The Lancet's Flawed Editorial on Trans Youth

Addressing cherry-picked evidence and partisan misrepresentation.

On May 14th, 2021, The Lancet published an editorial titled “A flawed agenda for trans youth”.

This contains a number of weak or flawed arguments and rhetorical framing that I believe are far below the quality one might reasonably expect from a publication as prestigious as The Lancet.

On April 6, 2021, amid a flood of new bills to curb the rights of transgender and gender diverse (trans) youth in the USA, Arkansas became the first state to prohibit doctors from providing youth (<18 years) with gender-affirming treatment: puberty blockers, hormone therapy, and gender-affirming surgery.

From the outset, the focus is on the political and legal situation in the US, which of course is not reflective of the global picture. Seen from the UK, our legislative, medical and political landscape are markedly different, but that has not stopped this article being shared approvingly by UK-based lobbyists such as Stonewall’s Nancy Kelley:

Here we see that editorials such as this are not merely narrowly focused on the specifics - and ethics - of care of vulnerable youth, but actually in service of wider political lobbying. This is evident from the language and framing of the whole editorial:

However, what the bills seek to protect appears to be traditional gender norms, using a vulnerable group in a protracted culture war. The bills' socially conservative advocates create fear by focusing on emotive issues, honing the same messaging around protecting women and children that was used in earlier campaigns against abortion and same-sex marriage. As clinicians, it is important to use evidence to debunk the false claims being made.

The author castigates “social conservatives”, and links opposition to euphemistically titled “gender-affirmative care” as akin to anti-abortion or anti-gay marriage.

This is a binary framing that bears no real relation to the actual breadth of opinion and concern out there. For sure, many social conservatives are in opposition on those grounds - but there is a failure to recognise and account for the positions of the many people who come from an entirely different position. People who embrace and encourage gender nonconformity, who fought for gay marriage, and who now see current attitudes as a regressive approach to behavioural stereotypes that are harming predominantly gay and lesbian youth.

Disproportionate emphasis is given to young people's inability to provide medical consent, a moot point given that—like any medical care—parental consent is required.

This is not a moot point. A parent does not have unlimited power to subject a child to elective medical treatment. Indeed, this is the entire crux of the matter: is the treatment necessary? Does the potential benefit outweigh the potential harm? Is a child capable of understanding what they are consenting to?

This is why so much of this is framed in life-or-death terms - because absent some imminent threat, there is no justification for subjecting a child to experimental treatment in the first place.

Supplanting parents with the law for this decision presumes that a parent living alongside their child cannot grasp what is best for them, despite often witnessing many years of struggle.

And yet, parents abuse their own children, and sometimes the duty of the state is to intervene in the best interests of the child. This is a legitimate conflict - simplistically pretending it doesn’t exist, or that a balance is not needed to be struck, denigrates the debate.

Driving this consent narrative is the anxiety evoked by focusing on the minority who regret transition (estimated as 1% of adults who had gender-affirming surgery as adolescents).

This cites a recent meta-analysis of 27 articles, going back to the 80s. As such, I think it has the following weaknesses for making this specific claim:

  • It covers decades of adult transitioners. Adults are not directly comparable to children because there is wide variation in the persistence of dysphoria past adolescence (as high as 88% in a recent study). This is a key point of contention with early intervention, because this would indicate a nearly 9-in-10 chance of unnecessarily and permanently medicating a child. If regret samples are only drawn from the pool of those who persist into adulthood, then of course regret measures will be lower.

  • It covers surgical outcomes only. This again does not apply to children maybe given puberty blockers and hormone treatments.

  • Patients lost to followup or who (for whatever reason) do not proceed to surgery are often not accounted for - and by the above metric these could easily be patients who presented for treatment, before desisting, something much more likely with younger patients. For example, the meta-analysis cites the following paper as having a cohort of 132, only 2 of whom express regret:

    But actually, the paper starts with 546, which becomes 201 participants, only 136 of whom proceed to surgery, 4 of which are lost to followup. This is a very different picture, with 75% of the recruited sample an unknown quantity - and it is those lost to contact, or refusing to participate, or who simply drop out that are most likely to contain those with regret.

Whatever else, I don’t think that regret rates of adult surgical transition are a useful proxy for regret rates of children who have been affirmed as the opposite sex from a young age and proceed through puberty blockers to cross-sex hormones. I think these are entirely different groups, and using the best-case success rate of one to downplay concerns about the other is disingenuous.

However, in any situation when medical treatment will alter a person's identity, no one can know whether post-treatment regret will occur; therefore what matters ethically is whether an individual has a good enough reason for wanting treatment. Regardless of law makers' stance on identifying with a gender other than one's birth-assigned sex, the autonomy for this decision lies with young people and their parents.

Autonomy, but also clear and informed consent. A child who simplistically believes they are in the wrong body, who may be struggling with internalised homophobia - or homophobic parents - and comorbid mental health issues. Who has been told by people they trust that blockers and other interventions are necessary, and that they will simply go through the “correct” puberty for their “identity”, is being told lies. Phrasing such as “birth-assigned sex” is part of that lie - for sex is determined at conception, and cannot be changed. The association of the word “gender” with “sex” is part of that lie. How can anybody meaningfully consent when surrounded by such imprecise language? Why are children encouraged to change their sex characteristics to express their “gender identity”? What does any of this even mean? When even the Lancet publishes misleading data about rates of regret, or the reversibility and side effects of blockers (see below), how can a child understand this complicated and contradictory picture and offer informed consent?

More fear is stoked by rhetoric about a malevolent threat to children. Social conservatives in the USA, UK, and Australia frame gender-affirming care as child abuse and medical experimentation. This stance wilfully ignores decades of use of and research about puberty blockers and hormone therapy: a collective enterprise of evidence-based medicine culminating in guidelines from medicalassociations such as the Endocrine Society and American Academy of Pediatrics. Puberty blockers are falsely claimed to cause infertility and to be irreversible, despite no substantiated evidence.

Again, the editorial frames opposition as “socially conservative” - and completely ignores the social progressives who are expressing concern. This is simply not a narrative that fits the polarised binary of US liberal/conservative politics. In fact - especially in the UK - opposition is largely left wing, from those who don’t believe that gender nonconformity is something that should be medicalised, and who are worried at the prevalence of gay and lesbian youth in the cohort of children now being referred for paediatric transition.

It is telling also that the study offered to rebut the claims about infertility or irreversibility of blockers is not applicable. The cited paper is a study of the effects of blockers as a treatment for several conditions, but the author here cites the outcome when treating precocious puberty, ie in the instances where a young child is given blockers to halt early pubertal development for a short period, and then allow the remainder of normal adolescence to continue as much as possible.

This is not at all applicable to the treatment of children who go on to cross-sex hormones. These children never experience natural puberty. Blockers in this instance do not delay, they prevent it entirely, and substitute with synthetic hormones to encourage the development of opposite sex characteristics. This is a wholly different treatment pathway, and yes, blockers cause infertility and in some cases complete loss of sexual function, as well as other long term issues.

And the paper itself confirms this:

It believe The Lancet are wholly wrong to present this position with such certainty, and that by making claims that are contradicted by the given citation they fatally undermine this claim.

The dominance of the infertility narrative, usually focused on child-bearing ability, perhaps reveals more about conservatives' commitment to women's role as child-bearers.

Again, this does a huge disservice to the actual debate. The focus is on such things as fertility and sexual function because these are the very things children are incapable of consenting to lose. A child cannot know if they will never want to have a child of their own. A child too young to experience an orgasm cannot consent to never experiencing one.

Puberty blockers are framed as pushing children into taking hormones, whereas the time they provide allows for conversations with health providers and parents on different options. Gender transition involves many decisions over a long time, and those who take hormones do so because they are trans. Contrary to claims of a new phenomenon, trans youth have always existed; historians show they have sought trans medicine since it became possible: the 1930s in the USA.

The concern is that affirming the social sexual transition of a child too young to understand what sex is, is fixating on a fantasy identity that then becomes a medical one, again before a child is too young to know the implications. This is something borne out by the difference in desistance rates between children left to resolve their gender identity in adolescence (ie, allowing non-conforming boys and girls to simply be authentically nonconforming boys and girls) which are up to 88%, and the <1% desistance rate seen with the affirmation approach at the Tavistock. If the intervention itself is fixating and medicalising an otherwise fluid identity, is that really in the interests of the child? And again, this was found in the Keira Bell case - blockers are not in practice “a pause” for “time to think”, rather an early intervention to avoid the development of secondary sexual characteristics and lay the ground for inevitable cross-sex hormones.

Focusing on potential harms ignores the fact that wellbeing is broader than physical health alone. The harms to wellbeing posed by prohibiting care are huge. Being a marginalised group (<2% of US youth), trans youth already experience the stress of discrimination and stigmatisation. They have high rates of depression, anxiety, and suicide: almost double the rates of suicide ideation of their cis peers. As Laura Baams discusses in her Comment, puberty blockers reduce suicidality.

Except as the published work by the Tavistock shows, this is not true. Blockers don’t improve mental health outcomes at all, and indeed the focus on avoiding the development of secondary sex characteristics may even be creating distress.

Additionally, such studies of mental health and suicidality are skewed both by sex differences and confounding comorbidities. Notably, girls are more likely to suffer poor mental health than boys, especially lesbian and bisexual girls. There are large numbers of co-presenting conditions, like eating disorders and self-harm - and it is specifically among girls that we are seeing a large rise in identifying as trans or non-binary.

The author says they have poor mental health because of discrimination and stigmatisation. However, another hypothesis might be that children are identifying as trans as a response to homophobia (as has been reported at the Tavistock), or - in the case of girls - as an escape from a highly sexualised culture of objectification, or experiencing social contagion in friendship groups as has been shown with eating disorders and self-harm in the past. Do they have poor mental health because they are trans, or do they identify as such in response to poor mental health and other social factors?

Separating out whether identifying as trans is a cause of or a response to such things is difficult, but statements like the above are reductive and simplistic. The author leaves no room for such alternative interpretations of the same evidence, which again falls into the whole polarised culture-war framing of the article. Such alternatives invariably are not given weight in pieces like this because they do not fit that narrative.

Removing these treatments is to deny life.

And here is the crux of it - the emotional blackmail. The only thing that could possibly justify the risk of unnecessarily sterilising children is the threat of death.

Moreover, whereas the bills focus on medical treatments, the care trans youth receive is far wider in scope. Those seeking care typically also see social workers and psychiatrists, and much of health providers' work involves listening, talking, and setting up support in their families, schools, and communities. Health providers also discuss with them the idea that gender is something we “do” in social practice and can take many forms.

I struggle to see what the point of this paragraph is. If wider care and therapy are not under threat, why mention them? If the focus of legislation is on medical interventions, then talking about other forms of care is irrelevant. If people are arguing for less medical intervention and more of these wider social measures, then what is the author taking issue with?

Indeed, some choose social transition without medical treatment, and it is useful to remember that the notion of gender dysphoria perpetuates the historical pathologisation of gender diversity. Challenging the current social construction of male–female will undoubtedly ease trans youths' lives, reducing the pressure of rigid definitions. But alongside these social aspects is a pressing need for medical care.

This is pure doublespeak. What is more pathologising of gender diversity than the medication of children who display it, to “fix” their bodies so that they match their expression?

It is precisely the opposition to the pathologisation of gender nonconformity that is at the heart of many progressive objections to the current treatment regime.

We would agree that encouraging children to express themselves however they like is the aim - but we argue that telling them that they need to somehow “correct” their bodies in order to do this is a regressive step. You cannot literally change sex, and telling young children that you can, or connecting such things to stereotypical dress and behaviour and ephemeral feelings is so bizarre that I am still staggered as to how prevalent such a conservative idea is among supposed “progressives”.

Indeed, the idea that you can literally change your sex in this way also means that you can literally change your sexuality. With the right treatment, apparently a gay child becomes the straight one they truly were all along. Can the author really not see how some gay and lesbian people might be appalled by such measures? Might see such interventions as conversion therapy?

This editorial is partisan and polarising. It relies on limited or questionable evidence, does not consider the full range of contradictory evidence, and focuses on a narrow - and false - political framing of a complex and wide-ranging issue. It does nothing more than provide superficial legitimacy and ammunition to a particular political stance, rather than any sort of informative or open assessment of the evidence or genuine criticism.

As such, it is no different to 99% of what is written on this subject, but I do feel that The Lancet ought to aspire to more.