They Know Not What They Do

Late last year, I read the High Court ruling in Bell v Tavistock so I could write a case note on it for CapX. Bell concerned the capacity of children and young people under the age of 16 to consent to gonadotropin-releasing hormone agonists, also known as puberty blockers, followed by cross-sex hormones. These drugs facilitate transition for those suffering from gender dysphoria, and form part of the treatment plan for what used to be called “getting a sex-change.”

However, before I could comment on the judgment or its merits, the first thing that leapt out at me was how the trial was full of bad litigants. People hadn’t compiled data requested by the court (despite being able to do so). Organisations tried to join as interveners despite not having any evidence to add that had not already been adduced by the principal parties. Arguments were made with no foundation in legal authorities, and more than that, did not even attempt to pretend to have any such foundation.

Naturally, this irritated the High Court no end, so much so that several times in the judgment the three judges say they are “surprised” by a party’s activities, which is commonly acknowledged judge-speak (at least in Blighty) for “hopping mad.”

This sort of behaviour has been a running sore in recent high-profile matters. I did wonder, as I read the Bell judgment, if it has roots in an assumption many people acquire as they grow up, viz., lawyers are essentially spongers who do no socially necessary work. Over and over again, I’ve had clients suggest that if legal professionals have an expectation or a procedure we want followed, it’s just an affectation with no purpose.

Now I’ve read Abigail Shrier’s Irreversible Damage: The Transgender Craze Seducing Our Daughters, I am satisfied the thin evidence-base so alarming to the High Court can only partly be laid at the feet of lazy litigants and counsel who have committed the cardinal error of endorsing their clients’ beliefs instead of representing them. The evidence-base for a great deal to do with gender dysphoria and its mutilated child, “transgender medicine,” is close to non-existent. The extent to which we know three-fifths of bugger-all is astounding.

The Latest Craze?

In Bell, the High Court ruled young people (under the age of 16) could not consent to treatment with puberty blockers or cross-sex hormones. As part of that ruling, it described such treatments as “experimental,” observing that “one of the issues raised in these proceedings is the non-existent or poor evidence-base, as it is said to be, for the efficacy of such treatment for children and young persons with gender dysphoria.” Shrier makes the same point, using bigger data sets taken from the much larger US population. In doing so, she highlights an issue that also took centre stage in the English court’s deliberations: all these gender dysphoric girls, what about them?

Historically, “gender identity disorder”—what became “gender dysphoria” in the DSM-5—was a genuinely dreadful psychiatric affliction between 75 and 90 per cent male. In both sexes, it struck early—among children as young as four—who then experienced miserably unhappy childhoods. Think Jan Morris in the UK, or Deirdre McCloskey and Brandon Teena in the US. As recently as 2011, the split among children presenting for treatment on the NHS was roughly 50/50 between natal girls and boys; by 2019 the split had become 76 per cent in favour of girls. And yes, while there has been a recent sudden surge in female referrals, total patient numbers have also swollen by more than 3,000 per cent. Instead of being singular cases, they come in clusters and, strangest of all, this notably slow-building condition strikes later—in adolescence—and without warning.

A malady once confined to roughly one in 10,000 people is now relatively common. Not as common as homosexuality, but it’s safe to say there’s probably one trans kid in every school. And with girls, they talk each other into it in concert. This last is cancelled obstetrician Lisa Littman’s argument, at least. That is, what she calls “Rapid Onset Gender Dysphoria” is an example of “peer contagion,” where girls take on each other’s ailments. Sociologists of popular culture sometimes draw comparisons with “crazes”—think Pokémon or yo-yos. And, in sociological terms, adolescent obsessions with knitted leg-warmers or dyed hair are benign. Where, however, the crazed obsession turns inward—to mortification (anorexia, bulimia), self-harm (cutting), and hormones/surgery (transition)—then the stakes are much higher. As Shrier suggests, the girls rushing headlong into transition “are not getting the treatment they most need.”

Littman was sacked from her hospital consultancy after a campaign against her best described as “demented.” She has published no more papers on peer contagion among adolescents presenting as transgender, and nor has anyone else. This leaves open the possibility that there is a genuine unmet medical need among (mainly) adolescent girls and (more) adolescent boys of which clinicians had previously been unaware. The problem, however, is that we have no further research and nothing to replicate, so whether or not this is the case is simply unknown. And the reason no research has been done is because individuals (academics and medical specialists) who do so put their careers at risk. Shrier provides a grim roll-call of psychiatrists, gynaecologists, psychologists, counsellors, cosmetic surgeons, and psychotherapists run out of town on a rail for expressing doubts or concerns or even simple curiosity about “gender affirming treatment.”

In other words, the lack of scholarship harms both “sides” in this interminable manifestation of what, I suppose, is “culture war.” It’s entirely plausible the NHS’s Tavistock clinic (returning to Bell momentarily) could defend claims against it in future litigation. For that to happen, however, research simply has to be done. You and I may be able to fly by the seat of our pants, but courts cannot and doctors should not. They know not what they do should never be something said of people in the business of doling out life-altering hormones and major surgery.

Questions Not Asked

Shrier shares a background with me—she’s a lawyer-writer, someone who started in practice before turning to non-fiction—and so brings law’s concern for evidence to her journalism and commentary. After reviewing what little we do know about girls and gender dysphoria, she presents for testing by researchers a hypothesis of her own: In short, we’ve contrived to make adolescence so miserable for recent cohorts of tweens and teens—especially girls—that some of them seek to identify their way out of it.

It starts with early and horrible puberties, an age trendline descending first among girls and then, a decade or so later, boys. Primary school teachers are now confronted with girls developing breasts at nine and menses at 10, while, in classes a little above them, 11 and 12-year-old boys sprout facial hair and speak with voices like a Moog synthesiser gone wrong. Girls especially find their emotions unmanageable.

These pubertal children—for that’s what they are—no longer wear the epithet “mall-rats” because malls are closing across the US. Even in countries where they still profitably exist, youngsters don’t “hang out” in them. Instead, they stay indoors and communicate with peers on devices, isolated from each other in a way people born before 1990 struggle to credit. Statistically, these home-bound kids look good: teen pregnancy and abortion rates have plummeted. So have rates of sex offending, up to and including rape. A majority of the young people presenting at gender identity clinics in the US have not only never had sex. They’ve never kissed anyone and, incredibly, “many have never masturbated.”

Shrier is not alone in noticing the extent to which members of the “health professions” have switched from using their professional expertise to diagnose and treat mental illness to a self-assessment model where the patient’s own views—whether of gender dysphoria or something else—are never questioned.

At the same time, depression and anxiety have gone through the roof. So has self-harm and suicide. The old rule of thumb that more teen girls attempted suicide than teen boys but more boys succeeded is going into reverse. Social media makes everyone anxious and sad—at least a little bit. But it hits adolescents harder, and adolescent girls hardest. Sometimes, too, there’s evidence for what gender non-conforming people of my generation call “transing the gay away.” A little boy who likes dressing in his mother’s most glamorous outfits or a little girl who can not only spell carburetor but knows how to fix one is diagnosed with “gender dysphoria” and solemnly told he or she was “born in the wrong body.” Troubling but plausible allegations that some religious conservatives—particularly Muslims—prefer a trans kid to a gay kid have emerged in parallel.

Then there are the co-morbidities—not only autism, which the High Court spotted in Bell—but anorexia, bulimia, and borderline personality disorder. Shrier takes the reader on a scarifying tour of websites where these ailments are flown like flags in a military parade. Yes, celebratory “pro-ana” and “pro-mia” places exist, along with entire campaigns fetishising the black-and-white thinking characteristic of both autism and BPD. Often, these serious conditions are seen not as disorders to treat but identities to celebrate.

Shrier is not alone in noticing the extent to which members of the “health professions” have switched from using their professional expertise to diagnose and treat mental illness to a self-assessment model where the patient’s own views—whether of gender dysphoria or something else—are never questioned. In pointing out just how dangerous this is, Shrier draws on psychoanalyst Lisa Marchiano’s insight that one doesn’t treat suicidal ideation by giving sufferers exactly what they want. “We treat suicide first of all by keeping people safe,” she says, “and by helping them become more resilient.” Marchiano’s concern is shared by commentator Josh Slocum, who uses his weekly podcast to observe how “affirmative therapy” encourages confused adolescents’ self-destructive impulses.

Irreversible Damage concludes with advice, the most salient aspect of which is “don’t get your kid a smartphone.” It’s the fate of human beings, every time a new communications technology emerges, to fail utterly at using it responsibly. This is something we’ve known since Aristotle and his observation that the ability to write things down atrophies memory; there are still Early Modernists out there who blame the printing press for Europe’s wars of religion.

Big Tech and its baleful influence aside, is Shrier right? Are the people she cites at least onto something? The idea that little kids shouldn’t be sitting around the house, noses crawling like snails on the glass of sundry screens, is intuitively appealing. Menses arriving so early—often coinciding with a lack of exercise and fresh air, sometimes comorbid with obesity—should surely invite more scholarly attention. Perhaps it hasn’t because doing so among tween girls in particular plays into stereotypes of female irrationality. However, pathologising girlhood and its emotional lability—treating it with drugs up to and including puberty blockers, flattening it out, or obliterating it with euphoria (a common side-effect of ingesting testosterone)—isn’t a reasonable response either.

At the least, Shrier’s claims should be tested not only because it’s the job of science to try to find its way to the truth, but because courts also need evidence. I’ve already spotted “no-win-no-fee” firms fishing in transgender medicine’s waters. I do not want my profession hauling on the railway brake as the medical profession leaves the tracks.

At the moment, and in this area, doctors truly know not what they do.