New Book “Irreversible Damage” Is Full of Misinformation

There's been a lot of stir about Abigail Shrier's new book Irreversible Damage: The Transgender Craze Seducing Our Daughters. The book's central (and false) premise is that there are massive numbers of transgender youth who are not truly transgender, but rather just confused, and that they are all being rushed into gender-affirming medical interventions and surgeries that they will later regret. As a physician and a researcher who has dedicated my career to taking care of and understanding transgender youth, I recognized the book as bizarre and full of misinformation. I assumed it wouldn't gain much traction. I was wrong.

I should have realized the internet has dramatically changed the way politically charged misinformation spreads. Online, it often doesn't matter what's actually true. The book, full of irresponsible journalistic practices and outright falsehoods, has taken off. After it snowballed to fame on Twitter, The Economist even named it a book of the year. Given the length of their list, I'm giving them the benefit of the doubt that they don't fact-check each book.

Within medicine, gender-affirming care for transgender and gender diverse youth is not controversial, outside of a few fringe groups like The American College of Pediatricians (an anti-LGBTQ group that is not to be confused with The American Academy of Pediatrics). There is broad consensus from The American Psychiatric Association, The American Academy of Pediatrics, The Endocrine Society, The American Academy of Child & Adolescent Psychiatry, and The World Professional Association for Transgender Health that gender-affirming medical care is appropriate for transgender youth so long as clinicians follow guidelines set forth by these major medical organizations (e.g., The Endocrine Society Guidelines). As one can read in the guidelines, recommended interventions depend on the developmental stage of a person, and a young person must meet specific criteria to be eligible for treatment. I wrote about this careful stepwise approach for The New York Times a few years ago.

Much of the attention Irreversible Damage has received is due to Shrier’s talent for stirring controversy. After the book was briefly removed from Target’s website due to (reasonable) accusations of transphobia, Shrier used the moment to claim a supposed infringement of her freedom of speech. She wrote about it in The Wall Street Journal. It didn't matter that the first amendment doesn't mean you can force Target to sell your book; emotions had been rattled, and the book received a flurry of attention. This concerns me.

Transgender youth are commonly harassed and experience stigma in their communities, which has led to substantial mental health disparities, including high rates of suicide. Recently, radical social conservatives have been trying to take away their medical care by threatening to put parents and doctors in prison if they follow standard-of-care medical practices to support these adolescents. This book adds fuel to that fire. But even scarier is that it tells parents to reject their children's gender identity, which is one of the greatest predictors of suicide attempts among transgender kids.

Transgender youth deserve better than mass consumption of misinformation about them. Here are some things you should know about Irreversible Damage.

Shrier did not interview most of the transgender adolescents she wrote about.

Shrier's book tells the stories of several young people who came out as transgender to their parents. The book claims that these adolescents and young adults were not actually transgender, but actually just confused. The problem is Shrier didn't actually interview any of these people she wrote about.

The author’s note points out that she only interviewed their parents, who uniformly did not accept their children’s transgender identities. Many of them were estranged from their kids because the children were so hurt by their parents' rejection. To actually understand the psychology of these young people, one would need to talk to them, not simply rely on stories from parents with whom they do not speak.

To make things worse, the author's note explains that Shrier changed details in the book to ensure the transgender people she wrote about would not be able to recognize themselves. In doing so, she ensured they could not provide their side of the story or point out any inaccuracies in her reporting.

The author claims she is apolitical, but the book was published by Regnery Publishing, a publisher whose mission is advancing politically conservative viewpoints.

Shrier claims that her book is apolitical and that she is a neutral investigative journalist. But her publisher Regnery calls itself “America’s leading publisher of conservative books.” Its other titles include The Biden Deception and The Conservative Mind. It boasts that its list of authors, “reads like a ‘who’s who’ of conservative thought and action including Ann Coulter… and many more.”

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Further arguing against Shrier’s objectivity is her crass and offensive language throughout the book. For example, when discussing the highly personal decision to undergo gender-affirming surgery, Shrier commented:

"Since they almost never undergo the phalloplasty necessary to achieve one of the defining features of manhood, it’s hard not to see their male identifies as fragile; a quick trip to the urinal, and the jig is up.”

Shrier claims that “in most cases—nearly 70 percent—gender dysphoria resolves," and thus youth should not be provided gender-affirming medical care. That statistic is false.

Shrier incorrectly uses this statistic to claim that trans youth shouldn't be offered gender-affirming medical interventions because most will change their minds and later regret their decision. The studies Shrier refers to used an old diagnosis of “gender identity disorder,” not the DSM-5 diagnosis of gender dysphoria.

The reason this is a problem is that one could meet this diagnosis without being transgender. The old criteria largely focused on gender expression (think a tomboy or a cisgender boy who likes “feminine” toys). Those kids aren’t transgender, so it’s not surprising that most of them weren’t transgender at follow-up. This problem with the “gender identity disorder” diagnosis from the DSM-IV was fixed for the DSM-5.

Furthermore, those studies were of very young prepubertal children. Under the current medical consensus, gender-affirming medical interventions are not offered to prepubertal youth. They are only offered after youth have reached adolescence. Once youth reach adolescence, it’s rare for transgender youth to later decide they are cisgender.

Shrier claims that a large number of kids who say they are transgender are actually LGB and afraid to say so because transgender identity carries less stigma than being LGB. Actual data suggest otherwise.

In one of her major arguments about how she thinks transgender youth aren't really transgender, Shrier writes about a teenager named Riley who told her that, due to contemporary social pressures, adolescents today can’t come out as LGB and need to come out as transgender instead to be accepted.

She argues that these kids aren't really transgender but rather just afraid to tell people they are LGB, so they choose to transition. This is complete nonsense. A recent large study by GLSEN found that transgender students experience more hostility at school than LGB students. The same study found that nearly 1 in 4 transgender kids needed to change schools because they were harassed for being transgender. Data from The Centers for Disease Control and Prevention show that adolescents are far more likely to self-identify as lesbian, gay, or bisexual (10.5 percent) than transgender (1.8 percent).

Shrier states there is evidence that providing adolescents with puberty blockers makes them more likely to continue to identify as transgender. That’s false.

Shrier dedicates much of the book to arguing that we shouldn't allow transgender youth to access pubertal suppression because she believes it makes them more likely to "persist" in their gender identity.

First off, it’s inappropriate to suggest that being transgender is a bad outcome. However, Shrier also simply misunderstands the scientific literature. She notes that only 1.9 percent of adolescents who started pubertal suppression in a large study in The Netherlands did not proceed to gender-affirming hormones (i.e., estrogen or testosterone). This is not because pubertal suppression made them identify more strongly as transgender. Rather, it is a result of the strict guidelines followed in the Netherlands before an adolescent is considered eligible for pubertal suppression: six months of attending a specialized gender clinic and undergoing rigorous assessment.

Shrier ignores all of the data showing that gender-affirming medical care results in improved mental health outcomes for transgender youth.

Though Shrier is quick to provide anecdotes from teenagers like "Riley" and stories from estranged parents as evidence, she is relatively less interested in the peer-reviewed scientific research that shows the benefits of gender-affirming medical care for transgender adolescents. I've listed several in the references for those interested in reading more.

In summary, physicians from The American Academy of Pediatrics and The Endocrine Society have issued clear guidelines regarding how to best support transgender youth. I encourage readers to rely on trustworthy sources such as these rather than books like Irreversible Damage. Transgender youth deserve for the public to have accurate information on how to best support them.