One of the most contentious issues of current times is that of transgenderism and what treatments should be available for transgender children. The issue has become sensationalized among on the right and a cultural touchstone on the left, but I have many questions about how common gender dysphoria is as well as the best way to address it.
There is some publicly available data on the number of transgender Americans. WiseVoter puts the national average at 0.5 percent and lists state data on a map. States with high shares of the transgender population seem to follow no discernible pattern. Both red and blue (and purple) states having both high and low levels. North Carolina has the highest percentage of transgender population at 0.87 percent (behind the District of Columbia at 0.92 percent) while Missouri has the lowest level at 0.2 percent.
The UCLA Williams Institute has another page of resources that breaks down the data more for youth. Nationally, the group puts the average at 1.4 percent of 13-17 year-olds, slightly higher than the national average for all ages. This means that there are an estimated 300,000 transgender teens nationally.
Some estimates are higher. A Pew study from 2022 found that 5.1 percent of young adults (under 30) identify as trans, including three percent who are nonbinary. Interestingly, there is a large age disparity with 3.1 percent of adults under 25 identifying as trans compared with only 0.5 percent for those aged 25 to 29.
There have been reports that indicate a sharp increase in the number of transgender Americans. In 2022, the New York Times reported that “the number of young people who identify as transgender has nearly doubled in recent years.”
Why this is true is uncertain, but I can think of a number of possibilities. The most obvious scenarios are either that the number of transgenders is rapidly increasing or that transgenders are more comfortable in coming out openly about their feelings to researchers. Other likelihoods could be that the statistics are flawed (the Times article notes that methodology has changed) or that the coolness factor of transgender in popular culture encourages more young people to claim that label. Another possibility is that transgender is being diagnosed more frequently because of changing definitions and social norms.
Even with the increase, transgender students and athletes are rare. For example, the UCLA data notes 8,500 transgender youth from 13 to 17 (1.18 percent) in my state of Georgia. Divided by 2,308 public schools, that works out to about 3.7 transgender students per school. Even fewer of those would be athletes.
The number of transgender athletes is harder to pin down, but a Newsweek report estimated the total number at less than 100 nationwide. The same report noted that of 15 transgender athletes competing in North Carolina high school sports, only two were trans girls (biological males). When Utah moved to ban transgender competition in high school sports, there were only four transgender athletes statewide and only one was competing in girls’ sports.
However uncommon transgenderism is, it is an issue. It doesn’t seem to be an emergency, however. We have time to study the issue and decide rationally on how to deal with it.
Part of the problem is that there are competing political ideologies. On the right, it has become a trope to demonize transgenders and their advocates as perverts and groomers. On the left, there’s a tendency to attack anyone who resists the notion that transgender youth should be granted whatever medications and surgeries that they want.
I know I say this a lot, but I think they are both wrong.
The rise of self-identified transgenders is curious and to some extent troubling, but it’s not a crisis. It certainly isn’t something that needs to be front-and-center on national newscasts and websites every night. I do have some sympathy for those who charge that the right-wing media is using the issue to rally their base and cash in on the anguish of families. Transgenderism can be a personal or family crisis, but it is not a national one.
On the other hand, I also agree that people who aren’t old enough to vote or drive aren’t old enough to be making decisions about surgeries that could impact their life and health decades down the road. It’s well established that rational thinking and impulse control are not strong suits for teens and adolescents.
On yet another hand (that’s three if you’re counting), there is also some truth to the claim that parents have the right to raise their kids as they see fit. People on the right are quick to claim parental rights are inviolable when it comes to vaccines, critical race theory, and the like but don’t want to acknowledge that if parents have rights in these areas, they also have to extend rights to people who hold different opinions on sexuality (if they want to logically consistent anyway, if they don’t mind being hypocrites they can claim rights and deny them to others).
I frequently like to point out that rights apply to our enemies as well. If we are going to be a free nation, then we are going to have disagreements about what sort of behavior is acceptable and sometimes you just have to let it go. If freedom only applies to people who make the choices that we want them to make, that’s not really freedom. True freedom includes the liberty to make bad, stupid, and sometimes even harmful decisions.
But rights are not absolute. How far should parental rights be extended in this area?
I think it depends on exactly what sort of behavior is being discussed. If a parent wants to let their child dress as the opposite sex or pick different pronouns, then I’d grant them a lot of leeway in that direction. Along those same lines, going to drag shows where there is no obscene or lewd behavior is going to fall under parental rights and freedom of expression.
Parents have the right to seek treatment for transgenderism for their children. Many of the arguments against transgender therapies could be (and have been) applied to gay conversion therapies by folks on the opposite side of this argument. Personally, I’m in favor of allowing both sorts of therapy under the First Amendment’s guarantee of free speech, which as it turns out, also applies to doctors and therapists.
I am less swayed by the parental rights argument when it comes to treatments that are more invasive and have the potential to do lasting damage. For example, I’m fine with talk therapy, but I’m more hesitant when it comes to prescribing hormone blockers and other drugs (none of which are FDA-approved for treatment of gender conditions), which often come with the possibility of serious side effects. I’m more leery still of allowing sex-reassignment surgery. I’ll note here that governments have a long history of regulating drugs and surgical practices, especially for minors.
It’s also worth noting that it isn’t just Republicans who are skeptical or cautious about gender dysphoria care. Forbesreports that European nations are becoming more restrictive of the treatments citing a low certainty of benefits and a “risk-benefit ratio of youth gender transition ranges from unknown to unfavorable.”
So what is the appropriate treatment for transgender youth? It’s possible that the best answer is to give it time.
As one online source puts it, “You may also find out that the feelings you had at a younger age disappear over time and you feel at ease with your biological sex.”
That advice is not from a pastor or Republican congressman. It’s from Britain’s National Health Service.
It is possible that intervening with medical treatments can short-circuit the body and mind’s own corrective actions that allow people to become confident and content with their own gender. Maybe by trying to help affirm the mental state of transgenderism, we are really doing long-term harm to both the mind and body.
One way to get an answer is to let the process play out. Forbes pointed out that 12 states have banned or heavily restricted treatment for gender dysphoria while five states have acted to protect access. This is an example of the laboratories of democracy in action, in this case acting as actual medical laboratories. We should be able to track data and determine which approach achieves better results.
The downside is that people are going to be hurt by the different laws, but which policy would be the one to hurt them? Everyone has an opinion, but science seems to lack a consensus.
As a live-and-let-live kind of guy, I think that many of the transgender issues can be settled by the principle of “if it doesn’t hurt someone else then it falls under freedom of expression.” Put another way, if someone does something but it doesn’t affect you, then it’s none of your business. To a great extent, that applies to how other parents raise their children.
This is an issue that has good people (and bad people) on both sides. Facing someone with a different opinion doesn’t necessarily mean that you are looking at a bad guy. It may just mean that you have a different understanding of the facts or a different emphasis on the best policy.
And in general, trans people should not be attacked for what may very well be a mental health issue. At the very least, they should be treated with the same respect and dignity that we should offer to all of our fellow humans. That’s basic human decency.
Very well put. There’s a lot of “unknown” here.
IMHO it’s reasonably clear male->female trans athletes keep enough of the “male” package that they should probably be banned. That’s harsh but we ban athletes for less and I don’t see good alternatives.
For perspective, I’m 6’8″. I’m also not big for a male in my family. If I go trans I’m not going to shrink.Report
We should probably start the discussion by recognizing some basic facts.
The number of sex reassignment surgeries on minors is tiny. Like fewer than 300 teens 13-17 received breast surgery in the US.
The number who get bottom surgery, is even fewer, like maybe around 60.
https://www.reuters.com/investigates/special-report/usa-transyouth-data/
Keep both those numbers in mind. Three hundred, and fifty.
Now the number of teens 13-19 who got nose jobs- PERMANENT IRREVERSIBLE surgical alteration of their face- was on the order of 30,000.
Thirty Thousand!
The number of teenagers getting permanent irreversible life altering facial surgery is ONE HUNDRED times larger than the ones getting top surgery.
And no one cares.Report
There’s also a pretty decent percentage of those top surgeries going to teens who have them for other reasons. I know a woman who had breast surgery in her teens because she’d developed early and top-heavily and wanted to spare her back pain.Report
The problem is that a trans teen probably will find themselves developing in ways that cause them severe distress. Puberty-blockers are thus sometimes justified because the distress will only persist and grow stronger for lots of teens. Alleviating the distress can outweigh the potential risks of such treatments. The side effects of puberty blockers are not so severe that we should simply ban their use. At most we might need to be more careful about how long they can be used, but a) minors can be capacitous (see Gillick competence) for some things and b) this has to be carried out on a case by case basis. There is no need for a blanket ban on puberty-blockers
Puberty blockers are not specifically approved by the FDA for treatment of gender dysphoria in children. But this does not mean that they are not FDA approved simpliciter. They are approved for use with children who for some reason or other start puberty too early. Using it for transgendered teens is just off-label usage which is common for lots of things and is not a weird thing that’s going on.
Conservatives have drummed up a moral panic about this. There are some physicians who have engaged in malpractice by progressing care too quickly without taking care to confirm that the child/teen is indeed transgendered. But this is against existing guidelines.
Actual rates of post-op regret are very low. 1% or less.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099405/
This number is significantly lower than regret for vasectomies, knee replacements etc. This is to be expected since physicians are usually and justifiably very careful since this is a huge decision.
Now we get to parental rights. Parental rights here are more limited than you might think. Jehovah’s Witness parents, for instance, do not have the right (legally or morally) to refuse blood transfusions for their children. Medical best interest rules the day in such cases. The same thing applies here. If it is in the medical best interest for a teen to transition, then parents do not have a right to stop it.
I don’t think gay conversion therapy is just people talking about people straight. I don’t think anyone talking at me will get me to be gay. I don’t see how one could talk a gay person straight. If that is all that is going on here, then these therapies seem fraudulent. If it is not just talk, then the question becomes whether what is happening has veered into abuse.
1st amendment or more generally, freedom of conscience concerns permit people to believe whatever they want about the morality of being gay or trans. But transitioning and gay conversion therapy are significantly different in at least 1 important respect.
Gay teens typically don’t want to be in conversion therapy while trans teens typically want to medically transition. Regardless of assessments of competence, we should be much more careful about conversion therapy because it violates their assent (and potentially their consent as well). Thus the former may all things considered not be in gay teen’s best interests while the the balance of probability favours the latter being in trans teens best interests.Report
A Trans Teen? Excuuuuse me. An Autistic Teen will find themselves developing in ways that cause them distress. CHANGE causes them distress.
And there are a LOT MORE autistic teens than trans teens. (over ten times.).
Now, if you tell an autistic teen that all he/she has to do is “trick” the psychologist (and, it might not be that much of a con…).
Rates of post-op regret are significantly understated due to the 50% yearly suicidal ideation of trans teens and adults. In short: if they regret removing the ability to have orgasms, they tend to kill themselves.Report
Here is the difference between being autistic and being trans. Once the body stops changing, the autistic person stops feeling distressed. For the trans person, finishing their natural puberty maximises the distress. The autistic teen is distressed by change in any direction. The trans teen is not distressed by the changing as such, but by it becoming something that they do not want it to be. It can make sense why different courses of treatment might be recommended here.
Now, if you tell an autistic teen that all he/she has to do is “trick” the psychologist (and, it might not be that much of a con…)
So wait some autistic persons may also be trans? So what?
Rates of post-op regret are significantly understated due to the 50% yearly suicidal ideation of trans teens and adults. In short: if they regret removing the ability to have orgasms, they tend to kill themselves.
Suicidal ideation is not actual suicide.
And gender affirming care improves mental health.
https://abcnews.go.com/Health/gender-affirming-care-trans-youth-improves-mental-health/story?id=96510337#:~:text=Interest%20Successfully%20Added-,Gender%2Daffirming%20care%20for%20trans%20youth%20improves%20mental%20health%3A%20Study,trans%20youth%2C%20the%20report%20said.&text=Gender%2Daffirming%20hormone%20therapy%20improves,England%20Journal%20of%20Medicine%20showed.Report
The 20,000 trans folk study had only 16% of them wanting to obtain hormones. As such, I think we’re in the majority when we say “puberty blocking hormones are a bad idea for most trans folk.”Report
That’s not how clinical care works.
those who want hormones get it and those who don’t don’t. Those who don’t want hormones don’t get to decide for those who do even if the former are in the majority.Report
The link is to a meta-analysis that incorporates studies crossing multiple decades (several are in the 80s and 90s) and countries. The rapidly increasing acceptance and visibility over the last few years especially in the US would naturally be expected to affect the rate of post-op regret. It would be good to have a sense of what the “current” rate is (over, say, the last 5 years). Though in the current climate, it’s hard to trust any particular study anyway — I’d expect there to be a thumb on the scale somewhere.Report
To add to your point no one knows the long term impact of a number of these treatments on children, and I certainly wouldn’t compare it to something where the cost benefit analysis is obvious, as Murali did to an emergency blood transfusion. My father in law was on Lupron for years for prostate cancer. It, along with the cocktail of drugs and treatment he was on, extended his life for about 15 years, but the quality declined over time. The Lupron in particular caused severe osteoporosis and by the end movement was painful and the guy was made of glass. His technical proximate cause of death wasn’t the cancer but a minor fall inside his own home that due to the state of his bones fractured his skull and resulted in massive brain hemorrhaging.
My mind isn’t closed to the possibility of situations where it makes sense but we’re talking really difficult trade offs with potentially major impacts on health over the individual’s life.Report
As we know more things might change, but, and this is crucial, it is, given our current evidence, the best of many bad options for a not insignificant number of cases.
There is some moral risk here, but it is wrong (because authoritarian) for us to demand that others be cautious when things only at risk of being wrong (but not certainly wrong). For a discussion of why this might be the case, let me toot my own horn here.
https://link.springer.com/article/10.1007/s10677-022-10360-2
For an ungated penultimate draft, click the title in this link below
https://philarchive.org/rec/MURIRBReport
Here is a more recent article
https://journals.lww.com/plasreconsurg/Fulltext/2023/07000/Regret_after_Gender_Affirming_Surgery__A.41.aspxReport
Thanks, that’s helpful. I think it’s specifically minors who are the population of concern, but it’s good to see both such a small regret rate and also (based on the intro) evidence of people in the profession taking the concern very seriously. Unfortunately a lot of the online discussion of these issues is dominated by zealots who are quick to dismiss every potential concern that cuts against their own opinion (and vilify people for even mentioning them).Report
Studies can’t be both long-term and following the recent glut of cases, because the new cases haven’t been been around long-term.Report
The tell is going to be what the lawsuits look like over the next 5-10 years.Report
I suppose for those of us who are concerned about regret among minors due to faddism or excessive zeal, it’s a fair question to ask what post-op timeframe we would expect the regret to show up.Report
Regretting childlessness seems to hit in the 40’s.Report