Progressives need to engage with the specific questions about youth gender care

Abstract values of freedom and equality don't deliver all the answers

Last week Jamelle Bouie wrote a tour de force column titled “There Is No Dignity in This Kind of America.” The piece surveys conservative attacks on trans people in America, including Donald Trump’s proposal to drastically curtail trans adults’ access to medical care, the extreme Abbott/DeSantis moves to ban gender-affirming care for teenagers under all circumstances, and the increasing conservative hysteria over drag shows.

Bouie skillfully elevates these controversies out of the weeds and into the level of principle — “in the democratic ideal, we meet one another in the public sphere as political and social equals, imbued with dignity and entitled to the same rights and privileges” — and argues persuasively for a politics of dignity. He notes that while we best know Frederick Douglass as an anti-slavery activist and advocate for racial equality, he was a broad-minded and forward-thinking visionary who fought for a range of causes that he saw as linked by the quest for human dignity. This loops back to a call for solidarity:

The denial of dignity to one segment of the political community, then, threatens the dignity of all. This was true for Douglass and his time — it inspired his support for women’s suffrage and his opposition to the Chinese Exclusion Act — and it is true for us and ours as well. To deny equal respect and dignity to any part of the citizenry is to place the entire country on the road to tiered citizenship and limited rights, to liberty for some and hierarchy for the rest.

Put plainly, the attack on the dignity of transgender Americans is an attack on the dignity of all Americans. And like the battles for abortion rights and bodily autonomy, the stakes of the fight for the rights and dignity of transgender people are high for all of us. There is no world in which their freedom is suppressed and yours is sustained.

It’s an excellent piece, and it helped me articulate why I disagree so strongly with the segment of Slow Boring’s audience that wants me to join them in complaining about elective pronouns and the contemporary progressive vocabulary of cis-versus-trans. These linguistic shifts are not just some pose or studied effort to slice the political salami just so — they speak to this core question of dignity.

I would add, with a gesture at Judith Shklar, that decent people are on guard against the politics of cruelty. Cruelty can be tempting and it can be fun, but even the worst of us know that cruelty is wrong. So there are always people seeking a higher justification for their cruelty, a reason that being an asshole is actually a high-minded undertaking serving some crucial purpose. And today’s backlash to trans rights clearly involves people doing this — bullies and wannabe bullies being jerks for sport.

And when bullies are working to make so many people’s lives harder, it’s enormously important, as Bouie does, to articulate the guiding principles that help us push back against their conservative crusade.

But it’s also important not to avoid venturing into the weeds of the specific policy questions we’re facing, and this is where I think progressives are falling short.

The opioid epidemic happened in the details

Chris Hayes wrote a great column in advance of the State of the Union address urging Joe Biden to say something about America’s relatively low and anomalously declining life expectancy. As he noted, one big piece of this is the very high and rising level of drug overdoses in the United States:

And overdose deaths are shockingly high. More than 107,000 people died of drug overdoses in 2021 alone. Overdose numbers have been trending in the wrong direction for years now, hitting certain sections of the country particularly hard.

Drug overdoses, like homicides, exert a disproportionate impact on life expectancy because they kill relatively young people. And while the opioid epidemic is objectively hard to solve, explaining why the United States came to have such a large opioid problem is relatively easy.

When pharmaceutical companies developed a new generation of opioid painkillers, they set out to sell those drugs to people, sponsoring propaganda campaigns that were less than truthful about how much less addictive these new drugs are and the range of conditions that opioids can usefully address. The line between chronic and acute pain was blurred, and these companies took advantage of the fact that it’s cheaper and easier to fill a prescription than to undertake an intensive course of physical therapy. Some doctors overprescribed opioids in perfectly good faith; others unscrupulously operated pill mills for personal gain. Often it was hard to know where exactly the line was — when good faith errors are also lucrative, it’s easy to not ask questions.

But the point I’d like to make is that at a very high level, a lot of what the pharmaceutical industry said was completely correct:

• Chronic pain is a huge problem that really was underrated by conventional medicine and was (and is) crying out for solutions.

• Technological innovation really has dramatically improved health care over the years and changed the world for the better.

• New medicines routinely attract crank detractors who exaggerate risks and harm people (consider contemporary anti-vax enthusiasm), and it’s not unusual to see “moral panics” about new trends that are later seen as totally unjustified.

The problem with the whole thing wasn’t the abstract values Purdue Pharmaceutical was appealing to — it was in the specific details of the implementation.

And that’s what I think mainstream liberal commentators are, perhaps inadvertently, ducking on trans rights. It’s good and correct to support the principles of equal dignity and anti-cruelty and to affirm the core claims of everyone to live their lives as they see fit. But delve into the “reader picks” favorite comments on the piece and you’ll see lots of New York Times readers are worried not by what’s in the column, but by what isn’t.

Here’s Michael:

I am a gay man, but I think there needs to be a step or two back taken from what has become the politicization of medical treatment for children who may be transgender. Several years ago, a family living on a street in my neighborhood announced by way of a transgender flag that appeared on their porch that their eight-year-old until then son had recently informed them that he is trans. Since then, children of three other families living on our block have had such an epiphany. Four trans children on one block in Pittsburgh, Pennsylvania? I think not.

Here’s Auriandra:

Being transgender is not a problem. Biological males competing in women’s sports is a problem, at least after Middle School. I also have concerns about physical transitioning at a young age, before a person has reached adulthood. We do not consider people under 18 to be mature enough to vote, drink or have sex with an older person, yet want to make an exception when it comes to undergoing surgery or medical treatment that is in many cases irreversible.

Here’s Helen Elaine:

As a feminist woman, I too want to be treated with dignity. That means recognizing that in some important areas, the difference between male and female humans need to be respected. Surely the transgender activists should recognize that women's rights are in no way complete or guaranteed at this time, and perhaps they could be our allies instead of our adversaries when we state that, in some important areas, we need our spaces.

I don’t share every concern these commenters are raising. But the structural commonality among their points is that affirmation of an equal right to human dignity does not determine a unique answer to all of these questions.

Facts are important

Also last week, NYT Opinion published the results of a focus group headlined “These 12 Transgender Americans Would Love You To Mind Your Own Business,” which I think is extremely understandable.

The vast majority of trans adults are, after all, not competitive athletes or otherwise implicated in these edge-case questions. They want what they are entitled to, which is to be treated with dignity and respect and to be allowed to live their lives as they see fit. Note also that when the Times pushes them on the most controversial issues, these trans panelists themselves are not dogmatic. Phunky says minors shouldn’t be allowed to have irreversible medical procedures. Joseph agrees with Phunky at a high level and mentions hormone blockers as an example of a reversible treatment that should be offered to teens.

This is where you get into the reality that abstract political values don’t always answer factual questions.

Phunky and Joseph agree that teens should be able to get reversible gender-affirming treatments. But are puberty-blocking medications reversible? According to the United States government they are, but the UK’s NICE says there is no good clinical evidence on this.

Importantly, because youth gender dysphoria treatment is an off-label use of drugs that were originally created to treat precocious puberty, the big clinical trials that were conducted for FDA approval don’t really speak to the issue at hand in a clear way. Again, this is not some special feature of gender-affirming care or the fault of anyone in the trans community. But it’s also not a fever dream of the reactionary right. A structural feature of American health regulation is that the FDA sets a very high bar for approving drugs but a very light regulatory bar for their off-label use. Pharmaceutical companies have no incentive to organize new clinical trials because their medication is already being used for this purpose and the market is growing.

This is one of these things where it’s such a political hot button that most of the people offering any commentary on the issue have very strong feelings. I have scanned some of the relevant arguments from qualified professionals and it really strikes me as understudied and somewhat hard to say. My point, though, is that the enduring values articulated by Douglass and channeled by Bouie can’t determine any particular factual conclusion about the impact of medications.

Meanwhile, despite the attention given to the controversy about the reversibility of puberty blockers, the current World Professional Association for Transgender Health recommendations say that “hormones could be started at age 14, two years earlier than the group’s previous advice, and some surgeries done at age 15 or 17, a year or so earlier than previous guidance.” WPATH has its reasons for making this recommendation, but I don’t think Phunky and Joseph are drawing the line the way they did as an attack on the dignity of trans people. It’s quite possible they would change their stance if they knew that WPATH had changed its recommendation — people often have weakly held views and defer to expert organizations. But at a minimum, the current WPATH recommendations are laxer and the science of puberty blockers more uncertain than a casual scan of the coverage would lead you to believe.

What are clinics actually doing?

WPATH is obviously not some right-wing group. These are professionals who’ve dedicated their lives to trans health care, and they are strongly in favor of medical treatment for trans youth, including hormones and surgeries where appropriate.

They’re also at pains to say that these treatments shouldn’t be undertaken cavalierly, writing that “before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken, as outlined above.”

Rachel Levine, the transgender assistant secretary at HHS, similarly wants the public to know that “it’s not like anyone who arrives automatically gets medical treatment.”

But what’s actually happening in the clinics that provide these treatments? Chad Terhune, Robin Respaut, and Michelle Conlin investigated for Reuters and found that in practice, clinics often take a more aggressive approach than that recommended by WPATH and Levine:

In interviews with Reuters, doctors and other staff at 18 gender clinics across the country described their processes for evaluating patients. None described anything like the months-long assessments de Vries and her colleagues adopted in their research.

At most of the clinics, a team of professionals — typically a social worker, a psychologist and a doctor specializing in adolescent medicine or endocrinology — initially meets with the parents and child for two hours or more to get to know the family, their medical history and their goals for treatment. They also discuss the benefits and risks of treatment options. Seven of the clinics said that if they don’t see any red flags and the child and parents are in agreement, they are comfortable prescribing puberty blockers or hormones based on the first visit, depending on the age of the child.

“For those kids, there’s not a value of stretching it out for six months to do assessments,” said Dr Eric Meininger, senior physician for the gender health program at Riley Hospital for Children in Indianapolis. “They’ve done their research, and they truly understand the risk.”

This is, again, a factual question that can’t be resolved through an appeal to abstract values. It’s not rare for actual behavior to diverge from the academic ideal, especially when health clinics get paid for performing services, not for not performing them. Moving to a world where half the country bans these treatments in all circumstances while the other half lets clinics operate unregulated is not a wise and judicious compromise. What we need is for these services to be broadly available under the kind of well-considered circumstances that WPATH recommends and Levine describes, rather than what Reuters uncovered or what Jamie Reed describes as the actual rushed practice at the clinic she used to work with.

Asking questions is important

There’s an internet trope about the guy who’s “just asking questions.”

You don’t want to be that guy. The “just asking questions” guy is operating in bad faith or with a desire to wound people or be cruel or impugn their dignity.

But the process of asking questions — good faith questions with the aim of discovering answers grounded in facts — is fundamental to journalism and to policymaking. I always liked the title of Al Gore’s movie “An Inconvenient Truth” because it captures what makes the climate change issue difficult: fossil fuels are incredibly useful, and the discovery of negative externalities associated with burning them was extremely inconvenient! By the same token, it is extremely inconvenient that widely prescribing OxyContin as a chronic pain treatment doesn’t work and leads to widespread drug addiction. Chronic pain is a very serious problem, and the existing protocols for treating it require a ton of time, labor, and money and are only partially effective.

For all the reasons Bouie outlines, it would be in many ways convenient to stand in unequivocal solidarity with people whose dignity really is under assault from a conservative movement that hasn’t reconciled itself to the gay rights revolution but knows it’s too politically weak to overturn it.

But the very rapid increase in the number of children identifying as trans raises questions about the extent to which the use of gender-affirming medications has been clinically studied, about the actual operation of clinics, and about how the concept of affirming children is being implemented, in practice, by fallible human bureaucracies.

There is also the question of why the increase is preponderantly among people with XX chromosomes.

Progressives like to think of themselves as being on “the right side of history” when it comes to social and cultural controversies, and tend to see solidarity on trans issues as a natural successor to supporting gay marriage and the Civil Rights Act. There is a long tradition of cultural conservatives warning that the newest liberation movement is “going too far” and being proven wrong. There is also a very long tradition of pathologizing girls and young women who don’t conform to patriarchal definitions of femininity. Progressives normally think the pathologizers are on the wrong side of history. And I think there is some reason to believe that at the intersection of clinicians who want to maximize their customer base, pharmaceutical companies that are happy to have new customers, left-wing institutions prioritizing allyship over analytical rigor, and a robust culture of anathematizing anyone who says the “wrong” thing on this topic, we are now in a new era of medicalizing teen girls’ discomfort with patriarchy while downplaying what appears to be a widespread youth mental health crisis.