The Dangerous and Muddled Logic of Gender Medicine

Gender medicine is riddled with contradictions. On the one hand, clinicians frame “gender dysphoria” as a clinical diagnosis that demands “medically necessary” treatments. On the other, they often adhere to the “gender incongruence” model, which holds that having a cross-sex identity is not a medical problem, but instead a normal expression of “human diversity.” Consequently, they argue, access to surgeries and hormones should not be conditioned on the experience of “sex distress.”

These contradictions have human costs. Newly released videos, featuring Johanna Olson-Kennedy and Rob Garofalo—prominent gender clinicians and members of the World Professional Association for Transgender Health (WPATH)—underscore the dangerously muddled logic of gender medicine and reveal how practitioners undermine their supposed “standards of care.”

In March, journalist Ben Ryan released videos of Olson-Kennedy, a gender clinician at Children’s Hospital Los Angeles, training mental-health providers on how to treat “sex-distressed” youth. In one slide, Olson-Kennedy notes that what separates the affirmative model—which emphasizes supporting and validating a person’s “gender identity”—from other historical ways of treating sex distress is that it “follows the child,” meaning treatment eligibility flows from the child’s identity claim, which is not subject to dispute.

“Follow the child” is predicated on two assumptions: that a child has accurate self-knowledge and that “gender identity” is immutable. Olson-Kennedy claims that everyone has a gender identity, which is not subject to social influence and is stable by age four. Later, however, she contradicts herself. “Not everybody who has this experience in childhood is going to continue to identify as a different gender,” she says.

This is a remarkable admission. Trans activists often assert that a person’s “gender identity” is immutable—not subject to change or social influence. Despite being wary of sex stereotypes, gender activists define what it means to be a man or woman in terms of adherence to these stereotypes. A person’s self-proclaimed “gender identity” often reflects the degree to which he believes he conforms to sex-stereotypical attributes.

The popularization of this radical notion has confused untold numbers of young people. One girl on Reddit, for instance, said that, though she had “always felt like [a] girl,” she now believed she was “(probably) FTM” (female-to-male) because she disliked dresses and skirts as a child and preferred animal plushies and dinosaur toys to baby dolls and Barbies.

Self-understanding is subject to change, though. One study found that nearly two-thirds of female detransitioners—girls who adopted and then abandoned a transgender identity—said they changed course after revising their “personal definition of male and female.”

Defenders of the pediatric gender medicine often assert that the “standards of care” for trans-identifying people feature safety guardrails, such as biopsychosocial assessments to rule out alternative diagnoses and to ensure that any mental-health conditions are well-managed. The very idea of safeguards presupposes that not everyone should be eligible for treatment.

But in practice, gender-medicine clinicians often repudiate these guardrail measures, which they argue prevent children from accessing needed care. In her presentation, for example, Olson-Kennedy implies that parents who seek multiple psychiatric referrals for their children are engaging in “conversion therapy.”

Under the gender-incongruence framework, Olson-Kennedy’s logic makes sense. If every child’s identity claim is to be taken at face value—if children “know who they are”—then performing an independent assessment to ensure “diagnostic clarity” is not just irrelevant, but a stigmatizing evil. Olson-Kennedy is obviously worried about inadvertently shaming a child by questioning their identity. This leads Olson-Kennedy to pushback against “a scenario whereby individuals have to prove their ‘gender’ before they can be affirmed either socially, legally, and certainly medically.”

In candid moments, these physicians even argue that psychiatric evaluations are unnecessary. In a video workshop on “Supporting Trans Young People” that Erin Brewer shared with City Journal, Robert Garofalo, a prominent gender clinician at Lurie Children’s Hospital of Chicago, claims that performing a “psychological battery of tests” on trans-identifying minors is unnecessary:

I’ll turn to the child and be like, ‘Yeah, so, what gender identity do you have?’ You know, there’s no form, there’s no scale, there’s no psychological battery of tests that needs to be done. Really, the young person can answer that question for themselves. Sometimes that’s news . . . to parents who think that they’re going to come in and have this evaluation that is going to help determine their child’s gender identity, when really our work sometimes is just getting them to recognize that anyone’s gender identity, be it trans or otherwise, is a normal variation. . .

Garofalo believes his role as a physician is to help trans-identifying minors feel “authentic.” “If a medical provider thinks they have the answer [to whether medical interventions are appropriate], then they’re the wrong medical provider,” he said. “The answer lies within the young person and the family. Your job as a healthcare provider is to help them along that path—to find the answers and solutions that feel authentic and healthy for them.”

This is a radical reimagining of the doctor-patient relationship. Instead of using their specialized knowledge to make medical decisions in the “best interests” of their patients, “affirming” clinicians outsource their judgments to minor patients and their families. Rather than addressing patients’ gender dysphoria, these clinicians validate–and entrench–children’s mistaken perceptions about their bodies.

In a statement worth quoting in full, Garofalo explains how he tries to convince reluctant parents to support their child’s desired treatments:

Most of the young people that come in are wanting to figure out . . .  how fast they can get on hormones and what is the safest process to do that. I would say 80 percent of the young people that come are often really activist in their mindset and come dragging their parents to the medical visit. . . . The counterweight to that is the parents who are often coming in with questions about how can this be done safely, is this really the right decision, and so it’s really a bit of a puzzle to put the pieces together to make sure that you are meeting the patient’s needs but also moving the parents along . . . in a way that continues to get them educated so that they feel comfortable with the decisions that they’re about to make, because the truth is that these young people need their parents support to be well and to do this well, and so it’s our job as pediatricians to make sure that the entire family unit in some ways hopefully moves forward in an ideal situation in a way that feels supportive and nurturing. So, it’s usually the young person who comes in knowing exactly what they want and us trying to navigate a process of having that done safely and allaying parents fears.

Of course, no “safe” way exists to give a child an extraordinarily high dose of cross-sex hormones. But perhaps even more troubling are Garofalo’s efforts to manipulate parents—“mov[ing] the parents along”—into consenting to irreversible medical interventions for their children.

Reading detransitioner lawsuits, it’s hard to square the alleged conduct of physicians and mental-health providers with even WPATH’s recent treatment guidelines. Those standards imply that after appropriate assessment and screening, “affirming” care may not be appropriate for some patients. But under the gender-incongruence framework, children are deemed eligible for treatment in practically every case. When Olson-Kennedy and Garofalo describe their incoherent and dangerous visions of gender-affirming care, the gap between the field’s standards and real-world practice becomes clearer. As the saying goes, “when someone shows you who they are, believe them.”

Photo by AaronP/Bauer-Griffin/GC Images via Getty Images