Why gender medicine isn’t science, and isn’t medicine, Part 1

My keynote at the CASC conference in Adelaide, 18th October 2025

I was fortunate enough to be invited to give one of the keynote speeches at the inaugural conference of the Gender Healthcare Summit organised by the Coalition Advancing Scientific Care, an Australian organisation seeking to bring evidence-based considerations to gender medicine, especially for minors. My talk was an hour long, so I’m going to share my speaking notes in three separate posts in the next few days. This is the first.

With the speakers and organising committee

Imagine that we’re here to talk about some other medical specialty. It’s not very realistic, because in no other area of medicine would I, a non-medic, be here, giving a keynote – and that’s not to say anything particularly about the specific position I take on gender medicine, because the conferences run by organisations that take the diametrically opposite position to me on gender medicine also have a lot of non-medics speaking at them. WPATH and its regional variants such as EPATH have been led by people who aren’t medics at all — they’re just people who identify as trans — and anyone can join, all you have to do is pay a fee. People like family therapists join because it makes them look like they have some sort of expertise in gender distress. And as well as specialist sessions in advances in surgical techniques and the like, those organisations’ conferences have sessions about topics like “social media creations by transgender and gender-diverse individuals” and “experiences of group voice training in transgender and gender-diverse people”.

But anyway, suppose that this was a conference on a different area of medicine. Everyone present would share a broad understanding of the following:

• What it means for the specific body part or system they’re considering to function properly — what it is to have a healthy immune system, or circulatory system, or hip joint or whatever.

• What sorts of things can go wrong with that body part or system — over or underactive immune system; irregular heartbeat; pain and stiffness on using the joint, that kind of thing — and what the symptoms would be.

• How to carry out a differential diagnosis to distinguish the specific thing that has gone wrong — we don’t talk about “fever” or “chest pain” as specialties, because those can be caused by lots of different conditions, and care has to be taken to work out what is causing any particular patients’ symptoms.

• Why things go wrong — post-viral syndrome; narrowing of the arteries; deterioration of the cushioning within the hip joint, whatever.

• What can be done to return the body part or system to healthy functioning, entirely or partly.

• If that isn’t possible, what can be done to ameliorate the symptoms — that is, to mitigate or control the harms done, and note that that means having an idea of what it means to feel better or worse — there are value judgments here.

• The likelihood of successful intervention, and how successful.

• The negative effects of the treatment if any — and there usually are negative effects.

I admit that there is less agreement on psychological diagnoses than on physical diagnoses, and on what causes mental illness compared with what causes physical illness. But there is still a pretty solid shared understanding of what it means to be functioning well.

The first parts of this framework would not be part of the conference schedule, because they’re all foundational. They’re fundamental to the meaning of health and health care, and of the best understanding in a particular field. What there would be is the later parts — insights into changing treatment protocols; new operation techniques or drug regimens; evidence about outcomes, downsides and so on. All the things that come from churning through the machinery of science-based or evidence-based medicine: case studies, prospective and longitudinal studies, double-blinded randomised controlled trials and systematic evidence reviews.

It’s easy to forget that this machinery can only crank into operation because we start with a shared understanding of what it is to be healthy. Without that you can’t even start to think about what can go wrong because you don’t know what “wrong” is. And you can’t come up with hypotheses for why and how it went wrong. And you’ve no hope of generating plausible ideas about treatment.

I think you can see where I’m going with this: gender medicine isn’t medicine, because nobody knows what it is to have a healthily functioning gender. I suppose someone working in the field would say that it’s “not suffering from gender dysphoria”, but that’s just a fancy way of saying “not suffering distress about something undefined” — and note too that people in the field insist that there is nothing wrong with being trans, it’s a natural variant, which is odd when the way they think people end up deciding that they are trans is generally that they suffer distress about this undefined thing called gender. And without knowing what it is to have a healthy gender, or gender identity, it’s not possible to say what it means to have a malfunctioning one, what might have caused that, and how it can be treated.

Saying someone has gender dysphoria is like saying their humours are out of balance. That was the ancient Greek theory for what made people well or unwell, which lasted until the Middle Ages — the four humours were blood, phlegm, yellow bile and black bile. The treatments were things like bloodletting and purging: they were junk because the theory was junk. It’s the same with gender medicine. The treatments offered — puberty blockers, cross-sex hormones, chest and genital surgeries and also things like voice training — are like bloodletting and purging. There isn’t any reason to think they would work.

You could do scientific research on the four humours, if you wanted. You could propose hypotheses, set up trials, generate findings and so on. And you’d generate data, and hypotheses for future research. But this would be falling into the trap that Harriet Hall, a doctor who died in 2023 who was a proponent of rationalist medicine and opponent of quackery, called Tooth Fairy Science. It’s like you decided that there was a Tooth Fairy, and it would be good to work out how to maximise the amount of money she left.

Hall wrote:

“You can study whether leaving the tooth in a baggie generates more Tooth Fairy money than leaving it wrapped in Kleenex. You can study the average money left for the first tooth versus the last tooth. You can correlate Tooth Fairy proceeds with parental income. You can get reliable data that are reproducible, consistent, and statistically significant. You think you have learned something about the Tooth Fairy. But you haven’t. Your data has another explanation, parental behavior, that you haven’t even considered. You have deceived yourself by trying to do research on something that doesn’t exist.”

All this is to say that criticisms of gender medicine generally start too far downstream. It’s true what the critics say: that there are no good studies showing positive outcomes for any of the interventions, and there is no evidence that puberty blockers or cross-sex hormones “save lives”. But there’s something prior to that, which is that there is no reason to think the sorts of things done in gender clinics even might work. The whole thing is based on an invention, just as humours were.

When we start our criticisms with the paucity of evidence we give the gender doctors too much credit. The burden of proof lies with them, not us. They should have to start by saying what is wrong with someone who is experiencing distress to do with their gender, and why the sorts of treatments they offer might work.

Even if every finding of the critics is negative — and it really does tend to be — by taking it all seriously we’re paying it a compliment it doesn’t deserve. Because we’re implicitly accepting that the sorts of things they’re doing might work, and as with the Tooth Fairy, there are endless things they might try: different hormone treatments, different genital surgeries, different timings, all the add-ons like voice training, facial feminisation surgery and so on. They won’t run out of hypotheses to test, but there’s no reason to do any of it in the first place.

One of the reasons we don’t see that gender medicine is Tooth Fairy Science is that it’s such a big claim. It’s hard to accept that an entire field of medicine simply shouldn’t exist. Medical scandals aren’t generally like this. They’re things like the pelvic mesh scandal, in which a lot of women were severely injured by having a synthetic mesh implanted to treat pelvic organ prolapse. You can totally see why someone might think this treatment would work. The scandal isn’t that it was hypothesised or tested, it’s that it wasn’t properly tested and women whose condition was made worse were ignored so the practice went on too long.

Most people quite naturally presume that gender doctors know what they’re about in the same way that cardiologists or immunologists do, because why wouldn’t ordinary people think that? Gender doctors are credentialled, they’ve got research journals and clinics and learned societies and all. So most people, even if they give credence to some criticisms of gender medicine, simply think the field has “gone too far” in a way that we’re pretty familiar with from other fields of medicine. That gender clinicians have just been incautious.

And many of the people who see up close how badly wrong it has gone have a narrow focus: someone they love has got caught up in it and very naturally they become hyper-focused on what they can try to say to that person to get through to them. They want to know what the evidence is regarding specific interventions, because it’s no longer any use to them to say it shouldn’t be happening at all.

Another reason we don’t see the emptiness of gender medicine is that gender clinics are doing a damn good imitation of medicine. Judith Butler famously said gender was an “imitation for which there is no original” – that it’s meaningful only because we do it over and over again. Well, the people working in gender medicine are performing the rituals of medicine: making appointments, doing consultations, coming up with diagnoses, writing prescriptions, doing blood tests, referring patients to other specialists like surgeons and endocrinologists, and making claims about outcomes and efficacy. When they interact with funding bodies, insurers and governments they talk as if what they are doing is medicine.

But the rituals are empty, in the same way that Butler claimed gender rituals are empty. The expression “gender dysphoria” functions as nothing more than a placeholder to make sentences that look similar in form to the kinds of sentences you might utter about angina, say, or multiple sclerosis, or schizophrenia, but because the expression is meaningless the sentences are meaningless.

In fact gender medicine is purely performative – which should delight queer theorists, since they love performativity. And the theme of the performance is the hyper-liberal, or hyper-individualist, claim that each person has a true self and knows that true self, and when they give expression to that true self they by definition cannot be wrong because the true self is the declaration. The purpose of gender medicine is to give an appearance of solidity to a specific sort of declaration of one’s true self — to your gender identity. What the clinics are selling is identity validation.

If you think that this is the sort of thing a gender identity is — a thing that the individual in question can utter into being by stating it — then it’s not just gender clinics that have this purpose. It’s everything that they would call “gendered” and the rest of us would call single-sex. To them, the reason for having women-only or men-only spaces, services or sports is so feminine people and masculine people can perform their femininity and masculinity respectively.

Actually that’s not quite right, because there isn’t any requirement to perform your gender, just to state it. Nothing further than the statement is required of the person making it: it’s other people who have to do the work by believing that statement — that is, by “affirming” that gender. The expression “gender self-identification” is a misnomer — it’s not something you have to do, beyond proclamation, it’s a demand that other people affirm you as being the gender you state yourself to be. Opening the door marked F or M is a way of declaring your gender identity.

There’s no place for other people’s judgment, indeed no role at all for other people except as supporting actors or appreciative audience. No room for them to say they don’t fancy joining in the performance, or to be a critic and say it’s not a very good performance. They’re not allowed to say: “OK, you say you’re a woman, that you’re living as a woman or have a female gender identity, but you don’t seem very female to me.”

A woman can do the most obviously unmasculine thing possible, namely get pregnant, and still be “living as a man” as long as she says she’s a man. A man can do the most obviously unfeminine things possible, namely impregnate or rape a woman, and he’s still “living as a woman” as long as he says he’s a woman. Because “men can get pregnant” and “women can rape too”.

It’s a bait and switch. They replace the physical reality of biological sex with something called gender or gender identity, which they don’t define. People who aren’t au fait with what’s going on think this is something defined. Generally they think it’s something very sexist, like “women are the kinds of people who do feminine things.” But at least that’s a little bit objective. Instead it’s just a man saying “I’m a woman.” There’s no there there.

To drive this home, think about what it means to be gay or straight — to have an exclusive, or at least nearly exclusive, interest in sleeping with people of one sex or the other. But if a man told you he was gay and you knew that he was married to a woman, and you had known him for a long time and he had only ever had girlfriends and ever boyfriends, you would feel entitled to think he was being untruthful or at least inaccurate.

Now suppose we changed the definition of being a gay man to “performing gayness” — the equivalent of “living as a woman”. You’d end up with a definition something like “loves Kylie and musical theatre, works as a ballet dancer or hairdresser” (insert your favourite stereotypes here). There is some truth to the stereotypes, that is why they exist — but my point is that at least they are still objective. Even by this definition it would be possible to say of someone that they weren’t gay, even if they claimed to be.

But what is happening with gender goes one step further. There’s nothing objective left, not even the stereotypes. All that remains is the statement.

In 2019 the LA Review of Books ran an article about Pete Buttigieg and his husband, which riffed off a cover image in Time magazine showing the two of them looking very normie together. The title of the piece was “Heterosexuality Without Women” and the strapline below was “This photo is about a lot of things, but one of its defining features is its heterosexuality.”

That’s the definition of gay as performing gayness. It’s not enough to be having sex with, indeed marrying, someone of the same sex. I guess Buttigieg and his husband just weren’t camp enough. That regression to stereotypes is depressing enough, but even as it was written it was already passé.

The previous year Miley Cyrus married Liam Hemsworth — a rich and beautiful heterosexual couple, her in a big white dress and him in a suit, photographed for a lifestyle magazine — and she said this was what a “queer wedding” looked like. I don’t have any pretensions to being anything other than boringly heterosexual, but I can tell you that wedding would have been far too hetero for me.

But Miley Cyrus understood what “queer” means much better than the author of the LA Review of Books article. It means nothing except saying “I’m queer.” And it’s the same with everything to do with gender identities. To have one is nothing more than to say you have one.

From experience of talking to a lot of people who haven’t been educated — indoctrinated if you like — in gender beliefs, they think that what is being talked about is either an observable personal characteristic, probably innate, or a serious physical or mental health condition. Something inherent and diagnosable. They think that to fail to acknowledge it in someone, and treat it if they are unhappy, would be unethical.

I think people inside the gender ritual know perfectly well that most people outside it totally misunderstand what they are saying. They know that the judges who side with the parent who wants to block puberty, and the social workers who say a 13-year-old should get cross-sex hormones, and the teachers who affirm a child’s gender, and the parents who go along with the gender therapist’s advice to use preferred pronouns, think that there is a special sort of person who is “trans”. But those inside the system know that all it takes to be this special sort of person is to say that you are this special sort of person.

When you finally see the gulf between what people outside the gender ritual think people inside the gender ritual are talking about, and what they are actually talking about, it makes the physical interventions even more monstrous. If what the clinics are selling is validation — and if Miley Cyrus and Liam Hemsworth can be “queer” in their utterly traditional white wedding — then why do the clinics give people drugs and surgeries? Why can’t they just say to their patients what they claim to believe: that women can have penises, men can get pregnant, trans women are women, trans men are men and non-binary identities are valid, and it’s transphobic to think you need to do anything to your body to validate your identity? Why do they stop the “wrong puberty” and cut off the penises and breasts? What even could “gender-affirming care” mean, when all that having a gender identity means is saying you have that gender identity?

They are trying to ride two horses, simultaneously claiming that this is medicine, which means you have to do medicine-like things — to claim that something is out of alignment, and that you are offering treatment to bring it back into alignment — but also claiming that people are what they say they are and trans people don’t “transition” because they always were whatever they say they are.

And why are they riding two horses? Well, the answer depends on how cynical you are. I have no doubt that a lot of the people inside the gender ritual have got lost in the contradictions, and genuinely think they are doing the right thing. But I will make three observations.

First, a lot of people who go into medical fields have a “saviour complex”. But even compared with other fields of medicine, gender medicine gives people a lot of power and a lot of self-validation as “good” and “progressive”. They get to rescue suffering children and help them to be reborn as the selves they were always meant to be. They get to remodel human flesh. And they get to lecture the world about morality while they’re at it.

Second, there’s something powerfully pagan about it: the greater the physical sacrifice the more real the belief. If you cut off parts of your body and sacrifice your reproductive system to your gender identity, then surely that gender identity is real. For all that devotees claim to take everyone’s claims about their gender identities at face value, it’s a bit unsatisfying to just leave it at that. Taking irreversible measures in the service of your gender identity is a type of commitment device: you’re showing that it’s really real, and you really mean it.

And third, this is a lucrative business. As the American journalist Upton Sinclair famously said: “It is difficult to get a man to understand something when his salary depends upon his not understanding it.”

With Patrick Clarke of CASC, Riittakerttu Kaltiala of Tampere University and Jillian Spencer of Queensland Children’s Hospital, in the Adelaide Hills, October 19th 2025

I’ll publish the second of three parts of my keynote in a couple of days.