Are advocates of “affirmative therapy” pulling back?

The other day I got an email from a reader suggesting that perhaps extreme “affirmative-care” activists for transsexuals are backing off of some of their more extreme claims—most notably that some adolescents who demand to transition from one sex to the other might be influenced, perhaps to their detriment, by social pressure.  I have little doubt that this occurs, and that it has influence some young people, for it’s been amply documented. Abigail Shrier’s book Irreversible Damage gives some examples, but that’s not the only source. Some trans people as well as authors have recounted this kind of pressure.

What I don’t know is how many transitions or requested transitions would have occurred without social pressure (which is often intense and always “affirmative”), nor are there much data about transsexuals who bowed to social pressure and then had regrets. (As far as I know, the vast majority of adult transsexuals do not have regrets.

The online impetus to transition is, of course, only part of the “affirmation” of this species of therapy, which involves a rah-rah-go-ahead concatenation of treatment from parents, doctors, and psychiatrists.  These people don’t mean to do harm by giving puberty blockers to children or adolescents; they think they are not only doing good, but are also adhering to what many in the therapeutic community see as the “best practice” for children or adolescents with gender dysphoria. Those standards are promulgated by an organization mentioned below.

Many of these with gender dysphoria”suffer from mental problems, are confused, or might really be gay, which behooves everyone to ratchet back on the instant affirmation. I’ve reported before that European countries are beginning to pull back on affirmative therapy, employing puberty blockers only in clinical trials, and practicing a more objective and watchful therapy whose purpose is to analyze and support rather than to affirm.  The U.S., however, seems to be digging in its heels, holding onto practices that in some cases could be harmful.

Let me emphasize that I don’t object to “affirmation”, but only after rigorous psychological (and medical) investigation shows that transitioning sexes would be the helpful thing to do. What you can’t do is put kids on a treadmill that involves medical intervention merely on the word of the patient and his/her desires alone. The patient much surely be old enough and mature enough to give rational consent.

And while I think there should be age limits for taking hormones (probably 16 or 18, but surely after puberty), I don’t approve of puberty blockers, whose long-term safety (despite the claims below) is not known. On the other hand I also don’t approve of states banning “gender affirming care” unless they specify exactly what they’re banning vis-à-vis psychological therapy and medical practice. Like abortion, such a complex medical issue should not be put in the hands of the state.

But I digress. Here’s the email I got from the reader, who referred me to the NBC article shown below:

Did you know that in the Standards of Care Version 8 released in July this year, the World Professional Association for Transgender Health, or WPATH, they give credence to the possibility of the social contagion hypothesis. Plus, NBC actually covered it. Notice how CHILDREN and trans activists suddenly poo-poo WPATH (previously considered to be the eminent authority on trans health issues). Also, the significance of 4,000+% increase in FTM [female to male] transition is because the majority of transitions prior to around 2015 were MTF. I think it’s important to pay close attention to the Tavistock situation and I’m glad you are.

The Tavistock Gender and Identity Development Service (GIDS) in London practiced hardcore affirmative therapy, often on adolescents, for several decades, treating thousands of young people and helping them transition. But it was closed after a scathing report on poor practice written by an external reviewer, Dr. Hilary Cass. Tavistock is now closed and its activities, made less “affirmative”, are being farmed out to clinics in London and Manchester (see this NYT article for details).

But when you actually read the NBC piece, from June, there’s not much reason to be heartened. Yes, there’s some pulling back from outright rejection of the “social contagion” hypothesis, but otherwise it’s a mess of contradictory claims and anecdotal testimony from patients. Click to read:

But the pulling back doesn’t consist of much,, and even that is drawing criticisms from activists (emphases below are all mine):

The World Professional Association for Transgender Health, or WPATH, a nonprofit professional association devoted to transgender health, will release its Standards of Care Version 8 in July. The last time the standards were updated was in 2012.

The nearly 400-page guidelines, which the association’s president, Walter Bouman, described in an emailed statement as “the most comprehensive set” of guidance ever produced for health care providers who support transgender people, include many significant changes, according to a copy of the guidelines that WPATH shared with NBC News.

The change that is drawing the most criticism is a new chapter dedicated to adolescent care, which was previously part of the chapter on care for children. The chapter presents conflicting statements on support for adolescents: It gives credence to the claim that more young people might be coming out as trans due to “social influence.” It also notes that there’s limited longitudinal research on the effects of gender-affirming care for adolescents, but a growing body of recent studies show it’s beneficial enough that withholding care would be unethical. 

Well, the second sentence seems to be a grudging admission, while the last one I don’t know how to interpret.  What does the growing body of studies say? And surely there can be hardly any data on “gender affirming care” versus “other kinds of care that are more objective and less affirming”! I suspect the data show that gender affirming care is better than no care, which it probably is in terms of self-assessment of patients, but the real question is of the relative efficacy of different kinds of care, some of which may result in out homosexuality rather than gender transition, and for that comparison I would bet shekels to donuts that there are no data.

WPATH is even more grudging about social contagion (my emphasis), devaluing the idea using the words “anecdotal evidence” and “small percentage”.

WPATH’s new chapter on adolescence also states that there has been a “sharp increase in the number of adolescents requesting gender care,” and that anecdotal evidence from a small percentage of people who have changed their minds about being transgender shows that some young people might believe they are trans due to “social influence.” 

But the biggest hedge is to point out that “social contagion” is just one result of social influence:

Regarding criticism of the information in the adolescent chapter about social influence, WPATH said in a statement that, “When discussing social influence, it is important to discuss that it is only one aspect of social development for adolescents, which should also include a discussion of the positive aspects of social connectedness and a feeling of belonging.”

. . . Ducar added that painting transness as a “social contagion” propagates “this myth of ‘grooming’ that the right wing has really been spreading,” even though there’s no data to support it.

(Dallas Ducar is “a psychiatric nurse practitioner and co-founder and CEO of Transhealth Northampton, a trans-led organization that provides health care to trans and gender diverse patients in western Massachusetts.”) But social contagion is not the same thing as “grooming”, and taking the former seriously doesn’t mean you accept the latter. And I don’t know of gender dysphoric youth going online and having their peers tell them that transitioning is a bad idea. It’s nearly always “affirming”, for the advice is often given by those who have transitioned and are seeking post facto affirmation.

According to WPATH, a bunch of peers on the internet telling you to go ahead and have puberty blockers (and telling you where to get them), surgery, and hormone treatment gives you a sense of belonging, which is good. In the abstract, a sense of belonging is good, but probably not when you’re looking for people to tell you to change sex, and how to do it.

There’s more:

Advocates say that language is evidence that WPATH has been influenced by the culture war debate created by some Republicans over the last few years, and it ignores the lived realities of transgender youths themselves.

“We know trans childhood is not a trend,” said Dallas Ducar, a psychiatric nurse practitioner and co-founder and CEO of Transhealth Northampton, a trans-led organization that provides health care to trans and gender diverse patients in western Massachusetts. “We know that gender diversity is part of the human experience. It’s been documented since the Neolithic period and the Bronze Age.”

OF COURSE it’s a trend, whatever its cause. Below are referral rates to Tavistock in just ten years. If you can’t see a trend, you’re blind. As for the Neolithic and Bronze age, well, ten to one we have early historical examples of people of one biological sex saying that they feel like they’re of another, but from these early periods? I’d like to see the  specific claims.

Not only that, but WPATH seems to be making the standards for transitioning more relaxed:

WPATH will make a number of changes to its recommendations for adolescent care in the new chapter. The group will lower the minimum recommended age that providers can prescribe hormone therapy to 14, from 16, if an adolescent has parental consent and meets a list of other criteria, including undergoing a comprehensive evaluation regarding their gender identity.

The association will also lower the minimum recommended age for some surgeries such as chest masculinization and breast augmentation to 15 and 16, respectively, down from 18 in the previous guidelines.

What about PUBERTY? Is that a criterion? And what about puberty blockers? Hormone therapy at fourteen? Is a child capable of making decisions about her whole life at that age? (Parents, many whom have heard that they should be “affirming”, aren’t of much use here.) If WPATH have tightened the criteria for allowing transitioning, that is good, but lowering ages seems to me a precipitous thing to do.

In the end, the article seems to strive for balance by giving both a positive and negative views of “affirmative care”:

Here’s the negative, which isn’t really an attack on affirmative care, but a call for more evidence before it’s practiced:

Allowing adolescents to access treatments worries some advocates who say there isn’t enough research to ensure that the care is safe in the long term.

“The body of evidence to support (hormone replacement therapy) or surgery for anybody, really, but especially for people who are young, it’s extremely flimsy,” said Corinna Cohn, who had gender-affirming surgery when she was 19 and felt afterward that she was “never going to finish becoming myself.”

Cohn, now 47, testified in favor of an Ohio bill in May that would’ve barred gender-affirming medical care for minors and would have also prohibited medical professionals from referring a minor to a different doctor for such care. She said she supported the bill because it would have given people who received transition care as minors the ability to sue their doctors if they regretted the procedure as adults and believed they weren’t mentally sound enough to consent to treatment.

And the response by Ducar:

Ducar said the assertion that there isn’t enough research to support gender-affirming care for adolescents isn’t true.

She said puberty blockers and hormones have been prescribed to cisgender children and cisgender adults for decades, and the scientific research in those populations has shown that the treatments are safe.

“We need to be investing more research money into understanding long-term effects of hormones or blockers or surgery in specific trans populations” — something she said Transhealth Northampton is working on — but “the lack of a robust amount of studies in specific trans populations does not imply that it’s not a valid form of treatment.”

As far as I know, puberty blockers haven’t been used long enough to show that they’re “safe”, and while hormone treatment may be “safe”, it also has side effects like sterility. The side effects of “bottom surgery”, too, are often dire.

As for the last paragraph, let’s see it again:

“We need to be investing more research money into understanding long-term effects of hormones or blockers or surgery in specific trans populations” — something she said Transhealth Northampton is working on — but “the lack of a robust amount of studies in specific trans populations does not imply that it’s not a valid form of treatment.”

If we don’t understand the long-term effects of surgery, hormones, and puberty blockers, then how can they represent a “valid form of treatment”? To me, “valid” means “safe and has been shown to work”.  But maybe WPATH has a different understand of the term.

In the end, the article just shows me that WPATH only reluctantly admits that maybe a few kids have transitioned because of social pressure, but hey, social pressure can be a good thing! And they’re still making quasi-scientific statements that aren’t supported by data.

Until recently I thought that if wokeness was going to recede in America, the first place we’d see it would be in the transsexual controversy, with a greater insistence on proper experimentation and care. After all, wokeness in medicine has the potential to do far more actual harm than wokeness in, say, academia, so the price of getting it wrong is higher.  This is what the Europeans are realizing. But in the U.S., not so much. My bellwether of wokeness has lost its bell.

Uncle Joe doesn’t help:

I declare Joe Biden completely wrong and a danger to children. Where did the 8 year old figure come from? A focus group? End of quote, repeat the line. https://t.co/fMF8QnVrCI

— Chloe Cole ⭐️ (@ChoooCole) September 12, 2022