all anonymous. There's no verification that these were actually, that these people are actually parents, never mind that they are parents of transgender youth. So you don't know how many of the people responding to your survey actually have children who are trans. There's no strict definition of rapid that I've seen in this research. So they just say, you know, was it a quick process, did it seem overly quick? And that isn't scientific. The next issue is that they don't have any information from the children. So the parents' perception of this experience may be rapid. The parents may say, oh, they went online and a month later they were trans. The children may have been feeling that way for years. So what you would really need to do is identify a group of children who were trans and ask the children and the parents how long before they transitioned did they start experiencing feelings of being the wrong gender. And that would give you some information on how quickly it happened. And then you would have to find a sample of children who are cisgender and see how many of them became trans, eventually came out as trans, and how many of them, and how quickly that happened. And then you might be able to say, well, some group of them were rapid, quote unquote. But the research that's been done so far to establish this diagnosis is just terrible.
SM: And I get frustrated even hearing you explain that, because I think, you know, for even me, a journalist who researches this quite a bit, I'm not an epidemiologist, but I know how to research things. And it is tricky to separate fact from fiction here, right? So for parents or American citizens who are trying to find really strong research, what are kind of tips you'd offer them to be able to say, “this is legitimate research, this is good?” Because I think there's so many people in the U.S. and beyond who just genuinely and honestly don't understand what's trustworthy these days.
GMK: I think that's a very difficult question because it takes time and effort and expertise to properly appraise scientific research. It's very easy to be misled by studies if you don't have the right training and experience. So if you just go online and someone sends you a link to a study that's been published, you may be convinced of things that aren't true because they've misunderstood the research, because the research is garbage, all sorts of things. I think when it comes to study appraisal and knowing what research is good, you kind of do need an expert.
SM: Why do you think it's so damn hard to have these conversations? People don't want to have them in the media in general. You know, it's like pouring gasoline on a fire sometimes. Why do so many people avoid having these conversations about gender-affirming healthcare?
GMK: I think particularly in the United States, it's because of the politicized elements of the discussion. Because really, when you're talking about gender-affirming care for trans youth, you are talking about a tiny, tiny group of people. The number of children who access gender-affirming care of any kind in the United States, I think the most recent estimate I have seen is that it was somewhere in the region of 0.2% of children. So generally the estimates are that about 1% of people between the ages of ten and 17 identify as trans. Below the age of ten, kids tend not to express, the numbers are so low that they're hard to measure. The actual issue that we're talking about is incredibly minor. And I don't mean to be blasé about people's experience. I just mean that there is no reason why we should be having a huge national or international debate about this issue. It's really just a matter for healthcare professionals and patients, in my opinion. The three biggest killers of children in the United States are guns, automobiles and drugs. And yet gender-affirming care is one of the biggest media discussions. And how often do you see an article about car safety in the New York Times?
SM: Very interesting. Yeah. Based on what you know about the research and everything you've studied, do you think gender-affirming care should be illegal for trans kids?
GMK: No, I don't think making it illegal is likely to help the situation. But I also don't know enough about the ban or the Supreme Court decision to give you a strong opinion on what they're actually doing.
SM: Well, they ban blockers, hormones, bottom surgeries, all of those things.
GMK: So that's similar to the United Kingdom, which I do know a fair bit about. And I think that the decision to do so in the UK is not based on good evidence. I think that banning treatment leaves people with only one choice, which is to see a psychologist or a counselor about their gender dysphoria. And we know that there's basically no evidence around that at all. So basically what you're doing is throwing out all of the evidence that we've gathered so far on medication, saying we don't like that data, and giving people only one option, which is the least well-evidenced option.
Footnotes of Studies and Key Facts Cited in Our Interview:
(8:35) Meyerowitz-Katz cites the research of Dr. Karin Nadrowski, a German who is associated with the anti-trans group “Therapy First.” (University of Leipzig, Germany):
Nadrowski’s research argues that due to increasing access to pornographic content on the internet, young girls worldwide are experiencing gender dysphoria. She argues that treatment of gender dysphoria must begin by observing children’s online content and offline relationships with adults. She argues that forms of digital sexual abuse/exploitation could influence young girls to not want to become women and influence child sexual abuse. She also adds that girls with autism may be more confused due to ‘mentalization capacities.’ She concludes that reasserting beliefs of gender equality may help gender dysphoria.
(13:20) Netherlands study, Leiden University Medical Center:
A study from the Netherlands showed that of all adolescents seen at the Amsterdam gender identity clinic, around 75% started with puberty suppression and the other 25% did not. The vast majority of the adolescents who start puberty suppression subsequently start gender-affirming medical transition. The follow-up studies that are available show that psychological functioning has significantly improved after puberty suppression, gender-affirming hormones and surgeries. Longer-term follow-up data on treatment satisfaction, psychological functioning and possible discontinuation of affirming treatment are currently being collected (no results yet).
(6:50) Critique of Cass Review 2024:
A critique written by healthcare scholars summarizes how the Cass Review “levies unsupported assertions about gender identity, gender dysphoria, standard practices, and the safety of gender-affirming medical treatments, and repeats claims that have been disproved by sound evidence.”
For Meyerowitz-Katz’ seven-part series looking at the Cass review, click here.
(14:10) Jack Turban Study:
Jack L. Turban, an American psychiatrist, who researches the mental health of trans youth, provides one study on the factors leading to detransition. Turban found that out of a total of 17,151 (61.9%) participants who reported that they had ever pursued gender affirmation, only 2242 (13.1%) reported a history of detransition. Among those who had detransitioned, 82.5% reported at least one external driving factor. These external factors included pressure from family and societal stigma.
A total of 15.9% of respondents reported at least one internal driving factor, such as fluctuations in or uncertainty regarding gender identity.
(15:40,18:30) Rapid Onset Gender Dysphoria and Reddit:
In online forums, parents have reported that their children seemed to experience a sudden or rapid onset of gender dysphoria, appearing for the first time during puberty or even after its completion. Parents describe that the onset of gender dysphoria seemed to occur in the context of belonging to a peer group where one, multiple, or even all of the friends have become gender dysphoric and transgender-identified during the same timeframe. Parents also report that their children exhibited an increase in social media/internet use prior to disclosure of a transgender identity.
(22:10) 2024 UCLA Study
An estimated 300,100 youth ages 13 to 17 in the U.S. identify as transgender.
According to a new report by the Williams Institute at UCLA School of Law, 93% of transgender youth aged 13 to 17 in the U.S.—approximately 280,300 youth—live in states that have proposed or passed laws restricting their access to health care, sports, school bathrooms and facilities, or the use of gender-affirming pronouns.
Additional reporting by Sophie Holland.
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Such a good piece!
Thank you for this information. This is exactly what people need to know to be better informed.