Pediatric Gender Medicine and the Moral Panic Over Suicide

Hyperbolic rhetoric about suicide rates may do more to increase suicide than prevent it.

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In a recent exchange between Senator Josh Hawley (R-MO) and Berkeley Law professor Khiara Bridges on the ramifications of the Supreme Court’s decision to overturn Roe v. Wade, Hawley wanted to know whether the Court’s decision affected women as a class. After initially informing Hawley that not all “cis women” have the “capacity for pregnancy” while some “trans men” and “non-binary” people do, Bridges appeared caught between her loyalties to gender identity ideology and to the long-held idea that abortion is a women’s issue. And so rather than clarify her position, Bridges berated Hawley for his “transphobic” line of questioning, insisting that he and those like him are the reason why “one in five” transgender people attempt suicide.

The affirm-or-suicide mantra has become the central strategy of contemporary transgender activism, and at times it would seem that activists have little else in their rhetorical arsenal. Federal courts have used it to impose new policies on schools under Title IX. When Florida passed the Parental Rights in Education Act—a law that limits classroom discussion of gender identity and sexual orientation to “age appropriate” circumstances and that requires schools to notify parents when their children are being “socially transitioned” to the opposite gender—Secretary of Transportation Pete Buttigieg agreed with his husband Chasten that it would “kill kids.” Florida’s law was in response to, among other things, books like Gender Queer: A Memoir, which contains graphic depictions of oral sex, appearing on school library shelves. The book’s “non-binary” author, Maia Kobabe, countered that her book’s presence in libraries was “life-saving.”

A few weeks later, transgender Assistant Secretary for Health and Human Services Rachel Levine used the same word to justify the federal government’s support for “gender affirming” interventions. Neither Levine nor President Biden, who has given his own imprimatur to the controversial practice, seemed to care much that Europe’s most progressive welfare states have been moving in the opposite direction, placing strict limitations on the use of puberty blockers to treat adolescents in distress presumably because of their “gender.” Scandinavians are not indifferent to teen suicide. Rather, they have examined the evidence behind the affirm-or-suicide claim and have found it wanting.

Despite the unwaveringly confident manner in which these claims are often asserted, there is no good evidence that failing to “affirm” minors in their “gender identity” will increase the likelihood of them committing suicide. As I discuss below, that claim is based on a small handful of deeply flawed studies that, at most, find loose correlations between “affirming” interventions and improved mental health. Some find no reduction of suicide at all, and a new study claims to find that puberty blockers actually increase the risk of suicide.

Not only is the empirical basis for the affirm-or-suicide mantra shoddy at best, but its dissemination is also profoundly irresponsible. Such extreme rhetoric limits our ability to better understand and respond to mental health problems in vulnerable youth, and may itself contribute to the real and documented phenomenon of “suicide contagion.”

Part of the problem is the vagueness of the term “suicidality.” There is a difference between thinking about suicide, attempting it, and actually doing it. And even within the first two categories, shades of grey prevail. A “suicidal attempt,” for instance, can mean climbing to a roof of a building without actually stepping onto the ledge, but it can also mean surviving a self-inflicted gunshot wound to the head. Women are far more likely to think about and attempt suicide, but men are more likely to die by suicide. Actual suicide is obviously more serious than suicidal attempts, and attempts more than ideation. Human beings may go through periods of depression in which they contemplate suicide, even seriously, but this does not mean that they are at permanent risk for suicide. It’s a messy, dark, and multifaceted topic ill-served by the moral panic-mongering of activists.

Gender activists commonly argue that roughly four in ten transgender-identified youth (TIY) attempt suicide when not socially and medically “affirmed.” Does the research bear this out? The simple answer is: no.

Firstly, surveys of TIY suicidality rely on self-report and do very little to vet respondents when they say they “attempted” suicide. Secondly, studies purporting to show that TIY are at elevated risk of suicide tend to compare suicide rates in TIY with rates in non-TIY—a deeply misleading comparison. This is because TIY, especially among the new clinical cohort of “rapid onset gender dysphoria” (ROGD) teenagers, exhibit extraordinarily high rates of mental health problems (psychological co-morbidities) quite apart from their gender-related distress.

To the extent proponents of the “gender affirming” approach recognize these co-morbidities, they regard them as the product of social hostility and lack of acceptance (though, oddly, they also claim that rapidly rising rates of transgender identification are the result of a society increasingly accepting of transgender identity). Yet no evidence supports this hypothesis and mounting evidence vitiates it. ROGD teens are known to have very high rates of anxiety, depression, history of sexual trauma, anorexia, and eating disorders, all of which typically precede their gender-related distress. And as we’ve learned from detransitioners, many continue to experience these problems long after they have gone under the knife. According to a review of the U.K.’s Gender Identity Development Service, roughly one out of three girls seeking gender transition has autism—a significant finding, considering that “being in the wrong body” might provide these teenagers with a convenient explanation for their social isolation. Regardless, each of these mental health conditions is a known predictor of suicidal behavior.

Thus, while it is true that suicidal behavior is much more likely among TIY, rates of actual suicide are extremely low within the population and there is no basis for believing that “affirming” them with puberty blockers, cross-sex hormones and surgeries will reduce those rates even further. Importantly, when researchers compared TIY with non-TIY with similar mental health profiles, the disparities in suicidal behavior reduced considerably, suggesting that it is not the lack of gender affirmation that seems to be driving suicidal behavior.

The dubious claims about mental health benefits from “gender affirming” medicine, alongside the obvious risks, is why Sweden and Finland have recently moved to restrict the practice, with the U.K. likely to follow suit. It is also why medical authorities in France, Australia and New Zealand have issued strong statements highlighting the uncertainties and experimental nature of “affirming” interventions.

The gold standard for finding a causal relationship between “affirming” medicine and suicide would be the randomized controlled trial (RCT). To date, no RCT has ever been conducted to study the effects of puberty blockers on mental health (including suicidality) of gender-distressed youth. For this reason, the FDA has never approved the use of Lupron or other puberty suppressants for gender dysphoria. Claims about the reversibility of puberty blockers, which are essential to “gender affirming” advocates’ ethical case for allowing children to use them, rely entirely on referencing the drug’s original purpose, which is treating precocious puberty.

As for their safety, the risks of puberty blockers are not fully known but are thought to include cognitive impairment and bone malformation. It is becoming increasingly clear, however, that another major risk is iatrogenesis, meaning that the use of puberty blockers to “treat” gender dysphoria virtually guarantees the persistence of the condition and continuation of the patient to more extreme and risky types of intervention.

At nearly $40,000 per implant, which lasts for one year, these drugs are extraordinarily expensive and a potentially lucrative source of revenue for drug manufacturers. So why not expand the market by getting FDA approval for a new type of use? Considering how ROGD could be a goldmine for drug companies, why not conduct RCTs? One reason is that activists and professional medical organizations already insist puberty blockers are safe and medically necessary interventions. If this is true, then withholding such interventions from minors with gender dysphoria (something required in a controlled experiment) would be unethical and even life-endangering. Another reason is the common (but misguided) belief about reversibility of puberty blockers: once the “pause” button is lifted, the thinking goes, adolescent development can seamlessly pick right back up as if nothing happened.

Authorizing RCTs for puberty blockers would require that activists allow their basic assumptions to be put to the test, but the intrusion of identity politics into medicine makes that unlikely. “Gender affirming” care is premised on the conviction that medical professionals should never steer a patient toward a non-transgender over a transgender outcome, as doing so assumes that transgender identity is abnormal or, at any rate, less preferable than “cisgender” identity. In the United States, identity politics has been framed as “civil rights,” so it is in the name of this venerable tradition and its robust judicial supervisory mechanisms that activists have waged holy war against alternatives to “gender affirming” care such as “watchful waiting” or therapy-only.

In countries without a strong civil rights state, medical rationales for “affirming” interventions can be more easily interrogated and, if necessary, challenged. Sweden, Finland, France and the U.K. have either recognized or are on the verge of recognizing the experimental nature and inherent risks of puberty blockers. Medical authorities in these countries have come under pressure from activists, but due in part to the absence of potent analogies to Jim Crow they have been able to weigh the pros and cons and consider the trade-offs of “affirming” interventions—precisely the kind of considerations that American “rights talk” is designed to make verboten.  These countries have “pressed pause,” but on the use of puberty blockers rather than puberty itself.

A 2011 Swedish study found that, even after medical transition, “transsexual” patients were nineteen times more likely to die by suicide than non-transexuals, but the study’s lack of adequate controls makes it difficult to draw any definitive conclusions. It does, however, cast serious doubt on the belief that “gender affirming” interventions are medically necessary measures for preventing suicide. Meanwhile, suicide remains an extremely rare event for TIY, even among the ROGD cohort. Between 2010 and 2020, the U.K.’s Tavistock Clinic recorded four deaths by suicide out of a total of 15,000 patients—and this notwithstanding the two-year waiting period for the clinic’s services.

At present, the studies purporting to find that puberty suppression in minors leads to reduced suicidality come nowhere near the level of causal determination normally required before approving new drugs or old drugs for new uses. I recommend anyone who hasn’t already done so to read Jesse Singal’s long Substack post on the flaws in these studies and how media tend to overlook them.

Among the serious deficiencies of studies such as those published by psychiatrist and “gender affirming” advocate Jack Turban are reliance on biased samples (the subjects in Turban’s studies were recruited through transgender advocacy and support groups) and non-random assignments of treatment. The latter is especially important: Turban and colleagues compared subjects who wanted hormonal interventions but didn’t receive them to those who wanted and received them. One of the reasons the former but not the latter received these interventions, however, might be because they were already more psychologically stable to begin with. The subjects of Turban’s studies would have been exposed to treatment protocols implemented before the surge in “affirming” therapy, meaning under the more rigorous “Dutch protocol,” which emphasized prescreening for mental health co-morbidities as a precondition for receiving hormones. In short, nothing in Turban’s studies can refute the possibility that improved mental health was the result of something other than medical suppression of puberty.

Here we must note a perennial problem for science in a democratic society, which is that science can neither explain itself to the non-scientific public, nor can it present a self-explanatory plan of political action. Science requires mediators to interpret its findings and make them relevant to contemporary concerns, which are invariably value-laden and often political. Despite acknowledging—if not as forcefully as he should have—within his own study the limitations of his findings, Turban sold his work to an eager media environment as having found strong evidence that puberty blockers are life-saving and medically necessary. And they gobbled it up uncritically.

What makes an RCT reliable as a source of knowledge about causality is the “R.” Before the FDA can approve a new drug, it must have confidence that the reason why some subjects got the drug and benefitted from it while others did not is not some factor related to the positive outcome itself. For example, if an experimental drug for schizophrenia is given only to subjects who are hospitalized and the recipients experience improved mental health, researchers may falsely conclude that it was the drug that caused the improvement when in fact it was the hospital setting where patients were exposed to other therapeutic supports. Ideally, chance (i.e. randomness) alone should determine who gets the drug and who doesn’t.

In the absence of RCTs, and to avoid the pitfalls of studies like those of Turban and colleagues, researchers might try to approximate causality by introducing unrelated criteria for assigning treatments to some subjects but not others. Random chance is the ideal unrelated criterion because, almost by definition, it is the most unrelated to any measurable outcome. Short of that, researchers can seize on second-best proxies for randomness.

That is what Jay Greene, a former university professor who recently joined the Heritage Foundation, did in a new study investigating the causal relationship between puberty blockers and suicide. Greene’s “natural experiment” uses state minor consent rules—that is, laws that permit minors to consent to medical treatment without parental approval—adopted well before and for reasons unrelated to gender dysphoria. For that reason, they are exogenous to the outcome. “Whether adolescents live in a state that imposes fewer or no restrictions on accessing puberty blockers and cross-sex hormones,” Greene explains, “is effectively random and should have nothing to do with later outcomes other than through the mechanism of receiving those interventions or not.” The fact that a blue state like Connecticut lacks a minor access provision and is thus coded as more restrictive for puberty blockers, while red states like Texas and Missouri have such provisions and are coded as more permissive, is not a problem for Greene’s research design, but an advantage. It suggests that Greene has not introduced a confounding criterion for treatment assignment.

Using this admittedly counterintuitive—but in the social sciences, well recognized—research design, Greene finds that puberty blockers actually increase the risk of suicide by 14 percent. It must be emphasized, however, that the causal link here is weak. It comes nowhere close to proving conclusively that puberty blockers increase suicide. Greene’s study is simply less bad than competing studies, including those by Turban and colleagues, which purport to find that blockers reduce suicide.

Now, there is a danger, as the saying goes, in making the perfect the enemy of the good. A political scientist by training, Greene knows that policymakers must often make choices on the basis of imperfect information; policymaking is rarely a choice between good and bad options, but more frequently between bad and worse ones. Faced with weak evidence for the dangers of blockers and even weaker evidence for their therapeutic benefits, a reasonable policymaker would prefer to halt their use pending further research.

When I posted a shortened version of this comparison of Turban and Greene on Twitter, Turban responded that his work, unlike Greene’s, was peer-reviewed and published in a “high-impact” journal (Pediatrics). As Turban surely knows, peer-review may increase the likelihood of a claim being true, but hardly guarantees it. And peer-review is only as good as one’s peers and the degree to which a field hasn’t been captured by fashionable political ideologies. While peer-review remains the most reliable mechanism for sorting science from pseudoscience, it has taken several serious and deserved blows to its reputation over the past few decades.

I’m not even referring to the hoaxing of the so-called “Grievance Studies,” where peer review is often little more than gatekeeping by postmodernist identitarians who cannot distinguish their own research from pure gibberish, or even to the low standards of the law reviews, where reviewers are law school students with little expertise in law (let alone in more substantive areas of scientific inquiry). A recent survey found a spike in the number of peer-reviewed article retractions, most of them “highly cited articles published in high-impact journals.” And of course, the academy has spent the past decades purifying itself of heretics (such as Colin Wright and myself) who might otherwise challenge approved research narratives. In short, even under these ideological conditions peer-review is nothing to scoff at, but to invoke it as proof of concept is either naïve or disingenuous.

Take Pediatrics, the journal of the American Academy of Pediatrics (AAP) that published Turban’s 2020 paper on puberty blockers and suicide. In 2018, Pediatrics published a paper entitled “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents,” by Dr. Jason Rafferty and others. The article contains a shocking number of errors, omissions, and blatant mischaracterizations of the available research on pediatric gender transition, some of them so fundamental and egregious as to suggest bad faith in the authors. The article’s central conclusion—that “gender affirming” medicine is the only ethical and scientifically-grounded approach to treating gender-related distress in youth—is negated by its very own citations, to say nothing of its flawed logic. I recommend Dr. James Cantor’s fact-checking of the AAP paper; it is one of the most thorough and devastating refutations of an academic “study” I have ever read.

Unfortunately, policymakers—including, most recently, a Trump-appointed federal judge—regularly cite the AAP statement and other unsubstantiated statements by American medical organizations as conclusive evidence that the gender-affirming approach is “settled science” and that it saves lives. A faulty peer-review process, it would seem, can be more dangerous than no peer-review process when it bestows false confidence or complacency.

The problem is worse than the mere mistaking of correlation for causation. The obsessive emphasis on “gender” as being both the source of and solution to suffering ultimately distracts parents, clinicians, teachers, and patients themselves from pursuing more effective strategies of mental health improvement. A teenage girl with a history of sexual abuse or eating disorders is ill-served by medical professionals who mistake the symptom of her distress (gender distress) for its underlying cause. A common complaint from a rising number of detransitioners is that no one was there to help them explore the true sources of their suffering. They have a point.

A known complaint among American medical providers is that systemic pressures discourage them from conducting careful and drawn-out diagnoses. Two friends of mine, both doctors, have raised this complaint to me several times in the past year alone; both wish they could spend more time with their patients in order to better understand their problems. One recently started his own practice in order to give his patients the quality of care they need and deserve.

One aspect of the gender affirming approach that makes it so attractive to therapists is its simplicity: it provides a single, easy, indeed all-too-convenient explanation for what is wrong with a teenager in distress. And it has the additional advantage of deferring to that teenager’s self-diagnosis, leaving her temporarily satisfied that she is finally being listened to. The affirm-or-suicide mantra lubricates this process by injecting it with a sense of urgency. Is this “gender ideology”? Perhaps, but it is no less the combination of a misguided belief about suicide, the pressures of a healthcare system that incentivizes swift diagnoses and expensive treatments, and an unchecked ethos of medical consumerism.

Another perverse outcome of the affirm-or-suicide narrative is that it may itself contribute to suicide. Social scientists and health officials have warned of a “contagion” effect following public discussions of suicide. A 2020 study found that teen suicide “increased significantly” in the month following the release of the Netflix series “13 Reasons Why,” which deals with—and some critics argue glamorizes—that subject. As one group of experts recently emphasized, “any conversations about suicide should be handled with great care, due to its socially contagious nature.”

Many countries, including the United States, have media guidelines on how to report on suicide so as not to inadvertently encourage people to engage in the behavior. Among the things that the CDC has warned not to do is “[p]resenting simplistic explanations for suicide.” As the agency explains, “Suicide is never the result of a single factor or event, but rather results from a complex interaction of many factors and usually involves a history of psychosocial problems.” It's difficult to imagine a more “simplistic explanation” than “kids will kill themselves if their gender identity is not affirmed.”

If there is scant evidence for the affirm-or-suicide narrative, and if using that narrative as a strategy for “transgender rights” might have negative repercussions for the very people activists and policymakers claim to want to protect, why do they continue to tout it? Some, perhaps, might simply not have given the matter much thought. Or perhaps they are uniquely vulnerable to emotional extortion due to some pathological excess of empathy or unexamined ideological assumptions. But I suspect that there are at least three additional motives at work, whether conscious or not.

First, as Colin Wright, myself, and other commentators on the trans phenomenon have argued, the trans movement is mired in confusion and self-contradiction. Activists tell us that the body has no relevance for being male or female, but also people with a male (or female) “gender identity” need a male (or female) body in order to live “authentic” lives; that women deserve their own category of sports but that access to that category should have nothing to do with physical sex distinctions; and that gender identity is an innate, immutable, even biologically derived, and socially valuable property of persons, but also that it is a system of social subordination to be resisted through “non-binary” and “queer” performances. When skeptics want to get beyond the contradictory statements to the truth of the matter, they are told that “getting at the truth is deeply transphobic.” The suicide panic enables activists to change the subject, diverting attention away from their contradictions.

Unlike other critics of gender ideology, I tend to think that what we have seen unfold in Western societies is equal parts “gender ideology” and a therapeutic attitude underwritten by half-baked relativism (or is it relativism underwritten by a therapeutic attitude?).

Second, from a more practical point of view, hyperbole surrounding the suicide threat is designed to get us to overlook the fundamentally experimental nature of pediatric gender medicine, suspend everything we know about adolescent psychology, and create an exception in our normal application of principles regarding patient autonomy and consent. The famed trans activist and child therapist Diane Ehrensaft argues, for instance, that just as we would allow a child to sever a limb to save his life, so too we must allow children to sacrifice their future reproductive and health prospects on the grounds that “gender affirming” care is life-saving. Any medical treatment, but especially one targeted at minors, requires a careful weighing of pros and cons, benefits and risks. The point of suicide alarmism, it seems to me, is to get us to not do this careful balancing act.

Third, transgender interest groups, which are now for the most part ideologically captured gay rights interest groups, face strong incentives to exaggerate threats and present themselves as standing in between transgender youth and impending doom. Obviously, alarmism is not unique to the world of LGBT advocacy organizations; pretty much all “public interest” groups who face collective action problems rely on what the late political scientist James Q. Wilson called “purposive incentives.” For an entity like the Trevor Project, an organization founded over two decades ago for the purpose of preventing suicide by (mainly gay) youth, public belief in a suicide epidemic is vital for soliciting donations, securing grants, recruiting talent, and exercising influence over the policy process. Especially under Democratic administrations, bureaucrats in federal and state education departments will cite Trevor Project statistics on LGBT suicide as justifications for more aggressive regulation of schools. None of this is to suggest that the people who work at Trevor are being dishonest, but only that they face strong institutional incentives to exaggerate the suicide threat.

Teen suicide is one of the most horrific and tragic events that can befall any parents. To exploit this primordial fear for political gains is cynical. If activists wanted to get serious about addressing the supposed “epidemic” of suicide among transgender youth, they would do three things. First, they would read the studies on suicide more carefully. Second, and as a result, they would take the therapeutic focus off of gender and, without completely excluding gender from the picture, place it on the more plausible causes of teen distress. And third, they would resist the temptation for suicide fearmongering and lay off the simplistic narrative that suicide results from not being “affirmed” in one’s “gender identity.”

We should not hold out hope that activists will do any of this, however, given how invaluable the suicide threat has been toward achieving their goals in the political arena.

Leor Sapir is a fellow at the Manhattan Institute where he writes on gender identity policies. Sapir received his Ph.D. in Political Science from Boston College and completed a postdoctoral fellowship at the Program on Constitutional Government at Harvard University. His academic work has dealt with American political culture, constitutional government, and civil rights regulation. Twitter handle: @LeorSapir

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Organizations to Support

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