Wente Is Getting It Wrong ... Again

I suppose it should come as little or no surprise that Margaret Wente is getting things wrong again.  This time, she is expounding on the treatment of transgender children.

Suddenly transgender kids are everywhere – in the news, on Dr. Phil and in your neighbourhood. School boards have developed detailed transgender policies. Clinics to treat transgender kids have sprung up. A condition that used to be vanishingly rare, perhaps one in 10,000 children or less, now seems common. In a random sampling of 6th- to 8th-graders in San Francisco, kids were asked if they identified as male, female or transgendered – 1.3 per cent checked off the transgendered box. 

She concludes with:

It’s a mark of social progress that we are increasingly willing to accept people on their terms, for who they are. But maybe we’re manufacturing more problems than we’re solving. If we really want to help people, we should remember the old rule: First, do no harm. 

Through the entire article, she relies on two authorities - Dr. Kenneth Zucker and Alice Dreger.   Zucker, along with his colleague at CAMH Ray Blanchard, have long been seen by the transgender community as deeply problematic - for good reason.

Ken Zucker is a psychologist at the Clarke Institute (aka "Jurassic Clarke") in Toronto. Zucker is famous for forcing gender-variant children into reparative therapy to conform to his expectations for male and female behavior in children. He considers transsexual women a "bad outcome" for gay men. 

Zucker is a darling of the "ex-gay" movement because of his work "curing" gender-variant children. Here is a piece featuring his work via ex-gay group NARTH (National Association for Research & Therapy of Homosexuals): 

http://www.narth.com/docs/gid.html 

Zucker promotes his NARTH-like notions of reparative therapy for kids with gender variance, reviewed here on another ex-gay site: 

http://www.leaderu.com/orgs/narth/childhood.html

We already know that so-called "reparative therapy" doesn't work for homosexuality, what on earth makes Zucker, or anyone else, think that it has any validity for transgender people.

As for Ms. Dreger, anyone silly enough to get into bed with J. Michael Bailey and defend the atrocious work that he wrote called "The Man Who Would Be Queen" has a serious credibility problem in the first place.

Quoting from Ms. Dreger, Wente draws the following:

Here’s more unwelcome news from Ms. Dreger. A child’s gender issue may merely be a symptom of other family problems. “The dirty little secret is that many of these families have big dysfunctional issues. When you get the clinicians over a beer, they’ll tell you the truth. A lot of the parents aren’t well in terms of their mental health. They think that once the child transitions, all their problems will magically go away, but that’s not really where the stress is located.” Clinicians won’t say these things publicly, she says, because they don’t want to sound as if they’re blaming gender problems on screwed-up families. 

Can we dredge any more old tropes?  We used to blame the parents for their kids being gay, now we're replaying that same ridiculous script when someone's child turns out to be transgender?  Give me a break.  If Ms. Wente had bothered to even do a little bit more research, she would have found that Ms. Dreger is grossly distorting the picture.

The WPATH SOC V7 provides the following guidance to mental health professionals:

Provide family counseling and support- ive psychotherapy to assist children and adolescents with exploring their gender identity, alleviating distress related to their gender dysphoria, and ameliorating any other psychosocial difficulties. 

This is extremely important when examining what Dreger is saying.  Namely that she is implying that the treatment community has a mass conspiracy afoot to deny that there are "other problems" that are at the root of being transgender.  If that was the case, the WPATH SOC would not contain language like this.  Dreger's claims are very similar to those of Walt Heyer - whose misadventures negate his own claims of misdeeds and malice on the part of the treatment community.

Wente's argument also draws the following from Dreger:

For some people, including some adolescents, transgender treatment is lifesaving. But these treatments are neither simple nor benign. They may, among other things, retard maturation, suppress your growth or render you sterile. And in the end, medical science cannot create a body that makes you forget you were born the other sex. “Some kids need it, but for the kids who don’t, it’s dangerous,” she says. “All else being equal, it’s better to avoid long-term hormone therapy and major surgery that removes a lot of tissue.” 

Disturbingly, data on long-term outcomes for transgender kids are scarce. No one is tracking the evidence on puberty-blocking intervention either. “We are doing major interventions and we have shockingly little idea what the outcomes are,” Ms. Dreger says. You get the sense that what we have is not so much a rational approach to a psychosocial issue as a radical ideological experiment. 

Let's see ... the percentage of the population that is transgender is tiny to begin with.  It's going to be an even smaller percentage who are going to be able and willing to express those desires before they reach puberty.  Ironically, most transsexuals know that they are trans long before the age of puberty.  If the option not to go through "the wrong puberty" exists, dear god, but it would be a blessing for so many.

Dreger's claim that there is a lack of long term consequences data available is also highly questionable.  Given the fact that Dr. Spack has been been running his clinic in Boston since 2007, the criticism about "long term consequences" is debatable.  The fact is that just about every transsexual who has transitioned wishes that they had done so earlier than they did.  We already know the consequences of insisting that transsexuals go through puberty the wrong way, and then try to undo it through transition as adults - the psychological trauma is no small thing to deal with, and the cost of living life in the wrong body is impossible to calculate.

Quoting Zucker:

Gender dysphoria (formerly known as gender identity disorder) means being at odds with your biological sex. It’s not the same as being born with ambivalent genitalia, or being gay. The popular shorthand is “being born in the wrong body,” although that formulation probably does more harm than good. Sex-reassignment treatment is appropriate for some (although by no means all) adults who are unhappy with their gender identity, and some go on to live significantly happier lives. 

But for kids, especially younger ones, the issue is much more problematic. Gender confusion is often temporary. About three-quarters of little kids who have issues with their gender – boys who want to be princesses, girls who throw their dresses in the garbage – will be comfortable with it by adolescence, according to Dr. Zucker. (Many of them will grow up to be gay or bi.) Gender confusion can also be a handy label for whatever ails a child (or her family). That’s why Dr. Zucker takes a watch-and-wait approach. He even advises parents of princessy six-year-olds to say, “You’re not a girl. You’re a boy.” 

The point that needs to be made (again), is that the WPATH SOC is similarly clear about caution regarding the introduction of physical interventions:

Before any physical interventions are consid- ered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken, as outlined above. The duration of this exploration may vary considerably de- pending on the complexity of the situation.  ...

In order for adolescents to receive puberty- suppressing hormones, the following minimum criteria must be met: 

1. The adolescent has demonstrated a long- lasting and intense pattern of gender non- conformity or gender dysphoria (whether suppressed or expressed);
2. Gender dysphoria emerged or worsened with the onset of puberty;
3. Any coexisting psychological, medical, or social problems that could interfere with treatment (e.g., that may compromise treatment adherence) have been addressed, such that the adolescent’s situation and functioning are stable enough to start treatment;
4. The adolescent has given informed consent and, particularly when the adolescent has not reached the age of medical consent, the parents or other caretakers or guardians have consented to the treatment and are involved in supporting the adolescent throughout the treatment process. 

These are not trivial claims, and an ethical practitioner is going to be very careful in making this kind of assessment and recommendation ... and that is for a reversible intervention.

Here is where Ms. Wente makes me quite annoyed.  Her article makes it sound like there is a sudden epidemic of children who are transgender springing up, and that these children are being "exploited" by greedy treatment providers.

Of course, she engages with Zucker and Dreger, two people who are going to validate her assumptions.  Does she expand her research to include Dr. Spack?  No.  Does she even take the time to review the WPATH SOC?  No.

Ms. Wente should be ashamed of doing such sloppy research, and the Globe and Mail should be embarrassed for publishing such tripe.

Distorting Reality ... Further

My semi-regular traipse through the religious right-wing blogs and news aggregators turned up a particularly ridiculous piece about Boston Children's Hospital opening a pediatric gender clinic.

To read the Lifesite article, one would think that they were proposing to offer young children all sorts of things that children shouldn't need to deal with:

Dr. Spack’s interest in transgender issues has included association with bondage and sadomasochistic groups—he presented a workshop at the Transcending Boundaries conference in Worcester last November, organized by PFLAG and co-sponsored by the New England Leather Alliance.

Of course, one might rightly wonder if there is a moral justification for trying to force a child to be dishonest with themselves, as it is not unusual for transgender people to report that they "knew" by the time they were old enough to understand that boys and girls are different.

I find it particularly amusing that Lifesite tries to tie Dr. Spack's work back to both the Gay and Lesbian world as well as to the BDSM. While an interest in human sexuality is going to lead (eventually) to contact with transgender people, inferring a relationship between gender identity and BDSM is laughably irrational.

Certainly, in recent months, there have been stories in the news about young transsexuals receiving treatment that have caused a stir among the "social conservatives" who seem utterly incapable of empathizing with anybody.

Anyhow, I went digging to see just how badly Lifesite's pseudo-journalism had mangled reality. A few minutes with Google turned up some much more reasonable information, starting with this news release.

On February 23, a new multidisciplinary clinic at Children's Hospital Boston's saw its first patients with what are called disorders of sexual differentiation (DSD). ... While Children's has long treated the physical manifestations of DSDs, the new clinic is also designed to address psychosocial issues that may arise from genital and gonadal variability. In addition to urologists, endocrinologists and geneticists, the team includes social workers, nurses who have run support groups and a research psychologist.

Okay, now we start to get something resembling a bit of sanity here. We aren't talking about "just" transsexuals, but also intersex children. Knowing that in recent years, the idea of treating intersex cases as some kind of emergency that required immediate surgical intervention has been questioned
, it's not surprising that hospitals would start to offer services which involve the child as well:

In the past, DSDs were regarded as medical emergencies that needed to be addressed immediately. Parents were not always involved in the decision-making process, which varied from center to center. In recent years, however, adult patients have formed national advocacy groups that have changed the thinking about how to manage DSDs, and today, families are intimately involved in the decisions.

"It's more important to make the best decision than to make the fast one," says Norman Spack, MD, of the Endocrinology division at Children's, who co-directs the new clinic with David Diamond, MD, of Urology. "In some cases, it can take weeks to decide what's best for the patient," he says. "It's a team decision now, and no matter what's done, the parents need support and the children need to be followed." Follow-up research will be conducted to determine the efficacy of the approaches taken and patient satisfaction as they enter adult life.

If you are going to deal with the ambiguity of intersex patients, it seems not unreasonable to extend the clinical mandate to include gender identity patients as well, which is what this clinic appears to have done:

Unique in the Western hemisphere, the clinic will also care for children and young adults who present as transgendered—those who have no known anatomic or biochemical disorder, yet feel like a member of the opposite sex. Such feelings can emerge early, even in the preschool years, and can cause considerable psychological distress. For that reason, transgendered young people are often assumed to have a psychiatric disorder and are placed on psychotropic medications. By late adolescence, a high percentage have attempted suicide.

Ah - something considerably more intelligible emerges from the picture. Again, the reality is far from the hysterical screaming of Lifesite's authors, and grounded in a legitimate concern on the part of the practitioners for the well being of the patients. I believe the correct term would be "empathy" - something that the howling nuts at Lifesite have completely lost somewhere along the way.

Of course, The HBIGDA Standards of Care for transgender youth are pretty clear about the caution with which treatment must proceed:

2. The assessment should explore the nature and characteristics of the child’s or adolescent’s gender identity. A complete psychodiagnostic and psychiatric assessment should be performed. A complete assessment should include a family evaluation, because other emotional and behavioral problems are very common, and unresolved issues in the child’s environment are often present.
3. Therapy should focus on ameliorating any comorbid problems in the child’s life, and on reducing distress the child experiences from his or her gender identity problem and other difficulties. The child and family should be supported in making difficult decisions regarding the extent to which to allow the child to assume a gender role consistent with his or her gender identity. ...

Although the Clinic does not state that they are aligning their practice with the long-established SOC guidelines, it seems unlikely to me that they would deviate significantly from them either. Those guidelines have been in use for quite some time now.

[Update:]
The Toronto Star has an interesting article about young transsexuals this morning. (Which reflects the commentary made by the gender clinic above)
[/Update]

Walt Heyer, Detransition and the WPATH SOC

Running around the internet, and speaking in various venues is a somewhat rare creature by the name of Walt Heyer who claims to be an "ex-Transsexual".  For the most part, I would ignore the man's claims, but I think it is important to review his position, as he continues to be a very vocal opponent of the treatment options open to transsexuals today - in particular he is overtly hostile to the idea of GRS (referring to it as "fraudulent", but also he is overtly hostile to the legal accommodations such as changing of gender markers on legal identification documents.  

As such, he represents a significant problem to the advocacy for equal rights for transgender people as a whole.  I spent a considerable amount of time a while ago reviewing Mr. Heyer's autobiography and his "Paper Genders" book.

Mr. Heyer’s case presents an excellent example of the importance of the principles embodied in the more recent standards of care, as well as serving as a counter-argument to those who argue that medical treatments related to cross-gender identity should be available “on demand”.

Mr. Heyer presents himself as a “former transsexual” or “ex-transsexual”.  He claims to have transitioned, had Gender Reassignment Surgery and subsequently de-transitioned after several years living as a woman.  He is actively campaigning against the treatment currently made available for transsexuals, mostly within the circles of the religious right wing of American political discourse.

However, much of Mr. Heyer’s assertions need to be understood in the context of his own history, and how his past aligns with respect to the WPATH SOC. 

[Warning - This is a lengthy essay]