At the 2019 conference of the U.S. Professional Association for Transgender Health (USPATH), a trans-identifying psychotherapist asked the resident panel how their group might influence its international parent organization, WPATH (the “W” stands for “world”), “in terms of being more affirming” and crushing “transphobic nonsense.” The question is a paradigm of the way that many in the American transgender movement see themselves — as a vanguard boldly leading other countries to gender nirvana. In some respects, the U.S. is a global outlier. But not in the way trans activists imagine.

Before it had its current name, WPATH was the Harry Benjamin International Gender Dysphoria Association, after the German-born American endocrinologist who wrote The Transsexual Phenomenon (1966). For years, the prevailing therapeutic wisdom had held that when it came to sex-related distress, it was easier for a patient to change his thinking than to change his body. But this view was challenged by mid-century sexologists who developed a new theory of “gender identity” (a term coined by psychiatrist Robert Stoller), according to which the patient wasn’t confused and in need of mental-health treatment so much as onto something and in need of physical alteration. This idea caught on as new drugs and surgeries were developed to bring about the bodily changes.

WPATH asserts its own recommendations as the “best available science and expert professional consensus.” The latest version, Standards of Care Version 8, was released in September of last year. Early drafts had included specific age guidelines for different forms of treatment, but the published standards did not. There is a reference to “susceptibility to social influence” among some young people (a vague acknowledgment of social contagion), but the authors’ bigger concern was “unnecessary barriers to care.”

The preference of WPATH, and indeed of most American medical organizations, is for “gender-affirming care.” Under this model, a clinician’s role is not to evaluate a patient’s proclaimed gender identity but to affirm it while facilitating whatever kind of transition the patient desires. The model “originated in the USA,” wrote Hilary Cass, a former head of the Royal College of Pediatrics, in her independent review of Britain’s gender youth clinic. Cass pointed to the lack of a global consensus among medical professionals on standards of care for those who identify as transgender. Soon thereafter the clinic was closed over safety concerns, on Cass’s recommendation.

Increasingly, clinicians in Europe are looking at America as an example of what not to do. It’s the Dutch, however, who can take credit for first experimenting with transition treatments for children. In the 1990s, childhood gender dysphoria was a rare condition, affecting mostly small boys. Some clinicians in Utrecht and Amsterdam considered whether early transition might yield more positive results than adult transition, which emerging research was correlating with poor mental-health outcomes. Puberty blockers were justified as being reversible and diagnostic in nature. But that claim was implausible at the time and is now demonstrably false. The negative effects of puberty blockers on bone mass, cognitive and emotional development, penile growth (as this relates to vaginoplasty), and sexual functioning have since been established. Meanwhile, prescribing a child puberty blockers significantly reduces the chances that he will desist from gender dysphoria by the end of adolescence, as happened under traditional talk therapies in up to 80 percent of cases.

Nevertheless, Norman Spack, an American pediatric endocrinologist, recalled in a 2015 interview with the Seattle Times that he was “salivating” at the opportunity to bring the Dutch protocol to Boston Children’s Hospital, which he did in 2007. In 2015, the Gender Management Service at the hospital was one of the recipients of a $6 million National Institutes of Health grant for a five-year longitudinal study, with no control group, of puberty blockers on children as young as eight years old and of cross-sex hormones on children supposedly as young as twelve years old. In 2017, however, a California-based endocrinologist, Michael Laidlaw, used FOIA requests to reveal that the minimum age for cross-sex hormones had been lowered to eight. In 2021, the study was renewed for another four years. As of January 2023, two participants in the group of 315 had died by suicide.

Stephen Levine, a psychiatrist, and Julia Mason, a pediatrician, outlined in the Journal of Sex & Marital Therapy in January of this year the flaws of the early Dutch studies: a “high risk of bias,” “incompleteness of evidence regarding physical health risks,” and “poor generalizability/applicability to current cases.” Michael Biggs, a sociologist at Oxford University, has pointed out that not only was the evidence for the Dutch protocol weak, relying on “a small number of observations and incommensurable measures of gender dysphoria,” but that a study conducted in Britain failed to replicate what evidence there was. Journalists at the Dutch newspaper NRC have called for an independent investigation like the one that led to Cass’s report in the U.K.

Then there is the issue of “rapid-onset gender dysphoria,” a term coined by the medical doctor and researcher Lisa Littman in 2018. Over the last ten years, unprecedented numbers of female adolescents with no prior history of gender dysphoria (the persistent desire to become the opposite sex) have presented themselves at gender clinics.

In 2020, a Finnish review concluded that “gender-affirming” treatment was “experimental” and that talk therapy was preferable. Swedish medical authorities concluded that, for minors, the risks of medical transition “currently outweigh the benefits.” The French National Academy of Medicine urged similar caution in 2022, as did the Norwegian Healthcare Investigation Board in 2023. The Europeans cite the new demographic of (disproportionately female) adolescents, the greater visibility of detransitioners (those who experience post-transition regret), and insufficient evidence of the effectiveness of the treatments as reasons to be cautious. But in the United States, as Levine et al. note, “medical organizations so far have chosen to use their eminence to shield the practice of pediatric ‘gender affirmation’ from scrutiny.”

American gender clinicians have avoided accountability by pointing to recommendations from the governing bodies of major health associations: The American Academy of Pediatrics, the Endocrine Society, the American Medical Association, the American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and — of course — WPATH all support “gender affirmation.” But as the Canadian sexologist James Cantor has pointed out, the American Academy of Pediatrics’ 2018 policy statement on gender-affirming care not only ignored the clinical debate but “misrepresented the contents of its citations, which repeatedly said the very opposite of what the AAP attributed to them.” As doubts about the affirmative model spread across Western Europe, why didn’t these American organizations lead the way by engaging with their critics’ concerns? Rachel Levine, President Biden’s assistant health secretary, has said that “there is no argument among medical professionals about the value and the importance of gender-affirming care.” This is a blatant lie.

In The Age of Entitlement, Christopher Caldwell argues that the apparatus for rights-based causes was set in unstoppable motion by the passage of the Civil Rights Act. The gay-rights and feminist movements were packaged as an extension of civil rights. So too is transgenderism. In July 2014, Time magazine ran a cover story featuring the transgender actor Laverne Cox and heralding the arrival of a “new frontier of civil rights.” Bruce, now Caitlyn, Jenner made a similar appearance the following year on the cover of Vanity Fair — though in a bizarre turn of events Jenner is now the right-wing face of transgenderism, having opposed child transition and the participation of trans-identifying male athletes in female sports.

Speaking about medicalized gender transition at the 2023 GLAAD Media Awards, White House press secretary Karine Jean-Pierre said that American children “belong to all of us.” Medicaid, which covers “sex reassignment” procedures, also covers child transition in many states, including Oregon, where minors can obtain “gender-confirming” hormones and surgeries without parental consent. Both Minnesota and California have passed “trans refuge” legislation for children whose home states ban medicalized gender transition for minors. The ACLU is backing a ballot initiative in Ohio that would end parental-consent and parental-notification requirements for minors who seek abortion or sterilizing transgender drugs and surgeries.

Some conservatives have responded in kind. In Texas, Governor Greg Abbott called on the state’s department of family and protective services to investigate parents who, often acting under medical direction, green-light their child’s transition. Yet despite such excesses, the main conservative effort has been to ban medicalized transition for children and to enshrine parental-rights protections. Already a variety of laws to this effect have passed in over a dozen states, including Florida, Texas, and Arkansas.

If there is no equivalent culture war in Europe, it is in part because the medical profession is still engaged in an evidence-based debate there and its clinicians are more accountable.

In European countries, the exact number of children transitioning is easier to come by because of centralized health-care systems and greater government oversight. In the U.K., for instance, there were 72 children referred to the National Health Service’s gender youth clinic in 2009–10, most of whom were boys. But in 2019–20, there were 2,729, most of whom were girls. In the United States, we don’t know even approximate numbers but have reason to think they’re high. The New York Times reports that the U.S. has “more than 60 comprehensive gender clinics, . . . along with countless therapists and doctors in private practice who are also seeing young patients with gender identity issues.” The national number of young people identifying as transgender is 300,000, according to the Williams Institute, a policy-research organization associated with UCLA’s law school. We do not know what percentage of them are undergoing medicalized transition.

In the United States, the clinical landscape of gender medicine is, in the words of one surgeon in the field, “the new Wild West.” Planned Parenthood, under the umbrella of “reproductive rights,” boasts on its website: “If you are eligible, Planned Parenthood staff may be able to start hormone therapy as early as the first visit.” The Daily Wire reported on Shayne Taylor, a doctor at Vanderbilt University Medical Center’s Clinic for Transgender Health, who boasted that “female-to-male bottom surgeries . . . are huge moneymakers.” Out of pocket, double mastectomies cost between $15,000 and $50,000. Some youngsters try crowdfunding their surgeries.

There are many areas of medical research and treatment in which the United States is the envy of the world. But in transgender health care, the U.S. is an outlier as a case study in what to avoid.