Today, social justice imperatives are deeply entrenched in the medical profession. As a close observer of such trends, I have noted a concerted effort to transform the mission of medicine from improving health to advancing social justice and to morphing the identity of the physician from healer to an activist. Nowhere has this ethic been more aggressively pursued than within the realm of gender medicine and scholarship. I chaired the panel on Censorship Around Gender Research and Medicine with panelists Michael Bailey, Diana Blum, and Carole Hooven, held at the Censorship in the Sciences: Interdisciplinary Perspectives conference at the University of Southern California in early January. The speakers that followed me elaborated upon the forms of censorship manifest in treating gender dysphoria (in the context of human psychology and biology), and in studying its origins and expressions. In what follows I share my personal perspective on the ideological subversion of medicine.
For the past 25 years I have been chronicling the erosion of medical excellence and values under the weight of social justice ideology. After the death of George Floyd, the simmering problem became white hot.
One of the earliest post-Floyd examples entails an epidemiologist from the Johns Hopkins Bloomberg School of Public Health who felt moved to urge her Twitter followers to march in protest of police action against black men. “The public health risks of not protesting to demand an end to systemic racism greatly exceed the harms of the virus,” she exhorted [1].
Her imperative was scientifically incoherent—there is no way she could have quantified and predicted the benefit of marching. Yet days later, 1,200 health professionals cheered her on in an open letter [2].
Most troubling to me was not the hypocrisy—though you just know she never would have applied a similarly generous risk-benefit calculus to an outdoor pro-life rally— but the now-publicized fact that she blurred her professional role. And that 1,200 of her colleagues thought that was fine.
The job of epidemiologists is to inform the public about risks, not to tell others what risks are worth taking or what their moral prerogatives should be. The Johns Hopkins professor and her associates had allowed their own moral commitments, as opposed to objective metrics of risk, to shape their advice.
Within the weeks and months that followed, the American Association of Medical Colleges informed medical schools that they “must employ anti-racist and unconscious bias training and engage in interracial dialogues” [3]. In the spring of 2021, the American Medical Association, AMA, advocated “mandatory anti-racism [training]” as part of its vision that all physicians “confront inequities and dismantle white supremacy, racism, and other forms of exclusion and structured oppression” [4].
Clinical responses were influenced by anti-racism and equity agendas. One bioethicist argued in the New York Times that if hospitals needed to ration ventilators—a fleeting but major concern in the winter of 2020—they should prioritize black patients in the spirit of reparations [5].
When the COVID-19 vaccine became available, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC) concluded that race should supersede age as a prioritization category. Why? Because the oldest cohort in America is whiter than the general population [6].
Thankfully the CDC never followed the Committee’s advice. The CDC scientists rightly recognized that the odds of serious illness in older people were far greater than in younger individuals. One CDC official even said that a race-based vaccine allocation plan would result in up to 6.5 percent more COVID-related deaths overall, many of them among black senior citizens [7].
Furthermore, the Committee’s proposal flies in the face of well-established laws of clinical triage, which depend upon patient need and prognosis. Schemes to distribute scarce resources on the basis of group identity deal a serious blow to public trust in the medical system.
More and more, I am seeing an effort to change the mission of medicine to serving social justice and to morph the identity of the physician to an activist, facts and hypothesis testing and forthright acknowledgement of uncertainty be damned.
Nowhere has the ethic of clinical care been more systematically tainted than in gender medicine and scholarship. In their talks, Michael Bailey and Carole Hooven—both of whom have devoted their careers to the biology and psychology of sexuality—and Dr. Diana Blum provided vivid details.
I had one memorable closer encounter. I like to call it a textbook case—literally—of social justice medicine run amok.
In the fall of 2023, the American Psychiatric Association, APA—I used to be a member—published Gender-Affirming Psychiatric Care [8]. The association’s publishing arm hailed it as “the first textbook in the field to provide an affirming, intersectional, and evidence-informed approach to caring for transgender, non-binary, and/or gender-expansive (TNG) people.”
The textbook should never have been published. Instead of providing even-handed analyses of the controversies within a still-evolving topic of gender dysphoric youth, the volume approaches it as a settled matter [9].
The volume, for example, instructs clinicians to take at face value a teen patient’s request (even a child’s request) for transition on its face. “Clinicians should … always allow patients autonomy in their care,” authors wrote. Accordingly, the editors and authors advocated for puberty blockers (chemicals that suppress the natural hormonal development and the appearance of secondary sexual traits) and then cross-sex hormones (estrogen or testosterone) to produce the physical characteristics aligned with the patient’s gender identity.
When it comes to gender-affirming surgery, some textbook authors cautioned that “the [mental health] clinician should never place barriers to surgery, only identify those that exist and assist with overcoming them.” (Emphasis added.)
As a practicing psychiatrist, I would have expected this volume to probe how to conduct productive interviews with all patients, especially children and young teens, who consider themselves candidates for a gender-affirming approach. After all, this book has the seal of approval from the American Psychiatric Association.
It should have advised clinicians to examine, over many sessions, young patients’ experiences and developmental struggles, to learn about their home lives and social worlds, as well as to treat them for the frequent co-occurring issues, such as depression, anxiety, and posttraumatic stress disorder, which sometimes manifest as gender dysphoria. Such foundational steps are ignored [10].
Gender-Affirming Psychiatric Care also fails to mention desistance—the phenomenon wherein gender dysphoria diminishes before transition—as a phenomenon worthy of high-quality studies. Lisa Littman (a physician who identified "rapid-onset gender dysphoria," ROGD) and colleagues suggest a straightforward analysis of desistance that entails selecting a random group of transgender-identified youth and following them over time, while assessing relevant factors (e.g., gender dysphoria, transition steps, current adjustment, and sexuality) repeatedly [11,12]. To counteract self-report bias, additional informants (e.g., parents and therapists) would be enlisted. This design would help identify predictive factors for many kinds of outcomes.
Nor does the textbook mention the robust debate surrounding ROGD. This term, which is not part of the DSM, refers to a young person’s sudden insistence, during or after puberty, that one is trans. The phenomenon seems to overwhelmingly affect girls. Some doctors recognize ROGD as real—bitter debate surrounds its existence—and regard it as the product of social contagion fostered by peers and social media.
Finally, a reader gets no sense that gender-affirming care is the subject of vigorous international scientific debate. Authors ignored the 2022 decision by Sweden’s National Board of Health and Welfare to suspend hormone therapy for minors except in very rare cases and limited mastectomies to research settings [13]. Nowhere mentioned is the fact that the Norwegian Healthcare Investigation Board now defines all medical and surgical interventions for youth as “experimental treatment” and that the French National Academy of Medicine advises caution in pediatric gender transition [14].
The textbook also failed to mention that, in 2020, the United Kingdom’s National Health Service commissioned a comprehensive review of puberty blockers and cross-sex hormones [15]. The interim review conducted by Hilary Cass, honorary Consultant Paediatrician at Evelina London Children’s Hospital, was published in 2022—two years before the textbook appeared. It concluded that “the available evidence was not strong enough to form the basis of a policy position” [16].
Several months after the textbook appeared, the National Health Service released the much-publicized Cass Review, formally known as the Independent Review of Gender Identity Services for Children and Young People [17]. The 2024 review, as foreshadowed by the 2022 interim report, concluded that medical gender transition interventions, such as puberty blockers and cross-sex hormone therapy, have not been shown to provide overall benefit. This is of special concern, given both known and unknown risks of those treatments.
The Cass Review’s 32 recommendations would bring the UK into greater alignment with the other European countries. For example, the report stipulated that although masculinizing and feminizing hormones will remain available to youth over 16 years of age, they should be undertaken only with “extreme caution. … There should be a clear clinical rationale for providing hormones at this stage rather than waiting until an individual reaches 18” [17].
The current policy climate for gender care is fraught. Contrary to the textbook’s full-speed-ahead approach, I subscribe to informed modesty about our understanding of these issues and restraint regarding both chemical and surgical interventions. I believe existing evidence isn’t strong enough to support an unhesitating, gender-affirming approach to youth. But neither do I think that state-imposed bans and limits on gender-affirming care should be endorsed when they apply to the care of adults or interrupt the treatment of youth already in progress [18].
At the same time, blanket denial of the reality of gender dysphoria is unacceptable. Legislation is too rigid to guide specific care—it is not credible to say that there are never instances of youth who might benefit from gender-affirming care—and it turns health issues into partisan battlefields. Conversely, it is hard to look to the usual advisers on clinical protocols, namely professional organizations and state medical boards, as they are mainly in sync with the orientation of this textbook.
Gender-dysphoric youth deserve a comprehensive and clinically judicious textbook from the country’s premiere psychiatric association, not a volume that omits essential facts and perspectives in the service of a political agenda.
The good news is that the plight of such youth has received enormous public attention—rightly so, as parents are deeply concerned about their teenage children, mostly girls, rushing into irreversible biological changes. High-profile stories of young women who regret their choice have brought lawsuits and get noticed [19].
And in October 2024, the New York Times reported the case of a researcher who withheld data on the impact of puberty blockers on adolescent mental health. [20] The researcher, who ran the country’s largest youth gender clinic at the Children’s Hospital Los Angeles, received a multimillion-dollar grant to study the effect of puberty blockers.
When the results showed negligible improvement in depression and suicidal ideation, she was reluctant to publish them, telling the Times that she worried that her “study’s results could be used in court to argue that ‘we shouldn’t use blockers [in adolescents] because it doesn’t impact them.’”
Outside of the transgender issue, troubled domains of medicine are not as well known. But they exist. Medical schools and professional organizations have also compromised standards in teaching, research, and even in clinical care in the name of equity and identity politics [21].
At present, the policy landscape has shifted. President Trump signed one of his earliest executive orders, eight days after his inauguration, aimed at cutting federal support for gender transitions for people under age 19. On June 18, the Supreme Court handed down a 6-to-3 decision upholding the ability of states to ban or limit gender affirming care for minors. As of mid-July, the Children’s Clinic in Los Angeles closed. Stanford Medicine, the University of Pittsburgh Medical Center and Children’s Hospital of Orange County, University of Chicago Medicine, and Children’s National Hospital in D.C. all announced they will end or dramatically scale back services for trans youth. (Incidentally, the kind of research proposed by Littman and colleagues may now be moot due to the administration’s cuts in federal research funding.)
The public needs to become as aware of these broader transgressions, as it is of the more circumscribed but high-profile debates and politics surrounding gender medicine in youth.
[with references]
Senior Fellow, American Enterprise Institute and Lecturer, Yale University School of Medicine |
