The dangers of gender-affirmative care

The Biden administration recently announced a plan to ban “conversion therapy” and dismantle barriers to “gender-affirming care” for transgender-identifying children and adolescents. A few days later, Congresswoman Pramila Jayapal introduced the  “Transgender Bill of Rights” on Capitol Hill which sought to legislate what the Biden Administration proposed to impose by executive order.

On this issue, the Democratic Party assumes the mantle of righteousness. Who could oppose “life-saving” “gender-affirming care”? Who supports “conversion therapy”, which the Biden administration described as “a discredited and dangerous practice that seeks to suppress or change the sexual orientation or gender identity of LGBTQI+ people”?

The reality diverges sharply from the loaded language the Biden Administration deploys, lifting terms directly from the most radical trans activists occupying positions at the outermost extreme of an ongoing debate between different factions of gender clinicians.

The dispute over how best to treat gender-questioning children that the Biden Administration seeks to resolve by enshrining “gender-affirming care” and stigmatising “conversion therapy” boils down to whether or not clinicians regard the children in their care as exceptions to everything we know about child development, human biology, sexual orientation, and more. Attending closely to the language of the activists with whom the Biden Administration has sided provides a masterclass in how to manipulate language to normalise risky and invasive medical intervention on a class of people — children — who are widely understood to be unable to provide consent in other contexts.

For exploratory providers, a child’s transgender identification is the beginning of a clinical inquiry that will travel through the individual patient’s biography, their social context, and the templates the culture at large offers that young patients use to make sense of suffering. Nothing magical or transformative happens when a patient experiences gender dysphoria or expresses a transgender identity. Children and adolescents remain children and adolescents. Clinical practice does not overthrow itself when a young patient changes her pronouns.

For affirmative clinicians, on the other hand, the declaration of a transgender identity and the desire for a particular gender presentation suffice. That’s what affirmation means: no further inquiry required. A transfer of loyalty takes place when affirmative clinicians are confronted with “trans” children and adolescents: clinicians’ sense of responsibility shifts from the patient in front of them to the patient’s transgender “alter”. Doctor and patient then collude to slice and drug the patient’s body into compliance with the new identity regime.

Across the Atlantic, countries such as Sweden, Finland, and the United Kingdom are stepping back and shifting away from hormones and surgeries and toward exploratory psychotherapy as evidence of harm mounts. It’s remarkable that the United States government has chosen this moment to double down, without reference to serious inquiries underway at home and abroad.

Rather than bending the arc of history toward justice, the Biden administration has put the full force of the federal government behind a treatment model that amounts to little more than an unregulated medical experiment on vulnerable children and adolescents. Don’t let the language of civil rights fool you.

To understand gender affirmation and the people who push it, we need to take a closer look at their belief in the utterly exceptional “transgender” child. What do affirmative clinicians believe about such a patient, who arrives in their office with a label firmly affixed? Affirmative care starts not with a question or a clinical assessment but with a moral imperative: validate the patient’s transgender identity.

Presented with a “transgender” patient, what else matters? Does a patient’s age or developmental stage matter? What about his or her sex or sexual orientation? What parts of a patient’s life story — or medical history — stand out?

Gender clinicians such as Johanna Olson-Kennedy prefer to talk about gender-questioning three-year-olds as “people”. And they are people. But when we talk about three-year-olds as “people”, rather than toddlers, important information gets lost, with consequences. When we talk about “people”, we think adults. We think autonomy. When we talk about “toddlers,” we think: tiny humans who need constant care and guidance, who cannot be trusted to brush their teeth or cross an empty street, much less start down a medical pathway.

That’s the reason Olson-Kennedy talks about “people” when she’s referring to toddlers. The ideas that underpin gender-affirming care lose their moral force when translated from “people know who they are” to “toddlers know who they are”.

What about sex and sexual orientation? As recently as the mid-2000s, medical providers understood cross-sex identification in childhood and adolescence to be a normal stage of homosexual development, resolving in the majority of cases as the child moved through adolescence and became comfortable with his or her sexual development and sexual orientation. Long before the concept of gender identity took root, the idea of being “born in the wrong body” resonated with many young gays and lesbians — not to mention medical providers, who viewed homosexuals as “inverts” in need of psychological or surgical “correction”.

Affirmative providers overlook, downplay, or outright deny the overrepresentation of same-sex attracted youth among youth seeking transition. But clinicians who rate the “gender presentation” of “transgender” preschoolers on a scale from stereotypical girl (fitted, sparkly, frilly) to stereotypical boy (baggy, sporty) inevitably sweep up children whose rejection of gender stereotypes is rooted in their same-sex orientation. Affirmative providers such as Diane Ehrensaft argue that “prototransgender youth use [same-sex] sexual identity as a stepping-stone toward their transgender true gender self”, a rhetorical move that overwrites the connection between homosexual development and gender dysphoria, and equates accepting your same-sex sexual orientation with pursuing irreversible medical interventions.

Much like their views on same-sex attraction as a “stepping stone” toward a young person’s “transgender true gender self”, affirmative providers treat just about any mental health comorbidities as secondary to gender dysphoria. Suicide attempts, psychotic episodes, anorexia nervosa, depression, anxiety, autism, obsessive-compulsive disorder, experiences of sexual abuse and trauma, and substance abuse aren’t taken as reasons to question or delay transition but instead are treated as evidence for the need to accelerate transition.

In order to grease the skids, affirmative providers have invented or adapted a wide range of new medical concepts, all of which operate to obscure what they do from the public and from providers themselves,  scrambling the complex clinical presentations they need to parse — and manipulating patients, parents, and policymakers. These concepts include “wrong puberty”, “sex assigned at birth”, “reconstructive surgeries”,  and “internalised transphobia”.

Reconceptualising patients as “wrongly sexed” (thus in need of reconstructive relief) and giving allegiance over to the patient’s transgender “alter” over the physical patient and her social and medical history skew clinical assessments and lower clinicians’ barriers to providing experimental medical interventions. Girls become “boys”, not in reality, but in the way gender clinicians talk about reality. Elective double mastectomies on girls become “reconstructive chest surgery” on “boys”. Exploratory therapy to understand where distress over sex and gender originates becomes “conversion therapy,” something no ethical clinician would practice. Drastic, life-altering medical interventions — such as “pausing” puberty and all the cognitive, physical, and emotional development that goes along with it — become conceptualised as non-interventions on the one hand, “life-saving” on the other. In any case, language becomes detached from reality, skewing risk analysis.

This language of determined identities and autonomous “people” speak to the way affirmative clinicians see their role: deferring to patient self-identification and facilitating hormonal and surgical interventions to bring patients’ bodies in line with how they want to “wear their gender”, Meanwhile, activists inside the medical profession push for policy changes to lower the age at which minors can consent to transition — a priority of the forthcoming guidelines from the World Professional Association for Transgender Health — and remove requirements for parental assent. California legislators are on the verge of passing a bill that would equate denial of “gender-affirming care” with child abuse, a move advocates say would turn California into a “sanctuary state” for trans-identifying children.

Ask for stronger evidence or stricter safeguarding measures and you’ll get an earful about suicide and self harm: affirmation is a “matter of life and death.” (Never mind that researchers had to cook bad survey data at extremely high temperatures in order to make such dire claims.)

Affirmative clinicians frequently compare gender dysphoria to endocrine conditions such as diabetes. Take Johanna Olson-Kennedy, dismissing the need to explore the causes of a young person’s distress over gender: “I don’t send someone to a therapist when I’m going to start them on insulin”. Never mind that medical providers can test for diabetes (and monitor whether the treatment is working), while relying on patient testimony to initiate medical transition. Never mind that untreated diabetes kills. Analogies to cancer also abound, especially when clinicians need to justify serious risks like permanent loss of fertility and the very real possibility that patients will lead shorter, sicker lives after medical transition. Ask clinicians and they’ll tell you that gender dysphoria, like cancer, is a life-threatening condition. In the absence of supporting evidence, this is emotional extortion, nothing more.

Affirmative clinicians evade the possibility of regret and detransition. They prefer to talk about “gender fluidity” or “gender journeys”— “journeys” that may include puberty blockers, cross-sex hormones, and elective double mastectomies. Journeys that could not and should not have been avoided, in other words.

Affirmative providers also cleave to a narrow set of explanations about why patients experience regret and detransition, pinning regret and detransition on lack of social support for the patient’s transgender identification. By placing the blame on factors outside the medical system, providers avoid the suggestion that regret and detransition may be the result of inadequate evaluation or inappropriate medical interventions. This interpretation also keeps patients firmly within the ideological framework that underlies affirmative care. Under this framework, a patient remains “really transgender”, even if external factors conspire to keep the patient from living out that identity. Even if the patient disavows their transgender identity entirely.

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If affirmative providers’ belief in the exceptional “transgender” child bears out, we can make a strong case for affirmation. But if this belief is merely an article of faith, nothing more, clinicians risk doing serious harm to their patients under the banner of affirmation. In other words, if gender-dysphoric children and adolescents are truly exceptions to everything we know about identity formation, child and adolescent development, how humans make sense of distress and their susceptibility to social influence, the role of sexual orientation in gender dysphoria, and more, then affirmation may be the right approach.

But what if supporters of gender-affirming care are wrong?

What if children who identify as transgender are just that: children? What if they hurt, like other children? What if they’re trying to figure themselves out and learn how to navigate the strange world they live in, like other children?

What’s changed are the ideas and expectations that we’ve raised children on and the way we’ve turned them loose in an online world whose terrain no one has mapped. Many of these children have grown up with extended experiences of online disembodiment. They may not be free to run around outside with their friends but they’re free to roam the darkest corners of the Internet. Who knows what strangers and strange ideas they encounter there.

These children have grown up hearing a very new and confusing set of fairy tales about gendered souls that can end up in the ‘wrong bodies’. Adults who should know better — adults who do know better — have made these children impossible promises.

Children who identify as trans aren’t sages. They aren’t sacred. They haven’t been endowed with wisdom beyond their years. It’s not fair to treat them as exceptions to the safeguards we place around children, so that when they grow up and change their minds and ask why we let them do this, we say: You wanted it. You asked for it. You were so sure. What else could we have done?

There’s a way in which everything that touches trans must be exceptional — the children, the stakes, the feelings, the possibility of knowing anything for sure — because if these kids aren’t exceptional, then we threw everything we knew out the window. We didn’t ‘help’ exceptional children but harmed ordinary ones, struggling with ordinary challenges of development, sexual orientation, identity, meaning, and direction.