Physiological Plausibility

Like so many parents of a trans-identified child, I am a nerd who has extensively researched the science and social phenomena of transgenderism. Most recently, I listened to 30 hours of WPATH lectures from their 2022 Montreal conference. The video was released after Daily Caller reporter, Megan Brock, submitted a series of FOIA requests to the institutions where WPATH contributors work. Genspect held a webinar with reporter Brock, but the Daily Caller article was short, sharing only a handful of quotes. Eliza Mondagreen has also reported on this conference. I decided to watch these videos in the hopes of understanding how doctors and mental health professionals justify what they do. I didn’t learn much that would surprise PITT readers, but this internal dialogue provided me with new insights into the madness of this crowd.

As Mondagreen pointed out, WPATH’s gender-affirming members are entirely bought into this ideology. Their standards of “care” are not evidenced-based, and the surgeries they recommend are ghoulish and beyond the realm of medical possibilities. No matter. “Giving people access to gender-affirming care is suicide prevention. Period,” according to Jennifer Slovis, a Kaiser family practitioner. This sentiment was repeated by nearly every speaker. Chris Booth, MD, said that despite the “naysayers,” the evidence shows that gender-affirming care does “a world of good and improves on many parameters” for these individuals. Mind you, this was in 2022, two years after WPATH commissioned a review of the literature that found no benefit from hormonal treatment to trans-identified youth – a study that WPATH suppressed.

The speeches hit all the key trans social justice buzzwords: societal discrimination, health disparities, discomfort, microaggressions, minority stress, trauma-informed, sex assigned at birth, gender identity/expression, authenticity, neurodiverse friendly, bias, check your bias, cis-heteronormativity, privileging the binary, intersectionality, barriers, and embodiment goals. And there were a lot of new terms, including pansexual, polysexual, and skoliosexual. Alex Laungani, a surgeon, began his presentation with an apology for any terms he might get wrong in this quickly evolving field. During the question-and-answer session, people introduced themselves with their profession and their pronouns, which just aren’t necessary for this type of interaction. Lastly, Dan Metzger, an endocrinologist, ended his presentation with a slide displaying, “First do no harm. Doing nothing is harmful”.

Presenters were adamant that ROGD is not a thing and compared its adherents to anti-vaxxers. In response to a question on psychiatric contraindications, Dahl responded, “This is not a thing”. After comparing gender-affirming care to wisdom tooth extraction, he noted that most people get “happier” with gender-affirming care, which he saw as evidence of good mental health.

All you parents who don’t affirm will be pleased to hear Ren Massey, psychologist, complain that kids whose parents aren’t supportive will doubt themselves and slow down the process. Massey is a trans-identified female who seems to regret that he hadn’t transitioned sooner, but he seemed fragile and at times on the verge of tears.  Psychologist Wallace Wong said that he helps parents address their irrational fears and grief, shows them the evidence, and teaches them the terminology. He points to research that 94% of kids who start social transitioning continue as evidence of kids knowing who they are. This same data pointed Dr. Hilary Cass to conclude that even social transitions may be irreversible and urge caution. No one “believes” in detransition, and Massey went as far as to state that most detransitioners retransition.

Scott Leibowitz, psychiatrist, recommended talking to parents differently until they are on board, but he did recommend involving parents unless they were deemed harmful (no indication that the parents have a voice in this determination). Leibowitz stated that puberty blockers are a negotiating tactic when parents are reluctant to transition kids. If the parents are resistant, he addresses their child’s mental health issues before transition, but he believes that transition helps with mental health, so it should go first. Massey had a lot of advice to offer. He tells his patients that there are people with whom you process gender transition and others to whom you announce transition. This last category included Massey’s parents who received an email from him announcing his transition with many helpful links. His guidance on battles not worth fighting hinted at estrangement. Another psychologist had recommendations for building a family of choice that is gender-affirming, ritual farewells for first names at birth, and for the parents he offers role-playing or simulation of a post-suicide ceremony.

Where do these professionals want to take our children? Leibowitz promoted screening for gender for all kids and developing their gender literacy and competence while preventing them from caving into the gender binary. The follow-up discussion said that gender is crystallized in children by the time they are four years old and early transition would help trans kids avoid trauma and minority stress. Another psychiatrist chimed in that cis people also need to come to terms with their gender. In his presentation, John Strang, Director of Gender and Autism at a medical school, noted that he rarely saw individuals with intellectual disabilities seeking to transition, which led him to express concern that this population is underserved. He encouraged psychologists to rehearse with their autistic patients so that these kids can communicate their gender needs and goals to doctors, and he then shared resources directed to autistic kids who are trans-identified.

Listening to all this, I conclude that our kids, some socially awkward or with other mental health co-morbidities and stuck in the house during COVID, didn’t stand a chance.

Next up: the medical doctors.

The medical presentations can be distilled from the opening remarks of Marshall Dahl, endocrinologist, “Not only are the medications off label, the whole field is off label”. The experimentation is an open secret among WPATH members – open to WPATH members but secret to the general public to whom they ply their medicine as evidence-based. Many discussions centered on how to provide hormones and at what dosage, but no one referred to dose-response curves that measure patient responses at different dosages. In reply to a comment from the audience, a doctor suggested running an experiment with 10 patients testing two treatments in two groups to compare results. I did not get the feeling that this experiment would be presented to an institutional review board that approves and monitors biomedical research on human subjects. A doctor noted that blood clots in patients taking estradiol are dose related while dismissing risks from taking estradiol.

That the lack of data has serious consequences for patients is demonstrated in a case in which a trans-identified man who was taking spironolactone off-label as an anti-androgen was reporting lightheadedness. The patient was also taking another medication to treat his high blood pressure. Rather than give the patient two high blood pressure medications (spironolactone is approved to treat high blood pressure), a doctor recommends that the patient obtain an orchiectomy.

Dahl stated that he loves testosterone because it does what it is supposed to do, and the results, such as the deepening of the voice or facial hair, are evident. I understood that estrogen might be less predictable. Joshua Safer, endocrinologist, explained how testosterone and estrogen work with the former dominating such that people with high levels of testosterone won’t develop breasts even with the same level of estrogen. Laungani stated that an orchiectomy is a reasonable approach to avoid anti-androgens. Mind you, this is all an effort to suppress testosterone so that estrogen can have the desired cosmetic effects. One doctor pointed out that there are many non-medical options for desired cosmetic outcomes such as laser hair removal or makeup.

How do these doctors justify giving patients cross-sex hormones without research into potential outcomes?

A doctor from the audience asked about progesterone for a trans-identified male patient who learned about it on the internet. Dahl explained his approach to these questions. He first considers the physiological plausibility and conducts a thought experiment. He knows of a Canadian doctor who gives trans-identified male patients progesterone, which she claims increases breast growth. Dahl thinks the cardiovascular risks are low although he admits that the existing data is only for women and, while he recommended against it in his presentation, he didn’t see the harm in prescribing it even though no one knows how the hormone would work in males. He then went on to joke that he has heard that it makes trans-identified males feel as if they are cycling. The audience laughed.

Source: Slide from Dahl’s presentation at the 2022 WPATH Montreal Conference

They know they are working in a “data-free space”. They discussed one progesterone, cyproterone acetate, and Dahl reported that the Dutch observed meningiomas in young people and that it may cause breast cancer and heart disease. This suggests these doctors should understand the physiological plausibility that cross-sex hormones can have severe side effects.

The manner in which most doctors presented the risks of treatment suggested that any informed consent is undermined by the doctors themselves. They repudiated warnings of the side effects of hormones, such as venous thromboembolism (VTE) or unstable/evolving psychiatric issues, because they had never seen them. In reference to the latter Dahl claimed, “It is not a thing.” Laungani said surgeons worry about VTE and ask patients to stop taking hormones in the weeks before surgery, but endocrinologists are convincing him this is not a risk, so he seemed open to allowing patients to continue with hormones while undergoing surgery and then conducting retrospective studies. Other known risks, such as an elevated breast cancer risk in natal males, are explained away as a condition that should be monitored as in any female. Slovis claimed that hormones are not killing trans people, and she attributed the high death rates among trans individuals to AIDS, suicide, and drug use – all the result of societal discrimination. These doctors even dismissed patient complaints of brain fog and lightheadedness to “reading things on Reddit” because they could not fathom the physiological plausibility of the symptom. Another doctor did not believe that testosterone would make trans-identified females more aggressive and asserted that any self-reported increase in aggression was likely a result of patient anxiety.

Doctors admitted to not addressing tough issues with patients. Metzger reported that he doesn’t conduct genital examinations after putting kids on blockers because he didn’t want them to be uncomfortable. Another doctor won’t mention the body parts the trans-identified client wants to get rid of to avoid discomfort. There were some discussions of fertility preservation, which aligns with what was reported by Mia Hughes.

Laungani presented on transgender surgeries in an anodyne voice with seemingly sincere expressions of concern for those suffering from gender dysphoria. But his manner belied the ghoulish nature of these surgeries and poor outcomes. He gleefully presented complication rates for phalloplasty (40-80%) accompanied by 100% satisfaction rates. He said he was open to nonbinary surgical requests too. In medical discussions, one doctor expressed excitement about uterine transplants. Someone noted that colon cancer risks in trans-identified males with neo-vaginas may be. . . gosh, I don’t even want to imagine what they were saying. And of course, Laungani has performed mastectomies on minors with parental support.

Nevertheless, they clung to the Dutch Study and the belief that they are saving lives. The only discussion of ethics came during a legal panel on how gender-affirming doctors could use medical ethics boards to confront hospital leadership who are reluctant to get on board with transgender care.

One last point, one of the criticisms of Mia Hughes, author of the WPATH Files, was that she reported based only on the leaked materials, which could have been taken out of context. The WPATH Tapes prove that this was not the case.