I'm Thankful For Respectful Discourse
A detailed comment by a trans-identified reader sparks a rare, in-depth conversation
This post started life as a reader comment last Sunday, then grew into something more interesting and important.
I was surprised to receive a thorough, thoughtful and respectful challenge to something I’ve published here, by someone with an opposing view derived from personal experience. This is not to say I’ve had disrespectful, unthoughtful comments from trans-identifying readers — just that the direction of traffic in the information ecosystem mostly brings people to TransMuted who don’t need much persuasion to agree with what I write.
In the case of trans-identifying adults, I’m obviously not in a position to tell them about their own experience, but unless they ‘transitioned’ in adolescence, they may not have been compelled to locate the weaknesses in the pediatric approach. Really, why would they?
Thanks to Freddie deBoer, who regularly publishes work submitted by some of his 50,000 subscribers, my piece on Rapid Onset Gender Dysphoria which ran here last month also landed on Freddie’s Substack a few days ago. His audience is of the heterodox type, smart with wide-ranging interests, and includes two trans-identifying adults who not only took the time to read my essay but offered comments I found interesting and worth engaging with.
The comment from a reader named Julia is copied below, with permission, in its entirety. I made two formatting changes for clarity: passages in which Julia quotes from my essay are in italics, and numbered notes are added that correspond to my responses. (These aren’t links, just markers, because I think you should read this post from top to bottom.)
The conversation began last Sunday. I’m publishing it on Thanksgiving to symbolize my feeling about the whole experience, beginning with Freddie deBoer’s generosity as a high-profile writer amplifying low-profile writers because he can, and wants to; extending to those of his readers who’ve since subscribed to TransMuted (welcome!), with others offering articulate critiques of my criticism of a social anomaly that has profound meaning in their lives. All this feels to me like ‘discourse’ as it was designed to work, and I’m feeling grateful and hopeful because of it. —JPA
1 - Julia’s comment
I found this post through an advertisement on another blog, so apologies if I'm intruding. But as a trans woman myself I can't in good conscience leave without giving my thoughts. Plus much of the information written here is plain wrong.
>Trans-identifying men are prominent among the ‘experts’ who hand down the guidance of care for all gender-questioning patients. This departs from the principle of clinical neutrality that governs good science.
This framing of this point implies that trans people cannot be experts in their own conditions. (1) Cisgender people have a very hard time understanding what gender dysphoria feels like -- what better person to explain that than someone who actually lives with it? Trans people have suffered for decades trying to receive medical care to alleviate their dysphoria from doctors who don't understand their suffering and are often times forced to lie in order to conform to cis expectations of what trans people ought to be. "From a prepubertal age I always played with the opposite of my assigned gender's toys"; "I am only attracted to the opposite sex and would never enter a homosexual relationship post-transition"; "I enjoy putting on makeup and wearing dresses and heels and I strive to be as feminine as possible"; "I am disgusted by my genitals and want to have the body of my identified gender in order to have heterosexual sex". Fortunately the world is changing and with informed consent practices and trans-positive healthcare, trans people are able to be more truthful with their doctors.
>Children given puberty blockers followed by cross-sex hormones will reach adulthood without having experienced puberty at all.
This is not true. An AMAB [assigned male at birth] child who takes puberty blockers and then estrogen will go through a female puberty. An AFAB child who takes puberty blockers and then testosterone will go through a male puberty. Even a trans person goes through their assigned gender's puberty, they can go through a "second puberty" when starting HRT. Speaking from experience, your body and emotions change in a very similar way as during your "first puberty", only... it's the other way around. (2)
>Teenage girls may embark on a lifelong relationship with synthetic testosterone administered weekly or bi-weekly.
Why would a girl take testosterone? It only makes sense for trans men to take testosterone, not cis girls. (3) Misgendering the article's subjects is unhelpful.
>Known side effects include: elevated risk of heart attack, type 2 diabetes, thyroid disease, autoimmune disease, bone loss, premature menopause, impaired sexual function, cognitive impairments, and mood disorders including suicidality. (4)
This is all true (I assume). But other effects may be: lowered risk of breast cancer, increased libido (which may be a good or bad thing), cognitive improvements due to increased happiness and reduced depression, and the cessation of suicidality due to alleviating gender dysphoria. It's a two-way street. Yes, hormones, especially testosterone, can have negative effects. But they are only prescribed because the positive effects are deemed to outweigh the negative effects.(5)
>This treatment is not shown to resolve dysphoria.
Um, yeah, sure. It works for me. Sometimes transitioning can make dysphoria temporarily worse as people take a closer look at their bodies. But that most often is the hard part before it gets easier and hormones start having their intended effects. And the alternative is repressing it until..., I guess until you die? If you have a reputable study in mind that shows that HRT doesn't resolve dysphoria I'd be happy to look at it but my feeling is that no such study exists.
>Even when genital surgeries go as planned, female patients don't get a functioning penis, nor do male patients gain anything resembling a woman's internal genitalia, but rather an empty cavity. Common complications are severe and include anal or rectovaginal fistulas, severe bowel injuries, infections, inflammation and, of course, sterility.
Bottom surgery is a big deal. But no one undergoes it without knowing the risks, and rates of regret are surprisingly low compared to other "cosmetic" surgeries (nose jobs, liposuction, etc.). Again, misgendering your article's subject is unhelpful and disrespectful. This section is sensationalist and unconvincing to me.(6) I will note that "functioning penis" and the subsequent description of vaginoplasty is subjective and many trans people are happy with their postop genitalia, even if they cannot get an erection, conceive a child, or menstruate. I don't think bottom surgery patients undergo surgery thinking they're about to get the vagina/penis of their wildest dreams. Our desires have to come up against the limits of current medical technology somewhere.
>Testosterone will cause her female genitalia to atrophy.
In fact the opposite is true. Testosterone causes the clitoris to grow bigger. Many trans men feel euphoric from this and choose to think of it as a small penis rather than a clitoris.
>As her estrogen secretion is suppressed, early menopause ensues, and a hysterectomy may be indicated. Should she undertake these 'therapies', she will likely never experience an orgasm, much less bear a child. Image is, literally, everything.
...What? It doesn't really make sense to think of someone on testosterone as going through menopause. Women who experience negative symptoms from menopause do so because they have no significant estrogens *or* androgens in their body. As a result, many begin HRT, a perfectly natural remediation.... but that's besides the point. As for trans men being unable to experience an orgasm, I've never heard of anything crazier, and I can speak from personal (ok, strictly speaking secondhand) experience here, lol. Trans men can get pregnant as well, there are many breathless tabloid articles about it you can find with a quick google search. (7)
>In fact, a closer inspection of the available research shows a much greater likelihood of suicide among post-op transgender patients than among youth whose desire for medical transition is postponed or denied.
Citation, please. My impression is the data shows the complete opposite. (8)
I won't pick out any quotes in particular but the push to "drop the T" from LGBT makes me very sad. Cisgender gay and bi people will not make themselves more genuinely accepted by marginalizing trans people. They will achieve a veneer of acceptance from the right-wing but will quickly find themselves on the chopping block when it becomes politically expedient. It's true that trans people are different from cis gay people, but gay men and gay lesbians are also different, yet they have (for the most part) chosen to band together as political allies because they experience the same hatred and can find community with each other.
I hope you will take my response with grace and respect as I hope I have done the same for you.
***************************
2— My response:
I do, Julia, and you have. Thank you. I will do my best to respond in kind to each of your points in turn.
The essay we’re discussing was originally published as a chapter in the new book Women’s Rights: Gender Wrongs, which describes the many and disparate ways gender identity ideology has impacted the lives of women and girls in Europe, Africa, Asia, the Americas and Australia/NZ — a massive scope. I won’t ask you to read the book, but I will speak to why such a book is necessary as it helps explain my use of sex-based nouns and pronouns as rooted in the importance of a shared, common language rather than disparagement or disrespect of anyone who identifies as the opposite sex.
The book is centered on the Declaration of Women’s Sex-Based Rights, which updates and reaffirms the Convention on the Elimination of All Forms of Discrimination Against Women (CEDAW), adopted in 1979 by the UN General Assembly. Its principles are:
Women’s rights are based on sex; motherhood is an exclusively female status; women and girls have the right to physical and reproductive integrity, freedom of opinion and expression, peaceful assembly and association, political and athletic participation, protection from violence targeting women and girls, and protection of the rights of the child.
The current framing of transgender legal status, known as ‘self-ID,’ enables opting in and out of biological sex on the basis of one’s feelings about gender. This reimagining of human sexual dimorphism, though it may seem intriguing and expansive from a philosophical standpoint, has more prosaic implications for females. It is in many cases a zero-sum proposition that compromises women’s safety — such as when men convicted of violent crimes self-identify into women’s prisons— and opportunities, such as when men self-ID into women’s competitive sports. The chapter that immediately follows mine, by Coach Linda Blade, explains the price female athletes have already been forced to pay for an expansively interesting idea that got way out ahead of material reality.
The book is essentially a travelogue of related testimony, and it informs my belief that language first has to do the work of communicating via words with meaningful definitions. Only then can it graduate to poetry and philosophy.
My contribution to this book was the article you read, Rapid Onset Gender Dysphoria and its Discontents. Whatever authority I have to write on the subject of ROGD comes from my experience with a daughter who suddenly embraced it at 13, some seven years ago; and the research in which I’ve immersed myself as a result. The links responding to your specific questions appear in the book, though I omitted them in the Substack post.
Taking your points in order:
1. Regarding WPATH’s [World Professional Association for Transgender Health’s] guidance coming from transgender activists, which I said departs from the principle of clinical neutrality: I grant that the lived experience of activists can have value in communicating to young patients with dysphoria. However, WPATH issues medical and surgical guidance, not just friendly counsel. Moreover, the clinical studies on which its current pediatric guidelines (the 8th Standards of Care, or ‘SOC-8’) rest have been deemed “low to very low quality” by systematic evidence reviews that prompted Sweden, Finland and England to reverse their policies on ‘affirmative care’ for minors. France, the Netherlands and (based on very recent developments, so more tentatively) Australia appear to be following suit.
2. I have no medical training but will invite fact-checking of the following assertion by any and all endocrinologists out there:
It isn’t possible for a female to go through male puberty, nor for a male to go through female puberty. As you correctly state, females can not achieve erections, nor ejaculate sperm, and males will never menstruate nor ovulate. This is because we’re born with gametes specific to our sex, and these — like each of the trillions of cells in our bodies —are sex-coded and immutable.
Puberty blockade followed by cross-sex hormones can indeed make it look as though a person has changed sex, but chemical manipulation of secondary sex characteristics is, as I think you also acknowledge, cosmetic. Cross-sex hormones can bring mood changes, as can other drugs.
The consequences of aging from childhood to adulthood absent natural puberty are not fully understood because most of the subjects involved in the experiment — humanity’s unwitting beta testers— are only partway through it. Concerns about brain development are based on the interdependence of the body’s systems and organs, which evolved prior to ‘gender-affirming medicine.’
3. ‘Why would a girl take testosterone? It only makes sense for trans men to take testosterone.’ Proceeding from that statement: how does a clinician diagnose a trans man as someone distinct from a ‘cis’ female? WPATH offers no evidence-based answer to that fundamental question, nor do they point to any need for differential diagnosis, nor express concern nor even curiosity about the sudden exponential growth of teen girls presenting with ROGD.
4. This study explains the known side effects of testosterone on females who take it consistently over time.
5. ‘But they are only prescribed because the positive effects are deemed to outweigh the negative effects.’ True, but again, who’s doing the deeming? WPATH, an advocacy organization run by stakeholders, not a medical society bound by standards of scientific evidence. You might counter by pointing to the American Academy of Pediatrics and other bona fide medical societies that have followed WPATH’s lead, and you would be right. However, the AAP is finally engaged in its own belated systematic evidence review, the results of which are likely to replicate the conclusions of the European medical bodies referenced above. We should return to this question when the review process is complete.
6. As this study indicates, the complication rates of genital surgeries are in fact dramatically higher, and the outcomes far more debilitating, than is the case with any other category of elective cosmetic surgery.
7. This paper discusses sterility and loss of sexual response resulting from puberty blockers followed by cross-sex hormones. Even the trans-identifying medical pioneer Marci Bowers acknowledged these effects when asked about her patient Jazz Jennings, as recounted here:
From Psychology Today, 11/12/21:
Abigail Shrier is a journalist and author of a controversial 2020 book, Irreversible Damage: The Transgender Craze Seducing Our Daughters. She recently interviewed two doctors (both trans themselves) who provide treatment to trans youth. One, Marci Bowers, is the surgeon who treated reality TV star Jazz Jennings, whose life and transition are chronicled in the show I Am Jazz. Describing her treatment of Jennings, Bowers states,“If you’ve never had an orgasm pre-surgery, and then your puberty's blocked, it's very difficult to achieve that afterwards. I consider that a big problem, actually. It's kind of an overlooked problem that in our ‘informed consent’ of children undergoing puberty blockers, we’ve in some respects overlooked that a little bit .... if they’re not able to be responsive as a lover ... how does that affect their long-term happiness?” In her show, Jennings described that she had never had an orgasm.
8. Risk of suicide: this longitudinal Swedish study followed 324 post-surgical trans patients for 30 years (1973-2003) and found completed suicides occurred at a rate nineteen times that of the matched cohort in the general (non-transgender) adult population.
I don’t like closing with that last study. I don’t celebrate the suffering or the ill-treatment of any human being. I’m especially troubled by the evident lack of concern for medical ethics displayed by WPATH: without comment, WPATH deleted its entire draft chapter on ethics just before publishing its current standards of care. Why would they do that?
One or more of the seven US detransitioner lawsuits currently underway might soon force clarity and resolution upon what is now a medical framework that’s far too murky and politicized to justify high-risk experiments on healthy young bodies, even when their feelings of dysphoria are real and acute.
Regarding those feelings: the demonizing of exploratory developmental therapy as ‘conversion therapy’ only broadcasts the perverse incentives of trans activists and entrepreneurs for whom the worst-case scenario is a child who learns to love his or her body the way it always was, rather than become a lifelong medical patient.
The lack of curiosity and courage shown by elected Democrats — the only party I’ve ever voted for, by the way — is joined by a thoroughly cowed legacy media. Together, they prolong and exacerbate harm by promoting the idea that informed skepticism is ‘right-wing hate.’ None of this own-goal obfuscation is kind or helpful to trans-identifying adults. Gay and lesbian ally-ship is suffering too.
Julia, I come to this topic with an acute concern for the pediatric cohort, but I also feel compassion and care for the community with which both you and my daughter seem to identify. Her experience with ROGD has impacted our family in harsh, destabilizing ways in which ‘trans joy’ has not been a feature thus far, in our first seven years. However, personal anecdote isn’t data, and I can hold two thoughts at once. I assume you’re an adult and I believe you when you say you’re doing well. I hope that doesn’t change, and I’m truly grateful for your good-faith contribution to this dialog.
1. I'll pass on addressing this.
2. You can define puberty (definition A) as the process after which an individual becomes capable of sexual reproduction. And yet doing so excludes anyone who is sterile and also excludes some people who are intersex. What do sterile individuals undergo when their sex hormones surge and they experience the effects of that during their teenage years? Under the former definition, this doesn't count as puberty. Furthermore, I don't think it's necessary to focus heavily on menstruation, erection, or ejaculation. Suppose we take for example a man in his early 20s who has chest hair, facial hair, pubic hair, a deep voice, and a penis of average size. Now suppose he's never gotten an erection or ejaculated in his life. Should we say this man has never undergone puberty? What do we call the process during which he has received his masculine features? I think definition A is not useful and I would prefer to use definition B: puberty is the process by which an individual's sex hormones surge and their body begins to change in accordance with that. This doesn't exclude sterile or intersex people and includes trans people who feel that they have undergone a second puberty. Better yet, why not qualify puberties as trans or cis? Definition C: a person who undergoes a cis puberty receives a surge in sex hormones in accordance with their assigned and identified gender and more often than not is afterwards able to reproduce. A person who undergoes a trans puberty receives a surge in sex hormones in accordance with their identified gender, but not their assigned gender (and note that reproduction is irrelevant for this definition).
3. You write: "How does a clinician diagnose a trans man as someone distinct from a ‘cis’ female?" It's really quite simple. Note first that in this paragraph, I use man and woman solely in the gendered sense, not in the sexual sense. A trans man is someone who was assigned female at birth and wants to become, is in the process of becoming, or already has become, a man. We can discuss what it means to be a man or a woman and there is no uniform agreement on this in the trans community but I prefer to think of it in this way: if you go out into the world, and people call you "sir", or use masculine pronouns for you, or just simply put treat you as a man (and there are hundreds of little things that go into that), then you are a man. And vice versa for women. Even though I was assigned male at birth, I go out into the world and people call me ma'am and use feminine pronouns for me and catcall me on the street and, as far as I can tell, assume that I am a woman. Therefore I am a woman.
To put it shortly: someone is trans if they want to be trans. That's it. If an adult wants to be able to take cross-sex hormones, they should be able to. If someone under 18 wants to be able to take cross-sex hormones or puberty blockers, maybe they should be forced to wait for a year or so. Maybe. I don't know, I came out after I was 18.
4. That website is broken so I can't read the full results. I won't trust a quick summary without any evidence backing it up. And from what I can see, it looks like it would refer to puberty blockers rather than testosterone.
5. In all honesty, I don't think sex hormones should be locked behind a prescription, at least for adults. When I refer to the "positive effects outweigh the negative effects", I generally trust the patient's judgement. I think it should be doctors' jobs to inform the patient of all the potential effects and then let the patient decide. If someone chooses to start undergoing HRT and then they feel bad about it for whatever reason, they can always stop. The trouble is, a lot of the time the positive effects are: "I feel good"; "I feel comfortable in my own body"; "I am able to look in the mirror without cringing"; "I enjoy having sex and am able to do it without dissociating or having a panic attack". These are not things that doctors can predict and they're not really things that patients can predict either. For me personally, starting HRT felt like jumping off a precipice. It was really scary! But now looking back on it, I realize it was more like walking down a long staircase, one step at a time. You can always stop, turn around, and go back! Yes, you might have some breast tissue developed or your voice may have deepened. However, those physical changes *are* things doctors can warn you about. And if you have second thoughts about those things, well maybe HRT isn't for you, and that's ok!
6. First off, the Daily Mail is not really trustworthy and is known to be sensationalist. But I'll engage with this point on these terms. The headline is obviously sensationalist: "Half have *life-threatening* complications". Please. Looking at the article, what I think it's referencing is that 54% of women who have had a vaginoplasty report pain two years after the surgery. After further research, they may be citing https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5697604/ this study which says that 54% of trans men have urinary complications after phalloplasty. I should note the sample size is 19. However, just because complications may occur, doesn't mean patients regret their decision. The same article cites another article which reports that trans men "generally have a good quality of life and experience satisfactory sexual function after SRS" https://pubmed.ncbi.nlm.nih.gov/21699661/ (the article is unavailable from this link but you could find it on Library Genesis I'm sure). Honestly though, the Daily Mail article is citing studies left and right in its infographics and it's hard to trust any one number. I can speak from experience here as someone who just one week ago had a consultation about full-depth vaginoplasty. I am aware of the risks of pain, dilation, bleeding, tightness, loss of depth, urinary incontinence, imperfect hair removal, numbness, and lack of lubrication. To be honest, I am not 100% sure I will go through with it. But I have over a year to decide and I can always decide I don't want to do it. I will note that even in the Daily Mail article, one of the infographics shows that only a reported 1% of children expressed regret after receiving a mastectomy.
7. I can't find any discussion of a loss of sexual response in that article. It is mostly focused on potential sterility and bone density loss as a result of puberty blockers. Which I will admit are possible results! But no one starts taking puberty blockers without knowing the risk of permanent sterility and the loss of bone density is a known problem. I will also say that this response does not address my point, which is that it is strange to say that trans men will not be able to bear a child after transitioning and false to say that they will not be able to orgasm after transitioning. For the first point, I find it unlikely that many trans men would want to become pregnant and give birth. I can only assume that would be extremely dysphoria-inducing. And for the second point, I haven't seen any evidence to say that trans men are unable to experience orgasm. Two other things should be noted: many cis women are unable to experience orgasm and that's perfectly normal if somewhat unfortunate, and there's a whole lot more to sexual pleasure than just orgasm.
8. I'll just counter with another study. https://pubmed.ncbi.nlm.nih.gov/31581798/ I'm not sure how to proceed here as I'm sure we can both cite study after study that shows that SRS does or does not make people want to kill themselves.
Ultimately I just want people to be happy and from my experience, trans people tend to be a lot happier when they are able to take the hormones and undergo the surgeries they want. When I first came out, I desperately wanted there to exist some doctor who could tell me "You're trans. Now here's how to fix it." I was desperately afraid and uncertain. But now I don't think that should exist anymore. There should be doctors that say, "It looks like you're unhappy with your body. Here are medications you can take that have the following effects, and I have other patients like yourself that like taking them. You can take them if you want, but you don't have to." I think realizing you're trans comes from spending time with other trans people; having sex; spending a lot of time looking at your own body and thinking if you would like it or not if it looked different; trying out different gender expressions and seeing if you feel good or not. Because ultimately that's all that should matter! Whether you feel good or not.
Sorry but it is not possible to have respectful discourse with a trans activist. You can have a respectful gaslighting session, a respectful struggle session maybe, if that's not too much of an oxymoron, you can use such sessions to demonstrate their true nature to the reader unschooled in the ways of narcissistic gaslighting; but not discourse. They are purveyors of BS, plain and simple. You cannot make any progress with them, because they are not operating at an honest and rational level. They have a mental illness which inhibits that ability.