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

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 20th 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:

nonbinary medical pathways slide

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.

wpath-karasic-cultural-humilty-and-sfdph-cropped1

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.

winters-trans-kids-are-more-mature

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.

meghan murphy enbie tweet.jpg

 

 

 

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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?