Earlier this month, Democrats on the Oregon House Committee on Behavioral Health and Health Care voted down a proposed amendment requiring that patients who seek reversal of gender-transition treatment (“detransition”) receive the same care and coverage as patients pursuing gender transition. Refusing to take seriously mounting evidence of medical harm and regret from gender transition, Oregon Democrats would apparently rather protect doctors from liability than protect patients’ right to ethical care.
H.B. 2002 puts the state on a path to becoming a “gender-affirming sanctuary” for minors who seek “gender-affirming” drugs and surgeries but live in states that have banned these interventions. The law mandates insurance coverage for the full range of “affirming” procedures, which, based on the World Professional Association for Transgender Health’s (WPATH) most recent Standards of Care, can include anything from run-of-the-mill hormones and facial feminization surgery to boutique procedures—such as “penis-preserving vaginoplasty” for individuals who identify as members of both sexes or the creation of a “flat front” for individuals who identify as “eunuchs.”
WPATH has eliminated all age minimums for such drugs and surgeries. As long as a therapist is willing to write a letter of support for a procedure and a doctor is willing to perform it, Oregon law will mandate the procedure for coverage by private insurance and government-funded Medicaid.
The bill also protects doctors who provide “gender-affirming care” to minors traveling from states where such interventions have been deemed experimental and banned from standard medical practice. How? By ensuring that their liability-insurance premiums don’t go up. Oregon politicians correctly predicted that malpractice-liability insurance premiums for the state’s doctors will skyrocket, rendering it financially unfeasible to provide “gender-affirming care” at scale. At first, patients will come to Oregon from around the country to undergo gender transition; a few years later, some will return to sue. Any malpractice-insurance company worth its salt will anticipate this and want to hike premiums now, to protect itself against the cost of future payouts. The new Oregon bill preemptively curbs the insurers’ ability to do so, keeping the “gender-affirming” machine operating with the state’s full protection from future damage claims.
H.B. 2002’s framers have strategically bundled these highly controversial procedures with abortion rights, a less controversial issue in deep-blue Oregon. The bill pairs pharmaceutical and surgical interventions for gender-questioning youth with measures to ensure abortion access.
Legislative bundling is common practice in American politics, but trans medicine advocates have made an art of it. For instance, 20 states have passed laws designed to make exploratory therapy—misleadingly labeled “conversion therapy”—a risky proposition for mental-health professionals. They have done so, in many cases, by defining “gender identity” as a subset of “sexual orientation.” It’s unclear whether the lawmakers who voted for these provisions had any idea about the key differences between the two meanings of “conversion therapy”; transgender policymaking frequently piggybacks on naïve associations with gay rights. However noble lawmakers’ intentions, the consequences of their actions are troubling: parents in these states struggle to find a therapist who will not instantly “affirm” their distressed child but instead conduct a comprehensive assessment to determine whether the child’s gender issues are secondary to other problems—such as ADHD or sexual trauma—and thus treatable through less invasive means.
Efforts to improve H.B. 2002 via the amendment process failed. Republican state legislator Ed Diehl’s defeated amendment would have ensured detransitioners the same rights as transitioners by mandating that insurance cover detransition procedures. It would also have extended the amount of time that patients harmed by gender-affirming care have to file lawsuits against medical providers. Finally, it would have required the creation of an advisory committee, including detransitioners, tasked with developing a comprehensive informed-consent process to ensure that the young patients expected to flood Oregon’s clinics will receive a full disclosure of the risks and uncertainties associated with this practice. (Many European countries now say that “gender-affirming care” has an uncertain or unfavorable cost–benefit ratio.)
At the committee hearing, Diehl argued that “it’s indisputable that some youth are being harmed. We are not following adequate assessment processes and we’re catching kids in this process. And I feel for those kids [and] young adults. . . . So, if we’re going to go ahead with gender-affirming care without fixing any of these underlying problems or even researching these underlying problems, we’re going to end up with more children and more young adults being harmed. . . . Currently, you can get gender-affirming treatment covered by insurance. But if you face regret and you want to change, that is not covered under insurance.”
Committee chairman Rob Nosse, a Democrat, immediately tried to change the subject. “This is a bill that’s ultimately about insurance coverage, not treatment modalities and standards of care,” he said. When pressed, Nosse insisted that H.B. 2002 “already covers” detransition procedures. This isn’t true, as since confirmed by legislative counsel.
It is often said that stories are more compelling than numbers. Stories of what detransitioners have to endure, physically and psychologically, often for the rest of their lives, must be read to be believed. When Nosse, who presided over the defeat of the detransition amendment, questioned a U.S. study showing a 30 percent detransition rate among adults, Diehl shared the story of a young Oregon man who undertook “gender-affirming” treatment while grappling with serious comorbidities, including meth addiction. The man underwent an orchiectomy (removal of the testicles) and received breast implants, only to “immediately face regret.” But the insurance system that had been so quick to cover implants and castration refused to cover removal of breast implants. The man ultimately had to pay out of pocket and could not afford full anesthesia for the procedure. “That’s not right,” said Diehl.
Nosse expressed disbelief in both the detransition statistics and the credibility of the patient’s story. He suggested that the doctor who removed the man’s breast implants should be investigated for using local, rather than general, anesthesia for the procedure.
Reactions to the Democrats’ dismissal of detransition care depend in part on how common one believes the phenomenon is. One of the most commonly cited studies reports a 13.1 percent detransition rate but claims to find that 82.5 percent of detransitioners self-reported “at least one external factor” (e.g., “societal stigma” or familial rejection) driving their decision. The percentage of people who detransitioned due to “uncertainty or doubt about [their] gender identity” works out to 2.4 percent. Physician Marci Bowers, the president of WPATH, recently cited this study in a New York Times op-ed and concluded that “the vast majority” of detransitioners sought to reverse their decision “because of external factors” and not “because they have been misdiagnosed or their gender identities had changed.”
But this study was based on adult responses to the U.S. Transgender Survey of 2015, a deeply flawed sample. Many of the adults in this study pursued medical transition before the explosion in transgender identity, which even WPATH recognizes in its latest Standards or Care may be due (in part) to “psychosocial factors.” More concerning is that, to be eligible to participate in the survey, participants had to identify currently as transgender. By its own methodology, the survey excludes from the outset all individuals who once identified as transgender but no longer do—in other words, detransitioners. Such a survey can hardly provide a reliable picture about the rate of regret and detransition.
And that rate appears to be far from rare. A 2021 survey of 100 detransitioners found that three-quarters never reported their decision to their providers, suggesting the real possibility of a much larger group of individuals harmed by “gender-affirming care.” Many cited social influences as driving their decision to pursue gender transition. Some recent studies have found a detransition rate between 10 percent and 30 percent. But even if the rate is 1 or 2 percent, it behooves us to remember that the transgender movement itself demands comprehensive reform of social institutions and beliefs systems in order to accommodate a group that represents only 1 or 2 percent of the population. Any argument against detransition recognition and medical care on the grounds that detransition is “extremely rare” can be flipped to assert that the philosophical and medical demands of transgender activists should be dismissed for similar reasons.
The only responsible answer to the question, “How common is detransition?” is that we won’t know for another decade or so. Nonetheless, several considerations suggest that the rate will be far higher than “affirming” advocates predict. First, a growing international consensus holds that the clinical presentation associated with “rapid onset gender dysphoria”—mainly female, with high rates of comorbid psychiatric conditions and no history of childhood gender-related distress—may be behind the rapid rise in referrals. Second, the American affirmative model is reluctant to conduct differential diagnosis due to its reliance on “minority stress” theory, resulting, one can assume, in a higher rate of false positives in gender-dysphoria diagnosis. Third, given the current political climate over trans medicine, detransitioners face severe harassment and intimidation from prominent transgender activists, who regard them as dangerous apostates. The “minority stress” framework that these advocates favor could equally explain why more detransitioners do not come forward.
At the Oregon hearing, Diehl echoed worries about how the affirmative model lacks basic guardrails compared with the more cautious European approach. “We are not following good standards of care. And so, what happens there is, yes, some kids are helped, but other kids are damaged.” Rep. Nosse snapped: “I think that’s ridiculous. I’m sorry.” But if “you think it’s ridiculous,” Diehl replied, “then you need to talk to some of the parents that I’ve been talking to. Talk to the therapists that I’ve been talking to, talk to the doctors.”
As it turns out, doctors who support and practice “gender-affirming care” have already confirmed the suspicions of their critics. In hearings on a pediatric gender medicine ban in Texas, an affirming pediatric endocrinologist conceded, against the explicit statement of the American Academy of Pediatrics, that medical transition “is almost always the answer” for minors who reject their sex. The president of the Texas Psychological Association was asked whether she has ever refused to write a letter of recommendation for hormones for a minor who wanted them; she couldn’t (or wouldn’t) recall a single case.
A Reuters investigation from last year found that “none” of the providers at 18 pediatric gender clinics across the U.S. “described anything like” the months-long mental-health assessments required by the Dutch protocol that pioneered “gender-affirming care” and that are endorsed—albeit not consistently—by WPATH. Seven of these clinics said that they green-light minors for medical transition after a single visit, depending on their age, assuming they don’t see any “red flags,” and provided that the patients and their parents are in agreement. The director of the gender clinic at Boston Children’s Hospital recently admitted that her clinic gives out puberty blockers “like candy.” If all these drugs did was to provide a reversible “window of time” to consider next steps, that would be one thing. But we know with growing confidence that that is not how they work in practice. Virtually all children who go on blockers decide to continue with medical transition.
Given an ideologically charged clinical environment in which guardrails are seen as malicious and kids are assumed to “know who they are,” it would be shocking if the rate of regret and detransition a decade or so from now was only 1 or 2 percent. When the time comes, thousands of young American adults will be seeking justice for the harms they suffered at the hands of doctors they trusted. And unless things change in states like Oregon, the victims of gender medicine will do so while footing their own medical bills.
Oregon Democrats have turned their backs on the victims of gender medicine because, politically speaking, they have no choice. Recognizing detransition as an urgent area of gender health care and insurance coverage weakens the claim that “gender-affirming care” is safe and evidence-based. It contradicts the narrative that “trans kids know who they are.” It undermines gender-affirming clinicians’ faith—a word I use advisedly—that they have reliable tools to distinguish “true trans” kids from kids who are merely going through a phase or who are alienation from their own bodies on account of deeper, unresolved issues like history of sexual trauma.
Faced with Diehl’s accusation of hypocrisy, Nosse did what most politicians would do: he tried to cut the discussion short. But Diehl was adamant. “You are uninformed,” he told his colleague. “And you’re going to live to regret these decisions that have been made.”
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