IndustrialComplex

Tears streamed down Chloe Cole’s face as she spoke about her detransition journey in October 2022 during the “First Do No Harm Unity Rally” in Anaheim, California.¹ It was held in protest outside the American Academy of Pediatrics annual meeting. Cole was just 13 when the physicians attending that conference “fast-tracked” her down the “destructive path” of “gender-affirming care,” a form of medical arson that involves puberty blockers, cross-sex hormones, and surgeries to ostensibly correct the “error” of having been born in the wrong body.

Cole painted a portrait of a young girl suffering under the shadow of mental health issues. She was plagued by anxiety, depression, pubertal struggles, and body dysmorphia. It all was exacerbated by a kaleidoscope of caricatures of what it means to be a woman today. “I saw how girls and women are portrayed in media from cartoons to Instagram posts to porn,” she said. “I tore myself apart because on all fronts, there was some ideal that I failed to achieve.”

“The girls and women I knew growing up always talked about how horrible being a woman is, how terrible periods are, how unbelievably painful pregnancy and childbirth are, and never the blessings that come with any of it,” Cole continued. “This association with femininity was inevitable.” She said it also made her double mastectomy—the surgical removal of both breasts—at 15 years old inevitable. But Cole has since wiped away her tears. Last year, she announced a lawsuit against the Kaiser Permanente healthcare system.²

The filing states Cole was “coerced” to undergo “gender-affirming care” based on falsehoods. Cole, who had struggled with perceived “gender dysphoria” starting at age 9, was convinced by doctors that her mental health issues would not resolve unless she were to socially and medically transition. They also told Cole and her parents that forgoing that would put her at a high risk of suicide. Neither Cole nor her parents were made aware of the high desistence rate for children diagnosed with gender dysphoria. Instead, they were locked in the path, the door slammed shut behind them.

Cole’s parents told her they were given the following ultimatum: “would you rather have a dead daughter or a live son”? So began the transformation that left a young girl’s mind and body broken.

Detransitioners

Cole isn’t the only one suing. More victims are coming forward to tell their stories, even as physicians in the United States plow forward with promoting “gender-affirming care” as an unalloyed good.

In June, Kayla Lovdahl filed a lawsuit against Kaiser. Two of the doctors who treated Cole are implicated.³

Like Cole, Lovdahl said she experienced mental health issues from a young age. At 11, she was exposed to transgender influencers online. Lovdahl was on puberty blockers within a year. All it took to get this life-altering ball moving was a consultation with Susanne E. Watson, a psychologist and the clinical director of the Multi-Specialty Transitions Department at Kaiser Permanente Oakland Medical Center. Watson determined Lovedahl was transgender after a 75-minute evaluation. According to the filing, Lovedahl’s physicians “promptly placed her on puberty blockers and testosterone at age 12.” She received a double mastectomy within six months, when she was 13.

Lovedahl eventually detransitioned and received the therapy she needed all along, but the ordeal left her with emotional and physical scars that will take a long time to heal.

In North Carolina, Prisha Mosley filed a lawsuit in July against several parties she said railroaded her into transitioning. Mosley was sexually assaulted when she was 14. It resulted in a miscarriage and deep emotional wounds. At Moses Cone Memorial Hospital, she would see physicians for psychiatric issues including depression, anorexia, and obsessive-compulsive disorder.⁴

In January 2015, Mosley was seen at Cone Health’s Tim and Carolyn Rice Center for Child and Adolescent Health for an 80-minute evaluation related to her eating disorder. She had just been discharged from the emergency department. During that meeting, a resident concluded that a “gender identity crisis” was “most likely the underlying issue that drives her eating disorder and emotional distress.” That started the process of doctors guiding Mosley along the transition roadmap. According to the lawsuit, Mosley received a “depo shot” while she was being seen for mental health issues. The injection was intended to stop her from having periods as the first step in transitioning. It was done without Mosley’s parents being made aware. She was a minor.

In Texas, Soren Aldaco filed a lawsuit over the summer against the Crane Clinic for Transgender Surgery.⁵ Like the others, Aldaco was plagued by psychological stressors, including the loss of a grandmother and discomfort with her body when she went through puberty early. She, too, turned to the internet, where she came under the influence of transgender content. She even entertained and experimented with the idea of living as a boy. It didn’t help.

Her psychological issues worsened, crippling her ability to function normally. Aldaco’s parents admitted her to Mesa Springs Psychiatric Hospital in Fort Worth after a manic episode. There, at the age of 15, she was “relentlessly pressed” about her gender identity by a doctor named Sreenath Nekkalapu. Without conducting any “meaningful or comprehensive psychobehavioral examination,” Nekkalapu jumped to “the conclusion that the sole explanation for Soren’s psychotic break was her needing to embrace a transgender identity, after only knowing her for mere minutes,” the lawsuit states. The following year, Aldaco began attending a “transgender support group” in Fort Worth called Trans-Credence International, where children and adolescents would be paired with “elders” who would guide them in their “gender journey.” Through that group Aldaco connected with Del Scott Perry, the doctor who put her on gender drugs. Although Perry does not identify as transgender, he regularly attended the meetings and built a clientele list through them.

After their first half-hour appointment at his office, Perry gave her a prescription for “her first round of crosssex hormones, anastrozole (an estrogen blocker) and testosterone cypionate (together with the anastrozole, the ‘cross-sex hormones’), at an outrageously large, off-label dosage,” the filing states. Aldaco was 17. According to the lawsuit, Perry “never sought or obtained any written parental consent” from her parents. She also went under the knife at Crane Clinic for a flawed and excruciating double mastectomy. Her doctors downplayed the complications and were indifferent toward her cries for help. When she was finally seen for emergency treatment at a hospital in Dallas, surgeons diagnosed Aldaco with “massive bilateral hematomas.” They had to re-open the incisions made at Crane Clinic to drain blood and other bodily fluids. Aldaco’s physicians promised a troubled young girl happiness; they gave her a living hell and a butchered body.

The most recent case is Luka Hein, a 21-year-old Minnesotan who began transitioning when she underwent a double mastectomy at 16. Three years prior to that, in 2015, Hein’s parents divorced. It was devastating for her. The filing states that within a year, Hein was suffering from anxiety and panic attacks that “immobilized” her.⁶ “She lost her appetite, became easily angered, started cutting, and expressed suicidal ideation,” the lawsuit says. “She began counseling with a therapist and a psychiatrist who diagnosed depression and generalized anxiety disorder. Her psychiatrist put her on antipsychotic medication, but she continued to spiral downward.” Hein eventually broke down and ended up in a “partial psychiatric program” where she was diagnosed with depression.

Worse still, Hein fell victim to a sexual predator online around this time, which sent her spiraling further, resulting in increased antipsychotic medication as part of her daily regimen.⁷ It was also around this time that Hein became aware of “transgender influencers who extolled the virtues of hormones and surgery.” That, coupled with the trauma she had experienced, put her on the path to transitioning. She found her way to a therapist who affirmed her gender confusion in 2017. After a 55-minute consultation, Hein was diagnosed with “gender identity disorder.” The fact that she was on a cocktail of medications and plagued by a variety of psychiatric issues only seemed to validate that diagnosis. The following year, on her very first visit to a gender clinic, Hein was fast-tracked for breast removal surgery at 15. When Hein’s parents expressed concerns about the procedure, they were told that Hein “would take her own life.”

Hein progressed to testosterone but stopped after four years “due to heart irregularities, aching joints, and pelvic pain.” Like Aldaco and all the rest, Hein was promised a cure-all. But by the time she decided to detransition, Hein could not function or get out of bed.

Most high-profile cases of people quitting transitioning involve females. But there is a growing number of males who are also piecing their lives together after being encouraged to go down this road. One of them agreed to be interviewed for this report.

The Life Of Richard

Richard Anumene doesn’t like the term “detransitioner” because, he says, it legitimizes a falsehood. People can’t transition into what they’re not. He knows that now, after undergoing hormone therapy and surgeries.

“Desister” is the term Richard prefers because he desisted the delusion of transgenderism. But not until after undergoing his final procedure: a vaginoplasty.

“My entertaining that lifestyle choice was due to my adverse childhood experiences,” he said. His childhood was filled with physical and sexual abuse from his parents and his brother. “My disgust with myself is a result of my sexual abuse that I endured as a child at the hand of my now deceased older brother, who committed suicide in 2018.”

That abuse was the driving force behind the psychological distress that led Richard to seek gender therapy.

“That really was the cause of my disassociation of self, my dislike of myself, my dislike of my genitalia . . . my not wanting to grow up into a man,” he said. “I didn’t want to become like my brother. I didn’t want to become like my dad.”

Richard’s mother and father immigrated from Nigeria to the United States, settling in California. The family moved around the state, but Richard was raised in what was essentially a Nigerian enclave, growing up under a faith system that combines traditional African beliefs and Christianity. Many Nigerian Christians believe in witchcraft. Richard’s father accused his mother of it and separated from her. Home life was chaotic and broken.

The parents would fight and vent their anger on Richard and his four siblings when they were together. All the while, Richard said, his brother would sexually violate him. He’d also force him to watch pornography. The sexual abuse began before Richard was ten.

“I’ve been on psych medicine since I was seven years old,” he said. “I’ve been in and out of hospitals across the state since I was seven.” Yet Richard’s father continued to ignore the source of the problem: abuse at home.

“We never even had therapy for all of the familial problems.” Culturally, it was taboo for his father, as a traditional Nigerian patriarch, to acknowledge them.

Pretending it wasn’t happening didn’t make it go away. Sexual violence shattered Richard’s self-conception. He began wearing women’s clothing from a very young age. But it was never explicitly sexual. Richard described this period as one of incoherence, a desperate attempt to disassociate himself from the boy whose body was being violated.

One day, Richard was caught cross-dressing by his father, who took all the clothes and burned them in the yard. He was booted out of the house. It wouldn’t be the last time. A period of itinerant homelessness followed. The lack of a familial support system exacerbated everything.

Around the time he turned 17, Richard began to conceive of himself as a woman in a more concrete way. A social worker put him in touch with Carlos Morales, a counselor associated with the World Professional Association for Transgender Health (WPATH). According to Richard, Morales encouraged him to seek gender therapy to affirm his new identity as “Alice.” His transition began at the Gender Pathways Clinic at Kaiser Permanente San Francisco Medical Center.

Hormone therapy for Richard started at 19. All it took was a single, brief consultation. After that followed facial feminization and vaginoplasty surgeries. At no point, Richard said, did anyone counsel him against transitioning. His diagnosed psychiatric disorders stemming from years of abuse gave no one pause. Indeed, despite his documented history of mental illness, Richard said the whole process was treated like nothing more significant than getting a tattoo. Everything was paid for through Medi-Cal, California’s Medicaid program.

There was little to no follow-up care. Richard said the vaginoplasty left him with recurring bleeding and pain. It also disabused him of the idea of transitioning. He had made a terrible mistake. But where were the medical guardrails that should have stopped him from getting to that point?

In the aftermath, no one wanted to admit or even consider the possibility that they had enabled him to do something not in his best interest. Morales was defensive when confronted. So was Richard’s surgeon. “They tried to pin the blame on me,” he said.

Since desisting, Richard has filed a lawsuit against Kaiser Permanente, Morales, and a social worker.

A surgeon interviewed for this report calls people like Richard “full-circle patients.” This person asked not to be named. He is certified by the American Board of Plastic Surgery and is a member of various medical societies.

Between 2015 and 2016, he worked extensively with trans-identified individuals at a facility on the East Coast. The patient coordinator was a member of WPATH. “The coordinator was always very pushy,” he recalled. “It was always about doing more surgeries.”

Though he continues to practice, he no longer sees people seeking transition procedures. I asked him why.

“The patients were getting younger,” he said.

“I remember I saw a 19-year-old once.” This particular patient wanted a double mastectomy. “I didn’t do it,” he said.

Since then, his opposition to transgender medicine has only grown. He blames medical societies for failing to uphold standards of care that would protect patients from irreversibly damaging their bodies.

“The prevention, delay, or whatever pharmacological and especially surgical disruption of the process we call puberty is a crime against humanity,” he told me. “It’s horrible what we do to kids.” His voice sank, and he became emotional and had to pause during our discussion to collect himself. He likened transition therapy to eugenics. It’s also a “new brand of medicine” that can be “exploited” by the medical industry, he said.

Many surgeons receive compensation based on their productivity, which is measured in “relative value units” (RVUs). The number is derived from the amount of work and effort physicians expend for each patient, service, and procedure. RVUs are used to determine how much to pay doctors.

Approximately one-quarter of the 15 million operations Americans have each year are unnecessary. Saying no to an operation, even an unnecessary one, means less take-home pay, and as coverage for certain procedures increases, so do the incentives. Back surgeries are a good example. There are two options for treating a herniated disk: a discectomy and a lumbar spine fusion. The former takes 45 to 90 minutes, with patients usually out the door on the same day. The latter takes longer and often requires a hospital stay of two to three days. Unsurprisingly, “the number of lumbar fusions increased steadily among people covered by Medicare between 2004 and 2009,” according to STAT.⁸ Medicare spending on lumbar spine fusions has increased 500 percent over that time, while the rates of the surgeries have also risen.

It is difficult to put a precise price tag on the process of sex-trait modification, given the sheer variety of procedures offered; the wide range in costs; and the additional unknowns of required follow-up, potential complications, etc. However, based on the data provided by Grand View Research, the following can be considered a very rough (and likely conservative) estimate of the total cost for both a male and a female to undergo the complete sex-trait modification process.

There are common threads that run through all these accounts. Mental health issues are often present, ranging from mood, anxiety, post-traumatic stress, and personality disorders. In 2021, the Australian Journal of Psychology published an analysis of data from gender clinics in the United States and the Netherlands that showed mood and anxiety disorders were the most common psychiatric conditions observed in patients diagnosed with gender dysphoria.⁹ Another study¹⁰ published in Nature Communications, a highly regarded peer-reviewed journal, concluded that autistic people are three to six times more likely¹¹ than neurotypical people to feel confused about their gender. It is worth noting Cole has said she is autistic and that being on the spectrum while undiagnosed was one of the things she struggled with as a young girl.

A gender dysphoria diagnosis often acts as the basis for starting or accelerating gender care, which is accompanied by the specter of suicidality: people, parents in particular, are told that unless they go through with transitioning, the risk of self-harm increases by over 40 percent, to cite a common statistic. But that oft-mentioned figure comes from the U.S. Transgender Survey, an anonymous online survey conducted in 2015 by the National Center for Transgender Equality, a nonprofit advocacy group.¹² Likewise, in a similar anonymous survey, The Trevor Project, an LGBTQ advocacy group, reported that 52 percent of respondents said they had considered suicide.¹³ However, as Reuters noted, citing a number of experts, “online surveys have become common in science, but researchers say they may not be fully representative of the larger population being studied.”¹⁴ Even the 2015 survey states that it is “not appropriate to generalize the findings in this study to all transgender people.” It is also worth noting that organizations like The Trevor Project receive significant financial contributions from corporations that sell the drugs used in “gender-affirming care.”

More recent research tells a different story about the relationship between “gender-affirming care” and self-harm. A landmark Finnish study published in February showed that providing adolescents and young adults with drugs and surgeries related to transgenderism did not appear to have any meaningful effect on suicide rates.¹⁵ “Clinical gender dysphoria does not appear to be predictive of all-cause nor suicide mortality when psychiatric treatment history is accounted for,” the authors found. In other words, individuals with a history of mental illness were more likely to kill themselves than those who simply identified as transgender. Similarly, a California study published in 2021 found that the attempted suicide rate among trans-identified men who underwent a vaginoplasty was twice as high during the post-surgery period compared to the pre-surgery period.¹⁶ “Patients undergoing [gender-affirming surgery] with a history of prior psychiatric emergences or feminizing transition are at higher risk and should be counseled appropriately,” the authors noted.

Nevertheless, medicalized transitioning has gained legitimacy with the help of medical groups like the American Academy of Pediatrics and the Endocrine Society. The aforementioned WPATH is another key organization. Its standards of care provide treatment guidelines for others to follow around the world and are also used to justify insurance coverage and gender medical interventions. Yet even WPATH has been forced to concede that there is a dearth of studies behind the long-term effectiveness of these treatments for adolescents with gender dysphoria. Its latest guidelines, published in September of this year, state that “the number of studies is still low, and there are few outcome studies that follow youth into adulthood.”¹⁷ WPATH also makes the remarkable admission that “a systematic review regarding outcomes of treatment in adolescents is not possible.” The organization was recently embroiled in controversy when leaked messages obtained by Environmental Progress revealed that WPATH members “demonstrate a lack of consideration for long-term patient outcomes despite being aware of the debilitating and potentially fatal side effects of cross-sex hormones and other treatments.”¹⁸ Specifically, they “show that patients with severe mental health issues, such as schizophrenia and dissociative identity disorder, and other vulnerabilities such as homelessness, are being allowed to consent to hormonal and surgical interventions.”

Like WPATH, the Endocrine Society acknowledges that behind its recommendations for “gender-affirming hormone treatment” and surgery, “the quality of evidence is usually low.”¹⁹ In 2009, the society’s influential journal recommended treating “transsexual adolescents” with puberty blockers that are mainly manufactured by Endo International and AbbVie Inc.²⁰ To date, these drugs are prescribed off-label, meaning that the U.S. Food and Drug Administration (FDA) has not approved them to be used in gender care for children. Their only approved use in that regard is for treating central precocious puberty—when a child begins to go through puberty too early. But they have been controversial from the start.

Take Lupron, the most commonly prescribed puberty blocker. It was conceived by a joint venture between Abbott Laboratories and Takeda Pharmaceutical Co. After that venture was dissolved, Abbott transferred its pharmaceutical division to AbbVie, a spin-off company that has made Lupron since 2013. In 1985, Lupron was approved by the FDA to treat prostate cancer. It works by cutting off the hormones that worsen the condition and results in chemical castration. It was subsequently approved for other uses, including precocious puberty, in 1993. A review of federal records by the Center for Investigative Reporting and Kaiser Health News revealed that the FDA official who approved the drug for use in children had strong reservations about the quality of the supporting evidence.²¹ He called its approval “regrettable.” More than 32,000 adverse event reports have been filed with the FDA for Lupron products, including nearly 18,000 serious cases and over 3,000 deaths.²²

Since 2013, there have been 1,152 adverse event reports for Lupron Depot-Ped, which is used to treat early puberty in pediatric patients and off-label to block puberty to start the process of medicalized gender transitioning. A closer look shows 82 cases of depression, psychotic disorders, emotional distress, and antisocial and suicidal behavior between 2013 and 2023. An investigation by Reuters made similar findings, which alarmed Dr. Brad Miller, division director of pediatric endocrinology at the University of Minnesota Medical School and M Health Masonic Children’s Hospital.²³ Miller and other doctors told Reuters they had repeatedly asked companies like AbbVie to seek FDA approval for drugs used in gender care and to conduct research to establish their safety in that regard. But the companies have always refused. “They would say it would cost a lot of money to get approval,” Miller said. “And they were not interested in going there because (transgender treatment) was a political hot potato.”

Yet medical practitioners remain trigger-happy. At 18 gender clinics across the country, Reuters found that most do not have stringent protocols to determine whether a patient would be best served by undergoing the life-changing process of transitioning. Seven clinics said that, depending on the age of the child, they will begin prescribing puberty blockers based on the first visit if there are no “red flags.” But the red flags in the cases of detransitioners didn’t give anyone pause—in fact, their red flags seemed to rationalize the start of treatment. Adults have also reported being pressed to subject their children to transitioning. Reuters interviewed the parents of 39 minors who had sought “gender-affirming care.” Of that number, 28 said they felt “pressured or rushed to proceed with treatment” for their kids. Some said their children were recommended for puberty blockers after consultations lasting just 15 minutes. Despite so many serious concerns, prescriptions for blockers among minors doubled between 2017 and 2021, according to Komodo Health, a company specializing in products for analyzing medical data.²⁴ Patrick Brown, a fellow at the Ethics and Public Policy Center, told the Daily Mail that prescriptions for hormone therapy have risen at about the same rate.

The proponents of these drugs insist there is no harm in utilizing them because the effects are reversible if a child decides to stop. But that’s problematic for a number of reasons. A study published in The Lancet in October 2022 found that most adolescents who start puberty suppression treatment continue along the “gender-affirming care” spectrum into adulthood. Moreover, there are, in fact, lasting side effects.²⁵

The New York Times commissioned an analysis that examined seven studies from the Netherlands, Canada, and England involving about 500 “transgender teens” from 1998 through 2021.²⁶ “Researchers observed that while on blockers, the teens did not gain any bone density, on average—and lost significant ground compared to their peers,” The Times reported. A review commissioned by The Times of observational studies found that bone density growth typically flatlines during puberty suppression, which comes with a lifetime of repercussions. Indeed, two studies that tracked bone strength in patients using blockers concluded that many lag behind their peers and do not catch up to them. “That could lead to heightened risk of debilitating fractures earlier than would be expected from normal aging—in their 50s instead of 60s—and more immediate harm for patients who start treatment with already weak bones,” The Times noted. A Texas teenager who went on blockers at age 11 showed osteoporotic levels of bone density in a scan taken a few years later. This is happening everywhere. In Sweden, one “transgender adolescent” who took the drugs from the age of 11 to 14 developed osteoporosis and sustained a compression fracture in his spine. He now suffers from chronic back pain and a “permanent disability”—not reversible—because of the puberty blockers.

All of this is to say nothing of the ramifications concerning neurodevelopment and fertility that might arise from suppressing puberty, which is still only one part of gender care.²⁷ According to a study published in March in the Journal of the American College of Cardiology, people with gender dysphoria on hormone therapy face increased “odds of ischemic stroke, pulmonary embolism, STEMI, NSTEMI, drug abuse, and hypothyroidism.”²⁸ STEMI is a heart attack with a completely blocked coronary artery; NSTEMI is a heart attack that occurs when a heart’s need for oxygen isn’t met. People with gender dysphoria who used hormones were at nearly seven times the risk of ischemic stroke, nearly six times the risk of heart attack, and nearly five times the risk of pulmonary embolism compared to gender dysphoric people who had never used hormone replacements. An American College of Cardiology press release billed the study as “the largest to date examining the cardiovascular risks of gender affirmation therapy in this historically understudied population.”²⁹

And while there is a paucity of data as to the rate of complications that arise from various surgical procedures, some of what we do know does not look good. Take the double flap phalloplasty, which uses flesh, typically from the forearm, to construct a “penis” for “transgender men.” One study published in Microsurgery reported complications as high as 53 percent.³⁰ Researchers in another medical journal, Current Urology, cited different studies that show “urethral complications scaling between 25% and 75% following masculinizing gender-affirming surgery.” While some aspects of “gender-affirming care” are less risky than others, the fact is that there is an alarming knowledge gap about the complications and long-term consequences of these treatments. The following paragraph from Mosley’s lawsuit should throw cold water on the idea that any of this can simply be “reversed” with the ease of flipping a light switch:

Prisha has experienced, and expects to continue to experience, pain and suffering and emotional distress as a result of living in a body that has not developed the way it should have, with a voice she is unable to lift up and with which she is unable to sing, without her breasts and the ability to nurse a child, with shoulders that are too broad and heavy and a waist and hips that are too small and narrow, without her natural hair growth and with unwanted and unnatural body hair growth, with vaginal atrophy, and potentially without the ability to conceive a child.³¹

Britain’s National Health Service banned puberty-blocking drugs for minors experiencing gender confusion in March. A doctor said it was “not possible to accurately track the outcomes and pathways that children and young people take through the service” while using these drugs.³² The risks outweighed the available evidence.

We know two things for certain at this point: there is little hard evidence in support of medicalized transitioning, and the demand for treatment is increasing. Why? Part of the problem is that a kind of quasi-religious belief accompanies the proliferation of transgenderism. We are essentially proceeding on “faith” that normalizing these procedures will do more good than harm in lieu of serious data. But that is not the whole picture. There lurks beneath the surface of “best practices” an incentive structure and a market, both real and potential. The religiosity about transgenderism seems to blind people to these realities. Consider that in 2012 Abbott Laboratories, which spawned AbbVie, paid $1.5 billion to settle accusations that it had promoted a drug for uses not approved by the FDA.³³ Then, in 2018, Abbott and AbbVie agreed to pay $25 million to resolve allegations of employing kickbacks and unlawful marketing methods to induce physicians to prescribe TriCor, a cholesterol drug.³⁴ Most recently, AbbVie paid $2.7 million to settle a lawsuit accusing the company of using kickbacks to incentivize Humira prescriptions.³⁵ Yet the gender industry remains above all suspicion of greed and corruption.

Determining just how many people, including minors, identify as transgender and are seeking “gender-affirming care” is a difficult task for myriad reasons. However, confronting this question is a key step in understanding the scope of the problem with an eye toward justice and compensation for victims who were hurried along the transition roadmap by people they trusted to do no harm.

In the autumn of 2022, Reuters partnered with Komodo to investigate how many young people have sought and obtained “gender-affirming care.”³⁶ This pioneering analysis was the first of its kind. Komodo needed to sift through its enormous database of U.S. insurance claims and other medical records on approximately 330 million Americans. Komodo concluded that at least 121,882 children ages 6 to 17 were diagnosed with gender dysphoria from 2017 through 2021. Of that number, 17,683 U.S. children began using puberty blockers or hormones during that period. Over 42,000 of those children were diagnosed in 2021 alone—an increase of 70 percent from 2020. But here is an important caveat: “This tally and others in the Komodo analysis are likely an undercount because they didn’t include treatment that wasn’t covered by insurance and were limited to pediatric patients with a gender dysphoria diagnosis. Practitioners may not log this diagnosis when prescribing treatment.”³⁷

Indeed, the Williams Institute on Sexual Orientation and Gender Identity Law and Public Policy reported in June 2022 that more than 1.6 million adults (ages 18 and older) and youth (ages 13 to 17) identify as transgender in the United States.³⁸ About 300,000 fall into the 13-17 category.³⁹ If any of these otherwise qualifying people were not covered by insurance or were not, for whatever reason, diagnosed with gender dysphoria before receiving treatment, they would be invisible to Komodo. Nor would the company be able to see, for instance, those individuals who started puberty blockers that they acquired online through the gray market of unregulated suppliers.⁴⁰ Clearly, this data is extremely difficult to compile and analyze.

Still, Komodo’s analysis provides an important snapshot, the tip of an iceberg toward which we are sailing blindfolded. It underscores the speed at which gender confusion, as a social and peer contagion, is spreading among Americans and America’s youth especially. And that, of course, is accompanied by and symbiotically connected to a burgeoning gender industry with incentives for administering these treatments as access to them is mainstreamed and liberalized. In New York, for example, Gov. Kathy Hochul’s administration has moved to put public dollars toward streamlining “gender-affirming care.” Hochul’s Health Department awarded $500,000 in new contracts for “The Transgender Clinical Scholars Training Pilot Program” to Mount Sinai Hospital, plus additional funding to Community Health Care Project-Callen Lorde Health Center in Manhattan, and Mary Imogene Bassett Hospital in Cooperstown.⁴¹ The program will train and prepare already licensed clinicians to support patients initiating or undergoing the process of transitioning. In 2021 alone, the Mount Sinai Center for Transgender Medicine and Surgery performed 861 surgeries.⁴²

At present, 26 states have Medicaid policies that explicitly cover transgender-related health care.⁴³ Puerto Rico and the District of Colombia do as well. The Williams Institute estimates that approximately 276,000 of the 1.3 million adults who identify as transgender are enrolled in Medicaid.⁴⁴ Of that number, 60 percent have affirmative access to coverage for “gender-affirming care” under policies in state law. Exactly how many people are using Medicaid to receive some form of gender care is unclear. But Komodo’s analysis of insurance claims found “top surgery,” or breast removal, is the most common among teens. At least 776 mastectomies were performed on Americans ages 13 to 17 with a prior gender dysphoria diagnosis from 2019 to 2021, according to Komodo.⁴⁵ The cost for the procedure ranges from $6,000 to $10,000.⁴⁶ That excludes consultation fees, hidden fees, medical supplies, and so on.

As previously mentioned, increased rates of gender dysphoria are driving increased demands for these expensive treatments. One study published in JAMA Network Open found that “gender-affirming surgeries” (GAS) conducted in the United States nearly tripled between 2016 and 2019.⁴⁷ As with Komodo, this analysis broke new ground despite methodological difficulties.

Researchers looked at records from 2016 to 2020 from the Nationwide Ambulatory Surgery Sample (NASS), the only all-payer surgery database in the United States that tracks qualifying same-day operations. “The ambulatory surgeries selected for inclusion in the NASS are therapeutic procedures which require the use of an operating room, penetrate or break the skin, and involve regional anesthesia, general anesthesia, or sedation to control pain,” the website reads.⁴⁸ Researchers focused on diagnosis codes for “gender identity disorder” or “transsexualism” or a personal history of sex reassignment. Under these parameters, they identified 48,019 patients and a “remarkable increase” in the number of GAS procedures performed over time. Overall:

• 25,099 patients (52.3 percent) were aged 19 to 30
• 10,476 (21.8 percent) were aged 31 to 40
• 3,678 (7.7 percent) were aged 12 to 18 years

Health system encounters for gender identity disorder rose from 13,855 in 2016 to 38,470 in 2020. They also found that among encounters with a billing code for gender identity disorder, there was “a consistent rise in the percentage that were for GAS” from 4,552 (32.9 percent) in 2016 to 13,011 (37.1 percent) in 2019. There occurred a brief decline in 2020 due to COVID-19. The most common procedures were as following:

• Breast and chest procedures: 27,187 patients (56.6 percent)
• Genital reconstruction: 16,872 patients (35.1 percent)
• Other facial and cosmetic procedures: 6,669 patients (13.9 percent)

Now here is another caveat. Dr. Devin Coon, a board-certified plastic surgeon in the Division of Plastic Surgery at Brigham and Women’s Hospital and an associate professor of surgery at Harvard, told CNN after reviewing this analysis that the figures are likely undercounted. “It’s very easy to say who had a knee replacement. It is not like that for gender-affirming surgeries,” Coon said.⁴⁹ He noted the inherent difficulties of attempting to identify GAS patients based on procedure codes. Nevertheless, he concluded that the general picture appears true to life. “It is reasonable to look at the study, though, and say the trends in here are probably reflective of the overall trends,” Coon said.

But is it possible to put an overall dollar sign on all the relevant treatments and procedures combined? The American Principles Project commissioned a market analysis by Grand View Research, a business consulting firm, to shed some light on that question.

Grand View Research examined two broad, interlocking parts of the gender industry: surgery and hormone therapy. The former includes everything from mastectomies and scrotoplasty to voice feminization, where the vocal folds are altered to achieve a higher pitch and thus a more feminine voice. It also examined how some of the key players are profiting.

According to its analysis, the sex-reassignment surgery market size was $4.12 billion in 2022. That is expected to grow at a compound annual growth rate of 8.4 percent from 2023 to 2030. Consistent with Komodo’s analysis, mastectomies dominated the surgery market with the largest revenue share in 2022. Meanwhile, estrogen had the largest revenue share of the hormone market.

The fact that many of the drugs utilized in the process of transitioning are prescribed off-label makes it difficult to determine exactly how much revenue is generated specifically from their use in “gender-affirming care.” However, Grand View Research was able to generate estimates of how much money is being made by companies that offer these services and thus utilize these products. The figures were produced based on an in-house estimation model that considered criteria such as market presence, service offering, locations, overall revenue, strategic initiatives, and state regulations.

At just over $205 million in 2022, Cedars-Sinai Medical Center in Los Angeles was among the top groups for market revenue derived from sex-reassignment surgery.

In 2016, Mount Sinai became the first organization in New York City to offer these surgeries. According to this analysis, the Mount Sinai market revenue share in 2022 was $136 million. In its 2021 annual report, the Mount Sinai Center for Transgender Medicine and Surgery indicated that approximately 41.7 percent of the “transfeminine” population aged 25 to 34 and 25.8 percent aged 15 to 24 underwent sex-reassignment surgery.

Grand View Research also estimated hormone therapy product revenues for manufacturers, such as AbbVie. According to this analysis, which comes with inherent limitations, AbbVie’s “gender-affirming care” revenue share for puberty blockers, estrogen, and testosterone in 2022 was $51.6 million. The firm anticipates that the market for “gender-affirming” hormone treatments is expected to experience “significant growth” as the availability of these services increases.

In 2002, United States Secretary of Defense Donald Rumsfeld introduced the public to an analytical technique called the Johari window. It was developed by two psychologists in the 20 th century but has been adapted for applications outside the field. Most people remember it as Rumsfeld’s “unknown unknowns” moment. Commenting on the lack of evidence behind allegations that the Iraqi government had supplied weapons of mass destruction to terrorist groups, he said:

Reports that say that something hasn’t happened are always interesting to me, because as we know, there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say we know there are some things we do not know. But there are also unknown unknowns—the ones we don’t know we don’t know. And if one looks throughout the history of our country and other free countries, it is the latter category that tends to be the difficult ones.⁵⁰

To borrow from Rumsfeld, what are the known knowns, known unknowns, and unknown unknowns of the “gender-affirming care” industry?

We know that, according to Grand View Research, the industry as a whole was worth just over $4 billion in 2022. However, we also know that this analysis is incomplete. As is the case with the Komodo analysis, we know there are inherent limitations to what kind of patient and provider data can be gathered and reviewed. We know that Komodo does not know about patients who underwent treatment without insurance or were not diagnosed beforehand. We know the study published in JAMA Network Open cannot know about patients who received treatment without the relevant codes. So that leaves us with the unknown unknowns. We don’t know what we don’t know, so we have to get creative. We have to think outside the box, starting with the assumption that the market is likely, or could be, much bigger than $4 billion. Dr. Shayne Taylor, a university professor and a physician at the Vanderbilt Clinic for Transgender Health, gives us good reason to suspect that.

Vanderbilt University Medical Center launched its Transgender Health Clinic in 2018. That was no easy feat in a Southern state dominated by Republican politics. But the skids got greased when Taylor told Nashville about the clinic’s profit potential. She said during a lecture the same year the facility opened its doors that “gender-affirming care” is “a big money maker.” After all, patients are repeat and often lifelong customers. Taylor explained:

These surgeries make a lot of money. So, female-tomale chest reconstruction could bring in $40,000. A patient just on routine hormone treatment, who we’re only seeing a few times a year, can bring in several thousand dollars because it requires lots of visits and labs that actually makes money for the hospital. Now, these I got from the internet, but it’s from the Philadelphia Center for Transgender Surgery, which has—does a lot of surgery for patients. I just wanted to give you an idea of how much these bottom surgeries are making. And this is—I think this has to be an underestimate. This is for vaginoplasty, they’re saying, they’re quoting roughly around $20,000 for a vaginoplasty, but that doesn’t include your hospital stay, that doesn’t include your post-op visits, that doesn’t include your anesthesia, your OR. So I would think this has to be a gross underestimate. I think that’s just, like, the surgeon’s piece of it.⁵¹

It worked. The clinic didn’t just open. Taylor grew the number of patients from just 1 to over 2,000 in four years.

Taylor’s reference to the Philadelphia Center for Transgender Surgery is notable. In October 2023, the Pennsylvania Family Institute reported that over $20 million in state taxpayer dollars had been used to subsidize “gender-affirming care” for minors since 2015.⁵² The fact this information was obtained through a Right-To-Know Request with the Pennsylvania Department of Human Services raises the question of whether it would have appeared in any of the aforementioned analyses.

According to the institute, the Keystone State was spending almost $14,000 per day in 2022 on transgender services and surgeries. “From 2015 to 2022, Pennsylvania has had a more than 8,200 percent increase in taxpayer funding for these drugs, surgeries, and services through these state insurance programs for children,” the institute states. The spigot opened after Pennsylvania hospitals lobbied to expand state coverage of “gender-affirming care” in 2015. The following year, the Pennsylvania Department of Human Services announced the state Medicaid program would cover all related services. And this is where we return to trying to understand what we can’t see.⁵³

Tennessee Gov. Bill Lee launched an investigation into Vanderbilt’s transgender clinic in September 2022. There was confusion as to what exactly sparked the inquiry. According to Attorney General Jonathan Skrmetti, it wasn’t the lecture in which Taylor discussed just how profitable transgenderism can be. Instead, Skrmetti told NewsChannel 5 that the impetus was Taylor’s comments in a separate video from 2019 about manipulating billing codes to get paid by insurance companies that won’t cover “gender-affirming care.”⁵⁴ In that video, Taylor said: “So for the patient who gets a big bill because their insurance doesn’t cover any transgender-related codes I usually write ‘endocrine disorder not otherwise specified’ to allow me to order the labs that I want.”

As far as Skrmetti is concerned, this is a run-of-the-mill fraud investigation. “The government is allowed to set limits on what is going to be reimbursed, private companies are allowed to set limits on what’s going to be reimbursed,” he said. “And if a doctor, in the coding process, uses a code that is not the most accurate code for the explicit purpose of avoiding those limitations, they are trying to get money that they are not owed.” That’s all true. But it also shows just how much is happening under the radar and why virtually every attempt to quantify the size of the gender market yields a conservative estimate. A study published in Medical Care, an official journal of the American Public Health Association, noted that large administrative databases “often do not capture gender identity data, limiting researchers’ ability to identify transgender people and complicating the study of this population.”⁵⁵ The authors retrospectively analyzed administrative claims data for insured adults using two strategies to improve the accuracy of identifying transgender people. They had initially used “gender identity disorder” diagnoses codes to identify transgender people in administrative data. In their retrospective analysis, they looked for “endocrine disorder not otherwise specified” (Endo NOS) codes—which is what Taylor discussed using—and a transgender-related procedure code. They also looked for receipt “of sex hormones not associated with the sex recorded in the patient’s chart (sex-discordant hormone therapy) and an Endo NOS code or transgender-related procedure code.” The researchers identified thousands more transgender-identified patients through this method but found many others who could not be classified.

Given all these inherent difficulties and blind spots, all the known unknowns and unknown unknowns, we can see how the gender market easily has the potential to be much larger than a few billion dollars.

Let’s assume the Williams Institute is correct that there are roughly 300,000 people between the ages of 13 and 17 who identify as transgender. Based on data from the Philadelphia Center for Transgender Surgery,⁵⁶ the cost of fully transitioning ranges from $124,000⁵⁷ to $140,450.⁵⁸ Taking the smaller number and multiplying it by 300,000 still yields a market in excess of $37 billion. Yet even that number would seem conservative to some transgender activists. In an interview with Forbes, Robbi Katherine Anthony (who prefers going by RKA), the CEO of transition tech company Euphoria, said the sex-reassignment market could be as big as $200 billion.⁵⁹

“Our estimates place the average cost of transition at $150,000 per person. Multiply that by an estimated population of 1.4 million transgender people, we’re taking [sic] about a market in excess of $200B. That is significant,” RKA told Forbes. “That’s larger than the entire film industry.”

The $1.4 million figure RKA cited appears to have been drawn from a Williams Institute study published in 2016.⁶⁰ The institute released the latest figure of 1.6 million trans-identified individuals in 2022, two years after RKA’s interview with Forbes. In other words, that already massive market potential has only grown.

It is important to keep in mind that any analysis of the current or potential market size would not include visits to the emergency room, costs arising from conditions and complications related to transitioning, revision surgeries, and so on. For example, a study in the medical journal Plastic and Reconstructive Surgery found that up to a third of patients “undergo secondary surgical revision to address functional and aesthetic concerns after penile inversion vaginoplasty.”⁶¹ A similar study in Aesthetic Plastic Surgery reported that revisions for transfeminine vaginoplasty are frequent.⁶² These are lifetime, repeat customers, and there are more of them all the time. According to a Definitive Health report published in January 2024,⁶³ gender dysphoria diagnoses rose in nearly every U.S. state between 2018 and 2022.⁶⁴ The report also noted that 84 percent of respondents to a survey conducted by the National Center for Transgender Equality said they “liked the idea of using gender-affirming hormone therapy,” while 55 percent were actively using hormones. Surgeries, too, are on the rise, and, according to the authors, “over the last two years, the share of patients paying for gender-affirming surgeries with Medicaid and other government plans has gone up.”

Going a layer deeper, we find the burgeoning transition tech industry, of which people like RKA are a part. Although it has received little attention (for example, it does not factor into the Grand View Research analysis), this sector is well-funded, supported by powerful people, and streamlining the transitioning process.

Take Euphoria, which bills itself as the “Adobe equivalent” for gender transition. In 2021, Euphoria raised more than $250,000 in funding.⁶⁵ Among its prominent backers were Chelsea Clinton and LGBTQ venture capital firm Gaingels, which has raised more than $800 million.⁶⁶ Euphoria digitally escorts users through transitioning with a suite of apps: Bliss, Solace, and Devotion. Bliss is a financial planning app that helps users save money for expenses related to transitioning. Solace provides resources “to guide transgender people through whatever process of gender transition they desire.” RKA calls it a “compendium for gender transition,” with information on everything from how to change your name to how to get health insurance coverage.⁶⁷ Devotion offers “affirmation” messages based on user data. Bliss and Devotion are available to users ages four and up. Solace is available for 17-year-olds to download. It features a “child mode” for “parents and guardians to use on behalf of their child.”

Euphoria’s apps are free, though Solace offered a “set of premium services” for a monthly subscription.⁶⁸ Transgender telehealth companies such as Plum, Folx, and equalityMD are driven by the subscription model. Like Euphoria, they represent a segment of the market that remains unquantified.

Plum charges up to $99 per month for access to healthcare by “a licensed medical provider who is an expert in trans healthcare.” It also facilitates drug prescriptions, labs, telehealth appointments, and more. The monthly fee does not cover the cost of prescriptions. EqualityMD starts its subscription service at $79 per month, which gets users access to therapists, doctors, and nurses certified with “cultural competency training” through the National LGBTQIA+ Health Education Center at the Fenway Institute. Folx offers a comprehensive price list that states at the top: “All costs below do not include your $39.99 monthly membership.”⁶⁹ It shows that an estradiol patch can cost between $175 and $582 every 90 days.

Transgender telehealth and tech were, until recently, uncharted waters. Nevertheless, it has already attracted significant amounts of cash. In 2021, Plum and Folx raised $14 million and $25 million in Series A venture capital funding.⁷⁰ Folx celebrated by boasting that it was the “first national venture-backed queer and trans brand.” That might have been true then. But Folx won’t be the last, for the simple reason that the market for transgender medicine is huge and only promises to grow in ways known and unknown. Transgender tech, for example, raises questions about data mining, which can also be lucrative.

Transition therapy is on the rise in the U.S. even as it is curtailed elsewhere because of the market dynamics and incentives unique to this country. Healthcare is mostly run as a for-profit private enterprise in America, and transgenderism is profitable and only promises to be more so with time. Moreover, medical practitioners will continue recommending and administering blockers, hormones, and surgeries as long as they feel safe from liability.

But rolling back the clock on alleged medical progress is not impossible. It was not so long ago that the prefrontal leucotomy, or lobotomy, was considered a medical miracle. It shares many parallels with transgender medicine.

The lobotomy emerged from the field of experimental neurology at Yale, pioneered by a physiologist named John Farquhar Fulton in the 1930s. After removing the frontal lobes of monkeys, he observed that they became so docile and indifferent that he said it “was as though they had joined a happiness cult.”⁷¹

Egas Moniz, a Portuguese neurologist, believed it was possible to do to humans what Fulton had done to apes. Moniz developed the leucotome, a steel instrument used to sever the connections to the frontal lobe. A series of tests involving patients suffering from schizophrenia ensued. The prefrontal leucotomy was found to be an effective treatment for that and other mental disorders, like depression. Moniz would later win a Nobel Prize for his work.

However, it was the American neurologist Walter Jackson Freeman II who popularized lobotomies as a psychiatric treatment. Freeman was a founder of the American Board of Psychiatry and Neurology. Today, the board instructs diplomates on transgender medicine. And like transgender medicine, the lobotomy was considered effective and basically safe. Freeman lobotomized more than 200 patients by 1942. Through his charisma and manipulation of the media, Freeman portrayed the procedure positively to the public. It did not take long for Freeman to shift his view of the procedure as a last resort to a “treatment of choice.” Moreover, lobotomies were fairly simple to do, which made them a good source of revenue. That also added to its perception as a miracle cure. “The urgent hope for the dramatic and the magical in patients; the seductiveness of the facile and quick procedure for the psychiatrist; the exploitation of the easy and the profitable by the least competent therapist led . . . to a sickening abuse of this procedure,” wrote psychiatrist William Gaylin.⁷²

By the 1950s, criticism had grown fierce. The Journal of the Norwegian Medical Association condemned the treatment in 1959 as “random, indiscriminate and lacking in neurophysiological and neuroanatomical insight.” Freeman’s final lobotomy was conducted in 1967. It ended in the death of the patient.

Lobotomies are technically still legal in the U.S. But few, if any, doctors today would perform one. Least of all, on a minor experiencing bodily distress. It would violate the “do no harm” principle and there’s too much liability involved.

Introducing that kind of liability to transgender medicine might be the best way to turn the tide, in addition to state or federal legislation. Detransitioners could hold the key.