A Response to Grace Lavery, Part I: On “Gender Affirmative” Care And “Watchful Waiting” And Where They Really Differ
I was going to start this post with some throat-clearing about social media, and Twitter in particular, being a terrible venue in which to discuss anything controversial, but it’s 2019 and you likely know the deal by now: Everyone’s always too mad, groupthink-rewards baked right into the structure of the platform, endless contextless screencapping, yadda yadda yadda.
Okay, so: Grace Lavery, an English professor at UC — Berkeley, did a thread about myself and my work (me and my work? English professors) on transgender and gender nonconforming (TGNC) kids and adolescents a couple days ago that doesn’t fall into those traps, mostly.
I have significant quibbles with it that I’ll explain piece by piece, but it’s genuinely worth responding to, first because it captures the debate and stakes pretty accurately, and second because it’s a model of someone trying, in mostly good faith, to critique my work and understand why some people are upset about it. (Click on over and read it now if you’d like, though I’ll embed the specific things I’m responding to throughout.)
Suffice it to say I’m not going to get in the general habit of responding at length to a tweetstorm here or anywhere else, but I think in this instance it will be useful and hopefully further nudge this conversation another inch in the generally reasonable and prosocial direction Lavery’s thread started. I also like the idea of going long on my response so that this piece will be more than just a response to her specific tweetstorm: Now this can sit on the internet for a long time and hopefully serve as a useful resource for the growing number of people interested in these issues.
(Briefly, for those unfamiliar with my work, some other stuff I’ve written on this and adjacent subjects: Here’s my piece on a gender-identity clinic that was closed because of what appeared, in light of my reporting, to be false and overblown claims about the controversial sex researcher running it, who eventually was awarded a large settlement because of those claims; here’s my Atlantic cover story on TGNC young people and detransitioners and desisters that caused some controversy; here’s a feature story on a promising approach to get people to be less transphobic — or at least less supportive of transphobic legislation — that I wish people would read because the activists and researchers behind it have so much to teach anyone interested in making the world a little bit better; here’s a piece on a personality characteristic that appears to be linked to transphobia; here’s a blog post about how a lack of bathroom access could increase trans people’s suicide risk; and here’s an “as told to” photo essay with Laura Jane Grace of Against Me! [yes, being a journalist has its upsides sometimes] about an emotional show she performed in North Carolina in solidarity with trans people opposing a “bathroom bill” there. I’ve also done a couple Medium posts defending my more controversial work in this area and highlighting what I view as mistakes other journalists have made in covering this area. Oh, and also, sometime soon-ish I’m going to launch a newsletter dealing at least partially with points of conflict between science and social justice and how to try to resolve them: You can subscribe here.)
As I got to work on this I realized it makes sense to break it up into two posts. This one will talk about Lavery’s conceptualization of the present debate over treatment approaches for TGNC kids and why I think she is focusing on superficial areas of not-really-disagreement and neglecting an area of potentially important disagreement. The second will dive way too deeply into the desistance debate (again), and I’ll publish that one when I get to it. Could be a week, could be longer — I’ve got some other stuff going on.
Before I begin, I should point out that I’m responding to a tweetstorm with many, many words expressed in a different, much more expansive format. There’s a bit asymmetry of here — Lavery didn’t have the space to do quite as much hedging and hemming and hawing as I’m going to do here, and seemed to be seeking to provide a broad overview of the controversy rather than to get in the weeds like I’m about to. Plus, she didn’t ask me to respond to this, and of course has no obligation to engage further. My hope is her tweetstorm and my response will stand as a self-contained point-counterpoint that people will at least find informative in some way or another.
One other thing: I just want to repeat my call for more people who claim to be interested in this issue and who write or express opinions about it online to call up real-life gender clinicians who have lengthy experience working with trans and gender nonconforming kids. It’s a very specific area of work, there is a lot of misunderstanding among the public about what goes into it, and people get fairly basic stuff wrong with alarming frequency. Now, I don’t think this responsibility should fall on Grace Lavery, who has a full-time job in an entirely different area, to do this sort of journalism. I just wish others would. You can even just be lazy and ask any of the clinicians cited in my Atlantic article for an on- or off-the-record chat. They’re nice people — I promise! (Oh, and my standard long-Medium-post disclaimer applies here: When I inevitably notice typos, or want to make small wording changes that don’t affect the meaning of the sentence in question, I reserve the right to do so. Any changes more substantive than that will be signaled with an update note at the top of the post.)
Is This Really As Simple As “Affirmative Care” Versus “Watchful Waiting”?
In her tweetstorm, after noting the general sequence in which young people “are diagnosed with gender dysphoria, received treatment with hormone suppressors, and given encouragement to change name and pronoun in schools and other social environments,” she lays out a view of the present debate on this subject in which there’s this protocol — “affirmative care” — on the one hand, and a different approach — “watchful waiting” — on the other.
Then, later on — I’m jumping ahead here just so I can make this whole section about this particular issue — she elaborates further:
Okay, so the first and most important thing is that the way she describes things is, strictly speaking, incorrect: This sequence in which kids “are diagnosed with gender dysphoria, receive[] treatment with hormone suppressors, and given encouragement to change name and pronoun in schools and other social environments” is perfectly compatible with “watchful waiting.” Full-stop. To the extent there’s a debate here, it’s about timelines — and I’ll get back to that in a bit. (I’m going to use “affirming” and “affirmative” interchangeably, because I lack the discipline to be consistent.)
But let me zoom out a little, because I’m actually not convinced it’s useful to frame the debate this way. The idea that in terms of their general approach to helping TGNC kids, American clinicians and others are choosing between “gender affirmative care” on the one hand and “watchful waiting” on the other, is somewhat of an oversimplification, and I worry it will misinform people.
I hate to do that thing where I say To really understand this, you gotta read this academic paper, but, well… The best way to understand why Lavery might be drawing too bold a line between these two models is to read the excellent and accessible paper “Affirmative Practice With Transgender and Gender Nonconforming Youth: Expanding the Model.” The authors point out, in short, that when it comes to the nitty gritty of working with TGNC young people, the idea of “affirmative care” is actually fairly underspecified. Everyone agrees it’s a good thing, and agrees on part of its definition — don’t do conversion therapy, don’t shame kids for their gender identity or gender expression, generally act like a decent human being in all other interactions with your patients — but in fact there’s also a lot of fogginess surrounding what it means to be an “affirming” clinician in practice, in the situations clinicians actually experience in their day-to-day work.
If I could pick one paragraph on the subject of gender dysphoria from an academic journal and force everyone to read it, it might be this one from that paper:
<blockquote>The Merriam-Webster’s Online Dictionary defines the term affirm as “to say that something is true in a confident way” (Affirm, n.d.). Inherent in this definition when applied to clinical work with TGNC youth is the notion that the gender identity and related experiences asserted by a child, an adolescent, and/or family members are true, and that the clinician’s role in providing affirming care to that family is to empathetically support such assertions. Such an approach may appear straightforward at first pass, but a conceptual treatment model for which the underlying definition describes a single moment in time applied to the dynamic changes that occur in the process of child and adolescent identity and brain development is a challenge. To be affirming of an individual’s identity at one point in development, yet take into account the various unknown factors shaping that individual’s identity, requires an approach that neither over- nor underemphasizes the potential complexities involved in determining how gender fits into the larger picture for a given youth (American Psychological Association, 2015).</blockquote>
What all this often translates to, in clinical practice, is that an affirming clinician may believe a given kid kid may benefit from some time exploring their views of gender, the source of their distress surrounding it, and so on. Sometimes that means slowing things down a bit. “Affirming care does not privilege any one outcome when it comes to gender identity, but instead aims to allow exploration of gender without judgment and with a clear understanding of the risks, benefits, and alternatives to any choice along the way,” Aron Janssen, the clinical director of the Gender and Sexuality Service at Hassenfeld Children’s Hospital, in New York, told me for my Atlantic article. “Many people misinterpret affirming care as proceeding to social and medical transition in all cases without delay, but the reality is much more complex.” Diane Ehrensaft, another highly regarded clinician, sounded a similar tune: “This is what I tell kids all the time, particularly teenagers,” she said. “Often they’re pushing for fast. I say, ‘Look, I’m old, you’re young. I go slow, you go fast. We’re going to have to work that out.’ ” Even young affirming-clinicians-in-training — or at least those being trained by competent clinicians — get this message: “I would say ‘affirming’ isn’t always doing exactly what the kid says they want in the moment,” one young clinician-in-training working under Laura Edwards-Leeper, a leading clinician featured in my story, told me when I visited her class.
I don’t want to wrongly attribute to Lavery the claim that no affirming clinician would ever delay anything, or view a child’s distress about gender in a more nuanced light then Well, you’re definitely trans and definitely always will be, so let’s get you transitioned! — she doesn’t say that and I very much doubt she believes that. But I do think the way she lays things out with her choice of screencaps — the supposedly “affirming care” one doesn’t mention any of the uncertainty about a child’s long-term gender-identity development, while the “watchful waiting” one does — implies a dichotomy that doesn’t really exist.
In fact, just about any competent gender-affirming clinician would agree with this part of the statement Lavery attributes to the “watchful waiting” position, via the UK’s Royal College of Psychiatrists:
The College supports psychiatrists in fully exploring their patient’s gender identity (involving their families where appropriate) in a nonjudgemental, supportive and ethical manner.
The College acknowledges the need for better evidence on the outcomes of pre-pubertal children who present as transgender or gender-diverse, whether or not they enter treatment.
This is something that comes up again and again: There really isn’t any much great outcome data when it comes to TGNC kids. That’s part of the reason, in addition to common sense about child and adolescent development, that many clinicians do advise patients and families, all else being equal, to take a gradual, exploratory approach to the complicated subject of gender and gender identity.
So to position “watchful waiting” clinical work with TGNC youth as standing in opposition to “affirming care” clinical work doesn’t capture the full clinical dexterity of the best gender-affirming clinicians. In my interviews with them, these clinicians walked me through all sorts of scenarios in which doing their job properly entails a bit of what, at least in the colloquial sense, is implied by the term “watchful waiting.” A lot of kids arriving at a gender clinic for the first time have never before in their lives had the opportunity to talk openly about their gender identity. Having a good, compassionate therapist is a vitally important milestone for them, and can be the start of a process that takes them in a million different directions.
And yes, sometimes this process will look a bit like something people might call “watchful waiting.” How is the kid responding to therapy? To a little bit more freedom to express themselves how they want with regards to their clothes and hair? To a new friend group? Is their dysphoria worsening? Are they suicidal? Lavery links to one short document on the “affirming” side of things, but doesn’t link to the plenty of other documents from trusted groups like the American Psychological Association and the World Professional Association for Transgender Health that at least nod to some of the hidden complexity contained within the term “affirming care.” This, for example, is from my Atlantic article:
There is no shortage of information available for parents trying to navigate this difficult terrain. If you read the bible of medical and psychiatric care for transgender people — the Standards of Care issued by the World Professional Association for Transgender Health (Wpath) — you’ll find an 11-page section called “Assessment and Treatment of Children and Adolescents With Gender Dysphoria.” It states that while some teenagers should go on hormones, that decision should be made with deliberation: “Before any physical interventions are considered for adolescents, extensive exploration of psychological, family, and social issues should be undertaken.” The American Psychological Association’s guidelines sound a similar note, explaining the benefits of hormones but also noting that “adolescents can become intensely focused on their immediate desires.” It goes on: “This intense focus on immediate needs may create challenges in assuring that adolescents are cognitively and emotionally able to make life-altering decisions.”
The WPATH guideline are from 2011, before “affirming” was firmly in the lexicon But its guidelines are rather frequently referenced by people advocating for affirming care. The APA document, meanwhile, contains the term “trans-affirmative” 17 times. Suffice it to say both sets of guidelines are, by any reasonable definition, affirming. And suffice it to say they also recognize the complexity of this sort of work by invoking the exact sort of language Lavery attributes, via screencap, to the watchful waiting approach.
So there’s just less daylight between “affirming care” and “watchful waiting” than Lavery claims, at least in certain areas, and I don’t like the idea of parents or patients who encounter a clinician who suggests something like watchful waiting for a given person at a given moment in their development to assume this clinician is operating from a backwards or outdated mindset. Things are more complicated than that.
Let me give one concrete example from my own reporting that I absolutely love. This was from an on-the-record interview, but I feel weird about dragging clinicians back into this controversy by name when it’s just for a Medium post, so I’m going to refer to this one, whose actual gender I’m not revealing, as “Dr. Smith” and say he’s male. Dr. Smith explained to me that he once had a patient who was a bit freaked out about the fact that he felt his gender identity was flipping back and forth, almost on a daily basis. He desperately wanted to resolve this — he wanted to know whether he was cis or trans. Rather than focus too much on the question of “what” he was, Smith encouraged a broader sort of exploration:
I basically told this patient, It’s okay to feel that way. This person at first felt like there was a problem, that it was not right to feel this way, they want to be either trans or cis, they don’t want to be both. And it’s too complicated for them to manage this, and that nobody would believe them that they’re going through. And was very fearful of very people labeling them as crazy. And so I simply just said, You’re allowed to feel this way — now let’s understand why. We then took sessions into a completely different direction: We talked about family, we talked about the gender roles, we talked about the upbringing, we talked about this kid’s father and the relationship with the father, and we talked about all sorts of different things that were not necessarily directly related to gender. And this kid saw dichotomies within their life that happened that they never really had an understanding of initially, or a consciousness of initially. And he said, You know what? I think what’s going on with my gender is the same dichotomies that I experience with my relationships with other people and friends and how I feel about schoolwork, and this and that. And I think that helped this person make meaning of their experience. That brought a reduction in stress. Does that person maybe want hormones? Maybe? Would that person benefit from hormones? [A bit more skeptical-sounding:] Maybe. But again, we are there to make meaning of their experience so that we feel more comfortable knowing that an irreversible intervention makes sense to them.
That is, to my layperson’s eyes, a wonderful example of what compassionate gender-affirming care looks like. And yet it certainly reads like technically this kid’s path to hormones was slowed down, right? That’s what I mean by this stuff being a bit more complicated than actively affirming a kid’s identity on the one side, or just “watchfully waiting” him sit there, tormented by gender dysphoria, on the other. Competent clinicians have a broad set of tools at their disposal, and they use different tools at different times. I have no doubt that Smith did not stand in the way of this kid getting hormones if hormones were what this kid needed (this interview took place awhile ago), but I also have no doubt that the kid benefited from understanding how the swirling forces around him affected his own sense of gender — exactly how any of us would benefit from such exploration.
That said, obviously — obviously — there are times when waiting is not appropriate. If a kid is entering puberty and experiencing immense distress at the changes starting to take place, no competent clinician would say “Well, let’s talk about things for another year before thinking about puberty blockers.” And because so many trans people have faced unreasonable wait times, and still face a severe lack of access to hormones, it is eminently fair for Lavery, and for any other empathetic human beings, to be sensitive to these sorts of concerns. If I’m starving to death and read an article about how everyone in America is eating too damn much pizza, I will feel like the author is missing the point.
But there’s a middle ground between “Let’s do endless, circuitous talk therapy until you try to kill yourself, proving to me that your concerns about gender dysphoria are worth taking seriously” and the idea that there’s some big divide between affirming clinicians and those who think a bit of waiting and exploration is sometimes appropriate. There are some concrete examples of what all this looks like in practice in my Atlantic article — check out the Orion Foss and Delta stories. Foss transitioned, Delta didn’t, and I just don’t think a fairminded reader could argue that either of them were mistreated by the clinicians they interacted with.
Here’s The Actual Debate Surrounding “Watchful Waiting”
Lavery used “watchful waiting” in a fairly colloquial sense, defining it, for the purposes of her tweetstorm, as being “what it sounds like.” But it has a more formal definition, too. It’s generally attributed to the The Center of Expertise on Gender Dysphoria at the VU University Medical Center Amsterdam, aka “the Dutch clinic,” which is viewed by many as the leading gender clinic in the world and by everyone as the clinic that has produced the most and the most fine-grained data.
The Dutch clinic invented puberty blockers and a specific protocol about the process of going from assessment to diagnosis to blockers to hormones should look like. That’s the “Dutch protocol.”Here’s an accessible 20-page paper from the founders of this approach, Annelou de Vries and Peggy Cohen-Kettenis, laying it out. In reading the paper, I detected a great deal of overlap between what the Dutch clinic does and what goes on at the affirmative clinics whose clinicians I interviewed (clinicians to whom I’d eagerly refer any kid who might have gender dysphoria): All these clinics take assessment very seriously, and take careful, individualized approaches to each patient that involve, among other things, exploring family dynamics, making sure a kid feels safe and nurtured in his or her everyday life, dealing with co-occurring mental-health problems if there are any, and, in many cases given the correlation between gender dysphoria and autism spectrum disorders, also providing support centered on a child or adolescent’s ASD.
There’s one pretty big exception, though. The Dutch clinic takes a more conservative approach to full childhood social transition than an increasing number of affirming clinics in the U.S. do. That’s in large part because the Dutch researcher have been tracking cohorts of kids with gender dysphoria for as long as anyone (not very long in the grand scheme of things), and have discovered that for a lot of them, the GD goes away in its own in time — that is, it desists. Now, here I am dipping a toe into a firestorm of a debate that I’m mostly going to relegate to my next post, complete with emails from one of the key figures clarifying a lot of stuff, but it’s a necessary toe for explaining the Dutch protocol. Whatever you yourself think about the desistance debate, it is a true fact that those running the Dutch clinic believe genuine desistance is common, and that this belief informs their approach.
So their general approach to social transition, as laid out in that paper, is that “Because most gender dysphoric children will not remain gender dysphoric through adolescence (Wallien & Cohen-Kettenis, 2008), we recommend that young children not yet make a complete social transition (different clothing, a different given name, referring to a boy as ‘her’ instead of ‘him’) before the very early stages of puberty.” In their view, and in their experience, enough of these kids will want to “change back” if they do fully socially transition that that decision should be delayed a bit. De Vries and Cohen-Kettenis explain that “limit setting” with regard to “cross-gender” behavior is okay, but only if parents don’t induce a sense of shame. “For example, if a young boy likes to wear dresses in a neighborhood in which aggression can be expected, they could come to an understanding with their son that he only wears dresses at home,” they write. “In such a case, it is crucial that the parents give their child a clear explanation of why they have made their choices and that this does not mean that they themselves do not accept the cross-dressing.”
Another reason for the Dutch clinicians’ specific recommended timeline is that they believe the initial onset of puberty, before anything that’s physically irreversible happens, offers important diagnostic hints about a child’s gender-identity development. This, too, is based on their own research: “To date, we do not yet know exactly when and how gender dysphoria disappears or desists,” they write. “Clinical experience has shown that this most often takes place right before or right after the onset of puberty. This is also confirmed by youths in a qualitative study in whom the gender dysphoria disappeared after puberty (Steensma, Biemond, de Boer, & Cohen-Kettenis, 2011).” So, “If the eligibility criteria are met, gonadotropin releasing hormone analogues (GnRHa) to suppress puberty are prescribed when the youth has reached Tanner stage 2–3 of puberty (Delemarre-van de Waal & Cohen-Kettenis, 2006); this means that puberty has just begun. The reason for this is that we assume that experiencing one’s own puberty is diagnostically useful because right at the onset of puberty it becomes clear whether the gender dysphoria will desist or persist.” It’s important to emphasize that the Dutch clinic offers blockers early in puberty. The researchers are not suggesting that gender dysphoric young people should have to develop full-blown, painful-to-them secondary-sex characteristics, and only then be eligible for treatment. Rather, “Starting around Tanner stages 2–3, the very first physical changes are still reversible.”
Okay, so: Here’s an actual area of disagreement. Clinics in the States are, on net, turning more and more to full early social transition, and in some cases people are making pretty serious claims about what happens if you do anything but allow a young gender-dysphoric kid to transition fully at a young age. The Dutch clinic disagrees. This is the sort of debate that should get more airtime, as long as it’s conducted in an informed way.
“Informed way,” in this case, means acknowledging that the Dutch clinic appears to have racked up some impressive results so far, but that there are also some limitations to what can be drawn from them. An important 2014 study in Pediatrics on a cohort of patients at the clinic who went through the puberty-blocking, hormones, and (for some) surgery process found that “Gender dysphoria had resolved” and “Psychological functioning had steadily improved, and well-being was comparable to same-age peers.” These young people, all of whom went through the intensive, let’s-not-jump-into-anything assessment process the clinic favors, seem to be thriving. Their experiences offer strong evidence that if you give kids with persistent and severe gender dysphoria puberty blockers, hormones, and access to surgery (for those who later want it), they can look quite similar to their cisgender peers in terms of their psychological health. This is a vital scientific finding.
But on the other hand, a skeptic of the Dutch clinic’s reticence about early full social transition could say: The youngest kid in this cohort was just 11 at intake, so this study can’t really tell us anything about kids who, say, arrive at the Dutch clinic at 6 with gender dysphoria, go through four or five years of “watchful waiting,” and then get on a social and physical transition track. Here, honestly, is where my knowledge of the Dutch clinics’ research output reaches its limit, as does my desire to do a lot more reporting in a Medium-post context where I’m literally just saying Here’s the debate that we should be having rather than I, Jesse Singal, wholeheartedly and with no reservations support this approach, but for what it’s worth I sent an email to de Vries and Thomas Steensma, another researcher-clinician there, to make sure I have this right, and if and when they get back to me I’ll stick their response here:
[SOON-TO-BE EXCITING “THE RESEARCHERS RESPOND” PLACEHOLDER PARAGRAPH]
I do think there’s a subset of people who are very selective about which research findings out of the Dutch clinic they endorse, and which they ignore or nitpick in ways that aren’t warranted (more on which in the next post). So people are quick to note that the Dutch clinic proves that blockers and hormones “work,” but ignore the broader context of that clinic’s approach: Don’t let a kid with GD get too far into puberty, but don’t rush anything, including full social transition, either. And put a premium on mental-health support and assessment. I feel like there’s a tendency for the same people to both point to this Pediatrics study as evidence of the importance of allowing young people to transition and to then make make what are, to my mind, unfounded claims about how deeply harmful it is to do in-depth assessments or therapy related to gender dysphoria, which doesn’t make sense.
I’m not making this up: There is an actual strain of thought within a subset of trans activism — note that I’m not attributing this view to all or even a majority of trans activists or allies — that in-depth assessments of TGNC youth, or extensive exploration in therapy settings, are themselves inherently harmful. I heard this first-hand from Edwards-Leeper, who is as knowledgeable about the current state of professional debate on this subject as anyone:
The six trainees on Edwards-Leeper’s Transgender Youth Assessment Team spoke about the myriad ways mental-health issues and social and cultural influences can complicate a child’s conception of gender. “I would say ‘affirming’ isn’t always doing exactly what the kid says they want in the moment,” one said. Another added: “Our role as clinicians isn’t to confirm or disconfirm someone’s gender identity — it’s to help them explore it with a little bit more nuance.” I asked the students whether they had come across the idea that conducting in-depth assessments is insulting or stigmatizing. They all nodded. “Well, they know what reputation I have,” Edwards-Leeper said with a laugh. “I told them about things almost being thrown at me at conferences.”
Those conference troubles signaled to Edwards-Leeper that her field had shifted in ways she found discomfiting. At one conference a few years ago, she recalled, a co-panelist who was a well-respected clinician in her field said that Edwards-Leeper’s comprehensive assessments required kids to “jump through more fiery hoops” and were “retraumatizing.” This prompted a standing ovation from the audience, mostly families of TGNC young people. During another panel discussion, at the same conference with the same clinician, but this time geared toward fellow clinicians, the same thing happened: more claims that assessments were traumatizing, more raucous applause.
These fears don’t come from nowhere. My guess is they are usually expressed by adult trans people who themselves faced unwarranted wait times, delays in care that had nothing to do with compassionate exploration or reasonable concerns, and all the other terrible crap that was hurled at trans people for a long time, and which continues to be. So when they hear clinicians talking about “slowing it down,” “exploring things,” and so on, these concepts have a certain threatening sting to them. But it can simultaneously be true that the fears expressed by assessment-skeptics come from a reasonable historic place and that they aren’t quite reasonable if we’re talking specifically about the work of clinicians like Edwards-Leeper or her onetime colleagues in Amsterdam (Edwards-Leeper helped bring the puberty-blocking protocol to the States in the first place).
Some of this stuff isn’t complicated: Trans people deserve respect. They deserve to have their identities validated. They (obviously!) deserve to be allowed to use the bathroom in a safe and dignified manner, and to be free of housing and employment discrimination. But there is actual debate about some of the specifics of how to best help TGNC kids in a balanced way that both respects who they are now and takes into account who they might become. It’s silly to pretend otherwise, and no amount of social-media outrage geared at conflating “There is a clinical debate going on here that we should talk about publicly” and “We should debate whether trans people have the right to live and be happy,” as though those two sentiments even share the same planet, will change the fact that this is complicated, and that when you actually call up clinicians and talk to them about it, they can talk your ears off about it for hours, in fascinating and heartbreaking detail.
Like I said: Lavery, to her credit, didn’t fall into these traps: She said, in effect, “This is the debate people are having and why I favor one side of it.” I just think she slightly misstated the terms of that debate, ignoring its most substantive aspect, and the areas of genuine disagreement between the “watchful waiters” and everyone else. Then again, it was just a tweetstorm! And I made the decision to turn it into a whole thing, because I want to try to expand the space in which people can talk about this issue and understand the flawed but oftentimes informative science behind it.
—
Okay, so eventually I’ll also reply to some of Lavery’s claims about gender-dysphoria desistance. That reply might not come until a week from now, or later, but a quick preview because I can’t resist:
-I think Lavery falls for certain common tropes and claims about the desistance literature that lead people who are skeptical of desistance, and who view it as a threat to trans people, to underestimate its true prevalence — I have retreated from the 80% estimate and think other people should as well, but there is no evidence to suggest it’s “rare,” and plenty to suggest it’s “common,” however you want to interpret those terms, among kids with genuine gender dysphoria. I’ve always tried to make a stronger claim than that it “merely exists.”
-I think she’s absolutely right to point out that desistance claims can be used to harm trans kids (as I’ve stated repeatedly, no desistance estimate should ever be used, on its own, to make a clinical decision about an individual person).
-I’ve got some emails from Steensma that highlight important and neglected aspects of this conversation: He thinks a study of his that found a desistance rate of about two-thirds in his clinic underestimated the true desistance rate there but that it shouldn’t be taken as an accurate estimate desistance in other settings because the concept is so context-specific and the study in question wasn’t designed to answer exactly this question (see also here).
-I think that some people have argued, or come close to arguing, that desistance is an all-out myth rather than that the 80% figure is a myth, but that Julia Serano isn’t one of them — in my view of events, I accused her not of doing that but of discounting detransitioners’ experiences in a specific way that I will explain, but which is different from attributing to her the idea that desistance is an all-out myth. Serano, to my knowledge, has never claimed desistance is an all-out myth. If someone points me to a place where I made this exact claim, I’ll delete it and note the deletion.
-More soon.
