There was a feeling, not very long ago, that debating "trans issues" was sort of a niche occupation. Something remote from everyday lives. Well, if that was ever true, it isn't now.
Historically, there has been a distinct pattern in those presenting with gender dysphoria. They were predominantly pre-school aged boys, and they had usually begun signalling their gender confusion from very young - choosing female roles in games, showing dissatisfaction with their own bodies. And they were rare - around 0.005-0.014pc of the population - ie, fewer than 1 in 10,000 people, for natal males, and much lower again, 0.002-0.003pc, for natal females.
This changed about 10 years ago and, currently, around 2pc of high schoolers in the US identify as transgender, an increase of about 1,000pc. The UK has seen an increase of 4,000pc, and three-quarters are now girls.
There has also been a change in the process of how these girls arrive at their sense of identification. Often this has been sudden, without the early signals, and appears in clusters rather than as singular cases. These girls are predominantly white, and middle class. A majority have one or more psychiatric diagnosis, around a third are autistic and almost half have engaged in self-harm prior to the onset of the gender dysphoria. Often, now, identifying as trans occurs before these girls have had any significant sexual experience. These teens - the average age is 12 to 15 - report feeling distressed and isolated.
However, once they adopt a trans identity, they are connected with a supportive and vocal online trans community which is quick to affirm them in their new identity. Through this community, they have access to information around medical interventions to support their trans identity. Having so much information means they are inclined to lead treatment, and are capable of going elsewhere if they don't access what they want.
This is the backdrop against which Abigail Shrier has written Irreversible Damage, a detailed look at the context and consequences of this rise in transgender identity. Shrier, a journalist with the Wall Street Journal, begins this book by making a persuasive case for the steadily growing malaise among girls and young women - "the statistical explosion of bullying, cutting, anorexia, depression, and the rise of sudden transgender identification is owed to the self-harm instruction, manipulation, abuse, and relentless harassment supplied by a single smartphone".
She paints a picture of youth in crisis, looking for solutions to their feelings of anxiety, isolation and self-dislike. However, she is openly sceptical about what she describes as "the current trans epidemic plaguing teenage girls", saying this has little to do with the experiences of adults who transitioned in previous generations. In fact, she says, "The Salem witch trials of the 17th century are closer to the mark. So are the nervous disorders of the 18th century... Anorexia nervosa, repressed memory, bulimia, and the cutting contagion in the 20th." For these girls, she says, "distress is real. But... self-diagnosis, in each case, is flawed."
Irreversible Damage is a dense and troubling read, although Shrier's style is engaging. The sheer weight of information takes some grappling with. The debate is intensified by the very stark reality - that rates of anxiety, depression, self-harm, and suicidal ideation for transgender youth, adolescents, and even adults are shockingly high. Shrier tackles the question of whether gender dysphoria is causing the suicidal ideation, and asks, is there evidence that affirming these young people improves mental health problems? The answer, she says, seems to be no.
At the core of the debate is this: a growing number of teenage girls who are deeply unhappy, who do not wish to pursue the lives they see laid out for them, and who have chosen a radical refutation of that life, saying, "I am, at a fundamental level, someone else."
Shrier questions the reception these girls and young women get when they first apply the word "trans" to themselves. She points out that being trans has no scientific markers. It can't be measured or analysed. It depends on an individual's say-so, and can begin with statements such as: feeling different, not fitting in, feeling uncomfortable in your body.
Her point, and it's a fair one, is that there is scarcely a teenage girl alive who won't answer yes to those. Those feelings are the fundamental condition of adolescence. And therefore she advocates "watchful waiting" over affirmation and intervention.
If all these were academic arguments, there wouldn't be much urgency to them. The trouble is, that having once identified as transgender, there are routes for these young people that involve significant medical intervention. There is the question of puberty blockers (previously used to chemically castrate sex offenders), and whether these are a harmless way to "buy time", and then, later, cross-sex hormones, and surgery.
But halting puberty is not without health consequences, including the risk of suppression of normal bone density development and greater risk of osteoporosis, loss of sexual function, interference with brain development, and possibly suppressing peak IQ. These are the physical effects. There are also the psychological effects of remaining in a child-like state while their peers grow and mature. For girls wanting to transition, next comes the question of testosterone, and that too has health implications, including risks of vaginal atrophy, muscle aches, painful cramping due to endometriosis, painful orgasms, increased sweating, moodiness, and aggression. Long-term effects include heightened rates of diabetes, stroke, blood clots, cancer and heart disease.
Shrier's final chapter contains a series of steps parents can take in order to try and enhance their daughters' well-being, and much of this consists in celebrating what it means to be female. She rightly makes the point that far too much of the discourse around being female is negative. Instead, here, alongside such fundamentals as - take away their smartphone, assert your authority as a parent - Shrier recommends talking about how wonderful it is to be a girl and celebrating all the glorious ways in which girls are different to boys.