Activist-clinicians tout “cultural humility” & surgery-on-demand for “nonbinaries” & “genderfluids”

Update Dec. 31, 2015: Please see here for instructions on how to submit comments to the World Health Organization (WHO) on their proposed new diagnosis code “Gender Incongruence” and “Gender Incongruence of Childhood.” The public comment period will end soon, so time is of the essence.


A funny thing happened to me recently as I was trudging down yet another Got-Dysphoria?-Must-Transition-or Die rabbit hole.

I came to the realization that those of us who are wringing our hands over the rush to diagnose dysphoric children as trans are way, way behind the curve. That battle has mostly been won (and not in our favor).

Trans activists and “gender specialists” have moved on. Now, they are advocating for fully “depathologizing” transgender, yet at the same time, normalizing the idea that even part-time demiboys, “gender fluids,” and other assorted “nonbinaries,” aka “NBs” (the catchall term for anyone who doesn’t fall neatly into the trans man or trans woman box) deserve hormones and surgeries on demand— fully paid for by insurers.

It’s a neat trick they’re trying to accomplish: convince the public that being on the “trans spectrum” is normal, just like being gay or lesbian. Yet, paradoxically, extreme treatment is still medically necessary for some. How does that work?

As they have been all along, trans activists are riding the gay and lesbian liberation movement coattails to further their agenda. Once classified as a psychiatric disorder, homosexuality is now considered normal; it was removed from the DSM (the Diagnostic & Statistical Manual of Mental Disorders) in 1973. In other words, being gay or lesbian has long been depathologized—in my view, a very good thing.

Now trans activists are pushing for the same thing for transgender. In the DSM-IV, “gender identity disorder” (GID) was the label for what ailed a person who wasn’t happy with their biological sex. That was replaced by  gender dysphoria in the DSM-V. No longer a “disorder,” it was the name for the feeling of discomfort or distress with one’s sex.

The next step?  Activists and gender specialists (I’m starting not to see a lot of difference between the two) want to get rid of the idea of distress or dysphoria as a prerequisite for “transition.” The new term they’re after is “gender incongruence:” a mismatch between one’s idea of gender and one’s actual biological sex. The talk amongst activists and clinicians is that there is no disorder, dysphoria, or distress of any kind necessary to obtain services. “Gender incongruence” is a normal variation in human experience.  But you still need some code to be in the DSM, because–reimbursement. You know, billing.

Funny: When homosexuality was depathologized, the need for billing and treatment for that former “disorder” disappeared entirely.

(Note: The screen capture below was taken from a 9/24/15 post on the WPATH page which, oddly, has since been removed. )

wpath gender incongruence

But wait: How can something that is normal still require treatment? Major, possibly lifelong, medical procedures and drugs?

Let’s hear from one activist-clinician who can explain this a whole lot better than I can. Because it turns out, in certain places, this depathologized-yet-highly-medicalized normal variation is already being implemented as a matter of policy, and fully paid for by the taxpayer. And not only that: you don’t even have to have full time “incongruence” to get your breasts or penis lopped off, on demand. You get it just because you say you need it. And if your gender clinic operates under the increasingly common “informed consent” model,  no psychologist or psychiatrist is going to stand in your way. You, and only you, will have the right to diagnose yourself as needing the wallet-busting fully funded services of plastic surgeons and endocrinologists.

Dan Karasic, MD, is a psychiatrist affiliated with the San Francisco Center for Excellence in Transgender Health. He also is a key player in WPATH and one of several activists and clinicians crafting revisions to the DSM and the WPATH Standards of Care (SOC).

Karasic is quite active on the WPATH public Facebook page, frequently advocating for depathologization and greater access to surgery and hormones for those on the “gender spectrum.” [Please note: The WPATH Facebook page is viewable by the public, so all the information revealed in the screenshots below, as of this writing, is a click away.]

As Dr. Karasic says here, the San Francisco Department of Public Health will fully fund surgeries for even “nonbinary” folks:

WPATH Karasic cultural humilty and SFDPH cropped

Lest any wayward clinician have questions about the wisdom of all this, doubts are no longer acceptable. Acceptance and understanding are not enough in San Francisco. One must have humility. And that extends to “nonbinaries.” Only they/them know. They/them get to decide. Not you, with your outmoded and quaint “clinical judgment.” (Question: If you’re nonbinary, what would you be transitioning to? Oops, sorry. Humility lapse here.)

There are several members on the WPATH Facebook page who agree that any skeptical doctors (such as, evidently, some at San Francisco General Hospital–SFGH) need to be brought firmly into line, and that nonbinaries should get their top surgery too. 

WPATH top surgery for non binaries

Are nonbinaries only receiving surgeries and hormones in cutting-edge San Francisco? Apparently not. In March of this year, WBUR Boston touted reported on medical treatments for nonbinaries on the US East Coast in Not Male Or Female: Molding Bodies To Fit A Genderfluid Identity. 

Jones is part of a growing group of young adults who are genderfluid and are using hormone therapy and surgery to create bodies that matches this identity.

“It’s molding my body to fit my mind, physically changing myself so that I feel more comfortable as a person,” said Dale Jackson, a 33-year-old author who lives in Atlanta. Jackson takes a low dose of testosterone for two reasons. First, because he’s worried that a full dose would exacerbate his anxiety. And second, because a half dose helps him moderate the effects.

I like the idea of being in the middle,” Jackson said. “This allows me to explore my masculine side, but I don’t want to push it too far.” Jackson does not want a big bushy beard or arms so hairy “that gorillas were looking at me like, is that our cousin?”

Comfort, exploration, wants, not wants–what’s not to like? And it’s certainly important to calibrate the testosterone dosage so as not to increase pre-existing anxiety.

Both Jones and Jackson are under the care of physicians who are helping them pursue a more gender neutral body. But there are no guidelines. So far, in the emerging world of transgender medicine, protocols assume that patients want to end up on one end of the spectrum or the other, male or female, says Dr. Tim Cavanaugh, who runs the transgender health program at Fenway Health.

An estimated 100 to 150 of Fenways Health’s 1,500 transgender patients are genderfluid. Most of the genderfluid patients are transitioning from female towards male. So how do doctors know how much testosterone will produce the effects these patients are looking for?

To a certain extent we’re making it up, but I’d like to think of it more as finessing the regimens that we have based on the individual person’s desires and needs,” Cavanaugh said.

Ten percent of your caseload is “genderfluids” who are trying to “mold” their bodies to be more “gender neutral.” And most of them are female. (Wouldn’t a paragraph asking why that is be of value here? Silly me. That’s old school journalism.)

“There are no guidelines”—yet. And if you’re genderfluid, you are transitioning “towards” the opposite sex (even though, presumably, if you’re “fluid” you’re already somewhere in between, but the logic of gender identity is not…logical).

…some genderfluid patients say they cannot find peace without medical intervention.

“I had an incredible amount of dysphoria around my chest, it was consuming. I got to the point where in order for me to thrive and to do the work I wanted to be able to do and just live my life, I needed to have surgery,” said Taan Shapiro, a 33-year-old a teacher and parent in Boston who had surgery to create a flatter, more masculine looking chest.

Shapiro, who uses the pronouns they and them, says some strangers assume they are a teenage boy, others that Shapiro is female. Shapiro is not planning any more surgery or hormone therapy.

“Where I am is where I’m at and I feel good about myself,” Shapiro said, “[in a place] somewhere between male and female.”

This sounds an awful lot like elective surgery. People get procedures like breast augmentation, liposuction, face lifts, tummy tucks, to “feel more comfortable.” Someone might even say they need a taxpayer-funded nose job to “thrive” and just “live their life.” That the “incredible amount of dysphoria” they experience because of their big nose is all consuming. (Likely the late Michael Jackson would have agreed.)

To be fair, Dr. Cavanaugh does voice a few words of doubt about all that money he’s making the wisdom of medical treatment for nonbinaries:

If gender is a product of social construction, then using medicine to fix every patient’s discomfort may not be the best long term solution, Cavanaugh says.

“I hope we are headed to a place where we recognize that gender is not one thing or the other, not male or female, and that culturally we can become more comfortable with that idea,” Cavanaugh said. “Hormones and surgery are always going to be options for people, but I really hope that we won’t feel compelled to use them as much as we do now.”

Hm. I wonder what other means there might be to address people’s discomfort with a socially constructed gender identity?

The WBUR article was discussed on the WPATH Facebook page, and some members were not pleased with this meek bit of dissension in the ranks: the medical model is the way to go!

WPATH nonbinaries surgery critique wbur

So there you have it.  It’s “super problematic” for Dr. Cavanaugh to suggest that some “nonbinaries” (i.e, people without rigid gender-stereotyped personalities) aren’t going to be served by the “medical model.”

How will activist-clinicians continue to walk the delicate line between normalization/depathologizing the “trans spectrum” while still hoodwinking encouraging the taxpayer to pay for expensive plastic surgeries and long-term hormone treatment? Stay tuned!

For now, there’s lots more to read in this thread on the WPATH Facebook page. Rest assured that the activist-clinicians are hard at work to make sure insurers are on board with any and all treatment, on demand, for transmasculine, transfeminine, genderfluid, and nonbinary folks. After all, gold-plated body modification is not just for the garden variety, binary transgender man or woman. That is so 2013.

But sarcasm aside (for now), if these activists and clinicians are really serious about depathologizing? Here’s what they’d do:

Celebrate gender nonconformity. Teach people to respect and take care of their bodies, just as they are.  Work to build self esteem in teens, and mentor them to know that their bodies, the product of millions of years of evolution, are good and whole, and that there is no need to cut or drug themselves to be “comfortable” or to fit anyone’s idea of male or female. Develop therapies that help people realize their bodies and brains are not two disconnected units, but indivisible, complete,  and right. Encourage kids to dress, think, and pursue interests as they like. Celebrate uniqueness and diversity in men and women.

I realize my prescription for truly depathologizing gender nonconformity might put a few people out of work. But our kids are worth it. Aren’t they?

7-year-old “trans activist” used in campaign by Transgender Europe, a German NGO partially funded by US State Department

US taxpayers, did you know that some of your hard-earned money goes to a foreign NGO which uses a 7-year-old child to promote a trans activist agenda? Transgender Europe (TGEU), which is celebrating its 10th anniversary, states on its website (see bottom of page) that the US State Department is a donor.

TGEU State Dept funding

How is it that a US government agency is funding a foreign trans activist organization?

President Obama issued a directive in December 2011 to heads of executive branch agencies (which would include the US Department of State):

I am deeply concerned by the violence and discrimination targeting LGBT persons around the world whether it is passing laws that criminalize LGBT status, beating citizens simply for joining peaceful LGBT pride celebrations, or killing men, women, and children for their perceived sexual orientation.

President Obama’s memorandum goes on to list five areas for support of foreign NGOs: Combating Criminalization of LGBT Status or Conduct Abroad, Protecting Vulnerable LGBT Refugees and Asylum Seekers, Foreign Assistance to Protect Human Rights and Advance Nondiscrimination, Swift and Meaningful U.S. Responses to Human Rights Abuses of LGBT Persons Abroad, Engaging International Organizations in the Fight Against LGBT Discrimination.

Pursuant to the memorandum, the Global Equality Fund was established as a funding mechanism, “a collaborative effort led by the U.S. Department of State, bridging government, companies and NGOs with the objective of empowering LGBT persons to live freely and without discrimination.”

In September 2014, the US embassy in Budapest issued a statement on their website:

…Charge d’Affaires  of the U.S. Embassy in Budapest, M. Andre Goodfriend, delivered opening remarks at the 5th European Transgender Council Meeting, a gathering of 200 transgender activists, allies, researchers, and funders, in Budapest, Hungary – the first such conference to take place in Central and Eastern Europe. …

He congratulated the activists on the success of their efforts thus far, and emphasized that holding the conference sent a strong signal that the human rights of transgender persons should be protected everywhere.

The Department remains committed to advancing the goals of the Presidential Memorandum on International Initiatives to Advance the Human Rights of LGBT Persons, and to expanding its support, through the Global Equality Fund, embassy and consulate outreach, partnership with like-minded governments, corporations, and private foundations, and by continuing to learn from and partner with civil society organizations – such as Transgender Europe and TransVanilla [a Hungarian trans activist organization]- to promote and protect the human rights of transgender persons.

If the US State Department was only involved in “promoting and protecting human rights” and helping people to live “freely and without discrimination;” if it were about the right to nondiscrimination in jobs, housing, education; the right to protection against violence for all LGBT people, I’d be completely on board. But organizations like TGEU are taking this further.

Production values on the 1.5 minute promo featuring the 7-year-old are high. The video was clearly made by skilled professionals, with excellent camera work, fine sound engineering, and a catchy guitar soundtrack. This is not the work of an amateur.

The child also has a “public figure” Facebook page (aka a fan page), adorned with stereotypically “feminine” trappings, and describing the child as “a 7-year-old trans activist.”

WN Facebook

What is the 7-year-old trans activist being used to promote? The “depathologisation” of trans people. On its website, TGEU “calls on the World Health Organisation and governments to ensure that gender variant children are not labelled as sick.”

So far? Sounds good. Gender nonconformity is not a pathology. Let little girls and little boys look, play, and behave any way they like.  Is this what TGEU is promoting?

The Depathologisation Resources page links to this proposal by the GATE working group, which argues for abolishing the “gender incongruence” diagnosis being considered for the next version of the international diagnosis codes (ICD-11). The group praises Argentina, which

… passed the first gender identity law in the world that recognizes the human right of trans people to access legal recognition and transition-related health care services (including hormone therapy and surgical procedures) without requiring any kind of diagnosis.

So depathologizing appears to mean dumping any “disorder” diagnosis and just giving trans-identified people whatever they want. But for children, TGEU seems to argue for a different approach:

Gender variance in childhood does not require any medical interventions such as hormone therapy or surgical procedures. Rather, children need information and support in exploring their gender identity and expression and dealing with sociocultural environments that are frequently hostile to gender variance…research indicates it is impossible to reliably distinguish between a gender-variant child who will grow up to become trans and a gender-variant child who will grow up to be gay, lesbian, or bisexual, but not trans. As such, by conflating gender variance and sexual orientation, the proposed GIC category amounts to a re-pathologization of homosexuality.

Later in the document, we find this:

Further, the imposition of a diagnosis of gender incongruence on a child contradicts the principle that childhood development is a process of change and exploration. Such a diagnosis, which attempts to establish a concrete definition of a child’s gender identity precisely during the phase of life when essential aspects of identity are most in flux, is likely to create the presumption that the child is transgender, whether or not that is in fact the case.

This sounds like TGEU falls squarely in the camp that would criticize labeling children as trans, doesn’t it?

Yet in the video, the 7-year-old isn’t talking about  being “gender variant.” The kid is a boy talking about living as a trans person. A girl. If TGEU believes that children should not be presumed to be transgender, why on earth are they promoting this child as a “trans activist”?

The child’s parents are also featured on the website. What are their views on the “depathologisation” question?

Bex and James are the Family Support Officers at Gender Liberation, and Willa is the youngest activist….

As parents of a trans child they were concerned that ‘gender incongruence in childhood’ is listed in the International Classification of Diseases, particularly because others could use this classification as a tool to deter them from supporting their daughter, and it could further stigmatise Willa and keep people from accepting her.

We made the choice, we made the decision that we had to listen to our child, because we love her unconditionally.”

“Trans children only need to go through social transition, and therefore having a category in the ICD-11 that pathologizes gender diversity in childhood is completely unnecessary.”

big special girl

“She’s my special big girl and always will be.”

And there we have it.  “Gender variant” children “need” to go through social transition. Yet the very document TGEU uses in their depathologisation campaign states that the majority of these kids will desist and perhaps grow up to be gay or lesbian adults. That there should not be a “presumption” that they are transgender.

In addition, there is a body of evidence, originating with and continuing to this day, from the Dutch team who pioneered pediatric transition, indicating that social transition can be harmful. It can lock a child into a transgender identity and make it more difficult for a child to “desist.” Not only that: Being a social media star and receiving plaudits from parents and other important adults for conforming to gender stereotypes is a powerful incentive and reward. And this particular child has had a law dedicated to him. Can anyone think it would be possible for him to change his mind, after all that?

So why do they “need” social transition?  Why can’t these kids just play and explore without being coddled in the notion that they are really the opposite sex? Why do they “need” to be called “trans activists” at age 7?  What does TGEU actually believe?

Watch the video and decide for yourself: Is this 7-year-old child being encouraged to “explore their gender identity and expression”? Or would you say the child is more being urged to assume a “concrete definition…precisely during the phase of life when essential aspects of identity are most in flux… likely to create the presumption that the child is transgender”?

My life having to live as a boy was very bad. Until one day I told my mum and dad that I felt I was a girl….so they let me dress as a girl indoors….they let me live as a girl…after that when they saw that this was truly who I was they let me live as a girl….Now I am very happy living as a girl… trans kids need to be listened to. We don’t have a disorder and you can’t change us. .. we should just be allowed to live as we are because we KNOW who we are.

butterflies

So there’s agreement between organizations like Transgender Europe and critics like me. These kids aren’t “sick.” They don’t have a “disorder” just because they aren’t conforming to rigid gender stereotypes. But we differ radically in the conclusions we draw.

Transgender Europe operates campaigns—partially funded by me and other Americans–that promote the idea that a boy who plays with fairy dolls and wears pink dresses is actually a girl who should be “socially transitioned” before the world on YouTube and Facebook, defined as transgender, and who, at puberty, will be ready for all the medical services that money (and the taxpayer) can provide.