"Proper Transsexual" v "Fashion Statement"

NY Times "Protocol" Episode I

The US Supreme Court ruling in the Skrmetti case, expected this month, will determine the constitutionality of state bans on pediatric gender medicine (known by its advocates as “youth gender-affirming care”). In the run-up to this ruling, the New York Times has released a podcast series -- “Protocol” -- on the subject. To those of us who have been studying this subject for five to ten years, it sets off on a depressingly familiar path.

Let’s start with the framing. The first podcast starts with people screaming opposing views on pediatric gender medicine, to convey the message: this is a highly polarized subject. We then get an intro: Trump announcing his Executive Orders, interspersed with the desperate voices of trans-identifying people: one saying he now feels like an asylum seeker in his own country and the other saying that being able to “transition” saved her life. Then the narrator says:

“It’s only been about two decades since trans and gender non-conforming kids in the US have been able to get medical treatment to ‘transition.’ Now, the federal government is looking to end it.”

Excuse me? “Gender non-conforming kids” means kids who do not follow other people's ideas or stereotypes about how they should look or act based on the female or male sex they were born. These are often fantastic, bright, unconventional kids. They do not need medical treatment. The idea that they do is monstrous and reactionary.

“Trans kids” means kids are children who do not “identify” with their birth sex. Whether or not this is explained in terms of the metaphysical concept of “gender identity,” it essentially means the same as “gender non-conforming kids.” It’s a question of degree. As my regular readers will know, I totally reject the notion that some kids are “born in the wrong body.” Some kids detest the expectations attached to their sex, and the bodily changes that are linked to these expectations, so much that they “identify” as the opposite sex, or no sex at all. The labelling of these interesting but often distressed children as “trans” links them to completely different groups – such as middle-aged men who enjoy wearing their wives’ underwear and then decide to “identify” as women, and often as “lesbians.” This is a nonsensical link that disregards everything we know about the developmental psychology of children. It harms those children and society at large. Nonetheless, it is clearly a narrative that the New York Times – like the Democratic leadership ­– appears determined to reassert.

We then get a little historical background from many decades ago. We are told how ineffective psychotherapy was in treating “trans patients.” The majority who were given therapy – according to an unnamed “foundational medical book from around this time” -- became “miserable, unhappy members of the community, unless they committed suicide.” This shocking assertion is just left there, without any pushback or nuance, without any mention of the development of evidence and insights in this field, especially in European countries, over the past several decades. The conclusion that “what these patients needed was to change their bodies” is simply stated, unchallenged.

There is a brief interview with the Dutch medical psychologist and gender guru Peggy Cohen-Kettenis, who decided to treat children in the 1990s since they found it so distressing to have to wait to receive hormones. The children could not bear the changes of puberty and blocking them made them happier. (At this time, puberty blockers were still presented as safe and reversible, buying “time to think”).

The episode moves to an interview with FG, sometimes known as Patient Zero. FG was the first child to be given a puberty blocking drug (triptorelin) for gender dysphoria at age 13, way back in 1987. Strikingly, although the tiny numbers of trans-identifying kids at that time were almost exclusively boys, FG was a girl.

I feel slightly uneasy about discussing FG’s subsequent medical history, but I think glossing over it — which is what the NY Times does — creates a sanitized impression that is unhelpful to any young person considering these interventions — or to their parents and friends.

FG later took cross-sex hormones and had several operations (mastectomy, hysterectomy, ovariectomy, metoidioplasty (lengthening of clitoris), and “testes implantation”).

FG is now over 50. She [everyone in the podcast uses male pronouns for her throughout] turns out to be a very garrulous, intelligent individual, with a perfect English accent and command of idiom (her mother was English) and working in the medical field. Her domestic surroundings are depicted as a comfortable home with bookshelves and dog toys. FG presents a very positive view of her “transition” but the account makes me wince. She recalls her girlhood, when she hated girls’ clothes and liked to play soccer. She felt like a boy — as so many lesbians and other “gender non-conforming” women did in childhood. She says she has always kept her hair short (prompting the interviewer, Azeen Ghorayshi, to say “Wow!” for some reason. Azeen giggles a lot throughout, suggesting a certain embarrassment.) At age 11, FG wrote a poem that was interpreted as indicating a suicidal state of mind. She insists she was not in fact suicidal at all, but was happy the poem was misinterpreted this way, since it facilitated admission to the treatment she wanted. In spite of saying she had absolutely not felt suicidal, she says the interventions “saved my life.” A bit confusing.

Cohen-Kettenis wrote about FG in 1998[1] and again in 2011.[2] In the later article, she wrote that FG felt happy and had a good job in the medical field but still had feelings of shame about her genital appearance and had difficulty forming intimate relationships (she was a lesbian). However, she had no regrets about the “transition” and there were no serious health issues. She did regret the metoidioplasty and was considering phalloplasty. It was a persistent source of dissatisfaction that she was scarcely able to urinate standing up and could not have sexual intercourse. Her “depression subscore” was high.

The NYT interview does not go into any of these uncomfortable details. FG is basically happy about the “transition” because people now view her as a man. That is clearly what matters most to her. The interviewer is respectful of FG’s privacy. That means no questions about relationships, about persistent unhappiness about her body or sexual function, or about any other physical issues. Fair enough: that would have been uncomfortably intrusive. Which is why an interview that was calculated to capture only the superficial aspects of a person’s life, not balanced by any alternative facts or insights, was such a bad idea.

The podcast only quotes from the 1998 article by Cohen-Kettenis and not the later, more revealing article published thirteen years later. If this was a deliberate decision to avoid the most difficult issues, I think it is an ominous sign for the rest of the series.

The episode leaves us with a clear statement, as articulated by FG: some children are “true transsexuals” – and FG was fortunately recognized as such by the Amsterdam clinicians -- ­while others are treating “trans” nowadays as something of a “fashion statement.” Now for the other episodes – to see if the whole series is going to promote the message that the Dutch Protocol was absolutely fine and life-saving – despite all the accumulating evidence to the contrary.

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[1] Cohen-Kettenis and Van Goozen, “Pubertal Delay as an Aid in Diagnosis and Treatment of a Transsexual Adolescent,” European Child and Adolescent Psychiatry 1998.

[2] Cohen-Kettenis et al., “Puberty Suppression in a Gender Dysphoric Adolescent: a 22-year follow-up” Archives of Sexual Behavior 2011