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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.

  • 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.

    Interesting how this statement does not include a source.

  • I see a lot of ultra-conservative opinions in these comments.
    If I had submitted to the “wisdom and counsel” of my late mother I’d not be able to write here.
    I’d be 6 feet under.

  • It is widely know in all cultures that children are not in a position to make intense decisions of which they know little about. Part of respecting parents is to submit to their wisdom and counsel. A doctor or counsellor has NO PLACE in the life of a child. That right is the families. It is quite interesting to see how Senator Pauls questions were avoided. And BTW, for those people who believe in God and believe He knows what he’s doing, it’s quite an affront to suggest that He was mistaken when He made male and female. Somehow He must be ignorant of the biological differences. LEAVE THE CHILDREN ALONE!

  • What a load of lies. First off, puberty blockers are USED TO CHEMICALLY CASTRATE SEX OFFENDERS.

    Secondly, there is a sub Reddit of de-transitioners full of the heart-rending, personal stories of thousands of kids who have done irreversible damage to themselves while under the spell of Gender Pied Pipers like the authors of this article.


    The Trans Industry is what this is – these poor kids – lifetime and very expensive medical experiments – are Big Business to Big Pharma:

    Trans-Tech Is A Budding Industry: So Why Is No One Investing In It?
    Dec 2020

    Trans-tech is a budding industry with an enormous opportunity, RKA claims. “Our estimates place the average cost of transition at $150,000 per person. Multiply that by an estimated population of 1.4 million transgender people, we’re taking about a market in excess of $200B. That is significant. That’s larger than the entire film industry.”

    Transgender Patients- Calculating the Actual Cost

    Sex Reassignment Surgery Market size to exceed $1.5 Bn by 2026
    March 2020

    Venture capitalists back online transgender service PLUME

    The 2015 national survey mentioned was released by the National Center for Transgender Equality, a transgender advocacy group, and is considered garbage in, garbage out.

    This is the Opioid Epidemic Part II – doctors and pharmaceutical companies pushing extremely dangerous drugs on kids. But it’s worse than the Opioid Epidemic because charlatans are also convincing children and young adults to hack off their healthy flesh.

    Stat – you should be ashamed of yourself for publishing this dangerous tripe. I can’t trust you again.

  • This is ridiculous. If you have a child or have ever been a child, you know that their emotions and ideas are all over the place. Anyone saying a 13 year old is capable of deciding to change the essence of who they are on their DNA, is either lying or insane. Kids this age say their life is over if a boy they like sees them trip in the hallway. It is a much simpler concept to know right from wrong in terms of taking another life or violence against someone. How does a boy “know “ what it feels like to be a girl when he has never been one? He doesnt. He knows what it feels like to be confused about his own sexuality

  • That is a pediatrician I would never take my kids to.

    There are people who are convinced(because of mental illness) they are possessed by the “devil” or “demonic spirits”. Should they have “satanic” affirming surgery or “care”? Attach a few prosthetic horns and make permanent surgical changes to their body so they “feel” more like their “inner self”?

    The pediatrician in question was projecting “his/her” personal choices on children(minors) who are not qualified, experienced, and/or mature enough to make permanent life changing decisions. Anyone who thinks they are is not qualified to be a pediatrician. The ophthalmologist senator obviously understands this common sense logic.

  • So what? Adults get to make decisions like this every day. Currently millions of people are getting Covid vaccines under an Emergency Use Authorization, in which the longer term risks are stated as unknown on the form. Just because the effects are “unknown” does not preclude a legal adult (age 13 in the US for crimes like 1st degree murder) from making a decision.

  • With regards as to how old one should be to make life-altering decisions, I find it amusing to read comments about how someone who is not an “adult” should not be able to make those decisions. The age that one is considered an “adult” is very uncertain. Consider alcohol. In the US, the age is 21, except in Puerto Rico and the US Virgin Islands, where it is 18. In Canada, it is 18 or 19, depending upon the province. In most European and South American countries, it is 18, although there are some countries with an age of 16. Now let’s consider the age for marriage in the US: for no parental consent, it is 18, except in Mississippi, where it is 21. Now consider how old you can be to be tried as an adult in the US. It varies by crime and state, but here is what Illinois had established: Anyone 13 years old and above can be tried as an adult if he or she has a record of previously breaking the law or commits a serious crime. Minors who are 15 or 16 years old are automatically tried as adults for certain offenses, including murder, aggravated criminal sexual assault, and armed robbery with a firearm. My point is, if someone as young as 13 “can be tried as an adult”, which presumes that they can make adult-style decisions and that they have failed to follow the law, why then can’t they make health decisions at the age of 13 and older?

    • US law (see the State of Illinois, for example), allows for the trial of a 13-year old “as an adult” for certain crimes. Presumably, the courts have found that there is compelling scientific evidence that 13-year old individuals possess sufficient maturity and understanding with regards to various criminal issues that their age is not a mitigating factor or excuse. If a 13-year old can be imprisoned for life or executed, because a court has judged that they have sufficient mental competency and maturity to know better, then why can’t they make serious health decisions at that age?

    • I have a beloved cousin who has allowed her daughter to engage in gender changing hormone therapy at age 14, also allowing a troubled teenage “lover” to live with them. What was once a beautiful blue eyed, slender young girl is now a grotesque, husky, acne faced, unhappy creature. Whatever the motive, my question is: what happens after this young girls genials are mutilated, she is 18 yrs old, and regrets ever having all of these things done to her as a minor. Her parents could be held criminally responsible right? Of course they could and none of these idiototic brainwashed leftists have thought of this reprocussion. Why? Because they have no morals and they don’t care what happens to you and me, only that their agenda is forwarded. Do not be deceived.

    • Clearly few of the respondents here have raised children. If you have not, then you have no qualification to be able to debate the merits of decision making from age 13 to whatever. You are clueless and clearly have forgotten the idiocy of your childhood only to continue it into adulthood. Leftists are so friggin annoying, the lot of you are much like the do-nothing losers in high school who could only find merit in themselves by arguing against everything, no matter the logic involved. Like dyeing the hair purple, putting discs in your ears, and tattoing satan on their breasts. And you all still do it don’t you? Thank you for serving me coffee and gasoline you idiots. When your tattooed children, as adults, turn on you for your immoral decisions I hope you get what you deserve. It is WRONG to allow a CHILD to be mutliated, against nature, by a doctor. Nothing you can get CNN to say will change that. You are not fit to be parents. PERIOD!

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