Although my public health training focused on infectious diseases, I care about a wide range of public health issues. My job cuts across domains, and also personally I want people to be comprehensively healthy and not merely free from contagions. So when I saw that health-improving and potentially life-saving interventions were being labeled as child abuse and used as the sole grounds for investigating parents, I was baffled and dismayed. I don’t understand how providing treatments which have demonstrated health benefits can be considered abuse. And now some states want to make providing those treatments a felony.
Now, before we get into the details, let me remind you that I am not a clinician. I am not recommending any particular course of treatment for any individual. Such decisions are best made between patients and healthcare providers familiar with their history and condition, with input from parents or other caregivers where appropriate. I am a public health scientist trying to reconcile the evidence of improved health outcomes from these treatments with the allegation that they constitute abuse.
We often discuss recent research findings here, so let’s look at this paper published a couple of weeks ago. A cohort of transgender and nonbinary youths were surveyed regarding their mental health symptoms, including suicidal thoughts and symptoms of depression. They were then followed for one year and asked the same questions again at 3 month intervals. During that year, some of them received one or more treatments known collectively as gender-affirming care; these treatments include puberty blockers and hormone therapies. The treatments were not randomized; the researchers recorded who received which treatments as part of their care outside of the study. Youths who received gender-affirming care were significantly less likely to report symptoms of depression and suicidal thoughts afterwards.
This is not the first study to look for and find mental health benefits of these treatments. The paper itself has a number of references; there was also a larger study published last year looking specifically at surgical therapies which found benefits including reduction of suicidal thoughts. From what I can gather, the most notable aspect of this latest study is how quickly the benefits are realized. And that strikes me as particularly relevant to the news from Texas. If treatments are being delayed or suspended, even temporarily, out of concerns over legal actions, that means in the short term there will be people experiencing more depression and more suicidal thoughts than they would have otherwise, which can mean long-term or even permanent harm.
After all the public scrutiny of randomized clinical trials in the past 2 years, these nonrandom survey studies may raise questions about methodology. Surveys are widely used tools in public health. Still, self-reporting and nonrandom treatments make it more difficult to eliminate all possible sources of bias and confounding. For example, perhaps the youths who received gender-affirming care have better overall access to healthcare or differences in their support networks compared to those who did not receive the treatments. When multiple studies show the same effect, that reduces the likelihood that there are unidentified effects which are the true causes. Still, if questions about the methodology remain, the answer should be to design more rigorous studies rather than criminalizing treatments which the evidence suggest lead to improved outcomes.
I am also aware that there are instances of individuals who have received some of these treatments and later regretted them, possibly because these mental health benefits were not realized for them. It is a lamentable reality that the benefits of many if not all of our therapeutics are not apportioned equally to every person who receives them. Results vary with everything from acetaminophen to the latest SARS-CoV-2 retrovirals. If one concludes from that observation that we need better, more discerning diagnostics so that we can better predict who will benefit from which gender-affirming therapies and who will be best served by other treatments, I agree. But I cannot see how we can conclude that therapies which have reduced harm for many are actually abusive just because they have not benefited every recipient.
In conversations around this topic, I have seen concerns about disrupting the normal course of puberty. While I can understand why that might sound concerning, I do not think it negates the observed benefits of puberty blockers and other gender-affirming therapies. For one thing, the onset of “normal” puberty has gotten earlier in recent decades, and varies between populations. But more substantively, in a strict sense all healthcare interventions represent a deviation from what would occur normally or naturally. That is why they are called interventions. There is nothing natural about cracking open a person’s ribcage and removing their heart to replace it with another. Disrupting the normal cell cycle of growth and division sounds deleterious, but as chemotherapy it can treat various cancers. There is no question these are life-saving procedures. That is the standard we apply to healthcare therapies–do they demonstrate a net improvement in health?
There also seems to be concerns about the new-ness of gender-affirming care, a term that has less than a decade of history in Google Trends. Compared to some healthcare interventions, gender-affirming care for transgender and nonbinary individuals is a more recent concept; at the same time, puberty blockers and hormone therapies have a history of use for treating other conditions. In light of that recency, I certainly don’t oppose careful consideration of options for each individual in consultation with knowledgeable clinicians and in conjunction with clear consent processes for any treatments. After all, like many pharmaceuticals they can have side effects which need to be weighed against the potential benefits. As with all such decisions, we use the available evidence while acknowledging the remaining uncertainty.
Of course, there are also religious concerns that are raised about affirming transgender identification. In addition to not being a clinician, I’m also not a theologian, so I don’t expect to have a definitive take on that front either. I should also acknowledge that I don’t really expect the Bible to enumerate all the varieties of the human experience, so the most commonly cited verses on this topic are not as clearly relevant to me as they seem to be to some. Still, for whatever it’s worth, I find myself thinking about Paul writing about ensuring that his body serves him, not the other way around. Obviously he was addressing a very different context. Nevertheless, I can’t help but wonder if the principle is more broadly relevant. When gender-affirming care is opposed with reference to genetics, is that prioritizing someone’s genome over their mental health? And is that the right ordering?
I’d also observe that life is a profoundly robust phenomenon. By that I mean that life persists in a wide variety of contexts, in the face of numerous disruptions and perturbations. We can recover from or survive with divers injuries, maladies and afflictions. For that, we can be grateful that God has created life to be so tenacious. As a result of that robustness, there can be and will be many different ways to be alive and to be human. Variations are to be expected. So perhaps we should consider being thankful for those variations as well as the robustness that makes them possible, rather than trying to normalize the most common configurations.
Andy has worn many hats in his life. He knows this is a dreadfully clichéd notion, but since it is also literally true he uses it anyway. Among his current metaphorical hats: husband of one wife, father of two teenagers, reader of science fiction and science fact, enthusiast of contemporary symphonic music, and chief science officer. Previous metaphorical hats include: comp bio postdoc, molecular biology grad student, InterVarsity chapter president (that one came with a literal hat), music store clerk, house painter, and mosquito trapper. Among his more unique literal hats: British bobby, captain’s hats (of varying levels of authenticity) of several specific vessels, a deerstalker from 221B Baker St, and a railroad engineer’s cap. His monthly Science in Review is drawn from his weekly Science Corner posts — Wednesdays, 8am (Eastern) on the Emerging Scholars Network Blog. His book Faith across the Multiverse is available from Hendrickson.
This article is deeply uncharitable. It uses the specter of complicity in the deaths of children to advocate for a political (not scientific!) position, hedged safely beyond the realm of criticism with reminders that the author is neither a physician nor theologian. It fails to engage with any serious arguments for the position that we should not approve giving minors puberty blockers. I think this is irresponsible, especially because it gives such short shrift to InterVarsity’s own doctrinal positions on gender identity.
Of course all medical treatments include intervention in some sense. But the traditional Christian view of healthcare is that medical interventions should promote the proper function of the human person: providing a patient with a functioning heart advances this goal, but inhibiting the natural development from child to adult does not. True, there are a few limited, non-randomized studies that indicate hormonal therapy can produce at least short-term benefits to trans or nonbinary youth with respect to depression and suicidal ideation. But no Christian ethic allows outcomes alone to determine the morality of an action; this article does not even consider the /moral/ tradeoffs that are relevant to the debate. The author also fails to consider whether alternatives to gender affirming therapy (alternatives that may not pose the same moral problems) could also achieve these goals.
This article also lacks nuance and assumes that state legislatures are operating in unilaterally bad ways. The bills in question restrict not only hormonal therapy, but surgical intervention for minors to change their sex. California, Washington, and Oregon all allow such surgeries for children as young as twelve, which even the World Professional Association for Transgender Health says is contrary to the standard of care for minors. Does the author also object to portions of the bill that outlaw such surgical intervention? Or is he “baffled and dismayed” at the idea that Christians would oppose to parents and physicians who facilitate the surgical mutilation of children’s’ genitals? The article doesn’t say.
As I alluded to at the outset, and have stated explicitly elsewhere, I am a public health scientist. Public health frequently intersects with policy and politics; as such, it is difficult and not necessarily desirable to discuss public health science apart from politics. So yes, since I am commenting on policy, I am taking a political position, one which is informed by science. To be clear, however, I am not affiliated with any political party and am not articulating a position in order to align with any political group. As for the “specter of complicity in the deaths of children” we are talking about a population with an elevated risk of suicide and interventions which mitigate that risk; I’m not sure how to talk about this topic from a public health perspective without mentioning the relevant outcomes. These also include quality of life issues like depression, which I also mentioned. Is the objection that I mentioned suicide at all, or how I mentioned it?
In terms of caveats, perhaps I overdid it, but I wanted to draw clear limitations on my professional expertise, first and foremost because personal medical recommendations are a serious matter and I want to be very clear that I am not qualified to offer it. I was also making an attempt at intellectual humility; rather than trying to put myself beyond criticism, I thought I was lampshading areas where I expected the most criticism. Evidently I was wrong on several levels.
In terms of morality, it is true that I did not explore ethical questions. I am skeptical that I am capable of doing so to your satisfaction. But in the interest of acknowledging your concern, I will make some comments and we can see if they are in the right direction. Are we talking about issues of consent? Those are certainly relevant, which is why I tried to emphasize informed decision making and the participation of parents or guardians when minors cannot consent for themselves. Of course, there are also acts which are not permissible regardless of consent. Do you consider administration of puberty blockers in that category, regardless of what they are used to treat? If so, fair enough. If not and they are permissible to treat other conditions, then it seems we are in the territory where tradeoffs and outcomes do matter. In that case, it becomes a question of what constitutes a state of health for these individuals. That is the point at which I look at the literature and see that the best outcomes in terms of quality of life and survival have been achieved via gender-affirming care. Alternatives have been tried and found unsuccessful or less successful. Do you have alternatives in mind that have not been tried?
I’d also add that my main point in writing was to call attention to that evidence, which does not always appear to be part of the conversation. For example, the attorney general of Texas did not cite any of those studies in his opinion. In terms of mental health outcomes, the main citation was a single study that compared long-term outcomes in people treated for gender dysphoria with long-term outcomes in people who never experienced it; that sort of study is not designed and cannot speak to the relative efficacy of different therapies. Legal opinions are different that literature reviews; I don’t know what he was obligated to do. But I believe an awareness of the research and the growing consilience across studies needs to be considered.
In terms of nuance, yes, there are multiple separate interventions and I could have spent more time discussing them individually. At the same time, the proposed legislature and legal opinion were broad and undifferentiated and as such contradict the standard of care which you cited. If they are able to provide an alternative which is consistent with the standard of care, I would not be opposed. But what was put forward at the time of writing did not make sense to me, especially in the absence of reference to the evidence of health benefits, and so that is what I was commenting on.
Hi Dr. Walsh,
Thank you for your thorough & patient response. Let me begin by offering an apology: I should not have said that your caveats about areas of expertise “hedged [it] safely beyond the realm of criticism” or been snarky in my response rather than seeking to understand your position better. That was, hypocritically, uncharitable of me, and not a good way to advance a healthy conversation. Mea culpa, and I will try here to focus on dialoguing well rather than rhetorical flourish. I’ve not responded to everything you say point-by-point, but let me know if there’s anything from my first comment you’d like me to clarify.
Let me also say that (as an attorney), I don’t think the Texas legal opinion was written with the care needed in this fraught area. I think that the parent-child relationship is a sacred one, and I’m reticent to give the state broad-reaching power to jeopardize those relationships.
To be fair to Texas, however, the memo does recognize that the child abuse statutes would not apply in cases of medical necessity. So if it were the case that gender-affirming medical interventions (GAMI) were the only reasonable way to prevent someone’s severe depression or suicide [I specify medical interventions because the opinion did not address counseling or other purely psychological therapy], I don’t think it would be prohibited under even the memo’s reading of the relevant statutes. Plus, the memo argues that GAMI *can* constitute child abuse, not that it _always_ does. I think that also relates to why the memo does not address evidence like the studies you’ve cited: its argument was that, because GAMI prevents the natural development of the reproductive system, it thereby causes “material impairment in the child’s growth, development, or psychological functioning.” (see Tex. Fam. Code sect. 261.001). That can be true—especially for surgical interventions, which by definition prevent the natural development of the reproductive system—even if GAMI has collateral benefits to the child’s mental health.
At any rate, I think most of our disagreement is more fundamental than the specific Texas policy. As to some of your specific questions about my initial comment, part of my concern was the tension between your emphatic opposition to the Texas policy on the one hand and your careful caveats on the other. You seem pretty committed to the view that denying GAMI to minors is wrong and that there is, in fact, a time “[w]hen normal isn’t normative” with respect to gender identity (maybe I’ve misinterpreted your view, or the confidence you have in it—please correct me if I have). The disconnect for me, including with your discussion of suicide, is that your caveats undermine the strength of your position. It’s fine if you think that most evangelicals are in error about the normative relationship between sex and gender identity, but strong criticism should be supported by strong reasons if it is to be persuasive. I think that epistemic humility is a good thing (and, to be clear, I not only lack training in medicine or psychology, but I’m not a scientist, either. And I certainly think your training is more relevant to addressing the science here than my own is).
In light of your response, I guess my error was thinking that your primary goal was setting forth a positive defense of providing GAMI to adolescents, rather than drawing attention to Texas’s failure to engage with what you see as all of the relevant data. So again, I apologize to the extent that I complained about something orthogonal to the point of your post.
Another concern I had was the lack of context for your discussion with respect to how gender-affirming care plays out in the real world. It’s one thing to consider GAMI for the sake of *treating* severe depression or suicidal ideation. But those simply aren’t the standards of care that gender-affirming clinicians have developed. The WPATH, for example, lists two justifications for hormonal treatment for minors: “(i) their use gives adolescents more time to explore their gender nonconformity and other developmental issues; and (ii) their use may facilitate transition by preventing the development of sex characteristics that are difficult or impossible to reverse if adolescents continue on to pursue sex reassignment.” Neither of these goals, it seems to me, are desirable from a Christian point of view. So I think your defense of the collateral benefits of hormone therapy needs to take account of the fact that desired outcomes are themselves contrary to an historically informed, broadly ecumenical Christian position on the normative implications of gendered creation. As for your defense of surgical intervention, even the WPATH standard of care recommends against it for minors. I’m still not sure whether you think that Christians should (in principle) approve surgical transition for minors based on the possible collateral benefits to mental health. If you don’t, then I don’t see how your bringing up the Almazan & Keuroghlian study is relevant to whether the Texas policy is morally objectionable.
For potential alternatives, the Tordof et al. study points out that substance abuse and resilience are modifiable co-contributors to depression and suicidal ideation; these can certainly be addressed apart from GAMI, not simply “through multidisciplinary gender-affirming care,” as the authors suggest. As I’ve mentioned, I’m not a physician, psychologist, or scientist (though I believe Mark Yarhouse has developed a framework for addressing gender dysphoria that is not GAMI dependent). But it seems to me that the Tordof et al. study itself identifies at least some alternative avenues to mitigate risk apart from GAMI. In my view, that should factor into assessing the tradeoffs of whether GAMI is ever medically necessary or appropriate.
Dr. Walsh,
I’ve been thinking about our exchange, and I think I’ve come up with a more concise way to articulate my concerns. The primary reason you think Christians should oppose policies like Texas’s is that some evidence indicates GAMI can be beneficial to minors’ mental health. But that fact does not, without considering other issues at stake, justify GAMI for minors. Here’s an analogy: some evidence indicates that amputation of healthy limbs resolves the psychological distress attributable to Body Identity Integrity Disorder, a condition where patients experience dysphoric mismatch between their body image and their physical body. [1] But a Christian worldview that appreciates the holistic integration of the mind and body should not use those mental-health outcome alone to conclude that amputation is the appropriate treatment for a BIID patient–especially a minor.
Obviously, there are differences between BIID and trans* / nonbinary issues (one of which is that, apparently unlike BIID, most youth gender dysphoria desists without medical intervention). But the principle holds: it is important to consider these issues holistically. I felt that your post was too quick to dismiss other concerns that Christians might have, even though those are essential to knowing whether the mental health outcomes could justify GAMI for minors.
Perhaps your point was mainly that Texas (and most Christians) similarly fail to be holistic because they consider only their sexual theology and not the potential mental health benefits that GAMI has for minors (though, as I noted above, the presence of some benefits may not be determinative of the *statutory* question the Texas memo was addressing). But reading your post, it seemed like your primary goal was to argue that the putative mental health benefits should be the determinative factor, not merely an additional one, to consider.
I hope this comment helps you understand where I was coming from.
JD
[1] See Blom, Rianne M. et al. “Body Integrity Identity Disorder.” PloS one vol. 7,4 (2012): e34702. doi:10.1371/journal.pone.0034702
Also, to be clear–I wasn’t citing the WPATH standards of care to endorse them. I merely wanted to point out that even physicians and medical ethicists who unqualifiedly deny that sex carries normative implications for gender don’t believe minors should receive surgical interventions (despite their possible mental health benefits) and see whether you thought it was relevant to evaluating the wisdom or goodness of Texas’ policy.
JD,
Apologies accepted. I understand these are topics which elicit strong emotions. Caring about what’s best for other people, especially children, is admirable and worth working at even through some bumps.
Perhaps I can start by further clarifying my purpose. As a public health professional, my primary concern is that criminalizing gender-affirming care, either via new statutes or application of existing abuse statutes, will cause harm. Not all individuals may experience that harm, but at a population level there is risk of harm. The evidence for that is all of the literature on the efficacy of such treatments; I referenced Tordoff et al as especially relevant to short-term outcomes. I think we should be working to minimize the harm to an already at-risk group.
I recognize that the evidence is not nearly as substantial when it comes to the specific question of surgical transition for minors. As I indicated earlier, if we were talking about more focused regulation of those treatments specifically to be consistent with the existing standard of care, I would not see the same need to be opposed.
I recognize that the claim is these treatments can themselves represent harm, such as the risk of permanent sterilization. Clearly such risks should be discussed with patients, and I have no reason to think they are not in the general case. But the substantial majority of patients who receive these treatments do not view them as harmful, or at least consider the net result more beneficial than harmful. And there are ways to mitigate the possible risks, such as freezing eggs and sperm.
I agree that health should be considered holistically. I believe that the healthcare professionals and patients (and guardians as appropriate) are doing so in these cases. I suppose I could have addressed that more explicitly; I probably took for granted that was a baseline of practice. Clearly different folks balance the various aspects of health differently, which is another reason why I wanted to make clear that I was not advocating for any specific course of treatment. But there is now decades of practice incorporating these therapies into holistic course of treatment with many positive results. Taking those options away or punishing individuals for using them seems like it needs a much stronger justification than concerns over risks that have been known all along.
And yes, treatment for substance use disorders and other supportive care should certainly be a part of that holistic approach where applicable. If that mitigates the suicide risk and improves quality of life, great. I want healthcare professionals using every option at their disposal to improve the health and welfare of these individuals, because not every patient will have the same needs or respond to the same therapy. That’s why I don’t want to see the therapeutic options limited.
Secondarily, I’ve seen little awareness or discussion of the actual research on these treatments, which is why I wanted to bring some more attention to it. Other conversations this post has generated in other channels has only reinforced that there was a need there. For me, that fits into a broader pattern of individuals being outspoken on scientific topics for religious reasons without actually having a depth of knowledge on those topics. Perhaps I am overly sensitive on that front, or over-generalizing, but it is definitely part of where I am coming from. As a confessing Christian, I don’t want to ask anyone to give up their religious beliefs; I want to model robust engagement with science in conjunction with religious beliefs.
I see your point about body integrity identity disorder. I recognize that amputation is not the standard of care in those cases, although it has been employed in a very small number of situations. But if we are analogizing to treatment of other conditions, there are multiple ways to go. For example, prophylactic mastectomies are now considered for patients with certain genetic risk factors for breast cancer. That’s a significant surgical intervention with its own set of risks and tradeoffs. But we know it will save some lives, so we allow it as an option. I think the same thing is true of these gender-affirming therapies. And so I think they should be available, and the decision to use them should be made by those who best understand both the treatments and the patients.