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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.

  • If kids, unable to drive, vote, buy a house, have a history of medical science saying their brains are not formed until the mid 20’s, that alone raises a red flag about this. I raised that issue to a legislator who wanted 16 year olds to vote and they admitted they hadn’t thought of that.

    There is medical literature indicating lots of kids have had that in past years and grow out of it. How about those who have indicated it didn’t work for them like they thought? Maybe making a change will not do what these kids think, given the other side that has spoken about the changes and it didn’t solve their issues.

    Stats I saw on 60-40 splits for wanting to change back (40%) indicates the medical community needs to reassess their criteria. While at it, if one believes minors can make this decision, then make them emancipated adults in the eyes of the law. Saying they can’t handle guns or vote until they’re older, but make a change like this, just is not logical.

  • Seriously? Children of that age have little idea of gender, erotic attraction and sex. They are being sacrificed on the altar of political correctiveness. This whole thing reminds of when lobotomies were widely performed and seemed to be a great way to treat mental illness. We look back now and say “What were they thinking?”

  • This article’s writer/ journalists have precisely what medical credentials?
    None !
    I don’t see any credentials beside the names of Sai Shanthanand Rajagopal and Henna Hundal ? I don’t see a Phd not a MD affixed to their monickers .
    But I do see applicable expert credentials beside the name of current best selling author and academic scientist in the field Dr Debra Soh who has a book out currently entitled “The End of Gender”
    Wherein Dr Soh explains that the vast majority of gender dysphoric youth if left alone without medical intervention WILL eventually come out of the closet affirmatively as young adults in their twenties age range simply as homosexual and NOT transgender.
    Hence Dr Soh an expert in the field is 100% against transitioning minors !
    Dr Soh also states gender IS binary and that there are only two genders and those two genders are biologically determined and are NOT social constructs . Dr Soh states gender and biological sex are synonyms and mean the same thing .
    Dr Soh states that gender is NOT a spectrum hence we can determine her to mean that the fad of “non-binary” is just that a fad of peer pressure and peer influences but that non-binary is non existent, as per I reiterate gender is of only two biologically determined sexes which are binary .
    I wholeheartedly concur with Dr Debra Soh who gives all the science that proves her assertions in her current best selling book “The End of Gender”
    Dr Soh states that parents have a bias against their children being homosexual “Gay” hence if they readily agree their child is ostensibly “transgender” then they are socially excepted but being openly Gay has a social stigma even still hence left alone , those children will come out as just simply a gay female or a gay male in early adulthood.
    Dr Soh predicts many future medical malpractice law suits are in our not too distant future as a large mass of adults who had as children been allowed to transition to the opposite gender.
    Law suits shall be the determining factor to put a halting bridle on this fad policy of the left of transitioning children .
    This article also has taken out of context what Rand Paul articulated and twisted the narrative to suit the ostensible “journalist’s” leftist yet erroneous position .

  • Unfortunately this commentary is poorly thought through, inaccurate to the point of propaganda, and beneath the reputation of Boston Children’s and McGill.
    Where is the control population in this ongoing social experiment ?

  • I firmly believe there is a night and day difference between biological sex is determined by the chromosomes, and gender dysphoria, which is not. Your biological sex cannot be “switched around”. The term “sex change” is incorrect. You are performing surgical procedures, along with estrogen therapy, to affirm the chid’s belief that will make him a girl, or the opposite.
    Personally, I am 75 years old, born a biological male and raised as such. From my earliest recollections, I felt different, but didn’t understand why. Later in my adolescent years (through High School), I was bullied severely. My oppressors hid it well. I never fought back; just took away from my physical and emotional health. This was the beginning of the quest to unravel the mystery of those “Feelings” I had in my formative years. At times I was reclusive, depressed, anxiety reigned supreme. I found relief by dressing in my perceived female gender; however temporary, but very necessary in my eyes. I spent many sessions with MH professionals, which ultimetly led to a diagnosis of G.I.D. as it was known at that time. I remained closeted until 1971 when I married a very special lady. I decided not to hide it any longer. It would have been much worse for me. 50 years later, we are still together, enjoying a better quality of life. Legally we are husband and wife, but we didn’t want the conventional route and use words like “other half, partners, better half, etc. We consider ourselves to be “Each other’s other half”.

  • Starting with a conclusion and creating the data is not “science”.
    Supplying millions of Federal money through Planned Parenthood is just incentivizing more fraudulent medical procedures already rampant.
    This is ideological garbage.

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