Autonomy as a ploy

With scant evidence of health benefits for paediatric medical transition, advocates are distorting bioethics to justify treatment on demand

Photo by Thiago Rocha on Unsplash

Activist insecurity

My reporting, below, from the Berlin meeting of the Society for Evidence-based Gender Medicine (SEGM) follows the Chatham House rule, which means I can relate what was said, but not who said what.

SEGM has been smeared as a “hate group” and speakers can be forgiven for preferring anonymity. The venue for the September 11-14 conference was a secret. Some of the activist hostility online was just comical—the idea of SEGM as a “clerical fascist” project—but the distant murder of Charlie Kirk, long a target of trans-antifa rage, cast a shadow over the meeting in Berlin.

The program brought together current and former gender clinic directors, medicos of various specialisations, psychotherapists, philosophers and researchers who did not always agree. There was no hint of “anti-LGBTQ+ hate”; SEGM’s president happens to be an openly gay man, the psychiatrist Dr Roberto D’Angelo.

An entity such as SEGM does constitute an inconvenient challenge to the idea of a monolithic LGBTQ community united in uncritical support of “gender-affirming care”. Those who cry “hate” only betray their insecurity.

One thread running through the Berlin conference was the trans medicalisation of some teenagers who might otherwise grow up as gay or lesbian in healthy bodies. Shortly after the meeting wound up, a new organisation, LGB International, was launched. Part of the backstory is some years of alarm about the TQ medical venture. As Bev Jackson, who co-founded LGB Alliance in the UK in 2019, said: “Many young LGB people are being encouraged to think they must be ‘trans’—and need drugs and surgeries—instead of accepting that they are simply attracted to people of the same sex”.

Back to SEGM’s Berlin meeting. I intersperse my paraphrase of speakers’ remarks and arguments with direct quotes, some lightly edited for readability.

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Worth a Nobel

“If somebody would be able to prove there is a gender identity that is completely independent of biological sex in every person on the planet, that would probably be a Nobel prize.” And yet this unproven construct—better viewed as a young person’s self-interpretation—is used to promote the provision of puberty blockers and cross-sex hormones.

Goodbye to benefit

The debate about paediatric medical transition has all but finalised the question of evidence. Multiple systematic reviews have shown the evidence base for hormonal and surgical interventions to be weak and uncertain; this lack of good quality evidence is unlikely to be remedied in the foreseeable future. Meanwhile, key figures advocating for the gender medicalisation of minors have suggested that the justification should no longer be proven benefits, such as reduced gender dysphoria or improved mental health. Instead, they argue that adolescents be given these medical treatments to respect their “autonomy” or enable achievement of their personal “embodiment goals”—regardless of whether or not the result is better health outcomes.

Ethical inversion

“The basis of the classic medical ethics principle of autonomy is the right not to have treatments imposed against your will. Doctors can’t just do whatever they like to you, and quite right, but that does not automatically translate into ‘Doctors have to give you what you want’. That is completely different.” In paediatric medical transition, patient autonomy is being pushed as a positive right that imposes a duty on clinicians to set aside their scruples and give the young person the desired treatment. “[It’s] getting whatever I want, because I want it. That’s the toddler approach to autonomy.”

Not normal medicine

“When you hear the argument that the young person should actually be given puberty blockers or cross-sex hormones because of autonomy—because they really want it—then autonomy becomes the medical indication itself, and I would see that as a very dangerous development. The principles of beneficence [that treatment brings benefit] and non-maleficence [‘do no harm’] still apply, and I find it highly problematic to have the field of ethics now being used in a way to defend a position that is scientifically untenable. We don’t have clear evidence for profound and long-lasting benefits for these particular [hormonal] interventions.”

Dr Chatbot

On the fast-track “informed consent” model that gender clinicians promote for young adults. “They’re not saying that informed consent of the patient is necessary to receive treatment. They’re saying it’s sufficient to receive treatment. All the patient needs to do is be informed of all the risks and benefits to consent, and then they should have the treatment. It pretty much eliminates the role of the doctor as the expert with the capacity to exercise his or her judgment in a way that affects the outcome for the patient. It presents reasonable disagreements between the patient and the doctor about the appropriateness of the treatment as paternalism. What would the medical profession look like if we use this as the measure of whether a patient should get some treatment or not? I can see the doctor being like a chatbot. It shifts ethical responsibility from the doctor to the patient, the patient bears all the responsibility.”

Grief, not regret

The term “transition regret” implies that the young person had agency and gave informed consent, but those conditions are not met in a clinic where gender-affirming care is pushed as the only option. “If you get hit by a bus, you’re probably not going to say you regret getting hit by the bus, but you may say you regret having not looked both ways crossing the street.” A patient might regret trusting the medical system. But the better term is transition grief, not transition regret. The grief arises from the physical or psychological harm done by medical transition. “The realisation that transition has started to hurt you is experienced as a traumatic event.”

A doctor’s duty

“Even if real informed consent could be obtained, it is still the obligation of the physician to only offer treatment that reasonably can be said to be, on balance, beneficial—and currently we simply don’t have the evidence to make that claim, and as such, as a doctor, you should first look to less invasive interventions, which would mean awaiting further identity development.”

26 surgeries

“Cross-sex hormone treatment changes permanently the gene expression [explains an endocrinologist]. Long-term treatment may harm otherwise healthy young people.” In females, testosterone use can lead to incontinence, sexual dysfunction, stenosis or narrowing of the vagina, necrosis and chronic pain. One Hamburg outpatient clinic reportedly has 20,000 trans clients, including females who have given birth.

A Nordic finding suggests that even if the trans-identified mother ceases testosterone for the term of the pregnancy, the unborn child is still exposed to this drug, which can cause birth defects. In Sweden, there are cases of children with osteoporosis after puberty blockers; the practice now is to put girls on birth control instead, then give them testosterone at age 18. The endocrinologist met one young adult who had undergone 26 trans surgeries—“I have never seen any cost-benefit studies on these things, what is the economic burden on society?”

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Video: SEGM president Dr Roberto D’Angelo opens the Berlin conference and defends the society’s mission

Conversion therapy

“It’s disingenuous to claim that social transition is not a clinical intervention. It is actually a key component of the gender-affirming treatment model.” Influential treatment guidelines misrepresent the evidence on this adult enabling of a cross-sex identity. Full social transition in childhood is the best predictor that gender dysphoria will persist, whereas studies predating the fashion for pre-pubertal social transition reported desistance rates of 85 per cent.

Some clinicians “have raised concerns about gender dysphoria as either a phase of homosexual development and or the impact of internalised or external homophobia, leading to a wish to transition to the other sex. We should have quite serious concerns that early social transition might be unwittingly converting some children who would have become homosexual adults to trans adults.”

Betrayal

“It’s painful and difficult [as a psychotherapist] to sit in the room with somebody who has undergone full surgical modification and realises later on that he’s a gay man and no longer has a penis. Their sense of betrayal is vast, they feel that no one in the medical community told them what they were in for. They don’t know how to be gay men and they no longer see themselves as trans women. Often their bodies are so feminised that the idea of going back and passing as a man is completely out of reach. So they’re just stuck.”

Identity outfits

“[Teenagers are] being groomed, not in the traditional sense but digitally by algorithms designed to manipulate their identity on TikTok, YouTube, Reddit, Discord. These platforms aren’t just where they hang out, they’re the loudest voices in your child’s life right now and those voices are smart, slick, often designed as funny, motivational.

“But what they’re really doing is hijacking your child’s need for identity, certainty and connection, selling them a worldview. Right now, they’re under pressure to be someone, and fast. Online there’s no room for uncertainty, no space to figure it out slowly. So they start trying on identities like outfits, seeing what gets a reaction, what makes them feel powerful, what helps them belong.”

AI absorbs all the posts, position papers and guidelines on gender, identifies young people online with angst, loneliness, a body that doesn’t feel right. And those with autism spectrum disorder are especially vulnerable because of their affinity for virtual contact and their offline difficulties with friendship and belonging.

Diagnostic brands

“Young people are encouraged to monitor their ‘mental health’ and translate their emotions into mental health terminology.” Diagnoses and identities have become brands. “Although people are free to self-identify as they like, it is contradictory to use it as the basis for insisting on the right to medical interventions. It is entirely unclear in what sense an identity can or should be ‘treated’. There are many disadvantages to having these hybrid diagnosis-identity super labels. First of all, a label becomes impossible to challenge, it’s not just something you have, it’s who you are—it limits options for potential change. And it rarely works beyond the short term; there may be a catastrophic revelation that you have not in fact found your authentic self.”

Don’t ask

“The gender-affirming care model is essentialism—that kids with gender dysphoria are ‘born that way’—and as a result, you’re not allowed to ask what is going on, so you can’t tell because you can’t ask.”

Mixed messages

Online spaces, such as Reddit, used by trans-identified youth reveal something quite at odds with the familiar claim that clinicians should follow the lead of young people, who know who they are. “Online, I didn’t see that kind of certainty or confidence. I saw wall-to-wall confusion and doubt, and a need for reassurance.” For example, one Reddit poster confessed “it makes me worry that the reason I feel uncomfortable socially transitioning is that I’m somehow not trans and that I’m just confused, but that can’t be right because online and in my own head, I’m very happy with they/he pronouns and being treated like a guy.” Such doubters often invoke “internalised transphobia” or “imposter syndrome” to bolster their sense of trans identity.

Scholars documenting the now familiar harms of excessive social media use often felt the need to provide a trans carve out. “The researchers will suggest that what is toxic for everybody else is somehow protective and life enhancing for this particular group of young people, often in defiance of their own results that suggest these young people are also negatively impacted—or even more negatively impacted—by the overuse of social media.”

A belated trial

Gender clinicians and researchers, including the prominent Dutch researcher Dr Annelou de Vries, have begun talks about future research. They realised they held different opinions on what would constitute “really clear cases” for prescription of puberty blockers. “What we have agreed upon is that there is a need for an RCT [randomised controlled trial] on puberty blockers. We are now discussing the protocol within the Nordic countries.” One idea is that female minors, now mostly denied puberty suppression in some more cautious jurisdictions, would join the trial in the hope of accessing these drugs.

Moving target

The meaning of a diagnosis such as gender dysphoria keeps changing because of an internet-accelerated “looping” of mutual influences between society, patient, clinician and the diagnostic category. “Anything that doesn’t have clear biological predictability or biological markers is going to shift with the culture and is going to keep shifting as the culture changes.” This would undermine the claim of a long-term clinical trial to test the effect of puberty blockers on wellbeing; the results could not be generalised over time. “In 20 years, the cohort will have shifted again, because the culture will have shifted.” The classic idea of trans used to mean acceptance as the opposite sex. “Now, it’s available to young people to want to be ‘trans’, whatever that may be. [These females] want a trans body, they don’t necessarily want a male body.”

Out of the ordinary

On the unusual nature of paediatric medical transition. Gender dysphoria is the only condition in the diagnostic manual of mental disorders, the DSM, “where we aim to alter the body of a child at the onset of puberty in two stages of endocrine treatment followed by surgery in adulthood. It’s an exceptional intervention and it demands exceptional evidence.”

The gender exception

“If we think about puberty blockers, you’re offering a treatment that stops a normal, really important neurodevelopmental process to treat something that is based in psychological distress. And I cannot think of any other presentation of psychological distress that you would treat by stopping a normal neurodevelopmental process.” Judging by expectations, a successful outcome of treatment is for the young person to pass as the opposite sex. “It’s very rare that we would treat someone and the outcome that we’re looking for is to change other people’s minds.”

What do they expect?

Clinicians should go beyond an explanation of the risks and benefits of paediatric medical transition and test the realism of the young person’s expectations. “If their expectation is that ‘I will become a member of the opposite sex’, then they’re not making an informed decision.”

Look to the ratio

The choices of adolescents may not be autonomous because they lack full neuropsychological development and are prey to external influences via peer groups and social media. “Procuring informed consent is the mechanism by which clinicians respect patient autonomy.” And in any event, autonomy cannot trump the related ethical requirements that treatment delivers benefits and does not harm. “The principles of non-maleficence and/or beneficence are violated when an intervention lacks a positive risk-benefit ratio.”

Immature brains

Adolescent thinking is different from that of children or adults. In their stage of neurodevelopment, they are driven to seek group membership and they will take risks. A decision at age 15 is unlike a decision at 25.

Catchy symptoms

If ideas and desires can be socially contagious, especially among adolescents, why should the same not be true of symptoms when there is no clear underlying physiological pathology? The spread of eating disorders and non-suicidal self-harm is well documented. TikTok-mediated tics have recently been reported. In Finland, head banging used to be confined mostly to psychosis, intellectual disability or deep autism. “But nowadays head banging is a commonplace. It’s particularly spreading among adolescent girls with difficulties in emotional regulation.” The contagion appears to be radiating from the country’s south. Such psychogenic phenomena suggest stress in a population.

Perils of safety

Why does a psychiatric diagnosis become desirable? “The more safe the society is, the more safe it is expected to be—and the less possible it is to accept negative experiences and emotions. Psychiatric self-diagnosis becomes an identity in a situation where identity formation has become more and more difficult.”

Multidisciplinary PR

“I’ve had the opportunity to look at other clinics and how they operate. Parents are very reassured that this is a multidisciplinary team decision. But when looking into how those teams actually operate, the mental health professional is often farmed out from the team, they have different credentials. The people who are doing the hormone assessment and the initial evaluation don’t know the mental health professional. And so the team is like a PR rhetorical concept, but they aren’t working in the same room with the same case at the same time deliberating the individual characteristics of the patient.”

Co-experts

“The evaluation [of gender-distressed youth] is a cooperation between two experts—[the psychotherapist] and the parents. They know this child better than any mental health professional could get to know this child, and so they know the strengths and the limitations, they know the emotional patterns and most importantly, they know what happened to the child and their family in the first five years of life. The patient does not know what happened to him or her in the first five years of life. So, any comprehensive evaluation, I believe, must involve the parents. [In this process] I clarify that I don’t believe that their parents are ‘transphobic’. They’re trans worried, they’re trans weary, they’re trans concerned. And we all have this same question, what is going on here?”

Gender enigma

The concept of gender identity used to make sense. In the 1960s, the researchers Stoller and Greenson defined it this way—“Gender identity refers to one’s sense of being a member of a particular sex.” So, it meant the conviction that one is either male or female. But today’s orthodoxy is quite different—“Gender identity refers to a person’s internal sense of belonging to a particular gender.” Gender, itself not defined, has replaced sex. And we are told that “a person’s gender identity cannot be altered by coercion or medical intervention”. Yet this theory makes medicalisation the only solution to gender dysphoria. If gender identity cannot be changed, then the body must be.

ROGD

The diagnostic manual, DSM, should add an age-of-onset specifier to capture the new clinical phenomenon described by Dr Lisa Littman as rapid-onset-gender dysphoria (ROGD). Work has begun on DSM-6, the next iteration of this document from the American Psychiatric Association.

Or AGP

Autogynephilia (AGP), the term popularised by sexologist Dr Ray Blanchard for a male’s arousal at the idea or image of himself as female may explain some of the recent increase in medical transition. “I see no good evidence of a separate syndrome of male ROGD. The male ROGDs, by their parent reports, look awfully similar to the autogynephilic participants that we surveyed.” Those surveys turn up exposure to “sissy porn”, a genre linked to but not causative of AGP. “I don’t think AGP is becoming more common—what’s becoming more common is for autogynephilic males to look to transition.”

Selective stigma

It is “complete and utter nonsense” to argue that destigmatisation required the removal of gender incongruence from the mental health chapter of the World Health Organisation’s diagnostic system ICD-11. “WHO did a survey of a bunch of psychiatrists and others and asked them to rate how stigmatising various mental disorders were. Guess what diagnosis was rated as having the most stigma? Schizophrenia. It wasn’t taken out of the mental health chapter, so that stigma argument is ridiculous.”

Work within

“If you’re part of the establishment, then stay inside, and challenge from within, don’t quit. There are a lot of outside voices [critiquing paediatric medical transition]. They don’t have nearly the credibility of the voices of the people who are on the inside—inside a medical society, inside a university or a medical school. Talk to your peers internally, share evidence, initiate evidence-based discussions. Post professional debates. There are many voices in this debate that are speaking with passion and feelings. They’re speaking to the hearts, and they’re very important. But there is a distinct deficit of professionals who can intellectually, rigorously, scientifically engage with this topic in a cool, calm and collected way. So if you’re that person, please don’t quit. Stay inside.”