On this week’s episode, Vice President of Policy at IWF Hadley Heath Manning joins to discuss this month’s policy focus—The Risks of Gender-Transition Treatments in Adolescents. As the number of young people who identify as transgender have increased—nearly doubling between 2017 and 2022—I can’t think of a more timely topic. We discuss the gender-transition treatments children are encouraged to undergo, and how the risks and physical costs are often minimized or ignored, including irreversible treatments. Patients, as well as the parents of minor patients, deserve to know this information.

Hadley Heath Manning is vice president for policy at Independent Women’s Forum and Independent Women’s Voice and a Senior Blankley Fellow at the Steamboat Institute. Hadley has testified before Congress and state legislatures on various policy issues. She also appears frequently in radio and TV outlets across the country and is a regular guest on the Fox Business Network. Her work has been featured in publications such as the Wall Street Journal, Forbes, POLITICO, and many others.


TRANSCRIPT

Beverly Hallberg:

And welcome to She Thinks, a podcast where you’re allowed to think for yourself. I’m your host, Beverly Hallberg, and on today’s episode, it’s our policy focus, entitled The Risks of Gender Transition Treatments in Adolescents. As the number of young people who identify as transgender has increased, nearly doubling between 2017 and 2022, I couldn’t think of a more timely topic. In this episode, we look at the gender transition treatments children are encouraged to take, and how the risks and physical costs are often minimized or ignored, even those that are irreversible.

And we have a wonderful person on to talk about this today. She is one of the co-authors of the report. Hadley Heath Manning joins us. Hadley is the Vice President for Policy at IWF and Independent Women’s Voice, and a Senior Blankley Fellow at the Steamboat Institute. She has testified before Congress and state legislatures on various policy issues, and she appears frequently in radio and TV outlets across the country. Hadley, always a pleasure to have you on She Thinks.

Hadley Heath Manning:

It’s always a pleasure to join you.

Beverly Hallberg:

And I want to let our listeners know that as always, you can find the policy focus on iwf.org. Again, the policy focus for this month is entitled The Risks of Gender Transition Treatments in Adolescents. And I also want listeners to know that there’s a wonderful series that you can find on IWF. It’s called the Identity Crisis series, and this is produced by Kelsey Bolar. She documents the stories of detransitioners. So a lot of material on iwf.org. I encourage people to go there, but Hadley is going to break it down for us. And Hadley, as I was reading this policy focus, there was a startling statistic to me, and that is today, about 5% of young people say they identify as transgender or non-binary, meaning they do not identify as male or female, so either transgender or non-binary. This is a startling stat.

Hadley Heath Manning:

It really is. And I think a lot depends on your age, and which part of the country that you live in. If you live in a big city or a rural area, you might hear more about this topic, or less about this topic. I actually spoke with someone who spent 30 years working in a public school system, and she said, “I probably worked with 50,000 students during that time, and I never encountered this.” And I said, “Well, that’s because you retired some time ago.” And now this has really become a much more prevalent issue, a much bigger question for schools, for medical professionals, and particularly for parents, as they navigate this difficult topic.

Beverly Hallberg:

And so one of the things that we do hear about, even this month of June, which is when this policy focus is released, and that is Pride Month. So we’ve seen a lot of rainbows and other things being discussed. We see that in schools, children dressing up with teachers. But of course what we’re talking about here is when you do have a child and a parent decide to move forward with some type of treatment, whether that’s puberty blockers, or even going to that last step, where there is gender reassignment surgery.

But I think it’s important to go back and look at the history of this. In the policy focus, you talk about something known as the Dutch Protocol, which became the international so-called gold standard practice in the mid-nineties, about the treatment of adolescents with gender dysphoria. Tell us a little bit about the Dutch Protocol, because that’s when all of this kind of started, when we think about medical intervention. And what have we learned today, since that was a few decades ago?

Hadley Heath Manning:

Right. Well, as the name implies, the Dutch Protocol started in the Netherlands in the 1990s. And the Dutch Protocol in a nutshell is sort of a three-step process for gender-questioning adolescents. So it starts with puberty blockers. This is the first step on the Dutch Protocol. And puberty blockers, as also the name implies, delay puberty, or they block the natural processes of puberty. They have been used for quite some time in patients who have what we call precocious puberty, or people who start to develop too early, or before what we consider a healthy period for the natural process of puberty. But now puberty blockers are being used in many more patients, particularly gender-questioning patients. And so that’s step one of the Dutch Protocol.

Step two are cross-sex hormones. So for little boys, they’d be given puberty blockers, and then eventually they’d be started on estrogen. Estrogen is a hormone that’s in much higher levels in women. And conversely, little girls would start on puberty blockers, and then their step two would be to take testosterone. And testosterone is something that naturally occurs in men about seven to eight times higher levels. So basically giving the body these cross-sex hormones is what causes those secondary sex characteristics, or the things that typically start happening to people during puberty, hair in certain places, breasts in certain places, to start developing in a way that appears or mimics the opposite sex. So we’re talking about giving adolescents opposite sex hormones in step two of the Dutch Protocol.

And then finally, step three is a surgery, or multiple surgeries, to again, alter the body to appear more like the opposite sex, and to accord with what professionals and other pro-gender transition folks are calling the gender identity, the preferred gender identity of the patient. So in that step three, you would, for example, in a patient who is a girl, you would have a double mastectomy to remove any breast tissues that might have developed. You’d have a hysterectomy or a phalloplasty. And of course, different patients decide how many steps they’re going to take, or which surgeries they’re going to go forward with. Sometimes patients don’t go through all of the things that I’m mentioning, but I’m just describing the entirety of the process. And then in boys, have a penectomy, and also a vaginoplasty.

So these are some pretty big words. I have to give a lot of credit to my co-author, Havilah Wingfield, who helped do just a ton of the research for this report. But if you want to learn more about the Dutch Protocol and how it came to the United States in about year 2007, I encourage you to read our whole report.

Beverly Hallberg:

And is the Dutch Protocol still looked as the gold standard practice today? Or do you find … And maybe it’s not in the United States, people look at it differently, but how does the international community look at it?

Hadley Heath Manning:

Right. Well, there’s this organization that people should become familiar with the name, because they’re a very big player in the world of transgender health or transgender medicine, and that is the World Professional Association for Transgender Health, or WPATH. And WPATH kind of sets the standards. So they adopted pretty much the Dutch Protocol, and started setting standards for clinicians across the world about what would be considered a healthy age or timeframe to start delivering some of the various steps of the Dutch Protocol process.

And it’s interesting that you ask about the international standard, because what we’ve seen, actually, Beverly, is a divergence in the way this is going internationally. Some of our peer countries in Europe started on this path a little bit earlier, as you might imagine, since the Dutch Protocol was developed in the Netherlands. And so some of our peer countries allowed more adolescents to start the process of these gender transition treatments, this regimen. And more recently, they’ve actually started to curb access to these treatments. They’re starting to have more skepticism about the necessity, or the health, or the risk benefit of providing some of these treatments, and whether or not we’re doing good safeguarding or good vetting of the patients who are allowed access to these treatments.

Meanwhile, WPATH has been actually decreasing the average age, and most recently removed any specific age requirements for minors seeking gender transition treatments. So in other words, whereas they might have said in the past that, “Oh, let’s don’t start puberty blockers until a child is at least 12 years old,” that was the initial recommendation with the Dutch Protocol, now there’s no specific age recommendation for the minimum age. So you could start a child younger than 12 on puberty blockers. And of course, this raises a lot of questions.

Beverly Hallberg:

Right. How young are children when their parents may choose to put them on puberty blockers, and a doctor would go along with that.?

Hadley Heath Manning:

Well, that’s the thing, is that today, actually the FDA hasn’t approved of the use of puberty blockers for this use, and there’s really no long-term longitudinal studies that support the use of puberty blockers for this use. And because WPATH has removed any specific age recommendations, it’s really at the discretion of the doctor, of the healthcare provider. And so there’s really not one simple answer to that question. It’s basically as early as parents and the patient, the child, can find a doctor who will agree to prescribe these drugs.

Beverly Hallberg:

Well, let’s look at some of the consequences of taking a puberty blocker, whether that is before the age of 12 or around the age of 12. What would a child experience, and what could be some long-term changes in their body based on using puberty blockers?

Hadley Heath Manning:

Right. So in the process of researching for this brief on iwf.org, I found that it can be kind of difficult to separate out the risks associated with puberty blockers and cross-sex hormones, because most people who are experiencing gender dysphoria, and who start on a puberty blocker, something like 95% of them also go on to use cross-sex hormones. And so it’s very unlikely that a gender-questioning child or adolescent starts on puberty blockers, and that’s the only piece of the Dutch Protocol that they complete. Most of the time, those patients are also taking cross-sex hormones. And so it’s difficult to find studies that look specifically at only the consequences of taking puberty blockers. Most of the time, these patients are doing step one and step two in tandem.

However, we know, because there is a group of patients, the precocious puberty patients, who have used puberty blockers for some time to simply delay puberty for usually a limited period of time, and then the puberty blockers are stopped, and the natural process of puberty begins, that there are still some risks associated with puberty blockers alone. And the most discussed one has to do with bone mass density. Because during the process of puberty, our bones get stronger, people get bigger, you can surely recognize this in young men, their bodies just seem to get more manly, but people who take puberty blockers are at risk of a lower bone mass density. This puts them at risk for diseases like osteoporosis. And of course, because there’s no minimum age requirement for starting puberty blockers in gender-questioning patients, we’re looking now at some patients who have been taking puberty blockers for a longer period of time.

So there’s one particular case study of a patient who used puberty blockers for three years, and this patient then experienced bone mass density that was two standard deviations below the mean of what they should have in terms of the strength of their bones. So osteoporosis, bone fracture, these are some of the risks that are most well known and most discussed when it comes to puberty blockers.

Beverly Hallberg:

And then there’s also the other side of this, which is, what does this mean for sexual pleasure down the road? So you even talked about there could be an increased loss of the ability to have orgasms, a loss of fertility. What do we know about sexual pleasure and also reproductive health, if a child does go through both the puberty blockers and the cross-sex hormones?

Hadley Heath Manning:

Right. And particularly if they go through that third and final step, well, it’s never really final, because many transgender, or patients who identify as transgender, have to continue taking cross-sex hormones for an indefinite amount of time. It comes down to the patient’s preference, I think, in a lot of cases. But because of the way that these pieces work together, puberty blockers can stop the maturation of eggs or sperm. This is part of the process of stopping puberty. And many patients, I imagine nearly universally, have not experienced sexual pleasure, haven’t experienced an orgasm, I should say, before starting on the puberty blockers, and it’s going to be very difficult for those patients to have that experience after changing their bodies, suppressing puberty, taking cross-sex hormones, and in many cases, removing bodies’ organs that are most involved in sexual pleasure and also reproduction.

And this is not just me guessing at this. We actually quote in the policy focus, Dr. Marci Bowers, who’s a well-known leader, I think, in the world of transgender health. She is the current head of WPATH, the organization that I mentioned earlier. She’s done transgender surgeries on adolescents and other patients. And she actually says that one of her concerns about the direction that this specific regimen is going is that, I’ll quote from her, “If you’ve never had an orgasm pre-surgery, and then your puberty’s blocked, then it’s very difficult to achieve that afterwards.” And she goes on to describe how, from a cosmetic perspective, many of the surgeries that she and her colleagues can perform to make the body look like the opposite sex don’t necessarily imbue those parts with the same function that people who haven’t gone through this set of treatments, like people who they refer to as cisgender, people like you and me, Beverly. Our parts develop naturally, and they have a function, and a cosmetic look, but the transgender surgeries can only mimic the latter.

Beverly Hallberg:

Now, of course, we haven’t had these long-term studies on this, because this is all a new practice. As we said, it started in the nineties, and then in the United States in about 2007, that some of these practices took place here. But what I’ve wondered, especially since puberty blockers are not approved by the FDA for these purposes, when a patient is interested in taking them, and that’s probably with parents being alongside the child as well, are they told that these could be some side effects? Or is this sold as, “This is completely safe, natural. This is good”? Or are they saying, “Look, here are the trade-offs that you’re going to experience if you take these drugs”?

Hadley Heath Manning:

Yeah. I think that there’s two notes there. One is, yes, I do believe that some people, because we’re all biased, even doctors, even professionals, even people who do scientific study, I mean, I think we learned this during COVID, everyone has a bias, right? And so when you’re looking to investigate something or prove something, you enter that question, you enter that arena with a bias. And so I think that there is a bias among certain people in the medical industry to minimize the risks associated with these treatments.

However, I think as a second piece of this, many providers, and doctors, and clinicians, they see that these are risks, and they understand that these are risks. And this would include Dr. Marci Bowers, whom I quoted, who admits that there are risks to sexual function, to reproductive health, and so on, to general health. However, they view this as an important and necessary offering that the medical community should make to gender questioning adolescents because of the risk of suicidality among these patients. And it’s well known that adolescents who are experiencing gender dysphoria do experience higher risk of suicidality, higher risk of self-harm.

However, the big question, there, Beverly, of course, is how is this related to their gender dysphoria versus other potential factors?

Beverly Hallberg:

Right.

Hadley Heath Manning:

And also, how does their treatment plan, or the direction that they go, how does that affect their risk of suicidality? And there’s a big, big debate there, but that’s certainly worth investigating and talking about more, because if you say there’s a risk of lower bone mass density, or there’s a risk of, you may not have children in the future, these are risks that are hard for parents, let alone adolescents, to compute, vis-a-vis the chance that this child may harm or kill him or herself. I mean, that is a very emotionally heavy and very difficult environment to make very serious medical decisions in.

Beverly Hallberg:

I’ve done some research, just looking into the sex reassignment surgeries, to figure out what actually takes place, how do they perform these types of surgeries? What are the successes of the body parts to function properly? And this is going to be a little bit graphic, but I think it’s important to discuss, when you do have a biological girl who wants to turn her body into a male body, what they have to do to create the penis is actually have the skin for that, and they do a skin graft off of the girl’s arm. So a whole forearm, the skin is gone. It’s pretty terrible to look at. When we think about these sex reassignment surgeries, they’re pretty invasive. And I’ve also heard lots of reports about the patients struggle to urinate after. Obviously there’s a sexual pleasure side of this as well. But just function, the function of these organs, it doesn’t always go well, does it?

Hadley Heath Manning:

No. I mean, there’s certainly, with any surgery, you have a risk of complication, infection. I think a big question when it comes to these surgeries are, “Are they medically necessary?” When we embark on a heart transplant or other major surgery, we’re doing it because otherwise the patient is facing a medical problem that is not related to mental health, but it’s related to physical health. And so that’s, I think, a big divergence when it comes to these surgeries compared to other surgeries. But of course, there’s always the risk of complication, infection. And not to mention, when it comes to gender transitioning, there’s the risk of regret. And this is something that also doesn’t get discussed very frequently. It’s very much minimized by the community that’s in favor of these treatments. However, as you mentioned earlier, Kelsey Bowler at IWF has done an excellent job documenting, these are real people. People do desist, or detransition, and then they have enormous regrets about lost ability to breastfeed, or changes to their voice, or changes to their appearance that they’ll never be able to truly reverse completely. So that’s a part of this discussion as well.

You’re right, Beverly. Some of this stuff does get graphic, and to be honest with you, for me, it gets uncomfortable to talk about these things. I didn’t really want to write this policy focus. I didn’t really want to do the research or open my eyes to some of these things. However, it’s become such an important topic. And I think there are so many parents out there who are concerned. They’re concerned about what their kids are being taught at school about sex and gender. There are parents, “If this happens to my child, how am I supposed to respond? Who can I trust?” I think is a big question, particularly in the medical field. And so our goal in writing this was to simply spell out the information to discuss whether or not informed consent is something that can really happen unless patients get all the information, if patients are of an age where they can make a good decision for themselves, and process all the risks and benefits.

But I didn’t really want to write it. I didn’t really want to look at what the research says, because I’d rather just pretend like this is not happening. However, I think it’s important for all Americans, regardless of whether or not you have someone in your life who’s experiencing gender dysphoria, to learn about this issue, because it really affects us all.

Beverly Hallberg:

And I liked how you ended the whole policy focus, and that was focusing on the fact that the human brain does not finish development until the age of 25. So what we are doing in many cases is, especially with minors given this ability to make these life-altering decisions, when for many of them, it could be something that they decide later on that they actually feel more in line with their biological body. That of course, all of us in junior high and high school, we had lots of conflicting feelings about our bodies, and that for many young girls, this seems to be more of a trend, where from peer pressure of their girlfriends maybe, that they feel like, “Well, maybe I’m a boy.”

And so we’ve had Abigail Shrier on the show, who has talked about that gender dysphoria, and how we see it more of a clique, and lots of girls talking about this. But I thought that that element was so important, that our minds haven’t even finished developing at age 25. And yet here we are, in many cases giving children, minors under the age of 18, this ability to make life-altering decisions based on how they feel in one moment.

Hadley Heath Manning:

Right. And some of the things we’ve discussed, orgasm, reproduction, breastfeeding, these are things that you can’t comprehend. You may not even understand what these things are below a certain age, and what is at risk, and what you may lose when you pursue some of these treatments. So I think it’s very important for adolescent patients, for the parents to have this information, to parents to be very involved, to be asking questions along the way. And in terms of the 30,000-foot view, I think this area of medicine deserves more scrutiny, deserves more oversight, it deserves more accountability. We can’t just allow this to be something that’s up to the individual doctor’s discretion. It needs to be something that, we need to be able to give doctors more evidence. We need to do those long-term longitudinal studies. We need to look to our peer countries, who have studied this for a longer period of time, who have had more experience, more decades of offering these treatments to younger patients, and see what they’re doing.

It’s no wonder, it’s no surprise, that after experimenting, going down this road, several countries have recently come out and said, “Actually, we’re not going to allow young patients to have access to these treatments.”

Beverly Hallberg:

It’s a hard topic, but it’s an important one. And even one that state legislatures are having to decide on how they want to handle this in their own states. So I encourage everybody to read it. It is called The Risks of Gender Transition Treatments in Adolescents. You can find it on iwf.org, and one of the co-authors, Hadley Manning, here with us today. Thank you so much for breaking it down.

Hadley Heath Manning:

Thanks, Beverly.

Beverly Hallberg:

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