Controversy erupted here on Science-Based Medicine with a recent publication of a review of Irreversible Damage: The Transgender Craze Seducing Our Daughters by Abigail Shrier. As a family physician who provides affirmative care to transgender adults and youth, I’d like to offer my perspective on the topic.
In brief, Shrier’s book is a fear-filled screed, full of misinformation, biological and medical inaccuracies, logical fallacies, and propaganda. In it, she argues that young cisgender women are “seduced” into believing that they’re transgender by a predatory Internet and social environment.
The book is hardly a pillar of scientific inquiry, either. Rather, it is written in a journalistic style, as might be expected given that Shrier is a journalist with a Bachelor of Philosophy degree and a J.D. and does not claim any particular scientific or medical training. Where citations are provided for claims – a rare phenomenon in this book! – they usually reference newspaper articles, social media posts (usually Reddit or YouTube), or personal interviews or conversations. The book is published by Regnery publishing, a conservative and Christian publishing center which has previously published books from such bias-free authors as Dennis Prager and Ann Coulter.
As physicians and scientists, however, we must look to science to guide us. Unfortunately, the field of transgender science and medicine is one where bias has long haunted the literature. This is most obviously seen in the debates surrounding autogynephilia, a hypothesis proposed by Ray Blanchard (whom Shrier praises) which suggests that transgender women are transgender because of a fetish. The hypothesis has been thoroughly rejected, and I will defer to Julia Serano for her breakdown of the many reasons why. One must thus interpret the literature surrounding transgender issues carefully, particularly for literature that is more than a decade or so old. For those interested, Julia Serano has written many a paper summarizing many of the issues surrounding transgender science.
Shrier makes far too many claims to address them all in a single post. She spreads a lot of misinformation about what we know about treating gender dysphoria and why we know what we know and practice medicine the way that we do. Instead of writing several long posts worth of refutations, I’ll try to summarize and discuss her core points and then focus on the science and medicine of transgender health. I am hardly the first person to critically evaluate Shrier’s book or the concepts she discusses; there are a lot of good readings out there for those inclined to dig in deep in all the aspects. A couple of them are listed at the end of this post.
Shrier’s themes and false major claims include:
- Gender and sex are binary and dependent almost solely on chromosomes and, while transgender and intersex people exist, they are exceedingly rare.
- Gender identity has no biological correlate.
- Parents, particularly mothers, know their daughters completely and therefore would have known that their daughters were transgender before they reached the teen years.
- The ability of a teenager to know themselves and determine their own course in life is questionable at best.
- Being a (cisgender) teenage female is hard, and the Internet has made this worse as it causes a constant bombardment of social pressure. The documented worsening of mental health in the current generation, compared to prior generations, is because of the Internet.
- The massive increase in the number of people who were assigned female at birth (AFAB) seeking to transition is because gender dysphoria is a social contagion, like anorexia and non-suicidal self-injury before it. According to Shrier, teenage girls (i.e., AFAB) are being “seduced” into “cults” and “indoctrinated” into thinking they are transgender boys thinking that it will fix their psychiatric distress.
- Physicians, surgeons, mental health providers, and schools are actively doing harm to teenagers who were AFAB by providing gender affirming care because some might regret their decisions in the future. Those who provide gender affirming care are doing as much harm as they would be if they were to help someone with anorexia avoid food.
- Those who do not embrace the current standards of care have been unfairly and forcibly removed from their positions (e.g., Kenneth Zucker). Parents are being forced to go along under the threat that their child with attempt suicide if they do not.
- The correct way to handle a gender questioning young person is to evaluate for other causes and encourage them to embrace their sex assigned at birth. This approach would not cause harm, whereas affirming their stated identity (or supporting their explorations of gender) does cause harm to them, their family, and their community.
- There is a way to prevent your child from becoming transgender, and that includes not letting your child have a smartphone, maintaining your parental authority, minimizing your child’s access social media (or, preferably, not allowing it), and celebrating femininity. If your child becomes steeped in “gender ideology”, doing anything and everything including removing your child from their school and friend groups and moving the entire family across the country, is reasonable and should be considered. The family would not be wrong in doing so and no one has ever regretted it or caused harm by doing so.
There are two aspects of those claims most relevant to the medical care I provide for transgender people which I would first like to address.
Claim #1: Gender dysphoria is normally vanishingly rare and its increase is because it is a social phenomenon being spread by social contagion, with particularly massive increases in the numbers of transgender people who were assigned female at birth.
Calculating the prevalence of gender dysphoria is an immensely difficult proposition even now. The US census does not collect data on who is transgender. Many health care systems, my own hospital included, do not have electronic health records that record gender identity information in an easily retrievable format. Even for systems that do include this information, exactly how to collect it and display it so as to capture all transgender people is not standardized. The current consensus on best practice is a two-step approach (one example can be read here), with one question asking for sex assigned at birth and another asking for current gender identity. However, my own research during my medical school years showed that this, too, was controversial with both transgender and cisgender (i.e., non-transgender) patients.
The best modern estimate of prevalence is from the Behavioral Risk Factor Surveillance System, a yearly telephone survey administered to a random sample of adults in the United States in English and Spanish using the two step approach. This results in an estimate of 0.6%. Modern attempts to characterize the population into a simple sex ratio results in an overall estimate of 1:1, as is seen in the US Trans Survey, a population-based survey of transgender and gender non-conforming people in the United States.
This is radically different from the old estimate of prevalence in the 1990s which was roughly 1:10,000 to 1:30,000 with a sex ratio of 3:1 of transgender women to transgender men in the United States and Europe. However, these old numbers came from the Netherlands and only included individuals who had received hormone therapy and surgery, not all people with gender dysphoria. In that era we also knew that the sex ratio was not universal in all countries. In Japan the ratio was flipped, with far more trans men than trans women presenting to local clinics.
In order to interpret this change, one must first understand just how much the field of transgender science and medicine has changed since the 1990s. Back then, it was called “transsexualism” and prominent members of the medical and sexology communities actually pondered whether being transsexual was a fetish, while nonbinary identities were unheard of. There was only one way to be a transgender person, and if you deviated from that path you were likely to be denied medical care, leading many transgender people to lie out of necessity. Therapy and “real life experience” (social and/or legal transition) were required before hormone therapy could be administered, without regard to the patient’s physical safety in doing so or the cost/utility of the therapy. In the United States none of this care was covered by health insurance as it was considered elective. Costs could easily run into the tens (or even hundreds) of thousands of dollars. One transgender person I know spent around $90,000 around the year 2000 on just surgeries. It was also rare to hear about transgender people, causing an unknown number of transgender people to live their whole lives without experiencing relief from their gender dysphoria. Physicians and surgeons who could provide affirming care were exceedingly rare and it was not uncommon for patients to travel across state lines seeking care. That’s not to say that it’s easy for many transgender people to access and pay for care now, but it has improved. In the modern era, many insurances do cover transgender-related health care. In my own state of California it is illegal to exclude coverage for such care, and there are many, many more physicians and surgeons providing care.
As for the idea that more young people are seeking services and that more of them were assigned female at birth, that turns out to have some possible basis in data. Not that one could tell from Shrier’s citation of a twitter post referring to the American Society of Plastic Surgeon’s data on gender confirmation surgery statistics:
Between 2016-2017, the # of sex reassignment surgeries in the US for natal females QUADRUPLED and the ratio flipped, with FTM now accounting for 70% of all SRS (1 yr ago it was 46%)
This is a public health EPIDEMIC disproportionately affecting young women! https://t.co/MnM6IqZJbe pic.twitter.com/m41liRmeEy
— EZ (@ZaneEmma) November 30, 2018
This is an incomplete picture of the scope of such surgeries, as they are performed not just by plastic surgeons but also urologists, gynecologists, general surgeons, craniofacial surgeons, and more. (The Crane Center has such a variety, as an example.) The strongest data I could find were referral trends to clinics providing transgender care. This is also a skewed sample, requiring youth to not only have spoken up about their symptoms but to have been heard and supported enough by their parents for them to have taken them to see their physician and then to have been fortunate enough to have a physician who speaks their language, knows where to refer them and for the youth to subsequently be able to attend appointments at a specialty clinic and be able to afford that specialty care.
Having worked in the field of transgender care and having treated youth myself, I can tell you that none of those factors are guaranteed. They are uncommon, if not rare in many communities. Among transgender people who are out to their immediate families, around 1 in 2 transgender people have been rejected in some fashion by their families, 1 in 10 have experienced violence at the hands of their family members, and 8% were kicked out of the house. I will also note that the vast majority of transgender people who have been known to be murdered are transgender women of color. It’s more dangerous to come out as a transgender woman than as a transgender man, and it would not surprise me to see that reflected in clinic referrals.
While the actual population of transgender people may have increased and the composition of the population has changed, we know that correlation is not causation. One need not point fingers at the boogeyman of the Internet and “social contagion” to find an explanation. We’re likely measuring more accurately, and societal norms and legal protections have changed sufficiently such that people can publicly self-identify more safely.
Claim #2: Treating gender dysphoria with affirmation and puberty blockers is premature and causes harm because some children will change their mind.
All medical treatments carry a risk of harm. That’s why we talk about numbers needed to treat and numbers needed to harm and we counsel our patients carefully on the risks and benefits of any given treatment. Affirmative treatment for transgender youth is no different. If we deny an entire population appropriate medical care for fear of what might happen to a minority of the patients we will, in fact, be doing harm, and, contrary to the claims made by people like Shrier, we do provide informed consent to those seeking care. At the first clinic I worked with, where I learned much of transgender medicine for the first time, all patients initialed and signed multiple pages describing all the risks, both theoretical and known. This informed consent process existed for both adult and minor patients.
The concern about patients who may change their mind is very old and largely unfounded. One meta-analysis of transgender adults found, at most, a 1% regret rate amongst those who had undergone surgery, including those who had regrets about surgical complications (i.e., unrelated to the transition itself). The oft-cited “80% of children will change their mind” statistic comes largely from four observational studies from 2008 to 2013 in Canadian clinics. In general, these studies started before the age of 12 and followed up in later adolescence/adulthood (anywhere from after age 15 to after age 17).
These studies have some significant flaws. The authors included many gender nonconforming children (e.g., male children who like dresses), not just those who verbalized that their gender differed from the sex assigned at birth. That’s actually a huge distinction, as many gender nonconforming children are not and never were transgender. Their sample was flawed to begin with, and they relied on DSM III & IV definitions and diagnostic criteria, which do not match modern understanding. To be clear, older understandings of gender identity and transgender issues, like those which shaped the DSM III and IV, were formed primarily by cisgender (i.e., non transgender) people with little to no input from transgender people themselves.
The other major criticism of these studies is in the definitions and the follow up. If a participant dropped out of the study they were categorized as “desisters” along with children who no longer were considered to have dysphoria. That clearly was an assumption and artificially inflated the numbers of children who “changed their minds”. Additionally, some studies defined “desisters” using reporting from people other than the participant. It’s also unknown what happened to these young people in their twenties, thirties, or beyond. The studies themselves are behind paywalls, but many criticisms are publicly available. Research on the social-cognitive development of transgender children continues.
Lastly, as clearly noted in the American Academy of Pediatrics statement, complete with many citations of their own, we use affirmation, pubertal suppression, and hormone therapy in youth because it leads to improved psychological outcomes. The literature is abundant and clear on this topic. Blocking puberty with GnRH agonists is, unlike what Shrier claims, safe and reversible in the pediatric population. Were it not, these medications would not have been in use for decades for precocious puberty.
Finally, I’d like to offer a bonus section of rapid-fire responses to some of Shrier’s other claims.
- Throughout the book, Shrier frequently conflates gender identity and sexual orientation. Sexual experiences and sexual orientation are not related to gender identity. Transgender people can be any sexual orientation.
- “Parents know their children best and have the child’s best interest at heart”. Really? In the United States during 2019, 0.89% of children were reported to be neglected or abused (likely an underestimate due to underreporting), and 77.5% of that neglect and abuse was at the hands of parents. I have seen child abuse in my own practice. It’s not uncommon.
- “Testosterone is associated with endometrial and ovarian cancer”. Actually, we don’t know if it is or not in transgender people. We have little-to-no long term data. However, histological studies have found that testosterone in transgender men is associated with atrophy of the endometrium, which would suggest a far lower risk of cancer. The theoretical concern of testosterone and cancer comes from cisgender women with polycystic ovarian syndrome which has a much different hormonal profile than transgender men.
- “The doses of testosterone are massive and driven by desired physical appearance”. This claim is also not true in the modern era. We aim for physiological levels of testosterone (i.e., around the same level as a typical cisgender man’s) and do regular hormone level testing to ensure we’re not going into supraphysiological ranges which are known to cause harm.
- “Biology is a binary and differences of sex development (DSDs) are vanishingly rare”. False. DSDs are as common as 1 in 5,000 births, and increase to 1 in 200 or 1 in 300 if you include hypospadias and cryptorchidism. Biology is very, very well known to be a spectrum.
- “There is no biological correlate of gender identity or transgender”. This is still actively being investigated, but doesn’t appear to be true. This page has links to several interesting studies.
- “Attempting to prevent a child from transitioning will not harm them. Delaying transition and allowing natal puberty to continue will not harm them.” Conversion therapy has been demonstrated to do immense harm. The history of conversion therapy for transgender youth has been excellently summarized, and the harms of delaying transition-related medical care were summarized in the American Academy of Pediatrics review I referred to above.
In total, I simply cannot recommend this book to anyone honestly seeking to understand transgender science and medicine. Shrier has written a book in an attempt to prove her specific point, not to explore the nuances of a complex field. While there may be some legitimate concerns (e.g., that of how to support those who choose not to continue to transition or to detransition), the overall narrative in Shrier’s book is so tainted by biased language and misinformation that it throws into question its own legitimacy. I am also very concerned that this book, and others like it, will continue to be used as a primary source in efforts to prevent transgender youth from accessing desperately needed medical care.
For those interested in reading other critiques of Shrier’s book, I recommend these two:
As a cisgender physician, I owe much to all of my transgender friends, coworkers, patients, and all the advocates and trailblazers who have so openly shared their experiences. Thank you all for empowering me with the knowledge required to speak on your behalf.