Of note, today, of all days, when the Supreme Court of the United States is to consider state bans on treatments for gender-affirming care of transsexual youths, virtually every internet site on the subject is blocked.
Nevertheless, I am a medical student in 1967. I do not need the internet; I lived through the beginning of gender-affirming care. My memory is clear.
I am reminded of the story of Dr. John Money, a psychologist at Johns Hopkins Hospital. He is known for his work in psycho-endocrinology and developmental sexology. His claim to fame is one of his patients, Bruce Reimer. Bruce is one of twin boys who undergo simultaneous circumcisions seven months after birth. Bruce Reimer has what could best be described as a botched job, and his penis is cauterized off. Now there is the issue of sexual ambiguity. Dr. Money’s solution is to rename Bruce “Brenda,” remove his testicles, create rudimentary female external genitalia, use estrogen, and raise him as a girl, reserving a surgical neovagina for when the time is right.
This turns out to be a colossal mistake. Brenda Reimer was so damaged by this decision that later he decides to call himself David, to reverse the harm already done and to acknowledge his true karyotype. Nevertheless, he is sterile and can never father children. David commits suicide in 2004. Dr. Money dies in 2016, never regretting the mistake. This is the tragedy upon which all other so-called research on gender-affirming care is based.
For some, this never happens. According to them, bans on best medical care represent an extreme and coordinated political attack on transgender people. Such bills specifically target transgender youth and block their access to research-based best practices endorsed by the American Academy of Pediatrics, the AMA, and other academic authorities. Twenty-six states, more than half the country, have such bans in effect or set to come into effect. The Supreme Court needs to reverse these bans.
First, looking closer at the American Academy of Pediatrics’ position, indeed, it accepts the benefits of gender-affirming care. However, according to it, this remains a controversial topic, in which misinformation and uncertainty regarding gender-affirming care and resulting consequences on policy underscore the necessity for more research.
The recommendation of the American Academy of Pediatrics, actually, reflects the nuances of gender-affirming care treatment goals, for which it deserves credit. The topic is far more complex than others prefer and deserves more scrutiny from those in the media who reflexively oppose the ban. Its position, actually, provides a counterpoint to the contemporary media narrative. In short, even for the American Academy of Pediatrics, this subject is not as monolithic as others would prefer.
Second, nowhere in the academy’s position are found the words “standard of care.” Instead, “best practice” is used. A best practice is not a standard of care. A standard of care is that which is expected, with 95 percent confidence, of any competent and prudent practitioner when faced with a medical condition. A standard of care is science. A best practice is consensus. Consensus is the opposite of science. Standard of care is a term in medical malpractice. Oddly, this story over transgender rights begins with a botched circumcision, a medical malpractice case.
Taken further, is the final authority over what is expected of any competent and prudent practitioner when faced with a medical condition the physician or the Supreme Court of the United States? Doctors decide using 95 percent confidence. Judges decide using preponderance of evidence—50 percent probability plus a scintilla.
In my wildest imagination, I would never expect the connection between medical malpractice and the Supreme Court to be over gender-affirming care. Yet, in the final analysis, it makes no difference because a decision for gender-affirming treatment, or any treatment for that matter, is between the doctor and the patient, or a party that represents the authority for the patient. Such is the case when John Money recommends the immediate amputation of Bruce Reimer’s testicles, estrogen therapy, and the surgical creation of a neovagina at some later time. Today, although this would have been banned by some states and a tragedy potentially averted, there is no such ban in Maryland. Better advice would have been: “Get a lawyer.” John Money’s legacy would be very different.
Howard Smith is an obstetrics-gynecology physician.
