A leaked recording of a session from the World Professional Association for Transgender Health's recent conference sheds light on how care providers approach complex cases of gender dysphoric adults.
It's amazing hearing doctors say they have an opinion about a patient but they wouldn't want their judgment to take precedence over the expertise of the patient. A patient who is explicitly seeking help from a doctor. What must these doctors think the point of a doctor is? Just being a pathway to drugs and treatment? I struggle to fathom how this makes sense in any other context in medicine. "When a patient says they want Oxycontin, don't railroad them! Just meet them where they are on their journey of pain relief!"
It's worth keeping in mind that a lot of psychiatry is fairly service-oriented. As anyone who's ever sought Xanax or Prozac can attest, it's not exactly a challenge to convince a doctor to provide them to you. Granted, cross-sex hormones likely have a much greater long-term impact on the body. But benzos are addictive and SSRIs can have troubling sexual side effects, which in rare cases are permanent.
But these psychiatrists seem to rarely have said no or present the patients with known, proven, medical alternatives. I don't see in the article why the patient with the pituitary tumor wasn't given more information about treatment of his tumor. With the first patient, it seemed to me that they might be on the autistic spectrum, but the doctors never mention why they didn't give the patient some information for autism, or send them to a therapist who might work with the patient.
On the one hand, one doctor entirely dismisses the possible impact of sexual trauma, and another doctor seems to prefer sexual trauma as the over arching reason for gender dysphoria (while being somewhat dismissive of other causes such as autism.)
I get it that these doctors are human beings with the inevitable biases of being a human being, but, in general, they seem too comfortable and not very questioning of the affirmative care model.
Very true, I suppose that's how we got into this opioid crisis. I wonder if the people at WPATH watch the recent Hulu and Netflix shows about it and think that Richard Sackler is the good guy.
It was saddening too for me to listen to these two books. It was bearable by listening to them in their audiobook formats. Somehow, driving in and around Vancouver (BC) in the rain, listening to these two books, made me very reflective. There is a compassionate quality to Quinones' writing that captures the tragedy of it all.
I've listened to quite a few WPATH presentations at this point (I think it's good to know how they speak with each other on these topics). It's actually pretty unusual to come across a really bonkers, quotable moment, and on the surface no one comes off like a villain. What you get is a bunch of well-intentioned people who live in a shared reality where the following things are true (repurposed from a comment I made on a different post earlier this year): 1) everyone has an innate, ineffable, but also potentially flexible thing called a "gender identity", 2) for people whose bodies don’t align with their gender identity, the greatest and highest good is to alter their body with hormones and surgeries to bring the two into alignment, 3) these are safe, effective, and ALWAYS medically necessary, 4) anything interfering with easy access to these is “gatekeeping” and is bad, 5) anything that normalizes them and makes them easier to get is “gender affirming” and is good, 6) the gender affirming community is a small, brave, beleaguered community defending access to these treatments against dark forces who are conspiring to take them away.
And that's how you end up with earnest conversations like this. None of these individuals should have even come close to getting (or nearly getting) these procedures but for the ideology motivating the doctors. Worse, the ideology actively interferes with the patient getting treatments that are more likely to help them in the long term and are much less invasive, like learning distress tolerance and resilience, CBT, ACT, and even psychiatric medications when necessary. And when they do, like in the case of the patient who was prescribed the SSRI, it seems to be in spite of the ideology or as a stopgap until they can get the "real" treatment of sex-trait modification procedures.
It's its own kind of tragedy. These are doctors who clearly mean well and want to do good, but for various social reasons have been taken in by an ideology that has hijacked those good intentions to actively do medical harm to the very people they want to help.
Well said. These doctors are there to guide the patients through their "gender journey" and not be an actual medical and psychological professional who should lead them to cures and to what their true problem is - like unresolved sexual trauma and the like.
I myself identify as trans junkie. That means that I have a profound vision of myself as a heroin addict. I expect that physicians will get me prescriptions to fulfill my self-assessed view of my trans junkie nature. I use "he/him/they/just/shoot/me/up" as my pronouns.
Wow - Profiles in Cowardice much? Why are people wasting over 100K in medical education, only to become codependent YesPeople to their patients?
Trans medicalization is the only health protocol where the customer is always right even if it is clear to the rest of humanity the patient is bat-shit crazy & an insufferable narcisscist to boot.
I don't get the overwhelming concern of doctors who worry they might be "gatekeepers."
Once, in preparation for a flight to Europe, I went to my doctor and asked for something to help me sleep on the plane. We've known each other a long time, so she's familiar with my medical status and history, and she asked me exactly why I wanted the pills, how long was the flight, etc. She then prescribed me three pills, which was just what I needed to get through. She didn't hand me two months' supply of Valium for a six-hour flight, because it's her *job* to make sure medical interventions are safe and proportional to the need. So she was absolutely right to want to know more about what I was asking for.
These gender treatments are pretty radical, and doctors are well within their rights to make sure patients who want them actually *need* them. If that's "gatekeeping"...well, some gates should bloody well be kept.
I'm not an expert on the medical literature like you being a a journalist of medicine could you go into more depth of why you didn't find that meta-analysis convincing could you explain some of the problems with the study you had or could you write an article explaining why the meta-analysis was wrong
"Dr. Schnitzlein was eager to counterbalance such reluctance to prescribe hormone therapy with an assurance that the team was not there to tell people “no” or to make patients’ quest to obtain cross-sex hormones more cumbersome."
How can this be called medicine if the doctor is never allowed to say, "no."
And how can it be called a "gender journey" - a journey that for them can include detransition - if there are no protocols, supports, ICD codes, or programs for people who want to get off hormones, get reconstructive surgery, counteract the effects of T on the voice, or get therapy for returning to an identity that matches their biological sex? So that journey can only go one direction down a very narrow path?
To be clear, she never flat-out said that she wouldn't say no. But that is what she clearly meant. That is what all of them were telegraphing. They clearly were concerned about these patients. But saying yes, or at least keeping the patient engaged and trustful, was far more important than expressing those concerns directly. You can hear the whole session if you're curious: https://benryan.substack.com/publish/posts/detail/151883155?referrer=%2Fpublish%2Fposts
Great work as always, Benjamin!
It's amazing hearing doctors say they have an opinion about a patient but they wouldn't want their judgment to take precedence over the expertise of the patient. A patient who is explicitly seeking help from a doctor. What must these doctors think the point of a doctor is? Just being a pathway to drugs and treatment? I struggle to fathom how this makes sense in any other context in medicine. "When a patient says they want Oxycontin, don't railroad them! Just meet them where they are on their journey of pain relief!"
It's worth keeping in mind that a lot of psychiatry is fairly service-oriented. As anyone who's ever sought Xanax or Prozac can attest, it's not exactly a challenge to convince a doctor to provide them to you. Granted, cross-sex hormones likely have a much greater long-term impact on the body. But benzos are addictive and SSRIs can have troubling sexual side effects, which in rare cases are permanent.
But these psychiatrists seem to rarely have said no or present the patients with known, proven, medical alternatives. I don't see in the article why the patient with the pituitary tumor wasn't given more information about treatment of his tumor. With the first patient, it seemed to me that they might be on the autistic spectrum, but the doctors never mention why they didn't give the patient some information for autism, or send them to a therapist who might work with the patient.
On the one hand, one doctor entirely dismisses the possible impact of sexual trauma, and another doctor seems to prefer sexual trauma as the over arching reason for gender dysphoria (while being somewhat dismissive of other causes such as autism.)
I get it that these doctors are human beings with the inevitable biases of being a human being, but, in general, they seem too comfortable and not very questioning of the affirmative care model.
If you listen to the full audio, you'll hear in all their voices that they never want to say the wrong thing. https://benryan.substack.com/publish/posts/detail/151883155?referrer=%2Fpublish%2Fposts
Haven't listened to the audio yet, but I will.
Very true, I suppose that's how we got into this opioid crisis. I wonder if the people at WPATH watch the recent Hulu and Netflix shows about it and think that Richard Sackler is the good guy.
Worth reading (or listening to in their audiobook versions):
Dreamland: The True Tale of America's Opiate Epidemic, by Sam Quinones
The Least of Us: The True Tale of America and Hope in the Time of Fentanyl and Meth, by Sam Quinones
I have it, but I already read Dopesick and it just about killed me. I don’t think I can handle another one.
It was saddening too for me to listen to these two books. It was bearable by listening to them in their audiobook formats. Somehow, driving in and around Vancouver (BC) in the rain, listening to these two books, made me very reflective. There is a compassionate quality to Quinones' writing that captures the tragedy of it all.
I will try to read (or listen to) Dopesick.
I just got off the phone with a relative who lost her daughter to the opioid crisis. It really strikes home. And it makes me very mad.
I've listened to quite a few WPATH presentations at this point (I think it's good to know how they speak with each other on these topics). It's actually pretty unusual to come across a really bonkers, quotable moment, and on the surface no one comes off like a villain. What you get is a bunch of well-intentioned people who live in a shared reality where the following things are true (repurposed from a comment I made on a different post earlier this year): 1) everyone has an innate, ineffable, but also potentially flexible thing called a "gender identity", 2) for people whose bodies don’t align with their gender identity, the greatest and highest good is to alter their body with hormones and surgeries to bring the two into alignment, 3) these are safe, effective, and ALWAYS medically necessary, 4) anything interfering with easy access to these is “gatekeeping” and is bad, 5) anything that normalizes them and makes them easier to get is “gender affirming” and is good, 6) the gender affirming community is a small, brave, beleaguered community defending access to these treatments against dark forces who are conspiring to take them away.
And that's how you end up with earnest conversations like this. None of these individuals should have even come close to getting (or nearly getting) these procedures but for the ideology motivating the doctors. Worse, the ideology actively interferes with the patient getting treatments that are more likely to help them in the long term and are much less invasive, like learning distress tolerance and resilience, CBT, ACT, and even psychiatric medications when necessary. And when they do, like in the case of the patient who was prescribed the SSRI, it seems to be in spite of the ideology or as a stopgap until they can get the "real" treatment of sex-trait modification procedures.
It's its own kind of tragedy. These are doctors who clearly mean well and want to do good, but for various social reasons have been taken in by an ideology that has hijacked those good intentions to actively do medical harm to the very people they want to help.
Well said. These doctors are there to guide the patients through their "gender journey" and not be an actual medical and psychological professional who should lead them to cures and to what their true problem is - like unresolved sexual trauma and the like.
Ok, this is pretty straightforward. They’re plastic surgeons providing the cosmetic procedures their customers want.
Which is like, whatever.
But insurance shouldn’t be paying for this.
Put another way, if this is normal and they are in the wrong body, why do they need hormones?
I myself identify as trans junkie. That means that I have a profound vision of myself as a heroin addict. I expect that physicians will get me prescriptions to fulfill my self-assessed view of my trans junkie nature. I use "he/him/they/just/shoot/me/up" as my pronouns.
Wow - Profiles in Cowardice much? Why are people wasting over 100K in medical education, only to become codependent YesPeople to their patients?
Trans medicalization is the only health protocol where the customer is always right even if it is clear to the rest of humanity the patient is bat-shit crazy & an insufferable narcisscist to boot.
I don't get the overwhelming concern of doctors who worry they might be "gatekeepers."
Once, in preparation for a flight to Europe, I went to my doctor and asked for something to help me sleep on the plane. We've known each other a long time, so she's familiar with my medical status and history, and she asked me exactly why I wanted the pills, how long was the flight, etc. She then prescribed me three pills, which was just what I needed to get through. She didn't hand me two months' supply of Valium for a six-hour flight, because it's her *job* to make sure medical interventions are safe and proportional to the need. So she was absolutely right to want to know more about what I was asking for.
These gender treatments are pretty radical, and doctors are well within their rights to make sure patients who want them actually *need* them. If that's "gatekeeping"...well, some gates should bloody well be kept.
Never forget what happened to John Mulaney when he said to his doctor: "Sometimes I get nervous on airplanes."
I'm not an expert on the medical literature like you being a a journalist of medicine could you go into more depth of why you didn't find that meta-analysis convincing could you explain some of the problems with the study you had or could you write an article explaining why the meta-analysis was wrong
Is there any systematic reviews showing the negative effect of gender affirming care
What do you think of that meta-analysis I linked I'm not convinced I'm not an expert so I can check it's not or not what do you think
Looks like more do the same for this field: the research isn’t so hot.
Hey could I ask you to point out some of the flaws in that study cuz I'm not an expert in it
Hey I fixed the link now you can access it for Google scholar this is the paper that claim gender affirming care reduces suicide I'm not an expert so I'm not sure could you take a look at this and see if it's about or not https://scholar.google.com/scholar?hl=en&as_sdt=0%2C33&q=a+response+Suicide-related+outcomes+following+gender-affirming+treatment%3A+a+review+Daniel+Jackson&btnG=#d=gs_qabs&t=1732116851151&u=%23p%3DbXbKGu3cYwYJ here's the Google scholar link where you can download it here
Hey could you take a look at this I was in a debate with a transgender have I get and they showed this man analysis to me could you take a look at it https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10027312/you're
The link is broken.
Did you respond to this I already posted like once but here's the fooling https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10027312/
"Dr. Schnitzlein was eager to counterbalance such reluctance to prescribe hormone therapy with an assurance that the team was not there to tell people “no” or to make patients’ quest to obtain cross-sex hormones more cumbersome."
How can this be called medicine if the doctor is never allowed to say, "no."
And how can it be called a "gender journey" - a journey that for them can include detransition - if there are no protocols, supports, ICD codes, or programs for people who want to get off hormones, get reconstructive surgery, counteract the effects of T on the voice, or get therapy for returning to an identity that matches their biological sex? So that journey can only go one direction down a very narrow path?
To be clear, she never flat-out said that she wouldn't say no. But that is what she clearly meant. That is what all of them were telegraphing. They clearly were concerned about these patients. But saying yes, or at least keeping the patient engaged and trustful, was far more important than expressing those concerns directly. You can hear the whole session if you're curious: https://benryan.substack.com/publish/posts/detail/151883155?referrer=%2Fpublish%2Fposts