In a tense exchange on Thursday during the Senate confirmation hearing of Dr. Rachel Levine, President Biden’s nominee for assistant secretary of health, Sen. Rand Paul exposed his lack of understanding about — or perhaps prejudice against — transgender youth.
After misrepresenting transgender health care as genital mutilation, Paul (R-Ky.), an ophthalmologist, asked Levine, an openly transgender pediatrician, whether minors should be able to request hormone therapy and gender-affirming surgery.
“You’re willing to let a minor take things that prevent their puberty and you think they get that back?” Paul said. “You give a woman testosterone enough that she grows a beard, you think she’s going to go back looking like a woman when you stop the testosterone? You have permanently changed them.”
Paul’s line of questioning reflects a wider set of misconceptions around transgender medicine — namely, that there is an epidemic of youth hastily undergoing sex changes that they later come to regret. Levine aptly responded that transgender medicine has “robust research and standards of care” — peer-reviewed standards of care designed to prevent Paul’s doomsday scenario.
In fact, puberty blockers, along with hormone therapy and gender-affirming surgery, are medically effective in treating gender dysphoria in youth without generating any long-term desire for reversals. Here’s how the multi-staged standards of care work for a young person who enters a clinic for gender-affirming care.
Youths do not make their own gender-affirming decisions ad hoc, as Paul claims, after “read[ing] on the internet about something about transsexuals.”
Before a doctor prescribes some kind of physical intervention, standards of care established by the World Professional Association for Transgender Health require a gender-questioning youth to undergo comprehensive psychological evaluation and counseling. Typically, an entire team of psychological evaluators, pediatricians, and endocrinologists weigh in to determine if the youth has “persistent, well-documented gender dysphoria” before proceeding with any treatments.
This initial assessment and affirmation phase is protracted — so much so that some youths initiate the process of socially transitioning, whereby they begin presenting in society as their correct gender, with new pronouns, clothing, and the like). Contrary to Paul’s implication, youths don’t rashly advance to the physical transition stage.
If medical experts do recommend physical treatment, patients have the option to begin taking puberty blockers, which constitute a safe and reversible approach to halting puberty. These drugs suppress the release of sex hormones, including testosterone and estrogen, during puberty, putting puberty on by halting the onset of secondary sex characteristics such as breast development and voice deepening. This pause provides another extended reflection period to assess if gender dysphoria is persistent and requires further intervention.
Puberty blockers are fully reversible, cause few side effects, and have an overtly positive impact: They significantly reduce suicidal thoughts among transgender youths. The potential long-term side effects — infertility and bone density issues — are monitored by physicians through regular checkups. Contrary to Paul’s sensationalized assessment, puberty blockers for youths only present well-studied, monitorable side effects.
Pausing puberty is effective. Most youths who receive gender-affirming care choose to further their physical treatment and do not opt to restart natural puberty, thereby circumventing some surgeries that would alter their post-pubescent secondary sex characteristics. According to a large cohort study in the Netherlands, only 1.9% of transgender adolescents who finished their courses of puberty blockers withdrew from the next typical step of physical transition: hormone therapy.
The standards of care require hormone therapy for at least one continuous year before doctors perform “top” (breast removal/construction) and “bottom” (vaginoplasty/phalloplasty) surgeries. Although WPATH recommends gender-affirming surgery only after a youth reaches the age of majority or consent, a growing body of evidence indicates that early gender confirmation enables patients to better acclimate into the next significant stage of life, such as college or the workforce.
Paul’s primary argument, which centers around regretting gender transition, references “dozens and dozens of people who’ve been through this [gender affirming surgery] who regret that this happened and a permanent change happened to them.”
Empirical studies, however, show this isn’t a widespread phenomenon. In a 2015 national survey of nearly 28,000 transgender people in the U.S., only 8% of patients detransitioned — and of that 8%, two-thirds detransitioned temporarily. Most important, only 0.4 percent of the those surveyed said they detransitioned because gender transition was not right for them. Instead, the few who permanently detransitioned most often cited parental and spousal pressure as the reason for doing it. Gender transition regret, as Paul decries, is statistically scarce.
Paul’s characterization of transgender health care for minors — a characterization unfortunately commonplace in political circles — is factually inaccurate, rhetorically dangerous, and medically unsound. Levine’s historic confirmation would offer a welcome departure from the deluge of misinformation that some U.S. leaders continue to propagate around gender-affirming care.
Sai Shanthanand Rajagopal is a researcher at the Center for Gender Surgery at Boston Children’s Hospital. Henna Hundal is public health graduate student at McGill University and a researcher at the Max Bell School of Public Policy.