Transgender medicine and the “coalition of the fringes”

Wilfred Reilly began from an article he had written for National Review about transgender mass shooters.** He argued that the usual public definition of “mass shooting” had become so broad that it mixed gang attacks, domestic killings, and Columbine-style attacks into one bucket. Using the narrower definition he preferred, he said transgender or non-binary shooters were markedly overrepresented among recent cases. His next question was physiological: what happens when a biological female receives male-range testosterone without having spent adolescence learning to manage the aggression, libido, and physical changes that accompany it?

Testosterone is an endogenous hormone, and replacing a deficiency differs from giving a biologically normal female enough testosterone to induce male secondary sexual characteristics. Reilly’s concern went beyond terminology. “Pure testosterone is a pretty powerful drug,” especially for what is effectively experimental manipulation in young people.

Reilly found that a large majority of children with gender dysphoria eventually grew out of it if allowed to pass through puberty without medical transition. “Up to ninety percent of these kids will just get through this phase if they’re just allowed to get through this phase,” he said. He regarded the “affirmational model” (sic) as an inversion of ordinary clinical reasoning because it could move quickly from a child’s stated identity toward social transition, puberty suppression, hormones, and surgery without first resolving trauma, autism, sexual abuse, or ordinary pubertal distress.

The central problem, for Reilly, was physical reality. Hormones and surgery can alter appearance, while chromosomal sex, skeletal structure, reproductive anatomy, and other sex-linked features of the body remain. “You can’t actually become the opposite sex,” he said. He later sharpened the point with a computer analogy: “The problem isn’t hardware not matching software, if you will, it’s software not matching hardware.”

That claim has consequences beyond medicine. If sex is a biological category, women’s sports, prisons, changing rooms, and other sex-separated spaces cannot operate coherently when self-declared identity overrides sex. Reilly noted that genetic testing can identify biological sex from saliva, blood, or other tissue even when a person identifies otherwise. The body continues to provide information that language cannot erase.

The same contradiction appears in politics. Reilly compared transgender identity with transracial identity. Activists generally reject a white person’s declaring himself black, especially when racial identity controls scholarships, preferences, or reparative claims; yet some of the same institutions accept a male person’s declaring himself female, even where sex controls protected spaces or athletic competition. Reilly traced the resulting conflict inside feminism, where women organized around sex-based interests increasingly found themselves in organizations that defined womanhood through identity.

He called the larger arrangement the “coalition of the fringes,” borrowing a phrase he attributed to Barack Obama. The coalition tries to gather groups outside an imagined mainstream into one political bloc. Reilly’s objection was structural: many of those groups have incompatible interests. “The members of the Coalition of the Fringes have nothing in common and hate one another,” he said, using feminism and Islam, labor and illegal immigration, and women and transgender activists as examples.

The same principle carries into addiction policy. Reilly argued that elite reformers often apply theories to poorer people that they would never use within their own families. Looking at my work on the forgotten early opioid wave and methadone, he asked what had not been tried, then answered with the ordinary standards of family life: limits, abstinence, treatment, and consequences. “A good starting point would be the solutions that the members of the upper class would apply to themselves and their families if they had these problems.” Reality places limits on theory. Medicine, politics, and social policy become unstable when words are required to outrank bodies, incentives, and observed behavior.

**(recorded April 19, 2024)