The New York Times has published a new investigative report on the pediatric gender clinic at Washington University in St. Louis, home of case-manager-turned-whistleblower Jamie Reed. Last February, Reed alleged in The Free Press that her former clinic was harming adolescents with invasive and unnecessary treatments. “What’s happening to children,” she said, “is medically and morally appalling.”
Reed tried to raise her concerns with her superiors at Washington University but was shut down. She decided to file a sworn affidavit about the medical abuses she witnessed with the Missouri attorney general, an action that triggered a multiagency investigation that remains ongoing.
The Times’s article represents the first attempt by a major left-of-center newspaper to corroborate Reed’s claims. The author, Azeen Ghorayshi, says that “some of Ms. Reed’s claims could not be confirmed” and that “at least one of her claims included factual inaccuracies.” On the whole, however, Ghorayshi corroborates much of what Reed has said about her former clinic. Most important is the clinic’s disregard for clear “red flags.” Adolescents with serious mental health problems were prescribed puberty blockers or cross-sex hormones when they should have received mental health support.
Ghorayshi and the Times deserve credit for a well-researched article. Ghorayshi does a good job allowing different sides in the controversy to be heard. Her discussion of the medical research, though not the focus of her article, is refreshingly honest and accurate. Considering the pressure exerted on the Times and its reporters by transgender advocacy organizations like GLAAD to toe the ideological line, it takes courage to write a piece as rigorous and as thoughtful as this one.
And yet, the article has problems. Two in particular stand out. The first concerns the question of satisfaction and regret, and the second involves the role of mental-health interventions in pediatric gender medicine.
If the reader comes away from the Times piece feeling ambivalent about the St. Louis clinic, that is because Ghorayshi contrasts Reed’s allegations of wrongdoing with stories of families who say they are satisfied with the treatment their children received there. “It’s clear the St. Louis clinic benefited many adolescents,” says Ghorayshi.
But is it?
As a matter of principle, it is wrong to use satisfaction and regret as the benchmark for judging whether pediatric sex trait modification (PSTM) is a medically necessary and ethical practice. If medicine is to retain its authoritative role in human affairs, patient satisfaction alone cannot determine when interventions are medically necessary. Self-reported satisfaction is how we judge cosmetic procedures, not medically necessary ones. The role of the doctor is to heal, not please. Pleasing, though not unimportant, is secondary and subordinate to healing. Bitter pills are coated with sugar to make pleasing to patients, but it doesn’t follow that sugar is good for you or that doctors should encourage patients to eat it to their heart’s desire. Failure to distinguish the pleasant from the good can result in serious iatrogenic harm. More broadly, it can corrupt medicine and reduce it to mere consumerism.
Ghorayshi is right to take interest in the satisfaction of patients and families who attended the St. Louis clinic. But to leave it at that and to imply that patient satisfaction is a valid counterargument to Reed’s allegations is to miss the far deeper and more significant ethical issues involved. Worse, it’s to take a side in that ethical debate without presenting the competing arguments in a serious way.
I’ve written in the past about the vital importance of providing readers with context about the satisfaction/regret question, especially when it comes to how we think about the St. Louis clinic. If journalists contribute to the public’s (misguided) belief that short-term satisfaction of distressed teenagers with drugs and surgeries is ultimately what matters, they should at least mention that the validity of this framing is itself a key part, if not the heart, of the scientific and medical debate over PSTM.
Research in gender medicine has found no necessary relationship between subjective satisfaction and more objective measurements of mental health and psychosocial functioning. One of the first follow-up papers on gender medicine published by Dutch clinicians in 1988, right around the time they began experimenting with hormonal interventions in adolescents, reflected on the question of subjective versus objective measurements of improvement. The paper acknowledged “a trend” in existing research on adult transsexuals at the time: “the subjective well-being of the transsexuals has increased, whereas an ‘improvement’ in their actual life situation is not always observed.”
A 2020 study by Finnish gender clinicians in the Nordic Journal of Psychiatry did look at more objective outcome measures. To assess whether hormonal interventions are beneficial, the authors used “proxies for adolescent development” including “age-appropriate living arrangements, peer relationships, school/work participation, romantic involvement, competence in managing everyday matters and need for psychiatric treatment.” The researchers found that patients “who did well in terms of psychiatric symptoms and functioning before cross-sex hormones mainly did well during real-life. Those who had psychiatric treatment needs or problems in school, peer relationships and managing everyday matters outside of home continued to have problems during real-life.” Thus, “Medical gender reassignment is not enough to improve functioning and relieve psychiatric comorbidities among adolescents with gender dysphoria.” Presumably, most of the patients were satisfied with their treatment.
The pivot in PSTM research from objective to subjective metrics may reflect an exasperation of the field with trying to find good, causal evidence of improvement in mental health and psychosocial functioning. It may also reflect the true but rarely acknowledged purpose of sex-trait modification, which is to achieve “embodiment goals,” i.e., desired cosmetic outcomes.
Let’s assume, however, that satisfaction/regret is the appropriate benchmark for evaluating the ethics of PSTM. What does the empirical literature tell us about satisfaction and regret from hormonal or surgical interventions? “The number of people who detransition or discontinue gender treatments is not precisely known,” Ghorayshi observes. “Small studies with differing definitions and methodologies have found rates ranging from 2 to 30 percent.”
Ghorayshi is correct. Given the poor quality of research in this field, we do not currently know the true rates of satisfaction and regret among adults who transitioned as adults. Still less do we know about regret and satisfaction in those who transitioned as adolescents. Another problem with relying on satisfaction—especially when, as is often the case in this field of research, follow-up happens mere months after procedures—is that it may be confounded by placebo and Hawthorne effects. (The latter term refers to “the phenomenon where clinical trial patients’ improvements may occur because they are being observed and given special attention.”) Rigorous long-term data, which is more important than short-term data when it comes to adolescent decisions, will take at least another decade to collect and analyze.
Also missing from the Times piece is any serious treatment of the question of harms. Ghorayshi implies that detransitioners were harmed, but in her sworn affidavit Reed documents several instances of harm suffered by patients receiving gender-transitioning care that go unmentioned in the Times piece. These include a teenage girl who experienced bleeding vaginal lacerations following testosterone injections (a known side-effect) and another girl whose clitoris got so large from taking the androgenizing hormone that it painfully chafed against her underwear when she walked.
After conducting an internal investigation, in which it never bothered to interview Reed, Washington University reported that it did not find evidence of any “adverse physical reactions” among those treated at the gender clinic. Not a single case.
Considering how hard this is to believe, it would have been appropriate for Ghorayshi to probe deeper into this matter. Medical treatment decisions by their very nature require balancing benefits against harms. At a time when Americans need to hear the truth about what is known and not yet sufficiently studied about the side effects of these powerful drugs, Ghorayshi’s piece comes across as somewhat sanitized. Ghorayshi mentions 18 patients and families who say that they had “overwhelmingly positive” experiences at the St. Louis clinic, one patient—Alex—who discontinued testosterone after “realiz[ing] she was nonbinary,” and a file compiled by Reed and her coworker that documented 16 instances of detransition. What do these numbers tell us? The answer: close to nothing. The St. Louis clinic apparently had 613 patients who were medicalized during the relevant timeframe (Ghorayshi mentions 598, a number she takes from Washington University’s internal investigation, but Reed’s documents show otherwise). Since we don’t know the fate of the other patients, it’s impossible to draw any conclusions about the overall rates of regret or satisfaction. But again, whether most patients at the St. Louis clinic are satisfied or not is no rebuttal to Reed’s allegations. Using subjective satisfaction as the sole metric is reasonable for cosmetic procedures, but not for “medically necessary” ones.
This brings us to the second problem in the article. “The turmoil in St. Louis,” Ghorayshi writes, “underscores one of the most challenging questions in gender care for young people today: How much psychological screening should adolescents receive before they begin gender treatments?”
The key word here is “before.”
Ghorayshi’s question seems to suggest that the debate between Europe and the U.S. is over how much mental-health screening and counseling to offer adolescents before putting them on a medical track. In truth, the European countries have adopted an approach that emphasizes, for most gender dysphoric adolescents, mental health support instead of hormones.
Though she notes the divergence in medical policy in Europe versus the U.S., Ghorayshi doesn’t fully explain the nature of this divergence and understates its extent. True, Europe hasn’t banned hormonal interventions altogether. But if the restrictions now in place in Finland, Sweden, and Denmark (the situation in the U.K. is more complicated) were implemented in U.S. clinics, the majority of American teenagers now being put on the medical track would receive only mental-health support. In Denmark, for instance, the rate of intake-to-medicalization at the country’s centralized gender clinic was 65 percent in 2018. After restrictions were imposed, the rate fell to 6 percent in 2022.
Ghorayshi mentions a Washington Post op-ed from 2021 by two psychologists, Laura Edwards-Leeper and Erica Anderson, who support the early medical-intervention model albeit with guardrails. According to Ghorayshi, Edwards-Leeper and Anderson “warned that American gender clinics were prescribing hormones to some children who needed mental health support first” (my emphasis). But what Edwards-Leeper and Anderson actually argue in their op-ed is that comprehensive mental-health assessment is needed to figure out whether medicalization is appropriate—a subtle but crucial difference. Such assessment is necessary for differential diagnosis and avoidance of unnecessary and potentially harmful medicalization.
Thus, it’s not just that patients referred to the St. Louis clinic were not receiving “mental health support first.” If judged by Scandinavian standards, which are far more in line with the principles of evidence-based medicine, many or most patients at the St. Louis clinics were likely being given drugs they should not have been prescribed at all. While some may believe that current restrictions in Europe are about “trying everything again from scratch,” an equally plausible explanation is that this is the first step in a bigger retrenchment that will result in firm age restrictions. Time will tell.
Ghorayshi calls Republican laws “draconian,” but the truth is that these laws reflect a view of the underlying medical research and a policy stance much closer to those of European health authorities than those held by Democrats and U.S. medical associations. Condemning Republican laws while implying that the European changes are consistent with evidence-based medicine is, to put it mildly, puzzling.
Related to this is an impression Ghorayshi gives that a root cause (or even the root cause) of dysfunction at the St. Louis clinic was the sharp surge in the number of teenagers, many with serious psychological problems. The subtitle of the article itself says that the clinic “was overwhelmed by new patients and struggled to provide them with mental health care.” The article’s first sentence describes a clinic “buckling under an unrelenting surge in demand.” Ghorayshi later mentions the U.K.’s Tavistock clinic, where long wait times created pressures on clinicians to “affirm” and refer for hormonal treatments rather than do careful mental-health assessments.
But long wait times were only one of the problems identified by physician Hilary Cass in her investigation of the U.K. Gender Identity Development Service (GIDS). The other, and arguably more important problem, was the existence of “an affirmative approach” that “originated in the USA.” GIDS clinicians, Cass wrote, “feel under pressure to adopt an unquestioning affirmative approach [that is] at odds with the standard process of clinical assessment and diagnosis that they have been trained to undertake in all other clinical encounters.” Ghorayshi mentions this pressure on the clinicians but makes it seem as though it were somehow caused by the growing waitlists.
While Ghorayshi acknowledges the “affirming” model as part of the problem, she does not grapple with the true nature of that problem: the infiltration into medicine of a novel set of ideas, including that children have an innate and infallibly knowable “gender identity” and that “a child’s sense of reality” is the “navigational beacon to orient treatment around.” Ghorayshi’s use of terms like “transgender children” and “8-year-old transgender daughter,” though probably intended as a show of respect, implies that kids can know that they have a permanent transgender identity. Current research does not support this belief. Common sense and millennia of experience contradict it. The U.S. Endocrine Society itself says: “With current knowledge, we cannot predict the psychosexual outcome for any specific child.”
It is odd that in the short section of Ghorayshi’s article where she directly discusses the affirmative approach, the patients’ stories she tells all have happy endings. Indeed, she writes: “It’s clear the St. Louis clinic benefited many adolescents.” European health authorities have said the opposite: the current affirmative approach is a major cause of unsafe practices.
Moreover, the surface similarities between the St. Louis clinic and the Tavistock clinic obscure the more significant differences. As Hannah Barnes discusses in her book on Tavistock, GIDS was founded on a strong ethos of psychotherapy rather than medicalization. The story of Tavistock’s collapse is largely one of institutional mission creep: the founding ethos of 1989 was gradually replaced with a new understanding of the role of mental-health clinicians as rubber-stampers for experimental drugs.
In contrast, U.S. pediatric gender clinics were founded well after the Dutch started their experiment with puberty blockers and, it can reasonably be argued, for the purpose of offering these drugs. Endocrinologist Norman Spack, the founder of the first clinic in Boston, would later recall “salivating” at the prospect of using puberty blockers for children entering adolescence. In contrast with the Tavistock clinic, which referred patients to nearby hospitals for endocrine consultations, American gender clinics regularly employ endocrinologists like St. Louis’s Christopher Lewis, who, Ghorayshi notes, has prescribed hormones to patients after only a single visit. As the old saying goes, if you’re a hammer, every problem is a nail.
Given these important differences in the founding purpose, personnel composition, and sense of mission in American versus English clinics, it makes little sense to imply that the rush to medicalize at St. Louis was due to inadequate staffing of mental-health professionals. The surge in referrals may have been an aggravating factor, but it is not the root cause. The true root cause is the new ideology of gender and the mountain of subpar research that has been created to justify early intervention.
Ghorayshi and the Times deserve much credit for a report that is more thorough and balanced than many that we’ve seen from the newspaper of record in recent years on this issue. They are operating in a political environment in which even mere skepticism of PSTM is seen by some as complicity in “genocide.” They are challenging the received wisdom of their own political tribe, which is never easy.
On the other hand, the Times itself has promoted the narrative that PSTM is “medically necessary” and “life-saving,” and that criticism of it reeks of ignorance and bigotry. The trek back to impartiality and devotion to truth-telling will be long and arduous, but it begins with articles like Ghorayshi’s on Reed and the St. Louis clinic.
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