The Good Fight
Helen Joyce on Youth Gender Medicine

Helen Joyce on Youth Gender Medicine

Yascha Mounk and Helen Joyce discuss the evidence base for the use of puberty blockers and cross-sex hormones in young people.

Helen Joyce is an Irish journalist and the Director of Advocacy at Sex Matters. She is the author of Trans: When Ideology Meets Reality.

In this week’s conversation, Yascha Mounk and Helen Joyce discuss the findings of an independent review by Hilary Cass of gender identity services for children and young people in the United Kingdom; how government and public health institutions in the UK have come to take a more skeptical view of gender-affirming care for young people than in the US; and the need for a more thoughtful and nuanced approach to trans issues which considers the rights and safety of all individuals involved.

The transcript and conversation have been condensed and lightly edited for clarity.

Yascha Mounk: You're one of the big voices in the debate about trans issues around the world and particularly in the United Kingdom. The UK has undergone a real change in where institutional thinking is on some issues relating to trans rights, particularly when it comes to youth gender transitions.

Tell us a little bit about the Hilary Cass report, which made big headlines around the world (strangely, not as much in some mainstream American news outlets) and which really seems set to change the consensus view shared by both the Conservative Party and the Labour Party in the United Kingdom about the appropriate approach to youth gender medicine.

Helen Joyce: Hilary Cass is a very eminent pediatrician. She was a former president of the Royal Society of Pediatrics. and she was asked about four years ago by the government to look specifically at National Health Service treatment, and specifically for children in England and Wales. That's basically one clinic, the clinic called GIDS (Gender Identity Development Services) at the Tavistock Clinic in London, because that's the one specialist service for the whole of England and Wales that looks at under-18s. And there have been worries about that service for years now. I mean, it's shocking to hear this, but the first whistleblower from that service was in 2004, a psychiatric nurse who was shocked to see 16-year-olds being given hormones after just four appointments after what she thought was a terribly superficial discussion beforehand and very little explanation of what the long-term permanent outcomes would be.

There've been a series of whistleblowers, there was a court case with Keira Bell. Concern mounted that this was not a proper NHS facility held to the same standards as other sorts of healthcare, and in particular healthcare for children. And the government commissioned Hilary Cass to do a review.

Mounk: And Keira Bell for those who don't know her is somebody who transitioned from a biological female to a male gender identity when she was a teenager. 

Joyce: That's right. She was at GIDS, but she actually aged out. So she was actually seen by the adult services, but she very quickly went on to testosterone and had a double mastectomy and then quite quickly regretted it. And Americans misunderstand what Keira's case was about—it wasn't an attempt to get compensation. She wasn't suing the clinic. She took a judicial review, which is a mechanism whereby you can challenge a legal authority, a public legal authority, which you say has not lived up to proper standards.

Mounk: And Persuasion was the first to publish her first-person account of her transition and why she came to regret it and how it showed some of the shortcomings in this service. 

Joyce: Yes, that was great that you did that, because you did that very early. So then the interim report came out about two years ago, in fact from the Cass Review, and already it was clear that it was going to be quite critical overall. Those of us who are worried about the way that gender medicine proceeds, especially in pediatric clinics, were hoping that she would give further credence to the arguments we've been making for years that this is not really medicine; children are being subjected to an uncontrolled experiment on the basis of shoddy or no evidence. 

Mounk: Tell us a little bit more about those medical concerns because I understand the prima facie case for why you might want to have gender transition early on, right? If people are severely gender dysphoric, if they feel deeply uncomfortable in their body and don't just wish to live as the other gender, but wish to pass as the other gender, then intervening early on makes a huge difference, right? So I can see the kind of initial case for why we should want people, even at a relatively young age, to have access to some of those treatments. The problem, of course, is that those treatments then come with severe medical risks, including some foreseeable consequences like infertility in many of those cases. 

Why is it that if you're actually concerned for the wellbeing of these troubled young people, you have reason to be skeptical about these youth gender transitions?

Joyce: It's really interesting to hear you describe the rationale because the thing is the rationale has changed entirely at least twice in the period that they've been doing it. So the very first people who did it were in Amsterdam, a Dutch clinic, and their rationale wasn't anything like you described. What they believed was that there were such things as transsexual children and that they could identify them. They didn't have any claim that they were giving a pause or anything like that. They thought they had found children who inevitably or nearly inevitably would continue to identify as members of the opposite sex and they exclusively considered passing as their sole outcome. It's quite shocking when you read and listen to those people talking now, very clearly thinking that these children were in such dire straits that nothing could be done for them, like everything that happened to them in the way of sterility, shame about their genitals (because you can't give people functioning genitals of the opposite sex) and their inability to form relationships and so on, all of that was just accepted that these are the sort of people who can't have that. The sole consideration was whether they would pass.

And then the rationale changed to being about a pause button. They said give people time to think, give them time between when they're 11 or 12 and puberty is likely to start, and 16, when they could consent to something more extreme or permanent. But the thing is that what makes gender distress resolve is that period between 12 and 16, it is learning to understand yourself as a sexual adult being and so on. And those two things are contradictory: They don't need time to think if you've identified the right people. If you haven't identified the right people, then you really need to be sure that people will desist during that period, then, if they're not the right ones.

But the thing is, almost nobody desists; if you take puberty blockers, you're 98% likely, is the best evidence we have, to go on to cross-sex hormones. So when you choose puberty blockers, you are choosing cross-sex hormones and those have permanent impact. 

To the extent that people say puberty blockers are a pause button, that's just false, almost nobody stops on them. These are a very major intervention in a child's development at a very critical point. There are two major developmental sprints in life, and one of them is toddlerhood, and the other one is puberty. And toddlerhood turns you from being someone who's entirely dependent to someone who can grow and learn, and puberty turns you into an adult. And a million, trillion things happen during puberty to your brain and your body. We all know this. Anyone who's had children has seen it happen. I have two sons and they're both adults now. It looks like a fast-forward of a tree growing. The child gets up and they're an inch taller. It's amazing. And everything changes in your brain as well.

It sounds like it's a little tweak to stop and delay puberty, but it's actually a huge shutdown, overnight, of an entire endocrinological system. It's like putting somebody into menopause overnight. You would only do that if the thing on the other side of the scales was really big. And that I'm afraid to say is why American cheerleaders for youth gender transition talk about suicide so much. They say that if you don't give children these things they will inevitably or nearly inevitably kill themselves. Hilary Cass says not only is there no evidence of that, it's not true. Puberty blockers are not a treatment for child suicidality. They do not reduce child suicide. The rate of child suicide among children who are severely gender distressed is higher than among the average child. It's still extremely low, and it's about the same as those with other children who are not gender distressed, who have the same mental health conditions, because children with gender distress do have a lot of mental health conditions. 

Mounk: I want to come back to each of these points because I think they're both very important. First, as I understand you, you're saying there's two separate kinds of arguments against puberty blockers, the first being that people who take puberty blockers then nearly always go on to take cross gender hormones and some percentage of those people may regret doing that. That's obviously a very strong argument. And there's a broader objection here, which is that even if people don't come to regret changing gender in that kind of way, there's still a question about whether it is acceptable to interfere in the process of puberty to such an extent. And whether, of course, 12 to 14-year-olds are able to consent to all of the kinds of consequences that has. Here it feels like we're much more in the realm of trade-offs, where I am very concerned about the kind of medical consequences that these treatments may have. I'm also very conscious of the fact that we don't really know yet fully what kind of consequences they have, because, for example, when you have a loss of bone density, which appears to be the case, that may not be a huge problem when you're 25 or 30, but it may come to be a giant problem once you're 60 or 70. And we simply haven't been making these kinds of interventions long enough to know to what extent that is going to be a problem. But of course, I do also see what's on the other side here, which is to say that if somebody strongly feels that they want to live as the other gender, and they do want to pass, that is a compelling interest. And it's just harder to think about how to balance those things. 

I understand this doesn't exist at the moment, perhaps it'll never exist, but let's imagine we figure out the protocol that just solves the detransition problem—no false positives, no false negatives. How do you think the balance of trade-offs ends up falling on the rest of those cases?

Joyce: Yeah, great question. So we're just imagining that we've identified the right kids and we accept that puberty blockers have potentially very negative consequences. I mean, if you go on puberty blockers at the beginning of puberty, straight on to cross-sex hormones, you will not just be infertile, you will be sterile. There will be no fertility to protect or to preserve. You will be inorgasmic, probably, and you will probably not understand your own sexuality therefore. 

These are enormous things, the sorts of things that get called major human rights abuses when you look back at them in history. You would not do these things lightly. I think fundamentally those are unethical things to even offer to a 10 or 11-year-old because I don't think a 10 or 11-year-old can understand them, even if they say they can. And we saw this play out in fact in Keira Bell's initial hearing. It turned out the clinic had given puberty blockers to three 10-year-old girls, natal girls, and all three had not done anything that you could call counseling on the consequences, in particular the consequences for fertility. And so when asked why, speaking for the endocrinologist, the lawyer said something that is a grotesque fantasy, which is that if those girls wanted to have babies when they were older that were their own, physically, they could come off the puberty blockers around 14 for six months and go through a couple of cycles of egg harvesting once their ovaries had developed a bit, and that then they could freeze those eggs and they could use them in the future. And every part of that is sheer nonsense.

The idea that a 10-year-old could understand what is involved in that—I've actually done IVF three times, both my children are IVF, so I've gone through egg collection. This is not something you could explain to a 10-year-old. It's hard to accept as an adult. The second thing is, who the hell is to carry these babies? If you take testosterone as a female person, your reproductive system is going to go through changes that require you to have your womb removed quite quickly. Testosterone is very bad for the uterus and for the vagina—it thins the skin, it causes bleeding, it causes a lot of pain. So you are putting yourself on a path to hysterectomy at age 10. And children of 10 don't typically know whether they want children and they say silly things like, I'll just adopt. They don't know what adoption is like. We considered that when we were trying to have children. It's very hard and it's not about you, it's about the child.

So this entire thing is a fantasy, every bit of it, and they didn't tell those children any of that. But anyway, you can't. How can you explain to a 10-year-old you're never going to have an orgasm? It would be a totally inappropriate conversation. So I think fundamentally, even if you were identifying the right children, you would simply not be able to get informed consent at that age. And then the last thing I'd say is, why the rush on passing, especially for girls? It's true that a boy who goes through male puberty is going to struggle to pass as a female testosterone does very major things to the body. But women who take testosterone as adults have a much easier time passing as men because they grow facial hair, if they've got the genes for balding they go bald, they build up muscle, their voice breaks. All of these, by the way, are the reasons why it's very hard to detransition for a woman, much harder than it is for a man. So why? Why the rush? 

The only thing that really happens that you're going to have to have a medical intervention to change is that your breasts grow and I just don't see that that's something that you can weigh up against—you know, you're going to lose your reproductive organs. It's a major operation to have a hysterectomy, even when it's being done to save your life. It's not easy. My mother had it in her fifties and she took a year to recover. This is not ethical. It's not an ethical thing to offer a 10-year-old and they will not understand it.

Mounk: Let's circle back for a moment to the point about suicide. So you're right, this has become an increasingly large portion of the rhetoric, certainly in the United States.

We had a piece in Persuasion about Nex Benedict, a teenager in Oklahoma who committed suicide. And this is widely ascribed, including by the president (at least implicitly), to them being transgender and perhaps being bullied for it. The actual facts of the case seem much more complicated than that. This is obviously a very understandable concern, especially if you're a parent to children who are gender dysphoric: The idea that they might be at this highly elevated risk of suicide understandably scares people deeply. 

Why is it that this talking point in your view is erroneous? What is the evidence that this is simply a mistaken way of thinking both about the actual risk that these gender dysphoric young people are at of suicide and how best to counteract that risk?

Joyce: I don't know about the States, but certainly in the UK, any death of an under 18, an unexpected death, like whether that's a murder or a suicide or a car accident or whatever, is automatically added to a particular record and investigated. So we actually have pretty much perfect figures on suicides of under-18s. And Hilary Cass looked at them and it is simply not true. It is just not true that there is a very elevated risk among the children who are, you know, seen by gender clinics or whatever. Obviously there are lots of kids who identify as trans but no doctor ever finds out about that. They socially transition and they haven't even been to their family doctor, it's quite common now, especially if you include non-binary. But there just aren't a lot of child suicides, thankfully. So it's never been plausible, as the number of kids who identify as trans has increased, has rocketed, has multiplied by thousands of percent, that this is a serious driver of suicide, because the figures just don't add up.

It's very, very important not to talk about it like that as well. What the suicide charities and helplines say is never attribute suicide to a single motivation, because it never is one. It never is one thing. And it's called the Werther Effect: You say, oh, people who have these characteristics are suicidal and they kill themselves this way, and suddenly everybody's doing that thing. So you don't describe suicide methods, you don't describe characteristics, you don't suggest that the world would be better off without them or any of those things. And here we are doing all of that.

But the other thing to remember is that these children typically have comorbidities. They have other conditions. One of my colleagues at Sex Matters, where I work, Michael Biggs, who's on the board, has done an interesting study looking at the children on the waiting list for Tavistock because it's quite long. And compared with the average children for their own age, they do have a little bit of an elevated risk. But if you look at what we know about those children being Autistic Spectrum Disorder, being same-sex attracted (that's you know one of the more obvious ones increasing suicide risk, as it happens, being same-sex attracted) it all disappears. So I think they do it because you need to have a motivation for doing what people instinctively understand to be a very major intervention in a child's life. 

The only reason that you would risk a child's brain development, bone development, consign them to sterility, make sure that they won't have a happy sex life, would be that they're going to die otherwise. 

Mounk: And one of the things that I do find striking in general in this current moment is a tendency to catastrophize about the world in pursuit of social justice. We see that in other kinds of areas as well. And I get the instinct behind that, which is, the more we talk about it, the more people will understand the genuine forms of discrimination and injustice that exist and then it'll motivate people to go and fight against them. But I can't help notice how blithely we often risk instilling genuine fears in people and perhaps even leading to genuinely bad consequences in the process of that: If you tell people that every time they step out into the street they're at risk because people hate them so much, that will very understandably lead a lot of people to grow to be deeply anxious about their interactions with the world in a way that has very, very negative consequences for them. And if the risk of suicidality is not what these activists claim, the people advancing that point should really think about how much fear they are instilling in parents and in children in a way that presumably does genuine harm to them. 

Joyce: I think I'm more cynical than you. I don't think your description of their motivation is correct. I think it's moral blackmail. I think in all these cases, it's people saying “My cause is so important that you must accept all of it as a full package, 100%. And if you speak against it, you're a bad person.” And that requires really inflated rhetoric. The outcomes have to be catastrophic.

And they really lose credibility by doing this because hardly anything is like this. But you are so right about the negative consequences for the kids. It's something that's really, really upsetting me at the moment because, rightly, the consequence of the Cass Review has been basically a halt on any new prescriptions of puberty blockers for under-18s—actually in Scotland as well, even though they have a separate regime and a separate clinic. Scottish puberty is not different from English puberty, shall we say. 

This is not an ethical treatment, that's what we said, we should not be doing it. But think of the kids who've been sold it as the thing that's going to save their lives. There are kids on waiting lists, thousands of them, who have fixated (understandably enough, because of the narrative) on this thing as the thing that is literally going to save their lives, and now they're being told that this awful demon, Hilary Cass, doesn't want them to have it. 

Mounk: So as I understand it in the United Kingdom now, both the government and the soon to be government (which is to say, the Labour Party, if the polls are to be believed) have accepted the main findings of the Cass report. So this means that there's been a real change in the public discourse in the United Kingdom and in what the main political forces promise to do. And we've seen similar transitions in a number of other European countries, including in some of the Scandinavian countries. Here's something that I find very interesting about the developments in the United Kingdom, which is that you now have what appears to me from the outside to be a relatively broad political and institutional consensus that has really transformed over the course of the last five or ten years. The government has accepted the main findings of the review but so has the government in waiting.

And of course when you look at the institutional position of the Democratic Party, it is now light years away from where the British Labour Party lies. Why is that?

Joyce: This issue has become part of the Democratic package on one whole set of issues and part of the Republican package in the exact reverse. So if you are a typical woman in the UK who feels strongly that there has been overreach in the trans campaign and that you think that gender medicine has really lost its way, you're actually typically left-wing, you call yourself a feminist, you're active in the Labour Party. The women who have been leading all of this are left-wing women here. And then those women are not saying to get rid of abortion, or to go back to traditional gender roles. They're saying the opposite. They're saying women can be whoever they want to be, men can be whoever they want to be. Don't let your biology hold you back. 

Mounk: Indeed, and just as a side note, one very weird part of the discourse among certain transgender activists in the last years has been this strange resurrection of very restrictive gender norms, where people are told, if you're a girl, but you like playing sports, then perhaps you're really kind of male. And if you're a boy, but you like playing with dolls, then perhaps really you're a girl, which is the most simplistic version of that argument, but one that is quite widespread.

Joyce: Yes, and it's the only one that you can give to children. So I can imagine that an adult would mean something very hard, possibly impossible, to express by saying, “I've always felt I was really a woman,” or “I've always felt I was really a man.” I mean, the best evidence that I found when I was writing my book dates from a review paper around 2000 that looked at the development of gender distress and concluded that gender nonconformity came first and gender distress only developed if gender nonconformity was stigmatized—so a little boy who was shamed by his dad for being a sissy is somebody who's at risk of one day looking around him and saying “I really wish I was a girl. I was meant to be a girl, why am I this way?” 

In countries where people who were enormously atypical for their sex are able to fit into a sort of a third gender role that is not stigmatized, they tend to do that and they typically don't feel any distress about it: so the Faʻafafine in Samoa (the words mean “in the manner of a woman”) are men who dress as women, but they don't take any sort of hormonal or surgical interventions and they aren't called women. They don't find this distressing. They don't find their sexed body distressing. They just regard themselves as not typical men. So gender distress is something that we create by stigmatizing extreme gender dysphoria or extreme gender nonconformity, in most occasions. 

Mounk: So broadly speaking, I think it’s true in the United States that people are very sympathetic to those who struggle with gender identity. They certainly think that it's a free country and part of it being a free country means dress as you like, present yourself as you like, and by and large, though it’s perhaps a little bit more controversial, people feel that if you have a preference to be addressed in a particular kind of way, they will often choose to indulge that. But when it comes to questions like sports, when it comes to women's shelters or prisons, that is where the resistance to the more extreme reaches of trans activism comes in very strongly. 

What do you think would be a more healthy movement for trans rights? Which is to say that when you speak to people like Andrew Sullivan or Jonathan Rauch—who were really among the first to argue for same-sex marriage—for example, they described that they first had to win a fight within their own movement to turn that into a universalist struggle. Those people within the gay rights movement said, “I don't want to get married. That's a bourgeois, hetero institution. We want a revolutionized society.” And people like Andrew Sullivan and Jonathan Rauch had to win those debates internally, to say, no, there's something positive about the special recognition that a lifelong bond between two people gets from the state and society. The way we're gonna win this is to say our love is like yours, why are we being excluded from this? 

I think one of the things that's gone wrong within this debate is that the anti-universalist, more extreme side has won within the trans rights movement, which I think is connected to a broader set of changes in our culture and the receptivity to those kinds of universalist causes. But there is surely a core of a trans movement which is legitimate. I mean, certainly when I think about the kind of mockery of trans people that was very mainstream 15 or 20 years ago, fighting against that and fighting for greater recognition of the struggles and difficulties that people with gender dysphoria face is genuinely an important cause. The problem with it is not that they haven’t identified an injustice that they're fighting against; the problem is that that cause has been captured by an extreme position that is anti-universalist in key respects and therefore both makes genuine mistakes about how society should be organized and also becomes incapable of actually capitalizing on the genuine sympathy that by now most people in these opinion polls and in these focus groups actually have for trans people. Which is the reason why people get negatively polarized: They say: “Well, hang on a second, if accepting trans people means that I'm supposed to also accept A, B, C, D and E propositions, well then I'm not so sure about the original premise.”

What would, according to you, a more philosophically liberal, universalist trans movement look like?

Joyce: I think it would look like something that the people who lead what is currently called the trans movement aren't looking for, is the problem. So you can have consequentialist theories about why gay marriage is a bad idea if you want. You can say… that's just not what marriage is, it's about children or something like that if you want. It's pretty hard to argue that a same-sex couple marrying has large and measurable and direct consequences that are unavoidable for other people. Like you have to make arguments about the whole of society or something like that if you want to make an argument that it's harming other people.

Mounk: I acknowledge that there's obviously some areas where there's just a genuine decision to be made and the choices seem relatively stark—either you allow a biological male who's transitioned to a female gender identity to compete in women's sports or you don't. But there may be a way of having some form of gender self-ID without those consequences. So I saw with mild concern that the German government recently passed a gender self-ID law. And I thought, for the reasons that you outlined in the British case, that would short-circuit an important debate and potentially set the country down the wrong path. But when I looked into it—and I haven't looked into it closely enough to be fully confident in what I'm saying—my best understanding of the law is that this refers, for example, to how you are described in your passport, to the way in which the government will address you, and other kinds of things. But the law also explicitly says that women's shelters, for example, are entitled to make their own decisions about who to admit. And so that is simply decentralized and each women's shelter in its own right can make a decision about whom they count as a woman. And so this to me seems at first blush like a reasonable compromise.

Does that seem to you like the outline of a reasonable way of running society?

Joyce: It's basically what we have here in the UK in that we have a Gender Recognition Act that dates from 2004 and it changes your legal sex for some but not all purposes. And the purposes are ones to do with the government. It's, for example, what it would say on your marriage cert. And it was explicitly said at the time in the debate in parliament that it didn't have an impact on individuals, people stood up and said, well, what about the wife of the man who transitions? Is she meant to pretend that she married a woman? Well, no, of course it doesn't override history and individuals can have their own freedom of speech and conscience and so on—sadly, it hasn't actually played out like that. The practice went a long way away from the law and a woman who says, “That's fine, the government says that you're a woman in some circumstances, but I don't,” will find that she faces consequences. People don't think these things through. The reason why we bother to say M&F on passports and on driving licenses is that the person who's most likely to steal your passport from you and use it is the other adult who lives with you. 

If there are people who are really very uncomfortable with the fact that they are being identified as male or female, I'm fine with accommodating them. It's the same as thinking about a space where there are people who are Orthodox Jewish or who need consideration for halal food, or how you think about Jehovah's Witnesses and blood transfusions—there are people who need accommodation, is the right way to think about it. We just have to think it through. What are all the situations? What are all the needs? Where are the rights in all these situations? Thinking about it like a religion is the best way to think about it: This person has a set of beliefs about themselves and possibly about the world, and we will accommodate it maximally because we are a pluralistic, secular society. But we are not going to require everybody to buy into a belief system that they don't hold and we're not going to impose costs on other people that they haven't accepted and that are outsized. 

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The podcast that searches for the ideas, policies and strategies that can beat authoritarian populism.