Activism for the rights, medical treatment, and well being of trans and gender diverse youth must continue—just with a little more nuance and respect for research and the scientific process.
This is the first thing that The One Percent has posted that's got me a bit frustrated. If we are talking about transition-related healthcare in terms of "effective treatment" it begs the question of what exactly we expect hormones and surgeries to do for a person psychologically, and what constitutes "damage" in that arena.
The vast majority of the trans people I know do not think of gender-related healthcare in these terms, but rather in terms of bodily autonomy, where a gender-related diagnosis is a necessary evil to be able to exert desired control over the shape of one's body. It's not comparable to cancer treatments because it's not a "treatment" for anyone but a tiny number of people whose distress is extreme-- trans people have leaned on "I need this or I'll die" rhetoric even where it isn't accurate to every individual because there are so many hurdles between simply allowing us to do with our bodies as we please.
The primary lack of trust is between patients and clinicians because of a history where "because I just want to" is not seen as a good enough reason to transition, and between children and parents who believe they are incompetent to make this specific decision-- as if any other decision made by or on behalf of a child is not equally as "life-changing and irreversible". Everyone clutches their pearls over hormones and top surgery in a way that we don't for, say, letting children risk traumatic brain injuries playing football, or deciding whether to teach them another language, or raising them in church.
When I started testosterone at 21, I personally did not know for sure if hormones were going to "solve" anything for me-- I didn't know if testosterone would cure my dysphoria, let me "pass" as a man at least some of the time, if it would even effect me in the ways I was hoping for (or if it might change my body in ways that might distress me more than what I was already working with). I couldn't afford a gender therapist and didn't think one would help anyway, so I talked to trans friends instead (most of them my own age and, yes, on Tumblr) and the general advice was merely that transition is a trust fall; hormones only do what hormones can do, and "fixing you" is not on that list. But you can transition if you feel like it, and you can move at whatever speed you like, and if it sucks, you can stop! And I simply decided that, whatever came of it, I would more gladly cross that bridge of "regret" when I came to it than spend my life wondering about what could have been.
As it turns out, starting testosterone was one of the best things I have ever done for myself, one of the few big decisions I have been 100% certain I was correct on, even though I had no way of knowing that at the time. I obviously can't (and don't) promise that anyone who takes the same trust fall will be so lucky, but this way of discussing transition ahead of time-- as an expression of agency in itself, a validation of my right to make choices for my own future-- was highly effective for foreclosing on the very possibility of regret for me. This sort of framing is basically nonexistant in the cacophany of discussion about trans children because we already presume that children are incompetent to make their own decisions this way, and it loads all kinds of baggage onto adults to likewise justify why transition must be something other than what it is: a choice about one's future which is *always, necessarily* both reasoned and limited.
I think Jules Gill-Peterson (Histories of the Transgender Child) and Andrea Long Chu (My New Vagina Won't Make Me Happy) are the only people I have seen who openly advocate that the possibility of regret (or the failure to "cure" something) should not stop anyone from transitioning, even though it's maybe the most consistent attitude I have seen among the millennial generation of Tumblr Trans Kids that everyone loves to roll their eyes at. The use of children, autistic people, and people on the internet as euphemisms for people whose agency should be questioned and limited, and the inability to talk about transition in terms of bodily autonomy, are consistent problems in reporting-- it's why people are mad at the New York Times and the Atlantic, and why this piece kind of throws me off. I expected The One Percent to already be conscious of all this and not fall into hand-wringing about what young people decide to do with their own lives.
Thanks again for these comments, Jesse. We are on Substack to share research-based information about detransition/retransition and to give voice to a wide range of community perspectives. The three of us chatted about your comment and agree with many of your points, but wanted to also offer these points in response:
In the literature and in both of our studies (some are published, some are on the way to being published), we’ve seen many people who sought medical transition in the hope that it would resolve deep-seated issues or who had very high (sometimes unrealistic) expectations about treatment. As you mentioned, we’ve also seen people who made a connection between their gender transition and previous psychological issues (psychiatric diagnoses or more general problems such as low self-esteem), wishing they had received more support in the decision-making process. Other times, having never been formally assessed by clinicians as part of making treatment decisions, people detransition after receiving a new diagnosis (this seems to more often happen most frequently with ASD and BPD). Of course, many trans people who are thrilled with transition also have these diagnoses and will never detransition, but the experiences and thoughts shared in the post above are real and representative of many detrans folks - are there also other perspectives? Absolutely.
From our respective studies, and other published literature, some people consciously or unconsciously transitioned because they were suffering and wanted to feel better. Trans care is tricky, because people pursue treatments for different reasons. Some want bodily autonomy/expression and trans joy; while others are trying to find relief from pain; and many do want to have a formal GD diagnosis and support and guidance from clinicians. Clinicians debate what ought to even be thought of as a positive or negative outcome of treatments, which raises ethical dilemmas - especially when you have a group of young people start emerging who feel hurt or let down by treatment. All outcomes must be researched and considered.
We have a longer essay we are going to publish in the coming weeks on this, that relates to one of your points: the push to promote wide-reaching psychological benefits/reductions in suicidality from treatment that happened via research and activism 10-15 years ago was a strategic move to improve access to care. But this message was also taken at face value by some people accessing this care (and parents, and many clinicians), particularly in a pediatric context. This is important to understand when hearing from detransitioners who feel lied to and then frustrated with community indifference towards their regret. Very complicated situation where trans medical treatments are envisioned as different things by divergent groups (trans, detrans, clinicians, researchers, etc).
We all completely agree that transition is a transformative experience, so you can’t fully grasp its implications beforehand. It is very hard, if impossible, to reliably predict where a transition goes 5, 10, 15, 20 years into the future. However, research on detransition does highlight the need for stronger informed consent practices, which are not necessarily at odds with bodily autonomy. At worst, stronger informed consent practices will improve decision-making by providing people with more information. This approach to clinical practice could also help to explore patients' values, and more pro-actively explore subjective expectations for treatment, setting realistic goals, etc. But this is also quite different if we are talking about a young adult, versus an older adolescent, versus a parent making a medical decision on behalf of a 10, 11, or 12 year old child.
Thanks again for offering some feedback and we always welcome questions and comments.
Sure. I know that your purpose here is to spread more information, to strengthen informed consent, which I completely agree with. But this piece has a frankly clickbait title and is not about the need for informed consent, it's about the way the author thinks that activists have gone wrong, with apparently not enough "respect for the scientific process."
I suppose I just don't find this piece informative. Why does it matter that the demographics have changed as to the sex of who is seeking out transition-related healthcare, or that more people are doing it? Why is it relevant that they're often teenagers, or autistic? Of course I want to know why, of course I want to see more studies and arm doctors with more knowledge, but calling it "the cost of overzealous activism" is implying there should be some inherent cause for concern. What exactly does "discussing medicine separate from identity" even mean? Why even is it that doctors or people on tv should shoulder the responsibility of giving nuanced guidance through transition-- is that actually their job, or someone else's?
I ask all these rhetorically-- I'm sure you could write an essay on each one, and maybe you already have plans to! I just mean that you must understand that leaving these answers implied is begging a lot of questions from both a trans audience and a trans-antagonistic one-- as in, two groups of very likely to gravitate to this newsletter. It feels very strange to read this piece and then re-read the prior piece linked at the end, to find that this one follows basically none of the earlier's advice. You dedicated a whole post to what is wrong with the comparison between transition healthcare and knee surgery regret rates-- a good post, I thought!-- but here we are comparing puberty blockers to experimental cancer treatment.
Considering that I write fairly consistently about my own mixed feelings about trans culture and my place in the landscape of medical gatekeeping, I know how hard it is. Part of the nuance *I* try to hold is in understanding what implications I make to a mixed audience of people who know next-to-nothing about trans issues *and* people who have very strong feelings about it in opposing directions. If this piece is what you consider simply "sharing other perspectives," then this goal may turn out to be at odds with the goal of educating the public about value-laden conflicts in interpreting research. I really think you've at least got to be clear about *what* values a given testimonial is bringing to the table-- the NYT got in so much trouble for a piece that was honestly pretty even-handed, in my opinion, then you know how high the bar is set for communication if you want to lower temperatures rather than raising them.
Thanks Jesse, for taking the time to provide such a thoughtful response. We appreciate this and agree with a lot of it. There is a lot to chew on and we will respond back to some of your points and questions in the coming days.
1. if we’re talking about surgical modification of the genitals that doesn’t reflect the minor’s truly informed, persistent, insistent, consistent identity and best interest, how about non-consensual genital cutting of young boys as a comparison? Causes more pre-pubertal total penile loss in the US than trans youth surgery in even the worst nightmares of anti-autonomy people.
2. I had a client who had been in the evaluation at one of the two gender clinics in Finland, and his case dragged on and on and finally they just gave him the F64.9 diagnosis on grounds that he wasn’t doing well enough in education and employment, and he couldn’t express his feelings verbally with enough insight and nuance. So he was a LOT like an average Finnish guy! So if you’re too much like the stereotype of the gender to which you wish to transition, that’s not good either.
And some colleagues have the gall to wonder why trans patients seem to come to us with a script they’ve learned from somewhere…
3. I would not prescribe hormonal treatment to a young patient without spending a LOT of time with them (even if I worked at a gender clinic, or in a country where it’s done more widely). I know it’s a cop out, but I don’t trust my skills enough.
4. On the fourth hand, for topical hormone treatments, you do have to apply them at home every day and — notoriously — the external changes aren’t sudden or gigantic (at first). Since the person using HRT isn’t suffering from impaired judgment the way a person with e.g. schizophrenia is, it’s reasonable to ask someone who told essentially unchanging narrative persistently, consistently, to different clinicians, for months, to also bear some responsibility for telling the truth to their clinicians or, if they mislead them, using the HRT, day in, day out, for years while knowing they didn’t really meet the diagnosis criteria in full honesty.
Agreed. The only pushback on the article is that it still employs some activist terms such as “assigned female at birth,” and “trans youth” instead of “trans-identified youth.” But I wholeheartedly endorse the spirit of this article, and will be saving it for future conversations with those with whom I disagree.
This is the first thing that The One Percent has posted that's got me a bit frustrated. If we are talking about transition-related healthcare in terms of "effective treatment" it begs the question of what exactly we expect hormones and surgeries to do for a person psychologically, and what constitutes "damage" in that arena.
The vast majority of the trans people I know do not think of gender-related healthcare in these terms, but rather in terms of bodily autonomy, where a gender-related diagnosis is a necessary evil to be able to exert desired control over the shape of one's body. It's not comparable to cancer treatments because it's not a "treatment" for anyone but a tiny number of people whose distress is extreme-- trans people have leaned on "I need this or I'll die" rhetoric even where it isn't accurate to every individual because there are so many hurdles between simply allowing us to do with our bodies as we please.
The primary lack of trust is between patients and clinicians because of a history where "because I just want to" is not seen as a good enough reason to transition, and between children and parents who believe they are incompetent to make this specific decision-- as if any other decision made by or on behalf of a child is not equally as "life-changing and irreversible". Everyone clutches their pearls over hormones and top surgery in a way that we don't for, say, letting children risk traumatic brain injuries playing football, or deciding whether to teach them another language, or raising them in church.
When I started testosterone at 21, I personally did not know for sure if hormones were going to "solve" anything for me-- I didn't know if testosterone would cure my dysphoria, let me "pass" as a man at least some of the time, if it would even effect me in the ways I was hoping for (or if it might change my body in ways that might distress me more than what I was already working with). I couldn't afford a gender therapist and didn't think one would help anyway, so I talked to trans friends instead (most of them my own age and, yes, on Tumblr) and the general advice was merely that transition is a trust fall; hormones only do what hormones can do, and "fixing you" is not on that list. But you can transition if you feel like it, and you can move at whatever speed you like, and if it sucks, you can stop! And I simply decided that, whatever came of it, I would more gladly cross that bridge of "regret" when I came to it than spend my life wondering about what could have been.
As it turns out, starting testosterone was one of the best things I have ever done for myself, one of the few big decisions I have been 100% certain I was correct on, even though I had no way of knowing that at the time. I obviously can't (and don't) promise that anyone who takes the same trust fall will be so lucky, but this way of discussing transition ahead of time-- as an expression of agency in itself, a validation of my right to make choices for my own future-- was highly effective for foreclosing on the very possibility of regret for me. This sort of framing is basically nonexistant in the cacophany of discussion about trans children because we already presume that children are incompetent to make their own decisions this way, and it loads all kinds of baggage onto adults to likewise justify why transition must be something other than what it is: a choice about one's future which is *always, necessarily* both reasoned and limited.
I think Jules Gill-Peterson (Histories of the Transgender Child) and Andrea Long Chu (My New Vagina Won't Make Me Happy) are the only people I have seen who openly advocate that the possibility of regret (or the failure to "cure" something) should not stop anyone from transitioning, even though it's maybe the most consistent attitude I have seen among the millennial generation of Tumblr Trans Kids that everyone loves to roll their eyes at. The use of children, autistic people, and people on the internet as euphemisms for people whose agency should be questioned and limited, and the inability to talk about transition in terms of bodily autonomy, are consistent problems in reporting-- it's why people are mad at the New York Times and the Atlantic, and why this piece kind of throws me off. I expected The One Percent to already be conscious of all this and not fall into hand-wringing about what young people decide to do with their own lives.
Thanks again for these comments, Jesse. We are on Substack to share research-based information about detransition/retransition and to give voice to a wide range of community perspectives. The three of us chatted about your comment and agree with many of your points, but wanted to also offer these points in response:
In the literature and in both of our studies (some are published, some are on the way to being published), we’ve seen many people who sought medical transition in the hope that it would resolve deep-seated issues or who had very high (sometimes unrealistic) expectations about treatment. As you mentioned, we’ve also seen people who made a connection between their gender transition and previous psychological issues (psychiatric diagnoses or more general problems such as low self-esteem), wishing they had received more support in the decision-making process. Other times, having never been formally assessed by clinicians as part of making treatment decisions, people detransition after receiving a new diagnosis (this seems to more often happen most frequently with ASD and BPD). Of course, many trans people who are thrilled with transition also have these diagnoses and will never detransition, but the experiences and thoughts shared in the post above are real and representative of many detrans folks - are there also other perspectives? Absolutely.
From our respective studies, and other published literature, some people consciously or unconsciously transitioned because they were suffering and wanted to feel better. Trans care is tricky, because people pursue treatments for different reasons. Some want bodily autonomy/expression and trans joy; while others are trying to find relief from pain; and many do want to have a formal GD diagnosis and support and guidance from clinicians. Clinicians debate what ought to even be thought of as a positive or negative outcome of treatments, which raises ethical dilemmas - especially when you have a group of young people start emerging who feel hurt or let down by treatment. All outcomes must be researched and considered.
We have a longer essay we are going to publish in the coming weeks on this, that relates to one of your points: the push to promote wide-reaching psychological benefits/reductions in suicidality from treatment that happened via research and activism 10-15 years ago was a strategic move to improve access to care. But this message was also taken at face value by some people accessing this care (and parents, and many clinicians), particularly in a pediatric context. This is important to understand when hearing from detransitioners who feel lied to and then frustrated with community indifference towards their regret. Very complicated situation where trans medical treatments are envisioned as different things by divergent groups (trans, detrans, clinicians, researchers, etc).
We all completely agree that transition is a transformative experience, so you can’t fully grasp its implications beforehand. It is very hard, if impossible, to reliably predict where a transition goes 5, 10, 15, 20 years into the future. However, research on detransition does highlight the need for stronger informed consent practices, which are not necessarily at odds with bodily autonomy. At worst, stronger informed consent practices will improve decision-making by providing people with more information. This approach to clinical practice could also help to explore patients' values, and more pro-actively explore subjective expectations for treatment, setting realistic goals, etc. But this is also quite different if we are talking about a young adult, versus an older adolescent, versus a parent making a medical decision on behalf of a 10, 11, or 12 year old child.
Thanks again for offering some feedback and we always welcome questions and comments.
Sure. I know that your purpose here is to spread more information, to strengthen informed consent, which I completely agree with. But this piece has a frankly clickbait title and is not about the need for informed consent, it's about the way the author thinks that activists have gone wrong, with apparently not enough "respect for the scientific process."
I suppose I just don't find this piece informative. Why does it matter that the demographics have changed as to the sex of who is seeking out transition-related healthcare, or that more people are doing it? Why is it relevant that they're often teenagers, or autistic? Of course I want to know why, of course I want to see more studies and arm doctors with more knowledge, but calling it "the cost of overzealous activism" is implying there should be some inherent cause for concern. What exactly does "discussing medicine separate from identity" even mean? Why even is it that doctors or people on tv should shoulder the responsibility of giving nuanced guidance through transition-- is that actually their job, or someone else's?
I ask all these rhetorically-- I'm sure you could write an essay on each one, and maybe you already have plans to! I just mean that you must understand that leaving these answers implied is begging a lot of questions from both a trans audience and a trans-antagonistic one-- as in, two groups of very likely to gravitate to this newsletter. It feels very strange to read this piece and then re-read the prior piece linked at the end, to find that this one follows basically none of the earlier's advice. You dedicated a whole post to what is wrong with the comparison between transition healthcare and knee surgery regret rates-- a good post, I thought!-- but here we are comparing puberty blockers to experimental cancer treatment.
Considering that I write fairly consistently about my own mixed feelings about trans culture and my place in the landscape of medical gatekeeping, I know how hard it is. Part of the nuance *I* try to hold is in understanding what implications I make to a mixed audience of people who know next-to-nothing about trans issues *and* people who have very strong feelings about it in opposing directions. If this piece is what you consider simply "sharing other perspectives," then this goal may turn out to be at odds with the goal of educating the public about value-laden conflicts in interpreting research. I really think you've at least got to be clear about *what* values a given testimonial is bringing to the table-- the NYT got in so much trouble for a piece that was honestly pretty even-handed, in my opinion, then you know how high the bar is set for communication if you want to lower temperatures rather than raising them.
Thanks for sharing your thoughts, Jesse. We appreciate hearing from you!
Thanks Jesse, for taking the time to provide such a thoughtful response. We appreciate this and agree with a lot of it. There is a lot to chew on and we will respond back to some of your points and questions in the coming days.
Much appreciated. 👍
1. if we’re talking about surgical modification of the genitals that doesn’t reflect the minor’s truly informed, persistent, insistent, consistent identity and best interest, how about non-consensual genital cutting of young boys as a comparison? Causes more pre-pubertal total penile loss in the US than trans youth surgery in even the worst nightmares of anti-autonomy people.
2. I had a client who had been in the evaluation at one of the two gender clinics in Finland, and his case dragged on and on and finally they just gave him the F64.9 diagnosis on grounds that he wasn’t doing well enough in education and employment, and he couldn’t express his feelings verbally with enough insight and nuance. So he was a LOT like an average Finnish guy! So if you’re too much like the stereotype of the gender to which you wish to transition, that’s not good either.
And some colleagues have the gall to wonder why trans patients seem to come to us with a script they’ve learned from somewhere…
3. I would not prescribe hormonal treatment to a young patient without spending a LOT of time with them (even if I worked at a gender clinic, or in a country where it’s done more widely). I know it’s a cop out, but I don’t trust my skills enough.
4. On the fourth hand, for topical hormone treatments, you do have to apply them at home every day and — notoriously — the external changes aren’t sudden or gigantic (at first). Since the person using HRT isn’t suffering from impaired judgment the way a person with e.g. schizophrenia is, it’s reasonable to ask someone who told essentially unchanging narrative persistently, consistently, to different clinicians, for months, to also bear some responsibility for telling the truth to their clinicians or, if they mislead them, using the HRT, day in, day out, for years while knowing they didn’t really meet the diagnosis criteria in full honesty.
Methodical and useful statement on how we got here and how to unpick the stalemate. Clinicians, researchers and activists take note.
Agreed. The only pushback on the article is that it still employs some activist terms such as “assigned female at birth,” and “trans youth” instead of “trans-identified youth.” But I wholeheartedly endorse the spirit of this article, and will be saving it for future conversations with those with whom I disagree.
Socially or medically “transitioning” children is child abuse.