Bill Maher Showed You the Tip of the Iceberg
By Anonymous
The HBO television show Real Time with Bill Maher, hosted by American comedian and political commentator Bill Maher, recently aired a segment on the rise of trans-identification among young people. The segment, which can be viewed here, is a great introduction for people who might not have seen much about this topic. His monologue was packed with information, but necessarily short, the “tip of the iceberg” for a very complex issue. Here is more information regarding what he said, with quotes from his segment illustrating the tip of the iceberg followed by more detailed, related information.
Tip of the iceberg: “When things change this much this fast people are allowed to ask what’s up with that.” -Bill Maher
Iceberg: There’s been a huge rise in young people coming into clinics, and instead of the predominant population being childhood onset boys (2:1), it is pubertal and postpubertal girls dominating (2:1 or 4:1 depending on the country). At the largest pediatric gender clinic in the world, GIDS Tavistock, there were about 50 people 18 and under presenting for care in 2009 and over 1700 in 2016. It went up by a factor of over 34 in just 7 years. Similar large rises were seen in other countries.
Some claim, without evidence, that this rise is due to increased acceptance. Their explanation is just a guess. The French National Academy of Medicine, Swedish evidence review, and the UK Cass Review explicitly state this rise is an open question, with the French spelling out a concern of social contagion and the effects of social networks.
A common comparison is made to the rise in left handedness, which rose from about 2% in 1900 to 12% by around 1940, i.e. a growth of about a factor of 6 in 40 years. If left handedness had risen by the same rate as trans identification has, everyone (100%) would have been left handed in about a decade.
Tip of the iceberg: “Giving puberty blockers to kids” -Bill Maher
Iceberg: Kids under 18 are being given puberty blockers, hormones and even surgeries. How carefully is it being done? According to a Washington Post op-ed by Laura Edwards-Leeper and Erica Anderson, two prominent psychologists in the field of gender medicine, titled The Mental Health Establishment Is Failing Trans Kids “doctors and psychologists and social workers are ready to start hormones after one short visit.”
Once they’re over 18, even when they aren’t yet even legally able to smoke or drink, young people can get hormones using “informed consent”, which means no mental health evaluation is required. Genital surgery is also available at age 18, after a certain period on hormones, but the time requirement can be waived. Double mastectomies are occurring for kids as young as 13.
Tip of the iceberg: “Hinders the development of bone density which is kind of important if you like having a skeleton […] fertility and the ability to have an orgasm” -Bill Maher
Iceberg: Puberty blockers supposedly help young people buy time to think about how their mind and body relate, but they chemically castrate young people and lower sexual desire, and seem to affect brain maturation, in addition to harming bone development. They haven’t been shown to be reversible though it is often claimed they are. And most (61%-98% of) kids who weren’t socially transitioned in the past outgrew their gender dysphoria, while those on puberty blockers in studies have been seen to mostly (over 95% of the time in one study) go on to hormones. Not exactly the same samples but a big difference in outcomes!
Hormones are taken for life. They lead to atrophy and histological changes to the gonads and impair sexual function, increase cardiovascular risks (VTE, strokes, heart attacks), alter the brain and confer increased risks to the immune system. The vaginal and uterine atrophy from testosterone can lead to pain, and estrogen even has an FDA box warning for its on label uses. Chronic conditions and shortened life are also associated with being trans-identified.
The drugs are all off-label with the FDA because the benefits have not been shown to outweigh the risks (puberty blockers are on label for precocious puberty for children, but none of these drugs are on label for gender dysphoria at any age). It’s not even been shown that the drugs (or surgeries) can be relied upon to help mental health or gender dysphoria. Surgery is of course irreversible and if gonads are removed the person is castrated/sterilized and has a permanent iatrogenically caused endocrine disorder. Sexual function is also affected if sex organs are removed.
Given these dangers, and unclear benefit, it is worth noting that one set of criteria to start these treatments is based on “standards of care” written by a special interest group, WPATH, which are neither “standards of care” nor evidence based. They are just practice guidelines. “Unlike standards of care, which should be authoritative, unbiased consensus positions designed to produce optimal outcomes, practice guidelines are suggestions or recommendations to improve care that, depending on their sponsor, may be biased.” In a rigorous guideline review, 5/6 reviewers did not recommend the 2012 WPATH guidelines, while the last reviewer recommended them only if modified (they were found to have no list of key recommendations or auditable quality standards, and some “extracted statements might have been intended as recommendations or standards, but many were flexible, disconnected from evidence and could not be used by individuals or services to benchmark practice.”). Although the “W” in WPATH is for “world,” these are not being followed all over the world. For example, a more cautious approach is being taken by countries responding to rigorous reviews of the limited evidence available (e.g., Finland and others below).
Another set of similar guidelines from the Endocrine Society found that all the evidence behind their own treatment recommendations was low quality, very low quality, or ungraded quality (except for confirm diagnosis, counsel for fertility preservation, and treat medical conditions that might interfere with hormones). Low and very low quality mean “the true effect may be substantially different from the estimate of the effect” and “the true effect is likely to be substantially different from the estimate of effect” respectively. In other words, you can’t estimate very well what the outcomes might be if you do these treatments.
Tip of the iceberg: “Why Sweden and Finland have stopped” -Bill Maher
Iceberg: Sweden’s largest hospital restricted new treatments for minors to clinical trials (but none are underway), with the National Health Board deeming after its evidence reviews that “the risks of puberty suppressing treatment with GnRH-analogues and gender-affirming hormonal treatment currently outweigh the possible benefits, and that the treatments should be offered only in exceptional cases.“
Finland put strong restrictions on those under the age of 25 after doing evidence reviews and finding interventions didn’t seem to help functioning and psychiatric comorbidities.
The UK is redoing its guidelines after finding the evidence had very low quality certainty (meaning you can’t tell if interventions will help or not!) for gender dysphoria, mental health or quality of life outcomes, for 18 and under.
The French National Academy of Medicine noted “there is no test to distinguish a “structural” gender dysphoria from transient dysphoria in adolescence. Moreover, the risk of over-diagnosis is real, as shown by the increasing number of transgender young adults wishing to “detransition”. It is therefore advisable to extend as much as possible the psychological support phase.”
Florida just did a Medicaid review and found that “several services for the treatment of gender dysphoria – i.e., sex reassignment surgery, cross-sex hormones, and puberty blockers – are not consistent with widely accepted professional medical standards and are experimental and investigational with the potential for harmful long term affects.[sic]”
Tip of the iceberg: “Some children identifying as trans are falling under the influence of their peers and social media” -Bill Maher
Iceberg: There’s a big concern of social contagion due to both the unexplained rapid rise in cases and reports by parents, detransitioners, and therapists, including therapists who help some young people medicalize.
Tip of the iceberg: Dr. Erica Anderson “says i think it’s gone too far” -Bill Maher
Iceberg: There are whistleblowers all over the world, including Sweden (the Trans Train documentary just won Sweden’s top investigative award), the UK Tavistock (“Calls to end transgender ‘experiment on children’” and a recent expose), France, the Netherlands (and here), Germany (context here), and more. Note that different whistleblowers and different experts are calling for different protocols. Dr. Anderson is by no means the most cautious. Whistleblowers from earlier scandals are also noticing the resemblance (e.g., Carol Tavris helped stop the repressed memory scandal). A lot of people are trying to get the word out!
Tip of the iceberg: “Trans is innate” -Bill Maher
Iceberg: Trans is not one thing! Case studies, first person reports, and parent reports have all found that there are many pathways into gender dysphoria and many pathways out of the distress. Some currently less well known pathways include some young people interpreting their mental distress (Asperger’s and other autism spectrum disorders, anxiety, depression, trauma, including from sexually maturing, OCD, etc.) as meaning they are trans, or interpreting their being pre-gay as being trans. (In the past some of those with trauma might have developed anorexia, now that form of distress has also sometimes been interpreted by young people as being trans.) The chart on page 57 of the Cass interim report illustrates many of the known ways in and out of gender dysphoria. One pair of therapists says “we have observed that the desire to transition is often connected to an attempt to distance the person from the psychic pain related to internal and/or external traumatic experiences” while another notes “I typically found that after anything from 6-12 months in the group the initial Gender Dysphoria had been completely resolved. The Gender Dysphoria was a solution that their mind had come up with to make sense of the confusion, which they happened to find in a gender framework. Once they had come to the conclusion that gender was the framework they had stuck with it.” Many variants of temporary trans identification can be helped by mental health support.
It is unclear how to identify whose gender dysphoria/trans-identification is not temporary. Some clinicians, including the whistleblowers Drs. Edwards-Leeper and Anderson, have assessments they think will identify those whose gender dysphoria will not go away with maturity, mental health, or other support. Their assessments have not been shown to do so, however, they do try to screen for some known kinds of transient gender dysphoria. These assessments are often based in some way on the paradigmatic youth “Dutch protocol” (see the 2014 paper here), which had criteria in order to try to avoid medicalizing those with transient trans identities, including requiring young people to be psychologically stable, and with gender dysphoria which also had to be “lifelong extreme.” The Dutch also did not test their criteria with controls or by seeing how the gender dysphoria of those who met their criteria evolved as they reached developmental maturity (without medical intervention), however, a group of adolescents disqualified from medical treatment by their criteria no longer wanted medical treatment later on. For those treated, the classic 55 person Dutch study from 2014 didn’t follow up beyond 1 year past the final surgery, a short time compared to observed median post surgery regret times (for a different, older, group) of 5-6 years. As far as psychological stability, according to the list of current (“SOC7”) WPATH requirements, now one just needs to be psychologically stable enough to adhere to treatment, or for young adults, to have “comorbidities under control”, where no one defines what that is.
Many US practitioners do not even consider doing assessments or offering mental health support, following the affirmative “model” instead. This model assumes that mental health issues are likely to be secondary, that is, due to “minority stress” of being trans. Studies have not shown that minority stress is the primary source of mental health comorbidities for those who are trans-identified. Those adopting the affirmative model also tend to assume that if any negative outcomes occur with medical intervention that minority stress is also the cause. Alternative possible explanations for poor medical treatment outcomes, such as cases where gender dysphoria was driven by other issues and/or where the hormonal and surgical treatments are the wrong treatment (and harmful), are often not even considered by many of these therapists. (It seems there is no way to disprove the claimed role of minority stress, making its role unfalsifiable.) The affirmative model is directly contradicted by the wide variety of cases where mental health support was key to understanding gender dysphoria and sufficient for resolving it. (The adoption of affirmation by the American Academy of Pediatrics was not based on evidence: “not only did the AAP statement fail to include any of the actual outcomes literature on such cases, but it also misrepresented the contents of its citations, which repeatedly said the very opposite of what AAP attributed to them.”)
Many clinicians are misinformed and don’t even realize mental health issues can underlie gender dysphoria or that addressing them may help gender dysphoria resolve. Because of the affirmative model and related misunderstandings, and in spite of the observed cases where comorbidities turn out to be the main issue(s), a therapist in the US who explores gender dysphoria can even be (inaccurately) accused of doing unethical conversion therapy, making it very difficult to try to identify (and support!) whatever is driving the gender distress.
Tip of the iceberg: “They’re kids, it’s all phases” -Bill Maher
Iceberg: Yes. And, again, there is no clinical test to determine when a transgender identity is not transient, especially for young people who are changing quickly as they head towards developmental maturity around age 25. As mentioned above, the French National Academy of Medicine specifically notes this (“there is no test to distinguish a “structural” gender dysphoria from transient dysphoria in adolescence”); more about this serious ethical issue is spelled out in a recent review. However, even without a clinical test, many of the assessment based approaches see comorbidities or adolescent onset as red flags. The older Dutch protocol and some of the new national policies exclude these cases from medical treatment for young people.
Another phase for young people with gender dysphoria is post transition, or detransition. (It is sometimes incorrectly claimed the number of detransitioners is small, in fact, the number of people who detransition is, shockingly, unknown; studies quoting numbers are either flawed or very narrow in applicability.) For those who regret, detransition has been observed to happen on average after 5–10 years, depending on study. How bad is the regret? One convenience sample of detransitioners found that one of the greatest needs (60%) was learning to cope with feelings of regret.
E.g.(Sinead Watson): “Some of us will now never be able to have children and many of us live with great distress and regret every day”
and (Tullipr): “I tell myself to wake up, because I know its just a dream. And I awaken to a living nightmare.”
As Keira Bell said: “I was an unhappy girl who needed help. Instead, I was treated like an experiment.”
And….what do the MDs have to say for themselves? “I guess time and data will tell” (Safer, NYT, 2022).
This essay is just the tip of the iceberg itself and we hope Bill Maher will keep going and reveal more of it.
One can also find more information from the many great resources out there, including:
Society for Evidence-Based Gender Medicine
Substacks (again, there are many more out there which are also excellent!)
- PITT substack (PITT, Parents with inconvenient truths about trans)
- Gender Clinic News | Bernard Lane
- Broadview by Lisa Selin Davis
- prude posting (Helena’s substack)
- Tullipr’s substack
This essay was written by an anonymous parent, dozens of whom work with Genspect behind the scenes.