A (hopefully) non-controversial basis for a debate over transgender care

In June 2015, Rachel Dolezal, the president of the Spokane chapter of the National Association for the Advancement of Colored People (NAACP), resigned from her role. Rachel, who identified as a transracial black woman, was contradicted by her biological parents, who said she has German and Czech and “traces of Native American” ancestry. Photos from her childhood showed that Rachel was born white, with blonde hair and blue eyes. According to her brother, she started darkening her skin and perming her hair in 2011. Even today, Rachel continues to self-identify as Black and recently changed her name to Nkechi Amare Diallo, a Nigerian phrase meaning “Gift of God.” A documentary on her on Netflix tells a tragic tale of her life: as the New Yorker states, “a primitive power game between mother and child, one that forecasts calamity.”

The documentary shows that story of Rachel Dolezal is, at its core, a tragedy with psychological origins. To quote the New Yorker again, “Dolezal is a pathological liar, but…she is also a victim…[the] shots often linger on this garrison of delusion, the place where Dolezal’s theories about “racial fluidity,” as she calls it, run wild.” Many parents of this forum will find the entire article instructive.¹ However, the sympathy that we might feel for her delusional state does not make her narrative accurate. It does not make her Black.

In light of this “Rachel saga,” here are a few statements that can be said non-controversially.

1. Black people exist in the United States.

2. Black people have been historically marginalized and mistreated. There is no doubt of the suffering that they have gone through during various periods of history. And this marginalization and mistreatment continue to the current day.

3. Therefore, Black people and their voices must be advocated for.

4. However, if a non-Black person claims to be Black because they "self-identify" as Black, we do not jump to affirm them. Not only do we not jump to affirm them, but after such a ruse is discovered, society makes fun of such people on late-night TV, however tragic their origin story might be.

In these four statements above, replace the words Black people with any other historically-marginalized community – for example, the Indigenous people, or gays, or lesbians – and we would say the same thing. Society will not condone someone who starts darkening their skin artificially, appropriates a racial stereotype, and then self-identifies as Black.

The reasons why we don’t condone such acts of “self-identification” are legion and wholly non-controversial. It is unjust to the actual marginalized community. It is also degrading and dehumanizing to assign and appropriate some of their perceived stereotypes.

Furthermore, we end up diluting the very movement of that community when we let anyone self-identify as a member. The Rachel Dolezal saga ended up hurting the people who supported her—the next time the supporters want to advocate for their positions, their detractors will surely bring up this episode.

Similarly, in a world where people just need to self-identify as transgender, there will probably be many bad-faith actors masquerading as members of the community. Their reasons can vary widely. Some organizations might see this as a way to stay relevant—or solvent. After all, it can be difficult to raise money for a cause when there is widespread support among the public and bipartisan support in Congress. And evolve these organizations did – around a new issue that was barely on their radar a couple of decades earlier.

For some other actors, it is a profitable endeavor in this age of social media and online content. Views equal clicks equal advertising revenue; for some influencers, those revenues can be substantial. There is a captive audience waiting for new content that promises to be a balm to all the problems in their lives – and, in fact, gives them legitimacy: there’s nothing wrong with you – you are just a member of a community that has been historically oppressed. All you have to do is free yourself from your “despised flesh” – to use the term from the poem from Carla Kaplan’s book I mentioned earlier – and make yourself congruent with your gender identity.

Other profiteers see a burgeoning business opportunity – in other words, actively court this captive audience because “sex reassignment surgery is gaining popularity among the young transgender population,” while the “improving reimbursement scenario” is expected to drive market growth. If it seems like satire, it isn’t – these are quotes picked up from a report by a market research firm for the healthcare industry.

And it is with this audience that we see a reenactment of the Rachel Dolezal tragedy. These are the victims who, one day, might face the same opprobrium of society. And, like Dolezal, that day, they might not get any sympathy (“so all this time you were a phony?”). The organizations affirming them right now might send a “heartfelt apology” – or, at most, fire their CEO – and move on. A few online actors might get slapped on their wrists. But for the overwhelming majority participating in this tragedy – the young and the impulsive (we already know from neuroimaging studies that the “adolescent brain continues to mature well into the 20s” who have no idea what “long term” means – the long term implications of these treatments will hit home.

And hit home, they will. For unless the human body somehow miraculously changes once we declare ourselves transgender, medical science has established what is going to happen to these young people over the next few decades. That the brain gets affected by an excess of either estrogen or testosterone has been known for some time. After several decades of research, a lot is still unknown about the brain and the effects of the hormones on the brain. However, in what we know, researchers note possible higher risks of Alzheimer’s (because of ventricular enlargement) and schizophrenia (due to higher glutamate levels) for transgender women, as well as other types of psychopathology

In the Alzheimer’s Association International Conference (AAIC) of 2021, it was reported reported that transgender adults report more subjective cognitive decline than cisgender adults and that depression and cognitive disability are higher among transgender and nonbinary adults. (The press release highlighting the study also mentioned that “it is known that transgender adults experience a greater number of health disparities considered risk factors for dementia – including higher cardiovascular disease, depression, diabetes, tobacco/alcohol use, and obesity.”) There is evidence of brain damage in mice cells. Research shows that testosterone therapy in transgender men can suppress ovulation and alter ovarian cell structure, while estrogen in transgender women can lead to reduced sperm production and testicular atrophy. Several studies have pointed to the increased risk of cardiovascular disease, blood clots, ischemic stroke (this is where the blood flow reduces to the brain, and its cells start dying within minutes), and heart attacks.

Among the patients in the Amsterdam cohort (in other words, from the center that started it all; also note the large size of the cohort and the length of time they were followed: 2927 transgender women and 1641 transgender men followed over five decades), “cause-specific mortality in transgender women was high for cardiovascular disease, lung cancer, HIV-related disease, and suicide”; “cause-specific death in transgender men was high for non-natural causes of death”; and “no decreasing trend in mortality risk was observed over the five decades studied.” Another study from Sweden that followed a sample of 324 sex-reassigned patients over 30 years found that such patients “have considerably higher risks for mortality, suicidal behavior, and psychiatric morbidity than the general population.”

In this age of excessive information, it is easy to gloss over all these studies. Sometimes they look like words piled on top of other words. But even then, as one reads the list of increased risk factors in published clinical research – heart attacks, ischemic stroke, lung cancer, brain damage, and other yet-unknown changes to the brain – one cannot but realize: medical transition is not the safe panacea as we have been told. Heck, if it was just fertility issues that could be taken care of by cryopreservation, one might think of that as a side inconvenience. But no, this is so, so much more.

As the parent of a young adult who has identified as a transgender woman for the past year and a half, I could not but experience a sinking feeling in my heart as I went through the Amsterdam clinic study. There is a chart called “Cumulative survival in transgender women and transgender men during follow-up” on page 4. The vertical axis shows the overall survival probability, while the horizontal axis marks the years since the start of hormonal treatment. Even before year 10, the odds of survival have statistically deviated from the general population – and it gets horrifically worse after that. The standardized mortality ratio (i.e., the ratio of the number of deaths observed in a population over a given period to the number that would be expected over the same period if the study population had the same age-specific rates as the standard population) is, on average, twice that of the general population. Stated simply, on average, in the coming years, I have twice the chance of holding a dead child in my hands compared to the general population. My apologies…let me correct the previous sentence and restate my risks. My risk is even higher since I should look at the chart for transgender women, whose odds of survival are significantly worse.

In its latest Standard of Care Version 8 (SOC-8), WPATH mentions that the objective of the document is to provide “clinical guidance to assist TGD people in accessing safe and effective pathways to achieving lasting personal comfort…optimizing their overall physical health, psychological well-being, and self-fulfillment.” As far as physical health goes, all the clinical research mentioned above shows that medical transition makes matters significantly worse. But what about their psychological well-being?

From a psychological point of view, we know that surgeries do not result in better mental outcomes for the patients (this was a retraction from the authors’ earlier claim that they do). A recent paper that was covered extensively in the press looked at the mental health outcomes of youths receiving gender-affirming care and claimed that they were doing better than those who did not. The authors came to this conclusion not because the youths receiving care did better (they didn’t) but because the youths who did not have access to care apparently did much worse. I say “apparently” because it was pointed out that the cohort of children not receiving care decreased from 92 at the beginning of the study to just 6 after twelve months (eTable 3 in the supplement). So, any conclusion from just these six remaining subjects was meaningless: what if the remaining 86 became much better and decided not to take part in the study anymore?

As for the other research on mental health outcomes, the Economist noted succinctly, “though some studies have found short-term improvements in mental health, these disappear in long-term studies.” Several long-term studies confirm this conclusion, for example, a comprehensive 3-year study of 873 transgender men and women published in 2021 (if anything, the study indicated that by the end of the three years, the conditions had worsened for the patients). Another seven-year study from 2019 showed that the “prevalence of mental disorder diagnoses” was more than double for “transgender hospital encounters” (as compared to cisgender patients).

Even if we go by the 2015 survey data that is routinely used by transgender-affirming researchers, its evidence shows that estrogen “is associated with greater suicidality among transgender males [almost twice], and puberty suppression is not associated with better mental health outcomes for either sex.” And the physical harm from puberty blockers is becoming increasingly apparent to the medical community, thanks to the prescription of such drugs to so many children (the lead investigator behind the principal drug, Lupron, whose on-label use is for metastatic prostate cancer, noted the side effects without mincing words: bone loss, cognitive, metabolic and cardiovascular effects, and a leading cause of morbidity among adult men. This is something that has been established after four decades of study). The current crop of doctors in the US does not even seem to know about the dangers of hormonal therapy – as the Economist recently mentioned, “Trans ideology is distorting the training of America’s doctors.”

And over the next few decades, the brunt of this ignorance will be borne by a vulnerable population of children and young adults as they age. As with any medical intervention, the effects are not observed – nor are properly researched – in surveys of patients carried out after a few months (here’s one particularly egregious example: claiming improvement just three months after mastectomies), but only in long-term clinical studies. However, the damage to this vulnerable population will already be done. Remember what happened during the opioid crisis?

This is not to suggest that some of these young people won’t turn out to be transgender. Historically, the population of transgender people in several countries has been estimated at a fraction of a percentage point in several countries. The numbers from Scotland, Belgium, and the Netherlands (home of the Amsterdam clinic) are quite consistent—at around 0.008%. All these studies are based on surveys sent out to general practitioners, psychologists, and surgeons who have treated this population and not on self-identification. To be sure, that is less than one-hundredth of a percentage point. Or, described in another way, if you meet 10 new people a day, it will take about three years and four months to meet a transgender person. Extrapolating these percentages would lead to a small (but non-zero) number of young people whom medical interventions might help—and if by “help” we mean interventions that double the risk of having a dead child in your hands, I am not sure whether most parents would even qualify them as such.

Unlike in the US, while being contentious, the debate in some of the other countries, especially in Western Europe, has been somewhat less politicized. One difference might have been their nationalized healthcare, leading to better data about outcomes. We often know what has happened to a patient as they move through the system across different clinics and providers (it gets a bit more complicated sometimes as the transitioned individuals can change their identification numbers in some countries). In contrast, in the US, we have no idea what happens to a patient if they don’t come back to the clinic where they started treatment, an issue that plagues much of the extant research on transgender care.

Today, as the results from the first wave of young people treated on these drugs start to trickle in, Sweden (where the treatment of the large numbers of gender-dysphoric young people started a few years before the US), along with many countries in Europe, like Finland and France, is urging caution on allowing youth who identify as transgender to transition medically rapidly. The data (and this is clinical data, not from surveys of the patients after a year or so) – even from the past few years – is alarming.

The NHS in the U.K., which has the largest pediatric transgender clinic in the world, decided to close it down recently, citing the shoddy quality of research that promotes medical transition. These were not one-line putdowns in some random blog but a systematic review of the available literature till 2020, with a clear description of their methodology. There are two documents, one looking at the research on the efficacy of puberty blockers and the other looking at the research on the efficacy of gender-affirming hormones. Together, they run into nearly 300 pages, and their recommendations were incorporated into the Cass Report.

And in the midst of all that is happening in these countries, we are expected to believe that the medical establishment in the United States is not motivated by money and is suddenly doing the right thing. Does that not sound even remotely strange?

The mainstream press in the US has often criticized the for-profit US healthcare system – rightfully – in that it has delivered significantly worse care than many of its OECD counterparts. The countries that are urging caution today are among those that deliver superior healthcare to their citizens. These countries have been at the vanguard of transgender rights. The UK had established the largest pediatric transgender clinic in the world. Sweden was the first country in the world to allow transgender people to change their sex in 1972 legally, and trans parenthood in 2019. It started treating the burgeoning population of young patients who identified as transgender several years earlier than in the US. So when these progressive (and, incidentally, often much happier) countries urge caution, should we not look at what they found?

And finally, if these interventions are so safe, how come the drug manufacturers have turned down the opportunity to conduct clinical studies and make their drugs available for on-label use? It should be easy money! Think about it – different doses, different branding, inflated pricing, and limitless possibilities for new revenue! The drugs have already been discovered, and all that is left is to carry out clinical trials. They are apparently completely safe. What’s more, since gender dysphoria causes intense distress, they can expect that most patients will rush for a cure. It’s also a large population to cater to—Pew Research Center found that “about 5.1% of young adults in the U.S. say their gender is different from their sex assigned at birth.”² That is a large market – enough to make these drugs break into the top 300 prescribed drugs. And finally, insurance companies in most states have to cover it. In an age where we can get prescription medication for restless legs, why this sudden reticence?

Are the judgments from the opioid crisis too recent to ignore? Or is it because these companies are well aware that the drugs in question have severe side effects, including death? Or is it that they severely doubt the population estimates? In other words, do they believe that the population percentages are in line with the estimates from other countries – 0.008% – rather than the 5% estimated from the Pew survey (which would then imply that over 99.8% of these young adults today identifying as transgender are misguided and wrong)?  And in which case would they be staring at huge class action lawsuits with hundreds of thousands of plaintiffs a few years down the line?

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I have gone on for much longer than I intended when writing this article. So I will conclude here.

This newsletter often preaches to the converted—i.e., to the people who believe that the current transgender care model is fatally flawed. Anything that I have written here would probably not be news to you.

However, to any “mainstream” person – and especially a mainstream news reporter – who might read this article, this appeal is for you. I am not trying to convince you of the shoddy quality of the current research on transgender care – many other articles do that with much greater detail than what I have touched upon. All I am hoping for is this – can there be a debate around the issue where all of us agree that transgender people have a right to advocacy?

And then we can also agree that advocacy and the correct medical care for transgender people are Two. Separate. Issues. An analogy might help here. Cancer patients need advocacy. Because of their ailments, they suffer enormously. They need all the help that they can get. However, regarding their care, we all agree that every patient needs different, personalized care. Once a person has a medical condition and wants medical treatment, medical criteria should apply. The oncologists who treat cancer patients are guided by clinical research conducted over years, not patient surveys about how they feel after a few months. Similarly, when discussing the right medical care for our vulnerable children (as opposed to their civil rights), can we leave the rhetoric of advocacy aside and look at the actual clinical research on the drugs and their effects decades down the line?

1. Dolezal wasn’t the first white woman who wanted to become black. Carla Kaplan’s “Miss Anne in Harlem: The White Women of a Black Renaissance” describes white women in the 1930s who wanted to become (what was then called) a “voluntary Negro.” The book opens with a poem, “White Woman’s Prayer,” which went as follows: “I writhe in self-contempt, O God…Free me from my despised flesh and make me yellow...bronze...or black.”

2. As an aside, the identification as transgender is most prominent in the 18-29 age group. It is interesting how dramatically that identification falls in the 30-49 age group and yet again in the 50+ age group – if you are transgender, you will identify yourself as transgender regardless of your age group, right? Transgender activists might say that because of the affirmative culture these days, more young people feel comfortable coming out as transgender. However, if you look at the accompanying chart, you will see that the most dramatic reduction in identification is among people who identify as transgender (from 2% to just 0.3%) and not so much among those who identify as non-binary (while identification as non-binary decreases around 57% for people in their 30s and 40s, identification as transgender decreases by a whopping 85%). However, those who reach their 30s identifying as trans (0.3% of the population) mostly continue to identify as such in their 50s (0.2%). While these numbers are significantly smaller than the 5% estimates, these estimates from self-identification are still an order of magnitude larger compared to the estimates from the several countrywide clinical studies.