The secret life of gender clinicians: Reporting from inside WPATH
On WPATH’s private forums, clinicians occasionally express reservations about what they’re being expected to do, such as the social worker who wondered whether she should write letters for surgery for “several trans clients with serious mental illness… Even though these clients have a well-established trans gender identity, their likely stability post initiation of HRT [hormone-replacement therapy] or surgery is difficult to predict. What criteria do other people use to determine whether or not they can write a letter supporting surgical transition for this population?”
Her colleagues quickly put her in her place: “My feeling is that, in general, mental illness is not a reason to withhold needed medical care from clients,” an “affirming, anti-oppressive” gender therapist responded. “My assumption is that you’re asking this question because you’re taking seriously your responsibility to care for and guide your clients. Unfortunately, though, I think the broader context in which this question even exists is one in which we, as mental health professionals, have been put inappropriately into gatekeeper roles. I’m not aware of any other medical procedure that requires the approval of a therapist. I think requiring this for trans clients is another way that our healthcare system positions gender-affirming care as ‘optional’ or only for those who can prove they deserve it.”
Another gender clinician referred dismissively to the recommendation that mental illness should be “well controlled” before initiating hormonal and surgical interventions: “I am personally not invested in the ‘well controlled’ criterion phrase unless absolutely necessary… in the last 15 years I had to regrettably decline writing only one letter, mainly [because] the person evaluated was in active psychosis and hallucinated during the assessment session. Other than that, everyone got their assessment letter, insurance approval, and are living [presumably] happily ever after.” Everything hinges on that “presumably”.
For years, gender clinicians have reassured patients and parents that the evidence would eventually bear out the lofty promises of transition: that transition is life-saving; that psychotherapeutic approaches to gender distress don’t work and instead constitute unethical “conversion therapy”. But as the data starts to come in, transition appears unlikely to live up to these high expectations.
During the Ireland conference, researchers bracketed discouraging findings with upbeat statements of belief such as: “We all know gender-affirming care is effective.” A Swedish researcher who found that psychiatric hospitalisation increased after patients initiated puberty blockers or cross-sex hormones told the audience that she was “really concerned”, not about the results themselves, but “about how results will be interpreted” because, “as you all know, there are improved mental health outcomes following puberty blockers and gender-affirming hormones” — even when the research can’t find those benefits.
Not only is it not true that no other medical procedure would require a therapist to sign off (as the commenter below (William Shryer) notes, but, more importantly, most medical procedures (I might dare say all, with the exception of Lobotomies) are a response to a physical issue, not a psychological complaint. Even worse, concerning "gender dysphoria," there is no ability to confirm the diagnosis beyond asking questions of the individual and relying entirely on their self-report of discomfort. What other purely psychological ailment warrants surgery? I can think of none. Even if I'm wrong and such surgeries for purely psychological symptoms exist, I'm quite sure they would require the "gate-keeping" of the patient's therapist.
From the conference-goers' comments, the belief among them is that synthetic chemicals and surgeries to create the false appearance of being the opposite sex are - for anyone who, at any time, requests them - the most wonderful thing on Earth, with no downside.
How did the medical community run so far off the rails with this?
From this therapists perspective so much of this poor research methodology and political correctness all emanates from poor training in our professional schools. They have become hotbeds of political correctness and tend to discard years of solid data on the developing person. When it comes to solid developmental training they get an “F”. We used to have to perform mental health evaluations on those wanting bariatric surgery to determine if they were emotionally stable to handle a change in body shape and could follow directions post surgery. This was seen as being responsible for the patient and the surgeon. All of this has fallen by the wayside as we now are supposed to join the patient where they’re at even if that place borders on delusional denial. We see this taking place in our society on a maga scale right now. In my opinion it all goes back to hard nosed clinical training and not the approach of, “we love the poorly educated.” Anna Freud said it best in one of her famous writings. Denial in the service of the ego only protects the individual from the obvious or that which they cannot handle. Joining a patient in their denial serves no clinical purpose, and violates the oath to “do no harm”.