About that Twitter shitstorm: Affirmation—not assessment—is imperative
“In theory there is no difference between theory and practice—in practice there is.”
I have to confess: this has been bugging me for days.
Jesse Singal (always) does his homework. He’s right about what the Standards of Care say. He’s right about how any reasonable person with basic reading comprehension skills would interpret that sentence. He’s right about the content and drift of the citations, which suggest that clinicians exercise caution in evaluating patients with “complex presentations.”
And—of course—Singal is also right when he says: “If journos can't follow WPATH's lead without getting attacked by their colleagues, coverage of this issue will be impossible. Which is maybe the point?” Yes, that’s the point.
But Edmiston—for all Edmiston’s unforced errors—is right about what WPATH means by that sentence in practice—even though the sentence does not come out and say it and even though the citations suggest otherwise. That sentence was never meant to stand between patients and gender affirmation. Edmiston understands what the Standards of Care are: a performance of professional responsibility and scientific rigor, without the burden of actual responsibility and rigor. The Standards are a PR ploy and a malpractice shield, not a guide to preventing medical harm to patients.
Ultimately, the Standards of Care are a front for a radical, quasi-religious movement within medicine.
The thing is, Jesse Singal is a Reasonable Person—possibly the most Reasonable Person on Twitter—and he’s writing in good faith. So, he takes the Standards of Care at face value:
"Why wouldn’t you at least delay the hormones discussion until you’re sure that the child can sufficiently distinguish between gender identity, gender roles, and sexual orientation? You’d be negligent to do anything but that — this is what experts mean when they talk about the importance of “a more extended assessment process” in some instances."
Of course, responsible clinicians would delay the hormones discussion. Of course, clinicians would be negligent to do otherwise. But gender medicine isn’t responsible. And it’s not accidentally irresponsible. It’s programmatically irresponsible. It is because that responsibility is a fiction that we have ‘gender-affirming care’ at all.
Elsewhere in the chapter, the authors write, “We recommend health care professionals assessing transgender and gender diverse adolescents only recommend gender-affirming medical or surgical treatments requested by the patient when.… [among many other criteria] the adolescent’s mental health concerns (if any) that may interfere with diagnostic clarity, capacity to consent, and gender-affirming medical treatments have been addressed.”
But I went to WPATH. There were whole sessions devoted to transitioning people with every imaginable comorbidity—like patients presenting with ‘multiple personalities’ who disagree about what irreversible interventions ‘they’ want to pursue. Previous Standards of Care specified that comorbid mental illnesses should be “well-controlled” before initiating pharmaceutical and surgical interventions. But one of the achievements of the Eighth Standards of Care was the relaxation of that restriction. A cause for celebration.
There were sessions that were absolutely contemptuous about “assessment,” like the Sunday morning session titled ‘Framework for Conducting a SOC8-Informed “Comprehensive Biopsychosocial Assessment” for Adolescents: Perspectives from TNB2S and Adjacent Clinicians.’ Every time the presenters mentioned the words “comprehensive” and “biopsychosocial” and “assessment,” ironic air quotes appeared. The moral imperative is not to evaluate patients carefully to ensure interventions are appropriate but rather to “steer clear of lengthy assessments that assume pathology.” Clinicians err whenever they believe they can discern a “‘true’ gender identity beyond what is articulated by a person” or when they “overfocus on identity” [read: evaluation and diagnosis] at the expense of attending to a patient’s “embodiment goals,” even as presenters acknowledge that these goals may evolve over time. Presenters scolded WPATH for including “problematic language like ‘careful,’ ‘comprehensive, ‘ongoing,’ ‘overt time,’ and ‘iterative’” in the adolescent chapter, claiming the authors were “influenced by fear and anxiety”—and the need to appear responsible. “The answer always seems to be more assessment and more time,” one presenter seethed. “And that’s gatekeeping.” “More ‘careful’ assessment means more time and that leads to disproportionate delays for neurodiverse youth and youth with mental health differences.”
The Standards of Care instruct clinicians to “assess the direction of the relationships that exist between any mental health challenges and the young person’s self-understanding of gender care needs and then prioritize accordingly” (p. 563). The presenters ravaged this concession as “pathologizing”: “[The text] assumes [clinicians] can determine that direction… these presentations are rare but even if [mental health comorbidities] are there, there’s that humility piece and you don’t know whether that relationship [between mental illness and transgender identity] is actually there.” The Standards advise clinicians to keep an eye out for “hopelessness” and “no future thinking” but presenters said they see these presentations "frequently” and are concerned by the idea of withholding treatment just because the patient can’t imagine a livable future. Providers need to “think flexibly.” These presenters openly resented the responsible tone the Standards of Care affect, but authors of the WPATH Standards of Care sent the exact same message in their own sessions: affirmation—not assessment—is imperative.
Everything at WPATH conspires to lower clinicians’ barriers to providing risky and highly experimental interventions on paper-thin justifications. Clinicians may be too blinded by their own “cisgender” privilege to understand and evaluate their patients, so why not defer? Hormones and surgeries are “not a forever decision” and “can be stopped at any time”—so why not drug and slice away?
This is critical for people outside the field of ‘gender-affirming care’ to understand: if patients simply are transgender—that is, if trans identity is not susceptible to social influence or potentially symptomatic of deeper mental health issues—then nothing else matters. It doesn’t matter if patients show features of autism and the combination of rigidity, nonconformity, and hyperfocus that goes along with it. It doesn’t matter if they’ve experienced sexual abuse and trauma that make them recoil from their sexed bodies. It doesn’t even matter if they’re psychotic, though—“ideally," as Dan Karasic pointed out—such patients wouldn’t be “actively psychotic.” But, needless to say, clinical encounters can’t always meet such lofty ideals.
Theory and practice—the Standards of Care and what actually happens in the exam room—have nothing to do with one another. Everything in the Standards of Care that sounds cautious and responsible comes with an understanding that’s supposed to go unspoken: We don’t really mean it. We just need to say this. If a patient shows up with serious comorbidities, of course we have to say that they must undergo a “comprehensive” “assessment” and that the clinician must remain open to the possibility that the patient might not really have gender dysphoria and maybe shouldn’t really transition. But you know how important the work we all do is.
In other words, the Standards of Care are a lie that everyone involved in gender medicine pretends to believe. When reporters like Singal and Chait try to hold gender clinicians to WPATH standards (something I think is worth doing, by the way!), savvy clinicians will respond: Yes, of course we “assess” patients very carefully, what do you think this is, the Wild West?
Among other, more obvious mistakes, Edmiston’s most grievous error was not pretending to believe the lie.
I think you have come to the heart of the matter. The clinicians need to appear responsible, even as they continue to act irresponsibly.
The NY Times letter imbroglio has forced the contradictions into the sunlight.
I am reminded of a quote from a great American baseball player, Yogi Berra:
“In theory there is no difference between theory and practice -- in practice there is.”
I would also add this from Supreme Court Justice Louis Brandeis:
“Sunlight is the best disinfectant.”
There’s an angle to this that’s not getting discussed. Psychology and psychiatry are fields that have had poor records of treating mental illness. They bounce from one idea to the next - psychoanalysis, lobotomy, biomedical, pharmacological, social systems - with routinely disappointing results and research that can’t be replicated. Right now they’re being forced to deal with increasing publicity due to studies showing the mediocre results of SSRIs and the debunking of the “chemical imbalance” myth. Practitioners are realizing how limited their treatment toolboxes are. They are patched my onto the idea of affirmation only, drugs and hormones, because they *need* it to work. They need *something* to work.