Trans on trial

Ritchie Herron dialed the number for the Northern Region Gender Dysphoria Service every day for months. When the receptionist answered, he raised his voice in frustration, demanding to know why he didn’t have an appointment yet. On a frigid day in January 2015 he finally got that ­coveted slot at the clinic in his hometown of Newcastle, a city nestled on the River Tyne in northern England.

From the time he was 9, Herron felt different. Bullies plagued him at school, and his parents’ divorce fractured his home life. Pain led to isolation, and the internet offered his only escape from the four walls of his bedroom. He was first introduced to transgenderism as a young boy by adult male transvestites in an online chat room. They seemed kind, and he was lonely. But looking back, he believes they were grooming him.

That experience set him on a path that spanned three decades, hundreds of appointments at the Gender Dysphoria Service, and dozens of prescriptions. It all culminated in one life-altering day just before his 31st birthday when he had a vaginoplasty: a surgery in which his male genitals were reconstructed to resemble female genitals.

Herron’s surgery lasted over twice as long as planned. Major blood loss required a blood transfusion. When he came to his senses days later, his surgeon wheeled over to his bedside with a bright procedure light and showed him the result. Herron gasped at the sight of the wound and was instantly flooded with regret.

“When I finally got out of bed and stood in the full-length mirror I just broke down. It was horrible,” Herron recalled. As he described that dreadful moment, Herron’s head fell into his hands, his short, dark brown hair spilling forward. And he wept again.

Today, five years after his surgery, Herron is living life as a man. But the nightmare is hardly over. He suffers from serious complications related to the vaginoplasty and other treatments. His symptoms include pain, urogenital disorders, and sexual dysfunction. He is suing the National Health Service, the publicly funded healthcare system in England, for the permanent damage done to his body.

The now 35-year-old is one of many turning to the courts for relief. A growing number of young men and women, known as detransitioners, are speaking out about the inappropriate and harmful treatments they received at gender clinics in countries across the Western world. And they want those responsible held to account.

Malpractice lawsuits against doctors, therapists, and hospitals providing “gender-affirming care” in the United States and abroad have started to pile up in recent months. Following an investigation last year, the U.K. government announced it would close the Gender Identity Development Service at London’s Tavistock and Portman NHS Foundation Trust, a gender clinic for minors, this spring. Scotland, Sweden, and Finland have also suspended treatments for minors.

Alarmed by the spike in life-altering treatments, some U.S. states are stepping in. On March 29, Kentucky became the latest of 11 states to ban harmful medical interventions on minors, joining Alabama, Arizona, Arkansas, South Dakota, Tennessee, Utah, Mississippi, Florida, Georgia, and Iowa. And Nashville’s Vanderbilt University Medical Center and the Methodist Le Bonheur Healthcare ­system in Memphis both paused so-called “gender-affirming care” following public and professional scrutiny. Still, in the United States, appeals from those shocked by the gender transitioning of minors have largely fallen on deaf ears. Those who object to the idea that a man can become a woman—or vice versa—are most often labeled bigots. But now, lawsuits and the threat of financial liability may do what appeals to science and reason could not: Get doctors to rethink what they’re doing.

JANE WHEELER IS a former healthcare attorney and president of Rethink Identity Medicine Ethics. The nonprofit’s mission is to improve treatment for gender-nonconforming youth through education and research. Wheeler, a lesbian who describes herself as center-­left politically, believes current practices in caring for minors experiencing gender ­dysphoria are unethical. That’s because few studies have probed the reasons for the sharp rise in diagnosis of the condition in recent years. England’s Tavistock gender clinic reported a 53-fold increase in just over a decade. Research about the long-term effects of the medical and psychological treatments currently provided in gender clinics is also lacking.

But the legal path to challenging these clinics is far from clear.

To show malpractice, lawyers for minors and other gender clinic patients need to show a breach of the standard of care for treating gender dysphoria, Wheeler said. Legal principles vary by jurisdiction, but in many that standard is determined by the way doctors treat patients in the same community, or in a similar community. But because these treatments are so novel, the standard of care has not yet been tested by courts and most state medical boards. Instead, doctors and hospitals are relying on treatment guidelines issued by ­medical associations such as the World Professional Association for Transgender Health, the Endocrine Society, and the American Academy of Pediatrics. All these groups push a no-questions-­asked form of gender-­affirming care.

But Wheeler notes they have a conflict of ­interest: “These societies or associations have a bias to help their members make more money.” Expanding the scope of practice to include often-lucrative ­gender dysphoria treatments ­creates a new revenue stream for healthcare professionals.

Legislation and courts will have to establish the boundaries of what is appropriate care, she added.

The 8th U.S. Circuit Court of Appeals blocked a ban on interventions for minors passed earlier in Arkansas, and a district court put a similar Alabama ban on hold. The 11th circuit is set to rule on that case soon, after hearing oral arguments in November 2022. Over half the remaining states have adopted or are considering similar legislation. In some states, proposed bans extend beyond the age of 18 or even criminalize violations. From a legal perspective, the lack of informed consent may make a better case. Informed consent is a process in which the doctor explains to the patient the risks, benefits, and possible alternatives of a procedure or treatment. Age of consent varies among states. When patients are 18 or older—and in some states as young as 15—parents are not required to approve medical procedures.

Stephen Levine, a professor of psychiatry at Case Western Reserve University, echoes concerns raised in pending litigation over lack of informed consent in a March 2022 article in the Journal of Sex & Marital Therapy. After a review of the literature, he and his co-authors found that current informed consent processes fail to disclose a vital statistic: About 85 percent of gender identity issues resolve with time. They also fail to admit the low quality of evidence supporting the effectiveness of medical interventions or handle the issue of suicide appropriately. Instead, they commonly use a “transition or die” narrative.

Levine also concludes that minors and parents must be told that medical interventions are often irreversible and that no careful long-term studies exist to show whether the interventions improve health or do not cause harm.

Chloe Cole speaks about her gender transition at a news conference outside the U.S. Capitol. Tom Williams/CQ Roll Call/AP

DESPITE THE LACK of evidence supporting the effectiveness of radical treatments, parents are often pressured into giving consent.

That’s what happened to Chloe Cole. Now 18, Cole’s radical treatment included puberty blockers and testosterone at 13 and a double mastectomy at 16—all supported by angst-ridden parents who caved when doctors said, “Would you rather have a dead daughter or a live son?”

Cole’s attorney, Harmeet Dhillon, is suing California’s largest medical system, Kaiser Permanente, and the affiliated ­doctors who treated Cole. The teenager has become a detransitioner lightning rod.

Cole’s facial features and style, including long black hair, makeup, and oft-donned skirts, are feminine. And yet her voice retains a masculine pitch—one of the many side effects of her treatment. Dhillon’s opening salvo to providers recites a litany of other losses: possible infertility, unwanted hair growth, loss of feminine body shape, and loss of healthy breasts.

But Cole herself offers the most tragic assessment. “I have been emotionally and physically damaged and stunted by so-­called medical professionals in my most important developmental period. I was butchered by an institution that we trust more than anything else in our lives.”

Dhillon lays out the deficiencies in the consent obtained from Cole’s parents: They weren’t told her gender dysphoria would likely resolve in time without treatment, or that puberty blockers and hormone therapy came with specific risks. Nor were they told no studies had assessed the long-term effects of the drugs. Doctors didn’t show Cole pictures of what women who had double mastectomies looked like after surgery.

“It’s not loving to lie to a child,” Cole said in a Fox News interview. “It is not ­loving to disrupt a child’s natural, healthy development, or to encourage them to do so.”

In mounting a defense in such cases, Wheeler said, surgeons will likely point to the guidelines as outlining best practices. Or they may point the finger at others, like mental health therapists, further down the treatment ladder.

The Tavistock Centre Guy Smallman/Getty Images

BACK IN ENGLAND, attorneys are building a class-action lawsuit against Tavistock, the country’s only gender clinic for minors, which is set to close this spring following a devastating critique by Dr. Hilary Cass. England’s National Health Service appointed Cass, a retired clinician and former president of the Royal College of Paediatrics and Child Health, to investigate after complaints ­surfaced about the “gender-affirming” treatment model used at Tavistock.

NHS officials also were alarmed at the significant increase in the number of ­referrals of minors to the clinic for gender identity issues at the same time the clinic moved from a psychosocial and psychotherapeutic model (talk therapy) to ­medical interventions via puberty blockers and hormone therapy. Some clinicians complained that if they questioned medical interventions, they risked getting labeled as transphobic.

Among other findings, an interim report issued by the Cass Commission in February 2022 concluded that there was a “lack of consensus and open discussion about the nature of gender dysphoria and therefore about the appropriate clinical response.” Also damning, given Tavistock clinicians’ push for hormone treatments, was the commission’s finding that it was “not able to provide advice on the use of hormone treatments due to gaps in the evidence base.”

In public comments about the case, attorneys for minors treated at Tavistock indicate the Cass Commission findings will provide a basis for their claim that minors received improper treatment.

London attorney Thomas Goodhead Molly Darlington/Reuters/Alamy

In a Times Radio interview in August 2022, London attorney Thomas Goodhead said the impending class action “is going to be one of the largest medical negligence scandals of all time.” A partner in Pogust Goodhead, an international firm with decades of experience in mass tort ­litigation, Goodhead estimated about 1,000 former patients would seek relief.

While acknowledging those who say treatments helped, Goodhead pointed to the larger picture—what he called ­“systemic failings in terms of the way that treatment has been delivered and the complete lack of evidence for the affirmation-­only model of treatment.”

Yet Goodhead also pointed to a nonmedical dynamic at work. “I just find that we have allowed … an ideological capture of a clinic, rather than actually following evidence-based healthcare, which provides the foundations to the delivery of all other types of healthcare under the NHS.”

Missouri Attorney General Andrew Bailey David A. Lieb/AP

SO WHY DID “gender-­affirming care” get a pass on the kind of evidence-based scrutiny demanded of other forms of healthcare?

“This is an old scandal, this is an old problem,” said Jane Wheeler. “Trans likes to look at itself as something very special and very exceptional. And my attitude is it’s going to be knocked down and shown to be not special at all. And that’s going to be a very brutal process for many people to face.”

That process is well underway. In early February, a former employee at Washington University Children’s Hospital in St. Louis came forward with eerily similar allegations about minors being pushed into medical interventions in the hospital’s pediatric gender clinic.

Jamie Reed filed a 23-page affidavit with Missouri Attorney General Andrew Bailey accusing her former employer of harming children—misleading parents about care, failing to adequately assess patients, and automatically placing children who have serious mental health ­problems on life-altering puberty blockers and hormone therapy.

“Doctors at the Center routinely pressured parents into ‘consenting’ by pushing those parents, threatening them, and ­bullying them,” says Reed, who claims she saw those tactics firsthand. She says she asked doctors to obtain written consent for procedures but they refused.

In an article breaking the story for the Free Press, Reed described herself as a political liberal to the left of Bernie Sanders and married to a transgender man. That makes her an unlikely ally of the Republican attorney general. But despite her political and moral alignment with the transgender community, she was appalled by what she saw at the clinic.

U.S. Sen. Josh Hawley of Missouri Graeme Sloan/Sipa USA via AP

On Feb. 9, Bailey announced a multi-agency investigation. Republican Sen. Josh Hawley followed with an announcement of his own investigation, calling it “a ­sickening account of forced sterilization and child abuse.” He fired off a letter to Washington University Chancellor Andrew Martin and St. Louis Children’s Hospital President Trish Lollo seeking answers and the retention of documents for review. Bailey followed up with a March 20 emergency regulation classifying gender transition interventions as experimental and imposing additional, temporary protections, even as legislators consider a bill to limit the procedures.

But parents happy with the treatment their children received at the clinic are also speaking out. Parents, patients, and one of Reed’s former co-workers contradicted her account in a story for the St. Louis Post-Dispatch. They contend the clinic didn’t push children into treatment but saved their lives instead. The Post-Dispatch said it contacted more than 30 people, including patients, parents, therapists, doctors, critics, and supporters of the gender clinic in checking Reed’s claims.

One of Reed’s attorneys, Ernie Trakas, defended her account: “It is not surprising to me that the negatively affected families have not yet come forward. Parents have a strong instinct to protect their children’s privacy.”

Jeff Barrows, an obstetrician/gynecologist and senior vice president of bioethics and public policy for the Christian Medical & Dental Associations, is astounded that the medical industry has allowed “gender-­affirming” treatment to get so out of hand. Barrows, a trim man with salt-and-pepper hair and loads of energy, also has a master’s degree in medical ethics and worked for decades on the problem of human trafficki­ng. But in recent years, he’s shifted his attention to the transgender movement. Now an expert on gender-affirming medical treatment, he advises state legislatures seeking to ban it.

At a standing desk surrounded by floor-to-ceiling books, Barrows shook his head in disbelief. “If you told me when I was in my practice 20 years ago that I’d be talking about these things, I would have thought, who’s going to talk about doing a hysterectomy on a transgender male? And yet now, here we are in 2023.”

Like Wheeler, Barrows says there is a lack of evidence to support the treatment guidelines issued by the World Professional Association for Transgender Health and other groups. “So what would I do as a practitioner? I would be very hesitant to get involved in this at all. I mean, even aside from my Christian principles and Christian beliefs, I would look at this as so new that I would be getting out on the edge of a tree limb, medically and legally.” Doctors faced with any other kind of medical condition where the majority of patients improve without medical intervention would just wait, treating only those whose condition persists, he added.

Barrows characterized “gender-affirming care” as an “assembly line” process, beginning with social transitioning like dress, name, and pronoun changes that almost invariably lead to puberty blockers and hormone therapy if not surgical interventions. “Once they’ve started, it’s very difficult to get off,” he said.

RICHIE HERRON KNOWS that all too well. “It’s like a slope that gets steeper with every appointment,” he said. “Eventually you are just free-falling, and there is no way you can climb back up, you’re just sliding all the way down.”

Herron attributes his inability to get off the “assembly line” to two factors. First, the medications he took to facilitate the transition contributed to his mental problems. Prior to his ­gender clinic treatment, doctors diagnosed him with obsessive-­compulsive disorder and prescribed a high dose of an antidepressant. The initial treatment for his gender dysphoria was Zoladex, a drug that suppresses testosterone and is known to cause depression, mood swings, and hallucinations. Then doctors ­prescribed a high dose of estradiol, a synthetic form of estrogen that has side effects including problems with mood and thinking. On this cocktail of mood-altering drugs, Herron’s mental and emotional state deteriorated rapidly to the point that he felt out of control. “I was definitely mental. I was, like, unhinged,” he said.

The second reason Herron couldn’t get off the “assembly line” was the gender-affirming treatment he received from ­psychologists at the gender clinic. “Psychosexual therapists” met with him regularly over the course of five years to discuss his gender dysphoria, but Herron says they never allowed him to explore the idea that transitioning to become a woman might not be the right choice. They even told him he was the “perfect candidate” for surgery because his feminine features would allow him to blend in as a woman.

When he questioned transitioning or surgery, therapists said he had “internalized transphobia” or “cis-sexism.” Internalized transphobia is often stated as the cause of negative outcomes for transgender people receiving gender-affirming treatment.

Herron wishes that instead of pushing him toward gender transition, doctors had addressed his childhood trauma. “Those things could have been talked through properly, but they weren’t,” he said. Instead, doctors used his trauma to justify his need for surgery. “And the only person resistant in the gender clinic was me! … I was the only one saying, ‘I don’t think surgery is right. I don’t think surgery is right.’ And then they just pushed it and pushed it and pushed it.”

Jane Wheeler has a hopeful, if sober, forecast for the future: She sees the seemingly entrenched transgender ideology collapsing over the next two to five years. She predicts legislation will bar medical interventions for minors in the majority of states, then demand more detailed requirements for informed consent, and finally, expand statutes of limitation allowing detransitioners to sue doctors on discovery of complications even years later. All of that will have a “chilling effect,” she says.

Yet the underlying problem—man’s constant attempt to define his own reality—remains.

“What does it mean to be human?” Wheeler asks. “Society is at a crossroads of having to face what that means. And technology is asking us that question. What does it mean to be human?”

—WORLD has corrected this story to reflect that the American Academy of Pediatrics promotes a gender-affirming model of care for children experiencing gender dysphoria. The American College of Pediatricians opposes the uses of hormonal interventions in such children.