Patient Autonomy or Medical Responsibility? 

There’s been a lot of talk about the Dutch protocol lately, which is finally coming under sustained scrutiny—just 20-odd years after this approach to treating gender-dysphoric kids was spread around the world.

A group of Dutch clinicians attended the World Professional Association for Transgender Health conference in Montreal this past September, where they presented the results of their first longitudinal study, following a cohort of teenage patients into their mid-30s, though—like so many studies in this area—this study suffers from high drop-out rates. Less than 50% of eligible patients participated in the follow-up study.

The Dutch said they were interested in whether patients who transitioned as children and teens experienced changes in gender identity, sexual orientation, and desire for children of their own over time. Researchers asked whether patients continued to identify as “binary trans” or whether their identities were now more “fluid.” They found that 18% of children and 31% of teens experienced “multiple attenuations” of their gender identity over time. “Multiple attenuations” conveniently lumps trans/nonbinary identification together with detransition so that there are no detransition numbers to point to. This allowed researchers to report cheerily on the profusion of gender identities their patients had adopted over the years, from “elf” to “fairy” to “friendly non-intimidating woman,” while burying the uncomfortable reality that some patients detransitioned, too.

On the question of sexual orientation, many patients reported changes over the study period. At the outset, the patients were almost exclusively same-sex attracted. But after undergoing puberty suppression, cross-sex hormones, and other interventions, a sizable share of female patients and a subset of male patients reported a change in sexual orientation.

Of the patients researchers actually managed to follow up with, more than one in four (27%) said they regretted that gender transition had rendered them infertile. A further 11% said they weren’t sure how they felt about the loss of their fertility. Fifty-six percent of patients said that they now wanted children, with many expressing that their desires had changed since they themselves were children; 21% of patients said they were simply too young to understand the consequences when they embarked on medical transition as preteens or young teenagers.

And now, years later, surrounded by evidence of regret and harm, the Dutch clinicians joked that they’re “not really interested in prediction.” One researcher said “I can predict how I’ll feel in one minute—still nervous!—but I cannot predict how I will feel tomorrow.” The audience laughed.

But it’s not funny. This is an adult in a conference room joking that she has no idea how she’ll feel tomorrow—after all, anything could happen between now and then!—to gloss over evidence that distressed children and teens can’t consent to sign away the rest of their lives.

At a conference that so often devolved into sheer insanity—like endorsing ‘gender-affirming care’ for eunuchs and people who claim multiple personalities—this particular WPATH session was restrained and reasonable-sounding. That’s why it was so chilling.

All around the world, gender clinicians look to the Dutch. And the Dutch have no idea what they’re doing and they never did and they never will. Circumstances outside of their control are forcing them to talk about regret and detransition and all they can come up with is: “Respecting someone’s autonomy also includes that the person has the right to make a decision which they may later regret.”

If these clinicians were talking about regretted tattoos, I’d agree. But they’re talking about irreversible interventions with lifelong consequences that they carried out on minors under the banner of medicine.

Of course, such clinicians would rather talk about patient autonomy than medical responsibility. Of course, they refuse to translate “some patients changed their minds later/experienced multiple attenuations of their gender” (autonomy framework) into “we harmed patients” (medical responsibility framework).

I find myself thinking about this episode of Gender: A Wider Lens every day since it aired (almost a year ago!) because Sasha Ayad and Stella O’Malley are prompting Thomas Steensma and Annelou De Vries to plumb depths they’ve never even considered.

One of the impressions I can’t shake is that these clinicians had such bargain-basement expectations for their patients. In effect, they ask: Why would we expect these people to have meaningful relationships or be happy in their bodies that we altered because they were unhappy in their bodies? They acted like it was unfair to expect better outcomes—by which I mean, they acted like it was unfair to the clinicians, not unfair to the patients. Instead, we get these odd disquisitions on “regret” (safely contained in air quotes). What does it mean if a patient “regrets” medically unnecessary and life-altering/life-limiting surgeries and hormone regimens? De Vries and Steensma want us to unpack our ideas about what “regret” means. It’s “too binary” to say a patient “regrets” or doesn’t regret surgery. (Maybe we just need to ‘queer’ our concept of what a good medical outcome is!)

If clinicians like Steensma and De Vries are allowed to control the conversation about regret and detransition, then that conversation will be about autonomy (mistakes were made but not by me, in other words).

If you went down a medical pathway and lost your fertility along the way and 10 or 15 years later, that’s “troublesome” to you—wasn’t that revelation just part of your “gender journey,” your process of self-discovery?

Yet those of us who insist that people with gender dysphoria deserve better, who believe that every child who struggles with gender dysphoria can grow up to lead a full and meaningful life, and that doctors shouldn’t circumscribe children’s futures by medically experimenting on them are the villains. Make it make sense.