Science ‘Woefully Inadequate’ About Child Gender Transition: Expert

Key witness testifies in nationally watched trial

Toddler At Children's Hospital for Surgery on Oct. 11, 2022. Getty Images

LITTLE ROCK, Ark.—One big question should frame the debate over transgender medical treatments, especially for minors, an expert witness testified in a federal trial here: “We can feminize bodies and masculinize bodies. The issue is: Should we?”

That question isn’t asked often enough, Dr. Stephen Levine said on Nov. 28 during a trial that will serve as the nation’s first legal test of a law banning transgender medical procedures for minors.

Whether the procedures should be done depends on outcomes for patients, Levine told U.S. District Judge James Moody Jr. But a “politicized” atmosphere is clouding the search for answers, and the scientific evidence is “woefully inadequate,” said Levine, a psychiatrist who has been treating transgender people for five decades.

James Moody Jr., judge in U.S. District Court for the Eastern District of Arkansas. Courtesy: Judge Moody

“This looms over all of us,” Levine said. “Are we harming people? Or are we helping people?”

Lawyers from the Arkansas Attorney General’s Office called Levine as their first major witness in a battle over the constitutionality of the Save Adolescents From Experimentation (SAFE) Act.

The SAFE Act, signed into law in 2021, has been on hold while a lawsuit filed by the American Civil Liberties Union (ACLU) plays out.

Moody, who already heard from the ACLU’s witnesses in October, reconvened the trial after a monthlong recess. The testimony in October included emotional statements from parents of transgender youths who are already undergoing procedures, as well as experts who assert that the procedures are beneficial for minors. The case is being closely watched because Arkansas’ law inspired similar legislation in more than a dozen other states. Some of the other laws are also facing challenges in court.

Testimony in the Arkansas case is expected to last through Dec. 1. Moody has not indicated when a ruling might be forthcoming.

He listened intently as Levine testified, often turning toward the witness chair and leaning forward.

Pursuit of ‘Happily Ever After’

Levine, who founded Ohio’s first gender clinic, said he frets over procedures going “full-speed ahead” for transgender-identifying youths, despite a lack of high-quality, long-term studies on outcomes for this rapidly expanding group.

That’s why Levine favors putting on the brakes to gather more evidence—and to share the findings with young patients and their parents before they proceed with life-changing gender transitions.

Even so, under cross-examination, Levine stopped short of fully endorsing the SAFE Act.

“I’m here to represent a balanced view” of the relevant science, Levine said, rather than to tout the law.

Dr. Stephen Levine, a clinical psychiatrist who founded an Ohio gender clinic in 1974, is concerned about hormones being used to treat distressed transgender children. Courtesy: Dr. Stephen Levine

As for the science, Levine said it’s about answering a question. And “you can’t even ask the question if you ‘know’ the answer,” he said.

Many advocates of transgender procedures believe they already “know” that the treatments are the best way to help trans-identifying youths, Levine said.

“They believe these people will live happily ever after,” Levine said, “even though they have no data to show that.”

His summary of the current scientific findings: “The expected benefits that the advocates support may not be delivered. They’re likely not to be realized (and) the harms seem to outweigh the benefits. That’s the state of science, 2022.”

‘Unconstitutional’

Despite Levine’s strong opposition to medical procedures being used for “gender transition” of minors, Levine made some concessions  under cross-examination by Leslie Cooper, an ACLU attorney.

At times, Levine’s exchanges with Cooper were spirited. “You and I are crossing each other at a very high altitude,” Levine told Cooper after one particularly frustrating go-‘round.

Still, Levine agreed the SAFE Act probably should have carved out exceptions for patients already undergoing treatments. Levine also said he dislikes the idea of lawmakers imposing their will on medical professionals, parents and patients.

The ACLU wants the law thrown out, alleging it unconstitutionally strips parents of their rights to consent to treatment for their children. Under the SAFE Act, medical treatments that are allowed for other purposes would be banned from use for gender transition. Thus, the law  “discriminates on the basis of sex and transgender status,” the ACLU argues.

The ACLU filed suit on behalf of four transgender-identifying youths, their families and two doctors.

The Attorney General’s Office counters that the state has a compelling public interest to protect children who are considered vulnerable and ill-equipped to handle certain responsibilities. Across the nation, a host of activities that are legal for adults are illegal for minors; in Arkansas, for instance, no one under 18 can have piercings or tattoos on nipples or genitals—not even with parental consent.

‘Affirming’ Model Critiqued

Michael Cantrell, assistant solicitor general for the Attorney General’s Office, questioned Levine about the “gender-affirming” care for which ACLU witnesses had expressed high regard.

Levine, who testified for more than five hours, says the label, “affirming care” sounds nice, but it amounts to “medicalization” of transgender people. The “affirming” model dictates that doctors should readily accept a patient’s declaration of transgender identity and proceed from there.

But  “affirming” results in little or no attempt to understand the patient as a person, along with life history and circumstances, Levine said.

Stickers on the back of a car show support for the American Civil Liberties Union of Arkansas and for "Trans Magic," on a vehicle parked outside U.S. District Court, Little Rock, Ark, on Oct. 17, 2022. Janice Hisle/The Epoch Times

That process contrasts sharply with processes used to help people with other medical or psychological conditions,  the 80-year-old clinician said, declaring: “We ought to treat ‘trans’ people like the rest of us. They deserve thoughtful, compassionate, scientifically informed care.”

Levine sees a need to root out factors that may be contributing to a person’s “gender dysphoria,” or distress over gender identity mismatching one’s body.

For example, some people have discovered that they had used transgender identity “to escape from even thinking about the events that happened to them as children,” Levine said.

Other people have realized that they were gay or lesbian, not transgender, Levine said.

And, often, people who identify as transgender have underlying conditions that need to be addressed, such as autism.

But the affirmation approach precludes or discourages exploration of such possibilities, Levine said.

Alternatives to Medicalization

Instead of the affirmative approach, Levine favors psychotherapy for adolescents. He notes about a dozen studies concluded that the vast majority of young people will retreat from a declared transgender identity if given time to mature and reconsider any possible medical procedures.

Psychotherapy requires a long-term, trusting interaction with a mental health professional. Countries such as Sweden, Finland and the United Kingdom are now emphasizing psychotherapy and moving away from prescribing hormones and surgeries to young people, Levine said.

But the United States seems to be going in the opposite direction. Large, influential medical organizations and activist groups are encouraging American doctors to give patients the hormones and surgeries that they are insisting upon receiving, Levine said.

“I’m one of the people saying, ‘Wait a second,’ ...look at the lives of adults who are trans,’” Levine said.

Even after undergoing desired medical “transition” procedures to change their outward appearance, transgender adults experience higher-than-average rates of suicide, mental issues, certain physical problems and sexual dysfunction, Levine said. All of these problems are compounded by lifelong effects on relationships and overall functioning in society, he said.

Lack of Informed Consent

Often, known risks of medical transitioning—and the unknowns—are not explored in any meaningful way with young patients and their parents, Levine said.

In a recent professional article, Levine and two co-authors struck a chord when they wrote about the topic of “informed consent”—or lack thereof—for young trans-identifying patients.

Published in the Journal of Sex & Marital Therapy, Levine’s article has been downloaded almost 46,000 times since its March publication, he said.

That article, “Reconsidering Informed Consent for Trans-Identified Children, Adolescents, and Young Adults,” ranks as that journal’s most-downloaded selection worldwide, Levine said.

In the article, Levine lists factors that sabotage informed consent: inaccurate assumptions, poor quality of patient evaluations, inaccurate and incomplete information.

Professionals are responsible for ensuring that patients and their parents clearly understand possible risks, benefits and unknowns about gender procedures “as they prepare to make this often-excruciating decision,” the article says.

But many doctors are ill-informed or biased toward “ideology” or advocacy. Some may be unaware that a number of studies suggesting positive outcomes for medical gender transitions are seriously flawed or were retracted, Levine said.

Notably, a small, flawed Dutch study on medical transitioning of minors was misconstrued as proof that these procedures benefited adolescents, Levine said.

Belief in that conclusion spread to the point where the Dutch study influenced treatment decisions across the globe—which shocked even the authors of the study, he said.

Meanings Surface Later

While doctors are obligated to avoid doing harm to patients, they’re also expected to honor patients’ treatment choices. Sometimes those principles conflict, Levine said, and in recent years, giving patients what they want has become king. At the same time, doctors are under pressure to handle increasing numbers of patients more quickly.

Levine worries that doctors’ willingness to comply with young people’s insistence on transitioning can produce lifelong regret—as some “detransitioners,” those who disavow their transgender identity or discontinue treatments, have painfully disclosed.

“These medical events, these surgical events, they have meaning,” Levine said. “But the meaning does not appear for years later. And then they have a different life trajectory.”