Collecting my thoughts from USPATH

I wanted to do a quick post on a things from the USPATH conference.  First of all, thanks to my fellow presenters and to USPATH for having us.  I thought the other presenters did an amazing job and I was really pleased to have people who attended the symposium come up to me throughout the conference to sincerely thank us for providing fresh perspectives on the subject of detransitioning.  I think it is a huge step in the right direction. Thank you to all who came out (or wanted to come but had schedule conflicts.)  It was really heartening to see you there.

I am sure pretty much everyone who reads this blog knows Dr Kenneth Zucker (who was one of those who came out to our panel) had his own symposium cancelled the following day following a large protest by those who perceived his participation as an act of violence (through inflicted trauma) against the Trans community.  I posted the following on the WPATH facebook page and usually when I post there I don’t repost it here for lack of context , but in this case I will repost it here.

“I have to say that I am disappointed in WPATH’s no-platforming an invited speaker. I saw the protest, and for me it was a sad and chilling reminder that voices that run counter to traditional Trans talking points are often silenced by the community. As a detransitioner, I have experienced it directly time and time again. I am thankful that the detransition mini-symposium was low profile enough not to be the subject of a similar ban as I know that there are those who feel the voices of detransitioners are not “helpful” to the community and need to be minimized. While I respect the passion and advocacy of the protesters (many of whom were represented in a powerful symposium on the academic and clinical marginalization of WOC within the field of Trans care which was one of the best sessions I attended) I see the actions of calling for no-platforming those that they disagree with as a step backwards, not forwards.”

Today, some of the ideas for the 8th iteration of WPATH’s Standards of Care were discussed.  I applaud a lot of these ideas, such as moving more towards making the document much more evidenced based and also the solicitation of a more diverse group that is representative of the population served is determining the standards.

I know that a call was made to remove the data on desistance from the document because of “bad data”. This comment was met with some of the strongest applause of the session today (discussing the upcoming SOC). I strongly urge WPATH and its membership to aggressively pursue trying to get better data on this and keeping it as an important part of the standards.  Unfortunately, because desisters often fall off the radar, this is historically difficult to track.  And that is part of the problem …

We have to do better not to let them fall through the cracks.  We need to be better prepared to anticipate desisters. We need to have Standards of Care in place to meet the needs of those who “desist” or detranstion. Any substantive discussion of the issue  is sorely lacking at this point. The subject was not even brought up in the opening remarks of what needs to be added to the SOC, which did actually surprise me because my impression was that this was on the radar for WPATH as an emerging issue.   To not even get a mention was disheartening and worrying.

I have offered whatever assistance I can to WPATH in helping move forward in developing standards for this population and I encourage other detransitioners to do the same because yours is the input they need the most.  I am ever the optimist (sometimes to my own detriment) and I know that others might worry that this as an exercise in futility. I get that and understand.  But at least I believe it is important to try so I will offer whatever I have.

I encourage those who work with the population to work with researchers to aggregate better data on who is desisting.  Longitudinal studies are key (and will continue to take time of course)  but case studies are still helpful here as well, because it is important to learn what happened and begin to consider what interventions, supports and resources may be helpful to this population.  Of course we need more researchers on this topic as well so who wants to sign up or collaborate with a (soon to be) MSW? We should not be afraid to be curious on this most important topic. We need to be prepared to have some ideas of what to do when youth (and adults) begin to desist/detranstion. I have a feeling that a lot of clinicians are lost here just because there is so little information on the topic and so few venues to share information and discuss this topic openly and without fear of professional marginalization.   (Full disclosure, I am nervous even writing this here as someone who is going to be entering the job market in a few months.)

It was also worrying to hear the continued devaluation of the skills of mental health professionals in this field (ironically often coming from clinicians themselves.)  One of the ideas floating was opening up who can do gender related assessments to ANY providers who work with the Trans youth population (partly due to the shortage of available clinicians and the growing demand.)  For a lot youth, there are other issues going on (i.e. family systems, environmental factors, risk for suicidality, DV, trauma and other cognitive or  neurodevelopmental issues) that I believe ARE important to be assessed for that I do think that only clinicians have the training and the professional obligation to be uniquely qualified to perform. To forfeit the opportunity to provide a holistic and thorough assessment seems like a profound disservice.  And to be clear, I agree that most youth who identify as Trans certainly don’t need to be subjected to a distressful battery of tests such as the MMPI, TAT etc., but basic clinical assessment and judgement I believe is an ethical responsibility. This is especially so within the context that many are advocating that the requirements for minimum age for surgical procedures should also be eliminated.  (Another interesting proposal was the elimination of requiring testosterone for adolescents requesting chest surgery … which on one hand I support as less invasive but also worry that the magnitude of such surgery is minimized in the process.  I have heard from some that in retrospect this became too became a source of regret.)

That is all I have for tonight. I do want to emphasize once again that I believe that most of the providers I met with are working tirelessly to provide the best care they are able for a population desperately in need.  I also believe that this conversation must proceed in a way that does not inhibit the needs of those who (I believe) need access and benefit from these services. Unfortunately the political reality is that this population is especially vulnerable right now, so of course due diligence in how information is used and disseminated is more important than ever!  But that does not mean we need to silence the conversation … we just need to move carefully and mindfully, with respect and compassion.  And while continued passionate activism from the Trans community is absolutely essential and helpful, it cannot dictate the science itself as that does not do anyone a service.

I am going to upload my presentation slides from USPATH in the next day or so for anyone curious … they are mainly bullet points of what I was talking about so I may or may not do a quick video version.  I also want to make an effort to republish a small portion of reader comments from my blog from those who have so eloquently described their own experiences, which is the content that I feel needs to be heard the most so unlike my own postings I recently restored temporarily I may leave those up for awhile.

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Comments

  1. says

    Well, to be quite fair, all people who detransition do so because they didn’t put enough thought into their identity in the first place. Trans stuff requires a ton of soul searching, and is something that necessarily involves a great deal of pain– not only from the fact that there is a dissonance between internal identity and outward presentation but also due to anti trans sentiments and the related idea that cis people are more important than trans people. Sure, detransitioning happens but it’s really really shitty to hold back legit trans people and hurt them further just on the off chance they haven’t thought things deeply enough or have confused feelings. Surgery takes a TON of time, money, and effort to get and the current wpath standards of care are quite sufficient (maybe even a little too onerous). Hormones and presentation are not irreversible and the majority of ‘harm’ from them for people who are not trans is to the ego, which they should just get over it. Sure, there are some physical changes such as boob growth, terminal hair growth, and/or voice lowering but all of those can be ameliorated– every single one of them can be changed quite easily in transition in the first place :). Once again, cis people are never more important than trans people and care should NEVER favor cis over trans. In fact, given the aforementioned stigma against trans people, care should slightly favor them– just so they can feel comfortable in at least one part of the world. Everyone questioning their identity should explore it with a professional– especially one well versed in lgbt matters– but tht doesnt mean they should gatekeep, just provide an welcoming and helpful environment. Remember, all of the first steps of transition are mostly temporary and they can easily be reversed. There is no harm in exploring things and people should never be discouraged from doing so even if they decide agianst it due to the stigma or not having a good outlook on passing or just confusing their feelings. Also, reparative therapy is objectively harmful– it should never be defended by decent people.

    • REtransition says

      Hailey I really appreciate your comment. I want to take a quick minute to reply to a few things because I think that they are important. First and foremost your very first sentence: “Well, to be quite fair, all people who detransition do so because they didn’t put enough thought into their identity in the first place.” How do you know this? And you are not just talking about some people who detransition, but ALL people? If we as a community are trying to move towards empathy and understanding of other’s personal journeys, I am not really sure how you can say this. And mainly on a personal level, it hurts, because I did a TON of soul searching. This is something I struggled with since the 1970s (yup I am old) and spent COUNTLESS hours thinking about, discussing with friends and families, following an earlier version of the SOC, spending A LOT of money talking to therapists about, attending support groups, reaching out to other Trans people. And even with all of that I moved slowly and deliberately. I had no problem getting letters (even from those who were “sticklers”) To dismiss my experience right out of the gate hurts, to be honest, but I know it is a common view of detransitioners that many hold, but it is something that desperately needs to change because I know that other eventual detransitioners have struggled with their own soul searching before deciding to transition.

      You also state “Hormones and presentation are not irreversible and the majority of ‘harm’ from them for people who are not trans is to the ego, which they should just get over it.” I will only address hormones for now – again how do you know this? The complex interactions of hormones on the human body are still not understood and have been the subject of a lot of controversy (a notable concern, to give but one example for postmenopausal women considering HRT) in terms of lasting impacts of HRT on our organs, our endocrine systems and neurological functioning. There is a lot more going on than just “boob growth” and the other changes in phenotype you describe. As someone who now has a thyroid that no longer functions I can’t help but wonder if my own experiences with HRT (and going back and forth) had something to do with this.

      You said: “Once again, cis people are never more important than trans people and care should NEVER favor cis over trans. ” I agree with this wholeheartedly. Although I am stopping short what sounds like a call for affirmative action, I believe that we as a society (and this includes organizations such as WPATH) must be mindful of the social and structural stigmatization of Trans people that extends in subtle ways beyond outright transphobia, and the many limits that places on their own agency, professional opportunities and other key domains that are essential to being an active part of our society.

      As to your remark “Also, reparative therapy is objectively harmful– it should never be defended by decent people,” I agree passionately with this. I just want to make sure that we continue to delineate between reparative therapy and, when appropriate, not inhibiting clinicians from being able to, when appropriate and as part of an affirming approach, explore with children the ways that they can feel good about their bodies and their ways of being in the worthwhile still being affirming, supportive and agnostic as to what that child ultimately wants. I believe that many gender affirming clinicians who work with GNC children take this approach and I think it would be helpful if they helped lead the conversation as to what this looks like so that others have a better idea of what is and is not appropriate.

      • Anonymous says

        Thank you for addressing Hailey because all I could say after reading that reply was , “Wow. Uh ok then. Thanks for the assumptions and close-minded views.”
        I’m old too and spent 30+ years soul-searching before finally medically and socially transitioning.

        • REtransition says

          I appreciated her leaving feedback. Unfortunately, the views she is expressing are not uncommon and are oft-repeated and reinforced within the some segments of the Trans community where there is no opportunity to respectfully challenge.

          • Anonymous says

            I know, which is why I’ve completely separated myself from everyone, including blood family, who think similarly to her. Life is too short and fragile to have toxic people in our lives.
            I respect those who have the courage to have a respectful debate, minus blanket statements and judgments.

  2. A Noun (human) says

    I find it appalling that Dr. Zucker was not allowed to speak after being invited because some folks can’t deal with hearing anything that disagrees with their thinking. As clinicians we are ethically bound to utilize a holistic approach with clients who claim to be trans* before signing off on lifelong medical treatment and the still unknown long-term affects, surgeries that cost thousands of dollars, and everything else that goes along with being trans*, which is not for the faint of heart. Would medically and socially transitioning ‘cure’ the mental health issues that are most likely present, or does the latter have nothing to do with it? If we don’t question, we don’t know.

    During college, I actively pursued an internship at an LGBT health clinic and was shut down as a ‘gatekeeper’ when I questioned my supervisor about three different individuals who stated they were trans* (out of more than 100) that I was tasked with conducting their comprehensive biopsychosocial assessments. Individuals who should have been required to attend psychotherapy to look at the underlying issues they brought to my attention during the assessments. It was made clear to me that the assessments were something the agency had to do, but didn’t pay attention to anything other than the one question that covered their butt legally (“The long term effects of hormone therapy are not yet known; are you ok with that?”)

    It is our job as clinicians to question, dissect, and process, issues that clients bring to the session and I’ll be dammed if people are going to tell me otherwise. Going from one extreme (total resistence) to the other (blind acceptance) does not help clients or clinicians. Not talking about the possibility, and reality, of folks transitioning back to their assigned gender and natal sex can set up clients for (more) mental health issues, and clinicians who are incompetent to help them. We certainly don’t need more of the latter.

    The motto to ‘do no harm’ doesn’t mean to blindly accept; it means, to me, to be able to ethically question the motive and desire of our clients to medically and socially transition, to look at any and all underlying mental health issues, so we can fully, and competently, support our clients, and our clients can make INFORMED decisions.

    I am a trans man and licensed social worker and I refuse to drink the Kool-Aid.

  3. Molly W. says

    I would agree that almost all the research on gender dysphoria is about white people, with the exception of some studies from Asia. This is a serious problem that should be addressed.

    I am also extremely concerned about the censorship of Dr. Zucker’s expertise and research.

    The data on desistance is strong. We know that most children who were diagnosed with gender dysphoria desisted. Most of them grew up to be gay men or lesbians.

    This conclusion comes from the best longitudinal follow-up data we have on children with gender dysphoria.

    The results from the clinic where Zucker worked were replicated by the Dutch clinic; most children desist. These experts describe children as having “plastic” (i.e. changeable) gender identities.

    So far we have no data that can be used to say which child will desist or persist ahead of time. Children with more severe gender dysphoria are more likely to persist, but on the other hand even most of the children with more severe gender dysphoria desisted. In addition, social class was related to persistence; children from families of a higher social class were more likely to desist.

    A Dutch study also found that the period of middle school when puberty begins was critical in whether or not kids desisted – this is based on what the teens themselves said. In other words, waiting until puberty to transition children is the sensible thing to do.

    A follow-up study found that a small number of teens came back to transition as adults, but most did not. The people who desisted are not changing their minds.

    Keep in mind that the Dutch clinic is generally supportive of transition; they are the people who pioneered giving puberty blockers to teenagers who still had gender dysphoria.

    There are flaws in the studies – the sample sizes are small. Not everyone responds to follow-up studies.

    These are unfortunately common flaws in all studies of gender dysphoria, including follow-up studies of transition and studies of regret.

    But even with the flaws we can say this – a large number of children who had gender dysphoria identified as their birth sex when they were older. There is no way to know ahead of time which children will feel this way. They were as happy as the people who grew up to transition.

    This is a very good reason to be cautious about transitioning children socially or medically.

    • pauldirks says

      Your thoughts are exactly my own Molly- well put. Do we need more data? Yes. Are there some flaws here and there (as you mention)? Yes. But in any growing field you must build on the best data you have. And the best data says that there is majority desistance of GID young people- Singh, Walliens, Drummond, Green.

      The only way to downplay the data is “divide and conquer”; to point out the (internally recognized) individual limitations of each of the studies to discredit the whole. Somehow it escapes the notice of those who do this that this goes against the very scientific enterprise, and leaves one at the place where we can’t know anything about the desistance or persistance of GID at all! If that’s the case, why on earth would the “default” in this void of information be affirmation,s drugs and surgery?

      Simple question to those who have problems with the desistance data: give us an example of better data. Until then, any “desistance myth” talk looks more like propaganda than science.

      Paul Dirks
      WOMAN Means Something

      • Arlene Lev says

        I think part of the problem is what Diane Ehrensaft has referred to as “apples and oranges.” We confuse “gender non-conforming” behavior with gender dysphoria. We confuse cross-gender play, with a desire to live as the other sex. And parents generally have quite a bit of anxiety about gender (not just cross-gender) which gets projected into all ways onto their children.

        I also think that much of the literature on desistance came out in the early days of the gay liberation movement, making “gay” the preferred choice. Being trans at the time was an extremely rare “choice.”

        I appreciate all your voices. I have been opposed to Ken Zucker’s treatment for a long time, but I respect his developmental thinking about kids. I do not think silencing people we don’t like is a solution. I think we need more voices at the table not fewer.

        For those who do not know me I am a cis lesbian woman, 59 years old, a social worker and family therapist, author of Transgender Emergence, and a strong advocate for LGBTQ people.
        Ari Lev

        • says

          The issue for me is that I don’t think these kids cleave cleanly into “apples” and “oranges”. I think there are some kids that could go either way depending on culture, experiences and other factors, and if you have a culture that pushes more of them into medical interventions then more of them will have medical interventions. I still think all things being equal having no medical interventions is better than having medical interventions, but also want them available to those who need them. I do think there are some people who can’t thrive without them.

          Where did all of these kids come from? As others point out, there aren’t historical records of children being in intense distress about their bodies and committing suicide when it wasn’t possible to medically transition. There are also a lot more of them now than in say the 90s. I think we may be somewhat responsible for creating them.

          Even if they do cleave cleanly into “apples” and “oranges” I don’t think we have the ability to divide them with perfect accuracy. I don’t think Diane Erenshaft’s “I wish” vs. “I am” distinction does the job. In fact the folks at r/asktransgender see it as a developmental stage to go from “I wish” to “I am”. When people do this their dysphoria seems to intensify. I suggest the reverse in one of my videos to consciously go from “I am” to “I want” to disidentify to create more flexibility and not lock oneself into one solution. Several people have reported that to reduce their dysphoria to me.

    • REtransition says

      One thing that I find rich is that there is the desire from some to get rid of desistance data and yet major activist/writers keep publishing faulty or misleading data on the rates of detransition and/or regret (both of which terms relating to multifaceted concepts that are not addressed either) The idea behind removal of “desistance/persistence” data within the SOC that was floated was to “focus on healthy global development rather than outcomes of gender development”. I believe both need to be looked at and can’t be entirely separated because they are so interrelated, especially since developmental stages don’t end with youth and the gender piece may become more pronounced at a later stage (in one of the many variants of “regret” even when that does not lead one to desire detransition. And of course, changing the focus just makes it all the more difficult for people to talk about this.

Hi, diverse opinions are welcome here I just ask that comments be on topic. Also, if you are posting anonymously please know that sharing your opinions is more helpful to this site than sharing unverifiable life experience or identities