For years the New York Times is the world's leading woke newspaper and has always unhesitatingly supported transactivist demands, jubilating critical voices. The treatment of JK Rowling is exemplary. In 2022, a violent subscription campaign invited people to imagine Harry Potter without its creator: the ultimate in cancell culture (see here) Misogynistic and aggressive gesture -the initiative turned out to be a boomerang and many female subscribers threatened to unsubscribe. A few months ago The Newspaper published an opinion piece by Pamela Paul in defence of the writer 24 hours after an open letter, signed by 170 employees of the newspaper, had once again taken the British writer to task, accusing the newspaper of anti-trans 'prejudice'.
But today the prestigious newspaper seems to have unequivocally changed course, probably 'woken up' by the 'get woke, go broke'.
A few days ago she published a very long article, which we propose hereafter in translation, again by Pamela Paul, in which she questions the effectiveness and lawfulness of affirmative therapy for gender non-conforming minors (puberty blockers, hormones, surgery). Paul interviews some detransitioners, young people who have discontinued hormone treatment administered almost always in a hasty manner and in the absence of studies and hard data. And he questions whether this may be the way to treat children with dysphoria.
A sensational turnaround while -finally- also in Italy we have reached the point where we have pursued for years here, alone and with our bare hands, with the inspection at Careggi and the decision of the National Bioethics Committee to re-examine the issue of the off-label use of triptorelin to 'stop puberty' in minors .
Original article NYT here
Pamela Paul Feb. 2, 2024
Translation Mara Accettura
Grace Powell was 12 or 13 years old when he discovered that it could be a boy.
Growing up in a relatively conservative community in Grand Rapids, Michigan, Powell, like many teenagers, was uncomfortable in her own skin. She was unpopular and often bullied. Puberty made things worse. She suffered from depression and was in and out of therapy.
"I felt so detached from my body and the way it was developing felt hostile," Powell told me. It was classic gender dysphoria, a feeling of discomfort with one's gender.
Reading online about transgender people Powell believed that the reason he did not feel comfortable in his body was that he was in the wrong one. Transition seemed the obvious solution. The narrative he had heard and absorbed was that if you don't transition you will kill yourself.
At 17, eager to start hormone therapy, Powell broke the news to her parents. They sent her to a specialist to make sure she was serious. In the autumn of her senior year she started hormone therapy. The summer before college she underwent a double mastectomy, then left as a transgender man named Grayson for Sarah Lawrence College, where she was assigned to a male roommate on a male floor. At six feet, he felt like a very effeminate gay man.
According to Powell, during her medical or surgical transition, no one ever asked her about the reasons for her gender dysphoria or depression. At no time was she asked about her sexual orientation. And at no time was she asked about any previous trauma, so neither therapists nor doctors ever knew that she had been sexually abused as a child.
"I wish there had been more open conversations," Powell, now 23 and in detox, told me. "But I was told there is a treatment and a thing to do if that's your problem, and that will help."
Progressives often portray the heated debate on the care of transgender children as a clash between those who seek to help increasing numbers of children express what they believe their gender to be and conservative politicians who do not allow children to be themselves.
But right-wing demagogues are not the only ones who have inflamed this debate. Transgender activists have pushed their own ideological extremism, in particular lobbying for a treatment orthodoxy that has come under greater scrutiny in recent years. According to this model of care, doctors are expected to affirm a young person's gender identity and even provide medical treatment before or even without exploring other possible sources of discomfort.
Many of those who think a more cautious approach is needed - including parents, doctors and people who have undergone gender transition and later regretted the procedures - have been attacked as anti-trans and intimidated into silencing their concerns.
While Donald Trump denounces the 'gender madness of the left' and many trans activists describe any opposition as transphobic, parents in the broad American ideological centre can find little dispassionate discussion of the real risks or trade-offs of what advocates call gender confirmation care.
Powell's story shows how easy it is for young people to get caught up in the lure of ideology in this atmosphere. "What should be a medical and psychological problem has turned into a political problem," Powell lamented during our conversation. "It's a mess."
A NEW GROWING GROUP OF PATIENTS
Many transgender adults are satisfied with their transition and, whether they started transitioning as adults or teenagers, feel that it was a life-changing choice, if not a salvation. The small but rapidly growing number of children expressing gender dysphoria and transitioning at an early age, according to doctors, is a recent and more controversial phenomenon.
Laura Edwards-Leeper, founding psychologist of the first gender clinic in the United States, said that when she started her practice in 2007, most of her patients had long-standing, entrenched gender dysphoria. Transition clearly made sense for almost all of them, and any mental health problems were generally resolved by gender transition.
"But that is no longer the case today," he said. While he does not regret having transitioned the previous cohort of patients and opposing government bans on transgender medical care, he says: "As far as I know, there are no professional organisations intervening to regulate what is happening.
Most of his patients now, he said, do not have a history of childhood gender dysphoria. Others refer to this phenomenon with some controversy as rapid onset gender dysphoria (ROGD) in which adolescents, particularly young girls, express gender dysphoria despite never having had it when they were younger. They often have non-gender-related mental health problems. Although professional associations claim that there is a lack of quality research on rapid onset gender dysphoria, several researchers have documented the phenomenon and many health professionals have found evidence of it in their practices.
The population has changed dramatically,' said Edwards-Leeper, former head of the Child and Adolescent Committee of the World Professional Association for Transgender Health (WPATH) the organisation responsible for setting gender transition guidelines for medical professionals.
For these young people, he told me, 'you have to take time to really assess what is going on, listen to the story and get the parents' perspective to create a personalised treatment plan. Many skip this step completely'.
However, health professionals and scientists who do not think that doctors should automatically accept a young person's self-diagnosis are often afraid to speak out. A report commissioned by the National Health Service on the Tavistock gender clinic in the UK, which, until its closure was ordered, was the only health centre in the country dedicated to gender identity, noted that 'staff in primary and secondary care told us that they felt under pressure to adopt an affirmative approach without discussion and that this was at odds with the standard process of clinical assessment and diagnosis that they were trained to undertake in all other clinical encounters'.
Of the dozens of students he has trained as psychologists, Edwards-Leeper said, few still seem to provide gender-related care. Although her students have left the field for various reasons, "some have told me that they felt unable to continue because of the reactions, the accusations of transphobia, that they were pro-evaluation and wanted a more thorough process".
They have good reason to be wary. Stephanie Winn, a marriage and family therapist from Oregon, trained in gender acceptance and treated several transgender patients. But in 2020, after coming across detransition videos online, she began to doubt the gender affirmation model. In 2021, she advocated for a more considered approach to gender dysphoria, urging other practitioners to pay attention to detransitioners, people who no longer consider themselves transgender after undergoing medical or surgical interventions. She has since come under attack from transgender activists. Some have threatened to send complaints to her licensing board, claiming that she was trying to change the minds of trans children through conversion therapy.
In April 2022, the Oregon Board of Licensed Professional Counselors and Therapists notified Winn that she was under investigation. Her case was eventually dismissed, but Winn no longer treats minors and only practices online, where many of her patients are concerned parents of children with trans identities. "I don't feel safe having a physical place where people can find me," she said.
The detransitioners say that only the conservative media seems interested in telling their stories, which has left them exposed to attacks as being like tools in the hands of the right, something that has frustrated and baffled every detransitioner I have interviewed. These are people who used to be the transidentified children that so many organisations say they want to protect - but when they change their minds, they say, they feel abandoned.
Most parents and doctors are simply trying to do what they think is best for the children involved. But parents who have doubts about the current model of care are frustrated by what they see as a lack of options.
Parents told me that it is a struggle to balance the desire to compassionately support a child with gender dysphoria and at the same time seek the best psychological and medical care. Many believed their children were gay or were dealing with a variety of complicated issues. But they all said they felt pressurised by doctors, schools and social pressure to accept their son's declared gender identity even though they had serious doubts. They feared that the family would split if they did not unreservedly support the social transition and medical treatment. They all asked to speak anonymously in order to be able to maintain or re-establish a relationship with their children, some of whom are currently estranged.
Many of those who questioned their son's self-diagnosis told me that it had ruined the relationship. Some parents simply said: 'I feel like I have lost my daughter'.
One mother described a meeting with 12 other parents in a support group for relatives of trans-identified young people, where all participants described their children as autistic or otherwise neurodiverse. To all the questions the woman running the meeting replied: 'Let them transition'. The mother walked away upset. How can hormones help a child with obsessive-compulsive disorder or depression? she wondered.
Some parents have found refuge in anonymous online support groups. There, people share advice on how to find caregivers to explore the causes of their children's distress or to look after their children's health and general emotional and developmental well-being, without automatically accepting their children's self-diagnosis.
Many parents of children who consider themselves trans say their children were introduced to transgender influencers on YouTube or TikTok, a phenomenon intensified for some by isolation and online cocooning during Covid. Others report that their children were taught these ideas in the classroom, as early as primary school, often in child-friendly ways, through curricula provided by trans rights organisations, with concepts such as the gender unicorn.
DO YOU WANT A DEAD SON OR A LIVE DAUGHTER?
After Kathleen's 15-year-old son, whom she describes as an obsessive child, suddenly told his parents that he was trans, the doctor who was supposed to assess whether he had A.D.H.D. instead referred him to a person who specialised in both A.D.H.D. and gender. Kathleen, who asked to be identified only by her first name to protect her son's privacy, thought the specialist would do some kind of assessment or evaluation. This was not the case. The meeting was brief and started shockingly. "In front of my son, the therapist said: do you want a dead son or a live daughter?".
Parents are routinely warned that to pursue any avenue outside of supporting a child's self-declared gender identity is to put a gender dysphoric young person at risk of suicide, which to many seems like emotional blackmail. Proponents of the gender affirmation model have cited studies showing an association between this standard of care and a lower risk of suicide. But these studies have been found to have methodological flaws or to be less than conclusive. An investigation into the psychological effects of intersex hormones, published three years ago in the Journal of the Endocrine Society, the professional organisation of hormone specialists, found that 'no conclusions could be drawn about death by suicide'. In a letter sent to the Wall Street Journal last year, 21 experts from nine countries stated that this investigation was one of the reasons why they felt there was 'no reliable evidence to suggest that hormone transition was an effective suicide prevention measure'.
Furthermore, the incidence of suicidal thoughts and attempts among dysphoric youth is complicated by the high incidence of conditions that accompany dysphoria such as autism spectrum disorders. As a systematic review states 'children with gender dysphoria often present with a range of psychiatric comorbidities, with a high prevalence of mood and anxiety disorders, trauma, eating disorders and conditions on the autism spectrum, suicidality and self-harm'.
But instead of being treated as patients who deserve impartial professional help, children with gender dysphoria often become political pawns. Conservative legislators are working to ban access to gender-based care for minors and occasionally for adults as well. On the other hand, however, many doctors and mental health workers feel their hands are tied by pressure from activists and organisations. They say it has become difficult to practise mental health care or responsible medicine for these young people.
Paediatricians, psychologists and other physicians who disagree with this orthodoxy, believing it is not based on reliable evidence, feel frustrated by their professional organisations. The American Psychological Association, the American Psychiatric Association and the American Academy of Pediatrics have wholeheartedly endorsed the gender affirmation model.
In 2021, Aaron Kimberly, a 50-year-old trans man and nurse practitioner, left the British Columbia clinic where his work focused on the intake and assessment of young people with gender dysphoria. Kimberly received comprehensive screening when she successfully transitioned at the age of 33, which resolved the gender dysphoria she had experienced since childhood. But when the gender affirmation model was introduced in his clinic, he was instructed to advocate the start of hormone treatment for incoming patients, regardless of whether they had complex mental problems, experienced trauma, or were in any way 'seriously ill'. When he referred patients for further mental health care rather than immediate hormone treatment, he said he was accused of what they called 'gatekeeping' and had to change jobs.
"I realised that something had gotten completely out of control," said Kimberly, who later founded the Gender Dysphoria Alliance and the L.G.B.T. Courage Coalition to promote better gender care. Gay men and women have often told me they fear that same-sex attracted children, particularly effeminate boys and gender non-conforming tomboy girls, will be transitioned during a normal childhood stage and before sexual maturation, and that gender ideology may mask and even foster homophobia.
As one man who has transitioned and is now in a gay relationship said, 'I was a gay man pumped up to look like a woman and I was dating a lesbian pumped up to look like a man. If that's not conversion therapy, I don't know what is'.
"I transitioned because I didn't want to be a lesbian," Kasey Emerick, a 23-year-old woman and detransitionist from Pennsylvania, told me. Raised in a conservative Christian church, she said, "I believed homosexuality was a sin". At 15, Emerick confessed his homosexuality to his mother. Her mother attributed her sexual orientation to trauma - Emerick's father had been convicted of repeatedly raping and assaulting her when she was between 4 and 7 years old - but after catching Emerick texting with another girl at the age of 16, she took away her phone. When Emerick collapsed, her mother committed her to a psychiatric hospital. During the hospitalisation, Emerick told herself: 'If I had been a boy, none of this would have happened'.
In May 2017, Emerick started searching for 'gender' online and came across trans advocacy websites. After realising she could 'choose the other side' she told her mother: 'I'm sick of being called a lesbian and not a real girl. If she had been a man, she would have been free to have relationships with women.
In September, she and her mother met with a licensed professional counsellor for the first of two 90-minute consultations. The girl told the counsellor that she wished she was a boy scout rather than a girl scout. She said she did not like being gay or a butch lesbian. She also told the counsellor that she suffered from anxiety, depression and suicidal ideation. The clinic recommended testosterone, which was prescribed by a nearby L.G.B.T.Q. clinic. Shortly afterwards, she was also diagnosed with A.D.H.D. She developed panic attacks. At the age of 17, she was allowed to undergo a double mastectomy. "I thought, 'Oh my God, I'm having my breasts removed. I'm 17 years old. I'm too young for this'. But she underwent the operation.
"Transition felt like a way to control something when I couldn't control anything in my life," Emerick explained. But after living as a trans man for five years, Emerick realised that his mental health was only getting worse. In the autumn of 2022, she came out as a detransitioner on Twitter and was immediately attacked. Transgender influencers told her she was bald and ugly. She received several threats. "I thought my life was over," she says. "I realised I had been living a lie for over five years."
Today Emerick's voice, permanently altered by testosterone, is that of a man. When she says she is a detransitioner, people ask her when she intends to stop taking testosterone and live like a woman. 'I stopped a year ago,' she replies.
Once, after telling her story to a therapist, the latter tried to reassure her. If it was any consolation, the therapist remarked: 'I never imagined that you were a trans woman'. Emerick replied, "Wait, what gender do you think I am?".
To the diktat of trans activists that children know their gender best, it is important to add something that all parents know from experience: Children change their minds all the time. One mother told me that after her teenage son backed out of a trans identity before any irreversible medical procedure, the boy explained: 'I was just rebelling. I see it as a subculture, like being goth'.
"The job of children and adolescents is to experiment and explore their place in the world and an important part of that exploration, especially during adolescence, is about their sense of identity," Phoenix-based professional counsellor Sasha Ayad told me. "Teens at that age often present themselves with a lot of certainty and urgency about who they think they are at that moment and the things they would like to do to enact that sense of identity."
Ayad, co-author of 'When Kids Say They're Trans: A Guide for Thoughtful Parents', advises parents to be wary of the gender affirmation model. "We have always known that teenagers are particularly malleable in relation to their peers and their social context, and that exploration is often an attempt to overcome the difficulties of that stage, puberty, coming to terms with the responsibilities and complications of young adulthood, romance and the solidification of one's sexual orientation," he told me. For providing this kind of exploratory approach in her practice with gender dysphoric youth, Ayad has been challenged twice for her licence, both times by adults who were not her patients. Both times the charges were dismissed.
Studies show that about eight out of ten cases of childhood gender dysphoria resolve by puberty and 30% of people on hormone therapy discontinue use within four years, although the effects, including infertility, are often irreversible.
Advocates of early social transition and medical interventions for young people with gender dysphoria cite a study from 2022 that showed that 98% of children taking both puberty blockers and cross-sex hormones continued treatment for short periods, and another study that followed 317 children who socially transitioned between the ages of 3 and 12, which found that 94% of them still identified as transgender five years later. But these early interventions can consolidate children's self-concept without giving them time to think or to mature sexually.
THE TRANSITION PROCESS DID NOT MAKE ME FEEL BETTER
At the end of her first year at university, Grace Powell, terribly depressed, began to dissociate, to feel detached from her body and reality, something that had never happened to her before. In the end, she says, "the transition process did not make me feel better. It magnified what was wrong with me".
"I expected everything to change, but I was just myself with a slightly deeper voice," she added. "It took me two years to start transitioning and living like Grace again."
She tried in vain to find a therapist who would treat her underlying problems, but they kept asking her: 'How do you want to be seen? How do you want to be seen? Do you want to be non-binary? Powell wanted to talk about her trauma, not her identity or gender presentation. She eventually underwent online therapy by a former employee of the Tavistock clinic in the UK. This therapist, a woman who broke away from the gender affirmation model, spoke to Grace about what she considered her failure and her efforts to reset herself. The therapist asked questions such as: Who is Grace? What do you want from your life? For the first time, Powell felt that someone was seeing and helping her as a person and not simply trying to fit her into an identity category.
Many detractors say they face ostracism and silence because of the toxic politics surrounding transgender issues. "It is extraordinarily frustrating to feel that something I am is inherently political," Powell told me. "I have been accused repeatedly of being a right-wing person who is creating a false narrative to discredit transgender people, which is just absurd."
While he believes that there are people who benefit from the transition, "I would like more people to understand that there is no one-size-fits-all solution," he said. "I wish there could be dialogue."
In a recent study published in Archives of Sexual Behavior, about 40 out of 78 young trans people interviewed said they suffered from rapid onset gender dysphoria. Trans activists have fought hard to censor any discussion of rapid onset gender dysphoria, despite evidence that the condition is real. In its guide for journalists, activist organisation GLAAD warns the media against using the term, as it is "not a formal condition or diagnosis". Human Rights Campaign, another activist group, calls it 'a right-wing theory'. A group of professional organisations issued a statement urging doctors to remove the term from use.
No one knows how many young people regret after social, medical or surgical transitions. Trans activists often cite low regret rates for gender transition, along with low figures for detransition. But these studies, which are often based on self-reported cases at gender clinics, probably underestimate the real numbers. None of the seven detrans I interviewed, for example, ever thought of reporting to the gender clinics that had prescribed them the drugs they now consider a mistake. Nor did they know any other detrans who had done so.
While Americans argue furiously about the basis of transgender assistance, a number of advances in understanding have occurred in Europe where the early Dutch studies that became the basis of gender affirmation assistance have been widely questioned and criticised. Unlike the current population of gender dysphoric youth, the participants in the Dutch studies did not have serious psychological conditions. These studies were full of methodological flaws and weaknesses. There was no evidence that an intervention was life-saving. There was no long-term follow-up with any of the 55 study participants or the 15 who withdrew. A British attempt to replicate the study stated that it 'did not identify any changes in psychological well-being' and that further studies were needed.
In countries like Sweden, Norway, France, the Netherlands and Great Britain - long considered examples of gender progress - medical professionals recognised that early research on medical interventions for childhood gender dysphoria was flawed or incomplete. Last month, the World Health Organisation, explaining why it is developing 'a guideline on the health of trans and gender diverse people', stated that it will only deal with adults because 'evidence is limited and variable regarding long-term outcomes of gender-affirming care in children and adolescents'.
But in America and Canada, the results of these widely criticised Dutch studies are falsely presented to the public as established science.
Other countries have recently stopped or limited medical and surgical treatment of gender dysphoric youths, pending further studies. In the UK, the closure of the Tavistock clinic was ordered next month, after an investigation commissioned by the National Health Service found shortcomings in the service and 'a lack of consensus and open discussion about the nature of gender dysphoria and therefore the appropriate clinical response'.
Meanwhile, the American medical establishment has become entrenched, stuck in an outdated model of gender assertion. The American Academy of Paediatrics has just agreed to conduct further research in response to the efforts of years of dissenting experts, including Dr Julia Mason, a self-described 'bleeding-heart liberal'.
The real threat to transgender people comes from Republicans who want to deny them rights and protections. But the doctrinal rigidity of the progressive wing of the Democratic Party is disappointing, frustrating and counterproductive. "I've always been a liberal Democrat," said one woman whose son retired after social transition and hormone therapy. "Now I feel politically homeless."
She noted that the Biden administration has "unequivocally" supported such confirmatory care for minors in cases where it is deemed "appropriate and medically necessary". Rachel Levine, assistant secretary for health at the US Department of Health and Human Services, told NPR in 2022 that "there is no discussion among medical professionals - paediatricians, paediatric endocrinologists, adolescent medicine physicians, adolescent psychiatrists, psychologists, et cetera - about the value and importance of gender confirmation care".
Of course, politics should not influence medical practice, be it birth control, abortion or gender medicine. But unfortunately, politics has hindered progress. Last year, the Economist published an in-depth investigation into the American approach to gender medicine. Editor Zanny Minton Beddoes contextualised the issue from a political perspective. "If you look at European countries, including the UK, their medical facilities are much more careful," Beddoes told Vanity Fair. "But here - partly because the issue has been embroiled in the culture wars, where there are the lunatic extremes of the Republican right - if you want to be an honest liberal, you feel like you can't say anything."
Some people are trying to open the dialogue, or at least provide an outlet for children and families to seek a more therapeutic approach to gender dysphoria. Paul Garcia-Ryan is a New York psychotherapist who works with children and families seeking holistic and exploratory treatment for gender dysphoria. He is also a detransitioner who, from the age of 15 to 30, fully believed he was a woman.
Garcia-Ryan is gay, but as a boy, he said, 'it was much less threatening to my psyche to think that I was a straight girl born in the wrong body - that I had a medical condition that could be treated'. When he went to a clinic at 15, the doctor immediately claimed he was a female and instead of exploring the reasons for his mental distress, simply confirmed Garcia-Ryan's belief that he was not meant to be a man.
Once in college, he began the medical transition and eventually underwent genital surgery. Serious medical complications from both the surgery and the hormonal medication caused him to reconsider what he had done and detransition. He also reconsidered the basics of gender affirmation that, as a licensed clinical social worker at a gender clinic, he had been taught and had provided to patients.
"They make you believe these slogans," he said. "Evidence-based care, life-saving care, safe and effective, medically necessary, the science is established - and none of it is evidence-based."
Garcia-Ryan, 32, is now chairman of the board of Therapy First, an organisation that supports therapists who do not subscribe to the gender affirming model. He believes that transitioning can help some people manage the symptoms of gender dysphoria, but he no longer believes that people under the age of 25 should make a social, medical or surgical transition without first undergoing exploratory psychotherapy.
"When a professional affirms a gender identity for a young person, he or she is implementing a psychological intervention that narrows a person's sense of self and closes down his or her possibilities to consider what is possible for them," Garcia-Ryan told me.
Instead of promoting unproven treatments for children, which polls show many Americans do not like, transgender activists would be more effective if they focused on a shared agenda. Most Americans across the political spectrum agree that transgender adults need legal protection. They would probably also support further research into the needs of young people who manifest gender dysphoria so that they can receive the best possible treatment. A change in this direction would be a model of tolerance and acceptance. It would prioritise compassion rather than demonisation. It would require moving beyond the politics of culture war and back to reason. It would be the humane way to go. And it would be the right thing to do.