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

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

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

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

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

Doc two big favors

The benefits & drawbacks of blocking testosterone

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

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

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

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

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

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

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

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

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

Alter surgery

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

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

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

milrod jsm 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Dutch 2016 intestinal abstract

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

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

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

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

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

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

DSM 5 gay

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

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

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

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

Age is just a number when it comes to neovagina surgeries

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

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

karasic jsm piece in press

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

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

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

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

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

karasic jsm 2

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

karasic jsm maturity

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

karasic jsm micropenis

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

karasic jsm consent

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

Shriveled raisins: The bitter harvest of “affirmative” care

by the parents of 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].

rainbow-health

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?

trans-men-want-children

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.

la-leche-chestfeeding

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.


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.

Olson orig post.jpg

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

“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.

rixt-et-al-on-sterlization

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.

olson-orgasm

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

low-orgasm

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.”

Burleton orgasm.jpg

(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.

maasch-et-al-earlier-surgeries

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.

uspath-minor-surgery-1


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”

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!

Karasic OP

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.

Reasons for stopping data

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.

Karasic most not male

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

FTM identity

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.

nonbinary people

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.

feelings about transition

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.

Dimensions clinic

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:
detransition helped dysphoria

“…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.

Karasic regret rates are low.jpg

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. try it out.jpg

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,

12K trans men.jpg

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

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.

WPATH mom of 15 yr old

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:

WPATH mom 2

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):

tescher

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

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.

insurance appeal

Dr. Karasic couldn’t be happier.

karasic happy

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”

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. )

wpath gender incongruence

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:

WPATH Karasic cultural humilty and SFDPH cropped

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. 

WPATH top surgery for non binaries

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!

WPATH nonbinaries surgery critique wbur

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?