Part I: Three days at the European Professional Association for Transgender Health 

I spent last week traveling up and down Muckross Road in Killarney, Ireland. I walked south to the European Professional Association for Transgender Health conference and north to Genspect’s The Bigger Picture. The two conferences could hardly be more different. What follows is part one, covering my experiences at EPATH, with updates from Genspect: The Bigger Picture to come.

Six months ago, I went undercover at the World Professional Association for Transgender Health conference in Montreal. Compared to WPATH, with its disdain for optics and flair for controversy, EPATH looks almost reasonable. To be fair, it would be difficult to outdo WPATH, with its celebration of eunuchs and exploration of how to help patients who claim to have multiple personalities decide which irreversible surgeries to get, when those ‘personalities’ disagree.  

Clinicians at EPATH acknowledge a few open questions, even though they insist the benefits outweigh the (still unknown) risks. They share data that reflects poorly on the pharmaceutical and surgical interventions they push, even if they bracket every negative finding with the reassurance that “we all know gender-affirming care is effective.” They admit that patients seeking transition today don’t look or sound much like patients seeking transition 20 years ago, but warn against overfocusing on the explosion of adolescent girls identifying as trans. Rather than explore what may be going on with adolescent girls, EPATH presenters urged that clinicians pay attention to “more important stigmatization of AMAB [male] than AFAB [female] LGBT youth.” In other words, increased media attention to trans issues has forced EPATH to acknowledge a few points of contention. EPATH just doesn’t think that any of that really matters. Just one of EPATH’s 235 abstracts featured detransition. Not one even mentioned desistance. (By way of comparison, a single surgical procedure—vaginoplasty—got 59 mentions.) Affirmation is still the order of the day, even if today’s patients don’t look much like the patients that came before them, and even if transition didn’t work out for patients from earlier cohorts. 

In other words, EPATH puts in real effort to ‘pass’ as a respectable association, backed by scientific evidence and engaged in ongoing, open inquiry. But this is an appearance—nothing more. 

In his opening address, outgoing EPATH president Joz Motmans rebuffed “anti-gender” “attacks” as part of a “far-right” political campaign

“In the light of anti-woke tendencies, gender has become the new entry point for far right parties and organisations to use as a target to gain electoral votes. We are not the first target group, look at the anti-migration debate, the anti-vaccination debate, the anti-you-name-it debate, and we will definitely not be the last.”

He then quoted sociologist Sarah Bracke: 

“An individual may publicly claim that the earth is flat, that vaccines cause autism, that climate change does not exist, or that gender is binary, without being oppressed or persecuted. With caveats: like any other right, this right of freedom of speech is not absolute. Moreover, if it constitutes a demonstrable threat to another individual, and incite hate speech or violence, then intervention must be taken. In addition, the right to free speech does not imply an obligation for others to listen. This insight is sometimes in danger of being lost: you can say what you want about the climate or vaccines, but freedom of expression usually does not mean that others are obliged to give you a platform. So you are not censored or ‘cancelled’ if you don’t get that platform… All this differs in principle from academic freedom. There, statements such as ‘the earth is round’ and ‘the earth is flat’ do not enjoy the same protection. One is supported by a plethora of scientific evidence, the other is not. If you are convinced that the Earth is flat and publicly proclaim it, then there is no place for you in the scientific field at this point in history – in scientific publications or in the classroom.” 

In other words, the censorship and cancellations will continue—but the targets of such campaigns deserve to be excluded from the public debate. Just as flat-earthers don’t belong in geology departments, gender-critical researchers and clinicians don’t belong in universities and healthcare settings. Meanwhile, EPATH remains committed to “keep[ing] an open mind in this hostile time” and acting in the “most transparent and public way we can” (absolutely no journalists allowed, though, sorry). 

Motmans also struck out at Genspect, insisting that EPATH itself “see[s] ‘the bigger picture.’” Why, he asked, would anyone think EPATH thinks the “science is settled”: why entertain hundreds of abstracts? Why come together for a conference at all if the science is settled? 

“We respect everyone’s freedom of speech, but we choose not to listen to it,” Motmans said. 

The next speaker to take the podium—Tina Kolos Orban of the Transgender Equality Network of Ireland—took an even darker path, proclaiming that the “gender-critical movement is a totalitarian and genocidal force that targets not just trans people but all institutions that uphold democracy and individual human rights.” 

The inclusion of such extraordinary claims—without any evidence to substantiate those claims—marks the sharp deterioration in conditions in the field of gender medicine, even since the WPATH conference just six months ago, which was riddled with fearmongering about suicide but notably short on claims of outright genocide. Now invented claims of an ongoing “trans genocide”—driven by critics brazen enough to question a highly experimental treatment model for children and adolescents—is front and center on one of the biggest stages in transgender health. 

Orban also shamelessly linked criticism of experimental pharmaceutical and surgical interventions on youth to homophobia, racism, xenophobia, Islamophobia, ableism, and misogyny. The message to attendees? Don’t entertain critiques or you risk aligning yourself with far-right causes, “genocide,” and “totalitarianism.” 

Having already overdosed on bombast, the final act of the opening plenary struck an oddly defensive note: Jon Arcelus, co-chair of the WPATH Standards of Care 8 committee, treated the audience to a lengthy comparison between SOC-8 and other clinical guidelines for eating disorders and HIV/AIDS. The comparisons were mostly quantitative—not qualitative—in nature. Did you know the eighth Standards of Care included 1,800 references, 37 “systematic evidence reviews,” and that recommendations were approved by 128 members? But the number of references cited says nothing about the quality of the references cited. WPATH told us they excluded any evidence that does not start from the assertion that gender diversity is a “normal and expected variation of human diversity.” He defended the Standards of Care for making “strong recommendations based on weak or non-existent evidence.” After all, he pointed out, medical authorities found it appropriate to treat novel diseases like COVID-19 despite lack of evidence for the safety and efficacy of interventions and he asked: “do we stop treating anorexia because evidence [for interventions] is low or very low?” Again, what we have here is the appearance of scientific inquiry, intended not to inform but to reassure. Trust us. We know what we’re doing. We have 1,800 references. 

After being duly inspirited, terrified, and insulated against criticism, attendees dispersed to the day’s breakout sessions. I sat in on a session sharing “outcome studies of transgender adolescents starting gender-affirming medical treatment,” which included updates from Switzerland, the Netherlands, France, Sweden, and the United Kingdom. 

Context doesn’t matter when evaluating the potential sources of transgender identification and the desire for transition. Under the affirmative-care model, a patient who presents him- or herself as transgender is transgender and all other context is effectively stripped away. Once a patient comes out as trans, nothing else matters: not the patient’s age or developmental stage; not any details from the patient’s life history, like sexual abuse or being bullied for being gay; not the often serious comorbidities that travel alongside gender dysphoria. 

But whenever and wherever outcomes data is inconvenient, context suddenly matters again. “I invite you to consider the context,” a clinician from the United Kingdom’s Gender Identity Development Services (GIDS) said, after reporting that adolescent patients experienced a rise in self harm and deterioration of social-communication skills six months after initiating ‘gender-affirming’ treatment. She pointed to the Keira Bell case, COVID lockdowns, minority stress, and “unrealistic expectations for global improvement” to explain poor outcomes among adolescent patients receiving “life-saving, gender-affirming care.” A Swedish researcher had the misfortune to find that “youth with gender dysphoria diagnoses face persisting mental health challenges after initiation of treatment with puberty blockers and gender-affirming hormones,” including increased psychiatric hospitalization, expressed that she was “really concerned about how results will be interpreted,” since “as you all know, there are improved mental health outcomes following puberty blockers and gender-affirming hormones.” “Gender-affirming treatment is supposed to alleviate gender dysphoria,” the researcher reiterated. “It would be a good thing if it alleviated other mental health challenges but even if mental health challenges persist, that doesn’t mean it’s not the right treatment for gender dysphoria.” In response, a prominent Dutch researcher mused: “What should we use as an outcome measure? Mental health needs? What if you ask the kids: are you happy with the treatment and they say, ‘yes, we are happy’?” 

Other researchers pointed—inevitably, invariably—to the minority stress model and the role of “internalized transphobia” in the persistence of poor mental and physical health outcomes. It would be unreasonable to expect too much from treatments—even treatments that have been offered to patients as a cure-all. Perhaps this sobering realization lies behind the decision to roll out new terminology, replacing ‘gender-affirming care’ with ‘gender-affirming medical treatment.’ Then clinicians can say that a patient’s physical embodiment goals pursuant to a sense of ‘gender incongruence’ were met, even if the patient’s mental health crashed. 

In a disturbing update on the “intersection” of autism and transgender identity among patients at the Dutch clinic, researchers reported that—out of 30 patients potentially eligible to participate in a 17-year follow-up study—four had declined to participate, two had detransitioned, one who had not detransitioned expressed serious regrets about vaginoplasty, and two had “passed away.” Only at the end of the presentation did the researchers admit that the two patients who had “passed away” had in fact died by suicide. The deaths of these two patients—the researchers said—showed that there are “two sides of the coin,” that there’s “no crystal ball,” and that the issue “should not be dealt with without nuance.” What a ‘nuanced’ approach looks like, nobody bothered to specify. Is it possible that “nuance” means glossing over negative outcomes so no one draws the wrong conclusions? The presenters preferred to dwell on the “diversity” of their “trans-autistic” patients, with their variety of self-identifications 17 years after they started down the path to transition: “fairy,” “elf,” “non-binary,” “friendly non-intimidating woman,” “cis” (read: detransitioned). “Each referral,” the presenters said, including the patients who died and the patients who detransitioned or experienced regret, “followed their own unique path with regard to their gender identity and mental health trajectory.” 

Over and over again, researchers and clinicians presented damning findings that suggest something is going seriously wrong in the world of ‘gender-affirming care’ and then neglected to apply their findings to their work, which remains imperative and life-saving—even when patients die. 

At EPATH, presenters and attendees alike skirted the difficult issues gender raises. On Friday, one presenter explained that she would not be sharing quotes from her research because “they were really triggering and it’s the last day of the conference.” In other words: let’s avoid touchy subjects so we don’t spoil the mood. 

But the mood of the conference was strange—uneven—like a family holiday after something has gone badly wrong, where nothing that needs to be said will be said. The pieces of the conference refused to fit together. There’s a genocide underway but social acceptance is greater than ever before. We’re under attack by a global movement that seeks our annihilation but more optimistic than ever before about the future of the work we do. The evidence is troubling but gender-affirming care effective. Everything is hunky dory, except for all the things that aren’t. Don’t worry. Worry. Was I the only one who left confused about how I was meant to feel?

So many questions aren’t asked, so many presentations end with no questions from the audience at all. Instead, there’s an awkward pause where inquiry and debate should be. It’s as though the questions that should be asked cease to exist. Patients expressed satisfaction six months after undergoing a double mastectomy. But why had patients sought such surgeries? How will patients feel in five years, or 10? Is this medicine or customer service provided under a limited warranty: customer satisfaction guaranteed—for six months?

I want to say there was no human curiosity at EPATH. But that’s not quite true. What there is is more insidious in that it’s harder to see: for every normal human need and impulse, ‘gender-affirming care’ provides a surrogate. 

In place of free-ranging curiosity about what drives patients to seek such drastic interventions, there is a bounded curiosity about how patients identify and what novel “treatment wishes” patients will express in the future. 

In the place of self-reflection, clinicians meditate on their “positionality” and “privilege.” One researcher spent nine minutes of a 20-minute presentation pontificating on the impossibility of neutrality. 

In place of scientific inquiry, we find ‘multiple ways of knowing.’ A session titled “Transgender adolescents and bone mineral density: Strengthening knowledge from multiple perspectives” enabled researchers to downplay the only measurement of bone density that really matters. Nonetheless, this was one of the few sessions where an attendee dared to ask a hard question: “Is there a threshold of worry [when it comes to bone density of adolescents undergoing puberty suppression]?” After an uncomfortable pause, a British clinician said: “I guess I’d worry more the lower they go,” before bursting into nervous laughter. “In the end, we need the data on fractures to know [how low is too low] and we won’t have that for a while.” Besides, as another clinician helpfully pointed out, “pediatric osteoporosis is also a problem beyond trans health” and no one knows the extent of the effects of (experimental) puberty suppression versus other factors on pediatric osteopenia and osteoporosis. 

My sense is that when EPATH attendees think of Genspect, meeting just down the road, they feel misunderstood. Clinicians may feel that they are being accused of not caring about their patients. Of course, most of them do care—very much so. This deeply held sense of being a caring provider lets criticisms bounce off. But care can be misguided. Our best intentions can mislead—and harm. That is what has happened in the field of ‘gender-affirming care.’ 

What you make of transgender pharmaceutical and surgical interventions comes down to a question of belief. To a believer, the situation looks one way. ‘Gender-affirming care’ is effective, no matter what the evidence says. Believers see “reconstructive chest surgery for transmasculine minors” as “life-saving” and puberty blockers as a “harmless pause button” to save a child from undergoing “non-consensual puberty.” To the nonbelievers—whether they’re lifelong heretics or detransitioners or other recent defectors—the very same situation looks different. We see doctors performing breast amputations on troubled girls, clinicians running a risky experiment that shuts down a child’s pituitary gland, with unknown effects on that child’s cognitive, physical, and psychological development and wellbeing. 

I keep turning over Motmans’ words: “We respect everyone’s freedom of speech, but we choose not to listen to it.” 

This is a remarkable admission for the president of a professional association, especially when you consider that the speech Motmans and EPATH are “choos[ing] not to listen to” includes mounting evidence of medical harm and regret. The accusations EPATH chooses not to listen to are serious and cut directly at the organization’s stated aims: “To promote mental, physical and social health of transgender people in Europe. To increase the quality of life among transgender people in Europe. To ensure transgender people’s rights for healthy development and well-being.” 

The conference ended by blasting “Don’t stop believin’ / Hold onto that feelin’.” Believin’ is the glue that holds everything together: the fantastical claims, the impossible promises transition makes, that data that suggests the wrong things to those of wavering faith… 

Without belief, ‘gender-affirming care’ comes tumbling down.