The doctrine of covenant signs is, at every turn, the doctrine of grace—what we receive from God is his promise to be our God and to have us as his people. We do not self-constitute as members of his family; we are included under his wings as he spreads them over us in covenant love. 

Abstract
The figure of Abraham creates a covenantal framework for biblical theology that allows baptism to be considered in relation to the Bible’s developing story line. On this credobaptists and paedobaptists agree. I suggest, however, that reflecting on Abraham also requires baptism to be located in relation to the doctrines of Christology and anthropology, and the theology of divine agency in covenant signs, in a way which points to the validity and beauty of infant baptism. Locating baptism in this way sketches a theology of paedobaptism which has a richer view of Jesus, a more attractive understanding of creation, and a more powerful conception of what God is doing in the sacraments than is present in credobaptist theology.

That feeling of a baby’s brow against the palm of your hand—how I have loved this life.—Rev. John Ames, in Gilead.1
Collin Brooks wrote that the difference between David Lloyd George and Winston Churchill in a debate was that while Lloyd George had the gift of getting on the right side of a man, Churchill had the gift of getting on the right side of a question.2 Christian brothers in debate are charged with emulating both British Prime Ministers: there is a need to be on the right side of our brethren and the question. The former is surely not difficult; the latter is arguably more difficult.
Debating baptism-its mode, its subjects, and its meaning-is notorious ground for speaking past each other, precisely because the folly of standing on any other ground can seem so self-evident to both sides. Furthermore, changing one’s mind on the issue is connected to so many more issues than merely theology. Livelihoods, family relations, professional careers, and even ministries are often weighty factors in how one reaches decisions. Upton Sinclair said, ‘It is difficult to get a man to understand something when his salary depends on his not understanding it.’3 In light of this, some may suggest the waters are best not muddied any further.
Martin Salter and I have a good track record of ignoring such suggestions, and have previously thrown ourselves into each other’s shallow and deep waters respectively in the attempt to convince that the other position is mistaken.4 Now we are going to try again. Perhaps this is naïve. But we are going to try boldly. Churchill said, ‘Success is stumbling from failure to failure with no loss of enthusiasm.’
The task in our essays is to explore the place of Abraham in the theologies of baptism espoused by padeobaptists and credobaptists.5 In this article I will treat Abraham in paedobaptist theology by suggesting that the question we need to be on the right side of is this: Who is a child of Abraham? We could inflect it slightly: How does one become a child of Abraham? Some may feel this is the wrong question and that it skews the whole presentation; others will think it is the right question but that I am on the wrong side of the right answer. But I ask it precisely because I take it to be the question which Paul is engaging and answering in the polemical sections of Romans and Galatians. Any perspective on Abraham and the theology of baptism can emerge only on the other side of trying to answer this question first of all.
I will make my case with three points, and for the sake of interest will frame my points polemically against the credobaptist position. I will argue that the credobaptist approach to the Abrahamic covenant has, first, an inadequate Christology; second, an unbiblical anthropology; and third, a reductionist theology of baptism. Put differently, Abraham in paedobaptist perspective reveals credobaptists to have an impoverished view of Jesus, a dualist doctrine of creation, and an anemic conception of divine agency in covenant signs. These points are intended to widen the lens of a potentially moribund debate and to provoke a spirited-but-smiling interchange among brothers, not a bitter exchange among opponents.6
1. The Christology of Baptism: Its Covenantal Structure
Credobaptists argue that Christ as the seed of Abraham is a fulfillment motif which renders invalid the genealogical principle on which the practice of paedobaptism rests so heavily. The genealogical principle is what we find in Gen 17:7 and passim: ‘I will establish my covenant as an everlasting covenant between me and you and your descendants after you for the generations to come.’ What God establishes with Abraham, as head of his family and household, God also establishes with his family and household, and that principle within the covenant of grace continues across both old and new administrations. But here is the credobaptist objection:
[T]he covenantal argument for infant baptism also fails to see that the genealogical principle is transformed across the covenants; it does not remain unchanged. Under the previous covenants the relationship between the covenant mediator and his seed was primarily physical-biological (e.g., Adam, Noah, Abraham, Israel, David). But now, in Christ, under his mediation, the relationship between Christ and his seed is no longer physical but spiritual, i.e., it is brought about by the work of the Spirit, which entails that the covenant sign must be applied only to those who in fact profess that they are the spiritual seed of Abraham.7
With such highlighting of the spiritual seed of Abraham, one could easily get the impression that this aspect of biblical theology is unknown to classic Reformed theology. In fact, it is not a challenge to paedobaptism, precisely because the Reformed understanding of how the covenant is fulfilled in Christ is far richer and more nuanced than many standard Baptist presentations.
Although the contexts are not identical-and there are important differences and nuances in argument-Abraham is a major player in the argument of Paul’s letters to the Galatians and Romans.8 In each case, Paul is concerned to show that the righteousness which justifies comes from God through faith in Jesus Christ, and not by works of the law. Douglas Moo argues that Paul singles out Abraham as the reference point for expanding his argument, not just because the Jews saw him as their father, but because he was esteemed as the exemplar of Torah-obedience with his righteousness tied to that obedience. In contrast, Paul seeks to show this was not in accord with OT Scripture. More than this, Paul focuses on Abraham ‘because of the decisive role the OT gives to him in the formation of the people of Israel and in the transmission of the promise. Both Paul’s insistence that justification is by faith alone and his concern for the full inclusion of the Gentiles in the people of God make it necessary for him to integrate Abraham into his scheme.’9
In Galatians, the particular context is table-fellowship with Gentiles and the argument from Abraham is introduced with the issue of whether the reception of the Spirit is based on observing the law or faith in Christ. In Romans, the argument from Abraham is connected to how the circumcised and uncircumcised are justified. In both cases, Paul is expounding Gen 15:6 against his interlocuters: “Abraham believed God, and it was credited to him as righteousness.” The matter of sequence is absolutely crucial: Abraham believed God and was counted righteous before he received the sign and seal of circumcision. This sequencing of faith first, and everything else second, is at the heart of Paul’s argument as to why the Gentiles can now be treated as righteous in God’s sight without being circumcised or observing the law. For it was always so.
In Galatians, however, the matter of sequence is tied to a bigger issue of chronology. It is not just important that faith came before circumcision; it is just as important that the promise came before the law. Paul’s understanding of biblical chronology is the key to Gal 3, and it is what we need to see in examining v. 16, which is one of the central verses credobaptists use in developing their fulfillment critique of the genealogical principle: ‘Now the promises were made to Abraham and to his offspring. It does not say “And to offsprings”, referring to many; but, referring to one, ‘And to your offspring’, which is Christ.’
The strangeness here is not really Paul’s singular understanding of the collective plural noun-there are good ways of understanding this.10 Rather, the question here is: why does Paul need to make this point at all? Why does he need to say the promises were spoken to Abraham and Christ? Answer: chronology.
For if chronology is the linchpin of Paul’s argument-which came first, promise or law?-then notice that by so arguing, Paul has a problem. It is easy to prove that the Abrahamic covenant came before the Sinai covenant, that promise came before law, but then did not the law come before Christ? Paul is going to argue in v. 17 that the covenant came first and the law (430 years later) cannot annul what came first. But Paul’s own argument about chronology could be turned against him by the Judaisers; it does not help to argue that what comes earlier is more foundational when the law comes earlier than Christ.
This is why v. 16 is so important. Paul is saying that the promise, which came first, was in fact a promise given to Christ and not just to Abraham. F. F. Bruce says that the prefix προ in προκεκυρωμένην (v. 17) indicates that the covenant was validated at the time it was given, long before the law, and was complete in itself with all the confirmation it required from the authority of the God who made it.11 That covenant, validated before the law arrived, was a covenant with Christ. So if Christ is the seed of Abraham who received the promises as well as him, then there is a vital sense in which, while Christ appeared after the law, he nevertheless also preceded it. I think this point is essential to Paul’s argument. Before Moses ever appeared on the scene, before Sinai, Paul is arguing that Abraham’s covenant was also Christ’s covenant.
This means we need to nuance the language we use when speaking here about Christ and the promises given to Abraham. Salter uses the word ‘fulfillment’ on several occasions, and that is right and proper, but I would argue that staring at Gal 3:16 leads us to say not just that Christ fulfills the promise to Abraham but that the promise was made to him as well. To be clear, I am not suggesting that Paul is here arguing for, or dependent on, belief in Christ’s pre-existence; that is not his point. Rather, the assertion is simply that when Christ appeared in time he did so as the one with whom the Abrahamic covenant was made, not simply as the one who fulfilled it. For that is what the text actually says. Christ’s relationship to the promise is twofold: he received it, as well as fulfilled it.
As far as I can tell, this perspective has been all but lost in modern biblical studies. But a text like Gal 3:16 was fertile ground for the development in classical Reformed theology for the belief that the covenant of grace was made with Christ in a way which structured the way in which it was also made with Abraham and his seed. This verse funded the belief that Christ is not just the fulfiller of the Abrahamic covenant; he is also the foundation of it. The position is well expressed in The Westminster Larger Catechism:
Question 31. With whom was the covenant of grace made?
The covenant of grace was made with Christ as the second Adam, and in him with all the elect as his seed.
This is not exegetically unwarranted. Bruce says of Paul’s surprising point in Gal 3:16: ‘In the first instance the reference is to a single descendant, Christ, through whom the promised blessing was to come to all the Gentiles. In the second instance the reference is to all who receive the blessing; in v. 29 all who belong to Christ are thereby included in Abraham’s offspring.’12
In the great federal passages Rom 5 and 1 Cor 15, Paul does not argue from Adam and Abraham, but from Adam and Christ as the two great covenantal heads. In Isa 42:6, the Lord addresses his servant: ‘I will keep you and will make you to be a covenant for the people and a light for the Gentiles.’ Christ is a covenant representative, the second Adam who restores what the first Adam lost, and so he is the mediator of the covenant of grace and the head of a new humanity. Focusing on Adam and Christ is a startling bypassing of the whole story of Israel and the promises to Abraham, unless, of course, what God was doing redemptively in Abraham and the promises is somehow included in what God was doing in Christ.
This is what Reformed theology has argued. Bavinck, for instance, says that Noah, Abraham, Israel and others were not the actual parties and heads in the covenant of grace (although we might say that the choice of ‘actual’ is infelicitous): ‘On the contrary, then and now, in the Old and New Testaments, Christ was and is the head and the key party in the covenant of grace, and through his administration it came to the patriarchs and to Israel. He who had existed from eternity, and had made himself the surety, also immediately after the fall acted as prophet, priest, and king, as the second Adam, as head and representative of fallen humankind.’13
This understanding within Reformed theology itself became the soil in which grew the idea of a covenant of redemption, the pactum salutis, which helped to distinguish within the covenant of grace as it was ‘ready-made from all eternity’ between the three persons of the Trinity with Christ as head and guarantor, and as it was applied and executed in time with Christ as mediator.14 The covenant of grace is founded on Christ, fulfilled in Christ, and bequeathed by Christ.15 This understanding is nicely expressed in The Westminster Confession of Faith, chapter eight, on Christ the Mediator:
It pleased God, in his eternal purpose, to choose and ordain the Lord Jesus, his only begotten Son, to be the Mediator between God and man; the Prophet, Priest, and King; the Head and Saviour of his Church; the Heir of all things, and Judge of the world; unto whom he did from all eternity give a people to be his seed, and to be by him in time redeemed, called, justified, sanctified, and glorified.16
The credobaptist critique of the genealogical principle works by focusing on Christ as the fulfillment of the covenant of grace, but it is undermined by not reflecting at all, as far as I can see, on the fact that Christ is its foundation before he fulfills or bestows it. Salter and others, such as Gentry and Wellum, argue that the covenant of grace is a story with a destination that paedobaptists have failed to arrive at: it is heading somewhere, namely, to fulfillment in Christ. But I wish to suggest that the covenant of grace is a story with a beginning that credobaptists have failed to start: it is founded on Christ before it ever progresses to Christ. The credobaptist traces a line from Abraham to Christ, but in reality the line to be traced is from Christ to Abraham to Christ again. Abraham is Christ’s seed, before Christ is ever Abraham’s seed.
Two implications follow. First, notice what this does to Gentry and Wellum’s argument that under the previous covenants (Adam, Noah, Abraham, Israel, David) the relationship between the covenant mediator and his seed was primarily physical-biological. That simply cannot be true. If from all eternity the Father gave to his Son a people to be his seed, the foundational relationship has always been spiritual, not physical (although I hasten to add that I dislike Gentry and Wellum’s distinction between physical and spiritual, at least as they understand it). In other words, the primary relationship between God and his people is a decretal one, primary in the sense of being logically and chronologically prior to any outworking of that relationship in space-time history. The seed are in Christ before they are in the world. Arguing for ‘physical-biological’ in the old covenant and ‘spiritual’ in the new is first and foremost the result of an inadequate Christology.
This leads to the second implication. It is this understanding of the covenant of grace which provides a deep covenantal foundation to the way that Paul is arguing in Galatians and Romans. What we find in Salter’s work, and also at the heart of Gentry and Wellum’s critique of paedobaptism, is that in the new covenant the primary relationship between God and his people is a spiritual one based on faith: ‘all of the realities of the new covenant age and the benefits that come to us are because of our faith union in Christ.’17 Paedobaptists, of course, do not disagree with this. On the contrary, if the covenant of grace is made with Christ and his people who are his seed, then it follows that he does not save them in two different ways, either physically in the old covenant and spiritually in the new covenant, or by the law or works or circumcision in the old covenant and by faith in the new covenant. Paul’s whole point in both Romans and Galatians is that there has only ever been one way of salvation, and it is by faith, and neither by bloodline nor Torah-obedience.
To try and put this even more clearly, Paul cannot be arguing that because Christ is the fulfillment of the promise, the genealogical principle is therefore invalidated. For the very promise, being founded on Christ, in itself and from the moment it was given, showed that genealogy was never a guarantee of inheritance or true sonship. The genealogical principle could be as invalid at the time of Abraham as it was around a meal-table in Antioch, as Peter says, ‘thanks, but no thanks,’ to the ritually unclean. Paul rebuked Peter because it was his very genealogy (‘we who are Jews by birth know that . . .’) which should have taught him that neither it nor the law makes him clean: he was not justified by being either a Jew, or a law-keeper, or by being both together (Gal 2:15). The repeated rebuke of the prophets to Israel was that genealogy as a source of religious pride was an insult to the God who himself had instituted the genealogical principle!
From the beginning of the covenant with Abraham onwards, you could be a son of Abraham and a child of God. From the beginning, you could be a son of Abraham and a child of the devil. From the beginning, you could be a Jew and yet not be a Jew (Rom 2:28-29). You could be a son of Abraham and yet not be a son of Abraham. From the beginning, you could be circumcised and have Abraham as your father, or not have him as your father, depending on whether you walked in his footsteps of faith or not. From the beginning, you could be uncircumcised and have Abraham as your father, or not have him as your father, depending on whether you had his faith or not. It is not that there is now a spiritual understanding of the genealogical principle-it was always there.
This is an attempt to argue that if Paul is saying that the promise fulfilled in Christ introduces something fundamentally new into the Abrahamic covenant, then Paul’s argument in Romans and Galatians falls apart, for its very logic depends on him giving the Judaisers their own Scriptures and showing them that what he is saying is not, in fact, new but has always been the case. Rather, what is new now is that because the curse of the law has been removed in Christ, the gates to God’s family are taken off their hinges. In Christ, the genealogical principle is not abandoned; it is recalibrated to a truly international scale.
One of N. T. Wright’s chapter headings in his latest book on Paul, where he treats Rom 4 and Gal 3, is ‘The People of God, Freshly Reworked’.18 I think the Reformed, with our stress on the one people of God throughout all of Scripture, can be comfortable with this. For as a concept, at least, the idea of a fresh reworking of God’s people is not in the introduction of something radically new into the covenant, but in how the death of the Messiah under the curse of the law allows what was always there now to be drawn out and come to fruition: a single family of Jew and Gentile in covenant relationship to the God who made the world. The gospel announced in advance to Abraham that all nations would be blessed through him can now in fact be taken to the nations-the death and resurrection of the Seed of Abraham sets free a world imprisoned by sin by lifting the curse pronounced against it. But this is a change in scale, not in soteriology. It is a change of administration, not a change of substance or structure. The Mediator is one. The covenant is one. Salvation is one. ‘Abraham believed God, and it was credited to him as righteousness.’ For Jew, Gentile, Christian, it is and always has been so.
Who is a child of Abraham? Abraham and Paul both return the same answer to our question. Old covenant and new covenant, the answer is the same: a child of Abraham is one who has the faith of Abraham in the God who gives righteousness to those who believe. A child of Abraham is one who has faith in Christ and belongs to Christ (Gal 3:29). How do you become a child of Abraham? By coming to Christ and believing in him. You become a child by having faith.
2. The Anthropology of Baptism: Its Covenantal Subjects
I am aware, of course, that the final lines of the above point are precisely where my credobaptist brothers and sisters remain perplexed. They may wish to point out that the title of my article has a follow-on line, ‘Fathers of faith, my fathers now! because in Christ I am‘.19 If you become a child of Abraham by faith in Christ, then how is it possible to regard children who do not have this faith as Abraham’s children and therefore worthy recipients of covenant signs?
In his lovely exposition of the Heidelberg Catechism, Karl Barth expresses just such incredulity when he comes to Question 74. Are infants to be baptized? The Catechism’s positive answer to this question ‘comes as a surprise’ because up to now ‘we have heard that baptism is the confirmation or establishment of faith by the assurance of its origin in the blood and spirit of Jesus Christ.’ In Barth’s view, ‘All the previously discussed constitutive marks of baptism (especially the faith of the baptized) are suddenly ignored.’20 At the same time, Barth admits of the Catechism’s position that ‘Baptism is handled in this unexpected and unfounded way in all classical Protestant theology, even in Calvin.’21 The sheer breadth and impressive pedigree of the mistake must at least give credobaptists pause. What is going on when justification sola fide can be as highly prized as it is in Reformation theology and when baptism as sign and seal of that faith is as joyfully administered to infants as it is in Reformation theology? One clue is that sola fide is understood covenantally.
I will argue in this second point that if the genealogical principle is not invalidated in the new covenant, then it is one part of forming a biblical anthropology of fathers and children, and covenant heads who act in representative ways towards their progeny. In credobaptist theology, by contrast, an unbiblical category of human person opens up: the autonomous individual who relates to God outside of the normal web and complex of family relationships, societal location and covenantal structures. The way to enter a relationship with Christ is only by personal volition, and this is because faith must be personal and individually real. The latter is true, of course, but the means of reaching that point in credobaptist theology is crudely modern and divorced from how the Bible conceives of the family, and in particular the father.22
Pause for a moment and think how strange our evangelical concept of ‘asking Jesus into my heart’ as a decisive conversion moment would be in the world of OT covenant relationship. Do we see anything resembling a normative crisis moment conversion of children to Yahweh in the OT? We do not. Rather, faith in the God of the covenant as the heart of the covenant relationship is meant to be passed down through the generations to those born within the covenant. One of the primary means for this is education (Deut 6:4-9). In Ps 78, Asaph is determined to pass on ‘what our fathers have told us’ (v. 3). The things learned from those who went before him will not be hidden from the children who come after him: ‘we will tell the next generation’ (v. 4).
Another means of transmission that God uses-along with nurture, inculturation, and education-is the sign and seal of the covenant. In my view, this is where so many credobaptist critiques of paedobaptism founder. Credobaptists often struggle to understand paedobaptism for the simple reason that their conception of circumcision is inadequate. Salter’s explanation of the meaning of circumcision in the OT gives subordinate importance to the apostle Paul’s explanation of its meaning in Rom 4:1l: circumcision is the sign and seal that God gives righteousness to the one who has faith. Instead, while credobaptists typically admit there was a spiritual meaning to the rite, the weight of emphasis falls on its meaning being tied to land, blessing, dynasty, and the provision of a male line to Christ.23
This mistake marks a decisive fork in the road between credobaptist and paedobaptist theology, not least as far as the place of Abraham within each is concerned. With Barth, for instance, there is significant stress on circumcision as a physical marker of national distinction, such that this premise has interpretive influence over his understanding of Israel and the church.24 Paedobaptists, however, contend that it is impossible to read Gen 17 all the way through and conclude that circumcision’s physical or national significance is primary. Circumcision was always a gospel sign. It was a mark of the everlasting covenant. In 17:10, God even calls circumcision itself ‘my covenant’ (more on this below), and in 17:13, this covenant in the flesh is to be an everlasting covenant.
So when Gen 17 is read alongside Rom 4:11, a theological premise of paedobaptism emerges. Abraham had faith and then was circumcised. It was sign and seal of the righteousness he had by faith, and yet it is that same sign and seal which he is told to place on his male offspring. Same sign, same meaning: his children do not receive a circumcision which meant something different for them than it meant for Abraham. It was for Abraham the mark in his flesh of the eternal covenant, which had at its heart the truth that God counts as righteous the one who has faith-which he did. It was for his children the mark in their flesh of the eternal covenant, which had at its heart the truth that God counts as righteous those who have faith-which they did not. Yet.
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To preach God’s counsel in these ways requires boldness. Paul was humble, but he was also bold: “I did not shrink from declaring to you anything that was profitable” (Acts 20:20; see also Acts 20:26–27). The temptation can be to shrink back to maintain popularity, but that was not Paul’s way. Rather he unfolded God’s counsel with confidence and boldness: “declaring . . . teaching, . . . testifying, . . . proclaiming, [and] . . . admonish[ing]” (Acts 20:20–31).

What does it mean to “preach the whole counsel of God” (Acts 20:27)? That question surely occupies the hearts of all gospel preachers. Perhaps the best way to answer this question is to consider the context of Paul’s statement to the Ephesian elders in Acts 20. When we do this, we see three things clearly involved in preaching the whole counsel of God: the life of the preacher, the content of preaching, and the method of preaching. Additionally, we see that preaching God’s Word faithfully brings consequences—that is, it is effective.
The Preacher’s Life
Acts 20:17–38 contains Paul’s farewell address to the Ephesian elders. As he bids them farewell, Paul reflects on his life among the Ephesians, and he makes clear that his call as a preacher was intertwined with his life. The context for preaching the whole counsel of God is a life that is consistent with the message preached.
Paul makes this explicit when he directs the elders, “Pay careful attention to yourselves” (Acts 20:28). Only someone living a godly life can go on to faithfully declare the whole counsel of God. This is the constant message of the New Testament (1 Tim. 3:1–7; Titus 1:5–9).
Paul specifically highlights several important features of his life:

Consistency. “You yourselves know how I lived among you the whole time from the first day that I set foot in Asia” (Acts 20:18). He essentially says to them: “You know I have lived a consistent and transparent life. My life is an open book.”
Humility. “Serving the Lord with all humility” (Acts 20:19).The calling to preach God’s Word is a calling to humble service, which marked Paul’s life.
Endurance. “Trials that happened to me through the plots of the Jews” (Acts 20:19). Paul had to endure. Hard times came upon him, and he was tested. But he endured.
Compassion. “I did not cease night or day to admonish everyone with tears” (Acts 20:31). Here we have the heart of a pastor. His words are not harsh. He does not stand indifferent to the sufferings and well-being of his people. He weeps over them.
Self-denial. “I coveted no one’s silver or gold or apparel” (Acts 20:33). In other words, “I am not in ministry to enrich myself. I am not one of those who peddle God’s words for gain” (see 2 Cor. 2:17).
Prayer. “And when he had said these things, he knelt down and prayed with them all” (Acts 20:36). Paul praying for his flock was as natural to him as breathing.

So, Paul tells the Ephesian elders that preaching the whole counsel of God is bound up with the life that the pastor lives.
What Is the Whole Counsel of God?
Entirely in harmony with his life, Paul had a message to proclaim. He has been entrusted with a revelation from God, which for us today is found in all its completeness in the Bible (2 Tim. 3:16–17). Paul was to declare all the counsel of God. He could not ignore the truths that press on the sins of society and of the church. He had to proclaim the truths of God’s sovereignty in salvation that humble man. He needed to drive home the application of God’s Word to all areas of life, and it is the same for any who would preach today.
Paul preached God’s whole counsel in a specific way: “I did not shrink from declaring to you anything that was profitable” (Acts 20:20).
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Some critics describe the kind of treatment offered at places like the Transgender Center where I worked as a kind of national experiment. But that’s wrong. Experiments are supposed to be carefully designed. Hypotheses are supposed to be tested ethically. The doctors I worked alongside at the Transgender Center said frequently about the treatment of our patients: “We are building the plane while we are flying it.” No one should be a passenger on that kind of aircraft.

I am a 42-year-old St. Louis native, a queer woman, and politically to the left of Bernie Sanders. My worldview has deeply shaped my career. I have spent my professional life providing counseling to vulnerable populations: children in foster care, sexual minorities, the poor.
For almost four years, I worked at The Washington University School of Medicine Division of Infectious Diseases with teens and young adults who were HIV positive. Many of them were trans or otherwise gender nonconforming, and I could relate: Through childhood and adolescence, I did a lot of gender questioning myself. I’m now married to a transman, and together we are raising my two biological children from a previous marriage and three foster children we hope to adopt.
All that led me to a job in 2018 as a case manager at The Washington University Transgender Center at St. Louis Children’s Hospital, which had been established a year earlier.
The center’s working assumption was that the earlier you treat kids with gender dysphoria, the more anguish you can prevent later on. This premise was shared by the center’s doctors and therapists. Given their expertise, I assumed that abundant evidence backed this consensus.
During the four years I worked at the clinic as a case manager—I was responsible for patient intake and oversight—around a thousand distressed young people came through our doors. The majority of them received hormone prescriptions that can have life-altering consequences—including sterility.
I left the clinic in November of last year because I could no longer participate in what was happening there. By the time I departed, I was certain that the way the American medical system is treating these patients is the opposite of the promise we make to “do no harm.” Instead, we are permanently harming the vulnerable patients in our care.
Today I am speaking out. I am doing so knowing how toxic the public conversation is around this highly contentious issue—and the ways that my testimony might be misused. I am doing so knowing that I am putting myself at serious personal and professional risk.
Almost everyone in my life advised me to keep my head down. But I cannot in good conscience do so. Because what is happening to scores of children is far more important than my comfort. And what is happening to them is morally and medically appalling.
The Floodgates Open
Soon after my arrival at the Transgender Center, I was struck by the lack of formal protocols for treatment. The center’s physician co-directors were essentially the sole authority.
At first, the patient population was tipped toward what used to be the “traditional” instance of a child with gender dysphoria: a boy, often quite young, who wanted to present as—who wanted to be—a girl.
Until 2015 or so, a very small number of these boys comprised the population of pediatric gender dysphoria cases. Then, across the Western world, there began to be a dramatic increase in a new population: Teenage girls, many with no previous history of gender distress, suddenly declared they were transgender and demanded immediate treatment with testosterone.
I certainly saw this at the center. One of my jobs was to do intake for new patients and their families. When I started there were probably 10 such calls a month. When I left there were 50, and about 70 percent of the new patients were girls. Sometimes clusters of girls arrived from the same high school.
This concerned me, but didn’t feel I was in the position to sound some kind of alarm back then. There was a team of about eight of us, and only one other person brought up the kinds of questions I had. Anyone who raised doubts ran the risk of being called a transphobe.
The girls who came to us had many comorbidities: depression, anxiety, ADHD, eating disorders, obesity. Many were diagnosed with autism, or had autism-like symptoms. A report last year on a British pediatric transgender center found that about one-third of the patients referred there were on the autism spectrum.
Frequently, our patients declared they had disorders that no one believed they had. We had patients who said they had Tourette syndrome (but they didn’t); that they had tic disorders (but they didn’t); that they had multiple personalities (but they didn’t).
The doctors privately recognized these false self-diagnoses as a manifestation of social contagion. They even acknowledged that suicide has an element of social contagion. But when I said the clusters of girls streaming into our service looked as if their gender issues might be a manifestation of social contagion, the doctors said gender identity reflected something innate.
To begin transitioning, the girls needed a letter of support from a therapist—usually one we recommended—who they had to see only once or twice for the green light. To make it more efficient for the therapists, we offered them a template for how to write a letter in support of transition. The next stop was a single visit to the endocrinologist for a testosterone prescription.
That’s all it took.
When a female takes testosterone, the profound and permanent effects of the hormone can be seen in a matter of months. Voices drop, beards sprout, body fat is redistributed. Sexual interest explodes, aggression increases, and mood can be unpredictable. Our patients were told about some side effects, including sterility. But after working at the center, I came to believe that teenagers are simply not capable of fully grasping what it means to make the decision to become infertile while still a minor.
Side Effects
Many encounters with patients emphasized to me how little these young people understood the profound impacts changing gender would have on their bodies and minds. But the center downplayed the negative consequences, and emphasized the need for transition. As the center’s website said, “Left untreated, gender dysphoria has any number of consequences, from self-harm to suicide. But when you take away the gender dysphoria by allowing a child to be who he or she is, we’re noticing that goes away. The studies we have show these kids often wind up functioning psychosocially as well as or better than their peers.”
There are no reliable studies showing this. Indeed, the experiences of many of the center’s patients prove how false these assertions are.
Here’s an example. On Friday, May 1, 2020, a colleague emailed me about a 15-year-old male patient: “Oh dear. I am concerned that [the patient] does not understand what Bicalutamide does.” I responded: “I don’t think that we start anything honestly right now.”
Bicalutamide is a medication used to treat metastatic prostate cancer, and one of its side effects is that it feminizes the bodies of men who take it, including the appearance of breasts. The center prescribed this cancer drug as a puberty blocker and feminizing agent for boys. As with most cancer drugs, bicalutamide has a long list of side effects, and this patient experienced one of them: liver toxicity. He was sent to another unit of the hospital for evaluation and immediately taken off the drug. Afterward, his mother sent an electronic message to the Transgender Center saying that we were lucky her family was not the type to sue.
How little patients understood what they were getting into was illustrated by a call we received at the center in 2020 from a 17-year-old biological female patient who was on testosterone. She said she was bleeding from the vagina. In less than an hour she had soaked through an extra heavy pad, her jeans, and a towel she had wrapped around her waist. The nurse at the center told her to go to the emergency room right away.
We found out later this girl had had intercourse, and because testosterone thins the vaginal tissues, her vaginal canal had ripped open. She had to be sedated and given surgery to repair the damage. She wasn’t the only vaginal laceration case we heard about.
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