Careful Assessment is Not Happening

This recent article highlights a phenomenon that many concerned about the teen trans trend are seeing regularly – the extensive screening that many in the public believe happens before a young person is referred for hormones or surgery isn’t happening. According to the article, the parents called several therapists looking for someone who could help their newly gender dysphoric daughter explore and manage these feelings.

“Every therapist we spoke with – and we spoke with quite a few – told us that if a teen says they are trans, then they are, and the parents’ job is to affirm and help them transition. There was no therapist who would say to Abby, ‘This is not my experience of you.’  No therapist was interested in exploring the possibility that something other than being born into the wrong body could be operating here.”

Very similar accounts can be found on the blog 4thwavenow.

Like many who read this blog, I phoned gender therapists during the weeks after her announcement that she was trans. Without even meeting my child in the flesh, all four of these therapists talked to me like this trans thing was a done deal. I wrote about one of those conversations here. One very friendly therapist, who identifies as FTM and whose website stressed “his” commitment to “informed consent,” assured me that there was no need for my daughter to first experience a sexual or romantic relationship before deciding whether she was trans. “Most of the young people just skip that step now,” the therapist said.

When I speak of my concern about this trend to those unfamiliar with this issue, one of the predictable responses is that my fears must be misplaced because extensive therapy is required before any treatment can begin. There is no need to worry that a young person might undertake permanent, drastic alterations to his or her body, because anyone who doesn’t really need this treatment will be identified by professionals.

Unfortunately, this is not always the case.

This article in Slate describes the shift away from gatekeeping to informed consent. Even gender clinics that focus on children and youth such as Mazzoni operate under an informed consent model. If the child or teen declares themselves trans and consents to treatment along with the parents, that is all that is needed for treatment.


Here is an example of a consent form of testosterone therapy.

One of the most striking findings of the detransitioner survey conducted by Cari Stella is that 65% of those who medically transitioned had no therapy at all.  The pattern appears to be the same in the US and the UK. Screening is minimal to non-existent. The model is affirmation and informed consent. If you say you need this treatment, your healthcare provider will not stand in your way.

A Reddit user posted about their experience at a gender clinic. This user was approximately 19 years old when they sought treatment. This user was pleased with the lack of gatekeeping they experienced.

Dr. Timmins was unconcerned about the patient’s history of self-harm, and was careful not to question the patient’s motivation. From this account, it does not appear that Dr. Timmins explored the patient’s mental health history very deeply.

He did offer the helpful suggestion of freezing eggs, since testosterone can affect fertility. One would think that, given the acknowledged reality of severe side effects of treatment, it would be advisable to assess and counsel more carefully, but this account clearly indicates that did not happen.

Instead, Dr. Timmins had other advice:

The doctor recommends getting lots of visible tattoos, to make sure the patient isn’t mistaken for a 12 year old boy.  Stay away from the arm, though. You might need that skin for phalloplasty.

Taking a look at some of the poster’s other comments elsewhere on Reddit, we learn that they have a history of sexual trauma, abuse, depersonalization and derealization, dissociation, substance abuse, and self-harm.

It would seem to make sense that a history of any one of these issues might make a health care provider want to assess and counsel thoroughly to make sure that the desire to transition was not a maladaptive coping mechanism. But these kinds of considerations don’t seem to apply in transgender medicine.

In the US, Dr. Johanna Olson Kennedy is one of the leading pediatricians working with trans identified youth. She is explicitly against any kind of gatekeeping, as she made clear recently on the WPATH Facebook page.

I would point out that gatekeeping for serious medical intervention is indicated not because trans people are mentally ill, but because it is standard practice in medicine to evaluate the appropriateness of any treatment before prescribing it, especially if that treatment has a potential for adverse consequences. Any parent knows that a child’s self-diagnosis of an ear infection is unlikely to result in a prescription for antibiotics. Responsible physicians will take the time to examine the patient to see if such treatment is really indicated. Wouldn’t this seem even more necessary when the treatments are associated with serious side effects such as loss of fertility or liver damage?

Dr. Olson Kennedy appears unconcerned about potential regrets. For those who change their minds later, bodily changes and possible sterility will have all been part of their “gender journey.”

Which brings me to my final point. Our Reddit poster contends that they are happier now that they are taking testosterone, and that they are certain this is the right course. Even if one transitions for the “wrong” reason, where is the harm? If this is a treatment pathway that really helps some people, why shouldn’t we make it available to them?

Because we have no idea what the long-term effects of being on cross sex hormones will be. Because we have sufficient reason to be concerned that there could be serious adverse effects. Because if someone transitions as a maladaptive way of coping with trauma, the time spent transitioning may be time lost to healing. Because there are certainly ways of addressing dysphoria that are less risky. 

For those of you coming to this issue for the first time, it simply isn’t the case that young people are being carefully evaluated before being put on medications that are being used off-label and have not been studied for their safety long-term.