Six years later, I’m not so sure.

The hysterectomies went well. They were uncomplicated, and no one told me they regretted their surgery. But even though we were earnest, well-meaning clinicians, were we doing the right thing?

In 2019, I took a job as an Obs and Gyn doctor at a nonprofit in Iowa, after my private practice went out of business. I had a wife, twins in preschool, and a toddler. And, after working for a Catholic organization previously, I loved the progressive policies of my new employer. They provided medical transition services for transgender patients and even sponsored an out-of-hours LGBT clinic for patients who might not have felt comfortable in a mainstream doctor’s office. I was at the clinic, enthusiastically, once a month to provide my expertise.

I was quite surprised, though, that the clinic seemed almost exclusively T, without much LGB. Call me naive, but for the past decade, I had my head down: training, getting married, having kids and starting my practice. And by the time I looked up, the LGBT world was very different from the last time I had really been around other gay people.

I also had some uncomfortable questions: hadn’t we learned in medical school that most pediatric gender dysphoria resolves by adulthood? If so, did it make sense for young adolescents to transition to the opposite sex? Was it really plausible that transgender female athletes didn’t have a biological advantage over natal females? The accepted answers seemed counterintuitive to me. Nonetheless, I was on board, assuming that the experts who crafted medical society guidelines around gender medicine had followed the usual process, carefully weighing the evidence, and had reached a scientifically based consensus before making their recommendations regarding gender medicine.

And so, for a few years, I became the go-to gynecologist for gender-affirming hysterectomy referrals and other gynecology care for transgender patients. Although this was a very small part of my practice as a full-scope Ob/Gyn in a rural underserved area, I loved it. I enjoyed taking care of my patients. Some would drive hundreds of miles from their homes elsewhere in rural Iowa to receive their care with us. I was, I felt, providing a much-needed service. The patients came in knowing exactly what they wanted: a hysterectomy. Unlike hysterectomies for abnormal bleeding or pelvic pain which require full diagnostic tests, there was no need to document prior attempts at treatment, failures, and impact on the patient’s life. “Gender dysphoria” always got approved (with the requisite two letters, one from a mental health professional and one from a PCP). Unless they had a major contraindication, such as uncontrolled diabetes, we could just book them in.

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Of course, I counseled my patients. Would they like their ovaries conserved or removed? I was adept at discussing the risks and benefits of both approaches. I offered referrals for egg freezing if they desired oophorectomy. I discussed surgical risks and expected recovery. But these surgeries were still, I would joke to my assistant, “my easiest consult of the day”.

But as the years went by, I couldn’t help but notice some troubling trends. The trans patients who came to me had more and more mental health complications. I also started seeing a fair percentage of them who were really quite feminine — not very different in their gender presentation from my biologically female patients.

Then came the see patients who truly stymied me. One who particularly struck me was just 21 years old, born a female but who now identified as nonbinary. They requested a hysterectomy to conform to what they saw as their gender identity, but otherwise did not desire transmasculine medicalization such as testosterone or mastectomy, and had classically feminine mannerisms and dress.

I began to feel more uneasy that hysterectomy — surgery that carries numerous surgical risks, and results in irrevocable lifelong infertility — was necessarily the right thing for this new group of trans patients. But if they didn’t have any contraindications per se, I couldn’t really say no. After all, according to the American College of Obstetricians and Gynecologists, a hysterectomy is “medically necessary for patients with gender dysphoria who desire this procedure”.

I thought the World Professional Association for Transgender Health (WPATH) guidelines might help my dilemma. But as I puzzled over the “nonbinary” section, I found no clarity. The guidelines said that “motivations for accessing (or not accessing) gender-affirming medical interventions, including hormone treatment, surgeries, or both are heterogeneous and potentially complex and should be explored collaboratively before making decisions about physical interventions”. Though that seemed like solid advice, I did not feel particularly well equipped to do so as a surgeon, rather than a mental health professional.

Still wondering how best to take care of my patients, I went on a private online forum for O&G doctors to ask about how others addressed nonbinary individuals who requested gender affirming hysterectomy. I was told my question was “transphobic”. I was told that the surgery was “life saving” (presumably due to the suicidality brought on by the presence of one’s natal uterus).

This didn’t sit well with me. I wondered about one of my patients, who had detransitioned just a few years after her hysterectomy. Conventional wisdom said detransition almost never happened; that the rate was just 1%. Well, I certainly hadn’t done a hundred hysterectomies for gender affirmation. So what was going on here?

Curious as to whether detransitioning was more common than we thought, I found my way to Hannah Barnes’s excellent book, Time to Think, which detailed the scandal at Britain’s national youth gender medicine clinic, the Tavistock Center. Barnes found that distressed adolescent girls with no longstanding history of gender dysphoria were requesting to become boys at skyrocketing rates and being prescribed puberty blockers and testosterone with very little medical or psychiatric evaluation, while any adults raising concerns were labelled “transphobic”.

Similarly, through reading Jesse Singal’s work on the scientific basis of youth gender medicine, I learned about the relatively flimsy evidence it is built on. Certainly, there have been studies that seem to show favorable short-term mental health outcomes for youth who access gender medicine. But there have also been scandals about burying the outcomes of major studies at Johns Hopkins and Children’s Hospital of Los Angeles. It seems nobody has published a long-term study on how these young people are doing. In fact, the Tavistock in London, which was forced to close, failed to retain or share data on thousands of children. It seems that nobody knows the true rates of detransition for young people, but according to the most credible expert in the field, Dr Kinnon MacKinnon, who is himself an openly transgender man, “it is very unlikely to be only 1%”.

I was surprised that in America there were no specific requirements for the psychological evaluation of young adolescents before it was agreed that they were ready to start transitioning. WPATH guidelines say that the young person should have demonstrated “a marked incongruence between one’s experienced/expressed gender and assigned gender, of at least six months’ duration”, but in practice, even this minimum requirement has not consistently been followed. Even the minimum standard of a basic mental health evaluation of the patient, as advised, is controversial. Dr Johanna Olson-Kennedy, president-elect of the US division of WPATH, has been an outspoken advocate of the “informed consent” model, deeming the requirement of any psychological evaluation prior to starting a medical transition to be excessive gatekeeping.

And while things are changing in Britain, where puberty blockers are no longer allowed for under-18s, there are many youth gender clinics in America which routinely provide prescriptions for puberty blockers or hormones at patients’ first appointments, even when a patient does not have a longstanding history of gender dysphoria since early childhood.

I also discovered an emerging population of detransitioners, individuals who took steps to medically transition and who have now reverted to their natal gender identity. Although some do not regret the changes they made to their bodies, others are profoundly distressed by them and have serious and credible critiques of the gender medicine system as it stands.

I had just assumed the experts crafting guidelines were ensuring that there was a body of evidence supporting the incontrovertible long-term benefits for these extraordinary treatments that were being performed on young people: puberty blockers, cross-sex hormones, and double mastectomy.

However, since there was no unbiased scientific organization of experts on transgender issues, American medical organizations relied on WPATH to guide them. Why wouldn’t they? As upstanding evidence-based scientific organizations, they generously assumed their counterparts were the same. But the holes in the evidence behind WPATH’s official standards of care become more obvious, suggesting that these organizations can rely only on themselves to evaluate the evidence. Interestingly enough, the American Society of Plastic Surgeons conducted its own review of the evidence, and, contrary to the interests of its own members, concluded that gender affirming mastectomy for minors is not ready to be rolled out.

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Let me be clear. I understand that the profound psychological pain of gender dysphoria is real. And many adults have found happiness after medical transition. But what isn’t clear is whether medical transition for adolescents still developing their identities is the solution that many hope it is. A 2024 study from Finland — a progressive nation, with a strong social safety net and a tradition of women’s rights — found that medical transition in gender dysphoric adolescents did not decrease the risk of suicide.

After all, is it really credible that gender dysphoric adolescents, who we know have existed across societies for millennia, have recently become distraught to the point of widespread suicide because they could not access puberty blockers, cross-sex hormones, or mastectomies — none of which was available anywhere in the world until the first youth gender medicine clinic opened in the Netherlands in the Nineties? This is a serious claim. If it were true, of course, medical and surgical transition should be available to any gender dysphoric adolescent who desired it. But the evidence that medical transition itself — rather than the compassion and acceptance the patients find in a youth gender clinic — prevents suicide, is truly scanty.

In medicine, sometimes we get ahead of ourselves. New treatments which seem so promising at first don’t always work. The widespread prescription of oxycodone as a panacea for chronic pain in the 2000s is a good example. The doctors who prescribed it wanted to help their patients, but just didn’t realize the real harms caused by oxycodone until they became common enough to see.

I’d like to believe that we are people of science who realize when it is time to course correct. On gender medicine, the time is now.

It is time for experts in our professional organizations need to make evidence-based recommendations for standards of care. We need to seriously ask ourselves what the safest, least harmful interventions are in youth gender medicine, and hold these interventions to rigorous, data-driven standards. It may be reasonable at this juncture to halt new medical and surgical treatments for minors (puberty blockers, cross-sex hormones, and mastectomies and other surgeries) outside of well-designed, lengthy clinical trials. It is time to provide resources within the institutions of mainstream medicine for people who seek detransition care.

And to question whether “gender dysphoria” as an indication in and of itself for hysterectomy, without abnormal bleeding, pain, or any other diagnosis, should continue to bypass all of the checks and balances in our healthcare system for major surgery. My fellow gynecologists, if we are people of science who know right from wrong and care about our patients, we can surely find the courage to do this.

This is an edited version of a piece first published on The Ob/Gyn Power Project.

Given the politics and personalities involved, it’s tempting to accuse both men of being as deliberately offensive as possible — even to Roman Catholics, who won’t love the performative and irreligious tone of their materials. And as one straight man I know said, Yiannopoulos’s and Yardley’s new trad-bromance “looks pretty gay”. Yet Yardley seems to represent an incipient trend. He is one of a handful of detransitioners I personally know of who have turned toward Catholicism’s restrictive sexual dogmas (still no blowjobs, folks) and teachings on biological sex in order to change their lives.

While not all insights gained from the experience of being trans and back again are reliable — especially when staged for an online public — their voices are worth hearing for what they reveal about the so-called vibe shift, a younger generation’s turn away from sexual-liberationist paradigms, and the role of Christianity in it. This, even as the attention-seeking quality of their discourse recalls nothing so much as the gender trend just a few years ago — only now in the opposite direction.

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Yardley is of the first generation of young people to launch their medical transition during puberty as part of the Tumblr-fueled gender revolution, and believes he will face permanent fertility consequences as a result. He says that he was a feminine-looking boy, who liked female things and had mostly female friends, and who was often misgendered. He didn’t know why he was different, but “other people informed me of it”. Around the time Lady Gaga’s “Born This Way” came out, in 2011, he wondered if being transgender might be the answer. He went to the Children’s Hospital of Philadelphia and says he was goaded into transgender care. The therapist recommended by the clinic “immediately bought into it that I was really a girl”.

Today, he is graceful, tall, and girlish in photos, and easily passes as a biological woman. But he has grown to regret his transition for a host of what are becoming the usual reasons: concerns about how cross-sex hormones were affecting his health; physical pain; fatigue with what other detransitioners have called “trans OCD”, an obsessional focus on one’s body; and a dawning realization that the desire for transgenderism spawned from an original mental-health issue that being transgender wasn’t fixing. “I was never comfortable with it,” Yardley tells me.

Like some male-to-female transitioners, he says that at least part of his attempt to become a woman was in order to cope with same-sex feelings of attraction without having to declare himself as gay. He now objects to the characterization of sexual orientation as a fixed and immutable identity. He also rejects the idea that being a feminine boy meant he was actually a girl. “Gay and trans are the same thing”, he tells me. “Both result from an original trauma to your gender that can be healed”.

It’s fairly easy to diagnose a swing from one utopian extreme to another, which comments like that exemplify. But it’s less easy to dismiss the critique of categories of sexual identity and sexual orientation, acknowledged by scholars on both the Left and the Right to be a fairly recent invention. For most of human history, as Michel Foucault pointed out, heterosexuality or homosexuality did not exist as identities; both were invented in the late 19th century as a means of normalizing heterosexual behavior, while treating same-sex-attracted people as “abnormal”. That the invention turned on its makers and ended up providing the grounds for gay liberation is one of history’s delicious ironies. Today’s proliferation of increasingly niche identities and orientations, and the practice of changing them as a person evolves, supports the argument that these identities aren’t as hard-and-fast as they appear.

Some of the excesses of Yardley’s and Yiannopoulos’s publicly performed hard-Right Catholicism seem like they could be trolling. But Yardley’s explanation over the telephone sounds heartfelt. He was raised nominally Catholic, he says, and as early as 2020, when it became clear to him that being trans wasn’t making him happier or more socially comfortable, he began to research dissenting opinions. A Catholic priest was the first person ever, he says, to tell him something most human beings have believed throughout history — “No, you’re a man, and you can’t get out of it.”

Another outspoken detransitioner, Ray Alex Williams, has run a YouTube channel on the subject since 2023, and published an essay on Substack on 24 February headlined, “How Catholicism Solved My Autogynephilia Problem.” Williams’s essay begins with the acknowledgement that people will think he has “gone off the deep end” and has gone “from one extreme cult to another”. During a follow-up phone conversation, he reveals that he isn’t officially Catholic yet; his religious-conversion experience is fewer than two weeks old; and his girlfriend broke up with him over it. The headline, in this case, seems like a deliberate distortion in a bid for clicks. However, as he tells it, his “desperate search for moral clarity” has been years in the making, and he believes he needs such clarity to help him combat the destructive role his sexual desires have played in his life.

Autogynephilia, or AGP, is contested cultural territory. Defined by the eminent Canadian sexologist Ray Blanchard as “a man’s paraphilic tendency to be sexually aroused by the thought or image of himself as a woman”, it generally involves not just the erotic desire to be a woman, but accompanying fantasies of being used and abused for being female, often these days following the tropes of the “sissy” subgenre of pornography.

When they don’t deny autogynephilia altogether, transgender activists object to the term because it pathologizes the set of sexual desires it describes, and opens the door to the claim that trans people with these desires are not women, but just men with an obsessive paraphilia. (Yardley explicitly disavows AGP as having had any role in his experience.) One thing is certain, though: the set of desires itself is fairly common.

New York magazine books critic Andrea Long Chu has been open that such impulses fueled her transition, and discussed how sissy porn shaped her identity in remarks at the New York Public Library in 2018. Chu said that she started watching “a lot” of pornography as a middle-school boy, and described a progression in her tastes from “run-of-the-mill, mainstream pornography” to “JOI” (jerk-off instruction) videos, in which a female performer demeans the male viewer. From there, Chu “went down a humiliation track … until I hit sissy porn…. My porn addiction had all along been waiting for something like sissy porn … because now if I’m reading in retrospect, the whole thing was about trying to access a kind of sexuality that wasn’t about being a man”. Trans actress and Euphoria star Hunter Schaefer wrote along similar lines in a now-deleted Instagram post the same year: “My sexual orientation was not gay. It was not straight. Nor pan. It was an attraction, is an attraction, always, to misogyny. My gender was SO influenced by a need to be used by men.”

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Detransitioner Williams chronicles a lifelong struggle with a similar set of feelings and desires, which led him to transition to female in 2015, at the age of 28. He says he didn’t have “an underlying predisposition to hate my male body”, though that started after he became trans. Williams lived as a woman for eight years, which he says decreased the sexually fetishistic aspects of his behavior (and his libido), but had other negative consequences, such as extreme social anxiety. He also, in 2020, developed a pulmonary embolism and almost died, he says, which he attributes to taking cross-sex hormones. Attempts to detransition and manage his resurgent AGP in a healthy way, along lines suggested by Phil Illy’s book Autoheterosexual: Attracted to Being the Other Sex, were a failure, despite finding a bisexual, kink-positive partner who accepted his sexuality.

The activist stance on these desires is that they are neutral in themselves and can be considered a sexual orientation, and that any negative consequences come from social stigmatization. Williams’s experience could bear that out. Despite finding willing partners and accepting circles, he continued to feel shame, confusion, and social discomfort from his gender urges and sexual practices. However, he also found that indulging his desires oriented him towards masturbation and away from his partner, and that his desires followed patterns of other addictions in his life, requiring ever-greater stimulus for diminishing rewards, and ultimately bringing unhappiness instead of pleasure.

One day, high on cannabis — another persistent addiction struggle, he writes — and ready to engage in his fetish, Williams had the revelation that both his marijuana smoking and his sexual behavior were self-destructive and pathological in the same way, and had to stop. “Immediately”, he writes, he had the desire to get back into religion, which he had experimented with before on his detransition journey, but this time, he was drawn to Catholicism, specifically for its intensity of pageantry and ritual and its strict sexual doctrine. He understands that his new convictions might seem suspect or “mentally unstable”, he says, but he now believes that the inner voice of shame and disgust that he hasn’t been able to silence has a transcendental cause, and is distinguishing a fundamental right from wrong.

Not all of the new detransitioners are drawn by Christianity’s oldest branch. Sierra Weir, 37, who goes by the name Exulansic on X and Substack, has since 2021 devoted herself since to exposing the ugly side of the gender trend, for simpler but similar reasons of mental and physical health. Weir did a double-major in gender studies and linguistics at the University of California, Berkeley, and says she was once “really into” transgenderism. She transitioned medically to male when she was 23 but began to have ideological disagreements with the trans orthodoxies and experienced harmful and dangerous health outcomes from hormone therapy. She says she now has osteopenia (low bone density, a precursor to osteoporosis) which is a known risk factor with Depo Provera, which she took to suppress menstruation, and she has been recently diagnosed with lumbar degeneration, which she believes is related. She is vituperative against her former doctors, whom she believes misdiagnosed her and exacerbated her problems. “It just ruined my life”, she says.

Weir’s social media channels circulate lurid news items about crimes by transgender women, and frequently discuss suicides by distressed transgender people all genders and ages — material that can legitimately be read as stigmatizing for transgender people seeking public acceptance. She also writes and films disturbing stories on mostly biological female victims of terrible mental and physical health outcomes and botched surgeries. However, she says, “I’m not against individual people who are trans, and I have a great deal of compassion and empathy. I’m speaking out because I don’t want harm to come to them.” (She may or may not now be on the right side of history, but once again, it’s the scare tactics of the original trans movement: if we don’t all believe this right now, people will die.)

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In addition to believing that hormones and surgeries are physically risky and damaging in ways people aren’t told about, she believes that cross-sex hormones can cloud a person’s thinking — making them more likely to opt for risky procedures — and exacerbate previous mental health issues. “The hormones were affecting my ability to think and my ability to remember”, she says. Having detransitioned, she feels like “I don’t have brain fog anymore.” She believes that people suffering from gender dysphoria from any of these conditions “deserve to have optimal health and to understand their predicament”, and that medical providers are “abdicating that responsibility.”

Prior to Elon Musk’s purchase of Twitter, now X, Weir was “being banned from all platforms of note”, she says. Now she’s free to critique the movement she was once a part of, and with the same zeal. Yardley, for his part, attributes the wave of detransitioners not to the vibe shift or a trend, but merely to the passage of time. It’s been several years since the transgender tipping point, he says, and people have “passed that first sense of euphoria that people get from accomplishing any goal” and begun to have doubts. “So many people are detransitioning because so many people transitioned”, he says. That conclusion, as least, sounds reasonable, and like something we should be open to learning from.

But let’s hope the pendulum doesn’t merely swing from one brand of too-certain conviction to another. The Roman church, in addition to its prohibition of most sexual acts, asks adherents to cultivate lives of silence, contemplation, and prayer. Those who have embraced the Church as a refuge from online ideologies might want to take up these practices — instead of plunging head-long into the next performative mania.

Gids had been established in 1989, to help distressed teenagers navigate their feelings of gender dysphoria, but changes in leadership along the way led to a dramatic shift in its clinical approach. In recent years children routinely found themselves on a medical conveyor belt before the psychological effects of early adverse experiences were fully explored. Much has been written about the blanket application of an “affirmation-only” approach to a complex caseload, which too often put children on a single pathway to life-long medicalisation. By 2020, Gids had prescribed puberty blockers to more than a thousand children. 

In most academic discourse, a “no-debate” approach, such as the one described at Gids, will be stifling and unproductive — but in medicine, it will inevitably result in harm. All clinical practice should be centred around the careful consideration of competing possibilities. It is unsurprising that children were harmed at Gids when a single-minded certainty usurped clinical curiosity.

One year on, Gids remains open, although it no longer accepts new referrals. The plan is to replace the moribund service with regional hubs offering the holistic care required by young people struggling with their gender identity. The promised new services are still taking shape, but before they have even opened their doors to the ever-accumulating backlog of referrals — last rumoured to be upwards of 8,000 young people — concerns have been raised about history repeating itself. Some of the senior clinicians from Gids have seamlessly transferred into new leadership positions, despite appearing to have learned little from its terminal failings.

In April 2023, Prof Gary Butler, the lead endocrinologist at Gids and a clinician appointed to a leadership role in its replacement service, questioned any need to rethink the model. He told a conference audience that Gids was already working in “exactly” the way that Dr Hilary Cass had called for in her thorough review of services for children and young people with gender incongruence. It is difficult to see how anyone could reconcile the service described in Time to Think — BBC Newsnight reporter Hannah Barnes’s careful and balanced account of the failings reported by multiple Gids clinicians — with the holistic approach recommended by the Cass Review.

Its recommendations tear down the exceptionalism that allowed things to go so wrong at Gids; evidence-based practice will be the bedrock of the new service, just as it is in every other NHS clinic.  Those working within the new services will be contractually committed to follow Dr Cass’s recommendations, which place a new emphasis on integrated models of care and evidence-based treatments, recommendations that should be as uncontroversial as motherhood and apple pie.

But, then, motherhood and apple pie aren’t quite as uncontroversial as they used to be. And an evidence-based practice may not be quite the unifying foundation if the clinicians involved cannot agree on the evidence base.

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Earlier this month, a group of 21 eminent clinicians working across nine countries in the field of gender distress wrote an excoriating open letter in response to a bold claim from Stephen Hammes, president of the Endocrine Society. In a letter to the Wall Street Journal, Hammes had stated that more than 2,000 studies had provided a clear picture that gender-affirming care improved the well-being of gender diverse people and reduced the risk of suicide; if that were true, it would be very reassuring and closer to certainty than we often get in many medical specialities. The authors of the response, who included Dr Anna Hutchinson and Dr Anastassis Spiliadis, two of the original whistleblowers at Gids, noted that this claim had been contradicted by every single systematic review of the evidence, not least one published by the Endocrine Society itself. They noted that recommendations for clinical practice should be aligned with the best available evidence, rather than a position that exaggerated the benefits and minimised the risks.

Not all evidence is equal. There are hierarchies of evidence in science, often represented as a pyramid. The lowest level is “expert consensus”, which is barely evidence at all. Who decides who is an expert? The process of reaching a consensus can result in a compromise where lots of people agree collectively what nobody actually believes individually. Consensus may have nothing to do with empirical truth. Expert medical consensus can be very wide of the mark, sometimes disastrously so: in the early 1900s, it was expert medical consensus that smoking cured asthma and other lung diseases. It is well within living memory that the expert consensus for treating back pain was bed rest and plenty of it. We now know this is likely to increase pain and prolong recovery.

The history of medicine is littered with these examples, and there are treatments we are recommending now with the full blessing of expert consensus that will eventually prove to be ineffectual at best, fatal at worst. But perhaps the biggest problem with consensus, particularly in the area of gender medicine is the chilling effect it has on debate. As Michael Crichton, the physician and author of Jurassic Park, said: “The claim of consensus has been the first refuge of scoundrels; it is a way to avoid debate by claiming that the matter is already settled.”

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Fortunately, most branches of medicine now rely on more rigorous forms of evidence to inform their practice. Further up the “evidence pyramid” are case reports and studies that compare the outcomes in patient groups before and after treatment, with and without control groups. Close to the top of the evidence pyramid are the results from randomised controlled trials. All of these kinds of research can provide valuable information (some more than others) but no study is perfect and no study design can control for all of the biases that might have influenced the results. So sitting right at the top of the evidence pyramid are the meta-analyses and systematic reviews. These studies systematically evaluate the quality and quantity of all of the relevant evidence that has been published in peer-reviewed journals. These independent reviews summarise what we really know and how confident we can be in that knowledge. Bodies such as the National Institute for Health & Care Excellence (Nice) produce the gold standard in clinical practice guidelines based on these kinds of independent meta-analyses.

In 2020, Nice examined the evidence for puberty blockers. They concluded that “the results of the studies that reported impact on […] outcomes of gender dysphoria and mental health (depression, anger and anxiety), and […] body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria were of very low certainty”. In other words, there is no good quality evidence supporting the use of these drugs on these outcomes.

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It seems likely in the heated debates that surround gender medicine that many people are confusing “expert consensus” — the evidence right at the bottom of the pyramid — for the gold standard in clinical practice guidelines, which are based on evidence and right at the top.

This conflation appears to have been responsible for the mutual bafflement in the heated exchange between Republican Dan Crenshaw and Dr Meredithe McNamara earlier this month, in a debate in the US House Committee on Energy and Commerce on gender-affirming care. While Dr McNamara insisted trans healthcare was based on “standards of care”, the senator countered with the stark lack of evidence from any systematic reviews. Both appeared exasperated with the failure of the other to grasp the importance of their incontrovertible evidence. Just as not all evidence is equal, neither are all clinical guidelines or standards of care. They can be developed from evidence at the top of the pyramid (as in Nice guidelines), but more often come from the bottom and simply represent expert consensus with all its inherent flaws and biases. The stamp of approval from a learned society does not trump the rigours of a Nice review.

Since no high-quality evidence for the benefits of puberty blockers has been found in systematic reviews, it is unsurprising that even the doctors who work in this field have described themselves as building the plane while flying it. With mounting concerns for the possible harms associated with medical pathway of puberty blockers and cross-sex hormones (including reduced bone density, disruptions to neurodevelopment, impaired sexual function and infertility) — not to mention the growing numbers of detransitioners for whom this was never an appropriate treatment pathway, one might extend their aviation metaphor as an attempt to build a plane while flying it while someone else throws out all the parachutes and sets an engine on fire.

Who would put any children on that plane? Or volunteer to pilot it?

The only rational response in such a situation would be to ground the plane immediately. The interim recommendations of the Cass Review combined with the upcoming closure of Gids effectively do this, but the pressures on a new service to immediately take to the metaphorical skies again will be significant.

However, there is another way. Practice guidelines based on expert consensus cannot be mistaken for those based on systematic reviews. Where the systematic reviews indicate little evidence for benefit and potential for significant harm, the service should proceed with the caution that would be applied in any other branch of medicine.

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Cass has emphasised that just as there are many pathways into gender dysphoria for young people, so there could be many ways out. For some, that may still be a medical pathway, with its unevidenced outcomes and multiple inherent risks. The new teams will be tasked with explaining these uncertainties in uncompromising detail to ensure the truly informed consent of those who wish to embark on this experimental approach. Fortunately, the new service model means that other treatment pathways will now also be available.

Bringing gender distress firmly back into the fold of mainstream mental health services for children and adolescents means that these vulnerable children can finally begin to benefit from the therapeutic input and safeguards they have been denied for far too long. It can’t begin soon enough.

As a result of being repeatedly sexually assaulted in her teens, Watson began to feel hatred towards her female body. She was spending a lot of time on the internet, and began following a number of young trans men who were speaking positively, “if not euphorically”, about their transition. “I feel like I was groomed online,” says Watson. “According to Tumblr and YouTube, becoming a trans man would be the answer to all my problems.”

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Watson’s testimony echoes the experiences of many. The controversy surrounding the Gender Identity Development Service at the Tavistock and Portman NHS Trust in London, which is to be closed following a review by Dr Hilary Cass OBE, has led to a number of young women speaking out about their deep regret at medical transition.

Watson self-referred to the Sandyford in 2014, having spent time in a psychiatric unit following a severe mental breakdown. “I burned my house down while trying to kill myself,” she says, “and made out to the doctor it was because I was really a trans man and needed to transition. That was bullshit.” Watson was suffering from depression, dependent on alcohol, and struggling to accept that she was a lesbian.

Almost a year later, she was finally given an appointment at the Sandyford. “I walked up to reception and said my name is Sean Watson and I’m here to see a gender therapist.” She explains how the clinician put her at ease, immediately confirming her trans status and using “he/him” pronouns for her, all of which put Watson “on a high” of validation. “I thought: ‘These are professionals, if I wasn’t trans they would tell me, so the fact that they are affirming me means that I am trans.’”

“They must have looked at my GP records which showed a very long history of mental illness and trauma,” says Watson. “They didn’t once say to me, ‘We can see that there’s been some sexual abuse in your past, I wonder if that might have impacted on how uncomfortable you feel being a woman’.”

Understandably angry about everything she was put through, Watson now asks: “Why didn’t they ask why I wanted to live as a man, and talk these things through with me before starting me on a path of irreversible treatment?”

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After that first appointment, the Sandyford gave Watson a pamphlet that listed the side effects of testosterone, and asked her what changes to her body she was hoping for. “I said a deeper voice, a beard, fat redistribution and muscle mass. They were like, ‘Oh, OK, you know you might lose your head hair, get acne, and gain a lot of weight as well? How would you feel about those changes?’ I said I didn’t care. So basically, they were warning me I might be a bald, fat, spotty man.”

When patients attend a gender identity clinic, they are not supposed to transition until they have enough “lived experience” as the opposite sex. So, when the Sandyford asked how long Watson had been living as a man, she said, “two years”. That was all the evidence they needed. Within five months of her first appointment, Watson was given her first dose of testosterone. “The nurse told me to inject it every three weeks and said that I had to increase the dose steadily. I was given full vials and warned not to inject the lot. But of course I did.”

Watson soon experienced chronic abdominal and pelvic pain; clitoral irritation and discomfort due to enlargement; vaginal dryness and discomfort; and bladder problems such as a very regular urge to urinate, difficulty holding in urine, and wetting the bed. There was also the possibility that, although she still had female genitalia and reproductive organs, she was now infertile due to the testosterone.

After two years on testosterone, the Sandyford prescribed a double mastectomy, which was carried out in 2017. “The clinician told me the waiting list had increased from one year to two, because there was a huge increase in demand, as more young women were identifying as transgender,” says Watson.

“The nurse said ‘We need to make sure your breasts are healthy enough to remove’, before examining me, which sounded surreal,” Watson tells me, stunned that only healthy tissue could be surgically removed. “She then warned me that there was a possibility I would lose complete sensation in my chest and that my nipples may die and fall off.”

After the surgery, once the pain eventually subsided, Watson found that her chest area was completely numb. “I expected to feel elated, but it was the strangest feeling, having no breasts, and I began to wonder what on earth I had done.” Feeling has never returned to this part of her body. “Following the medical transition, I have been left with an overwhelming sense of loss, and intense despair over the irreversible changes I underwent as a vulnerable young woman.”

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On returning to the hospital to have her stitches removed, Watson was asked if she would give permission for a photograph of her chest to be in a catalogue, to show subsequent patients the various stages of healing. “I was like, ‘I don’t care. I got my surgery’. And I often wonder, now that I bitterly regret the whole thing: is my surgery, is my photo in that book being used to show other young women going under the knife right now? And the thought fucking sickens me.”

Having decided not to attend the Sandyford for regular blood tests — a requirement for those injecting testosterone — because she no longer trusted them, Watson stopped all contact with the clinic. They never followed up to see how she was. The only medical support she had was from her sympathetic GP, who admitted that gender identity was outside his field of knowledge but tried to support her as best he could. After confiding in him that she had stopped taking testosterone and now deeply regretted transitioning, Watson finally heard from Sandyford again. But by this time, two years had passed since her surgery.

“I got a letter from them saying ‘We’re more than happy to speak to you. If you ever do want to come in, call us and make an appointment’. But that was the last place I wanted to be,” she tells me. “I needed therapy but ended up being referred to one who had clearly swallowed the whole trans ideology and when I said I regretted my transition, said ‘perhaps you are non-binary’!”

In despair, Watson bluntly explained to the counsellor: “I can’t be a man. You can’t change sex. Pumping me full of cross-sex hormones and cutting off body parts is not going to make me a man.” Astonishingly, the counsellor then turned to a trainee who had been sitting in on the session and said: “Although Ms Watson thinks you can’t change sex, that’s her view, not mine.”

Feeling suicidal yet again, Watson decided that she could not bear to carry on living in limbo, or to put her family and loved ones through any more pain and worry. She began to research “transgender regret” and “detransition” online and found “a surprisingly large number of them. And then they told me their stories. I basically went from being horrifically depressed and suicidal to so fucking angry.”

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I contacted Sandyford for comment and received the following response: “Patients attending Sandyford’s Gender Identity Service undergo a full assessment by a multi-disciplinary team of psychiatrists, sexual health doctors, psychology and occupational therapists. The evaluation takes multiple engagements over an extended period of time to ensure patients fully understand the process, are aware of all implications and are enabled to make fully informed choices.” But, as Watson explains, she only ever saw one clinician, at most half a dozen times.

Watson is calling for the Sandyford Gender Identity Service to be shut down. “I never thought I was a man, I just didn’t want to be a woman. They should never have affirmed me. It was their job to scrutinise the problems I was having that led me to that place.”

These days, Watson refers to herself as bisexual and is in a happy relationship with a man, which was something she would not have considered pre-transition. “Until I was 27, I had never been attracted to men, but my sexuality changed with testosterone. This has also happened to loads of other women I have spoken to.”

Having spent four-and-a-half years on testosterone, she still has facial stubble and a deep voice. As part of her healing process, Watson is paying for laser treatment for her beard, as well as counselling. “For the therapy, I cannot believe the difference. To sit and speak to a clinically-neutral professional who seems genuinely interested in listening to me and offering solutions that will actually help me felt so cathartic.”

Watson says she’s not the only one who is glad she is back to being herself: “Sean was an arsehole. Very argumentative, rude, constantly trying to appear like a tough guy. My sister hated him. She said I seemed really angry and bitter when I was Sean.”

Meanwhile, the recommendation of Dr Hilary Cass’s report on the Tavistock gender clinic — that it be shut down and replaced with a more “holistic approach” — gave Watson hope. Finally, she is optimistic that the transing of swathes of gender non-conforming and traumatised females will be recognised for what it is: the biggest medical scandal since Thalidomide.

After being prescribed puberty blockers at 16, and undergoing a double mastectomy when she was 20, last year Bell decided to detransition, at 23. She is now taking action against the Tavistock and Portman NHS trust, which operates gender identity clinics in Britain, to stop them from ‘rushing’ other teenagers down the same path.

“There was no exploration of the feelings that I had, no psychiatric assessment,” Bell told This Morning. “It was very brief and based on my recent past. There was no in-depth discussion.”

As a result of her decision to transition, Bell will probably never be able to reproduce, nor will her body or voice recover completely from the impacts of testosterone and surgery. Many other girls are having similar changes of mind; more and more are coming forward to say they were sent down the path to transitioning with little information or warning of the long-term implications.

The trouble is, therapists and medical practitioners are reluctant to interrogate these kids and their wishes too deeply, increasingly fearful of being labelled bigoted or transphobic, or even accused of practising “conversion therapy”.

This particular development is currently playing out in Canada. In 2015, Dr Kenneth Zucker was fired from the Centre for Addiction and Mental Health Gender Identity Clinic (GIC) in Toronto, which he had run for more than 30 years, after trans activists called his approach “conversion therapy”. It transpired that this actually meant “watchful waiting” — rather than immediately starting patients who think they have gender dysphoria on the transition process, he thought it better to first try to “help children feel comfortable in their own bodies.” If the dysphoria persisted, Zucker would support them in their path to transitioning.

Today, his approach is close to being criminalised.

Last month, David Lametti, the current Minister of Justice and Attorney General of Canada, reintroduced proposed amendments to the Criminal Code, which would criminalise “conversation therapy”. In principle, most can understand the practice of attempting to turn gay people straight as damaging. But Bill C-6 is dangerously deceptive, in that it conflates this outdated intervention with the practice of affirming “gender identity”.

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Lametti told the Canadian House of Commons that “conversion therapy refers to misguided efforts to change the sexual orientation of bisexual, gay, and lesbian individuals to heterosexual [or to] change a person’s gender identity to cisgender”. But while conversion therapy, as it is understood conventionally, is a harmful practice, it shouldn’t be used to describe interventions involving children who believe they suffer from gender dysphoria. Indeed, it is the trend of transitioning children that is more likely to cause harm.

It is common practice to talk about depression, mental health and suicide when discussing the supposed need to “affirm” gender identity in kids, in order to start them on the path to transition. Lametti told the House of Commons of Canada that “scientific evidence” shows people who undergo conversion therapy “must deal with its negative effects such as anxiety, self-hate, depression, suicidal ideation, and attempted suicide”. He fails to mention that while this may be true of gay and lesbian individuals subjected to this practice, there is no evidence to support this claim with regard to youth who are not “affirmed” in their supposed gender identity.

Lisa Marchiano, a Jungian analyst in the US, explained in Quillette that the young female detransitioners she sees in her practice were all “suffering from complex social and mental health issues” at the time they decided to transition, and that “transition often not only failed to address these issues, but at times exacerbated them or added new issues”. Girls struggling with puberty, mental health issues, sexual identity, bullying, trauma, eating disorders, or gender roles will not be helped by testosterone and surgery. The real risk is that, with no caution, these practices will ruin their lives.

Over 90% of children who start on puberty blockers go on to take cross-sex hormones, eventually getting surgeries like mastectomies. But the blockers themselves can also have significant side effects, as Bell’s lawyer argued in court, including loss of fertility and sexual function, as well as decreased bone density. The impact on brain development is not yet fully known, but we do know that the surge of sex hormones at puberty triggers important changes in the adolescent brain, connected to cognitive development. Puberty is not only about developing breasts or body hair, it is a necessary part of developing into a healthy adult in many other ways.

Treatments for so-called “trans kids” remains experimental, yet few in Canada are asking why we are experimenting on kids. The number of referrals to the gender clinic at British Columbia’s Children’s Hospital rose from seven in 2007 to 80 in 2017. The trans clinic at Toronto’s Hospital for Sick Children sees over 200 referrals each year. Ten years ago, the CHEO, a children’s hospital in Ottawa, saw one or two patients a year with concerns about “gender identity”. In 2018, 189 patients were referred to the clinic. And while a decade ago an equal number of boys and girls were coming to the CHEO clinic, today, 75% of patients are female.

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Conflating sexual orientation and gender identity has proven to be a very successful means of manipulating public opinion, and those who wish to support gay and lesbian individuals to live joyful lives have come to believe that supporting gender identity ideology is the same thing. It is not.

Many governments and institutions across many countries are now treating “gender identity” as the determiner of biological sex — that is to say, that if one feels more connected to feminine stereotypes, one must be female, even if one is actually male. As a result, questioning gender norms, feeling uncomfortable in one’s body, experiencing same-sex attraction, or preferring toys or clothing typically associated with the opposite sex, is no longer just a normal part of growing up, but a that sign a child may be “trans”.

Bill C-6 proposes to criminalise those who profit from or advertise “conversion therapy”, which would include therapists and medical practitioners who do not practice the “affirmative model” — which means confirming “trans identity” unquestioningly. Choosing not to encourage a child to transition; suggesting a teen wait, and see if the “gender dysphoria” sticks a few years before beginning the process of transitioning; and challenging the concept of “gender identity” itself would potentially set a therapist or medical practitioner up for criminal sanctions.

It is already difficult to question the legitimacy of gender identity ideology in this climate, and it is practically impossible to access therapy that might allow a teen to grow out of their desire to transition, as so many do. Bill C-6 will make it illegal to offer therapy that does not approach transition as the best path.

The conflation of sexual orientation and gender identity in Bill C-6 is no accident. Lametti argued that his bill is an extension of Bill C-16, which added gender identity and gender expression to the Canadian Human Rights Act and Criminal Code in 2017. Passed with little debate, Bill C-16 set a precedent, leading provinces across Canada to adopt policies allowing males to access women’s same sex spaces. Along with some other feminists, I argued that such legislation would endanger women and girls and reinforce sexist gender roles fought against for decades. We weren’t listened to. But it is, indeed, what came to pass; males have been allowed access to women’s prisons and refuges — and even female beauty therapists are bullied into handling male genitalia.

The ball is already rolling with Bill C-6. Schools in British Columbia and Alberta have adopted SOGI, a programme to direct instructors on how to teach children about gender identity ideology. It claims to be aimed at stopping discrimination against and bullying of LGBTQ kids, but it does much more than that. SOGI insists that “Everyone has a sexual orientation and gender identity” and directs instructors to teach primary school kids that, “When babies are born, doctors and parents usually decide if the baby is a boy or girl. However, not everybody will grow up feeling like or identifying as a boy or a girl.” Students are to “look for clues” that tell them if a boy is really a girl. Lesson plans for teachers direct them to “ask students, what does it mean to feel like a boy or to feel like a girl?”

It is one thing to attempt to stop bullying and depression and suicide in teenagers who feel different and out of place. But it is quite another to indoctrinate children into gender identity ideology.

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By Julie Bindel

Teaching girls and boys that sexist stereotypes determine their sex, and saying that if a young boy prefers dresses or dolls that means he is a girl, is dangerous. Teaching girls that if they don’t conform to old-fashioned notions of femininity they are not girls, but boys, is harmful.

Kids should be free and encouraged to explore a variety of interests, sure. And they should not be shoved into categories if they don’t conform. But they should not be led, by adults, down a path to harmful prescriptions and surgeries without any room for debate — in a country where such debate is about to be criminalised.

While Canada appears to be eager to be first to adopt gender identity policies and legislation, it is not the only country enmeshed in this trend. When 28-year-old Charlie Evans, from the north-east of England, announced that she was setting up a setting up a charity called The Detransition Advocacy Network, hundreds of girls and young women contacted her with their concerns about having transitioned. In the UK, the number of adolescents referred for “gender treatment” has increased from 97 in 2009 to 2,510 in 2017-2018, and among girls from 40 to 1,800 — a 4,400% increase in 10 years.In the United States, surgeries for females transitioning to “male” increased by 289% between 2016 and 2017.

In 2017, our Canadian political representatives ignored the few women who dared speak up about their concerns about Bill C-16. Now we’re facing yet another dangerous bill that will prevent therapists from doing ethical work, and set institutions and practitioners up for very serious legal cases like the one brought forward by Keira Bell. It will restrict freedom of speech and honest debate, and more importantly it will destroy the lives of thousands of kids. I hope all politicians will listen, before it’s too late.

Meghan Murphy is a writer in Vancouver BC and the host of The Same Drugs.