Medicine’s conscience

The care of gender-distressed young people demands scientific curiosity and a willingness to admit mistakes

Dianna Kenny

“Medicine is a science of uncertainty and an art of probability.” Sir William Osler

Every generation of physicians inherits two legacies: the discoveries of medicine and its mistakes. The first is celebrated. We rightly honour those whose insight, perseverance and compassion have relieved suffering and saved, prolonged and transformed our lives.

The second legacy receives less attention. It resides not in our monuments but in our memory—in abandoned treatments, discarded theories and the sobering recognition that medicine has, at times, continued practices long after evidence of their harms had become known. Bloodletting continued for centuries despite mounting clinical observations that it frequently weakened and hastened death rather than healed. Lobotomy survived long after devastating cognitive and emotional consequences, including irreversible personality changes, had become evident and which rendered lobotomised individuals “ruined human beings”. Its originator, António Egas Moniz, was awarded the Nobel prize in 1949.

Mercury remained a treatment for syphilis despite its recognised toxicity. The horrific side effects—which included tooth loss, severe ulcerations, neurological damage, kidney failure and death—were often rationalised by doctors as the “disease leaving the body”. Heroin and radium-based patent medicines continued to be marketed long after their dangers were increasingly apparent. More recently, recommendations that infants sleep in the prone position persisted despite accumulating evidence of increased mortality by sudden infant death syndrome until systematic re-evaluation transformed neonatal care. These examples differ in their scientific context, but they share an uncomfortable lesson: medicine does not always abandon harmful practices as quickly as hindsight suggests it should. Why?

The answer is rarely ignorance alone. History reveals that the correction of medical error is often delayed by forces extending well beyond the evidence itself. Scientific evidence is indispensable, but for practice to change, evidence must first overcome the psychological, social, economic and institutional forces that resist its implications.

History is therefore more than a record of medicine’s past. It is medicine’s conscience. It reminds us that the greatest threat to scientific medicine has seldom been a lack of intelligence or compassion.

More often, it has been the gradual erosion of the epistemic virtues upon which scientific progress depends: intellectual humility, curiosity, openness to criticism, tolerance of uncertainty and the willingness to revise cherished assumptions when new evidence demands it.

These virtues are not signs of indecision. They are the disciplines that distinguish science from ideology and clinical wisdom from clinical certainty.

The challenge of gender distress

The lesson of history is not that new ideas should be feared, but that they should remain open to the same dispassionate scrutiny that ultimately distinguishes scientific progress from medical fashions. Few contemporary areas of medicine test these principles more profoundly than the care of children and adolescents experiencing gender-related distress. During the past decade, youth gender medicine has become one of the fastest-growing, most ethically contested and most socially charged areas of clinical practice. It has also become one of the most difficult environments in which to ask ordinary scientific questions.

Questions regarding long-term outcomes, developmental trajectories, informed consent, psychological assessment, adverse effects and alternative models of care have increasingly become intertwined with political advocacy, institutional reputation, professional identity and broader cultural debates. Under such circumstances, maintaining the habits of mind that have traditionally protected medicine from error becomes especially challenging. This essay does not seek to resolve every controversy surrounding youth gender medicine. Rather, it asks a more fundamental question.

What happens when the conditions that enable medicine to correct itself begin to erode?

Throughout the history of medicine, episodes of delayed self-correction have displayed recurring features. They have rarely resulted from a single cause or a single individual. More often, they have reflected the convergence of institutional, psychological, social and economic forces that made re-examination increasingly difficult, even after evidence of harm had begun to emerge.

---

Two-phase science: Science shifts into revolutionary mode when unexplained anomalies mount up and force the overthrow of a scientific paradigm, according to philosopher of science Thomas Kuhn.

Paradigm pitfalls

Thomas Kuhn observed that scientific communities work within paradigms—shared assumptions that determine which questions are asked, which observations are considered important and which explanations appear plausible. Paradigms are indispensable. Without them, scientific inquiry would become directionless. Yet paradigms also possess a remarkable capacity for self-preservation. Anomalous findings are often regarded initially as exceptions rather than invitations to reconsider prevailing assumptions. Only when contradictory evidence accumulates beyond a critical point does the profession begin the slow process of re-evaluation. Medicine is no exception.

Indeed, the stakes are often higher because therapeutic paradigms become intertwined with professional training, institutional reputation, public policy, regulatory frameworks and the understandable desire of clinicians to believe that they are relieving rather than causing suffering. Under such circumstances, abandoning an established model of care requires considerably more than new evidence. It often requires a willingness to question one’s own professional identity. Financial incentives can reinforce existing practices by rewarding their continuation and discouraging alternative approaches.

Recovered memory therapy illustrates how a compelling therapeutic narrative, reinforced by professional conviction and moral urgency, can become resistant to methodological criticism even after concerns regarding suggestion and false memories began to emerge. Each example differed in its particulars, yet each reminds us that medicine’s greatest challenge is not discovering new knowledge but relinquishing old certainties.

Regulatory environments create additional caution if clinicians fear that questioning accepted practice could expose them to professional sanction. There have been many recent examples of health practitioners losing their registration and facing court for expressing opinions in opposition to the prevailing zeitgeist. This is a major impediment to reversing harmful practices in gender medicine; that is, the institutional capture of organisations that create laws, policies and practices.

Equally powerful are the psychological forces that influence every human enterprise. Among the most important is identity-protective cognition. Social psychologists use this term to describe our tendency to interpret evidence in ways that preserve beliefs central to our personal or professional identity. Physicians are no more immune to this tendency than anyone else. When a particular model of care becomes closely associated with one’s understanding of compassion, ethical practice or professional integrity, disconfirming evidence can be experienced not merely as an intellectual challenge but as a threat to one’s moral identity.

Closely related to identity-protective cognition is moral identity investment. These are not accusations. They are ordinary features of human cognition. Clinical positions sometimes become woven into a physician’s sense of being a “good and compassionate” doctor. Under these circumstances, changing one’s mind carries a psychological cost extending well beyond scientific disagreement. It may feel like an admission of having failed patients, colleagues or deeply held moral commitments. Such pressures are rarely acknowledged explicitly, yet they can exert a profound influence on the interpretation of evidence.

Every generation of physicians eventually encounters a clinical problem that tests not only its scientific knowledge but also its intellectual character. Such moments ask more of the profession than technical competence. They ask whether medicine retains the capacity to examine itself with honesty, to distinguish evidence from advocacy and to revise accepted practice when accumulating evidence begins to challenge prevailing assumptions. Youth gender medicine represents such a moment.

The imperative to investigate

The rapid increase in presentations of children and adolescents experiencing gender-related distress has been one of the most striking developments in modern clinical practice. Particularly notable has been the demographic shift from predominantly natal males presenting in early childhood to predominantly adolescent natal females presenting during or after puberty. Such a dramatic epidemiological change should stimulate scientific curiosity. In medicine, unexpected changes in disease patterns are not inconveniences to be explained away. They are invitations to investigate. They encourage clinicians to ask what has changed, why it has changed and whether multiple causal pathways may be contributing to apparently similar clinical presentations.

Yet one of the most remarkable features of the contemporary debate about gender-related distress has been the extent to which ordinary scientific questions have themselves become controversial. Questions regarding developmental trajectories, spontaneous resolution, co-occurring psychiatric disorders, autism spectrum disorders, family dynamics, trauma histories, peer influences, and online communities have, at various times, been interpreted not simply as scientific questions but as moral or political statements. So, too, with questions about informed consent, long-term outcomes, fertility, sexual function, bone health, neurodevelopment and psychological formulation. Clinical caution has sometimes been portrayed as a lack of compassion or equity.

Medicine has always depended upon the freedom to ask difficult questions. The physician’s first responsibility is not to confirm or deny a patient’s explanatory framework, but to understand it. Curiosity is the beginning of diagnosis. It is also the beginning of psychotherapy, developmental formulation and scientific inquiry. Once curiosity is constrained by ideological expectations, and demands for conformity supersede scientific inquiry, medicine risks exchanging investigation for affirmation and hypothesis for conclusion. This concern extends beyond individual consultations. It raises broader questions regarding the conditions under which evidence can be examined objectively.

Throughout the history of medicine, therapeutic orthodoxies have often become closely aligned with professional identity. When this occurs, questioning accepted practice may be experienced as questioning the integrity or compassion of those who provide it. Contemporary social psychology offers helpful frameworks for understanding this phenomenon—social contagion, conformity and groupthink, the use of shaming and scapegoating to create in-groups and out-groups, and political correctness, which in its extreme form is known as wokeism.

Advocacy’s trap

Youth gender medicine presents additional challenges. Unlike many areas of clinical practice, it has evolved within an environment characterised by extraordinary social and political attention. Advocacy organisations, professional colleges, governments, educational institutions, social media platforms, activist networks and traditional media have all become active participants in shaping public understanding of gender identity and appropriate models of care. Such involvement is understandable.

The welfare of vulnerable young people rightly attracts public concern. Yet the convergence of advocacy and medicine has historically required exceptional vigilance. Medicine functions best when clinical questions remain open to clinical investigation, even when they intersect with matters of profound moral importance. The profession must therefore guard against allowing therapeutic orthodoxy to become insulated from critical appraisal. This does not imply that current models of care are necessarily incorrect. It does imply that no model of care should be regarded as beyond re-examination.

Systematic evidence reviews in several countries including the UK, the US, Sweden, Finland, and Germany have all converged on the same conclusion regarding the very-low quality of evidence for the practice of youth gender medicine. Increasing emphasis on comprehensive psychological assessment and recognition of continuing uncertainty regarding long-term outcomes, illustrate that international medicine is already engaged in such reappraisal, demonstrating that medicine is attempting to perform one of its most important functions: the willingness to revisit accepted practice when evidence evolves and correct itself when shown to be in error. Whether that process continues will depend not only upon future research but also upon the profession’s willingness to sustain dispassionate collegial scrutiny despite social, political and institutional pressures.

History offers a consistent warning. Medicine is least able to correct itself when questioning prevailing orthodoxy becomes professionally costly. That warning deserves careful consideration today. The issues raised by youth gender medicine therefore extend beyond endocrinology, psychiatry or adolescent medicine. They concern the integrity of scientific medicine itself. They ask whether clinicians remain free to investigate complex developmental phenomena without predetermined conclusions; whether competing hypotheses may still be examined respectfully; whether evidence that challenges established practice can be discussed without fear; and whether the welfare of individual patients remains the profession’s overriding concern. These are not merely questions about gender medicine. They are questions about the future nature and practice of medicine.

Professor Dianna Kenny is the author of Gender ideology, Social Contagion and the Making of a Transgender Generation (Cambridge Scholars Publishing, 2024.) Use the code AUTHOR40 to get a 40 per cent discount. She is also the author of inTRANSigence: Gender Ideology, Social Contagion, and the Scandal of Youth Gender Medicine (Hexa, 2025.)