Fortress on a fault line: Shaky evidence undermines pediatric gender medicine

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by Susan Nagel

Susan Nagel holds a master’s degree in public affairs and worked as a planner/contract manager for the children’s mental health unit of a metropolitan county. Her daughter has been trans-identified for eight years and briefly medicalized. Nagel wrote an earlier piece for 4thWaveNow in 2017.

Here, Nagel provides an overview of the weak evidence being utilized by medical organizations to justify “affirmative care” for gender dysphoric young people. Particularly (and, increasingly, ONLY) in the United States, gender clinicians rely on the questionable recommendations of the World Professional Organization for Transgender Health (WPATH), the American Academy of Pediatrics (AAP), and the Endocrine Society to justify drug and surgical interventions for increasingly younger children.

The article is supported by extensive endnote sources. Readers seeking a deeper investigation into the poor evidence base for “affirming” pediatric gender medicine are encouraged to delve into these sources.

Editor’s note: Since the drafting of this article, an important exposé of WPATH has been released by the Environmental Progress organization, entitled The WPATH Files. The exposé features posts from an internal WPATH discussion forum, as well as footage from an online panel discussion. We encourage interested 4thWaveNow readers to examine the full document (linked above). X (formerly Twitter) users may want to search the #WPATHFiles tag to see press and other pertinent coverage of the controversy ensuing from the release of the exposé.


As of this writing, 23 states have passed laws restricting pediatric “gender-affirming” care[1] which may include medical interventions such as puberty blockers,[2] cross-sex hormones, and surgeries.[3] News coverage of these laws frequently notes that these procedures are endorsed by medical associations such as the American Academy of Pediatrics (AAP), the World Professional Association for Transgender Health (WPATH) and the Endocrine Society. [4]  Given the backing of these trusted organizations, the media and the public may believe that these interventions are safe and effective, and that the proponents of such restrictive laws are motivated by hate for trans people. However, a closer look at the guidelines for gender care published by these medical associations reveals that their endorsements are not based on solid evidence and are cavalier about risks.

Two medical associations, WPATH and the Endocrine Society, acknowledge within their own guidelines the poor evidence base for their positions.

WPATH’s Standards of Care

WPATH’s 2022 Standards of Care for the Health of Transgender and Gender Diverse People (SOC) asserts there is a “… slowly growing body of evidence supporting the effectiveness of early medical intervention…” for gender-diverse youth. Yet WPATH concedes that “… the number of studies is still low, and there are few outcome studies that follow youth into adulthood.” In fact, the number of studies is so low that WPATH claims a systematic review regarding outcomes is impossible, so it provides a short narrative review instead. [5]

Using a narrative rather than a systematic review to develop treatment guidelines is a troubling choice. Evidence-based medicine is built upon systematic reviews.  A systematic review examines every study on a chosen intervention, evaluates the results of each study for multiple sources of bias, and reaches a conclusion about an intervention based on the totality and quality of the evidence.  A narrative review can pick and choose which studies to review and uncritically accept study authors’ conclusions. [6] [7]

Even with the low bar of a narrative review, WPATH’s summary of the available research does not inspire confidence. The studies reviewed had small sample sizes.[8] and [9] only one followed adolescent patients into early adulthood, with subjects averaging 20.7 years old at study’s end.[10]

WPATH calls this Dutch study “the most robust longitudinal evidence supporting the benefits of gender-affirming medical and surgical treatment in adolescence.”[11] Indeed, this study is considered the “foundation” of the current practice of pediatric gender medicine.[12] Among its flaws, the Dutch study had no control group[13] and employed different measures of gender dysphoria pre and post treatment, thus hampering a meaningful comparison.[14] Fifteen subjects were dropped from the study, including four who developed serious health problems during treatment, thus skewing the results.[15] One of these subjects died from necrotizing fasciitis after undergoing genital surgery. [16] As Oxford Professor Michael Biggs wrote in his damning analysis of the research, “A fatality rate exceeding 1% would surely halt any other experimental treatment on healthy teenagers.”[17] With the Dutch study as its best evidence supporting affirmative care, WPATH is on shaky ground.

To the careful reader, WPATH fosters additional skepticism by asserting that puberty blockers are “fully reversible”[18] while stating in other places that the effects of puberty blockers on bone-mass,[19] neurodevelopment,[20] sexual health, and future surgical outcomes[21] are either not “well established,” “in need of continued study,” or “unknowns.”[22] WPATH also says patients considering puberty blockers should be informed of potential loss of fertility.[23]

Do puberty blockers cause infertility? Why is fertility a concern for a fully reversible drug?

From WPATH’s Standards of Care 8th Edition, (page S118)

Here is the issue: WPATH recommends that children begin blockers in very early puberty [24] before gametes (i.e. sperm or ova) have matured.[25] If children discontinue puberty blockers and seek no further treatment, natural puberty should occur, thus the claim of reversibility.[26] But children seldom end treatment with puberty blockers.  Almost all (between 93% and 98%) go on to take cross-sex hormones (CSHs)  [27] [28] [29] which requires continuous suppression of their own endogenous hormones.[30] [31] [32] Under these conditions, the gametes will not mature, with a likely future consequence of sterility.[33] [34] [35]  As late as 2020, there were no studies verifying the impact of puberty blockers followed by CSHs on fertility.[36] WPATH, AAP and the Endocrine Society all confirm this protocol threatens fertility[37] yet they nevertheless endorse it.[38]

From WPATH’s Standards of Care 7th Edition, (page 51)

From the AAP’s Policy Statement, (Footnote c. of Table 2 on page 6)

From the Endocrine Society Guidelines, (page 3878)

In addition to the risk of infertility, CSHs increase the risk for blood clots. [39] [40] [41] Even if the risk for blood clots returns to normal if a person stops treatment with CSHs, the consequences of a single blood clot can certainly be irreversible. CSHs also cause permanent changes to the body including deepening of the voice, increased body and facial hair, clitoral growth, and thinning scalp hair for natal females[42] and breast growth for natal males.[43]

From the NHS’s Cass Review of gender identity services (page 38, section 3.31)

While it is not known for certain why most children continue onto CSHs after puberty blockers, England’s National Health Service (NHS) has questioned whether puberty blockers ‘lock” children into gender identities by stopping maturation processes.[44] [45] Given the near certainty that children will continue onto CSHs with their risks and permanent changes, calling puberty blockers fully reversible is misleading.

The Endocrine Society’s Clinical Practice Guideline

Unlike WPATH, the Endocrine Society did use systematic reviews to inform its 2017 clinical practice guidelines.[46] Consequently, the Endocrine Society is able to document that all but one of its recommendations regarding the treatment of adolescents are based on low or very low-quality evidence. [47]

The AAP’s Policy Statement

The AAP’s 2018 policy statement on pediatric gender care[48] has caused alarm among both outsiders and even some AAP members.

Surprised by its affirmation-only approach, Canadian psychologist and sexologist James Cantor fact-checked the studies cited in the AAP’s policy statement. [49]  He found the AAP statement failed to reference outcomes from 11 studies that followed gender-dysphoric (GD) children as they matured. Every one of these studies, “…found the same thing: Over puberty, the majority of GD children ceased to want to transition.”[50] An affirmation-only approach makes no sense when research shows most children grow out of their gender dysphoria. Cantor also found the AAP statement relied heavily on research regarding adult sexual orientation which does not apply to GD children.[51] Cantor concluded, “Not only did AAP fail to provide compelling evidence, …. AAP’s recommendations are despite the existing evidence.”[52]

From “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy, (page 6)

There have been at least eleven recent lawsuits filed by detransitioners[53] [54] who claim to have been harmed by “affirmative” gender care. One of these plaintiffs,  Isabelle Ayala, named the AAP as a defendant in her 2023 lawsuit against the clinicians who treated her.  Ayala began testosterone treatments about a month after her first visit to a gender clinic at 14. Physicians repeatedly increased her testosterone dose over the next year despite worsening depression and a suicide attempt. Ayala later detransitioned and came to understand her discomfort with her body stemmed from mental health comorbidities and the trauma of a childhood sexual assault, something her caregivers did not explore. Ayala’s suit accuses the AAP of misrepresenting the evidentiary support for its treatment recommendations and describes the AAP policy statement as “rife with outright fraudulent representations.”[55]

Some AAP pediatricians have been attempting to bring change to the organization. Each of the past three years, members of the AAP have submitted resolutions asking the AAP’s annual leadership forum for a review of the evidence regarding pediatric transition.[56] According to Julia Mason, one of the pediatricians involved, a resolution failed in 2020 because no one in leadership would second it; it was voted down by leadership in 2021 despite members placing it among the top five resolutions of interest in online voting; and it was “effectively bur[ied]” in 2022, when “…the AAP enforced for the first time a rule that shut down member comments….“[57]

AAP Policy Statements expire after five years unless reaffirmed.[58] The AAP Board of Directors voted to reaffirm the 2018 policy statement on gender-affirming care in August 2023.  According to an AAP press release, AAP leadership is “…confident the principles presented in the original policy … remain in the best interest of children.” Due to their concerns about the bans on “affirmative” care passing in many states, the AAP Board also “…authorized development of an expanded set of guidance for pediatricians based on a systematic review of the evidence.” Although the announcement of a systematic review is excellent news, declaring confidence in the 2018 policy statement prior to conducting the review seems to place the cart before the horse.[59]

European countries change course based on systematic reviews

So here is where “affirmative” care stands in early 2024: The AAP has misrepresented the evidence, WPATH has claimed systematic review is impossible, and the Endocrine Society has deemed low quality evidence sufficient to recommend risky treatments for minors. Yet health authorities in Finland, Sweden, and England are rethinking the use of puberty blockers and cross-sex hormones based on systematic reviews.  Finland’s 2020 treatment recommendations warn that “…gender reassignment of minors is an experimental practice,” and recommend psychosocial support, therapy and treatment of comorbid psychiatric disorders as “the first-line intervention”.[60] Swedish health authorities say the risks of treatment likely outweigh possible benefits,[61]  and along with England’s NHS now recommend that puberty blockers and CSHs be given only in the context of research programs. [62] [63]

From Sweden’s National Board of Health and Welfare 2022 Care of children and Adolescents with Gender Dysphoria Summary of National Guidelines, (page 3)

Transition does not prevent suicide

Mainstream reporting on gender care has not accurately conveyed the evidence and has often reiterated the gender affirmative advocates’ trump card; i.e.: medical interventions for gender dysphoria prevent suicide.[64] The literature does not support this claim. The systematic reviews commissioned by the NHS looked at the evidence related to mental health and suicide and found that CSHs may improve mental health, functioning and suicidality, but the evidence was of very low certainty.  The NHS cautioned that, “Any potential benefits of gender-affirming hormones must be weighed against the largely unknown long-term safety profile of these treatments….”[65] The NHS determined puberty blockers have little impact on mental health.[66] . A systematic review published by the Endocrine Society could not find sufficient evidence to “…draw a conclusion about the effect of hormone therapy on death by suicide.”[67]  Finnish researchers published a large study in February[68] that is the first to compare suicide rates among gender dysphoric patients who accessed gender reassignment services and those who did not. The study was also designed to tease out the role psychiatric morbidities play in suicide rates.  The study included 2083 adolescents who entered gender identity clinics and 16,643 matched controls. The researchers found,

  • Gender dysphoria does not seem predictive of suicide deaths.
  • “…medical gender reassignment does not have an impact on suicide risk.”
  • The, “[m]ain predictor of mortality in this population is psychiatric morbidity….” When researchers controlled for psychiatric treatment needs, subjects in the control group versus the gender dysphoric group did not have statistically significant different levels of death by suicide.

It is incredibly unethical to constantly plant the idea that young people will be suicidal if they cannot access transition services when the evidence does not support this claim.

Dr. Will Malone, one of the few endocrinologists to speak out[69] about the weak evidence base, summed up the state of pediatric gender medicine in an interview, ”… [W]e’re essentially running an experiment outside of experimental protocols, … [T]hat’s not how medicine is supposed to work. You’re supposed to do the experiments first, show that the treatment works, especially when you’re talking about infertility and sexual dysfunction long-term and … a four times increased risk of heart disease and a two to three times increased rate of development of blood clots and strokes….”[70]

The medical association endorsements of gender-affirming medical treatments for minors are not based on solid evidence. News sources should stop treating medical associations as oracles. They are institutions vulnerable to ideological capture, and the validity of their endorsements must be examined. Through their endorsements, medical associations are failing the patients, families, clinicians, lawmakers, judges, and reporters who rely on their advice.  Because of this carelessness, patient health has been compromised; vulnerable people too young to know their child-bearing wishes have been sterilized and/or left unable to breastfeed; patients have spent years and resources chasing unattainable goals, and families have been torn apart. Medical associations have betrayed the public’s trust and must return to the principles of evidence-based medicine to regain it. Gender-dysphoric youth have an equal right to care based on the evidence rather than ideology.


[1] Dawson, Lindsey and Jennifer Kates, “Policy tracker: Youth Access to Gender Affirming Care and State Policy Restrictions.” KFF, 31 January 2024. https://www.kff.org/other/dashboard/gender-affirming-care-policy-tracker/

[2] “Pubertal Blockers for Transgender and Gender-diverse Youth.” Mayo Clinic, 18 June 2022, www.mayoclinic.org/diseases-conditions/gender-dysphoria/in-depth/pubertal-blockers/art-20459075 Note: If you look at some of the works cited in this editorial, you will see references to gonadotropin-releasing hormone analogues (GnRH analogues or GnRHa) rather than to puberty blockers. The referenced Mayo Clinic site says, “The medications mostly commonly used to suppress puberty are known as gonadotropin-releasing hormone (GnRH) analogues.” I used the term, puberty blockers, in this piece because it is more descriptive than gonadotropin-releasing hormone analogues.

[3] Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (page 6). Note: Table 2 on page 6 lists the interventions.

[4] Below are quotes from six major news organizations demonstrating how reporters use the endorsements of medical associations to support the idea that gender-affirming care is safe and/or best practice.

      1. Olson, Jeremy. “‘It Got Very Bad, Very Quickly’: Families with Transgender Kids Seek Refuge in Minnesota.” Star Tribune, 6 May 2023. https://www.startribune.com/minnesota-transgender-refuge-children-families-move-gender-affirming-care/600272910/ Quote: “An estimated 40% of transgender children have attempted suicide, which is one reason the American Academy of Pediatrics and the American Medical Association endorse gender-affirming care.”
      2. Nawaz, Amna, and Matt Loffman. “Claiming Abuse, Texas Tries to Prevent Gender-affirming Care for Trans Children.” PBS News Hour, 24 Feb. 2022. https://www.pbs.org/newshour/show/claiming-abuse-texas-tries-to-prevent-gender-affirming-care-for-trans-children Quote: “Medical experts, including the American Academy of Pediatrics, say gender-affirming care is safe and best practice for transgender patients.”
      3. Ceron, Eron, and Kelsey Butler. “State lawmakers are pushing anti-trans legislation at record rates.” Wisconsin State Journal, 5 Apr. 2023. https://madison.com/news/national/state-lawmakers-are-pushing-anti-trans-legislation-at-record-rates/article_d8ac2a3f-bf67-5c4a-8be0-b868178fe54d.html Quote: “The American Academy of Pediatrics, the American Psychological Association, the World Professional Association for Transgender Health and other leading medical groups all recognize gender-affirming care as the standard of care for transgender youth.”
      4. Rayasam, Renuka. “The Transgender Care That States Are Banning, Explained.” Politico, 25 March 2022. https://www.politico.com/newsletters/politico-nightly/2022/03/25/the-transgender-care-that-states-are-banning-explained-00020580 Quote: “The American Academy of Pediatrics, the World Professional Association for Transgender Health and other medical associations have published detailed guidelines…” on the practice of gender-affirming care.
      5. Christensen, Jen. “Gender-affirming care, a ‘crucial’ process for thousands of young people in America.” CNN health. 25 April 2023. https://www.cnn.com/2022/04/21/health/gender-affirming-care/index.html Quote: “Major medical associations – including the American Medical Association, the American Psychiatric Association, the American Academy of Pediatrics and the American Academy of Child & Adolescent Psychiatry – agree that gender-affirming care is clinically appropriate for children and adults. The World Professional Association for Transgender Health’s guidelines, which are considered the gold standard and guide gender-affirming care around the world, say it should be a way for people to create ‘effective pathways to achieving lasting personal comfort with their gendered selves, in order to maximize their overall health, psychological well-being and self-fulfillment.’”
      6. Fawcett, Eliza. “After Arkansas Trial, Judge Weighs Legality of Ban on Care for Transgender Youth.” The New York Times, 4 Dec. 2022. https://www.nytimes.com/2022/12/04/us/arkansas-hormone-therapy-transgender.html Quote: “Leading medical associations, including the Endocrine Society and the American Academy of Pediatrics recommend access to such care for transgender people under 18….”

[5] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258,  Standards of Care – WPATH World Professional Association for Transgender Health (Page S46). Quote: “Despite the slowly growing body of evidence supporting the effectiveness of early medical intervention, the number of studies is still low, and there are few outcome studies that follow youth into adulthood. Therefore, a systematic review regarding outcomes of treatment in adolescents is not possible. A short narrative review is provided instead.”

[6]  Patole, Sanjay. “Systematic Reviews, Meta-Analysis, and Evidence-Based Medicine.”  Principles and Practice of Systematic Reviews and Meta-Analysis, by Patole, Sanjay (ed.), Springer, Cham, 2021, pp. 1-10. https://doi.org/10.1007/978-3-030-71921-0_1

[7] Abbruzzese, Zhenya. “Episode 118: Prioritizing Expensive & Invasive Interventions: American Healthcare w/Zhenya Abbruzzese.” Interview by Sasha Ayad and Stella O’Malley for the Gender A Wider Lens Podcast, YouTube, 16 June 2023  https://www.youtube.com/watch?v=YhLA02Dtupc&t=170s  (minutes 52:29 to 59:07).

[8] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S47). Quote: “To conclude, although the existing samples reported on relatively small groups of youth (e.g., n = 22-101 per study) and the time to follow-up varied across studies (6 months-7 years), this emerging evidence base indicates a general improvement in the lives of transgender adolescents who … receive medically necessary gender-affirming medical treatment.”

[9] de Vries, A. L. C., et al. “Young Adult Psychological Outcome after Puberty Suppression and Gender Reassignment.” PEDIATRICS, vol. 134, no. 4, 8 Sept. 2014, pp. 696–704, Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment | Pediatrics | American Academy of Pediatrics (aap.org)  Note: This is the citation for the Dutch study WPATH is discussing. WPATH and journal articles reference it as de Vries et al., 2014 or de Vries et al. (2014)

[10] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S46). Quote: “The 2014 long-term follow-up study is the only study that followed youth from early adolescence (pretreatment, mean age of 13.6) through young adulthood (posttreatment, mean age of 20.7).”

[11] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S51). Quote: “The most robust longitudinal evidence supporting the benefits of gender-affirming medical and surgical treatments in adolescence was obtained in a clinical setting that incorporated a detailed comprehensive diagnostic assessment process over time into its delivery of care protocol (de Vries & Cohen-Kettenis, 2012; de Vries et al., 2014).” Note: WPATH refers to both de Vries & Cohen-Kettenis, 2012 and de Vries et al., 2014 as the most robust longitudinal evidence supporting gender affirmative medical treatments.  De Vries et al., 2014 is the study I critique in this paragraph of my editorial. De Vries & Cohen-Kettenis, 2012 is not a study but a description of the protocol used in de Vries et al., 2014.

[12] Dutch researchers pioneered the treatment regimen of puberty blockers followed by cross sex hormones and surgery(ies), so the regimen has become known as the Dutch Protocol.  The Dutch study referenced by WPATH, i.e. de Vries et al., 2014, is used to justify this now widespread protocol, so that is why I discuss it in such detail.  Sources for the information in this endnote are below.

      1. Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 ‌(page 1). Quote: “The use of Gonadotropin-Releasing Hormone agonist (GnRHa) drugs to suppress puberty in ’juvenile transsexuals’ was first proposed in print in the mid-1990s (Gooren & Delemarre-van de Waal, 1996). Developed by three clinicians at Utrecht and Amsterdam, this intervention became known as the Dutch protocol.”
      2. Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27, Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (page 2). This journal article describes how the de Vries et al., 2014 study helped spread the Dutch Protocol. Quote: “To demonstrate problems in the existing research, we discussed two seminal studies that gave rise to the now-common practice of performing gender transitions on young people by giving them puberty blockers, cross-sex hormones, and ‘gender-affirming’ surgery (de Vries et al., 2011; de Vries et al., 2014).” (page 4) Quote: “There is no argument that the Dutch experience, and in particular two Dutch studies—de Vries et al. (2011), and de Vries et al. (2014)—forms the foundation of the practice of youth gender transition.”

[13] Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27, Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (page 5). Quote: “Besides the lack of a control group and a small final sample of 55 cases with key outcomes available for as few as 32 individuals, there are three major areas of concern that render these studies unfit for clinical or policy decision making.”

[14] Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27,  Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (pages 7-10). Note: The Dutch study used the Utrecht Gender Dysphoria Scale (UGDS) to measure levels of gender dysphoria in their subjects. The UGDS has different scales for males and females. For a male subject, the researchers used the male version of the scale before transition and switched to the female version after transition and vice versa for female subjects. This means the researchers are asking males questions about how they feel about being men before transition and questions about how they feel about being women after transition. To measure a change, researchers should have developed an instrument that could be used both pre and post treatment. In the link at the end of this note, two gender therapists familiar with the Dutch study point out that subjects probably would have answered the post-treatment scale the same way without any intervention. That is, a male who wants to transition would react positively to statements about being a woman before doing any medical treatments, so the answers indicate nothing about the effectiveness of the treatment.  The answers only indicate the subject’s desire which has not changed. https://www.youtube.com/watch?v=UnmAQGVdpr8&list=PLngVCeAoK6vudCwfy0R2Rvg_SH2QxBJTu&index=2

[15] Abbruzzese, E., et al. “The Myth of ‘Reliable Research’ in Pediatric Gender Medicine: A Critical Evaluation of the Dutch Studies -and Research That Has Followed.” Journal of Sex & Marital Therapy, 2023, pp. 1-27, Full article: The Myth of “Reliable Research” in Pediatric Gender Medicine: A critical evaluation of the Dutch Studies—and research that has followed (tandfonline.com) (page 7). Quote: “Fifteen subjects were dropped from the study and relabeled ‘nonparticipants.’ This subset, however, was not random, but instead heavily skewed toward subjects who experienced serious problems, including 3 who developed severe diabetes and obesity and 1 death following surgical complications.”

[16] de Vries, A. L. C., et al. “Young Adult Psychological Outcome after Puberty Suppression and Gender Reassignment.” PEDIATRICS, vol. 134, no. 4, 8 Sept. 2014, pp. 696–704, Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment | Pediatrics | American Academy of Pediatrics (aap.org) (page 697). Note: This citation is to the referenced Dutch study. Quote:‌ “Nonparticipation…, 1 trans female died after her vaginoplasty owing to a postsurgical necrotizing fasciitis.”

[17] Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 (page 8). Note: Biggs states that the use of puberty blockers contributed to the patient’s death. Quote: “The authors did not mention the fact that this death was a consequence of puberty suppression: the patient’s penis, prevented from developing normally, was too small for the regular vaginoplasty and so surgery was attempted with a portion of the intestine, which became infected (Negenborn et al., 2017). A fatality rate exceeding 1% would surely halt any other experimental treatment on healthy teenagers.”

[18] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S112). Quote: “Since this treatment is fully reversible, it is regarded as an extended time for adolescents to explore their gender identity by means of an early social transition.”

[19] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S114). Quote: “…the long-term effects on bone mass have not been well established.” and (page S65) Quote: “…there are concerns delaying exposure to sex hormones (endogenous or exogenous) at a time of peak bone mineralization may lead to decreased bone mineral density. The potential decrease in bone mineral density as well as the clinical significance of any decrease requires continued study.”

[20] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S65). Quote: “The potential neurodevelopmental impact of extended pubertal suppression in gender diverse youth has been specifically identified as an area in need of continued study.”

[21]Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S64). Quote: “This underscores the importance of engaging in discussions with families about the future unknowns related to surgical and sexual health outcomes.”

[22] See the quotes in footnotes 19 through 21 for the references to “not been well established,” “in need of continued study” and “unknowns.”

[23] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S256 under the section on Puberty blocking agents). Note: On this page, WPATH lists one of the criteria for receiving puberty blockers as informing the patient of the “…reproductive effects, including the potential loss of fertility….”

[24] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S112). Note: WPATH provides the following guidance for determining when to start puberty blockers, “When a child reaches an age where pubertal development would normally begin (typically from 7-8 to 13 years for those with ovaries and from 9 to 14 years for those with testes), it would be appropriate to screen the child more frequently, perhaps at 4-month intervals, for signs of pubertal development (breast budding or testicular volume > 4 cc).”

[25] Finlayson, Courtney, et al. “Proceedings of the Working Group Session on Fertility Preservation for Individuals with Gender and Sex Diversity.” Transgender Health, vol. 1, no. 1, 2016, pp. 99–107, https://www.liebertpub.com/doi/10.1089/trgh.2016.0008 (page 100). Quote: “Pubertal suppression treatment, prescribed to youth with gender dysphoria as early as Tanner state 2 of puberty, pauses the development of undesired puberty, including some irreversible secondary sexual characteristics, but also prevents maturation of primary oocytes and spermatogonia to mature oocytes and sperm.”

[26] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S157). Quote: “GnRHas impact the maturation of gametes but do not cause permanent damage to gonadal function. Thus, if GnRHas are discontinued, oocyte maturation would be expected to resume.” and (page S158) “GnRHas inhibit spermatogenesis. Data suggest discontinuation of treatment results in a re-initiation of spermatogenesis, although this may take at least 3 months and most likely longer.”

[27] “The Cass Review Independent Review of Gender Identity Services for Children and Young People: Interim Report.” NHS England and NHS Improvement, Feb. 2022, The Cass Review – Independent review of gender identity services for children and young people: Interim Report  (page 38. section 3.31). Quote: “The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway which culminate in progression to feminising/masculinising hormones by impeding the usual process of sexual orientation and gender identity development. Data from both the Netherlands and the study conducted by GIDS demonstrated that almost all children and young people who are put on puberty blockers go on to sex hormone treatment (96.5% and 98% respectively).”

[28] Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, ‌https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 (page 5). Quote: “Subsequent experience in the Netherlands and other countries confirms the fact that 96%-98% of children who undergo puberty suppression continue to cross-sex hormones.”

[29] Van der Loos, Maria ATC, et al. “Children and adolescents in the Amsterdam Cohort of Gender Dysphoria: trends in diagnostic and treatment trajectories during the first 20 years of the Dutch Protocol.” The Journal of Sexual Medicine, vol. 20, Issue 3, March 2023, pp. 398-409, https://academic.oup.com/jsm/article/20/3/398/7005631?login=false  (page 407). Note: In this document, the Dutch researchers themselves acknowledge that most children who take puberty blockers continue to cross sex hormones. Quote: “The majority of adolescents (93%) using GnRHa go on to start with GAH [gender-affirming hormones]. This finding may imply that GnRHa treatment is used as a start of transition rather than an extension of the diagnostic phase.”

[30] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S115, Statement 12.6). Quote: “We recommend health care professionals measure hormone levels during gender-affirming treatment to ensure endogenous sex steroids are lowered and administered sex steroids are maintained at a level appropriate for the treatment goals for transgender and gender diverse people….”

[31] Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558  (pages 3885-3886). The Endocrine Society Guidelines state that one of the major goals of cross sex hormone therapy is “…to reduce endogenous sex hormone levels, and thus reduce the secondary sex characteristics of the individual’s designated gender….”

[32] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S115). Note: This page in the SOC explains that in addition to taking estrogen to develop female secondary sex characteristics, natal males must also take medication to block endogenous testosterone production to prevent development of male secondary sex characteristics. Testosterone both blocks the production of endogenous estrogen and develops male secondary sex characteristics, so natal females do not need a second medication to block estrogen production.

[33] Mayhew, Allison C, and Veronica Gomez-Lobo. “Fertility Options for the Transgender and Gender Nonbinary Patient.” The Journal of Clinical Endocrinology & Metabolism, vol. 105, no. 10, 14 Aug. 2020, pp. 3335–3345,‌ https://academic.oup.com/jcem/article/105/10/3335/5892794?login=false (page 3337). Quote: “… significant concerns have been raised regarding the viability of fertility options for gonads that have not undergone puberty.”

[34] Joyce, Helen. Trans: When Ideology Meets Reality, Oneworld Publications, London, 2021 (page 91). Quote: “But there is no doubt about an indirect harm that will be suffered by any children who start taking them [puberty blockers] young enough to avoid puberty altogether: sterility. Cross-sex hormones cause the secondary sex characteristics of the desired sex to develop – breasts, beards, and so on – but only a person’s own sex’s hormones can cause their ovaries or testicles to mature.”

[35]  “Pubertal Blockers.” UCLA Gender Health Program,  https://www.uclahealth.org/sites/default/files/documents/Pubertal_Blocker_Patient_Information.pdf   Note: This is an information sheet on puberty blockers from the UCLA (University of California Los Angeles) Gender Health Program. Quote: “If the pubertal blockers are started in early puberty, you may never be able to make fertile sperm or eggs, especially if you decide to continue on to hormone therapy later.”

[36] Mayhew, Allison C, and Veronica Gomez-Lobo. “Fertility Options for the Transgender and Gender Nonbinary Patient.” The Journal of Clinical Endocrinology & Metabolism, vol. 105, no. 10, 14 Aug. 2020, pp. 3335–3345,‌ https://academic.oup.com/jcem/article/105/10/3335/5892794?login=false (page 3337). Note: I say, as late as 2020, because this 2020 journal article states, “To date, there are no studies addressing fertility potential of gonads treated with pubertal suppression and subsequent gender-affirming hormone therapy, but significant concerns have been raised regarding the viability of fertility options for gonads that have not undergone puberty.”

[37]This endnote contains quotes from the AAP Policy Statement, the Endocrine Society Guidelines, the WPATH SOC 7th edition, and the WPATH SOC 8th edition demonstrating that the medical associations know treatment with puberty blockers in early puberty followed by cross sex hormones threatens fertility.

          1. Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (p. 6, Footnote c. of Table 2). This quote is buried in a footnote under a table. Quote: “The effect of sustained puberty suppression on fertility is unknown. Pubertal suppression can be, and often is indicated to be followed by cross-sex hormone treatment.  However, when cross-sex hormones are initiated without endogenous hormones, then fertility may be decreased.”
          2. Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S118). “Pubertal suppression and hormone treatment with sex steroid hormones may have potential adverse effects on a person’s future fertility.”
          3. Coleman, Eli, et al. “Standards of Care for the Health of Transsexual, Transgender, and Gender NonConforming People, 7th Version.” World Professional Association for Transgender Health, 2012, pp. 1-112, https://www.wpath.org/media/cms/Documents/SOC%20v7/SOC%20V7_English.pdf (page 51). Note: The seventh edition of WPATH’s SOC was more explicit about the impact of starting drug treatments on people with immature reproductive systems.  Quote: “A special group of individuals are prepubertal or pubertal adolescents who will never develop reproductive function in their natal sex due to blockers or cross-gender hormones.”
          4. Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558 (page 3878). Note: The Endocrine Society Guidelines say that to be eligible for puberty blockers, adolescents must be “…informed of the effects and side effects of treatment (including potential loss of fertility if the individual subsequently continues with sex hormone treatment)….”

[38] In the following quotes, the AAP, WPATH and the Endocrine Society endorse the protocol of puberty blockers followed by cross sex hormones as a standard treatment for gender dysphoria.

          1. Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (p. 6). Quote: “Most protocols for gender-affirming interventions incorporate World Professional Association of Transgender Health and Endocrine Society recommendations and include [ 1 or more] of the following elements….” The elements listed include social affirmation, puberty blockers, cross-sex hormone therapy, gender-affirming surgeries, and legal affirmation.
          2. Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health (page S115). Quote: “When GnRHa treatment is started in the early stages of endogenous pubertal development, puberty corresponding with gender identity or embodiment goals is induced with doses of sex steroid hormones similar to those used in peripubertal hypogonadal adolescents. In this context, adult doses of sex steroid hormones are typically reached over approximately a 2-year period (Chantrapanichkul et al., 2021).”
          3. Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558 (page 3871, sections 2.1 and 2.4). Quote: “2.1 We suggest that adolescents who meet diagnostic criteria for GD/gender incongruence, fulfill criteria for treatment, and are requesting treatment should initially undergo treatment to suppress pubertal development.” and “2.4 In adolescents who request sex hormone treatment (given this is a partly irreversible treatment), we recommend initiating treatment using a gradually increasing dose schedule after a multidisciplinary team of medical and MHPs has confirmed the persistence of GD/gender incongruence and sufficient mental capacity to give informed consent, which most adolescents have by age 16 years.”

[39] Coleman, E., et al. “Standards of Care for the Health of Transgender and Gender Diverse People, Version 8.” International Journal of Transgender Health, 2022, pp. S1 – S258, Standards of Care – WPATH World Professional Association for Transgender Health  (page S254, Table 2). Note: Table 2 lists the clinically significant risks associated with cross sex hormones as venous thromboembolism in natal males, polycythemia in natal females, and infertility in both. The reference cited in endnote 49 defines venous thromboembolism as blood clots that block blood flow. The reference cited in endnote 41 defines polycythemia as an increase in red blood cells that increases the risk of blood clots. Rather than get into a discussion of venous thromboembolism and polycythemia in this editorial, I simplify by saying cross sex hormones increase the risk of blood clots. There are other risks associated with cross sex hormones, but to be conservative, I limited my discussion to those WPATH says are clinically significant. I do not know if the risk for venous thromboembolism or polycythemia reverses if a person stops treatment with CSHs, however, the consequences of a blood clot may certainly be irreversible.

[40] “Venous Thromboembolism.” Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/22614-venous-thromboembolism

[41] Johnson, Jon. “Polycythemia: Everything you need to know.” Medical News Today, 31 March 2023, https://www.medicalnewstoday.com/articles/polycythemia

[42] “Masculinizing hormone therapy.” Mayo Clinic, 21, February 2023 https://www.mayoclinic.org/tests-procedures/masculinizing-hormone-therapy/about/pac-20385099 Quote: “Some of the physical changes caused by masculinizing hormone therapy can be reversed if you stop taking testosterone. Others, such as a deeper voice, a larger clitoris, scalp hair loss, and increased body and facial hair, cannot be reversed.”

[43] “Feminizing hormone therapy.” Mayo Clinic, 21, February 2023 https://www.mayoclinic.org/tests-procedures/feminizing-hormone-therapy/about/pac-20385096 Quote: “Some of the physical changes caused by feminizing hormone therapy can be reversed if you stop taking it. Others, such as breast development, cannot be reversed.”

[44] “The Cass Review Independent Review of Gender Identity Services for Children and Young People: Interim Report.” NHS England and NHS Improvement, Feb. 2022, The Cass Review – Independent review of gender identity services for children and young people: Interim Report (page 38. section 3.31). Quote: “The most difficult question is whether puberty blockers do indeed provide valuable time for children and young people to consider their options, or whether they effectively ‘lock in’ children and young people to a treatment pathway which culminate in progression to feminising/masculinising hormones by impeding the usual process of sexual orientation and gender identity development.”

[45] Biggs, Michael. “The Dutch Protocol for Juvenile Transsexuals: Origins and Evidence.” Journal of Sex & Marital Therapy, 19 Sept. 2022, pp. 1–21, https://www.tandfonline.com/doi/full/10.1080/0092623X.2022.2121238 ‌(page 5). Note: Biggs has also questioned whether puberty blockers cement trans identities rather than giving patients more time to explore their identities.  Quote: “GnRHa was posited to provide space for therapeutic exploration of gender identity, without the pressure of the physical changes accompanying puberty (Delemarre-van de Waal & Cohen-Kettenis, 2006). This claim was plausible, though it was also plausible that stopping normal cognitive, emotional, and sexual development would impede such exploration.”

[46] Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558  (Paragraph titled, Evidence, on page 3869). Quote: “This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation approach to describe the strength of recommendations and the quality of evidence. The task force commissioned two systematic reviews and used the best available evidence from other published systematic reviews and individual studies.”

[47] Hembree, Wylie C, et al. “Endocrine Treatment of Gender-Dysphoric/Gender-Incongruent Persons: An Endocrine Society Clinical Practice Guideline.” The Journal of Clinical Endocrinology & Metabolism, vol. 102, no. 11, 13 Sept. 2017, pp. 3869–3903, https://academic.oup.com/jcem/article/102/11/3869/4157558 (pages 3871-3872). A description of the evidence grading system is found on page 3872 in the section titled, Method of Development of Evidence-Based Clinical Practice Guidelines. Recommendations and suggestions for treating adolescents may be found on page 3871: sections 1.4, 1.5 and sections 2.1 through 2.6; and page 3872: sections 5.5 & 5.6. At the end of each recommendation or suggestion, the supporting evidence is graded.  The supporting evidence for seven recommendations has a grade of “low quality,” and the supporting evidence for three recommendations has a grade of “very low quality.” The evidence for one recommendation to give adolescents information on options for fertility preservation has a grade of “moderate quality.”

[48] Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for

[49] Cantor, James M. “Transgender and Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7, https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (page 1). Quote: “Although almost all clinics and professional associations in the world use what’s called the watchful waiting approach to helping transgender and gender diverse (GD) children, the AAP statement rejected that consensus, endorsing only gender affirmation…. With AAP taking such a dramatic departure from other professional associations, I was immediately curious about what evidence led them to that conclusion.”

[50] Cantor, James M. “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7,  https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (page 1).

[51] Cantor, James M. “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7, https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (pages 2-3). Note: Cantor discusses how the AAP inappropriately cites research regarding conversion therapy for adult homosexuals in its recommendations for treating GD children. Quote: “That is, in the context of GD children, it simply makes no sense to refer to externally induced ‘conversion’: The majority of children ‘convert’ to cisgender or ‘desist’ from transgender regardless of any attempt to change them. ‘Conversion’ only makes sense with regard to adult sexual orientation because (unlike childhood gender identity), adult homosexuality never or nearly never spontaneously changes to heterosexuality. Although gender identity and sexual orientation may often be analogous and discussed together with regard to social or political values and to civil rights, they are nonetheless distinct-with distinct origins, needs, and responses to medical and mental health care choices.”

[52] Cantor, James M. “Transgender And Gender Diverse Children and Adolescents: Fact-Checking of AAP Policy.” Journal of Sex & Marital Therapy, 2019, pp. 1-7, https://www.ohchr.org/sites/default/files/Documents/Issues/SexualOrientation/IESOGI/Other/Rebekah_Murphy_20191214_JamesCantor-fact-checking_AAP-Policy.pdf (page 6).

[53] The list of lawsuits appears below:

      1. Plaintiff’s Petition. State of Rhode Island Superior Court. Isabelle M. Ayala American Academy of Pediatrics, et al. Case Number: PC 2023-0542B. Submitted 23 October 2023. https://dw-wp-production.imgix.net/2023/10/Ayala-v-AAP-Complaint_stamped.pdf
      2. Plaintiff’s Original Petition. District Court of Tarrant County, Texas. Soren Aldaco v. Del Scott Perry, et al. https://first-heritage-foundation.s3.amazonaws.com/live_files/2023/07/Aldaco-Plaintiffs-Original-Petition-Final.pdf
      3. First Amended Complaint. Circuit Court of The State of Oregon for the County of Multnomah. Camille Kiefel v. Amy Ruff, et al. Case No.: 22CV29327. Submitted 12 December 2022. https://static1.squarespace.com/static/5f232ea74d8342386a7ebc52/t/63a0afdfc02f9322762974cf/1671475168006/Kiefel+First+Amended+Complaint+%28file+stamped%29.pdf
      4. Plaintiff’s Complaint. Superior Court of the State of California in and for the County of San Joaquin – Stockton Branch. Kayla Lovdahl v. Kaiser Foundation Hospitals, Inc., et al. https://s3.documentcloud.org/documents/23848578/layla-jane-lawsuit.pdf
      5. Plaintiff’s Complaint. Superior Court of the State of California in and for the County of San Joaquin – Stockton Branch. Chloe E. Brockman a.k.a. Chloe Cole v. Kaiser Foundation Hospitals, Inc., et al. Filed 22 February 2023. https://s3.documentcloud.org/documents/23693707/chloe-complaint-clean.pdf
      6. Plaintiff’s Complaint. District Court of Douglas County, Nebraska. Luka Hein UNMC Physicians, et al. Case Number: D01CI230007381. Submitted 13 September 2023. https://www.nationalreview.com/wp-content/uploads/2023/09/FILE_3605.pdf
      7. Plaintiff’s Complaint and Jury Demand. State of North Carolina County of Gaston in the General Court of Justice Superior Court Division 23 CVS 2375. Charlie Mosely a.k.a. Prisha Mosely a.k.a. Abigail Mosely v. Eric T. Emerson, et al. Filed 17 July 2023. https://s3.documentcloud.org/documents/23882834/prisha-mosley-complaint.pdf
      8. First Amended Complaint. Superior Court of the State of California for the County of San Francisco. Richard Ikechukwu Anumene a.k.a. Rika Ilay Abbir v. The Permanente Medical Group, Inc., et al. Case No.: CGC-22-598800. Filed 10 May 2022. https://detranshelp.org/wp-content/uploads/2023/07/Richard-Ikechukwu-Anumene-Frirst-Amended-Complaint-Filed.pdf
      9. Verified Complaint for Damages. United States District Court for the District of Massachusetts Eastern Division. July R. Carlan a.k.a. Shape Shifter v. Fenway Community Health Center, Inc. Case 1:23-cv-12361-RWZ. Filed 12 October 2023. https://mnf-law.com/wp-content/uploads/2023/11/ShapeShifter-v-Fenway.pdf
      10. Amended Complaint. Providence/Bristol County, Rhode Island Superior Court. Hannah Ulery v. Jason R. Rafferty, et al. Case Number: PC-2023-05366. Submitted 23 October 2023. https://legalinsurrection.com/wp-content/uploads/2023/11/Ulery-Amended-Complaint-filed.pdf
      11. Davidoff, Judith. “Firm suing UW doctors over transgender care seeks clients for similar lawsuits.” Isthmus, 5 January 2024. https://isthmus.com/news/news/firm-suing-uw-doctors-over-transgender-care-seek-clients-for/ Note: This is a story about a suit filed by a “Jane Doe” against the Injured Patients and Families Compensation Fund and the University of Wisconsin Hospitals and Clinics Authority. The plaintiff’s petition is not available.

[54] “Eleven Lawsuits by Detransitioners in the US.” BROADview, 7 December 2023. Newsletter https://www.broadview.news/p/eleven-lawsuits-by-detransitioners?r=25omz6&utm_campaign=post&utm_medium=web Note: This newsletter states that in addition to the eleven public lawsuits listed in the endnote above, six private detransitioner lawsuits have been filed.

[55] State of Rhode Island Superior Court. Isabelle M. Ayala v. American Academy of Pediatrics, et al. Case Number: PC 2023-0542B. Submitted 23 October 2023. https://dw-wp-production.imgix.net/2023/10/Ayala-v-AAP-Complaint_stamped.pdf

[56] Mason, Julia. “Saving Child Medicine from Gender Ideology with Julia Mason.” Interview by Benjamin Boyce for the Benjamin A. Boyce Podcast. YouTube, 3 October 2022. https://www.youtube.com/watch?v=3iAd6tSzSYE (minutes 33 to 38:30 and minutes 50:09 to 52:45).

[57] Mason, Julia, and Leor Sapir. “The American Academy of Pediatrics’ Dubious Transgender Science.” Wall Street Journal, 17 August 2022. https://www.wsj.com/articles/the-american-academy-of-pediatrics-dubious-transgender-science-jack-turban-research-social-contagion-gender-dysphoria-puberty-blockers-uk-11660732791

[58] Rafferty, Jason. “Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents.” Pediatrics, vol. 142, no. 4, 2018, pp. 1-14, https://publications.aap.org/pediatrics/article/142/4/e20182162/37381/Ensuring-Comprehensive-Care-and-Support-for (sidebar, page 1).

[59] Sulaski Wyckoff, Alyson. “AAP reaffirms gender-affirming care policy, authorizes systematic review of evidence to guide update.” American Academy of Pediatrics, 4 August 2023, Press release, https://publications.aap.org/aapnews/news/25340/AAP-reaffirms-gender-affirming-care-policy?autologincheck=redirected

[60] Recommendation of the Council for Choices in Health Care in Finland (PALKO/COHERE Finland) Medical Treatment Methods for Dysphoria Related to Gender Variance in Minors – unofficial translation. Palveluvalikoima Tjänsteutbudet, 2020, pp 1-11 https://segm.org/sites/default/files/Finnish_Guidelines_2020_Minors_Unofficial%20Translation.pdf (page 8). Note: I found the link for this report at the bottom of this webpage: https://segm.org/Finland_deviates_from_WPATH_prioritizing_psychotherapy_no_surgery_for_minors

[61] Care of Children and Adolescents with Gender Dysphoria Summary of National Guidelines. Socialstyrelsen The National Board of Health and Welfare, Dec. 2022, pp. 1-6 https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2023-1-8330.pdf  (page 3). Quote: “At group level (i.e. for the group of adolescents with gender dysphoria, as a whole), the National Board of Health and Welfare currently assesses that the risks of puberty blockers and gender-affirming treatment are likely to outweigh the expected benefits of these treatments.”

[62] Interim Service Specification: Specialist Service for Children and Young People with Gender Dysphoria (Phase 1 Providers) Publication Reference: PR1937_i. NHS England, 20 Oct. 2022, pp. 1-26, ‌https://www.engage.england.nhs.uk/specialised-commissioning/gender-dysphoria-services/user_uploads/b1937-ii-specialist-service-for-children-and-young-people-with-gender-dysphoria-1.pdf (page 16). Quote: “Consistent with advice from the Cass Review highlighting the uncertainties surrounding the use of hormone treatments, NHS England is in the process of forming proposals for prospectively enrolling children and young people being considered for hormone treatment into a formal research programme with adequate follow up into adulthood, with a more immediate focus on the questions regarding GnRHa. On this basis NHS England will only commission GnRHa in the context of a formal research protocol.”

[63] Care of Children and Adolescents with Gender Dysphoria Summary of National Guidelines. Socialstyrelsen The National Board of Health and Welfare, Dec. 2022, pp. 1-6, https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/artikelkatalog/kunskapsstod/2023-1-8330.pdf (page 4). Quote: “The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) concludes that existing scientific evidence is insufficient for assessing the effects of puberty suppressing and gender-affirming hormone therapy on gender dysphoria, psychosocial health and quality of life of adolescents with gender dysphoria [2]. Knowledge gaps need to be addressed and the National Board of Health and Welfare recommends that these treatments be provided in the context of research.”

[64] Below are quotes from three news sources suggesting that gender-affirming care reduces the risk of suicide.

      1. Olson, Jeremy. “‘It Got Very Bad, Very Quickly’: Families with Transgender Kids Seek Refuge in Minnesota.” Star Tribune, 6 May 2023. https://www.startribune.com/minnesota-transgender-refuge-children-families-move-gender-affirming-care/600272910/ Quote: “An estimated 40% of transgender children have attempted suicide, which is one reason the American Academy of Pediatrics and the American Medical Association endorse gender-affirming care.”
      2. Ferguson, Dana, et al. “Minnesota to join at least 4 other states in protecting transgender care this year.” National Public Radio, 21 April 2023. https://www.npr.org/2023/04/21/1171069066/states-protect-transgender-affirming-care-minnesota-colorado-maryland-illinois Quote: “’Frequently, we will talk about gender-affirming care as life-saving health care. And we’re not saying that to be dramatic,’ says Dr. Angela Kade Goepferd, chief education officer and medical director of the Gender Health program at Children’s Minnesota. Kade Goepferd says kids who can’t access care ‘are at significantly higher risk of worse mental health outcomes, including ’”
      3. Davies, Tom. “Federal judge blocks much of Indiana’s ban on gender-affirming care for minors.” AP. 16 June 2023. https://abcnews.go.com/US/wireStory/federal-judge-blocks-indianas-ban-gender-affirming-care-100153581  Quote: “Indiana’s Republican-dominated Legislature approved the ban after contentious hearings that primarily featured testimony from vocal opponents, with many arguing the gender-affirming care lessened the risk of depression and suicide among transgender youth.” and,  “The ACLU had provided ‘evidence of risks to minors’ health and wellbeing from gender dysphoria if those treatments can no longer be provided to minors — prolonging of their dysphoria, and causing additional distress and health risks, such as depression, posttraumatic stress disorder, and suicidality,’ Hanlon said.”

[65] Evidence Review: Gender-affirming hormones for children and adolescents with gender dysphoria. NICE The National Institute for Health and Care Excellence, Oct. 2020, pp. 1-156. (page 14). Quote: “Results from 5 uncontrolled, observational studies suggest that, in children and adolescents with gender dysphoria, gender-affirming hormones are likely to improve symptoms of gender dysphoria, and may also improve depression, anxiety, quality of life, suicidality, and psychosocial functioning. The impact of treatment on body image is unclear. All results were of very low certainty using modified GRADE.”

[66] Evidence Review: Gonadotrophin releasing hormone analogues for children and adolescents with gender dysphoria. NICE The National Institute for Health and Care Excellence, Oct. 2020, pp. 1-131. (page 13). Quote: “The results of the studies that reported impact on the critical outcomes of gender dysphoria and mental health (depression, anger and anxiety), and the important outcomes of body image and psychosocial impact (global and psychosocial functioning), in children and adolescents with gender dysphoria are of very low certainty using modified GRADE. They suggest little change with GnRH analogues from baseline to follow-up.”

[67] Baker, Kellan E., et. al. “Hormone Therapy, Mental Health, and Quality of Life Among Transgender People: A Systematic Review.” Journal of the Endocrine Society, 19 February 2021, pp. 1-16, https://doi.org/10.1210/jendso/bvab011  (page 13, Table 6).

[68] Ruuska, Sami-Matti, et al., “All-cause and suicide mortalities among adolescents and young adults who contacted specialised gender identity services in Finland in 1996–2019: a register study.” BMJ Mental Health, 17 February 2024, pp. 1-6, https://mentalhealth.bmj.com/content/ebmental/27/1/e300940.full.pdf (pages 1 and 5).

[69] Malone, William. “resisting adolescence  – episode 2.” Interview by Posie Parker for the Biological Woman’s Hour Podcast, SoundCloud, 26 May 2020 https://soundcloud.com/posie-parker/resisting-adolescence-episode-two (Minutes 15:43- 16:10). Quote: “In my private conversations, the majority of endocrinologists feel the same way that I do: alarmed at the widespread application of these interventions that don’t have proven benefit with known risk. Most are unwilling to speak out though because of … what happens in the current climate when you do speak out, … you’re targeted.”

[70] Malone, William. “The Hormone Health Crisis with Endocrinologist William Malone, MD.” Interview by Benjamin Boyce for the Benjamin A. Boyce Podcast. YouTube, 12 July 2019, https://www.youtube.com/watch?v=z4RYl75zdMY (minutes 45:10 to 45:48).

The Echo Chamber: How affirm-only clinicians emotionally blackmail parents, influence US government policy & hinder debate about gender medicine

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UPDATE: Here is 4thWaveNow founder Denise Caignon’s speech at the Genspect: Bigger Picture conference in Denver, Colorado November 4, 2023.

Please click the link below to view a PDF of the slide presentation Denise presented during her speech at Genspect’s The Bigger Picture conference in Denver, Colorado, November 4, 2023.

Denise only had time to present a subset of the slides you’ll see in the PDF, so even if you attended the conference, there is more content here than you saw there.

Please note that the slides are rich with clickable links to public content, including videos, Twitter threads, and more. Simply hover over text and/or images to view.

Genspect 4thWaveNow slide presentation November 2023. Click to view PDF

 

4thWaveNow and Transgender Trend meet in Denver

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The first weekend of November 2023, 4thWaveNow and Transgender Trend founders Denise and Stephanie met in person for the first time at the Genspect:The Bigger Picture conference.

Though they’ve been in touch since 2015, Stephanie and Denise had a lot more to say when they finally got to spend time together in the mile-high city. They talked politics, gender and–best of all–cemented their relationship as friends and colleagues as they hiked the Rockies and talked nonstop.

Since a video is worth way more than 1000 words, we’ll let you see what they had to say in this interview recorded when they were together at the Denver conference.

Federal government embraces affirmative care: 4thWaveNow founder discusses in first public appearance

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Seven years on, 4thWaveNow founder Denise (also known as Marie) made her first public appearance in a conversation with YouTuber/podcaster Benjamin Boyce on April 9, 2022. The lively interview is available on YouTube (full video) as well as Spotify.

http://https://youtu.be/88Dk5U0uiqY

The central theme of the “calmversation” was the US federal government’s embrace of “affirmative” care for gender dysphoric minors–whether their parents are onboard or not.

Denise and Benjamin also talked at length about the organizations currently engaged in promoting gender-identity instruction in US schools, a practice that has been in place for many years. In addition, they touched on some rather controversial topics, including the choice of some “affirming” parents to purchase fake penises (“packers”) and tucking underwear for their small children.

The day after her chat with Boyce, Denise added some more detail and clarifications about the topics they discussed. You can find them in this Twitter thread, also compiled here.

TMI: Genderqueer 11-year-olds can’t handle too much info about sterilizing treatments–but do get on with those treatments

On April 7, 2021, the UC San Francisco Child and Adolescent Gender Center offered a Zoom “training” entitled “Fertility Issues for Transgender and Nonbinary Youth.” Advertised widely on Facebook, the session was led by well-known gender therapist Diane Ehrensaft and a colleague, and was attended by over 100 people via Zoom. A recording of the session was provided to 4thWaveNow by an attendee. This article will draw on a few excerpts from the session, available for viewing here and here.

There’s a lot to unpack in the nearly two-hour long session, and we hope to address it more fully in future writings. For now, this piece will focus on one key theme explored in the session:

Future reproduction is pretty much foreclosed as a possibility for children who have been puberty-blocked and who subsequently continue on (as nearly all do) to cross sex hormones, but the “benefits outweigh risks” to move the child from, as Ehrensaft puts it, “gender dysphoria to gender euphoria.”

The fertility-wrecking aspect of the blockers>cross-sex hormones regimen isn’t new ground for those of us who’ve been closely following the accelerating trajectory of pediatric transition in the last few years. Indeed, gender clinicians themselves have known and talked about it for years. The issue is that biological reproduction depends on full maturation of gametes (sperm and ova), and gamete maturation depends upon a person completing their natal puberty.

But what may be new to our readers is that Ehrensaft–a developmental psychologist by training– herself recognizes a concern that child-transition skeptics have repeatedly pointed out: tweens and young teens undergoing these treatments are not developmentally mature enough to comprehend the full magnitude of irreversible sterilization. (Interestingly, she also discussed this three years ago at the 2018 WPATH conference in Buenos Aires.)

Although Ehrensaft (as you might guess) continues to recommend these treatments, in her Zoom presentation, she explains in detail that clinicians, parents, and other adults involved in the child’s care shouldn’t overburden a child with “TMI” –too much information—too many details– about the momentous decision to undergo interventions that result in permanent chemical sterilization.

Now is as good a time as any to dispense (again) with a typical reaction expressed when anyone talks about fertility and trans kids. Many trans activists routinely pooh-pooh the idea that people should be concerned about the loss of future fertility in medically-transitioned children. “You just think women should be baby machines! Not everyone wants to have babies!” Again we state (as we have previously): The issue is not whether a child should ever want “genetically related” (to use Ehrensaft’s term)  offspring when they reach adulthood. It is that it is a human right to make the decision to reproduce–or not–when one has reached adulthood.  Stated more plainly: Sterilizing children is a human rights violation. Until quite recently, these statements would not have been considered remotely controversial—but here we are.

Before delving further into yesterday’s Zoom session, let’s briefly review some of Ehrensaft’s previous remarks on the sterilization of trans kids.

Regular readers and followers of the 4thWaveNow Twitter account will be aware of Ehrensaft’s now-infamous presentation at a 2016 conference in Santa Cruz, CA, perhaps best known for the segment on barrettes and onesies. Less well known perhaps is her opinion, expressed in the same venue, that parents who might want to protect their children’s foundational human right to decide (yea or nay) about reproduction as adults (as opposed to middle school-age) are wrongly interfering with their children’s “dreams” and only balk because of a selfish desire for “genetically related” grandchildren.

“We have to work with parents on—these aren’t your dreams, we have to focus on your child’s dreams, and what they want.”

It appears Ehrensaft has not changed her views much on this in the last 5 years. In the April 7th 2021 Zoom session, Ehrensaft again appeared to relegate any worries or ethical concerns about sterilizing an 11- or 12-year-old child to nothing more than a self-centered parental desire for grandchildren.  Note that in the slide reproduced here, the 11-year-old “assigned female at birth” identifies as “genderqueer.”

Back in 2016, Ehrensaft waxed enthusiastic that many of the puberty-blocked trans kids she has worked with are mature beyond their years, capable of choosing adoption over biological offspring, just as a thoughtful adult might do after careful deliberation. (Interestingly, Ehrensaft seems to have moderated her opinion on this somewhat. In last week’s session, she cautioned clinicians that such pronouncements could possibly be “almost a reflexive response” from some young clients who just want to obtain blockers or hormones, an “overblown altruism”.)

But Ehrensaft’s key point back in 2016 was that puberty blockers and cross-sex hormones are directly analogous to fertility-robbing chemotherapy treatments for children with terminal cancer, since both are “life saving” and urgently required interventions. The message is powerful (whether accurate or not) and more than enough to chasten any loving parent: Denying your middle schooler blockers and hormones is tantamount to letting a child with terminal cancer die for lack of treatment.

We have, of course, heard the life-saving claim many times before: that dysphoric tweens require these treatments for survival, despite risks to not only their future fertility, but also potentially to their sexual function. There is no historical evidence for this claim (in fact, child and youth suicide rates have increased since the advent of pediatric medical transition).(A thorough examination of the flaws in the “suicide or transition” orthodoxy would require another 3000-word article, but for those interested, see here, here, and here for some more reading on the subject.)

Now let’s take a closer look at Ehrensaft’s April 7th Zoom presentation.

You may have heard that puberty blockers are supposed to “buy time” for the dysphoric child to decide whether to proceed further with medical intervention. Indeed, that was the original intent when puberty blockers were first prescribed to gender dysphoric children in the Netherlands.  But there’s a reason why the original Amsterdam clinician-researchers were (and still are) cautious about recommending social transition for younger children: Their goal was to prevent those children who might outgrow their gender dysphoria from embarking on lifelong, unnecessary medicalization; to avoid concretizing what is for some a transient gender confusion. The Dutch engaged in lengthy evaluation and recommended blockers for a carefully assessed cohort of their young patients. Even then, the blockers were meant to buy time.

But Ehrensaft and other “affirmative” clinicians have turned the more cautious “watchful waiting” approach on its head in the last decade or so. No longer is a child encouraged to leave the question open as to whether they will become lifelong medical patients; now they are “affirmed,” often as young as toddlerhood; and at the first sign of puberty, in Ehrensaft’s words, they urgently desire blockers to

 “ward off an unwanted puberty that they’ve been thinking and worrying about for years…These kids who have socially transitioned many years prior, they don’t NEED more time to explore their gender. They’ve known from an early age what their authentic gender was…they’ve been living their affirmed gender for many years by the time they reach puberty.”

For these children, blockers (and the cross-sex hormones which nearly inevitably follow provide “continuity of care in gender affirmation and discontinuity in potential capacity to ever create progeny with their own genetic material.”

So common is social transition (in the US at least), Ehrensaft reported on April 7th, that US researchers have found upwards of 90% of kids requesting pubertal blockade have already socially transitioned. The full ramifications of this increase in social transition (encouraged by affirmative therapists like Ehrensaft) have never been explored in a controlled study. It’s interesting that affirmative clinicians readily follow the Dutch protocol for the use of puberty blockers, while utterly dismissing their cautions about early social transitions.

So if children “affirmed” (and therefore socially transitioned) since early childhood are now justifiably candidates for blockers and then cross hormones, what is the responsibility of clinicians and parents in consenting to these interventions, given that (in her words) “blocking puberty takes away options for fertility for most?”

Ehrensaft acknowledges that a child at Tanner stage 2 (that is, the earliest sign of puberty— “as early as 8 or 9 years old”) is not emotionally or psychologically equipped to understand sex or reproduction, beyond much more than a simple, concrete description of sperm + egg. What’s more, she says, asking a child to consider the mechanics of sex and reproduction at this age may actually be psychologically harmful!

“Fertility considerations about blockers followed by hormones brings on the storm before the lull is over”… So we now have a child who could be as young as 8, 9 who has to think about sex, babies, and future roles rather than games and game playing, which is where we situate development at this period…it’s a developmental stretch and it can create emotional stress.”

She calls this “the disruption”– the “developmental disarray” which could result from informing a child still interested in games and make-believe (and though she doesn’t say it, at an age when some may still believe in Santa Claus or the Easter Bunny):

“So we’re needing to acquire the child’s assent for medical interventions and that requires asking a child prematurely to take on sex and drugs but no rock and roll.”

So what to do if you don’t want to stress out the child with TMI when they are at the “just the facts” stage of development — when you “may get a lot of squirminess about sex or around sex”?  Do you talk about how the jaunty boy sperm meets the cute girl ovum (like the slide picture shows) but stay silent on the icky stuff about sex? After all, they’re not ready (and may even be disgusted by) the “rock and roll” older adolescents become intensely interested in with full-on puberty and sexual maturation.

Pretty much, says Ehrensaft. Instead of giving them more information than they need or can handle,”adults should limit themselves to simplistic explanations about reproduction but not sex.

The question arises: If a child as young as 8 or 9 years old “can’t handle” information about sex, how can they handle deciding whether they are OK with losing the right to reproduce (or not) as an adult, when given “just the facts”?

Ehrensaft buttresses her points by highlighting the developmental framework popularized by the late Erik Erikson (one of the 20th century’s most respected developmental psychologists), which rests on the notion that successful and healthy maturation and adult identity consolidation occurs in stages. She notes that children being asked to decide about their future fertility are “two or three” stages behind the age when they would be better equipped to comprehend the gravity of that choice.

It’s not surprising she would be familiar with the giants in that field; though best known as a gender therapist, Ehrensaft, as mentioned previously, is a PhD developmental psychologist. (It’s much less widely known that in the 1990s, she also had some involvement, as a psychotherapist, in the widely-discredited “satanic ritual abuse” preschool controversy.)

But very unlike Erikson, Ehrensaft’s analyses & recommendations always stem from an untestable confirmation bias: that “gender identity” is a native, fundamental property of the human brain, present from birth (as she said in that 2016 talk, babies “probably know their gender as early as the beginning of the second year of life…they probably know even earlier but they’re really pre-pre verbal”).  In contrast, Erikson’s work made no mention of innate gender. Rather, he emphasized identity development as a long process, involving an essential “crisis” that is often not resolved until one’s 20s. In fact, Erikson posited that a person might not attain healthy adult psychological integration if they did not experience an identity crisis. Another question arises:  Could gender dysphoria, for at least some children and adolescents, be something that needs to be struggled with for successful resolution and maturation, instead of ameliorated (short-circuited?) as Ehrensaft and other affirmative clinicians now do via social transition and hormone blockers?

After warning her audience not to burden tweens with TMI, she rather abruptly notes that

“Those of us who provide this care have been accused of sterilizing children. And what I would say is, we are not sterilizing everybody—[quickly revises] anybody.

Yet this is precisely what Ehrensaft has told her audience affirming clinicians are doing, just with different words (e.g., “they won’t be able to have a genetically related child”): These treatments WILL permanently take the choice to reproduce away from a child who has been puberty-blocked and then moves to cross-sex hormones. A dictionary definition for that is sterilization.

Not missing a beat, she continues:

I would encourage us to hold this in mind: That when people—when adults—confront medical infertility it is a very very difficult road and there are certainly and people may go through some really hard times but there’s not a high suicidality rate for infertile people facing medical infertility. But we do know there are alarmingly high rates of self harm and suicidality and suicidal thoughts among both adults and youth who experience extreme gender dysphoria. And I will say that one of the things I’ve read recently while reading a research study it struck me one youth talking about fertility preservation. I have to decide between saving myself and holding the option of someday having a child…to me it’s a choice between that potential child and my life.”

What research study? Who conducted it? And why would children believe (or be encouraged to believe) they must make a “Sophie’s Choice” between their own lives and that of potential future offspring?

“But as we communicate the fertility information to youth, hold in mind, not many people become suicidal about medical infertility, but many do about gender dysphoria.”

Where are the references for this statement? Where are the studies comparing the “not many” infertile adults who never become suicidal, with adults who were sterilized at the dawn of puberty? Where is the NIH-funded research looking at how chemically sterilized trans kids subsequently feel at 20, 35, 40 and later (much later for males) about having their reproductive choices foreclosed when they were 10 or 12 years old?

To her credit, Ehrensaft does acknowledge there are real ethical issues to ponder here. She even poses the same question many pediatric transition skeptics regularly do:

 “Is a child really able to foresee into the future and foreshorten fertility … And how can a child two or three stages behind Erikson’s stage 7 anticipate what they will feel two or three stages later?”

She provides no answer to her own question; in fact, she simply poses more questions, and says it’s “for us to start [emphasis added] finding out. And we are.”

How can this not be seen as an admission that the entire “affirmative” pediatric-transition enterprise is, in fact, an experiment–with unknown future consequences?

Ehrensaft wraps up this part of the Zoom session with an anecdote she says she heard from another gender clinician, Scott Leibowitz, MD:

“I want to mention one intervention I learned from Scott Leibowitz. Which is, in making these decisions with youth about fertility and their future fertility, once they’ve made the decision, he invites them to write a letter to themselves at age 30, and write their present-age self to their 30-year-old self explaining to them what process they went through to make the decision they did that may have implications for future fertility at age 30 or 25.:

What does Ehrensaft (and Leibowitz, assuming she has represented his views accurately) think this letter-writing exercise will accomplish “after [the child has already] made the decision” that they will never reproduce? Is this meant to serve as an apology of sorts to the regretful adult? That 30-year-old future self, with a 30-year-old brain and all its more nuanced and experience-tempered understanding of the world, its fully developed frontal lobes, will see this letter by his or her child-self and feel — what? Does any 30-year-old look upon the writings or thoughts of their 12-year-old self and see wisdom? They will likely “forgive” their 12-year-old self, but …

Ehrensaft presents this anecdote as if it’s some kind of a solution to the question she posed: How can a child at an early stage of emotional, psychological, and intellectual development make a decision several years before they are equipped to fully comprehend it?

To sum up the 4thWaveNow reaction to the main message imparted in this Zoom “training”: Ehrensaft’s use of (accurate) developmental psychology to justify the impossibility of obtaining informed consent from minors, with only the emotional blackmail of suicidality as a rationale, is nothing short of mind-blowing.

But maybe this is all much ado about nothing. After all, as Ehrensaft’s colleague Jen Hastings, MD told her Zoom audience, maybe none of this will matter in a future when reproductive tech and genetic engineering liberate us from our biological constraints:

“Gametes may soon be irrelevant.”


The complete April 7, 2021 Zoom training can be viewed (in two parts) here and here.

 

Dutch puberty-blocker pioneer:  Stop “blindly adopting our research”

by Grace Williams

On February 27, Algemeen Dagblad, the second-most widely read newspaper in the Netherlands, published an astonishing article. Written by Berendien Teteleptal, the author reports that “more research on sex changes in young people under the age of 18 is urgently needed. Doctors who provide transgender care in Nijmegen and Amsterdam say they know too little about the target group and the long-term effects.” (See here for an English translation of the article.)

What makes this article surprising is that it was a Dutch team of researcher-clinicians (one of whom is extensively quoted in the piece) who pioneered the use of puberty blockers in children with gender dysphoria; this practice is now widespread in the western world.

VU University Medical Center, Amsterdam

After reading this article, I went back through some of the posts on 4thWaveNow that have mentioned Dutch research. One of the posts dates back to November 2015, not long after Denise, the founder of 4thWaveNow, started blogging, entitled “Skeptical ethicist: ‘A medical doctor is not a candy seller’.”

In the post, Denise describes an article published in June 2015 in the Journal of Adolescent Health. Published by a group of  Dutch gender dysphoria researchers, the authors report on a qualitative survey of 17 gender clinics in 10 Western countries. The survey revealed that quite a few professionals on these teams (pediatric endocrinologists, psychologists, psychiatrists, and ethicists) have reservations about early medical treatment. “The article concludes in a way that makes me feel a whisper of hope for the future.”

Several professionals mentioned that participation in the study made them think more explicitly about the various themes, and it encouraged them to discuss the issues in their teams. In the Dutch teams, we therefore introduced moral deliberation sessions to talk about these ethical topics. The first reactions of the professionals were positive; the sessions made them rethink aspects of the protocol.

That the top Dutch researcher-clinicians are now openly discussing their concerns in the mainstream media shows the prescience of Denise’s whisper of hope from almost six years ago. Does their concern stem from these “moral deliberation sessions” they started after the 2015 empirical ethical study? Could another factor be the  recent ruling in the Keira Bell case by the British High Court, limiting the use of puberty blockers in gender-dysphoric children?

Quoted in the aforementioned article by Tetelaptal, Thomas Steensma, one of the lead researcher-clinicians at the Center of Expertise on Gender Dysphoria in Amsterdam, asks some critical questions that U.S. “affirmative” clinicians largely ignore. Teteleptal writes:

Because what is behind the large increase of children who have suddenly registered for transgender care since 2013? And what is the quality of life for this group long after the sex change? There is no answer to those questions. And that must happen, think Steensma and colleagues from Nijmegen.

“We don’t know whether studies we have done in the past can still be applied to this time. Many more children are registering, and also a different type,” says Steensma. “Suddenly there are many more girls applying who feel like a boy. While the ratio was the same in 2013, now three times as many children who were born as girls register, compared to children who were born as boys.”

Steensma also raises questions about the effect of early medical intervention on future fertility:

It is still unclear whether these administered hormones affect the fertility of boys and girls. “We just don’t know,” says Steensma. “Little research has been done so far on treatment with puberty blockers and hormones in young people. That is why it is also seen as experimental. We are one of the few countries in the world that conducts ongoing research about this. In the United Kingdom, for example, only now, for the first time in all these years, a study of a small group of transgender people has been published. This makes it so difficult, almost all research comes from ourselves.”

Not only does he lament the lack of research, Steensma expresses frustration that some practitioners are applying Dutch research without adequate assessment of their patients:

We conduct structural research in the Netherlands. But the rest of the world is blindly adopting our research. While every doctor or psychologist who engages in transgender health care should feel the obligation to do a proper assessment before and after intervention.

The Dutch have always exercised more caution

The Dutch have always been more careful in their use of interventions like puberty blockers, taking care to conduct thorough assessments before proceeding. Many Dutch clinicians have practiced what has been characterized as “watchful waiting,” in contrast to the affirmation approach promoted by the most prominent gender clinicians in the United States.

It’s worth noting that it’s not just medical transition for which the Dutch have urged a slow and deliberative approach. As reported in this 2016 4thWaveNow post, the Dutch have also advised caution when it comes to social transitioning of young children. In a 2011 journal article, Steensma et al. write:

As for the clinical management in children before the age of 10, we suggest a cautious attitude towards the moment of transitioning. Given our findings that some girls, who were almost (but not entirely) living as boys in the childhood years, experienced great trouble when they wanted to return to the female gender role, we believe that parents and caregivers should fully realize the unpredictability of their child’s psychosexual outcome. They may help the child to handle their gender variance in a supportive way, but without taking social steps long before puberty, which are hard to reverse.

A 2013 study conducted by Steensma et al. found that social transition was one of the factors associated with the persistence of gender dysphoria. “Childhood social transitions were important predictors of persistence, especially among natal boys,” the authors write.

No medical consensus

Recently, at about the same time the article discussing Steensma’s concerns were reported in Algemeen Dagblad, transgender woman Rachel Levine appeared before a US Senate committee in a hearing to confirm Levine as President Biden’s assistant secretary of health. During the hearing, Senator Rand Paul asked Levine this question: “Do you believe that minors are capable of making such a life-changing decision as changing one’s sex?”

To which Levine responded: “Transgender medicine is a very complex and nuanced field with robust research and standards of care that have been developed, and if I am fortunate enough to be confirmed as the assistant secretary of health, I will look forward to working with you and your office and coming to your office and discussing the particulars of the standards of care for transgender medicine.”

Never mind that Levine failed to provide a public, direct answer to the senator’s question; note how differently Levine describes transgender medicine from how Steensma characterizes it. Levine refers to “robust research” and “standards of care.” Meanwhile, Steensma, who conducted the very research on which many US “affirmative” clinicians are basing their treatment protocols, tells a reporter: “Little research has been done so far on treatment with puberty blockers and hormones in young people. That is why it is also seen as experimental.”

If you had heard only Levine’s testimony on this matter, you might be excused for concluding that there is widespread medical consensus for the use of medical interventions in gender dysphoric minors, but you would be wrong. As Dutch researchers noted in the 2015 journal article mentioned above, “in actual practice, no consensus exists whether to use these early medical interventions.” This was true in 2015, and it remains true in 2021.

It would, of course, be going too far to suggest that Steensma no longer believes that puberty blockers and cross-sex hormones should ever be used in the treatment of adolescent gender dysphoria. Clearly he believes it’s appropriate in certain cases. In fact that’s the hallmark of the Dutch approach: individual assessment, tailored to each unique case. According to  this article published by the same author on February 28 in de Gelderlander, another Dutch publication,

Steensma does not endorse the judgment of the British court. According to him, there are children who can oversee the consequences. “But that’s an individual process. You can’t compare individuals with one another. We are not saying that hormone treatments are good for everyone. We would also never say that they are not good for anyone. We make the assessment per person.”

Again, though: In contrast to the “Wild West” of pediatric transgender medical care in the United States, where minors can get puberty blockers, hormones, and sometimes even surgery with very little assessment, the Dutch approach has traditionally been considerably more cautious and nuanced. In the de Gelderlander piece Teteleptal writes, “Steensma is perturbed by the method of some clinics and practitioners in America, for example, where puberty blockers seem to be the solution to everything.” ( English translation here.)

 

Steensma is not alone amongst Dutch clinicians. Annelou L.C. de Vries   a psychiatrist with the Department of Child and Adolescent Psychiatry at Amsterdam University Medical Centers, who, like her colleagues, has published widely on pediatric gender issues for many years. In a commentary published in the October 2020 issue of Pediatrics, de Vries writes:

According to the original Dutch protocol, one of the criteria to start puberty suppression was “a presence of gender dysphoria from early childhood on.” Prospective follow-up studies evaluating these Dutch transgender adolescents showed improved psychological functioning. However, authors of case histories and a parent-report study warrant that gender identity development is diverse, and a new developmental pathway is proposed involving youth with post puberty adolescent-onset transgender histories. These youth did not yet participate in the early evaluation studies. This raises the question whether the positive outcomes of early medical interventions also apply to adolescents who more recently present in overwhelming large numbers for transgender care, including those that come at an older age, possibly without a childhood history of GI [gender incongruence]. It also asks for caution because some case histories illustrate the complexities that may be associated with later-presenting transgender adolescents and describe that some eventually detransition.

Given their stated concerns, we can hope Steensma, de Vries and their colleagues, as well as researchers in other countries, will design studies to explore why there’s been such a dramatic increase in the number of gender-dysphoric adolescents with no history of childhood gender dysphoria, as well as why some of these young people later detransition. Lisa Littman’s 2018 paper based on parental reports is a good first step, but much more research is needed. Social contagion, along with other potential factors such as internalized homophobia, sexual trauma, autism and other neuro-atypical conditions, deserve careful and ongoing investigation by gender-dysphoria researchers.

A birthday campaign for JK Rowling: Balanced media coverage of gender identity issues

Did you know that JK Rowling’s and Harry Potter’s birthdays are coming up soon?

Many of us have felt heartened and grateful for JK Rowling’s recent contributions to the discussion around gender ideology. Rowling shares a birthday with her beloved literary progeny – July 31. Harry Potter fans will recall that the boy wizard receives his first Hogwarts’ acceptance letter a week before his 11th birthday. When his Aunt Petunia and Uncle Vernon refuse to let him see the letter, more and more “letters from no one” begin to arrive, finally inundating his aunt and uncle.

The Hogwarts’ motto is Draco Dormiens Nunquam Titillandus (Never Tickle a Sleeping Dragon), but sometimes sleeping dragons do indeed need to be tickled. We thought we would show our support for Joanne on her birthday by sending “letters from no one” to The Guardian, the BBC, and The New York Times. All we are asking for is constructive dialogue in the mainstream media. Please download the letter, print it three times, and send it to the New York Times, the BBC, and the Guardian in time for it to arrive around July 31. Alternatively, you may copy the text (printed below) and paste it into an email. Or better yet, do both! You may feel free to sign it and give a brief description of yourself, or you may simply send without signing.

Once you’ve printed your letter, please take a picture of it and post the photo on social media using the hashtags #ItsNotHateToWantDebate and #HappyBirthdayJKR. Tag in the journalists and the outlets. And please help spread the word!

Let’s send as many letters to each of these media outlets as Hogwarts sent to Harry at Uncle Vernon and Aunt Petunia’s house.

Looking forward to seeing you at Hogwarts!

For a downloadable PDF of the letter, click here.

To copy and paste the letter into an email, see the text of the letter below.

 

To the BBC, The Guardian and The New York Times:

We are writing to request that you widen your scope when reporting on gender diversity. A progressive society is characterised by a respect for thoughtful discussion and we hope that journalistic outlets of your stature could explore multiple perspectives on these important questions rather than stifling debate by covering only one side.

In her recent personal essay, J.K. Rowling outlined her concerns that extremist ideology was negatively impacting vulnerable groups. She highlighted several pressing aspects of this issue that have received scant coverage in the liberal media. The international reaction to Rowling’s essay demonstrated both the lack of public awareness about these issues and the urgent need for honest and respectful dialogue.

In Harry Potter and the Philosopher’s Stone, Harry begins to receive numerous copies of his Hogwarts’ acceptance letter a week before his birthday on July 31 – which is also Rowling’s birthday. These letters marked a new beginning for the fictional boy wizard. We hope these letters that you are receiving will signal to you that there are many from across the political spectrum who wish to have a good-faith discussion about gender ideology and its impact on women, children, adolescents, and also on lesbian, gay, and bisexual people.

It is our hope that together we can help to usher in a new beginning where we can have important conversations that until now have been substantially ignored by the liberal mainstream media. Given our mutual desire to support gender non-conforming individuals, we believe that it is vitally important for leading media to cover these crucial and under-reported stories.

  • The extraordinary growth in the number of adolescents with gender dysphoria
  • The link between increasingly rigid gendered expectations and gender dysphoria in childhood
  • The social pressures on lesbian, gay and bisexual youth to conform to sex role stereotypes and/or change their bodies
  • The complex issues facing the growing number of detransitioners
  • The potential impact the enshrinement of gender identity has upon sex-based rights, single-sex spaces, and sports for women and girls

 After receiving his letters, Harry travelled to Hogwarts on September 1. We would like to follow up with you in early September to see how we might bring more nuance and depth to the current coverage about gender issues.

Hope to see you at Hogwarts!

#ItsNotHateToWantDebate                #HappyBirthdayJKR

The Guardian
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90 York Way
London, N1 9GU,
United Kingdom.

guardian.letters@theguardian.com

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@guardian

The New York Times
620 8th Avenue
New York, NY 10018
USA

letters@nytimes.com

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@NYTimes

BBC
BBC Broadcasting House
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haveyoursay@bbc.co.uk

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Celeb trans kids: Will the Gender Fairy bring dreams—or genital surgery nightmares?

Fourth in our series featuring Dr. Curtis Crane, phalloplasty surgeon. Part 1 is here. Part 2 is here. Part 3 is here.

4thWaveNow contributor Worriedmom has practiced civil litigation for many years in federal and state courts.


by Worriedmom

These days, the world (or at least the media) certainly does not seem in short supply of telegenic, winsome, and appealing “transgender children.” One recent example is Jacob LeMay, pictured here, who as a nine-year old prompted Presidential candidate Elizabeth Warren to commit to seeking Jacob’s input and guidance on her choice for Secretary of Education.

This wasn’t Jacob’s first time in the spotlight, either. As a transgender five-year-old, Jacob’s story was featured on NBC Nightly News and the Today Show. Because at the age of four, sensitive to what they interpreted as gender distress on his part, Jacob’s parents offered “a number of choices,” one of which was whether to start life anew as a boy.

Jacob’s parents have been generous with their transgender parenting expertise, sharing insights with Harvard’s Graduate School of EducationGood Morning America, New Hampshire Public Radio, “Here and Now” on Boston’s WBUR, and MSNBC, among others. Jacob’s mother, Mimi, has already written her memoir chronicling the family’s journey.

Some might find the idea of a memoir just a bit premature given that Jacob’s transgender journey is, at this point, only five years in duration, but honestly, you’d have to be a real meanie to object. Jacob is an undeniably cute kid, the entire family is good-looking, relatable, and well-educated, and they certainly seem to care a great deal about Jacob, as well as Jacob’s future well-being.

And while one might envision a series of memoirs, detailing Jacob’s life of fulfillment, it’s also entirely possible that this will be the first and only installment.

Even in the few short years since the “transgender child” became the media’s go-to story, several stars have skyrocketed to prominence, only to disappear. Remember Coy Mathis’ brave fight to use the little girls’ room at age six? No word on Coy’s doings since Coy was featured in a 2016 documentary film, “Growing Up Coy.” Similarly, Willa Naylor, the transgender eight year old and author whose sympathetic story motivated the entire country of Malta to change its laws, has been radio silent since 2016.

Lila Perry, the Missouri high school student whose quest to use the girls’ bathrooms and locker rooms triggered a student walk-out, similarly has not been heard from since 2015.  Where do they all go?

It may be that Jacob’s transgender story will, at some point, go dark. We may never know whether Jacob, who like the others has been frequently lauded as “brave” and “inspirational,” will have the happy ending that early childhood transition, we are told, is guaranteed to produce.

Stories are important, but unfinished stories can be deceptive. Before we can confidently predict that Jacob, and peers will live “happily ever after,” we should take a look at another story.

This story received no media attention. There are no soft-focus interviews, picture books, or product tie-ins.

This is the story of M.

The only reason we know about M’s story at all is because M was one of at least nine former patients of Dr. Curtis Crane, late of San Francisco and currently of Austin, Texas, who filed medical malpractice or other personal injury cases against Dr. Crane. M’s case (CGC-17-560690) was, like the others, filed in the civil division of the San Francisco Superior Court under the pseudonym “John Doe.” (Note: Although M was repeatedly “doxxed” in the court records by the attorneys on all sides, we retain his privacy here, as we have no interest in shaming or causing further sadness to M [we use M’s preferred pronouns for the same reason].)

The court file reveals M’s journey to manhood, which, in his own words, entailed “many surgeries.” M’s transition journey is detailed below and all of the information is taken directly from the court file:

  • According to his attestation, M’s efforts to become a man began in late 2003 with a “social transition.” According to medical records, M was born in 1977, which made him 26 years old at the commencement of the transformation process.
  • In 2004, about six months after his social transition, M began treatment with male hormones.
  • In 2005, M received a bilateral mastectomy.
  • In 2006 M received a total abdominal hysterectomy with bilateral salpingo-oophorectomy (which meant that M’s uterus, cervix, fallopian tubes and ovaries were all surgically removed).
  • In 2009, M received a metoidioplasty, an operation that uses tissue from the clitoris, which has typically been enlarged from testosterone use, to form a “neo-penis.” This operation was performed by the famous Dr. Miroslav Djordjević of Serbia, which was in the process of becoming an international hub of transgender surgery.

Alas, M’s gender journey was far from over.

  • In 2011, M underwent his first phalloplasty or surgical construction of a penis, with Dr. Toby Meltzer. This operation was not planned to, and did not, include construction of a functioning urethra. (We note that Dr. Meltzer has also been widely panned by at least some of his SRS patients.) The tissue to form the neophallus in the 2011 surgery was apparently taken from M’s back, and left behind a “dog ear.” During the 2011 surgery with Dr. Meltzer, M also received a vaginectomy (surgical removal of the vagina) and a scrotoplasty (construction of an artificial scrotum).

After all of this, M continued to suffer from gender dysphoria. In 2014, M came under the care of Dr. Curtis Crane. The surgical consent form indicates that M was to receive:

The plan for this surgery was to remove the “old” phallus from 2011, and to re-construct a new one, this time with tissue from M’s left forearm (M underwent electrolysis and laser hair removal on the forearm area for six months prior to the surgery to prepare the skin for transplant). The new penis would have a functioning urethra. The lawsuit against Dr. Crane arose because, while M alleged that he repeatedly told Dr. Crane and his staff that he did not need a vaginectomy and a scrotoplasty, those having already been performed by Dr. Meltzer in 2011, M stated that Dr. Crane over-rode his instructions and both cut into the area where M’s vagina had previously been, and damaged and dis-placed M’s scrotum (as discussed more fully below).

The legal papers contain another interesting and tantalizing suggestion that is never developed in the record. Specifically, M alleges that when M complained to Dr. Crane that vaginectomy and scrotoplasty were listed on M’s informed consent document, when those operations were not supposed to be performed, Dr. Crane reassured M that they were listed on the document either as a typo or for billing purposes [emphasis added]. A curious fact, if true.

According to court records, M’s lawsuit against Dr. Crane was dismissed on March 15, 2019. As is customary, there is no indication whether Dr. Crane, or his insurer, paid any damages to M.

Following the 2015 phalloplasty and other procedures with Dr. Crane, incredibly, M required at least three additional surgeries. In April 2016, M underwent a “phallus shortening” procedure, which involved “telescoping entire phallus into suprapubic area.” In November 2017 M went to Cedars-Sinai Hospital in Los Angeles and received a urethroplasty in a two-stage procedure, to close the neourethra which was placed by Dr. Crane. Then, in March 2018, Dr. Garcia and another surgeon again performed surgery on M, this time to “re-place” the existing penis (which was also displaced), and to re-orient M’s scrotum. In his lawsuit against Dr. Crane, M alleged that during the 2015 surgery, Dr. Crane had “displaced” his scrotum by three centimeters, leaving it immediately adjacent to his anus. Moreover, M claimed, Dr. Crane had moved M’s testicles from their customary “side by side” position and re-placed them one in front of the other.

In March 2019 (following the three post-Crane surgeries), M stated that he still had an abscess in his pelvis where his vagina had been. Moreover,

At this point, words cannot really begin to describe M’s ordeal.

M was forced to take off work from September 2015 through February 2016 (5 months), then returned to work in March of 2016, but had to stop working again in November 2017. It’s unknown whether he ever returned to full-time work (in a court filing dated March 2019, M stated that he had been out of work for “the majority” of the past three years). The filing also stated that, because of the surgeries he had undergone, M had to assume a new job for which he was paid 50% less, and was then living “paycheck to paycheck.”

M alleged that his out of pocket expenses for the September 2015 surgery with Dr. Crane were approximately $6,500, while his out of pocket expenses for the November 2017 surgery with Dr. Garcia were approximately $4,000, and he expected to spend about $4,000 more for the “last” surgery in the spring of 2018.

M’s out of pocket expenses pale in comparison to the price tag for the surgery performed by Dr. Crane, however, which was approved by the Ontario Ministry of Health and Long-term Care in the amount of $126,508.  Given that fact, the total financial cost of M’s gender journey is no doubt somewhere north of a million; the personal cost is, of course, incalculable. And yet M’s gender dysphoria endures.

So returning to the celebrity trans kids at the beginning of this article: What do you suppose young Jacob, and Jacob’s transgender peers, are hearing about their likely futures? Do you think that, being young children after all, they expect that one day the Gender Fairy will pay a visit? Or do they believe that, as Diane Ehrensaft claims, “God got it wrong,” and someday they will return to the womb and re-emerge as their correct gender? After all, nobody is better at magical thinking than young children, and raising a girl as a boy, or vice-versa, is implicitly, if not explicitly, affirming the child in the belief that one day her wish will come true.

M’s phalloplasty story isn’t suitable bed-time fare, at least not for Jacob. But for Jacob’s parents, and their many peers, perhaps it should be. After all, the Gender Fairy could someday deliver a real-life nightmare.

Benji/gnc_centric: On being kicked off Twitter and Medium

by Benji, gnc_centric

 Benji/gnc_centric—in the words of her now-suspended Twitter profile—is a “socially detransitioned dysphoric female,” a “homoSEXUal not homoGENDERal” lesbian.  Benji, a Canadian activist, writer, and YouTuber, writes here about how she was recently suspended from Twitter and subsequently Medium for (she believes) referring to the biological sex of a certain UK trans woman. Benji joins many other women whose voices have been censored by Silicon Valley tech companies. (4thWaveNow is also currently under a Twitter lockdown for similar reasons.)

Despite being silenced on some platforms, Benji is still very much active on the Internet. See the bottom of this article for ways to contact her and to see her work.

 4thWaveNow is pleased to host the below article, originally published in a slightly different form on Benji’s now-suspended Medium account.

Benji wrote another piece for 4thWaveNow earlier this year, about her less-than-supportive experiences in a Toronto trans-teen support group.

We will continue to offer 4thWaveNow as a platform for others who find themselves in a similar situation; please let us know if you would like to be published here.


 My Twitter Suspension

On the morning of December 11th, I was tweeting away as usual when at 11:40am, I tried to reply to a tweet and this is what I saw:

I went to check my account and saw this:

I had just recently reached 4000 followers so I was very upset. I checked the hashtags where I posted most, #TransTheGayAway #DiscussingDysphoria #Detrans and #QueerRapeCulture and all my tweets have been erased from Twitter.

I was confused, so I checked my email to see what offence I had committed and found this:

I can only assume that this happened because I referred to a trans woman, Katy Montgomerie, as a male. If she wasn’t a male, she wouldn’t have dysphoria and wouldn’t have anywhere to transition from; the whole concept of “Male to Female”. I struggle to see how this tweet is “hateful”.

Context

On December 7th, 4th Wave Now tweeted a thread about an affirmation-only parent support group on Facebook, specifically about a thread in that group that had developed on the topic of families with multiple trans children.

Katy Montgomerie replied in the thread, claiming that families with multiple trans kids are statistically likely and nothing to be concerned about. Katy then went on to say that the parents who run 4th Wave Now are anti trans; desperate not to have trans kids. The reality is, that the daughter of one of the founders of 4th Wave Now is a 22 year old, detransitioned lesbian.

The tweet that is missing from this thread is here:

This tweet is not visible because it violates Twitter’s rules, as “hateful conduct” for a similar reason to mine; referring to a Katy, a trans woman, as a “natal male”. 4thWaveNow explains their current situation here and here.

Here’s where I responded to Katy, after being tagged into the thread by 4thWaveNow, the missing tweet is the one I was suspended for because it was ruled “hateful.”

The missing tweet is at the top of this article but I’ll put the text here so you don’t have to scroll up. I tweeted:

“This is nonsense. Where are you getting this? A 4000% increase in females transitioning in the UK isn’t just because ~acceptance~. You presume to know the female motivators for transition when you are in fact male. What do you base this on?”

Here’s one source for the 4,400% increase in female minors in the UK being referred for transition that I was referencing

On Twitter, Katy says she has detrans friends and wants to help detrans people, but I’ve only ever seen her dismissing detransition as so rare that it’s not relevant enough to merit a change in the way transition is prescribed. She says she is a friend to detrans people but attacks one of the few websites –4thWaveNow– that will amplify our writing about our experiences. She says she supports detrans people but calls any resource we use “anti-trans”. Obviously, she has her own ideology to propagate and this is her method. I would advise detransitioned people to steer clear of her on Twitter and Medium.

Appeals

As soon as I understood that I had been suspended, I appealed to Twitter. Predictably, they said they were looking into it but (initially) did not respond beyond that. I don’t have much faith in Twitter or their review process, so on December 15th, I filed a complaint with the Better Business Bureau. I know a few women who’ve had their Twitter accounts suspended and were able to reverse this using the BBB, so I was cautiously optimistic.

This was my appeal to them:

I have been using twitter for many years, mostly for lesbian activism. A few days ago, my account @gnc_centric was indefinitely suspended for “hateful conduct” which is shocking because the tweet that is cited is not at all hateful. I believe that this is the result of targeted reporting by homophobes who do not like what I have to say. I appealed to Twitter but they have not explained why my tweet was hateful or why it rises to the level of an indefinite suspension. I am appealing to you because for me, Twitter is a powerful networking tool and I need it to stay in contact with journalists and other professionals, as part of my activism.

They immediately replied, saying that they were looking into it. On the morning of December 23rd, I awoke to find this response in my email.

It’s true I’ve been put in Twitter jail a few times. If I recall correctly, I’ve had my account locked twice, for 12h and had it locked once, for 7 days (thanks @AidanCTweets 😉). As you can imagine, I did not wish violence on anyone or say anything cruel or tweet with malicious intent. I would love to be able to go through how I “violated Twitter rules” each time, but I can’t access my old tweets now and I didn’t keep track of it as it happened.

This was my reply to this result:

I am rejecting this response because: if you were to review the history of all the times I’ve violated the twitter rules, you would see that the tweets in question were all just as innocuous as this one. I have never tweeted anything violent or hateful but because of mass reporting, I’ve had my account locked several times. I thought the BBB would see I’m not using the Twitter service in hateful or violent way and see the reality of the situation; those who oppose me will find ways to disrupt my use of Twitter, regardless of the reality that I’m not hateful or violent. Twitter is woefully unable to screen reported tweets and as a result this has happened to me repeatedly.

This was the response I received on December 24th:

I can’t believe the irony of this response. I would really, really, REALLY like to know, who experienced “targeted abuse” by me. Not to be too narcissistic, but am I not the one in this situation who is unable to “feel safe expressing diverse opinions and beliefs” on Twitter? I’ve had multiple short suspensions for expressing my beliefs, is that not “abusive behaviour” on the part of those who see me as a threat? “This includes behaviour that harasses, intimidates, or uses fear to silence someone else’s voice”. I can’t believe they sent ME this message, when I’m the one who has been continuously harassed and now, silenced on Twitter.

What makes me so angry is that extremist ideologues know this is how Twitter works, and they are meticulous in their reporting. Their goal is to get the most vocal women who question gender ideology off of the platform and they know exactly how to do it.

Medium Suspension

On December 25th (Merry Christmas!) I checked in to see what people on Twitter were saying about GNC Centric… and they were saying my Medium account (where this article was originally posted on December 23rd) had been suspended. I suspect that this happened because I mentioned Katy Montgomerie– and the fact that they were male–in my Medium piece.

I searched for my Medium on incognito and found this:

So I checked my email and found this:

Since Medium has very similar policies to Twitter, I will not bother attempting to appeal this suspension. When I was first suspended from Twitter, I planned to post much more on Medium; what I used to post as Twitter threads I would now format as short articles.

Since this is obviously now impossible, I’ve made alternate plans. For the time being, I will be guest posting on other sites like here on 4thWaveNow and Graham Linehan’s blog. I’m now in the process of building my own website (finally!) where I can’t be censored and I’m very much looking forward to that! I’m also going to start posting YouTube videos more regularly now.

In 4thWaveNow’s first article about their concurrent Twitter suspension, they have two quotes from Orwell’s 1984. They seem relevant as ever, so I’ll add them here as well.

“It’s a beautiful thing, the destruction of words.” — George Orwell, 1984

“But if thought corrupts language, language can also corrupt thought.” — George Orwell, 1984

 

Contact

Now that I’m no longer on Twitter (though I’m keeping an eye on what’s going on there 🤨) I’m spending more time on other social media. The most direct way of contacting me now is through email.

 

📲Social Media 💁🏻‍♂️
Email ► GncCentric@gmail.com
Tumblr ►https://gnc-centric.tumblr.com
Reddit ► https://www.reddit.com/user/GNC-centric
Spinster ► https://spinster.xyz/@GncCentric
YouTube ► https://www.youtube.com/c/gnc-centric

 

Update: Twitter remains obstinate in defamatory lockout after Better Business Bureau complaint

Last week, we wrote about Twitter’s lockdown of our account for use of the scientific term “natal male.”

We filed a complaint with the Northern California Better Business Bureau. That complaint was today rejected, with Twitter [in its boilerplate response] doubling down on its defamatory claim that we engaged in “hateful conduct,” specifically: threatening, directly attacking, and promoting violence.

If we continue in this “abusive behavior,” so sayeth our Twitter Overlord-bot, we are risking our account.

Once again, below is the tweet Twitter claims to be “abusive behavior,” worthy of the potential forfeiture of over 13,000 followers (including many prominent journalists, politicians, and others who wield political and public opinion influence) and five years of substantive information shared with the public.

Were we surprised by Twitter’s automated response? Of course not; it’s par for the course in the current zeitgeist, where totalitarian-minded scolds running the most influential social media platform in the world believe it is their solemn duty to serve as Reeducation Nannies for the teeming masses.

In the two weeks since our lockout, other thought criminals have also been Twitter-jailed or perma-banned for their “abusive behavior” (otherwise known as telling truths certain trans-activist tattletales don’t want you to know). Fellow inmates include reasonable trans people like MarsBruh, a trans man who goes out of his way in his interview series to feature diverse viewpoints, and detransitioned lesbian activist and Youtuber gnc_centric, who as of this writing has also filed a BBB complaint--to no avail–to reverse her permanent suspension from Twitter.

There have been many more before us, and there will undoubtedly be more to come who’ll be ejected from the 21st century public square and condemned to Big Tech thought-crime prisons.

Nevertheless, despite our cynicism, we believe it’s important to keep telling our truth, and that now includes rejecting Twitter’s libelous edict:

Since our previous post on the matter, our Twitter lockout has been written up in a very good article by Libby Emmons in the Canadian Post Millennial, and the journalist Jesse Singal confirmed via Twitter that “simply describing what being trans is could lead to you losing your account.”

And as everyone not living in a cave now knows, just a few days ago beloved author of the Harry Potter series, JK Rowling, has come under international fire (including ridiculous propaganda pieces in major US outlets such as NBC, CNN, and the onetime paper-of-record) for tweeting her views about biological sex in regard to the recent UK court case against Maya Forstater.

The 4th_WaveNow Twitter account is fairly well known, but is puny by Twitter standards. Banning JK Rowling (and others with 1M or more followers) from the public square for her past or future thought crimes might be a bridge too far–but for how long?

Maybe Rowling and other celebrities with adequate financial wherewithal and intestinal fortitude should put their heads together and try pushing that biological (aka “natal”) sex envelope a wee bit further on Twitter.

Just a thought. You know, just to see what might happen…