WPATH, part I: "The dignity of risk and the right to regret"

Picasso detail, Femme assise avec chapeau bleu

I’m planning to do a series of posts on sessions from the World Professional Association for Transgender Health—starting with this Saturday morning session on the subject of “the dignity of risk and the right to regret”—which is an enlightened way of saying “some patients are going to regret this but here’s why that’s no big deal!”

I haven’t gotten through all of the recorded sessions yet, but the main theme I’m noticing is that it’s just no longer possible to avoid the subject of regret and detransition. Rather, it’s necessary to at least pay lip service to these subjects. So presenters will talk about detransition but insist on calling it “retransition,” or they’ll talk about detransition “without regret,” or regret without detransition. What’s still missing—and what I suspect can never be addressed in these circles—is the subject of medical harm and the responsibility that clinicians bear when patients are harmed.

As you’ll see below, we’re nowhere near having that conversation.

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I’m going to structure this post as a series of reminders and observations. Remember that every time the speakers talk about the “dignity of risk” and “the right to regret,” they’re talking about teenagers undergoing irreversible, experimental hormonal and surgical interventions performed by doctors under the aegis of medicine. The speakers seem to have lost sight of this:

So it's normal for adolescents to take risks, it's normal for humans to take risks. And one of those things we do is we talk about the risk-benefit analysis that can only be completed by the person who is making the decision. And the individual, when it comes to risky decisions, has a right to choose how much risk and what type of risk they find acceptable, regardless of their age. Necessarily, with some exceptions, right? Like we don't let two-year-olds drive cars. But people have the right to decide how much benefit is enough and how much harm is enough to help them make a complex decision and to curtail the right to risk. The right to take risks is to curtail autonomy. So that's why it's called the dignity of risk is that there's dignity in being able to make decisions that you might regret later, even if it makes means making a quote-unquote “bad” decision.

So a little bit more in context is that when we talk about protecting children from harm, sometimes, like obviously we should protect children from obvious harms, but sometimes excessive protection of children may be harmful. In the disability context, we think of this as a children who have some kind of physical disability, their parents may be being very concerned about them dating, right? So they may be like concerned about them dating, concerned about potential exploitation to the point where they're not able to participate in social functions with their peers, not able to participate in the normal risk-taking of adolescents. So they don't have that opportunity to grow and learn through making decisions that later they wish they hadn't.

Notice the extremes the speaker goes to when she needs to find an example: individuals have the right to make risky decisions but we don’t let two-year-olds drive cars! That would be crazy! She gives the actually contested territory—teens making life-changing decisions about medical interventions—a wide berth.

She then moves on to talk about the kinds of risks teenagers typically take:

All teenagers and all humans learn best from doing, even if it means doing something dumb, making a mistake. You know, we want people to… we want teenagers to take risks while we can provide them support. Like we want your kid to take a risk while they live with you. So, and this has to do with sexual development and other parts of adolescent development. So sexual development is not just one thing. It's your body parts, it's your space, it's your gender, it's your, the relationships you see in your life, it's the sex you see in media, it's the way you express your gender, it's your physical development of puberty. It's boundaries. Like, what are you okay with? … Orientation and activity are all normal parts of development. Like, can people take risks with all of these different areas as a normal part of developing your sense of self as a human?

So, the right to regret is sort of the thing that comes out of the dignity of risk, is it's this idea that, like, an autonomous person can make decisions they wish they hadn't later, right? We have all done things where we're like, oh, that was not great, right? But that's part of being a person and part of learning and growing. So we allow and encourage teenagers to make decisions and make mistakes in all kinds of domains. It's the right to have a broken heart, right? Like, the right to date someone that maybe it wasn't a great idea. It's the right to do something where later you're lying awake at night 10 years later going, oh, God, that was terrible. It's the right to say something and then later just feel like vomiting because you're so ashamed of your previous behavior, right? But without that right of being deeply ashamed in the future, you don't learn about how you feel about things.

Again, she’s talking about the “right to have a broken heart” and the right to say something stupid but what she’s really talking about is the (much more questionable) “right” for a teenager to… have her puberty blocked in an experimental medical intervention or undergo a double mastectomy. Are these just learning experiences that teach us how we “feel about things”? Or is something greater at stake here? (Meanwhile, teenagers aren’t the only relevant actor in transition! Let’s call this the magical-disappearing-medical-provider maneuver).

Notice, too, how often she’s checking in with the audience: “… right? … right? … right?” I don’t think this is just a verbal tic or an excess of feminine agreeability and consensus-seeking. She’s constantly looking for affirmation that what she’s saying sounds reasonable and makes sense. My guess is that she’s suppressing the suspicion that her comparisons—broken hearts/stupid comments/regretted hormonal and surgical interventions—don’t stand up to scrutiny. She looks for social support in the bottomless way an insomniac reaches for sleeping pills.

She then embarks on a lengthy tangent: look at how the 50 states set different ages when parental consent is and isn’t required! In some states, she points out, “you can be pregnant and not be able to consent to your own epidural.” How dumb is that?

But, again, it’s totally beside the point.

Then she talks about abortion and Dobbs at great length so that she can bind the two subjects—abortion and transition—together in her listeners’ minds in the hope that analysis and the emotions abortion stirs up carry over to her real subject: youth gender transition and how state bans on hormonal and surgical interventions are rooted in “misunderstandings” about youthful capacity to make decisions about medical care. She criticizes policymakers for their comments about adolescent brain development, claiming that it’s “not as straightforward as people making policies would like people to believe.”

And so it’s important to keep that in mind. Also, as mentioned previously, experimentation and risk-taking are a normal part of development.

—which, again, yes! Experimentation and risk-taking are normal parts of adolescent development! But medical experimentation isn’t—and shouldn’t be—a normal part of adolescent development. We are talking about two entirely different things here: what risks teenagers take and what procedures should clinicians provide.

I think most parents prefer that eventually their kids are able to get a job and support themselves. And all of that is inherently risky to do. And so we want adolescents to take risks, appropriate risks that don't cause irreparable harm, so that as adults they're also able to take risks and then able to, like, you know, take care of themselves and have jobs and that sort of thing.

So, if we want kids to be able to hold down jobs when they grow up, then we should… I’m sorry, what?

But again, I’m letting her use of the passive voice infect me: the question isn’t “should we let teenagers take puberty blockers and cross-sex hormones” but “should doctors prescribe puberty blockers and cross-sex hormones.”

She then moves on to the subject of ‘hot’ and ‘cold’ cognition. ‘Hot’ cognition is emotional, impulsive. ‘Hot’ decision-making may occur under the pressure of peers or may be driven by sense of urgency. ‘Cold’ cognition, on the other hand, is deliberative, rational. These are useful ways of thinking about thinking! Or these were useful ways of thinking about thinking—until the speaker defined the decision to take cross-sex hormones as an example of ‘cold’ decision-making:

So, we know now really that there are hot decisions and cold decisions. Hot decisions are ones that are made in the moment, sometimes, but they tend to be more reactive or more based in emotion. They aren't always in the moment though, if you think about. So, in the US, the legal age to buy alcohol is 21. If a 16-year-old wants to buy alcohol and throw a party, that's not typically something they can impulsively do. So while that would be considered a ‘hot’ decision, it may be days in the making. So when we simplify it as, like, impulsive versus not, sometimes that impulsivity is a decision that's made over a few days and can be influenced. You can see the part below with peers and so who the patient is around or the person is around also influences their ability to make decisions. So if they're with a peer that is making an impulsive decision that maybe wouldn't be one they would normally make, they may be more likely to make that decision.

The same with, like, so our ‘cold’ decisions. These are deliberate, future-oriented, informed decisions. So what birth control should I be on? Should I be on birth control? Other medical decisions would include HRT [hormone replacement therapy]. So these are decisions that they're allowed to have time to think about. So no one is, you know, developing dysphoria, going to the doctor and getting prescribed something within a couple of days because that may put them more in the hot decision category. These are kids that have had this identity for years and, you know, have waited for the appointment for months or years, depending on, you know, what part of the world and what part of the country in the US they're from. These would fall under the cold decision-making that we believe really is basically at the level of a young or middle-aged adult by about age 14, and for some adolescents that's even younger, some that's a little later. Obviously there's variation, but by and large, most adolescents are making these cold decisions at the level of adulthood by about age 14. The impulsive decisions, that's much later can be into the 20s, really, that you see those decisions start to be filtered more through those mature frontal lobes.

This is how you turn a potentially useful concept inside-out. Defining the decision to transition as an example of ‘cold’ cognition ignores the sense of urgency young people feel (the clock is ticking; every delay in transition delays the start of your real, authentic life; every moment that puberty progresses unchecked undoes the future you desperately desire); the peer pressure; the sky-high emotions that inevitably accompany the belief that transition is the only way to deal with distress.

Thus, a clinician can recognize the risks of ‘hot’ cognition and the unique susceptibility of young people to making bad decisions under duress, and then insist that those conditions don’t apply where they so obviously do.

She then shifts to discussing parents’ fear that their children may someday regret transition and the shell game continues:

Parents are often worried about whether their child may change their mind when they make a certain medical decision. You know, parents feel, I think, like they're being asked to make a decision for their child as opposed to with their child because of kind of the legal requirement to consent to treatment. And so there's worry often from parents, what if my—you know—we make a medical decision and then my child regrets that in the future? Will they blame me? Parents often worry that having a trans child means that their kid's going to have a hard life. And so there can be some grief or worry about someone harming their child because of their identity. [Parents wonder:] How do I know if this is real? Gender identity is not something that we can test. You know, most medical things, there's some sort of diagnostic test that's easy to kind of guide decision-making. And we don't have a way to test someone's sense of their gender identity.

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We want to create space for complexity. So we want young people to understand that it's okay to not fit neatly into a box, that people can have different gender embodiment goals even while using the same term to describe their gender, that that's okay. And also recognizing that sometimes we bump up against the medical reality that we can't always achieve everybody's embodiment goals. And then we want to make sure that that information is delivered in a developmentally appropriate and accurate kind of manner and then recognizing that these are ongoing conversations and that medical decisions are ongoing over a lifetime time. So, how do we frame kind of this medical decision-making process? We always want to remember and recognize that individuals are the experts on their own identity. Again, we don't have a way to test or confirm somebody's identity. People are pretty good at finding an authentic path for themselves. We give them space to do that. Reminding families that we are not making a decision about a young person's identity, we're making decisions about a medical intervention and then normalizing that family decision-making is not unique to gender affirming medical care.

Here’s where clinicians shirk responsibility for the active role they play in transitioning their patients: “individuals are the experts on their own identity… we don’t have a way to test or confirm somebody’s identity. People are pretty good at finding an authentic path for themselves. We give them space to do that.” That’s all these clinicians are doing, in their own minds: ‘giving’ ‘people’ ‘space’ to find their own ‘authentic path.’ A more honest and descriptive sentence would replace every word. Actively intervening on a patient’s endocrine system is not ‘giving space.’ Teenagers are, of course, people, but their age and developmental stage always matters and should never be hidden behind overbroad terms. How on earth did medicine get tangled up in any individual’s quest for ‘authenticity’? What does ‘authenticity’ have to do with leveraging medical technologies to change everything about oneself?

She concludes by discussing the four principles of medical ethics: beneficence, non-maleficence, autonomy, and justice:

And this is really our obligation to act in the best interest, interest of the patient, you know, acting in a way that promotes health. At the end of the day, we want to help patients decide what is best for them. Non-maleficence, you know, the avoidance of unnecessary harm. I think a lot of times people are dropping the ‘unnecessary’ part. You know, we often make decisions that may come with some harm, but we also have to think about the benefits of those decisions or the risks of not undergoing a certain intervention. So, you know, avoiding what harm we can when making decisions is important as well from a—from an ethical perspective when helping patients make decisions.

She’s using the language of medical responsibility here, but she’s emptied the concept of all meaning.

And then autonomy, and I think this is really where the, you know, dignity of risk and right to regret falls in. So autonomy, you know, the concept that we all have the right to decide what happens to our bodies and ourselves, you know, as children, as we've discussed, often our caregivers, our parents, our family support system serves as a surrogate decision makers for us. But as we develop increasing capacity, you know, cognitively, emotionally, as Corey was talking about, we begin to develop the skills to make these decisions for ourselves and participate more in the decision making process, you know, generally throughout adolescence, until we are able to make those decisions more independently, you know, but using the support of the family system until then. And we often rely on our support networks to help us make decisions, you know, even—even as adults and into our old age and middle age, because that's the way we can make the best decisions.

She makes a familiar move here: collapsing age distinctions, as though children and adolescents need support in decision-making the same way middle-aged adults and seniors do! This isn’t reckoning with childhood and adolescence as distinct developmental stages, with distinct vulnerabilities. Throwing teens in with adults is meant to obscure, not illuminate.

So some derivatives of autonomy… are, you know, informed consent, truth telling, confidentiality. And I would propose that the dignity of risk and right to regret should be included here as well. You know, informed consent, you know, just making sure everyone knows the benefits, the risks, alternatives to whatever treatment options they may be seeking, that they're voluntarily able to choose what is best for them and that they truly understand, that they're able to demonstrate understanding of the risks and benefits of potential treatments or non-treatments. Truth-telling, I think is important for us as providers, really being honest about what we know and what we don't know, you know, what the literature supports, what it doesn't support, what what clinical experience has shown us and being honest about the fact that we're continuing to learn about the diversity of gender experiences and what gender care needs are, but that this should not preclude potentially people from accessing care… And again, we've been talking about the dignity of risk and right to regret. And I would say that falls under autonomy. People have the right to make decisions that may come with some risk and some future regret and just hoping—I think our role is to help them balance all that. So again, young people can make the best decisions with themselves, often within the context of their—their family system.

And then the last ethical principle that is last in the list—again, they're all equally important, but that I think is really important, but probably beyond the scope of us to get into too much too today is justice. So just want to mention it. Making sure that everyone, you know, gets fair, equitable and appropriate treatment. I think, if this is “to each according to their need,” we probably could do a full week conference on the concept of justice in relation to gender-affirming care.

Strong “some animals are more equal than others” vibes.

At the end of the session, the speaker says: “The only person who knows what you are going to want in 15 years is you in 15 years.” Like so much of what’s been said, this is, of course, true in a trivial sense: the future! So unpredictable!

Apparently, the inherent unknowability of the future leads people to very different places when it comes to assessing the risk of irreversible interventions to assuage transient identifications.

For me, this discussion of the “dignity of risk” and “right to regret” shows how completely gender clinicians have absolved themselves of the responsibility they in fact owe their patients. This entire conversation about regrets (everybody has regrets!) and not being in any position to judge people’s identities and how everybody has different embodiment goals even if they use the same labels—it’s all beside the point. It’s a sideshow distracting clinicians from the real questions they need to grapple with: Are these interventions safe and effective? Is it ethical to intervene on patients’ bodies in these ways, for these reasons? At the most basic level: is this medicine? Or are these just cosmetic interventions that alter and harm the body without effectively treating the distress?

In other words, when we call these interventions ‘medicine,’ are we making false promises to vulnerable patients?

I’ve always sought to understand what it is gender clinicians think they’re doing. I still think that’s important. I still try. But there’s an extent to which it just… doesn’t matter. It doesn’t matter what these clinicians tell themselves they’re doing. It doesn’t matter if they’re good people who—by a complicated process of indoctrination and desensitization and self-absolution—ended up doing bad things or bad people doing bad things. Gender-affirming clinicians have had so many opportunities to reconsider: every time the expected results don’t pan out, say. But they’ve shirked every reckoning. They conceive active interventions as a kind of passive ‘holding space.’ Gender clinicians have conceptualized their work in a way where they bear no responsibility for their actions and therefore are capable of anything, as long as the patient asks for it.