Kidney Markets and Gender-Affirming Care

Why you shouldn't overrate the trans issue

Conservatives are disgusted with the idea of providing “gender-affirming care” to minors. Liberals, in contrast, consider being able to do so one of the great human rights issues of our time.

Whenever there’s a political debate that interests me, one of the first things I usually do is look for some basic statistics on what is going on. Recently, Reuters provided what I believe are our first nationwide estimates based on reliable data. In 2021, around 42,000 kids between 6 and 17 were diagnosed with gender dysphoria, a 75% increase from the previous year. But only around 4,200 initiated hormone treatment, 1,200 started on puberty blockers, and 282 got “top surgery.” What is euphemistically called “bottom surgery” for minors appears to be extremely rare. The treatment numbers are probably an underestimate since they only include those that are covered by insurance and come with a gender dysphoria diagnosis, but given how our medical system works they probably capture the vast majority of cases.

All total, we can therefore say at most maybe around 7,000 children a year between the ages of 6 and 17, out of 49 million total, initiate some kind of potentially irreversible process. This comes out to about 1 in 7,000 kids. Just looking at those diagnosed with gender dysphoria, it’s closer to 1 in 1,200, but if they’re not getting chemical or surgical interventions, it’s not that big of a deal. To put these numbers in some perspective, 1,777 juveniles were murdered in the US in 2020, more than those recorded as receiving top surgery and puberty blockers combined.

Biden talks to trans leader. Source.

Every year, thousands of Americans die because they can’t find a kidney donor. One estimate says 4,500 in 2012, and another 43,000 as of a 2018 study. The exact numbers don’t matter that much for deciding what to do about the problem, as they are almost all completely preventable deaths. The risks to a kidney donor are very small, relative to the fact that they can help save a life. Apparently, most of us are walking around with a spare kidney we don’t really need, while perhaps tens of thousands each year go to the grave because theirs have failed. If we were an altruistic species, people would be lining up to donate their kidneys, but we’re of course self-interested, so we don’t. Without extreme social pressure behind a cause, we virtue signal only until there is a real cost, even if it’s small.

Still, there is a natural solution to this problem. You can let the people who have an extra kidney sell one of them to those who need it more. Unfortunately, in 1984 Congress passed the National Organ Transplant Act, which banned the sale of organs. There’s no plausible reason for this policy. If you worry about the poor being taken advantage of, simply set a price high enough, and give government subsidies if you must (you’ll remove from the market poor people who probably need the money the most, but policies like this make people feel good). Even if donors did get a bad deal, the harms they would face couldn’t possibly match the harms to potential recipients that result from banning organ sales. People just find the whole thing icky, even if some might come up with sophisticated sounding phrases like “preventing commodification” to justify continuing this mass murder.

Let’s say you oppose the entire trans agenda. You think it’s all based on lies, and that every child undergoing gender-affirming care is a tragedy. How much should you prioritize the issue compared to everything else in the world? I would argue not that highly.

When I bring up the low numbers involved to people I talk to, they often will point to trans as part of a larger agenda. There are two human sexes, there are natural differences between them, and they have different roles to play in society. Giving credence to the idea that you can be “gender fluid” or “transition” from one sex to the other probably has all kinds of negative mental health consequences, since embracing your own sex is fundamental to being a psychologically well-adjusted human being. Trans ideology is also seen as an assault on concepts like objective reality and truth.

Someone could make an equivalent argument from the left. Why are Democrats so obsessed with defending trans healthcare for minors, despite its unpopularity? An intelligent liberal might say that gender roles are harmful, and we should be trying to subvert them whenever possible. Not only is it good for some kids to get puberty blockers, but when we provide them to children we are striking a blow against patriarchy and for LGBT rights, which are much broader issues.

I’m sympathetic to the conservative view here. If it’s worth standing up to big trans, it’s not because of the kids directly influenced by the movement, but as part of a symbolic proxy battle over differences far more significant than how to medically treat a few disturbed children.

Still, I can’t convince myself that stopping big trans is more important than allowing kidney markets. This is because the latter issue also has symbolic significance, as a manifestation of what Bryan Caplan calls the anti-market bias. And this is an idea that has historically done much more harm than feminism or LGBT rights, serving to justify the enslaving of billions, and even today keeping people around the world much poorer than they otherwise would be. If you have to choose between living under a government that doesn’t believe in gender roles and one that doesn’t believe in markets, you would have to be ignorant or a real crank to choose the socialist patriarchy. And in fact, no one ever makes such a choice, as we can see in migration patterns.

Moreover, I’m not even sure that trans ideology in its popular form does blur gender lines all that much. While some aspects of the official ideology surrounding LGBT stress gender fluidity, the most prominent representatives of the doctrine seem to subscribe to a sort of gender essentialism that has otherwise gone out of favor over the last half century. Conservatives have criticized Dylan Mulvaney and other trans activists for engaging in a kind of minstrel show with women as the target. One may lament such disrespectful behavior, but it seems to reinforce a belief in sex differences and gender roles rather than subvert them.

I’m only using kidney markets as one example of a cause that you should care more about than trans. There are of course many others, and I’d argue that, no matter what your politics, you probably give too much thought to the issue.

I think that the focus given to trans issues on both sides reflects our general obsession with sex. I confess to sharing in this obsession! But rationally it makes little sense.

That being said, if conservatives want to use trans as a wedge issue in order to gain votes and otherwise enact desirable policies – hopefully like legalizing organ markets – that’s fine. But the question at that point is whether talking about the subject is politically useful, rather than being about its inherent importance.

If I was going to give advice to liberals, it would be to not underestimate how much this issue serves as a kind of glue that motivates the right and holds it together. Nothing that Democrats or the media say about “misinformation,” “fake news,” or “election deniers” can ever reach conservatives as long the left keeps taking the positions that it does on gender identity. In conversations among conservatives, I have found that someone referring to trans issues shuts down any debate about just how crazy liberals are, with everyone agreeing that, yes, the fact that they are like this makes it absolutely essential to keep them out of power. Even among the general public, perhaps nothing contributes more to the popular perception that American elites are out of their minds. Just as how this issue shouldn’t be that important to conservatives, liberals are similarly making an error when they let trans activism subvert their other political goals. But for them it’s a much more consequential mistake, as they are also on the wrong side of public opinion.