Affirming Care Is Not A “Conveyor Belt”

In reading the essay “Current Concerns About Gender Affirming Care In Adolescents”, it occurred to me that there is a fundamental misrepresentation about what Gender Affirming Care means, and the anti-trans movement has exploited it to their advantage. 

Before I delve into that too deeply, let me take you back to the days of “big hospital gender clinics” in the 70s and 80s.  There was one in Canada that stood out and that was the program at the Clarke Institute for Psychiatry (now known as the Centre for Addiction and Mental Health (CAMH)). The gender identity program there was notorious in the transgender community by the 1990s.  The reason for the notoriety was that it was very much a “conveyor belt” model, and the program was designed to be as obstructive as possible.  At one point, adult patients were not allowed access to Gender Affirming Hormone Therapy (GAHT) until they had lived full-time in their desired gender for two full years.  Patients were often told they had to change careers and take on jobs that were “more typically feminine”, and of course if you weren’t “passing pretty”, you were criticized for it.  The entire program was designed to make it as difficult as possible to transition - and this was not unusual for other similar programs that grew up in the 1970s.  They all had a very narrow understanding of what it meant to be transgender, and if you didn’t fall perfectly into the little box they had constructed, well I guess transition wasn’t for you.

That kind of program is very much a conveyor belt model - you either follow their steps, and do them to the satisfaction of the gatekeepers who are managing it, or you aren’t going to transition.  

Gender Affirming Care is portrayed by the anti-trans movement as though it’s a straight line of “social transition -> puberty blockers -> GAHT -> Gender Affirming Surgeries”.  This is not only inaccurate, but it is profoundly misleading.

The core principle of the model is the second word of the name: “Affirmation”.  This literally means you affirm the person as they are presenting themselves to you. If they tell you that they feel feminine (or masculine) you accept that statement at face value.  In other words, you meet the person where they are at that time.  That doesn’t mean that you blindly start making treatment decisions based on that - especially if the person before you is a child.  

There are all kinds of principles at play here, but one of them is careful observation.  You don’t tell the person that you “don’t believe them” - implicitly or explicitly.  Instead, you monitor over several visits while you gather background.  Each time you meet with them you meet them where they are. Your job is to monitor for consistency (or inconsistency), to check in with how they are feeling as they take steps on their path.  

BUT, there’s a big point here:  the person making the changes is who decides what steps they are willing to take.  Nobody else gets to dictate that.  That means if they start saying “hey, this isn’t feeling right”, or “I’m feeling really anxious now”, then it’s important to spend time processing with them what they are experiencing.  For some, that may be nothing more than “stumbling over a tree root on the path”, for others, it might be an indicator that it’s time to turn off the path they are on.  You process with the person, meeting them where they are at, and you help them make their best decision at that time.  

When matters like medical interventions such as puberty blockers, or GAHT come up, it’s really important to discuss the implications frankly with the individual and their parents (at least when we are dealing with youth).  I disagree that the youth is somehow “unable to form consent” here based on their age.  By the time puberty is beginning, the individual is capable of understanding a lot - claiming that they can’t possibly understand what they are doing not only infantilizes them, but it denies them agency at a time when that agency is critical.  Yes, parents have to consent as well for obvious reasons, but it’s also important to gather consent from the child.  If the child says “I’m not sure I’m ready for that”, or “I don’t understand”, something along those lines, then of course caution is needed.  Such is the complexity of consent.

Likewise with GAHT, open and frank discussions need to be had because the implications of GAHT are enormous.  Again, consent matters here.  Consent has to be formed appropriately with the individual.  Going from puberty blockers to GAHT isn’t “automatic”.  Some will decide to step away, others will not. Again, the decision here has to belong to the person making the changes, and nobody else.  

The principle I am describing is really the notion of a non-judgmental space where the person can be heard - more or less the core of Rogers’ Client Centred Therapy.  

Critics try to portray the process as some kind of forced progression, when the reality is that the progression is being put in the hands of the person transitioning, and the role of the caregiving team is to help the person along THEIR path, wherever it may lead.  Human development is rarely a straight line, and for transgender people - especially youth - it unquestionably is not a straight line.  As adults, our job is to ensure that they have a stable, loving environment that doesn’t question the steps that they choose to take. 

For the most part, the “doubters” like Dr Levine strike me as having lost sight of the big picture, and they are getting hung up on hypotheticals instead of enabling people to make their best possible lives.