An Open Letter To Margaret Wente

Dear Ms. Wente,

I thought that as a journalist you were supposed to do some research before you go writing stories.  In the case of your August 2, 2014 column in The Globe and Mail, it is painfully obvious that you haven't even bothered to try.

As a child, Lindsay Leigh Bentley desperately wanted to be a boy. She refused to wear dresses and adored going hunting with her dad. She loved sticks, guns, motorcycles and monsters. She chopped the hair off her Barbies. Her parents had to cut her own hair short because she refused to let them brush it. Her best friends were boys. In childhood pictures, she looks fierce, and tough as nails. 

These days, her worried parents would probably hustle her off to the nearest gender-identity clinic.

Had you done even the slightest bit of actual research, you would have discovered that there is very little that is so simple about the treatment of Transgender youth.  The World Professional Association for Transgender Health Standards of Care (WPATH SOC) would have been a good place to start.  (Take note of this reference, we will be coming back to it)

...But it is also the story of advocacy run amok, in which a small but militant group of activists has managed to strong-arm well-meaning people into believing that gender is not innate but “assigned,” that those who are “trapped in the wrong body” would be happier with radical hormone treatments and mutilating surgery, and that children as young as one or two should be pushed along a path whose implications they are far too young to understand.

Wow ... how many twists and lies can you put into a single paragraph, Margaret?  Let's start enumerating them:

Really, Dr. McHugh?

For reasons somewhat beyond my comprehension, the Wall Street Journal has decided to give Dr. Paul McHugh another podium from which to spew his nonsense.  "Transgender Surgery Isn't The Solution" is yet another attempt by McHugh to justify his hostility towards providing transsexuals access to gender reassignment surgery.  

I've taken McHugh's previous writings apart in Debunking Dr. Paul McHugh, but this is a new column, and he's tried to throw a few new angles in.  Unlike most anti-trans writers, McHugh tries to actually use some objective research to support his position ... like a lot of such people, he tries to twist it to suit his ends.

Yet policy makers and the media are doing no favors either to the public or the transgendered by treating their confusions as a right in need of defending rather than as a mental disorder that deserves understanding, treatment and prevention. This intensely felt sense of being transgendered constitutes a mental disorder in two respects. The first is that the idea of sex misalignment is simply mistaken—it does not correspond with physical reality. The second is that it can lead to grim psychological outcomes.

For all that many in the Trans* community direct their ire at CAMH's Dr. Zucker, they should be at least somewhat thankful that it was Zucker not McHugh sitting on the DSM V Gender Issues committee.  I fear the results of McHugh being on that board would have been far, far worse.

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.

Distort Things Much?

Over at his blog (where he has conveniently turned off comments), we find Walt Heyer madly scribing away, and getting it horribly wrong.

He refers to three cases of what he supposes are gender transition regret:

1) Like the physician who wrote me. He became a “trans woman.” Yes, a physician! Even after following all the standards of care, he found regret and detransitioned back to his male birth gender. This physician looks back and now says, “If I could only go back to the day before my surgery in March of 2005--I would run from that surgeon’s knife.” Sadly, the approval process for surgery does nothing to reduce such stories.

2) Like the ABC news guy who wanted everyone to accept him as a transgender woman. Don Ennis, an ABC News editor, suffered a gender identity crisis, switched his gender twice in a three-month period, and posted a workplace memo attributing his actions to amnesia. Don became Dawn. Amnesia or multiple personality disorder? Anyway this is like many of the regret letters I get from guys who were completely convinced they were women trapped in a men’s bodies only to discover later they had some psychological problems. http://www.nypost.com/p/news/national/guy_again_eKq3Jw6LjgsjpBdmZklrtM

3) Like the NFL cheerleader, Texas native Philip Porter, who made the decision to transition back to his male birth gender after a whopping 32 years living as a transgender woman.

“I was born male, and always felt more female than male as a child growing up, to the point of before I could talk, [I thought] ‘I should be over there with the girls in dresses. After 34 years on female hormones, Philip started having discomfort with “hot flashes” so he discontinued using them. “I just said ‘Ok, I’ll stop taking these for awhile but it’s not going to change back after 34 years of taking them.’”

“And after that, it just started happening,” he continued. “After about 6 months to 9 months being off of them, ‘you know, you never gave yourself a chance to sort of live as a male. What would that be like?’ And it kind of was something in my mind that started as just a little thought that kind of like snowballed. And you know, I mean that’s just kind of how it happened.

It was just that simple, even after 32 years. So what is a “real” transgender? Is 32 years not long enough? 

His first case, I am somewhat suspicious of.  Heyer keeps on referencing this person, but they appear to have no public profile whatsoever.  The story cannot be verified independently, and given Mr. Heyer's propensity in the past for fabrication, and distortion, I am deeply suspicious of its veracity as presented on Heyer's blog.

The second case Mr. Heyer refers to actually shows us a case of the WPATH SOC working in the manner described.  The story of Don Ennis has been fairly widely publicized.  Exactly what motivated him to step back from transition is unclear to me.  In any case, he attempted transition and stepped away from it after a fairly brief time period.  This is not particularly unusual, nor does it represent any kind of failure of the treatment protocol itself.

As for Philip Porter, his story is unusual.  I am not at all sure that his choice to detransition after 30 years tells us anything other than people can, and do change.  Nothing in his story speaks of "regretting" his transition or time as a woman, so it seems more than a little specious to claim that as some kind of proof that the SOC as a treatment protocol is a failure.

Detransitions are now becoming BIG BUSINESS. The Sava Perovic Foundation website reports that worldwide more than 1,500 persons who got sex change surgery later decided they had made a mistake.
According to a doctor I know, Dr. Sava Perovic was the greatest urogenital surgeon of our time treating probably every anomaly of the reproductive organs and the urinary system that you can think of. Dr. Perovic was also responsible for teaching SRS to surgeons in Thailand. His foundation is now offering reversal surgery for regretters. 

Mr. Heyer needs to do a much more careful reading of the Sava Perovic Foundation's website.  Yes, it does mention GRS reversal procedures - but it is also abundantly clear that those surgeries are provided based on the same kind of psychological assessment that the WPATH SOC requires in the first place.  In short, the WPATH SOC exists for a reason, and their surgeons won't provide surgery for someone seeking GRS (or reversal of GRS) without appropriate psychological assessments.  I think it is important (if not vital) to note that the Sava Perovic Foundation also provides GRS services - and is rightly quite insistent that the WPATH SOC be followed.

There are only a limited number of ways that the WPATH SOC will fail to protect a patient - and most of them are the direct result of the patient attempting to "game" the system instead of being brutally honest with themselves.  I would be willing to bet that the vast majority of those "inappropriate" GRS procedures are the direct result of the patient managing to lie their way through the evaluation process.  As I have noted before, Mr. Heyer admits in his own autobiography that he lied routinely in his pursuit of GRS.  A reality that calls into question the accusations he makes of the treatment community.

Book Review: Sex Change - It's Suicide by Walt Heyer

I have spent the last few days wading through Walt Heyer's latest self-publish book entitled "Sex Change - It's Suicide".

I'd like to say that it brings something new to the table.  It doesn't.

Frankly, this book is a mess.  It consists largely of the author pounding on the table and blaming the high suicide ideation/attempt rate identified in the 2010 NTEC study on the treatment community.

He doesn't really make any new arguments relative to what he argued in "Paper Genders".

Heyer has tried to make the case that the current treatment for transsexuals is horribly flawed.  This is largely predicated on his own disastrous attempt to transition in the early 1980s.  More or less, his claim is that because he transitioned while suffering from an undiagnosed dissociative disorder that everybody else who attempts transition is suffering from something other than what they think.

Unfortunately, Heyer makes enormous leaps of inference and asserts his position as fact without substantiating his position.  The majority of his evidence is anecdotal, or it is made in reference to deeply flawed research which has been largely debunked.

Heyer is no friend of the transgender community.  Although he speaks the words of compassion and advocacy for appropriate treatment, his underlying agenda is to prevent transgender people from having access to the treatment programs that are known to be effective.

[Update 16/08/13]
Heyer seems to have pulled the original Sex Change - It's Suicide title, and re-released under the title "Gender Lies and Suicide"

The summary of the book appears to be more or less identical to "Sex Change - It's Suicide" version, so I doubt there's anything particularly new other than a change of title.
[/Update]

[More after the jump]

More From The "I Regret GRS" Club

Another pseudo-anonymous letter allegedly from a transsexual who regrets having GRS has been posted on Walt Heyer's blog.

Why do I say "pseudo-anonymous"?  Because, frankly, I'm not at all sure that Heyer hasn't written it himself - there are some significant overlaps with aspects of Heyer's own story which I have critiqued in detail already.  I am not at all convinced that we aren't looking at a sock puppet.

However, even if it is a 'sock puppet', it is worth taking a closer look at what is said - in part because it attempts to critique the latest edition of the WPATH Standards of Care.

I have tragically come to realize my story is fairly typical of most MtF persons. I was molested by my "trusting" grandfather at age 3, father was killed at age 5 and while my mother remarried; you could essentially say I grew up without a "father figure" or role model.

There are a couple of things here that set off alarm bells for me.  First is the "I was sexually molested" line, and the attempt to link it to "most MtF" transsexuals.  The religious right wing, aided and abetted by people like Heyer love to try and associate transsexuality with some kind of flawed upbringing - in particular sexual abuse or the absence of an appropriate father figure - both are common tropes, with no basis in evidence.  Yes, a percentage of transsexuals were sexually abused as children, but so are a percentage of non-transsexuals.  Any attempt to declare a causal link here is sloppy reasoning or wishful hypothesizing.

By my late thirties, this feeling of a "feminine core" continued. It led me to purchase online and experiment with Estrogen and an Anti-Androgen. My body slowly started to feminize. I dieted and exercised feverishly and got my body down to an acceptable female weight. I felt great; this must be who I am?

I remarried again in my early forties to a wonderful woman. Yet, the programming in my mind was so scrambled by then that it was difficult to differentiate between reality and fantasy. By the time I started seeing a gender therapist and a surgeon they were as convinced as I was that I was female.

Since I was already on estrogen, the endocrinologist felt morally/ethically obligated to continue that same protocol and at least monitor it and prescribe it legally. I received my first letter for surgery after a year and the second after two years. My childhood issues were jotted down by the therapists almost as if a side note. (A very common failure in approving surgery.) At no time did I tell my family, consider my career or even consider talking to the love of my life of my plans. This "sickness" and it is a sickness, consumes and takes over your life! You will lie to everyone around you as you continue to lie to yourself to get it done.

Thought number one here:  The person seems to have started by self-medicating - taking hormones apparently without the supervision of a doctor or even a psychologist.  I've seen this line before - almost always from people who attempted transition that shouldn't have in the first place.

The second point here is that the person does not appear to have engaged with a therapist until they had walked a long ways along the physical transition path.  This is consistent with Heyer's own biography, in which he clearly did not engage with a therapist on any consistent basis.  It has long been my opinion that there is nothing wrong with regularly being in contact with a therapist during gender transition.  While it is not essential to transitioning successfully, an objective cross-check cannot hurt.

The author does not tell us how long he engaged with therapists to gain the letters for surgery, and ethically, the therapist is only obliged to do an assessment.  Unresolved issues related to past abuse are ultimately up to the patient to decide if they are willing to pursue and resolve them prior to having surgery.

Lastly, and perhaps most importantly, the author clearly could not be living full time at the point where they acquired the letters for surgery.  Not only were they not working in their chosen gender, but even their spouse was not aware of their plans.  Given the dramatic effects of hormones, I am somewhat puzzled how this could possibly be, unless communication in the relationship had broken down to the point that the couple were keeping separate rooms.  I find this particular aspect of the story far too close to Heyer's own story.

The recently published WPATH Version VII has simply allowed the medical community to open the "floodgates" for this very tragedy to unfold. To get on cross gender hormones and then have surgery has become almost as simple as going to the convenience store for a pack of gum. If the client wants it, give it to them. "Real Life Test"? Maybe, maybe not, depending on your circumstances, occupation, etc. It is a billion dollar industry that thrives on your illness.

The most recent edition of the SOC does not make it "easier" to get access to hormones - an assessment and referral letter is still needed.  Whether or not all doctors who see transsexual patients implement this requirement is another matter entirely.

A careful reading of the current SOC is pretty clear, and there is a lot of clinical flexibility in the system.  Given the incredible diversity of gender variant people that are being identified, and the fact that they all have somewhat different needs, this is not surprising.  Again, for someone considering transition, it is more important than ever to engage with a treatment team that includes experienced professionals who understand the subtleties and shades of grey appropriately.

Get help. Don't mutilate your body. The psychiatrist, psychologists, and surgeons will enjoy a wonderful life. You, however, could end up with a tortured life, ending up penniless, possibly unemployed, without family or friends and maybe even homeless. And that's if you haven't tried or committed suicide by then! All so you can become the girl you "think" you are inside and wanted to be! People, God or whatever you believe in made you in the correct gender. It is encoded in your very DNA. If you think differently, get real help; but, DON"T CHANGE IT.

Gender is not just physical sex;  even if all aspects of it are somehow encoded in our DNA, such a perspective is a gross oversimplification.  It is well known that genes are expressed differently in each individual.  The biochemical system that is the human body is not absolute and deterministic in nature or function.

Lastly, the implicit notion that transsexuals are somehow lying to themselves has been tested and disproven repeatedly.  Even the DSM IV test clearly established the difference between delusion and the transsexual's experience.  A story like this is, to me, a cautionary tale - one that tells us all that when undertaking something as subtle and complex as gender transition, that there is much to be said for being cautious in how you approach the subject.   If you find yourself having to lie, or cover things up, then you better get to a place where those lies are no longer necessary and see if you can live with yourself openly.

On Psychological Care In Managing Gender Dysphoria

This will be a somewhat lengthy post.  In part, because I find the space I am about to discuss multi-faceted, and the discussion around each facet of the conversation is non-trivial.  The involvement of mental health professionals in the process of Gender Transition (I will use the term "transition" from here on in) is complex and the subject of many strongly-held opinions within the transgender community.    This essay will be my attempt to lay out for readers my perspective on things.

Readers should note that these are my opinions today.  Time, evidence and rational counterpoint may well convince me to revise my position.

[Warning:  Lengthy Essay Follows The Jump]