Leaked exchanges stir trans debate
Puberty blockers, sterility discussed by medical staff
Leaked discussions provide a rare glimpse into the private conversations between doctors caring for the growing number of children identifying as transgender.
Exchanges include concerns that minors can't always fully grasp the extent to which the medical interventions they are agreeing to are impacting them, especially those that have potentially permanent effects like sterility; whether the minimum standard age for genital surgery — 18 — should be considered an “arbitrary” number; and whether starting children on puberty blockers as young as age nine is “robbing” children of a key period of sexual development.
The files, leaked from within the World Professional Association for Transgender Health (WPATH), an influential body that provides guidance on treating gender distress, were published this week by U.S.based Environmental Progress (EP), a non-profit headed by author and journalist Michael Shellenberger.
Shellenberger received a collection of screenshots of messages from an internal WPATH chat system and a video of a May 2022 internal panel discussion.
In the leaked messages and video footage, doctors, therapists, social workers and activists discuss specific cases and share advice on how to treat youth and adults with gender dysphoria.
Whether the files are as damning as EP claims is debatable. “There are aspects that don't shine a particularly good light on WPATH, but I also don't think this is the scandal EP is making it out to be,” said Julia Malott, a transgender woman, and a National Post columnist.
But the leaked discussions come amid increasingly politicized debates over policies banning puberty blockers and gender-affirming hormones for children under 16, and concerns that some children may have ultimately “desisted” if they had not been shuttled so fast on a path of medical transition.
With over 2,000 members, WPATH sets standards of care for treating gender dysphoria. Most of what Canada has implemented has been done in alignment with WPATH recommendations.
One of WPATH's central tenets is that youth diagnosed with gender dysphoria have access to puberty blockers and gender-affirming (cross-sex) hormones, provided they have the emotional and cognitive maturity needed to provide informed consent.
In the videotaped panel, a prominent Canadian endocrinologist discusses the challenges of getting proper informed consent when starting youth on testosterone or estrogen, and the permanent changes that can happen. “I think the thing you have to remember about kids is that we're often explaining these sorts of things to people who haven't even had biology in high school yet.”
Discussing the potential loss of fertility, and options to preserve fertility, with a 14-year-old is “always a good theory,” he says in the video, because many will go on to cross-sex hormones that will leave them sterile. But, “I know I'm talking to a blank wall,” he says. “And the same would happen for a cisgender kid, right? They'd be like, `Ew, kids, babies, gross.' ”
“We try to talk about it, but most of the kids are nowhere in any kind of a brain space to really, really, really talk about it in a serious way,” he adds. “I — that's always bothered me, but you know, we still want the kids to be happy, happier in the moment, right?”
He says he wasn't surprised by a recent Dutch report about reproductive regret, telling those assembled that, “now that I follow a lot of kids into their mid-twenties, I'm like, `Oh, the dog isn't doing it for you, is it?' They're like, `No, I just found this wonderful partner” and now want kids.
He also expresses concern that puberty blockers may be “robbing these kids of that sort of early to mid-pubertal sexual stuff that's happening with their cisgender peers.”
In a post to the internal messaging forum, a Halifax nurse practitioner describes a patient with PTSD, major depressive disorder and traits of schizoid personality disorder who was eager to start hormones.
“My practice is based fully on the informed consent model, however this case has me perplexed; struggling,” the nurse wrote.
“I'm missing why you are perplexed,” a University of California, San Francisco psychiatrist responded. “The mere presence of psychiatric illness should not block a person's ability to start hormones if they have persistent gender dysphoria, capacity to consent,” and the benefits outweigh the risks, he said. “So why the internal struggle as to `the right thing to do'? This is harm reduction and so doing nothing is not a `neutral option.' ”
Other posts include discussions about complications from masculinizing testosterone therapy for females transitioning to male, such as vaginal atrophy and pelvic inflammatory disease. Other exchanges involve a small but notable increase in demand for novel, “non-standard” surgeries for people who are nonbinary, identifying as neither solely male or female, surgeries such as penile-preserving vaginoplasty or “nullification,” meaning removal of external genitalia. Such surgeries aren't performed in Canada. However, Ontario's Health Services Appeal and Review Board recently ruled in favour of a 33-year-old nonbinary male patient who identifies as “female dominant” who is seeking public coverage for surgery at a clinic in Austin, Texas, to create a vagina while preserving the penis.
WPATH's standard of care for nonbinary people is quoted in the appeal board's decision.
Shellenberger's group alleges that the leaked files reveal some WPATH-affiliated members are “violating bedrock principles of medical ethics and informed consent” and placing adolescents “on a medical conveyor belt.” The private conversations, the group said, contrast with WPATH's public stances that doctors are providing age-appropriate care children can understand.
But critics said the leaked files are “deconstructed,” isolated and often innocuous conversations between doctors, many of whom show caution. There are concerns hormones are being prescribed by family doctors who don't “really know necessarily everything about trans care.” Some members express concerns that as access to transition becomes easier, more detransitioners will follow. A few youth “seem to feel that they should be allowed to switch back and forth merely at their request . ... I am not comfortable with that at this point; we need a better understanding of how to handle this type of situation,” one clinician wrote.
On the internal message board, Dr. Marci Bowers, WPATH's president, acknowledged that “our counselling and informed consent process could use tightening. We all need to be better and not afraid to listen.”
But Bowers also said that acknowledging that detransition exists “even to a minor extent is considered off-limits for many in our community. I do see talk of the phenomenon as distracting from the many challenges we face.”
When asked if chatroom conversations had been excerpted or presented in their entirety, EP responded that “they are whole discussions, as provided to us by the source/sources.”
“I fully believe WPATH means well and while there are improvements to be made and more caution to be had, I don't foresee this being the end of WPATH,” Malott said.
Concerns over informed consent are valid, Malott said. But she rejects the argument that consent in a minor is impossible. “I do think the younger the child, the bigger the risk and that, in my view, is why we involve parents.”
She also struggles when the argument pivots from “kids can't fully understand what they are agreeing to,” to “we can never do this, and it's abuse to do it even when a parent and a doctor are on board that this is the right thing for the child.”
“We also have plenty of success cases that can be pointed to as well, and this report seems to completely gloss over, or flat out deny, that there are thousands and thousands of success cases,” she said.
“Some kids really are on the ledge. We need to take that seriously. That doesn't mean every kid who says, `I think I'm a girl' should be given hormones.”
WPATH did not respond to a request for comment before deadline.