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Trump’s latest Executive Order — and boy has he been busy with Executive Orders! — takes aim at gender-affirming care for transgender youth. He claims this life-enriching and medically sound practice is, in fact, a collective effort by Radical Doctors to ravage confused children with aggressive and unnecessary surgeries, thus permanently preventing them from ever being able to birth a child into the planet he actively seeks to destroy.
Protecting Children From Chemical and Surgical Mutilation directs the Office of Health and Human Services to establish new guidelines for “promoting the health of children who assert gender dysphoria” or other “identity-based confusion” and to re-evaluate the DSM-V. It directs the Secretary of Defense to ensure trans children of military service members cannot get medical care. It asks the Attorney General to “prioritize enforcement of protections against female genital mutilation,” despite the objective fact that a phalloplasty is not female genital mutilation.
This order will face substantial legal pushback before any of it can be realized, but we fear early compliance as well as the impact of ideas like this on the broader cultural landscape.
It’s Not Just Conservatives Who Support Trump’s Views on Gender Affirming Care
Unfortunately, many of our own political allies share some of the views that enabled zealotry against trans people to reach this fever pitch. They are regularly fed anti-trans ideology and propaganda from the very same media outlets that are presumed to support liberal, left-wing causes. Some of the worst anti-trans journalism in recent memory comes from The New York Times and The Atlantic. Newsweek just declared that JK Rowling “won the culture war.” Liberal pundits blamed trans allyship for the Dems’ 2024 losses, despite Harris never taking an explicit pro-trans rights stance during her campaign. When Sarah McBride’s ability to pee at work was under attack, Alexandra Ocasio-Cortez seemed to be the only Democrat interested in defending her.
Democrats are backing down on trans rights, and they need to stand up. In this post, I’ll attempt to go over some of the major talking points that might come up when speaking with potential allies about gender-affirming care.
What is Gender-Affirming Care?
It’s not “Junk Science,” like Trump says. Gender-affirming care is evidence-based care that affirms the patient’s sense of their own gender. It can include talk therapy, speech therapy, or medications like puberty blockers or hormone therapy, depending on each patient’s individual needs. This care reduces depression and suicidality amongst transgender youth, and every major medical organization has condemned efforts to criminalize and curtail it.
With minors, doctors have very specific guidelines, advised by WPATH (World Professional Association of Transgender Health) to be intentional and careful while providing treatment to ensure the child’s gender incongruence has been longstanding, they’re mature enough to provide informed consent, mental health concerns have been addressed, and the youth is aware of potential reproductive health effects. The WPATH Guidelines is hardly the radical document Trump claims it is, it’s actually quite cautious and often acknowledges when research lacks conclusive determinations.
It’s often claimed that gender nonconforming and neurodivergent kids are being swiftly misdiagnosed as transgender and rushed into surgery when they are simply tomboys, or gay, or autistic. WPATH standards of care acknowledge that diverse gender expressions in children do not always indicate a transgender identity and directs providers to rule out other potential causes of incongruence. They recommend healthcare professionals working with gender diverse children receive training in autism and neurodiversity. While professionals are advised to support children who desire to be acknowledged as their identified gender, there’s no recommendation for immediate medical interventions.
Good parents and doctors can work together to understand the child’s feelings and choose the right course of action.
People Under 18 Rarely Undergo Gender Affirming Surgery, and Actual Children Almost Never Do
Sec.1 of the executive order claims growing numbers of impressionable children are being “maimed” and “steralized” under “radical and false claims” that “adults can change a child’s sex through a series of irreversible medical interventions.”
This is not true.
A study from Harvard analyzing 2019 data found “little to no utilization of gender-affirming surgeries by transgender and gender-diverse (TGD) minors in the U.S.” In fact, cisgender males comprise the vast majority of minors’ gender-affirming surgeries, accounting for for 80% of gender-affirming breast reduction or removal procedures. It’s much easier and more common for teens to get irreversible cosmetic surgeries (which are often gender-affirming in their own ways).
Generally accepted guidelines are to wait until a patient becomes a legal adult to perform surgeries, but exceptions have been made. For teenagers (16-17), generally only “top surgery” is offered, and only after the patient has been “consistent and persistent” in their gender identity for multiple years. It’s not a choice made lightly, quickly, or in isolation. Phalloplastys, which Trump defines as “female genital mutilation,” are only performed on adults. Phalloplasty actually isn’t very popular amongst trans adults, either — only 4%-13% of trans men will receive it.
The process of obtaining gender-affirming surgery is cumbersome, consisting of numerous appointments, approvals and tests. Waiting lists for surgical appointments can be up to two years long. There are truly so many steps! For example, patients seeking vaginoplasties are required to do a full year of hair removal treatment on the surgical site before their surgery.
Ultimately, regardless of age, these are decisions that should be made by a patient, their parents and their doctors — not by the government.
Puberty Blockers Are Not “Chemical Mutilation”
Puberty blockers have been used to treat cis kids with precocious puberty since the 1980s and their application to trans youth is supported by all major medical organizations. They don’t actually “block” puberty, they “pause” it, giving kids a chance to hold off on physical changes that could harm their mental health and be expensive or invasive to repair later in life. Discontinuing blockers returns them to a pre-destined pubertal development, which can be assisted by gender-affirming hormone therapy.
They’re also not widely prescribed. In England, where the National Health Service began issuing new guidelines prohibiting doctors from prescribing puberty blockers to minors? Less than 100 minors in England were already receiving them.
What is the Impact of Hormone Blockers on Fertility?
The Executive Order also argues that “mutilated children” will eventually “grasp the horrifying tragedy that they will never be able to conceive children of their own or nurture their children through breastfeeding.”
Firstly, this assumes an ascription to a value system that prizes reproduction as an empirical and universal desire. Getting breast implants or reductions can also potentially harm a woman’s ability to breastfeed, but that remains legal, even for teenagers. Ultimately, many lifesaving medical interventions offered to children can hinder future reproductive options.
That said! Puberty blockers do not impact one’s ability to conceive in the future. The science on hormone replacement therapy’s long term impact on fertility is still evolving — but those concerned about it can hedge their bets by freezing sperm or eggs prior to starting treatment. Trans men generally seem to be able to get pregnant a few months after stopping testosterone. For trans women, it’s still unclear, some find testicles fail to bounce back to their initial robust levels, other researchers have found the opposite. Honestly it’s hard enough to get answers about what drugs impact the fertility of cis women, let alone trans women, because there’s so little funding for women’s health research.
The reference to breastfeeding is honestly unclear to me — I’m confident that recipients of chest surgery are not horrified or shocked later in life to learn it may impact their ability to breastfeed. Hormones don’t permanently impact milk supply in humans who would otherwise be able to breastfeed, and apparently, some trans men and trans women can breastfeed.
Doctors disclose these possibilities to their patients and they can make decisions from there based on what they feel is best for their health and family. It’s not a surprise.
Do People Regret Gender-Affirming Care?
Trans youth who transitioned at a young age report “high levels of satisfaction with their care,” and only 3% discontinued hormone therapy. Regret is also rare for gender-affirming surgeries. There’s no singular conclusive study, but rates of regret seem to generally hover around 1% but could be even less.
This is an extraordinarily positive outcome. Nearly half of gastric-bypass surgery patients experience some regret about their surgeries, one in five patients regret knee replacement surgery and breast implants. Rates of satisfaction with antidepressants are far lower, but we accept that as par for the course.
In other words; no other medical procedure requires a 100% satisfaction rate to be legal and we shouldn’t expect that of gender-affirming care.
But What About All Those Stories I’ve Seen and Read About People Who Regret Gender-Affirming Surgeries?
Nobody can speak for every de-transitioned person, and we don’t have to deny the possibility that people undergo surgeries or treatments they later regret in order to promote more access to trans health care for everyone. But; we also live in a transphobic world, and many eventual detransitioners face discrimination, bullying, vulnerability to violence and ostracisation post-transition.
These stories do seem to be everywhere sometimes, which is also by design. Some de-transitioners, undergoing a vulnerable and traumatic experience and feeling estranged from LGBTQ+ community, have been recruited by right-wing, anti-trans communities to become spokespeople for anti-trans causes. “I had no limits on how far I would go to please people and help them win,” says Elisa Shupe, a trans woman who briefly detransitioned and became a right-wing hero by doing so. “At every turn, I had people heaping praise on me, which motivated me to do more and more.”
Stories about de-transtitioners are often shared as evidence that the gender-affirming care model is broken, like this recent New York Times piece, which describes behavior from a doctor that, if true, isn’t consistent with any model of care, let alone gender-affirming care. Criminalizing gender-affirming care due to doctors like that would make as much sense as criminalizing back surgery because of Christopher Dunstch. But, often failures in standards of care are a result of healthcare in this country being a total shitshow that incentivizes expedience and makes mental health care nearly impossible to access!
The world and gender and sexuality and our bodies — it’s so fucking complicated. Literally everyone, even the people who hate us, would benefit from a more expansive idea of what it means to “look like” any specific gender and to open our minds to the possibility of gender journeys that take unexpected turns, or outright change mid-life, rather than curtailing and limiting options of gender expression and medical treatment.
“A transition can be beneficial to some people and ‘hellish’ for others,” write trans academics Daniela Valdes and Kinnon MacKinnon in The Atlantic.”These are not opposing viewpoints. They simply reflect a wide range of real outcomes of medical interventions that can fundamentally transform a person’s body and their life.”
In Conclusion….
Let’s be clear: these efforts are not really about concern for the bodies of children, nor do they reflect an actual problem that requires political intervention. The right-wing is seizing trans issues not because they’re relevant to many Americans but because: trans issues are ripe for sensationalization, it’s popular amongst many Democrats too, it makes big money for anti-gay groups running out of LGB issues to oppose, it fits in with an overall push towards conservative and traditional gender roles and because it somehow remains culturally accepted to be vile and cruel to trans people, particularly to trans women. Also, trans people are a small and vulnerable group with little political capital. These efforts are a distraction and a waste of time and resources. Ensuring cis kids and trans kids get the healthcare they need requires more research, not less, certainly not defunding any hospital or medical school that performs gender-affirming surgeries.
The directives in this order are at worst illegal and violent. At best — they save nobody, help nobody, and harm everybody.
this is so helpful, thank you for laying it all out like this.