Pediatric Gender Medicine -

Lipfert replies, Ryan responds

It’s my pleasure to introduce this letter and response to a recent article by Ryan about pediatric gender medicine. Mr Lipfert is a pre-medical student and Mr. Ryan is a journalist.

Pediatric Gender Medicine: Dispatches From a Deceptive Medical Field

This is a controversial topic, and it is not usually well covered in medical journals or the lay media. Here, at Sensible Medicine, we present a range of views. I think this was a fascinating dialog, and I commend both Lipfert and Ryan for writing. If you believe in what we are doing, and want to support us, become a subscriber, and share this post with a friend.

Vinay Prasad MD MPH

Mr. Colton Lipfert

A prior post by science journalist Benjamin Ryan critiques how gender researchers caved to political pressure and suppressed data showing that puberty blockers failed to improve psychological outcomes for gender distressed minors. I have several concerns with his piece.

First, I am concerned with how Ryan characterizes trans advocates: He writes they are a “cabal” that is creating a “fearsome buffer zone” around the truth; that they are ready to “attack, silence and cancel any researcher… who dares step out of line”; He states that WPATH, an activist-medical organization for transgender health, is “shadowy and deceptive.” 

To be clear, I don’t think any group is above criticism, and I have no problem with Ryan criticizing advocates who suppress scientific findings. But, in my opinion, there is a difference between criticism and demonization. Describing trans advocates as a “cabal” that “bully,” tell “falsehoods,” “attack,” and “silence” truth-tellers implies they are both wicked and threatening. 

In reality, trans people are some of the most marginalized and discriminated against people in America. They are unemployed at double the rate of the general population. 90% of trans people experience workplace harassment. 30-50% of trans people attempt suicide. 24% experience severe domestic violence (the national average is 18%). A quarter of trans people die by the age of 69, as opposed to 77 for the general population. Major American political figures refer to them as “filth” that “should be eradicated.” It may seem like trans people have a powerful presence online and in Universities, but make no mistake—they are a marginalized and vulnerable minority.

Second, Ryan writes that he met with countless parents of transgender youths who, despite being liberal, were “heartbroken, terrified and alone,” at their child’s new gender identity. “They love their children,” he says, “but they sincerely do not believe that a medical gender transition will help them.”  I think it’s normal to be worried, even skeptical, if a minor is rushing into irreversible treatment, but heartbroken goes too far. If I came out as gay to my parents and they were heartbroken, you would say they’re at least a little homophobic. Why would it be different for trans people?

Third, Ryan implies (through a series of anecdotes about scared parents) that gender interventions in minors are common. In reality, gender intervention in minors is a rare and slow process: While more than 42,000 minors were diagnosed with gender dysphoria in the U.S. in 2021, only 1,390 (3%) of gender dysphoric minors took puberty blockers and 282 (0.7%) received a mastectomy. Most patients have to wait years to receive any kind of treatment, including puberty blockers. And while it’s questionable whether gender interventions improve mental health outcomes, 95% of transgender patients do not regret hormonal treatments and 99% do not regret their surgery. 

I think it’s reasonable (and not transphobic) to be skeptical of the evidence for these gender interventions. There should be better data before these treatments become commonplace among minors. And I agree with Ryan that researchers should not withhold data because of political pressure. But I worry about Ryan’s demonizing language, transphobic comments, and a fear-mongering tone, which are not needed to make a point about scientific integrity, but to paint a minority group as dangerous and threatening. 

Reply from Mr. Ben Ryan

I accept criticism from Mr. Lipfert of my use of inflammatory language in my previous essay, “Pediatric Gender Medicine: Dispatches From a Deceptive Medical Field.” Turning up the temperature in this combustible debate is counterproductive. Mea culpa.

However, a number of the characterizations Mr. Lipfert offered regarding transgender people in general and pediatric medicine in particular are not mutually exclusive to, and do not contradict, the perspectives I presented.

For one, he points to the long waiting lists kids must endure to be seen at gender clinics. People often conflate this waiting time with the robustness of the psychosocial assessment that kids, once they’re in the door, are at least meant to receive. Just because the former process is lengthy does not mean the latter is. In fact, many clinics require only a brief psychological assessment before gender dysphoric children are referred to endocrinology for puberty blockers and cross-sex hormones. This month, my reporting revealed that since 2018, the policy at Boston Children’s Hospital has been to provide kids a single two-hour assessment appointment.

Mr. Lipfert is correct that the transgender population is profoundly vulnerable and is burdened with high rates of mental and physical illness. However, this does not change, and is distinct from, the fact that there is a network of activists and thought leaders who aggressively police the topic of pediatric gender medicine in the public square. These individuals engage in remarkably underhanded tactics to intimidate and even terrorize people who speak critically on this issue. These shameful efforts harm the public’s understanding of this subject by instilling a chilling effect across multiple disciplines, including academia, public schools, and media, in which people resort to self-censorship to protect themselves and their careers.

Here is a prime example:

As journalist Jesse Singal has documented, the trans activist Andrea James publishes a defamatory page on her web site of any public figure, no matter how remote, who speaks with even a remotely critical voice about pediatric gender medicine. She brands all of us “anti-transgender activists,” regardless of how absurd such an epithet might be.

Somehow, Ms. James has managed to at least effectively massage the Google algorithm so that these defamatory pages are routinely placed toward the top of a web search of our names. These pages, which are filled with wildly defamatory claims as well as eerily specific details about our families (mine identifies the year of my mother’s death), can prove devastating to many professionals, such as psychologists, whose livelihoods depend on maintaining their good name. These pages are presented as a warning to others not to defy trans activists, lest they too be branded a heretic and cast out in shame.

Mr. Lipfert falsely claims that I referred to a cabal of “advocates”. The word I used was “activists.” There is a profound and obvious difference between those two categories. He is wrong to claim I used the softer term.

But on the subject of advocates, one of the reasons we know that WPATH is indeed shadowy and deceptive is that its leadership routinely prioritized advocacy goals—namely, wide open access to, and insurance coverage of, gender-transition treatment and surgeries—over sound and transparent science when orchestrating the 2022 revision to its trans-care guidelines. Subpoenaed internal records have proved this.

Mr. Lipfert is in no position to dismiss whether the distraught parents who reach out to me about their trans-identified children are, as they have indeed told me, heartbroken over what they believe is their troubled child adopting such an identity as a maladaptive coping mechanism.

He also makes what is a common, yet very likely false, comparison between homosexuality and transgender identity. Researchers simply do not know whether the origins of cross-sex identification are akin to those of same-sex attraction—meaning that the disposition is fixed at an early age, unchanging, and not a product of social influence. Relying on such a simple heuristic to conceptualize gender-identity formation can prevent young people from engaging in the necessary soul searching to determine whether the permanent changes resulting from gender-transition treatment and surgeries are right for them.

We also do not know the long-term impact of prescribing puberty blockers and cross-sex hormones to children, including what the ultimate detransitioning rate will be. This is still a nascent medical field, and most longitudinal studies of such treatment have a follow-up of only a year or two. Plus, the profile of gender-dysphoric youths has changed dramatically in recent years, making it hard for research to keep up.

Mr. Lipfert makes an apparent reference to the recently published paper by Princeton’s Kristina Olson, which found that nearly all adolescent respondents to a long-running survey study who had taken gender-transition medications were satisfied with the treatment. But this is a group of children who socially transitioned at an average age of six. And they entered the study between 2013 and 2017. They are not representative of today’s typical minor presenting at a gender clinic: an adolescent natal female with a high rate of psychiatric comorbidities who only betrayed signs of gender dysphoria upon puberty’s onset.

As far as I understand it, Mr. Lipfert’s claim that gender-transition surgery has a 99% satisfaction rate is reference to research in adults, not children. Even so, such research is also typically compromised by substantial loss to follow-up (see, once again, Mr. Singal’s coverage). And let’s not forget that of the 55 people assessed from the original Dutch cohort of gender-dysphoric minors given puberty blockers, hormones and gender-transition surgeries, one died from complications resulting from their vaginoplasty.

Mr. Lipfert further cites incorrect or misleading statistics about the number of minors receiving these medical interventions.

In an analysis of medical claims data, Leor Sapir of the Manhattan Institute found that 320,000 to 400,000 minors received a gender dysphoria-related diagnosis from 2017 to 2023. Lexis-Nexis, meanwhile, reported that the annual gender-dysphoria diagnosis rate doubled from 2019 to 2023. Importantly, Dr. Sapir’s analysis of a subset of these gender-dysphoric youth found that the majority of them no longer had such a diagnosis in their medical file within six years. A recent German study similarly found that these diagnoses are typically impermanent in young people, especially the natal female adolescents I mentioned earlier.

These findings cast serious doubt on a claim that pediatric gender medicine leaders have long made: that gender dysphoria presenting in adolescence is very likely permanent. If such a diagnosis is, in fact, typically impermanent, this questions the wisdom of providing drugs and surgeries to minors that have permanent effects, including infertility and the lack of a capacity to breastfeed.

According to a conservative estimate by Dr. Sapir, over 1,000 minors received a double mastectomy for gender dysphoria in 2021. From 2017 to 2023, there were an estimated 5,288 to 6,294 such surgeries, including 50 to 179 girls who were 12.5 years old or younger.

In another conservative estimate, the nonprofit Do No Harm found that 8,579 minors received puberty blockers, cross-sex hormones, or both between 2019 and 2023. All told, at least 14,000 children received such treatments, surgeries or both during this period.

As I said before, it is vital that the public develops a more trenchant understanding of this wider issue and these specific statistics and scientific findings. Obfuscating or mischaracterizing research regarding this complex subject helps no one, least of all children who are distressed about their gender.