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Besides teenage girls, another new group was referred to us: young people from the inpatient psychiatric unit, or the emergency department, of St. Louis Children’s Hospital. The mental health of these kids was deeply concerning—there were diagnoses like schizophrenia, PTSD, bipolar disorder, and more. Often they were already on a fistful of pharmaceuticals.

Being put on powerful doses of testosterone or estrogen—enough to try to trick your body into mimicking the opposite sex—-affects the rest of the body. I doubt that any parent who's ever consented to give their kid testosterone (a lifelong treatment) knows that they’re also possibly signing their kid up for blood pressure medication, cholesterol medication, and perhaps sleep apnea and diabetes. 

There are rare conditions in which babies are born with atypical genitalia—cases that call for sophisticated care and compassion. But clinics like the one where I worked are creating a whole cohort of kids with atypical genitals—and most of these teens haven’t even had sex yet. They had no idea who they were going to be as adults. Yet all it took for them to permanently transform themselves was one or two short conversations with a therapist.

Other girls were disturbed by the effects of testosterone on their clitoris, which enlarges and grows into what looks like a microphallus, or a tiny penis. I counseled one patient whose enlarged clitoris now extended below her vulva, and it chafed and rubbed painfully in her jeans. I advised her to get the kind of compression undergarments worn by biological men who dress to pass as female. At the end of the call I thought to myself, “Wow, we hurt this kid.”

How little patients understood what they were getting into was illustrated by a call we received at the center in 2020 from a 17-year-old biological female patient who was on testosterone. She said she was bleeding from the vagina. In less than an hour she had soaked through an extra heavy pad, her jeans, and a towel she had wrapped around her waist. The nurse at the center told her to go to the emergency room right away.

We found out later this girl had had intercourse, and because testosterone thins the vaginal tissues, her vaginal canal had ripped open. She had to be sedated and given surgery to repair the damage. She wasn’t the only vaginal laceration case we heard about.

Bicalutamide is a medication used to treat metastatic prostate cancer, and one of its side effects is that it feminizes the bodies of men who take it, including the appearance of breasts. The center prescribed this cancer drug as a puberty blocker and feminizing agent for boys. As with most cancer drugs, bicalutamide has a long list of side effects, and this patient experienced one of them: liver toxicity. He was sent to another unit of the hospital for evaluation and immediately taken off the drug. Afterward, his mother sent an electronic message to the Transgender Center saying that we were lucky her family was not the type to sue.

Here’s an example. On Friday, May 1, 2020, a colleague emailed me about a 15-year-old male patient: “Oh dear. I am concerned that [the patient] does not understand what Bicalutamide does.” I responded: “I don’t think that we start anything honestly right now.”

There are no reliable studies showing this. Indeed, the experiences of many of the center’s patients prove how false these assertions are. 

Many encounters with patients emphasized to me how little these young people understood the profound impacts changing gender would have on their bodies and minds. But the center downplayed the negative consequences, and emphasized the need for transition. As the center’s website said, “Left untreated, gender dysphoria has any number of consequences, from self-harm to suicide. But when you take away the gender dysphoria by allowing a child to be who he or she is, we’re noticing that goes away. The studies we have show these kids often wind up functioning psychosocially as well as or better than their peers.” 

When a female takes testosterone, the profound and permanent effects of the hormone can be seen in a matter of months. Voices drop, beards sprout, body fat is redistributed. Sexual interest explodes, aggression increases, and mood can be unpredictable. Our patients were told about some side effects, including sterility. But after working at the center, I came to believe that teenagers are simply not capable of fully grasping what it means to make the decision to become infertile while still a minor.

To begin transitioning, the girls needed a letter of support from a therapist—usually one we recommended—who they had to see only once or twice for the green light. To make it more efficient for the therapists, we offered them a template for how to write a letter in support of transition. The next stop was a single visit to the endocrinologist for a testosterone prescription. 

The doctors privately recognized these false self-diagnoses as a manifestation of social contagion. They even acknowledged that suicide has an element of social contagion. But when I said the clusters of girls streaming into our service looked as if their gender issues might be a manifestation of social contagion, the doctors said gender identity reflected something innate.

Frequently, our patients declared they had disorders that no one believed they had. We had patients who said they had Tourette syndrome (but they didn’t); that they had tic disorders (but they didn’t); that they had multiple personalities (but they didn’t).

The girls who came to us had many comorbidities: depression, anxiety, ADHD, eating disorders, obesity. Many were diagnosed with autism, or had autism-like symptoms. A report last year on a British pediatric transgender center found that about one-third of the patients referred there were on the autism spectrum.

This concerned me, but didn’t feel I was in the position to sound some kind of alarm back then. There was a team of about eight of us, and only one other person brought up the kinds of questions I had. Anyone who raised doubts ran the risk of being called a transphobe. 

I certainly saw this at the center. One of my jobs was to do intake for new patients and their families. When I started there were probably 10 such calls a month. When I left there were 50, and about 70 percent of the new patients were girls. Sometimes clusters of girls arrived from the same high school. 

Until 2015 or so, a very small number of these boys comprised the population of pediatric gender dysphoria cases. Then, across the Western world, there began to be a dramatic increase in a new population: Teenage girls, many with no previous history of gender distress, suddenly declared they were transgender and demanded immediate treatment with testosterone. 

Soon after my arrival at the Transgender Center, I was struck by the lack of formal protocols for treatment. The center’s physician co-directors were essentially the sole authority.

At first, the patient population was tipped toward what used to be the “traditional” instance of a child with gender dysphoria: a boy, often quite young, who wanted to present as—who wanted to be—a girl. 

During the four years I worked at the clinic as a case manager—I was responsible for patient intake and oversight—around a thousand distressed young people came through our doors. The majority of them received hormone prescriptions that can have life-altering consequences—including sterility. 

I left the clinic in November of last year because I could no longer participate in what was happening there. By the time I departed, I was certain that the way the American medical system is treating these patients is the opposite of the promise we make to “do no harm.” Instead, we are permanently harming the vulnerable patients in our care.

Today I am speaking out. I am doing so knowing how toxic the public conversation is around this highly contentious issue—and the ways that my testimony might be misused. I am doing so knowing that I am putting myself at serious personal and professional risk.

Almost everyone in my life advised me to keep my head down. But I cannot in good conscience do so. Because what is happening to scores of children is far more important than my comfort. And what is happening to them is morally and medically appalling.

For almost four years, I worked at The Washington University School of Medicine Division of Infectious Diseases with teens and young adults who were HIV positive. Many of them were trans or otherwise gender nonconforming, and I could relate: Through childhood and adolescence, I did a lot of gender questioning myself. I’m now married to a transman, and together we are raising my two biological children from a previous marriage and three foster children we hope to adopt. 

The center’s working assumption was that the earlier you treat kids with gender dysphoria, the more anguish you can prevent later on. This premise was shared by the center’s doctors and therapists. Given their expertise, I assumed that abundant evidence backed this consensus. 

All that led me to a job in 2018 as a case manager at The Washington University Transgender Center at St. Louis Children's Hospital, which had been established a year earlier. 

That’s the question behind the two main criticisms of “Girl.” One is that neither Dhont nor his co-writer, Angelo Tissens, nor the young actor who plays Lara, Victor Polster, are transgender

The other objection, the one that has prompted foes to label the film “traumatizing” and “sickening,” involves scenes near the end.

The outrage has played out ferociously online. The film critic Oliver Whitney wrote in The Hollywood Reporter that “Girl” is the “most dangerous movie about a trans character in years.” Whitney, who identifies as trans masculine, told me that seeing a trans girl mutilating herself suggests “it’s part of her survival, and that’s harmful.” He said he was most upset that the film “sends a damaging message to all audiences, but especially to trans folks suffering from dysphoria who may not have access to medical care or information about medical transitions.”

Three trans women who saw the film at a screening in Los Angeles said it was the film’s dark territory that made it compelling. Crystal Stull told me “Girl” was “the closest that cis people in society will ever get to understanding just how bad dysphoria can really get.

Ann Thomas, the founder of Transgender Talent, a talent listing service for trans people, chastised the campaign against it.“The message these arrogant trans activists are saying is that Nora doesn’t have the right to tell her story,” said Thomas, who also defended “Girl” in an opinion piece for The Advocate.

“We’re worried about harm reduction,” said Elena Rose Vera, the deputy executive director of Trans Lifeline, who has not seen the movie. “We just want to protect our community.”

Monsecour told me she hoped the trans community knew that “Girl” was a beginning, not an end.“I have a platform to speak with ‘Girl,’” she said. “Without ‘Girl,’ I wouldn’t have that. There’s a lot of work to do, but I’m confident that more trans people will tell their stories.”

Today, there are many more people like Claudia who regret transitioning, and who feel their mental health problems were ignored when their condition was put in a neat box marked ‘gender dysphoria’.

some mental health professionals were deeply concerned with the medicalisation of children. They believed these children required talking therapies, not irreversible hormonal and surgical interventions. But these staff were in a difficult position: they were under pressure from ‘powerful lobbies’ to opt for medication

the service was coming under pressure to recommend the prescription of drugs more often and more quickly, and that the independence of professional judgement was also coming under increasing pressure. Young patients may threaten suicide if their anxieties are not immediately addressed. Parents and others may threaten to complain and there are powerful lobbies from older patients pressing for the use of medication, which even more worryingly, is now available without regulation via the internet.

Clinicians feared the consequences if they refused to comply with what patients, and their parents, wanted. Sonia Appleby, a former safeguarding lead, told Barnes that those who spoke out against the transition of children were ‘demonised’.

It includes and rests upon a critical redefinition of what is known as “sex.” We usually think of this as simply male or female, on biological grounds (as opposed to a more cultural notion of gender). But the Equality Act would define “sex” as including “gender identity,” and defines “gender identity” thus: “gender-related identity, appearance, mannerisms, or characteristics, regardless of the individual’s designated sex at birth.”

What the radical feminists are arguing is that the act doesn’t only blur the distinction between men and women (thereby minimizing what they see as the oppression of patriarchy and misogyny), but that its definition of gender identity must rely on stereotypical ideas of what gender expression means. What, after all, is a “gender-related characteristic”? It implies that a tomboy who loves sports is not a girl interested in stereotypically boyish things, but possibly a boy trapped in a female body

So instead of enlarging our understanding of gender expression — and allowing maximal freedom and variety within both sexes — the concept of “gender identity” actually narrows it, in more traditional and even regressive ways. What does “gender-related mannerisms” mean, if not stereotypes?

it bans single-sex facilities like changing, dressing, or locker rooms, if sex is not redefined to include “gender identity.” This could put all single-sex institutions, events, or groups in legal jeopardy. It could deny lesbians their own unique safe space, free from any trace of men

This is the deeply confusing and incoherent aspect of the entire debate. If you abandon biology in the matter of sex and gender altogether, you may help trans people live fuller, less conflicted lives; but you also undermine the very meaning of homosexuality.

If you follow the current ideology of gender as entirely fluid, you actually subvert and undermine core arguments in defense of gay rights. “A gay man loves and desires other men, and a lesbian desires and loves other women,” explains Sky Gilbert, a drag queen. “This defines the existential state of being gay. If there is no such thing as ‘male’ or ‘female,’ the entire self-definition of gay identity, which we have spent generations seeking to validate and protect from bigots, collapses.”

There is a solution to this knotted paradox. We can treat different things differently. We can accept that the homosexual experience and the transgender experience are very different, and cannot be easily conflated. We can center the debate not on “gender identity” which insists on no difference between the trans and the cis, the male and the female, and instead focus on the very real experience of “gender dysphoria,” which deserves treatment and support and total acceptance for the individuals involved.

We can respect the right of certain people to be identified as the gender they believe they are, and to remove any discrimination against them, while also seeing biology as a difference that requires a distinction.

We can believe in nature and the immense complexity of the human mind and sexuality. We can see a way to accommodate everyone to the extent possible, without denying biological reality. Equality need not mean sameness.

We just have to abandon the faddish notion that sex is socially constructed or entirely in the brain, that sex and gender are unconnected, that biology is irrelevant, and that there is something called an LGBTQ identity, when, in fact, the acronym contains extreme internal tensions and even outright contradictions.

What we may not be able to do for much longer is work profitably. If a universal basic income emerges, or if technology renders our bodies and minds unnecessary for the success of our societies, we will still need to work, to do things. But we will almost certainly have to to reimagine what work is like, what work outside of the motives of profit or efficiency can mean, what value we attach to what we do each day, and how we do it.

The world we live in is a product of a capitalism that has made us all immeasurably better off, even as it has made us more and more unequal. But that world is clearly beginning to repeal itself, to render unnecessary the vast bulk of humanity’s labor, and the vast capitalist system has only existed for a blink of an eye in humanity’s long history. We are fools if we think it will go on forever. We will have to generate a new culture of work

In fact, Boot deserves great kudos for his honesty. Richard Haass, the Pope of the Blob, deserves credit too for recognizing that “the situation on the ground is something of a slowly deteriorating stalemate … Although the U.S. and its European partners cannot expect to win the war or broker a lasting peace, it should be possible to keep the government alive and carry on the fight against terrorists.” How’s that for a pep talk!

Boot argues that the U.S. should literally be the world’s policeman: “U.S. troops are … policing the frontiers of the Pax Americana. Just as the police aren’t trying to eliminate crime, so troops are not trying to eliminate terrorism but, instead, to keep it below a critical threshold that threatens the United States and our allies.”

My guess is that this ever-extending police project is unstoppable in the foreseeable future. And that is true of most empires: They never unwind voluntarily. They devolve into stalemates, and collapse only when the imperial power has so bankrupted itself morally, politically, and financially that the only choice is defeat at a time not of our choosing.

Capitalism, she continues, has “produced this cornucopia around us. But the young seem to believe in having the government run everything, and that the private companies that are doing things for profit around them, and supplying them with goods, will somehow exist forever.”

you can call Ms. Paglia a feminist capitalist. “While I believe that boom-and-bust capitalism is inherently Darwinian and requires moderate regulation for the long-term greater good,” she says, “I insist that capitalism has produced the glorious emancipation of women.”

“Everything is so easy now,” Ms. Paglia continues. “The stores are so plentifully supplied. You just go in and buy fruits and vegetables from all over the world.” Undergrads, who’ve studied neither economics nor history, “have a sense that this is the way life has always been. Because they’ve never been exposed to history, they have no idea that these are recent attainments that come from a very specific economic system.”

By contrast to her flaming public persona, Ms. Paglia is positively conventional in the classroom. “As I constantly stress,” she says, “my base identity is as a hard-working, no-nonsense schoolmarm—like the teaching nuns of global Roman Catholicism

She asks me to “stress that I do not teach ‘my’ ideas in the classroom.” Instead, she teaches “broad-ranging” courses and considers herself responsible for her students’ “general education—in which there are huge and lamentable gaps, thanks to the tragic decline of public education in this country.”

“There’s no doubt whatever,” she responds, “that I have had a radical gender dysphoria since earliest childhood. Never once in my life have I felt female.”

This strange alienation from standard human life certainly helped sharpen my powers of social observation,” she says, “and eventually made me a writer.” Her many years of researching and writing “Sexual Personae,” she adds, “exorcised a lot of my accumulated hostility toward the gender system.”

Any endocrinologist or other physician who rejects this approach is alleged to be endangering the health and even the life of his patients.

Research shows that some 80% of children with “gender dysphoria” eventually come to terms with their sex without surgical or pharmaceutical intervention

But are these patients really “transgender”

Multiple studies have found that most kids who are confused or distressed about their sex end up realizing they’re gay—nearly two-thirds in a 2021 study of boys

This makes sense: Gay kids often don’t conform to traditional sex roles. But gender ideology holds that feminine boys and masculine girls may be “born in the wrong body.”

In this light, “gender-affirming care” looks a lot like conversion therapy.

Now it takes the form of rendering teenagers sterile and sexually dysfunctional for life.

linicians from the main U.K. transgender service referred to prescribing puberty blockers as “transing the gay away”—a play on the description of old-fashioned conversion-therapy as “praying the gay away.” A clinician who resigned from the U.K. service accused it of “institutional homophobia.” Clinicians at the service had a “dark joke” that “there would be no gay people left at the rate Gids”—the Gender Identity Service—“was going.”

Consistent with conversion therapy, physicians are telling young gays and lesbians that something is wrong with them, based on a regressive view of what it is to be male or female

The resulting interventions often create lifelong medical problems, both physical and mental. Contrary to advocates’ claims, there’s no evidence that puberty blockers, cross-sex hormones, or surgeries reduce the risk of suicide.

Children who take this road face a lifetime of pain, infertility and anguish

society has been told that accepting transgender identity is the same as accepting gays and lesbians. But it isn’t. Even well-intentioned acceptance of transgender identity disproportionately harms them

“This is a complete misrepresentation of the definition of abuse in the family code,” Christian Menefee, the Harris County attorney, said in an interview.

“We don’t believe that allowing someone to take puberty suppressants constitutes abuse,”

Governor Abbott’s effort to criminalize medical care for transgender youth is a new front in a broadening political drive to deny treatments that help align the adolescents’ bodies with their gender identities and that have been endorsed by major medical groups.

Arkansas passed a law making it illegal for clinicians to offer puberty blockers and hormones to adolescents and banning insurers from covering care. But the law was temporarily blocked by a federal judge in July after the American Civil Liberties Union sued on behalf of four families and two doctors.

Several such bills were also introduced in Texas. None passed.

She said that blocking gender-affirming care and forcing teenagers to go through the physical changes of puberty for a gender they don’t identify with was “inhumane.”

“Our nation’s leading pediatricians support evidence-based, gender-affirming care for transgender young people.”

A growing number of transgender adolescents have sought medical treatments in recent years. Transgender teenagers are at high risk for attempting suicide, according to the Centers for Disease Control and Prevention. Preliminary research has suggested that adolescents who receive such medical treatments have improved mental health.

“What is clear is that politicians should not be tearing apart loving families — and sending their kids into the foster care system — when parents provide recommended medical care that they believe is in the best interest of their child.”

“It’s designed to make parents scared,” he said. “It’s designed to make doctors scared for even facilitating gender-affirming health care.”

“Minors are prohibited from purchasing paint, cigarettes, alcohol, or even getting a tattoo,” Jonathan Covey, director of policy for the group Texas Values, said in an emailed statement. “We cannot allow minors or their parents to make life-altering decisions on body-mutilating procedures and irreversible hormonal treatments.”

Professional medical groups and transgender health experts have overwhelmingly condemned legal attempts to limit “gender-affirming” care and contend that they would greatly harm transgender young people.

“Gender-affirming care saved my life,” they said in a statement. “Trans kids today deserve the same opportunity by receiving the highest standard of care.”

a 2022 Reuters investigation found that some American clinics were quite aggressive with treatment: None of the 18 U.S. clinics that Reuters looked at performed long assessments on their patients, and some prescribed puberty blockers on the first visit.

As Cass writes in her report, “The toxicity of the debate is exceptional.” She continues, “There are few other areas of health care where professionals are so afraid to openly discuss their views, where people are vilified on social media and where name-calling echoes the worst bullying behavior.”

The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.

he notes that the quality of the research in this field is poor. The current treatments are “built on shaky foundations,” she writes in The BMJ. Practitioners have raced ahead with therapies when we don’t know what the effects will be. As Cass tells The BMJ, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”

Our natural human tendency is to be too confident in our knowledge, too quick to ignore contrary evidence. But these days it has become acceptable to luxuriate in those epistemic shortcomings, not to struggle against them. See, for example, the modern Republican Party.

In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “The Ethics of Belief.” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases.

“It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote

A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”

Since the Trump years, this habit of not consulting the evidence has become the underlying crisis in so many realms. People segregate into intellectually cohesive teams, which are always dumber than intellectually diverse teams. Issues are settled by intimidation, not evidence

her core conclusion is this: “For most young people, a medical pathway will not be the best way to manage their gender-related distress.” She realizes that this conclusion will not please many of the young people she has come to know, but this is where the evidence has taken her.

She writes in her report, “The option to provide masculinizing/feminizing hormones from age 16 is available, but the review would recommend extreme caution.