In May, the Department of Health and Human Services published a comprehensive review of treatments for gender dysphoria in minors that was swiftly criticized, in part because the names of its authors were withheld.

I am one of the authors. As Health and Human Services said upon publication, the review is going through the peer review process, for which anonymity is preferred. My co-authors and I discussed additional reasons for anonymity, including that disclosure might distract attention from the review’s content or lead to personal attacks or professional penalties. Those who have raised concerns about the field of pediatric gender medicine are well aware of the risks to reputations or careers.

The hostile response to the review by medical groups and practitioners underscores why it was necessary. Medicalized treatment for pediatric gender dysphoria needs to be dispassionately scrutinized like any other area of medicine, no matter which side of the aisle is cheering it on. But in the United States, it has not been.

I was familiar with the other authors — there are nine of us in all — and I was confident that we could produce a rigorous, well-argued document that could do some good.

Collectively, we had all the bases covered, with experts in endocrinology, the methodology of evidence-based medicine, medical ethics, psychiatry, health policy and social science, and general medicine.

I am a philosopher, not a physician. Philosophy overlaps with medical ethics and, when properly applied, increases understanding across the board. Philosophers prize clear language and love unraveling muddled arguments, and the writings of pediatric gender specialists serve up plenty of obscurity and confusion.

The review was prompted by an executive order signed by President Donald Trump at the end of January, which set for us a May 1 deadline.

The order’s inflammatory and tendentious language understandably roused suspicions among liberals.

But the review wasn’t written by zealots busily grinding axes. In fact, liberals were in the majority. Some of us were paranoid that the White House would try to control the content of the review or even alter it prepublication; that worry proved unfounded.

I am hardly a fan of the current administration: I have never voted Republican, and as an academic from Cambridge, Massachusetts, I hold many of the liberal beliefs of my tribe. That includes support for the right of transgender people to live free from discrimination and prejudice.

The review describes how the medicalized “gender affirming care” approach to treating pediatric gender distress, endorsed by the American Medical Association and the American Academy of Pediatrics, rests on very weak evidence. Puberty blockers followed by cross-sex hormones compromise fertility and may cause lifelong sexual dysfunction (among other adverse effects); surgeries such as mastectomies remove healthy tissue and carry known risks of complications. Medical procedures always have downsides, but in this case no reliable research indicates that these treatments are beneficial to minors’ mental health.

One of the most important chapters provides an ethical analysis, arguing that pediatric medical transition is ethically inappropriate because of its unfavorable risk/benefit profile.

We agree with the health authorities in Sweden, who reached the same conclusion in 2022. The argument is quite simple — “medical ethics 101,” as one of my colleagues put it — and does not rely on contested claims about consent or regret, which is how the ethical debate is often framed.

After surveying all the evidence, and applying widely accepted principles of medical ethics, we found that medical transition for minors is not empirically or ethically justified.

The review adds to the work of Hilary Cass, a respected British pediatrician, who concluded in a report commissioned by health authorities in Britain that this “is an area of remarkably weak evidence.” Cass was chosen because she is not a gender clinician and can thus assess the field impartially. Subsequently, Britain’s (left-wing) Labour government banned puberty blockers for the treatment of gender dysphoria outside clinical trials indefinitely. The government’s health secretary is considering similar restrictions on cross-sex hormones for patients under 18.

Some European countries have moved in the same direction, including Finland, Sweden, Norway and Denmark. Following age restrictions on puberty blockers and hormones in the state of Queensland, the Australian government is in the process of developing new clinical practice guidelines.

Why is the United States, as Cass has observed, “out of date” on treatment for gender distress in young people? One reason is our fragmented health care system: more centralized systems in Europe and Britain prioritize cost-effectiveness, which requires careful evaluation of the evidence of medical benefit. Centralization also makes it easier to establish national treatment guidelines.

Another reason is the stark division in the U.S. along political party lines. Adding to the mix is a problem not confined to this country: many adults in the room were driven to prudent silence by aggressive activists. “There are few other areas of healthcare,” Cass wrote in her foreword, “where professionals are so afraid to openly discuss their views, where people are vilified on social media, and where name-calling echoes the worst bullying behaviour.”

The price of speaking out no doubt contributed to the collapse of medical safeguarding in the United States. A more subtle influence is the language used by proponents of pediatric medical transition, which is euphemistic and often misleading. “Gender-affirming top surgery” sounds entirely positive, and papers over the salient fact that the breasts of physically healthy teenagers are removed. Patients who undergo irreversible surgery and later regret it are said to have “dynamic desires for gender-affirming medical interventions.”

The usual words to indicate a young patient’s sex are disallowed: female children are “individuals assigned female at birth” or “trans boys,” and are never simply “girls.” This has the Orwellian effect of making plain truths impossible to state.

The review squarely addresses an uncomfortable topic: the link between childhood-onset gender dysphoria and same-sex attraction. Gender dysphoric young children are gender-nonconforming, and early gender nonconformity is strongly associated with later homosexuality.

In a 2011 Dutch study of 70 adolescents, which together with its follow-up forms the scientific foundation of today’s pediatric medicalized pathway, only a single patient reported being heterosexual.

The days of medicalizing same-sex attraction are supposed to be shameful history. The review suggests that the old days are back under the new guise of care for “gender-diverse youth.” Speaking for myself, the progressive embrace of this regressive practice is one of the great ironies of the modern age. The review is a sober examination of what by any standards are drastic medical interventions for physically healthy minors. It deserves to be read by people of all political leanings. Whether its early critics bothered to do so is unclear.

Mere hours after publication, the president of the American Academy of Pediatrics, Susan Kressly, claimed that the review was undermined by reliance on “a narrow set of data.” A glance at the evidence synthesis (or even just the separate appendix) by anyone familiar with evidence-based medicine would show that this complaint is preposterous. The hypocrisy is blatant: the AAP’s policy statement for the treatment of gender-dysphoric youth is unsupported by its own citations.

Equally baseless was the statement issued by the World Professional Association for Transgender Health the day after the review’s publication, saying it “misrepresents existing research.” If it does, why not clinch the case with some examples? Yet none were provided.

Critics have mostly settled on the allegation that the review’s endorsement of psychotherapeutic approaches — in line with best practice in the U.K, Finland, and Sweden — amounts to “conversion therapy” for gender identity.

Once this activist phrasing is granted, the negative association with long-discredited gay conversion therapy does the rest. Never mind that we replied in advance: The chapter on psychotherapy has a section titled “The charge of ‘conversion therapy’.”

I wish I could say my own profession has modeled rational debate about these controversies. After the report was published, a philosopher who runs a popular blog reported that my name appeared in the metadata of the appendix.

He called my presumed involvement “appalling.” On social media, a prominent senior philosopher accused me (“Herr Byrne”) of contributing to a “project of extermination,” to the approval of other senior philosophers. This illustrates the inevitability of online comparisons to Nazis, if nothing else.

To quote Cass again, “This must stop.” Though the current administration seems not to grasp the point, we all stand to benefit from free and open inquiry, in medicine, academia and in society more broadly. That does not mean elevating crackpots or taking wild conspiracy theories seriously. It means that objections should be made using arguments and data, not shaming or ostracizing.

There is much to admire about modern health care, but it has taken some gravely wrong turns, from lobotomies to the pathologization of homosexuality and the opioid epidemic. More wrong turns are inevitable. What we should do is promote a culture which makes it easier to turn back. Such a culture is animated by the scientific spirit — a willingness to question assumptions, to seek new evidence, and to resist pressure to conform from our in-group.

That is exactly what has been missing from the debate over youth gender medicine, and we liberals must take some blame. The more liberals who can rise above tribal loyalties and publicly dissent, the better.

Alex Byrne is a professor of philosophy at MIT.