In recent months, several red-state legislatures have sought to restrict gender-transition procedures for minors. Critics of these efforts often describe them as “anti-trans” or “anti-LGBTQIA+.” In a ruling striking down Florida’s prohibition against Medicaid coverage for “gender-affirming care,” U.S. district judge Robert Hinkle referred to Florida’s legislation as “purposeful discrimination against transgenders.” If language sets the terms for how the public thinks about politics, then these critics’ framings are sure to confuse.
Referring to legislation as “anti-trans” channels the language of civil rights. But while conceptualizing the gender-identity debate this way may be a powerful rhetorical strategy, it obscures the best practices for treating gender-distressed youth. Such a strategy implies that any critics of affirmative care must be motivated by prejudice against trans-identifying people, rather than by an evidence-based vision for how gender dysphoria should be conceptualized and treated.
Start with the contradictions of the pro-affirming side, where two competing visions of gender affirmation sit uneasily alongside one another. First is a medical understanding—according to which doctors are treating a diagnosable condition, gender dysphoria, which appears in multiple forms that people experience for various psychological and developmental reasons. Dysphoria can afflict people who do not identify as transgender, though gender dysphoria and transgenderism are often conflated. In this framework, affirmative care is a medical solution to a medical problem.
Second is the gender-diversity understanding, which decouples dysphoria and gender identity and maintains that all variations in gender identities are entirely natural and healthy. It also holds, crucially, that requiring a diagnosis of gender dysphoria to access affirmative medical care is a harmful form of gatekeeping, an argument advanced in the American Medical Association’s Journal of Ethics.
The gender-diversity paradigm values patient autonomy above all else. It holds that doctors are not treating a pathology as much as they are offering cosmetic procedures to help their patients become their “truest selves.” The goal is not necessarily to resolve dysphoria but to help patients achieve “gender euphoria.” On the AMA website, one physician-advocate, Aron Janssen, describes affirmative care as “patient led,” with “no single, objective outcome for somebody seeking a sense of identity.” The underlying logic of this treatment resonates with many people, intuitively aligning with America’s expressive-individualist culture.
Yet everything we know about the nature and persistence of gender dysphoria suggests that the civil rights framework is a category error. The “transgender child” exists only in relation to gender schemas that are themselves sociocultural phenomena. Gender dysphoria is real, but it is not a perfect proxy for a cross-gender identity. Moreover, gender-related distress is not one clinical entity; it can have varied presentations, etiologies, and subtypes.
To speak of “trans kids,” in other words, is to presuppose that these kids are all part of one natural category that demands one kind of treatment approach. That’s not the case. When the pro-affirming side of the debate labels kids experiencing gender dysphoria as “trans,” it conflates two categories (gender dysphoria and transgender identification) and does these young people a grave disservice.
A minor undergoing gender dysphoria will probably not identify as transgender permanently. Research shows that such symptoms follow an unpredictable developmental course. Notably, even the clinical practice guidelines for treating gender dysphoria, authored by the pro-affirming Endocrine Society, concede that most children (roughly 80 percent) who present with gender dysphoria outgrow it by adolescence, and that a considerable number of these children turn out to be gay or bisexual. Most striking of all, however, is the clear acknowledgment that no clinical assessment exists to “predict the psychosexual outcome for any specific child.” In other words, there is no reliable mechanism to determine which young people will outgrow their dysphoria and which young people will persist.
This concession exists in irreconcilable tension with, say, the activist slogan that “trans kids know who they are.” If gender dysphoria is not permanent, then what is a “trans kid?” Rather than referring to a natural category, the American Psychological Association’s page on “Understanding transgender people, gender identity and gender expression” is a classic case of concept creep. According to the APA, “transgender” is an umbrella term for “persons whose gender identity, gender expression or behavior does not conform to that typically associated with the sex to which they were assigned at birth.” Under this definition, transgender persons include those who simply express themselves, or behave, in unconventional ways for their sex. Such a definition serves to reinforce stereotypical tropes about men and women, quietly policing the boundaries of acceptable gender expression for boys and girls.
Of course, some boys have what we would consider more feminine temperaments, and some girls have what we would consider more masculine temperaments. But allegedly progressive adherents of gender ideology insist that some personalities or forms of expression are the special province of men and women, exclusively. More significantly, they claim that these gendered attributes—not our sex—define us as men and women.
In reality, assuming that “gender identity” exists at all, surely it refers to a belief about how well one’s personality, preferences, and habits conform with cultural heuristics of masculinity and femininity. If a person has internalized the rigid schemas of gender ideology, then her interpretation of where she falls along an artificial masculine–feminine gender continuum will dictate her understanding of gender. If her view of gender changes, so will her self-appraisal and resulting gender identity. Indeed, in physician-scientist Lisa Littman’s study of detransitioners, nearly two in three female detransitioners cited a “change in their personal definition of male and female” as one of their reasons for detransitioning. These young women may have felt alienated by the sex-stereotypical definitions of women that gender ideology peddles and believed that they could reconcile themselves with their bodies only by expanding their definitions of womanhood to reflect their personalities.
Not every declaration of a cross-gender identity is the result of a gender schema influencing one’s self-appraisal. But in certain sub-populations, like the identity-confused population with comorbidities described by Kaltialia-Heino or Littman’s ROGD (rapid-onset gender dysphoria) sample, it would be irresponsible not to entertain the premise. It’s also irresponsible not to mention that the rise of dysphoria diagnoses in teen girls coincides with a teen mental-health crisis that is particularly dire among girls. During these challenging developmental years, is it any surprise that gender non-conforming, psychologically vulnerable girls might feel disconnected from their sex by the onslaught of gender messaging and become dysphoric as a result? Or, alternatively, should we be shocked if they see in public messaging an explanatory framework that explains their preexisting general distress as gender dysphoria?
If psychological evaluation involves exploring the underlying dynamics behind a patient’s problem, then “gender-affirming care” is the enemy of competent evaluation. When your only interpretive tool is a gender hammer, everything looks like a gender nail.
The framing of this debate matters. Rhetorically powerful language evoking civil rights and referring to “trans kids” demagogically obscures reality. Transgenderism is a constructed category containing a heterogeneous population of dysphoric and trans-identifying people, following a unique trajectory and possessing idiosyncratic needs. Ordinary Americans must understand what is at stake in this debate. They cannot do so if journalists, judges, and politicians obscure the truth.
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