The Only Way Out of the Child-Gender Culture War

The U.S. is becoming an outlier. Punitive bans won’t help. Better evidence will.

A waiting room in a doctor's office
Eric Audras / Getty

Sunny Bryant is only 9 years old—but already an old hand at testifying before lawmakers. The youngster from Houston was 4 when she first asked her mother, “Why did you make me a boy? I wanted to be a girl,” as she was being strapped into a car seat. Since then, Sunny and her mother have spoken at the Texas legislature at least five times, entering the political spotlight amid a nationwide surge in attempts to ban child gender transition. This year, 12 states have passed laws to prohibit or sharply restrict the practice.

On March 27 this year, Sunny missed school and waited until late into the night to speak in front of a Texas House of Representatives committee as it considered H.B. 1686, which would ban puberty blockers, cross-sex hormones, and gender surgery for under-18s in the state. (The bill is currently pending.) “If you pass this bill and we stay in Texas, I’d grow up looking like my dad, and that’s a scary thought,” she told the legislators. “I want to grow up looking like me—nobody else, just Sunny.”

How parents and doctors can best support children like Sunny is a fraught question, because of the uncertain medical evidence and the volatile political climate in the United States. A polarized, incendiary debate over child transition is playing out in red and blue states alike: H.B. 1686 is one of more than 450 bills proposed or passed in this year’s state legislative sessions that the American Civil Liberties Union characterizes as anti-LGBTQ. On a single day in Florida two weeks ago, the Republican-dominated House debated limits on drag shows, a bill restricting the provision of trans-inclusive bathrooms, and a ban on youth transition. “I feel like they’re making these kids the ‘other’ and trying to make them out to be bogeymen and bogeywomen,” Fentrice Driskell, the Florida House’s Democratic leader, told me. In a committee hearing last month, for example, Representative Webster Barnaby, a Republican, referred to trans people as “mutants” and “demons.” (He later apologized.) Of the ban on child transition, Driskell added, “This will lead to more transgender youth taking their lives.”

In the United States, then, the debate around child gender medicine has split along partisan lines: Left-leaning activist groups and the White House regularly describe child transition as “lifesaving” and raise the specter of suicide if care is withdrawn. Meanwhile, Texas Governor Greg Abbott and former President Donald Trump have called medical transition “child abuse.” If the most extreme red-state bills go ahead, both parents and doctors could face prosecution for giving a child access to treatment.

I believe that these bans on child transition are unhelpful, illiberal, and in many cases disturbingly punitive—and I say that as someone with serious reservations about the most influential model of child gender care in America.

More than 100 gender-care clinics in the United States treat children, according to Reuters. Because the U.S. health-care system is decentralized, and because a long-awaited study of youth gender care funded by the National Institute of Child Health and Human Development has yet to report its full findings, establishing exactly how patients are being treated in these clinics is difficult. But from the statements of leading practitioners, we do know that many have rejected a model called “watchful waiting,” where extensive talk therapy is preferred to puberty blockers, cross-sex hormones, and surgery—or at least seen as a prerequisite for those medical interventions.

Instead they favor “affirmative care,” which is grounded in the belief that “kids know who they are,” even though a 2016 review of the available studies estimated that, without medical interventions, gender dysphoria in children resolves itself during or after puberty in about 80 percent of cases. (Supporters of medical treatment dispute the validity and relevance of that research.) Seven of the 18 U.S. clinics surveyed in the Reuters investigation said they were comfortable prescribing hormones to minors on their first visit. “Providers and their behavior haven’t been closely studied,” wrote Laura Edwards-Leeper and Erica Anderson, two experienced clinicians in the field, in The Washington Post in 2021, “but we find evidence every single day, from our peers across the country and concerned parents who reach out, that the field has moved from a more nuanced, individualized and developmentally appropriate assessment process to one where every problem looks like a medical one that can be solved quickly with medication or, ultimately, surgery.”

The reason many American liberals give for supporting “gender-affirming care” for children is that they believe the science is settled. Rachel Levine, the assistant secretary for health in the Department of Health and Human Services, has claimed that there is “no argument among medical professionals” about “the value and importance of gender-affirming care.” The truth of that statement depends in part on the definition of gender-affirming care. Every child experiencing distress deserves supportive treatment, which can take a variety of forms. But the statement by Levine, who is herself trans, can be interpreted as suggesting specifically that hormonal and surgical interventions, perhaps even for younger minors, are uncontroversial among clinicians and indisputably backed by sound science. They are not.

In the face of red-state bills, such medical groups as the American Academy of Pediatrics, the Endocrine Society, and the World Professional Association for Transgender Health, or WPATH, have maintained a united front—nothing to see here—even though many pediatricians who oversee care for children are much less certain. Quite understandably, those on the American left who pride themselves on “following the science” on vaccines and climate change take their cues from these powerful institutions on this polarized topic too. Yet as The BMJ’s editor recently said, with scientific understatement, “The strength of [American] clinical recommendations is not in line with the strength of the evidence.” Gordon Guyatt, a physician and professor at McMaster University, in Canada, who coined the term evidence-based medicine in 1991, goes even further. He has called the current American guidelines “untrustworthy.”

To skeptics, the American medical guidelines appear less evidence-based than consensus-based. A sharper way to put that would be that medical associations, under political pressure from activists, may have succumbed to well-intentioned groupthink. The draft version of the latest WPATH guidelines, for example, included minimum recommended ages for surgery. But these were removed from the final version at the very last minute, with no official explanation. (The only such recommendation that remains is a minimum age of 18 for phalloplasty, a surgery after which three-quarters of trans patients suffer complications.) Whatever the reason for the recommended age limits being dropped, the effect is to imply that there is no age at which a patient is not yet ready to make such an important decision. In the U.S., you must be 21 to buy alcohol in a bar. Can it really be taboo to say that 16 is too young for a mastectomy—or 14, or even 12? And yet somehow it is.

Several European countries that once tacked toward affirmative care have recently looked at the evidence and revised their treatment protocols. Sweden’s new guidelines, developed alongside a formal review by that country’s National Board of Health and Welfare, state that the risks of puberty blockers and cross-sex hormones “currently outweigh the possible benefits” and that they should be given only in “exceptional” cases or research settings. Health authorities in England and Finland have also proposed new guidelines that would restrict the use of puberty blockers. Norway’s health-care watchdog states that “the knowledge base, especially research-based knowledge for gender-affirming treatment (hormonal and surgical), is insufficient and the long-term effects are little known.” In France, the National Academy of Medicine now states that, because of the possibility that a social contagion is driving up case counts, doctors should prescribe hormones with “the greatest reserve.” Minors should also be informed about the “irreversible nature” of treatment, and the possibility of “impact on growth, bone fragility, risk of sterility, emotional and intellectual consequences and, for girls, symptoms reminiscent of menopause.”

The U.S. is not a complete outlier in terms of its approach to treatment; medical experts in other developed countries including Italy, Spain, Canada, Australia, and New Zealand still recommend puberty blockers. But some of these are expressing more caution. In August, a leading practitioner in Canada, Joey Bonifacio of Toronto’s St. Michael’s Hospital, called for the country’s doctors to “slow down.” A month later, Charlotte Paul, an epidemiologist and emeritus professor at the University of Otago, wrote in The New Zealand Herald that her colleagues had “pleaded” with her to raise concerns about the treatment, because they feared for their jobs if they did so. “They doubt whether there is sufficient psychological assessment for children with gender dysphoria before they are prescribed puberty blockers,” she wrote. Even in the Netherlands, where the so-called “Dutch protocol” for using puberty blockers was originally conceived, dissent is building about the treatment. “Until I began noticing the developments in other EU countries and started reading the scientific literature myself, I too thought that the Dutch gender care was very careful and evidence-based,” Jilles Smids, a postdoctoral researcher in medical ethics at Erasmus University, in the Netherlands, told the journalist Frieda Klotz for an Atlantic article. “But now I don’t think that any more.”

Across the world, doctors are expressing caution over side effects, acknowledging the experimental nature of medical interventions, and entertaining the possibility that the recent surge in teenage trans identification is socially driven rather than solely evidence of previous underdiagnosis. That has put much of Europe on a different path from the United States. Either these countries—including some of the most progressive and LGBTQ-friendly nations on Earth—are secretly as right-wing as Abbott and Florida Governor Ron DeSantis, or they know something America doesn’t.

With all that said, it can’t be right to prosecute loving parents for seeking care for their children that has been recommended to them by their doctors. Just as we lack proof that current treatments are categorically “lifesaving,” we do not have evidence that they constitute “child abuse.”

The bans are also harmful because of the possibility of unintended consequences, as with abortion restrictions that prevent women experiencing natural miscarriages or molar pregnancies from receiving treatment. Ireland’s abortion ban caused the death of Savita Halappanavar, a 31-year-old woman who developed blood poisoning after doctors refused to give her drugs to complete a miscarriage. Child-transition bans might have similarly unpredictable effects by stopping families in need from seeking help or discouraging doctors from offering any form of support.

Another reason to oppose the bans is that they are fueling what I would call reactive polarization. When red states ban child transition, many on the left instinctively jump to defend medical interventions. This tendency is intensified when youth-gender bills come packaged alongside overtly anti-LGBTQ legislation, as in Florida two weeks ago. Yet child transition should be treated differently from debates over drag-queen story hour—and differently from adult transition, too, where the case for relying purely on informed consent is much more compelling.

The European evidence is part of what persuaded Leor Sapir, a researcher at the right-leaning Manhattan Institute, to testify in favor of the proposed ban in Texas. The other part was his conviction that the American medical system cannot be trusted to moderate itself. “Are these bans the perfect solution? Probably not,” he told me. “But at the end of the day, if it’s between banning gender-affirming care and leaving it unregulated, I think we can minimize the amount of harm by banning it.” Corinna Cohn, a Gender Care Consumer Advocacy Network board member who herself transitioned as a teenager, has also testified in favor of similar legislation. “In a perfect world, the policies would be more nuanced than full bans,” she told me via email. “In practice, there are only two possibilities: a total lack of accountability (status quo), or a ban on the practice entirely.”

These should not be the only two available options. Science is supposed to be a self-correcting process, but that cannot happen when political considerations quash good-faith debate.

Outside of conservative outlets, journalists are reluctant to engage with child transition because of the abuse it generates and the potential for being ostracized by their peers: An open letter to The New York Times by contributors criticizing its coverage of trans issues cited the red-state bills as a reason not to question the progressive consensus. When The BMJ accurately described the flimsiness of the current evidence base, British LGBTQ groups demanded an apology and suggested that the article’s author and the journal’s editor should disclose whether they held “so-called ‘gender critical’ beliefs as this would represent a significant undeclared conflict of interests.” In the five years since the journalist Jesse Singal wrote an Atlantic cover story that aired doubts about the affirmative model, some trans activists have relentlessly demonized him, likening him to Goebbels and accusing him of having blood on his hands.

In the middle of this storm, is there a way forward? I asked Sarah Warbelow, the legal director of the Human Rights Campaign, which fights against the bills, what she believed the ideal regime would be. “We really should be looking towards medical professionals who are well trained in this area of medical care to be working with families to make these decisions,” she told me. I agree—medical decisions are best left to doctors with firsthand knowledge of the patient in front of them, not legislators in a state capital pursuing a culture war.

But persuading politicians on the right to trust physicians will be difficult, because of conservatives’ feeling that the profession has become ideologically blinkered. Critics of the affirmative model often point to the Miami-based surgeon Sidhbh Gallagher, who has 250,000 followers on TikTok and talks about her job as “yeeting the teets,” as an extreme example. (As of last fall, Gallagher’s youngest mastectomy patient, according to The New York Times, was 13 years old.) In the absence of bans, a regime more like the European ones would require doctors to become gatekeepers.

To find a way through this deeply polarized subject—and to make sure that gender-nonconforming children are given the best care, based on the soundest evidence—the only hope is that American medical associations will conduct comprehensive formal reviews of the available studies and take account of the findings of European countries.

A proper systematic review of child-transition care by the American medical establishment might well uncover the same blurry picture now agreed upon by doctors in England, France, Norway, Sweden, and Finland. Clinical guidelines would have to change as a result, stressing the importance of assessment and therapy, and clinics would have to get better at collecting long-term follow-up data. In the meantime, the United States should take after Europe. Requiring medical assessment and counseling before prescribing puberty blockers or hormones to minors would be neither illiberal nor punitive, and insisting that patient outcomes be tracked over several years will give us better data on what works.

That would offer a middle ground between the total bans of the red states and an unregulated, activist-driven regime under which, at some clinics, a minor can obtain testosterone at a first appointment. A more reasoned approach would represent a triumph over partisans on both sides, and—most important of all—do right by the thousands of children seeking care every year.