In June 2023, Jesse Ehrenfeld was inaugurated as president of the American Medical Association (AMA), one of the largest and most influential physicians’ organizations in the U.S. Ehrenfeld has said the U.S. has “a health care system in crisis.” He identifies many areas of concern, including physician burnout, increased medical costs, and insurance company interference in care.

All of these are serious problems that most people would like to see addressed, but another of his concerns is more controversial—legislative action governing the practice of medicine:

There are so many backseat drivers telling us what to do. . . we’ve got regulators that are discarding science and telling physicians how to practice medicine, putting barriers in care. . . .in at least six states, now, if I practice evidence-based care, I can go to jail. . . . It’s frightening. When a patient shows up in my office, if I do the right thing from a scientific, from an ethical perspective, to know that that care is no longer legal, criminalized and could wind me in prison.[1]

Ehrenfeld is referring to regulations on abortion and so-called gender-affirming care that have recently been adopted by several states. Ehrenfeld talks freely about being the first openly gay president of the AMA, so it comes as no surprise that LGBTQ concerns would be important to him. And while he does not specify exactly which laws he finds problematic, his comments raise many questions worth asking, especially about care for those with gender dysphoria. For starters, since he claims that states are legislating against evidence-based medicine, what is the evidence?

Evidence-Based Medicine & Gender-Affirming Care

“Evidence-based medicine” refers to a specific way of applying medical research to clinical questions.[2] Different types of evidence are divided into levels in a hierarchy. At the top are meta-analyses of numerous randomized controlled trials; at the bottom is expert opinion. Doctors must use their judgment to determine which evidence is most compelling, as well as most relevant to a specific patient.

When it comes to treating children and adolescents with gender dysphoria, the state of the evidence is complicated at best. Numerous entities have put forth their own guidelines, two of the most influential being the World Professional Association for Transgender Health (WPATH) and the Endocrine Society. Both recommend “gender-affirming care,” which has been defined as “an approach that aims to alleviate distress by validating an individual’s gender identity and expression.”[3] This focus on validation means that gender-affirming care rejects any notion that gender incongruence is a mental disorder (as was held until quite recently), and as well rejects any attempts to help the gender-incongruent patient identify with his or her birth sex (which is now labeled conversion therapy).

While WPATH and the Endocrine Society claim that their guidelines follow the best possible evidence, it turns out that their evidence is in fact lacking: “these guidelines are based on relatively low-quality evidence (ie, expert opinion), and there is a need for more robust studies to strengthen evidence-based approaches to care.”[4] Numerous outlets are beginning to realize this, as exemplified by a recent article in The Economist, “The Evidence to Support Medicalised Gender Transitions in Adolescents Is Worryingly Weak.” Thus, the claim that laws forbidding certain hormone treatments and surgeries on minors prevents doctors from practicing “evidence-based care” is flimsy at best.

A number of factors contribute to the weak evidence base for gender-affirming care. With the explosion of gender dysphoria cases being a very recent phenomenon, there have not been many studies done, nor has there been time for longitudinal studies and long-term follow up. Additionally, those studies being put forward as support for gender-affirming care are often deeply flawed.[5] Nevertheless, proponents continue to support interventions such as hormone treatments and surgery for adolescents.

Puberty Blockers, Hormones & Suicide

The dearth of evidence is especially notable for puberty blockers and cross-sex hormone treatments, for which a British study found the evidence to be “weak, discouraging and in some cases contradictory.”[6] The claim is often made that the purpose of puberty blockers is to buy time for children to mature and decide if they really want to transition, but a recent Dutch study shows that up to 98 percent of those who began taking puberty blockers continued with gender-affirming treatment at follow-up.[7] Proponents see this as good news—as evidence that protocols are working and that the adolescents being prescribed hormones are the ones who really need them. There is another explanation to consider, however. Starting a child on puberty blockers might lock them into a trajectory they cannot escape, whereas if they had not taken puberty suppressors, they might have been among the large number of adolescents for whom gender dysphoria resolves during puberty.

Either way, it seems that puberty suppressors are not functioning to buy time but to set children on a path to transition. Unfortunately, despite claims to the contrary, there is little to indicate that this will be beneficial. Studies have found that hormone treatments did not lead to any mental health benefits,[8] and potential long-term side effects (such as lower bone density) remain unknown.[9] Others suggest that hormone treatment does not even reduce suicidal ideation, which is one of the reasons touted for its necessity.

In fact, some researchers have pointed out that, despite dire claims that gender-affirming care is necessary to save lives, the risk of suicide among trans adolescents is “relatively similar to that of youth referred to generic child and adolescent mental health services.”[10] This is in no way to downplay the issue; those experiencing gender dysphoria clearly have an elevated rate of suicidality, and this needs to be taken seriously and treated compassionately. But claims that gender-affirming care is “lifesaving” are at best overblown, and at worst, little more than emotional manipulation.

First, Do No Harm

Proponents of gender-affirming care are fond of saying that the science is settled and that “doctors agree” that validation, hormones, and even surgery are the best options. As the above demonstrates, the science is anything but settled, and the unknowns remain far greater than the knowns. Interventions such as cross-sex hormones and surgery remain experimental. They can have numerous unpleasant side effects and are difficult if not impossible to reverse should the adolescent have a change of mind. Several nations have recognized this, and countries such as Finland, Sweden, France, Norway, and the U.K. are all calling for further research while also limiting these types of interventions.

Why, then, are doctors in the U.S. so adamant to move forward with gender-affirming care, especially when it can bring with it real harms? The answer may be wrapped up with Ehrenfeld’s assertion of a crisis in medicine. While he sees such issues as physician burnout or increasing medical costs as independent problems to be addressed, these issues are more likely symptomatic of a deeper problem.

The Practice of Medicine

In the West, doctors have traditionally practiced in accordance with the Judeo-Christian Hippocratic tradition, whose guiding principle is “First, do no harm.” Doctors were seen as professionals. When you went to the doctor, you did so because he was the expert, and you trusted him to know and tell you the best course of treatment. While this led to issues of paternalism, it was still generally true that, because of their training and experience, doctors could be relied upon to recommend the most beneficial treatment and to act in the best interest of their patients.

In recent years, however, medicine has shifted to what Farr Curlin and Christopher Tollefsen have criticized as a “provider of services model.”[11] Physicians are no longer seen as professionals but rather as technicians whose purpose is to satisfy the desires of their patients. As long as what the patient wants is legal and technologically possible, physicians are expected to provide it. This can be clearly seen in gender-affirming care, as well as in discussions over abortion and euthanasia. It does not matter that the evidence for gender-affirming care is weak or that significant harms may result; once a patient has identified transition as the desired treatment, a provider of services model says that nothing should be allowed to stand in the way.

This new model helps explain why some state legislatures are moving toward prohibiting certain procedures—if the only limits on care are legality and possibility, then the only way to stop harmful practices is at the level of legality. Doctors such as Ehrenfeld may not like this approach, but it is the only option available when patient autonomy is made primary. This also helps to explain the other symptoms of the crisis in medicine, such as physician burnout and insurance company interference. When physicians are seen as mere technicians, they lose their “authority of expertise” and the ability to exercise their own clinical judgment, which can lead to lower morale and physician burnout. These in turn open the door to third parties—whether legislators, insurance companies, or lobbyists—interfering with patient care.

How can we move forward from here? In the realm of gender-affirming care, we need more physicians to be honest about the evidence and stop allowing ideology to drive patient care. And if physicians don’t want legislators to interfere with their work, they should stop promoting experimental treatments on children as if they are “settled science.” More generally, though, we must address the real crisis in medicine. If we want sane medical care that prioritizes the good of the patient, and not patient desires, then a return to Hippocratic principles would be a good start.

Notes

[1] Norah O’Donnell and Alicia Hastey, “New American Medical Association President Says ‘We Have a Health Care System in Crisis,’” CBS News, June 15, 2023.

[2] Steven Tenny and Matthew Varacallo, “Evidence Based Medicine,” in StatPearls (Treasure Island, FL: StatPearls Publishing, 2023).

[3] Andrew A. Dwyer and Debra L. Greenspan, “Endocrine Nurses Society Position Statement on Transgender and Gender Diverse Care,” Journal of the Endocrine Society 5, no. 8 (2021).

[4] Ibid.

[5] Jesse Singal, “The Media Is Spreading Bad Trans Science,” UnHerd, April 18, 2023.

[6] “The Evidence to Support Medicalised Gender Transitions in Adolescents Is Worryingly Weak,” The Economist, April 5, 2023.

[7] Maria Anna Theodora Catharina van der Loos et al., “Continuation of Gender-Affirming Hormones in Transgender People Starting Puberty Suppression in Adolescence: A Cohort Study in the Netherlands,” The Lancet 6, no. 12 (2022).

[8] Jesse Singal, “Researchers Found Puberty Blockers and Hormones Didn’t Improve Trans Kids’ Mental Health at Their Clinic. Then They Published a Study Claiming The Opposite. (Updated),” Singal-Minded, April 6, 2022.

[9] “Evidence for Puberty Blockers Use Very Low, Says NICE,” BBC News, April 1, 2021.

[10] Alison Clayton, “Gender-Affirming Treatment of Gender Dysphoria in Youth: A Perfect Storm Environment for the Placebo Effect—The Implications for Research and Clinical Practice,” Archives of Sexual Behavior 52 (2023): 483–94.s

[11] Farr Curlin and Christopher Tollefsen, The Way of Medicine: Ethics and the Healing Profession (Notre Dame, IN: University of Notre Dame Press, 2021), 2–4.