The Science is Not Settled: An American Skeptic’s View of Trans Care for Youth

Aims: This paper defines the disagreements that have deeply divided American clinicians about the prescription of puberty blockers, cross sex hormones, and various surgeries for trans-identified minors. The basic question is what types of evidence should determine clinical management. The issue has not been resolved. Its attendant cultural controversies have spawned lawsuits on ten separate topics in the United States. Method: This paper presents the current arguments of the proponents of affirmative care and those of skeptics. These arguments are found in professional literature and in court documents. Results: Twelve of the most contentious issues are discussed: trustworthiness of the benefits; permanence of a trans identities; biological determinism; ethical priorities; informed consent; impact on suicidality; significance of co-morbidities; autism; processes of evaluation; hegemony of the World Professional Association for Transgender Health; childhood social transition. Despite scientific skepticism, major American medical institutions view these arguments as biased. Conclusions: Perspectives of patients, parents, sociologists, anthropologists, and spokespersons for moral, religious, social justice, and political considerations contribute to the polarized culture. Court decisions are subtly influenced by these perspectives, but their judgments are based on constitutional interpretations. The recent United States Supreme Court ruling upholding Tennessee’s ban on hormonal and surgical care does not mean that all affirmative care is banned throughout all 50 states. The author’s view is that since outcomes are uncertain, parents, not professionals, should be more widely recognized as key decision makers.