The moral of this story is clear: failure to achieve informed consent is a failure on the part of the clinician, a failure of imagination and flexibility, not a recognition that some patients — whether because of age or mental illness or intellectual disability — will simply not be able to consent.
On WPATH’s private forums, clinicians occasionally express reservations about what they’re being expected to do, such as the social worker who wondered whether she should write letters for surgery for “several trans clients with serious mental illness… Even though these clients have a well-established trans gender identity, their likely stability post initiation of HRT [hormone-replacement therapy] or surgery is difficult to predict. What criteria do other people use to determine whether or not they can write a letter supporting surgical transition for this population?”
Her colleagues quickly put her in her place: “My feeling is that, in general, mental illness is not a reason to withhold needed medical care from clients,” an “affirming, anti-oppressive” gender therapist responded. “My assumption is that you’re asking this question because you’re taking seriously your responsibility to care for and guide your clients. Unfortunately, though, I think the broader context in which this question even exists is one in which we, as mental health professionals, have been put inappropriately into gatekeeper roles. I’m not aware of any other medical procedure that requires the approval of a therapist. I think requiring this for trans clients is another way that our healthcare system positions gender-affirming care as ‘optional’ or only for those who can prove they deserve it.”
Another gender clinician referred dismissively to the recommendation that mental illness should be “well controlled” before initiating hormonal and surgical interventions: “I am personally not invested in the ‘well controlled’ criterion phrase unless absolutely necessary… in the last 15 years I had to regrettably decline writing only one letter, mainly [because] the person evaluated was in active psychosis and hallucinated during the assessment session. Other than that, everyone got their assessment letter, insurance approval, and are living [presumably] happily ever after.” Everything hinges on that “presumably”.
For years, gender clinicians have reassured patients and parents that the evidence would eventually bear out the lofty promises of transition: that transition is life-saving; that psychotherapeutic approaches to gender distress don’t work and instead constitute unethical “conversion therapy”. But as the data starts to come in, transition appears unlikely to live up to these high expectations.
During the Ireland conference, researchers bracketed discouraging findings with upbeat statements of belief such as: “We all know gender-affirming care is effective.” A Swedish researcher who found that psychiatric hospitalisation increased after patients initiated puberty blockers or cross-sex hormones told the audience that she was “really concerned”, not about the results themselves, but “about how results will be interpreted” because, “as you all know, there are improved mental health outcomes following puberty blockers and gender-affirming hormones” — even when the research can’t find those benefits.
“There’s an expectation that gender-affirming hormones will improve somebody’s mental health problems,” Johanna Olson-Kennedy, one of the leading US gender clinicians, said on the opening night of the Denver conference. Why? Because “they improve gender congruence”. In other words, if a patient doesn’t want breasts and a surgeon removes her breasts, the treatment was a success, even if her mental health deteriorates and even if she experiences regret down the road. Clinicians dismiss detransition as one of multiple possible “attenuations” of gender identity, alongside “elf”, “fairy”, and “friendly non-intimidating woman”. If a patient changes her mind later, clinicians can simply treat this new manifestation of gender incongruence by the same means: no harm, no foul.
Meanwhile, gender clinicians speak with remarkable frankness about overcoming their reservations, including the plastic surgeon who recounted the alarm he felt the first time a patient requested gender nullification surgery: an intervention that involves removing all external genitalia to create a “smooth” Ken doll-like appearance. But this surgeon soon conquered his hang-ups: he now performs “a lot” of these surgeries and promotes the procedure to his more cautious colleagues. These kinds of stories frame doubt as something to be vanquished, not investigated.
And if doubts persist, there’s always emotional blackmail. In Denver, an obese patient berated the plastic surgeons in the audience, telling them “you wouldn’t be hearing from me today” had the patient not found a surgeon willing to bend the rules and perform a double mastectomy: “I had contacted over a dozen plastic surgeons in the state of Colorado, all of them telling me they refused to do surgery on me. The surgery I so, so desperately needed so as to not kill myself. Only because of my BMI.”
So if a clinician dares to enforce standard medical practices or exercise her professional judgment, she may drive her desperate patients to suicide. The most questionable sessions end with no questions at all.
But what about the rest of us? What are we entitled to know about this bold new frontier in medicine? In Denver, public-relations specialists cautioned clinicians to spare reporters, policymakers, and parents the details of what “gender-affirming care” entails. In fact, even the use of the term “gender-affirming care” is discouraged: “When [people] hear it, they think ‘trans kids in the driver’s seat,’” health policy expert Kellan Baker said. “Many of us here, we all support trans kids in the driver’s seat because it’s their bodies, their lives. But when you think about folks who don’t know trans people, they are very scared by the idea that young people are making irreversible decisions and that nobody else has any oversight over these decisions. The term “medically-necessary care” is better, he said. “Essential medical care. Prescribed medical care.”
Presenters also recommended that gender clinicians avoid specifics. Avoid ages (“this care is highly individualised and age-appropriate”). Avoid giving information about the effects of puberty blockers and hormones. Avoid discussing the ins and outs of surgeries. In practice, “holding [the public’s] hands and helping [them] understand” looks more like covering their eyes and telling them whatever they need to hear to feel at ease. “The dinosaurs are scared,” Baker deadpanned.
This is how an entire field of medical practice became committed to virtuous obscurantism. Gender-affirming clinicians feel misunderstood by their critics. They don’t trust outsiders to put the work they do in the right light. There’s always a risk that someone will look at life-saving reconstructive chest surgeries for transmasculine minors and see the wrong thing: doctors performing breast amputations on troubled teen girls. Therefore, in order to defend the “life-saving” work they do, they must dissemble, obscure, or practise other forms of “heavenly deception”.
Critics of gender-affirming care fall somewhere along the spectrum of transphobia — with dinosaurs at one end, genocidaires at the other. In Ireland, a keynote speaker described “the gender-critical movement [as] a totalitarian and genocidal force that targets not just trans people but all institutions that uphold democracy and individual human rights”. In Denver, a state legislator announced that policymakers passing restrictions on youth gender transition “will kill children. Not with their own hands. But they will.”
The result of this Manichean worldview is that there is no possible dialogue with critics and no room for serious dissent within the movement itself: “If we are fighting amongst ourselves the forces of oppression have won,” as outgoing USPATH president Maddie Deutsch put it. No one, at any conference, discussed the risks and unknowns around puberty blockers and their possible effects on brain development, or the evidence that suggests blockers may change the course of a child’s life by turning what may have been a developmental phase into a permanent condition.
In one of the most extraordinary moments in Ireland, outgoing EPATH president Jan Motmans said: “We respect everyone’s freedom of speech, but we choose not to listen to it.” The auditorium burst into applause. But the speech they’re choosing not to listen to is the mounting evidence that something has gone wrong in the field of gender medicine.
The conviction of being on the right side of history is why criticism doesn’t stick. Clinicians don’t see themselves reflected in critiques. They are, for the most part, decent people, capable of feeling genuine horror when they accidentally say “hey guys” instead of “hey folks”. Their best impulses — their empathy, their humility in the face of what they don’t understand, their sincere desire to help distressed patients — have been hijacked by an ideological movement within medicine. In the process, they have lost sight of what they do.
This blindness sets in more or less the moment a patient sets foot in a gender clinic — when a distressed girl transforms into a “boy” in need of affirmation. Gender clinicians see empowerment in overlooking a patient’s limitations. They have come to believe that medical responsibility to their patients requires them to dismantle the guardrails that stand between vulnerable patients and life-altering interventions.
Nothing illustrates this more clearly than a session on “neurodiversity-affirming gender-affirming care” in Denver, which overflowed with suggestions for clinicians working with autistic patients to achieve their surgical goals. To make autistic patients more comfortable, clinicians should dim the lights, keep an assortment of fidget toys on hand, drop the small talk, don’t try to make eye contact, avoid open-ended questions. If a patient won’t — or can’t — speak, the clinician should ask for a thumbs up or thumbs down. A good gender clinician helps patients anticipate the sensory reactions they might have to injections, surgeries, stitches, blood, and pain.
Over and over again, I’m struck by the realisation that these clinicians have thought of everything. Everything, that is, except: what if they’re wrong?
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