Medicalized Gender Transition and the Silence of Medicine and Bioethics

Last week brought news of the death of Peter Buxtun, the whistleblower who exposed the infamous Tuskegee Syphilis Study. Though the study is now universally recognized as one of the great scandals in the history of American medicine, for years Buxton’s colleagues in the Public Health Service ignored his complaints and dismissed his insistence that it violated basic ethical standards to deceive and withhold effective treatment from the Black sharecroppers who were the study’s subjects. His colleagues could not see or would not see the ethical problems that seemed plain to Buxtun.

A similar dynamic appears to be working today with respect to medicalized gender transition for children. By that I mean, specifically, the practice of treating children who experience gender dysphoria with puberty blockers, cross-sex hormones, and surgeries that suppress, redirect the development of, or remove a child’s otherwise healthy secondary sex characteristics.

For example, bioethicists are lauding the courage of Peter Buxton and lamenting the way he and other past whistleblowers were characteristically suppressed and sacrificed before they were taken seriously. Yet bioethicists have remained silent as the Department of Justice has indicted Dr. Eithan Haim for blowing the whistle on Texas Children’s Hospital conducting, Haim alleges, medicalized gender transition procedures that were outlawed by the Texas legislature. The DOJ has not charged Dr. Haim with making false charges but with unlawfully looking at medical records “with malicious intent.” Haim is being prosecuted as a criminal despite never disclosing any protected health information nor having history or motive of “caus[ing] harm to TCH’s physicians and patients” (the DOJ’s charge). In an apparent attempt to suppress criticism of medicalized gender transition, the US government is threatening to put this whistleblower in jail for up to ten years.

To my knowledge, the bioethics community has been silent as the DOJ brings suit against a whistleblower, much as the field has been silent as well-established ethical guardrails for pediatric medicine have been set aside in the “gender affirming medicine” project.

I suspect that future students will study the medicalization of gender dysphoria in children much as today’s students study Tuskegee and the history of the once popular practices of lobotomy, “normal ovariotomy”, and conversion therapy for homosexuality. Future students will wonder: how could the medical profession repeatedly fail to see and address ethical problems that were lying in plain sight?  

Medicine and bioethics have soul-searching to do: What has prevented their members from seeing and bringing scrutiny and open debate regarding ethical problems with medicalized gender transition in minors? Why have bioethicists not seen problems with practices that transparently set aside the norm of and act directly contrary to children’s healthy secondary sex characteristics, rendering many sterile, permanently disfigured, and permanently incapable of healthy sexual function? All of this in pursuit of affirming gender identity and reducing gender dysphoria, the DSM 5 criteria for which depend entirely on what the child perceives and desires.

Where are the voices of pediatric ethicists? What happened to the longstanding recognition that children do not have the maturity to consent to medical interventions, and that parents and physicians have a fiduciary duty to act only in ways that are consistent with the child’s medical best interest? What happened to the precautionary principle? What happened to ethical concern for vulnerable subjects? What about the imperative to avoid sterility-causing interventions in children unless the intervention is clearly medically necessary? 

Where are the voices of American physicians and bioethicists more generally? Given widespread disagreement about these practices among the public (witness 25+ state legislatures outlawing them for minors), where are the symposia and debates? Leaders in American medicine and bioethics have remained silent even as our European medical colleagues (see, for example, the recent Cass report from the NHS) have publicly concluded these practices are clinically and ethically ill-founded. Even as the editor of the British Medical Journal has reminded the medical profession, “Offering treatments without an adequate understanding of benefits and harms is unethical.” Even as the New York Times (not Fox News) has published piece after piece asking why the US health care community is doubling down on a practice that has such problematic features and has not been shown to work even on its own terms? Even as prominent gay (e.g., Andrew Sullivan) and lesbian (e.g., Kathleen Stock) intellectuals have decried what appears to be, in some cases, a kind of medicalized conversion therapy for kids with same-sex attraction. How, in the face of all of this, can medical and bioethics experts keep their heads down and look away?

As a physician and medical ethicist, I personally should have spoken up sooner and more often, but I have been hindered by the fear that prevents would-be whistleblowers from speaking up about unethical practices—the fear of being labeled a pariah and suffering social and professional sanction. I know from personal conversations that many academic physicians and bioethicists believe medicalized gender transition for minors is bad medicine, but they are afraid to speak up, and for understandable reasons. As Upton Sinclair noted, "It is difficult to get a man to understand something, when his salary depends on his not understanding it.”

To date I have been cancelled overtly only once: when medical students at Michigan State University mounted a successful, last-minute, campaign to prevent me from giving the 2022 Foglio Lecture on Spirituality and Medicine. A student learned that, years earlier, I raised ethical concerns about medicalized gender transition in a conference at the University of Chicago and later expanded on those concerns in a book. In that book, Chris Tollefsen and I argue that the medical profession increasingly sets aside its historical commitment to act only in ways that are consistent with a commitment to the patient’s health, objectively understood, opting instead for a provider of services model that prioritizes doing what a patient asks over what the patient’s health requires. Medicalized gender transition, we argue, is a singular expression of this pattern, corrupting contemporary medicine and medical ethics.

The medical students at Michigan State alleged (I was told) they could not feel safe if I was allowed to speak to them even about an unrelated topic. So, the school administrators cancelled my talk as I was boarding the plane to Michigan, thereby joining the DOJ in sending a loud signal to students and practitioners: those who dare to challenge these practices will be treated as beyond the pale, and their arguments will be suppressed rather than engaged.

Then last fall I was invited to give a lecture on the topic of my choice as part of a series devoted to “Challenges in Contemporary Clinical Ethics.” The series was sponsored by the University of Chicago’s MacLean Center for Clinical Medical Ethics, where I served on the faculty from 2004-2013. I accepted, and proposed a talk titled “Detransitioners, Civil Discourse, and the Silence of Clinical Ethics.” As the date for the talk neared, I learned from colleagues that some faculty, outraged that I would be allowed to speak on this topic, sought to have the talk cancelled. To its credit the MacLean Center did not cancel the talk, though they did cabin it by turning off their usual livestream (and recording) of the event and by inviting (with my consent) two colleagues to present formal rebuttals immediately after my lecture.

Over the subsequent months, the ethical problems with contemporary “gender affirmation” practices have become more glaringly obvious to me, as I have been called as an expert witness by states facing legal challenges to laws that restrict medicalized gender transition to adults.¹ In that work I have seen manifest evidence of what Pamela Paul described this month in the New York Times.  

This project of medicalizing “gender affirmation” in children will not end well, and it is time for bioethicists to bring the ethical scrutiny that is the point of our field. It is time for those who see the problems to follow the courageous examples of people like Peter Buxtun and say so, publicly. If medicalized gender transition in minors is good medicine, the arguments and the data will bear that out. In my judgment, so far they do not.

Farr Curlin, MD, is Trent Professor of Medical Humanities and Co-Director of the Theology, Medicine and Culture Initiative at Duke University. He is co-author of The Way of Medicine: Ethics and the Healing Profession (Notre Dame, 2021).

1. I am paid an hourly rate for my work as an expert witness in these cases.