A Tale of Two States: Gender-Affirming Care in Florida and New Jersey

Florida is converging with social democratic Europe in the treatment gender dysphoric youth while New Jersey is going the opposite direction

Today’s guest post is by Lisa Selin Davis, the author of TOMBOY, a nonfiction book about gender-nonconforming girls that grew out of an op-ed she published in the New York Times in 2017. In a recent Callin interview, Davis talked about how she avoided looking too deeply into the transgender movement while researching TOMBOY out of a mingled sense of caution and incredulity at what she was hearing.

“People were contacting me and telling me scary stories that sounded like right wing conspiracy theories,” she said. And I thought, "There's probably some truth to it, but come on." And they said, "Please, talk to detransitioners and please look at the research that shows that the bulk of gender nonconforming kids with gender dysphoria will not grow up to be trans, but most will grow up to be gay.”

Since the publication of her book, Davis has been reporting on — and trying to publish — about a movement that has placed itself — and much of American society with it — out on a limb by placing gender dysphoric children on a pathway to lifelong medicalization on the basis of confident claims about the safety and efficacy of a range of social, hormonal, and surgical interventions that do not have anything close to the evidence-based consensus its advocates assert on its behalf.

Wesley Yang @wesyang

The virtually lawless aggressiveness and lack of rigor with which this policy is being pursued is breathtaking

This has placed the United States — its Blue states and federal government especially — in an odd situation. It is moving rapidly to embrace protocols for gender-affirming care, which proceeds from the premise that gender dysphoric youth are best regarded and treated as having discovered their true selves in accordance with a dogmatic ideology, which is now being taught as fact in a growing number of early elementary school classrooms. The ideology holds that gender identity is an internal subjective feeling untethered to one’s body or genetics, and that modifying own’s body or endocrine system is merely a form of matching one’s external packaging to one’s true self.

It is doing so at the very moment when several European countries, having reviewed the same body of scientific evidence that American officials brandish as the predicate for an alleged consensus on behalf of gender affirming care, are pulling back from gender affirmative care. European states are pulling back on the basis of the expert assessment of evidence that guides social democratic policymaking in the non-profit, state-run healthcare systems that predominate and to which American liberals and leftists look to as models. Europeans embarked on the experiment earlier than the U.S. in hopes of seeing successful outcomes. When the evidence failed to confirm their hopes, they pivoted in accordance with it. The US federal government and Blue states are pulling in the opposite direction based on a pseudo-consensus manufactured and enforced by a well-organized activist constituency that for reasons unique to the US political system has unusual clout in the policymaking process. The same activist constituency that used intimidation to manufacture a consensus by silencing critics within the medical establishment has largely succeeded in imposing a blackout on any reporting not in the service of that pseudo-consensus throughout mainstream US media.

In the following post, Davis analyzes state guidelines regarding gender-affirming care in two states, Florida, and New Jersey. She notes the irony that it is Florida, the state whose governor has recently come under fire as the avatar of Red State reaction, whose guidelines comport with the evidence-based protocols being promulgated in enlightend Social Democratic Sweden, Finland, and France. The more one learns about this ongoing story, the more such painful ironies come to the surface. Good, right-thinking liberals of America! Bracket your initial reflexes and look beyond the partisan framing of this story. There is much more here than meets the eye.

On this topic, Year Zero intends a subtle shift in approach and tone, from the wry irony and Olympian detachment that it is its hallmark, to serving as a news outlet on the one live subject that more than any other is the paradigm case for ideological succession in year zero.

By Lisa Selin Davis

Recently, the US Department of Health and Human Services released a fact sheet about gender-affirming care for young people, aiming to educate Americans about how best to care for kids with gender dysphoria. But there are actually few properly established facts when it comes to these treatments, and how a state or organization interprets what little evidence we have can lead to very different policies.

For instance: One “fact” HHS showcases is the oft-repeated Trevor Project statistic that “52 percent of LGBTQ youth seriously considered attempting suicide in the past year.” Other studies, however, show a suicide rate of .03% and some clinicians have critiqued the heavily biased survey which resulted in this static.

Another “fact”: “Medical and psychosocial gender affirming healthcare practices have been demonstrated to yield lower rates of adverse mental health outcomes, build self-esteem, and improve overall quality of life for transgender and gender diverse youth.” Medical bodies in the UK, Finland and Sweden suggest that these studies are too low-quality to make such claims, and in fact the science is not settled. The Society for Evidence-Based Gender Medicine has thoroughly fact-checked the HHS’s assertions.

The HHS also includes a chart detailing various interventions and how reversible they are—or not.

This anodyne graphic trivializes the seriousness of these interventions, and muddles the reality of what we know, and what we don’t know, about them.

Social transition, for instance, is a psychological intervention in which a child lives as the opposite sex by changing appearance or name/pronoun, without medical invention. It has shown some short-term benefit for a young, gender dysphoric child. But it’s thought to increase dysphoria at puberty (those who don’t socially transition are likely to desist suffering from gender dysphoria). To understand the long-term impact, we would need carefully controlled studies—right now, we have none.

“Social transition for young children is a field fraught with conflicting perspectives and limited research,” begins a 2017 paper in PEOPLE: International Journal of Social Sciences. The paper claims that “findings indicate social transition for young children results in positive changes in the mood of the child and the child-caregiver relationship as well as improvement in general social relationships.” However, two years later, the same author noted in another paper that there was “little evidence that psychosocial well-being varied in relation to gender transition status.” Fraught with conflicting perspectives, indeed.

And while most kids will go through their natural puberty if they go off blockers, the long-term effects on brain, bone and heart health remain unknown. As multiple evidence reviews have noted: “The quality of evidence for [puberty blockers and hormones] was assessed as very low certainty.”

In Sweden, some children had such debilitating bone injuries from puberty blockers that the premier children’s hospital there stopped administering them. Meanwhile, almost every child in studies who goes on puberty blockers goes onto cross-sex hormones, so it appears less a reversible intervention than a first step toward further medicalization.

As for hormone therapy, males who take estrogen could have the breasts they develop reduced or removed. Females who’ve taken testosterone can get laser hair removal. But there are long-lasting effects of these chemicals and we have very little long-term research on kids who take them, including their link to infertility. If they’re partially reversible, as the fact sheet says, the question is: which part?

The U.S. Government apparently won’t admit any of this complexity or uncertainty. Neither will the New York Times. But other government medical organizations, like France’s National Academy of Medicine, have. The Academy urged “great medical caution” given “the many undesirable effects, and even serious complications, that some of the available therapies can cause.” Those include: “impact on growth, bone fragility, risk of sterility, emotional and intellectual consequences and, for girls, symptoms reminiscent of menopause.”

Their conclusion: “extend as much as possible the psychological support phase.”

Europe and the United States seem to be at odds. The evidence used to stall gender affirming interventions across the Atlantic is used to assert its safety and efficacy here.

Except in Florida, where their own statement on “Treatment of Gender Dysphoria for Children and Adolescents” seemed to echo the sentiments of several European countries. Trans issues sometimes make strange bedfellows.

“Systematic reviews on hormonal treatment for young people show a trend of low-quality evidence, small sample sizes, and medium to high risk of bias,” the Florida memo warns. “A paper published in the International Review of Psychiatry states that 80% of those seeking clinical care will lose their desire to identify with the non-birth sex. One review concludes that ‘hormonal treatments for transgender adolescents can achieve their intended physical effects, but evidence regarding their psychosocial and cognitive impact is generally lacking.’” [Emphasis theirs.]

That must be hard for some supporters of gender-affirmative medical interventions for children to believe when the U.S. Government cited evidence of its own showing that puberty blockers and cross-sex hormones can mitigate depression and suicidality—evidence which the American Academy of Pediatrics used to draft its pro-affirmation policy, along with many other medical and psychological trade and advocacy groups.

But the evidence is low-quality and low certainty, which means that the actual effect may be quite different from what’s estimated. When evidence is marked this way, it includes risks of inconsistency, indirectness, imprecision and bias. And if you’re going to socially transition kids, or block their puberty, or give them cross-sex hormones or remove healthy body parts, you should probably have some high quality and high certainty evidence. But the truth is, we really don’t.

So when the Florida Department of Health acknowledges the “lack of conclusive evidence, and the potential for long-term, irreversible effects,” the resulting policy looks really, really different than policy based on the AAP’s interpretation of that low-certainty evidence. It looks, well, like Europe.

Here’s what Florida suggested for treatment of kids with gender dysphoria:

• Social gender transition should not be a treatment option for children or adolescents.

• Anyone under 18 should not be prescribed puberty blockers or hormone therapy.

• Gender reassignment surgery should not be a treatment option for children or adolescents.

• Based on the currently available evidence, "encouraging mastectomy, ovariectomy, uterine extirpation, penile disablement, tracheal shave, the prescription of hormones which are out of line with the genetic make-up of the child, or puberty blockers, are all clinical practices which run an unacceptably high risk of doing harm." 

• Children and adolescents should be provided social support by peers and family and seek counseling from a licensed provider.

I realize how harsh this seems to those who believe trans kids require urgent medical interventions. I’ve also seen people asking, if social transition is banned, whether short hair will be outlawed for girls, or nail painting for boys, which shows me how many young people, and adults, believe that gender stereotypes and gender identity are interchangeable. But the truth is, these recommendations are in line with what some of the countries with the best healthcare systems in the world are doing.

I’m not saying that the decision might not spring from an ideological bent, or that Florida Republicans aren’t aiming to mop the floor with us liberals in the fall, using trans kids as a wedge issue, and that this isn’t part of their scheme. I’m saying these guidelines are similar to those created by countries using evidence (or lack of evidence) as their north star, not politics. Holding Florida aloft this way creates cognitive dissonance for many of us. We’ve got to get past the dizziness to the point where we can see clearly, even what we’re seeing is the people we hold in the lowest regard doing the right thing.

What happens when a state doesn’t consider all the evidence, or look to Europe as a model? Look at deep-blue New Jersey, where state guidelines for transgender students assert that “School districts should be mindful of disputes between minor students and parent/guardians concerning the student’s gender identity or expression.” Sounds reasonable enough—be aware of tensions within a family. But mindfulness quickly transforms into secret-keeping. “School district personnel should have an open, but confidential discussion with the student to ascertain the student’s preference on matters such as chosen name, chosen pronoun to use, and parental communications.” In other words, parents have no role to play, and are not part of the process. It’s up to teachers, school administrators and kids whether parents should even be notified.

Maybe this seems reasonable to many progressive parents. After all, a person should come out in their own time and way, and many gay adults remember teachers providing a palliative defense against familial rejection; they were adults who offered a safe space when it was far less socially acceptable to come out. But it’s one thing when a kid has trouble mustering up the courage to tell his parents he’s bringing another boy to the prom. It’s another thing to perform a psychological intervention on a kid that often leads to a desire for cross-sex hormones or surgeries without involving the parents.

But these guidelines—and the vast majority of states have something similar—are also based on an earlier era, when there was far less acceptance of LGBT people (and almost no awareness of the concept of gender identity), and they are built on the assumption that parents are potential dangers to their kids. The guidelines go on to suggest resources from the New Jersey Department of Education’s “Child Abuse, Neglect, and Missing Children” web site, as if any parent questioning social or medical gender transition is an abuser.

This assumes that it’s possible to determine for certain whether a child is transgender. But it’s not knowable beyond one’s own declaration. There’s a further assumption that social transition is the right response to a declaration of a transgender identity, but, as noted above, that’s not clear at all. Though of course some children have stealthily lived as the opposite sex many times in history (Joan of Arc, anyone?), social transition is a very new and under-studied psychological intervention.

Despite the Biden Administrations assertions or the AMA’s endorsement, affirmation isn’t the only treatment option, and it’s not actually clear how to help the thousands of kids with gender dysphoria, even the ones who’ve had it since early childhood, as opposed to the adolescent-onset cohort that has exploded in the past few years.

Because we have no clarity about such matters, and because adolescent-onset gender dysphoria often appears with other mental health problems, it’s vitally important to keep parents in the loop.

And that culture of secrecy, of shielding children against their parents with no due process, no determination of a parent being unfit to rear their own kids, does seem to be rampant. Ironically, it’s just what Libs of TikTok was exposing. Though journalist Taylor Lorenz decided to characterize the videos she wrote about in her exposé as anti-LGBT and spreading “groomer” myths, she didn’t appear to consider the content of the videos. Lorenz wrote:

“Tyler Wrynn, a former English teacher in Oklahoma, posted a video telling LGBTQ kids shunned by their parents that Wrynn was ‘proud of them’ and loved them; it was featured on Libs of TikTok last week. Since being featured on the page Wrynn has been barraged with harassment and death threats.”

What Wrynn said was, “If your parents don’t accept you for who you are, fuck them. I’m your parents now.” It’s true that after Libs of TikTok posted the video, the teacher was asked to resign—not because the district was waging war on LGBT youth but because that is not an acceptable way for a teacher to behave. Yet this is the fault not just of the teacher but of guidelines that actively encourage teachers to replace parental authority and relationships. In this upside-down world, stranger danger has been upended, and now the parents are the threat. Yes, some parents are abusive, but the vast majority love their kids and want to help them in any way they can.

Maybe groomer is the wrong word, because the fear among parents, liberal and conservative alike, is not that their children are being molded into future sex slaves. The fear is that they are being indoctrinated into a set of beliefs—beliefs that not everyone shares—about gender that the medical establishment, and much of liberal culture, has rushed to embrace before the evidence is in.