Straight to the point

This was no ordinary medical conference. Over the course of three days, I learned a great many things. That eunuchs are one of the world’s oldest gender identities and that doctors should not judge their strange desires for castration but fulfil them. That, “ideally, patients wouldn’t be actively psychotic” when they initiated testosterone, but that psychotic patients consent to take medication like stool softeners and statins all the time and “people don’t pay that much attention”. That it would be “ableist” to question an autistic girl’s insistence on a double mastectomy. That patients who claim to have multiple personalities that disagree about which irreversible steps to take toward transition can find consensus — or at least obtain a quorum — using a smartphone app.

It is hard to shock me these days — but as I moved around the World Professional Association for Transgender Health’s symposium in Montreal in September 2022, I often felt as if I’d slipped sideways into some strange universe that operated in accordance with other laws: where up is down and girls are boys and medicine has left its modest brief — healing — far behind in its breathless pursuit of transcendence.

I wasn’t really supposed to be there. I hadn’t misrepresented myself — I am what I claimed to be: a graduate student researching gender identity — but this was a convocation for believers and I’m a sceptic. When WPATH, the world’s most prestigious and influential gathering in transgender healthcare, came to Montreal, I couldn’t resist the opportunity to see up close the people and ideas I had pursued through so many articles and books.

I wanted to know what gender clinicians were saying behind closed doors. I wanted to see how they understand the work they do, the patients they serve, and the criticism they face. That’s why I began attending WPATH conferences, starting with the symposium in Montreal, followed by the European Professional Association for Transgender Health conference in Killarney, Ireland, in April, and the US Professional Association for Transgender Health conference in Denver, Colorado, just a few weeks ago.

After years of flying under the radar, the field of transgender health care is facing serious questions about whether minors can consent to life-altering interventions; what role factors like autism, sexual orientation, and social influence may play in the explosion of children and young people identifying as trans; and what to make of mounting evidence of medical harm, regret, and detransition. In response, the field of trans healthcare is becoming ever more secretive. There is a sharp demarcation between what gender clinicians say in public and what they say in private.

At these conferences, the big questions confronting transgender health care hardly feature. Instead, these conferences serve a different purpose: to shore up the faithful and cultivate a revolutionary vanguard within medicine. To this end, the proceedings revolve around a strange set of parables: that of the good gender clinician and the bad gender clinician.

In this world, being a good gender clinician means deferring to patients’ self-understandings and having the humility to serve even what one does not understand. The mark of a good gender clinician is her credulity in the face of brave new manifestations of gender.

“People outside this room get hung up on questions like ‘How can we make sure people are really trans and are not going to regret their transition later?’” one gender clinician in Denver mused. “I’m interested in giving the very best possible care to trans young people, the care that they need and deserve… it’s easy to roll down this pathway of ‘how do you know if somebody’s going to change their mind?’ or ‘how do you know if somebody’s really trans or not?’ and that’s not the conversation I’m really participating in.”

It’s difficult to imagine clinicians practising in other areas of medicine not asking such basic questions, especially when the basis for treatment is so murky. But a good gender clinician, looking at a patient, does not see what non-believers like you or I might see. A good clinician falls under the sway of the same fantasy as the patient and conspires with her to bring her transgender self into existence. Under this framework, there is no “really trans” or not. There is only what the patient says and the readiness of the clinician to put herself at the service of the patient’s vision.

A bad gender clinician, by contrast, feels an “entitlement to know” why a patient feels the way she does or why she seeks a particular intervention. She clings to a traditional conception of her role as a “gatekeeper” who evaluates and prescribes. She thinks she can “discern a ‘true’ gender identity beyond what is articulated by the patient”. She may believe she can “identify the ‘root cause’ of a transgender identity”, which is seen as pathologising. She may try to leave the door open to desistance — the most common outcome before gender clinicians started interfering with normal development by deploying puberty-blocking drugs — in which case she is guilty of “valuing cis lives over trans lives”.

A bad gender clinician is easily “intimidated” by complicated patients, while a good gender clinician knows how to secure consent even in the trickiest cases. Mental health difficulties become “mental health differences”. Severe autism or thinking you have multiple personalities living inside your head become empowering forms of “neurodiversity”. When it comes to assessment, “careful” and “comprehensive” have become dirty words: “The answer always seems to be more assessment and more time. That’s gatekeeping.”

During the Denver conference, presenters role-played how to secure informed consent for a hysterectomy and phalloplasty in the case of a schizophrenic, borderline autistic, intellectually disabled “demiboy” with a recent psychiatric hospitalisation. At no point do the role-players encounter any real barriers. Instead, they persevere. At first, the patient struggled to understand why a phalloplasty might require multiple surgeries, but then the clinicians “explained everything” and the patient understood. This is called “lean[ing] into the nuance of capacity”.

The moral of this story is clear: failure to achieve informed consent is a failure on the part of the clinician, a failure of imagination and flexibility, not a recognition that some patients — whether because of age or mental illness or intellectual disability — will simply not be able to consent.

On WPATH’s private forums, clinicians occasionally express reservations about what they’re being expected to do, such as the social worker who wondered whether she should write letters for surgery for “several trans clients with serious mental illness… Even though these clients have a well-established trans gender identity, their likely stability post initiation of HRT [hormone-replacement therapy] or surgery is difficult to predict. What criteria do other people use to determine whether or not they can write a letter supporting surgical transition for this population?”

Her colleagues quickly put her in her place: “My feeling is that, in general, mental illness is not a reason to withhold needed medical care from clients,” an “affirming, anti-oppressive” gender therapist responded. “My assumption is that you’re asking this question because you’re taking seriously your responsibility to care for and guide your clients. Unfortunately, though, I think the broader context in which this question even exists is one in which we, as mental health professionals, have been put inappropriately into gatekeeper roles. I’m not aware of any other medical procedure that requires the approval of a therapist. I think requiring this for trans clients is another way that our healthcare system positions gender-affirming care as ‘optional’ or only for those who can prove they deserve it.”

Another gender clinician referred dismissively to the recommendation that mental illness should be “well controlled” before initiating hormonal and surgical interventions: “I am personally not invested in the ‘well controlled’ criterion phrase unless absolutely necessary… in the last 15 years I had to regrettably decline writing only one letter, mainly [because] the person evaluated was in active psychosis and hallucinated during the assessment session. Other than that, everyone got their assessment letter, insurance approval, and are living [presumably] happily ever after.” Everything hinges on that “presumably”.

For years, gender clinicians have reassured patients and parents that the evidence would eventually bear out the lofty promises of transition: that transition is life-saving; that psychotherapeutic approaches to gender distress don’t work and instead constitute unethical “conversion therapy”. But as the data starts to come in, transition appears unlikely to live up to these high expectations.

During the Ireland conference, researchers bracketed discouraging findings with upbeat statements of belief such as: “We all know gender-affirming care is effective.” A Swedish researcher who found that psychiatric hospitalisation increased after patients initiated puberty blockers or cross-sex hormones told the audience that she was “really concerned”, not about the results themselves, but “about how results will be interpreted” because, “as you all know, there are improved mental health outcomes following puberty blockers and gender-affirming hormones” — even when the research can’t find those benefits.

“There’s an expectation that gender-affirming hormones will improve somebody’s mental health problems,” Johanna Olson-Kennedy, one of the leading US gender clinicians, said on the opening night of the Denver conference. Why? Because “they improve gender congruence”. In other words, if a patient doesn’t want breasts and a surgeon removes her breasts, the treatment was a success, even if her mental health deteriorates and even if she experiences regret down the road. Clinicians dismiss detransition as one of multiple possible “attenuations” of gender identity, alongside “elf”, “fairy”, and “friendly non-intimidating woman”. If a patient changes her mind later, clinicians can simply treat this new manifestation of gender incongruence by the same means: no harm, no foul.

Meanwhile, gender clinicians speak with remarkable frankness about overcoming their reservations, including the plastic surgeon who recounted the alarm he felt the first time a patient requested gender nullification surgery: an intervention that involves removing all external genitalia to create a “smooth” Ken doll-like appearance. But this surgeon soon conquered his hang-ups: he now performs “a lot” of these surgeries and promotes the procedure to his more cautious colleagues. These kinds of stories frame doubt as something to be vanquished, not investigated.

And if doubts persist, there’s always emotional blackmail. In Denver, an obese patient berated the plastic surgeons in the audience, telling them “you wouldn’t be hearing from me today” had the patient not found a surgeon willing to bend the rules and perform a double mastectomy: “I had contacted over a dozen plastic surgeons in the state of Colorado, all of them telling me they refused to do surgery on me. The surgery I so, so desperately needed so as to not kill myself. Only because of my BMI.”

So if a clinician dares to enforce standard medical practices or exercise her professional judgment, she may drive her desperate patients to suicide. The most questionable sessions end with no questions at all.

But what about the rest of us? What are we entitled to know about this bold new frontier in medicine? In Denver, public-relations specialists cautioned clinicians to spare reporters, policymakers, and parents the details of what “gender-affirming care” entails. In fact, even the use of the term “gender-affirming care” is discouraged: “When [people] hear it, they think ‘trans kids in the driver’s seat,’” health policy expert Kellan Baker said. “Many of us here, we all support trans kids in the driver’s seat because it’s their bodies, their lives. But when you think about folks who don’t know trans people, they are very scared by the idea that young people are making irreversible decisions and that nobody else has any oversight over these decisions. The term “medically-necessary care” is better, he said. “Essential medical care. Prescribed medical care.”

Presenters also recommended that gender clinicians avoid specifics. Avoid ages (“this care is highly individualised and age-appropriate”). Avoid giving information about the effects of puberty blockers and hormones. Avoid discussing the ins and outs of surgeries. In practice, “holding [the public’s] hands and helping [them] understand” looks more like covering their eyes and telling them whatever they need to hear to feel at ease. “The dinosaurs are scared,” Baker deadpanned.

This is how an entire field of medical practice became committed to virtuous obscurantism. Gender-affirming clinicians feel misunderstood by their critics. They don’t trust outsiders to put the work they do in the right light. There’s always a risk that someone will look at life-saving reconstructive chest surgeries for transmasculine minors and see the wrong thing: doctors performing breast amputations on troubled teen girls. Therefore, in order to defend the “life-saving” work they do, they must dissemble, obscure, or practise other forms of “heavenly deception”.

Critics of gender-affirming care fall somewhere along the spectrum of transphobia — with dinosaurs at one end, genocidaires at the other. In Ireland, a keynote speaker described “the gender-critical movement [as] a totalitarian and genocidal force that targets not just trans people but all institutions that uphold democracy and individual human rights”. In Denver, a state legislator announced that policymakers passing restrictions on youth gender transition “will kill children. Not with their own hands. But they will.”

The result of this Manichean worldview is that there is no possible dialogue with critics and no room for serious dissent within the movement itself: “If we are fighting amongst ourselves the forces of oppression have won,” as outgoing USPATH president Maddie Deutsch put it. No one, at any conference, discussed the risks and unknowns around puberty blockers and their possible effects on brain development, or the evidence that suggests blockers may change the course of a child’s life by turning what may have been a developmental phase into a permanent condition.

In one of the most extraordinary moments in Ireland, outgoing EPATH president Jan Motmans said: “We respect everyone’s freedom of speech, but we choose not to listen to it.” The auditorium burst into applause. But the speech they’re choosing not to listen to is the mounting evidence that something has gone wrong in the field of gender medicine.

The conviction of being on the right side of history is why criticism doesn’t stick. Clinicians don’t see themselves reflected in critiques. They are, for the most part, decent people, capable of feeling genuine horror when they accidentally say “hey guys” instead of “hey folks”. Their best impulses — their empathy, their humility in the face of what they don’t understand, their sincere desire to help distressed patients — have been hijacked by an ideological movement within medicine. In the process, they have lost sight of what they do.

This blindness sets in more or less the moment a patient sets foot in a gender clinic — when a distressed girl transforms into a “boy” in need of affirmation. Gender clinicians see empowerment in overlooking a patient’s limitations. They have come to believe that medical responsibility to their patients requires them to dismantle the guardrails that stand between vulnerable patients and life-altering interventions.

Nothing illustrates this more clearly than a session on “neurodiversity-affirming gender-affirming care” in Denver, which overflowed with suggestions for clinicians working with autistic patients to achieve their surgical goals. To make autistic patients more comfortable, clinicians should dim the lights, keep an assortment of fidget toys on hand, drop the small talk, don’t try to make eye contact, avoid open-ended questions. If a patient won’t — or can’t — speak, the clinician should ask for a thumbs up or thumbs down. A good gender clinician helps patients anticipate the sensory reactions they might have to injections, surgeries, stitches, blood, and pain.

Over and over again, I’m struck by the realisation that these clinicians have thought of everything. Everything, that is, except: what if they’re wrong?

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