HHS Turns Wheels on Sex Changes for Minors

Rachel Levine, assistant secretary for health at the U.S. Department of Health and Human Services (HHS), recently made waves in predicting that “wheels will turn” on so-called “gender-affirming care” for minors. A new report clarifies that HHS intends to initiate much of the spinning, and that the department is willing to throw around the weight of the federal government to stop sensible state-driven reforms.

Moving Beyond Change Efforts: Evidence and action to support and affirm LGBTQI+ Youth is a newly published report commissioned and recirculated by the Substance Abuse and Mental Health Services Administration (part of HHS).

The report argues that a child’s expressed sexual and gender identity preferences should be affirmed by parents, schools, and medical practitioners: “Withholding timely gender-affirming medical care when indicated, withholding support for a gender-affirming exploratory process, and/or withholding support of social transition when desired, can be harmful because these actions may exacerbate and prolong gender dysphoria.”

Reality is far more complex and demands greater nuance and caution. Indeed, the full 111-page report reveals itself to be inundated with rhetorical sleight of hand, oversold claims based on evidence cited, and misrepresentation of basic facts. We highlight three particularly egregious examples below.

Claim #1: “The Minority Stress Model provides an empirically validated conceptual model for understanding how stress due to anti-LGBTQI+ stigma, coupled with general life stressors, puts individuals of diverse sexual orientation and/or gender identity at increased risk for negative behavioral health outcomes.”

Context: The “minority stress model” that the report endorses asserts that mental health distress typically arises from gender dysphoria rather than vice-versa. Attitudes toward the minority stress model differ across health systems globally – major medical organizations in the United States generally embrace the concept whereas European countries typically and increasingly reject it. Attitudes toward the minority stress framework have major implications for standards of care. If it’s true that mental health distress occurs from a lack of affirmation of enduring incongruence between gender identity and biological sex, then social and medical transition represent a sensible treatment protocol. If, however, expressions of gender dysphoria arise from psychosocial stressors or afflictions but do not signal lasting incongruence, then social and medical transition are more likely to cause harm than benefit.

Reality: There is a strong body of evidence to indicate that children with psychosocial distress, particularly homosexual or bisexual kids navigating their sexual identity, temporarily channel their emotions and anxiety as expressions of gender dysphoria. A study of children referred to gender clinics in Finland reported that 57% had been “significantly bullied at school” and that 75% were undergoing psychiatric treatment for other conditions at the time of their referral. Critically, another study relays that about 4 in 5 children who meet criteria for gender dysphoria will have such feelings recede during puberty. “Instead,” the study notes, “many of these adolescents will identify as non-heterosexual.” The phenomena of rapid onset gender dysphoria (ROGD) and detransition further illuminate the hazards in defaulting to social and medical transition in response to expressions of gender dysphoria.

Expressions of gender dysphoria are especially prevalent among autistic youth, a population that disproportionately struggles with impaired emotional processing and social isolation and vulnerable to the allure of medical explanations and solutions. A study out of the Tavistock gender clinic in the United Kingdom revealed that an estimated 48% of children seen in the clinic were mildly or severely autistic. Rather than acknowledge the high incidence of autism among referrals to gender clinics, the report notes that “some neurodiverse youth are gender diverse.”

Claim #2: “SOGI (sexual orientation and gender identity) change efforts, commonly referred to as ‘conversion therapy’ or ‘reparative therapy,’ are practices that aim to suppress or alter an individual’s sexual orientation or gender to align with heterosexual orientation, cisgender identity, and/or stereotypical gender expression…Efforts to change or suppress a person’s sexual orientation or gender identity are grounded in the belief that being LGBTQI+ is abnormal. They are dangerous, discredited, and ineffective practices.”

Context: The report repeatedly conflates conversion therapy (the practice of attempting to change an individual’s sexual orientation) with resistance to socially or medically affirming expressions of gender dysphoria. Historically, so-called “conversion efforts” referred to efforts to change an individual’s sexual orientation while it is now being used as a rhetorical weapon to describe any treatment that doesn’t automatically affirm a gender identity. For example, Wikipedia archives reveal that “gender identity” first appeared in the “conversion therapy” article in December 2021.

Reality:

Much of the push to conflate resistance to affirmation of gender dysphoria with conversion therapy originates from a 2020 paper authored by activist/researcher Jack Turban and colleagues which asserts that so-called gender identity conversion efforts are mentally detrimental to gender dysphoric youth. Notably, their findings have received strong criticism. For example, a letter to the editor in Archives of Sexual Behavior observes that “Their analysis is compromised by serious methodological flaws, including the use of a biased data sample, reliance on survey questions with poor validity, and the omission of a key control variable … Arguably, even more problematic than the flawed analysis itself is the simplistic ‘affirmation’ versus ‘conversion’ binary, which permeates Turban et al.’s (2020) narrative and establishes the foundation for their analysis and conclusions. The notion that all therapy interventions for GD (gender dysphoria) can be categorically classified into this simplistic binary betrays a misunderstanding of the complexity of psychotherapy.”

 The comparison between gender dysphoria and homosexuality is problematic for other reasons. Most critically, while an estimated 4 out of 5 children who meet the criteria for gender dysphoria will eventually desist in such feelings, there is no indication that majorities of children who express same-sex romantic preferences will eventually experience a cessation of those preferences. Resistance to affirming expressions of gender dysphoria is not a rejection of an individual’s identity. Rather, it is a sensible acknowledgement that most children who express gender dysphoria will not persist in such feelings and that affirmation of transitory feelings with irreversible medical treatments is harmful.

Claim #3: “Legal prohibitions on gender-affirming care (including medical treatment) are harmful to LGBTQ+ children and adolescents.”

Context: Some states are beginning to restrict minor access to medical transition interventions, including puberty blockers, cross-sex hormones, and surgery. Advocates of allowing minors to medically transition argue that these interventions are needed to decrease the high incidence of depression and suicide among gender dysphoric children.

Reality: Studies that claim that access to medical transition causes a decrease in depression and suicide are fraught with methodological problems. For example, a recent paper in the prestigious New England Journal of Medicine observed that children and adolescents who initiated hormones experienced modest improvement in self-reported mental health over time. However, the “study” did not feature a control group, so it is impossible to determine whether these modest changes represent an improvement over alternative approaches. Another recent paper concludes that restrictions on medical transition for children are associated with an increased in Google searches for “depression” and “suicide,” but close inspection plainly reveals that the underlying data does not support the conclusion.

Restricting minor access to medical transition is not simply a red state phenomenon. Sweden, Finland, and the United Kingdom – three of the most LGBTQ-friendly nations in the world – have recently moved to impose greater restrictions around minor access to gender-affirming treatments. Even before these restrictions, the nations of Western and Northern Europe all but banned sex reassignment surgeries for those under the age of 16. Indeed, states that allow for puberty blockers at 8, cross-sex hormones at 12, or double mastectomies at 13 – all of which have occurred in the United States – are far greater outliers from Western norms than are states that prohibit these interventions before age 18.

The proselytization of gender ideology is falling flat: The share of Americans who say that gender cannot be changed has increased in recent years and as of June 2022 six in ten adults agree that gender is determined by sex at birth. Part of the challenge for gender ideology advocates is that they are stuck between admitting lunacy or playing fast and loose with facts. HHS and the Biden White House for their part appear bearish on the prospect of turning wheels on the merit of honest arguments.