Detransition is a Mythology

(for Readers of the New York Times)

Imagine that the conditions for making decisions about your body were enclosed inside the following process:

1. First, you pay to meet with two psychiatrists. If you convince both that you deserve the body you want only because you are helplessly sick with something, you may proceed; if not, it’s all over before it began.

2. Next, you pay to undergo a physical exam by a general practitioner and a separate gynecological exam. You have no physical illness to be examined. In fact, ideally you will have a body free from illness. It is not clear what constitute good results from this exam.

3. Now, you pay to meet with a clinical psychologist, who will administer a series of opaque tests. He has you complete the Wechsler Adult Intelligence Scale, the Minnesota Multiphasic Personality Inventory, a Rorschach test, and the Draw-a-Person test. There are no obvious “correct” answers for these tests, nor does he explain what he is looking for. If the clinical psychologist nevertheless approves of your answers, you may proceed; if not, you wash out, several hundred dollars and weeks into this process.

4. You are summoned to a meeting of the entire staff at the clinic where you have been having these appointments. You sit quietly like a defendant on trial while documents called “screening reports” are read aloud by the psychiatrists, physicians, and clinical psychologist. These documents evaluate you in the third person, calling you by the wrong name and pronouns. You are told to bring your family members, friends, and romantic partner to attend the meeting with you, not for support, but so that they may answer questions from the staff about your body and state of mind. Your input is not needed at this time. At the end of the meeting, the staff takes a vote on whether you are “a transsexual person.” If the vote is unanimously ‘yes,’ you may proceed; if it is not unanimous, you are given the option of agreeing to pay for more sessions of psychotherapy until an unspecified time at which you convince the holdouts.

5. You are called into an exam room following the vote to talk with a nurse practitioner. She goes over the clinic’s decision with you and takes further notes on the emotional tone of your reactions. If you have made it this far, she tells you that today is a good day, for a countdown has begun. In one year, if you have continued to convince the clinic staff that you are who you say you are, and if you manage to keep on good terms with everyone in your life, keep your job, stay out of trouble with the law, you can reappear in front of the jury for a second vote. This period, she tells you, is called the “real life test.” It is designed to make sure you aren’t lying or mistaken about who you are. In the meantime, she hands you information on psychotherapy and a support group that meets nearby.

6. You return the following week to pay for an appointment with the physician, who will now prescribe you the hormones that you want. He tells you that he will only prescribe you a three-month supply because he would like to force you to return for tests and “follow-up” supervision during this trial period of being yourself. Before he writes the prescription, he asks you to sign a legal document indemnifying him from lawsuits. He says this process is called “informed consent.”

7. For twelve months, you return and pay for follow-up visits, mandatory one-on-one psychotherapy, and try to regularly attend group therapy sessions with other people like yourself. Never does a week go by when you are not submitting yourself for review. After a year of this, your therapist may recommend that you reappear in front of the clinical panel. More likely, he will say that you are not yet ready and that he will reassess you in another six months if you keep up the good work. From talking to other people you’ve met in group, you know that it takes, on average, two to three years before the therapist will make a positive assessment.

8. Almost a year after the first assessment, your therapist finally approves, and you reappear in front of the clinical panel for surgical assessment. Again, reports describing your attitude, accomplishments, sex life and physical attractiveness are read aloud in front of everyone—including things you told your therapist in private sessions. The clinicians take another vote. If the vote is unanimous in your favor, you are approved for surgery to grant you access to the body you want. If just one person says no—a nurse you’ve never spoken to before, or the gynecologist who only saw you once, two years ago—all your efforts and money were ultimately for nothing.

9. You were approved. You almost don’t believe it. Most people you know have not been so lucky. Almost three years after walking through the doors of this medical building, asking to be made who you are in the flesh, you go into credit card debt to pay the eight thousand dollars it will cost to obtain surgery.

Congratulations, this is a joyous day: you have now earned permission for your own body.

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This is not an imaginary story. It is a step-by-step summary of the procedures of the Gender Identity Clinic of New England, a multidisciplinary health center that opened in 1975 in Connecticut. In 1978, Michael Baggish, one of its staff members, published an article in a gynecological journal extolling the virtues of how difficult it was to medically transition there.¹ He and his colleagues did not invent this baroque and punishing system out of thin air, but rather adopted the prevailing norms of the field of trans healthcare, particularly those developed at Stanford University. There, at a symposium held in 1973, psychiatrist Norman Fisk proposed the “rehabilitation” program that stretched on, sometimes for five years, before surgery.² The full-panel trial and unanimous vote threshold, however, was a point of pride in New England’s unique approach. “Many clients who are easily discouraged or not seriously committed to the reassignment process are self-eliminated by these extensive preadmission procedures,” explained Baggish. The goal of the trans healthcare clinic was simple: to stop as many people as possible from transitioning. All other outcomes were subsidiary.

Lest there be any doubt, this is the fundamental premise of medicalizing transition to the present day. Fisk and his colleagues at Stanford played a founding role in the Harry Benjamin International Gender Dysphoria Association (HBIGDA), which is today called the World Professional Association for Transgender Health (WPATH). In 1979, HBIGDA published the first “Standards of Care” in the field, codifying the psychiatric approval system and “real life test” as the cornerstone of the rehabilitation consensus. While the standards have been revised several times in the intervening decades, the root function of psychiatric diagnosis and the delay of transition for as long as tolerable remain firmly in place, now codified under many state laws and private insurance plans.

Trans healthcare, in other words, has never been an honest endeavor. It places overwhelming, social manifestations of moral judgement and disapproval in front of the actual medical procedures and medications it offers, designed to pressure as many people as possible to wash out before getting what they want, and forcing the rest to “rehabilitate” themselves into productive, docile subjects of gender. This is because medicalization is premised on the idea that it is irrational and disgusting to transition, so no rational doctor would permit it except as a last resort. “Surgery is but an adjunct to successful treatment for those who present themselves as transsexuals,” said Dr. Ira Dushoff, head of a private gender clinic in Florida, to the Boston Globe in 1977. “Stringent psychiatric screening is the key. It is my hands that will effect the change, and I insist on being as certain as possible that the operation is appropriate.” To grant transition because a trans person has determined they would like it, Dushoff emphasized, was “‘equivalent to manslaughter.’”³

A field in which the helping professions see their role as tantamount to killing someone because transition is so reprehensible is the same field that we are told today by pundits is too naïve, too liberal, and too freewheeling, letting trans people do nearly whatever they wish with no guardrails. As Pamela Paul would have it, in a recent column, there is not enough attention given to the problem of “detransition,” the person who would regret undergoing this grueling process after realizing, belatedly, that they never really wanted to alter their body. The problem is that this was precisely the central preoccupation of the founding clinicians in trans medicine, constituting its core mission. Preventing detransition was the entire point of the Gender Identity Clinic of New England’s cruel process: the “irreversibility” of exactly the things people wanted to be irreversible meant that only those who could endure years of psychiatric interference, peer pressure, and afford thousands of dollars of bills would be granted minimal dominion over their own bodies.

Documented regret rates for medical transition are so unbelievably low compared to all other fields of medicine precisely because most people who have wanted to have never successfully obtained hormones and surgery at formal clinics.

At the origin of trans medicalization lies what remains a fatal flaw: there was, and is, no way to objectively diagnose someone as trans, except if you accept that they want to transition.⁴ The problem of detransition is therefore a mythology, the accumulated effect of decades of storytelling to justify why doctors and psychiatrists had to reject trans people without being able to say it was because they aren’t objectively trans. Detransition, much like its cousin, medicalization, are mythologies that rationalize the intense social hatred of transition acted out by clinicians, dressing it up as sober caution.

Any pundit today can take up the vast field of out-of-date studies from this era, online misinformation, and the cultural shock value attached to changing sex to rationalize a call for limits on transition, but they will get no closer to legitimacy than the brutality of the gender clinic of the 1970s. They call for more guardrails, more caution, or more psychological assessment, not needing to know that what they really call for is the medical totalitarianism of yesteryear, barely blunted in recent reforms. For at the heart of the myth that transition is something that people can accidentally do despite how impossible it is to obtain in the real world is an uncomfortable truth. There is a form of social and political control implemented by medicine, a way to sever an unpopular minority from their own bodies and then sell back limited access to their bodies if they will submit to a set of trials to prove they can be good people, or at least made better. The people opposed to that kind of medicalization simply think that trans people enjoy no right to their bodies at all, under any circumstances.

If you want to debunk the politicization of detransition, by all means, seek out credible sources that do so. My point is more elementary. I ask you this, New York Times reader: if, tomorrow, your ability to make decisions about your own body were taken away from you, and the only way to get it back was to submit to the process that trans people go through to transition, would you agree to those terms? If you would not, then why are you okay with it happening to us?

1. Michael Baggish, “Testing and Treating Sex Change Candidates,” Contemporary OB/GYN, Volume 12 (September 1978), J. Ari Kane-Demaios Papers, Box 8, Folder 9, Schlesinger Library, Radcliffe Institute for Advanced Study, Harvard University.

2. Donald R. Laub and Patrick Gandy, eds., Proceedings of the Interdisciplinary Symposium on Gender Dysphoria Syndrome (Palo Alto: Stanford University, 1973).

3. Herbert Black, “Is the Psychiatrist More Important than the Surgeon?” The Boston Globe, February 6, 1977, J. Ari Kane-Demaois Papers, Box 8, Folder 11.

4. Exemplary is “father” of transsexual medicine, Harry Benjamin, in The Transsexual Phenomenon (New York: The Julian Press, 1966), p 21: “We have as yet not objective diagnostic methods at our disposal to differentiate between the two [transsexualism and related “disorders” like transvestism]. We—often—have to take the statement of an emotionally disturbed individual, whose attitude may change like a mood or who is inclined to tell the doctor what he believes the doctor wants to hear.”