The L.A. Times Can Virtue-Signal to Transmisists All They Want…

…but I’m not backing down, and I stand by my comments.

Today, The L.A. Times published an article entitled “A transgender psychologist reckons with the rising number of teens coming out as trans,” in which they devote 99% of the time to increasingly more vile and transmisist Psychologist Erica Anderson. I was asked to comment and sent in 4 pages in response to 4 questions. They, of course, published what fit the rhetoric.

What was published concerning my remarks (and I 100% agree, regardless of how much they left out and how this was skewed):

“Being trans or gender diverse is not a mental illness, and compulsory psychotherapy is not the standard of care in the gender-affirming medical model,” said Dr. AJ Eckert, medical director of the Gender and Life-Affirming Medicine Program at the Anchor Health Initiative in Stamford, Conn., and the state’s first out nonbinary trans doctor.

“Forcing transgender and gender diverse youth through extensive assessments while their cis peers are affirmed in their identity without question conveys to [them] that they are not ‘normal,’ ” they said.

Eckert also dismissed the idea that peer pressure is driving some teens to identify as trans: “Is it trendy to be one of the most marginalized and vulnerable groups?”

In Eckert’s program, a patient learns about treatment options during a one-hour intake interview. Therapy is not required.

…and here is what I wrote. Note the tone of the questions asked by L.A. Times journalist Jenny Jarvie (i.e., I am not shocked by the article's tone.)

What are your thoughts/criticisms on the draft WPATH standards of care guidelines for adolescents?

There are necessary revisions needed in the WPATH Soc v8 draft Adolescent Chapter; the following are three examples that stand out to me.

The authors recommend that TGD (transgender and gender diverse) youth undergo a “comprehensive biopsychosocial assessment.” This assessment is poorly defined, and its benefits are unquestioned despite the lack of evidence for the approach and the high probability that the process will be harmful and pathologizing to those exposed. Forcing TGD youth through extensive assessments while their cis peers are affirmed in their identity without question conveys to TGD kids that they are not “normal”; a psychological investigation implies that asserting a TGD identity is an inherent problem. This “comprehensive assessment” is then discussed as a means to “explore gender-related issues.” Gender exploration is essential for all youth and should be encouraged when desired and led by youth. Coercing TGD youth into “gender exploration” rides the fine line of conversion/reparative therapy. The WPATH SOC draft insists this is not conversion therapy despite a well-known published legal strategy (Green 2017) to circumvent laws prohibiting conversion therapy by labeling the practice as “gender identity exploration and development.” There is no acknowledgment on behalf of WPATH of this and similar efforts to circumvent conversion therapy laws. Forcing a comprehensive assessment contradicts the WPATH principles of depsychopathologization, harm reduction, medical necessity, and informed consent protocols.

The WPATH Soc 8 draft Adolescent chapter references desistance research, which has been extensively critiqued, proven unreliable, and should not be cited as scientific fact. The idea that many youths will desist from a TGD identity encourages people to question whether we should support TGD youth in their identities in the first place. There is little evidence of desistance.

The draft notes “sudden self-awareness of gender identity” and “peer and/or social media influence,” entities that indirectly reference ROGD. ROGD, rapid-onset gender dysphoria, is not real and in no way should be applied to medical decision-making in TGD youth. A loud faction seems to believe that youth are asserting they are TGD because it is trendy. Is it trendy to be one of the most marginalized and vulnerable groups?

More TGD youth are visible now due to greater societal acceptance and visibility and somewhat improved access to health care. There have always been TGD youth.

ROGD is not a medical diagnosis recognized by any major professional association and has no good evidence to support its existence. The consensus of major health care associations, including the WPATH, is that ROGD use be eliminated from clinical and diagnostic applications.

The WPATH Soc. 8 draft states, “…being transgender or questioning one’s gender does not constitute pathology or a disorder. Therefore, individuals should not be referred for mental health treatment exclusively on the basis of a transgender identity.” This contradicts the WPATH Soc 8 draft Adolescent Chapter’s insistence on mental health care.

Do you think there should be mental health assessment for adolescents who seek medical treatment?

I do not support that a mental health assessment should be required to access gender-affirming care. Much of the mainstream rhetoric around TGD youth is misleading, alarmist, and not guided by research. Being trans or gender diverse is not a mental illness, and compulsory psychotherapy is not the standard of care in the gender-affirming medical model.

Those who oppose gender affirmation often claim that the approach means no mental health involvement or parental input. Therapy is often a crucial part of the treatment approach, helping families accept and nurture their TGD child and helping the child develop coping skills and deal with dysphoria-related distress. Gender-affirming care is nuanced, complex, and comprehensive. In the gender affirmative approach, parental and medical guardian input and mental health are crucial elements to care.

Some will have you believe that there are numerous detransitioners, people who stop their gender affirmation and revert to their assigned at birth gender roles. The narrative perpetuated is that TGD health care is dangerous and harmful, and many people regret making the giant mistake of gender affirmation. Not only are there statistically insufficient numbers of detransitioners, but regret is the least common reason for one to stop gender affirmation.

In the gender-affirming framework of health care, gender diversity is depathologized, and being TGD is not considered a “disorder” that needs to be reversed. Other mental health issues do not cause one to believe they are TGD. Indeed, the opposite is true; TGD people develop mental health issues such as depression, anxiety, and suicidal ideation often due to minority stress in a society where there is still debate around affirming youth in their identities even though scientific research overwhelmingly supports an affirmative approach to care.

How does assessment typically work for teens who come to Anchor’s Gender and Life-Affirming Medicine Program? How long does the process typically take? What does it involve?

Gender-affirming care is multilayered and looks different for everyone, depending on age, the timing of puberty, and family attitudes.

By the time we see patients at Anchor Health, they have at least started puberty. There are no medical or surgical interventions for youth that have not started puberty. In most states, no one under 18 years old can start gender-affirming hormones and/or puberty blockers without parental or other medical guardian consent. Parental and/or medical guardian input is required and vital to a youth’s well-being, and we collaborate with children and their families to create individualized affirmative frameworks wherever possible. Given that youth often need both parents’ permission to make legal or medical changes, this can create the need for a holistic approach that educates and supports all family members.

The ”process for assessment” of a TGD youth involves an hour-long intake visit with the patient and their medical caregiver(s). We do not require therapy because being TGD is not a pathology. We provide patients and their families with information about treatment, address questions and concerns, and ensure they have all the necessary information to make an informed decision. Subsequent follow-up visits depend on all specialized medical care parameters, such as when and what treatment is started, what clinical and bloodwork monitoring is indicated, and addressing family and patient concerns.

Extensive therapy is not supported by evidence and often delays gender-affirming medical interventions that can be lifesaving. Puberty does not stop; throwing up roadblocks to health care access means an uncertain waiting time during which secondary sexual characteristics develop, which frequently exacerbates gender dysphoria and leads to higher depression, anxiety, and suicidality. Puberty suppression is often urgent, and there should not be an insistence on delaying this life-saving care to complete comprehensive psychological assessments “over time.” Puberty blockers are a pause button; puberty is irreversible and can cause long-term trauma for TGD youth.

A study of over 300 TGD children aged 3–12 (Gulgoz et al. 2019) found that TGD children identify with their gender as strongly as cis children. The researchers note that this was especially surprising since the transgender children were, before social affirmation, treated as a gender other than the one they currently identify as. Most cis and TGD children know their gender around age 2 or 3. According to another recent research study (Zaliznyak et al., 2020), most TGD children with gender dysphoria experience dysphoria around age 7. Given this information, gender dysphoria often persists for years before patients take any steps toward gender affirmation.

Pseudoscientific, transphobic views garner the most attention and largest platform and often inform decisions around fundamental rights. TGD children deserve love, support, and thoughtful medical care as cis children do. Caretakers of all children need specific, accessible, and culturally relevant frameworks to raise the resilient and creative generation we need. TGD children are targets in the current political and culture wars. Still, the gender culture wars are about who has the right to exist in their own body and whose body we consider credible, autonomous, and worthy.

Anchor Health emphasizes an approach that centers our patients, in this case, TGD youth, and supports them in their gender affirmation, regardless of what that looks like.

Do you see SOC8 as a step back from the current guidelines, because it adds roadblocks to transition, such as minimum ages for blockers, hormones and surgeries, and because it requires that kids meet the “diagnostic criteria of gender incongruence” and demonstrate “persistent” gender incongruence or gender non-conformity for “several years”?

Yes, I see the current draft version of SOC8 as a step back. There are enough roadblocks to gender affirmation for youth without adding these additional, unwarranted requirements. The vast majority of trans youth in the U.S. lack access to competent, responsible, and affordable care.

There should be no minimum age for blockers, as puberty starts at different ages for individual youth. A minimum age makes no sense since we are using blockers to pause incongruous puberty. Do you wait until someone who started puberty at 10 is 12 years old and damaging, permanent changes have already happened to their body, and their mental health has suffered?

The idea that “persistence of gender incongruence for years” is a requirement for access to gender-affirming and life-saving interventions is damaging, pathologizing, and privileges report of arbitrary mental health or medical professionals over parental report, and, most importantly, over the patient report. “Several years of documented gender incongruence/non-conformity” places a child’s asserted identity under scrutiny and the opinion of a medical provider. Parental report is also problematic, as some parents may maintain that they “never noticed signs” in their trans child when there are several reasons the child may not disclose their identity and hide who they are, such as being socialized in a way that precludes gender variance from cisgender identity. The concept of “rapid onset” or “sudden self-awareness of gender identity” is only accurate regarding parental awareness of their child’s identity. No one supporting ROGD and related nonsense has asked trans youth whether their identity was a rapid or sudden decision, and it never is. There is no evidence that more extended and more careful assessments, more rigid requirements, and conscious denial or delay of care lead to lower rates of detransitioning or regret or fewer youth electing to pursue gender-affirming medical interventions.

These guidelines forget the most crucial aspect of supporting and affirming trans youth: listening to trans youth and believing them. As I’ve noted before, there is no harm in socially affirming youth, and puberty blockers are a pause button. We need to spend less time scrutinizing trans identities and more time supporting our trans patients and fixing the institutional structures that marginalize them and blame them for being themselves.

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The GLAM Doc

AJ Eckert (they/he) is Connecticut’s first out nonbinary trans doctor and Medical Director of Anchor Health’s Gender and Life-Affirming Medicine (GLAM).