WPATH & The Advocate aim to suppress new research on adolescent gender dysphoria

Posted on February 25, 2018 by 4thwavenow

by Brie J

On February 20, The Advocate, one of the leading LGBT publications in the US, ran an article which attempted to invalidate data collected by physician and researcher Lisa Littman from parents whose children experienced Rapid Onset Gender Dysphoria (ROGD). The author, Brynn Tannehill, immediately posted the article to the WPATH Facebook page.

In the thread, Tannehill (along with Jo Hirst, author of the Gender Fairy), suggested The Journal of Adolescent Health should be asked to retract and/or apologize for publication of Littman’s preliminary findings. UCSF’s Dan Karasic, MD (moderator of the Facebook page and WPATH official) agreed.

Littman’s abstract had been accepted for poster presentation and the poster was presented at the March 2017 Annual Meeting. (The full paper has not been published yet, and we look forward to its availability).

Note: Interestingly, as of this writing, four days after they were written, the last three comments have been deleted from the original thread.

The dismissal of Littman’s work, and the move to suppress it, is unconscionable. For one thing, some young people (like my daughter) who experienced ROGD have already desisted. Others, who were supported in procuring medical intervention, have already experienced regret. Many more desisters and detransitioners are sure to follow.

This trend has not gone unnoticed by at least some in WPATH. For example, veteran WPATH clinician Rachael St. Claire, in a Facebook post on January 5 of this year, made this comment (notice that commenting was turned off immediately after St.Claire posted):

This concern is echoed by UCSF clinical psychologist Erica Anderson, herself a transgender woman, in a recent Washington Post article:

“I think a fair number of kids are getting into it because it’s trendy,” said Anderson, who was married for 30 years and fathered two children before transitioning seven years ago.

I’m often the naysayer at our meetings. I’m not sure it’s always really trans. I think in our haste to be supportive, we’re missing that element. Kids are all about being accepted by their peers. It’s trendy for professionals, too.”

In addition, clinics around the world have noted a sharp increase in the number of girls presenting for treatment in the last few years.

A once-rare condition is now increasingly common. It is surely in the interest of all people who care about gender dysphoric youth to investigate the reasons for the increase, and Littman’s work is an early contribution to this effort.

The ostensible reason given for Karasic et al’s desire to have Littman’s abstract retracted is that the data comes from a self-selected group of parents, culled from websites where such parents gather, in an anonymous survey format, and is thus deemed to be worthless. Yet advocates for pediatric transition constantly promote other survey studies, also culled from “self selected” groups (such as the Williams Institute suicidality survey), as well as research conducted by investigators who only recruit subjects from pro-early transition organizations (such as Kristina Olson’s two studies), with no attempt to broaden their samples to children who are not socially or medically transitioned.

In fact, Littman’s work is the first to study this new presentation of gender dysphoria, and she collected information from the people who know these children and teens better than any transgender advocate, endocrinologist, psychologist, or therapist ever could — their parents.

But you’re not listening to us.

Littman’s study, according to its critics, is contentious for a few reasons, but most notably for using the term “Rapid Onset Gender Dysphoria” as a descriptor for a new kind of trans-identifying youth, primarily natal females, who during or after puberty, begin to feel intense unhappiness about their sexed bodies and what it means to feel/be/present as a woman.

Let me emphasize: What is “rapid onset” in this population is the dysphoria, not the gender atypicality. What distinguishes these young people from the early-onset populations studied previously is that they may have been happily gender nonconforming throughout childhood (though some were more gender typical), but they were not unhappy (which is all “dysphoric” really means), nor did they claim or wish to be the opposite sex. The unhappiness set in suddenly, in nearly every case only after heavy peer influence, either on- or offline.

This phenomenon has only recently been noted by clinicians directly involved in treating gender dysphoric youth, as well as other mental health professionals. While there is no lack of evidence for adolescent emotional and behavioral social “contagions,” Littman’s research is the first to collect data on this phenomenon as it relates to identifying as transgender.

Even though rapid onset gender dysphoria has been noted by other researchers and clinicians who work with these populations, The Advocate and WPATH’s Dan Karasic consider the descriptor “junk science.” In a swift attempt at censorship, Karasic deleted all but one of my comments on the public WPATH Facebook page and then banned me from the group when I asked him to please consider the experiences of young people, like my daughter, for whom gender dysphoria set in hard and fast after being exposed to the idea that her gender nonconformity was in fact a sign of being transgender.

Interestingly, after I was purged, Karasic posted links to both my and my daughter’s stories on 4thWaveNow, and unfounded accusations were leveled against me and 4thWaveNow; since I was banned, I was not able to respond to them.

Interested readers may refer to these Twitter threads should you want more blow-by-blow details:

The subject of the linked article twice, in a public forum, accused 4thWaveNow of "attacking my children" in the writeup. Is there any basis for this claim? https://t.co/qwSqvaFGPX

— 4thWaveNow (@4th_WaveNow) February 22, 2018

https://twitter.com/BJontry/status/966728843649204224

https://twitter.com/BJontry/status/966479677098401792

It is concerning, given Karasic’s reaction to Littman’s research, that he and others evidently leave no room for a teenager to be incorrect about how they are interpreting their feelings, no room for a clinician to be incorrect when recommending transition, and no room for a parent to understand what is going on with their own child. It is narrow minded and short-sighted, especially considering there is no long-term data supporting the benefits of early medical transition for gender dysphoria or consensus from the medical community about best treatment methods.

This lack of consensus, while well known and acknowledged by the international medical community, has been ignored by many transgender advocates, along with the “gender affirmative” recipients of a $5.7 million NIH grant, who, with the help of the mainstream media, have manipulated the public into believing early social transition, pubertal blockade, and early cross-hormone treatment constitute settled science.

To be clear, in “Early Medical Treatment of Children and Adolescents With Gender Dysphoria: An Empirical Ethical Study,” a 17-clinic international study published in The Journal of Adolescent Health, the authors explain that:

As still little is known about the etiology of GD and long-term treatment consequences in children and adolescents, there is great need for more systematic interdisciplinary and (world- wide) multicenter research and debate. As long as there are only limited long-term data in support of the guidelines, there will be no true consensus on treatment. To advance the ethical debate, we need to continue to discuss the diverse themes based on research data as an addition to merely opinions. Otherwise ideas, assumptions, and theories on GD treatment will diverge even more, which will lead to (even more) inconsistencies between the approaches recommended by health care professionals across different countries. (372)

I am sure some WPATH members, like the treatment teams in Lieke et al., “feel pressure from parents and adolescents to start with treatment at earlier ages.” I know there are others, besides those reported in Lieke et al. who:

[…] wondered in what way the increasing media attention affects the way gender-variant behavior is perceived by the child or adolescent with GD and by the society he or she lives in. They speculated that television shows and information on the Internet may have a negative effect and, for example, lead to medicalization of gender-variant behavior.

“They [adolescents] are living in their rooms, on the Internet during night-time, and thinking about this [gender dysphoria]. Then they come to the clinic and they are convinced that this [gender dysphoria] explains all their problems and now they have to be made a boy. I think these kinds of adolescents also take the idea from the media. But of course you cannot prevent this in the current area of free information spreading.” –Psychiatrist

It is unconscionable that transgender advocates, and the leading international body concerned with transgender medicine, would seek to quash data that address unsettled and mostly unexplored areas of concern. It is incredibly important that ROGD be included as a research point because the main studies used to justify the use of puberty blockers, cross-sex hormones and surgery in adolescents required “persistent gender dysphoria since childhood” and “no serious comorbid psychiatric disorders that may interfere with the diagnostic assessment” before the patients were eligible for medical intervention. In other words, none of the participants in these treatment studies had adolescent-onset of their gender dysphoria and none of the participants had serious psychiatric issues.

It is a huge leap to assume that an entirely different population of adolescents with a different presentation of symptoms will have the same results as the adolescents in the Amsterdam cohort. An additional gap in the research is that because all the desistence and persistence studies are about adolescents who had childhood onset of gender dysphoria, the persistence and desistence rates for adolescent-onset gender dysphoria are unknown.

In all areas of medicine, best practices come from intense discussion and research into indications and contraindications, and into risks, benefits, and alternatives. Yet, WPATH’s Karasic, along with the trans advocates who have prominent roles in the organization, appear to believe it is in their community’s best interest to shut down all discussion about contraindications, risks and alternatives. This is inappropriate and undermines the very concept of informed consent.

Furthermore, The Advocate article suggests that Littman’s sample is biased because it gathered data from “unsupportive” parents. This framing is both fallacious and dangerous to gender nonconforming and dysphoric youth. It suggests that the only path for gender dysphoric youth, even those with a rapid onset, is full affirmation including fulfillment of requested medical interventions. It also implies that parents aren’t able to be both supportive and cautious.

I have spoken to some of the parents who participated in the study. Few could be described as “unsupportive.” In fact, almost overwhelmingly, these parents supported their children in thinking about their gender identity and helped facilitate their preferences for atypical gender presentation and interests (taking them for haircuts, new clothing, and so forth). Many sought professional mental health consultations and treatment for their children. But what many of these parents did not support for their underage teenagers were hormonal and surgical interventions. This is an important distinction: Littman’s sample were supportive parents who were unsupportive of a particular medical treatment option.

It is entirely possible to be supportive parents invested in our child’s well-being and not agree to unproven medical procedures for which there is no consensus from the medical community of long-term safety or benefit to the majority of dysphoric youth. However, the loudest voices in pediatric transgender medicine often cite Kristina Olson’s descriptive research about early social transition for children which relies on the methods that they decry as “junk” when used in Littman’s research (targeted recruitment and the collection of data from parents). Kristina Olson recruited her sample from support groups and conferences to find parents who have socially transitioned their children, which might consist only of parents who are supportive of early social and medical transition. So is it an acceptable method for both studies, junk for both studies, or are the WPATH activists simply going by whether they like or dislike the findings?

As all parents know, we can tell when our children are suffering. To remain credible, advocates for gender dysphoric youth and the international organization which claims to be concerned with generating best practices in the field of transgender medicine must acknowledge that ROGD exists and there are some trans-identifying youth who arrive at their identity from external social pressures, and at times, internalized homophobia.

Related to this last point, the WPATH Facebook page wasn’t the only place my respectful questions were deleted. In a comment on The Advocate article itself, I asked Tannehill and Advocate readers to consider the recent research into how homophobic name-calling influences (hint: greatly) children’s perceptions of their gender identity.

My comment was swiftly scrubbed from existence. For those interested in reading “The Influence of Peers During Adolescence: Does Homophobic Name Calling by Peers Change Gender Identity?” the full text is here.

Finally, the fact that ROGD is being discussed by the conservative media is not, no matter how many “incriminating” links Tannehill dropped in the Advocate piece, a legitimate reason to discredit the data. The irony is not lost on many 4thWaveNow parents that our stories are covered by media outlets we typically avoid. In this politically charged climate, it is important for researchers, clinicians, and parents to work together to “first do no harm” even when those we otherwise disagree with call for the same cautions.

Clearly, Brynn Tannehill and Dan Karasic do not speak for all members of WPATH. I know for certain that they do not speak for many professionals currently working with gender dysphoric youth who see in their own practices what can only be described as “rapid onset gender dysphoria” in an increasing number of adolescents, particularly girls. Clinicians are aware of the rapidly growing numbers of young people requesting services and the possibility of social contagion; there are those among you who are concerned by the potential for misdiagnosis and the subsequent harm that will come to some of your patients as a result.

It is time for those with concerns to speak out. Please do not allow your ethical and professional concerns to be held hostage by ideology.

Not plural-phobic: USPATH psychiatrist promotes transition for multiple personalities

Posted on December 29, 2017 by 4thwavenow

This is another in a series of posts examining statements made by top gender specialists at the inaugural USPATH conference in Los Angeles in February 2017. (See here, here, and here for more.)

Note: The audio recordings linked in this post, as well as the presentation slides, were provided by an attendee at Dr. Karasic’s USPATH presentation.

Dan Karasic, MD, plays an important role in the area of transgender health care. He is clinical Professor of Psychiatry at University of California, San Francisco, and a practicing psychiatrist for the Transgender Life Care Program at Castro Mission Health Center, as well as at his faculty practice at UCSF. He is also the co-chair of the recently formed USPATH, on the Board of Directors of WPATH, and, as such, has been instrumental in the ongoing development of WPATH policies and standards.

With so much experience, as both a clinician and trans advocate, Karasic’s statements and clinical judgment carry a lot of weight. So it’s of particular interest that his presentation at a mini-symposium entitled DEVELOPMENT OF GENDER VARIATIONS: FEATURES AND FACTORS at the inaugural USPATH conference last February should focus on a topic as controversial as this: medical transition for one or more “alters” of people with multiple personalities (MPD)—also known as dissociative identity disorder (DID).

MPD/DID had its diagnostic heyday in the late 20^th century, peaking in the 1990s. The public was fascinated by the idea that one human being could comprise more than one identity or personality, and novels, films, and breathless media coverage proliferated. The disorder was thought to be the result of trauma or abuse, but has since that time been subjected to the same skeptical reassessment as the now widely debunked recovered memories and satanic abuse diagnoses (MPD/DID was, in fact, often associated with/comorbid with both).

There is something eerily familiar in this excerpt from a 1999 book by Joanne Acocella about the rise and fall of the MPD diagnosis .

Another important circumstance in Carlson’s case, as in other MPD histories, was the media. During the period of Carlson’s therapy, magazines and newspapers were retailing utterly unskeptical stories about MPD. So was the evening news. MPD experts went on TV with their patients in tow. Bennett Braun, of the nine-hour abreactions, appeared on the Chicago evening news with his star patient. At his bidding she “switched” on camera—now she was “Sarah,” now “Pete”—thus providing early training for prospective MPs in the television audience.

More important than the news were the talk shows. Phil Donahue was apparently the first talk-show host to present a program on MPD; he was followed by Sally Jessy Raphael, Larry King, Leeza Gibbons, and Oprah Winfrey. Meanwhile, celebrities were coming forward with their tales of childhood sexual abuse: Roseanne Barr, La Toya Jackson, Oprah herself. Some of them claimed to be multiples as well. Roseanne, who had unearthed twenty-one personalities within herself—Piggy, Bambi, and Fucker, among others—made the rounds. Again and again on the talk shows it was stressed that MPD was not rare; it was common, and becoming more so. “This could be someone you know,” said Sally Jessy Raphael. Oprah’s program was called “MPD: The Syndrome of the ’90s.” Today, as people are sifting through the wreckage created by the MPD movement, many therapists are blaming the media for spreading the epidemic. They are passing the buck, but still they have a point.

In the late ’90s and into the present day, a number of critical papers appeared in the clinical literature, and the verdict from many clinicians and researchers was that often cases were at least partly iatrogenic:

Although the relative paucity of data on the role of iatrogenic factors in DID renders a definitive verdict premature, several lines of evidence converge upon the conclusion that iatrogenesis plays an important, although not exclusive, role in the etiology of DID:

(a) The number of patients with diagnosed DID has increased dramatically over the past several decades (Elzinga et al., 1998); (b) the number of alters per DID case has increased over the same time period (North et al., 1993), although the number of alters at the time of initial diagnosis appears to have remained constant (Ross, Norton, & Wozney, 1989); (c) both of these increases coincide with dramatically increased therapist awareness of the diagnostic features of DID (Fahy, 1988); (d) a large proportion or majority of DID patients show few or no clear-cut signs of this condition, including multiple identity enactments, prior to therapy (Kluft, 1984); (e) mainstream treatment practices for DID patients appear to verbally reinforce patients’ displays of multiplicity and often encourage patients to establish further contact with alters (Ross, 1997); (f) the number of alters per DID case tends to increase over the course of DID-oriented therapy (Piper, 1997); (g) therapists who use hypnosis appear to have more DID patients in their caseloads than do therapists who do not use hypnosis (Powell & Gee, in press); (h) the majority of DID diagnoses derive from a relatively small number of therapists (Mai, 1995); and (i) laboratory studies demonstrate that nonclinical participants provided with appropriate cues can successfully reproduce many of the overt features of DID (Spanos et al., 1985). Given the high rates of preexisting mental conditions among DID patients (Spanos, 1996), however, it seems likely that iatrogenic factors do not typically create DID in vacua but instead operate in many cases on a preexisting substrate of psychopathology, such as BPD.

As the authors of this article attest, some patients diagnosed with MPD got worse instead of better as they underwent treatment, and not a few came to realize that their deepening troubles were at least partly the result of the misguided efforts of their psychotherapists. Some high-profile cases ended up in court, like this suit brought by Pat Burgus, who settled for $10.6 million against her psychiatrist, Bennett Braun. Burgus had once believed she had 300 different “alters,” and she “recovered” memories under hypnosis that she had eaten human flesh and–among many other horrors–sexually abused her two sons. She blamed her therapist for convincing her these memories and personalities were real.

Before her ordeal was over, Pat would develop 300 personalities, attempt suicide twice, cut ties with her family in Iowa, and go to court to regain custody of her children. She would spend more than two years in the hospital; her children would spend three. And her insurance company would pay $3 million for a treatment regimen that today seems utterly fantastic….

… Since 1993, more than 100 patients nationwide have sued therapists over treatment for MPD, which was diagnosed in explosive numbers throughout the eighties. “In many of these cases, we see a situation in which the poor training and instability of the therapist, coupled with the vulnerability of the patient, creates a situation fraught with the potential for a folie à deux”—that is, a delusion shared by therapist and patient, says R. Christopher Barden, a lawyer and psychologist who served on the Burgus legal team.

MPD/DID remains today a controversial diagnosis. In a 2004 review paper, “The Persistence of Folly: Critical Examination of DID. Part II. The Defence and Decline of Multiple Personality or DID,” authors Piper and Mersky, make the crucial points bluntly.

Concerns about the validity of MPD/DID raised by skeptics in the psych literature seem to coalesce around the following: only a small group of therapists have been involved in diagnosing it; the condition often worsens and more identities/personalities arise after treatment has commenced; and its close association with the widely debunked notion of “recovered memories” of childhood abuse further undermines its validity.

Given the precarious legitimacy of the MPD/DID diagnosis, it seems clear that–if it’s going to be made at all–it should be done with extreme caution and, above all, with an awareness of the potential for iatrogenic conditions that might exacerbate it—most importantly, the influence of the treating clinician.

Yet MPD/DID is apparently very much alive in WPATH circles. Returning to Dr. Karasic’s presentation about “trans plurals” at USPATH, he offered several case studies, all of which involved medical transition of all or some of the “alters”:

In the case of this 20-year-old “AMAB,” as seems to be typical with gender affirmative practitioners, medical transition is reported as curative (or at least palliative) for a host of other problems apart from gender dysphoria; in this instance, the patient’s Bipolar Disorder 2 and Alcohol Use Disorder were “treated simultaneously” with the T-blocker spironolactone and cross-sex estrogen. The patient “did well,” and the 7 alters (including 3 in “co-conciousness,” 2 agender, 1 female) seem to have reached consensus about gender surgery later on–presumably the requested “genital nullification” .

Then there is the 27-year-old who identifies as a genderqueer “system.” Diagnosed with autism in childhood, this “AMAB” with a primary “front” female alter, has undergone hormone therapy and presently has 85 “headmates” that include alters, tulpas, and fictives.

Headmates, tulpas, “fronting,” co-consciousness: Dr. Karasic seems well versed in the insider jargon used by the trans plural community.

“So I’ve had several patients who identify as trans and plural

…and I guess I had a reputation as a psychiatrist who was not plural phobic.”

After discussing several cases of successful medical transition of alter identities, Karasic reported on an online survey of 250 self-identified “trans and plural” subjects conducted by three self-described members of the trans plural community, over a one-month period. From the data gathered, there seems to have been a plethora of different alter types reported by survey respondents.

Did these alters include “furries,” an audience member wanted to know?

Q: “…What are “damiens?” [sic] The other thing is, were all the alters human, or were there some alters that took on another form?

Karasic: …I think there are people who have alters that take different forms. And I have had somebody with a wolf, you know, and sometimes fictional characters who might not be human, who can become a headmate, basically.

Q: Separate from furries? We’re not talking about furries..

Karasic: No, no no, this doesn’t have anything to do with that. This is just different people’s identities, but there are people who may have within this a system with headmates. There can be kind of a variety of …headmates.

Last August, 6 months after the USPATH symposium, Dr. Karasic discussed his experiences with transitioning multiple personalities in a thread on the public WPATH Facebook page.

Dr. Karasic does acknowledge here the importance of mental health care for people with multiple issues, but per the informed consent model that Dr. Karasic subscribes to (evidenced by his many public statements, as well as the fact that his trans health clinics operate on the informed consent model), comorbid mental health problems are not seen as a barrier to medical transition instituted before treating other comorbid issues.

In the era before informed consent became the preferred approach , particularly in the United States, clinicians were often reluctant to initiate hormonal or surgical intervention in patients with comorbid, severe mental health issues. But in the age of gender affirmation, withholding medical transition is seen as restrictive—even immoral– “gatekeeping”—even if one runs the risk of one alter ego disagreeing with medical treatment and suing the provider in court for “violating the rights of one or more personalities“, as a commenter on the same thread hypothesized.

Taking this a step further, might one trans-plural headmate sue not only the surgeon or gender therapist, but one of the other headmates for forcing medical transition (or not) on the others?

Time will tell if the spectacular court cases brought by aggrieved clients who were diagnosed with DID/MPD in the 1990s will play out in a similar fashion within the labyrinthine world of trans plurals.

Meanwhile, the reader may find the concluding paragraphs of the previously cited Piper and Mersky paper relevant when weighing the plight of “trans plurals” and the clinical approach taken by at least one prominent WPATH clinician:

Wherever we look—whether at the posttraumatic model; at theories of repression; at the epidemiologic uncertainties and aggrandizements of the disorder; at the persistent proliferation of personalities; at the elusive data that attempt to sustain the claims of exceptional abuse; at the bland presentation of breathtaking assumptions such as cross-sex, cross-species, or cross-ethnic alters; or at the impossibility of proving almost any of the basic claims of the disorder—we encounter propositions that appear to be founded on beliefs and not on facts or logic. That such beliefs could prosper in a society or a discipline represents an embarrassing weakness of the academic and professional establishment of psychiatry.

Perhaps the closest example of another culture-bound movement that resembles the modern DID–MPD movement occurred in the late 19th and early 20th centuries, when mediums and spiritist practices were popular. Hacking notes that “multiple personality has long had close links with spiritism and reincarnation. Some alters, it has been thought, may be spirits who find a home in a multiple; mediums may be multiples who are hosts to spirits” (79, p 48). Much of the best turn-of-the-century English-language research on multiple personality was published by the London- or Boston-based societies for psychical research. However, After 30-odd years of high times around the turn of the century, mediumship, spiritism and psychical research went into radical decline. A zone of deviancy that was hospitable to multiple personality severely contracted (79, p 48).

When it becomes suspect to recommend MPD as part of psychiatric evaluation or treatment, the condition is diagnosed less frequently. For example, Pope and colleagues (80,81) and others (82) have shown that North American psychiatrists and psychologists are abandoning the notion of MPD–DID as an acceptable diagnosis. In these circumstances, we expect that the condition will revive momentarily and die several times before it finally ceases to be a ripple on the surface of the psychiatric universe. In the end, it is likely to become about as credible as spirits are today. Having attempted to rationally analyze the claims of MPD–DID, we trust that we have shown sufficient evidence to predict a steep decline in the condition’s status over the next 10 years and a gradual fall into near oblivion thereafter.

No menses, no mustache: Gender doctor touts nonbinary hormones & surgery for self-sacrificing youth

Posted on August 4, 2017 by 4thwavenow

This is another in a series of posts examining statements made by top gender specialists at the inaugural USPATH conference in Los Angeles in February 2017. (See here and here for more.)

Not so long ago, unremitting distress about one’s gender was the one and only reason for medical transition. Those days are over. With activists clamoring for a change from “gender dysphoria” to “gender incongruence” in the next revision to the international register of diagnosis codes, the ICD-11, the push is on for insurance-paid hormones and surgeries for anyone who believes their body is in any way “incongruent” with their “gender identity.” And this effort includes medical intervention for children and adolescents.

In this clip, excerpted from a USPATH symposium entitled “OUTSIDE OF THE BINARY – CARE FOR NON-BINARY ADOLESCENTS AND YOUNG ADULTS,” pediatric gender specialist Johanna Olson-Kennedy MD, discusses her views on medical interventions for “nonbinary” youth.

As always, we recommend that you listen to the recorded excerpt yourself, as well as reading the transcript included in this post. Time stamps are indicated by square brackets. []

According to Dr. Olson-Kennedy,

There are still people who want to embark on phenotypic gender transition—hormones and surgeries—who don’t meet this criterion [for gender dysphoria]. Well, what are we to do?

…And it’s great. I love this. I don’t like the word “pass” at all. Passing as a member of the other sex is not a criterion for treatment, whereas achievement of personal comfort and well being are. And that is really the crux of what should guide our care, as medical providers, as professionals in the mental health role.

How is this any different from elective cosmetic surgery? Trans activists will say it’s “medically necessary” because it is a guaranteed suicide preventative, a dubious claim at best. But how about a teen girl who hates herself and is self-harming because her breasts are (to her) too large or too small? What about her “comfort and well being”?

[:52] So, there are a lot of medical intervention possibilities for folks who have nonbinary identities. And again, this is really not for me to determine. It’s really for me to work with a person to determine what it is they’re interested in.

As we all know by now, the idea that a medical or psych provider should use diagnostic skills to determine whether a young person ought to undergo permanent drug or surgical treatments is so 20^th century.

[1:06] Some people are like, oh! no menses, no mustache. You know, assigned female at birth, “I really don’t want facial hair, I don’t want [inaudible], I’m super dysphoric about bleeding.”

So, there’s lots of options, certainly for menstrual suppression. I love—I was so excited to be in one of the first sessions that I went to, which was gynecologic care for trans-masculine folks, this “leave a gonad” thing.

So, it was this idea of, you know, maybe you don’t wanna have bleeding but you still want estrogen, and you want that support from a medical perspective. Or you just don’t want to go on testosterone.

It’s 2017, and designer endocrine systems are all the rage. Human beings should tinker and tamper with their delicate hormonal balance, because it’s what they want right here, right now. Mix and match–why not?

[1:48] There’s lots of these different things. Maybe a central blocker and low dose testosterone. I had a young person who went on testosterone for a year, and it was like, that’s enough, I’m fine with it. I’m masculinized enough, and that’s good for me. Or no medical intervention at all. That’s absolutely possible.

The slide below, from a different talk at the same USPATH conference, pretty well encapsulates this “treatment” approach:

So we see the mindset of “affirm-only gender doctors here; why so many of them don’t acknowledge there might be permanent harm done to young people who eventually detransition. There are no mistakes. It’s all part of the gender journey.

[2:06] So, for nonbinary assigned males, maybe just Spironolactone [an androgen blocker] or using a peripheral blocker only. That might be something that people opt for. I had a young person who really [inaudible] nonbinary identity, but kind of, very very huge fear of a large nipple areola complex. Like, “I just can’t even deal with that.”

All you women with large nipple areolas that you just can’t even deal with, maybe you can get Medicaid to cover that in your state? Worth a try.

It would be one thing if these people were arguing for elective, cosmetic treatments on demand, for adults. But activists and gender specialists not only want to retain a medical diagnosis, gender incongruence in the next version of the ICD-11; they want insurance to cover all trans-related treatments, for nonbinaries and anyone else who wants them. In fact, some public and private insurance policies (such as that of the San Francisco Department of Public Health) already provide such coverage.

Back to Olson-Kennedy and her areola-avoidant patient:

[2:33] So, we put them on Spironolactone for a while, and then eventually she came back and said I wanna go on estrogen. So there’s selective estrogen receptor modulators for people who do not want breast development. That could be a possibility. Maybe hormones, no surgery. No medical intervention, another possibility.

No medical intervention: Just one of many dishes in the smorgasbord of options for nonbinary, gender fluid youth. Who’s to say (certainly not a medical doctor), which is the least harmful of those possibilities in the long run?

[2:51] My observations: Sometimes nonbinary identities are strategic…to protect themselves, to protect their parents. What I can tell you for certain about trans kids, youth, is they do a lot of taking care of the people around them.

Here we see a theme we’ve heard from other affirm-only genderists: Trans youth are more mature than “cis” kids. They are extraordinarily prescient about their future; they know for certain what they will want at age 20, 30, 40.

Prominent gender therapist Diane Ehrensaft lauds her tween clients for having the wisdom and foresight to opt for adoption in the future—unlike their balking parents, whose only reason for objecting to sterilizing a 12-year-old is a selfish desire for grandchildren.

But there’s something else crucial to note about Olson-Kennedy’s comments: After initially lauding her young enbies for pursuing smaller nipple areolas, or choosing to halt their menstrual periods without sprouting a beard, she is now implying to her audience that nonbinary is only a stopover for many of these kids. They are only claiming this identity to “take care of” their parents, when what they really want is to go whole hog to a binary transition.

[3:18] “I will sacrifice my own comfort for the comfort of the people around me, who I know I’m making very uncomfortable with my gender.”

What an extraordinary assertion. Trans kids aren’t just mature beyond their years when it comes to making irreversible decisions about their bodily integrity and fertility. They also emanate Buddha-like concern for the feelings of others, especially their woefully ignorant parents. How long before we have religious sects led by trans kid gurus, like Tibetan child lamas on steroids?

And how does the claim that trans kids are precociously mature square with the accumulating evidence of a strong correlation between gender dysphoria and autism? Young people with autism are not exactly known for their self-sacrificing nature or their ability to reflect upon the feelings of others.

[3:33] And so, marking that out is really important. Because again, because expressing that [they are nonbinary] is often used as evidence that they are not trans. “No, well they don’t want to do this. Clearly, they’re not trans.” And having that conversation, and making sure that someone isn’t taking care of someone else at their own sacrifice.

Are they “taking care of someone else” or perhaps listening to a family member who just might have the best interests of the child at heart, more than a gender doctor who hasn’t known the kid their entire lives?

So, on the one hand, we hear that nonbinaries need treatments “to feel more comfortable,” and at the same time, we’re told that a significant number of martyr-like trans kids are “sacrificing” themselves by feigning a nonbinary identity for the comfort of their parents. Which is it?

The Guardian recently produced a mini-documentary on nonbinary milennials and their quest for comfort. Meghan Murphy dissected this bit of puffery, and took on the living nightmare of feeling uncomfortable in this article.

Well worth a look.

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

Posted on April 3, 2017 by 4thwavenow

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.”

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.

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.

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.”

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:

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.

Age is just a number when it comes to neovagina surgeries

Posted on March 20, 2017 by 4thwavenow

Note: For a more detailed look at the “Age is Just a Number” paper, see also this post.

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?

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!

Is 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.)

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!

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.

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?

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.

Shriveled raisins: The bitter harvest of “affirmative” care

Posted on January 26, 2017 by 4thwavenow

Note to readers: This is another in an ongoing series of posts which shine a light on the public statements made by gender specialists in various forums. The aim here, as always, is to inform the public, particularly parents, about the actions and self-reported thoughts and plans of individuals who are currently involved in providing hormones and surgeries to minors. All screen captures are from publicly accessible (i.e. not password-protected or otherwise private) websites. We intend to continue to exercise our free-speech right to report on these public statements, as well as publishing our personal opinions on pediatric transition and those who enable and promote it.

To anyone who may object to our work in this area, hear this: The backlash represented by 4thWaveNow, Transgender Trend, Youth Gender Professionals, and the increasing number of individuals and organizations who question the burgeoning increase in child and youth transition is precisely that: a backlash against the decision taken by trans activists and their media handmaidens to relentlessly promote pediatric transition—especially MEDICAL transition.

The final straw, for many of us, has been the shameless and daily attempts by activists, journalists, and some clinicians to misuse self-harm statistics as a weapon to bludgeon parents into submission. A recent article in Spiked Online exposed this immoral and deeply destructive tactic, and we will continue to expose it on 4thWaveNow.

Scattered through the posts on this site, we have discussed the fact that puberty blockers followed by (or used concurrently with) cross-sex hormones to prevent the “wrong puberty” in prepubertal kids results in irreversible sterilization. This is well-recognized fact, openly acknowledged by researchers and top pediatric gender specialists alike [see the bottom of this post for a collection of links on this matter].

The reason is that gametes (sperm and ova) require natural, biological puberty to mature to the point that they are viable for reproduction. It is not currently possible to freeze immature gametes, as it is for those of adult trans people who have been allowed to go through natal puberty.

Our point is not that anyone and everyone should have biological children or that women are only fit to be baby machines (a red herring “argument” that has been used against us by trans activists). It also has nothing to do with the demographics of who will ultimately decide to bear or father children. (I notice none of these activists cavalierly argue for sterilization of disabled or gay people, both of whom have a lower statistical rate of becoming biological parents). The point is that it is a human rights violation to sterilize minors, who by definition cannot consent nor understand what it means to give up that future right. And given that the majority of “persisting” trans kids are same-sex attracted, it is not a stretch to see that prepubescent sterilization of “trans kids” amounts in many cases to a form of proactive anti-gay eugenics—even if that is not the conscious intention. What’s more, as many parents know, the decision to reproduce may come later in life, even if we thought in our youth that we wouldn’t have wanted children. Most young people naturally don’t spend their time thinking about having kids of their own; they have other priorities at that stage of life, as well they should.

But does any of this matter if adult trans people aren’t particularly interested in reproduction?

Well, it turns out that several studies have shown that a majority of trans men and trans women desire to have biological children of their own.

But even setting aside research evidence, all you have to do is look at the increasing number of (sometimes sensationalized) media stories about “pregnant men” to know this is “a thing”.

There are a sufficient number of trans men becoming pregnant and giving birth that the premier midwifery organization in the United States has changed all its literature to be “gender neutral” in an ostensible effort to avoid “triggering” its clients with words like “woman” and “breasts.” Planned Parenthood now campaigns on behalf of “menstruators” and the venerable La Leche League has even scrubbed its language of inconvenient mentions of biological reality, to ensure that trans men who want to “chest feed” won’t feel excluded.

But when it comes to the fertility of trans people, trans activists want to have their cake and eat it too: Celebrate and support adult trans who decide (often unexpectedly) to reproduce, while fiercely lobbying for medical intervention which permanently sterilizes prepubescent children. There is really no way to square this contradiction. They constantly claim that stopping the “wrong puberty” is the only antidote to suicide, yet that “wrong” puberty is the one and only pathway to possible reproduction in the future.

Not to put too fine a point on it, but the very people arguing that the only alternative to these sterilizing pediatric treatments is suicide are very much alive, and quite a fair few of them (notably, several top MTF trans activists) have biological children of their own. “Do as I say, not as I do” is rightly ridiculed as hypocrisy when it comes to any other subject. How on earth did these people survive to adulthood, father children, yet now harangue us that the “wrong” puberty of these children must be stopped?

As to the weaponization of suicidality: There is no record in the history of medicine of children and teenagers killing themselves because they could not medically transition in childhood, or because they were “born in the wrong body.” (Since August when this piece was posted, we’ve been waiting for any evidence to the contrary.) Even the most frequently cited “41%” study of trans adults who have reported suicidal ideation doesn’t assert that medical transition cures suicidality.

Source: Williams Institute, 2014

So, given that

large numbers of adult trans men and women express a desire to have biological children;
no child or pre-adolescent can know for certain whether or not they will eventually want to reproduce;
it is a universally acknowledged human rights violation to sterilize minors;
and there is no evidence that early medical transition will ultimately reduce self harming behaviors,

we must ask: Why do gender specialists continue the reckless practice of promoting sterilizing hormones and surgical interventions on prepubescent children, who, by virtue of their undeveloped powers of reason and judgment, cannot meaningfully consent to such treatments? On what authority does any adult—including these children’s parents—have the right to make a decision for a minor that should solely belong to adults of reproductive age themselves?

Even if it turns out to be true that most of these kids won’t opt for biological reproduction in the future, what of the (already limited) pool of potential life partners they might fall in love with? It’s not at all uncommon for couples to part company over disagreements about whether to have children. And then there’s the issue of what genital surgeries do to sexual response and function. None of this is ever discussed in the glowing portraits of “trans kids” that we see daily in the mainstream media (though it is by the clinicians themselves—as you’ll see shortly).

The gender specialists are fully aware of the irreversible effects of their interventions. Gender clinics detail the risks of infertility and other permanent changes on their consent forms. Research articles, public statements, and news articles capture the admissions by prominent gender specialists (again, see the bottom of this piece for links). Some express reservations (but no accompanying intention to cease and desist or even slow down their caseloads); some mention it in passing. And some, as you’ll see in a moment, appear to lose no sleep at night over what they’re doing, but only express interest in the future market for even more high tech interventions for the young people entrusted to their care.

Last March, Johanna Olson-Kennedy, MD (herself a parent), one of the world’s most successful and best known pediatric gender specialists, posted a call on the publicly accessible WPATH Facebook page for earlier genital surgeries on minors. We wrote about it at the time in this post.

The irony is inescapable: By puberty blocking young people, endocrinologists create a situation where these youth naturally yearn for puberty, as they watch their unblocked peers mature and move on. Olson-Kennedy’s solution? More high-tech, expensive medical intervention; earlier cross-sex hormones, earlier sex reassignment surgery. An iatrogenic problem created in the first place by suppressing the perfectly healthy bodies of young people.

Just a few days ago, Olson’s original post was revived via several new comments supporting her radical idea. This one, by Susan Maasch, founder of the Trans Youth Equality Foundation (TYEF) is particularly striking. ( We wrote about TYEF—a purveyor of free breast binders (secretly to girls with “unsupportive” parents) and youth transition propaganda, last year.)

“Shriveled raisins”: The outcome of years of hormone treatment unnatural to the female body.

Other activists and pediatric gender specialists, including Rixt Luikenaar (ironically, an OB-GYN), Kathie Moelig (founder of TransFamily Support Services), and others acknowledge that sterilization (which their clients may someday regret) will result from early surgeries and hormones, but place their faith in high-tech medicine to find a way around it—eventually.

This unquestioning belief that medical technology will solve the problems created by zealous “affirmative” gender specialists is widely shared. Just a couple of days ago, NPR ran an article acknowledging that immature gametes can’t currently be preserved for future reproduction. But by drawing on fertility preservation research in cancer survivors treated with sterilizing chemotherapy, the pediatric-transition pushers hope that puberty-blocked children’s ova and sperm can eventually be coaxed to reproductive viability in a petri dish.

Both groups — young cancer patients and trans kids hoping to transition early — have a demand for fertility preservation at an age where it has not usually been possible. But researchers say they are drawing closer to a solution with new techniques to freeze, or cryopreserve, immature reproductive cells…

… they started to look for ways to grow that tissue in a petri dish, so it can develop into a mature egg. “We’ve had to borrow knowledge from other disciplines and sort of figure out how that applies to trans people … What can be frustrating sometimes is having to adapt and extrapolate all of this information from work that is not done for trans people.” — Zil Goldstein, Mount Sinai

Brave New World. Puts a whole new spin on “test tube babies.” Not to mention a future boost for the surrogacy industry.

No one in the mainstream media—in this case, NPR– seems willing to point out the obvious: If you let these kids simply mature naturally–as their healthy bodies are desperately fighting to be allowed to do–they can preserve their fertility and decide whether they want to choose hormonal or surgical interventions when they reach adulthood, with mature judgment and reasoning powers. There would be the added benefit of giving kids a chance to desist before it’s too late—as so many were allowed to do before “gender affirmative” treatment was advertised 24 hours a day, 7 days a week. Only a few years ago, this would have been seen as just common sense caution. Adults-only transition was the norm.

There are other ramifications besides infertility resulting from this reckless rush for earlier and earlier surgeries and hormonal treatments. Here, Olson-Kennedy and other commenters analyze the impact of surgeries on sexual function—but disagree on how much should be discussed with the kids themselves about their future orgasm potential after their genitalia have been surgically rejiggered.

At least one “practitioner” seems not to want concerns about orgasm potential to be a “hindrance” to a child achieving their “authentic self”:

Bringing us into 2017, Jenn Burleton, head of Transactive Gender Center, assured the Facebook group on January 18 that orgasm is a discussion topic amongst “caregivers” in Transactive support groups. Good to know parents and other adults feel empowered to make decisions for these kids about their adult sexual function and fertility in their “support groups.”

(Just a thought: how many of these people publicly pontificating about the sexual function of children consider how they’d have felt as teens if adults had been scheming about their orgasm potential, and the impact thereon from a surgeon’s scalpel?)

In January 2017, nearly a year after Olson-Kennedy’s original post calling for the WPATH Standards of Care 8 to support earlier genital surgeries, many clinicians, activists, and parent leaders of trans youth groups remain keenly interested in lowering age of surgeries for youth. From the sounds of it, “many many” surgeons are eager to oblige.

Dan Karasic, MD, director of a gender clinic at UC San Francisco, moderator of the WPATH Facebook page, and a key player in WPATH and the co-chair of the recently formed USPATH, helpfully informs us that a discussion on under-18 surgeries will take place at the inaugural USPATH conference February 5 2017. “Advocacy” to pressure insurance companies to get onboard and pay for genital surgeries on minors is also an important part of the discussion.

This isn’t the first time we’ve seen Dr. Karasic advocating for lowering the age for surgeries. In this post, we discussed his public support for a mother obtaining double mastectomy for her 15-year-old and her attempts to get her insurance company to foot the bill for it.

Again: The people advocating for drastic and irreversible medical interventions on minors have enormous power over the future lives of children. The decisions they have taken with their careers and activism will impact a generation of youth for a lifetime. These adults, trans or not, were allowed to mature without medical interference in the era preceding this Age of the Trans Child.

Some of the people weighing in are trans adults, among them MTFs who have fathered children and had successful careers, who were not subjected to tampering and scheming about their most private and personal bodily functions as children. And as much as the trans activists may claim they’d have welcomed such interventions as children, the fact remains: Somehow they made it to adulthood, fertility and sexual function intact, without killing themselves.

Exactly what authority gives these people the right to advocate for and perform medical experiments on children, “trans” or not? This is a question a lot more people need to be asking.

Meanwhile, the USPATH conference session on surgery in minors is on Sunday, February 5 at 10:15 AM in Los Angeles.

Readers will undoubtedly recognize some of the names on this panel.

For more information about the irreversible sterilizing effects of puberty blockers followed by cross-sex hormones on prepubescent children, see below. Readers contributions are welcome and will be added to this list.

Sahar Sadjadi, The Endocrinologist’s Office—Puberty Suppression: Saving Children from a Natural Disaster?

It must be remembered that puberty suppression as the first step to medical transition, if followed by cross-sex hormones, which has been the case for almost all reported cases, leads to infertility due to the permanent immaturity of the gonads and the reproductive tract. The absence of the discussion of sterilization of children as a major ethical challenge in this bioethics article, and many other clinical debates on puberty suppression, is striking. For any other group of children, such an intervention would be discussed extensively with ethics review boards. (What grounds might justify the permanent elimination of the child’s reproductive ability? Should parents be able to make such a decision for the child? Which futures are opened by the treatment and which ones are foreclosed? How might benefits be weighed in relation to the loss of reproductive capacity?) The media would likely react with investigations and questions about the long-term consequences of treatment. These “queer” children’s bodily integrity and reproductive rights should not be any less pressing than other children’s. Needless to say, children are not legally capable of consent, and 9–10 year olds are not capable of understanding all the health consequences of the treatment. Parents are asked to make life decisions on issues as critical as fertility for young children. Can they make an informed decision and evaluate benefits vis a vis risks when confronted with such horrendous forecasts for their children?

Unique ethical and legal implications of fertility preservation research in the pediatric population

Norman Spack, MD, founder of first US pediatric gender clinic:

The biggest challenge is the issue of fertility. When young people halt their puberty before their bodies have developed, and then take cross-hormones for a few years, they’ll probably be infertile. You have to explain to the patients that if they go ahead, they may not be able to have children. When you’re talking to a 12-year-old, that’s a heavy-duty conversation. Does a kid that age really think about fertility? But if you don’t start treatment, they will always have trouble fitting in. And my patients always remind me that what’s most important to them is their identity.

Brill & Pepper, The Transgender Child, 2008, p. 216

“The choice to progress from GnRH inhibitors to estrogen without fully experiencing male puberty should be viewed as giving up one’s fertility, and the family and child should be counseled accordingly”. For girls, sterilization is the outcome too, because “eggs do not mature until the body goes through puberty”

Diane Ehrensaft, video clip from conference. Time stamp: 5:06

“Another thing that’s a show-stopper around [parents] giving consent is the fertility issue. That if the child goes directly from puberty blockers to cross- sex hormones they are pretty much forfeiting their fertility and won’t be able to have a genetically related child.”

Robert Garofolo, PBS.org:

“It’s an imperfect field with regards to decisions we are asking these families to make,” acknowledged Dr. Robert Garofalo, who co-directs the Center for Gender, Sexuality and HIV Prevention at Chicago’s Lurie Children’s Hospital and is also working on the transgender youth study. Garofalo hopes the team will be able to study patients far beyond the current five-year term to address a host of questions that currently have no answers. Does hormone use in trans youth increase breast cancer risk? How well do adults who have transitioned as teens grapple with their loss of fertility? “These are things that are entirely unknown,” Garofalo said.

Top gender doc dismisses 203 detransitioned women as “not regretters per se”

Posted on September 3, 2016 by 4thwavenow

139

Note: All screenshots in this post were taken from the publicly accessible WPATH Facebook page on 9/3/2016. Please visit the thread in question for full context and to see any edits and/or additions that have been made since this post was published.

UPDATE 9/4/16: Several allegations have been leveled at the writers of 4thWaveNow and Cari in the most recent comments on the WPATH Facebook page. We invite you to read our post, Cari’s survey results, and the WPATH thread, then decide for yourself whether there are any distortions of fact in our reporting.

4thWaveNow would like to address the fact that the parents who create and manage this blog use pseudonyms; we also protect the anonymity of our commenters. All of us are keenly aware that we have no right to expose our children–some of whom have a social media presence–to the harsh light of public scrutiny. Our primary concern is protecting their privacy. And in this age of the Internet, compromising our privacy will compromise theirs. One has only to look at the history of what trans activists have done in their attempts to silence critics in the past, which have included vicious attacks on not only the adults who have spoken out, but at times upon their minor children. We are simply not willing to expose our children to this risk.

If it were possible to have an “honest dialogue” with the activists and public figures who are having such a huge (and in many cases, deleterious) impact on the lives of our children, we would welcome that. If we saw, even once, professionals acknowledging that there is indeed a social contagion going on amongst teenagers; if we heard any of the points we make being honestly engaged, it would be different. Instead, what we get are unceasing ad hominem attacks, professionals and journalists who should know better yelling “TERF!”, and constant accusations that unless we get behind the medical transition of our own children, we are driving them to suicide. This is not an atmosphere for reasoned dialogue. And that is why this blog came to be in the first place.

We will continue to provide a platform for people like Cari and others who have been frozen out of the public discussion on the issue of pediatric transition. Until mainstream journalists are willing to present a more balanced picture of this very serious and increasing trend in Western society, that work will be left to bloggers like us.

Two weeks ago, Cari, a 22-year-old former teen client of TransActive Gender Center in Portland, OR, announced an online survey designed to better understand the experiences of detransitioned women. She has completed work on this phase of her project, and today posted the survey results, with a detailed interpretation, on her blog.

I won’t be going into exhaustive detail about everything the survey revealed; Cari’s blog post provides an excellent write-up and analysis. What I will be doing, instead, is reporting on the reaction (posted on the public WPATH page) of Dan Karasic, MD, top gender specialist and UCSF psychiatrist—which amounts mostly to minimizing the significance of Cari’s work and attempting to discredit several of her most important findings.

Cari’s survey ran for only two weeks, from August 16 – 31. Most surveys recruit participants for months or even years. That over 200 women responded in such a short timeframe should put to rest any notion that “desistance is a myth.” And the fact that the survey was shared on social media means that it likely reached a demographic that most trans activists deny exists: young women who became interested in medical transition due, in part, to social contagion (a phenomenon currently being studied by a researcher at Mt. Sinai). As Cari notes,

“Leaving aside all the other data this provides, the sheer number of responses is pretty amazing. Given that the survey was open for 2 weeks and was shared through a couple of Facebook groups, most of which were private, and Tumblr, I think we can safely say that detransitioners are not quite as rare as some would like to have us think.”

In his Facebook post, Karasic attempts to dismiss the 62% of respondents who said that “political/ideological concerns” were a factor in their decision to detransition– by implying that these concerns are on par with people who reject their own homosexuality due to religious beliefs!

To be fair, Karasic does say that “some exploration” of negative reactions to hormones is appropriate (albeit in the no-gatekeeping, informed consent model). But comparing these women’s thought processes to evangelical Christianity? This is an astounding leap. “Political/ideological” concerns could mean any number of things, including that these women began to think more critically; that they began to question some of the rhetoric of transgender ideology and came to realize that they were, in fact, women–no matter how fervently they once believed otherwise. In fact, this is rather the opposite of someone going back in the closet because their religion told them they were evil sinners.

But that’s not even the worst thing about Karasic’s opening volley: He fails to mention that respondents could choose more than one reason for deciding to detransition. It’s either a willful or clueless misinterpretation of the data to imply that the only–or even the main— reason these women detransitioned was because of ideological concerns.

Of at least equal significance is the fact that 59.4% of respondents found alternative ways to cope with their dysphoria. For any other situation involving drastic medical interventions, the possibility of an alternate solution or “cure” would be of great interest. But no one on that WPATH Facebook thread is celebrating; in fact, they don’t even mention this key finding.

Karasic also dismisses the survey as “skewed” because it was posted in forums where people critical of transition could easily find it. This is rich. The few studies we are beginning to see of trans children and teens are being conducted by researchers using their own patients—children who have been socially and medically transitioned by parents and clinicians heavily invested (ideologically and financially) in the business of pediatric transition. And Cari’s survey looked at detransitioned people who, by definition, are rather more likely to be critical of transition in general; such an obvious point seems to be lost on Karasic and the other commenters who pile on to say the sample is “unrepresentative.” Unrepresentative of what?

In a followup comment, Karasic plays the well-worn “they weren’t really trans” card with another misread of the survey’s data.

What? A whopping 48% of the women in Cari’s survey formerly identified as trans man/FTM—nearly half.

It’s odd to see how easily Karasic discounts this group of women, given that “informed consent” based on self-reported identity is the standard of care he and others at WPATH increasingly support.

But here’s where Karasic’s reaction gets really interesting. Cari’s survey found that 42% formerly identified as nonbinary or genderqueer. So that’s 90% who did not identify as female. Just from reading Karasic’s comment, we might think he would not support transition for those 42%. Yet only a few months ago, he argued that medical transition should be freely available, via informed consent, to people who identify outside the binary.

Which is it, then? These detransitioned women weren’t really trans, so they goofed—but how can they have goofed, when Karasic actively promotes medical transition for anyone who wants it? Because who could possibly be excluded from self-identifying as “nonbinary”?

One of the most important findings in Cari’s survey (utterly ignored by Karasic and the other commenters) is that the majority of respondents not only had very limited therapy (aka “gatekeeping” in current trans activist lingo), but also believed, after the fact, that the counseling they received prior to transition was inadequate—as Cari herself has said about her experiences at TransActive Gender Center. Cari writes:

“117 of the individuals surveyed had medically transitioned. Of these, only 41 received therapy beforehand. The average length of counseling for those who did attend was 9 months, with a median and mode of 3, minimum of 1, and a maximum of 60. I’d like to have something cool to say here, but I’m honestly just stunned at the fact that 65% of these women had no therapy at all before transition.”

Why is it that Karasic and the others on the thread have nothing to say about this key finding? Given that this is a survey of people who chose to detransition—many of whom were quite unhappy about their transitions and the services they received from gender specialists—wouldn’t it be worth exploring the idea that some were perhaps too easily granted the opportunity?

What’s more, these women have, by and large, a very negative view of their transitions.

But Dan Karasic, like most activist-clinicians, is not really a believer in gatekeeping. As he said in another post just a few days ago, easy access to medical transition and cross-sex hormones is something to be desired—hopefully at the first follow up visit.

Presumably, the young clients at Dimensions seek medical transition to relieve their dysphoria. Interestingly, Cari’s survey found that the majority of detransitioned women saw improvement in their dysphoric symptoms after beginning to detransition:

“…cumulatively, 88% of the individuals surveyed experienced physical sex dysphoria. Individuals who experienced only social dysphoria were more likely to report that their dysphoria was improved by detransition (91%, versus 73% for individuals with sex dysphoria), and none of these individuals indicated a worsening of dysphoria, however even among those with sex dysphoria, only 9% reported that their dysphoria had increased since detransitioning.”

The implications of this are profound. If 59% of the sample found “other ways to deal with their dysphoria” which led them to detransition—and then, having detransitioned, found their symptoms improving still more—one would think this data would keenly interest Dan Karasic and his followers. What if there are cheaper and less drastic ways to deal with gender dysphoria?

To Karasic’s credit, he does concede—while stopping short of admitting that “real” trans people might actually regret their transitions– that some formerly trans-identified women do end up feeling their medical transition “wasn’t right for them.” But he manages to minimize even that.

It’s apparent that that Dr. Karasic, along with other WPATH members (in the comment below, “liked” by Dr. Karasic), don’t really see what the big deal is if some women change their minds about the hormones and surgeries that have forever altered their bodies.

They can just change back or quit hormones—what’s the worry? It’s all just an experiment anyway, kind of like tattoos and piercings.

These people seem not to be familiar with the growing number of detransitioned women who have their own blogs and websites, wherein they speak of their sadness at the irreversible changes wrought upon their voices; the body hair; the loss of their breasts; some have gynecological difficulties.

Activist-clinicians are invested in the idea that regret rates are low—even though this generation of young people is the first to experience medical transition. There is no data on long-term regret rates for these young people, and Karasic knows it, as do most other gender doctors. They don’t know. No one does. Cari deserves enormous credit for sticking her neck out to do this survey, because the gender doctors sure as heck aren’t going to do it for her and the other women who are in the same boat.

One wonders: How many of these women will it take for doctors like Dan Karasic to take them seriously? 500? 1000? Will there need to be 5, 10, 20, replicated studies, conducted over decades, thousands of women, before these gender specialists take their needs seriously, once they have detransitioned? (I will note that most of the studies utilized by trans activists and gender specialists to support what they’re doing consist of very small cohorts, with “low quality evidence,” as recently pointed out by the Centers for Medicare and Medicaid Services, but it’s convenient to dismiss data that doesn’t fit one’s narrative.)

So, what would constitute regretters “per se”? How many? What percentage? What criterion will satisfy Karasic and the other activists and clinicians piling on the Facebook thread to essentially say that Cari’s data (and Cari’s own experiences, presumably) are bunk?

Update 9/5/16: One very telling answer to the “How many?” question comes from a WPATH commenter who pontificates:

Increase your sample size to 12,000 and follow the subjects for 20 years, then report back to me with your findings. Maybe then, I might value your study.

Cari (who has joined the conversation on the Facebook page) replies,

And who is writing NIH grants to study thousands of detransitioned trans men? Who has in the past? It’s easy to sit on a high horse and shoot down the efforts of a 22-year-old who suffered medical harms and is interested in delving more deeply into the experiences of women like her. Easier still to tell her those harms won’t be worth taking seriously for 20 years, until there are thousands of regretters “per se.” In the meantime? Business as usual.

It’s predictable that trans activists are loathe to admit that detransitioners may be more common than they they think. But medical doctors? Wouldn’t one think that MDs, psychiatrists, and other gender specialists would demonstrate appropriate concern about people who went through medical transition but expressed profound regrets later on? Even more importantly: Why don’t people like Dan Karasic see it as a good thing that the women in Cari’s survey found other ways to deal with their dysphoria besides drastically altering themselves with hormones and surgeries?

How about showing some respect for this one detransitioner, Cari, who cares so much about this issue that she has created and written a fine analysis of a survey about detransitioned women? Rather than glibly dismissing her work as just another worthless TERF thing that can be safely ignored, wouldn’t it behoove Karasic and his followers to take her seriously? Why would a 22-year-old woman who had undergone years of testosterone injections, a double mastectomy, and who is now speaking out publicly via YouTube go to this much trouble if there weren’t a real issue here?

Why doesn’t WPATH as a whole start earnestly figuring out how to provide services for people who regret their transitions, or who need help and support for re-identifying with their natal sex? After all, the gender specialists got these people into it; do they feel no responsibility whatsoever to help them get out of it? Is the “care” provided by gender doctors a one-way-street? Apparently, if you ever decide to get off the trans bus, you’ll have to find your own way home.

The activists and clinicians piling on the Discredit the Detransitioner Survey thread seem a lot more interested in denigrating and dismissing the reality of detransition than attending to the medical and psychiatric needs of people harmed by medical transition. Activists pushing an agenda? Yeah—don’t want to talk about this. But doctors? Where is their commitment to learning the truth, however inconvenient that truth might be?

But then, the line between activists and clinicians seems to be rather blurred. I’m not sure there is much of a difference anymore.

Mom forces insurance company to cover double mastectomy for her 15-year-old, with support of WPATH & Dan Karasic, MD

Posted on January 17, 2016 by 4thwavenow

A 15-year-old cannot vote, sign a contract, drink, or get a tattoo. You can’t rent a car until you’re 25 years old. And in the US, the FDA has just proposed regulations to prevent minors from even using tanning beds.

Why all the restrictions? Well, last I checked, developmental psychologists, cognitive scientists, and informed members of the general public were aware that adolescents don’t have the cognitive wherewithal—the judgment, foresight, or awareness of future consequences–to make major, life-changing decisions, let alone suffer a bad sunburn. There has been so much replicated behavioral and neuroscientific research done on the subject of executive function in young people that it’s now considered settled science.

So the changes that happen between 18 and 25 are a continuation of the process that starts around puberty, and 18 year olds are about halfway through that process. Their prefrontal cortex is not yet fully developed. That’s the part of the brain that helps you to inhibit impulses and to plan and organize your behavior to reach a goal.

And the other part of the brain that is different in adolescence is that the brain’s reward system becomes highly active right around the time of puberty and then gradually goes back to an adult level, which it reaches around age 25 and that makes adolescents and young adults more interested in entering uncertain situations to seek out and try to find whether there might be a possibility of gaining something from those situations…one of the side effects of these changes in the reward system is that adolescents and young adults become much more sensitive to peer pressure than they they were earlier or will be as adults.

Another very readable (and amusing) article, “Dude, where’s my frontal cortex?,” sums it up thusly:

The frontal cortex is the most recently evolved part of the human brain. It’s where the sensible mature stuff happens: long-term planning, executive function, impulse control, and emotional regulation. It’s what makes you do the right thing when it’s the harder thing to do. But its neurons are not fully wired up until your mid-20s.

But the gender specialists at the helm of the World Professional Association for Transgender Health (WPATH) apparently never received the decades-old bulletin on adolescent brain development (or lack thereof), or so it seems. In the Brave New World of transgender “health care,” a 15-year-old can ask for and receive a double mastectomy, with mom’s blessing and collaboration. (In Oregon, a kid can decide to have her breasts removed whether mom approves or not, thanks to trans activists like Jenn Burleton and TransActive).

Last July, a mom posted to the WPATH public Facebook page, looking for advice on how to get “chest reconstruction” for her 15-year-old (i.e., double mastectomy. Why can’t these people use actual medical terminology, even amongst themselves? Do the providers and parents also get “triggered” by seeing a reference to female anatomy?)

[Note: For privacy reasons, I have chosen not to directly link to the (nevertheless) publicly viewable thread on the WPATH Facebook page.]

Seems mom’s insurance company balked at covering elective removal of breast tissue in people under 18.

Psychiatrist Dan Karasic, one of the key contributors to the WPATH Standards of Care (SOC), and provider at the San Francisco Center for Excellence in Transgender Health, is happy to help, citing the SOC chapter and verse (page 21 to be exact) that WPATH fully supports “chest surgery” for minors, although it’s apparently still “too limiting” for his taste:

Mom has already picked out the surgeon for her child, and another commenter, former Transgender Law Center employee Jason Tescher, recommends she try to “force” her insurance company to cover the cost (per the doctor’s website, $8500):

The WPATH thread went dark until today (more on that in a minute). But who is Dr. Mangubat?

In addition to being a popular presenter at Gender Odyssey, the yearly shindig for all things transgender, Dr. Mangubat is apparently well known as a surgeon who’s an easy touch for those looking for double mastectomies. As recently as six days ago, underage top surgery seekers on Reddit were recommending him:

Also, the surgeon I went to (Dr. Mangubat) did not require any kind of letter and I don’t think he requires patients to be on T either, but I could be wrong on that. It was as easy as emailing his office to set up a consultation and then I was immediately able to schedule the surgery.

As to the mom’s efforts to get insurance to cover the removal of her child’s breasts, an update appeared moments ago on the WPATH thread. Mom shares her good news: the insurance company has agreed to reimburse her for the double mastectomy that they “couldn’t wait for” and had done in August.

Dr. Karasic couldn’t be happier.

It’s likely only a matter of time before insurance coverage for teen surgery will be the norm. The Obama administration recently proposed new rules that will require all insurance companies to pay for “transition” services. One wonders just how many “identities” the transgender umbrella will cover when it comes to federally mandated health care services?

The entire Reddit thread that references Dr. Mangubat (as well as two other surgeons I’ve previously written about–Dr. Curtis Crane in San Francisco, and Dr. McLean in Ontario) is worth reading in this regard, because it’s primarily about “nonbinary” people who don’t identify as FTM getting access to “top surgery” on demand–exactly what providers like Dan Karasic promote and what is already happening, apparently, in San Francisco at taxpayer expense, as I detailed in a recent post.

As I also discussed in that post, Karasic is a major WPATH player pushing for the elimination of “gender dysphoria” as a requirement for “transition” services; he wants to replace GD with a new diagnostic code, “gender incongruence,” which would do away with the need for any distress, dysphoria, or disorder but still allow for billing for what amounts to a lifestyle choice–for anyone who claims “gender incongruence,” on demand.

So we know Karasic and WPATH are OK with 15-year-olds who ID as FTM undergoing irreversible surgeries. Does he also believe, as he does for adult patients, that a 15-year-old (or 13-year old?) who identifies as genderqueer, gender fluid, or non-binary should ALSO get insurance-funded double mastectomies?

Activist-clinicians tout “cultural humility” & surgery-on-demand for “nonbinaries” & “genderfluids”

Posted on December 27, 2015 by 4thwavenow

Update Dec. 31, 2015: Please see here for instructions on how to submit comments to the World Health Organization (WHO) on their proposed new diagnosis code “Gender Incongruence” and “Gender Incongruence of Childhood.” The public comment period will end soon, so time is of the essence.

A funny thing happened to me recently as I was trudging down yet another Got-Dysphoria?-Must-Transition-or Die rabbit hole.

I came to the realization that those of us who are wringing our hands over the rush to diagnose dysphoric children as trans are way, way behind the curve. That battle has mostly been won (and not in our favor).

Trans activists and “gender specialists” have moved on. Now, they are advocating for fully “depathologizing” transgender, yet at the same time, normalizing the idea that even part-time demiboys, “gender fluids,” and other assorted “nonbinaries,” aka “NBs” (the catchall term for anyone who doesn’t fall neatly into the trans man or trans woman box) deserve hormones and surgeries on demand— fully paid for by insurers.

It’s a neat trick they’re trying to accomplish: convince the public that being on the “trans spectrum” is normal, just like being gay or lesbian. Yet, paradoxically, extreme treatment is still medically necessary for some. How does that work?

As they have been all along, trans activists are riding the gay and lesbian liberation movement coattails to further their agenda. Once classified as a psychiatric disorder, homosexuality is now considered normal; it was removed from the DSM (the Diagnostic & Statistical Manual of Mental Disorders) in 1973. In other words, being gay or lesbian has long been depathologized—in my view, a very good thing.

Now trans activists are pushing for the same thing for transgender. In the DSM-IV, “gender identity disorder” (GID) was the label for what ailed a person who wasn’t happy with their biological sex. That was replaced by gender dysphoria in the DSM-V. No longer a “disorder,” it was the name for the feeling of discomfort or distress with one’s sex.

The next step? Activists and gender specialists (I’m starting not to see a lot of difference between the two) want to get rid of the idea of distress or dysphoria as a prerequisite for “transition.” The new term they’re after is “gender incongruence:” a mismatch between one’s idea of gender and one’s actual biological sex. The talk amongst activists and clinicians is that there is no disorder, dysphoria, or distress of any kind necessary to obtain services. “Gender incongruence” is a normal variation in human experience. But you still need some code to be in the DSM, because–reimbursement. You know, billing.

Funny: When homosexuality was depathologized, the need for billing and treatment for that former “disorder” disappeared entirely.

(Note: The screen capture below was taken from a 9/24/15 post on the WPATH page which, oddly, has since been removed. )

But wait: How can something that is normal still require treatment? Major, possibly lifelong, medical procedures and drugs?

Let’s hear from one activist-clinician who can explain this a whole lot better than I can. Because it turns out, in certain places, this depathologized-yet-highly-medicalized normal variation is already being implemented as a matter of policy, and fully paid for by the taxpayer. And not only that: you don’t even have to have full time “incongruence” to get your breasts or penis lopped off, on demand. You get it just because you say you need it. And if your gender clinic operates under the increasingly common “informed consent” model, no psychologist or psychiatrist is going to stand in your way. You, and only you, will have the right to diagnose yourself as needing the ~~wallet-busting~~ fully funded services of plastic surgeons and endocrinologists.

Dan Karasic, MD, is a psychiatrist affiliated with the San Francisco Center for Excellence in Transgender Health. He also is a key player in WPATH and one of several activists and clinicians crafting revisions to the DSM and the WPATH Standards of Care (SOC).

Karasic is quite active on the WPATH public Facebook page, frequently advocating for depathologization and greater access to surgery and hormones for those on the “gender spectrum.” [Please note: The WPATH Facebook page is viewable by the public, so all the information revealed in the screenshots below, as of this writing, is a click away.]

As Dr. Karasic says here, the San Francisco Department of Public Health will fully fund surgeries for even “nonbinary” folks:

Lest any wayward clinician have questions about the wisdom of all this, doubts are no longer acceptable. Acceptance and understanding are not enough in San Francisco. One must have humility. And that extends to “nonbinaries.” Only they/them know. They/them get to decide. Not you, with your outmoded and quaint “clinical judgment.” (Question: If you’re nonbinary, what would you be transitioning to? Oops, sorry. Humility lapse here.)

There are several members on the WPATH Facebook page who agree that any skeptical doctors (such as, evidently, some at San Francisco General Hospital–SFGH) need to be brought firmly into line, and that nonbinaries should get their top surgery too.

Are nonbinaries only receiving surgeries and hormones in cutting-edge San Francisco? Apparently not. In March of this year, WBUR Boston ~~touted~~ reported on medical treatments for nonbinaries on the US East Coast in Not Male Or Female: Molding Bodies To Fit A Genderfluid Identity.

Jones is part of a growing group of young adults who are genderfluid and are using hormone therapy and surgery to create bodies that matches this identity.

“It’s molding my body to fit my mind, physically changing myself so that I feel more comfortable as a person,” said Dale Jackson, a 33-year-old author who lives in Atlanta. Jackson takes a low dose of testosterone for two reasons. First, because he’s worried that a full dose would exacerbate his anxiety. And second, because a half dose helps him moderate the effects.

“I like the idea of being in the middle,” Jackson said. “This allows me to explore my masculine side, but I don’t want to push it too far.” Jackson does not want a big bushy beard or arms so hairy “that gorillas were looking at me like, is that our cousin?”

Comfort, exploration, wants, not wants–what’s not to like? And it’s certainly important to calibrate the testosterone dosage so as not to increase pre-existing anxiety.

Both Jones and Jackson are under the care of physicians who are helping them pursue a more gender neutral body. But there are no guidelines. So far, in the emerging world of transgender medicine, protocols assume that patients want to end up on one end of the spectrum or the other, male or female, says Dr. Tim Cavanaugh, who runs the transgender health program at Fenway Health.

An estimated 100 to 150 of Fenways Health’s 1,500 transgender patients are genderfluid. Most of the genderfluid patients are transitioning from female towards male. So how do doctors know how much testosterone will produce the effects these patients are looking for?

“To a certain extent we’re making it up, but I’d like to think of it more as finessing the regimens that we have based on the individual person’s desires and needs,” Cavanaugh said.

Ten percent of your caseload is “genderfluids” who are trying to “mold” their bodies to be more “gender neutral.” And most of them are female. (Wouldn’t a paragraph asking why that is be of value here? Silly me. That’s old school journalism.)

“There are no guidelines”—yet. And if you’re genderfluid, you are transitioning “towards” the opposite sex (even though, presumably, if you’re “fluid” you’re already somewhere in between, but the logic of gender identity is not…logical).

…some genderfluid patients say they cannot find peace without medical intervention.

“I had an incredible amount of dysphoria around my chest, it was consuming. I got to the point where in order for me to thrive and to do the work I wanted to be able to do and just live my life, I needed to have surgery,” said Taan Shapiro, a 33-year-old a teacher and parent in Boston who had surgery to create a flatter, more masculine looking chest.

Shapiro, who uses the pronouns they and them, says some strangers assume they are a teenage boy, others that Shapiro is female. Shapiro is not planning any more surgery or hormone therapy.

“Where I am is where I’m at and I feel good about myself,” Shapiro said, “[in a place] somewhere between male and female.”

This sounds an awful lot like elective surgery. People get procedures like breast augmentation, liposuction, face lifts, tummy tucks, to “feel more comfortable.” Someone might even say they need a taxpayer-funded nose job to “thrive” and just “live their life.” That the “incredible amount of dysphoria” they experience because of their big nose is all consuming. (Likely the late Michael Jackson would have agreed.)

To be fair, Dr. Cavanaugh does voice a few words of doubt about ~~all that money he’s making~~ the wisdom of medical treatment for nonbinaries:

If gender is a product of social construction, then using medicine to fix every patient’s discomfort may not be the best long term solution, Cavanaugh says.

“I hope we are headed to a place where we recognize that gender is not one thing or the other, not male or female, and that culturally we can become more comfortable with that idea,” Cavanaugh said. “Hormones and surgery are always going to be options for people, but I really hope that we won’t feel compelled to use them as much as we do now.”

Hm. I wonder what other means there might be to address people’s discomfort with a socially constructed gender identity?

The WBUR article was discussed on the WPATH Facebook page, and some members were not pleased with this meek bit of dissension in the ranks: the medical model is the way to go!

So there you have it. It’s “super problematic” for Dr. Cavanaugh to suggest that some “nonbinaries” (i.e, people without rigid gender-stereotyped personalities) aren’t going to be served by the “medical model.”

How will activist-clinicians continue to walk the delicate line between normalization/depathologizing the “trans spectrum” while still ~~hoodwinking~~ encouraging the taxpayer to pay for expensive plastic surgeries and long-term hormone treatment? Stay tuned!

For now, there’s lots more to read in this thread on the WPATH Facebook page. Rest assured that the activist-clinicians are hard at work to make sure insurers are on board with any and all treatment, on demand, for transmasculine, transfeminine, genderfluid, and nonbinary folks. After all, gold-plated body modification is not just for the garden variety, binary transgender man or woman. That is so 2013.

But sarcasm aside (for now), if these activists and clinicians are really serious about depathologizing? Here’s what they’d do:

Celebrate gender nonconformity. Teach people to respect and take care of their bodies, just as they are. Work to build self esteem in teens, and mentor them to know that their bodies, the product of millions of years of evolution, are good and whole, and that there is no need to cut or drug themselves to be “comfortable” or to fit anyone’s idea of male or female. Develop therapies that help people realize their bodies and brains are not two disconnected units, but indivisible, complete, and right. Encourage kids to dress, think, and pursue interests as they like. Celebrate uniqueness and diversity in men and women.

I realize my prescription for truly depathologizing gender nonconformity might put a few people out of work. But our kids are worth it. Aren’t they?

4thWaveNow

A community of people who question the medicalization of gender-atypical youth

Tag Archives: Dan Karasic