Brandt Files #3: Before the First Shot

Clinicians follow guidelines, according to guy who writes guidelines

Photo by Berta Ferrer on Unsplash

This post is part of the Brandt Files, a series on the lawsuit in which “trans kids” successfully challenged Arkansas’ ban on youth gender medicalization. Read the introduction to the series here, along with parts one and two of the series, which is all free and available to the public. 

The trial documents cited in this piece are available on the ACLU’s website in several files. Witness testimony is in the “trial transcripts.” Volume 1 contains Karasic; Volume 2 contains the parents of Parker and Sabrina; Volume 3 contains Hutchison; Volume 4 contains Cathey and Ho.

There’s an organization that calls its recommendations the “gold standard” for treating trans-identified patients. One of the drafters of those recommendations, the psychiatrist Dan Karasic, testified proudly about them in the Brandt trial. Then real-world clinicians and parents of patients testified, and reminded the courtroom that many in the US doesn’t operate on the gold standard anymore.

I’m referring to the World Professional Association for Transgender Health (WPATH). At the time of trial, version 8 of the WPATH Standard of Care (“SOC8”) had just been released to a certain amount of shock—they had removed all age restrictions for gender surgeries except phalloplasty, and most recommendations for how and when to treat young people with gender dysphoria contained caveats that essentially said, “Do whatever you want.” 

At trial, Karasic skipped over the caveats to portray SOC8 as a conservative document. And he insisted that it was “widely followed by” clinicians. When asked how he knew that, he answered:

“I have been a university professor for over 30 years and have done a lot of teaching, a lot of presentations on transgender health. I have done presentations and have done day-long trainings for the American Psychiatric Association for psychiatrists in transgender health and I’ve trained over 2,000 healthcare providers through WPATH’s education efforts. … [These providers] are in various degrees familiar with the WPATH Standards of Care and certainly use them.”

This self-flattering answer didn’t back up the promise that WPATH SOCs were widely followed. It became a familiar pattern. Karasic kept making bold, reassuring claims that fell apart later on – either a few seconds later, when he stopped making sense, or a few days later, when an Arkansas doctor or patient’s parent testified about their actual experience with trans healthcare.

The parties agreed that the first medical step of gender transition is hormonal: administering cross-sex hormones or, in the case of a child under 14 or so, puberty blockers. This post looks at how doctors decide to start that treatment for minors.

What’s Being Treated

Karasic testified that medicalization is only appropriate for patients who have been diagnosed with “gender dysphoria.” GD, by Karasic’s definition, is “distress about the incongruence between one’s gender identity and one’s sex assigned at birth.” While SOC8’s predecessor, SOC7, did not list this requirement, Karasic testified that it “establishes kind of an equivalent that the person has persistent gender dysphoria in order to receive treatment.”

The state’s attorneys introduced us to two actual Arkansas gender doctors: Janet Cathey, an OB-GYN at Planned Parenthood, and Stephanie Ho, a family physician in private practice. Judging by their testimony, they were not following WPATH recommendations – either SOC7 or SOC8. 

Ho and Cathey testified in depositions that they had medicalized not gender dysphoria but “gender nonconformity” – but at trial they both backpedaled to the plaintiffs’ party line. Here’s Cathey’s testimony at trial:

Q. Just to confirm, you testified today that you have never prescribed hormones to someone without a formal gender dysphoria diagnosis?

A. Yes, I would stick with that.

The next question at trial was whether she required patients to “get a mental health diagnosis before they receive hormone therapy.” Cathey responded “No.”

Plaintiffs called Michele Hutchison, a pediatric endocrinologist who had treated trans-identified youth in Arkansas until recently. The plaintiffs seemed to be showcasing her clinic, associated with Arkansas Children’s Hospital, as a paragon of guideline-following. But when Arkansas asked Hutchison if she would medicalize a nonbinary-identifying patient who lacked a GD diagnosis, Hutchison couldn’t rule it out:

Q. Would you prescribe puberty blockers or hormone therapy to that [non-binary] individual if they requested it?

A. Well, again, it would be on a case-by-case basis. We had, not to my recollection, been faced with that specific possibility, but I think we would have to take that on a case-by-case basis.

How Long the Condition Has Lasted

Karasic insisted that clinicians did not prescribe “hormones on demand.” How did he know?

Because that had “not been my experience with therapists that I work with and certainly goes against what we’ve been talking about[, the] WPATH Standards of Care.” 

When backing up that claim about the SOCs, he seemed to spin his wheels, repeating the same vague terms like “long-standing.” “There is a lot in [SOC8] that recommends that gender identity be long-standing and stable before treatment is given,” according to Karasic. Specifically, it requires a diagnosis of GD plus “years” of “gender diversity.” Karasic didn’t know how many years, but described it as “a chunk of time certainly.” He did not define the term “gender diversity,” nor did anyone else at trial. He also did not testify to SOC7’s durational requirement, which was even less specific about the timeline: “persistent, well-documented gender dysphoria.” 

The elephant in the courtroom was ROGD, or Rapid-Onset Gender Dysphoria: the description for teens who develop GD suddenly as adolescents, often in clusters and after fairly gender-typical childhoods. The idea of medicalizing these kids discomfits many people because it seems like they might be going through a phase or hating their bodies for some reason other than cosmic mismatch. The plaintiffs tried to wave away ROGD through several witnesses’ testimony. Karasic’s angle was that medicalizing ROGD kids was impossible because WPATH didn’t allow it – or at least, recommended against it. His argument, as I just distilled it, wasn’t convincing. And it was even less so after reading testimony by two parents of trans-identified plaintiffs, both of whom, in my non-expert opinion, seemed to have ROGD.

In July 2020, at age 15, the male plaintiff Sabrina came out to his parents as trans. He was diagnosed with GD that month. There is scant testimony about the boy’s mental health or functioning leading up to that time. As to his “gender diversity,” his father testified that he was surprised by Sabrina’s coming out because “Sabrina was not a – never had expressed interest in playing with dolls or wearing feminine clothes or anything like that.” He was also a “black belt in martial arts.” (Sabrina is the boy who discovered his gender identity playing Animal Crossing.) His father finally identified some early clues to his child’s “dysphoria”: Sabrina had “always insisted on wearing a shirt when going swimming” and hated public restrooms. 

Six months after the GD diagnosis, in January 2021, Sabrina was started on cross-sex hormones. His doctor was Stephanie Ho.

The female plaintiff Parker came out as trans “in the end of 2019” (when she would have been 14 or 15) and began taking testosterone in May 2021. Her father testified that when she came out, “he’d already started dressing more masculine, cut his hair off.” This suggests that the masculinity hadn’t been long standing. He did note her mental health had declined “right around puberty. … It was a fairly rapid decline.” 

In sum, Karasic tried to tell a story in which all trans-medicalized kids fit a certain mold, following the comforting narrative of “consistent, persistent and insistent” gender distress since childhood. Two of the plaintiffs broke it.

Mental Health Care

SOC8 recommends that mental health professionals be involved in a minor’s medicalization process from the initial decision until they become adults. SOC7 emphasized the importance of assessments by mental health professionals for trans-identified youth. Karasic confirmed these recommendations on the stand. 

Cathey and Ho testified that they did not require their minor patients to engage with a mental health professional. Here’s Ho:

Q. So you don’t typically require patients seeking cross-sex hormones to meet with a psychologist before getting a prescription, correct?

A. I don’t technically make them meet with a mental health provider, correct.

Informed Consent

Karasic testified that WPATH’s recommended informed consent process for a minor included a “cautious, thorough evaluation” of the teen’s “cognitive maturity” by someone who “generally is a mental health professional.” Their parents would be the ones consenting, but the provider would need to know the teen had an “ability for assent to consent.” 

Then “there’s also a second typically informed consent process,” possibly by a second provider. Karasic repeatedly referred to this step as a “discussion” or “conversation.” Along with explaining risks and side effects, this process should include “some discussion about … the limitations of what we know,” he testified, referring to the lack of high-quality research into medicalization. He agreed with the statement that there should be “discussion of whether the minor may have a different feeling in the future about their gender identity.” 

Cathey and Ho testified that they assessed teens themselves, despite not being mental health professionals (“no formal training, just years of doing it,” in Cathey’s words). Cathey’s assessments took place during a 40- to 60-minute appointment, which also comprised the informed consent process. 

But by the time Cathey conducted this meeting, the patient’s parent had already consented. Cathey had them sign informed consent forms before they met her, with unlicensed medical assistants, during a 15- to 20-minute session that also involved recording medical history and testing vitals. 

Q. To clarify then, do patients sign a consent form before they have discussed the risks with you?

A. Yes, just physically as far as the flow of traffic so to speak, that’s the way, yes.

How Karasic’s Ideals Became Fact

Karasic wasn’t confronted with the rogue practices of Cathey, Ho, or Parker’s clinicians. But he was asked to address a 2021 op-ed in the Washington Post by two pro-medicalization psychologists who feared the industry had recently been skimping on psychological assessments in the rush to transition kids, with no regard for SOC7. Karasic responded with gibberish:

“So I know they’re careful clinicians. I think they’re making comments about kind of maybe push-back within, but within really I think a fairly narrow confine of opinions of which, you know, are still variations of these opinions.”

In other words, Karasic totally knows what clinicians are up to in the real world.

But the judge, despite hearing all the other witnesses’ testimony, and being alerted to the Washington Post op-ed, somehow emerged from the trial innocent – and convinced that Karasic was a reliable source. WPATH SOCs, he wrote in his “Findings of Fact,” are “widely followed by clinicians.”

This is the third entry in The Brandt Files. Find past entries on the author’s profile page.

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More Information on How Clinicians Decide to Medicalize Kids

A youth gender clinic in St. Louis was exposed in 2023 by one of its case managers, Jamie Reed. To read her sworn account of how that clinic screened minors for medicalization, click here (pages 2-17).

A different WPATH drafter, Annelou de Vries, touted monthslong psychological assessments to Reuters, noting that SOC8 recommended “rigorous patient assessments” for youth. Reuters contacted 18 youth gender clinics across the US and found none followed the protocol she’d described. Seven were willing to prescribe hormones on the patient’s first visit. 

Medicalizing kids without providing therapy first sounds dodgy, but can we trust the mental health profession to counsel them appropriately? Lisa reported on how the industry has been captured by social justice ideology.