“The saddest thing about injustice in America is that it has to be proven to be believed.” 

Elle Lett is fired up. A transgender woman and statistician-epidemiologist, Lett expresses disappointment with a newly proposed data collection tool from the National Academies of Sciences, Engineering, and Medicine. The tool, Lett believes, is not sufficiently inclusive, as its creators deferred to proven methods.

“The way we have to prove y’all’s stuff is a direct output of white supremacy,” Lett says before concluding: “This is going to be uncomfortable, but the trans people who are defending this are trans masculine people, white trans masculine people.… Y’all live this world very differently.”

It is the first session of the 2022 Sexual and Gender Minority Health Symposium, hosted by Duke University and co-sponsored by its academic medical system, Duke Health. Following pre-recorded opening remarks from HHS’s Admiral Rachel Levine, Lett’s freewheeling comments set the stage for the rest of the two-day online symposium. Throughout, the proceedings took on Lett’s tone, emphasizing the primacy of granular intersectionality, the prevalence of identity-based oppression, and a flurry of faculty-lounge neologisms.

“We have to begin to decolonize gender,” notes media content creator Sir Lex Kennedy. “We have a very colonized belief of what gender is, and that’s because of imperialism and colonization.”

“How many women of color were at that national championship?” asks Penn State kinesiologist Jaime Schultz, commenting on the “really ugly” protests over Lia Thomas’s NCAA victories.

“All a penis is, is just a large clitoris,” opines Marci Bowers, celebrated as the first person to have delivered ​​more than two thousand babies and performed more than two thousand vaginoplasties.

In a session on “Queer Experiences of Autism,” “neuroqueer theorist” Nick Walker rails against “tame puppet autistics who have made their career by parroting the dominant discourse” and warns that autism is “being weaponized” by the “anti-trans” movement in the U.K. In the same session, Maxfield Sparrow (“astrologer,” “facilitator of creativity and community,” “metagender, transgender, and queer”) notes that “it’s really important to rebel against those restrictions of who one is allowed to be.”

At the end of the first day—for those who could make it through five hours of the above—Duke University Provost Sally Kornbluth closed out: “We live in a society where it’s become too easy to dismiss people we disagree with, or those who challenge our beliefs and assumptions. But that’s not how progress happens. We have to be as willing to hear others’ perspectives as we are to advocate for our own.”

Willingness to hear others’ perspectives? The symposium, no doubt, provided ample occasion for contentious disagreement, offering sessions on the hot button issues of teen transitions, transgender sport participation, and transgender law and legislation. And from the first moment of the symposium, there were murmurs of dissent—quickly shot down or explained away.

When Levine brought up health disparities, one audience member wrote in the Q&A, “Are you all aware that the lack of care for detransitioners greatly outweighs the lack of care that Dr. Levine is talking about?” A moderator quickly responded: “Care for detransitioners is important. We will have a another [sic] session that looks specifically at detransitioning.” It was the first of many instances of strategic, at times nearly hidden, rebuttal.

This rebuttal was most overt in the panel on “Sports Participation,” during which the specter of Lia Thomas loomed large. Virtually every argument in the session implied that women’s sports simply shouldn’t exist.

Liam Miranda, a researcher at the Inclusion Playbook and former trans athlete, declared that “people like sports because there isn’t really a level playing field.” Helen Carroll, of the National Center for Lesbian Rights, argued, “If I took 100 athletes and made a poster of them—big muscles, big hands, strong bones—you’re not going to be able to tell the difference.” That is, the difference between biological males and females. 

Meanwhile, the most revealing session was “Teen Transitions.” The panel included Johanna Olson-Kennedy, a prominent pediatric gender specialist, and Marci Bowers, a surgeon described on the symposium website as the “Georgia O’Keeffe of genitalia.” 

Bowers managed to strike a tone that, to an observer unfamiliar with the debate, could easily sound heterodox. (“We’re not immune to modification, to listening, to concern about detransitioners.”) When the moderator asked what research questions the panelists had, Bowers was quick to respond with two: the appropriate timing of transition and the problem of detransitioners.

This might sound like an opening for dissent, but it functioned like crisis management. Bowers’s main concern about timing? Vulvoplasty is more difficult to perform on a male child who has used puberty blockers. On the question of detransitioners, Bowers offered a number of scattershot comments, acknowledging but ultimately dismissing the problem.

“There are some high profile detransitioners, and you know, we have to listen to that.”

“Was therapy long enough to be satisfactory? You know, these are practical questions. Or is it just part of their journey, is it something they’re just working their way through in life?”

“You are in control. But, if you’re in control and you change your mind, this happens in other forms of surgery—breast augmentation, tubal ligation—they all have higher levels of regret than what we’re seeing.”

“Just because someone detransitions doesn’t mean it’s a negative impact on their life.”

For Bowers, detransitioners pose something of an academic problem, but no change is warranted, or even worth positing. Likewise for rapid onset gender dysphoria: “There can be some [peer] influences,” but this “isn’t the reason why people are coming out.”

The premise of the discussion, teen transitions, remained unquestioned. On the state of “teen transition science,” Olson-Kennedy asserted that “the existing body of evidence is very solid about the help, the improvement, that people experience, in their psychological wellbeing, in their depression, in their anxiety, when they are allowed to transition.” The same goes for mental health, per the clinical psychologist on the panel. “Without a doubt that’s been very clear to us for a while.”

Without a doubt? While U.S. federal agencies—and universities—double down on the necessity of gender transition for minors, in Europe things are not so settled.

Nearly two years ago, the Finnish Health Authority concluded that, “in light of available evidence, gender reassignment of minors is an experimental practice.” Through comprehensive reviews of evidence, many other countries have reached similar conclusions. In February of this year, the Swedish National Board of Health and Welfare changed its guidelines for teen transitions, noting “it is not yet possible to draw any definite conclusions about the effect and safety of the treatments based on scientific evidence.” In March, the National Academy of Medicine in France issued a press release on pediatric gender transitions, urging “great medical caution” given “the vulnerability, particularly psychological, of this population.”

The difference between us, here in the U.S., and them, in Europe, suggests an issue with evidence—and how it is used. In the journal Child and Adolescent Mental Health, a group of skeptical physicians examined a case study in how low-quality evidence ends up justifying high-confidence claims about child gender transitions. The authors liken this process to the telephone game: One high-profile paper demonstrates an association between puberty blockers and “suicidal ideation,” noting that the evidence does not establish causation. Then another paper—based solely on the first—creates “the strong impression of causality” between puberty blockers and reduced suicidality, calling them “potentially life-saving.” Then, in the medical journal Lancet, an editorial commenting on those papers goes even further: “removing these treatments is to deny life.”

This process also resembles the improv comedy tool “Yes, and,” which calls on improv actors to accept whatever their partners say and add their own twist. Rightly used, the heuristic leads to crowd-pleasing absurdities. It’s no different with medical research.

Throughout the symposium, “Yes, and” functioned as a modus operandi. Bowers, for example, cited a 2018 Cornell study, saying that “more than 4000 studies on a gender affirming approach” showed “people are better off psychosocially, reduced suicidality, improved social functioning.”

Not exactly. The Cornell analysis screened more than 4,000 studies, but it only identified 56 that assessed, in some broad sense, whether transition improves well-being. For the topic at hand, pediatric transitions, these studies are moot, to say nothing of their quality. But for Bowers, “that ship has sailed, there’s no question that that is beneficial.”

Medical schools have an incentive to adopt and promote the “Yes, and” principle, especially on the issue of gender. At medical schools across the country, the activist group White Coats 4 Black Lives has successfully elicited major diversity, equity, and inclusion (DEI) commitments. According to the organization’s vision document, “The liberation of queer and trans people from oppressive sexual and gender norms is an essential part of the world we hope to build.” Likewise, the Accreditation Council for Graduate Medical Education now requires systematic diversity measures in residency programs; its professional development series, designed to help programs meet the new requirement, includes a lecture for medical professionals that utilizes the “Genderbread Person.”

A conference on “gender and sexual minorities” is a great way to satisfy DEI requirements. All the better if it advances the cause of liberation.

Judith Kelley, Dean of Duke’s Sanford School of Public Policy, closes out the symposium, praising the speakers for their courage. Without any irony she concludes, “Our society right now is in a place where people with different views coming together and talking with each other is not modeled. And the people in this symposium have done that.”

John D. Sailer is a research associate at the National Association of Scholars.