Gender Peace Talks #1

Four detransitioners walk into a Zoom with gender-affirming clinicians

If you work at a gender clinic or a clinic like Planned Parenthood that offers gender-affirming medical interventions, and would be willing to have detransitioners come speak about their experiences, please reach out.

It was an experiment. After a difficult conversation with a gender-affirming clinician a few weeks ago, I asked if he would be willing to assemble some of his colleagues for what he eventually called a “gender listening session” with detransitioners. I wondered if witnessing their stories might inform their practice, and I was curious if they would be affected, hearing directly from these people who’d been deeply hurt—physically and emotionally—by the treatments they provide.

We agreed beforehand not to identify the clinic or share information about the event on social media, and the detransitioners acknowledged beforehand and at the beginning of the meeting that they had not been treated by these clinicians. I carved out a caveat that I could write about it after, with the agreement that I’d let my contact see a draft first. We also agreed that there would be no questions during the presentation, and that if any of the doctors had follow-up questions, they would send them to me and I’d pass them on.

The first person who spoke was a 30-something man who spent years living as a transwoman, and relayed how, had anyone actually followed up with him in the first 8 years or so, he would have been deemed a success. But even as he built a life for himself with his new identity—even as he “passed,” and by his very presence encouraged those around him to be more accepting of transgender women—he felt sicker all the time. His  vaginoplasty and his cross-sex hormones wreaked havoc on his body—fistulas, incontinence, fatigue, cognitive decline—and eventually he went off estrogen and began to take testosterone. He immediately felt better mentally as well as physically, and eventually detransitioned, realizing he was a gay man all along. He later wondered: Why was his natural femininity, and the research showing a relationship between such childhood gender nonconformity and later homosexuality, not considered by therapists and doctors? Why wasn’t the source of his discomfort, or belief that he was a woman, explored? Now, he’s left with no health care providers to help him; it’s difficult to obtain hormones since he no longer identifies as trans, and the complications from his vaginoplasty leave him with the options of leaving his body as is or risking an operation that might help, but might make his physical situation worse.

Next, three women in their mid-20s spoke, and their stories were so similar that I worried the clinicians would think they’d been coached. They weren’t. Rather, they are members of the novel cohort that many of you have heard about: teen girls with mental health conditions, but no history of gender dysphoria, who latch onto the idea that they’re trans, and believe that medical interventions will alleviate their suffering. Since we don’t have research, we don’t yet have the ability to evaluate whether their suppositions are true—but we do have their stories.

One detransitioner had been tomboyish as a girl; the others had been more traditionally and stereotypically feminine. All three had either been diagnosed as autistic or felt they would be if evaluated. Two had sustained sexual trauma. One had been socially transitioned young and gone on testosterone at 17, the others starting at 18 or 19. They’d all had their breasts removed, and one had undergone a hysterectomy, and all came to regret their decisions. None know if their time on testosterone has permanently affected their fertility, but they of course will never breast feed. Two had no idea they’d lose their singing voices—a side effect never communicated to them. In general, they felt that their evaluations, if they had any, were flimsy and superficial, not investigating the root causes of gender dysphoria or why they’d decided gender transition was the solution to their problems. Exploration, not affirmation, is what, in retrospect, they felt they needed.

One detransitioner said she thought clinicians should carefully gauge young people’s expectations before okaying medical interventions. She thought they would actually be able to transform her into a boy with a functional male body, not a medical patient who could take chemicals or undergo surgeries that would help her approximate the secondary sex characteristics of a boy. (As an example, see this book in a children’s library, which tells young readers that surgery can change a vagina into a penis, as if it’s entirely optional.) She suggested that knowing what kids wanted, and why, could help create better healthcare for kids with gender dysphoria.

These women, too, said they would have been initially deemed successes if clinicians had followed up with them in the first few years. For some of them, it took almost a decade to realize they’d chosen the wrong path.

When I had spoken to each of these people before the event, we talked for well over an hour, and could have gone on much longer. But we managed to squeeze these four presentations into 45 minutes, leaving 15 minutes to spare. I think the detransitioners were nervous, and though of course I have no way of knowing how the clinicians felt while listening to these stories, some of us interpreted the looks on their faces as stony, which didn’t make story-sharing easier—but that could have just been our perceptions, our projections, and not represent the clinicians’ experience at all. I haven’t heard from them, so I don’t know.

Perhaps because I’m the kind of person who feels uncomfortable with silence, I broke the rule I’d requested, asked the remaining two detransitioners on the Zoom if they’d take questions from the doctors. They agreed. My contact asked one question, about improving informed consent, and one woman reiterated her point about determining expectations and helping young people be realistic about what would transpire. Then a different doctor told us that he had helped hundreds of young people transition, and that he had been following up with them. Some, he said, cried with gratitude for what he’d helped them accomplish.

His response made them feel less certain that they’d been heard. It came across to us as defensive, or at least insensitive and inappropriate for such a delicate situation, and the Zoom ended on a difficult note for the detransitioners. My contact at the clinic thanked them, and one doctor said she will think about what they said, and acknowledged their bravery in sharing their stories. That gave me hope, because if one person in a clinic believes that reform may be necessary, that could lead to conversation, contemplation, introspection, and change. But the others said nothing.

I initially feared the event had done nothing to make the doctors consider pediatric and adolescent medical gender transition in a different light because I hadn’t received any feedback. But a few days after the event, my contact at the clinic reached out. After much prodding from me, he sent me a written response, which included the following:

“These horrific stories have furthered strengthened my position that expert psychological and psychiatric co-management must be part of the evaluation and treatment of every patient who present with gender dysphoria or in search of gender affirming care.

“In summary, my biggest take aways [sic] from the brave detransitioned patients who came and spoke to us of their own free will and in a setting free of prying eyes or political influence were that, (1) there is real pain and suffering amongst the transgender community who has detransitioned, (2) some patients who receive gender affirming care are undeniably irrevocably harmed in the process, (3), these patients need and deserve specialized care to help them regain as much function as possible though this is an area that is in need of tremendous additional research/experience to guide best practices, (4) the large majority of  patients who were harmed by gender-affirming care had pre-existing comorbid conditions that,  if more appropriately assessed, may have greatly reduced their risk of harm, and (5) even when patients do everything “right” there is still a risk of harm that must be fully described as part of any reasonable consent process.

“I am greatly appreciative of the detransitioners who came forward to share their stories and I hope that each of them know that their willingness to share has and will continue to affect my interactions with patients presenting with gender dysphoria and with greatly inform my consent discussions regarding risks/benefits/alternatives with those who do seek further intervention.”

Let’s take this as a win. He heard them. He agrees that careful evaluation is paramount. And it means that this event was worthwhile, that we should do it again, that intimate conversations are one important tool in a reform toolkit.

There’s still a long way to go, and you can see it in the coded language he used, and the way gender-affirming proponents often misinterpret research. My contact also described detransition as rare, and said they have only one known detransitioner at their clinic “who continues to follow up with us and reports being very grateful for access to the care they received as part of their gender journey (notably that patient never had any surgical intervention but did receive both blockers and cross-sex hormones).” But from what little research we have, it seems almost three-quarters of detransitioners don’t return to the clinicians who facilitated their transition. A recent study shows a 7 percent detransition rate, and an earlier study puts it higher, but not always due to regret.

He called detransition a “gender journey”—a term many detransitioners feel obscures the reality of what happened, which is that doctors made grievous mistakes. It’s hard to speak truth to deliberately obfuscating language. Think of how “top surgery” obscures the reality that the operation is a double mastectomy. (Imagine if this NYT headline had been “More Trans Teens Are Choosing Double Mastectomy” instead of “More Trans Teens Are Choosing Top Surgery.”)

The week after the event, one clinician in attendance made a public statement that gender-affirming care is “life-saving.” This unnerved one of the detransitioners, because the data on the relationship between transition and reduced suicidality is so low-quality that even The New York Times quoted long-term, prospective research which found that suicide attempts “seem to ‘occur during every stage of transitioning.’” In other words, transition does not seem to clearly mitigate risk of suicidal ideation or attempts, or completed suicides.

I know many adults who truly feel transition has saved or vastly improved their lives—adults who lived in their bodies for a long time and understood the consequences of their medical interventions and felt transition was worth it. I totally support them. I also know adults who deeply regret what they’ve done. Without any way to distinguish between these groups, how do we proceed? If I’m crusading for anything, it’s to grapple with that question.

I want to publicly thank these doctors for coming to the session. I know that they’re under great strain—pile-ups on social media, threats to pediatric gender clinics, legislative attempts to prevent gender transition until adulthood. While I cried so much during the Zoom that I had to turn off my camera at times, I imagine they regularly listen to young people sobbing out of desperation to change their bodies and identities and feel great sympathy and responsibility toward them—as I do, too. I know they feel that the treatments they offer are genuinely beneficial to some gender dysphoric youth. It’s just that the detransitioners who spoke felt the same way—and getting the treatments they wanted ended up hurting them.

Some of these detransitioners may want to stop these doctors’ practice of pediatric and adolescent gender transition, to prevent others from enduring the same amount of serious bodily harm—they may want them to wait until they are legal adults with more developed brains before they decide. But the majority of detransitioners I’ve spoken with are looking for reform and oversight of an industry and medical/mental health field that is unregulated except in states that have imposed restrictions through the heavy hand of legislation. They’re looking for their experiences to inform guidelines from clinicians and medical boards. They’re looking for a cost/benefit analysis to determine policy—and for it to be recognized that they are the costs.

Did the clinicians all write impassioned notes vowing to help reform pediatric gender medical care? No, but that’s a ridiculous expectation. It can take a long time for information to seep in, and for people to allow a seed of doubt to sprout and then seed change. But I hope that happens.

If you’re a gender-affirming clinician who is willing to have detransitioners come talk to you, for Gender Peace Talks #2, please reach out.

Photo by openclipart/Creative Commons