In therapy, the empty chair exercise invites a client to play the role of a different part of themselves or to take on the mantle of someone else to develop perspective-taking and empathy skills. It originated as part of gestalt therapy, developed by Fritz Perls, Laura Perls and Paul Goodman. The empty chair technique is a potent experiential gestalt-based technique that can help people work through unresolved emotions, grief or inner ambivalences.

The following piece is a written experiment — an attempt at something like an empty chair exercise with myself. Typically the therapist asks guiding questions to help the client integrate parts of themself they’d rather forget about. I have bolded the questions a therapist might ask, and responded from the place first of the Wounded Self and then later from the Healing Self.

From my Wounded Self position

Describe how you first learned about transgender identities

Well, the first time I ever encountered anything to do with gender nonconformity in real life was as a teenager, meeting one of my father’s friends. He was an eccentric older man who lived alone with his chihuahua and would sometimes come over for whiskey and dinner. We never talked about it directly with him present but after he left, I remember my parents saying that he was gay and sometimes dressed up as a woman. I thought it was odd and interesting but I didn’t give it much more thought.

Later, when I went to university, I encountered butch lesbians and gay men but not anyone trans until I made a friend who was going through the process of getting a diagnosis for gender identity disorder (at the time that was the term). This friend didn’t want to become a man necessarily, but she wanted to take testosterone and masculinize her body. Given that she was less masculine than I, I figured that maybe I could get a GID diagnosis too. And I did.

What were some of the signs that led you to believe you needed to transition?

For years up to my formal diagnosis I had struggled with suicidal depression, with social anxiety and with feeling that something was deeply wrong with me. I struggled to connect with my peers. I had difficulty feeling at home in my skin. I’d gone to therapists and psychiatrists; I’d been on a whole host of medications. Nothing seemed to help. I did’t really see a future for myself, so I decided to pursue a GID diagnosis as a last-ditch attempt to improve my life.

How did transition improve your life?

It took a lot of energy and focus to essentially reinvent myself. There was all the medical stuff, the legal stuff — getting a new driver’s licence and updating my academic documents — and then there was also the social stuff. The social stuff was complicated. While I passed relatively quickly once I started hormones, I still had to learn how to behave like a man. I couldn’t talk with my hands as much as before, in case I got read as gay. I had to learn how to date again and how to talk about being a trans man. Surprisingly, I dated more people after I transitioned than before. Probably because transition was a reset button that gave me a new sense of confidence. It helped me break out of my shyness, and my depression and anxiety — at least in the short term. I was even able to work again.

What were some of the signs that led you to question your transition?

About a year into my transition, a friend — also trans — died by suicide. It shocked me because I’d looked up to her as someone to emulate. She seemed confident on the outside. She had a stable job, a solid relationship, a strong voice in the community. It sent me into a tailspin and led to a new round of suicidal depression. Depression was the reason I’d transitioned in the first place. Clearly, it wasn’t a cure. A few years after that I had a mastectomy and I remember waking up and feeling depressed that I had had to remove healthy tissue to be comfortable in my own body. This experience was exacerbated because I was recovering next to a woman who had had her breasts removed due to cancer. She was surrounded by family and loved ones. Meanwhile, I was completely alone. While I didn’t regret removing my breasts it also didn’t feel good. It just left me feeling numb.

What really led me to question my transition, though, was when I started to hear about detransitioners. I saw myself in a lot of their experiences. It made me question whether my transition was as inevitable as I’d been led to believe. I started to wonder whether I could have learned to live a good life without transitioning, and with my body intact.

What were some of the associated feelings of what you’d been through?

The more I started to question the medical pathway I’d gone down, the more alarmed I felt. So much of my life had been spent chasing after something that at the end of the day is impossible (i.e. changing sex). And it really hadn’t delivered on its promise. I’d been told that transition would help me be less depressed and anxious. It did help initially. But the depression didn’t really go away, and the anxiety was still there too. I felt let down and I felt a bit angry too. Angry at the doctors, but also angry at myself for being so naive and stupid.

What are the qualities about you that enabled you to move forward?

I am someone who is stubbornly curious while also anxious and risk-averse. It’s an odd combination. I contain a lot of contradictions. I’m a reluctant rebel. I want to people-please and be liked, but I also I don’t like to be told what to do or think. I’ll comply up to a point but if I’m pushed too far I will walk away. I used to wish I could be more bold and just say what I really think without fear of what others might think in return, but as I’ve gotten older I also appreciate that more cautious side of myself. I do care what others think, and I don’t think that’s a bad quality. I care about others and I hope they will care about me too. That’s not a weakness.

What were the first steps you took to make changes for yourself?

I became more and more interested in learning about the science behind the gender affirming care model. I sought out the stories of detransitioners. I connected with service providers and researchers who were willing to ask important questions about the implications of telling a generation of young people and their families that transition is a cure for suicidal depression. I became curious about the cultural forces at play and the pressures that lead people to seek out medical solutions to their gender distress. I also started to reconnect with people from my own life who knew me before I transitioned. Some of those people I’d been estranged from for years.

Is there anything further you’d like to tell your Healing Self about your Wounded Self?

Just that I’m sorry I let you down. I wish I’d been able to find a better way through the darkness. Instead you are now stuck with a body that is permanently scarred, in a gender that you no longer identify with. I wish I’d been able to find a different path forward for you.

[At this point in an empty chair exercise, the client would move to a different chair to inhabit a different role or part. I am now moving to my Healing Self position, to answer the next number of questions.]

From my Healing Self Position

What is it like to travel from a wounded place?

It is very difficult. Particularly because it feels in part self-inflicted. I know that I didn’t create this mess alone. That there were a lot of forces already in place long before I made my way to the gender specialist’s office. But it’s hard not to feel like I should have known better. It’s hard not to feel like a fool. And then there’s all these voices out there now that basically want to wipe out trans people from public life completely. I don’t support that either, obviously. There’s not a lot of empathy out there, for anyone. It worries me.

What can you tell your Wounded Self are the qualities/strengths that brought you through your experience?

Your openness to new information, your curiosity, means you are also open to changing your mind when you realize that what you are told isn’t true. Your innocence means you are willing to give other people the benefit of the doubt. You operate in good faith with others until it no longer makes sense to do so. It means sometimes you will be let down by others but it also means you will open yourself up to new, meaningful connections. And that’s a good thing. Your search for real solutions can be frustrating at times, when they don’t immediately reveal themselves, but your persistence means you stay the course. I admire that about you.

What qualities/strengths have you held on to?

I’ve held onto my open heart. I don’t hate anyone. I don’t see myself as a victim either. Life is complicated and none of us get through it without taking a few wrong turns along the way. The wrong turn I took is bigger than most, and it has had some pretty dramatic impacts. But it also led to wonderful things — I met my wife, I went back to school and built a career I’m proud of. I love the life I have. I’m grateful for every part of it. My persistence has paid off in ways I could not have anticipated.

How does the healing journey look different for you, from you wounded journey?

Healing to me means embracing every single part of my journey — the good, the bad and the ugly. It means choosing to stay open to life, not numbing myself out from any of it, even when it’s painful. Healing means speaking the truth of my experience and being OK with not everyone liking me for it. I do care what others think but I also care about what I think, and what I know to be true. And I know that I did what I thought was right at the time. I didn’t do it to hurt anyone or mislead anyone. As I live my life ahead, I know that some will want me to detransition or disown other trans people. That’s not my path. I want to improve the path for others who may be navigating similarly difficult waters. I choose to focus on what that might look like. It’s easy to destroy and tear down. To build something new, something meaningful and strong, that is hard. I’m here for it.

How has this healing process changed you as a person?

It’s humbled me. It’s opened my eyes to the best of humanity and also some of the worst of humanity. It’s made me more cautious and maybe a bit mistrustful of people. It’s made me push myself to stay open, to risk being hurt for the sake of deeper connections with people I would never have met if I didn’t take that risk. Healing has meant letting go of anger and resentment. It’s meant refocusing on what matters and continuing to work on becoming the kind of person I wish I’d had in my own life. The healing process is a process — and some days I’m more successful than others.

What have you learned through the healing process?

I have learned to appreciate the little things in life. They aren’t really so little. Coffee and breakfast with my wife. Walking my dog along the river. Co-workers who inspire and challenge me. A relatively healthy body. A mind that no longer dreams of dying. Laughter and art. The sunrise peeking through amongst the clouds. The smell of wood burning in an outdoor fire-pit.

What lies ahead?

I’m not entirely sure. I want to continue to seek out moments of beauty, moments of laughter and connection, moments of joy and wonder. I will likely continue to look for opportunities to make a positive difference in the work that I do, to work with others who are equally committed to improving healthcare for all people who experience gender-related distress.

Is there anything else you’d like your Wounded Self to know about your Healing Self?

Just that I love and accept you. I wouldn’t be here without you.

In a world where men can declare themselves women, and women can have their breasts removed by stating that they are men, where some claim transwomen are literal women, and others insist on using sex-based pronouns regardless of the gender presentation of the person they are speaking to, gender itself has become a modern-day Tower of Babel phenomenon.

For those not in the know, the Bible contains a compelling cautionary tale against human pride and self-glorification that is often referred to as The Tower of Babel. In Genesis, the biblical story describes how the people of the earth once spoke a single language and decided to build a city and a tower high enough that they would be able to reach God Himself.

When God saw the humans striving to attain His heights, not out of love for Him, but out of their own selfish obsessions, He decided to thwart their plans. As punishment, he confused the languages of the people of the earth so that they could no longer understand each other.

Eventually so many languages emerged that humans no longer had a common understanding of how to proceed with building the Tower of Babel. The tower was never completed. Its builders never again achieved a single common language.

Regardless of your faith tradition (or lack of one) it is a story that has resonated through the centuries.

Navigating our modern gender wars can feel like living in the era of the Tower of Babel. We live in a world where some believe gender and sex are synonymous while others see them as separate and distinct. Some believe sex is materially real while others believe that it, like gender, is socially constructed. Some hold sex to be binary while others argue that it is a spectrum. Each person speaks their own sex and gender language and in doing so no single common understanding exists.

And in this cacophony of sex and gender-related definitions and terms, pronouns are one casualty.

Some believe calling a transwoman by she/her pronouns or a transman by he/him is a sign of politeness and respect, while others believe that doing so is to lie about material reality. The consequence of that lie, some argue, is that it has put women at risk in some of their most vulnerable moments — in the locker room, bathroom, at domestic violence shelters, hospitals or prisons. With no common definition of woman to protect women from violent men, what’s to stop those violent men from utilizing the existing confusion to push their boundary-violating behaviour to the next level?

Meanwhile, ordinary trans people, most of whom are non-violent, are attempting as best we can, to live a life that isn’t entirely centered on our genders. We, too, are striving for safety.

Pretty soon after I transitioned, people started calling me by male pronouns. I credit my relatively quick ability to pass as male as the result of my height and my relatively slender build (I am over six feet). At first, hearing male pronouns to refer to me felt odd, like I was being exposed when all my life I’d tried to simply blend in. But it also felt powerful. People were acknowledging something important about me for the first time. No longer were they comparing me to other women - even if that is what I literally was. Transitioning offered me freedom from my failures in the femininity department. Society at large no longer expected me to wear makeup, wear dresses or date men. They treated me as if I was a human being worthy of respect, even if I made no effort to beautify myself. Imagine that. I could wear men’s shirts and pants instead of the uniform I’d worn in school, i.e. a tight blouse and pleated school skirt. I could walk down the street without having creepy, untrustworthy men make pointed comments about my breasts, breasts which remained largely hidden behind sports bras and T-shirts, until I had them surgically removed.

When I legally changed my name to match my transmasculine identity, pronouns became the symbol of the effort I’d put in to reinvent myself. People who knew me as a woman sometimes slipped over their words, and caught themselves in time to correct themselves. When this happened, I felt a deep gratitude for the effort they were putting in to recognize me for the man I was putting a lot of effort into becoming. Not literally - I didn’t believe I was becoming an actual, literal man. But metaphorically. Or analogically. I believed I was enough like a man - whatever that means - that I might as well live my life as a man. And the acceptance of those around me, made me feel that they valued me enough to call me a metaphorical male. They didn’t have to believe I was male; only to treat me as if I were male — an honorary member of the brotherhood.

I assumed that no one who truly knew me actually believed I was a male - especially my health care providers. After all, actual males don’t need hysterectomies. Actual males don’t need pap smears. Actual males don’t have to worry about getting pregnant. Those were sex-based interventions that can only ever occur to females. At best, I saw myself as a female who existed in a kind of gender grey zone. A liminal space between the genders. I recall asking my endocrinologist whether she thought perhaps I might be intersex. She wrote down on her note pad the word ‘Intersex’ followed by a question mark. She had no definitive answer for me. She seemed remarkably incurious about it. It wouldn’t change anything if I was, she said. Since it appeared to be a hassle to determine, I dropped my inquiry. I didn’t want my gender struggles to be a burden, not even to my healthcare providers. I transitioned to escape the awkwardness of my gender. I knew that as a man I could focus on other things more easily, whereas as a woman, I would be constantly policed by other women, or harassed by men. I wanted neither.

How odd that we live in a time where both extremes of the gender wars insist fanatically that their all-or-nothing position is the one true position. The more ardent trans activists argue that they are literally, biologically the other sex regardless of their gametes, chromosomes or genitalia. They do not merely want to be treated like the other sex but instead insist that they are the other sex. At a certain level, I admire their clarity of vision even if I do not share it. I’m not constitutionally built for it.

On the other side, some very vocal gender critical voices insist that trans people should be called by the pronouns that match their sex because not to do so is to engage in a deception that harms women. But the truth is, we lie all the time to each other. We do not insist, at every turn, on calling a friend fat even if they technically are. We do not tell every person we talk to our deepest darkest secrets when they politely ask us: “How are you?”

We are capable of embracing analogies in a legal sense in cases where adults adopt babies from other parents. We call it adoption and for a fee, we allow all kinds of people who otherwise couldn’t have children to access the experience of parenting. We call these adults who do the adopting, parents, even as they are not literally the biological parents of the child they adopted. We do not consider that deception. We are capable of holding space for these adults as adoptive parents given that for all intents and purposes they are living the role and the responsibilities of what a parent is.

Similarly, we are able to offer an avenue for legal immigrants to become citizens of a nation-state they were not born to. If they follow the rules of the immigration process, they too can call their adopted country home. And if anyone were to tell them to ‘go back to where you came from’ we would rightly claim that they’d experienced discrimination. To call these immigrants citizens is not considered a lie.

I used to think of myself as a gender immigrant: I underwent a legal process that allowed me to give up my citizenship as a woman and claim my citizenship as a man. Metaphorically speaking. And it is important to state that because so much of the gender wars revolves around metaphors becoming confused with reality. The map has become mistaken for the territory.

The gender immigrant metaphor is an elegant metaphor, but it is not literally true. Womanhood is not so easily left behind. Manhood is not so easily embraced. And while citizens who were born in a particular country and citizens who immigrated there have had different pathways to becoming citizens, they share one thing in common — the land they live in. It is the common denominator.

The problem with gender is that there is no easily identifiable common denominator that connects the experiences of women with the experiences of transwomen, or men with transmen. Remove the body as the common denominator, and you are left merely with generalities and stereotypes. Remove the body, and the different voices are not speaking the same language. Our tower of Babel, our tower of common understanding, lies in rubble, unfinished.

While I understand why so many women have stood up and spoken up, I also am cognizant of those of us who are trans, who must still exist in this world. Some of us were medicalized as children, some as adults. Some of us have embraced our trans identities, others feel medically harmed but unable to return to a pre-transition state. We exist. And we must live our lives. Surely there must be a way for us to live together, without trans people needing to hide themselves away, without women having to fear for their safety. I don’t know what that future looks like but I hope that enough people can move away from extremism to find a space of common ground to build a shared future. I don’t see any other way.

Where 2026 is starting

I anticipated 2025 was going to have major developments for trans and nonbinary people and those impacted in one way or another by gender dysphoria. I was not wrong. What follows are some key developments over this past year that stood out to me. It is not exhaustive, nor does it aim to be.

Politically, much of the backlash that has followed the socially celebrated transgender tipping point of 2014 reached a peak in 2025 and is set to continue into 2026, starting with a number of detransition lawsuits that will hit the US legal circuit in the new year.

Trans women in sports remains a hot button issue, with some sporting associations choosing to change course on including trans women in the female category, following rising pressure from female athletes and their supporters. Real world impacts: trans swimmer Lia Thomas was banned from competing in the women’s swimming category, including at the Olympics. And, though they are not trans, Algerian boxer Imane Khelif and South African sprinter Caster Semenya both have faced removal from elite competitions due to questions regarding their genetic sex.

In the US, passport changes have generated confusion and fear among US citizens travelling while trans. Also, the US government’s call for the removal of trans military personnel from the US military underscored the shifting tides of transgender acceptance in public life. On the legal circuit, Chase Strangio from the ACLU became the first openly transgender lawyer to argue in front of the US Supreme Court, regarding a legislative ban on gender affirming care for minors in Tennessee in US v Skrmetti (tldr: the ACLU lost).

Across the pond, the UK is in the midst of launching a hotly contested puberty blocker study that seems built to satisfy exactly no one. While one side is opposed to the study existing, some on the other side resent that limits on puberty blockers are considered at all. In other UK news, the UK Supreme Court ruled that the law defines a woman as a biological female, allowing for the exclusion of trans individuals from single-sex spaces like female prisons and domestic violence shelters — though interpretation of the law varies.

In Canada, one province, Alberta, has chosen to deploy the notwithstanding clause to legally limit medical interventions for minors, causing an uproar among activist organizations across the country, and leading to a legal challenge that is ongoing. Meanwhile, the Canadian media landscape continues to sidestep and largely ignore the complexities of the gender debate (with some notable exceptions).

Across the other pond, in Australia, the female creator of an online app for women is appealing a ruling in the Giggle vs Tickle lawsuit that found she had discriminated by removing a trans woman from her female-only app. The original lawsuit was largely considered to centre around the question of what is a woman.

Online, temperatures rose to boiling levels as one of the founding fathers of evidence-based medicine sought to distance himself from how his research findings were being used (spoiler alert: his team’s systematic reviews found that gender affirming medical practices had very little high or even moderate quality evidence to back them). In a now infamous interview with Stella O’Malley and Mia Hughes, Dr Gordon Guyatt of McMaster University lamented the ways the reviews on gender affirming medical practices were, in his opinion, being weaponized by bad faith actors to deny patients access to care.

Back in the US, activists led a campaign to have the Society for Evidence-Based Medicine (SEGM) lose their continuing education (CE) accreditation, which they had acquired through Washington State University’s Elson S. Floyd College of Medicine over a 9-month vetting process. While the videos are still publicly available on SEGM’s website they are no longer accessible through WSU’s learner portal pending a review.

What’s next?

These are some areas where I hope we can make progress in the coming year, which are of course informed by my status as a healthcare provider and as a medically masculinized female (or, transman) who cares about people thriving within their communities:

• Clinical research and training: More research into the longterm health outcomes of those who have medically undergone treatments for their gender dysphoria, to better understand under what circumstances the results were objectively positive, neutral or harmful. As well, more research into the benefits and potential harms of psychotherapy as a treatment for gender dysphoria. I hope we will see more even-handed training for clinicians of all kinds on the complexities surrounding gender-related healthcare.

• More good faith dialogue across difference: While for too long supporters of gender medicalization and those who oppose it have existed in siloes, largely viewing the other side as bigoted, the time has come for building bridges. Each side has its extremists but I believe most people are seeking better understanding. My hope is that the new year can pave the way for a coming together and a moving away from outrage politics. I very much would like to see more open, respectful dialogue among clinicians, researchers, journalists, and policy-makers.

• A commitment to medical and social inclusion of detransitioners: My hope is that those who choose to detransition will find more spaces to tell their stories in the public discourse about gender-related healthcare, so that treatment for all can improve. If it is true that some benefit from medicalization, while others are harmed, everyone benefits if we become better at telling these stories. Those who detransition deserve competent care and my hope is that the new year will pave the way for more honest discussions within healthcare circles, and among legacy LGBT organizations, on how best to support them.

• A commitment to a reality-based pluralism regarding gender. Because of my medico-legal transition, I am treated socially as a man in most of my day-to-day interactions, yet I accept that I am a medically masculinized female and do not seek to impose any particular language (e.g. pronouns) or viewpoint on others. While the conversations continue around whether transwomen / transmen are men or women, and under what circumstances, I hope as a society we can also hold space for individuals, wherever they stand on the gender discourse, to co-exist. I am not the same person now that I was 20+ years ago when I embarked on my gender transition. People change and beliefs change. What stays the same is that we are all human beings doing the best we can with the knowledge we have.

I’ll end with a quote, the author of which is beloved by many and deeply reviled by others. Regardless, she clearly articulates values I share: freedom of speech, freedom of inquiry, liberalism, pluralism, and non-violence.

“If you believe free speech is for you but not your political opponents, you're illiberal.
If no contrary evidence could change your beliefs, you're a fundamentalist.
If you believe the state should punish those with contrary views, you're a totalitarian.
If you believe political opponents should be punished with violence or death, you're a terrorist.”

I realize my hopes for 2026 might be wishful thinking. I dare to wish. This is my call for dialogue with dignity. Join me?

Happy New Year all.

If one roams online trans forums as I do, one is bound to encounter euphoric posts by newly joined members expressing relief at having found their authentic self in their freshly embraced trans identities. One will encounter phrases like: “I’m finally becoming my true self,” followed by descriptions of how difficult their lives were before they “accepted” themselves as trans. The implications of these testimonials are that who they were before they “cracked their gender egg” was a false self that they needed to leave behind to become who they were always meant to be.

It’s a story familiar to me because it’s one that I also claimed as my own in the early stages of my gender transition. Having tried and failed at femininity, I concluded that I was a kind of gender outlaw that existed beyond the norms society imposed. I didn’t so much believe that I was a man, as that I was not a woman. As far as I was concerned, society was much friendlier to weird men that it was to tall weird women, and given I saw only two choices, living as a man was more appealing than the alternative. Strange as it may sound, living socially as a man allowed me to be more authentically me than the reverse.

Prior to transitioning I briefly considered living androgynously, but found that in practice this was largely impossible. So much of our lives are lived within the confines of a gender binary — friendship groups, passports, clothing aisles, intake forms, etc. We are talking more than 20 years ago now. These were the days before the category of nonbinary made it into public consciousness as a way of life and onto legal documents.

There wasn’t much about me that was feminine. Even before I transitioned, I liked to dress in jeans and button-down shirts. I wore no makeup and didn’t shave my legs. I hated wearing dresses and hated even more when strange men hit on me. Sex and sexuality scared me. I simultaneously felt ashamed of my lack of sex appeal to men and my inability to connect in meaningful ways with my female peers. All round, I felt like a fish out of water. My gender was like an ill-fitting dress.

In the early stages of my gender transition, I felt a great sense of relief. A large part of my relief came from giving myself permission to openly break the gender norms ascribed to me as a woman and that I had struggled with all my life.

Medical interventions were a vehicle for bringing my internal gender anguish into the material world so that I could do something about it. One could reasonably say that I externalized my gender problem. Externalizing is something therapists often do to help clients see their problems as separate from themselves and therefore manageable. Usually, though, externalizing one’s problems isn’t quite so literally interpreted.

Very little time passed, once I started with testosterone injections, before I started to grow facial hair, lower my voice, and blend in socially as a man. On the surface, my transition was a great success.

Below the surface, things were more complicated.

Terry Real, a marriage and family therapist and author of multiple books on relationships, distinguishes between what he calls “unbridled self-expression” and authenticity. Unbridled self-expression, he states, is the act of saying whatever is on your mind with no respect or empathy for the person you’re speaking to. Real argues that when one partner exists in a boundaryless, one-up position in relation to their romantic partner, bad things follow. Their behaviours eventually tend towards control and anger in what he calls a “love dependent” union.

I equate what Real calls boundaryless, unbridled, self-expression with entitled self-indulgence: the notion that your personal wants, impulses, perspectives and beliefs are more important than anything (or anyone) else. Real’s interest in this topic is personal — he considers himself a recovering narcissist and has written extensively on how gender conditioning prevents men and women from achieving meaningful, authentic intimacy.

Carl Rogers is another influential therapist who has thought deeply about the meaning of authenticity. Active in the early 20th century, Rogers is considered one of the founders of humanistic psychology, a branch of psychology that emphasizes human potential, the drive to personal growth and self-actualization.

Rogers believed that humans experience an innate drive to realize their full potential. The fully functional person emerges as a consequence of congruence between a person’s real self and their ideal self. Rogers theorized that a supportive environment characterized by unconditional positive regard can allow for the emergence of a self-actualized person fully in touch with their feelings, who is open to life experiences, and actively engaged in a process of ongoing growth.

For example, if a person strives towards integrity, any act that is misaligned with this value would take them further away from realizing their true self. Self-actualization, therefore is not a thing one is, but a process that relies on the person articulating and refining the values they wish to live by.

In Rogers’ work, the authentic self is not a state of being but rather a process of becoming. The actualized self emerges as a result of a constant striving to grow and improve.

Authenticity in all the wrong places

Contrast Real and Rogers’ reflections on personal and relational authenticity with group identity-based authenticities. Think of Tiktok influencers celebrating mental illnesses of various kinds as an authentic identity. Authenticity is made synonymous with diagnostic labels. Diagnostic labels become a doorway into belonging.

In these circles, authenticity is also sometimes used to justify bad behaviour. One way that claims of authenticity can be weaponized is when someone is called out for their abusive actions and their response is some version of: “that’s just the way I am”. The underlying message is that their status as a victim of social oppression justifies their abusive acts.

Certain aspects of personhood are of course difficult to alter; particularly those grounded in material reality. Things like height, eye colour, chromosomes, or age cannot be easily altered merely by wanting them to be different. But other aspects of personhood clearly are malleable. It’s why therapy works for many people. Someone who tends towards introversion, for example, can train themselves to be more extroverted. An anxious person can develop skills that diminish their susceptibility towards panic attacks. A depressed person can learn to think preemptively in ways that reduces their likelihood of relapse.

Some of the key controversies in the gender debate revolves around whether one’s sense of oneself as a man or woman or something else is a fixed, innate quality; or whether gender is instead fluid, and influenced by environment. It seems pretty obvious to me that environment plays a role. But to state this contradicts a sacred tenet used to justify gender-related medical interventions. Much of the rationale for medical gender procedures has historically relied on the premise that gender is biologically fixed, thereby requiring the body to be moulded to match the mind. Some medical experts like Dr Jack Turban, a gender-affirming psychiatrist, argue for the existence of a gender soul or a transcendent sense of gender.

But is there really evidence of an authentic gender self? And is it fixed? Research on detransitioners in particular challenge that belief. In a recent large mixed methods study of about 900 detransitioners across the US and Canada, researchers identified four different types of detransitioners: 1) those who strongly endorsed mental health-related factors and changes in self-identity as their reason for detransitioning; 2) those who endorsed changes in self-identity but remained moderately satisfied with gender-related medical treatments; 3) those who strongly endorsed discrimination and interpersonal factors as their reason for detransitioning; and 4) those who strongly endorsed discrimination factors as well as moderately endorsed healthcare access barriers as informing their choice to discontinue transition.

What can we make of this? It paints a pretty complicated picture of transitions and detransitions. It challenges the notion that gender is fixed, and also demonstrates a curious fact about humans: that we are endlessly reinventing ourselves. While debates rage on about the nature of gender identity and whether it is meaningful term to use at all, I’m more interested in how to think about living authentic lives.

Letting go of self-labeling

I didn’t really feel like I was living authentically until I stopped trying to convince myself (and everyone else) that I was a man. More importantly, I stopped worrying about being seen as a woman. Granted, I’m sufficiently medicalized now that even without any further testosterone use I will likely never again be easily recognized for what I am - a female. I can’t undo what’s done. I could pursue medical procedures to reconstruct my breasts, and start hormone replacement therapy for women. But to what end? To again have my entire existence revolve around gender?

The real freedom lies in recognizing that the identities we choose to focus on matter. And some identities are more important than others in the long run. Given a choice between prioritizing my gender identity or prioritizing my characterological identity, the latter is the one I care more about.

I don’t mind if you are cis, trans, gay, straight, or any other tribal label. I do mind if you’re respectful or not, if you are honest, trustworthy, reliable, or caring. I care if you are willing to engage in shared inquiry and dialogue. The tribal labels come and go and will continue to as cultures change. But universal values such as honesty, compassion, and respect for life endure because they matter for all of humanity.

Those are the identity characteristics I want to foster in myself. Those are the ingredients of an authentic self I look for in others.

In October 2025, Mia Hughes (author of the WPATH files) announced at the Genspect conference that Genspect was calling for a repsychopathologization of transgender identities. That is, Genspect is seeking to undo what it sees as a wrongheaded attempt by organizations like WPATH to normalize crossgender identification since the 2010s.

Designated a hate group by the Southern Poverty Law Center in 2024, and generally reviled among many trans activist groups, Genspect is a non-profit organization that claims to seek a healthy approach to sex and gender. As an organization, it has taken a critical stance on the gender-affirmative approach to gender distress, while advocating for the needs of parents who are skeptical of gender-related medical interventions, as well as offering counselling and psychosocial supports for detransitioners.

The basic premise of Genspect’s repsychopathologization campaign is that crossgender identification is an ‘extreme overvalued idea’, which they define as a rigidly held, false conviction that is shared by others in a culture or subculture. They argue that having a cross-sex identification is a mental illness and should be treated as such.

My initial reaction was surprise, a bit of horror, and also a sense of resignation. This moment is a long time coming, and perhaps what we need to stem the tide of young people seeking out medical interventions to solve their existential angst.

But will it cause more problems instead of less? It’s unclear.

Where once mental illness existed shrouded in secrecy and stigma, in today’s culture the opposite is true. If you don’t have a label, you might be viewed with suspicion. In an era where young people proudly announce their mental health diagnoses on social media as a badge of honour and claim it as as an identity, I’m not certain Genspect’s efforts will do much to dissuade a portion of young people from claiming a trans identity, as long as it is deemed desirable in their peer group.

I am also worried what this campaign means for the many of us who pursued gender transitions in good faith. I followed the medico-legal advice I was given, took steps to undergo a gender transition and in return was promised accommodations to live my life in peace in my chosen gender presentation.

It was a social contract.

Speaking from my own experience, I was only offered one treatment for my gender distress — a medical one. While I was offered therapy, it was as an adjunct to a medical transition. I was told that a medical transition would resolve my depression and anxiety. The endocrinologist who started me on hormones, told me that trans was a neuro-endocrinological issue.

While my endocrinologist situated the problem in my biology, Genspect is situating it in my mind. Both approaches are incomplete. Both explanations do not take into account the context within with my distress occurred. I offer that perhaps the problem of my distress shouldn’t solely be located within the individual.

Why am I the one being labelled as mentally ill, from Genspect’s perspective, and not the doctors who inflicted this on me and others like me? What exactly was my ‘extreme overvalued idea’ here? My desire to find a solution to my suffering? My trust in the healthcare providers that I turned to for answers?

I understand the impulse driving Genspect’s campaign. By calling crossgender identification a mental illness, they are seeking to reestablish a common language of reality for the culture at large — a reality that acknowledges that males are men and females are women and that it is, at the end of the day, impossible to change your sex. The best one can hope for is to emulate the other sex, becoming a simulacrum of the thing one desires.

Given that we currently live in a society where some seem to truly believe that hormones and surgery is a pathway to gender authenticity, perhaps the hard line that Genspect embodies in its campaign is a necessary corrective to this. But at what cost?

I cannot shake my discomfort with this campaign. It situates the illness in people like me while eliding the real locus of the dysfunction — the culture at large. After all, is it a mental illness to desire belonging, to want to relieve distress, to seek safety in an unsafe world? What of a culture that tells you your body is wrong, your sexuality is disgusting?

What about the adults who turn their backs on their effeminate sons or masculine daughters? Or the women who constantly police other women’s physical appearance? What about the men who continue to use homophobic slurs to describe other men who fail to meet implicitly-held standards of masculinity?

It’s a well-known secret in older lesbian circles that some lesbians sought to transition because they got tired of the homophobia they faced. For their gender nonconformity, they faced potential job discrimination, housing discrimination, social ostracism, or even physical attacks. Were they mentally ill for wanting safety? What of the people doing the discriminating?

For a lot of transmen like me, we transitioned because our gender nonconformity put us at risk, of social ostracism, and of potential violence. We didn’t believe we were literally becoming men. Transition was a pragmatic decision, that allowed a kind of invisibility that felt safer.

In my case, the reality of what was promised failed to live up to the hype. Nevertheless, I struggle to see my transgender identity as a mental illness. I know who I am and what I am; I live under no illusions. I also believe that I deserve a life of dignity.

I have no easy solutions here, but I do have a fear: that in Genspect’s fervour to re-establish sanity in the conversation about sex and gender, they are scapegoating a group of human beings while obscuring the context within which they came to their decisions.

I share a lot of Genspect’s sentiments: I do not believe there is such a thing as a trans child, unless by trans you simply mean gender nonconforming. Nor do I believe that medicalizing pre-pubescent or pubescent bodies is healthcare. Given that many gender affirming care-promoting clinicians don’t understand the consequences of the treatments they are evangelizing, my stance is that informed consent is impossible.

What I take issue with is Genspect’s jump from criticizing unsafe and experimental medical practices, to the claim that every person who ends up with a trans identity is pathologically mentally ill.

I had a severe case of clinical depression and anxiety that preceded my diagnosis of gender dysphoria. I sought help and I did all the things I was told to do — I took medication, I saw therapists. My mental distress did not wane. I chose a radical treatment because no one was able to offer me anything else that worked and I wasn’t able to find another way forward in my life. A desperate person will take desperate measures.

I sought a solution that ultimately proved the wrong answer to the wrong question. Rather than asking: “How can I get rid of this depression and fit in better?” I may have benefited from asking “How can I live a good life despite my depression, despite not fitting in, despite the cultural dysfunction around me?” But hindsight is 20/20 and who knows if that would have made enough of a difference.

I credit my relative sanity in the present to the recognition I had from the start that what I was embarking on was an experiment and not guaranteed to succeed. I still believe it was worth the risk, because the alternative seemed even more bleak. I didn’t feel like I had anything left to lose. I didn’t believe I was literally becoming a man. But I understood that I might have a more comfortable time in society being interpreted as a man rather than a woman. I was seeking social legibility.

My eccentricities as a female seemed less sharp, less socially disruptive when I was perceived as a man. I garnered a degree of social acceptance that eluded me before I transitioned.

My transition was a pragmatic social experiment. I knew that experiments can fail. And ultimately, I see my transition as something of a failed experiment. My depression and anxiety returned after I transitioned. I struggled for many years. Then slowly I started to heal, not because of my transition but despite it. I found a decent therapist who helped me reframe many of my self-sabotaging thoughts. I gained a new understanding of my motivations for transitioning. Once I started to admit to myself and those closest to me that I believed I’d been misdiagnosed, I finally could start to truly grieve and gain some acceptance of what had happened to me.

We can learn things from failed experiments. And I’ve learned a lot — about myself, about the limits of human understanding, and about the power of love to pierce even the darkest, bleakest of moments. Even though my transition was a mistake, it allowed me to meet my wife. If I hadn’t transitioned we likely would have never met. Before she met me she identified as straight. I never hid my trans status. She knew I was trans from the start, but she was attracted to me anyway. For that relationship, I will always be grateful.

When I eventually started doubting my initial gender dysphoria diagnosis out loud and I blurted out to my wife that I believed I had been misdiagnosed, she listened. She understood. Maybe not fully, but enough. Every human is broken in different ways, she said. To quote Leonard Cohen, “there’s a crack in everything, that’s how the light gets in”. She liked my light, and I liked hers.

But what’s one story? It’s an anecdote, not data. It’s my story though. And I’m still living it. Genspect can pathologize me and those like me all they want. But when I look at some of the extreme voices who seem to relish in humiliating trans people of all stripes, I think to myself: I’d rather be me than them. I acknowledge my brokenness. But them, they are riding their wave of self-righteous fury and purity politics without much of a care for the human beings they are targeting. We are all human, at the end of the day, doing our best in a constantly evolving, complicated world.

To harken back to my early church-going days: Let he who is without sin cast the first stone.

Living as a trans person in 2025 feels a lot different than when I first came out as trans in the early 2000s. We didn’t realize how good we had it. We were rare enough that not everyone knew what trans meant, but not so rare that most people had someone in their community who identified as trans.

Maybe it’s the algorithm, but I can’t go online without encountering some content related to trans identities - whether it’s Elon Musk tweeting about cancelling Netflix for promoting trans propaganda, or reading in the news about some new drama related to JK Rowling and her alleged transphobia.

For the most part, I try to keep my nose down, be a good worker, family member and citizen. But as a disaffected trans person who has decided to stay transitioned as the least damaging course of action for the people I love and work with, I’d be lying if I said it doesn’t wear on me.

In online trans circles the fear is real: US-based trans people asking for help on how to leave the country, posters expressing fear about their passports having their natal sex markers on them upon renewal despite years of living in a cross-gender identity, stories of being let go from jobs for dubious reasons.

The honeymoon period of trans acceptance is well and truly over — particularly in the US.

Part of me can’t help feeling that we as a community have brought some of this on ourselves, by refusing to talk with people who hold different beliefs from our own (the ‘no debate’ policy so common among trans activist circles), and by insisting that anyone who might have questions about the recent proliferation of gender identities is a transphobe. As a community, we demanded empathy and understanding from those around us, and yet we offered little of that back. We chose protest over persuasion.

Let’s face it, the trans community isn’t really much of a community. We are a mishmash of different groups with very different agendas, thrown together under the label of trans but with often very little in common. What does a middle-aged man with a successful career and children who decides to transition late in life have in common with a young girl who struggles to fit in, and is just about to enter puberty? Very little, I’d say. And yet both fall under the label of trans as if they have a shared experience.

So much of the turmoil around how trans people should be treated revolves around labels, language and definitions. Where the label trans used to refer to people with cross-gender identification who wanted to live in the other gender, it now includes people who self-interpret as genderfluid, agender, bigender, nonbinary, or gender nonconforming. This expansion of what trans means has complicated the work of healthcare providers who often are oblivious to the nuances of the gender world and in that ignorance are attempting to discern who will benefit from medical interventions that are a one-way trip to irreversible bodily changes. And while they try to sort through the complexities, the numbers of young people seeking care keeps on climbing. It’s a recipe for chaos.

Because the healthcare system has had such a fraught history of pathologizing gender nonconformity, by including for example homosexuality as a mental disorder in the DSM up until the 1970s, and because of the way AIDS patients were treated, often shrouded in secrecy and shame during the 1980s, one can hardly blame those of us who are gender nonconforming for having a paranoid bent; our history demands it. AIDS likely would not have received the attention (and research funding) it needed, if community activists had not spoken out loudly, protested, and demanded better from doctors, researchers, and government officials. Polite people struggle to have their voices heard, but scream loud enough and you’ll get attention.

That anti-authority streak within lesbian and gay activism carried over into trans activism. It’s understandable. But in the process of screaming and demanding our ‘rights’, we have trampled over people who matter just as much as we do, and people who are not being served by the things we are demanding. Here I am thinking of the gender-distressed young people who don’t necessarily ‘know who they are’. I’m thinking of the young person who was sexually assaulted and is trying to heal. I’m thinking of a teenager with autistic traits and fears of being alone who is desperately seeking a place to belong. I’m thinking of the anxious and depressed young adult who has been told all her life that she is ugly, worthless and stupid. I’m thinking of the young man who is in a toxic relationship with a person who tells him he’ll never be a man and as a result begins to believe he would be better off as a woman.

By demanding that hormones and surgery be handed out to anyone who asks, the most extreme voices in trans activism are causing actual suffering to people who deserve better care than that. By refusing to acknowledge the pain and suffering of those who are speaking up and saying that they have experienced harm, these extreme voices are showing a lack of empathy and understanding while continuing to demand that from others. It’s a losing strategy.

The way I think about this is as follows: if I received a medical treatment that benefited me, and then I later learned that others who received the exact same treatment than me had devastating outcomes, I would accept that some guardrails needed be put in place to prevent future harm, even if it disadvantaged people like me who could benefit from that treatment. Because I’m not the only person who matters.

I have yet to see any of the medical organizations that promote informed consent models of gender affirming care speak up publicly that perhaps safeguarding is called for to protect those who mistakenly seek comfort in a trans identity for an otherwise inarticulable suffering. Until that happens, my plea is to other trans people like me who care about everyone, not just trans people.

We need a better path forward that takes into consideration everyone’s needs.

In a recent interview with the TransNormal podcast, embattled Evidence-Based Medicine founder/researcher Dr Gordon Guyatt elaborated on the importance of client values and preferences in shared medical decision-making.

Guyatt has gotten embroiled in the hotly contested arena of gender affirming medical care (GAMC) after he participated in a series of systematic reviews looking at the efficacy of puberty blockers, cross sex hormones and mastectomies for the treatment of gender dysphoria.

The systematic reviews in question found low certainty evidence for these treatments. In a rare move, Guyatt and some (though not all) of his co-authors put out a statement decrying the misuse of his research to support legal bans on gender affirming medical care for minors.

In a statement on the McMaster University website, Guyatt and his co-authors called the weaponization of their research ‘unconscionable’ and sought to distance themselves from the Society for Evidence-Based Gender Medicine (SEGM), the organization that had originally commissioned the systematic reviews and funded them. SEGM is labelled a hate group by the US-based Southern Poverty Law Center (SPLC), though SEGM’s leadership strenuously deny this. SEGM has also stressed — and Guyatt et al. acknowledge this in their statement — that the researchers had complete research independence.

In his interview on the TransNormal Podcast, Guyatt made the argument that evidence never tells us what to do, as medical care always exists within a social context, and evidence must be interpreted through the lens of client values and preferences. Guyatt’s position appears to be that when the research evidence is low quality, as is the case here, client values and preferences become more important, not less. As long as clients understand the potential risks and benefits of a particular treatment, Guyatt argues that the client should have access to care. However he, in another interview, shies away from calling gender affirming medical care ‘medically necessary’.

The ethics of autonomy

Historically, medical ethics framed patient autonomy as a negative right; that is, autonomy in medical care used to mean the right to refuse a particular treatment (e.g. a patient who is a Jehovah’s Witness has the right to refuse a life-saving blood transfusion), rather than the right to demand a treatment (which would be positive autonomy). But in more recent years, this seems to be changing.

In addition to the evolving meaning of patient autonomy, the rationale for gender-affirming medical care specifically, has also shifted over time. Medical treatments for gender dysphoria were previously argued to improve patient mental health outcomes, reduce suicide risk and improve overall quality of life. However, studies looking at the link between gender affirming medical care and mental health outcomes have found a lack of evidence to support these claims,

Given that objective measures do not appear to show clear benefit for these treatments, the rationale for GAMC has shifted to a rights-based focus on patient autonomy instead. Canadian legal scholar Florence Ashley has argued for the right of patients to access medical interventions without gatekeeping and to achieve their ‘embodiment goals’. Under this rationale, outcomes are subservient to client desires.

This argument, that medical care should be based solely on a client’s desire for it, uncoupled from health outcomes, is perhaps taken to its extreme in the writings of Pulitzer-prize winning trans author Andrea Long Chu. In a surprisingly frank essay in New York Magazine, the author argues that minors should have access to these medical interventions, based on their desires alone. In other writings, Chu has acknowledged that gender affirming medical care has not improved her own mental health and, if anything, has worsened it. Yet, she defends her right to access medical interventions even if they don’t make her happy.

Where some might argue that Chu’s positions are fringe ones, the underlying stance (i.e. of medicine on demand, uncoupled from objective quality of life outcomes) is present in mainstream scholarly circles as well. For example, a peer-reviewed article in the BMC Medical Ethics journal recently argued that seeking to measure ‘effectiveness’ in pediatric gender care ‘required further reflection’.

While I doubt that Guyatt would support such an extreme interpretation of autonomy for GAMC, his emphasis on client values and preference above all else downplays the other important ingredients of ethical decision-making in medical practice — beneficence (acting in a patient’s best interest), nonmaleficence (the obligation to avoid wherever possible actions that could harm a patient), and justice (promoting fair distribution of resources and equal access to healthcare).

Because pediatric gender medicine involves children, the matter of patient autonomy and shared medical decision-making is especially fraught. How can a child truly understand what they are risking — longterm health-wise — when they pursue puberty blockers, cross sex hormones, or (in rare cases) surgery? Can a child truly know what they stand to lose or gain? Weighing a child's short-term desires against bodily autonomy over the lifespan is a consideration every clinician would do well to carefully consider.

For more background on the evolution of medical ethics and changes in rationale for pediatric gender medical interventions, please see Moti Gorin’s essay: What Is the Aim of Pediatric “Gender-Affirming” Care?

One of the most difficult aspects of realizing that my medical transition was built on untruths is that it has shattered my confidence in my own judgement. If I allowed myself to be duped to the point where I believed that medical transition from female to male was possible, what else have I been wrong about? How can I ever trust myself again? And how can I learn to trust again the institutions that allowed this to happen?

To know that I betrayed myself so profoundly is a shame that is hard to shake. I remind myself that at the time when I embarked on this medical experiment, my mental health was poor. Also, I did not make this decision in isolation. A whole infrastructure existed around me that nudged me forward, including a cultural movement that said that gender transition was not only possible but beneficial to socially awkward and gender non-conforming young people like me.

I remind myself that I am not the only one; that lots of intelligent people bought into the lie — many still do — that people can be born in the wrong body, and that altering the body to match the mind is a reasonable thing to do. People believe all sorts of wild ideas, because ultimately humans are not all that rational. One has only to look at the evolution of spelling in the English language to know that (though, through, and cough all end the same but sound different, for example).

We believe things, not necessarily because they’re true, but because believing them gives us a sense of agency, meaning, and purpose. Even a false belief can generate positive change. The placebo literature bears that out. My transition did — at least temporarily — propel me forward, out of a clinical depression for long enough that I was able to build a career. But when the lie starts to crumble, what happens then?

Coming to terms with a medical lie

With time, my fragile certainty about my so-called maleness waned. I had to face that I had embarked on this gender ‘journey’ not because of some innate male soul but because I was working through some pretty serious life events, which I’ve written about elsewhere. I was a masculinized female, and no amount of hormone injections, organ removal, and appendage construction would ever turn me into a male. It’s not possible.

What I don’t want is for this whole experience to harden me in ways that cut me off from the humanity of others, including those who still believe in gender transition as good medical care. I do not want to carry bitterness towards activists, advocates, and ideologically captured clinicians. I don’t want to forget how to love, how to keep my heart open and curious. In those moments where I wonder: why me? I remind myself that a more salient question is: why not me? What makes me so special that this shouldn’t have happened to me?

When I take a step back and look at how my life started and where I am now, I recognize how surreal a life I have lived. I have existed as two different genders across two different continents — a woman until my early 20s, and a man (socially) ever since. From tomboy to transman; from suicidally depressed to reasonably stable despite it all. By so many measures, my story is one of resilience, recovery, and growth. And yet, even for me, some days the grief over what I have done to myself, to my body, to the people around me, is hard to bear. What I would like to do is get to a place of forgiveness, including self-forgiveness, but the feelings of inadequacy and self-doubt make that difficult.

The shame is a weight that bears down on me with suffocating force at times. I will bear that shame because, well, I have no other choice. I will continue on because that is the commitment that I have made to myself and to my loved ones. But nothing about this has been easy.

I remind myself that we grow from our mistakes more so than from our successes. In the words of Enlightenment-era poet Alexander Pope: ‘To err is human; to forgive divine’. But what exactly was my error? Was I wrong for wanting to feel better, for seeking out help from the professionals that society had anointed as experts? Was my mistake that I wanted an easy fix to my feelings of loneliness and alienation? For wanting to be safe in a hostile world? Yet, how could I have known better?

Was my failure that I should have had the internal fortitude to know who — and what — I was? Yet for so much of my early life my family packed up and moved to a new house, town, or country, where we started all over again. How could I establish a secure foundation when I had no solid ground to build on?

Perhaps I was not skilled enough at critical thinking, given the multiplicity of internal contradictions built into gender medicine. For example, gender is sometimes described as fixed and innate, on one hand, and fluid and dynamic on the other. Children supposedly know who they were (i.e. trans) yet if left alone, those dysphoric children often grow up to be gay, not trans. Gender incongruence is framed as a natural variation not a pathology but also requiring ‘medically necessary care’. Gender dysphoria is the thing clinicians are supposedly treating yet some clinicians claim you don’t need gender dysphoria at all to meet the requirements for this ‘medically necessary care’.

The contradictions are dizzying if you take a moment to think about it. Yet there rarely seems to be time to think. The goal is to move as quickly as possible, with as little reflection as possible. No matter that the research points to higher rates of suicide post-medical transition, compared to the general population. Transition, it turns out, is not a panacea. But who needs caution when you can have surgery?

Was I too trusting? Too gullible? Stupid, perhaps? Yet, wasn’t it reasonable for me to trust the professionals? Surely, we have experts, people who have devoted themselves to study these issues, precisely because most of us can’t know everything about everything. Was it so unreasonable to expect that the researchers and early clinicians in the field would have done follow-up and outcome studies?

Of course, I now know that very few researchers and clinicians followed up with their patients, especially over the long term. Worse than that: the organizations tasked with creating guidelines for clinicians actively suppressed studies that undermined their claims.

I can forgive mistakes, but deception? That is harder to stomach. How do you heal and move on when leaders in the field of gender medicine continue to deny and mislead the public about the risks and harms?

Perhaps my mistake was that I should have known better. The reality is, I didn’t. So here I am, having already sacrificed my organs and my identity to a medical gender experiment gone awry. I am stuck a masculinized female and with no clear path back to womanhood and no desire for any further involvement with the medical establishment who did this to me.

I will bear the consequences of my decisions as best I can. I have no interest in living a life of resentment or rage, though at times it is tempting. Instead, I will do what I can, in my own quiet way, to make positive change. Slowly, with time, I may even learn to trust myself again. Not because I know all the answers, but because I’m more comfortable asking questions. Even questions about my own (litany of) flaws.

Recently I have been reading the HHS report on gender affirming care for minors. Since the report essentially advocates for psychotherapy as a first-line treatment for gender dysphoria in minors, I have been reflecting on my own experiences with the mental health system; what I have found helpful and what I have found less helpful.

In the past, I have said that I was misdiagnosed with what used to be called gender identity disorder (GID), now gender dysphoria — but that is not entirely accurate. To be misdiagnosed one must first undergo a diagnostic process, and while I thought that was what I was accessing, I now know that no such process occurred. My self-report was sufficient to land me the label of GID. Next steps were assumed - that what I wanted and needed was a medical pathway to social transition. No other options were seriously discussed.

While at the time of my ‘diagnosis', psychotherapy was offered, it was offered only as an adjunct to starting cross sex hormones and surgery, which were described as the primary treatments for GID. We did not discuss what GID actually was nor did we discuss that for some it dissipates without medical intervention. We also did not talk about the high complication rates of medical procedures or how a medical transition might impact on social interactions, relationships, or longterm health.

Granted, back in 2003, much of what we now know about gender dysphoria was not as widely discussed (e.g. high rates of autism/ADHD/neurodiversity), but as I remember it, very little time was spent discussing what remained unknown. The psychological assessment also involved minimal examination of the ways that gender dysphoria might show up for same-sex attracted individuals. Nowhere in the process did we discuss the possibility that the gender dysphoria could dissipate without medical interventions.

I was an adult when I was diagnosed with GID. I did not receive adequate information on what I was signing up for. I was also not informed that gender identity shifts can occur post transition, and that some people choose to detransition. Granted, at the time, the 1% myth was still widely held up as fact. Today, minors are accessing medical interventions and they are still lied to about what is known and not known. It remains common practice to hear clinicians make claims that puberty blockers are reversible, for example. This quite simply is not true.

My interaction with the mental health system did not begin with my diagnosis of GID. Growing up, I had a lot of difficulties with anxiety. As a child, little things would lead me to spiral — like social interactions with my peers (I feared judgement), or going to the toilet (I feared being sucked down when I flushed). I was something of a germophobe and would do things like brush my teeth until my gums were raw or wash my hands until the skin peeled off.

These unusual tendencies did not go unnoticed, particularly since my father was a psychiatrist himself. I credit him for helping me through some of these anxieties. Unfortunately, as his physical health deteriorated, my mental health issues increased. At 16, I engaged in problematic eating behaviours, restricting my food intake and refusing to eat dinner with the rest of the family. My parents had me consult with a neurologist, who I saw for one session and then never again. I briefly worked with a dietician to develop a meal plan, and remember seeing her a few times to monitor my weight.

Around the same time, my father also started bringing home antidepressant samples that the pharmacist reps dropped off at his office. My mother watched over me to ensure I was taking them. No one discussed with me why I was taking them or what they were supposed to do for me. I remember feeling out of control on them, not like myself at all. I eventually refused to take them, to my parents’ chagrin.

At 18, I left home to go to university. I thought leaving my parents behind would feel good, but starting over in a new city did not assuage my social anxiety. I became suicidally depressed. I reached out to the university’s counselling centre and worked with a talented therapist who helped me a lot. For one thing he seemed to care about my wellbeing. And he seemed worried about me. Given that by this point my biological family was understandably fatigued with my mental health challenges, and more focused on my dad’s physical health challenges (which were considerable), this therapist’s caring felt unfamiliar but good. I worked with him for as long as I could but the number of sessions I was allowed was limited and he eventually had to refer me out to someone else.

For the next three years, I worked with a psychodynamic therapist in private practice who was also a psychiatrist. She prescribed me a generous cocktail of psychotropic drugs including Citalopram, Ativan, Zyprexa and Wellbutrin to complement our talk therapy sessions. While I liked that she did not seem to tell me what to do, I also felt frustrated that she did not seem to have much in the way of solutions for how to lessen my anxiety and depression. She made vague comments about the ways my family’s dynamics contributed to my mental health challenges but did not offer me skills nor much insight.

The consequence was that I looked elsewhere for answers for what was wrong with me. I looked to the internet, and to the people around me. One of those people was a university friend who herself was planning to start testosterone following a GID diagnosis. Listening to her speak of her experience opened up a pathway I had not, to that point, considered. While I had always been gender nonconforming in appearance and demeanour, I did not think of myself as a man. But looking at her, I was more masculine than she was. She liked feminine clothes on some days and more masculine clothes on others. In today’s parlance, she might be called genderfluid.

In my naive way of thinking at the time, I considered that if she was receiving treatment for her gender dysphoria and her dysphoria was less intense than mine, then maybe I should receive treatment too. Armed with this new theory of what was wrong with me, I returned to my own therapist and told her that I thought I was trans. Given that she did not have much experience with trans patients, she referred me to a gender specialist. The gender specialist diagnosed me with GID - high intensity. Once I was equipped with a GID diagnosis, I was able to get a hormone prescription from an endocrinologist, and so my medical gender journey began.

But what if the gender specialist had said “yes you are experiencing gender dysphoria” and then had proceeded to explain that many cisgender people also experience gender dysphoria and a lot of butch lesbians in particular? What if that gender specialist had then explained that very little is as of yet understood of the causal mechanism behind gender dysphoria and that research is still in its infancy on the best treatment for it. What if that gender specialist had then suggested that I continue with psychotherapy to better understand the ways that gender dysphoria has presented itself in my life and to enumerate the ways that I had learned to cope with it? What if that gender specialist had worked with me to develop skills on how to deal with it psychologically and to focus on other areas of my life that were a struggle too?

For example, he could have helped me to address my social anxiety around my peers. He could have role played with me ways that I could respond to workplace bullying. He could have taught me ways of developing an internal locus of control, to learn to not let my happiness be dependent on the external validation of others. He could have talked to me about the ways my place in my family system had contributed to me feeling like an outsider and what it had been like to grow up with a father who suffered from chronic illnesses. He could have equipped me with ways of interrupting my perfectionistic, and ruminative thought patterns.

But these interventions would have required time and effort. They would have required me taking a long hard look at myself and how I was relating to the world around me. They would have required someone caring enough about me to want to put in the effort to work with me. While I think he cared about me well enough, I also don’t think he truly understood what I was struggling with. How could he have? He saw me for one 90 minute session before labelling me with GID. And I didn’t know enough to ask questions.

When I started hormones, I stopped taking the cocktail of psychotropic drugs my psychiatrist had prescribed me. The testosterone levelled out my mood and temporarily gave me a sense of confidence I could not remember having ever felt. That gender euphoria lasted maybe two years. By 2007 I was again having thoughts of suicide. No one, least of all me, brought up that hormones did not seem to be having the desired effect on my mental health. In 2008 I went ahead with a double mastectomy. In 2010 I had my uterus and cervix removed. By 2013 I was again seeing a therapist for suicidal thoughts. I was lonely, directionless, and lost. But I didn't question my gender transition.

Not until COVID hit did I begin to seriously reconsider my gender trajectory. By this point, I had gone back to school, started a new career and gotten married. My life felt meaningful for what felt like the first time. I credit my relationship for a lot of the improvements I experienced in my mental health. My work as a mental health counsellor also provided me with a sense of purpose and direction.

In my clinical practice, I listened and learned from my clients, some of whom had ambivalent feelings about their gender transitions. In my personal life, a handful of my friends chose to detransition. Others who continued to identify as trans saw their mental health deteriorate. As I revisited key moments in my own life, I recognized that my reasons for transitioning had not come from believing I was the opposite sex, but from my not knowing how to interact with the world around me as a gender nonconforming female.

With doubts increasing, I sought out a counsellor in private practice to talk through my thoughts, my ambivalences and my regrets. That therapist, steeped in the gender affirming therapy approach, was no help at all. He simply could not understand why I was questioning any of it. You pass, he said. As if that was all that mattered.

All this to say that psychotherapy is an umbrella term for a lot of different types of psychological interventions, with sometimes wildly divergent and even contradictory underlying assumptions. To date there are more than 500 different psychotherapy models out there. While the research is pretty solid that psychotherapy benefits mental health, what is less clear is how to optimize it for different populations.

I have experienced both the benefits of good psychotherapy, and the harms of it when poorly practiced. If reports like the Cass Review and the HHS report are going to advise psychotherapy as the appropriate response to gender dysphoria, I think we also need to talk about what therapy can realistically offer and not offer to clients. We need to clarify what we mean by psychotherapy.

The science seems pretty clear to me that gender affirming medical care—especially for minors and young adults—over-promised what it could deliver. Yet, I do not believe that science alone will lead us to a new vision of what good care might look like. The question of what good care might be isn’t just a clash about what the science says; it is a clash about values. Whether or not we choose to allow minors to medicalize is dependent on which values we as a culture choose to privilege. While the scientific process can help us better understand the short- and longterm ramifications of gender affirming medical practices, ultimately science does not tell us what to do, only what is and is not possible.

When clinicians approach the question of whether to medicalize minors from a values lens, rather than a scientific one, the consideration is less about risks and benefits, and more about beliefs about what makes life meaningful. Is the value of client autonomy in healthcare more or less important than the value of evidence-informed care? Is emphasizing a minor’s right to regret over an adolescent’s right to a natural puberty more or less significant? Whose experiences do we privilege? Those who say via self-report that gender affirming medical practices saved their life? Or those who say that the very same practices devastated them beyond repair? Should we make room for both experiences? Or is one more salient than the other? Is subjective experience more important than objective measures of wellbeing? Is short term euphoria worth the price of longterm health? What do we do when conflicting accounts co-exist in an ongoing battle for the hearts and minds of the general public?

These are not questions that science alone can answer. They are philosophical inquiries, about the meaning of values like choice, freedom, truth, and viewpoint diversity. Even the same value can take on different meanings depending on the frame within which it exists. For some, freedom means giving people the capability to alter their bodies and create new identities—even identity categories that have not historically existed in the law (e.g. nonbinary). For others, freedom means allowing a child to grow up with their body intact, so that they can make their own informed decisions as adults.

One segment of society may value the choice of bodily autonomy as a sacrosanct right, while yet another may see gatekeeping of invasive medical procedures as necessary safeguarding to protect the vulnerable.

Nonbinary people, or at least some who claim that label, may seek to undo the gender binary entirely—to demolish the very concept of gender roles and expectations. At the same time, others might point out that a nonbinary category reinforces gender stereotypes rather than dismantling them. While one group might believe a nonbinary identity is a pathway to authenticity, another group might frame the very same identity as the ultimate individualistic indulgence.

Science cannot tell us whether any of these interpretations are good or bad; it can only study the individual and social impacts of these cultural practices, and offer up hypotheses to explain their ramifications. What we do with the stories we generate from these hypotheses is a question of values, not data.

When I was 23 and faced with a future that seemed bleak and filled with despair, I chose hope over despair, and I reached for the best story available to me. The story that carried with it hope for a better future, was the story of being a man in a woman’s body, just waiting to break out of my shackles to become more authentically me. It was a story that offered a clear path, a destination, and a possibility of happiness. An alternative story I also received was one that said that I was mentally ill, that my depression was in my DNA, and it would follow me all my life unless I remained medicated. Even then, happiness was not guaranteed. Unsurprisingly, that story was less appealing — it offered no clear solutions, no defined path, no promise of sustained happiness. What story would you choose when faced with such options?

In retrospect, I wish I was offered a third story. Perhaps a story of struggle and persistence, a story that promised resilience and strength, love and adventure. I wish I was offered a vision that included seeing myself as capable and strong, rather than weak, broken and unstable. But I wasn’t offered that story—and I wasn’t imaginative enough to generate that story myself. Not then. Now, over 20 years later, that is the story that feels more true. I only sacrificed my fertility, my breasts, my identity, and many a relationship to attain it — a small price to pay I suppose.

I can forgive clinicians for not knowing better 10, 15, 20 years ago. Ignorance is not an excuse for incompetence, but I understand that healthcare is often an imperfect endeavour. Healthcare is filled with stories of hypothesizing, experimentation and risk-taking. When the risks work out we call it genius. When they don’t, we call it malpractice or negligence. The harms that come from not knowing better is an unavoidable consequence of clinical work—every clinician must wrestle with this truth.

None of us are always right; we can not know everything about every subject or client that comes to see us. But perhaps we can minimize harm by putting aside hubris and holding our hypotheses lightly. We might even consider listening to those who hold different viewpoints from our own—and allow ourselves to learn something from those other perspectives. But learning from those who are different, from those we might not even like, that is a difficult task. It requires moving beyond our own needs and wants, our own fragile egos. It requires prostrating ourselves before the gods of uncertainty.

In our culture we do not easily tolerate people changing their minds. We call it inconsistency, or worse, hypocrisy. We hold up outdated ideas as if they are gotcha moments from the past instead of potential demonstrations of deepening understanding. I think this is unfortunate. I admire much more the practitioner who recognizes the limits of their own knowing and remains open to course-correct when the evidence demands it.

But changing course when you are part of a larger system that has enabled you, is hard. It can feel like trying to redirect the Titanic away from an oncoming iceberg when you’ve already gotten too close. The gender affirming care ship may have seemed swanky at one time, but its hull is now damaged, its passengers and crew are jumping ship.

We need a new vision now—one that is inclusive of different experiences while also being grounded in material reality. As we build a new ship, we will need to listen to and include the voices of those who think differently from us. This might include those who practiced gender affirming care on minors, and those who did not. It might also include those who feel they have benefited from gender affirming care as well as those who feel strongly otherwise. It will require mediators and healers of all stripes to navigate new pathways forward. That is true inclusion. We need all hands on deck.

In a recently published paper in the International Journal of Transgender Health (a free copy of the full article is available at the author’s website), authors Ashley et al. make a bold claim. They write that gender assessments shouldn’t occur before starting gender affirming medical treatments because assessments do more harm than good. The authors argue that gender assessments are a form of gatekeeping where all of the power resides with the doctor and none with the patient; the problem with assessments as they see it, is that the patient must convince the doctor that they are ‘truly trans’ which means they are less likely to be honest about doubts and misgivings, negating the theory that assessments allow for gender exploration.

The authors also argue that assessments do little to prevent detransition regret. Rather than trying to prevent detransition, the authors claim that assessments should focus instead on normalizing detransition as part of what they call a gender journey. They make the case for allowing hormone prescriptions as part of gender exploration, essentially arguing that any attempt to slow the medicalization process down thwarts the patient’s embodiment goals.

The authors barely mention the risks of using hormones in an exploratory way — some testosterone-induced changes, for example, are permanent (e.g. dropped voice, hair redistribution, clitoral growth). As for surgeries, they argue that someone who goes through a mastectomy as part of their ‘gender journey’ is no different than someone who gets a mastectomy due to cancer — and any attempt to differentiate these experiences must come from bigotry.

Significantly, unlike cancer patients, the breasts of gender dysphoric patients are physically healthy and functional body parts. And despite what practitioners like Dr Johanna Olson-Kennedy claim, a person can’t just get fully functional breasts back once they’ve been removed. The best one can do is get a cosmetic facsimile involving breast implants, scarring, and lost sensation.

Before I critique their arguments further, let me at least highlight some points on which we agree:

1) In the past, doctors were paternalistic gatekeepers who had the power to withhold care from people based on their own preconceived biases rather than on any evidence base. This was a cruel state of affairs that should not be repeated.

2) As a consequence, patients who believed they were trans would often sanitize or change their life stories to fit into a narrative the doctors were more likely to buy, to gain access to medical interventions such as hormones and surgery.

3) People need a space to explore their feelings, doubts and thoughts in a safe, non-judgemental environment. This kind of honest exploration cannot happen when a client needs to prove their transness to their doctor to access medical care.

While these points lead the authors to dismiss assessments entirely in a display of all-or-nothing thinking, my own view is that we need to better define the role of assessments so that both practitioners and clients understand the value and purpose of the process.

What is a gender assessment?

Ashley et al. contrast what they call a ‘traditional’ gender assessment with their preferred informed consent treatment model. They argue that ‘gender assessments’ do nothing to prevent decisional regret in detrans individuals and create unnecessary barriers for trans individuals.

A few points about psychotherapy and assessments: While therapy often includes an assessment process, an assessment process is not by itself psychotherapy. Assessments in the mental health field serve to focus the work of psychotherapy, but therapy itself is a process of deepening self-exploration and self-understanding separate from mere assessment.

In the mental health field, assessments have different purposes and processes depending on the type. At least 4 common types of assessment can occur:

a) Diagnostic assessments

b) Biopsychosocial assessments

c) Functional assessments

d) Safety and risk assessments

Each type has its own purpose, utility and limitations. For example, in North America a diagnostic assessment is used to diagnose someone with a condition listed in the Diagnostic and Statistical Manual of Mental Disorders (currently we are at version DSM-5-TR). Diagnostic labels are particularly useful for insurance companies/reimbursement as the insurance companies typically want to know what people are being treated for and the DSM provides a common language for healthcare providers (e.g. psychiatrists, family doctors, psychologists, social workers).

A large limitation of diagnostic labels is that they are decontextualized, situating mental health problems within the individual as some kind of brain malfunction. Yet we know that mental health issues are not simply biomedical brain misfirings — mental health is influenced by people’s interaction with their environment and their environment’s interaction with them. Another limitation of DSM labels is that popular understandings of them often diverge from their clinical utility. DSM diagnoses can become life limiting for people, even if they are not meant to be. Some people can become trapped in seeing their diagnostic label as central to their identity rather than as a changeable component of it.

A biopsychosocial assessment, on the other hand, typically involves a mental health provider taking a careful history of a client’s background to identify all the possible contributing factors that might be influencing a client’s distress. Most mental health providers embrace some form of biopsychosocial understanding of their clients. They recognize that mental health is influenced by genetics, epigenetics, psychological and socio-cultural influences. Understanding a person’s medical history, their family background and developmental history, as well as their socio-cultural identities can help to better understand the person in context. It can also help identify a client’s internal and external resources, strengths, and supports. Unlike DSM diagnostic assessments, biopsychosocial assessments are not seeking to label a client with a particular condition, but are seeking to develop an individualized understanding of the person’s issues within the unique conditions of their lives.

Functional assessments can form part of a biopsychosocial assessment and tend to focus more on how a person’s symptoms might impact on their daily ability to perform tasks, meet responsibilities and take on different social roles. Functional assessments often focus on client strengths and limitations, and treatment plans are directed at improving a client’s overall quality of life. For example, a functional assessment might look at things like personal hygiene, interpersonal skills, life skills like cooking, cleaning, managing finances, and work performance. Once skills gaps in these areas are identified, treatment plans can target the skills that are missing to get the client to where they want to go.

Safety and risk assessments are common when addressing potentially life-endangering eventualities such as suicide, self-harm or domestic violence. In a domestic violence situation, for example, the therapist might devote the first few sessions to doing a structured interview with a client who has used violence in their intimate partner relationship to better understand the factors that might increase the risk of this occurring again. When working with a client who has been victimized, the therapist might spend a good proportion of time thinking through with the client, step-by-step, the warning signs of oncoming violence and the ways that the client might go about minimizing risk to self and children (if children also live in the home). While this assessment process might rely on validated formal tools, it is also something that is informally integrated throughout the therapy process.

In each of these cases, the assessment is meant to complement and inform psychotherapeutic interventions and can itself be therapeutic by helping clients think through and identify their own patterns of behaviour, socio-cultural influences, functional barriers, and safety risks. Rather than seeing the assessment process as an attempt to put barriers in the way of the client, assessments are better framed as a tool for targeting interventions more effectively.

Which type of assessment the authors are referring to when they critique ‘gender assessments’ is unclear and seems to shift as needed to benefit their argument that assessments as a whole should be removed from gender medicine.

Their emphasis on the importance of the patient’s decision-making control suggests that they believe that clients ultimately should decide their own treatment. But this is clearly an untenable position that directly contradicts a shared decision-making model, considering that those who access treatment may not fully grasp the risks, benefits or consequences of medicalization. Despite the authors’ suggestions to the contrary, an informed healthcare professional plays a pivotal role in the shared decision-making process.

While a client may be the expert in their own experience, the healthcare professional brings valuable expertise in (hopefully) understanding the existing research evidence and scientific debates in the field. However, because GAC activists within leading medical organizations such as WPATH have effectively silenced those who speaks about harms, clients are not currently getting an accurate picture of possible negative outcomes from gender affirming medical interventions. Unsuspecting clients go into assessment thinking they are getting an objectively neutral assessment when this is not the case.

Also the authors seem to believe that clients go into ‘gender assessments’ seeking medical care right off the bat, when in my own experience many go in seeking a space where they can think through whether they want medical care or not. They often want to be challenged so that they can think through their motivations and needs more thoroughly. But such challenging by a clinician can easily be misconstrued as ‘bigotry’ or ‘attempts at conversion therapy’ if the purpose of the assessment process is not clear from the start.

Proponents of an informed consent model of gender medicine often claim that as long as clients are given information about the benefits and potential risks, clients are best positioned to make a decision over whether medicalization makes sense. I would argue, however, that few are currently experiencing true informed consent. I’ll use myself again as an example — detransition was not discussed as a potential outcome with me, nor was I informed that gender shifts are actually pretty common post medicalization. From discussions with others who have gone through medicalization more recently than I, risks and complications of hormones and surgeries are often underemphasized while benefits are exaggerated given the body of evidence that currently exists. The research suggests more caution is called for than is currently practiced.

The ongoing denial of harm

Ashley et al.’s paper seems intent on placing the responsibility for regret squarely on the shoulders of detransitioners who experience regret and the clinicians who they say want to gate-keep everyone. They argue that detransitioners may lash out at their practitioners due to their own internalized shame and “unreasonable expectations”. I find this interpretation especially galling, as it reads as subtle victim-blaming and erases the many very real ways that people have described being actively encouraged by figures of authority (e.g. school counsellors, counsellors, nurses, social workers or physicians) to go down a medical path too quickly. While the authors acknowledge the ways clinicians might fail their clients, they attribute this failure to clinicians’ devotion to ‘transnormativity,’ rather than considering that these mistakes might be a consequence of rushing to interventions before proper assessments have occurred.

The authors write: “Instead of understanding detransition as a personal or institutional failure, clinicians should see detransition as one of many possible steps in a person’s gender journey”; a truly offensive notion that removes responsibility for these failures from the systems of care that contributed to them.

The authors also argue that: “Gatekeeping practices are often predicated on the beliefs that neurodivergence and mental illness can make people falsely believe that they are trans, and that disabled and mentally ill people cannot be trusted with deciding for themselves whether to initiate gender-affirming care.” This is yet another attempt to downplay the harm that happens when a clinician for whom every problem is a nail, uses a hammer in every case, rather than seeing that people are more than the gender issues they bring forward.

The link between neurodivergence and gender dysphoria is well documented and I see little value in denying that the characteristics that often accompany ASD, for example, might influence a patient’s belief that they are ‘really trans’ (e.g. these clients might struggle with obsessive, rigid thinking patterns or have difficulty fitting in socially and seek an explanation for this). In my own case, had I had a better understanding of my own neurodivergence prior to medicalizing, I may well have made very different medical decisions. To acknowledge these complexities is not bigotry.

Counter to what the paper claims, assessments are not antithetical to building a therapeutic alliance; rather, the assessment process can serve an important function in creating time (and space) for the client and healthcare provider to better understand the many complexities of the client’s unique presenting problem(s). This takes time but it is an intentional use of time that can contribute to a stronger therapeutic alliance and better longterm outcomes, if the client allows for it. But with GAC activists often actively encouraging gender-distressed clients to see any questioning within a healthcare context as an ‘erasure’ of their identity, clients often miss out on a potentially valuable exploratory process.

Final reflections

A common refrain from those who support a gender affirming model of care with no assessment, is that it is cruel to “force” people into psychotherapy or an assessment. The authors make that argument too: “Requiring gender exploration, psychotherapy or an assessment of co-occurring conditions raises severe ethical concerns, as they would not be fully consensual and undermine patients’ ability to end clinical relationships without prejudice.”

It’s an odd sleight of hand to describe common, relatively non-invasive healthcare practices like assessments and psychotherapy as “unethical” or “cruel” while apparently denying the many very real ethical concerns and harms of administering irreversible hormonal and surgical “treatments” to individuals who may not fully comprehend what they are signing up for.

To propose psychotherapy as as the first-line treatment for gender distress in youth, for example, is hardly a radical concept. To argue that patients should have the ‘right’ to the most invasive treatment possible for their ‘embodiment goals’ is to undermine healthcare’s most basic ethical tenet of ‘do no harm’. In fact, one might argue it is not healthcare at all.

There is a difference between client-led care and client-centred care. The authors seem to believe that client-led care is the ideal. I beg to differ. It may sound paternal (so be it) but clients do not always have a full understanding of the consequences of their own wishes, especially as minors. This is not to deny client agency or autonomy, but to allow that healthcare providers have an equally important voice in the shared decision-making process.

As an analogy: recently a loved one told me about how she has been suffering with severe menstrual cramps. She went to her doctor to ask for a hysterectomy. The doctor, assessing the risks and benefits for her client who had a physical disability that made a hysterectomy more risky than usual, talked my loved one out of it and offered an alternative, less invasive treatment instead. Was that conversion therapy? Or good, ethical healthcare based on shared decision-making principles?

A client with gender distress may want to undergo a sex change (for a variety of reasons) but that does not necessitate the doctor or therapist to immediately move forward with it. To do an assessment is to create the space for client and healthcare provider to better understand what might be driving their distress prior to moving too quickly to serious medical interventions with high complication rates. Remove the assessment process and you remove responsible care.

As a social worker I get lots of emails announcing upcoming trainings. One such email I recently received was for a training from the prestigious Couple’s Institute promoting a webinar on the biological origins of gender identity and sexual orientation by gynecologic oncologist and former surgeon Dr Kate O’Hanlan.

A self-professed lesbian, Dr O’Hanlan did not hide her disdain for recent pronouncements by President Donald Trump on gender (that there are only two), framing Trump’s statements as an attack on the entire LGBT+ community. She clearly believed that if only Trump had the information that she was sharing, he would stop ‘attacking’ sexual and gender minorities.

I couldn’t help feeling sympathy for Dr O’Hanlan. Her motives struck me as noble if naive. She seemed to truly believe that her research debunked the concerns of those who challenge gender affirming care. She was advocating for empathy and understanding, a goal I share. But sometimes empathy and understanding, when decoupled from a pursuit of truth, can lead us astray. I believe it’s led many a Gender Affirming Care (GAC) practitioner astray.

As so often happens in conversations about gender identity development and trans people, Dr O’Hanlan brought up the existence of disorders of sexual development (DSDs) as evidence that sex is a spectrum, even though this is not a scientifically sound argument (see the work of Colin Wright, Carole Hooven and Zach Elliot to understand why).

Essentially, O’Hanlan’s presentation argued that sexual orientation and gender identity both are hardwired from a very young age. She seemed to argue that because they are hardwired, they are unchangeable and unchanging. That is an assumption not supported by the available evidence and a conflation of at least two different issues. While sexual orientation in males seems to be relatively stable, it is less so in females. Gender identity on the other hand has only moderate stability over time, an inconvenient empirical finding that undermines the argument that ‘kids [always] know who they are’. This podcast interview with a mother of a child who desisted from a trans identity directly challenges such an idea.

While her presentation is well-cited, Dr O’Hanlan’s gender identity-related citations are mostly pre-2010. This is an important point because those of us who are immersed in the gender world, know that much has changed since then. While she does mention the recently released Cass Review, she does so only to categorically state that it is debunked, without providing any evidence to support that claim. While the Cass Review has faced a fair bit of backlash, it continues to cause reverberations across the globe, most recently in Australia. And given that the Cass Review’s findings are largely in line with every systematic review that precedes it, I’m not sure what Dr O’Hanlan means by debunked. In fact, the critiques of the Cass Review have recently faced their own scrutiny.

Near the end of her presentation, she makes a surprising claim to the roomful of attendees, most of whom are therapists. She states that all the patients she operated on, were assessed by two psychologists. Then she says: “I don’t think you [psychologists] can be tricked.”

It’s a revealing statement.

So many of the responses to those who oppose GAC, frame the issue as a battle between a big bad anti-trans hate machine seeking to eradicate a poor innocent vulnerable underdog minority from existence. It’s a very compelling David-and-Goliath story, where trans people play the role of David facing down a bigoted, conservative-leaning giant. Trump is a good stand-in for the part of the giant, with his grotesquely larger-than-life personality and menacing presence on the political stage.

In a world where trans people are an oppressed minority, the healthcare providers get to play the role of rescuer ferrying along a poor persecuted victim to the magical land called ‘Authentic Self’. In this land, everything goes: you want your breasts removed? Happy to oblige. Want breast buds? We can help you with that. Want no genitals at all? Sure, why not?

Hormones and surgery are the magical elixir that will alchemically turn stone into gold, or in human terms — boys into girls and vice versa. The elixir will even free the poor persecuted victim from the bonds of gender altogether, entering them into the magical land of ‘Nonbinary’ if they so desire; a place where identity itself is fluid and changing.

Dr O’Hanlan confidently argued in her presentation that psychologists are able to discern who is worthy and who is not from entering this magical land of creative transfiguration.

Even if it were true that gender identity development had biological origins — which of course it must because most phenomena involves some combination of bio-psycho-social interplay — this does not automatically mean that medical interventions are the best way forward.

Equally important to biology, are the socio-cultural forces that encase it. Those social forces can create dysfunctional environments. I believe that is what we are seeing with GAC. It is a social movement that does not care what is lost in its wake.

If being trans is not a medical condition, what makes any of this healthcare? Why would you want to permanently alter someone’s body when that person might very well feel differently about their identity 5 or 10 or 20 years later, if or when the cultural winds shift direction again? Why would you want to weaken a human’s physical health for the fleeting promise of gender euphoria?

These are the questions that have become more pressing to me as I come to terms with what was done to me and what I did to myself. Every decision has its tradeoffs and the tradeoffs I made seemed worth it as a 23 year old. But as someone in my mid 40s now, my priorities have changed. For one thing, I no longer take my physical health for granted. Where once I didn’t dream of living past 30, I now hope that I can live as long as possible.

Dr O’Hanlan pleaded with her audience to spread the word about her research: She wants a world that accepts sexual and gender minorities for who they are. I want that too. But I also want these minorities to grow up as healthy adults. GAC promises happiness but does not deliver for many.

Healthcare providers have been hoodwinked just as much as the public has. Their vulnerability is their desire to be helpful. What greater seduction than to believe that you can deliver authenticity through a syringe or a scalpel.

So, here’s my appeal to Dr O’Hanlan — your goal for a kinder, more inclusive world is a laudable one. But your facts are outdated, your narrative flawed. This is not a straight vs LGBTQ+ David-and-Goliath battle. It’s a battle over evidence suppression and the concealment of facts. The more you peel back the layers of the GAC onion, I believe you too will discover something rotten at its center.

Culturally speaking where we are today is not where we were when I started my gender transition. I’ve come a long way from those days too.

I was diagnosed with Gender Identity Disorder - High Intensity in 2003 at the age of 23. I started on cross sex hormones in 2004. I had my last gender transition-related surgery in 2010. When I embarked down a medicalized path, some truths were still held to be self-evident: people couldn’t literally change sex, gender medicalization was largely experimental and a treatment of last resort, the treatment involved potentially serious physical health risks, the changes were mainly cosmetic, and longterm outcomes were largely unknown.

I accepted those risks because the alternative seemed worse. I was tired of being a social misfit. Gender transition represented an opportunity for me to blend in to society more effectively. And, in large part, it worked. But I didn’t believe that I was actually literally turning into a male. Instead, I believed I was some kind of intersex being and because the world was binary I needed to do something to fit in as best I could. I wanted to integrate into society. While I asked to be tested for intersex conditions, my doctor refused, stating it was unlikely I had such a condition. I wanted desperately some physical marker to explain my difference. I never found one, other than years later learning that I had autistic traits. Autism is considered a neurodevelopment disorder.

As recently as 2017 I still very much believed what I’d been told by the community I thought I belonged to: that gender-affirming care was a force for good, that the world was filled with heteronormative bigots who hated trans people, that detransition was rare, that no one was getting harmed, and that there was such a thing as an internal gender identity that was unchangeable and unchanging.

Then in 2018, I read Jesse Singal’s article for The Atlantic, in which he highlighted voices that I hadn’t heard before. I kept waiting for the detransition stories I was seeing more of online, to be debunked as false rumours or just a small minority. While detractors claimed only 1% of transitioners would detransition, the ‘rare’ voices of detransitioners seemed to be expanding online at an alarming rate. I discovered Benjamin Boyce’s Youtube channel filled with interviews with people who had once thought they were trans and then came to realize that they were not. I discovered Genspect’s Detrans Awareness Day webinars. It was uncomfortable to realize that detransitioners were not a small cohort of outliers, but a growing presence that needed to be reckoned with.

Listening to story after story of people not so different from me, who came to realize that their transition was not the panacea they’d been told it would be, felt like a wrong note in an otherwise harmonious gender affirming symphony. Their counter-narratives to the narrative I was used to hearing was like a fly buzzing around in an otherwise quiet room. I kept trying to swat it away as irrelevant, the ravings of a small minority. But eventually I realized that I needed to deal with the fly. It took a few more years for me to do so.

In 2017-2018 I returned to university to get my Master’s in Social Work. Part of what motivated me to do so, was wanting to improve the quality of life for people like me — people who belonged to the 2SLGBTQ+ community; and more specifically, people who were trans. At the time, I naively still thought of the 2SLGBTQ+ as one community. I still believed that if straight people were just nicer to us, we would magically all be healthy. I offered the obligatory Trans 101 trainings to my peers and colleagues. I called upon them to be allies in our fight for human rights.

For the final year of my Master’s degree I did a capstone project looking at trans identity development and the different pathways I saw for people coming to conceive of themselves as trans. For example, there were those who had, since childhood, felt at odds with their sex and who desired a medical transition in order to integrate into mainstream society as the opposite sex (sometimes called transmedicalists). There were others who did not think in binary gender terms but saw themselves as something else entirely (e.g. nonbinary, genderfluid). Some did not want to blend in at all; they wanted to deconstruct gender norms and do away with gender roles entirely. Some saw trans as an identity in its own right, while others saw it as a process that ended once your medical transition was done.

As I met more trans people in person and online, what struck me was how different we all were from one another. Trans people’s motivations were clearly not the same, nor did we even have the same definition of what it meant to be trans. But what we all seemed to have in common was a disdain for straight people’s ignorance. It felt good to blame all our problems on the close-minded straights. Odd that we expected straight people to know our needs, when we did not have a clear understanding of our own wildly divergent and sometimes contradictory needs. Activist trainings often involved commiserating over the ‘emotional labour’ we had to do to educate straight people about who we were. Reflecting on this now, I wonder who we thought should do the educating if not us.

The online trans communities I belonged to were a mish-mash of people with different embodiment goals and understandings of their identities. And while these communities claimed to embrace diversity, that diversity did not extend to allowing critical, nuanced conversations about detransition experiences of regret or trans women in sports or trans women in women’s prisons or medicalizing children.

While those who developed the protocols that came to be called gender affirming care claimed no particular preferred outcome for their interventions, in practice it certainly didn’t feel neutral. The gender affirming care providers and researchers I was studying were singing the praises of cross sex hormones, surgery and puberty blockers as ‘life-saving medicine’ and ‘medically necessary care’. Every person I knew who expressed that they were trans seemed to get approved for hormones or surgery with minimal exploration of their motives or investigation of their psychological needs. Some were not assessed at all.

This wasn’t healthcare, I realized. Or not healthcare as I had always understood it. This was consumer-based care, using the tools of healthcare, where the client was the expert and the healthcare provider was simply a drug dispensery. You could just as easily replace the healthcare provider with a robot for all the critical thinking they were expected to display.

I reflected back to my own so-called GID diagnosis. I had gone to see a specialist because I had wanted help to better understand myself. I thought that the specialist was critically assessing me according to some standard of evidence and that based on his assessment he had determined that I was indeed trans. I now realized that this wasn’t true. I may have thought that his role was to tell me whether I was really trans, but he had already diagnosed me — if you can call it that — before he ever met me. That’s what self-ID means. There is no real diagnostic process. It’s just a rubber stamp and off you go.

I realized that if I chose to become a clinician at the end of my graduate degree, I would likely be expected to write letters of support for others to medicalize just like my so-called specialist had done for me. The thought disturbed me. And my discomfort about this left me feeling like a bad trans person. If transition had been so wonderful, why was I hesitant to give others the same opportunity I had. It took a while for me to be honest enough with myself to acknowledge that transition had not been so wonderful for me after all. I didn’t necessarily want to rubber stamp others into make the same decisions I’d made.

That acknowledgement was a turning point for me. I started to train a more critical eye on the things I’d been told were true. E.g. that GAC was life-saving (it is not true that puberty blockers lower risk of suicide) or that GAC was medically necessary (based on what?). I read the Cass Review, which commissioned multiple peer-reviewed systematic reviews and found the same thing that every other systematic review to date had found. The evidence for GAC was of low quality/low certainty.

I looked at the studies that proponents of GAC use to bolster their claims and found small sample sizes, high loss to follow-up rates, biased study designs, and attempts to bury or cover up findings that did not support their claims (see the Alabama Brief to the US Supreme Court for a disturbing overview of WPATH’s attempts to bury their own commissioned systematic review). And those claims about detransitioners — that they’re rare or inconsequential? There’s little evidence to back that up either. In the US, the number of legal challenges are growing.

If real, high quality studies that GAC was an effective treatment for gender dysphoria were to emerge, I would be more than willing to recalibrate my views. So far, though, the studies that proponents use to defend the practice have proven underwhelming. Most gender affirming providers have not tracked their clients’ long term outcomes. I know this from personal experience. None of the doctors who prescribed me hormones or performed my surgeries ever bothered to follow up with me. They probably count me among their success stories.

And so, here I am. I see no way back to a social life as a woman after more than 20 years of hormone treatment and surgical procedures — not without great disturbance to my own and family’s life. I have a social work career and a family I painstakingly built that I will not disrupt further by undergoing additional legal name changes or surgical procedures. I’ve given enough of my body and soul to the wrong-headed project of GAC.

I’ve decided to live my life a male-appearing female, at least for now. There’s cognitive dissonance in this, but I’ll survive. I choose to focus on using what little time I have left to do what I can to make sure the next generation receives accurate information and high quality care. They deserve as much. That is my mission.

I want to start by saying that I do not have any simple answers about what the best path forward is, when it comes to policy or healthcare decisions for gender dysphoric people as a whole. It’s a messy issue. No matter what, some people will get hurt. Bans create panic and disruption for individuals and families. Regulation and gatekeeping can lead to suffering for those who don’t have easy access to services. No gatekeeping puts those who are vulnerable at risk of being harmed.

My hope is that as I tell my story and explore my experiences further, some clarity might emerge that might be helpful. So far that clarity has remained elusive, at least to me.

Tell the truth.

I have always attempted to be as truthful as possible. Sometimes I have failed, either because of a lack of courage, or because I have not known how to put into words the truth I felt. Sometimes I have had difficulty interpreting my own thoughts and feelings. Yet, some might say, here I am, living a lie day by day. Presenting myself as something other than what I am. It is a burden on my conscience that I wrestle with daily.

Then again, I’m not entirely sure that what I am living is a lie. I have sought to change my legal status, my body, in order to socially belong as best I can, to exist in a way that does not further alienate people. I have made these changes gradually, with the support and encouragement of healthcare providers with whom I have tried to be as honest as possible. Yet, by making these changes, I have come to inhabit a space that is both real and not real.

Males cannot be females. Females cannot be males. I accept that. But societally we have created a space for females to be legally male even though they are not natally male, and vice versa. That ship has sailed. And that’s not on me. Other people created this space. I merely stepped into it.

I did not do this alone. An entire infrastructure was created before I ever went for my gender assessment and dysphoria diagnosis — an infrastructure that I thought was built on solid foundation. It was not. Should I have known better? Maybe I was too trusting. But the setting up of that infrastructure, that part is not my fault.

The question of fault, is one I struggle with. Not fault, exactly, but responsibility. What, as an adult, am I responsible for? And what am I not?

I am responsible for my decisions. But in all of our lives, there are times when surely we cannot be held responsible, even for that. Imagine, for example, a 75 year old woman with dementia who walks into traffic. Is she responsible for disrupting traffic and putting lives at risk? Yes, perhaps. But is she responsible for having the symptoms of dementia? Is she responsible for her caretakers’ neglectful oversight? Surely, no.

I accept that I went to a psychologist, a supposedly learned man who I thought was trained to understand the intricacies of the human mind. Someone who I thought was equipped with knowledge about how the brain worked, with knowledge that surpassed my own.

I told this psychologist a version of my life story that confirmed my belief that I was trans. The story included the truth as I saw it at the time. I had always been uncomfortable with my body. Puberty was brutal. I was attracted to both males and females. I had always been a tomboy. I had as a child been confused about my gender and my sexuality — for example, at age 12 I asked an adult how you can tell the difference between a male sheep and a female sheep. That adult told me, with a smirk, “because they are bigger”.

Well. I was a 6ft 1 teenager — taller than my father. Though I was slender, I was certainly bigger than most boys and girls in my class. Did being bigger make me a man? Or just a very tall girl?

As far as I know the assessing psychologist did not ask for the notes of my own psychiatrist that I had been seeing for 3 years. She had referred me there for an assessment because she did not feel qualified to do a diagnosis herself. At the time only a select few experts were approved to provide referrals for medical interventions.

Had he asked for collateral information, he would have learned of my struggles with sexuality, my history of depression and anxiety, especially as related to sex and my body. He would have learned about my ongoing difficult relationship with my parents and siblings, and my cultural disorientation, having grown up in two continents, not fitting easily into either. He would have heard what it was like to grow up with a disabled father who, I was told, was about to die at any moment. He would have learned that I was sexually assaulted by a stranger two years prior.

He would have learned that rather than feeling like a man, my dysphoria was more a realization that I did not feel like, act like, or fit in with other women.

But he asked none of that.

After a 90 minute appointment, he generated a brief psychosocial overview of my life. He wrote a letter stating that I was a transsexual, that I wanted to transition, and recommended that I be referred to an endocrinologist.

Three weeks after first declaring that I might be trans, after never expressing such a thought prior to this, an endocrinologist gave me a prescription for Testosterone.

What am I responsible for? What are they responsible for?

I was responsible for asking for help. I was responsible for talking to these experts about my struggles. I was responsible for not wanting my parents to be involved in my care, because I felt they judged me. Besides, I was an adult. I didn’t need them there.

I was not responsible for my diagnosis or treatment plan. That came from the experts I consulted with. I assumed it was backed by research — something I no longer believe. I was responsible for accepting their recommended treatment plan. Why should I have doubted them?

The mistake I made was to have had a preconceived idea of what was wrong with me. And they simply confirmed it, without testing it for size. I thought I was going in for a diagnosis and treatment. That’s not what I got. What I got was an assembly line: Patient says they’re trans = they are trans = they should be started on hormones = they should get on the waitlist for surgery.

Nowhere in this process did any of the medical providers push back and say: you know? Maybe we should look at your motivations for wanting to do this. What is it about living as a woman that is causing you so much distress? What have you tried so far? What are you willing to try? Let’s start with exploration first (e.g. If you had to live your life as a woman, what kind of woman could you be?)

No one asked about the sexual discomfort or pain I experienced during intercourse and I certainly didn’t bring it up. I felt too much shame and embarrassment about anything related to my body. It felt less shameful to change my entire physical being, my legal status as a woman, than to admit that penetrative sex was so painful as to be impossible for me. Even as I write this sentence I feel shame burn in my cheeks.

No one seemed the least bit curious about any of this, because they inhabited a space of certainty that up to then I had craved with all my heart. They knew what was wrong with me, and hormones and surgery would fix me. I wanted to believe them. I am responsible for believing them. But I am not responsible for the lie they told me. Perhaps they did not think it was a lie.

I do not know what to do with any of this. It feels like such a tangled mess. I want to be mad at someone, point the finger somewhere. I can point the finger at the psychologist who was so incurious. I can point the finger at the psychiatrist who, after I started my medical transition, fired me as a patient stating that she had nothing more to offer me. I can point the finger at the pharmaceutical companies and medical leaders who continue to turn a blind eye to the harms they have contributed to. And I can point a finger at myself, for being so gullible, so foolish, as to think that surgery would cure my mental anguish. I can point my finger at my parents, for years of emotional neglect. There are plenty of people to blame. Including me.

But what does that change, exactly? Let’s say it is all my fault. Or the doctor’s fault. Or my mother’s fault. Or my father’s fault. Or the psychologist’s fault. Does that undo the damage? Does that fix anything? This is not something that can be fixed through blame.

I don’t want to live a life of resentment. I still have years ahead of me (I hope). I’d like to spend it creating something constructive, rather than wallowing in regret for decisions I cannot undo. I am less interested in blame and more interested in figuring out how to build a system that actually better supports people who may have struggles like mine. If we could build a better system, what would be the key components? What would it look like?

I think it would need to involve:

• Time

• A focus on psychological as well as physical health

• Healthcare providers that look at the full human in context

• Honesty, about what we know and don’t know

• Honesty, about risks, common medical complications, and benefits, for those who choose to medicalize

• Collecting collateral information from family/friends

• Psychosocial support for clients navigating a world that is not required to accept them

• Ongoing competent medical and psychological support whether that person medicalizes, doest not medicalize, or chooses to discontinue medicalization

My story is just one of many, but I no longer believe that I am an outlier or all that rare. I am coming to terms with the mistakes I made and the reasons why I made them. My story isn’t over. I’m still figuring out how to put the puzzle-pieces back together again. Some pieces are missing, and probably always will be. That’s OK. I’ll leave the blame game to someone else. Plenty of people are ready to step up to that plate.

The question I regularly come back to is a different one: What is the best use of me, now? I don’t fully know yet. I’ll continue to tell the truth. Even if it’s inconvenient, to myself and others. Even if it doesn’t fit into everyone else’s preferred narrative.

The truth as I see it is that I sought out transition because I thought it would help fix my mental struggles. It didn’t. And yet, it did help me break out of old patterns for long enough to find a strange kind of footing in this world. By the time my depression and anxiety returned, at least I was alive to access psychotherapy that actually helped.

I am making my peace with living my life as a legal man while knowing that I am a natal female. I’m not sure I believe medical transition is ever the right answer, and doubly so for children. But while it may not be the right answer, for some it becomes the default answer and it is still possible to live a meaningful and even happy life after having medicalized.

This is the inconvenient truth as I see it.

The evidence that medical gender transition reduces suicide is flimsy at best. In fact, at least one study seems to indicate an increase in suicide in those who have medicalized. How do I square that with my own belief that transition saved my life? I think both statements can be true.

In Dec 2003, I went to see the psychologist who would diagnose me with “Gender Identity Disorder – High Intensity”. This followed three years of regular talk therapy appointments with a psychiatrist who also heavily medicated me (for anxiety and depression). My ongoing mental health struggles, including suicidal depression and an eating disorder, spanned back to my early teens.

In the short term, medical transition offered me a path forward in the world of the living; clear steps I could follow. The healthcare providers I consulted assured me I would feel better and I believed them. Finally, someone was offering me a solution to my problems, a lifeline. And because gender transition, socially, medically and legally, was such a long, drawn-out process, the end of the rainbow was just sufficiently out of reach to keep me motivated to continue. I had something to ruminate on that kept me focused away from death, which had become something of an obsession by that point.

I had tried all the traditional avenues I could think of to feel better. Doctors, therapists, social workers, books. I did not understand why I was so unhappy, and I could not understand why no one seemed able to help me. I wanted someone to rescue me from myself — yet no one seemed to have the answers I sought. The thought that this was as good as my life might ever get was terrifying. I couldn’t imagine myself living this way for much longer. I didn’t want to. I felt weak for not being able to get out of my funk. I felt like a failure for not measuring up to my parents’ and my own expectations.

What do you do when all the doors seem to shut in your face and you are left in the dark? I sent myself to a self-imposed solitary confinement. For weeks on end in my late teens and early 20s, I would literally lay in bed for most of the day, lights off, under the covers, door shut. The noises and lights of the world felt like nails on a chalkboard. The chitter-chatter of human voices in the distance pierced me like glass. I convinced myself that I was protecting others by withdrawing from social life.

Gender transition changed all of this. As I started down the gender transition path, I felt a new confidence in myself. For the first time in years, I felt hopeful about the future. I got my first serious job, had my first serious romantic relationship, stopped self-harming, and felt more able to connect with those around me. Life was looking up.

Once the novelty wore off, however, and the bi-weekly hormone injections became routine, the depression slowly started to creep back in, like a shadow spreading its pall across a dimly lit room. I cannot pinpoint the precise moment when I realized that I was again having suicidal thoughts. Likely it started in 2006, two years after my first hormone injection.

In April 2005, a close friend died by suicide, followed by my father’s death to cancer six months later and the implosion of my relationship with the remainder of my family. In the midst of this tsunami of loss, I clung to the raft of gender transition to keep me from spiralling completely out of control. Medicalizing my body was perhaps the most predictable, most controllable aspect of my life. While I felt no control over my father’s cancer, nor of life and death itself, and I did not seem to have the skills to resolve the interpersonal conflicts that plagued my family of origin, I at least could control how and when I injected myself with hormones, or which surgeries I chose to have.

These small acts gave me a sense of agency in the turbulent ocean of my life. They kept me grounded in the now, while the bones of my grief scattered across my shores. With every gender-related decision I was moulding myself into a new, more resilient person. One could say I was attempting to wash away that other version of me, that burdensome, depressed, fragile, flawed and largely useless young woman who seemed not to have gotten the memo on the rules of life and death.

That young woman’s body was a constant disappointment, from the painful monthly periods, to the acne covering her back and face, to her physical clumsiness and sensitivity to noise. Romantically, too, she had failed. Her first boyfriend had found her breasts wanting, and a greasy Texan passenger on a Greyhound bus sexually assaulted her on a cross-country road trip. Her body was offensive to lovers and abused by strangers. She struggled to connect with other women. Some even approached her with hostility — like the cleaning lady at an international airport who chased her out of the women’s washroom with a broom for apparently looking too much like a man. No one wanted her around. Not even me.

That young woman, whose mother despised her, whose father was disappointed in her when he died, whose siblings didn’t understand her, whose friends couldn’t really get close to her, that young woman had very little going for her. She belonged nowhere and with no one. I abandoned her too.

Sacrificing parts of her female body seemed like a small price to pay for the possibility of staying alive. She wanted to fit in, to love and be loved, and yes, to live. Yet who she was as she was then, seemed unlovable, by others or even herself. The depth of my self-loathing is hard to put into words.

I did what I needed to do to say alive. And for that reason, I am grateful that I transitioned. Was it the only option? I don’t know, truly. I had tried everything else. If I had it all to do over again, I don’t know that I would have done anything different — not based on the information I had at the time.

Turning point

As recent as 2017, I was still convinced that gender affirming medical care was a generally good thing. It had saved my life, so surely it could help others. Then I started listening to the stories of detransitioners. It started with Jesse Singal’s article and later I found Benjamin Boyce’s series of interviews with detransitioners. What struck me was how similar their stories were to mine. Like me, many of them had autistic traits. Like me, many struggled socially or had some kind of sexual trauma or loss.

It wasn’t just the stories I heard online that shifted my thinking. Also in my personal life, people I knew were living realities that ran counter to what was supposed to be. In 2022, a transmasculine friend slightly younger than me died by suicide after developing paranoid psychosis symptoms involving believing that he had given birth to multiple children. Another friend that transitioned around the same time as me, came out as a detransitioner and told a tale of being sexually exploited by a pedophile as a child. Another friend grew disillusioned with his trans identity and eventually chose to return to a butch lesbian identity instead.

Gender, I’d read, was supposed to be hard-wired. Kids knew who they were, the experts said. And yet, this was not my own experience, nor it seemed, the experience of those close to me who had followed a similar medicalization path to the one I had.

If this were true for me, and for at least some of my friends, then that meant we were medicalizing people, without knowing whether their gender identity would remain stable over time. We were irreversibly altering their physical bodies with no long-term studies to back up this practice. And increasingly, we were doing it to minors.

Realizing this made my pause. It was destabilizing to acknowledge that I had bought into a belief system for which there was little evidence — that someone could be ‘born in the wrong body’ or could ‘change sex’. Yet my own transition, I had to admit, had at least temporarily allowed me to reinvent myself sufficiently to find a footing in my own life, so that I could become a contributing member of society. I could not deny that it had benefited me.

As a woman, I had been a disaster – mentally ill, self-harming, suicidal, unemployed and unstable. As the male-appearing person I became, I still had some mental health struggles, but not anything close to as severe as before, and I was working, contributing to the larger community. Could I have learned to do so as a woman? Perhaps. But I didn’t. Transitioning was as close to a re-set button as I could get without killing myself.

I am not proud of transitioning, nor do I wish it on anyone else. If it can be avoided, I think it should. But in some cases, I think we must acknowledge that until the world finds a better way to nonmedically integrate gender variant people, we will always have a few who will seek to surgically and hormonally alter themselves in search of a better life. And for a few, medicalizing will help them thrive.

When I was a kid, I struggled with understanding my place in the world. Anxious by disposition, I also had to contend with an ever changing cultural environment as my family moved from one continent to another. One can say that a culture comes with inbuilt scripts for its members, norms of what to expect or do. The gender script especially caused me great stress growing up. I just didn’t seem to know how girls were supposed to behave from one culture to the next. Later, the script for how I was supposed to experience my sexuality also felt like a bad fit. Was I gay, was I straight? What I was, most of the time, was a misfit.

A popular narrative online of late is that gender affirming care is a new kind of conversion therapy — one that is converting gay people into trans people. Aside from it being a catchy catch-phrase, ‘stop transing the gay away’ captures a popular belief that most kids who experience some form of gender incongruence, if they were left alone, would simply grow up to be gay. This is at least somewhat borne out by research, though the research is not without controversy.

However, as psychologist Lisa Feldman Barrett likes to say when she talks about emotions and body budgets: all metaphors are wrong, but some are useful. I think the catch-phrase of ‘transing the gay away’ is a sometimes useful one but it feels incomplete.

Having spoken to and read the stories of a number of detransitioners, one story that has emerged from their voices is of the butch lesbian or effeminate gay man who for whatever reason developed a belief that they were trans and then later realized that they were gay not trans (here’s a recent example of just such a tale).

In a recent commentary “Affirming Everyone in the Rainbow: Is Gender-Affirming Healthcare “Gay Conversion Therapy?”, the authors (Kinnon R MacKinnon, Pablo Expósito-Campos, David J Kinitz, and Joey Bonifacio) take a closer look at this narrative and come to the conclusion that it is unconvincing. They argue that ‘transing the gay away’ can only be true if we assume that sexual orientation is innate and unchangeable while gender identity is not. They argue that because we have evidence that sexual orientation can shift over time for some, it is no more innate than gender identity is.

It’s an interesting argument but misses the point I think. The opposition that some feel towards how quickly young people are nudged in the direction of a trans identity is not that there is something inherently wrong with being trans, but that a trans identity comes with potentially serious medical ramifications for that individual. If a child could integrate their gender incongruence into a gay identity without needing serious medical interventions, surely that is a preferable outcome.

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The authors also argue that gender nonconformity isn’t always a precursor to a trans identity, and that the majority of trans people see themselves as a sexual minority post transition, undermining the claim that people are becoming trans due to homophobia. To me this argument does not particularly debunk the claim that gay youth are being transitioned, only that they are not the only youth being transitioned. As for the claim that young people are more likely to identify as a sexual minority following transition, what this could indicate is that youth are fleeing heteronormativity, regardless of sexual orientation.

This tracks with my own experience. Prior to becoming trans, I had struggled for years to fit in to a heteronormative culture. The societal waters I swam were very much discouraging of a gay identity. I knew no one growing up who was a lesbian — except for rumours about the conductor of a youth orchestra I was part of. But she was also vilified for being a ‘homewrecker’ (she slept with a married woman) and treated with suspicion by my disapproving mother. I did interact with some suspected gay men growing up, but again their sexuality was spoken about in hushed tones and shrouded in secrecy and ridicule. As HIV ravaged gay men’s lives in the 80s and 90s, the message I grew up with was that their life choices were the cause of the disease’s spread. AIDS was God’s punishment for immoral acts.

No surprise, then, that I did not exactly gravitate toward a gay identity even as I was trying to make sense of my same-sex attractions. Besides, I also experienced opposite-sex attractions so maybe I wasn’t gay after all, I told myself.

When I was finally diagnosed with gender identity disorder (now called gender dysphoria), the relief I felt was deep. Finally I could point to my newfound diagnosis as the source of my social discomfort; I didn’t fit in because I was actually wired differently. The diagnosis made it official. Had I been given an autism diagnosis, I imagine the relief would have been the same — though practically speaking, the outcome would have been very different.

Once I started to transition, I experienced a rush of excitement because to my mind my diagnosis had given me permission to imagine a life that wasn’t defined by the rigid expectations of a culture I didn’t fit into very well. I gave myself permission to ‘break the rules’ because I now felt I was allowed to. I wasn’t just a bad fit as a woman, I was trans and therefore I didn’t have to be a woman at all.

At the time, it made sense. Looking back, I cringe. I was so desperate to have an explanation for why I felt so awkward socially and in my own body. Up to then I had felt like a failed human. The trans identity offered me an off ramp, or an on ramp to a new way of life. I no longer was beholden to society’s rules; I could create my own. It was the ultimate act of personal agency.

Or so it felt at first.

Of course, I had escaped one box only to get trapped in another. I had escaped the box of woman, with all its accompanying accoutrements (makeup, dresses, sexual harassment, etc.) only to find myself in the box of man with all its baggage (men are scary, men are homophobic, men are misogynistic, men are violent). I didn’t want to be in that box either. 

I was like an entertainer who turned down a script because I wanted to be the scriptwriter, not an actor in someone else’s play. Only, when I put down the woman script, I was handed the man script and it sucked too. I needed a different genre entirely. And a different medium.

While prior to transitioning I had flirted with being a lesbian, it had not felt terribly comfortable as an identity for me. I don’t really understand why. Perhaps it was my early conditioning or the lack of strong role models. Perhaps it was because I ultimately wasn’t interested in femininity and what it represented to me (right or wrong). Perhaps if I had been invited to participate in a butch sub-culture, I would have found my place in it. I never did. In any case, I didn’t want to be a pretend man. I either wanted to be the real thing or nothing at all. My thinking was not particularly subtle or refined. I was desperate, and I was hurting.

As I had opposite sex attractions as well as same sex ones, I became interested in exploring the dating world of gay men. My trans identity afforded me a freedom to move beyond the heteronormative. I was a gender outlaw. No longer did I need to follow anyone’s script but my own. If I wanted to date gay men, and they wanted to date me, then why not?

Of course, looking back I now realize that I was still in someone else’s script, I just wasn’t aware of it. I had stumbled into the world of Queer, which is all about blurring boundaries, obfuscating difference and deconstructing categories for political purposes. I was a pawn in someone else’s army and I didn’t even know it. I think that’s true for lots of people who are drawn into the cultural movement that is trans.

That brings us back to MacKinnon et al’s article. We are not just transing the gay away. We are seeing an exodus out of straight culture. Particularly for those of us who struggle socially (those who are on the autism spectrum, for example), a trans identity is a way to say: screw your norms. It’s a way to carve out space to be different. Some choose to stay gender outlaws (e.g. nonbinary trans). While others re-integrate into familiar gender scripts that previously had been forbidden to them (e.g. binary trans).

And that would be fine, if it weren’t also coupled with a lie… A lie that claims that people can change sex, that gender identity is a transcendent soul-being inside of us. It’s a lie that is enabled by medical providers who mistake themselves for saviours doing god’s work by carving up physically healthy bodies on the altar of trans healthcare. This isn’t healthcare. It is a social movement using the tools of medicine to its own ends. 

If we want to put an end to this madness we need to have a discussion on a societal level of how to integrate the misfits in a way that strengthens society rather than weakens it. As a misfit, I want to be a contributor to society. I am willing to give voice to someone else’s script if it’s a good one. But right now, we need better writers.

My beating heart bleeds

drops like red rain

splashed across an open field

feeding the roots moist and thick

under the surface

so deep they scrape against my skin,

my bones lie in wait

I do not have the strength to tear them

from the soil

not even with two hands gripping

for a moment

I can’t breathe

then I relax

I breathe again

When I was diagnosed with Gender Identity Disorder in 2003 I thought I had found the answer to my struggles with depression and anxiety. I was proud of myself for the courage it took to ask for help and I was ready to embark on whatever the future held for me. I was honest about my gender nonconformity with the psychologist who assessed me. And I was open to those who were close to me that I felt not so much like a man, but definitely not like a woman. At the time I felt that if I had to pick how to live my life, I chose to live it as a man. It just so happened that was an option.

I wasn’t offered any other options for my gender dysphoria besides medical ones. I wasn’t offered any explanation for why I might feel gender dysphoric. It simply was. Like rain falling in the desert. I simply had to accept. So I did.

A diagnosis meant hormones and surgery. The message was clear — gender dysphoria was not something you could be talked out of. So I didn’t even try to better understand it. The psychologist who assessed me did recommend therapy but only to help me adjust to my new reality once I started medicalizing my body.

It seemed obvious, if not to me then to everyone else, that changing my body was the only way forward. Since nothing else had helped me feel less alienated from myself —not the litany of medications I had been on, nor the attempts at therapy for anxiety and depression that pre-dated my transition, I felt I had run out of options.

For years leading up to that moment, I had tried to live somewhere in between the masculine and the feminine, dressing androgynously and mixing mainly with lesbians socially. But even there I didn’t feel like I belonged. I remember a lesbian roommate once informing me that she could normally tell if someone was gay but that she had a hard time reading me. I recall the kid who pointed at me in a parking lot and asked their mother — is that a boy or a girl? I was asking myself that too.

I wasn’t stereotypically feminine but I wasn’t particularly masculine either. I wasn’t handy around the house or spatially gifted. I wasn’t good at math, I wasn’t interested in body building, I wasn’t a computer geek. I wasn’t a particularly good cook, I didn’t like dresses or makeup.

I was quiet, introverted, liked to read and listen to music, avoided conflict, kept to myself, and struggled to find my place.

I wanted an identity that helped me feel like I could belong. So much of the time I felt like I had neither belonging nor identity. I felt no kinship with the women in my life. I don’t say that with pride. There is not pride in it. It is the truth.

Travelling back in time and remembering exactly how depressed I was, is hard. You had to be there I guess. I was there but I wasn’t either. I was checked out most of the time. Dissociated. Distracted. Disaffected. Depressed and heavily dosed. Antidepressants, anti-anxiety meds, sleep meds, psychotropic meds of all sorts. I felt broken and I was treated as such.

My whole life is ambiguous. Did my gender transition save me? Or did it condemn me to a life so much less rich than it could have been? Did it shorten my lifespan or extend it? Hard to say.

I could drive myself crazy trying to revisit all the decision points that led me to where I am but what good is that? Fact is, here I am. A transman who doesn’t believe he is male. Never have, though I’ve tried. I accept that I am female. A masculine female of sorts. Not so masculine. Not so feminine either. Nonbinary then? I don’t like to define myself as a negative. Too often I have felt like an absence, an emptiness where something should be but isn’t. Words have a kind of power but I struggle to find the right ones still.

If I don’t believe I am male, will I detransition? I don’t know what that means. There’s no ‘there’ to go back to. From age 12-23 I was suicidally depressed and isolated. From age 23 onward I chose to live socially as a man. My transition coincided with my first serious job, my first relationship with a woman, and my first time truly living on my own.

Returning to a female social identity would mean a potential return to the hurting person I was before. I welcome her as part of me but I do not see myself inhabiting her socially. She is light, like a ghost, immaterial and floaty. Lurking in the shadows.

Here I am, then, in a gender no man’s land. No woman’s land. A nothingness, a something.

No matter what I do or say, I know there will be those who say I am not a real man, that I am living a lie. Perhaps they are right. And yet each day, I get up, put on the clothes I feel most comfortable in, trim the beard that cross sex hormones have induced in me even though I no longer take them. Perhaps I should be miserable. I am not. I still feel lost in the wilderness, it is true. But perhaps with age, one grows more comfortable with the wilderness and one’s place in it.

This is my path. And though I can’t see yet where it will wind its way, I am ready to walk it. I feel stronger than I ever have, and hopeful. I feel fragile and scared. But I know, so many feet walk next to me, so many lives have protected mine. I am grateful for this gift, this time I have in this mysterious world. I am a child of the universe, complex and beautiful.

While legally, socially, I am treated as a man, I accept that I am not a man biologically. 

When I expressed that I might be trans, an entire ecosystem emerged around me to complement the social messaging I received that medical transition was the way to go: healthcare providers who told me medical transition was the best treatment for gender dysphoria. I believed them when they said it would prevent suicide and make me feel more at ease in my skin. For a while I even believed that it worked. But then the suicidal thoughts came back and I struggled socially in ways different than before, and hard to articulate.

Medical transition was a choice I made based on the information I had available to me at the time, because I could not see a path forward for myself as a woman. No one seemed able to help me with that. And I did try — many, many years of therapy, as well as a cocktail of psychiatric medications. It didn’t work for me.

Telling someone to love themselves isn’t enough. How is the question. While I searched for ways to accept myself as female, no one had the answer for how to do so. Transition was a desperate act, but it was in a backwards way an attempt at self-love. It was me acknowledging that I was struggling. It was me reaching out for help and opening myself up to the views of others. Unfortunately the ‘help’ I was given was a lie. But I could not have known that at the time.

The lie only holds together if everyone buys into the belief that people can literally change sex. And not everyone does believe that, because quite simply it isn’t true. Nor should people have to buy into it. People should be allowed to believe in facts. The fact is humans are mammals, and like every other mammal in the world we come in two flavours. Sure, some people have extra spices added in (e.g. extra chromosomes, or anatomical differences), but essentially as a species we are divided into those who are designed to develop large gametes and those who are designed to develop small ones.

For me medical transition was a necessary step along my life path — I accept that. I wish it hadn’t been that way but it was. I regret parts of it now because of the steep cost to my body, my health, and my relationships. If I could have my life over again, I would not choose to transition. I wish I could have seen a way forward as a gender nonconforming woman. I simply couldn’t — I don’t know why. It was a failure of imagination that no one seemed to be able to guide me through.

I can’t have my life over again. And I see no point in punishing myself for what I did not know back then. And every decision comes with benefits as well as costs. The benefits are that I met my wife and we have built a happy life together over the past decade. That alone has made my strange life trajectory worth it. That I do not regret at all.

Until medical professionals stop abdicating their responsibility and start telling the truth (people don’t change sex, they just medicalize their bodies), stop lying to people about what medical transition can offer (there is no evidence it improves mental health), including openly discussing the many common harmful side effects, people will continue to embrace medical transition.

The technology exists. I doubt it’s going away any time soon. We need to figure out how to welcome everyone into the fold. But that does not mean we need to deny reality.

The reality is that I am a medically masculinized female who is legally recognized as a man. That does not make me a man. And it makes me different than most women.

What does healthy gender nonconformity look like? What can we do to create space for that?

That is a societal question that we will need to address.

I drafted the following letter over the holidays. I’m still not sure whether I want to send it. What’s done is done. Writing it, however, helped me clarify my thinking on what I experienced, and why I feel the way I do.

Dear Dr ______,

In 2010, you performed a total hysterectomy/oophorectomy on me after I was diagnosed with gender identity disorder by a gender specialist. You advised me that it was in my best interest to have a hysterectomy because a person injecting testosterone had a higher risk of cancer in the reproductive organs. You also told me that removing my uterus would mean I wouldn’t have to go for regular gynaecological exams, which you said would lessen my dysphoria. At the time, I did not truly understand what I was giving up (i.e. my ability to give birth), even though back then I didn’t think I’d ever want a child. I believed you because I wanted to. I hated everything about my female body and I didn’t think that would ever change. It did.

I am writing to you now, in 2024, as a former patient, to update you on how my life has unfolded since then. I know that as a medical specialist you may not often collect feedback from patients about their longterm outcomes. Perhaps hearing about those longterm outcomes is worth your time. Maybe it can even inform your practice moving forward.

When I was diagnosed with gender identity disorder, I was offered only one path for my dysphoria — medicalization and transition. I now wish that I had been offered a more thorough assessment and psychotherapy first. It took a single 90 minute psychological appointment with a gender specialist to alter the entire trajectory of my life.

More recently I learned that I have autistic traits that I think greatly contributed to why I thought I was trans. I was also sexually assaulted a few years prior to my starting on hormones. So many of my symptoms had to do with social difficulties, gender nonconformity, a confused understanding of sexual orientation, a discomfort with sex, and sensory issues. Once I received a diagnosis of gender identity disorder, though, these issues remained unaddressed. I was told medical transition was the way to resolve my mental health issues.

While initially my medical transition did make me feel better, I continued to struggle with depression and anxiety. By 2013, I was again experiencing suicidal thoughts. My relationship with my family of origin, which had always been difficult, worsened significantly following my gender transition, as they did not accept it. So toxic had our interactions become that I had to make the difficult decision not to attend my father’s funeral in order to not further upset my family. I still grieve over this.

I was told that medically transitioning would improve my mental health, yet a decade after I was diagnosed, I was still struggling with the same issues. I slowly came to ask myself: What had been the point? After undergoing a double mastectomy with male contouring for my chest, and a total hysterectomy/oophorectomy, I chose to stop short of having a phalloplasty. I realized that surgery was no cure for my difficulties. I chose to pursue psychotherapy instead.

Since then, I have managed to break out of my depression. I no longer think of myself as male and believe that I was misdiagnosed. I also no longer take medications, including testosterone. The changes to my body, however, are irreversible. I am now at a place in my life where I would have liked to have had children of my own as part of my family, but that door has permanently closed.

I have chosen to continue to live legally and socially as a man as I do not wish to disrupt my life or my family’s life further. I cannot go back in time and undo what was done to me, but I hope that by sharing with you how my perspective has evolved, that you will keep this in mind as you continue to work with patients who report gender-related distress.

I have encountered too many people who, like me, have experienced harm due to the unnecessary medicalization of psychological distress. It needs to stop.

© Nevit Dilmen, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons

Well, 2023 is behind us. Some highlights for me include:

Virtually attending the Genspect Killarney and Genspect Denver conferences. Both were amazing opportunities to learn from the brightest minds in the gender world. 

The Killarney Group released a draft version of its Gender Framework at the Genspect Denver conference. The framework will offer a non-medical response to gender-related distress, as an alternative to the medical model offered through WPATH’s Standards of Care Version 8 (SOC8). Version 1 of the Gender Framework will be formally released in September 2024.

I joined the LGBT Courage Coalition. It’s one of the few organizations out there that sees value in the LGB and T communities working together toward the common goal of improving gender-related healthcare for minors and adults. I’ve been honoured to play a small part in contributing a few Substack posts to the LGBT-CC blog, including How much regret is enough? , Is CASW's stance on social transition in schools justified? , The role of evidence and autonomy in gender affirming care , and A gender transition story: How my views on medicalization have changed over time. I’ve been drawn to the organization’s commitment to free enquiry and diversity of thought on issues pertaining to LGBT communities.

The Gender Exploratory Therapy Association has rebranded and is now called Therapy First in an endeavour to highlight its commitment to psychotherapy as a viable first-line response to gender-related distress. I’m excited to see what 2024 will bring for this organization. In a previous blog post I described how gender exploratory therapy is helpful for gender-related distress.

Detransition news stories hit the mainstream in 2023. Some pieces of note include an article in the Atlantic in January about the need to take detransitioners seriously, and a Reuters article on why detransition stories matter. Following an article in The Free Press, The NYT attempted to broach the controversy of what’s happening in gender clinics, and the Washington Post waded in on detransitioners with a confusing take. In Australia, Channel 7 News put the, well, Spotlight on the realities of de-transitioning in that country. Hannah Barnes’ book Time to Think also garnered plaudits for its even-handed investigation on what was going on in the UK’s Gender Identity Development Service (GIDS) — hint, it’s not good.

Detransition research in North America is on the rise and the DARE study launched at the end of 2023. Led by a research team out of Canada, it will be the largest sample across the US and Canada ever collected on the topic of detransition. This follows the Re/Detrans Canada Study, the results of which were shared earlier in the year.

Excited for the ongoing conversations in 2024 on how we can improve healthcare for all people navigating gender-related distress. If there’s a particular topic you’d like me to tackle in the coming year, please add it in the comments.

Happy New Year - and thanks for reading!