A “sinister mental trap”: One man’s journey back to himself

Potentilla is a detransitioned male who spends his days farming, making gardens, practicing herbalism, and reading Carl Jung. He is interested in history, human nature, and the occult, and greatly enjoys giggling with strangers, the utter improbability of life, taking long walks, and making music with friends. He is available to interact in the comments section of this post. Potentilla can also be reached at potentillacinquefoil@gmail.com, where he is happy to discuss these issues privately with concerned parents and people contemplating transition or detransition.


by Potentilla

I was born male and lived for the first five or so years of my life totally OK with that. As I got older and was taught postmodernism, white guilt and misandry, I started to hate my male body and wanted my maleness to be destroyed. I became suicidal and practiced self harm, including towards my genitals. I wanted to magically turn into a girl, and thus be redeemed.

Growing up, it was hard for me to conform to the norms of American masculinity. Part of this is that my dad is a reflective and empathetic man, and so my natural model is someone who himself doesn’t necessarily conform to gender norms. Nevertheless, I was ok with my body until maybe the age of 19, when I realized I’m attracted to other men and am both a “bottom” and somewhat swishy. Around 20 I had multiple crises; I moved to a gay hippie commune, I broke up with my first serious boyfriend, I did too many drugs, became homeless, and had several very confusing sexual relationships with women.

Slowly I came to believe that I was a repressed woman. It is a testament to my credulity that I could honestly assess my own life situation, and yet come to that conclusion. But that is exactly what happened. Trans let me explain away all my problems with a new and compelling narrative. This promise held enormous emotional appeal. At the time, I was living in a trans/genderqueer space where there was a cult-like atmosphere in regard to transitioning. Being trans made you an insider and conferred upon you sympathy, respect, and resources. Being merely gay was frowned upon.

For the past 10 years ago or so, I’ve “lived as a woman.” For the first 8 years of that, I was on cross sex hormones, when I began to use herbs to manage my health.  I had an orchiectomy about 7 years ago. After my surgery, every punk house was open for me to live in. I had become a protected class.

Even though I didn’t pass as a natal female, being trans made my life easier to navigate socially. People seem much more comfortable with a somewhat feminine man becoming a transwoman than a somewhat feminine male owning his maleness. It is fascinating that this is the case, that it was and is scarier for me not to pretend I’m a woman.

So, I had some very compelling reasons to transition, those being:

  1. unprocessed trauma concerning my gender
  2. poor mental health and poor reality testing
  3. social pressure
  4. social rewards
  5. a postmodern ideology that rewards transition

I believe that the trans movement has qualities that make it very similar to a cult. I became trans for the very same reason that people join cults; and similarly to those who escape cults, I’ve found profound healing in my slow path towards detransition.

Now, almost ten years later, it is clear that I am not a woman. In fact, it is obvious that I am still very much a male, but now with breasts and mutilated genitalia. That is an uncomfortable position to be in; not only was I mistaken; everyone knows it. But his uncomfortable reality is still preferable to the intense self-delusion and narcissism that I lived in and with for many years.

The Curse of Trans

While there is a certain temptation to accept all of this as personal failings; while there are certainly many ways that I have been weak and unstable, it doesn’t feel particularly genuine to try to explain my immersion into trans as solely a personal choice and experience. To understand trans sensu lato means understanding the ways it resembles a cult. I transitioned only after heavy indoctrination into genderist ideology. Most pertinent was the pernicious “cis” and “trans” dichotomy.

I believe this binary ideology to be a very profound curse to susceptible individuals. “Cis” is defined as someone who is okay with their body as it is, while “trans” means someone who isn’t okay with their gendered body, regardless if they physically transition or not. Given this definition, most people have at certain points of their lives been functionally trans. This is usually especially pronounced at puberty, and it is horrifyingly predictable that we’re now seeing a trend of trans children, given the intersection of pubescent dysphoria and genderist ideology.

When I encountered this false dichotomy, naturally I put myself on the side of “trans” because I have a long history of hating my gendered body. Once I accepted this as true, I was locked into the certain path of claiming I was a woman. This led to faith-based beliefs that “gender is innate” and “I am a woman,” which in turn led to the blind faith that “hormone replacement therapy will solve my problems” and “I’ll be so much happier after I’m castrated and no longer male.” This was compounded by the widespread belief that transgender feelings grow worse with time and inevitably lead to insanity or suicide if there is not medical intervention.

And away I went, my mind totally taken with genderist ideology, with full faith that transitioning was the only way to save my life.

This is why I consider “trans” to be a curse. I imagine the evil trans witch standing over the gender-nonconforming children lost in the woods, reassuring them that “cis people are comfortable with their bodies and trans people aren’t. I can help you become at home in your own body” as the children follow her deeper into the woods to be transformed. What the children don’t realize is that they must pay for this with a piece of the glowing, golden ball that is in their hearts. Later, only a few become disillusioned and decide to retrieve the piece of their heart that they lost. They wander alone hither and thither in the dark woods for many years to find the sacred springs where they wash off their deception, fear and helplessness, and find that the golden ball never actually left. They are still themselves, only disfigured and disoriented by the deal they made with the evil witch. But they are finally able to leave the dark forest and again become part of the human family.

glowing heart

I’m open to the idea that some individuals need to transition to live their authentic selves. There may very well be folks who genuinely and beautifully find themselves in transition. That being said, though, I believe it is inevitable that these stories of self-discovery through sex change, no matter how true they are or beneficial to the individual, contribute to the destructive myth of the trans/cis binary. I don’t want to generalize too much from my own experience, but I also strongly believe that transition does profound harm, even when it does help. People have the right to transition, but I also believe that the entire gender identity movement has become unfathomably destructive, especially to gender nonconforming young people who, for the most part, would almost certainly otherwise be homosexuals. There are areas of subtlety which I’m not sure how to explore in this regard, and they are beyond the scope of this essay.

Sense of Self

During the time I believed I was a woman, I enjoyed every step of transition, because it gave me an identity. I didn’t know who I was and a transgender narrative gave me a handle to understand myself. Rather than needing to take care of the wounded parts of my self, I created an entirely new persona, and I played that part every moment of every day.

This worked as a great solution for a time; I did a good job playing that part, rather than living as my authentic self, and was thus shielded from the vicissitudes of the world. This is of course textbook narcissism, which makes me wonder if trans is as much a cult of narcissism as a cult of gender.

With time however, my authentic self was nonetheless nurtured by my experiences and I began to become more genuine. This transformation had three parts:

1) Leaving the Trans Cult

After a nasty breakup, I left a queer land project and LGBT community where postmodern Marxist ideology was very dominant. I constantly self-censored to fit in with the group. My own political leanings tend towards Burkean conservatism, so I was more or less lying to myself and others. I attended mandatory sensitivity training which had the feel of a political indoctrination meeting. Almost every day, I ritualistically confessed my guilt as a white person in conversation with my peers, and they did the same with me. Over time I began to feel an actual intense guilt. And with that, I began to wake up to the fact that this sort of politic was bad for my mental health.

So after my nasty breakup, I left this queer community and got a live-in job at a farm. My coworkers there were much more free thinking, and I began to find it easier to think for myself. That year I worked 55-hour weeks and read about 60 books (including Spengler, Odum’s Ecology textbook, Marcus Aurelius, Homer, and more). This study, and the new milieu with new friends, allowed me the opportunity to learn that I’m strong and capable living on my own, and my worldview was massively expanded.

2) Going off Hormones

About 9 months after leaving the trans cult, I stopped taking hormones, and began taking herbs, and studying them, to maintain my health instead. I could pursue a passion that connects me to my inner self while showing me that I’m not dependent on maintaining a trans identity to meet my own health needs.

medicinal herbs

I’ve also developed skills which have helped many other people. In turn, I saw people valuing me for something deeper than my identity. I am very passionate about plants and have been my entire life. I am also open and spiritual in my psychological orientation. This makes the study and practice of herbalism deeply rewarding to my authentic self, and helped me become strong enough to escape from living mostly out of my trans identity.

3) Detransition

After leaving the queer land projects, I fell into several other social milieus where thoughts were heavily policed. By this point I had already stopped believing in the idea of transition, but kept up appearances for social benefit–and that social benefit was huge. Certain people would hire me because I was perceived as trans. I could find places to live with queer folks largely on account of my identity. Living in these environments, which were well stocked with self-appointed thought police, was bad for me, and I began contemplating leaving. Near the end of this time I developed debilitating chemical sensitivities, and decided my best bet was to live with my parents for a time. At that point, the entire trans narrative dissolved, and just as quickly, my chemical sensitivities became very easily manageable.

Some Closing Thoughts

Over the years, I’ve known dozens of trans people. Most had reasons that were less convincing than my own for transition, and as we’ve seen, my own justifications were rather feeble. This leads me to believe that, by and large, trans is a disingenuous ideology that is a current mass hysteria. It is also clearly something of an unintentional eugenics program against gender nonconforming folk. The entire enterprise makes me feel sick. It has become trendy to commit oneself to lifelong hormone therapy and surgical mutilation. I was not able to correctly appraise the situation at the time I became trans and deeply regret the decision now.

Going a little deeper, trans is profoundly sexist and actually creates less diversity in expression. I went from an authentic, studious, awkward, somewhat feminine man to performing full time as a trans woman. Eventually my authentic self reasserted itself, and now I’m slowly moving towards more integration. The trans narrative does much more than merely normalize mental illness; it creates mental illness. I would have never transitioned if I hadn’t been wounded by postmodernism and then given an escape hatch in trans. The narrative made me crazy just as much as my own predisposition made me vulnerable to it.

My sense is that no one wants to hear the voices of detransitioners until it is too late. My sincere hope is that some people who are considering transition, as well as parents with “trans” children, might read my essay and choose a brighter path than that of transition. Please learn from my mistakes and consider other options. Most dysmorphia goes away with time. The entire trans narrative is a sinister mental trap which is profoundly harmful. There are infinitely better ways to deal with the universal experiences of dissatisfaction and desire to be someone else.

Dental dysphoria: Transgender medical procedures trump essential dental care across the US

by Worriedmom

Tax time rolls around again, all too soon, and as I tally up the itemized deductions for my 2016 return, I realize, to my sadness but not my shock, that once again this year, our dental expenses are close to $13,000. Between four adult children needing a variety of dental services, and the fact that my husband and I are beset with age-related dental woes, some months I think I pay our dentist’s office rent all by myself. Although my husband has a generous medical plan through his employer, it does not cover dental expenses, other than those incurred in an accident, and this is typical of many employer-provided benefits packages. So, we pay.

And when I pay, I take a moment to think about the people who can’t pay – but they still have teeth. What do they do? What happens to them?

First, if you’ve ever had an untreated cavity or, worse, an infection or abscessed tooth, you know that the pain involved can be incredibly intense: you can’t think, focus, or do virtually anything, until the situation is addressed. The drugstore has shelves filled with ointments and gels for treating dental pain, not all of which are for teething babies! Second, poor dental health affects nutrition. Ability to eat and appetite are adversely affected by painful or missing teeth.

According to the Kaiser Family Foundation’s “Access to Dental Care in Medicaid” report, “Research has also identified associations between chronic oral infections and diabetes, heart and lung disease, stroke, and poor birth outcomes.”

A serious side effect of poor dental health in adults is its adverse impact on employment. People whose teeth are unsightly or missing are often deterred from seeking employment, or better jobs, and can suffer discrimination in hiring. Poor dental health is not a “protected class” for the purposes of anti-discrimination law, so employers are free to decline to hire a candidate on that basis.

cletusAs a final but not at all minimal side effect, consider the psychic distress and embarrassment experienced by people with unattractive teeth. In the United States in particular, missing, crooked, or discolored teeth are associated by many people with ignorance, lower class status, poverty and other negative social qualities.

At 4thWaveNow, we do understand that the plural of anecdote isn’t evidence, but two quick stories might shed some light on the magnitude of the problem:

  • A 28 year old man from my church, who lacks dental insurance, is living with persistent tooth pain. One week it becomes acute. He leaves work and seeks care in the emergency room, where it is found that an infection has spread to his entire jaw, and he will now (after spending four days in the hospital), lose all of the teeth on one side of his mouth. He has also lost his job. Eighteen months later, he is unable to afford to replace his missing teeth and is still unemployed.
  • Another friend has a failed root canal which wakes her up with screaming pain in the wee hours of the morning. By the time she receives emergency care from an endodontist at 3 AM, the infection is already so aggressive it is invading her soft palate. The endodontist tells her if she’d waited until the next day to seek care, the infection could have potentially gone septic, and/or reached her brain.

Yet, we all treat dental care as if teeth and gums are not even connected to the rest of the body…

How widespread is lack of access to dental care in the United States? According to the Centers for Disease Control, in the period 2011-12, 17.5% of children between the ages of 5 and 17 and 27.4% of adults between the ages of 20 and 44 had untreated cavities. In 2014, 62% of adults between the ages of 18 and 64 had a single dental visit within the previous year; more than one-third of adults had not. Put another way, a 2012 Kellogg Foundation report estimated that some 83 million Americans faced barriers to dental care.

Medicaid, as our non-United States readers may not be aware, is the US health insurance program that provides health care for low-income people from birth until approximately age 65; it also pays for nursing home care for destitute adults of any age. Medicaid is the primary way for low-income or disabled people to access health care (and access to Medicaid was expanded in states which opted in via the implementation of the Affordable Care Act in 2010). Medicaid is administered through the states, and although there are some things that the federal government says that states must cover, dental care is not one of them, except for people under the age of 21. While some states have decided to provide dental care as part of Medicaid, fewer than half provide comprehensive dental care for adults and some do not even cover dental care that is required due to an accident.

The map below of dental coverage availability under Medicaid shows that 15 states provide “extensive” dental benefits (defined as benefits that can be chosen from a list of over 100 dental procedures); 19 states provide “limited” dental benefits (fewer than 100 covered procedures); and as to both of these classes, the annual benefit “cap” is $1,000. Several high-population states, including Florida and Texas, are among the 13 that cover only emergency dental care, and 4 states provide no dental coverage at all.

medicaid dental coverage map.jpg

Access to dental care is also inconsistent: in 2009, due to severe budget strain, the state of California eliminated adult dental care as a Medicaid benefit and did not restore it until 2014. Similarly, Illinois removed this Medicaid benefit in 2012 and restored it only in 2014.

How much does dental care cost in the United States? As might be expected in a country with such a large population and highly disparate financial circumstances, the answer is, it depends. In Connecticut, a high-income state, the average cost of a cleaning ranges from a high of $85 to a low of $66. In Mississippi, a low-income state, the same cleaning cost range is $60 (high end) to $45. For full mouth X-rays, the Connecticut range is $132-$87 – and the Mississippi range is $102-$63. For a filling, the Connecticut range is $139-$84 (for a non-front tooth that hasn’t been filled before) and in Mississippi the range is $105-$65. Finally, in Connecticut the range for a root canal (ouch) is $1,258-$1,046, and in Mississippi, it’s $918-$738. (All prices sourced via Dental Optimizer, an online dental cost calculation tool.)

With prices like these (notice that the cost of a root canal would likely exhaust an entire year’s dental benefit even in a state that provided comprehensive dental benefits through Medicaid), it’s probably no wonder that so many adults in the United States go without adequate dental care. In fact, kind-hearted and generous dentists actually provide “Missions of Mercy” to underserved populations in the United States, similar to medical missions that visit places like Rwanda and Zaire. A free dental clinic recently offered in Hartford, the capitol of Connecticut, attracted over 2,000 people, including one man who waited in line for over 15 hours to see a dentist (and recall that Connecticut is a state that provides “extensive” dental benefits under Medicaid).  For another recent example, a free dental clinic held in South Carolina attracted people who waited in line for over two days for dental care.

Dental charity clinic.jpg

Well, that’s enough of those unsexy teeth. Although there have been several articles and studies decrying the lack of dental care provided to adults, and detailing the negative overall health impact of that deficit, it is safe to say that this subject does not begin to arouse the passion and outcry comparable to that surrounding the demands that transgender people’s transition-related expenses ought to be paid for (by somebody else). There are no groups that have formed to advocate for access to dental care. Research has not disclosed a single demonstration or protest or letter-writing campaign or organized action on behalf of adults who lack access to dental care.

By contrast, there has been tremendous activism in the United States centered on compelling private insurance companies and the Medicaid program to provide transition-related health care. Similar activist pressure for guaranteed nationwide coverage of transition services was also placed on the Medicare program, which serves seniors and disabled people, but an extensive review by CMS resulted in no national change in policy, because

Overall, the quality and strength of evidence were low due to mostly observational study designs with no comparison groups, subjective endpoints, potential confounding (a situation where the association between the intervention and outcome is influenced by another factor such as a co-intervention), small sample sizes, lack of validated assessment tools, and considerable lost to follow-up.

But putting Medicare aside, between court rulings and legislation, access to payment for transition-related medical expenses has greatly expanded in recent years. And, of even greater significance, many states have passed “non-discrimination” laws, which typically provide that public and private health insurers may not refuse to cover (“exclude”) coverage for transition-related health expenses.

trans healthcarenow

The map below shows that as of 2016, 14 states had determined to provide transition-related health care as a covered benefit under Medicaid, and had also mandated that all private insurers cover transition-related health care. An additional 5 states either provide Medicaid coverage for transition-related health care or a private insurance mandate, but not both. The remaining 31 states did not, as of 2016, have legislation or rules covering transition-related care and Medicaid and/or private health insurance. By contrast, it does not appear that there is a single state that requires private health insurers to provide dental coverage.

trans healthcare map.jpg

Let us consider the case of California in more detail. Due to “intensive advocacy,” in 2012 and 2013, the state of California issued directives requiring private health insurance companies to provide transgender services. In addition, since it was ordered to do so by a court in 2001, the state’s Medicaid program has covered transition-related health care. Regular readers of 4thWave Now will not be surprised to find that the standards set by WPATH govern the criteria for “medical necessity” regarding the provision of transition services.

Recall, as noted above, that in the 6-year period from 2009 to 2014, when California was in the midst of a persistent budget crisis, the state eliminated all dental care for adults from its Medicaid program. And now, let’s run the numbers:

Going back to Dental Optimizer, the mid-range cost of a checkup in California is almost exactly $200 ($89 for the cleaning and $108 for the x-rays). Mid-range for a filling is $130 and mid-range for a root canal is $1,030.

Looking at some typical transition-related health care costs, the first case of sticker shock pops up with Lupron:

How Much Do They Cost and Are They Covered by Insurance?

These agents (medicines) are expensive. Typically, Depot-Lupron costs range from around $700 (online) to $800 (Portland area) to $1,500 dollars a month elsewhere for the monthly preparation. The 3 month preparation is equivalent in price. The histrelin implant is approximately $15,000 total for the device and the cost of surgically implanting it.

A histrelin implant would typically be used to provide the GnRH agonist medication in place of monthly Lupron shots. Estimating the cost of monthly Lupron shots at $1,000, which seems reasonable if not conservative based on the article, it appears that a year’s supply of Lupron, used to suppress puberty in a potentially transgender child, would cost $12,000, exclusive of the cost of monthly lab tests. In dental terms, 60 people could have a dental checkup, or almost 100 cavities could be filled, or almost 12 root canals could be performed. It is difficult to estimate the “average” amount of time that a child might spend taking Lupron; some providers argue that starting Lupron at age 9 or 10 is appropriate, while others wait until age 12 or 13. Assuming five years of Lupron shots, this translates into 300 dental checkups, almost 500 cavities filled, and nearly 60 root canals.

Moving on to hormones, as pretty much all puberty-suppressed children do, the price tag drops. The cost of hormone treatment is estimated at approximately $100 per month, or dental checkups for 6 lucky people, about 9 cavities, and a bit more than one root canal.

It’s when the “re-assignment surgeries” enter the picture that things really escalate.

According to multiple sources, the price of basic genital reassignment surgery or genital reconstruction surgery) for a man transitioning to a woman ranges from $7,000 for a simple orchiectomy and vaginoplasty to $25,000 for orchiectomy and the more complicated colovaginoplasty. This is often, but not always, followed up by breast augmentation, which can run anywhere from $5,000 to $10,000. That’s a total average high of $35,000, but estimates for the two procedures combined have ranged from $10,000 to upwards of $50,000. [Source.]

Taking the $35,000 number as our benchmark, and recalling that this does not include any other procedures also frequently deemed medically necessary, the dental cost of surgical transition for one male to female patient equates to 175 checkups, or about 270 cavities, or almost exactly 34 root canals. Note also that many transitioning men do not plan to “settle” for these $35,000 “half-measures:”

Some of Grey’s medical expenses are covered by her insurance, Kaiser Permanente, including her hormone therapy, a portion of her gender reassignment surgery and preparatory genital electrolysis that has to be done before the surgery. The insurance does not cover facial electrolysis (beard removal), laser body hair reduction, breast augmentation or facial feminization surgery, all of which Grey considers vital to her survival as a transgender woman.

No one sees me as physically female, just obviously transgender. This makes me an outcast and puts me at an extremely elevated risk for discrimination and harassment,” Grey said. ‘Just covering hormones and gender reassignment surgery is a half measure that still leaves us exposed to great risks and complications in our everyday lives.

The sky’s the limit, apparently.

How about women transitioning to male?

For women transitioning to men, the initial costs can be higher, and the choices more complicated. Some estimates lower-end cost of a metoidioplasty—a procedure that “frees” a hormone therapy-enlarged clitoris from the body for use as a phallus—at $2,000. That said, there are estimates of more complex metoidioplasties, as well as procedures that add testicles and involve full phalloplasties that top $100,000. Often double mastectomies, ranging in cost from $15,000 to $25,000, and sometimes hysterectomies, which run from $7,500 to $11,500, are performed. [Source.]

Although it’s clear that most women who hope to transition to male do not currently opt for the full-on phalloplasty procedure (see this recent 4thWave article for some great reasons why), the fact remains that, as a matter of California law, should a woman wish to pursue this option, private and public insurance must cover the $100,000+ cost. The dental equivalent of one phalloplasty is checkups for 500 people, or 769 cavities filled, or 97 root canals.

To further extend the analysis, prompt and competent dental care, as illustrated by the story at the beginning of the article, can often ward off much more serious and expensive dental problems. Simple cavities turn into abscessed, infected emergencies that often lead to the loss of the tooth and even body-wide illness and disability.

ignore your teeth they go away

By contrast, we see that “reassignment” surgeries themselves can lead to serious complications and the need for multiple follow-up or repair surgeries. To take one example that has been extensively documented online, one person has to date undergone more than 20 major surgeries to attempt to repair the effects of a failed phalloplasty.

Another, unexplored, aspect of providing transition-related medical care is the long-term effects of these interventions on healthy human bodies. Will the administration of puberty-blocking drugs and massive hormonal tampering lead to long-term medical consequences (and expenses)? This is unknown at present, but some early indicators aren’t looking particularly good.

Of course, we could evaluate any medical cost trade-off relative to transgender care, not just dental care. For one poignant example, fertility treatment generally is not covered under Medicaid. The dental analysis is striking because millions of people are profoundly affected, but it is only one of many choices made in the hotly contested world of health care spending.

Every society, outside of college economics classrooms, has limited resources, and must make tough decisions about how to allocate them. In a world of scarce resources, constituencies compete for their share, and more powerful, vocal and well-financed groups, in a system such as ours, will be better competitors. This is why lobbying, according to one source, was a $3.12 billion industry in the United States last year. It must be acknowledged, however, that distributing healthcare resources in one direction automatically preferences that group at the expense of others that do not receive those resources.

I would submit that the decision to direct health care spending towards transgender people, who by all accounts comprise a tiny fraction of the population (albeit one with potentially astronomical medical costs), and not towards dental care for adults, proves the extraordinary advocacy power and reach of the transgender movement. It also demonstrates that, contrary to activists’ efforts to characterize transgendered individuals as marginalized and under-privileged, as a whole this group is remarkably privileged. When the numbers show us that phalloplasty for one person is the equivalent of dental checkups for 500 people, and we choose the phalloplasty, we cannot conclude anything other than that we have decided the needs and concerns of one person take priority over those of the 500 people who go without dental care. Are the pain and suffering experienced by the natal woman who desires an artificial penis, more important than the pain and suffering of 500 people going without dental care? It seems that the answer to this question, at least in many places in the United States, is yes. We should ask ourselves why, and we should also ask ourselves whether that is fair.

Insurance requirements are a “ridiculous” speed bump on children’s gender journeys

Yesterday, Johanna Olson-Kennedy, MD, one of the better known US pediatric gender doctors, railed against insurance companies who stand in her way. It seems they have the temerity to demand written evidence that her prepubescent clients are mentally prepared for the chemical blockade of their natural puberty.

The insurance companies also, inexplicably, want to see evidence that the children and their parents have actually agreed to this off-label (not FDA approved) and very expensive drug treatment.

johanna olson april 12 2017 eradicate gatekeepers

Olson-Kennedy wants WPATH, in its next Standards of Care (SOC 8), to “eradicate” the requirement that minors have some sort of psychological evaluation before embarking down the Lupron road (which leads in nearly every case to cross-sex hormones, as Olson-Kennedy well knows):

So, what a lot of people want to understand is, “If I give my child this blocker, can I take it away, if at the end of a certain amount of time they no longer have a trans-gender identity, or they don’t want to continue on to pursue a transition with cross-sex hormones.” The answer to that is, “Yes.” They are reversible. You can take them off without any problems or major medical problems. But it’s very rare that that happens. In my practice, I have never had anyone who was put on blockers, that did not want to pursue cross-sex hormone transition at a later point.

Olson-Kennedy is also no doubt aware of the growing controversy about Lupron and other puberty blockers, but that doesn’t seem to be a concern when it comes to insurance reimbursements.

This isn’t the first time Olson-Kennedy has publicly complained about the foot-dragging of insurance companies. Last September, she posted “unfounded” denial letters from insurance companies on the WPATH Facebook page–mostly having to do with the fact that puberty blockers have never been approved by the US FDA for use in chemically halting the puberty of healthy “trans” kids.

Johanna Olson complaining about blue shield sept 21 2016 cropped

Should insurance companies be in the business of paying for experimental treatments on children–some who (on Olson’s caseload) were actively suicidal? Take a look at these denial letters. Do gender doctors like Olson-Kennedy deserve this level of oversight?

Is my use of “experimental” warranted as an adjective–apart from the fact that, a full ten years after Norman Spack, MD first began to use GnRh agonists in his practice, these drugs are still not approved for this use by US regulatory agencies?

Take a look at these remarks by Rob Garafolo, MD, another top pediatric gender doctor, made in a PBS interview two years ago:

garafolo admits experimenting

Garafolo is referring here to the multimillion dollar NIH grant he, Olson-Kennedy, Spack, and others have received to study “trans kids.” He hopes to have more answers after, as Garafolo admits, the kids have been experimented upon for 5 years–and beyond. As he says, it’s an “imperfect field” and how these children will fare through a lifetime is “entirely unknown.”

 

“The money is flowing” to “suck people in:” Vaginoplasty & the case of Jazz Jennings

Social media has been abuzz the last few days with the release of a trailer advertising the upcoming third season of “I Am Jazz.” It’s only a two-minute clip, but it packs a wallop. We see Jazz crying while saying “I just really hate myself” which is intense enough (given Jazz’s admission in the prior season of being suicidally depressed). But the big news is Jazz’s desire to seek bottom surgery. In the trailer, we see Jazz in three different doctors’ offices. The news isn’t good.

Doctor #1: You’re about to turn 16 so…I think it’s feasible that you could have bottom surgery.

Doctor #2 : We’re just now getting children who have been on puberty blocking hormones. When it comes to the surgery, we don’t have the raw materials we need.

Doctor #3: Testosterone suppression did you two big favors here (gestures at his chest, pantomiming breasts) but it didn’t do you any favors “down there.”

Doc two big favors

The benefits & drawbacks of blocking testosterone

The “raw materials” down there are, of course, the child-like male genitals Jazz would have, having been on puberty blockers (since age 10) and estrogen (since at least age 12), according to the first episode of “I Am Jazz” in Season 1. The most commonly performed procedure in the United States to create a facsimile of female genitalia, called “one-stage penile inversion” is more complicated and requires more steps when the male genitalia are the size of a prepubescent child.

A prior 4thWaveNow post, “Age is Just a Number,” touched on a few points from an April 2017 article in the Journal of Sexual Medicine co-authored by gender therapist Christine Milrod and USPATH head and UCSF gender psychiatrist Dan Karasic, which discussed exactly Jazz’s situation: “bottom surgery” for minor boys. The prior post emphasized some surgeons’ belief that minors should have the procedure done while still in high school so that their parents can ensure compliance; even be “active” in the dilation routine required to keep the neovagina open to “maintain the vaginal depth involved” before the teen becomes distracted by college.

But there is much more to say about not only the surgeons who operate on minors, but also those who recommend SRS for puberty-blocked preadolescents.

Of the 20 (anonymous) surgeons surveyed in the Milrod-Karasic article, 11 admitted to operating on boys under the age of 18. Unless Jazz seeks the procedure overseas, it’s highly likely it will be one of these surgeons who will do Jazz’s “bottom surgery,” should it take place before age 18.

From the get-go, co-authors Christine Milrod and Dan Karasic make clear that the growing trend of operating on minors is out of compliance with the current WPATH Standards of Care (SOC 7). But it’s evident from this and other writings that Milrod and Karasic –both proponents of “affirmative gender care” for minors—are interested in changing those standards for the next version (SOC 8). And they are not alone; lowering the age for genital surgery is a very popular topic among top gender clinicians like Johanna Olson-Kennedy and others.

Who are these 11 surgeons? Not even one has ever published on the issue:

The surgeons who perform the procedure on transgender minors have, without exception, refrained from publishing any peer-reviewed outcome data or technical articles on this small but increasingly important population….

…When asked about the lack of published data on surgery in minors, most participants asserted that GCS in all age groups had been a very small part of surgical medicine until very recently and that data on large volumes of procedures were not yet available. Some also cited the perceived “taboo” or outright stigma in performing the surgery and therefore a certain reluctance to share results or specific techniques.

But there are a few surgeons (whether they are part of the group surveyed for this article, we don’t know) who have been featured in news articles about genital surgeries on males under the age of 18. One of them, cited by Milrod and Karasic in a footnote, is Dr. Gary Alter, who in 2014 performed vaginoplasty on a 16-year-old.

Alter surgery

Dr. Gary Alter first removed the testicles and inserted a tissue expander (similar to an internal balloon) in the scrotum several months prior to the final sex change. The expander was progressively filled with fluid through a port during several follow-up visits in order to stretch the scrotal skin and yield enough skin as a graft to line the neovagina. The expander thus enabled the patient to avoid taking skin harvested from the flanks with the resulting unsightly scars. After 2.5 months, the expander was removed during the vaginoplasty and clitoral creation.

Just as Jazz’s doctors said: without the necessary “raw material” of a mature penis and scrotum, surgical fashioning of an approximation of female genitalia requires some rejiggering.

Interestingly, the article about Dr. Alter tells us that the 16-year-old’s psychotherapist was none other than Christine Milrod. who penned a piece “How Young is Too Young” in the Journal of Sexual Medicine in 2014. In it, Milrod argues for new guidelines that would allow underage surgeries on a “case-by-case basis.

milrod jsm 2

Professionals across disciplines treating female-affirmed adolescents can utilize the proposed ethical guidelines to facilitate decision making on a case-by-case basis to protect both patients and practitioners. These guidelines may also be used in support of more open discussions and disclosures of surgical results that could further the advancement of treatment in this emerging population.

“This emerging population”—male minors seeking genital surgeries.

Gary Alter is not the only one who has performed vaginoplasty on underage males. This 2015 New York Times piece features another surgeon, Dr. Christine McGinn (a late transitioning, former military MD):

Several doctors said they had performed surgery on minors. Kat’s surgeon, Dr. Christine McGinn, estimated that she had done more than 30 operations on children under 18, about half of them vaginoplasties for biological boys becoming girls, and the other half double mastectomies for girls becoming boys.

.. Kat’s parents trusted her not only as a specialist, but also as a role model: She had been a dashing male doctor in the Navy, before becoming a beautiful female doctor in civilian life.

When questioning the ethics involved in performing risky, irreversible, sterilizing surgeries on people too young to give informed consent, it’s easy to point the finger only at the surgeons. But as is made abundantly clear in the Milrod-Karasic article, it is psychotherapists like Christine Milrod who are heavily relied upon by the surgeons to make the correct referrals. No minor simply walks into a surgeon’s office to ask for SRS without first being referred by a gender therapist.

Nearly all participants reported an overwhelming reliance on mental health practitioners to assess the minor’s psychological readiness for surgery. Statements including “completely” (Surgeon 9) or “extremely” (Surgeon 10) were used to emphasize trust in the diagnostic expertise of mental health providers.

Surgeon 3 concurred: “I rely on them entirely. I need to make sure that the patients have realistic expectations, that they are not. I need to judge their maturity level and that they can handle pretty significant stress of any surgical procedure. But I don’t pretend to be a psychologist or have any expertise in the diagnosis of gender dysphoria, that’s a decision that needs experts.

Surgeons operate; psychologists assess maturity and readiness. But even with the blessing and recommendations of a gender therapist, some of the surveyed surgeons clearly have some understanding of the immaturity of a 15-year-old brain. Here’s what Surgeon 18 had to say:

In addition, a few participants urged caution, suggesting that some adolescents engage in gender exploration as part of a developmental phase and as part of the current zeitgeist: “I think it goes along the lines of a young person’s mind still being in the developmental stage. Things may happen and they may reorient their thinking, not just whether they are trans or not, but they may reorient their thinking about which surgery will serve their transgender needs. It is not a binary or tertiary model where they are just gay, straight, bisexual, or trans; there are a whole host of colors in-between. Many trans patients do not want GCS—it could be that at 15 they do, and at 25 they do not.”

Surgeon 19 even alludes to social contagion and the fact that kids are being taught indoctrinated about trans issues in school as a factor in some of them thinking they’re trans:

Depending on how old they are, there are a lot of classes that adolescents, even preadolescents in elementary schools, are getting these days. And they are trying to figure out if they are doing it because it is a new norm, versus what they really want. I have seen some … children go through phases of in and out, of thinking transgender. So that would be my concern—is it because it is popular now?

Karasic and Milrod note that a third of the surveyed surgeons believe the current WPATH recommendation for no surgeries under 18 should stand (only a third?) But the main thrust of this article seems to be that minors should be allowed genital surgery on a “case by case” basis; as if some 15 year olds can be 100% sure they are doing the right thing, while others might not. (How to tell?)  Milrod and Karasic say the surveyed surgeons are not worried about a potentially misdiagnosed client who might regret what they’ve done later on:

Despite the legal impossibility to obtain informed consent from the underage patient, the vast majority of participants were not concerned with malpractice lawsuits from parents or even from the patients as adults in the future. Engaging in best practices, maintaining open communication with the patient and her parents, and above all providing good results were seen as protective measures against any legal action.

Do Milrod, Karasic, and the confident surgeons quoted in the article believe some younger adolescents develop their frontal lobes faster than others? Do they think that just because a 15-year-old says “I’m 100% sure this is what I want” (what adolescent doesn’t say such a thing?), they can be trusted to know how they’ll feel in perpetuity? No one in the “gender care” field seems to be calling for MRI screening of frontal lobe density, weight, or size as a possible screening tool to differentiate the “true trans” teens (who really ought to have their testicles removed and their penises inverted) from the others who might change their minds.

Despite a lack of concern about misdiagnosis, many of the surgeons voiced concern about a severe lack of expertise in the field. Here’s Surgeon 14:

I believe that anyone who is performing vulvoplasty should have a fellowship training that is at least one year. It is going to be a rough period figuring that out, but I think we will get there eventually. I have seen horrific unethical practices by surgeons who lie about their experience and horrific results surgically as a result of that. We are using transgender people as guinea pigs and the medical profession allows this to happen. WPATH has the ability to have some teeth and regulate this more. But we don’t.

Then there’s the heady opportunity to ride the bucking bronco of this new medical trend:

The term Wild West also was used by a few highly experienced surgeons who were alarmed at the absence of surgical standards and the ease of entering the subspecialty without any documented training. To remedy the potential influx of “a bunch of solo practitioners, basically cowboys or cowgirls who kind of build their little house, advertise, and suck people in” (surgeon 13), several participants called on the WPATH to assume a larger role in demanding more stringent professional requirements and contribute toward sponsoring fellowships and surgical trainings across the country.

It’s hard to argue with a call for more training and expertise if these surgeries are going to be performed. But the underlying ethical question remains unanswered: Should minors be operated on? Especially when (as Surgeon 14 goes on to say) a new crop of poorly trained entrepreneurial surgeons is keen to profit on the trans trend:

…And now all of a sudden because it’s in the media, and really, the biggest reason for why everyone is doing it now, is the money is flowing. Because now insurance is paying. And now all these institutions have to have a program yesterday. And they are not doing it correctly, in my opinion. Seeing a week’s worth of surgery—maybe for a mastectomy, or maybe for an orchiectomy, or some of these other surgeries that are closely related, but this surgery is very advanced. The complications have severe consequences on patients’ lives and you can’t learn it in a week. And that is what’s happening; someone is going to see someone with a reputable name; they learn for a week, and they start doing them. And that is completely unethical!

 So we’ve established that there is a dearth of skilled surgeons, and that the penile inversion procedure is problematic for males (like Jazz) who have stunted genitalia resulting from years on GnRh agonists (puberty blocking hormones). But there is an alternate procedure that can be done: crafting a neovagina out of intestinal tissue. It turns out that this procedure is done in Europe far more than in the USA (where, according to the Milrod-Karasic article, there is a strong bias toward “one-stage penile inversion”).

In particular, plastic surgeons were biased toward penile inversion augmented by scrotal grafts, sometimes adding flank grafts, tissue expanders, or donor matrix tissue,27e29 and decisively rejecting intestinal vaginoplasty that would require no such additional measures and eliminate the need for lifelong dilatation.

Indeed, several Dutch studies can be found in the literature that discuss advantages of intestinal vaginoplasty for patients who have been on puberty blockers for many years. Arresting puberty seems to have spawned a whole new specialty for Dutch surgeons. In this 2016 article, Primary Total Laparoscopic Sigmoid Vaginoplasty in Transgender Women with Penoscrotal Hypoplasia,” the, authors report generally good outcomes, apart from the fact that 1 of 42 subjects died from septic shock and multiorgan failure, and 17.1 percent suffered “long-term complications that needed a secondary correction.”

Dutch 2016 intestinal abstract

No doubt, Dutch surgeons are benefiting from the fact that pubertal blockade for gender dysphoric youth was pioneered in the Netherlands–a breakthrough heralded by the first US doctor to use it, Norman Spack, whose infamous statement about his enthusiasm for the practice was captured in the aforementioned New York Times article:

Dr. Spack recalled being at a meeting in Europe about 15 years ago, when he learned that the Dutch were using puberty blockers in transgender early adolescents.

I was salivating,” he recalled. “I said we had to do this.”

So, what does all this mean for Jazz? Clearly, the chemical stunting of Jazz’s genitalia–aka “penoscrotal hypoplasia”—is what prompted one of his/her doctors to say in the “I Am Jazz” trailer that “you can’t have the surgery you want.” But the intestinal method is available, at least in Europe. Then again as recently as 2015, Jazz seemed sort of ok with his/her birth genitals:

Surgery is a very big deal as it can be dangerous and very painful. While speaking with her doctor about the possibility of getting surgery someday, Jazz admitted that she has gotten used to her body just the way it is. She said she doesn’t feel awkward when looking down and seeing and seeing what’s there, but says, “Hey, thingaminga, how are you?”

In the promo for the new season, Jazz says “I’ve always dreamed of getting this procedure.” But this is only the trailer, so we don’t know what happens next until the season premiere in June. Maybe Jazz’s surgeon will go ahead with the modified penile inversion, involving donor skin grafts from Jazz’s own body, scrotal expanders, and all the rest. For the “cowboy and cowgirl” entrepreneurs who have hung out their shingle to “suck people in,” Jazz’s immature genitalia may be just another surgical challenge to overcome in the exciting new frontier of medical experimentation on teens frozen—like ancient insects in amber– in prepubescence; teens who, more likely than not, would have grown up to be gay in the bygone days before Big Medicine and Big Pharma stepped in to medicalize adolescent identity crises–as even the DSM-5 attests:

DSM 5 gay

But let’s not forget what several surgeons in the Milrod-Karasic article said: That they trust “completely” or “extremely” that gender therapists like Diane Ehrensaft, Christine Milrod, and all the other “affirmative” therapists will recommend surgery only for the correctly diagnosed youth in their care. So anyone questioning the increase in medical transition of minors should, above all, scrutinize the practices of these gender therapists.  Just how careful are they not to make a mistake? As Christine Milrod herself describes in her own “How Young is Too Young” piece,

[there is] “a genuine expression of fear among clinicians in making the wrong diagnosis, based on the fact that young people often experiment with gender role behavior as a consequence of normative identity development, and perhaps more so when the adolescent is gender variant”

OK, but given that “informed consent” is the current trend in practice, whereby adolescents who say they are trans are taken at their word while “gatekeeping” is derided, how easy will it be for US gender therapists to avoid making a wrong diagnosis—or any diagnosis at all?

Instead of grappling with these vexing issues, our media, academia, entertainment industry, and politicians remain in thrall to a medical fad which has resulted in a child celebrity whose most private struggles have been leveraged into a marketing bonanza.

Yes, let’s remember we’re talking about OUR kids

by Nervous Wreck, SunMum, BornSkeptical, Snowyball, & FightingToGetHerBack

Nervous Wreck (Twitter: @nervouswreckmom) is the mother of a rapid-onset transgender gifted female who “came out” after turning 18, was promptly affirmed on her college campus, and who sought treatment at an off-campus Informed Consent clinic.

 SunMum (Twitter: @Mum3Sun) is a UK academic and mother of a son who experienced sudden onset gender dysphoria.

BornSkeptical is the mother of  a 15-year-old girl who suddenly began to question her gender at the age of 13, now identifies as a gay boy, and plans to take testosterone and get top surgery when she turns 18. BornSkeptical wants to help her explore other options first.

 Snowyball (Twitter: @snowyball2) is trying to make sense of why her otherwise bright and happy teenage daughter is all of a sudden depressed and anxious following the unexpected realization that she is a boy born in the wrong body.

FightingToGetHerBack (Twitter: @FightingToGetHerBack) is the mother of a 16-year-old girl with autism who unexpectedly identified as a boy at age 13. After nearly a year of following the harmful advice of gender specialists, she has realized her daughter’s trans identity is the product of social contagion and autistic thinking. She is seeking therapeutic guidance to help her daughter, and pleading with journalists to expose what she considers the dangerous practices of gender therapists.

The following post is in response to a recent article and online chat in the Washington Post about transgender kids and teens; several 4thWaveNow parents participated in the chat.


On February 24, 2017, Steven Petrow, in his Washington Post “Civilities” column, used an email from a “worried mom” to kick off an article about transgender bathroom use in schools. He called it “Let’s remember, when we talk transgender law, we’re talking about our kids.

petrow original headline.jpg

Mr. Petrow describes receiving an email from a “worried mom” of a transgender teen. He assumes before he reads it what it is going to say:  “I figured that the mom was about to voice her anxiety about what rolling back the school protections could mean for her child.” But because Worried Mom doesn’t respond as Petrow thinks parents should, her email is used as a public example of how not to parent a transgender child.

Petrow forwarded the letter to “several parents of trans and gender-nonconforming kids and teens to get their read” and quotes their exemplary responses. Debi Jackson, mother of 9-year-old Avery, the transgender cover star of National Geographic’s gender issue understands Worried Mom’s concern, but explains that “Showing your child that you’re not going to judge as they go through this process is so important.” (Whether putting your young child on the cover of a magazine is necessarily beneficial to mental health is another question).

Another parent (who requests anonymity to protect her child) is more openly critical: “Every day I try to figure out where the line is supposed to be between supporting a child and encouraging a transition…. It sure sounds as if this particular mom is not trying to figure that out, that she’s decided what ‘side’ she’s on about an issue where there needn’t be sides at all.” Her advice is simple: “Just love your child.” (Worried Mom presumably needs reminding of that.)

For an “expert” perspective, Mr. Petrow reaches out to Diane Ehrensaft, Ph.D., a developmental and clinical psychologist at the University of California at San Francisco and author of “The Gender Creative Child.” Her advice? “We should always listen to parents.” Yet “the parent [should] also listen to their child, as at the end of the day, that child . . . will be the arbiter of their own gender identity.” (Translation, maybe?: we should listen to parents only if they say what we think they should say.)

Mr. Petrow makes it clear that parents should affirm their child’s decision to transition. He advises, “Use the name and pronouns that your kid (or another trans young person) relies on. If you’re not sure, ask — without judgment.” So how about we “listen to parents” without preconceptions, “without judgement”?  Mr. Petrow might have done this with the original email sent by Worried Mom, which we reproduce here in full:

Dear Mr. Petrow:    I have been reading your column for many years, have learned a lot from your perspectives, and in general, share your political views. I sense that your writing comes from a place of compassion and thoughtful consideration.    I am reaching out to you because there is an issue that you have been writing about lately that is of grave concern because it is very personal to me: that is, your reporting on the transgender issue.

The reason this is so personal is because my 16-year-old daughter told me she was transgender when she was 13. I was shocked. There had never been any signs of this. However, there were several kids at her school who identified as trans. She is also on the autism spectrum and very susceptible to mimicry and falsely identifying with groups in order to feel like she belongs.

What has happened is that therapists that I took her to for help did not question her beliefs but made her think she should transition and that I should blindly accept her assertion. They pushed me to accept hormone treatment, which I refused. As a compromise, I allowed her to wear a binder (which causes physical problems) and let her change her name and pronouns – and yet I know 100% in my heart that this is not real and I live in a constant state of anxiety about the psychological and physical damage this is causing. Mostly I worry about her future plans to fully medical transition as soon as she is legally able. I feel scared and powerless. The medical consequences are significant and irreversible.   It is impossible to convince a teenager – especially an autistic teen – of something that is a belief that can neither be proven or disproven. It is especially difficult when the media narrative seems to portray anyone who questions these beliefs as a bigot.

Following publication of Petrow’s article with the truncated version of the above email, many commenters wrote in to point out that he had failed to recognize the validity of Worried Mom’s concerns. And Worried Mom, the author of the email, also left this comment:

Mr. Petrow responded to my letter by stating that he would like to discuss this with me. I provided him with my contact information, but never heard back. It was only by accident that I learned that I had been selectively quoted pushing the very narrative that I had hoped I could get Mr. Petrow to question.  Such irony. The reason that I wrote to you, Mr. Petrow, was in the hope that you would see what is going on with our youth. The media seems very afraid to question the sudden increase in transgender identification in our youth. Common sense alone says that social contagion is a factor. And because of the politicization of this topic, parents like me are labeled bigots, told we don’t love our child…or as your “expert” stated, told that our child’s gender journey is “poetic.” I assure you that I am not a bigot, love my child unconditionally, and living with a teenage girl who thinks she is a boy is not a poetic experience.

Worried Mom also raised the issue with Mr. Petrow on Twitter. “I reached out because I trusted you would listen to me as the civil and respectful journalist that you describe yourself as,” she wrote.  (Mr. Petrow’s Washington Post column is entitled “Civilities.”)

Commenters on Petrow’s article were overwhelmingly critical of his stance. To his credit, on March 7, 2017, Mr. Petrow returned to the topic in his Civilities online chat. This could have been the perfect opportunity to present various perspectives on this complex and controversial issue, and to consider them in a balanced way.

Instead, Petrow invited only Dr. Michelle Forcier, Assistant Professor of Pediatrics and Adolescent Health at Hasbro Children’s Hospital to answer questions.  In 2016, Forcier had 400 patients on a transgender pathway. Rejecting “gate-keeping” or psychological evaluation as out of date, Forcier believes that “kids as young as two, three, four know what their gender is,” and compares gender identity to asthma: “You don’t have to prove to me you’re transgender, just like you don’t have to prove you have asthma.” (Unlike transgender identity, which is based on subjective feelings, there are objective tests of lung capacity in the case of asthma). Forcier, then, is no neutral “expert” but an evangelist for medical transition of kids. Perhaps Petrow’s plan was to allow Forcier to demolish the questions of “bigoted” parents. In any case, he did reach out in the hope of a lively confrontation, tweeting @4thwavenow and alerting his audience that “a sub-Reddit group of “gender critical folks” issued a “call to action” to get folks to join today’s discussion”.

You can find the complete chat via this link: Civilities: Taking all your questions about transgender teens with Brown U. expert Dr. Michelle Forcier and Steven Petrow.  In this post, we will highlight a few excerpts. In addition, some of the parents who sent in questions will explain in more detail what they made of Dr. Forcier’s answers.

petrow chat headline.jpg

The issues raised repeatedly in the chat revolved around some common themes: challenging the belief that there is a single “scientific” position on gender identity; asking why gender dysphoria increasingly appears out of the blue in troubled teens and why doctors do not look at existing mental health co-morbidities; and why the warning voices of detransitioners are not heard and not heeded. This question is emblematic:

My daughter certainly never seemed like a son to me, just a very creative intelligent girl who had trouble “fitting in” socially. But to so quickly get a prescription for testosterone for this out of the blue self-diagnosis feels very wrong. Dr. Forcier’s position is that parents of underage transgender kids who hesitate about medical transition could be charged with medical neglect with a report to child protective services. This goes against parental rights. […] Late teens/young adulthood is also the time when many mental health issues first show up…this is well known and documented. For instance, bipolar shows up at that time and it is known to distort the sense of self/identity. There are a growing number of detransitioners speaking up wishing they had been offered other treatment options, including mental health diagnostic testing with time for mental health treatment first. What do you suggest these detransitioners do to help the psychiatric community adjust their “one size fits all” treatment for gender identity issues in teens and young adults?

There are clearly many points to deal with here, but Forcier chose to first focus on the allegation that herposition is that parents of underage transgender kids who hesitate about medical transition could be charged with neglect and be reported to child protective services.” Forcier seemed worried that “the writer seems to know my position and I am trying to figure out how they actually ‘know this.’”

We know Forcier’s position on calling the authorities on some parents via a session on puberty suppression that she co-led at the February 2017 USPATH conference.  During the Q&A part of the session, Drs. Johanna Olson-Kennedy and Michelle Forcier explained that they are not afraid to involve the courts when they must to “bring along” “recalcitrant” parents.  A psychologist who runs a gender clinic asked whether there is a way to legally “force parents” to go along with the recommendations of a gender therapist to administer puberty blockers. Forcier explained that her team has been busy training family court judges in her region:

FORCIER: Yeah, there’s no precedent but you can again work with the child protection team for medical neglect. Work with one parent…at least to get things started. And again, you can do some education. We did education with judges in Rhode Island. We spent a half day with family court judges, telling them this is what gender and transgender is…

In the WaPo chat, Forcier seemed to deny that she advocated such an approach:

And I do NOT take the position that as the writer suggests ‘that parents with underage kids who suddenly insist they are transgender but as a parent have grave concerns about the only treatment option being medical transition could be charged with medical neglect with a report to child protective services’.

Forcier went on to claim that her approach is evidence-based: “There is reasonable science that supports listening to patients in regard to learning more about their gender identity. It does not mean, not asking questions or asking for more time to explore with a patient–but it is important with any medical issue or developmental concern to start with the patient.” Fair enough, although you hardly need “science” to remind a doctor to listen to their patient.  She reassured readers that she is flexible and responsive to individual patients:

We do espouse a very individualized, patient-centered approach to gender as with other types of youth care we provide. There is no one size fits all for gender. So first–it worries me that there is misinformation and mischaracterization of care and our practice. What is the harm of seeing how a child who is “different” explore their gender? Again, there just seems to be interesting bias against gender diversity and helping kids figure out who they are– a generally accepted part of adolescent development. So first and foremost–we want to get to know our kids well and there is not one size fits all…. second, accurate information is helpful for all parties!

But the parent who sent in the question was not reassured. She writes that her “big concern is with informed consent clinics, and the impact on young adults, newly on their own and full of youthful, optimistic self-assurance about their decision to live a transgender life”:

My perspective is as the parent of a transgender college student female who sought treatment after age 18, fulfilling her six months “real life” experience as a transman on a college campus…not exactly a real life experience. My child’s decision to identify as transgender was rapid onset after learning the concept only a year earlier at most, while attending a small high school where she felt a misfit, comparing herself to the other girls, as teen girls do. My child, the extremely smart yet highly anxious misfit who had a very stressful last two years of high school, picked up on the transgender option through online sites, a child who only the previous summer was happily frolicking in her swimsuit on a trip to the beach, not showing any signs of gender dysphoria, at least not beyond any other girl in puberty.

However, my child was able, at age 18, to go to an informed consent clinic only two times to get a prescription to start medical transition with testosterone. Two times. This has now become the norm. Teenagers are known for impulsive behaviors, and my child’s behavior is poster-child teen impulsive behavior. But apparently, no “asking for more time to explore with a patient” because this might be considered conversion therapy…simply exploring with a patient about gender expression. Hence, informed consent clinics in at least some states are indeed one size treatment fits all.

Another question took up the frequently reported link between autism and transgender identity: “Dr. Forcier, what is your explanation as to why kids on the autism spectrum are seven times more likely to have gender identity issues (and those at gender clinics 6-15 times more likely to have autism)? Do you believe that an autism diagnosis should be considered before a therapist tries to convince parents to support their child’s transition?”

The gaps in knowledge about autism and gender dysphoria did not translate to Dr. Forcier counseling caution in recommending irreversible treatment:

 FORCIER: We don’t know for sure. What we do know there seems to an association … We do know that with other neurologic conditions- there are menstrual and other reproductive health associations (epilepsy for instance). We do also know there is an association for gender and autism as well. For autism spectrum youth- maybe it is that not being as clued into or bound by social messages and constructs allows them a more fluid approach to gender and a greater willingness to express that more openly. For autism spectrum we know there are some differences in brain and neuro function… for persons whose assigned gender and anatomy/physiology is different than their identified gender (brain heart soul personhood gender) … this might be another way or manifestation of different ways brains are built or function in different ways.

This is curiously unscientific: Forcier glosses “identified gender” as “brain heart soul personhood gender.” For the more scientifically minded, there is a growing body of work on the link between transgender and autism. This 2014 paper co-authored by John F. Strang (a pediatric neuropsychologist with the Center for Autism Spectrum Disorders and the Gender and Sexuality Development Program at Children’s National Health System in Washington, D.C.), reports that participants in a study with ASD were 7.59 times more likely to express gender variance. Initial clinical guidelines were published in 2016 by Strang, et al, in an attempt to provide consensus guidelines for the assessment and care of adolescents with co-occurring autism spectrum disorder (ASD) and gender dysphoria (GD). But “why” there is an overrepresentation of youth with co-occurring autism spectrum disorders (ASD) and gender dysphoria (GD) is not yet known. Noticeably absent from the list of participants of these “consensus” guidelines is Tania Marshall, a specialist in the diagnosis of ASD in females. She states that the “majority of females do not receive a formal diagnosis until well into their adult years,” largely due to their very different coping mechanisms (as compared to males). As reported in this article by Aitken, et al, there has been a significant change in the sex ratio of adolescents referred to gender clinics: natal males outnumbered natal females up till 2006 when the ratio changed. How many of these young females fall within ASD but have fallen through current diagnostic tests that are based primarily on males? Please see this post. 4thWaveNow has previously published several other articles about the issue of ASD and transgenderism; see this and this.

Another parent asked what happens when transition makes a young person feel worse and actually intensifies dysphoria:

 Q: Gender clinicians claim that transition dramatically improves the mental health of gender dysphoric teens. If this improvement does not take place, is it right to reconsider either the diagnosis or the treatment? In the case of my child, who experienced sudden onset gender dysphoria aged 20 after a series of traumatic events, without any signs or expressions of gender dysphoria earlier in his life, transition followed by hormone therapy has been followed by a descent into social isolation, altered sleep patterns, anger problems and other symptoms of depression. We live in a socially liberal trans affirmative cultural setting and he attends a trans support group. I suspect other mental health problems and his family and general practitioner suspect that the problem is not gender. But gender clinicians refuse to consider any other diagnosis. In these circumstances, surely, a rush to accept the patient’s self-diagnosis is dangerous. Your thoughts?

Forcier conceded that “yes, many gender patients have other mental health comorbidities…” (thereby tacitly acknowledging that gender dysphoria can be seen as a “morbidity”). But whatever the co-morbidity, gender reassignment can go ahead: “Not sure that depression, anger, sleep issues after trauma negates an exploration of gender,” says Forcier. As this parent told us, “she didn’t address my suggestion that the problem may not be gender at all, a view held by the family doctor and by those who knew my son before he became ill. The fact that other professionals disagree with the transgender diagnosis evidently interfered with her upbeat narrative of brave kids and bigoted parents.”

Another parent wanted Forcier to recognize and respond to the fact that a large majority of gender dysphoric children desist and reconcile with their biological sex:

 How is it ethical to put children on a journey of lifetime hormone medication plus to endure the health risks of surgery when if those children are left to work their own life out, 80% will come to accept their biological sex?

Forcier’s reply:

Ethical questions are great when it comes to gender care, as NOT providing care seems to be more unethical and have worse health outcomes than providing care in this population. For example: How ethical is it to negate a person’s identity–to tell them you know them better than they do? How ethical is it to deny a person access to medication that is very safe, effective and proven to help persons with gender nonforming[sic] /diverse brain/identity and body experiences? The bias inherent in the question is interesting and deserves a response!

No evidence is provided for Forcier’s belief that “NOT providing care seems to be more unethical and have worse health outcomes than providing care in this population.” The medications she prescribes are not “very safe, effective” as recent studies on the side effects of puberty blockers make clear. Nor did she explain why it is ethical to medicate non-conformity (what Forcier calls “gender nonconforming/diverse brain/identity and body experiences”). Why should being different require hormones and surgeries?

Forcier then used a comparison between physical and mental disease; a puzzling response, if gender dysphoria is a naturally occurring variation (an assertion frequently made by trans activists and gender clinicians) rather than a disease:

FORCIER: Another good medical example, in trying to help us deal with offering or refusing to offer known safe effective medical care might be to liken this experience to other health concerns. For example, would you also propose letting a diabetic slip into diabetic ketoacidosis and coma before offering them fluids and or insulin if you suspected a high likelihood of diabetes? Would you wait for an asthmatic to collapse unconscious before offering oxygen and albuterol? Gender care has many safe medical options that in many instances are safer than withholding care. Additionally, this question has some other interesting perspectives… Transgender persons are never forced into surgical care- that is something that they need true understanding and consent to be able to engage in….The 80% data is not representative or accurate for the bulk of children who move towards blockers or gender hormones–not sure where that number came from but it is not correct.

Both asthma and diabetes are organic diseases which can be fatal and objectively identified. Gender nonconformity is a rejection of socially defined conventions and is not fatal. It is in no way like “other health concerns.”

And no one claims that 80% of the children “who move towards blockers or gender hormones” desist. In fact, nearer 100% of children “who move towards blockers or gender hormones” persist because social transition (which nearly always precedes medical transition), and blockers themselves, likely make desistance highly unlikely. Indeed, most “affirmative” gender clinicians, including Johanna Olson-Kennedy, Norman Spack, and others report near 100% persistence rates.

Forcier says she doesn’t know where the statistic “came from” that 80 percent of children who wish to be the opposite sex go on to accept their natal sex. This widely cited statistic is based on a multitude of studies—including those with children with severe gender dysphoria, including :

korte

  • “the majority of boys with GID showed desistence of their gender dysphoria when followed into adolescence and adulthood: 87.8% of the boys did not report any distress about their gender identity at follow-up and were happy living as males.” Devita Singh, “A FOLLOW-UP STUDY OF BOYS WITH GENDER IDENTITY DISORDER”, PhD, 2012.
  • “The exact number varies by study, but roughly 60–90% of trans- kids turn out no longer to be trans by adulthood.” James Cantor, “Do Trans Kids Stay Trans When They Grow Up?” January 2016.

Returning to the chat submissions, another parent who voiced genuine concern for her child was simply mocked as bigoted, and she asked Petrow to have a bit of empathy:

 What would you do if your child suddenly, out of the blue, announced they were transgender, wanted to change their name, pronoun, and buy a breast binder? What would you do if you suspected your child might have been influenced by the media? What would you do if you suspected your child had other mental health issues to deal with? Walk in my shoes for one moment. What would you really do if it was your child? What would you do if your gut feeling was that your child was making the biggest mistake of their life? What would you do if everyone around you was telling you to celebrate your child on their brave journey? Please, what would you do?

In reply, Petrow equated transgenderism with homosexuality:

PETROW: Honestly, your question reminds me of those from parents in earlier generations who learned their kids were gay or lesbian. So, here’s what I’d do: I would try to read materials from the most credible experts, speak with other parents of similar kids (which you can find at PFLAG), and, of course, talk with my child. In other words, I would try to keep an open mind and learn as much as I can. Many parents of gay kids caused great harm to their young ones by not accepting them and but not helping them to accept themselves. I hope we’ve learned since then…

To this parent, Petrow’s reply was seriously lacking. She comments: “Despite my obvious concern and anguish you replied with absolutely no compassion. You chose to accuse me of being a bigot and to liken me to ‘earlier generations who learned their kids were gay or lesbian’.” This comparison misses the point. She explains:

My child did indeed inform us she was a lesbian, a few weeks prior to announcing she was transgender. When she told us she was a lesbian, we were happy for her and readily accepted it.  I find it hard to believe that you cannot see the difference between a child who announces they are lesbian and a child who announces they are transgender.

Being lesbian does not require her to become a lifelong medical patient. Being lesbian doesn’t ask her to chop off her breasts. Being lesbian doesn’t ask her to spend her life in anxiety about whether she will or will not “pass” as a man. Anybody can see that the future for a gay or lesbian child is very different to the future of a transgender child and I think it is an extremely lazy tactic to label any parent who dares to question their child’s transgender declaration as like “earlier generations.

I have already read extensively from many credible experts; I have spoken to many other parents of similar kids and of course I have talked with my child. I am keeping an open mind and learning as much as I can. And it is with my mind fully wide open that I am helping my child to make the right choices in life.

Mr. Petrow advises this parent to “seek top notch treatment” for any “other mental health issues” her child might be experiencing. She respond: “You seem to have absolutely no understanding of mental health issues and how these could cloud a child’s judgement.” Oddly, given the comparison with homosexuality, Petrow also appearsto think that a transient transgender identity can be discarded without difficulty: “I’d also note that changing a name or pronouns, even wearing a breast binder, can easily be changed or reversed.” But this parent knows the lasting damage that binders can do:

 You mention that changing a name or pronouns or wearing a breast binder are ‘easily changed or reversed’ without any understanding of real life. To think that you have no awareness of the damage done by wearing a breast binder shows that you have done absolutely no research (back pain, chest pain, shortness of breath, bad posture, rib fractures, rib or spine changes, shoulder joint “popping”, muscle wasting, respiratory infections, abdominal pain, breast changes, breast tenderness, scarring, skin infections – in case you were wondering).

 Transition as gay conversion was the premise of another question:

 How do we encourage kids and adults that being a feminine boy or masculine girl is ok, when trans communities use these stereotypes to determine if a kid is trans? Most homosexual adults didn’t conform to their gender as kids, will this mean the number of homosexuals is going to decrease because of transitioning? Could this be seen as homophobic?

Forcier’s answer is that “We encourage kids to be AUTHENTIC!” But if being “authentic” leads to medication with off label prostate cancer medication and later perhaps to surgery, it is a dangerous course. To truly encourage kids ‘to be AUTHENTIC!’ would involve accepting gender nonconformity and allowing kids to live in their own bodies without medical intervention. In her view

The clinical and research data do not suggest there are overwhelming numbers of parents or providers pushing kids into the trans box as suggested in some of the comments. In fact, historically, it has been hard for folks to access providers who listen and take them seriously or offer to engage in plans that explore gender.

History apparently began around the turn of the 21st century, when the category of ‘transgender kids’ was invented. Before this, kids were rebellious, or unusual, or gender nonconforming. Even in the 20th century, when medical transition started to become available, no one suggested that minors ought to be considered transsexual or in need of medical services.

From the mid-16th  through the 19th century, boys were dressed indistinguishably from girls until between the ages of two and eight. ‘Breeching’ was the moment that a boy was put into trousers and had his hair cut. But Forcier asks us to accept current gender stereotypes as evidence of an innate identity. A body of research—including this 2017 longitudinal study of over 4000 young people—has repeatedly found that childhood gender non-conformity is strongly correlated with adult homosexuality.

GNC gay

 Transgender suicidality is frequently used to coerce parents into supporting transition, as another questioner suggests:

 Parents of transgender teens are often told about the high rates of attempted suicide among the transgender population. However, the studies from which these statistics are drawn do not indicate whether attempts occurred before or after transition. Given that several good quality studies indicate that suicidality continues to be high after transition (the Swedish study by Djhene et al. from 2011), what clinical evidence do we have that transition reduces suicidality?

 But Forcier, similar to many trans activists, has no problem leveraging suicide as an argument. This is agreat question!” and she goes on to claim that:

There is both research and anecdotal evidence that both disclosure and appropriate care can offer relief to gender nonconforming youth who are at risk for self-harm and suicide. Data include Amsterdam’s early studies (no suicides and no street drug use) as well as later studies such as:

de Vries AL, McGuire JK, Steensma TD, et al. Young Adult Psychological Outcome After Puberty Suppression and Gender Reassignment. Pediatrics 2014.

Spack NP, Edwards-Leeper L, Feldman HA, et al. Children and adolescents with gender identity disorder referred to a pediatric medical center. Pediatrics 2012; 129:418.

We have good data that disclosure AND LOVE & ACCEPTANCE by parents and families is protective. See Ryan, See Olson and other Family Acceptance Project studies. Also we would not expect all self-harm or suicidality to “disappear” or resolve completely even with good treatment options as there is still minority stress status effects and other ongoing macro and microaggressions that harm gender nonconforming persons on a daily basis.

Forcier’s answer is both manipulative and misleading. Parents are told that “disclosure AND LOVE & ACCEPTANCE by parents and families is protective.” This is manipulative because it assumes that to love is to uncritically accept whatever your child says. No responsible parent would accept this advice in relation to any other parenting issue.

It is also misleading because there is no reliable evidence that medical transition prevents self harm, which is readily acknowledged in the widely cited 2014 Williams Institute report about suicide in the US transgender population (also cited in Petrow’s original article).  According to psychotherapist Lisa Marchiano, “it may in fact be the case that suicidality is higher among those who have transitioned.” Studies such as this one found: “Those who have medically transitioned (45%) and surgically transitioned (43%) have higher rates of attempted suicide than those who have not (34% and 39% respectively).”

 Another parent expressed concern that teenage mastectomy is a drastic surgical intervention:

Trans teens in this country now receive drastic surgeries, e.g. mastectomy, as young as age 14. How can such young kids truly give informed consent for such radical measures? There’s a good reason we don’t trust young teens with huge decisions — they are immature, by definition. Their brains have not fully developed.

Forcier did not like this framing:

 This “drastic surgery” — again such biased language!–has really changed many trans boys and men’s lives- and has low risks and outcomes for complications and regret. Teens assent to surgery WITH parent consent… we are lucky that many parents understand waiting for arbitrary legal age of 18 for chest surgery for some young teens is cruel and harmful from a physical and psychiatric perspective.

“Drastic” is a term that has been used by more than one clinician who has worked with this population. James Barrett, lead clinician at the UK’s oldest Gender Identity Clinic, writes that “The treatment of disorders of gender identity is drastic and irreversible, so it should only be undertaken in a setting of diagnostic certainty.” By dismissing the parent’s concern about medical transition as “biased,” Forcier minimizes the serious and irreversible treatment she is dispensing. “Diagnostic certainty” cannot be possible in the case of teenage clients.  There is a reason why many psychiatric diagnoses (including personality disorders, schizophrenia, and others) are not made until adulthood because it is known that young people are not fully mature and can and do change dramatically. (For a recent article by a professional who does acknowledge the need for more “gatekeeping” for young trans-identified clients, see “Careful Assessment is Not Happening” on the First Do No Harm website.)

Speaking of diagnostic certainty, those who regret medical transition and decide to detransition– whatever their number — present a fundamental challenge to the notion of diagnostic certainty in teens. A parent asked

 Given the growing number of people, especially young women, who have detransitioned in recent years, don’t you think it does young women a grave disservice if we don’t help them explore why they might want to transition– especially those young women who never expressed gender dysphoria as a child? Many of the detransitioners have talked about the role that trauma played in their decision to transition. And even though my child experienced a traumatic event shortly before her announcement that she believed she was trans, the therapist was convinced not only that she was trans but that she might need to start testosterone even at the age of 14.

In response, Forcier brands parental worries about regret and detransition as the creation of “alternative facts”:

Forcier: I am unaware of your data–please provide. If you are a gender provider and doing research – please send – it would be important to look at this and incorporate into care. But for clarity’s sake- there is no large number of “detransitioning” kids… It is so important to stick to what is actually going on for the majority of gender care youth- not create “alternative facts” that support our opinions.

 “Gender providers” have shown scant interest in studying the population of detransitioners, so some of them have taken it upon themselves to gather data:

These informal surveys demonstrate the need for further research. The first formal survey study of detransitioners opened on March 17. It is being conducted by Lisa Littman, MD, MPH, Adjunct Assistant Professor, Icahn School of Medicine at Mount Sinai.

In addition to looking at these survey studies, Dr. Forcier could visit any of the multitude (and increasing number) of blogs set up by detransitioners such as

 The underreported experience of detransition is beginning to appear in the mainstream media: see Experience: I Regret Transitioning and the BBC documentary, Transgender Kids: Who Knows Best? which aired in January 2017 (archived version available to US viewers here). Forcier should also be aware that USPATH, the U.S. branch of the World Professional Association for Transgender Health hosted a panel of detransitioners at the same conference she presented at in February.

Some of the parents’ stories sent in to the chat are harrowing, revealing the frequent association of mental health issues with sudden transgender feelings:

 My female child turned 18 and only months after learning the concept transgender, was put on testosterone at an informed consent clinic in the LA area after only 2 visits to the clinic. We have a wealth of mental health issues in our families, including bipolar that is very genetic and shows up in older teens/young adults. My child is 19, technically an adult, now on T, but I very much see signs of bipolar. Do you think gender clinics should add controls back in to take longer time with young patients? brain science says the brain is still adolescent until at least age 25, not in any way an adult brain at age 18. My child never went thru any diagnostic testing for mental health issues or autism spectrum that could be clouding her/his judgement. I think only 2 visits to a clinic is way too fast to start any medical transition. Do you have some advice for what I might tell my child about getting this testing done now before getting too far with the HRT? treatment for bipolar could change how s/he thinks, and counsel for ASD would be needed first since ASD can also cloud judgement about social issues. And how can these gender clinics be made aware of the need for gatekeeping for young adults age 18-25 since they can definitely be impulsive and may be dealing with young adult mental health issues that need treatment first.

 “More questions than we can really address here,” says Forcier, but she says that “bipolar and gender are two very different things.” She rejects

some of the very biased terminology…. gatekeeping, as reparative therapy has led to significant harm in the trans community. And recommending “gatekeeping” for consent age adults has an interesting paternalistic, controlling twist. Docs who provide adolescent and young adult care are clear on the literature about the 18-25 years continued brain development. But just as we might listen to a 9 year tell us they have a sore throat, take a history, consider taking a throat swab. Or we might listen to a depressed 16-year-old tell us they are sexually active and need chlamydia testing… we need to listen and incorporate a holistic approach to these youths’ care.

The parent isn’t satisfied with this response, and persists:

 Actually there is documented overlap between bipolar and gender identity. There are some cases that have made it into the medical literature.  See here and here and here.

And you can easily search online and find conversations within the transgender and gender questioning population about how bipolar episodes affect how they feel regarding their gender identity. Indeed, here is an interesting article about how bipolar affects the development of self.

For lack of a better word, “gatekeeping” is the due diligence that used to happen to ensure a low probability of regret following medical transition. There are mental health issues that, once properly treated, can resolve the desire for a change of gender identity. It is the slower approach of “Gender Identity Disorder” that has been replaced with the affirming approach that most are now practicing. Yet, how can a young adult struggling with undiagnosed bipolar be expected to accurately know that a change of gender at age 18 won’t be regretted at a later age after they are actually diagnosed and treated? All for the lack of mental health due diligence.

This could indeed be the case for my child….mood disorders are prevalent in her father’s family and I’ve documented behaviors that look suspiciously like bipolar disorder. This makes it particularly distressing that you should find “gatekeeping” (again read this as simply “first do no harm” medical due diligence) as “paternalistic and controlling”. A feature of someone with bipolar disorder is that they are highly unlikely to see it in themselves. Diagnosis relies on the observations of family and friends. Helping them seek mental health assistance is certainly not paternalistic and controlling.

The association of gender dysphoria with other psychological problems has been well understood by clinicians and researchers for some time. In recent years, however, activists have worked diligently to prevent that information from being widely discussed. To take just one example, a 2003 survey of 186 Dutch psychiatrists reported on nearly 600 patients with “cross-gender identification” with these results.

dutch psychiatrists high comorbidity.jpg

In her final remarks, Dr. Forcier dismisses the parents who joined the chat thusly:

There seems to be lots of bias, misinformation, making statements about “data” that are not supported in the actual medical literature. I am also always struck by how many persons without gender expertise or significant experience with a cohort of gender patients have such strong, absolute opinions.

But these questions came from “persons” with first-hand knowledge of their own kids; parents who have read widely (including the “actual medical literature”); parents who care deeply and who view bland reassurances with due skepticism. For these parents, simply “affirming” their kids’ transgender identity is not just a matter of “etiquette” and appropriate language. The decisions made by doctors who prescribe hormones and surgeries have real life implications for the lives of those we love,  and it has become evident to many of us that transition is not the best solution for our kids. And as far as “gatekeeping” goes, it’s quite obvious that the easier it becomes to transition, the more transition regret we are going to see.

Speaking of “bias” (the word Forcier used repeatedly to denigrate the parents raising questions in the chat): If one were to go strictly by the comments of Steven Petrow and Michele Forcier, it seems to us that the professionals in the affirm-only gender field and their media handmaidens are the ones with the “strong, absolute opinions.”

And just a reminder: they are talking about our kids.

The Tortoise & the Hare: The differing trajectories of gay rights vs gender identity in US law

Worriedmom is the mother of four (allegedly) adult children. She lives in the Northeastern part of the United States.  Worriedmom practiced law for many years and now works in the non-profit ara. She is available to interact in the comments section of this post.


by Worriedmom

While writing a previous 4thWaveNow article about my experience as a PFLAG leader, I  thought back on my longstanding personal connections with gay, lesbian and transgender people.  I first became interested in this group of humans while in college in the late 1970s, on account of my then-best friend, a gay man.  I remember demonstrating against Anita Bryant’s mean-spirited Florida anti-gay activism, and being filmed by the local police department, which regarded gay people and their allies as dangerous subversives.  I recall that same police department barging into the local gay disco, lining up the women and men against separate walls, demanding identification and threatening to haul folks to jail and put their names in the paper.  My friend told me disturbing, haunting stories about the naked aggression and harsh daily bullying he faced in high school because he was a “feminine” gay man.

I knew these experiences were but the tiniest slice of the everyday discrimination, violence and prejudice faced by gay and lesbian people in those days.  For myself, even those few encounters with the unfairness and unkindness faced by gays and lesbians led me, first, to provide free estate planning for men with HIV, shortly after I got my law license; and, later, to advocate for civil union and then gay marriage in my home state.  Along the way, I also became a PFLAG chapter leader and spent countless hours devoted to the cause of equal rights for sexual and gender minorities.

As I thought about my own history of advocacy, one thing that struck me was how very long a road it had been, one that has lasted my entire adult life.  And what next occurred to me was that, by contrast, transgender rights, in both law and fact, have had an extraordinarily short history.  Compared to the length of time it took for gay and lesbian people, and more specifically same-sex marriage, to become mainstream, transgender rights have taken center stage in a virtual blink of the eye.  In both these cases, people have been asked to accept a new, expanded or different interpretation or meaning of something they’ve taken for granted: in the gay and lesbian rights area, marriage; and in the transgender rights area, gender or sexual identity.

This article briefly explores the evolution of the law and public policy in the United States as it relates to marriage, and the sexes.  (For space reasons, I will have to skim over and condense an incredibly rich, interesting and complex history. There is a great deal more to say and learn about every subject covered.)

Gay marriage: An idea long in coming

Although gay and lesbian subcultures certainly existed prior to the 1950s, particularly in larger cities and in areas impacted by the World Wars, the first organized groups in support of gay rights did not emerge until the early 1950s.  The Mattachine Society, for men, was founded in 1950, and the Daughters of Bilitis, for women, was founded in 1953.  The first public protests in favor of gay and lesbian rights occurred in 1963 at the White House, and in 1966 in New York City (a “sip-in” against anti-gay discrimination).

news clipping

Although the 1960s saw increasing efforts toward social visibility and against discrimination, the Stonewall Riots, in 1969, are largely regarded as the catalyst for the modern-day gay civil rights movement.  The energy and intensity produced from Stonewall led to the creation of the first “out” gay rights groups, and within two years, virtually every large city in the U.S. had its own gay and lesbian political action group.

Activism around gay and lesbian rights grew during the 1970s alongside other movements of personal liberation, such as the women’s movement, Black Power, Chicano Pride and others – although a serious backlash ensued as some religious conservatives began to mobilize in opposition.  The AIDS crisis of the 1980s, and the activism that it engendered, ensured the prominence of gay people in the public mind.

act up

The first hint in the United States that same-sex marriage might someday become a reality was in 1993, when Hawaii’s Supreme Court ruled that denying marriage to same-sex couples violated the Equal Protection Clause of that state’s constitution.  This ruling did not legalize gay marriage in Hawaii but did kick off an intensive round of anti-gay marriage lobbying and advocacy, which culminated in the 1996 federal Defense of Marriage Act (“DOMA”).  While it did not prohibit states from recognizing gay marriage, DOMA provided that for federal purposes marriage was to be defined as the union between one man and one woman only.  Under DOMA, states were permitted to refuse to recognize gay marriages performed in other states, which temporarily settled the issue in favor of the anti-gay marriage forces.  In 2004, President George W. Bush urged passage of a Federal Marriage Amendment to the United States Constitution, which would have further codified the definition of marriage as being between one man and one woman only.  The Federal Marriage Amendment was never adopted, although it became the subject of a raging debate.

2004 also saw tremendous activism around gay marriage in general, with anti-gay marriage amendments and statutes up for referendum in numerous state contests.  It later developed that the Republican Party had adopted the strategy of introducing gay marriage as a political “wedge” issue into as many state elections as possible, with the hope of bringing more conservative, motivated voters to the polls.

Although chastened by the crushing defeat of 2004, in which anti-gay-marriage initiatives won in every single state in which they were introduced, gay and lesbian activists persisted.  One bright spot was the Goodridge case in Massachusetts (2004), which legalized gay marriage for that state.  Connecticut became only the second state to recognize gay marriage, in 2008.  A dark spot was California’s infamous “Proposition 8,” also in 2008, when voters made same-sex marriage illegal in that state. A “middle ground” proposal to allow same-sex couples to enter into “civil unions” or “domestic partnerships” was often explored and adopted as an intermediate legal step.  Many states and groups saw tremendous debate and dispute over whether civil unions were an appropriate substitute for full civil marriage, should be sanctioned by the State, or whether the concept was the proverbial “camel’s nose under the tent.”

In 2009, a team of “super lawyers” attacked Prop. 8 in California on constitutional grounds, with the goal of creating a test case that could be ruled upon by the U.S. Supreme Court to establish gay marriage as the law of the land.  However, the Supreme Court declined to hear the California case in October of 2014, and as of that date just 19 states and the District of Columbia permitted same-sex marriage.  Thirty-one states had laws or statutes explicitly prohibiting it.  The period between October 2014 and June 2015 was one of a very rapidly evolving legal landscape, as state laws and constitutional amendments were successively ruled unconstitutional.  Finally, as of June 26, 2015, the date of the U.S. Supreme Court’s Obergefell decision legalizing gay marriage in all 50 states, gay marriage had been legalized in 37 states and the District of Columbia.  By then, every state in the union had had court cases bearing on the issue.

Although there was some resistance in a few quarters to the Supreme Court’s decision, most notably with the Kim Davis controversy in Kentucky, by and large negative public reaction to Obergefell was muted.  Whether or not people agreed that the Supreme Court had the right to alter the concept of marriage, and whether or not they agreed that the court’s application of the U.S. Constitution to the issue of same-sex marriage was correct, by the time the high court ruled in June of 2015, all sides to the conversation had had their say (and then some).  In fact, gay marriage attracted so much attention, analysis, fact-finding and commentary, that eventually people on all sides of the issue actually became weary of the discussion.

The key point is that, in ruling in Obergefell, the Supreme Court did, in fact, re-define marriage as that term had previously been used and understood in American society.  (To be clear, other societies in other eras have had other definitions of marriage.)  Many people objected to such a re-definition because they did not agree that it was appropriate, moral, legally justified, socially desirable or for other reasons.  Those arguments were heard and evaluated on their merits, and every party concerned had the full opportunity to make its case.  We had a robust national conversation about the definition of marriage which lasted, even dating strictly from the Hawaii decision, for some 22 years.

Re-defining “man” and “woman”: An idea not very long in coming

Although older readers may remember the well-publicized early cases of Renee Richards (in 1976) and of Christine Jorgensen (even further back, in 1952), until very recently, transgender people were primarily regarded by most Americans as exceptionally rare oddities.  Early political efforts around transgender rights and people only began to gather momentum in the late 1990s, with the first efforts to add “gender identity” to anti-discrimination laws in a few jurisdictions and the establishment of the “Transgender Day of Remembrance” in 1999 as the signal holiday of the movement.  It was not until 2014, when Time magazine declared that the United States had reached the “transgender tipping point,” that many Americans began to realize the significance of the transgender movement.  And most observers would agree that Bruce Jenner’s transformation into Caitlyn Jenner, in 2015, was probably the event that finally brought transgender people and their issues into wide public consciousness, if not acclaim.

Initially, the focus of the transgender movement appeared straightforward.  It seemed logical to include the “T” as part of the “LGB,” in that transgender people were also often viewed as sexual minorities.  Given that gay and lesbian people often were, and are, punished and discriminated against for being “gender non-conforming,” it appeared that including “gender expression” or “gender identity” as qualities to be protected under civil rights statutes was natural and appropriate.  For instance, in 2009, President Obama signed a law that added anti-transgender bias to the federal hate crimes law; President Obama also banned discrimination on the basis of gender identity among federal contractors via executive order in 2014; and in June of 2016, transgender people became eligible to serve in the United States military.  Efforts to enact a federal employment non-discrimination law covering transgender people (and gay and lesbian people, for that matter) have been unsuccessful to date.

In February of 2016 (just one short year before this writing, although it seems much longer), the North Carolina city of Charlotte passed an ordinance establishing certain civil rights protections for gay, lesbian and transgender people, including – most controversially – the requirement that transgender people be permitted to use the bathroom facility of the gender with which they identified.  In March of 2016, in a special session, the State of North Carolina passed a bill that voided the Charlotte ordinance and affirmatively required transgender people to use restrooms and locker rooms corresponding to their birth sex.  A firestorm of controversy, and needless to say litigation, followed.  Then, on May 13, 2016, the Civil Rights Division of the U.S. Department of Justice sent the now-(in)famous “Dear Colleague” letter to public school districts, informing them that under Title IX of the Civil Rights Act (which prohibits sex discrimination in education programs that receive federal financial assistance), as a condition of receiving federal funds, the districts would be required to make “sexed” school facilities, such as bathrooms and locker rooms, available to students based on the students’ “gender identity.”  Schools, including colleges and universities receiving federal funding, would no longer be permitted to require that transgender students use separate facilities.  According to the Dear Colleague letter, “[g]ender identity refers to an individual’s internal sense of gender” and “[a] person’s gender identity may be different from or the same as the person’s sex assigned at birth.”  While enforcement of the Dear Colleague letter had been stayed pending judicial resolution as to whether it is a valid interpretation of Title IX, it has now been revoked altogether by President Donald Trump.  Most observers agree, however, that the issue is far from settled.

As the “bathroom wars” illustrate, the current focus of the transgender rights movement appears, then, to have shifted, from the straightforward request that transgender (and “gender non-conforming”) people be protected against discrimination in areas such as employment, housing, and education, to a much broader proposition.  Specifically, many transgender advocates now posit that transgender people must be accepted, recognized and treated, for every purpose, as members of the sex with which they identify.  According to the Dear Colleague Letter, from henceforth, a person’s stated “gender identity” or internal sense of gender (gender previously thought of as the set of socially conditioned behaviors and personality traits commonly associated with a given sex) overrides or replaces that person’s biological or natal sex.  In fact, the very notion that there is something called “biological sex” is increasingly rejected in favor of the view that “sex” is “socially constructed.” The short-hand for this view is the oft-heard claim that “trans-women are women.”

Such a claim has profound implications for humans’ understanding of one of their most fundamental sources of identity: their sex.  The transgender claim that a person’s sex is not grounded in a set of objective, observable facts, and that it is bigoted and ignorant to believe that it is, represents a quantum shift in the way that most humans perceive reality and each other.

We cannot discuss the intellectual underpinnings of the modern transgender rights movement without a short detour into the critical theory known as post-modernism.  Post-modernism was originally formulated in the 1960’s  in opposition to the Enlightenment idea that:  “[t]here is an objective natural reality, a reality whose existence and properties are logically independent of human beings—of their minds, their societies, their social practices, or their investigative techniques. Postmodernists dismiss this idea as a kind of naive realism. Such reality as there is, according to postmodernists, is a conceptual construct, an artifact of scientific practice and language.  This point also applies to the investigation of past events by historians and to the description of social institutions, structures, or practices by social scientists.”  Post-modernism also rejects the idea that “[t]he descriptive and explanatory statements of scientists and historians can, in principle, be objectively true or false.” The postmodern denial of this viewpoint—which follows from the rejection of an objective natural reality—is sometimes expressed by saying that there is no such thing as “Truth.”  The transgender claim, that there is no objective category called “sex” for human beings, is thus a very post-modern way to view the world.

While post-modernism can provide an interesting and illuminating lens through which to “de-construct” theories, beliefs, and works of art, it seems to do a much poorer job at providing “words to live by.”  Human beings do need to act “as if” there is “such [a] thing as Truth,” if for no other reason that it is impossible for humans to live in community and interact with one another unless they share some consensus on what constitutes reality.

This is why, I believe, the core transgender concept, that “man” and “woman” do not exist as independent qualities, but are matters of subjective belief, is so immediately foreign, if not abhorrent, to most people.  A quick review of the comments on virtually every transgender-themed story on a mainstream platform, whether that is the New York Times or CNN.com, will show that the vast majority of people reject the post-modern view of sex, and in fact feel great discomfort when faced with demands that they adopt it.

Just Passing Through 18 hours ago

From dictionary dot com: de·lu·sion, noun. An idiosyncratic belief or impression that is firmly maintained despite being contradicted by what is generally accepted as reality or rational argument, typically a symptom of mental disorder. I’m a middle age man. Say I go to the closest middle school in my area and announce that in my heart, I truly believe I’m a 12 year old girl. I want to be a cheerleader, braid other girl’s hair, watch Justin Bieber videos, giggle and talk about boys. Of course, the administration with call the police and they will haul me away to the closest mental hospital. Someone will cry out, “you’re a 61 year old man, for God’s sake!” I will say, “so is Bruce/Catlin Jenner!” If a delusion is a delusion, why is one delusion celebrated and the other condemned?

Not buying it, and he’s got a lot of company.

It hardly needs saying that when we consider any other human physical qualities, whether that person is old or young, tall or short, or light or dark-skinned, we rely on what we observe or can measure to tell us where that person “fits” into any of these groupings.  Modern gender theory, however, tells us that for the specific category of sex (and only for sex, so far as I can tell), we cannot and should not base our conclusions on what we see and that sex differences have no basis in what we consider to be objective reality.

boy parts

This is a pretty heavy lift for most people.

queers gender

So is this.

To put it mildly, this is a paradigm shift.  In fact, it is a paradigm shift that has substantially broader implications than does expanding “marriage” to include same-sex couples.  In the case of marriage, as the well-worn slogan had it, “if you don’t like gay marriage, don’t have one.”  In other words, at the end of the day, the fact that same-sex couples could now be married had few ramifications for anyone other than the people involved – and, at any rate, all of the arguments were hashed out over decades.  An ancillary point is that by the time the gay marriage decision came down, most straight people knew (and knew they knew) gay and lesbian people.  They could sympathize with the desire of gay and lesbian people to be included in the definition of marriage, based on their personal familiarity with their lives and struggles.  And, of course, including gay and lesbian people within marriage did nothing to detract from or change the experience of marriage for people who were not gay and lesbian.

Re-defining sex as a matter of subjective belief has implications for every human.  In most of our daily lives, a person’s sex is irrelevant; it does not matter whether the people with whom we work or play are male or female.  However, there are important legal categories, statutes, categories and activities as to which sexual differentiation remains relevant, and if we re-define sex generally, we are re-defining it for all of these purposes.  This is where so much of the conflict emerges.  If we have decided that “sex matters” for some purposes, such as privacy, safety, re-dressing historic wrongs or inequities, competition in sports, religious observance and reproduction (to name just a few), re-defining what we mean by “sex” will have a ripple effect that extends to each and every one of these areas.

The 2016 Dear Colleague letter, while superficially addressed solely to educational institutions receiving federal funds, and while superficially concerned only with Title IX, codified the post-modern view of sex difference into law and federal policy.  This represented an incredibly swift, forced acceptance of an entirely new view of sexual difference for most people outside of academic or theoretical circles.  There has been virtually no opportunity for the public to think carefully about the issue, to research, consider, discuss, listen, or debate.  Efforts to think critically about what adopting this view implies for men and women are shut down and shamed as transphobic and bigoted.  Contrast this stunningly rapid adoption of the post-modern view of sex difference, with the decades-long fight of gay and lesbian people to be provided with basic rights and the evolution of society’s understanding of gays and lesbians as it related to marriage.

A social consensus may yet emerge to the effect that sex, and perhaps other human characteristics, is “in the mind of the haver.”  Society may also figure out different ways of grouping people – distinctions between the sexes becoming less important as people feel more comfortable in mixed-sex groups (a current example would be naturism), or as people become increasingly distanced from their physical bodies, whether through virtual reality or radical advances in medical technology.  “Sex” may simply cease to be a relevant category.  But we’re certainly not there yet.  When we look at how incredibly rapidly the post-modern view of sex has been imposed on our culture, it is hardly surprising that we are in a time of serious discord and dissension about it.  This is, at least in part, because re-defining human institutions from the “top down” is not a healthy thing for a society.  Telling the public that it must accept and internalize the post-modern approach to sex difference, long before we have had the chance to reach consensus about it, is unfair, almost certainly doomed to failure, and will result in a host of unanticipated consequences that will extend far beyond the local bathroom.

Age is just a number when it comes to neovagina surgeries

Trans activists constantly tell us “no one operates on minors.”  After all, the WPATH Standards of Care itself officially recommends genital surgeries only for those over the age of 18.

Anyone who has read this blog for awhile knows that such surgeries are already being performed on minors, at least in the United States. But how many know that gender doctors are openly discussing the advantages of early genital surgeries in highly respected medical journals?

karasic jsm piece in press

This piece, brand-new in the Journal of Sexual Medicine, co-written by Dan Karasic of UCSF’s Center for Excellence in Transgender Health, and Christine Milrod, psychotherapist at LA’s Southern California Transgender Counseling Center, makes it clear that WPATH members have been doing plenty of underage surgeries. And most surgeons quoted in the article [currently behind a paywall], despite a few concerns, are moving full speed ahead.

Their main criterion for determining surgical candidacy for vaginoplasty seems to be whether a young person can adhere to the “dilation schedule” necessary to keep the surgical wound (aka neovagina) from closing up. Any worries about brain development? Executive function? Ability to understand the many social, medical, and psychological consequences of this irreversible decision? Evidently not.

Age is just a number.  The “dedication” to adhere to the “dilation schedule” is a marker of maturity!

karasic jsm adhere to dilationIs there any lower limit for these surgeries? One surgeon opines that there “might” be a minimum age, but “I don’t know what that should be.”

(Heck, there are probably 8-year-olds who could adhere to the dilation schedule, so let’s not hem ourselves in with some arbitrary number.)

karasic jsm 2

Besides, college students are far too busy in their freshman year to keep up with their dilation schedules. Lots of other extracurricular activities to distract them!

karasic jsm maturity

How do you operate on stunted genitalia, after all those years on puberty blockers? Micropenises can be a problem in terms of creating an adult neovagina, but donor tissue and “scrotal tissue expanders” can be successful in some cases. Better than the alternative which some surgeons use, given the “concomitant morbidities” of persistent odors, colitis, and leakage of stool.

karasic jsm micropenis

And worries about potential lawsuits? Pshaw. We can’t get actual informed consent, but we’ve got the parents on board, and after all those years of gender affirmation, who’ll let a few side effects or lingering regrets get in the way?

karasic jsm consent

It’s a crap shoot they’re willing to take–even if a few of these young trans women end up unhappy with what they’re left with, like the six trans men currently suing one of the top gender surgeons in the US right now. After all, that’s what medical malpractice insurance is for.