A Warning for WPATH: More Therapy, Less Ideology

A focus on affirmation-only care has failed dysphoric kids like mine

Dear WPATH doctors,

You have asked for public comment on your new Standards of Care; I am providing my feedback on the chapter on Adolescent treatment.

I have a trans-identifying child whom we have been affirming for three years. The care we have gotten through this affirmation process has not been adequate. In fact, it was anti-therapeutic, resulting in three hospitalizations for mental health crises, several additional trips to the emergency room for self-harm, and eventually, a suicide attempt. However, the so-called “conversion therapy” ban in our state means we cannot access any other types of care—including exploratory therapy into other underlying causes of dysphoria. The current guidelines are failing dysphoric kids like mine.

Here is my feedback. Please listen.

Let’s begin with the terms you use. As part of a mental and physical health team, the terms you use to describe your care have an impact on how children and adolescents view their experiences and paths of treatment. Let’s take a closer look.

Nomenclature:

•       Gender diverse: The term “gender diverse” in reference to an individual patient is confusing. Gender diversity in youth is typical and there is nothing wrong with it. Gender nonconformity is not a disease. In fact, what we call “gender” or “gender expression” is merely is a pattern of associations and stereotypes associated with a particular sex; other than that it is meaningless. Therefore, using the term “gender diverse” to describe children is also meaningless. To alleviate confusion, this document should use language like “adolescents who do not adhere to typical gender stereotypes” or “gender -stereotype non-conforming” children instead. Better yet, you can simply call them “adolescents with dysphoria” or just plain “adolescents”.

•       Gender identity: Do not use these therapeutic guidelines as a means to establish an ideology apart from the available evidence. Clinical guidelines should not be written in a way that establishes a new belief system or set of religious-like ideas (like the idea of a gendered soul). These ideas are based on neither empirical evidence nor current understandings of evolutionary biology and should not be presented as scientific facts.  If WPATH wants to avoid appearing like activists promoting a set of religious beliefs, this document should use only scientific descriptions. Instead of using words like “gender identity” or “true gender,” use non-ideological terms like “gender dysphoria” or “a feeling of incongruence with sex (or the sex-ed body).”

•       Gender dysphoria: Please define this term. Understanding this condition is critical to being able to evaluate the risks and benefits of different courses of care. This document should also clearly state that gender dysphoria is a symptom, not an identity. This dysphoria can be associated with many other conditions (like ADHD, autism, depression, OCD, BPD). As a result, a dysphoric teenage female struggling with dysphoria around her changing body will not have the same experience (or therapeutic needs) as a middle-aged male struggling with autogynephilia. These experiences should not be treated as the same condition or as if they reference the same patient profiles. Lumping all experiences of dysphoria together under a single umbrella of “gender identity” or “gender diversity” prevents us from offering the care that best fits these patients’ needs.

•       Gender-affirming care: Since “gender identity” is not something that we can see or verify, please do not use the terms “gender-affirming care” or “gender-confirming care.” Instead, this document should rely on more tangible and scientific descriptions, like “administer opposite-sex hormones,” “conduct reconstructive surgery, ” or “perform a double mastectomy.” Using terms like “gender-affirming” is misleading as they suggest there is only one pathway to care—affirming the patient’s feelings.

•       Transgender: Please do not use the term “transgender” to describe patients. Since gender cannot be seen, verified, or proven, we should call these patients “adolescents experiencing gender dysphoria” or adolescents who “feel an internal incongruence with their sexed-bodies” or even adolescents “who espouse an identity of a different gender or sex.”

•       Conversion therapy: Perhaps one of the most egregious aspects of the gender therapy industry is that the term conversion therapy is being misused. It should not be applied to talk therapies for children exploring their experiences of dysphoria and anxiety about their bodies. Helping a child or adolescent feel safe and happy in his or her body is not conversion therapy. Stop using this word; stop lobbying for exploratory therapies to be banned. Instead, exploratory therapy directed towards self-acceptance should be lauded as the first line of care. Calling this approach to therapy “conversion therapy” and banning it from use demonstrates a clear activist agenda.

•       Other ideological or ill-defined terms:  Do not use words that don’t have an agreed-upon definition within the scientific community. Do not rely on adherence to ideological terms without first providing clear (and noncircular) definitions of what they mean. All terms around this care should be used consistently throughout each chapter and consistent with a provided glossary.

•       Additional definitions: This document should provide definitions for all key terms including “trans” “transgender” “transsexual” “gender nonconformity” “body dysmorphia” and “gender dysphoria”.

•       This document should also include a definition and description of adolescent-onset gender dysphoria also known as rapid onset or ROGD.

With that nomenclature business out of the way, we can proceed to feedback on the approach to care.

Overarching comments to address in this chapter on adolescent care:

•       As with all adolescent therapies, the first line of care should be the least restrictive, least invasive, and most directed towards acceptance. Therefore, this document should clearly state that the first therapeutic approach should be to help the patient feel safe and happy in his or her own body. To this end, a full course of exploratory therapy should be embarked on with the understanding that a resolution of the patient’s dysphoria is the best outcome. This exploratory therapy is an important first step in treating gender dysphoria; this is NOT conversion therapy. Calling it conversation therapy is misleading and unethical.

•       This document should explain that feelings of dysphoria and discomfort with the body are typical parts of the adolescent experience. These feelings are especially prevalent in adolescent girls for whom the development of breast tissue and the beginning of menstruation can cause anxiety and stress, which is often also focused on the body. In today’s hyper-online atmosphere, these anxieties may be further exacerbated by an overabundance of pornographic imagery that kids are routinely exposed to before they are developmentally ready to handle these feelings or the fear of unwanted sexual attention. What’s more, much of this pornographic material is terrifyingly aggressive and violent.

•       This document should also explain that adolescent boys can feel a different kind of anxiety around ideas like “toxic masculinity,” which may drive them to seek escape from their impending transformation into adult men. We also know that some dysphoric boys are influenced by video content like “hypno sissy porn.” The therapist should also be on the lookout for those males who may be struggling with autogynephilia (or AGP), a condition that can lead to a desire for hormonal and surgical changes to the body or involvement with highly sexualized dissociative animated content. You can find testimonies of boys with AGP on youtube.

•       This document should explain that feelings of dysphoria are so typical in adolescence that gender dysphoria cannot be adequately separated from typical adolescent experience. Therefore, beyond talk therapies, one should not be advised to proceed with hormonal or surgical treatment until the brain has matured (around ages 25-26) except perhaps in the most extreme cases, but even this is up for debate.

•       As the first line of treatment, adolescents should receive therapy that explores a full range of questions about the onset of these feelings, how they view gender roles in society, how they define boy v. girl, etc. An excellent example of these kinds of in-depth considerations can be found here:

•       Adolescents should also be probed about their social media exposure, including exploring gender ideology in places like Tumblr and Discord. Further, they should be asked about their online friends to be sure that vulnerable adolescents are not being contacted by older adults trying to influence their sexual or gender expression development. Some of these adults may call themselves a so-called “glitter family” and seek to alienate children from their families, which we know is dangerous for kids with mental illness. Sometimes, children and adolescents are singled-out and approached about gender ideology by teachers as well.

•       This document should inform parents and patients that for an overwhelming number of kids, gender dysphoria resolves on its own through adolescence—unless of course, we prevent maturation by blocking puberty or administering opposite-sex hormones.

•       Patients should be informed about the lasting impacts of hormonal and surgical treatments on their bodies including unwanted body hair, baldness, vaginal atrophy, and clitoral enlargements, and osteoporosis. Patients should also receive ample warnings about fertility and sterilization.

•       Patients should be made aware that they may never be able to achieve a full sexual function and that their transition care may prevent them from having a full sex life.

•       Patients should be informed that they cannot change sex. No amount of hormone replacement or surgery can turn them into the opposite sex.

•       Female patients should be informed that by removing their breasts, they will impede their ability to breastfeed any future children. They should also be informed about the harms of chest binding some not appearing until years later, and this practice should not be undertaken without consultation with a physician.

•       The story about suicidality should be amended to dispel the myths that one can have a “living daughter or a dead son.” This is a false narrative intended to scare parents. It’s also dangerous to tell suggestible youth. Instead, this document should inform parents and patients that suicide is higher in patients who have transitioned than in the general public.

•       This document should include a section on detransition. This section on detransition should include the fact the majority of people in the study (60%) detransitioned because they became more comfortable with their sex.

•       Social transition should NOT be treated as harmless or neutral. During this fundamental identity-building time, social transition starts a child on a path to medical transition. Therefore, patients should be advised that even social transition may have permanent consequences as it pushes people further on the path to more treatments—sometimes very quickly.

Additional issues that need to be addressed in this document:

•       Patients should be treated in accordance with the Gender Care Consumer Bill of Rights.

•       Doctors and therapists should not be permitted to initially discuss hormone or surgery with children under the age of majority without their parents present. They should also not raise the issue of hormones or surgery in front of children without parents’ explicit consent. Parents have a duty to protect the long-term health of their children—even if it causes some distress.

•       Children and adolescents with dysphoria have many comorbidities that can only be addressed with parental involvement. Therefore, transition should never be undertaken behind the parent’s back or in coordination only with a school.

•       Patients and parents should not be told that they have to make a choice between transition and suicide. This is false, manipulative, and dangerous to suggestible adolescents.

•       Patients and parents should be informed that patients who transition have a 20X (20 times!) higher suicide rate than the general public and that there is NO data on the outcomes of people who received exploratory talk therapy in place of transition. What’s more, these exploratory therapies are illegal in places with so-called “conversion therapy” bans.

•       Patients should know that long-term outcomes are not well-studied and all hormonal and surgical care for gender dysphoria should be considered experimental.

•       Patients should know that due to the experimental nature of this care, they may not have legal recourse to sue for malpractice in places where there are negative outcomes or adverse events.

•       Patients should be informed that both medical and hormonal transition involves a lifetime of care, thereby turning the adolescent into a “perpetual patient.”

•       Before embarking on any form of transition, patients should be counseled to consider the negative outcomes that some patients have as a result of their transitions, including video testimonials from detransitioners—both female and male. Many stories can also be found on https://www.reddit.com/r/detrans.   Photojournalism can also be a powerful tool to help visualize the long-term impact of transition and the permanence of both hormonal and surgical treatments.

•       Patients should be informed that their insurance may not cover therapy, surgeries, or hormones for detransition if they have regrets. This lack of coverage can leave patients with a new set of anxieties and dysphorias. They may also lack coverage for fertility treatments or reconstructive surgeries that come with detransition.

•       Patients should be made aware of the medical complications of surgery—especially of genital surgery and the lifetime of complications that can arise. They should be counseled to expect repeated surgeries as there are often issues that need to be revisited.

•       Therapists should look into the possibility of bullying from other kids and pressure them into group identification. They should also be on the lookout for kids who will bully detransitioners or desisters and tell them they merely have “internalized transphobia.” Therapists should also reinforce that being so-called “cis-het” is not problematic. In fact, they should know that most kids end up that way and we accept them as they are.

Specific feedback:

Introduction: (page 1 of chapter)

Do not call puberty blockers fully reversible. We know that almost 100% of kids proceed to opposite-sex hormones.

Adolescent Overview: (page 3 of chapter)

In places where this document states that research is evolving, please add that there remains much more that we still don’t know, including long-term biological (including sexual) and mental outcomes.

Replace “gender diverse” with adolescents expressing gender dysphoria (see note on nomenclature above).

This document understates the importance of the Littman papers making it seem like the research isn’t both powerful and valid. Please add that the methodology of her papers is one that is commonly used, and the studies have been peer-reviewed.

On the research: Make sure that the patient knows that since there is little long-term research, all hormonal and surgical care is considered experimental medicine. Because it is experimental medicine, patient should understand that he or she may not be able to have legal recourse to sue for malpractice if there are poor outcomes.

Section on Statement 4: (page 12 of chapter)

Notes on school should include guidelines for how to ensure that children who are not transitioning also feel safe and protected in their bodies. They should also have spaces for changing and menstruation with privacy and dignity. Single-sex spaces should be preserved for girls for protection, modesty, and mental health.

Section on statement 5: (page 13 of chapter)

Self-acceptance is not conversion therapy. Stop calling it this. You know better (see section on nomenclature).

Section on statement 7 (page 15 of chapter)

Please provide research on why you recommend hormonal birth control to stop bleeding in adolescent females. Since most cases of childhood and adolescent gender dysphoria resolve on their own in puberty, we should encourage children to be comfortable with body changes.  Puberty is not the problem, it’s the cure. Young females should learn to be comfortable with and accept the bleeding that their bodies do monthly.

Section on Statement 9 (page 17 of chapter)

This document should note that an overabundance of kids being put on this pathway too quickly are leading to shoddy care, long-term harm, and a generation that will be wracked by sexual dysfunction.

I hope you will take these recommendations into account. The mental health of our children is at stake. I would like to speak to a WPATH doctor about our experiences directly. I will make myself available to discuss these issues further.

Thank you,

A mom

Photo credit: Martin Dimitrov