Interesting question—I don't follow what too many psychiatrists say about this in public because it is so hard to find honest writing about this stuff. If they work for an academic medical center, then I would be worried if they could really speak honestly about this if they wanted to keep their job, but I could be wrong.
As for in private, I've heard a range of opinions. I haven't talked to any psychiatrists who are in favor of aggressive medical/surgical interventions for under-18 patients, at least to my knowledge. I can think of maybe two medical residents I've met who wanted to go into "gender affirming care" but those were not psychiatric residents. Most psychiatrists are similar to other people insofar as they don't think about the issue too much if it doesn't affect them, or they just nod along with the party line to stay out of trouble. I suspect there are quit a few Child & Adolescent psychiatrists who see that this is all pretty out of hand, but they can't say anything about it. Also, most people don't like to rock the boat, psychiatrists included. I've found many doctors, even very good ones, to be surprisingly thin-skinned, at least these days, and are really unprepared for substantial criticism of their views.
Ultimately I don't think many psychiatrists have deeply thought through the philosophical details of "gender" for themselves, mostly because they don't actually see or deal with it much.
Thank you for such a detailed and thoughtful answer. It’s got me thinking. I just listened to the Jamie Reed (the St Louis clinic whistleblower) on Triggernometry and she said something that really stuck with me about the doctors in the clinic that seems to fit with what you’re saying about not wanting to rock the boat. She said that doctors were like a cog in a machine and they felt like they had to keep spinning because if they don’t, it’s the whole machine that stops.
This attempt to keep the professionals from having to accept *any* responsibility for what they’re doing is going beyond the Dutch researchers, and the mental gymnastics, word games, and borderline gaslighting being used they’re even contradicting themselves in the excuses they’re creating to detach themselves from having any responsibility or accountability. Also note how casually any doubts the patient may have are brushed away in this article.
On the one hand there are the claims that detransition is “healthy” and “natural” and an expected part of the journey because there is no such thing as a fixed gender identity and it’s fine to medicalize phases:
“Yet in the trenches of trans health care, there is a growing idea that pushes back against the “one true gender for each individual” framing altogether—one that could allow us to resolve the bitterly divisive culture war over the psychological and medical care of transgender children. What if, instead of viewing gender as a fixed trait, we started to think of it as something that could evolve over the course of a lifetime? Or if detransitioning wasn’t considered a sign of failure and was instead regarded as a natural and healthy part of the gender development process?”
But then we have this definition of gender identity where it’s fixed and never changes but a person’s understanding and communication of it can change because they didn’t know the right words for their fixed, unchanging identity.
Here is Gender Spectrum's definition of the key term "gender identity."
"This core aspect of one’s identity comes from within each of us. Gender identity is an inherent aspect of a person’s make-up. Individuals do not choose their gender, nor can they be made to change it. However, the words someone uses to communicate their gender identity may change over time; naming one’s gender can be a complex and evolving matter. Because we are provided with limited language for gender, it may take a person quite some time to discover, or create, the language that best communicates their internal experience. Likewise, as language evolves, a person’s name for their gender may also evolve. This does not mean their gender has changed, but rather that the words for it are shifting."
So if a doctor transitions a child who later regrets what was done to him or her, the problem wasn’t poor assessment and lack of differential diagnosis, it’s the child’s use of the wrong words to describe their unchanging gender.
It’s like a tornado of moving goalposts and circular language - anything for professionals to avoid ownership and responsibility
I'm struck by how emotionally detached the Dutch clinicians (and many other clinicians) sound when I read about them. I get that it's normal to develop a mindset toward tough work that may include a dark sense of humor, but I'm troubled by their seemingly cavalier responses to children's regret. Unfortunately, this type of emotional detachment is often viewed as healthy and desirable and emotional distress like regret or concern about undesirable medical outcomes is either dismissed or seen as the fault/responsibility of the patient/client.
I'm also troubled by the decontextualized way in which autonomy is being viewed. Most 18 year olds are not fully autonomous. Until they're 18, children don't have the ability to make many legal decisions or the ability to seek legal recourse if they feel they've been wronged. It's also very common for children to lean on their parents financially and for help with major life tasks well into their twenties (often later), so how "autonomous" are they really? Should we really allow people to make irreversible decisions about their bodies before we allow them to drink or rent a car?
Drinking and car rental are both decisions that people need to be able to handle the consequences for and in many places, we've deemed 21 the age that that's possible. At what age do we feel comfortable saddling people with potentially life-long consequences for their decisions?
These clinicians sound like used car salesmen joking among themselves about selling a lemon to a stupid client. Oh well, they should have looked closer when they were buying.
For lobotomies, it was the development of less extreme treatments - psychiatric drugs - the caused them to fall out of favor.
One of the closest comparisons I can think of is the idea of repressed memories and the scandals that followed. I think believing in and medicalizing “gender identities” will follow a similar path. Despite researchers having serious doubts that people can repress a traumatic memory in that was, 70% of clinical psychologists believe in it (read this study for numbers across various mental health professionals and laypeople). Even with research studies showing that 25% of people could be made to “remember” something that never happened, psychologists and therapists believe in it and make it part of their diagnostic and therapeutic practice. Look at the wildly popular book The Body Keeps the Score - the bible for understanding trauma. The idea of repressed memories occurs throughout the book. Even with successful lawsuits against professionals for creating false memories in their patients (like the Ramona case), the practice and belief continues today.
I don't think it was entirely the appearance of better treatments that put psychosurgery out of favour. I happen still to have my copy of the Oxford Textbook of Psychiatry, 3rd edition, 1996. (1996 was well into the era of SSRI (Prozac-like) antidepressants.) It talks about surgery as a rare option for severe depression after a prolonged trial with non surgical measures, but also OCD and chronic anxiety, which is even more alarming. I think it declined more because of awareness that the cost of apparent symptomatic relief was life long impairment of the ability to live an independent life.
I had a quick Google for medical negligence cases involving lobotomy or leucotomy in the UK, and I couldn't find any. Part of this may be that when it was done it was in line with "respectable" medical opinion. We will have the same problem with action against those pushing gender affirming care as long as WPATH is the arbiter of international best practice.
Yes, the notion that there is going to be a wave of lawsuits that ends transition is not likely to come true. Having followed the existing professional standards is an absolute defense against a claim of malpractice.
You hit the nail on the head here. We're living through multiple overlapping medical scandals (opioids, gender med and now, in Canada, MAID) and close to the route of all of them is a model of patient autonomy in which the patient is always right, their judgement is never compromised and the role if the doctor is to give the patient what they want regardless of what medical evidence, clinical judgement or common sense may indicate. Another part of all of them is a seemingly hedonistic model of wellbeing in which a person's subjective experience of suffering in this moment is the only valid criteria or target for treatment and intoducing concerns about how a patient's mental state contibutes to such feelings or the impact a treatment might have on a patient's long term physical or mental well-being is simply paternalistic gatekeeping.
This is profoundly disturbing. The methodology and , worse, worse, the interpretation of the data would fail any degree or ‘A’ level basic statistics or social science methodology examination.
And the lack of empathy of that speaker is disgraceful.
Thank you for the wonderful article, as usual. The reason, of course, that someone would say “I can predict how I’ll feel in one minute—still nervous!—but I cannot predict how I will feel tomorrow," is because our self-perceptions are biologically based, and can spontaneously change over time. Brain function is a complex, non-ergodic process. It can't be predicted in the long run. This is a fundamental fact of physics which underlies chemistry, which underlies biology. Unfortunately, the discussion about gender is still operating somewhere around the high school biology level. I don't anticipate the 'talking heads'and influencers to change their positions soon. That would take some serious educational efforts on their part. You point this out clearly in your essay. Unfortunately, most people in this discussion still have not integrated what we actually know about the biological bases of behavior — including our self perceptions about gender — into their thinking.
I hate to keep harping on a point, however, a bunch of people who don't understand what they're talking about will never reach a clear understanding of the subject matter. That's what leads to the topic of your essay, sadly.
In any event, thank you again for a wonderful essay. I was your efforts. Sincerely, Frederick
This is Masha Gessen talking with David Remnick over at the New Yorker. This blew my mind for some reason. It seems callous to be so dismissive of this reason for regret. So unimaginative of other's pain.
"Yeah. I think there’s way too much focus on detransitioning. And what I think that’s about, in part, it’s almost like what Susan Sontag called the sex exception, except it’s the gender exception. We normalize regret in other areas of life. We do things and then we regret them. We have children and regret it. All the time. It’s perfectly normal. [Laughs.]"
In what insane world would it be perfectly normal to regret mutilating your body??
And btw, openly expressing regret over having children is not...."perfectly normal". I don't personally know anyone who said yeah I regret having kids but no big deal, it's all cool.
I think Masha Gessen is a shallow idiot in a pseudo-intellectual cloak.
This may be a case where the limits of her expertise are on vivid display.
Later on she opines:
"I think probably the biggest mistake is not recognizing that there are different ideas about transness within the trans community. Probably different trans communities. Certainly different experiences of transness. That, for some people, it’s an essential part of themselves. Some people are truly binary. Some people are truly nonbinary. Some people are still in negotiation with their identity."
A limitless number of possibilities but a difficult if not impossible social construct for the real world to navigate.
Wonderful article. I happened to read it after reading a piece in this month's Atlantic: https://www.theatlantic.com/magazine/archive/2023/05/american-madness-schizophrenia-mental-illness/673490/ about the treatment of severe mental illness and the problem of patient autonomy and refusal of treatment in the face of denial of illness which is a symptom of the illness itself. This lead in several cases, to people under the influence of delusions murdering loved ones, and the difficulty of treating them prior to this happening. The push to declare mental illness a societal definition problem rather than a biological illness led to deinstitutionalization and the current problem of homeless mentally ill folks who have the "right to refuse treatment". The balance between patient autonomy ( the patient is always right) and the physician authority( you have a treatable illness, and we should treat it even if you don't believe it) seems to swing back and forth over historical time. The Trans Child issue seems to me to be another of those questions about responsibility and the reality of biology over ideology...
"It seems if you harness your ideological cart to human emotion, you can get people to believe anything."
Unless those emotions are regret or fear and concern about long-term consequences. If we could get people to take those emotions more seriously, perhaps we'd see more caution and accountability.
As a physician, this is a difficult article to read. I’m smashing my head against the wall trying to figure out where “first, do no harm” went.
If you don’t mind me asking, what are your doctor colleagues saying about this issue? Both in private and in public?
Interesting question—I don't follow what too many psychiatrists say about this in public because it is so hard to find honest writing about this stuff. If they work for an academic medical center, then I would be worried if they could really speak honestly about this if they wanted to keep their job, but I could be wrong.
As for in private, I've heard a range of opinions. I haven't talked to any psychiatrists who are in favor of aggressive medical/surgical interventions for under-18 patients, at least to my knowledge. I can think of maybe two medical residents I've met who wanted to go into "gender affirming care" but those were not psychiatric residents. Most psychiatrists are similar to other people insofar as they don't think about the issue too much if it doesn't affect them, or they just nod along with the party line to stay out of trouble. I suspect there are quit a few Child & Adolescent psychiatrists who see that this is all pretty out of hand, but they can't say anything about it. Also, most people don't like to rock the boat, psychiatrists included. I've found many doctors, even very good ones, to be surprisingly thin-skinned, at least these days, and are really unprepared for substantial criticism of their views.
Ultimately I don't think many psychiatrists have deeply thought through the philosophical details of "gender" for themselves, mostly because they don't actually see or deal with it much.
Thank you for such a detailed and thoughtful answer. It’s got me thinking. I just listened to the Jamie Reed (the St Louis clinic whistleblower) on Triggernometry and she said something that really stuck with me about the doctors in the clinic that seems to fit with what you’re saying about not wanting to rock the boat. She said that doctors were like a cog in a machine and they felt like they had to keep spinning because if they don’t, it’s the whole machine that stops.
Yes, I'd be interested in this, too.
What happened to “First, do no harm”?
This attempt to keep the professionals from having to accept *any* responsibility for what they’re doing is going beyond the Dutch researchers, and the mental gymnastics, word games, and borderline gaslighting being used they’re even contradicting themselves in the excuses they’re creating to detach themselves from having any responsibility or accountability. Also note how casually any doubts the patient may have are brushed away in this article.
On the one hand there are the claims that detransition is “healthy” and “natural” and an expected part of the journey because there is no such thing as a fixed gender identity and it’s fine to medicalize phases:
“Yet in the trenches of trans health care, there is a growing idea that pushes back against the “one true gender for each individual” framing altogether—one that could allow us to resolve the bitterly divisive culture war over the psychological and medical care of transgender children. What if, instead of viewing gender as a fixed trait, we started to think of it as something that could evolve over the course of a lifetime? Or if detransitioning wasn’t considered a sign of failure and was instead regarded as a natural and healthy part of the gender development process?”
https://thewalrus.ca/new-gender-paradigm/
But then we have this definition of gender identity where it’s fixed and never changes but a person’s understanding and communication of it can change because they didn’t know the right words for their fixed, unchanging identity.
Here is Gender Spectrum's definition of the key term "gender identity."
"This core aspect of one’s identity comes from within each of us. Gender identity is an inherent aspect of a person’s make-up. Individuals do not choose their gender, nor can they be made to change it. However, the words someone uses to communicate their gender identity may change over time; naming one’s gender can be a complex and evolving matter. Because we are provided with limited language for gender, it may take a person quite some time to discover, or create, the language that best communicates their internal experience. Likewise, as language evolves, a person’s name for their gender may also evolve. This does not mean their gender has changed, but rather that the words for it are shifting."
So if a doctor transitions a child who later regrets what was done to him or her, the problem wasn’t poor assessment and lack of differential diagnosis, it’s the child’s use of the wrong words to describe their unchanging gender.
It’s like a tornado of moving goalposts and circular language - anything for professionals to avoid ownership and responsibility
I'm struck by how emotionally detached the Dutch clinicians (and many other clinicians) sound when I read about them. I get that it's normal to develop a mindset toward tough work that may include a dark sense of humor, but I'm troubled by their seemingly cavalier responses to children's regret. Unfortunately, this type of emotional detachment is often viewed as healthy and desirable and emotional distress like regret or concern about undesirable medical outcomes is either dismissed or seen as the fault/responsibility of the patient/client.
I'm also troubled by the decontextualized way in which autonomy is being viewed. Most 18 year olds are not fully autonomous. Until they're 18, children don't have the ability to make many legal decisions or the ability to seek legal recourse if they feel they've been wronged. It's also very common for children to lean on their parents financially and for help with major life tasks well into their twenties (often later), so how "autonomous" are they really? Should we really allow people to make irreversible decisions about their bodies before we allow them to drink or rent a car?
Drinking and car rental are both decisions that people need to be able to handle the consequences for and in many places, we've deemed 21 the age that that's possible. At what age do we feel comfortable saddling people with potentially life-long consequences for their decisions?
These clinicians sound like used car salesmen joking among themselves about selling a lemon to a stupid client. Oh well, they should have looked closer when they were buying.
Right. It's gross.
I wonder what it took, and how long it took, for lobotomies to be condemned as surgical treatments for mental health problems?
What other great medical scandals are there (if any) to compare with the scale and callousness of this one, as regards children?
For lobotomies, it was the development of less extreme treatments - psychiatric drugs - the caused them to fall out of favor.
One of the closest comparisons I can think of is the idea of repressed memories and the scandals that followed. I think believing in and medicalizing “gender identities” will follow a similar path. Despite researchers having serious doubts that people can repress a traumatic memory in that was, 70% of clinical psychologists believe in it (read this study for numbers across various mental health professionals and laypeople). Even with research studies showing that 25% of people could be made to “remember” something that never happened, psychologists and therapists believe in it and make it part of their diagnostic and therapeutic practice. Look at the wildly popular book The Body Keeps the Score - the bible for understanding trauma. The idea of repressed memories occurs throughout the book. Even with successful lawsuits against professionals for creating false memories in their patients (like the Ramona case), the practice and belief continues today.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826861/
I don't think it was entirely the appearance of better treatments that put psychosurgery out of favour. I happen still to have my copy of the Oxford Textbook of Psychiatry, 3rd edition, 1996. (1996 was well into the era of SSRI (Prozac-like) antidepressants.) It talks about surgery as a rare option for severe depression after a prolonged trial with non surgical measures, but also OCD and chronic anxiety, which is even more alarming. I think it declined more because of awareness that the cost of apparent symptomatic relief was life long impairment of the ability to live an independent life.
I had a quick Google for medical negligence cases involving lobotomy or leucotomy in the UK, and I couldn't find any. Part of this may be that when it was done it was in line with "respectable" medical opinion. We will have the same problem with action against those pushing gender affirming care as long as WPATH is the arbiter of international best practice.
Yes, the notion that there is going to be a wave of lawsuits that ends transition is not likely to come true. Having followed the existing professional standards is an absolute defense against a claim of malpractice.
You hit the nail on the head here. We're living through multiple overlapping medical scandals (opioids, gender med and now, in Canada, MAID) and close to the route of all of them is a model of patient autonomy in which the patient is always right, their judgement is never compromised and the role if the doctor is to give the patient what they want regardless of what medical evidence, clinical judgement or common sense may indicate. Another part of all of them is a seemingly hedonistic model of wellbeing in which a person's subjective experience of suffering in this moment is the only valid criteria or target for treatment and intoducing concerns about how a patient's mental state contibutes to such feelings or the impact a treatment might have on a patient's long term physical or mental well-being is simply paternalistic gatekeeping.
“Friendly non-intimidating woman” is surely the most sinister gender identity so far. It makes me think of the wolf in Little Red Riding Hood.
This is profoundly disturbing. The methodology and , worse, worse, the interpretation of the data would fail any degree or ‘A’ level basic statistics or social science methodology examination.
And the lack of empathy of that speaker is disgraceful.
Thank you for the wonderful article, as usual. The reason, of course, that someone would say “I can predict how I’ll feel in one minute—still nervous!—but I cannot predict how I will feel tomorrow," is because our self-perceptions are biologically based, and can spontaneously change over time. Brain function is a complex, non-ergodic process. It can't be predicted in the long run. This is a fundamental fact of physics which underlies chemistry, which underlies biology. Unfortunately, the discussion about gender is still operating somewhere around the high school biology level. I don't anticipate the 'talking heads'and influencers to change their positions soon. That would take some serious educational efforts on their part. You point this out clearly in your essay. Unfortunately, most people in this discussion still have not integrated what we actually know about the biological bases of behavior — including our self perceptions about gender — into their thinking.
https://everythingisbiology.substack.com/p/there-is-biological-evidence-for
I hate to keep harping on a point, however, a bunch of people who don't understand what they're talking about will never reach a clear understanding of the subject matter. That's what leads to the topic of your essay, sadly.
In any event, thank you again for a wonderful essay. I was your efforts. Sincerely, Frederick
This is Masha Gessen talking with David Remnick over at the New Yorker. This blew my mind for some reason. It seems callous to be so dismissive of this reason for regret. So unimaginative of other's pain.
"Yeah. I think there’s way too much focus on detransitioning. And what I think that’s about, in part, it’s almost like what Susan Sontag called the sex exception, except it’s the gender exception. We normalize regret in other areas of life. We do things and then we regret them. We have children and regret it. All the time. It’s perfectly normal. [Laughs.]"
In what insane world would it be perfectly normal to regret mutilating your body??
And btw, openly expressing regret over having children is not...."perfectly normal". I don't personally know anyone who said yeah I regret having kids but no big deal, it's all cool.
I think Masha Gessen is a shallow idiot in a pseudo-intellectual cloak.
This may be a case where the limits of her expertise are on vivid display.
Later on she opines:
"I think probably the biggest mistake is not recognizing that there are different ideas about transness within the trans community. Probably different trans communities. Certainly different experiences of transness. That, for some people, it’s an essential part of themselves. Some people are truly binary. Some people are truly nonbinary. Some people are still in negotiation with their identity."
A limitless number of possibilities but a difficult if not impossible social construct for the real world to navigate.
Wonderful article. I happened to read it after reading a piece in this month's Atlantic: https://www.theatlantic.com/magazine/archive/2023/05/american-madness-schizophrenia-mental-illness/673490/ about the treatment of severe mental illness and the problem of patient autonomy and refusal of treatment in the face of denial of illness which is a symptom of the illness itself. This lead in several cases, to people under the influence of delusions murdering loved ones, and the difficulty of treating them prior to this happening. The push to declare mental illness a societal definition problem rather than a biological illness led to deinstitutionalization and the current problem of homeless mentally ill folks who have the "right to refuse treatment". The balance between patient autonomy ( the patient is always right) and the physician authority( you have a treatable illness, and we should treat it even if you don't believe it) seems to swing back and forth over historical time. The Trans Child issue seems to me to be another of those questions about responsibility and the reality of biology over ideology...
Well. “Surgeon” is a profession that does attract psychopaths. For real.
"It seems if you harness your ideological cart to human emotion, you can get people to believe anything."
Unless those emotions are regret or fear and concern about long-term consequences. If we could get people to take those emotions more seriously, perhaps we'd see more caution and accountability.