Open letter to the Florida Board of Medicine
To:
Paul A. Vazquez, J.D.
Executive Director Florida Board of Medicine
BOM.MeetingMaterials@flhealth.gov
Dear Mr. Vasquez,
I am writing in regards to the proposed regulations on “gender-affirming” care currently under review in Florida. I am a Licensed Marriage and Family Therapist in private practice in Portland, Oregon. Over the past ten years, I have seen numerous people concerned with and affected by gender.
As a mental health professional, doing my job well requires adequate familiarity with how social norms, cultural trends, and popular narratives about issues of public concern, all intersect with the mental health issues that present in my office. It is also my job to “first do no harm,” and help mitigate loss of life to suicide, addiction, and other preventable tragedies.
A few years ago, I started to become increasingly concerned with the mental and behavioral health patterns I was witnessing in people who pursued “gender-affirming” medical care. I began intensively studying the issue of gender in conjunction with numerous important related factors, among them: suicide risk and self-harm; developmental psychology, especially in adolescence; autism, complex trauma, attachment, personality disorders, Munchausen by proxy, psychosomatic illness, secondary gain, and other interrelated psychopathology; social media; pornography; the pandemic’s influence on social connection; family and peer relationships; endocrinology; evolutionary biology; social contagion and mass formation; internalized homophobia and misogyny; and iatrogenic harm. And, as I learned about those who have been harmed by “gender affirming care,” I became increasingly concerned about this high-risk, poorly understood, and under-served population.
After my first year of studying in private, based on what I was learning, my heart compelled me to put my career and reputation on the line in order join other brave souls blowing the whistle on what many of us now believe to be a scandal that history will soon reveal to have destroyed many more lives than it claimed to have saved.
If possible, please watch this 8-minute clip in which I share the heart of my concerns as to why “affirming gender identity," particularly in youth, is dangerous, misguided, and a far departure from the normal standards of care for how clinicians treat any other mental health issue.
The issue of “gender-affirming care” has been most intense and fraught around how we treat children and adolescents in particular — and for good reason; it’s about how we protect the most vulnerable members of society. On the pro-trans side of the debate, you will hear the argument that these youth somehow magically “know who they are.” These same activists would like to relegate the roles of highly trained professionals, such as myself, to merely agreeing with the conclusions their young brains have arrived at — usually after thousands of unmediated hours on TikTok and Tumblr, by the way.
Allow me to bust these myths: these youth are no more certain of who they are than any of us were at their ages. There is zero evidence to suggest that trans-identifying teens are a special class of human that follows a markedly different trajectory with regard to what are normally long, complex, fraught, bumpy processes: developing a sense of identity; discovering one’s sexuality and relational needs; and making long-term decisions that will influence life outcomes decades ahead. If anything, the high rates of autism, trauma, and other psychopathological comorbidities in this population, suggests that these individuals are, on average, more fragile and slower to develop, and therefore all the more in need of caution and protection — not precociously ready to make life-altering decisions before their brains reach maturity (at roughly age 25).
Rather than being uniquely suited to make life-altering decisions, just like the rest of us were at their ages, if not more so, these adolescents are in fact highly suggestible, susceptible to social contagion, and not developmentally capable of consenting to the life-altering, permanent decisions involved in so-called “affirming care.” They are often especially socially naive, especially considering rates of autism being higher in this population. They have often been bullied, traumatized, and neglected in various ways. When transgender is trendy — and who can deny that it is? — opting in to that category scores immediate social approval and attention.
The rates of regret and detransition are unknown. But here are a few facts we do know. I am pulling these off the top of my head, and squeezing this letter out before leaving on a trip, but if requested I will happily find sources later:
Doctor and researcher Lisa Littman found that 75% of those who detransitioned never followed up with their care providers.
Anecdotally, from numerous interactions with detransitioners, I can tell you they have some of the lowest rates of trust in mental and physical health care providers that I have ever seen, so under-reporting will remain an issue.
The Reddit Detrans board has over 40,000 members.
Various studies have located the natural rate of desistence from gender dysphoria at anywhere between 60-90%, if youth who had dysphoric feelings were left to develop with the “watchful waiting” rather than affirmative care approach.
Those studies were based on youth who had significant, persistent dysphoria, at a time prior to transgenderism reaching nearly the level of trendiness as it currently enjoys in pop culture. Some studies have shown an approximately 40-fold increase in the number of natal girls identifying as transgender over the past decade or two. So if we assume that the dysphoria was more organic for those in the above-mentioned studies, whereas it is more socially influenced in today’s population, we can also assume that the desistence rate would also be even higher in today’s population, if only they weren’t allowed to rush into making life-altering decisions they are likely to regret.
A typical female taking testosterone will experience painful vaginal atrophy after about 4 years. This is but one of many forms of chronic pain trans identifying people will experience - more on that later. Anecdotally, according to my observations from interacting with numerous detransitioners, chronic pain and other physical impairments appear to be one of several common triggers for transition regret and detransition.
In the US, approx. 1.6 million people ages 13+ identify as transgender. The proportion of the population identifying this way has remained steady in adults over the past few years, but increased in adolescents.
Considering all these bits of information together, we can reasonably conclude that the population of people who will need comprehensive after-care due to post-transition regret and complications is currently in the tens of thousands, growing exponentially, and could potentially reach the millions.
You will hear from activists about the concept of a “male brain trapped in a female body,” and so forth. If you would like to know more about why those statements are inaccurate, please see Why Gender Matters, by Leonard Sax. Throughout the book he neatly summarizes a preponderance of data on the differences between males and females when it comes to behavior, biology, and the brain. In his later chapters addressing trans-identification, he looks at similar studies on the brains and behaviors of trans-identifying people and finds they are more consistent with their birth sex than their identified gender.
The concept of feeling that one is “in the wrong body” is, at best, an earnest metaphorical attempt to describe a feeling, and, at worst, a delusion that an individual never would have had were it not for negative online or peer influences. Factually, what we do know is that individuals who report feeling this way have less activity in regions of the brain associated with the mind-body connection. (See these two articles for more information: 1, 2). I would hypothesize this sense of disconnection to be more likely due to trauma (which causes dissociation); chronic neglect (in which the developing child never receives the attention to help bring her fully into her body, senses, and social environment); too much time spent in the virtual world; and lacks of physical activity, social contact, and interactions with the material world and senses. It follows, then, that those are the problems to be remedied: through somatic or relational psychotherapy; digital detoxes; increased quality time with loved ones and in the natural world; participation in sports, yoga or mindfulness; and so on. Unfortunately, as detailed in the articles referenced above, when the treatment prescribed is cross-sex hormones, activity in this region of the brain continues to atrophy — along with reproductive tissue and overall health.
Activists will intimidate you with poorly conducted studies about suicide risk in trans-identifying youth, conflating prevalence of suicidal ideation with behavior (two very different things). While it is true that this population expresses higher rates of ideation, that becomes less true when you adjust for their comorbidities, as almost all trans-identifying youth have underlying issues. We must also adjust our interpretation of data based on the fact that youth are advised in online forums to express suicidal ideation as a means of getting “affirmative care.” I have seen this myself in my clinical practice. The activists deliberately ignore the substantial factor of youth suggestibility, and their own egregious act of telling vulnerable youth that they will kill themselves—or should threaten to do so in order to get the “gender-affirming care” that social media has so cleverly sold to them. When we fail to recognize and treat underlying issues and comorbidities, and instead focus solely on the issue of gender, we are not likely to see a reduction in suicidal distress. Rather, we make individuals more vulnerable. They fail to attend to their mental health needs and instead fixate all their hope on the idea that being “affirmed” will resolve their distress. When that doesn’t happen, but their bodies have been permanently altered, they are more vulnerable to suicide risk than ever before.
The actual numbers will tell you a much different story than the activists do about suicide risk factors vs. protective factors. For example, it is well established that puberty blockers impair bone development, leading to chronic pain and disability, which are well established risk factors for suicide in adulthood. Compare this with the protective factors of being able to exercise and enjoy sports, hobbies, and leisure activities with minimal physical impairment.
We also know that puberty blockers, cross-sex hormones and surgeries limit, complicate, or eliminate altogether the potential for sexual pleasure and reproduction. Sexual pleasure is an important aspect of wellbeing and mood regulation for the vast majority of adults, and having a healthy, happy romantic relationship is among the greatest protective factors when it comes to mental health. Likewise, responsibility to loved ones, most importantly children, is a huge protective factor for those otherwise at risk of suicide.
“Gender-affirming care” destroys youth’s future abilities to enjoy sexual intimacy without pain, form loving relationships, reproduce, breastfeed, and have families, before they even get a chance to discover who they are, who they love, or what they want. Meanwhile, it induces chronic pain, inflicts permanent disabilities via shameful iatrogenic harm, and renders its victims forever reliant on the medical system. It experiments on the brains of vulnerable people through powerful mood-altering substances. Between all these factors and more, we are setting the next generation up for the worst suicide epidemic the last century will have seen. Although more data on long term outcomes is sorely needed, one study found that the long-term suicide risk was a shocking 19 times higher post-transition. Another study also showed higher rates of suicide amongst MTF and FTM transsexuals than amongst gender-nonconforming and cross-dressing individuals that did not medically transition.
When it comes to parenting, as well as how we collectively rear our society’s children through other supportive adult familial and professional roles, safeguarding and boundary-setting are important components of showing children that we care about their long-term wellbeing and scaffolding their development until they are able to make healthy decisions for themselves. Allowing immature people to make decisions they are not ready for and are likely to regret will be experienced for the rest of their lives as abandonment and betrayal, permanently damaging their abilities to trust their families, therapists, and doctors—and therefore, once again, elevating their risk of suicide.
Even adults who medically transition often regret it and face devastating consequences. Consider reading the blog of Michelle Alleva, or listening to Grace and Carol share their regrets about their mastectomies. I especially implore you to listen to the stories of males who have had orchiectomies, penectomies and vaginoplasties that have permanently damaged their entire pelvic region. Take, for instance, this interview between Blaire White and Shape Shifter, or the story of Ritchie Herron. In this interview, Oliver Davies wept to me about how he will not be able to have children with the love of his life because “gender affirming care” robbed his fertility. These men are entering adulthood feeling broken, devastated, permanently dependent on the medical system (here’s but one example), and worst of all—blaming themselves.
Medical professionals should have known better, should have protected them. Even without surgeries, cross-sex hormones are well known to induce endocrine, neurological, bone, and cardiovascular disorders. Plus, a few years on testosterone will force many women to undergo hysterectomies due to painful vaginal atrophy, so avoiding surgery may not be an option for many people once they have begun cross-sex hormones. Extensive data on this can be found at statsforgender.org.
Detransitioners, desisters, transition-regretters, ex-trans, and families otherwise affected by this issue, form a novel yet rapidly (exponentially!) growing population that is poorly understood. I am concerned about this population’s uniquely dangerous combination of suicide risk factors and lack of protective factors, plus the cherry on top: lack of trust in mental and medical health care professionals. Many of them rightfully attribute the pain, disability, shame, and regret they now must live with for the rest of their lives, with the professionals who enabled them to make such regrettable decisions. Anecdotally, from my own interactions with detransitioners, I can tell you that their mental health needs are some of the most complex and severe, while their willingness to seek help is lower than I have seen in any other population. This ought to be alarming. I do believe many “affirming” care providers will find blood on their hands down the line.
It is well known that this ideology is driving painful wedges between families: between children and their parents who are concerned for them, and between parents who have differing opinions on how they should treat their trans-identifying child. By allowing these medical technologies to be available to minors at all, the healthcare system triangulates parents who love and want to protect their children into being the bad guy. Please see, for instance, the heartbreaking stories at Parents with Inconvenient Truths about Trans, or listen to The Witness Podcast. The medical system needs to stop enabling this breakdown in the family. As a Licensed Marriage and Family Therapist, I believe it is our job as mental and physical health care professionals to restore harmonious functioning and healthy communication to family systems whenever possible, and we should question any ideology or trend that threatens to undermine the relationships that have the potential to be the most stable, loving and supportive of an individual’s long-term wellbeing.
See also: this YouTube playlist of episodes of my podcast that focus on the issue of gender; my blog, online resource list, and recommended reading list. You can follow me on Twitter for articles, interviews and retweets of pertinent news and studies on an ongoing basis.
I hope this has been helpful despite being a bit rushed and disorganized. I am happy to provide further information or dialogue with anyone inquiring sincerely about these concerns.
Thank you for your time and consideration.
Sincerely,
Stephanie Winn, LMFT
@sometherapist
