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PaperclipPerfector  1mo ago (text post)   28149 thread views

Culture War Roundup for the week of March 4, 2024

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WPATH Files

Hey guys have you heard about the WPATH Files? Well, you did, they were already brought up earlier this week, but unlike our resident doomers, I think they're worthy of a top level thread.

No, this isn't about the Eunuch Archive story breaking containment (although Genevieve Gluck is striking the iron while it's hot). Long story short someone on the inside of WPATH contancted Micheal Schelenberger and released some of their internal discussions. So what's all the hubbub about? At a cursory glance might even look like the WPATH members are urging additional caution. Well, let's take a step back.

To avoid going full-Putin, I'll start at Abigail Shrier's Irreversible Damage. A lot of the arguments presented in the book aren't new, but it's a convenient compilation - transition is serious shit with huge health implications, kids don't know what they hell they're talking about and shouldn't be taken at face value with regards to such a serious decision, past research shows most of would-be trans youth desist after puberty, new research indicates there might be a social contagion component to the recent increase in trans kids, puberty blockers themselves might be pushing kids further down the trans rabbit hole, etc., therefore we should hit the breaks on the whole thing.

A lot of the counter-arguments are also conveniently compiled in critical reviews of the book, or critical responses to positive reviews, for instance:

Within medicine, gender-affirming care for transgender and gender diverse youth is not controversial, outside of a few fringe groups like The American College of Pediatricians (an anti-LGBTQ group that is not to be confused with The American Academy of Pediatrics). There is broad consensus from The American Psychiatric Association, The American Academy of Pediatrics, The Endocrine Society, The American Academy of Child & Adolescent Psychiatry, and The World Professional Association for Transgender Health that gender-affirming medical care is appropriate for transgender youth so long as clinicians follow guidelines set forth by these major medical organizations (e.g., The Endocrine Society Guidelines).

(...)

Furthermore, those studies were of very young prepubertal children. Under the current medical consensus, gender-affirming medical interventions are not offered to prepubertal youth. They are only offered after youth have reached adolescence. Once youth reach adolescence, it’s rare for transgender youth to later decide they are cisgender.

(...)

She notes that only 1.9 percent of adolescents who started pubertal suppression in a large study in The Netherlands did not proceed to gender-affirming hormones (i.e., estrogen or testosterone). This is not because pubertal suppression made them identify more strongly as transgender. Rather, it is a result of the strict guidelines followed in the Netherlands before an adolescent is considered eligible for pubertal suppression: six months of attending a specialized gender clinic and undergoing rigorous assessment.

(...)

Though Shrier is quick to provide anecdotes from teenagers like "Riley" and stories from estranged parents as evidence, she is relatively less interested in the peer-reviewed scientific research that shows the benefits of gender-affirming medical care for transgender adolescents. I've listed several in the references for those interested in reading more.

The message is clear: We know what we're doing. We have strict standards that filter out those that might not benefit from transition. We have scientific consensus and studies, all you have is speculation and anecdotes. It is the departure from this deadpan, "we know what we're doing" discourse, delivered with iron confidence that I commented on earlier this year, and which is a useful lens to look at the WPATH Files through, given that it's one of the explicitly named organizations responsible for setting these supposedly strict standards.

Part of the Files is a video of the "Identity Evolution Workshop" held on Zoom by the WPATH, a significant portion of it is devoted to the question of informed consent:

Dianne Berg: Yeah, I just wanted to piggyback on all of the importance that comes up with the informed consent.

I often see people who, because there's such a backlog of therapists to do some of the mental health therapeutic support, I often see people who have already engaged in some sort of, and this is again with youth, some sort of medical intervention. And so one of the things I do is sitting with the youth and their parents and I say "so tell me more about what you know about that medical intervention", and kind of like what Dan was saying, children and young adolescents... we wouldn't really expect them... It's kind of out of their developmental range sometimes, to understand the extent to which some of these medical interventions are impacting them. And so I think I, I try to do whatever I can to help them understand, as best I can. But what really disturbs me is when the parents can't tell me what they need to know about a medical intervention that apparently they signed off for. And so I think informed consent has to happen very differently for parents.

(these are slightly edited for the removal of awkward speech patterns)

So there's a few ways to look at it charitably. One that comes to mind is "they aren't talking about issues with the current state of gender affirming care, they're describing the sort of problems a clinician will run into, and how to handle them". The problem with that is that they themselves would disagree with that interpretation:

Dianne Berg: I worked in an intersex, or disorders of sex development clinic for a number of years as the psychologist. And I would come in to the session with the parents and usually these were very young kids. (...) and the pediatric endocrinologist came out and said "yeah, they totally get it, they're on board, I don't have any concerns about their understanding". I would go in and I would say "okay, so tell me what you learned from him", and they'd just be like, "we have no idea what he was talking about." Because they, they feel deferential.

(...) And so I think the more we can normalize that it is okay to not get this right away, it is okay to have questions, the more we're going to actually do a real informed consent process. Then what I think has been currently happening and that I think is frankly, not what we need to be doing ethically.

One of the reasons for this state of affairs that they brought up is a simple lack of resources - "backlog of therapists", "20 minute medical appointments" - which is consistent with info that got out of the Tavistock or through whistleblowers like Jaime Reed. The other way to look at it is @gattsuru's "urging additional caution", which they are indeed doing throughout various excerpts of the Files, but if additional caution needs to be urged, because patients, or even their parents, don't understand what they're signing up for, that paints a very different picture than the one that Jack Turban painted in his review. This is a lot less "we know what we're doing" and a lot more "this is all new, and we're still figuring it out", the difference is portrayed in this analogy:

I don't know if other people do, but I really struggle with it, because I kind of want the kids that I work with, whether they're 9 to 13 and looking at puberty suppression or hormones in some ways to be a little pediatric endocrinologist. Like I want them to understand it at that level in an age appropriate way. And I struggle with that on one level because, well, when a kid takes diabetic medication, do they have to understand?

The reason for the discrepancy in the level of understanding that is expected, is acutally later explained by Jamison Green:

Jamison Green: They may be able to get their hormones prescribed through their primary care provider who doesn't really know necessarily everything about trans care. They're basically trying to be supportive and, you know, our health care system leaves us in the lurch all the time. I agree that we don't necessarily need to be able to have... If you have a known condition, like diabetes, you don't have to understand every nuance about what the insulin is going to do to you, in order to give informed consent, because there's so much experience with that. But in this field, this is all new, this is all contentious, and that's where we run into problems, because everyone's afraid.

And I know for a fact, people, even adults, even well educated, older adults, accessing care for the first time, sit down with the person who's going to prescribe their hormones, and they look at an informed consent form that says your hormones are going to do this, this, and this. They don't take any of that in yet because they're so scared that they're not going to get what they need. They're just.. "so show me where to sign".

The issue brought up in the second part of the quote, that patients might not want to read, talk about, or ask questions about their treatment because they're afraid this will result in them not getting it, is brought up later in the conversation, but this is where things go from bad to worse:

Dianne Berg: At least with the kid that I worked with, where we kind of got to, was not wanting to talk about things, because they were at that kind of [non-binary] place. But also that they really thought that if they said anything about this, and really delved into it, it would mean that their options for any of that medical transition that they had always thought they were going to do, would be off the table. And so they were like, I can't, I don't want to explore that the non-binary shift, because if I explore that, that means that I'm never going to be able to get estrogen, and it was kind of like having some education around - no, it doesn't mean that. What it means is we are trying to meet your embodiment goals.

(...)

It's a growing edge for me, so I certainly don't want to misspeak, but my understanding and what I'm trying to kind of incorporate in my clinical practice is, in some ways, moving away from what is your identity and therefore because you have this identity, you're going to want to do these particular medical interventions to change your body. Not having it be as identity driven, because I think that's been the historical basis of how things have operated.

(...)

At least I have had many clients tell me "I did not tell you the truth about a lot of things about my sexuality, because I figured if I told you that, you would gatekeep and assume it was a fetish" , or, you know, some of the terms that we no longer are using. And so I think there is a huge historical context to sexuality being seen as a way that creates barriers to access to care. And I think it's very important that we acknowledge that historical context, and that we work against that historical context, by talking more about positive sexuality and pleasure and that that they can go together and that it's okay, and not create barriers to care, because people have that belief that that's what we're going to do.

Ok, simply put: you can't tell me how you have it all figured out, how you have strict standards that filter out people who might change their mind later, and how rare it is for trans youth to change their identity, and how all the concerns raised are invalid precisely because you have it all figured out so much, only to turn around to talk about patients' shifting identitties, how they were hiding their motivations, or didn't want to ask questions because they were afraid tripping that filter stemming from those supposedly strict standards, and then for your response to be "don't worry about it, we'll give you the treatment no matter what".

This already got quite long, and I already got one or two other angles to approach this topic from, so I think this will become a series*. My general conclusion is: contrary to Jack Turban, and the general pre-2022-ish pro-trans discourse, gender affirming care, especially it's pediatric variant, is not uncontroversial within medicine, it's not The Science, it's an experiment. There is, of course, room for those within medicine, psychiatry and/or psychology, but rule #1 of ethical experimantation is that you tell people they're participating in an experiment. You don't tell them things like "would you rather have a happy daughter, or a dead son", you don't dismiss critics because you don't like their politics, and you don't try to push through bizarre social reforms on the back of The Science that just isn't there.

As always, time will tell if my conclusion is correct, I'm not going to pretend I'm not biased, and it's only natural for someone biased in the other way to come to a different conclusion, especially that a lot of people in these WPATH Files comments and transcripts come off as quite sympathetic. But before signing off, I'll allow myself a bit of speculation: this is either the tip of the iceberg, and/or WPATH members themselves think the organization is no longer credible, as WPATH membership dropped from 4119 to 1590 from January 2023 to 2024. This is after the Files were announced, but way before they were released, but it's hard not to get a "fleeing a sinking ship" impression from it, and in fact such a sudden departure of so many members might even be the cause of the Files being leaked (out of many disgruntled people, some decided to leak stuff), and the effect is yet to come.

*) Hey mods, are we still doing the "Culture War goes into the Culture War Thread" thing? I would really rather have these as standalone posts.

In the interests of stirring the pot, I'll link to this person's attempt at a fisking of the WPATH files, pointing out examples of factual inaccuracies, things taken out of context or similar. Without having read the WPATH files I can't speak as to whether their characterisation is accurate.

Still gets me that the word "fisking" - a word invented by online warbloggers for their supposed eviscerations of Robert Fisk articles and which, insofar as I remember it, often devolved to just laying the article out sentence by sentence and replying to individual sentences with "Oh come on!" and "Surely no-one can believe this!" -style fare - continues to live, even though most people would in fact probably agree that Fisk was more correct about whether Iraq War was a proper decision or not than the warbloggers.

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