Gender Medicine’s Hall of Mirrors

How institutional consensus and moral certainty replaced evidence in pediatric gender medicine.

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About the Author

Joe Figliolia is a policy analyst at the Manhattan Institute where he writes about ethics, society and culture with a particular focus on pediatric gender medicine. His writing has appeared in City Journal, The Dispatch, and the New York Post, among others. Figliolia earned an MA from NYU's Center for Experimental Humanities.

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From the collapse of a shared American monoculture and the rise of hyper-personalized information streams to the flood of AI-generated content, it has never been harder to separate digital wheat from digital chaff. The promise of shared cultural literacy feels increasingly remote as our information environment grows more complex, while our capacity for comprehension and critical thinking fails to keep pace. Even with access to more knowledge that makes the Library of Alexandria seem almost quaint in comparison, many of us remain lost in an informational hall of mirrors.

This problem is especially acute when it comes to subjects with a genuinely high barrier to entry. Pediatric gender medicine is one such topic. To understand it in any serious, holistic way requires at least a working familiarity with several disciplines that are typically siloed from one another: evidence-based medicine, endocrinology, clinical psychology, bioethics, and sociology, among others. Given that reality, it’s easy to understand the impulse to defer to supposed experts when time, background knowledge, or both are in short supply.

But a recent essay in Newsweek, titled “Bad Medicine—How Secretary Kennedy Is Jeopardizing LGBTQ Lives,” inadvertently illustrates the costs of uncritically outsourcing judgment to ostensibly authoritative voices who, in this case, fail to serve their function or the public interest. The piece is written by Adrian Shanker and Sam Ames, both of whom served in the U.S. Department of Health and Human Services (HHS) under the Biden-Harris administration. They characterize HHS’s recent peer-reviewed report on pediatric gender dysphoria as the product of conspiracy thinking and “transphobia,” while framing it as an extension of Health Secretary Kennedy’s more eccentric views on controversial topics like autism and vaccines. In doing so, the authors present themselves as clear-eyed defenders of truth cutting through pseudoscience.

This is unfortunate, because whether driven by bad faith or genuine scientific illiteracy, the essay amounts to a sweeping misinformation campaign against the HHS report—one that corrodes public trust in both experts and institutions. What’s at stake is nothing less than our ability to inhabit a shared, intelligible world governed by scientific norms rather than surrendering to the buzzing confusion of relativism.

What makes the Newsweek piece especially damaging to civil discourse is the gap between its sanctimonious confidence and its evident lack of engagement with the underlying material. Despite repeatedly asserting that the HHS report lacks scientific merit, the authors give every indication that they either did not read the report in full or, if they did, failed to understand it. This impression is hard to avoid given their reliance on claims that the report itself directly contradicts, as well as their apparent confusion about how evidence hierarchies function in evidence-based medicine.

Shanker and Ames declare the report “methodologically muddled,” but fail to expand on this critique. What they fail to acknowledge is that the report’s peer-reviewers—including evidence-based medicine experts from Belgium—praised its methodology as clear and reproducible. Nor did any reviewer dispute the central finding of the report’s umbrella review—a review of systematic reviews—that the evidence supporting medical transition is of only “low certainty.”

Although critics like Shanker and Ames portray the HHS report as a political hit job with predetermined conclusions, its findings are anything but surprising. Systematic reviews—the highest tier of evidence in evidence-based medicine—conducted in Sweden, Finland, and the United Kingdom have reached the same conclusion. Just weeks ago, New Zealand announced a pause on all new puberty-blocker prescriptions over ethical concerns. Yet Shanker and Ames appear either unaware of, or uninterested in, this international context, instead telling readers that the HHS report exists merely “to create the appearance of a genuine scientific debate.”

The authors also assert, irresponsibly, that so-called “affirming care” is a “common sense” intervention, claiming that decades of research demonstrate a 60 percent reduction in depression and a 73 percent reduction in suicidality and self-harm. But the characterization of these interventions as “common sense” falls apart under even minimal scrutiny. They remain unapproved by the FDA for the treatment of gender dysphoria, and their adoption was shaped in part by earlier efforts to address poor outcomes among adult transitioners, not by robust evidence of benefit in pediatric populations.

More troubling still, Shanker and Ames fundamentally misrepresent the evidence base itself, undercutting the HHS report’s central aim of helping the public understand what the science actually shows. The dramatic figures they cite trace back to a single 2022 observational cohort study by Diana M. Tordoff and colleagues, a study that has persisted in public discourse like an invincible zombie, despite having been carefully and repeatedly fact-checked since its publication. Its methodological flaws have been documented by Leor Sapir, Jesse Singal, and, several months ago, by me, after the study was cited in a Continuing Medical Education course by a member of the Texas Medical Association.

Readers should understand that within evidence-based medicine, studies like Tordoff et al. (2022) sit near the bottom of the evidence hierarchy for straightforward methodological reasons. As an observational study without a control group, it cannot establish causality. Any reported benefits are further confounded by the fact that participants simultaneously received psychotherapy and psychiatric medications. In short, the study design makes it impossible to isolate the effects of medical intervention itself. This is precisely why systematic reviews exist: to weigh the totality of evidence and assess whether an intervention actually works.

Either Shanker and Ames do not grasp this basic framework, or—perhaps even more troubling—they do and choose to ignore it. When writing confidently and publicly about one of the most conceptually and ethically complex issues of our time, there is a responsibility to get the underlying facts right, even when reasonable people may disagree about what those facts imply for public policy.

This abdication of responsibility extends to their defense of medical societies that endorse pediatric gender medicine, which they treat as conclusive evidence that the practices must therefore be evidence-based. As they write, “What the report fails to adequately address, is the longstanding consensus of every major medical organization that gender-affirming care is linked to improvements in the health of transgender youth” (and the consensus has recently shown signs of cracking with the groundbreaking position statement by the American Society of Plastic Surgeons opposing surgical interventions for minors). They go on to claim that “what was formerly a generally-accepted medical consensus has been thrown into a flashy culture war whose proponents rely on bluster and noise to appear on equal footing with empirical evidence.”

Contrary to their assertion, the HHS report devotes an entire chapter—Chapter 12—to explaining how U.S. medical associations arrived at an artificial consensus around pediatric gender medicine despite contrary findings in systematic reviews. As the report details, American medical organizations rarely evaluate the underlying evidence base for “affirming care” themselves. Instead, they tend to endorse guidelines issued by the World Professional Association for Transgender Health (WPATH) and the U.S. Endocrine Society—guidelines that have been deemed unsuitable for use in clinical practice because of serious deficiencies in developmental rigor. These guidelines have nonetheless done much of the heavy lifting in persuading the public that pediatric gender medicine is both safe and effective.

In WPATH’s case, the organization commissioned evidence reviews and then declined to publish them after the findings conflicted with its goal of expanding access to pediatric medical transition. The Endocrine Society’s recommendations, meanwhile, are classified as “discordant” in the parlance of evidence-based medicine, meaning their clinical guidance is not supported by the conclusions of their own systematic reviews, which focused largely on adult, rather than pediatric, transitioners.

The authors’ appeal to medical consensus also ignores a basic point that consensus-based medicine is not the same as evidence-based medicine. The very purpose of federal evidence standards was to move beyond professional agreement as an authority in itself. History offers no shortage of cautionary examples. Frontal lobotomies, insulin coma therapy for schizophrenia, and routine bloodletting were once considered standard care. There is good reason to suspect that many pediatric transition interventions will one day be viewed in much the same light.

Ironically, the authors’ uncritical deference to the U.S. medical establishment makes it more difficult to reestablish treatment for pediatric gender dysphoria on empirical grounds. What Shanker and Ames appear not to recognize is that the current position of many American medical associations is fundamentally at odds with the principles of evidence-based medicine. That tension helps explain why several European countries, which adhere more closely to EBM standards, have reversed course on pediatric medical transition. In the United States, by contrast, defenders of “affirming care” tend to rely on institutional consensus—an appeal to authority—rather than on the strongest available evidence.

There are also clear incentives discouraging U.S. medical associations from breaking with the consensus they helped construct. As I documented in a recent report on institutional capture within the Texas Medical Association, policymaking on “LGBTQ” issues is often delegated to ideologically homogeneous subcommittees, some of which carry intellectual or financial conflicts of interest. These bodies frequently treat “affirming care” as a civil rights imperative rather than as a medical intervention that should rise or fall on evidentiary grounds.

Finally, acknowledging error on pediatric gender medicine would carry significant reputational and legal consequences. Organizations such as the American Academy of Pediatrics, which continue to endorse pediatric medical transition, appear to be pursuing a short-term survival strategy of reputational preservation. But the longer these organizations hold out, the greater the damage is likely to be in the long term. Given the rapid leadership turnover in many professional societies—where presidents often serve only year-long terms—there is little personal incentive for those at the helm to correct course, even when doing so would better serve best interest of their organizations and the public they claim to care for.

At the individual level, many clinicians who have invested deeply in this intellectual project are likely grappling with a profound degree of cognitive dissonance. Confronted with the possibility that well-intentioned interventions may have harmed vulnerable patients, there are two paths available: revise one’s understanding in light of new evidence, or rationalize away that evidence to avoid damaging your positive self-concept. One of these paths is plainly easier than the other.

The issues raised by the Newsweek essay are complex, and I do not pretend to have all the answers. A good-faith exchange of ideas about gender medicine is not only desirable but necessary. Yet, as the article itself illustrates, too many participants in this debate—whether driven by tribal loyalty, ideology, or moral certainty—avoid substantive engagement with criticism, opting instead for ad hominem attacks or speculation about the sinister motives of “the other side.”

Some readers may recoil at the messenger. A Trump-era HHS Department is, for many, an uncomfortable source of authority. But dismissing the report on that basis alone would be a serious mistake. However imperfect the messenger, the message deserves to be confronted on its merits.

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