The School-to-Clinic Pipeline – City Journal

In July, the Department of Education’s Office for Civil Rights (OCR) published a 190-page proposal for new rules under Title IX of the Education Amendments of 1972. If passed, the rules would reintroduce Obama-era standards for defining and addressing “sexual harassment,” which means, in practice, restrictive speech codes, proliferating Title IX jobs on the public dime, and campus kangaroo courts. This time, the OCR intends to add a mandatory reporting requirement that would turn teachers and professors into enforcers of an infantilizing sex bureaucracy.

The most troubling aspect of the new rules, however, is what they do on the gender-identity front. Catherine Lhamon, whom Biden reappointed to the role of assistant secretary for civil rights at the Department of Education, in which role she heads the OCR, is considered a crusader on gender issues. The OCR intends to ramp up the pressure on school districts to adopt policies that will facilitate students’ gender transitions, even without the knowledge or consent of their parents. This marks a disturbing twist in the continuing saga of Title IX expansion, especially considering how the new policy is likely to harm girls disproportionately. Under the political cover of “civil rights,” the Biden administration is cementing the school-to-clinic pipeline.

The term “social transition” refers to the use of a person’s preferred name and pronouns and granting access to sex-specific accommodations like restrooms and sports teams that match that person’s “gender identity.” Researchers, clinicians, parents, and detransitioners (people who began or completed medical gender transitions but changed their minds and sought to reverse the process) have noted the self-fulfilling prophecy of social transition. “Affirming”—that is, agreeing with and supporting—a minor’s rejection of his or her body in favor of an alternative “gender identity” increases the chances that what would otherwise prove a temporary phase of confusion or distress will become a more permanent state of mind, i.e., an “identity.”

To date, 11 studies have examined rates of desistence/persistence of gender dysphoria in prepubertal children. All found that the vast majority (61 percent to 98 percent) desist by adolescence on their own or with counseling. Most, in fact, will come out as gay or lesbian—unsurprisingly, given that early signs of gender nonconformity are a known predictor of homosexuality. It was exactly for this reason that the Dutch experts who pioneered juvenile medical transition urged great caution in dealing with children and recommended no social transition before age 12—a dubious cutoff point, it turns out, but one that at least tried to distinguish between prepubertal and adolescent youths.

A 2022 study by Kristina Olson inadvertently confirmed the risks of early social transition when it found that 98 percent of children “affirmed” in their cross-gender identification at an early age retain that identification—that is, fail to come to terms with their bodily sex—after five years. For advocates of the “affirmative” approach, including Olson herself, this was evidence of the need to support children in their gender self-identification. For the more critical-minded, it underscored the iatrogenic risk of social transition—“iatrogenesis” meaning a medical intervention that is itself the cause of illness—since the only way to square Olson’s findings with the previous studies is to assume that “supporting” the children contributed to their gender dysphoria.

In her review of the National Health Service’s Tavistock Centre prior to the closure of its Gender Identity Development Service, Hilary Cass, former president of the U.K.’s Royal College of Paediatrics and Child Health, raised concerns about social transition. Using a minor’s preferred name and pronouns to validate his or her “gender identity,” Cass observed, should not be considered “a neutral act” but instead an “active intervention” in a child’s psychosocial development. An “affirmed” child reaching the Tanner II stage of physical development—typically between ages nine and 13—in a state of gender dysphoria will likely go on to receive puberty blockers, especially given the widespread (but false) assumption that these expensive drugs are “fully reversible” and merely buy some time for self-reflection. Three studies completed over the past four years show that 96 percent to 98 percent of those who begin puberty blockers go on to cross-sex hormones, a more extreme form of intervention that typically entails permanent loss of fertility and sexual function in addition to heightened risk of cancer and heart disease.

Puberty blockers have never been subjected to randomized controlled trials (RCTs)—the highest standard for clinical drug trials—in the context of gender dysphoria. (Claims about their safety and reversibility rest on their use for precocious puberty, a different condition with a different etiology, diagnostic criteria, and prognosis.) A major reason for this situation is that activists have already asserted, independent of evidence, that these drugs are “medically necessary” and “lifesaving.” On this view, subjecting puberty blockers to RCTs, which typically require control groups that get either no treatment or placebos, would mean condemning many teenagers to suicide. The use of puberty-blocking agents like leuprorelin (brand name, Lupron) remains FDA-unapproved and off-label.

In practical terms, then, when a school strives to create a “safe, welcoming, and inclusive” environment for transgender-identified students, it greatly increases the chance that children who might otherwise go through a temporary stage of identity exploration or confusion will reject their bodies in favor of a risky experimental medical protocol. Even for those who believe that someone can consent to medical “gender transition” at 16 but not, say, at seven, this should be sobering news. It means that a teacher’s expression of kindness and desire to be inclusive could have serious unintended effects. Given mounting evidence of the socially contagious nature of transgender identification among teenage girls with preexisting mental health conditions, parents are right to worry about the consequences of the new Title IX rules.

Transgender advocates make conflicting claims about social transition, as do federal judges. When the ACLU filed a federal lawsuit on behalf of the Virginia student Gavin Grimm, it appointed an expert witness who assured the judge that “social role transition is a critical component of the treatment for Gender Dysphoria”: “If any aspect of social transition is impeded,” the expert emphasized, “it undermines the entirety of a person’s transition.” By contrast, in a Wisconsin lawsuit, an expert appointed by the Transgender Law Center described social transition as a “non-medical process.” Yet on appeal, the seventh circuit approved the student’s use of desired restrooms on grounds that it was related to his “medically diagnosed and documented condition.”

Whether social transition is “medical” depends on how one defines it. If the term encompasses only synthetic hormones and surgeries, then social transition is not “medical.” If it includes psychological interventions, then social transition is undeniably medical. But even if one takes the first definition, social transition should be taken very seriously. As James Cantor, a Canadian psychologist who has served as expert witness for states seeking to restrict or ban pediatric gender transition, has observed, encouraging children to eat junk food and never exercise is technically not medical advice, but it has obvious medical consequences.

The United States has become an outlier in pediatric gender medicine. Medical authorities in Sweden, Finland, and, most recently, the U.K. have done some combination of closing down gender clinics, placing sharp restrictions on the use of hormones for treating youth in distress, banning surgeries outright, and issuing warnings about the “experimental” nature of pediatric medical transition, as Finland’s Council for Choices in Healthcare put it. These countries have based their decisions on systematic review of the evidence—an approach designed to synthesize scientific insight from a range of studies according to predetermined criteria, thus minimizing the risk of bias (through cherry-picking of studies) to support a desired conclusion. Earlier this year, Florida banned Medicaid from funding “gender affirming care” after a panel of experts commissioned by the state department of health conducted an “overview of systematic reviews.”

By contrast, the Biden administration, its media allies, federal judges, and transgender advocacy groups have resolved to follow American medical associations, which have not conducted systematic evidence reviews and have instead devoted themselves to promoting deeply flawed and ideologically driven research. The three most important such organizations are the American Academy of Pediatrics (AAP), the Endocrine Society (ES), and the World Professional Association for Transgender Health (WPATH).

“Given the socially contagious nature of transgender identification, parents are right to worry about the Title IX rules.”

In 2012, WPATH revised its standards of care to recommend medical transition for minors. That recommendation was based on a single flawed Dutch study. Candidates were eligible for hormones in the Dutch study only if their gender dysphoria had begun in early childhood and continued or intensified into puberty, and only after demonstrating no mental health problems that might cloud their judgment. Parental support was also deemed vital, since parents are typically a source of important information for the presiding clinician. These criteria alone make the Dutch protocol (and thus WPATH’s 2012 recommendations) inapplicable to the vast majority of youth presenting at gender clinics over the past decade. These youth are generally female (whereas the majority of the Dutch patients were male), have adolescent- or sudden-onset gender dysphoria, and exhibit high rates of mental-health comorbidities that began before the gender issues, including eating disorders, anxiety, depression, ADHD, and autism (one-third of adolescents referred to the U.K.’s Gender Identity Development Service at Tavistock had autism or other neuro-atypical conditions). The original study also suffered from methodological distortions, a very small sample size, and short follow-up periods. The only attempt to replicate its findings, recently undertaken in the U.K., failed to do so.

WPATH recently updated its standards of care for the eighth time (the first time since 2012), now adding a separate category for “eunuchs” (WPATH insists that “eunuch individuals may be aware of their identity as early as childhood or adolescence”) and eliminating the age minimums for hormones and surgeries. No new studies have appeared since 2012 to ground these revisions, and evidence suggests that even WPATH’s comparatively restrictive seventh version was wildly out of step with basic ethical standards.

In December 2021, psychologists Laura Edwards-Leeper and Erica Anderson warned in the Washington Post that the “mental health establishment is failing trans kids.” They noted the “skyrocketing” number of teenagers seeking medical transition, the fundamental differences between this patient cohort and the one for which pediatric transition was originally developed, and the fact that in the rush to “affirm” these kids, clinicians were providing “sloppy, dangerous care.” Edwards-Leeper was the founding psychologist of the first specialized pediatric gender clinic in the United States and serves as chair for WPATH’s Child and Adolescent Committee. Anderson is also a member of WPATH and herself transgender.

Five years after WPATH published its 2012 standards, the Endocrine Society released its own guidelines on pediatric medical transition. The guidelines did not tell clinicians whether, or how, to diagnose gender dysphoria in youth but instead made recommendations for what to do once a diagnosis is made. Perhaps that is why ES was willing to acknowledge the deep uncertainties and research limitations behind hormonal interventions. It ranked its own recommendations as resting on “low-quality” or “very low-quality” research. In a subsequent assessment of the evidence, published in 2021, six reviewers looked at the guidelines put forward by ES (2017) and WPATH (2012). Only one agreed that WPATH’s standards were well-grounded, and none found ES’s pro-intervention guidelines satisfactory.

As for AAP, the organization’s conduct when it comes to pediatric gender medicine is scandalous. In 2018, pediatrician Jason Rafferty and colleagues published a paper in the organization’s peer-reviewed journal, Pediatrics, contending that all available evidence suggests that psychotherapy should never be used as a first resort for minors who declare themselves transgender—and, indeed, that any approach that does not defer to the adolescents’ self-diagnosis and “affirm” it constitutes “conversion therapy,” a discredited approach to changing someone’s homosexual orientation. As Cantor found in a thorough fact-check, which was peer-reviewed, the Rafferty statement blatantly mischaracterizes the evidence (for instance, by relying on studies on homosexuality) and omits studies that do not support its conclusion. Nevertheless, AAP has endorsed the Rafferty statement and, to its eternal discredit, has systematically suppressed efforts by members to conduct a thorough evaluation of the research behind the “gender-affirming” approach.

Teachers and school administrators have neither the expertise nor the authority to make medical decisions for their students, especially when those decisions could have lifelong implications. Such decisions should be entrusted to parents or legal guardians alone, in consultation with a physician. After all, parents are the people most invested in their child’s well-being, understand his or her evolving needs the best, and will bear the long-term consequences of any decision.

Transgender advocates and their allies in K–12 schools counter that many parents are not “supportive” of their transgender-identified children and therefore should not be consulted about social transition. No doubt, cases exist where a student’s desire to look or behave like the opposite sex leaves him or her vulnerable to physical or emotional abuse at home—and, as with all such situations, these children deserve protection. But given what we know about left-wing activism, it’s unreasonable to trust in-house gender activists to determine what constitutes “abusive” parenting. Of course, parents often won’t take their child’s self-diagnosis at face value. But given everything we know about teenagers, puberty, and gender dysphoria, why should they?

How have we reached a situation where ideologically extreme and medically irresponsible decisions are made on a daily basis in American schools? The reasons are complex, but the structural forces shaping U.S. policy are a big part of the explanation.

Conservatives often criticize administrative government as being heavy-handed in shaping the minutiae of public policy. While this criticism is often sound, it overlooks the incentive structure of policymaking and how activists inside and outside government often try to achieve their ends. The OCR’s Title IX rules are actually vague. They do not define the key term “gender identity,” or specify when and under what circumstances schools are to involve parents in decisions regarding student gender transition. Nebulous administrative guidelines create legal uncertainty, leaving school administrators anxious about what counts as compliance. The Obama-era OCR used systemic investigations to pressure schools into signing consent agreements for measures that the OCR had no real legal authority to impose. Fearing OCR investigations and civil rights lawsuits by groups like the ACLU and Lambda Legal, risk-averse school administrators will understandably want to get on the good side of such organizations.

Schools thus face strong incentives to let transgender advocacy groups dictate their internal policies. By using ambiguous language, the OCR is de facto delegating regulatory authority to special-interest groups. The Gay, Lesbian & Straight Education Network’s Model Local Education Agency Policy on Transgender Nonbinary Students, which schools nationwide have adopted, states: “Medical information, recognition, or documentation are not required to change a student’s gender marker or name in the student database/information system.” On parental notification, it says that, absent parental approval, schools should adopt a student’s preferred name and pronouns off the record (changing the name in the database requires parental consent).

What we’re seeing with Title IX is simply a manifestation of the “public interest” politics created in the wake of the 1960s, when liberal reformers demanded expanded government programs but distrusted the institutions of government to carry them out. Public interest groups, it was thought, would sit as watchdogs over the policy process and, where necessary, use courts and administrative mechanisms to promote the interests (typically framed as “rights”) of the less politically or economically powerful. But because no mechanism of accountability exists to tie these groups to voters and because the people working for them are almost always ambitious ideologues, with neither the interest nor the desire to compromise on their policy positions, the frequent result is radical policies out of step with sound science or broad public approval. Nowadays, the main challenge facing school administrators on the gender-identity front is not whether to adopt policies that most parents would find abhorrent, but how to conceal those policies, once adopted, from parents.

In some instances, guidelines on parental involvement are based on state laws. In 2012, Massachusetts revised its civil rights code to include protection on the basis of “gender identity” in education. The state board of education subsequently issued the following guideline:

Some transgender and gender nonconforming students are not openly so at home for reasons such as safety concerns or lack of acceptance. School personnel should speak with the student first before discussing a student’s gender nonconformity or transgender status with the student’s parent or guardian. For the same reasons, school personnel should discuss with the student how the school should refer to the student, e.g., appropriate pronoun use, in written communication to the student’s parent or guardian.

In April of this year, parents in Ludlow, Massachusetts, sued their school district, alleging that it socially transitioned their two children without their knowledge or consent. The state department of education guidelines explicitly mandate such information be disclosed to parents for students under 14. According to the complaint, the district began introducing gender-identity concepts to kids at 11 years old. (In young children, merely learning that “gender identity” is independent of the body and susceptible to self-definition can create identity confusion where none would have existed.) By 2021, the couple’s daughter identified as transgender and e-mailed school officials, asking them to use her desired new name, along with any combination of “she/her he/him they/them fae/faerae/aer ve/ver xe/xem ze/zir” pronouns. The middle school principal allegedly responded with a “reply to all” e-mail instructing all copied parties to comply and, following the student’s wishes, avoid notifying the parents.

In 2015, the National Education Association partnered with the ACLU, Gender Spectrum, the Human Rights Campaign, and the National Center for Lesbian Rights to create a pamphlet titled “Schools in Transition.” The pamphlet’s “Appendix D: Gender Support and Gender Transition Plans” provides education bureaucrats with a highly detailed template for managing all aspects of student behavior and accommodation, including “what considerations must be accounted for in implementing this plan” in the event that the “guardian(s)” of the student are not “aware and supportive of their child’s gender transition.” In 2016, the American School Counselor Association adopted a policy on “transgender and nonbinary youth” that emphasized the need to “affirm” (agree with) students’ gender self-identification unquestioningly.

In line with most controversies in American life, the question of parental involvement has been subsumed under the heading of “rights” and litigated in the courts. On one side are those who argue that when schools keep parents in the dark about their children’s gender transition, they are violating the parents’ right to direct decisions relating to their children’s health and moral upbringing. On the other side are those who maintain that students have a right to privacy over their gender decisions, which includes keeping information from their parents, and that parental rights over medical decisions do not include the authority to make choices that subject children to serious harm. The latter claim has merit in the abstract, but whether it applies in this case depends on whether social and medical transition is “medically necessary” or even merely beneficial. All available research suggests that the benefits are, at best, speculative, while the risks—at least the known risks, since this protocol remains experimental—are serious.

One question currently in the courts concerns the relationship between transgender policies and the federal Family Educational Rights and Privacy Act (FERPA). The law grants parents the right to access school records for their children. Ominously, the proposed Title IX rules stipulate that when FERPA clashes with Title IX, the rules take precedence—so that, when disclosing information about students to their parents is thought to create a “hostile environment” for those students (as experienced by them subjectively), schools should keep quiet. That, at least, is how transgender advocacy groups and school administrators are almost certain to interpret the regulations.

Because Democrats and school officials invoke medical authorities to justify their unpopular policy choices, the current gender woes in our schools will probably not go away until medical professionals and organizations begin to face serious consequences for their actions. Reliable data are needed on just how many youths who show up at the office of their pediatrician, social worker, or school counselor end up on hormones. In response to a Wall Street Journal op-ed I coauthored with Julia Mason, a pediatrician, regarding what we called AAP’s “dubious transgender science,” AAP president Moira Szilagyi wrote: “Gender-affirming care can be lifesaving. It doesn’t push medical treatments or surgery; for the vast majority of children, it recommends the opposite.” But practitioners in the field who haven’t been overtaken by gender ideology don’t seem to agree. As one clinician told me, specialized gender clinics tend to assume that the teenagers they see have already been vetted for confounding mental health problems by local providers—but those providers, perhaps fearing accusations of “gatekeeping,” often assume that the gender clinics will do the vetting. This problem is similar to the one that Cass has observed in the U.K., which prompted the closure of the Gender Identity Development Service.

In June, Congressman Jim Banks and Senator Tom Cotton, both Republicans, introduced legislation in Congress to extend the statute of limitations on malpractice suits in this area of medicine to 30 years after reaching adulthood. Currently, most malpractice limitations run between one and three years; some research shows that regret tends to manifest about a decade after transition.

Whether Banks and Cotton’s Protecting Minors from Medical Malpractice Act will pass Congress remains to be seen. But even if it doesn’t, it is only a matter of time before the American medical establishment, perhaps prodded by threats of huge malpractice settlements and related insurance premium hikes or by negative publicity, catches up to its counterparts in Western Europe. Meantime, Catherine Lhamon’s OCR is giving gender activists in schools what might prove to be a final shot of testosterone in the arm.

Leor Sapir is a fellow at the Manhattan Institute.

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