While cancel culture has made its way into the United States' culture wars, there is another issue that has become prevalent: transgender issues. The pro-LGBT Williams Institute estimated in June 2022 that 0.5 percent of U.S. adults are transgender. In spite of transgender individuals representing a small percentage of the overall population, they have become a focal point for the political Left and Right alike. This has become clear when discussing the theme of gender transition, or what is also commonly referred to as gender-affirming care. The phrase "gender-affirming care" has become a catch-all for such procedures as puberty blockers, cross-sex hormones, and gender reassignment surgeries (e.g., mastectomy, penectomy).
The U.S. political Left along with various U.S. medical organizations are unquestionably convinced that gender-affirming care is about sound health care practices and saving lives. For the U.S. political Left, you would either have to be an idiot or a monster to get in the way of someone's happiness and wellbeing like that. If only it were that simple and if only the topic of gender medicine did not become so politicized.
For adults, I believe that they should be able to make an informed decision about what to do with their bodies as long as they do not harm others. If an adult discusses it with a doctor or other health professional and decides they want to transition, that is their life and their choice.
Much like children in libertarian philosophy more generally, the theme of gender-affirming care for adolescents is more nuanced. Childhood is a formative time in one's life. Children do not know what is best in part because they are not fully autonomous beings with mens rea. To quote Bill Maher, "Kids do have phases. Kids are fluid about everything. If they know at age eight what they wanted to be, the world would be filled with princesses and cowboys. I wanted to be a pirate. Thank God no one scheduled me for eye removal and peg leg surgery."
Take it from Dr. Riittakerttu Kaltiala, who is Finland's leading expert on pediatric gender medicine and has presided over gender transition treatments since 2011. Looking at the data in 12 studies, Dr. Kaltiala found that about four out of five children with cross-gender or gender variant behavior and are left to develop naturally do come to terms with their bodies and accept their biological sex.
While the U.S. political Left might see this topic as a no-brainer, things are more nuanced on the other side of the Atlantic. There are multiple LGBT-friendly European countries that have conducted systematic reviews of the available data on the topic of gender-affirming care for adolescents, whether it is Sweden, Finland, Norway, or the United Kingdom. What they have concluded that gender-affirming care is not evidence-based medical practice. Even The Economist recently published an article entitled "The evidence to support medicalised gender transitions in adolescents is worryingly weak."
Rather than hand out gender-affirming care as if it were candy, the aforementioned European nations are using it as the exception rather than the rule. Especially in Sweden and Finland, there are strict requirements for adolescents to qualify for gender-affirming care (e.g., no co-occurring mental health problems, undergo at least six months of psychotherapy, parental consent for hormonal therapy) and for any procedures to be done as part of clinical testing. France's main medical association, l'Académie National de Médicine, recommends that hormones should be used "in the greatest reserve." In these European countries, gender-affirming care is seen as a last resort rather than as a first resort.
The British media outlet Unherd covers in further detail how the U.S. political Left selects low-quality studies to draw a conclusion instead of conducting systematic reviews like they do in Sweden. To quote the Economist, "Medical science is not supposed to work this way. Treatments are supposed to be backed by a growing body of well-researched evidence that weighs the risks and benefits of intervention. The responsibility is all the heavier when the treatments are irreversible and the decisions about whether to go ahead are being taken by vulnerable adolescents and their anxious parents."
It is not only the irreverence for the scientific process or for finding evidence-based practice that I find troubling. It is the irreversible nature of these procedures. If you opt for a mastectomy or a penectomy and regret the decision later, it is not as if you can grow those body parts back. There have also been concerns about bone density, brain development, and infertility as a result of these procedures.
I generally think that bans are unwise policy and have harmful effects, which is why I will not go as far as saying that gender-affirming care should be outright banned. A lack of evidence does not justify a ban in so far as that proponents very well could be proved correct once proper clinical trials are complete and if there is adequate evidence to show its benefits.
I see the United States making a similar mistake with gender-affirming care that it did with its approach to the COVID pandemic. With the COVID pandemic, the U.S. political Left politicized the pandemic. It nearly exclusively obsessed over the costs of COVID. This one-sided view led to multiple harmful policies, including lockdowns, school closures, and travel bans. The cherry-picking of low-quality studies on the theme of gender-affirming care instead of more robust systematic reviews is reminiscent of what many on the U.S. political Left did with face masks. Ignoring the science during the pandemic not only increased non-COVID health costs, but it resulted in the accumulation of economic, education, and social costs. The powers that be silenced that debate and dissent during the COVID pandemic and we continue to pay the price for such folly.
I hope that the United States can learn from the mistakes of ignoring the science and silencing dissent that took place during the pandemic. We should be able to balance the concerns on both sides of the gender-affirming care debate while gathering more clinical data. In the meantime, this much is true: European nations had been practicing gender-affirming care for about a decade and realized that the evidence base is too weak to justify an implementation as liberal as it is in the United States. If given too freely, the harm can easily outweigh the benefits.
This is why the Scandinavian approach encourages psychotherapy and only allows for gender-affirming care sparingly and in a clinical trial setting. As we gather more clinical data, we can better determine whether or not gender-affirming care actually works and under what conditions it could be most beneficial, especially for children. Given the irreversible effects of gender-affirming care, not to mention the possibility for long-term harm, I agree that the caution within the Scandinavian approach is the more prudent and appropriate approach as we ascertain the truth on this procedure.
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