From the Washington Monthly we hear of a brand-new book published by the prestigious American Psychiatric Association (APA), a book dealing with (and all gung ho for) “gender-affirming” care. You know what that is: it’s the care that goes to a child with gender dysphoria, taking him or her directly to a therapist or doctor who affirms the child’s feelings of being born in the “wrong” body, then to prescribing puberty blockers and other hormones, and, then if the patient wants it, to excision of body parts: operations on genitalia and removal of breasts, along with hormone treatment that eliminates a patient’s ability to have an orgasm.
Click below see the book on Amazon. It’s $58 and, as you see below it, the 18 ratings on Amazon so far aren’t very laudatory. But according to Amazon it came out only on January 7, and the gender activists haven’t yet weighed in. But they will after they read psychiatrist Sally Satel‘s critical take.
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Why such poor reviews? Perhaps, as Sally notes in her description of the book in Washington Monthly, because it’s written by gender-affirming advocates and is woefully short on warnings about possible dangers of this kind of medical and psychiatric care. Nor does it appear to offer any alternative care that doesn’t wind up with hormone therapy.
Click to read:
Although the book is published by the APA, it doesn’t constitute “official APA guidance.” But here’s psychiatrist Sally Satel’s take (excerpts indented, bolding is mine):
Last fall, the APA’s publishing arm issued a textbook called Gender-Affirming Psychiatric Care. Described in accompanying promotional material as an “indispensable” resource, the book is written for mental health and primary care clinicians. The publisher, American Psychiatric Association Publishing, APPI, hails it as “the first textbook in the field to provide an affirming, intersectional, and evidence-informed approach to caring for transgender, non-binary, and/or gender-expansive (TNG) people.”
The “affirming, intersectional” textbook is not official APA guidance. Still, APA Publishing describes it as “rigorous” and “an expert view from fields that include psychiatry, psychology, social work, nursing, pharmacy, public health, law, business, community activism, and more. And because each of the 26 chapters features at least one TNG author, wisdom gleaned from lived experience bolsters the professional perspective provided throughout the book.” One would hope that “lived experience” might enhance the scholarship, but that is not the case here.
Affirming care for children with gender dysphoria, a condition that, according to the APA, refers to individuals who suffer from “a marked incongruence between one’s experienced/expressed gender and assigned gender [at birth],” is a major subject of the book. Unfortunately, though billed as a compendium of “best practices,” Gender-Affirming Psychiatric Care, instead of providing even-handed analyses of the controversies within a still-evolving topic of great clinical and social importance regarding the science of treating gender dysphoric youth, the volume approaches it as a settled matter when it is not.
The textbook’s treatment philosophy is that if a child or teen desires transitional steps, then the physicians should proceed, taking the patient’s request on its face. According to the authors, “Clinicians should … always allow patients autonomy in their care.” The authors further advocate for puberty blockers (chemicals that suppress the natural hormonal development and the appearance of secondary sexual traits) and then cross-sex hormones (estrogen or testosterone) to produce the physical characteristics aligned with the patient’s gender identity.
When it comes to gender-affirming surgery (which, for natal girls, can entail the removal of breasts, uterus, and ovaries, as well as penile construction; and for natal boys, involves the genital removal and the creation of a vaginal canal), patients first require a psychiatric evaluation before surgical consultation. In this evaluation, the authors say that “the [mental health] clinician should never place barriers to surgery, only identify those that exist and assist with overcoming them.” (Emphasis added.) While the final decision to operate ultimately lies with the surgeon, who is tasked with obtaining informed consent from the patient and guardian, a psychiatric greenlight is also necessary. Surely, there are times when a yellow or red light is appropriate. It’s telling that a book of 420 pages only mentions guardians once and in the context of saying that guardians and parents (who get five mentions) should not be part of decisions concerning their transitioning kids’ medical data. Parents are referenced only in the context of being unsupportive to their children’s desire to transition.
Satel has other beef. The book doesn’t cover the fate of youths who aren’t given this kind of care, many of whom become gay or no longer gender-dysphoric without affirmative treatments; the book doesn’t cover those who de-transition or reverse the process when it’s going on before medical treatment (“desisters”); the book doesn’t describe alternative treatments in which therapists don’t automatically buy into the patient’s wishes and narratives; and, most important, and, most important, the book doesn’t warn of the potential dangers of some of the medical treatments—dangers recognized by other Western countries.
First is the need for more objective care:
As a practicing psychiatrist, I would expect this volume to probe how to conduct productive interviews with all patients, especially children and young teens, who consider themselves candidates for a gender-affirming approach. After all, this is a book from the American Psychiatric Association’s publishing arm. As such, it should advise clinicians to examine, over many sessions, patients’ experiences and developmental struggles (such as emerging sexuality and identity formation), to learn about their home lives and social worlds, as well as to treat them for the frequent co-occurring issues, such as depression, anxiety, and posttraumatic stress disorder, which sometimes manifest as gender dysphoria in youth.
This would seem to be at the heart of any responsible psychiatric assessment of whether chemical intervention (which can be irreversible) and procedures as life-altering as “confirmation surgery” should be recommended. However, oddly, such foundational steps are ignored.
Here’s Satel on the lack of discussion of the dangers of affirmative therapy (again, we’re talking about young people who may not be mature enough to make such important decisions). To me, this almost verges on academic malpractice:
Finally, a reader gets no sense that gender-affirming care is the subject of vigorous international scientific debate. Remarkably, the textbook does not mention that in 2020, the United Kingdom’s National Health Service commissioned a comprehensive review of puberty blockers and cross-sex hormones and concluded that “the available evidence was not deemed strong enough to form the basis of a policy position” on their use. Similarly, in 2022, Sweden’s National Board of Health and Welfare suspended hormone therapy for minors except in very rare cases and limited mastectomies to research settings. Likewise, the Norwegian Healthcare Investigation Board now defines all medical and surgical interventions for youth as “experimental treatment,” and the French National Academy of Medicine advises caution in pediatric gender transition.
Regardless of the authors’ personal views, a textbook that is advertised as “rigorous—and timely” as well as “informative” should, at the very least, acknowledge, and ideally explore, the tension between the European and American approaches and elucidate the concerns raised by European medical authorities.
Why the lacunae? As Satel notes, every chapter has at least one likely gender-activist author (“TNG”), and this has resulted in the sorry situation where the APA gives its imprimatur to treatment that might be dangerous or, at best, ineffective. Do note, however, that Satel also opposes state-imposed bans or limits on treatment for adults.
Gender activism is one thing, but when it comes with the imprimatur of the APA and without mention of either alternative therapies nor warnings about the dangers of medical care that have been recognized by other countries, that activism is irresponsible.
The worst thing one can say about this book is that it’s probably going to be highly recommended by ACLU lawyer Chase Strangio.
That’s an extremely worrying review – I can’t think of any other branch of healthcare were such a one-sided approach would be considered acceptable, yet alone ethical.
In a related phenomenon, we have the DEI capture of the medical school establishment in the US (see Stanley Goldfarb’s discouraging and mordantly funny
“Take Two Aspirins and Call Me By My Pronouns”). I wonder why the US medical establishment (and outfits like the APA) is so susceptible to woke fashion crazes, including the genderism variety—in apparent contrast to the medical establishments of France, the UK, and the Nordic countries. Is it related to the fact that the latter
societies all have national health systems, in contrast to the US? Or are there other
differences, e.g. in medical training, that might account for the difference?
I suggest that woke fashion crazes are worse in the US because (1) wokeism developed in the context of race, and (2) race relations are way worse in the US than in the Europe. After wokeism had obtained a stranglehold on the discourse over race in the US (and dissent from that narrative was banished from the mainstream), it was then relatively easy to extend that stranglehold to trans issues.
As a Norwegian, I think the answer is, as you suggest: all about money. Seeing what’s happening in the US, I can’t imagine it can ever be so crazy here i Scandinavia.
I don’t agree with Bjorn wrt money. Canada has a health system that is fully publicly funded and similar to Scandinavia (there are some differences of course), but our medical establishment is a rainbow alphabet of two-spirit gender-affirming care (cf. the Amy Hamm fiasco in which a nurse is persecuted by her professional accrediting organization for saying that males can’t be women).
The US has far more extreme politics (and sadly exporting it with great effect). If the transgender trend had originated in Europe, it would have been hampered by the consensus-seeking style of politics that prevails there.
Where do you think “the Dutch protocol” for children was invented? And where is the NHS’s GIDS clinic aka Tavistock located? The socialist-humanist-conformist utopias in Scandinavia have been doing this for years, quietly and discreetly. OK, they did think they were doing God’s work, humbly correcting His mistakes, because medicine just isn’t all that lucrative in Europe, except for niche private practice to aristocrats. It’s also true that America’s militant wokeness and its propensity to monetize a social trend and make large fortunes off it are a force unique in the world. But it is also the place where courageous whistle-blowers have spoken out and laws are starting to change to protect children. And rich doctors and hospitals attract large lawsuits.
In Europe, there is now bureaucratic resistance but no legislation. In Canada not even that, so far, only doubling down.
Historians are going to look back on this as a scandal worse than lobotomy.
Imagine telling Freud and his contemporaries that 100 years in the future psychologists and psychiatrists will have access to MRIs and anticonvulsants and genetic screens for psychosis, but we’ll also have “gender-affirming” care, Tik-Tok, and power posing.
Scary. Let’s hope that more sober minds weigh in with the appropriate critiques of this position. Doctors who truly care about the mental health of children need to get hold of this fad and expose it as the danger it is.
My niece’s 16 year old daughter has asked to be called “they” and my niece is doing it. Let’s hope it’s a passing phase and doesn’t move to medical measures.
First step in a dangerous development is to give in to the pronoun demand.
Of course, in treating psychological conditions, it’s always a good idea and good medical practice just to let the patient choose the course of treatment, especially when the patient is an adolescent. Medical practitioners have undertaken years of education and training precisely so they can be valets providing exactly the medications, therapies and surgeries that such patients request.
My sarcasm tags disappeared…back to the drawing board.
Oh no, we got it! “Valets” was the tell.
In the 1960s, “radical psychiatry” was deemed radical because it held that schizophrenic delusions should be approached with empathy for the psychological struggle that underlay them. But R.D. Laing, Thomas Szasz, Claude Steiner, and the rest never advised that sport regulations, law, and the English language itself should be reconstructed to “affirm” delusions of people who claimed to be born in the wrong body. And the idea of endocrinological and surgical intervention to reconstruct their actual bodies in line with their delusion would have been limited to horror stories, back in those days. Something really has changed. One wonders why.
This is a good 20-minute presentation by Finland’s Dr. Kaltiala who is
“Riittakerttu Kaltiala is a professor of adolescent psychiatry, leader of one of the two nationally centralized gender identity units for minors in Finland, and committee member for national guidelines for health services related to medical and surgical gender reassignment. Dr. Kaltiala was the first leader of a national pediatric gender clinic to raise concerns regarding the risk-benefit ratio of treating gender dysphoric youth with puberty blockers and cross-sex hormones. ”
Thanks for the link.
The Amazon sample text of chapter headings was more than enough reason not want to have to try to read the book. But I found an page that explains how they struggled to hammer home their inclusive righteousness (or whatever this is):
” The “big acronym”: Similarly, there are many different acronyms for broader not-straight, not-cisgender, not-endosex communities, including lesbian, gay, bisexual, transgender; queer, intersex, asexual, and more (LGBTQIA +) or the more truncated LGBTQ+. Some include Two-Spirit (2S) in this acronym (2SLGBTQIA+), to explicitly name and acknowledge Indigenous identities and knowledges. We want to be specific in our terminology and to be inclusive in content rather than with lip-service alone; accordingly, we sought to include the IA when the work includes and pertains to intersex and asexual people and the 2S…”
Like trying to read the equivalent of fingernails on a chalkboard.
I can see why there is no Audio file version for this.
So sorry for over-commenting but “non-endosex communities”? WTF?
You really have to check out the editor Teddy Goetz: they/them, expensive haircuts, endless array of funky eyewear, bowties and suit jackets, all in the quest to blur an obvious female physique.
https://www.teddygoetz.com
Their (ha ha) web site features papers including this one that I hope Jerry might follow up:
“Using Animal Models for Gender-Affirming Hormone Therapy”
Krisha Aghi, Teddy G Goetz, Daniel R Pfau, Simón(e) D Sun, Eartha Mae Guthman, Troy A Roepke
Journal of the Endocrine Society, Volume 8, Issue 1, January 2024, bvad144, https://doi.org/10.1210/jendso/bvad144
The authors are a pot pourri of medical trans activists (we’ve met Simón(e) D Sun before in these pages). They propose to use mouse or rat experiments to document the beneficial effects of cross-sex hormones on mental health. I hope Jerry will review this and give us an opportunity to discuss the many ways in which such research is as dumb as a sack of hammers.
Just read the article: “We have recently proposed experimental design guidelines and areas of study for preclinical rodent models of gender-affirming hormone therapy in neuroscience.”
Just when I thought it couldn’t get any worse, it does.
The papers are really incredible. Mice and rats are among the *least* sexually dimorphic mammals. Imagine what it means for a mouse to have a gender identity, or for puberty blockers to delay the development of that identity, or for cross-sex hormones to change it.
Or imagine what it means to measure the effects of PBs and hormones on the mental health of a mouse. I’m sure an enterprising psychologist could come up with something (after all, they invented power posing). But in what way could it possibly be a model of gender dysphoria and the “benefits of gender-affirming care” in a 13-year-old aspie tomboy who’s been sexually abused and who, with some good counselling, could grow up to be a perfectly good lesbian if only Dr. Goetz would just leave her alone?
+1
From Teddy Goetz’s site: “Their lived experience as a non-binary/trans, queer, neurodivergent, chronically ill, Jewish person informs their writing, research, and clinical work.”
I’m too old for this.
I have forwarded this t PETA. They will not like it.
Sending study to PETA is a smart idea. (After reading Goetz I got stuck just thinking “But… that’s insane!” and found it difficult to think clearly after that.)
Will they at least provide the mice/rats with tiny gendered clothes, toys, makeup, whatever, to find out how effective is the study?
I hadn’t seen this “marker” in a bio before – “chronically ill.” Teddy’s bio includes, “Their lived experience as a non-binary/trans, queer, neurodivergent, chronically ill, Jewish person informs their writing, research, and clinical work.” Good grief!
Regarding:
Satel is 100% wrong on this. Here’s what Leslie MacMillan posted on this website a while ago – and he is, as is often the case, right on target (emphasis added):
Having said that, I could also support unprescribed, over-the-counter do-it-yourself cross-sex hormone consumption as a body-modification manoeuvre, like tattooing or piercing, in consenting adults. Hormones, while they have risks, are safer and less socially disruptive than alcohol and even cannabis, although the latter two drugs taken as part of a similar spiritual journey have fewer irreversible effects. Doctors would continue to treat complications of any lapse in wisdom just like we do now, but we wouldn’t be responsible (and liable) for a person’s decision to embark on it. “DIY” hormone therapy has been proposed seriously in the empowerment literature. If gender nonconformity is not even regarded as a “disease” but is simply on the spectrum of normal, why are doctors getting paid to “treat” it?
This would eliminate a double-bind for doctors, where we can be disciplined as hateful transphobes with licence suspensions if we don’t affirm by prescribing whatever the patient wants —even psychological assessments are condemned as trammelling autonomy — , yet we might be liable years later for those permanent effects in patients who then regret the decision and claim we didn’t obtain adequate informed consent. Since pharmacists, who now give medical advice, would then be liable for their counselling, it might be better to leave piles of boxes and vials of these drugs on the floor of the drugstore near the doors where they can be efficiently shoplifted by all who want them without anyone having later to answer uncomfortable questions.
I can see this matter, like other drugs with no claimed medical uses, resolving in two directions: legislative bans for minors and laissez-faire libertarianism for adults. That needn’t mean that men can become (or always were) women. It just removes medical involvement from a non-medical decision where it is resented in the first place.
see the new doc “the war on children.” Im asked why I get agitated about “people just wanting to feel free to express themselves.” No big issues there…even if a bit shocking. My biggest issue is with what is objective vs subjective reality. Advocates for the transsexual movement are asking us to replace objective reality with the subjective, in the name of “kindness.” For the first time in my life I am questioning how society defines “mental illness.” I suspect the criteria they use is somewhat based on 1. proportion of society it applies to 2. how efficable it’s treatment is. This exploding phenomenon is corrupting the universal search for the truth. Look at some of the weaponized language used. Sincerely, a university educated, cis-hetero-normative, neuro-divergent, agnostic, patriarchal omnivore from a high status, oppressive class, living at the poverty level in a town where the blog owner went to undergrad. Now validate me or you’re a nazi.
“To me, this almost verges on academic malpractice . . .”
I’ll suggest that it crossed that line. I know that some of your commenters want more science posts rather than ones about the politics of science, but I respectfully disagree, for now. A future PCC(E) will find precious little science worth posting about if the ideological rot continues.
Lots of teenagers are unhappy with their bodies. If we gave them hormone treatments for bigger muscles and nicer tits, their quality of life would certainly improve! And the downsides seem a lot lower.
“Hormone treatments for bigger muscles” such as the ones sold under the counter at your local bodybuilding gym? Whose side effects merely include fits of rage, shrinking testicles, heart damage, hair loss and a few other inconveniences, but hopefully not lifelong infertility? Not sure if I’m 100% on board with that recommendation.
Hormone treatments for nicer tits, on the other hand… that would be a worthwhile field of research. Not likely to get public grant money ATM, but I’m sure some companies would be willing to fund it.
Lots of teenagers are “unhappy” with everything without recognising how fortunate they are.
I am concerned that the author, who should be a leader in the field, hasn’t even completed residency???! Us on the west coast have one of those Dr. Jack L. Turban, who is considered authority on the subject and publishes papers twice a week, completed Psychiatry Residency in 2020 and Child and Adolescent Psychiatry Fellowship in 2022 and already has a title of Assistant Professor at UCSF… I considered attending a conference on the topic recently and all the speakers were in the residency or freshly out of it…
It seems like there is a lot of opportunism among the experts in Transgender Medicine