Hormones, at your service
How gender medicine offloads its duty of care onto the consumer | Part 3
This post brings together edited extracts from the historic detransitioners’ forum hosted on 12 March 2022 by the international parents’ group Genspect and its founder Stella O’Malley, a therapist in Ireland. The presentations by detransitioners were rich and nuanced, with insights that will be new to many people, especially to those who have only heard the activist claim that detransition is vanishingly rare.
Today’s post draws on the presentation by a detransitioner, Michelle, who analyses an important shift in the whole rationale for giving young people like her cross-sex hormones or surgery. She also asks, what do we really know about the outcome of medical transition, suicide risk and treatment regret? It’s not the simple, emotive story of “life-saving” doctors that is showcased in so many media outlets.
The Genspect webinar was sold out, and the Twitter hashtag #DetransAwarenessDay was trending in the US, Canada and the UK. Video from the forum has just been released.
Genspect, which went public in June 2021 to speak for the often silenced parents of gender-questioning young people, represents 18 parent organisations in 16 different countries.
“When we talk about evidence-based treatment, most psychiatric [treatment] has a low-quality evidence base. But what's really important is that you need to have a really good evidence base in place if you're going to go straight to an invasive treatment [such as cross-sex hormone drugs and surgery] that is going to cause permanent changes to your body.
“Medical transition was originally meant to treat a psychiatric condition. It's been called many things over the years, most recently gender dysphoria. Broadly, it's distress regarding one’s sex characteristics, and the desire to live as the opposite sex.
“The diagnostic criteria outlined the minimum length of time that the criteria must be present, [and required] significant distress. Access to transition historically involved ‘gatekeeping’ measures — what I might call safeguarding. It required referrals, talk therapy, a mental health evaluation, and so on.
“In the last decade, there's been a shift from treating a condition, gender dysphoria [described in psychiatry’s diagnostic bible the DSM], to ‘affirming’ gender identities.
[This gender affirming model is sometimes described as ‘child-led’ because it regards even very young children as experts in knowing their inner ‘gender identity’ — BL]
Back to Michelle: “The concept of a gender identity, as it's used today, evolved within postmodernist Queer Theory. Postmodernism rejects the idea of an objective truth, and it believes that all subjective realities are true. If you feel like a woman, you are one. And Queer Theory is concerned with challenging what is ‘normal’ within gender and sexuality.”
Offloading duty of care
“What happened [in gender medicine] is that an objective diagnosis has been replaced with a subjective identity, which can't be questioned any more, or looked into or measured. So, I say that transition has gone from being a treatment to being a service.
“[Under the psychiatric model], if the patient's symptoms diminish, we can say the treatment did work. If the patient worsens, we might suggest that some of the fault lies with the doctor, if they weren't careful determining which treatment was the best option.
“[But now] gender identity is whatever a patient says it is. So when I say [treatment has become] a service, it's a service for people who say that they're transgender. And if it is simply a service, and the patient isn't happy afterwards, [the suggestion is that] they can only blame themselves.
“This is where the duty of care is being offloaded from doctors onto the patients themselves. That doesn't seem such a big deal for adults. But when you think about the fact that there are children [undergoing medical transition] now, and doctors are allowing them to sign away their the liability, I feel it's so unfair.
“Doctors [no longer] have to determine whether [hormonal and surgical intervention is] the best treatment, because denying it to someone is [viewed as] a violation of their bodily autonomy.”
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Activism in the driver’s seat
“This shift was activist-driven, it wasn't evidence-based. We didn't suddenly get evidence that proved that anyone who says they're trans is the opposite sex or another gender; there's no empirical evidence of that. The whole thing was activist-driven, coming from ‘lived experience’ instead of empirical evidence.
“If we had empirical proof to measure gender identity, it might make sense to facilitate transition as quickly as possible. Empirical proof could have been a brain scan, measuring hormone levels or doing a blood test, but we don't have anything like that.
“The measurement that determines whether someone is truly transgender is that person’s satisfaction with transition. That's what all the studies are looking at — did their mental health get better? Are they happy?
“Most studies showing satisfaction are only following up [former patients] a few years after starting transition. If you followed up with me a few years after I started transition, I would have told you I was happy. I would have told you I was happy probably up until nine years following transition.
“The longest follow-up study, which was published in 2011, spans 30 years, and showed that the suicide rate 10-15 years after surgery was almost 20 times higher than the general population. That's pretty important. I mean, if we're doing this to prevent suicide, but the suicide rate is still so high, then what are we actually treating?”
How informed is this consent?
“The ‘informed consent’ model of transgender care is not the same as [the medico-legal concept of] informed consent.
“[Under this fast-track trans model] the patient doesn't have to meet the diagnostic criteria for gender dysphoria. The patient doesn't need a referral from a mental health professional, and doesn't need to undergo a mental health evaluation. The risks and benefits are discussed, but no alternative options are considered.
“[The American Medical Association says] doctors ‘should assess the patient's ability to understand relevant medical information and the implications of treatment alternatives, and to make an independent, voluntary decision’.
“You have to be psychologically sound and developmentally capable of understanding [treatment options] and able to make these decisions. If you don't have a mental health evaluation, how do you know that someone [especially a minor] is psychologically sound and developmentally capable?
“There are many unknowns in experimental treatment [such as medical transition for today’s adolescent-onset cases of gender dysphoria]. So, it's hard to be able to understand the implications, or how it’s going to affect you in the long term. [Under the trans ‘informed consent’ model, no alternative treatments, such as psychotherapy, are presented.]
“How can you know the burdens, risks and benefits of all your options, if you're only being given the one option? And the thing with ‘gender affirming’ care is, you affirm, affirm, affirm — and there's no questioning.
“People are essentially self-diagnosing, but they would probably say they're self-identifying.”
Autism not picked up
“[As for] my own experience, in 2010 I was prescribed testosterone by a general practitioner [in Canada]. I required letters from two mental health therapists. [One recommended testosterone for me, and the other said I was ‘psychologically able’ to make the treatment decision; neither therapist had experience with trans patients.]
“There was no formal mental health evaluation. There was no screening for any other psychiatric concerns. I had a medical history of depression, anxiety, self-harm, suicidal ideation.
“[When I was later diagnosed with autism] it was like seeing all of those pieces of the puzzle fitting suddenly and going, ah, that's why it all happened. And I feel like I was robbed, knowing that I could have had that knowledge seven years earlier, because many of those feelings were things that I classified as being ‘because I'm trans.’
“I thought I didn't fit in with girls because I'm trans, or I didn't like wearing dresses because I'm trans. ‘If you think you're trans, you are’ — which is what everyone online was telling me at the time.
“But [not liking] dresses and makeup, these were all sensory issues for me, because I am autistic. I was bullied because I'm autistic. I'm ADHD. I made impulsive decisions, including the one to transition. Being able to ‘pass’ as a man helped with my anxiety. I didn't feel like I was ‘meat’. I didn't have to smile as much, I didn't have to perform as much.”
Regret, the great unknown
“Most studies that conclude low regret [following medical transition] were conducted before the explosion of trans-identifying patients circa 2015. And most of [these studies] were specifically about surgery. We can't make conclusions about paediatric transition, because most of these people [in regret studies] were not transitioning as children. We can't make conclusions about the [trans] ‘informed consent’ model, because the people who they were studying didn't go through this model. They went through those ‘gatekeeping’ measures, way back when.
“And we can't make conclusions about adolescent-onset gender dysphoria or rapid-onset gender dysphoria because, if I remember correctly, most of these people [in regret studies] were either childhood-onset [cases] or they were already adults. So [today’s typical female adolescent-onset patient is] a completely new cohort that we don't really know very much about.
“Estimates of detransition and regret are unreliable, because many detransitioners don’t tell their health professionals. Many professionals are not following-up with their patients. Many studies have high ‘loss to follow-up’, greater than 20 per cent — [former patients who could not be tracked down to check outcomes]. We don't know if those people detransitioned, they might have just gone [to a different clinic], they might still be identifying as trans, they might regret it. Nobody knows.
“Follow-up times in studies are relatively short — for example, only a few years or less [after treatment began].
“[The 2018 Dutch long-term regret study found that on average, regret after surgery took 130 months to kick in.] And I read another study that said most people start to detransition within four to eight years. Even then, we don't have an actual number of detransitioners. Nobody really knows.
“[As for] the ethical dilemma around the transition, we have the trans rights activist position [that] transition regret or detransition is impossible to predict [at the time of treatment], and therefore it is unethical to try and prevent that outcome.
“[These activists would say] that because regret is rare, ‘gatekeeping’ might harm people who will benefit from transition, either by causing further emotional distress or by violating their rights of personal autonomy.
“My position as a detransitioner is that transition regret or detransition is impossible to predict. We do agree on that premise, [but I say] it is unethical to propose an invasive treatment as the preferred option, because the evidence base for transition is low quality, and because —
transition is socially, physically and mentally difficult on every single person that does it
most people who pursue transition are desperate and psychologically vulnerable
each of us only gets one body in our lifetime.”