The role of evidence and autonomy in gender affirming care:

A response to Wired Magazine

On July 7th 2023, Wired journalist Grace Huckins posted an article entitled ‘Trans People’s Mental Health Is Being Weaponized Against Them’ in which she frames a proposed law in Missouri as an attack on medical autonomy for trans adults.

The article starts with the claim that models describing trans identities as a mental illness are old and out of date. She refers to the World Professional Association of Transgender Health (WPATH)’s decision to move away from requiring ‘a full psychological assessment’ prior to accessing cross-sex hormones or gender-affirming surgery. She contrasts this with a recent decision by the Missouri attorney general calling on clinicians to assess clients for other mental health issues. 

While Huckins and I probably agree that healthcare decisions should not be legislated but should remain a decision between a healthcare provider and their patient, I take exception to Huckins’ claim that no evidence base is needed for gender affirming care, or that clinicians should forego the assessment process entirely and simply give patients what they want. It should be noted that even the WPATH Standards of Care 8 (SOC-8) that Huckins refers to encourages comprehensive assessments in the following scenario: “For TGD [trans and gender diverse] adults with a complex presentation or for those who are requesting less common treatments or treatments with limited research evidence, more comprehensive assessments with different members of a multidisciplinary team will be required” (WPATH SOC8, S31). 

Huckins frames the Missouri attorney general’s emergency rule as an attack on medical autonomy that targets autistic trans people and trans people who have other mental health conditions. She goes on to claim that so-called anti-trans campaigners are using the fact that trans people are more likely to experience co-occurring mental health conditions as a way of undermining trans identities. Since WPATH also calls for comprehensive assessments, and itself is part of that medical establishment, Huckins seems to undermine her own point.

As a trans person myself, I am all too aware that transphobia exists and that there are those who would rather trans people didn’t exist at all. That said, Huckins’ framing of the argument is both inaccurate and overly simplistic. This is not a battle between the ‘medical establishment’ and a so-called ‘anti-trans movement’. That is a false binary. The medical establishment is not a monolith on this issue — it is very much divided on the efficacy of gender affirming care — a number of systematic reviews have found that the evidence base for gender affirming care is lacking. 

Photo by Sara Bakhshi on Unsplash

GENDER AFFIRMING CARE — AN EVOLVING CONCEPT

The term has taken on a life of its own over recent years — it means different things for different people. Depending on context, it can mean providing medical treatment in general, with or without assessment and with or without hormones/surgery; or it can refer to the informed consent model with no diagnosis or assessment needed to access medical interventions. Some who are opposed to gender affirming care are opposed to any medicalizing at all, ever. Others who oppose gender affirming care are open to medicalizing in some cases but are opposed to the elimination of diagnosis, assessment and therapy. When everyone is using “gender affirming care” to mean different things, arguments get lost in translation.

Huckins seems to use the term to refer to patients having access to medical interventions on demand. She barely acknowledges the very real harms that can happen when someone who is struggling with mental health issues is erroneously led down a path of life-long medicalization and surgeries. She goes so far as to state that detransitioner stories are “only anecdotes” even though those ‘stories’ continue to climb in frequency. The author offers a single, remarkable sentence to hint at the potential harms of gender-affirming care: “While it is conceivable that autistic people or those with certain types of mental illness could fare worse than their neurotypical peers after receiving gender-affirming care—there’s little evidence on either side.”

Let the implications of that sentence sink in. Are we to interpret from this statement, that because we have no evidence one way or the other (which is in itself an acknowledgement that evidence FOR gender affirming care is lacking), the best course of action is to… medicalize people with life altering cross-sex hormones and surgical treatments and just… hope for the best? Again, Huckins undermines her own point. 

Huckins quotes legal scholar Florence Ashley, who makes quite the claim that gender affirming care should be given to anyone who chooses it for themselves regardless of the lack of evidence… because presumably bodily autonomy is more important than evidence based care. I cannot think of any other medical practice where this argument would hold water. By that logic, why not simply offer hormones via vending machine and cut out the healthcare provider entirely? While that may sound appealing to some, I prefer to live in a world where I can access the expertise of trained doctors and not have to rely solely on my own research to determine the best course of action.

As someone who experienced gender affirming care first-hand, I have a different view from Huckins’ and Ashley’s: when I go to my physician, I expect them to offer me a treatment plan informed by the best available evidence. If evidence is lacking for the efficacy of a particular treatment, I expect my physician to inform me of this. In my case, that is not what happened. I was told that my depression and anxiety was the result of my gender dysphoria and that once my gender dysphoria was treated my depression and anxiety would dissipate. That was not true. At best it was misinformation, and at worst, it was medical fraud. They sold me a lie — and now I have to live with the consequences of their misinformation. Yes, bodily autonomy is important — but so is the truth. And if the truth is withheld, then informed decision-making is not possible. 

WHAT THE RESEARCH SAYS (AND DOESN’T SAY)

Huckins makes the claim that no studies prove that autism and mental illness lead to poor gender-affirming-care outcomes, even as she refers to a study out of the UK that notes in its own conclusion that: “Neurodevelopmental disorders or ACEs suggest complexity requiring consideration during the assessment process. Managing mental health and substance misuse during treatment needs optimizing. Detransitioning might be more frequent than previously reported.” While Huckins is right that we need more evidence, this study certainly makes a good case for caution and sober reflection, not blind, unthinking affirmation. 

Her statement that no studies exist is also disingenuous, considering that those who have wished to study negative outcomes of gender affirming care have faced ongoing controversy and silencing attempts.

In another misleading sentence, Huckins refers to a recently released study from Denmark, which found that “trans people are markedly more likely to die by suicide than cis people”. Huckins uses that conclusion to argue for the potential benefits of gender-affirming care. This is a surprising position to take, considering that the study in question suggests exactly the opposite of Huckins’ claim. It suggests that gender affirming care does not bring trans suicide rates in alignment with cis suicide rates. If anything, It is another cautionary note in regards to the effectiveness of gender-affirming care.

OF COMPREHENSIVE ASSESSMENTS AND CONVERSION THERAPY

Huckins argues against comprehensive assessments for autistic patients seeking gender affirming care. As someone who only recently learned that I am high in autistic traits, I beg to differ. Speaking for myself, I can say that I would have benefited in knowing that my sensory issues, my discomfort with my body, my social/relational difficulties, had a cause unrelated, or not wholly related, to my gender. I would have made very different decisions about transitioning had I known that. Withholding that information from me undermines true informed consent. My gender nonconformity takes on a different meaning if I understand it as a product of my neurodivergence, rather than the result of me being ‘born in the wrong body’ -- a claim, by the way, for which there is no scientific backing.

In the conclusion of the article, Huckins makes the case that moving away from gender affirming care (i.e. requiring any form of assessment or diagnosis) is akin to engaging in conversion practices and that people should not be ‘forced’ to undergo psychological care prior to making physical changes to their body. What, then, would Huckins say about people being ‘forced’ to embrace a false narrative about their gender dysphoria (i.e. that it is a cure for psychological problems like depression and anxiety) and actively influenced to undergo hormones and surgery? This, when psychotherapy might well have helped relieve their gender dysphoria, without the reliance of taking cross-sex hormones for the rest of their life or having to risk serious potential surgical complications. Would that be considered ‘conversion practices’ too? 

Rather than seeing psychological assessments and psychotherapy as a barrier to care, what if we actually took patients’ mental health seriously and approached the experience of gender dysphoria from a bio-psycho-social framework? That would mean having to make an effort to understand gender dysphoria within the context of the individual patient’s life. It would mean doing more than merely taking a client history; it would mean engaging the client’s curiosity in their own decision-making process. Access to care is important — and everyone should have access to care — on that point Huckins and I agree. However, bad care is worse than no care at all, especially when we are talking about removing healthy body parts and functional organs. I should know. I underwent gender affirming care based on faulty and incomplete information. 

AUTONOMY: THE HIGHEST VALUE OF THEM ALL?

I agree with Huckins that autonomy is important. But what is autonomy? Autonomy doesn’t mean you get everything you want when you want it. Sometimes we need someone to highlight our blind spots, to hold us accountable to ourselves. Huckins offers the following metaphor in defense of gender affirming care: “Drivers experiencing mental illness may be more likely to get into an accident, but it would be absurd to propose that no person with a mental health condition be permitted to operate a vehicle.” It’s an odd comparison. If a driver had a mental illness that impaired their ability to drive safely, I would hope that someone would step in to remove their license (as an example: my father, who in his later years started to black out behind the wheel due to health issues, chose to voluntarily give up his driver’s license — for others’ safety and his own). Your right to drive is not more important than your and other people’s safety on the road. 

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