Compare and Contrast

(In Which We Compare the Requirements for Two Medical Treatments That Will Change the Course of Someone's Life, Oftentimes Irreversibly, and Find Out That the Requirements Are Radically Different)

To show how far away we are from a societally responsible response to rapid onset gender dysphoria (ROGD), one only needs to compare teenage GD "gender-affirming" medical care with teenage bariatric surgery.

Before I get too far, I'd like to describe (briefly anyways) what I mean by "a societally responsible response". To me, the adults supporting teen and pre-teen kids who are contemplating medical decisions that have long-term consequences need to be good stewards of the health (both physical and mental) of these young people. To that end, the adults need to meet them where they are: begin by listening to them, make an effort to understand where each kid is coming from, and become educated about the current challenges they're facing. Then, help guide the teen in terms of understanding the pros and cons of their medical decisions, as well as the risks. Do your best to ensure the best possible overall outcome for your teen.

As adults, we're not here to tell kids what to do, unless we think they're making a medical decision that is (a) irreversible (b) has long-term implications that are either unknown or not well understood or (c) will ultimately cause them harm and/or (d) that they will deeply regret at another developmental stage during their lifetime.

We're not here to tell kids what to do, but we are here to try to ensure that they understand their decisions: risks, benefits, likely outcomes, possible outcomes, implications for long-term health/viability, alternative treatments, and the pros and cons of both probable and likely mental-health effects.

We're not likely to tell them "No [you can't do this]". Guidance for surgeries that are risky, have long-term health implications, and forever alter the body and life trajectory of a very young person will look more like "No [you can't do this yet, just wait until you're older]".

Here in WA State, we give 13-year olds full HIPPA. It's a one size fits all based only on biological age. The laws don't allow for any nuance for kids who are developmentally delayed, emotionally immature, or have autism spectrum disorder (ASD).

We don't let our 13-year olds drive cars, or purchase alcohol or tobacco products, own guns, or vote, but we give them complete control of their healthcare decisions.

Want to know what your doctor and your 13-year old discussed at their last checkup? Too bad. Want to know why your 13-year old stopped (or started) counseling with a psychologist? Also too bad.

It is possible that, as a parent, you're fully aware of the mental-health challenges your 13-year old is facing, and said challenges are serious, but you are denied the right to exchange information with their counselor when your kid suddenly quits counseling for unexplained reasons? Absolutely. Is it possible that your 13-year old exhibits extremely avoidant behavior (avoiding change at any cost and trying to bury or ignore extreme psychological distress) and therefore will not seek medical care of their own volition, and therefore get themselves into a risky situation (say: self-harming), but WA State law prohibits your participation in the seeking of medical treatment due to HIPPA preventing an exchange of information with your 13-year olds MD? Yes, this happens all of the time.

This legislation really does have some unintended consequences, mainly: some teens need help, and are unable, or unwilling, to ask for it, and it's up to the "parent+counselor" or "parent+MD" to work together to help these kids out, and HIPPA is often used like a weapon to prohibit any exchange of information about the teen, thereby preventing necessary medical or psychological support.

It often acts as a barrier between parents and the people involved in providing healthcare to our teens (which is exactly what the law intends to do).

There was a recent article on NPR on the pros, cons, and risks of teens seeking bariatric surgery[1]. It highlighted some very important aspects of the surgery, mainly: the evaluation process that happens prior to surgery to determine if a given teen is sufficiently mentally healthy to undergo the surgery (and understand, and be able to live with, it's long-term effects).

Here are four relevant excerpts from the audio, along with the related text from the article itself:

Excerpt #1:

Here's the corresponding text of the article:

"Skeptics like University of California, Los Angeles surgeon Edward Livingston worry that children aren't old enough to understand its lifelong implications. Livingston says he formed this view based on his own limited experience in the 1990s performing the surgery on teenagers."
 
"Only a small percentage of children, he says, are sick enough to require the surgery for dire medical reasons. And, he notes, new medications and others in development can be highly effective. So Livingston advises parents: "Let them wait until they can make their own decision.""

Excerpt #2:

And the corresponding text of the article:

"Medical complications are also a concern. Shorter-term problems like infection or tearing can prompt hospital readmission for between 5% and 7% of patients within a month of surgery. Long-term effects like malnutrition or weight regain must be managed with extensive dietary and lifestyle changes, including taking daily vitamins."

Excerpt #3:

(The article text is exactly the same as the audio)

Excerpt #4: And last but not least, the most important excerpt:

And the text is highly germane here:

"A child's mental health is a huge part of the pre-surgical evaluation, which usually lasts at least six months and is lengthier and more involved for teens than adults. Patients must prove they're mature enough to understand and commit to the permanent changes in lifestyle and nutrition necessary after surgery — as well as understand the health consequences of not abiding by those."

So What's the Point?

The point is that this all seems pretty reasonable to me, ethically and procedurally. It meets my definition of a "societally responsible response [to childhood obesity]". Note that the parents and medical professionals involved in these decisions:

• Listen to the teen.
• Advise the teen on the risks and unintended consequences.
• Advise waiting, if possible, as surgery is always risky (regardless of the type).
• Perform a formal, decently rigorous mental health evaluation, over a decently long period of time, to try to assess whether the adolescent is ready to accept the consequences of this irreversible medical decision.

Note that nobody is saying "No", they're more saying "This is risky, so let's try to do a good job as stewards of your physical and mental health".

(Note that I didn't agree with everything in the article[2].)

The medical care I'm focused on here is both hormone therapy (puberty blockers and testosterone) as well as surgical interventions (e.g.: to reduce a person’s Adam’s Apple, or to align their chest or genitalia with their gender identity).

I think a quick examination of any potential barriers to this care, keeping in mind the barriers to bariatric surgery, will be illustrative of my point.

Is There Potential Parental Push-Back?

In short: No (see "Background" section above). In WA State, the age of medical consent is 13, and in Oregon, it's 15. The age of medical consent varies on a state by state basis (with no standard), but it's well understood that 13-year olds in WA State do not require parental permission to seek medical care (including gender-affirming care).

Is There Potential Psychiatrist Push-Back?

In short: No. In WA State, "conversion therapy" is strictly prohibited (as it probably should be), but the problem is that it's applied incredibly broadly, and includes self-diagnosed GD / ROGD.

E.g.: If a teen goes to a psychiatrist with a self-diagnosis of gender dysphoria, and the psychiatrist [quite ethically and quite rightfully] says something like:
 
"I can see you have a very high level of anxiety, and depression, and you mentioned possibly being on the autism spectrum (ASD) .. I have some mental-health concerns I would like to address, and so we're going to put gender dysphoria on the back-burner for now, as it's not the most likely explanation for what you're feeling"
 
... well, that doctor could lose their license (even if their diagnosis is correct).

The mere insinuation that a kid might not be experiencing gender dysphoria is enough for a medical professional to get into serious trouble here in WA State. I know for a fact that there are MDs and mental-health professionals that (a) do not believe a given teen is actually experiencing gender dysphoria while at the same time (b) is providing gender-affirming care to said teen.

I consider that to be highly unethical, but the WA State legislature appears to have tied the hands of the medical community (by effectively criminalizing the pursuit of an accurate diagnosis).

Is There Potential School Push-Back?

Not here in Seattle there isn't. Schools are tripping over themselves to broadcast their LGBTQ+/trans support systems. It's become standard practice for schools to change both the name and the pronouns of students who self-diagnose as having gender dysphoria without communication of any kind with the family[3].

I believe the schools hands are tied here too, but for vastly different reasons[4].

Is There Potential Psychologist Push-Back?

Nope. None here either. These folks are as limited in terms of exploring alternate diagnoses as the psychiatrists. Even when a counselor (a) has insufficient information to know whether a GD diagnosis is accurate or not or (b) doesn't believe their patient is suffering from GD, they are strictly prohibited from exploring alternative diagnoses (as well as strictly prohibited from measuring the veracity of the self-diagnosis)[5].

Is There Potential MD Push-Back?

Same story: not a chance. The medical community is similarly bound by the broadly applied conversion-therapy ban. Not even a whisper that GD is not an accurate diagnosis (while at the same time being obligated to provide gender-affirming care)[6].

I believe this is unethical, both due to the lost opportunity cost of helping treat a teens actual problems, as well as [potentially] applying treatment for a condition that a doctor doesn't believe a teen actually suffers from.

As I mentioned earlier: many doctors are well-aware what's happening, but "talking about it" is a total minefield (talking with the parents, or with the teen, or really with anyone), as it could accidentally articulate the very points I'm trying to make in this post.

So There's No Push-Back: Is There any Pull?

WA State is considered to be a "transgender safe haven state". Overall, this is a good thing. States like Florida are passing all kinds of hateful legislation (which IMO goes way too far in the opposite direction). WA State also recently passed a bill (Senate Bill 5599) that seeks to protect transgender and at-risk youth seeking gender-affirming or reproductive care in WA State.

So yes, there's an incentive to travel to a state like WA State for gender-affirming care[7] (having arrived from another state).

I'd be much more in support of this is we didn't remove any/all barriers to hormone therapy and gender reassignment surgery. In other words, if I thought we were actually being good stewards of the current generation of ROGD girls, instead of allowing them to be victimized. The removal of barriers (like an actual diagnosis) is, overall, harming the current generation of adolescent girls.

It's troubling: from a macro perspective, it seems like the "culture war" aspects of transgender care are the dominant force when states create legislation, and that's why the legislation is so unbelievably polarized (and why neither side is entirely right, and both sides have huge, obvious, systemic flaws). What's overlooked [paradoxically] is the actual healthcare of GD youth.

In comparing gender-affirming medical interventions to bariatric surgery (both for teens), we now know:

I honestly wonder why we've carved out this exception for gender dysphoria that not only removes the barriers to "gender affirming care", but we've criminalized anyone who might push back on a GD diagnosis.

I also wonder why everyone seems so keen on pushing girls into hormone therapy when so many people are de-transitioning. Nobody who is progressive wants to run the following youtube query: detransition video, but the stories are real (and I suspect: the lawsuits are coming).

Even though the source of the following video is politically conservative (and therefore the video will summarily dismissed by anyone who is progressive), I highly recommend watching Detransition: The Wounds That Won't Heal, to hear that person's story.

If you hate that source, check out this one. It hits on all of my points: self-diagnosis, no prescription to begin hormone treatment, no mental health eval prior to hormone therapy, no doctor involvement, a pathetic eval prior to top surgery approval (30 minutes!!) [top surgery is a big deal], later regrets their transition when they hit their 20s, detransitioning now, etc.

Or check out Sweden's U-Turn on Trans Kids: The Trans Train (Part 1): The New Patient Group & Regretters. It's an incredibly informative video. Here's the summary from YouTube:

We're effectively allowing a whole generation of young women to be railroaded into [yet another[8]] grand social experiment that can have serious, long-term, unintended consequences, instead of being excellent stewards of their mental and physical health.

It's not transphobic to wish for the best possible health outcomes for our teens. As parents, we're ethically obligated to do so.