March 7, 2024 - 10:00am

How does a professional organisation respond when a scandal breaks? Some issue smooth denials, leaving not so much as a seam for critics to pick at. Some finger bad apples. Others dare to admit faults and strive for transparency. The World Professional Association for Transgender Health (WPATH) took a rather different tack, issuing a bizarre statement this week in response to the publication of files exposing malpractice at the organisation.

WPATH President Dr Marci Bowers begins by marking the territory (“We are the professionals who best know
”) and appealing to authority (“widely endorsed by major medical organizations around the world”), before moving on to distort the conflict (the WPATH files are not, in fact, a bid to “de-legitimize” anyone’s identity). The stray comment about the shape of the world attempts to paint critics as anti-science, the equivalent of flat-earthers.

Bowers then asserts that “gender, like genitalia, is represented by diversity”, which sounds like the sort of meaningless twaddle Google Gemini cooks up. Bowers wraps up by twisting the stakes (patients “deserv[e] healthcare”) and minimising the scope of the organisation’s work (“small percentage of the population
 [that] will never be a threat to the global gender binary”), a plea in effect: leave us alone!

The statement is nonsensical because the brief was impossible. WPATH needed to speak simultaneously to two entirely different audiences — the world outside and the organisation’s own membership — who needed to hear entirely different things.

For decades, the field of gender medicine has insulated itself from scrutiny and criticism. The public and policymakers were never supposed to get a glimpse into the inner workings of the field. They were supposed to defer to the “experts” and not look too closely at what they were being asked to support.

The WPATH files look much too closely, shining a spotlight on risks and uncertainties and harms so specific that they will be difficult to forget: patients with tumours, patients whose ages and developmental delays and serious psychiatric conditions mean they could never meaningfully consent to the interventions they underwent, patients who regret being sterilised because they now want children. These files provide fuel for policymakers seeking to regulate youth gender transition and patients trying to sue. The fallout is just beginning.

WPATH’s members, on the other hand, need to see this brutal exposĂ© as a devious plot against a noble cause. WPATH has been preparing its membership for just such a faith challenge for years, instilling an embattled mentality. For years, the organisation’s conferences and events have promoted the narrative that gender clinicians are a misunderstood and persecuted vanguard within medicine who will be vindicated in the future but must suffer heinous accusations in the here and now.

Over the years I’ve spent researching gender medicine, I’ve come to see the field’s obvious harms as a product of enculturation. Becoming a good gender clinician means overcoming one’s reservations and doubts about the interventions provided in service of the cause.

Unlike medical practice in other areas — such as diabetes management or cancer treatment — the field of gender medicine has no objective markers of illness to go by, only the patient’s testimony that her body as it is is unbearable and must be changed. At WPATH’s 2022 conference in Montreal, I heard the same story over and over again: clinicians standing up and telling their fellow believers how they overcame their doubts. A plastic surgeon felt uncomfortable the first time a patient asked him to perform a “nullification” surgery, which removes all external genitalia. In a twisted recapitulation of the hero’s journey, the surgeon then worked through his reservations and now performs these extreme surgeries on a regular basis and encourages his fellow surgeons to follow his example.

The doubts gender clinicians recall are eminently reasonable: they wondered if pre-teens could really consent to sign away their future fertility. They worried about their patients’ troubled pasts and what role experiences of abuse and trauma played. They wondered if some of their patients would accept their bodies if given the time or change their minds months or years down the road. Then they “did the work” and came to see affirming a patient’s current gender identity as a moral imperative.

When I hear stories like these, I see clinicians who — at first contact with the field of gender medicine — knew better. Whether gender clinicians can return to the basics of their medical training and reconnect with their moral intuitions remains to be seen. But the damage they’ve done in the meantime is on full display.

Eliza Mondegreen is a graduate student in psychiatry and the author of Writing Behavior on Substack.