Last February, Jamie Reed went public in a sworn affidavit and in The Free Press with allegations that the Washington University Transgender Center (WUTC), where she was a case worker for over four years, was rushing minors into harmful medicalization. Since then, media outlets, including the St. Louis Post-Dispatch, the Missouri Independent, New York, and NBC have published articles that attempt to push back against Reed’s claims.
The common theme of these articles is that some parents dispute Reed’s account and are satisfied with the care their children received at the clinic. The unstated premise is that if Reed’s allegations were true, we’d expect to see many families coming forward to corroborate her reports of medical harm and few to dispute them. Since the journalists find more families in support of the clinic than against it, the reasoning goes, Reed’s allegations should be viewed with suspicion, if not dismissed.
Last week, MSNBC’s Chris Hayes tweeted that, against a single account by a mother who agreed with Reed’s claims, “there have now been *dozens* and *dozens* of interviews conducted that in no way bear out the original allegations. If what the ‘whistleblower’ was saying were true, I feel like we’d have a lot more than a single mom backing it up at this point?”
Hayes is wrong, and he should know better. Determining whether a clinic was operating in a harmful way is not simply a matter of tallying up the number of happy versus unhappy patients or families. Journalists who want to help the public understand both what actually happened at the clinic and the broader significance for medical care and medical ethics should be more scrupulous in their reporting on this ongoing story.
First, even if one accepts Hayes’ framing, it is unsurprising that more families who believe they had positive experiences have come forward compared with families having negative experiences. Anyone remotely familiar with the realities of pediatric gender medicine will instantly recognize the selection-bias problem at work here. It is almost definitionally true that dissatisfied families experience serious strains on the relations within the family unit and want to keep those strains private. Frequently in these scenarios, a child will express a strong desire for medicalization and at least one of the parents will be skeptical that puberty blockers or cross-sex hormones are the best therapeutic option. It is not uncommon for the decision over medicalization to drive a wedge between parents, or between parents and other family members.
For parents in these circumstances to go public with their story can worsen familial tensions and make an already difficult situation harder still. The story of Caroline, the mother mentioned by Chris Hayes, whose encounter with the St. Louis clinic was reported on in The Free Press, is a case in point. Caroline agreed with Jamie Reed that “when parents disagreed about their child’s treatment, the center would make things difficult for the objecting parent, especially in the case of divorce.” Caroline’s estranged husband was on board with puberty blockers for his child, while Caroline was not. After Caroline went public, her “non-binary” child took to Twitter to dispute her account of things (but ended up corroborating some of the most important parts of the mother’s story). This was a family feud unfolding before the drama-hungry eyes of (at last count) 26.7 million strangers.
A new book coming out by the organization Parents for Inconvenient Truths about Trans, which features essays by parents who have endured the relentless indoctrination in schools and the “gender affirming” medical gauntlet, illustrates the problem in grim detail. Many of the parents feared being accused of harboring “transphobic” attitudes and being indifferent to their kids’ suicidal tendencies. One parent I spoke with whose child attended the St. Louis clinic and who wants to remain anonymous told me that talking to the press would almost certainly result in the already-estranged child cutting parental contact off entirely. Faced with the fact that total estrangement would make it even more difficult to prevent unneccessary medicalization, the parent has decided to remain silent—at least for now. I imagine that this parent is not alone.
Meantime, parents on board with medical transition are likely to be on better terms with their kids and thus lack the deterrent against going public. It turns out that when a kid really wants something and her parents give it to her, she feels less estranged from them. Moreover, pro-medicalization parents are likely to be actively engaged in the promotion and defense of “gender affirming care,” not just anonymous clients. These parents often operate within “gender affirming” parent networks and support groups, which they can tap into in order to recruit others to convey a coordinated message of support for gender clinics.
That is what happened in the case of the St. Louis clinic. The same day that Reed’s story came out in The Free Press, TransParent, an organization for parents dedicated to “gender-affirming care,” sent out a letter to its subscribers. The letter, which was leaked to me, contained the following request: “We are looking for parents who would be willing to sit on a panel to discuss their experiences, write letters in support of the center, or otherwise tell their story in order to combat this article which we believe to be largely inaccurate. We are potentially working on a town hall to be covered by media outlets. If you have any contacts with the media, please let us know. We need people to show up for this urgent fight.” The letter went on to say that “we are trying to coordinate as fast as possible to get other views heard” but clarified that these “other views” should include only “positive words about your experience with the Gender Center.” In his investigative reporting on the hyper-partisan media coverage of Reed and WUTC, Jesse Singal found that Kim Hutton, one of the parents interviewed by Colleen Schrappen for her piece in the St. Louis Post-Dispatch, is a cofounder of TransParent and played a role in the establishment of WUTC—facts Schrappen failed to disclose to her readers.
Even if it turns out that a majority of families had positive experiences with WUTC, that is still not enough to judge the operations of a clinic. Suppose a cancer clinic misdiagnosed 20 percent of its patients with cancer when those patients had some other condition, and subsequently “treated” them with chemotherapy or surgeries. Even if the remaining 80 percent received fantastic care, few would regard such a clinic as safe and professional. While mistakes are always made in medicine and a zero percent false-positive rate is unrealistic, these events should be exceedingly rare and not a mere numeric minority of cases. This is especially true in an area of medicine that involves giving psychologically distressed children drugs and surgeries with life-altering and irreversible consequences.
To summarize this point, the finding of a dozen parents willing to share their positive experiences at WUTC does not constitute a refutation of Reed’s allegations. It tells us close to nothing about Reed’s overarching claim that the clinic was operating in a reckless manner.
This brings us to the second and more crucial point: short-term patient or parental satisfaction is not the metric we should use to judge pediatric gender medicine. Medicine is not consumerism. Doctors may not dole out untested and risky drugs to vulnerable patients and declare “caveat emptor.” Medical professionals have an affirmative duty to “first, do no harm.” Sometimes fulfilling this duty means overriding the desires of patients—for instance, the desire of addicts for powerful painkillers. Just as minors seeking pediatric gender services are more likely to believe that they “need” these surgeries to solve their problems, drug addicts who seek out doctors known to operate OxyContin pill mills may believe that opioids can solve theirs. In both cases, the patient’s subjective belief about what will work for him should not be the decisive factor in determining the course treatment. Nor should the patient’s satisfaction after getting the desired “treatment” be viewed as evidence of sound medical practice.
While subjective satisfaction is not unimportant, medicine runs a risk of doing harm by investing too much in patients’ self-reported feelings. This is one of the lessons of the opioid epidemic. The medical community’s adoption of pain as the fifth vital sign and deference to patients’ self-assessed pain levels paved the way for Purdue Pharma, maker of OxyContin, to create a new market on the backs of vulnerable Americans.
In the case of “gender affirming care,” it is important to distinguish between whether a teenager is satisfied with the treatment she received and whether her mental health actually improved as measured through validated mental-health tests. Researchers in this field often use metrics of dubious clinical value such as the Chest Dysphoria Measure, which measures a patient’s satisfaction with how her chest looks after getting a double-mastectomy. One recent study measured CDM in teenagers and young adults three months after “top surgery.” The day after the study appeared, CBS News ran an article with the headline: “Top Surgery Drastically Improves Quality of Life for Young Transgender People, Study Finds.” It should be obvious that asking teenage girls how they feel about their chests three months after getting a double mastectomy tells us very little about whether these procedures guarantee them “quality of life” in the long term.
Due to the health risks and uncertainties of puberty blockers, cross-sex hormones, and surgeries, the debate over pediatric gender medicine’s clinical value should prioritize long-term over short-term mental-health outcomes. A teenage girl distressed over the changes to her body due to puberty may report feeling better in the months after receiving puberty blockers or cross-sex hormones—but will she feel this was the right decision when she’s in her thirties and realizes that she cannot have biological children of her own? And what will that do to her mental health? How will a future of sexual dysfunction and trouble with relationships affect the psychological and emotional wellbeing of a boy who began medical transition at age 11? How will the known and anticipated side-effects from “gender affirming” hormones and surgeries, which include not just infertility but a number of agonizing physical consequences such as chronic and debilitating pain due to lack of bone mineralization, affect quality of life down the road?
But even if we grant that subjective satisfaction equates to mental health and that short-term satisfaction matters most, the very real possibility exists that placebo/nocebo effects can account for mental health “improvement.” Due to what is known as the “Hawthorne effect,” teenagers may show short-term improvement in mental health simply because they feel they are being listened to and taken seriously. “A patient who is part of a study, receiving special attention, and with motivated clinicians, who are invested in the benefits of the treatment under study,” explains Alison Clayton in an essential article on this subject, “is likely to have higher expectations of therapeutic benefits.” This is crucial because “[e]xpectation of outcome is a principal mechanism of the placebo effect and anything that increases patients’ expectations is potentially capable of boosting placebo effects.”
The same is true in reverse: in a social climate in which politicians, the media, civil rights groups, medical associations, and social media influencers tell young people in distress over their bodies that “gender” is the source of their problem, that drugs and surgeries alone will provide them with “gender euphoria” and “trans joy,” and that being deprived of these interventions is tantamount to a death sentence, a pernicious nocebo effect can take root in which patients experience real psychological distress at being denied something they have come to believe they desperately need.
A full investigation of WUTC is underway, and until the findings of that investigation are released and carefully scrutinized, it is irresponsible either to dismiss Reed’s allegations out of hand or to treat them as settled facts. Still, we have good reasons to believe the allegations are credible. Reed made them in a sworn affidavit and handed over evidence to Missouri authorities. (The fact that she has not been willing to share the same evidence with reporters like Schrappen of the St. Louis Post-Dispatch, who has consistently tried to discredit Reed, does not mean that the evidence doesn’t exist.) Further, Reed’s allegations bear striking resemblance to what Hannah Barnes found had happened at the Tavistock clinic in the U.K. and physician Hilary Cass said in her report to the National Health Service last year. Cass mentioned the existence of “an affirmative model” that “originated in the USA” as partly responsible for making the Tavistock clinic unsafe. Finally, in its own internal investigation, in which it (unsurprisingly) found no evidence of wrongdoing, the WUTC tacitly acknowledged some of Reed’s claims, including, for instance, the lack of a written informed-consent process.
Journalists should treat Reed’s allegations as an opportunity to educate themselves and their readers not simply about what to think about “gender affirming care” but more importantly about how to think about this controversial medical practice. Journalists have a duty to provide context and frame issues in ways that help citizens form sound judgments on matters of public interest.