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Relying on Experts Doesn't Remove Your Responsibility

In October, just two weeks apart, John Stewart and John Oliver covered the "trans issue" on their shows, The Problem with John Stewart and Last Week Tonight with John Oliver, respectively. I promised myself that I wouldn't write about either episode, both of which were covered extensively. I made the promise because I can watch neither in its entirety. I find them infuriating. I also have found it difficult to stop thinking about them. While contemplating whether I had to write just to let the anger go, I realized that the ire wasn't just because of those two episodes, but about what they represent: the loss of respect for people I have long admired. I don't mean Stewart and Oliver.

In the absence of a clear event like a death or deliberate end to a relationship, a loss is not always apparent. I began writing about the "trans issue" because I had not previously fully recognized the danger to children. I assumed that the people I know would appreciate having all the information I had gathered from diverse sources in an easily digestible form. I assumed they would feel as alarmed as I did over what was happening to adolescents. After writing on the topic for more than a year I have to finally admit I was wrong. The slow gradual loss of respect and the connection to relationships based on that respect is like holding a fist full of water only to find it has all disappeared upon opening the fist. My seemingly irrational anger at the episodes was both warranted and a reflection of grief not yet recognized. It is possible that acceptance is not only the final stage in the process of grieving, but sometimes the first necessity in triggering the process. 

In a sense, I should be grateful to Stewart and Oliver for helping me find a clarity I didn't realize I needed. They both used rhetorical tricks and provably false statements that felt incredibly anachronistic. Much of the advocacy for things labeled "trans"-- healthcare, rights, etc-- occurs in a discursive tidal pool inured to any real world events or lack of answers to ostensibly simple questions. Stewart interviewed the Arkansas Attorney General, Leslie Rutledge, on Arkansas' legislation banning adolescent medical transition. In the interview Stewart compared medical transition to cancer while asking why the state would trust the support of medical associations for one and not the other. It's worth noting that he asked this of a lawyer rather than one of the medical or psychological professionals consulted in drafting the legislation. Those professionals might have made clear that unlike "gender medicine" there are specific testable criteria that guide treatment for cancer. The mechanisms triggering a cancer in one individual matches the mechanisms triggering cancer in another, offering an evidence based standard of care across all those with that cancer. The occurrence of "gender dysphoria" that is the basis of "gender affirming care" is unique to each individual triggered by a diverse number of experiences from trauma from sexual abuse to internalized homophobia. In a sense, "gender dysphoria" is more a descriptive catch all for the result of experiences leading to a sense of body dysmorphia than it is an objective diagnosis.

In the portion of his episode I was able to withstand, Oliver talked about the role of puberty blockers. He made the point that they are reversible and merely give the adolescent time to consider whether "gender affirmation" is appropriate to continue. Puberty blockers, gonadatropin-releasing hormone agonists (GnRHa), prevent the release of hormones that trigger the changes in puberty that lead to physical, sexual, and cognitive maturity. Rather than give an adolescent a pause to consider treatment with their cognitive immaturity, they almost ensure that the child will continue medical transition as over 98% of adolescents on puberty blockers do. Clearly, it is not just a pause, it is a stepping stone that ensures medical transition. Which makes sense, because it's the first step in the adolescent "gender affirmation" process. For the tiny number who stop before moving on to cross sex hormones, what does it mean for puberty blockers to be reversible? How does one reverse time to recreate the time limited process of puberty?

There's an important line of demarcation on the "trans issue" that explains why these episodes felt anachronistic. We reached a point in time after which it has become increasingly impossible to accept the assertions of trans activists without deepening skepticism. I would place that moment in 2019. We had the premiere of the I Am Jazz series in 2015. It portrayed Jazz Jennings as a child born in the wrong body with a family supporting him to become his truest self to live life as his version of a girl. In 2017 The Endocrine Society promoted "gender affirmation" to its members as best practice for dysphoric children. The process entailed puberty blockers, followed by synthetic hormones for the opposite sex, and "gender affirming surgery" to cosmetically present non-functional genitalia of the opposite sex.

In 2018 Jennings underwent "gender affirming surgery" which was followed by several surgical revisions due to complications. Jennings mental health seemed to decrease after these surgeries leading to massive weight gain and a requirement for psychological evaluation before being allowed to attend college. The reasons illustrate the lie behind the idea that puberty blockers are reversible. Creating a facsimile of a vagina on a male usually involves inverting his penis. One consequence of stopping puberty with GnRH argonists is that male patients are left with a micro-penis. Patients like Jennings require material harvested from other body parts to complete the surgery. The complications of the surgery are likely to have had a negative impact on Jenning's mental well being. The impact of blocking natural cognitive development that leads to maturing emotional regulation is likely even greater.

Jennings' experience also brings up many questions around this process as best practice. One of the surgeons, Dr. Jess Ting, refers to it as a "one of a kind surgery" because Jennings is one of the first to undergo full puberty suppression. During the surgery Ting and Dr. Marci Bowers actively disagreed on the process down to specific incisions. "Gender affirmation" rests on the principle of informed consent rather than medical necessity. When Jennings was placed on puberty blockers at 11 in anticipation of the eventual surgery, the family was clearly never informed of the complications that suppressing puberty would create. Considering that Jennings was one of the first to undergo the process, did the doctors even anticipate this complication? True informed consent would have alleviated Jennings' concern that nerve damage from the third surgery might remove the possibility of future orgasm. Jennings need not have worried. The puberty suppression itself had already taken that possibility. Speaking at Duke University in May of THIS year Dr. Bowers said,

[A]n observation that I had, every single child who was, or adolescent who was truly blocked at Tanner stage 2, has never experienced orgasm. I mean, it's really about zero."

The televised experience of Jazz Jennings alone should be enough to give anyone pause before calling "gender affirmation" vital or life saving. Jennings' experience is one of many concerning factors that illustrates that "gender affirmation" is against the long term best interests of adolescents. His disturbingly public trajectory very much represents the difference between the skepticism over "gender" claims before 2019 and the mountain of evidence that all the claims are false accumulating after. 

In April of 2019 the first of a currently four part documentary series premiered in Sweden, Stopping the Trans Train. The second part premiered in October of the same year. The series explores the exponential growth in mostly girls presenting at Swedish gender clinics and the regret of some transitioners. The first episode was followed by medical experts demanding the government review the medical evidence for transition, and a 65% drop in patients presenting at gender clinics. On the day the second episode premiered famous transitioner Aleksa Lundberg appeared in the media to say that if he had the choice at that time, he would have decided against surgical transition. The third episode premiered in 2020 featuring Lundberg. The fourth episode was broadcast in November of 2021. It focuses on Leo, a female child who started puberty blockers at 10. Leo was diagnosed with spinal fractures and two malformed vertebrae after complaining about back pain. This was likely a result of GnRHa stopping the mineralization of the bones that occurs during puberty.

It is not hyperbole to suggest that this series played a primary role in in re-centering these medical decisions around evidence based science rather than ideological certainty. Prior to the first episode the Social Democrat government was considering lowering the age for medical transition and removing the need for parental consent. By February 2022, three months after the fourth episode aired, the use of puberty blockers and hormones for adolescents was limited to use only in well structured trials. This came almost two years after Finland became the first nation to deviate from the World Professional Association for Transgender Health (WPATH) guidelines based on a review of the evidence which severely limited the use of puberty blockers and hormones for adolescents.

Two similar reviews of the evidence for puberty blockers and cross sex hormones began parallel to an important trial in the United Kingdom that was decided in December 2020. Detransitioner Keira Bell brought a judicial review against the English Tavistock adolescent gender clinic. She felt that due to her underlying mental health issues she should not have been prescribed puberty blockers, testosterone, and given a double mastectomy. The high court ruled that adolescents lacked the maturity to give informed consent to the irreversible consequences of medical transition.

The systematic reviews of evidence conducted by Dr. Hillary Cass for the National Institute for Health and Care Excellence (NICE) released in March 2021, added to the concerns raised in the Bell trial. Both reviews found the evidence in support of GnRHa snd hormones to be weak and inconclusive. This was followed by a review by Cass of the Tavistock clinic, the largest gender clinic in the the world. As a result of the findings, Tavistock was condemned as unsafe has since been closed. Prior to the review of Tavistock, numerous people working at the clinic quit or were removed for stating similar concerns. Clinicians noted that it seemed like a form of conversion therapy. The new treatment guidelines focus on mental health services and recommend against even socially transitioning children.

Perhaps this slow awakening to my loss of respect is a reflection of my own discomfort with being susceptible to propaganda. I initially accepted BLM as a political operation, the possibility that the novel inoculations might control COVID infection, and the idea that "gender medicine" was based on evidence until forced to confront my doubts otherwise. My doubts around the "trans issue" started with the fact that the most central demand for the "most marginalized minority group in the world" was that everyone change their use of language rather than safety, housing, or even medicine. My doubts crystalized into certainty that the assertions of trans rights activists were all propaganda upon learning of the massive increase in mostly girls identifying as trans in a relatively short period of time and listening to an episode of a podcast. It was the fifth episode of Gender: A wider Lens, with therapists Sasha Ayad and Stella O'Malley. The episode featured endocrinologist Dr. Will Malone. He detailed the introduction of the "gender affirmation" guidelines to the doctors represented by The Endocrine Society now recommended by every major US medical association. Unlike every other medicine or protocol recommended in the past, the guidelines were offered based on a single study and with little discussion or pushback allowed.

My first reaction was such deep incredulity that I found myself diving down a rabbit hole of references and sources to confirm and better understand the risks he had mentioned from the protocol. Even then, I allowed myself to believe that the problem was a bastardization of the watchful waiting of the Dutch Protocol rather than understand that the Dutch Protocol, which is the basis of this use of GnRHa, was built on deeply flawed reasoning. The notion was finally and completely laid to rest on hearing the approach of the clinicians behind the Dutch Protocol, again on an episode of Gender: A Wider Lens. I was left with the feeling, shared by O'Malley and Ayad in a follow up episode, that the use of puberty blockers had more to do with a patient disturbed by puberty than her need to embody an identity. Long before the introduction of "gender affirmation" in the US, research had shown that the vast majority of adolescents with pervasive sexual dysmorphia grew out of it with puberty. It is deeply sick and monstrous that this protocol starts with chemically stopping the natural developmental process that would render the protocol unnecessary. There is not a single study that supports stopping puberty entirely for any reason. As with young people like Jazz Jennings, we are learning of the consequences in real time. This protocol has been likened to an experiment. Experiments have endpoints and rely on data. It would be more accurate to note that this is experimentation, the equivalent of just trying some things and seeing what happens.

The longer that I have participated in this conversation the clearer it has become that the most vocal advocates for giving adolescents puberty blockers that render them infertile and anorgasmic adults are adult men with autogynephilia who are completely intact. Men like Rachel Levine and Marci Bower, who transitioned later in life, usually after fathering children, are promoting the idea that they were "born this way" projecting their fantasy on these adolescents that they would better pass as women had their puberty been curtailed. The advocacy obviously isn't from personal experience that this best serves the children. They are completely apathetic about what is best for these children.

The irony is that the people who continue to advocate for adolescent "gender affirming care" would listen to these men while ignoring the people who have experienced adolescent "gender affirming care." One of the most significant aspects of the difference between what was assumed prior to 2019 and what has become undeniable since, is the growing number and public presence of detransitioners. The claim is that less than 1% of people regret transition. That is based on a model featuring heavy gatekeeping. The current model essentially affirms rather than explores the self diagnosis of the individual. As the number of young people transitioning has grown exponentially, so has the number regretting transition. There is little research on the rate of regret, but one study estimated that it may be 7-10% of people who transition. The detrans sub Reddit has over 41,000 members. Detransitioners, who were once mobbed on social media by activists, are sharing their experience with legislatures and medical professionals to stop the growing number of detransitioners. It is impossible to assert that "gender affirming care" is life saving without ignoring these individuals for whom it did more harm than good.

Reading online praise for Stewart, the repeated assertion that puberty blockers are reversible has helped clarify that apathy for the children, regardless of any professional or professed intention, lies at the heart of this continued advocacy. It doesn't matter if people truly believe that blocking their puberty and opposite sex hormones are in the best interest of children, belief doesn't change the reality that they are not. As Stewart and Oliver do, one can't hide behind the authority of the support of every medical association for "gender affirmation". On this, moral reasoning by proxy, trusting the "experts" doesn't relieve people of the responsibility for considering the results of their advocacy. Expertise is based on evidence and consistent predictable results. On the question of "gender affirmation" there are truly no experts. The people who claim expertise never ask, "should we do this?" This experimentation is immune to actual evidence, because the evidence says that we should not. Recognizing that what is lost may one day be found again, I remain optimistic that my respect may be re-earned. In this climate, "I was wrong" is a more valuable social currency than it has ever been. In the absence, it is best to remember that acceptance of what is lost is the final stage of grieving and moving on from that loss.


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