Michael Hobbes Is Spectacularly Wrong About Youth Gender Medicine

That’s because he doesn’t care what the truth is

Michael Hobbes insists, on Twitter, that the Cass Review (which I wrote about here) vindicates his own view that youth gender medicine is in solid shape, and that the various experts and clinicians to whom we entrust gender-questioning children’s and teenager’s well-being are doing a good and responsible job.

This has long been Hobbes’ stance. He simply cannot believe that some journalists have spent so much time covering this issue in a critical manner, given the overwhelming evidence that the system works. And plus, even if there were issues, so few young people are transitioning that who cares? Hobbes views this as a moral panic, full-stop — and this is a popular view on the left, often founded on distortions and misconceptions. 

For those who are unfamiliar, Hobbes is a pundit whose voice on these issues matters: he has built a career as an exceptionally successful DIY podcaster, probably one of the few self-made podcast millionaires. He originally became famous as the co-host of the blockbuster You’re Wrong About, which mostly revisited past controversies and explained how, well, we were wrong about them. These days he co-hosts Maintenance Phase, which involves a lot of debunking of obesity and weight-loss research, and If Books Could Kill, which involves a lot of debunking of airport bestsellers. Debunking really is his thing: he is trusted by a huge audience that views him as the last word on all manner of scientific and societal disputes.

The problem is, he’s exceptionally bad at it. Find me an even mildly complex subject he has discussed, and I will find you countless errors, misunderstandings, and, in some cases, what can only be fairly described as lies. And it isn’t just that he errs and misunderstands and lies quite frequently; it’s that he does it with the maximum possible amount of sanctimony and a complete absence of good faith. He has built a huge listenership out of the idea that American intellectual life is full of vapid morons stoking moral panics and peddling false cures, and he, Michael Hobbes, can help guide the curious but less informed reader through this morass. Far be it from me to disagree with his overall diagnosis, but I don’t think Hobbes is on the side he thinks he’s on.

A lot of the things Hobbes gets wrong are relatively low stakes, but some aren’t. Maintenance Phase, for example, is a profound train wreck of misinformation, and unfortunately, people do take their health and wellness cues from Michael Hobbes–style demagogues. (Seriously, just click this link, peruse for 20 minutes, and tell me this is a man you would trust to accurately predict where the sun will rise tomorrow morning.)

I’d like to give Hobbes the longer treatment he deserves someday, but because he produces so much bullshit, and because the bullshit asymmetry principle tells us that debunking bullshit takes orders of magnitude more time than excreting it, that will have to wait. For now, I just want to tackle a few of the misconceptions about youth gender medicine he has been propagating for years, and with renewed vigor since the Cass Review was published.

Disclosure: at this point, I dislike Hobbes personally. In addition to being an exceptionally bunkful debunker, he’s particularly mad at my work on youth gender medicine. He’s tweeted about me, from behind a block, hundreds and hundreds of times, and routinely mischaracterizes my work, sometimes so severely that I’m absolutely comfortable accusing him of lying about it. 

People are allowed to block whoever they want on Twitter, of course, and blocking certain people has slightly improved my experience on there. But to block someone and then tweet about their work over and over and over and over again, frequently misrepresenting or (at best) misunderstanding what they have said, and in some cases, as we’ll see, outright fabricating arguments they’ve never made. . . well, it’s weird behavior. Or if not weird, anti-intellectual and unprofessional. But Hobbes, like me, mostly doesn’t work for mainstream outlets or have any bosses, so there’s no accountability. He can lie and distort all day, and he is only rewarded for it. Anyway, I’d like to address a couple false claims he made about my own work, but I’ll relegate that to the end of this post, because it’s pettier and less important.

What’s much more important is his constant spreading of misinformation about the state of youth gender medicine research. He constantly exaggerates the evidence for these treatments, completely ignoring the steadily rising clamor of alarm bells going off in Europe. I believe this is a case of intentional dishonesty, not just ignorance, because in other contexts, he has said relatively sophisticated things about research methodology. For example, he sounded a note of caution about pediatric bariatric surgery in an episode of Maintenance Phase. While there’s some decent research, he argued, including randomized controlled trials, there are “very few studies that look longer than 10 years out.” In theory, he should be capable of applying these same standards of evidence to youth gender medicine. But as we’ll see, if Scott Alexander’s concept of “isolated demands for rigor” had a mascot, it would be Michael Hobbes.

That out of the way, let’s get to the debunking.

Hobbes’ Claim: We Have Good Long-Term Outcome Data On Young People Who Medically Transition, And It Gives Us No Reason For Concern

Context: Hilary Cass said in an interview with the editor of the British Medical Journal, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”

Why Hobbes is extremely wrong: Hobbes vehemently disputed Cass’s account, and claimed Cass is expressing a transphobic — sorry, sorry, polite transphobic — viewpoint rather than a scientifically grounded one. 

Over the course of two tweets starting here, he wrote:

This is Polite Transphobe position on gender-affirming care: We should ignore dozens of large-scale surveys, comprehensive clinic audits and observational studies showing low regret rates. Instead, we should listen to *hypothetical* data showing high regret rates. “We have no idea what happens to them in adulthood” is straightforwardly false. We have numerous clinic-based studies with up to 6 years of follow up. We have surveys of 20,000 adult trans people. They unanimously indicate high satisfaction and low regret. When all of the data points in the same direction you can’t just nitpick the methodology, you have to make an affirmative case for ignoring an entire body of research in favor of a hunch. You’ve had decades to produce evidence and you’re still going, “Just you wait!”

These are some very serious claims. If Hilary Cass, who was such a respected figure in British medicine that she was tasked with chairing this monumental and sure-to-be-controversial report, ignored a pile of solid evidence, that would be a genuine scandal.

But Hobbes is just unbelievably wrong here. I have no idea where this giant pile of convincing studies is, and I think that he’s simply assuming that any study that points in the general direction of supporting blockers and hormones constitutes good evidence, despite knowing that that isn’t necessarily the case (see his earlier caveats about bariatric surgery). For example, when Hobbes says there are “dozens of large-scale surveys” and that some of them have “20,000” people, he is referencing studies based on the United States Transgender Survey, which is a fundamentally useless instrument for evaluating medical treatment. 

As I’ve noted repeatedly, the USTS only includes individuals who currently identify as trans, and who chose to participate in a survey about being trans. To say that this limits the conclusions we can draw from the results is a wild understatement. If someone told Michael Hobbes he was being too skeptical of bariatric surgery, and as evidence they presented him with the results of an online survey from an internet forum called “How Bariatric Surgery Improved My Life,” Hobbes would be unmoved, because of course this is useless evidence — anyone whose life wasn’t improved by bariatric surgery likely wouldn’t be a part of such a group. 

Of course I’m exaggerating a bit for effect, and the USTS isn’t exactly like this hypothetical forum, but the point is that someone participating in the USTS currently identifies as trans and is actively engaged in trans life and trans communities. You couldn’t come up with a better way to exclude those who are unhappy with the results of medical interventions like hormones or surgery. But because Hobbes is for youth gender medicine, this constitutes good evidence, whereas RCTs for pediatric bariatric surgery that only follow up over 10 years are insufficient evidence. One of the most consistent aspects of his demagoguery is that his beliefs about what constitutes solid evidence vacillate wildly depending on whether he has a preexisting political commitment for or against a given claim. Again, isolated demands for rigor.

As for Hobbes’ claim that “We have numerous clinic-based studies with up to 6 years of follow up,” first of all, no — in the context of youth gender medicine, we definitely don’t! The studies we have offer mixed results, suffer from suspiciously missing data, are misconstrued by their own authors, and have other backbreaking problems. 

I don’t understand how Hobbes keeps missing such crucial points about this dispute given how well-known they are. But he’s been confident for quite some time that youth gender medicine “reduces both suicidal ideation and suicide attempts.” 

Here it might be interesting to compare three sources:

Michael Hobbes: Youth gender medicine “reduces both suicidal ideation and suicide attempts.”

WPATH Standards of Care: “Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood. Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible.”

An independent systematic review of youth gender medicine commissioned by WPATH and published in the Journal of the Endocrine Society, including studies with subjects of all ages: “We could not draw any conclusions about death by suicide,” write the authors, because only one study on the subject even met their minimum quality criteria. That study showed that those who had transitioned had a higher rate of suicide than a matched control group. If I were a hack, like Michael Hobbes, I’d pretend that this is proof transition worsens the risk of suicide. But it doesn’t! It’s a study with a high risk of bias. So, as the authors write, “We cannot draw any conclusions on the basis of this single study about whether hormone therapy affects death by suicide among transgender people.”

Michael Hobbes does not strike me as the sort of person who loses much sleep over the possibility that he might be wrong. But if he was, wouldn’t it cause him some sleepless nights that his own view, that these treatments are extremely powerful, reduce rates of both suicidal ideation and suicide itself, and have piles — towering piles! The biggest piles you’ve ever seen! — of evidence behind them. . . all of this runs directly counter to what WPATH, the Cass Review, the Journal of the Endocrine Society, and health authorities in Finland, Norway, and Sweden have found? Is any of this penetrating?

Hobbes can only pull off his bizarre claims about a towering pile of research supporting youth gender medicine by pretending that if you can point to a few studies that appear to show X, that’s good evidence for X. As it turns out, that’s not the case — you need to carefully evaluate studies on the basis of their quality. We’re decades into the age of replication crises, so anyone who is surprised by this hasn’t been paying attention. This vital concept that weak studies, combined, do not constitute sound evidence is why Cass commissioned systematic reviews, why those systematic reviews came back with a damning assessment of the evidence for blockers and hormones, and why Cass chose to deploy language she must have known would send ripple effects across the world of youth gender medicine: this is “an area of remarkably weak evidence.”

For anyone who doesn’t understand why it is perfectly reasonable, if not morally necessary, to discount a weak study on an important medical question, see here and here and here and here and here, as long as you’re willing to muck around in the weeds a bit. We aren’t talking minor methodological quibbles, like Oooh, it would have been nice if you had 2,000 kids in your cohort instead of 1,500! We’re talking — I’m repeating myself because this is worth repeating —  potentially crippling selection-bias issues, variables that suddenly go missing, researchers claiming treatments work when they simply don’t appear to, suicides of kids who went on hormones, and all sorts of really worrisome stuff.

Hobbes ignores all of this. Those posts took me many hours to write, because digging around in a study’s innards is time-consuming. Think about how much less time it took Hobbes to fire off his 10 millionth tweet about how there’s overwhelming evidence to support these treatments, because look at all these studies! Don’t worry, though — Hobbes has read all the abstracts.

I just don’t understand how Hobbes can claim, in good faith, that the studies we do have “unanimously indicate high satisfaction and low regret,” given the weakness of those studies. Cass, discussing the Swedish health authorities’ approach to reviewing the evidence, mentions “[t]he lack of clear data on how frequently detransition or regret occurs in young adults.” In the British context, she writes that “Estimates of the percentage of individuals who embark on a medical pathway and subsequently have regrets or detransition are hard to determine from [adult gender] clinic data alone.” If the Brits and Swedes don’t have this data, where is Hobbes getting it? The detransition studies we have offer rates from around 1% to more than 25%, and they all have weaknesses. A lot of them, I would argue, are so weak we can’t tell anything from them, often because they have very high lost-to-follow-up rates and/or they only counted individuals as detransitioners if they contacted the clinic where they received care to announce their detransition.

The few clinical studies that show low regret rates are also from clinics that engage in protracted, careful assessment processes. These results simply aren’t automatically generalizable to a context like the United States, where, as Reuters reported in 2022 (more on which soon), it’s hard to find a clinic that engages in the sort of careful, extended assessment process that used to at least theoretically characterize this area of medicine. 

Just about everything I’m saying here is stated, explicitly, in the Cass Review itself. So it’s on readers to decide who they find more trustworthy: Hilary Cass and her team of experts and the various Scandinavian countries that all came to more or less the same conclusion, or Michael Hobbes and his admittedly voluminous collection of outraged tweets.

The weirdest part of this is that Hobbes claims that the Cass Review itself found a low detransition rate among those who went through the NHS’s Gender Identity Development Service, or GIDS. His case rests on this screenshot from the review, which he tweeted out:

This is yet more proof that Hobbes either isn’t competent to read and understand this report, or he’s actively lying to his very credulous readers.

As it says right there in the screenshot, this is a subset of kids who were not referred to endocrinology. I guess it might be interesting, for certain purposes, to know how many kids weren’t referred to endocrinology reported having detransitioned, but one of the few beliefs Michael Hobbes and I share is that it matters a lot more whether kids regret and/or are harmed by youth gender medicine than whether they cycle through different identities without pursuing blockers or hormones.

Simply put, this isn’t a particularly interesting cohort for those latter purposes. These are kids who, for whatever reason, didn’t seek youth gender medicine. On top of that, as it says right there, one bullet point after what he highlighted, we don’t know anything about the longer-term outcomes of this group. Those who have followed the GIDS controversy closely — your non–Michael Hobbes types — know that a major problem the clinic had was losing track of kids once they transitioned to adult care (which some youth did after few or zero appointments, anyway, given how brutally long the waitlist grew to be). That’s a large part of the reason we have so little useful data out of England. And it says right there that GIDS doesn’t know whether 69% of those in this cohort of kids who didn’t seek hormones later did as adults. Obviously if it’s unknown whether they sought hormones, it’s also unknown whether they detransitioned. The 0.5% only refers to young people who announced that they detransitioned, and as Cass says right in her report, “those who do detransition may not choose to return to the gender clinic and are hence lost to follow-up.” There’s more in the section where Cass makes this remark that also runs counter to Hobbes’ very strong claims about detransition rates being low: 

15.49 A retrospective case note review from an NHS adult GDC [gender dysphoria clinic] (Hall et al., 2021) reported on the outcomes of 175 consecutively discharged service users; 12 cases (6.9%) met the criteria for detransitioning, and a further six had some ongoing uncertainties about their gender identities or treatment goals. 

15.50 Estimates of the percentage of individuals who embark on a medical pathway and subsequently have regrets or detransition are hard to determine from GDC clinic data alone. There are several reasons for this: 

• those who do detransition may not choose to return to the gender clinic and are hence lost to follow-up 

• the Review has heard from a number of clinicians working in adult gender services that the time to detransition ranges from 5–10 years, so follow-up intervals on studies on medical treatment are too short to capture this 

• the inflection point for the increase in presentations to gender services for children and young people was 2014, so even studies with longer follow-up intervals will not capture the outcomes of this more recent cohort.

Cass then notes that “One primary care audit from a multi-site general practice sited near a university (Boyd et al., 2022) reported on a cohort of 68 patients at various stages along the gender pathway with a mean age 27.8 years. Of 41 patients who were started on hormones, eight (20%) chose to stop after a mean period of 5 years (range 17 months to 10 years). These comprised six trans men and two trans women.”

So the Cass Review itself mentions an (admittedly small) study with a detransition rate of 20%, while cautioning that these figures can be underestimates when they rely on detransitioners actually coming back to the clinics to announce their decision. Hobbes doesn’t screenshot and remark upon this, but rather on an effectively irrelevant mention of a figure that is two orders of magnitude lower. Either he didn’t read the report, or he doesn’t care what it really says.

I vote both. 

Hobbes’ Claim: The Cass Review Found That Only A “Tiny” Number Of Kids Transitioned Within The NHS System, And They Were Assessed Comprehensively

Context: We’ll get back to this shortly, but for a long time Hobbes has been beating the drum that people like me are stoking a moral panic by drawing attention to the possibility that some kids don’t receive thorough assessments prior to receiving youth gender medicine.

So it goes here. In the same tweet where he made the detransition claim, Hobbes wrote:

Transphobes are doing a bizarre victory lap over a review of gender-affirming care in the UK. 

The only thing it found is what we already knew:

- Tiny number of kids transition

- Comprehensive assessments before receiving medications

- Vanishingly few detransition

Why Hobbes is extremely wrong: My impression of Hobbes’ Twitter-debunking “method” (such as it is) is that, having arrived at a document with his conclusions already in tow, he races through that document, screenshots bits that seem to support his pre-conclusion, and then blasts them out with his trademark tired incredulity: How could anyone be this dumb? I mean, just look at the screenshots!

I think that’s what’s happening here. As I go through the following two points, pay attention to the light-years–wide chasm between his claims and what the very document he is discussing actually says.

“Tiny number of kids transition”

Hobbes supports this claim with the following screenshot:

Hobbes helpfully highlights “500 patients a year,” the goal being to buttress his view that this is all just a moral panic over a tiny handful of very-well-taken-care-of kids. But this passage is talking about the earlier days of the NHS’s treatment of trans and gender-questioning youth, as evidenced by “On its establishment,” and comes after Cass has noted an exponential rise in referrals just one page earlier! In fact, that was one of the main factors motivating the commissioning of the Cass Review in the first place: as Cass notes, “in 2014 the number of referrals started to grow exponentially in the UK with a higher number of birth-registered females presenting in early teenage years (Figure 10).” That’s paragraph 2.23. Hobbes quotes paragraph 2.26. It’s right there!

As Figure 10 shows, about 600 young people a year were referred to GIDS in 2014, but it quickly grew to about 1,700 by 2017. This is all right there. Right in the report. 

Hobbes tweets out paragraph 2.26, but paragraph 2.23 explains the full context. Here’s the distance between Figure 10 and the paragraph Hobbes highlights to claim that there’s nothing to see here because the number of kids transitioning is so low:

On top of all this, the next figure in the Cass Review, Figure 11, zooms out to show a more dramatic rise. It likely would have been an even more insane-looking curve were it not for Covid.

So in under a decade the number of referrals to GIDS increased tenfold, from about 500 in the 2013–2014 year to more than 5,000 in the 2021–2022 year. Hobbes sums up this whole situation by claiming only 500 kids per year receive care at GIDS. I really think the only options here are that he is actively lying to fool his audience, or he’s completely unfamiliar with the background of the Cass Review and didn’t read it. I’d say it’s an even money proposition.

To be clear, and to grant Michael Hobbes a level of charity he would never in a million years grant any of his perceived enemies, Cass does, at one point, note that “Despite the growth in the numbers of children and young people requiring support from the NHS for gender-related issues, the number remains relatively small and there will still be a need for specialist tertiary care for some of the cohort.” Relatively small definitely isn’t tiny, but either way, who cares? Statistically speaking, there’s been an explosion in the percentage of kids seeking this medical care both in England and everywhere else, and it’s an undeniably interesting story, journalistically. Hobbes has, over the years, regularly covered controversies involving not just relatively small but tiny numbers of people. The “But it’s so few kids!” thing is a non-sequitur.

“Comprehensive assessments before receiving medications”

This might have been the closest I came, in reading Hobbes’ recent tweets, to shaving my head and traveling to Tibet to become a monk and never again go on the internet.

Here are the two screenshots Hobbes uses to support this argument:

First, averages can be deceiving, and if you dig into the data here you’ll see that a very large number of kids were referred to endocrinology well before their seventh visit.

It isn’t just the quantity of appointments we care about, anyway, but also their quality.

Cass addresses this rather explicitly, and it will shock no one familiar with Hobbes’ tactics that she comes to the opposite conclusion of what Hobbes is saying. Cass draws on the findings of a previously established “Multi-Professional Review Group (MPRG). . . [whose] remit [was] to review cases referred to the endocrinology clinic for puberty blockers to determine whether the agreed processes for assessment and informed consent have been properly followed.”

Part of the reason Cass had to lean so heavily on the MPRG was because the Gender Identity Development Service, the dysfunctionality of which touched off this entire controversy, didn’t participate in a survey distributed to European Union youth gender clinics by the York University team tasked with developing the Cass Review’s systematic reviews:

10.14 The University of York also invited GIDS to participate in the international survey (Hall et al.: Clinic Survey) to record practice in England, but GIDS did not respond. 

10.15 In the absence of a formal clinical audit from GIDS or a response to the international survey, the Multi-Professional Review Group’s (MPRG’s) updated report (Appendix 9) represents the most comprehensive review of clinical notes and approach available, albeit only for those children and young people referred for puberty blockers. 

Think of all the context Hobbes is excluding here: the clinic at the center of this controversy hasn’t been able to produce any formal findings about its own assessment processes and didn’t respond to an attempt to collect data on them. Hobbes’ response to all this: “Comprehensive assessments before receiving medications.” How could he possibly know that?

No, the young people who went through this system did not consistently get comprehensive assessments. Cass gives over a whole page of her report (137) to summarizing the MPRG’s findings about how slipshod and inconsistent the assessment processes were:

• The structure of the assessment process was rarely provided. 

• It was not clearly evidenced how thoroughly “gender identity and consideration of different options for gender expression” and “different treatment options/choices” [as per the Standard Operating Procedure] were explored. 

• There was inconsistent evidence as to whether the individual impact of social transition had been explored. 

• The clinical notes rarely provided a structured history or physical assessment even though the children and young people presenting had a wide range of familial and congenital conditions. 

• Sexuality was not consistently discussed. 

• The history of the child/young person’s gender journey was rarely examined closely for signs of difficulty, regret, or wishes to alter any aspect of their gender trajectory. 

• Autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD) traits or diagnoses were mentioned in the majority of cases, but it is not clear how fully or appropriately these had been explored. 

• No family trees were made available, making it difficult to understand family structure and relationships. 

• There was a lack of evidence of professional curiosity as to how the child/young person’s specific social circumstances may impact on their gender dysphoria journey and decisions. 

• Although external reports (for example, from the child/young person’s school) were useful, they were frequently not up-to-date.

I can’t resist doing this compare and contrast thing one more time:

Hobbes’ summary of the Cass Review: Young people received “comprehensive assessments before receiving medications.”

The Cass Review: GIDS clinicians “rarely provided” the “structure of the assessment process”; it’s unknown how often and in what depth certain vital elements of gender exploration “were explored,” and “[s]exuality was not consistently discussed”; “the clinical notes rarely provided a structured history or physical assessment even though the children and young people presenting had a wide range of familial and congenital conditions”; it’s unclear how the assessment process dealt with ADHD and autism, both of which were quite prevalent; and there was “a lack of evidence of professional curiosity” on the part of clinicians about their young patients’ social influences.

Seems pretty embarrassing to Hobbes! Or it would be, if he were capable of embarrassment or hadn’t so thoroughly built himself a Twitter safe space impermeable to disagreement.

Finally, even if this report had found that kids at GIDS did receive comprehensive assessments, of course that wouldn’t tell us anything about the situation here in the much less regulated and centralized American medical system. As I mentioned earlier, there doesn’t appear to be much assessment going on here, at least at the big gender clinics: an investigative team at Reuters reported in 2022, in interviews “doctors and other staff at 18 gender clinics across the country described their processes for evaluating patients. None described anything like the months-long assessments” that were practiced at the Dutch clinic that gave rise to youth gender medicine in the first place, and which has produced some of the only semi-usable data about patient outcomes.

Hobbes’ Claim: American Kids Are Never Fast-Tracked To Medical Transition

Context: I feel like I’ve fallen into some sort of trap even responding to this given how ridiculous it is, but Hobbes has long argued that those who are raising concerns about youth gender medicine’s assessment processes are stoking a — say it with me — moral panic. From Hobbes’ point of view, no one has presented any evidence showing this is true, and it’s blazingly obvious that actually, assessment processes are strictly written and enforced. 

What Hobbes Said: Most recently, in response to an article in The National Post about “How ‘social contagion’ could be driving some youth to identify as transgender,” he wrote, in part:

Are children who identify as trans due to peer pressure being fast-tracked into irreversible medical treatments? Again the answer is easy: No. They’re not.

Receiving gender-affirming care requires

- parental approval

- at least a year of social transition

- a referral to a gender clinic (wait times can be years)

- assessments by specialists

To believe that “social contagion” explains the rising number of youth transitions requires believing that kids say “I’m trans!” because they saw it on TikTok, then persist in that identity for years, navigating a gauntlet of social and medical barriers. Not only is this implausible on its face, but we have no evidence that it’s the case and mountainous evidence that it’s not. Years of this panic have not produced a single confirmed case of a minor being rushed into transition. Outlets like the Post focus on the narrow question of “social contagion” because it is plausible, but it’s also irrelevant. Who cares if kids think they’re trans for two weeks?

Previously, Hobbes has said “I’m not saying that these cases don’t exist because it’s a big country and the US healthcare system sucks but it’s really worth asking why YEARS of this panic has not produced a single verified example of the thing people are panicking about.” 

Note Hobbes’ exceptionally confident language whenever he spouts off on this subject. To Hobbes, it’s obvious that kids are receiving careful assessment and that we have no examples of cases where they didn’t. The evidence for this is “mountainous.” How he could know this given that no American clinics are publishing comprehensive outcome data is anyone’s guess. 

Why Hobbes is extremely wrong: Hobbes is just completely wrong. As Reuters showed, even at some of the biggest, best clinics they don’t follow anything like the Dutch protocol. We don’t really know what’s going on at the smaller, more under-the-radar gender clinics. Say what you will about Michael Hobbes, but surely he is capable of a Google search. Surely he is aware of this Reuters article. And yet he tweets stuff like this! I can’t overemphasize how strange this is. 

At this point he appears to be entirely grasping at straws. Three of the four “requirements” he lists for youth medical transition appear to be based on nothing but his overactive imagination. (Obviously none of the below applies to states that have banned or severely restricted youth gender medicine.)

parental approval — The truest one, though even this is false in Oregon, where a 15-year-old can access blockers, hormones, or surgery without parental permission.

at least a year of social transition — As far as I can tell, completely made up. The so-called “real-life test” is much less popular than it used to be, largely because trans activists have advocated against it — not unreasonably so, given that it’s overkill to force an adult to present as their felt sex for years before allowing them to medically transition, as was previously routine. It’s possible there is some American clinic that requires this, but I’ve never heard of anything remotely like it. There’s no evidence GIDS had this requirement, either.

This is a good reason not to block absolutely everyone who disagrees with you. One of us could have replied to Hobbes and said “hey, you might want to double-check that,” and then he could delete the tweet and post a correction. Ah, well.

a referral to a gender clinic — This depends a lot on context (such as insurance), but it’s definitely not any sort of hard-and-fast requirement. It took me 30 seconds to find a gender clinic that treats kids and doesn’t require referrals. 

assessments by specialists — Not a requirement, full stop. See my prior point.

As for Hobbes’ claim that there isn’t a single confirmed case of a kid being rushed into transition, I think this returns us, yet again, to his tendency to block everyone and his refusal to read anything that might challenge his very strongly held worldview. It’s just a startling level of credulity toward the medical establishment, even as he notes that it “sucks.” Recall that Hobbes is unsure whether pediatricians have sufficiently proven the benefits of gastric bypass for kids, because the RCTs go out only to 10 years. But he’s so confident in the professionalism of youth gender medicine that he doesn’t think there’s any over-diagnosing or under-assessing? Why? With apologies to Passover, Why is this area of medicine different from all other areas of medicine?

I can only use terms like weird or strange so many times in a single blog post, but what makes this claim of Hobbes’ exceptionally, super-duper weird/strange/whatever is the fact that leading youth gender clinicians themselves often say they don’t believe in comprehensive assessments. 

For example, AJ Eckert, head of the above-linked-to gender clinic, was quoted in a Washington Post article as saying “Gender-affirming medicine. . . [means] you are best equipped to make decisions about your own body.” Also: “Therapy is not a requirement in this approach because being trans is not a pathology.” 

In that same article, Johanna Olson-Kennedy, who is at the top of this field and helping to lead an ambitious, federally funded research effort (the one that disappeared some of its data in the New England Journal of Medicine), said “We don’t actually have data on whether psychological assessments lower regret rates.” In my own Atlantic article, she told me that she wouldn’t require someone to have a mental-health assessment before treating their diabetes, so she wasn’t sure why it’s so important to do it prior to putting a kid on blockers or hormones.

She also wrote in 2016:

Historically, mental health professionals have been charged with ensuring “readiness” for phenotypic transition, along with establishing a therapeutic relationship that will help young people navigate this very same transition. These 2 tasks are at odds with each other because establishing a therapeutic relationship entails honesty and a sense of safety that can be compromised if young people believe that what they need and deserve (potentially blockers, hormones, or surgery) can be denied them according to the information they provide to the therapist.

Most recently, article released earlier this month in the Journal of the American Academy of Child & Adolescent Psychiatry about pre-puberty-blocker assessment processes, Jack Turban, Jonah Thornton, and Diane Ehrensaft write: “Assessments prior to gender-affirming medical care have been controversial, given the history of these practices inappropriately creating barriers to care, particularly for TGD adults. This article is agnostic on this question, instead focusing on what is recommended under current guidelines.” Turban and Ehrensaft are, like Olson-Kennedy, near the top of this field.

So prominent youth gender clinicians themselves are apparently conflicted on whether comprehensive mental-health assessments should be a prerequisite before kids are referred for blockers and/or hormones, and there’s no binding rule or law in the U.S. that forces anyone to conduct such assessments. And yet somehow Michael Hobbes knows that these assessments are always or almost always conducted, and that kids are never or almost never rushed into transitioning. 

The problem here goes back (again!) to the fact that Hobbes never reads anything that might upset his worldview, and that he blocks anyone who disagrees with him. In at least one case, he preemptively blocked a detransitioner who says that the thing Hobbes believes never happened, happened. That might be part of the reason he doesn’t think it ever happens!

Chloe Cole, one of the most famous American detransitioners, has made the same claim. Here’s how part of her legal complaint against Kaiser Permanente reads: 

After being exposed for hours at a time to online transgender influencers, Chloe developed the erroneous idea that she was a boy. When Chloe informed her parents that she thought she was a boy, her parents didn’t know what to do and promptly sought guidance from the Defendants. Defendants immediately affirmed Chloe in her self-diagnosed gender dysphoria. They did not question, elicit, or attempt to understand the psychological events that led her to this belief, nor did they seek to evaluate or appreciate her multi-faceted presentation of co-morbid symptoms. Defendants should have performed an extended period of assessment and treatment comprising at least twelve weekly, one-hour sessions that should have included numerous informed consent discussions about the potential harms and hoped-for benefits. Instead, Defendants assumed that Chloe, a thirteen-year-old emotionally troubled girl, knew best what she needed to improve her mental health and handed her the prescription pad.

Then there’s “Isabelle.” Isabelle’s story is extremely sad and recounted in a lawsuit of its own. The American Academy of Pediatrics is named as a defendant, as is Jason Rafferty, a child psychiatrist who lead-authored the AAP’s extremely strange, poorly reasoned 2018 policy statement touting the benefits of these treatments.

According to her lawyers, Isabelle was sexually assaulted at 7, hit puberty at 8, and began cutting herself in the early days of puberty, at age 11. Around that same time, she started exploring trans-oriented areas of social media. She came out to her mom at age 12, and became increasingly convinced she was trans and that the only way out of her unhappiness and severe mental-health problems was to transition. 

To make a long and sad story slightly shorter, Isabelle’s mom was skeptical that she should transition, but her dad was in favor. Mom and dad separated, and Isabelle and her dad ended up in Providence, where they found Hasbro Children’s Hospital in Providence. 

The complaint picks up from there:

At her new patient visit on February 8, 2017, within two weeks of her 14th birthday, the clinician noted Isabelle’s family history of anxiety disorder, bipolar disorder, depression, and post-traumatic stress disorder, Isabelle’s previously diagnosed ADHD, depression, and anxiety, and her “significant scarring on [her] bilateral upper thighs,” evidencing her years of cutting. Isabelle told this clinician that she “ha[d] daily thoughts about wanting to die” and that she had attempted suicide the previous year. Given what was described as the “chronic nature” of her suicidality, however, Isabelle was not admitted on an inpatient basis but rather was sent home with “information on youth pride, specifically the transgender group on Tuesday nights.” She was also encouraged to attend her initial appointment with Dr. Horacio Hojman, a child psychiatrist, a week later. She did attend, and at that appointment, on February 15, 2017, the clinicians noted that Isabelle was “transgender” and that the reason for her reported suicidal ideation was that she wanted to “start hormone therapy” but that her mom—who “was not involved”—was “blocking [her] treatment.”

After turning 14, Isabelle became so suicidal she was admitted to an inpatient mental-health center. There she met Jason Rafferty. She attributed all of her anguish to the fact that her mom wouldn’t let her transition. The lawyers claim that “in a matter of minutes and based substantially, if not exclusively, on the endorsements of Isabelle set forth above, Dr. Rafferty concluded that Isabelle ‘would benefit [from] and meets criteria to consider hormonal transition,’ noting only a single ‘concern,’ namely ‘parental (maternal) refusal.’ ”

So that’s how youth gender medicine is allegedly practiced by the guy who lead-authored the American Academy of Pediatrics’ guidelines. You know where this is headed: Isabelle detransitioned and a lawsuit ensued.

Michael Hobbes, though, wants you to know that everything is fine. How he could know this is, again, the big question, especially given how thoroughly he seals himself off from dissenting views. I’m working on a book about this subject, and I’ve talked to plenty of parents who experienced what they saw as fast-tracking toward blockers or hormones or both, in a variety of contexts. It’s obviously something that happens, and it shouldn’t surprise anyone given that a subset of clinicians believe very strongly in these treatments and also look askance at the idea of requiring kids to get careful assessments. 

A Final Point About Michael Hobbes Being A Liar

I said I’d leave the most petty and relatively unimportant part for last. Hobbes has claimed, over and over and over, that I’ve said the detransition and/or regret rate is extremely high, or the rate of kids transitioning without assessment is very high. I do not believe I’ve said this anywhere, because my argument all along has been that kids are tracked very poorly through this system in the States and no one knows what happens to them or if their medical care benefits them in the long run.

But Hobbes’ strawmanning of his enemies’ perceived positions is relentless: he has tweeted this same lie about my work over and over, always with the same language, describing this claim as “the center of my journalism career.” “If someone accused me of having no evidence for the claim at the center of my journalism career I would simply post the evidence rather than saying they hadn’t done enough reading,” he tweeted here. “If someone accused me of having no evidence for the claim at the center of my journalism career I would simply post the evidence rather than complaining about sampling methodologies,” he tweeted here (after I pointed out that no, an online convenience survey of currently identifying trans people does not constitute medical evidence). “If I was admitting that my career was based on something backed by zero evidence I would simply not accuse someone else of fomenting a moral panic in the very next tweet,” he tweeted here.

So Hobbes, making very strong claims about how powerfully salutary youth gender medicine is and how carefully and competently and professionally it is administered, says he has “mountains” of evidence supporting these views. But he can’t explain how these studies could possibly contradict the results of a growing pile of government-sponsored systematic reviews that have actually examined those studies for quality, and which have all come to the same conclusion, which is that the evidence is quite weak. In fact, Hobbes simply pretends to not understand that you need to evaluate studies for their quality — unless the subject is obesity interventions, at which points he snaps back to demanding RCTs with 20-year followup times.

There is a ‘mountain’ of evidence here, it turns out — evidence that this field of research is a mess. Hobbes could know this, but chooses not to, instead walling himself off from reality and spreading a tremendous amount of potentially harmful medical misinformation in the process. Hobbes tweets constantly about this subject, and about all those idiots like me who are raising questions about it, and yet he appears to have never used the term “systematic review” in the context of youth gender medicine (I got the same single result when I searched for “systematic reviews,” plural). 

One of the only times Hobbes has even mentioned these systematic reviews came in 2023, when he tweeted “‘What about Finland, Sweden and the UK?!?!’ is becoming a weird catechism among the gender-critical crowd but they never explain why evidence reviews performed by other countries should guide US policy. We can look at the evidence ourselves!” So he’s comparing references to comprehensive, government-sponsored systematic reviews to… religious devotion. Lotta good faith going on.

Anway, I agree: the U.S. should conduct some sort of independent systematic review like these other countries did. It wouldn’t find anything different, but it would help resolve this controversy once and for all. It’s not going to happen, though, at least not under a Democratic administration.  But Florida, a state controlled by conservatives seeking to restrict youth gender medicine, did commission an independent system review of youth gender medicine, and that one came to the same conclusion as all the European ones (and was subsequently deemed transphobic for. . . reasons). Hobbes isn’t upset that these reviews were conducted by the wrong countries (or, I guess, the wrong state) — he’s upset at what they found and scrapping for any excuse to discount them.

Anyway, in summary:

Hobbes [for years, increasingly frothing at the mouth, calling everyone who disagrees an idiot or a bigot or an idiot-bigot]: WHERE ARE THE STUDIES? IF YOU THINK THE EVIDENCE IS FOR YOUTH GENDER MEDICINE IS WEAK, WHERE ARE THE STUDIES? YOUTH GENDER MEDICINE IS LIFE-SAVING!

Critics: Here are systematic reviews conducted by Finland, Sweden, and the U.K., all of which provide evidence for exactly the thing you are claiming is false.

Hobbes: Pshaw, like we should trust Europeans to publish science?

Michael Hobbes is a complete fraud, and it’s frustrating that he has carved out such a successful role as a debunker when he’s completely incompetent at it, when he lies about other people’s work, and when he refuses to engage in any sort of discussion with the many people trying to call him out on his endless, stupefying bullshit.

---

Questions? Comments? Systematic reviews of the quality of my newsletter writing? I’m at singalminded@gmail.com or on Twitter at @jessesingal.